A case of preventable surgical intervention: the effect of low-dose aripiprazole in an adolescent with trichotillomania and trichophagia

Introduction

Trichotillomania (TTM) is a chronic psychiatric condition classified within the “Obsessive-Compulsive and Related Disorders” (OCRD) spectrum in the current DSM-5, yet it exhibits neurobiological overlaps with impulse control disorders. The presence of comorbid trichophagia (hair ingestion) in TTM cases is not merely a clinical behavioral symptom; it also elevates the condition to a life-threatening level by potentially causing gastrointestinal obstruction. In this case report, we discuss the modulator role of low-dose aripiprazole augmentation—added to a Selective Serotonin Reuptake Inhibitor (SSRI) treatment—in impulse control and its preventive effect on secondary surgery in an adolescent with a high anxiety profile and a history of gastrointestinal surgical intervention secondary to trichophagia.

Case Presentation

A 15-year-old female patient, a 10th-grade student, was referred to our outpatient clinic by the surgical team following an operation for a hair and nail bezoar (trichobezoar) in her stomach. According to the history obtained during the interview with the patient and her mother, there had been a significant increase in hair and nail-pulling complaints over the past year, and the patient ingested the hair she pulled (trichophagia). Following the surgery, the patient was started on sertraline 25 mg/day at an external center. It was noted that she experienced a decline in academic functioning during her transition to high school, leading to her repeating the 9th grade, and that she faced persistent difficulties in romantic and peer relationships.

As a result of the mental status examination and psychometric evaluations, irritability, impaired sleep architecture, and somatic symptoms—such as tremors, numbness in the extremities, and dyspnea, which intensified during stressful periods accompanied by intense anxiety regarding harm coming to loved ones—were identified. The patient’s clinical presentation, dominated by fears themed around earthquakes and death, was evaluated in favor of Generalized Anxiety Disorder (GAD).

During outpatient follow-ups, the sertraline dose was titrated to 50 mg/day, resulting in significant improvement in sleep quality and irritability. However, due to the resistant continuation of impulsive hair-pulling behavior, aripiprazole was added to the treatment plan (gradually titrated to a maintenance dose of 5 mg/day). A dramatic reduction in hair-pulling behavior was observed following the augmentation. During the follow-up period, while the patient’s condition remained stable, she experienced a 20-day interruption in aripiprazole treatment due to difficulties in accessing the medication; it was noted that the impulse to pull hair relapsed rapidly during this brief period. Consequently, symptom control was re-established by readjusting the treatment.

Conclusions

With this case, we aimed to highlight the clinical importance of the dopaminergic stabilization provided by aripiprazole and the critical role of treatment continuity in resistant adolescent cases of Trichotillomania (TTM) and trichophagia. The “on-off” phenomenon, observed through the rapid relapse of symptoms during the patient’s 20-day period of treatment non-adherence, underscores the significance of continuity in biological treatment and the direct impact of the medication on impulse control. This clinical presentation demonstrates that an effective psychopharmacological intervention not only regulates psychiatric symptoms but also functions as a vital prophylactic barrier against “preventable surgical interventions” by inhibiting bezoar recurrence.

References

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