TREATMENT CHALLENGES IN MANAGEMENT OF ADOLESCENT TRICHOTILLOMANIA WITH COMORBIDITY: EVIDENCE-BASED CASE PER CASE APPROACH
Authors: Roosdy *Ireine Suantika Cornelia , Ngantung Edwin 
Published: February 2025

Abstract

Background
Trichotillomania (also known as hair-pulling disorder, HPD) is an obsessive-compulsive and related disorder characterized by a long term, irresistible urge to pull out one's hair, which affects significantly more females than males with a ratio of 10:1.1 Houghton et al study revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime psychiatric diagnosis, specifically, depressive, anxiety, addictive, and other body-focused repetitive behavior disorders.2 The usual course of trichotillomania with onset during puberty is chronic, with waxing and waning of symptoms if the disorder is untreated.3

Aims and Objectives
The study is meant to explore the challenges and barriers faced by clinicians when treating adolescents with trichotillomania and comorbidity, considering both clinical and psychosocial factors, and also in order to investigate the effectiveness of evidence-based treatment approaches, especially the pharmacological approach combined with cognitive-behavioral therapy (CBT) or habit reversal training.

Method
We conduct longitudinal study to follow the cases of trichotillomania during the past two years in Psychiatry Outpatient Clinic in Maria Walanda Maramis North Minahasa District General Hospital, Indonesia, and made a clinical records analysis from the hospital medical record from October 2021 to October 2023 to review clinical records and treatment histories, outcomes, and any recurring challenges.

Result
There are four trichotillomania cases in adolescent and all with psychiatric comorbidity, all female, aged 12 (AG), 15 (IM), and two 19 years old patient (ST and LK), from 1056 patients registered in the Psychiatry Outpatient Clinic during time of survey. AG has internet addiction comorbidity, IM has bulimia nervosa comorbidity, while ST and LK have severe major depressive disorder comorbidity along with prominent suicidal thoughts. Initial pharmacotherapy was fluoxetine twice daily has been inadequate on ST and LK but worked quite well on AG and IM. AG responded good with fluoxetine and low dose of clobazam, and reach full recovery within four months. IM had additional low dose of olanzapine and diazepam along the way to get her to full recovery from symptoms after 9 months. ST is still under treatment all the past two years due to treatment inadherence due to lack of family support and financial problems. ST had best result when treated with risperidone, clonazepam, and escitalopram, but due to her financial limitations she can only afford fluoxetine and clobazam. LK has just started therapy for one month and had showed best response with aripiprazole and valproic acid. All patients received cognitive-behavioral therapy along with pharmacotherapy.

Discussion & Conclusion
Trichotillomania requires a comprehensive treatment plan and interdisciplinary approach. Sertraline, fluoxetine, escitalopram are the SSRIs commonly used to treat the condition, while olanzapine and aripiprazole are the additional medication offered to enhance the effect of SSRI.4,5,6,7,8 In these four cases all medication has shown satisfying results with additional problem of treatment inadherence and financial problem that contributed to the unsatisfying result on one of the patient. Overall the evidence based case per case approach is the best strategy to manage challenges in practical daily clinical decisions.