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\begin{document}

\title{A Case of Trichotillomania (TTM) and Bulimia Nervosa (BN) in a Patient
with Adult-Onset Attention-Deficit/Hyperactivity Disorder (ADHD}



\author[1]{Rakshita Bhat}%
\author[2]{Faheem Vellekkat}%
\author[3]{Ivany Lestari Goutama}%
\author[4]{Praneet  Gill}%
\author[5]{Gauri Kakar}%
\author[6]{hafsa Jabeen}%
\author[7]{Krishnan Gireesh}%
\author[8]{Vivek Sanker}%
\author[9]{Umang  Gupta}%
\affil[1]{Bangalore Medical College and Research Institute}%
\affil[2]{Indira Gandhi Medical College and Research Institute}%
\affil[3]{Tarumanagara University Faculty of Medicine}%
\affil[4]{Government Medical College Patiala}%
\affil[5]{Datta Meghe Institute of Higher Education \& Research (Deemed to be University)}%
\affil[6]{Dow Medical College}%
\affil[7]{Kumaraguru College of Liberal Arts and Science}%
\affil[8]{Noorul Islam Institute of Medical Science and Research Foundation Medicity}%
\affil[9]{Nepalgunj Medical College}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{A Case of Trichotillomania (TTM) and Bulimia Nervosa (BN) in a
Patient with Adult-Onset Attention-Deficit/Hyperactivity Disorder
(ADHD)}

\textbf{Rakshita Ramesh Bhat\textsuperscript{1,2}, Faheem
Vellekkat\textsuperscript{2,3}, Ivany Lestari
Goutama\textsuperscript{2,4}, Praneet Singh Gill\textsuperscript{2,5},
Gauri Kakar\textsuperscript{2,6}, Hafsa Jabeen\textsuperscript{2,7},
Krishnan Gireesh\textsuperscript{2,8}, Vivek
Sanker\textsuperscript{2.9}, Umang Gupta\textsuperscript{2,10}}

\textsuperscript{1}Bangalore Medical College and Research Institute,
Bangalore, India

\textsuperscript{2}Team Erevnites, India

\textsuperscript{3}Indira Gandhi Medical College and Research Institute,
Puducherry, India

\textsuperscript{4}Tarumangara University, Faculty of Medicine, Jakarta,
Indonesia

\textsuperscript{5}Government Medical College, Patiala, India

\textsuperscript{6}Jawaharlal Nehru Medical College, Wardha, India

\textsuperscript{7}Dow Medical College, Karachi, Pakistan

\textsuperscript{8}Dean, School of Behavioural Sciences, India

\textsuperscript{9}Noorul Islam Institute of Medical Sciences,
Trivandrum, India

\textsuperscript{10}Nepalgunj medical college, BP Chowk-12, Nepalgunj
Banke, Nepal.

\textbf{Corresponding author:}

Umang Gupta

Nepalgunj medical college, BP Chowk-12, Nepaligunj Banke, Nepal

Email: dr.umaang@gmail.com

ORCID: 0000-0002-7911-8663

\textbf{ORCID Ids:}

Rakshita Ramesh Bhat: 0000-0002-2656-0044

Ivany Lestari Goutama: 0000-0002-3097-5859

Hafsa Jabeen: 0000-0001-9975-6585

Praneet Singh Gill: 0009-0005-4515-4542

Gauri Kakar: 0009-0006-4981-9932

Faheem Vellekkat: 0009-0006-5937-6792

Vivek Sanker: 0000-0003-0615-8397

\textbf{ABSTRACT}

Trichotillomania (TTM) is frequently considered an isolated disorder;
nevertheless, emerging evidence suggests that other psychiatric
conditions including obsessive-compulsive disorder (OCD); eating
disorders (EDs); and attention-deficit/hyperactivity disorder (ADHD) are
often found to coexist. Several studies showed that EDs, such as bulimia
nervosa (BN), were found in chronic hair-pullers, whilst OCD was
considered a factor in predicting the prevalence of EDs, as well as the
severity of TTM in the populations. While the relationship between TTM
with OCD has been quite well-documented, the evidence of its association
with BN and ADHD remains limited.

\textbf{Keywords: Trichotillomania, Bulimia nervosa, ADHD}

\textbf{INTRODUCTION:}

Trichotillomania (TTM) is a condition characterized by repetitive hair
pulling those results in hair loss, distress and disability in daily
functioning {[}1{]}. This condition has a global prevalence of 1-2\% in
the general population {[}2,3{]}. Although TTM is typically considered
an isolated disorder, emerging evidence suggests that it may be
associated with other psychiatric conditions, including
obsessive-compulsive disorder (OCD), eating disorders (EDs), major
depressive disorder (MDD), anxiety disorders, substance use disorder and
attention-deficit/hyperactivity disorder (ADHD) {[}2--5{]}.

In a recent study predictor of having an OCD in a TTM population were
examined and it was discovered that having an eating disorder diagnosis
was linked to a higher risk for OCD depending on how severe the ED was
{[}6{]}. It also suggests that OCD might be a factor in predicting the
prevalence of an eating disorder in TTM populations {[}7{]}.

Attention-deficit/hyperactivity disorder~(ADHD) is also commonly
comorbid with other psychiatric conditions, with up to 75\% of adults
with ADHD meeting diagnostic criteria for at least one more psychiatric
disorder {[}8{]}. It is a condition that affects the development of the
brain, identified by signs of inattentiveness, hyperactivity, and
impulsivity. In approximately 60\% of cases, these symptoms can continue
into adulthood {[}9{]}. Despite this growing body of evidence, the
relationship between trichotillomania, bulimia nervosa and ADHD remains
poorly understood. In light of the limited research on this topic, this
case report aims to provide a detailed description of a TTM patient with
comorbid BN, MDD and ADHD.

\textbf{CASE REPORT:}

The index case is a 25-year-old graduate who was brought to the
outpatient department (OPD) by her mother with involuntary hair-pulling
of one-year duration. On examination, she had patches of baldness over
her head, mainly over the crown region (Figure 1). She would pull
strands of hair as she felt restless and began pacing around the room.
Initially it occurred 3-4 times daily, later progressed to 8-10 episodes
for the past 2 months due to exam stress. Other than scalp hair, this
behavior did not involve the eyebrows, armpits or pubic area.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1. Physical examination of patient's scalp showed patches
of baldness over the head, mainly over the crown region.}

She has also been having intermittent binge eating attacks with
excessive exercising for 4 months and currently has a BMI of 20.7
kg/m\textsuperscript{2}. She binged mainly on junk food and each episode
lasted 45 minutes to an hour. She consumed around 7000-8000 kilocalories
per binge. She tends to exercise excessively in order to compensate for
the excessive eating. She has an intense fear of gaining weight and is
constantly preoccupied with thoughts of weight loss despite the binging.
She demonstrates no emesis, diuresis or diarrhea. She has no knuckle
calluses/ parotid swelling/dental erosion/pharyngeal tears. The patient
is amenorrhoeic and has not had her menstrual cycles for six months.
Prior to this, she had irregular cycles (40-45 days). Medical causes for
amenorrhea were ruled out and it was attributed to excessive exercise.
Results of the routine lab investigations performed are mentioned in
Table 1.

She was diagnosed with attention deficit hyperactivity disorder (ADHD)
at the age of fifteen and has been demonstrating symptoms congruent with
ADHD for approximately one and a half years. The patient had been
absent-minded and distracted during classes. Her academic performance
had been sub-optimal with especially poor results in mathematics. Her
teachers believed that her mediocre academic performance was not due to
inadequate effort or modest intellect but rather due to a lack of
concentration. She was often fidgety and found it hard to stay still.
Substance abuse was ruled out as a differential diagnosis considering
the age and symptom profile. The diagnosis of ADHD was made by a team
consisting of a pediatrician, a psychiatrist and a counselor. The
treatment plan was also devised by the aforementioned team. She was
prescribed methylphenidate 10 mg daily and was compliant with her
medication. She had periods of remission in between and had considerable
improvement in several symptoms. The patient was lost to follow-up after
about two years.

At the age of 22, she was diagnosed with major depressive disorder
(MDD). She had come in with symptoms of feelings of worthlessness,
insomnia and weight loss. The symptoms had been present for around four
months. She had multiple psychosocial stressors including academic
stress and personal relationship issues. Additionally, the patient also
had a worsening of her ADHD symptoms. She was put on bupropion
sustained-release tablets. A satisfactory response was not seen. She
seemed to have a slight improvement in depressive symptoms, however,
ADHD symptoms did not improve. She was hence taken off bupropion and
continued on methylphenidate. Additionally, escitalopram and clonazepam
were added. The dosage of escitalopram was increased slowly to 10 mg,
and thereby her symptoms slightly improved. The patient was on the same
medication for 8 months and was subsequently changed to Lisdexamfetamine
and escitalopram along with clonazepam which showed a better response
after 4 months. Clonazepam was stopped after that. The antidepressants
were gradually tapered after 7 months of treatment. However, for the
last 2 months, due to increased stress about her exams, symptoms of
involuntary hair pulling and bulimia worsened. So, she was restarted on
escitalopram, which showed a good response to bulimia but an
unsatisfactory response to impulsive hair-pulling. She is being followed
up for further dose adjustments in medications and cognitive behavioral
therapy (CBT) for habit reversal.

\textbf{Table 1. Laboratory and other investigation findings}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Parameter}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Parameter}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Results}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Reference range}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hematology\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hemoglobin\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8.7 g/dL\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Leukocyte count\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6,500/ mm\textsuperscript{3}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4500-11,000/mm\textsuperscript{3}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Platelet count\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
210,000/mm\textsuperscript{3}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
150,000-400,000/mm\textsuperscript{3}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Blood, Plasma, Serum\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Thyroid-stimulating hormone (TSH)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.2 \selectlanguage{greek}µ\selectlanguage{english}U/mL\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.4-4.0 \selectlanguage{greek}µ\selectlanguage{english}U/mL\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Free T3 (FT3)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 pmol/L\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.0-7.0 pmol/L\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Free T4 (FT4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.9 pmol/L\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.9-14.4 pmol/L\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Estradiol\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
27 pg/mL\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Pre-menopausal women: 30- 400 pg/mL Post-menopausal women: 0- 30 pg/mL
Men: 10- 50 pg/mL\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Other findings\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Ultrasound pelvis: within normal limits\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Ultrasound pelvis: within normal limits\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Ultrasound pelvis: within normal limits\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{DISCUSSION}

Similar to our present study, TTM usually presents first during
childhood or adolescence and has a chronic course, with a female
predominance of over 4 times to that of males {[}10{]}. TTM typically
manifests as isolated patches of hair loss, which are frequently
observed over the scalp's crown, occipital, and parietal areas. The
eyelashes, brows, pubic or other body hair are other areas that are
usually affected {[}11{]}. The involvement of scalp hair was seen in our
patient with patches of baldness mainly over the crown region, which
appears to be unique and correlates with the literature. Other than
scalp hair, this behavior did not involve the eyebrows, armpits or pubic
area.

According to the DSM-V, five outline criteria must be met for the
diagnosis of TTM, which include {[}1,2{]}:

\begin{enumerate}
\tightlist
\item
  Recurrent pulling out one's hair resulting in noticeable loss of hair
\item
  Increasing sudden feeling of tension before pulling hair out or while
  in attempt for resisting
\item
  Sense of pleasure, rewarding, or relief after behavior
\item
  The disturbance is neither accounted by another mental disorder nor
  due to other general medical condition
\item
  Causing clinically significant distress or impairment in social,
  occupational, or other important areas of function.
\end{enumerate}

Patients frequently have a history or concurrent diagnosis of other
psychiatric conditions, including anxiety or depression, similar to
OCD-related illnesses {[}12{]}. Although TTM and obsessive-compulsive
disorder (OCD) share many characteristics, TTM is a distinct clinical
condition with grave social repercussions and potentially fatal effects
if there is also associated hair consumption. According to literature,
eating disorders (EDs) should also be included in the spectrum of OCDs,
just like TTM {[}13,14{]}. The existence of TTM usually indicates a more
severe form of generalized impulse control disorder, which could involve
various related conditions, including EDs. A subjective sense of
compulsion and trouble controlling repetitive activities are two traits
shared by OCD and EDs {[}6,15{]}.

About 20\% of chronic hair-pullers are found to have eating disorders
{[}10{]}. Our case was identified to have intermittent binge eating
attacks with compensatory behavior like excessive exercising along with
TTM. In another study of smaller populations with trichotillomania,
Houghton et al. reported a prevalence range of 2\%-14\% for bulimia
nervosa {[}5{]}. TTM and EDs are both considered to belong to a limited
subset of diseases that also exhibit impulsive and compulsive elements
and have comparable pathophysiological causes, such as cortico-striatal
dysfunction, in addition to having comparable phenomenology and
functionality {[}14,16{]}. A recent study discovered that there is a
16-fold higher chance of developing bulimia nervosa in females than
males with OCD, which is consistent with our patient's findings
{[}17{]}.

Studying the comorbidity of EDs and TTM is crucial for developing new
therapeutic techniques to complement existing treatments like CBT.
Innovative approaches could focus on addressing shared underlying
vulnerabilities such as impulsivity or difficulties with emotional
regulation. 79\% of those who had TTM also had one or more mental health
comorbidities, with anxiety/depressive disorders, OCD, PTSD, and ADHD
being the most prevalent {[}12{]}. ADHD in general, is one of the most
prevalent neurodevelopmental diseases in children. Both TTM and ADHD are
difficult to define as both disorders share some common symptoms, in
which, people with TTM may have a hard time resisting the urge to pull
their hair, fidget or squirm in their seats, while similarly, people
with ADHD also have trouble focusing and easily distracted or impulsive.
The dysfunction of the reward system has been suggested as a potential
factor in hair-pulling behavior, with the dopaminergic system also
implicated in the pathophysiology of TTM {[}18{]}. Bhanji and Margolese
reported a case study in which TTM was effectively treated with the
dopamine/norepinephrine reuptake inhibitor, bupropion {[}19{]}.
Nevertheless, in our patient, bupropion was found to be ineffective.

The predominance of ADHD features in our patient mandated the management
to mainly include stimulants such as Methylphenidate or
Lisdexamfetamine. A study by Golubchik P et al. showed that
Methylphenidate was effective in the management of 9 adolescents with
trichotillomania and comorbid ADHD {[}20{]}. Methylphenidate showed
improvement in ADHD features, but symptoms of trichotillomania were
relatively resistant to management, which is consistent with the results
of our present case.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used for
the management of both TTM and EDs, with effective results in the
reduction of the symptoms of TTM, as seen in various literatures
{[}21--23{]}. Since our patient also had co-morbid MDD, it was apt to
add Escitalopram to the management. Despite being the first-line
treatment option, studies indicate that while antidepressants may help
alleviate depression and anxiety symptoms associated with
trichotillomania, they do not produce consistent positive outcomes for
the condition itself {[}24{]}. A study that analyzed the effectiveness
of SSRIs in treating trichotillomania using randomized controlled trials
reported a moderate level of improvement for all antidepressants
utilized in the treatment {[}22{]}.

Furthermore, it was seen that our patient did have an improvement in the
symptoms on this management for a few months but subsequently worsened
due to exam stress for the last 2 months. This was consistent with the
findings of Golubchik et al., who noted that exposure to stressful life
events was one of the key factors contributing to treatment-resistant
TTM {[}20{]}. Thus, it appears that certain factors, such as stressful
life events like exams or conflicts between parents and children, may
have a substantial impact on the effectiveness of treatment for TTM.
However, the vast majority of evidence indicates that the management of
TTM is most effectively achieved by combining pharmacologic and
non-pharmacologic treatment with ongoing follow-up and monitoring
{[}22{]}.

Case reports available in literature on trichotillomania with comorbid
eating disorders:\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Study; Country; Year\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Demographic Features\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Duration of Illness\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Comorbid Conditions\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Treatment Given\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Result\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
A case of trichotillomania with binge eating Disorder; China; 2021
{[}25{]}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
25 years old, Female\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
10 years\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
OCD, Depression, Anxiety Disorder, Binge-eating disorder\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Fuvoxamine, Bupropion, N-Acetylcysteine\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
All symptoms resolved, on follow-up\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Oxcarbazepine for the treatment of trichotillomania; Italy; 2010
{[}26{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
43-year-old Female\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Since adolescence\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Binge-eating disorder\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Oxcarbazepine\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
All symptoms resolved\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Trichotillomania and Anorexia Nervosa in an Adolescent Female; Canada;
1996 {[}27{]}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
17 years old, Female\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
2 years\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Anorexia Nervosa\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Did not consent to treatment\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Discontinued evaluation after diagnosis\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Obsessive-compulsive disorder, trichotillomania, and anorexia nervosa;
Kansas; 1994 {[}29{]}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
18-year-old Female\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6 years\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Major Depression, Anorexia nervosa, OCD\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Fluoxetine, cognitive behavioral and interpersonal psychotherapy.\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Symptoms improved\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Hypno-behavioral Treatment of Self-Destructive Behavior:
Trichotillomania and Bulimia in the Same Patient; Texas; 1986
{[}28{]}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
22-year-old Female\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1 year\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Bulimia Nervosa\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Hypno-behavioral approach\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
All symptoms resolved\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{CONCLUSION:}

Despite its infrequency, TTM can substantially have a negative impact on
mental status, life quality and psychosocial function, leading towards
patient behavioral aberrancies. Identifying any potential comorbidity is
essential to implement a thorough treatment plan. By identifying and
characterizing subgroups of individuals based on their unique clinical
features and comorbidities, we can gain more insight into the underlying
mechanisms of this condition and develop more refined biological,
genetic, and therapeutic studies. In this study, we present a patient
with a diagnosis of TTM and BN with ongoing adult onset of ADHD as well
as a history of MDD. Pharmacological treatments were planned and
prescribed according to existing comorbidities to approach the patient's
clinical condition effectively. Current evidence also supports the use
of a multidisciplinary approach including dermatologists, psychiatrists,
counselors, and even family members to effectively support and treat the
expanding and diverse patient group presenting with TTM and its
multifaceted nature.

\textbf{CONFLICTS OF INTEREST:}

None declared.

\textbf{AUTHOR CONTRIBUTION:}

All the authors contributed equally in drafting, editing, revising and
finalizing the case report.

\textbf{ETHICAL APPROVAL:~}

Ethical approval was not required for the case report as per the
country's guidelines.

\textbf{CONSENT:}

Written informed consent was obtained from the patient to publish this
report.

\textbf{DATA AVAILABILITY STATEMENT:}

The data that support the findings of this article are available from
the corresponding author upon reasonable request.

\textbf{REFERENCES:}

1. Diagnostic and statistical manual of mental disorders:
DSM-5\textsuperscript{TM}, 5th ed. Arlington, VA, US: American
Psychiatric Publishing, Inc.; 2013. xliv, 947 p. (Diagnostic and
statistical manual of mental disorders: DSM-5\textsuperscript{TM}, 5th
ed).

2. Keuthen NJ, O'Sullivan RL, Ricciardi JN, Shera D, Savage CR, Borgmann
AS, et al. The Massachusetts General Hospital (MGH) Hairpulling Scale:
1. development and factor analyses. Psychother Psychosom.
1995;64(3--4):141--5.

3. Sr C, L M, Bj S, Na F. Lifting the veil on trichotillomania
{[}Internet{]}. Vol. 164, The American journal of psychiatry. Am J
Psychiatry; 2007 {[}cited 2023 May 14{]}. Available from:
https://pubmed.ncbi.nlm.nih.gov/17403968/

4. Chamberlain SR, Odlaug BL, Boulougouris V, Fineberg NA, Grant JE.
Trichotillomania: neurobiology and treatment. Neurosci Biobehav Rev.
2009 Jun;33(6):831--42.

5. Houghton DC, Maas J, Twohig MP, Saunders SM, Compton SN, Neal-Barnett
AM, et al. Comorbidity and quality of life in adults with hair pulling
disorder. Psychiatry Res. 2016 May 30;239:12--9.

6. Zucker N, Von Holle A, Thornton LM, Strober M, Plotnicov K, Klump KL,
et al. The Significance of Repetitive Hair-Pulling Behaviors in Eating
Disorders. J Clin Psychol. 2011 Apr;67(4):391--403.

7. Keuthen NJ, Curley EE, Scharf JM, Woods DW, Lochner C, Stein DJ, et
al. Predictors of comorbid obsessive-compulsive disorder and
skin-picking disorder in trichotillomania. Ann Clin Psychiatry Off J Am
Acad Clin Psychiatr. 2016 Nov;28(4):280--8.

8. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et
al. The prevalence and correlates of adult ADHD in the United States:
results from the National Comorbidity Survey Replication. Am J
Psychiatry. 2006 Apr;163(4):716--23.

9. Jensen P. Book Review: Barkley, R. A., Murphy, K. R., \& Fischer, M.
(2008). ADHD in Adults: What the Science Says. New York: Guilford. J
Atten Disord - J ATTEN DISORD. 2009 Jun 11;13:97--8.

10. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence
of trichotillomania in college students. J Clin Psychiatry. 1991
Oct;52(10):415--7.

11. Franklin ME, Flessner CA, Woods DW, Keuthen NJ, Piacentini JC, Moore
P, et al. The child and adolescent trichotillomania impact project:
descriptive psychopathology, comorbidity, functional impairment, and
treatment utilization. J Dev Behav Pediatr JDBP. 2008
Dec;29(6):493--500.

12. Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender
correlates, and co-morbidity of trichotillomania. Psychiatry Res. 2020
Jun;288:112948.

13. Greenberg E, Grant JE, Curley EE, Lochner C, Woods DW, Tung ES, et
al. Predictors of comorbid eating disorders and association with other
obsessive-compulsive spectrum disorders in trichotillomania. Compr
Psychiatry. 2017 Oct;78:1--8.

14. Sallet PC, de Alvarenga PG, Ferr\selectlanguage{ngerman}ão Y, de Mathis MA, Torres AR,
Marques A, et al. Eating disorders in patients with obsessive-compulsive
disorder: prevalence and clinical correlates. Int J Eat Disord. 2010
May;43(4):315--25.

15. Richter MA, Summerfeldt LJ, Antony MM, Swinson RP.
Obsessive-compulsive spectrum conditions in obsessive-compulsive
disorder and other anxiety disorders. Depress Anxiety.
2003;18(3):118--27.

16. Boisseau CL, Thompson-Brenner H, Caldwell-Harris C, Pratt E,
Farchione T, Barlow DH. Behavioral and cognitive impulsivity in
obsessive-compulsive disorder and eating disorders. Psychiatry Res. 2012
Dec 30;200(2--3):1062--6.

17. Cederlöf M, Thornton LM, Baker J, Lichtenstein P, Larsson H, Rück C,
et al. Etiological overlap between obsessive-compulsive disorder and
anorexia nervosa: a longitudinal cohort, multigenerational family and
twin study. World Psychiatry Off J World Psychiatr Assoc WPA. 2015
Oct;14(3):333--8.

18. Carrion VG. Naltrexone for the treatment of trichotillomania: a case
report. J Clin Psychopharmacol. 1995 Dec;15(6):444--5.

19. Bhanji NH, Margolese HC. Alternative pharmacotherapy for
trichotillomania: a report of successful bupropion use. J Clin
Psychiatry. 2004 Sep;65(9):1283.

20. Golubchik P, Sever J, Weizman A, Zalsman G. Methylphenidate
treatment in pediatric patients with attention-deficit/hyperactivity
disorder and comorbid trichotillomania: a preliminary report. Clin
Neuropharmacol. 2011;34(3):108--10.

21. Gadde KM, Ryan Wagner H, Connor KM, Foust MS. Escitalopram treatment
of trichotillomania. Int Clin Psychopharmacol. 2007 Jan;22(1):39--42.

22. McGuire JF, Ung D, Selles RR, Rahman O, Lewin AB, Murphy TK, et al.
Treating trichotillomania: a meta-analysis of treatment effects and
moderators for behavior therapy and serotonin reuptake inhibitors. J
Psychiatr Res. 2014 Nov;58:76--83.

23. Koran LM, Ringold A, Hewlett W. Fluoxetine for trichotillomania: an
open clinical trial. Psychopharmacol Bull. 1992;28(2):145--9.

24. Johnson J, El-Alfy AT. Review of available studies of the
neurobiology and pharmacotherapeutic management of trichotillomania. J
Adv Res. 2016 Mar;7(2):169--84.

25. Zhao X, Wang S, Hong X, Lu S, Tang S, Shen Y, et al. A case of
trichotillomania with binge eating disorder: combined with
N-acetylcysteine synergistic therapy. Ann Gen Psychiatry. 2021 Sep
25;20(1):46.

26. Leombruni P, Gastaldi F. Oxcarbazepine for the treatment of
trichotillomania. Clin Neuropharmacol. 2010;33(2):107--8.

27. Pinhas L, Geist R, Katzman DK. Trichotillomania and anorexia nervosa
in an adolescent female: a case study of comorbidity. J Adolesc Health
Off Publ Soc Adolesc Med. 1996 Aug;19(2):141--4.

28. Hall JR, McGill JC. Hypnobehavioral treatment of self-destructive
behavior: trichotillomania and bulimia in the same patient. Am J Clin
Hypn. 1986 Jul;29(1):39--46.

29. Pryor TL, Martin RL, Roach N. Obsessive-compulsive disorder,
trichotillomania, and anorexia nervosa: A case report. Int J Eat Disord.
1995;18(4):375--9.

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