Clinical Association of OCD , Trichotillomania and Bipolar Disorder.

OCD and Trichotillomania may arise from the same spectrum of disorders .Patients may present with common obsessions like : contamination or harm to self or others fears,aggressive or sexual themes,forbidden thoughts ,simetry urges etc or they can exhibit compulsions like : washing,checking,counting,arranging ,etc.Trichotillomania can be triggered by different situations or places or specific events.
The potential medication treatment for both disorders could precipitate a manic episode in certain patients.However the clinical association of OCD,Trichotillomania and Bipolar Disorder is rare and there are just a few reports in the literature about this possible association.We report here the case of a 15 years old patient who presented initially with trichotillomania and OCD and later on was also diagnosed with Bipolar Disorder.the complex treatment and clinical evolution of this case is discussed together with a review of pertinent literature data.

In the winter of 2004 the patient a 15 year old white Caucasian female was treated by her primary care physician for baldness secondary to hair pulling over the bilateral frontal and parietal areas.The patient had a past history of obsessive ruminations since the time of early childhood (age 6) including different obsessive contents like : excessive worries about weather cataclysms.Throughout the years the OCD symptoms did not proeminently impact on her academic and social functioning and were described to have a cyclic intensity.In the last year before her treatment by the PCP the patient developed compulsive behaviors like demanding to see a doctor for minor complaints and wrapping duct tape around different environment objects.This symptoms were replaced later on by hair pulling behaviors that initiated the PCP assessment .The PCP performed a comprehensive physical examination and rulled out any dermatological condition causing baldness.He also performed routine labs including a chemistry panel and CBC which were all within normal limits. The patient was diagnosed by PCP with OCD and trichotilomania and started on treatment with Fluoxetine which was titrated gradually to 30 mg oral daily.Paradoxally the patient developed an increase in her compulsive behaviors (which almost subsided before the Fluoxetine) and 3-4 weeks later she started showing agitation,pressured and fast speech,sleep disturbances and mood swings. At this time the patients hypomanic symptoms were possibly related to the effect of Fluoxetine (which prevented us from establishing a diagnosis of Affective Disorder).The Fluoxetine was tapered down and discontinued and thereafter replaced with Paroxetine up to 20 mg daily.Subsequently the hypomanic symptomatology vanished but the hair pulling got worse and patient started to pull her eyelashes and had a secondary infection of her eyelashes after her first 2 weeks of treatment with Paroxetine.At that time the PCP discontinued the Paroxetine and restarted the patient on low dose of Fluoxetine up to 10 mg daily together with Quetiapine up to 50 mg daily.This medication combination caused excessive sedation
2.
interfering with the patient daily functioning.As a consequence of that the Quetiapine was discontinued .

After approximately 2 weeks on this treatment the patient status worsened considerably and she started to exhibit : mood swings ,flight of ideas,difficulty sleeping.The patient was staying up all night and working around the house. She had suicidal thoughts without a suicidal plan or intent and was referred to us for a psychiatric evaluation for inpatient treatment.On our evaluation we established that the patient is not actively suicidal and decided for intense outpatient treatment.We have endorsed the PCP diagnoses of OCD , Trichotillomania due to the past history of hypomanic symptoms related to Fluoxetine we could not further elaborate on the differential diagnosis between the Bipolar Disorder type II versus Cyclothymic Disorder.The Fluoxetine was discontinued and Sertraline 25 mg daily oral together with Mirtazapine 7.5 mg oral for sleep was started.In a couple of weeks the Sertraline was gradually increased to 100 mg daily .The pressured speech and the flight of ideas symptoms disappeared .Patient ceased having any suicidal ideation whatsoever ,her mood was stable and her hair pulling improved significantly . However after a month the patient developed again : mood swings , excessive worries about her daily chores with feelings of being overwhelmed and sleep difficulties.The Sertraline was discontinued and patient was started on Olanzapine up to 7.5 mg oral daily.Most of her affective symptoms remitted but after 2 months she gained 20 lb and had serious low self esteem feelings.

The Olanzapine was tapered to 5 mg oral daily but after one month of follow up the patient had to be admitted for inpatient treatment due to a clinical presentation of : decreased need of sleep, distractibility irritability, parts of the day when she was more talkative and exhibiting pressured speech.In parallel with this symptoms the last 7-10 days she also exhibited : profound mood swings,anhedonia,depressed mood,low energy,suicidal thoughts,decreased concentration ,feelings of worthlessness and low self esteem.The lab work done upon her admission including chemistry panel CBC,Thyroid function tests,ECG,physical examination were all normal.The absence of an antidepressant medication on her treatment together with the absence of an organic factor and the clear functional impairment associated with her symptoms establishes the Diagnosis of Bipolar Disorder type I with full criteria met for an acute Mixed episode with the specifiers Moderate, Without Psychotic Features.The Olanzapine was switched to Ziprasidone up to 160 mg daily and Sertraline up to 100 mg daily was subsequently added with partial remission of symptoms.

After another 2 months the patient exhibited again increased hair pulling behavior,depressive symptoms and suicidal thoughts.She was again re-admitted in the inpatient unit and all her medications discontinued.The lab work and physical examination were again normal.She was started on Lithium Carbonate up to 900 mg oral daily together with Citalopram up to 40 mg daily with very good remission of all her symptoms in a couple of weeks.After 6 months follow up on this medication combination the patient is stable and doing well.

Obessive compulsive disorder has been noted to be associated with comorbid tic diso rders, depressive & anxiety disorders, learning disorders, trichotillomania and disruptive behavior disorders (1). More recent studies are demonstrating comorbidity with bipolar disorder (2,3,4,5,6,7,8,9). There has been debate in the literature on trichotillomania being an impulse control disorder, obsessive-compulsive spectrum disorder or a movement disorder such as tics. There has been a genetic link between OCD and trichotillomania with increased rates of OCD among relatives with trichotillomania (10). These illnesses also occur as comorbid syndromes with elevated rates of OCD in trichotillomania up to 13-16% of patients according to Stewart et al(10). Stewart studied the prevalence of hair pulling in severely ill OCD inpatients comparing demographics, comorbidity, clinical and treatment features. One hundred fifty four patients with OCD were examined. Of the sample, 29 (18.8%) reported any hairpulling, 24 (15.5%) reported moderate to severe hair pulling and 12 (7.8%) had severe hair pulling comparable to that of a specialty trichotillomania clinic population.
Lochner et al(11) did a comparison study on trichotillomania and OCD to note similarities and differences. They compared 278 (148 males, 130 females) patients with OCD and 54 trichotillomania patients (5 males, 49 females). Their results indicate that OCD patients report significantly more lifetime disability although fewer trichotillomania patients reported response to treatment. OCD patients reported higher comorbid disorders. Both disorders were equally likely to worsen during menstruation but OCD onset or worsening was more likely associated with pregnancy.
More recent studies are documenting the frequent comorbidity between OCD and Bipolar disorder (BD). Kruger et al (2) determined the frequency of affective disorders in patients meeting DSM III criteria for OCD syndrome. The study sample was drawn from 676 patients admitted to a 12 bed clinical and research unit specializing in depression. Subjects, 224, were diagnosed with a mood disorder based on the Diagnostic Interview Schedule (DIS). Ultimately 149 cases were analyzed after 2 Psychiatrist agreed with diagnosis by the DIS. Thirty seven subjects received a diagnosis of Bipolar Disorder I, 7 Bipolar II and 105 with MDD. Thirty five percent 13/37 BP I patients showed a prevalence of OCD syndrome while 2/7 (28.6%) BD II and 37/105 (35%) MDD showed OCD syndrome. The results of the study suggested that OCD is equally common in bipolar as in unipolar subjects. Kruger et al (12) determined the frequency of OCD in recovered inpatient subjects with BP. Subjects, 143 with BDI/II disorder, had recovered from their current episode of depression or mania. One hundred and nine subjects were BD I and 34 were BD II. OCD was identified in 10/143 (7%). All of the OCD patients were BDII, male and had a higher incidence of prior suicide attempts than bipolar subjects without OCD.

Masi et al(4) explored the clinical aspects of 102 children and adolescents with bipolar disorder, OCD or comorbid OCD-BD (65 males and 37 females). Clinical features were assessed by using the CY-BOCS, CGI and the DICA-R. Patients were diagnosed with bipolar-37 (36.3%, 21 males & 16 females), OCD-35 (34.3%, 26 males & 9 females) and BD-OCD 30 (29.4%, 18 males &12 females). Results showed that BD II was more frequent in the BD-OCD than in BD alone. When comorbidity was present, age of onset was significantly earlier than pure OCD patients. According to CGI baseline scores, OCD patients were significantly less impaired than BD-OCD and BD patients while severity was similar in the latter patients.

The combination of OCD,Trichotillomania and Bipolar Disorder to appear in the same patient is rare and there are only few anecdotal case reports of this combination in the literature.Hamiel et al (13) described the case young woman suffering from trichotillomania and bipolar disorder and explained trichotillomania not as an OCD background related symptom but as a manic phenomenon which is associated with its connotation of mourning response.Hair pulling is described as an expression of magical thinking (in sense of primary thinking process) that gives the subject the illusion of control.

Treatment

Pharmacotherapy

The medications of choice for the treatment of OCD are the SSRI’s. Studies have shown effective treatment with Paxil, Celexa, Fluoxetin and Clomipramine (14,15,16,1). On the other hand, studies have shown SSRI can induce mania. OCD drug treatment with clomipramine and to a lesser extent with SSRI’s was associated with hypomanic switches in BD-OCD patients (Perugi et al(9)). Raja et al(7) assessed clinical characteristics of obsessive compulsive bipolar comorbidity which suggested that the presence of atypical symptoms should alert the physician about the possibility of a bipolar comorbidity in OCD patients therefore making mood stabilization a priority. Berk et al(17) reported 5 cases of OCD and antidepressant treatment emergence of manic symptoms using Clomipramine, Fluoxetine and Citalopram. Go et al (18) reported cases of patients receiving treatment for OCD developing manic behaviors. Six out of 20 patients that received SSRI treatment (Fluoxetine/Zoloft) developed mania or hypomania as compared to 20 controls. The switch to hypomanic symptoms was obvious in our case after the introduction and reintroduction of Fluoxetine.
Very few studies have been conducted to evaluate pharmacologic treatment of trichotillomania. There are mixed results of controlled trials evaluating the SSRI’s ability to be an effective treatment for trichotillomania, Woods et al(19). Individual case reports have shown some success (20,21,22) with treatment of SSRI (Fluoxetine, Celexa) in combination with the atypical antipsychotic Olanzapine. One case reported success with Buproprion 150 mg po BID (23) while another case reported Risperdal as the sole treatment (24).
The treatment of comorbid OCD with Bipolar Disorder and/or Trichotillomania is made more complex by different challenges related to the use of different combinations of medications . Keller (21) reports about four patients who benefited from Olanzapine
Augmentation of Trichotillomania treatment and suggest the combination of Citalopram – Olanzapine as being very effective.However the Olanzapine (and also the Quetiapine) was reported to induce OCD symptoms (25,26).In our case the combination of Lithium and Citalopram was beneficial .Berk(27) also reports a case of a person suffering from trichotillomania and bipolar disorder who was successfully treated with lithium.

The encounter of the three diseases (OCD,Bipolar Disorder and Trichotillomania) together is rare and only anecdotally reported in the literature .The clinical evaluation based on our clinical observations could at times be abrupt and the treatment is undoubtedly very challenging .The use of atypical neuroleptics to augment the SSRI’s or as mood regulators should very carefully assessed in case by case basis and demands close follow up of the patient.In our case and another case report lithium was proved to
Be very beneficial and could be a good choice in appropriate patients.Reviewing the literature one learn about the necessity to explore the meaning of Trichotilomania as symptom and possibly address it in therapy.

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Assistant Professor
Medical Director Outpatient and PHP
Medical University of Ohio at Toledo
Dpt of Psychiatry – Kobacker Center
3130 Glendale Avenue , Toledo ,Ohio
43614 – 5810 , USA.

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The Clinical Association between OCD , Trichotillomania and Bipolar Disorder – a case report and review of literature.