Trichotillomania in Patients Using Stimulant Medications: What is the link?

Stimulant Medications May Increased the Risk of Trichotillomania in Pediatric Patients.

Trichotillomania (TTM) is a mental health condition whereby an individual repeatedly pulls out his or her hair in a manner that leads to functional impairment or distress of some kind. It has been estimated that trichotillomania has a prevalence of somewhere between 0.6–3.6 % of adults. Studies have largely been done in college students and much of our epidemiology comes for these good studies. It’s clear that a fairly high proportion of humans pull their hair at times but don’t actually meet the formal definition of TTM. Prior published studies had suggested that TTM is more common in adult females but new data suggests it may have similar prevalence in males and females. The vast majority of people with trichotillomania have one or more mental health comorbidities such as anxiety/depressive disorders, OCD, PTSD, and ADHD.

A Closer Look at Stimulants and Trichotillomania

Stimulant medications are widely prescribed in the United States for the treatment of attention deficit hyperactivity disorder (ADHD). The most common prescription stimulants are methylphenidate (Ritalin®, Concerta®), lisdexamfetamine (Vyvanse®, Elvanse®), and amphetamine/dextroamphetamine combinations (Adderall®). Stimulants are also used for treating other medical issues besides ADHD. For example, Methylphenidate and amphetamines are also indicated for the treatment of narcolepsy, while lisdexamfetamine is indicated for binge-eating disorder.

The use of stimulants has increased considerably in the last decade. This is especially true in the adolescent population, which has experienced a marked increase in the diagnosis of ADHD. Among U.S. adults, recent data suggested that a total of 6.6 % of the adult population were reported to use prescription stimulants.

How do stimulants work?

Prescription stimulants work to raise the levels of dopamine and norepinephrine by a mechanism that involves blocking reuptake transporters in the central nervous system (CNS). Amphetamines and lisdexamfetamine also increase monoamine (ie dopamine, norepinephrine, serotonin) release from vesicles into the intracellular fluid of neurons.

Common Side effects of Stimulants

Given how widely stimulants are used, it’s important for practitioners to be aware of possible side effects. Side effects include decreased appetite, anxiety, diarrhea, dry mouth, insomnia, and rapid heart rate (tachycardia). More serious adverse effects include cardiovascular events, hypertension, peripheral vascular issues, serotonin syndrome, and psychiatric reactions (like mania or psychosis) can also occur.

New study Examines Trichotillomania as a Side Effect of Stimulants: How Common is it?

A new study set out to examine published cases of trichotillomania, tactile hallucinations, and delusional infestation caused by prescription stimulant use or abuse.

The authors found a total of 17 articles describing 22 case reports to include in their study.

Data Examining Relationship between Trichotillomania and Stimulant Use

The authors identified 8 cases of trichotillomania induced by prescription stimulant use. 7 patients were pediatric and one was an adult. Every patient received prescription stimulants for the treatment of ADHD. Hair-pulling began anywhere from several days to several months after starting medications or increasing the dosage. Amphetamine, lisdexamfetamine, and methylphenidate were all found to precipitate the disorder. In one case, hair-pulling was associated with delusions and required inpatient hospitalization under psychiatry care. Symptoms resolved or diminished significantly after discontinuation of stimulant medication in almost all cases. Reemergence of hair pulling occurred in one patient who was rechallenged with methylphenidate.

Data Examining Relationship between Tactile Hallucinations and Stimulant Use

The authors identified 8 cases of tactile hallucinations induced by prescription stimulants. All cases were reported in pediatric male patients ranging from 7-12 years old and every case involved patients receiving methylphenidate for the treatment of ADHD. Patients referenced feelings of their being bugs, rats, roaches, snakes, and flies crawling and touching skin. Five of the 8 cases featured associated visual hallucinations. Symptoms started several days to several years after initiation of methylphenidate. All symptoms ceased shortly after discontinuation of the medication.

Data Examining Relationship between Delusional infestation and Stimulant Use

Delusional infestation (also called delusions of parasitosis), is characterized by the fixed belief that a person's skin and/or body is inhabited by foreign pathogens. in this study, the authors identified 6 cases of prescription stimulant-induced delusional infestation.

There are 6 patients: 5 were adults and one was a 10-year-old pediatric patient. All cases reported use or misuse of amphetamines, except for the pediatric aged patient who was prescribed methylphenidate. All cases featured delusions of infestation. Three cases presented with excoriated lesions on the skin exam. Symptoms had been present from days to months with wide variations of onset of delusions after beginning stimulant use. 2 patients needed to be hospitalized for their symptoms, and 3 cases were treated with antipsychotic medications. All cases resolved within days to one month after decreasing dosage or discontinuing stimulant use.

Comment

This is a really helpful study for physicians and specialists of all kinds to know about.

The study showed that stimulants medications may be associated with trichotillomania, tactile hallucinations and delusions of parasitosis in some cases. Patients presenting with trichotillomania and tactile hallucinations induced by prescription stimulants tend to be pediatric male patients being treated for attention deficit hypersensitivity disorder. Symptoms resolve after stopping the stimulant. In contrast to stimulant induced trichotillomania and tactile hallucinations, patients presenting with stimulant induced delusional infestation were usually adults who were misusing or abusing stimulant medication.

In general, trichotillomania now is thought to affect both males and females. In this study, trichotillomania as a side effect of stimulants tended to affect more males. This may be explained by the observation that stimulant use is more than three times greater in males than females.

The exact reasons for these various side effects from stimulants are not clear. However, when one looks at the mechanism of action of these drugs one might get some clues. The increase in dopamine release by amphetamines and methylphenidate may be responsible for transiently inducing compulsive hair pulling in select patients.

Listen to the Article on Dr. Donovan’s Evidence Based Hair Podcast

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REFERENCE

Moattari et al. Adverse psychocutaneous effects of prescription stimulant use and abuse: A systematic review. J Dtsch Dermatol Ges. 2022 Jan;20(1):7-15.