Rare case of isolated hair-pulling behavior in an elderly

BACKGROUND-: Hair pulling behavior associated with a bald patch is rarely reported in a geriatric population. AIM: - To describe the psychopathological intricacies posing diagnostic and therapeutic challenges. CASE PRESENTATION: A 90-year-old lady, presented with insidious onset of repetitive hair-pulling behavior resulting in a huge area of baldness measuring 10*20 cm(2) over the parieto-central region. On evaluation, a history of ‘as if insects are crawling under the skin and producing itching sensations’ was reported. Ward-observation was notable for the anxious distress preceding hair pulling and feeling of relief after completion of the act. No history was notable for amnesia, delusions, hallucinations, obsessions, and compulsions, or any organicity. Brain imaging, viral markers, and nutritional parameters were within normal limits. No family history of neuropsychiatric condition was noted. Premorbid personality was suggestive of anankastic personality traits. The patient had bilateral senile cataracts and presbycusis. Hair-root examination of the bald patch revealed the absence of telogen hairs. A provisional diagnosis of Trichotillomania was considered. Because, she was not amenable for therapy, a trial of Tab Escitalopram 10mg/day was started, with reduction in the scores on Psychiatric Institute Trichotillomania Scale (PITS) from 36 to 20 in 4 weeks. CONCLUSION-: This is the first report on isolated hair-pulling behavior in the geriatric population. The age-associated sensory impairments pose a significant challenge in dissecting the phenomenology of hair-pulling behavior. However, effective use of behavioral observation with the help of a caregiver and proper use of pharmacotherapy can be helpful in the management of the condition.