A rare case of trichotillomania with antisocial personality disorder

Priti Singh1, Pratibha Gehlawat2, Rajiv Gupta3, Sandeep Soni4

1MD (Psychiatry), Professor, Department of Psychiatry, Pt BD Sharma PGIMS, Rohtak, Haryana, India

2MD (Psychiatry), Senior Resident, Department of Psychiatry, Pt BD Sharma PGIMS, Rohtak, Haryana, India

3MD (Psychiatry), Senior Professor, Department of Psychiatry, Pt BD Sharma PGIMS, Rohtak, Haryana, India

4Junior Resident, Department of Psychiatry, Pt BD Sharma PGIMS, Rohtak, Haryana, India


Trichotillomania (TTM) is characterised by recurrent and irresistible urge to pull out one’s own body hair. It is often associated with trichorrhizophagia in which there is a habit to eat the roots of pulled out hairs. It can also present with many comorbid psychiatric problems including personality disorders. High rates of comorbid mood, anxiety, and substance use disorders have been detected in patients of TTM. The lifetime prevalence of comorbid personality disorders has been much less extensively studied. We present a rare case of 28-year-old male having TTM with antisocial personality disorder and discuss difficult management issues with this comorbidity. Our patient improved with a combination of fluoxetine and sodium valproate.

Singh P, Gehlawat P, Gupta R, Soni S. A rare case of trichotillomania with antisocial personality disorder. Open Journal of  Psychiatry & Allied Sciences. 2015;6:68-70. Epub 2014 Dec 24.

Keywords: Impulse Control Disorders. Obsessive-Compulsive Disorder. Comorbidity. Bezoars.

Correspondence: hunt4prat_01@rediffmail.com

Received on 8 November 2014. Revised on 19 November 2014. Accepted on 30 November 2014.


Trichotillomania (TTM) is characterised by recurrent and persistent urge of one’s own hair pulling that often results in alopecia. Currently, it is classified as an impulse control disorder, in which the individual has an overwhelming urge to pluck out hair, which leads to momentary relief from associated anxiety.[1] Five to 18% of the patients of TTM have been reported to ingest their hairs.[2] Eating the roots of pulled out hairs is known as trichorrhizophagia,[3] and found to be often associated with TTM. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) places TTM in category of Impulse Control Disorder, and the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) in Habit and Impulse Control Disorder.[4,5] However, in recent times in view of similarities in underlying neurobiological underpinnings, and the treatment used for TTM and obsessive-compulsive disorder, there is a debate to classify TTM as an obsessive-compulsive spectrum disorder.[6-8]

            Comorbid psychiatric problems are common in children and adults with TTM.[9,10] High rates of comorbid mood, anxiety, and substance use disorders have been reported. The lifetime prevalence of personality disorders has been less extensively studied. We present a case of TTM in a young adult male with antisocial personality disorder to add to scarce literature available on this comorbidity, and discuss the difficult management issues.

Case report

A 28-year-old unmarried male educated up to primary level, from low socioeconomic status, belonging to rural background presented with five years history of pulling hairs from scalp, eyebrows, eye lashes, upper lip, chin, upper limbs, chest, and axilla leading to hair loss. His hair pulling was preceded by increasing tension and followed by relief in anxiety. The pulled hairs were swallowed by him at times. He also complained of pain abdomen on and off.

            On detailed history, it was explored from the family members that there was pervasive pattern of irresponsible behaviour, disregard to social norms, callus and unconcerned attitude since his adolescence. He was also indulged in harmful use of alcohol. His stubbornness and aggressive behaviour resulted in frequent fights and legal problems. He ultimately landed in prison implicated in a murder case under Section 302 Indian Penal Code and released on bail. The personality of the patient was assessed using the International Personality Disorder Examination Screening Questionnaire (IPDE-SQ).[11] His personality assessment showed high scores on antisocial personality traits.

His physical examination revealed thin built, complete hair loss over the scalp, eyebrows, upper arm, axilla, and legs. He also had tenderness in upper abdomen. On mental status examination, patient had irritable affect and ideas of helplessness without any delusions and hallucinations. His reality orientation was preserved. On investigations, no abnormality was detected in his haemogram, serum electrolytes, renal and liver function tests, electrocardiogram, and electroencephalogram. His ultrasound abdomen was also normal but diagnosis of trichobezoar was made on plain supine radiographs of abdomen and barium meal.

On the basis of available information, a diagnosis of TTM with comorbid antisocial personality disorder was made according to ICD-10. He was initially started on fluoxetine 20 mg which was gradually titrated up to 80 mg. Sodium valproate (up to 800 mg) was added to control his aggression. Initially, he did not cooperate for non pharmacological interventions for personality issues. Surgical opinion was sought for trichobezoar for which surgery was advised, but he refused for surgical intervention. With this treatment, his hair pulling behaviour was reduced significantly as well as there was improvement in his aggression. He is now being incorporated in the non pharmacological treatment, but his follow ups are irregular due to his legal issues. A written informed consent has been sought from the patient with explaining him that all his identification details would be concealed.


TTM is considered as a rare psychiatric disorder encountered in the clinical practice. Earlier studies have reported the prevalence of comorbid mood, anxiety, and substance use disorder with TTM.[2,12] The lifetime prevalence of personality disorders is less known. Swedo and Leonard[13] found a lifetime prevalence of 38% of their sample. It has been found associated with histrionic, borderline, passive/aggressive, avoidant, and obsessive-compulsive personality disorder in various previous studies.[13,14] Its association with antisocial personality disorder has never been reported earlier as in the present case.

Personality issues in this patient posed difficulty in management especially harmful alcohol use and legal complication. His imprisonment in between interfered with follow up and medication irregularities. Treatment also became difficult because of his non cooperation with non pharmacological interventions and need for surgery.

Significant improvement was seen with fluoxetine and sodium valproate. Previous case reports also suggest that the use of selective serotonin reuptake inhibitors (SSRIs) is useful in treatment of TTM.[7,8] This case also highlights the effectiveness of combination of SSRI and sodium valproate to take care of the associated personality issues. Trichobezoar in this patient is yet to be taken care of, and the authors are vigilant about his gastrointestinal symptoms that needed interventions.

Thus, it is concluded that TTM can also be associated with antisocial personality disorder, and this comorbidity should be carefully dealt with due to difficult management issues.

Sources of support: Nil. Declaration of interest: None.


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