The efficiency of valproic acid in a child with trichotillomania

J Clin Exp Invest www.clinexpinvest.org Vol 2, No 2, June 2011 Yazışma Adresi /Correspondence: Dr. Aysel Milanlıoğlu, Bitlis State Hospital, Department of Neurology Bitlis-Turkey, Email: ayselmilanlioglu@yahoo.com Geliş Tarihi / Received: 28.12.2010, Kabul Tarihi / Accepted: 05.01.2011 Copyright © Klinik ve Deneysel Araştırmalar Dergisi 2011, Her hakkı saklıdır / All rights reserved Klinik ve Deneysel Araştırmalar Dergisi / 2011; 2 (2): 214-215 Journal of Clinical and Experimental Investigations


INTRODUCTION
Trichotillomania is a heterogeneous disorder that is characterized by the recurrent pulling out of own hair leading to the noticeable hair loss, distress, and social or functional impairment.The common sites affected by trichotillomania are scalp, eye brows, eyelashes and other body hair.Lifetime prevalence seems to be in the range of 0.6-3.4% in the general population and about 1% in children. 1 Currently, trichotillomania is classified within the Diagnostic and Statistical Manual Fourth Edition (DSM-IV) as a disorder of impulse control along with pathological gambling, kleptomania, pyromania, and intermittent explosive disorder. 2 this article, we report a 9-years-old child who is diagnosed with trichotillomania and showed remarkable improvement about hair pulling in response to the treatment with valproic acid.CASE 9-years-old male child who is carried with his parents referred to the outpatient clinic with the newonset complaint of hair pulling of eyelashes.His family reported that he would be experience discomfort if they prevented him from pulling.On admission, eyelashes were totally removed and we learned that he was pulling his eyelashes throughout the day.He had normal development and also his medical and psychiatric history gave no abnormality.On mental status examination, he showed bright affect and excellent eye contact.He answered reasonably with using proper vocabulary to all the questions.There was any evidence of thought disorder which including obsessions on the basis of the current hypothesis that trichotillomania may be part of the obsessive compulsive spectrum of disorders.He had no behavioral or learning problems and difficulty for making friends at school.The family history was not significant for psychiatric illnesses or family problem.
For ruling out a possibility of other causes, we studied complete blood count, bio-chemistry, metabolic panel, electroencephalography, magnetic resonance imaging, and revealed normal findings.Finally, he was diagnosed with trichotillomania which takes place as one of the impulse control disorder classified in DSM-IV.
Recently, several studies have investigated that mood stabilizers decrease the symptoms of trichotillomania.Therefore, the anticonvulsant valproic acid has also been used as a mood stabilizer, was started on and gradually titrated to 1,000 mg/day.In the course of titration, any elevation of liver function test was noted due to the hepatotoxicity of this drug.Hair-pulling behavior dramatically decreased and resulted in significant regrowth of eyelashes.After providing the normal blood level of valproic acid, this behavior pattern did not recur.

DISCUSSION
Trichotillomania is a compulsive disorder diagnosed with patient's habit pulling out own hair belongs to the various parts of the body.It often affects female children and adolescents but our case was different because of the gender. 3though there are many case reports on effective treatments for trichotillomania, the data from controlled trials are scarce.To date, studies about trichotillomania treatment display nonpharmacological and pharmacological interventions, alone or in combination.The principle of nonpharmacological approaches in trichotillomania is behavioral therapy in the form of habit reversal techniques and also cognitive behavioral training.In terms of pharmacological theraphy, various treatment options such as antidepressants particularly serotonin reuptake inhibitors, atypical antipsychotics, opiod antagonists and anticonvulsants show potentially clinical benefits in treating impulsive features. 4The treatment of trichotillomania particularly in children has numerous limitations because of the disharmony to nonpharmacological approaches and side effects to pharmacological therapies.
Reviewing to the literatures, the therapeutical effects of anticonvulsants, which are used as mood stabilizers, such as lamotrigine, topiramate, okscarbazepine and valproic acid appear to gain significance in the treatment of impulsive control disorder.Our case, the second case in the literature with valproic acid, indicates that this treatment option is dramatically effective in reducing and even terminating symptoms of trichotillomania. 5However, we do not have enough experience about the effects of the long-term utility of this drug and imminencely behaviour changes after withdrawal of this drug.
Finally, this case report calls for further studies with a wide sample of patients are needed to prove the efficiency of the utility of valproic acid in the treatment of trichotillomania and the long-term maintenance of these benefits.