Stimulant-Induced Trichotillomania

Introduction

In order to meet criteria for trichotillomania as defined by the Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, a patient must have noticeable hair loss (alopecia) due to recurrent hair pulling, tension immediately before hair pulling, or when attempting to resist hair pulling, reduction of tension, or a feeling of pleasure or gratification, immediately following hair pulling, and significant distress or impairment in social, occupational, or other important areas of functioning. A prior report described the presentation of cocaine-induced trichotillomania, which resolved with the cessation of cocaine use (1). Here we describe the case of stimulant-induced trichotillomania that resolved with the discontinuation of stimulants and initiation of olanzapine. To our knowledge this is the first reported adult case of stimulant-induced trichotillomania.

Case Study

Mr. D is a 26-year-old, single, unemployed (self supported), domiciled, white man with a previous diagnosis of attention deficit hyperactivity disorder (ADHD), who was brought in by his girlfriend for evaluation for 3 to 4 weeks of compulsive hair pulling and plucking with tweezers that escalated on the day prior to admission.

The patient reported that he had been taking amphetamine/dextroamphetamine intermittently and erratically since age 14 when he was diagnosed with ADHD. As per collateral information, during high school and college, the patient would use illicitly obtained amphetamine to concentrate on schoolwork or use recreationally. He had been prescribed amphetamine/dextroamphetamine 20 mg 3 times daily or lisdexamfetamine 90 mg daily for about 1 year prior to admission. He would sometimes combine these 2 medications. He reported using the medication in combination with caffeine for “concentration and energy” at work.

Three months prior to admission, the patient lost his job secondary to conflict with his supervisor. Due to his girlfriend's concern about irritability and increased emotional sensitivity, the patient saw his psychiatrist 1 month prior to admission and was started on ziprasidone 40 mg at bedtime and an additional 20 mg daily as needed. Mr. D. was not regularly compliant with this medication. About 10 days prior to admission, his psychiatrist switched his regimen again from lisdexamfetamine to methylphenidate 36 mg daily. Mr. D reported he began combining the 3 stimulant medications he had in his possession although he was unable to give exact doses used.

A month prior to admission, Mr. D had noted some ingrown hairs in his inguinal region, which he began to pluck out. He reported that plucking often lead to a feeling of “release.” He would pluck in the mornings after showering until “time ran out” or his girlfriend interfered by questioning him. He described tension prior to plucking and release afterwards. He also felt that plucking was improving his “sex drive” and “flow,” though he denied increased frequency of intercourse or masturbation.

Over the month, he eventually progressed from pulling out inguinal hairs to pulling hairs out of the side of his head. He allegedly reported to a family member that he felt these hairs may have been wrapped around internal organs and that when he unbound these hairs, he felt relief. Initially he was able to conceal these areas on the lateral sides of his scalp with longer hair, but approximately 2 weeks prior to admission, he shaved his head in an attempt to decrease urges to pluck.

During the admission interview, the patient presented an envelope containing a strand of what appeared to be metallic duct tape and a single normal-appearing hair. He reported that he felt the hairs he was plucking may have been responsible for misalignment of his jaw and neck and that he needed to “undo the tightness of the kinky hair type.” He also reported that the release he felt by “unbinding” these hairs helped renew blood flow in the arteries distal to the site of hair removal.

Mr. D was voluntarily admitted to the inpatient locked psychiatry unit. Though he had a history of experimentation with hallucinogens in high school, he denied abusing any other psychoactive substances during this time period. All stimulants were discontinued and he was started on olanzapine 5 mg at bedtime. Medical workup, which included blood work, chest x-ray, and head computed tomography (CT) scan, were all within normal limits. Urine toxicology was negative.

Internal medicine and dermatology were consulted with no significant findings or further recommendations. Although initially withdrawn to his room, spending most of his time sleeping, within 3 days of admission Mr. D became an active participant in unit activities. He was compliant with medication dosing and involved in conversations about the importance of abstinence from use of amphetamines upon discharge. A family meeting was held 6 days after admission and patient was discharged home.

Conclusion

Although some information regarding stimulant-associated trichotillomania among youth is available (2), this is the first reported case of in an adult. Given the association in time between amphetamine intake, the symptoms of trichotillomania and the resolution of symptoms in the absence of amphetamine use, hair pulling was likely amphetamine induced. Psychostimulants have facilitative effects on dopamine and serotonin neurotransmission, which have been implicated in the etiology of compulsive behaviors. Thus trichotillomania with ADHD may be a complication of stimulant treatment or the unmasking of a latent neurobiological vulnerability (2).

It is known that psychostimulants can induce psychosis and that psychosis induced by methamphetamine is a typically transient phenomenon that involves symptoms of delusions and hallucinations. Psychostimulant psychosis can also be accompanied by an emotionally labile state, agitation, and seemingly irrational hostile behavior. These symptoms can be accompanied by repetitive stereotyped behavior and social withdrawal. Psychosis induced by methamphetamine is a typically transient phenomenon remitting rapidly following detoxification (3).

ADHD among adults has received increasing attention over the past few years (4). Medications used to treat ADHD are also abused by young adults in the attempt to improve concentration, lose weight, or enhance school performance (5). Given the increase in exposure of prescription amphetamines among adults, further study into the association between stimulants and adverse events such as trichotillomania is needed.