In treatment for trichotillomania, medications that alter the function of serotonin in the brain are frequently used because of the supposed similarity of "compulsive" hair pulling to obsessive-compulsive disorder. Therefore, many hair pullers end up being treated with serotonergic antidepressants (Prozac, Zoloft, Celexa, Paxil, Luvox, Anafranil, Effexor) which are known to help OCD. Even when hair pulling does not diminish on these medications, patients may continue on them because of the relief from coexisting anxiety and/or depression.


Serotonin, a chemical messenger between nerve cells throughout the brain and body, has a significant, if complicated, role in sexual response. Up to 20-30% of men and women taking serotonergic medications may complain of significant sexual dysfunction. Perhaps the most common complaint is that of having more difficulty reaching an orgasm -- in other words, more stimulation and a longer period of time is needed to climax. Typically, women are generally slower to respond in the first place so this may present more of a problem for them. (These medications are actually used to treat premature ejaculation in men). Other complaints include a less intense orgasm, erectile dysfunction, total inability to have an orgasm ("anorgasmia"), or decreased desire for sex.


Although not always talked about by prescribing physicians, there are often ways to get around these effects. First of all, although it may be a long wait, theses side effects often diminish with time - sometimes several months. Secondly, if the threshold of sexual stimulation needed has been raised, then intensifying and lengthening the time of stimulation may be all that is needed. Incorporating the use of a vibrator in the act of sex, for instance, is a lifesaver for many. If a partner is involved, it is important to reassure that partner that the slower response is due only to the medication, and not any diminished feelings for him or her, or an indication of lack of sexual "prowess".


Decreasing the dose of medication, though usually not possible, may alleviate many side effects. Another useful technique is taking a "drug holiday" by skipping one day's dose in advance of anticipated sexual activity. (This may not be particularly effective with Prozac, a particularly long-acting medication.) Since the therapeutic effect of the medications is a cumulative one but the side effects are more immediate, this can usually be done without any substantial reversal of the positive clinical effects.


There have been numerous reports in the scientific literature of sexual functioning returning to some men and women taking SRI's with the addition of another medication. One such medication is Periactin (4-8 mg one hour before sex) which temporarily reverses the serotonin effect. Unfortunately, as is often the case, actual clinical experience does not meet up to the expectation of success gleaned from these articles. Virtually everyone t whom I've suggested trying this medication has said something to the effect of, "I don't know if it would have helped - since it puts me to sleep I didn't have the opportunity to find out!" Other medications that have been used in this manner to help with arousal, erection and orgasmic function include Buspar (15-30 mg twice daily) Yocan (5.4 mg three times daily or before sex), and Symmetrel (100 mg once or twice a day). The latest and most successful medication used for this is Viagra (25-100 mg before sex) which is effective for both men and women. Some choices may be made based on desire for spontaneity versus planning for sexual activity.


Sexual desire or drive is not affected by intermittent use of these medications, however. To enhance general sexual interest as well as erectile and orgasmic dysfunction, daily use of stimulants can be helpful such as those used for attention-deficit disorder. These medications include Ritalin, Adderall, and dexedrine. Unfortunately these medications have an irritating effect on the nervous system that can increase hair pulling. Gingko Biloba has been reported to be helpful, but my patients that have tried it have not found it to be.


My usual suggestion is to add Wellbutrin to the SRI, decreasing the SRI dose if possible. Better yet, if severe anxiety or obsessive-compulsive disorder are not primary symptoms, substitution with Wellbutrin entirely (150-200 mg twice daily) may be the most useful option. In my experience, Wellbutrin is much more likely to help diminish hair pulling than SRIs anyhow.


Other medications helpful in the treatment of trichotillomania such as lithium, Depakote, Klonopin and Risperdal do not cause sexual dysfunction and may be considered.


Last, but certainly not least, consider whether medications are really indicated. If there are no other psychiatric conditions present that require medication treatment, cognitive-behavioral treatment is usually the best option when available.

Good Luck!


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