LAUSR

Trichotillomania (TTM) is an impulse control disorder characterized by hair pulling and marked hair loss. We describe a case of TTM developing starting atomoxetine with a diagnosis of attention-deficit/hyperactivity disorder (ADHD). An 11-year-old male patient was brought to our clinic by his family because of hyperactivity, easy boredom and irritability, academic failure, forgetfulness, and difficulty in organizing tasks and activities. The patient was diagnosed with ADHD at psychiatric evaluation based on DSM-5 diagnostic criteria and was started on atomoxetine. The family reported that 10 days after starting atomoxetine, the patient began playing with his left eyebrow, and later began pulling the hair in that eyebrow out, resulting in hair loss in that area. Examination revealed eyebrow pulling and associated significant eyebrow loss. TTM was diagnosed at subsequent evaluation. We provisionally attributed the development of the eyebrow pulling behavior after these findings to atomoxetine, and the therapy was discontinued. The eyebrow pulling behavior ceased after discontinuation of atomoxetine. Although TTM may be comorbid with ADHD, there was no previous history of TTM in our case, and the condition developed only subsequently. The most common manifestation in TTM cases is hair pulling and, less commonly, by pulling hairs from various other parts of the body, including the eyebrows, eyelashes, beard– mustache, armpit, and inguinal region. Studies have implicated serotonergic and dopaminergic dysfunction in the pathophysiology of TTM (Golubchik et al. 2011). One study of the development of compulsive behavior in patients receiving dopamine therapy reported cases of new-onset TTM. Compulsive behavior has been found to be associated with dopamine therapy and dopaminergic mesolimbic stimulation (Pourcher et al. 2010). TTM has generally been reported to develop after psychostimulant use. The facilitating effect of psychostimulants on dopamine and serotonin neurotransmission is reported to be potentially significant in the etiology of compulsive behaviors such as hair pulling (Pourcher et al. 2010). Atomoxetine, a nonpsychostimulant agent used in the treatment of ADHD, increases norepinephrine levels in the synaptic space by obstructing presynaptic reuptake. It thus has an indirect effect on dopamine levels (Ledbetter 2005). Atomoxetine indirectly affects dopamine levels and occurs by causing changes in the mesolimbic dopamine system, similarly to psychostimulants, and can thus lead to TTM (as in our case). Although side effects may be seen with the clinical use of atomoxetine, particularly headache, abdominal pain, decreased appetite, lethargy, nausea, vomiting, and vertigo, and less commonly tic disorder (Ledbetter 2005) and hair loss (Ceylan and Yalcin 2010), our review of the literature revealed no publications regarding the development of TTM. We think that more studies concerning the potential side effects of atomoxetine, the most commonly used agent in the treatment of ADHD after psychostimulants, such as the development or detection of TTM, are now needed.