Plain English Science: Drug-Induced Trichotillomania - Four Case Studies by Joseph Toles

Though the root causes of typical trichotillomania are poorly understood and hypotheses range from genetics, glutamate regulation, trauma, and many combinations thereof, a few case studies over the years have been able to induce trichotillomania using drugs. To be clear, they didn’t induce trich on purpose, they found that various substances incidentally cause hair pulling and that stopping these substances stopped hair pulling. They then wrote it down, published the science, and called it a day. So far, no studies seem to exist on trich as a side effect of any medication, but BFRB research is relatively young and case studies, though anecdotal, point a huge flashing arrow saying hey, look over here. Hopefully it is only a matter of time (and funding) before the research catches up and we get some proper peer-reviewed studies on substances that might cause or exacerbate trich symptoms. Anyway, here’s the science.

Adderall

In 2013, a 12-year-old girl was placed on daily Adderall (dextroamphetamine/amphetamine, both stimulants) to treat ADHD. Soon after, parents noticed hair pulling mainly from the frontal scalp. After determining no other underlying causes of pulling such as OCD, trauma, or PTSD, Adderall was replaced with guanfacine and hair pulling symptoms subsided permanently.

This isn’t the only case study involving amphetamine-induced trich, but it’s a bit more complicated. This study might be a bit more triggering.

A 26-year-old male with ADHD was admitted for 3-4 weeks of compulsive hair pulling using tweezers. The patient had a complicated history with amphetamines (both prescribed and illicit) as well as antipsychotics. A month prior to admission, he began plucking ingrown pubic hairs, feeling tension then release, as well as “improving his ‘sex drive’ “. He then began pulling hairs from the side of his head, feeling that “these hairs may have been wrapped around internal organs”. He shaved his head to decrease urges to pluck. He also believed hairs were responsible for misalignment of his jaw and neck and pulling would also increase blood flow. The patient had a history of experimenting with hallucinogens. Unsurprisingly, the patient was admitted to an inpatient locked psychiatry unit.

Narine, Chiranjir, Sajjad R. Sarwar, and Theodor B. Rais. “Adderall-Induced Trichotillomania: A Case Report.” Innovations in Clinical Neuroscience 10.7-8 (2013): 13–14. Print.

Hamalian, Gareen, and Leslie Citrome. "Stimulant-induced trichotillomania." Substance abuse 31.1 (2010): 68-70.

Fluoxetine

A 7-year-old was placed on fluoxetine after showing “excessive worries and shyness” and “excessive fear when separated from his parents” among other emotional issues resulting in his diagnosis with generalized anxiety disorder. The case study outlines his trich progression:

“Three days after starting the medication, symptoms such as pulling hair from his scalp and his eyebrows emerged. Ten days after starting medication, fluoxetine was stopped due to exacerbation of TTM symptoms. One week after stopping fluoxetine, the symptoms decreased and at the end of the third week TTM symptoms disappeared.”

It’s worth noting that some theories identify dopamine as a major player in trichotillomania neurochemistry. However, usually one would expect the opposite from fluoxetine. Fluoxetine has historically been used to treat trich, though results have ranged from helpful, to useful for only for comorbid depression and anxiety, to no better than placebo. It is important to note that those studies included far more people than this case study of one and should be given far more weight when considering treatments.

Bolat, Nurullah, and Mesut Yavuz. “Fluoxetine induced trichotillomania in a 7-year- old boy: a case report” Olgu Sunumu 17(Supplement 3) (2016) 45-47

Cocaine

A 24-year-old UK woman with a history of prostitution-funded cannabis, crack, heroin, and cocaine use was presented to a substance misuse clinic for substance abuse. The patient reported hair pulling from all parts of the body only while on cocaine, starting 30 minutes after smoking cocaine and persisting up to four hours, describing a cycle of tension and relief. The patient was treated with buprenorphine which appeared to halt trichotillomania symptoms. This case study ends on an uplifting note, with the patient abstinent from cocaine and heroin for the two months following the study.

George, Sanju, and Hamdy Moselhy. "Cocaine-induced trichotillomania." Addiction 100.2 (2005): 255-256.

Focalin

In my search for instances of substance-induced trich, I came across this forum and a few others in which at least four parents report kids on focalin (a stimulant used to treat ADHD) expressing trich-like symptoms. It’s particularly interesting because two of the above trich-inducing drugs (cocaine and amphetamines) are also stimulants. Now, let’s be frank here; case studies should be taken with an entire shaker’s worth of salt. A random internet forum should absolutely not be used to make judgments on any treatment, trich, ADHD, or otherwise. I hesitate to even include it here at all, nonetheless on account of the fantastically toxic response from the community.

It certainly seems possible for pharmacological substances to induce trichotillomania. However, there are some huge caveats here. First, half of the studies' subjects clearly had other confounding psychological and medical factors going on. Second and more importantly, case studies are reported precisely because they are the exception to the norm. The entire scientific community collectively seems able to find in grand total only four cases of drug-induced trichotillomania, which is very, very small compared to the sample size in studies of people with trichotillomania or people who use said drugs. Basically I’m saying not to drop your ADHD meds because of this article. But maybe don’t do so much cocaine; that might be good for you.