(Reprinted from In Touch #13 © 1996)
Medications have a role in the treatment of Trichotillomania, although for most people medications alone are not enough in the long run. No medication has been adequately studied for the long-term treatment of Trichotillomania, but Information is being gained through clinical experience and further research. Medication may be desirable to treat disorders often seen in addition to Trichotillomania, such as depression, even if the medication doesn't help the hairpulling itself.
When medications are helpful in reducing pulling, patients usually describe either a reduced urge to pull, more awareness of their pulling, or a new ability to resist the urges. These effects can make behavior therapy more approachable and easier. Sometimes a good approach may include tapering off the medication while actively participating in behavioral treatment, so that gradually increasing urges may be dealt with.
There are a number of different medications to try that have been effective for at least some hair pullers. As of 1995, many medications that can change brain activity have not yet been tried, and as they are, new medications may be discovered that are more effective than those being used currently. At this time, medications appear to provide a non-specific improvement-in other words, there is no one biological cause targeted by a specific neurochemical action that we know of.
Because of the superficial similarities between Trichotillomania and Obsessive-Compulsive Disorder (OCD), the specific OCD medications (Serotonin Re-uptake Inhibitors-SRIs) have been most frequently tried in the treatment of Trichotillomania. This group of antidepressant medications includes: clomipramine (Anafranil), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), venlafaxine (Effexor), and fluvoxamine (Luvox). As of 1995, only a couple of well-designed research studies have been performed using any of these medications for Trichotillomania, and they have been contradictory as to whether there is any measurable effect. What we see clinically is that some patients' hair pulling gets better, for some it gets worse, and some are unaffected by the medication. There may be a remarkable, immediate response that may fade over weeks or months. This may even be a "placebo" response that would be the same as to a sugar pill. As a whole, these medications are safe, and are worth trying, as some patients receive long-term benefits. Clomipramine, in my experience, is the most effective of this group, but so frequently causes significant weight gain that most of my patients have discontinued it after a year or so, even when it was still helpful.
No other type of medication has been studied alone for treatment of Trichotillomania in a scientific manner. There are always case reports and letters to the editor (of medical journals, etc.) about the success of one medication or another in one or two patients, but since no one reports failure to respond to a medication in this manner, these reports cannot give a balanced view. Medications that have been tried with some success have included lithium (Lithobid, Eskalith, etc.), valproate (Depakote), buproprion (Wellbutrin), buspirone (Buspar), trazodone (Desyrel), naltrexone (ReVia), fenfluramine (Pondimin), monoamine oxidase inhibitor antidepressants (e.g., Nardil, Parnate, etc.), tricyclic antidepressants (e.g., Elavil, Pamelor, Norpramin.) and minor tranquilizers such as clonazepam (Klonipin).
One small study showed that low doses of a neuroleptic, pimozide (Orap), was helpful when added to treatment with an SRI. Some children have been successfully treated with clonidine (Catapres). All of these medications have a variety of potential side effects and/or risks, and should only be prescribed by a psychiatrist for the treatment of Trichotillomania. Management of psychotropic medication side effects is an art that few other physicians are adequately familiar with. Blood tests must be performed at intervals when using lithium and valproate. Blood levels on the high end of the therapeutic range are generally required, in my experience.
The "try-it-and-see-if-it-works" approach is generally what must take place. Which medication to try first depends on potential risks or side effects, history of effectiveness for Trichotillomania, and other symptoms or disorders a hair puller may be experiencing. A depressed hair puller or a puller with Obsessive-Compulsive Disorder should try an antidepressant first, while a hair puller with Bipolar Disorder (with frequent manic episodes) should probably be treated with lithium or valproate. My own current practice is to try one of the SRIs with the fewest side effects (such as fluoxetine) first, and if it seems advisable, try other SRIs if there is little or no response. Should that fail to adequately treat the pulling, I would add or substitute valproate or lithium. I expect this practice to change as we gain further experience in other medications. In most cases, my patients are also treated with behavioral therapy, either individually, in a group, and/or in an intensive program.
Some of the medications require a trial of at least six weeks at the therapeutic dose or maximum dose tolerated to know if it is going to work for an individual patient. If a medication is not helping, it should be discontinued. If it is only partially helpful, another medication may be added to it. This should be done with careful supervision by a psychiatrist, as there are potential medication interactions.
If you have had significant success reducing hair pulling for over six months with a medication OTHER THAN AN SRI, I would like to hear about it. Write me at the Pioneer Clinic, 2550 University Ave. #229N, St. Paul, MN, 55114 or e-mail to CNovakMD@aol.com
Carol Novak, M.D., is the founder of the Pioneer Clinic, specializing in the treatment of Trichotillomania and Obsessive-Compulsive Disorder. She has treated approximately two hundred hairpullers. She can be contacted by writing to: The Pioneer Clinic, 2550 University Ave. W. #229N, St. Paul, MN, 55114, or through email: cnovakmd@aol.com.