LETT ERS T O '1'111' U)ITOR ess ential c linic al characteristic s of the di sor der , i.c . , alt ernation of different personalities which take co ntro l of the subject' s beh avior. Additiona lly , her c han ge s in manner of rela tin g to the e nv iro nme nt rend er ed her nonfuncti on al , and probably invo lved alterat ion s in reality tcs ting rat her than personali ty. No r has she disp layed an y dissoci at ive phenomena in the 2Yz years since her discharge fro m our hospit al. Th e possib ility ce rtai nly remain s , howev er , tha t thi s unu sual and perple xin g patient w ill manifes t suc h a disorder in the future . Prese ntly , the pa tie nt is IS- years old , lives at ho me with bot h parents, and atte nds a ma instre am hi gh sc hool. S he is a good st udent , ha s a boyfriend , ma ny friend s, an d doc s fashion mod e ling . On di scha rge from the resid ential tre atment ce nter a lmos t 2 year s ago no cli nical d isorde r was pre sent. Ou tp atient ind ividual and famil y therap y we re pre scribed becaus e o f family tu rm o il. She wa s see n only bri etly in o utpatie nt psych otherap y , where the dia gnose s o f " d ysthym ic di sorder a nd adjustm ent rea cti on to famil y problems " were gi ve n . Alt hough she is no longer in treatment , the out patient therapist remains in contact with the pati ent and her fam ily and feels the above d iag nos e s st ill apply. No psychotic , hyster ical , or co nve rs io n sy m pto ms hav e been noted . No sig n of Huntington ' s di sease or o the r ph ys ic a l illness ha s developed . T he pati en t continues to ha ve chro nic, mild ph ysical compl aints . Ma c S . So ko l , M .D . Cy nthia R. Pfeffer , M .D . G ail E. Sol omon , M. D . Aa ron H. Esman, M.D . Girard Robinson, M .D . Risa L. Go ld , M .D . Alison Or r-A ndrawes , M .D . New Yor k Hospital-C orn e ll M edi cal Cente r
Lithium Side Effect To the Editor: Although the lite rature is repl ete wi th art ic les s pec ify ing el evat ion s in th yro id stimula ting hor mone (T S H) leve ls dur ing the co urse of lith ium tre atment (ty p ically ne ce ss itati ng su pple me nt al artifici al th yro id hormon e ) , a com puter sea rc h fa iled to y ie ld a ny mention of potential ge net ic transmi ssion for suc h sus ceptibi lity. A unique pediatric hos pita lization prov ided ev ide nce for the su ggesti on of genetic vulnera bi lity to th is side effect. Whi le the use of lith ium in chi ld ren is not as prevalent as their adult psych iatri c cou nte rpa rts , it rem ain s a n import ant co m po ne nt of the pharmac olo gica l armame ntar ium fo r the treatm e nt of ped iatric bip olar sy mp tomatology an d explosi ve beh a vior. A 9- year-old Ca uc as ian mal e w ith a dia gn o sis o f bip olar disorder in the Ni cho ls Cottage C h ild re n ' s Inpatient Se rv ice s of New York Hos pital was efficaciou s ly tre ated with lit hium . He exh ibited a signific ant reduct io n in T. (T hyroxine) fro m 7.4 to 5 .9 mcg/di with a co ncom itant co mpens atory elevat ion in TS H from 3 .7 to 15 .3 Mcl U/ ml during the dru g trial. Th e addit io n of S ynth ro id ( I-T hy rox ine- 50 ug /day) to his d rug re g imen , successfully ret urned hi s TSI-! le vel s to nor mal (4 . .> M el U f ml) . The co nc ur rent hosp ital izati o n of hi s ma te rna l hal f-sib lin g , age 7, led to a s imi lar pharmacological d eci s ion re gard ing a lithium dru g trial. While the yo un ger brother w as no t dia gn osed as cle arly bipol ar as was his olde r sib li ng , many s im ilar fea tu res and int erm ittent aggressive expl o siveness , as we ll as lithium' s suc cess ful usc o n a family member, re su lted in the dru g trial. In a ma nner s im ila r to his o lder sibling, the yo unger broth er ex hibi ted an e lev a tio n in T S H fro m 4.8 to 20.8 M el U/ml, w h ile seru m T. fe ll from 6.4 to 4.7 mc g/d l as his lithium do sage was bei ng es tab lis hed . E nd ocr ine co ns u lta tio n led to the identica l recom me nda tio n fo r S ynthroid . Un like his o lder brothe r ,
J . Am .Acad . Child Adolesc . Psychiatry . 29 :3 . May 1990
the younger child d id not pro ve re spo nsiv e to lithiu m. T he med ic atio n was di sconti nued w ith the subsequen t ret urn to a normal TS H va lue (3 . 1 Mcl Ul m l). These two famil y memb er s re sp onded wi th s im ilar de gr ee s of co m pensate d hypothyroi d ism , in d irect contras t w ith the Inpatien t Unit ' s bas el ine o f approximately 2 8 previous lithium trials w ith c hil d re n , a ll resulting in no d isturba nce o f thy roid fun ct ioning . Will iam Picke r . Ph .D . Ga il Solo mo n, M .D . Joseph M . Ge rtner, M .B . , M.R .C. I'. Th e Ne w York Hosp ita l - Co rne ll Un ive rs ity Med ical Co lleg e
Hair Pullin g To the Editor: Th e recent rep ort by We lle r ct a l. ( 19 89) o n imipramine treatmen t of trichotilloman ia and co ex isting de press io n is an interesti ng a nd im portant ca se rep ort. It is also imp o rtant to no te, how eve r, th at al tho ugh the ch ild in the Well e r e t a l. rep ort presented w ith an ex trao rdin aril y pa tho logi c a l co ndit io n (ma jo r dep ress io n , att enti on defic it hyperact ivity di sorder, psych osomat ic pain , pic a) , much and per ha ps mos t hair pulli ng in ch ildre n is be nign . The d ive rgence bet ween the two ty pe s o f ca se s is para lle led by a si m ilar d ive rge nce in the literat ure . On the o ne hand , the pediat ric , beh a viora l, and d enn ato log ica l lite ratures describe mostl y cases in which hai r pulling pre sen ts as a beni gn habit , eas ily treate d wit h beh av io r mod ific ation , cou nsel ing, or ev en placebo ty pe intervention s (Mc hrcg an , 1970 ; l-riman c t aI. , 1984 , 1985 ; Fr iman and Hove , 1987 ; Ill ing wort h , 1987 ; Friman a nd k o sta in. 1990) . O n the othe r hand , the psych iatric lite rature desc rib es mo stly cases in which ha ir pulli ng coexi st s with patho log ica l co nd itions and is res istan t to treatme nt (Ma nio a nd Del gado , 196 8) . Th e d ivergen ce is prob abl y du e to a s pec tru m o f sev e rity in hai r pull ing cascs a nd corresponding diffe rential referral patterns (Fri ma n ct a l. , 1984; 19 85 ; Friman and Rostai n , 1990). Our concern is twofold . First , unle ss the d ivergence is emphasi zed in paper s o n hair pulling , the p re vale nt but fa lse notion that hai r pulling of itsel f s ig nifies psychopatho logy ma y be per petuated . Seco nd, so me children with benign hai r pulli ng may be o vertreated (c .g. , wit h im iprami ne) , unle ss providers are we ll informed a bo ut the d iverge nce betwe en be nig n and patho log ica l ca ses . A last iss ue in volves the lim ited informatio n on the extent and duration of the aba te ment of ha ir pu lling. Hai r pulling is usually practiccd covertly , exc ept in ver y yo u ng children , and thu s a variety o f indirect o utco me mea sure s have bee n used to assess the e ffec ts of treatm ent , e .g . , hair s pulle d, s ize of bald spots ( Fri mun e t a I., 1984; Fri ma n ami Hove , 1987) . Wc do not ta kc iss ue wi th the ab sen ce o f these measures in the We ller et al. paper beca use it wa s a c asc re port a nd becau se the primary tar get o f trea tm ent was depression . But we believe ex te nded, e mp irica lly deri ved foll ow -up me asu res s ho uld ac comp an y even a suggest io n that a pote ntiall y to x ic tre atment, su ch as imipram ine, be used for a frequ ent ly beni gn con dition , such as hair pulling . Pat rick C. l-ri ma n , Ph . D . An thon y Rostain . M .D . John M. Parr ish , Ph .D . W illiam 13 . C arey , M .D . Unive rsity of Pe nn sy lva nia Sch oo l of Med icine REl 'EREN C I,S
Friman . P . C . & Rostain , A . ( 1990). Tri choti lloma nia in ch ildre n: a caveat for primar y ca re . N . Engl. J. Med. Frimau, 1'. C. & Ho ve, G . (198 7) , Ap pa re nt co var iatio n bet we en c hi ld hab it d isorders : effects of success fu l treatment for thu m b suc k ing on un tar geted chro nic ha ir pulling . J. Appl . Bcha v, 1\ /I l11. • 20:42 1--· 426 .
489
LETTERS TO
ruu
EDITOR
Friman, P. C., Finney, 1. W. & Christophersen, E. R. (1985), Trichotillomania: issues and an answer to Ames. Behavior Therapy, 16:329332. Friman, P. C., Finney, J. W. & Christophersen, E. R. (1984), Behavioral treatment of trichotillomania: an evaluative review. Beliavior 'lhcrapv. 15:249-266. Illingworth, R. S. (1987), The Normal Child. New York: Churchill Livingston. Mannino, F. V. & Delgado, R.I\.. (1968), Trichotillomania in children: a review. Alii . .1. Psych iatrv , 126:505-511. Mchrcgau. 1\.. H. (1970), Trichotillomania: a clinicopathologic study. Arch. Dennrno!., 102:129-133. Wcllcr, E. B., Wcller, R. A. & Carr, S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old. .I. Alii. /vcad. Child Adolesc. Psychiatry, 28:952·-953. R. Weller and 10'. Weller reply: We agree with Drs. Triman, Rostain, Parrish, and Carey that many cases of trichotillomania arc "benign" and can be effectively managed as thcy describe. However, there is good evidence that some cases of trichotillomania arc associated with significant psychiatric illness (Oguchi and Miura, 1977; Stichcr ct al., 1(80). Unfortunately, the frequency of this association is unknown due to the lack of good epidemiologic studies (American Psychiatric Association, 1(87). Triman ct a1. arc justifiably concerned that "benign" hair pulling not be overtreated. However, we arc not suggesting or implying that imipramine be used to treat all cases of trichotillomania. Conversely, and just as importantly, it should not be assumed that trichotillomania is always benign. In some situations (such as described in our case report) more aggressive treatment may be justified. I\.s we suggest in our case report, when trichotillomania and major depression arc observed concurrently in a patient, treatment with antidepressants should /)1'.1'.
490
at least be considered (Krishman et al., 1984). Perhaps in such situations behavioral treatment alone may prove ineffective. Ronald A. Weller, M.D. Elizabeth B. Weller, M.D. The Ohio State University REl "ERENCES
Diagnostic and Statistical Manual of Mental Disorders (DSM-lll-R) , Third Edition-Revised. (1987), Washington, DC: American Psychiatric Asaociation. Krishnan, K. R., Davidson, J. R. & Miller, R. D. (1984), MAO Inhibitor therapy in trichotillomania associated with depression: case report..I. Clin. Psychiatry, 45:267--268 . Oguchi, F. & Miura, S. (1977), Trichotillomania: its psychopathologic aspect. Compr. Psychiatry, 18:177·-182. Stichcr, M. B., Abramovits, M. & Newcomer, V. D. (1980), Trichotillomania in adults. Cutis, 26:90-101.
Letters to the Editor are welcome. They will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of six references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents arc the sole responsibility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the .Iournal. Please direct your letters to John F. McDermott, Jr., M.D., Editor, .Iournal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St., Honolulu, HI 96826-1032.
.I.Am.Acad. Child Ado/esc. Psychiatry, 29:3, May 1990
Lithium Side Effect To the Editor: Although the lite rature is repl ete wi th art ic les s pec ify ing el evat ion s in th yro id stimula ting hor mone (T S H) leve ls dur ing the co urse of lith ium tre atment (ty p ically ne ce ss itati ng su pple me nt al artifici al th yro id hormon e ) , a com puter sea rc h fa iled to y ie ld a ny mention of potential ge net ic transmi ssion for suc h sus ceptibi lity. A unique pediatric hos pita lization prov ided ev ide nce for the su ggesti on of genetic vulnera bi lity to th is side effect. Whi le the use of lith ium in chi ld ren is not as prevalent as their adult psych iatri c cou nte rpa rts , it rem ain s a n import ant co m po ne nt of the pharmac olo gica l armame ntar ium fo r the treatm e nt of ped iatric bip olar sy mp tomatology an d explosi ve beh a vior. A 9- year-old Ca uc as ian mal e w ith a dia gn o sis o f bip olar disorder in the Ni cho ls Cottage C h ild re n ' s Inpatient Se rv ice s of New York Hos pital was efficaciou s ly tre ated with lit hium . He exh ibited a signific ant reduct io n in T. (T hyroxine) fro m 7.4 to 5 .9 mcg/di with a co ncom itant co mpens atory elevat ion in TS H from 3 .7 to 15 .3 Mcl U/ ml during the dru g trial. Th e addit io n of S ynth ro id ( I-T hy rox ine- 50 ug /day) to his d rug re g imen , successfully ret urned hi s TSI-! le vel s to nor mal (4 . .> M el U f ml) . The co nc ur rent hosp ital izati o n of hi s ma te rna l hal f-sib lin g , age 7, led to a s imi lar pharmacological d eci s ion re gard ing a lithium dru g trial. While the yo un ger brother w as no t dia gn osed as cle arly bipol ar as was his olde r sib li ng , many s im ilar fea tu res and int erm ittent aggressive expl o siveness , as we ll as lithium' s suc cess ful usc o n a family member, re su lted in the dru g trial. In a ma nner s im ila r to his o lder sibling, the yo unger broth er ex hibi ted an e lev a tio n in T S H fro m 4.8 to 20.8 M el U/ml, w h ile seru m T. fe ll from 6.4 to 4.7 mc g/d l as his lithium do sage was bei ng es tab lis hed . E nd ocr ine co ns u lta tio n led to the identica l recom me nda tio n fo r S ynthroid . Un like his o lder brothe r ,
J . Am .Acad . Child Adolesc . Psychiatry . 29 :3 . May 1990
the younger child d id not pro ve re spo nsiv e to lithiu m. T he med ic atio n was di sconti nued w ith the subsequen t ret urn to a normal TS H va lue (3 . 1 Mcl Ul m l). These two famil y memb er s re sp onded wi th s im ilar de gr ee s of co m pensate d hypothyroi d ism , in d irect contras t w ith the Inpatien t Unit ' s bas el ine o f approximately 2 8 previous lithium trials w ith c hil d re n , a ll resulting in no d isturba nce o f thy roid fun ct ioning . Will iam Picke r . Ph .D . Ga il Solo mo n, M .D . Joseph M . Ge rtner, M .B . , M.R .C. I'. Th e Ne w York Hosp ita l - Co rne ll Un ive rs ity Med ical Co lleg e
Hair Pullin g To the Editor: Th e recent rep ort by We lle r ct a l. ( 19 89) o n imipramine treatmen t of trichotilloman ia and co ex isting de press io n is an interesti ng a nd im portant ca se rep ort. It is also imp o rtant to no te, how eve r, th at al tho ugh the ch ild in the Well e r e t a l. rep ort presented w ith an ex trao rdin aril y pa tho logi c a l co ndit io n (ma jo r dep ress io n , att enti on defic it hyperact ivity di sorder, psych osomat ic pain , pic a) , much and per ha ps mos t hair pulli ng in ch ildre n is be nign . The d ive rgence bet ween the two ty pe s o f ca se s is para lle led by a si m ilar d ive rge nce in the literat ure . On the o ne hand , the pediat ric , beh a viora l, and d enn ato log ica l lite ratures describe mostl y cases in which hai r pulling pre sen ts as a beni gn habit , eas ily treate d wit h beh av io r mod ific ation , cou nsel ing, or ev en placebo ty pe intervention s (Mc hrcg an , 1970 ; l-riman c t aI. , 1984 , 1985 ; Fr iman and Hove , 1987 ; Ill ing wort h , 1987 ; Friman a nd k o sta in. 1990) . O n the othe r hand , the psych iatric lite rature desc rib es mo stly cases in which ha ir pulli ng coexi st s with patho log ica l co nd itions and is res istan t to treatme nt (Ma nio a nd Del gado , 196 8) . Th e d ivergen ce is prob abl y du e to a s pec tru m o f sev e rity in hai r pull ing cascs a nd corresponding diffe rential referral patterns (Fri ma n ct a l. , 1984; 19 85 ; Friman and Rostai n , 1990). Our concern is twofold . First , unle ss the d ivergence is emphasi zed in paper s o n hair pulling , the p re vale nt but fa lse notion that hai r pulling of itsel f s ig nifies psychopatho logy ma y be per petuated . Seco nd, so me children with benign hai r pulli ng may be o vertreated (c .g. , wit h im iprami ne) , unle ss providers are we ll informed a bo ut the d iverge nce betwe en be nig n and patho log ica l ca ses . A last iss ue in volves the lim ited informatio n on the extent and duration of the aba te ment of ha ir pu lling. Hai r pulling is usually practiccd covertly , exc ept in ver y yo u ng children , and thu s a variety o f indirect o utco me mea sure s have bee n used to assess the e ffec ts of treatm ent , e .g . , hair s pulle d, s ize of bald spots ( Fri mun e t a I., 1984; Fri ma n ami Hove , 1987) . Wc do not ta kc iss ue wi th the ab sen ce o f these measures in the We ller et al. paper beca use it wa s a c asc re port a nd becau se the primary tar get o f trea tm ent was depression . But we believe ex te nded, e mp irica lly deri ved foll ow -up me asu res s ho uld ac comp an y even a suggest io n that a pote ntiall y to x ic tre atment, su ch as imipram ine, be used for a frequ ent ly beni gn con dition , such as hair pulling . Pat rick C. l-ri ma n , Ph . D . An thon y Rostain . M .D . John M. Parr ish , Ph .D . W illiam 13 . C arey , M .D . Unive rsity of Pe nn sy lva nia Sch oo l of Med icine REl 'EREN C I,S
Friman . P . C . & Rostain , A . ( 1990). Tri choti lloma nia in ch ildre n: a caveat for primar y ca re . N . Engl. J. Med. Frimau, 1'. C. & Ho ve, G . (198 7) , Ap pa re nt co var iatio n bet we en c hi ld hab it d isorders : effects of success fu l treatment for thu m b suc k ing on un tar geted chro nic ha ir pulling . J. Appl . Bcha v, 1\ /I l11. • 20:42 1--· 426 .
489
LETTERS TO
ruu
EDITOR
Friman, P. C., Finney, 1. W. & Christophersen, E. R. (1985), Trichotillomania: issues and an answer to Ames. Behavior Therapy, 16:329332. Friman, P. C., Finney, J. W. & Christophersen, E. R. (1984), Behavioral treatment of trichotillomania: an evaluative review. Beliavior 'lhcrapv. 15:249-266. Illingworth, R. S. (1987), The Normal Child. New York: Churchill Livingston. Mannino, F. V. & Delgado, R.I\.. (1968), Trichotillomania in children: a review. Alii . .1. Psych iatrv , 126:505-511. Mchrcgau. 1\.. H. (1970), Trichotillomania: a clinicopathologic study. Arch. Dennrno!., 102:129-133. Wcllcr, E. B., Wcller, R. A. & Carr, S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old. .I. Alii. /vcad. Child Adolesc. Psychiatry, 28:952·-953. R. Weller and 10'. Weller reply: We agree with Drs. Triman, Rostain, Parrish, and Carey that many cases of trichotillomania arc "benign" and can be effectively managed as thcy describe. However, there is good evidence that some cases of trichotillomania arc associated with significant psychiatric illness (Oguchi and Miura, 1977; Stichcr ct al., 1(80). Unfortunately, the frequency of this association is unknown due to the lack of good epidemiologic studies (American Psychiatric Association, 1(87). Triman ct a1. arc justifiably concerned that "benign" hair pulling not be overtreated. However, we arc not suggesting or implying that imipramine be used to treat all cases of trichotillomania. Conversely, and just as importantly, it should not be assumed that trichotillomania is always benign. In some situations (such as described in our case report) more aggressive treatment may be justified. I\.s we suggest in our case report, when trichotillomania and major depression arc observed concurrently in a patient, treatment with antidepressants should /)1'.1'.
490
at least be considered (Krishman et al., 1984). Perhaps in such situations behavioral treatment alone may prove ineffective. Ronald A. Weller, M.D. Elizabeth B. Weller, M.D. The Ohio State University REl "ERENCES
Diagnostic and Statistical Manual of Mental Disorders (DSM-lll-R) , Third Edition-Revised. (1987), Washington, DC: American Psychiatric Asaociation. Krishnan, K. R., Davidson, J. R. & Miller, R. D. (1984), MAO Inhibitor therapy in trichotillomania associated with depression: case report..I. Clin. Psychiatry, 45:267--268 . Oguchi, F. & Miura, S. (1977), Trichotillomania: its psychopathologic aspect. Compr. Psychiatry, 18:177·-182. Stichcr, M. B., Abramovits, M. & Newcomer, V. D. (1980), Trichotillomania in adults. Cutis, 26:90-101.
Letters to the Editor are welcome. They will be considered for publication but may not necessarily be published, nor will their receipt be acknowledged. Letters should, in general, not exceed 750 words, including a maximum of six references. They must be submitted in duplicate and typed double-spaced. All letters are subject to editing and shortening; the contents arc the sole responsibility of the author. The Editor reserves the right to publish replies and solicit responses. Opinions expressed in this column are those of the authors of the letters and do not reflect opinions of the .Iournal. Please direct your letters to John F. McDermott, Jr., M.D., Editor, .Iournal of the American Academy of Child and Adolescent Psychiatry, University of Hawaii School of Medicine at Kapiolani Medical Center, 1319 Punahou St., Honolulu, HI 96826-1032.
.I.Am.Acad. Child Ado/esc. Psychiatry, 29:3, May 1990
