Trichotillomania in a Case of Vascular Dementia
A 79-year-old right-handed Hindu Indian male retired engineer was referred by his family physician to the psychiatry outpatient division of our private clinic. He presented with progressive cognitive and mental deterioration, involving memory impairment and executive dysfunction (difficulties in planning, sequencing, abstraction, and goal-directed behavior). This was coupled with behavioral and personality changes that began 3 years prior to the memory impairments and cognitive deterioration. His wife (main caregiver) reported deterioration in personal hygiene, an abandonment of personal interests and apathy with a lack of will to do anything. The patient just lay in bed all day long, locked up in his room. His magnetic resonance imaging brain revealed multiple infarcts in subcortical and cortical areas of the brain. The patient was diagnosed as having vascular dementia. The patient was started on Donepezil 10 mg per day and multivitamins were prescribed, with a 20% improvement in cognitive symptoms over a 4 week period. During the 3rd week of treatment he began pulling out his scalp hair throughout the day and multiple times. The patient gave no explanation for this act, and denied any feeling of tension prior to the act or deriving any pleasure from the act. He reported no pain, and had no insight regarding its compulsive nature or the potential harmful consequences to his skin. There was no evidence of any delusional beliefs or psychotic features related to his hair-pulling behavior. No history of similar symptoms, obsessive compulsive disorder or dementia in the family was present. The trichotillomania persisted despite treatment with several selective serotonin reuptake inhibitors (SSRIs) like Sertraline, Fluoxetine, Escitalopram, and Fluvoxamine (all separately in divided doses) and Mirtazapine with no improvement with any of the drugs. The patient had a mini mental status examination score of 16. The patient's informal neuropsychological exam showed marked memory deficits, executive dysfunction, and apraxia. No language deficits were noted except slowness in speech. A metabolic workup for treatable causes of dementia revealed no abnormalities that could contribute to his cognitive deficits. The patient followed-up for a few months and did not follow-up thereafter.