HITTING THREE BIRDS WITH ONE STONE: LITHIUM MONOTHERAPY IN A FILIPINO WITH NEUROGENETIC RISK FOR CHOREA DISORDER DIAGNOSED WITH TRICHOTILLOMANIA, BIPOLAR DEPRESSION AND SOCIAL ANXIETY DISORDER
Authors: Serofia *Mitz Santander 
Published: February 2025

Abstract

Background
Trichotillomania (TTM) is presently classified under obsessive-compulsive and related disorders (OCD) in the DSM-5. Findings in a large cohort of TTM cases indicated that 60% of them were clustered under "complex TTM” where cases presented as a combination of investigated comorbidities, including mood and anxiety disorders.1 On the other hand, behavioral problems and neuropsychiatric conditions like Huntington's Disease (HD) are also often present, and accumulating evidence suggests that OCD symptoms such as hair-pulling may precede the clinical onset of HD.2 Consequently, treatment of complex TTM proves challenging.

Objective
The goal of this article is to describe a case study from a patient with complex TTM presenting to our clinic with neurogenetic risk for chorea disorder and successfully treated with lithium monotherapy.

Method
This article reviewed the scientific literature on the prevalence of complex TTM and described the patient's case in detail including its management.

Case Presentation
The author presents a case of a 23-year-old Filipino female who went to the clinic for uncontrollable hairpulling. Her history began with symptoms of social anxiety at around seven years old as she adapted to a new school. Her struggles intensified when her aunt left, and her distant mother became emotionally neglecful. She took on responsibilities beyond her age, caring for her siblings and a newborn, exacerbating her stress and leading to the onset of hair-pulling behavior. Over time, she experienced depressive and anxious episodes marked by academic struggles and fear of social situations. Family issues persisted leading her to endure verbal abuses at home. Her mental health deteriorated further, manifesting in alternating episodes of depression and hypomania. Despite recognizing the severity of her hair-pulling, she hesitated to seek help. Tragedies, including her mother's diagnosis of “chorea disorder” and her father's death, heightened her distress, aggravating compulsive behaviors. Recent concerns over worsening hair-pulling, resulting in visible bald spots and interference with daily tasks, prompted consult. On examination, she had a bald spot on the parietal area, exhibited anxious mood but denied any obsession or compulsion to hair-pull. She spoke coherently and had intact cognitive tests. Her initial YBOCS score was 25 (moderate severity) and Massachusetts General Hospital (MGH) Hair Pulling Scale score was 14. Along with behavioral interventions, lithium 450mg monotherapy was initiated, targeting both hair- pulling and bipolar depression. After five months, improvements were observed in her quality of life, with a recorded 71% reduction in MGH hairpulling score. She remained symptom-free for 1 year and continues to take 450 mg of lithium daily.

Discussion and Conclusion
This case illustrates the role of lithium in complex TTM. In one study involving patients with TTM and bipolar disorder, authors found that women had a decrease in hair-pulling symptoms after lithium. The response was attributed to the role of sex hormones in the pathophysiology of TTM.3 This case report also shows the potential use of lithium as an off-label medication for patients with neurogenetic risk to develop chorea disorder because of its neuroprotective function, as shown in one case series.4

References
1.Lochner, C., Keuthen, N. J., Curley, E. E., Tung, E. S., Redden, S. A., Ricketts, E. J., Bauer, C. C., Woods,
D. W., Grant, J. E., & Stein, D. J. (2019). Comorbidity in trichotillomania (hair-pulling disorder): A cluster analytical approach. Brain and behavior, 9(12), e01456. https://doi.org/10.1002/brb3.1456
2.Molano-Eslava, J. C., Iragorri-Cucaló n, Á., Ucró s-Rodrí guez, G., Bonilla-Já come, C., Tovar-Perdomo, S., Herin, D. V., & Orozco-Cabal, L. (2008). Obsessive-Compulsive Disorder Symptoms in Huntington's Disease: A Case Report. Revista Colombiana de Psiquiatrí a, 37(4), 644-654.
3.Sharma, V., & Corpse, C. (2008). Lithium treatment of trichotillomania with comorbid bipolar II disorder. Archives of women's mental health, 11(4), 305–306. https://doi.org/10.1007/s00737-008- 0026-5
4.Danivas, V., Moily, N. S., Thimmaiah, R., Muralidharan, K., Purushotham, M., Muthane, U., & Jain, S. (2013). Off label use of lithium in the treatment of Huntington's disease: A case series. Indian journal of psychiatry, 55(1), 81–83. https://doi.org/10.4103/0019-5545.105522