Trichotillomania, also known as trichotillosis) is the compulsive urge to pull out (and in some cases, eat) one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is classified as an impulse control disorder by DSM-IV and is often chronic and difficult to treat.

• seen in infants, peak age 9-13;
• may relate to OCDs - most common association

nail biting (onychophagia) and skin picking (dermatillomania), tic disorders and eating disorders.

Tx

rule out comorbid conditions (OCD, borderline, and depressive disorders)

sertraline is useful post myocardial infarction

Fluoxetine is preferred in children and adolescents if indicated

citalopram and escitalopram are associated with dose-dependent QT interval prolongation

fluoxetine and paroxetine have a higher propensity for drug interactions

Not suitable for pregnancy

warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine

GI side effects are most common

Give PPI if taking NSAIDs also

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

Discontinuation symptoms