Trichotillomania and trichophagia: challenges in the therapeutic approach

• DOI: https://doi.org/10.22533/at.ed.15942124200210

• Palavras-chave: Trichotillomania; trichophagia

• Keywords: Trichotillomania; trichophagia

• Abstract:

  Presentation: female patient, 28 years old, presenting with trichotillomania and trichophagia; reported that the practice of pulling out and swallowing one's own hair began in childhood, at the age of 9, and the problem worsened over the years, resulting in current baldness. She was unable to indicate the reason for the practice, but identified that it occurred in moments of emotional stress and the act brought relief from tension. As a child, she was referred by the school to CAPS IJ and started treatment with Imipramine 75mg/day; at 13 years of age, she abandoned treatment due to refractoriness to the condition and psychophobia at school; she returned to treatment in 2019, at the age of 25, at the reference CAPS III with the introduction of Paroxetine and Clonazepam; A new switch was carried out due to non-response to the medications referred to as Escitalopram and Levomepromazine, in addition to Clomipramine, which remained until May/2022. Due to increased psychomotricity, homicidal and suicidal ideations, delusional persecution and bizarre practice of trichotillomania and trichophagia in relation to your dog, Risperidone and Escitalopram were introduced in an off-label dose and Clomipramine was withdrawn. During pharmacological adjustment, there was no regular adherence to psychotherapeutic treatment. Discussion: the use of Escitalopram, Levomepromazine and Clomipramine, in usual doses, did not prove to be sufficient to contain obsessive thoughts with delusional content of a persecutory nature, nor suicidal and homicidal ideations, which worsened the patient's condition. The situation worsened to the point of pulling out and ingesting her dog's hair, in addition to mentioning that she felt like drinking the animal's blood. It was necessary to extrapolate the Escitalopram dose to 30mg/day; in September/2022, Risperidone was gradually escalated to a dose of 5mg/day and Diazepam was introduced at 10mg/day. There was improvement in trichotillomania, trichotillophagia, paranoid delusional thoughts, bizarre behavioral practice of trichotillomania and trichophagia in relation to his pet and suicidal and homicidal ideations. Final considerations: the real challenge in managing the psychiatric entity consisted of the difficulty in remitting symptoms through drug monotherapy in patients without adherence to psychotherapy. It was only possible to glimpse sustained improvement with off-label use of SSRIs in association with high-dose atypical antipsychotics and benzodiazepines.