LEITERS TO THE EDITOR
loss (American Psychiatric Association Press, 1987). It is accompanied by an increasing sense of tension immediately before pulling out the hair and of relief afterwards. Trichotillomania, a rare disorder seen most commonly in females, cuts across socioeconomic and cultural groups (Krishnan et al., 1985). It is often associated with anxiety, depression, and behavior disorders (Oguchi and Miura, 1977). Weller et al. (1989) recently reported the case of a 7-year-old girl with trichotillomania and depression who responded to imipramine pharmacotherapy. They postulated a relationship between depression and trichotillomania, though the nature of this relationship remains unclear. We present a case report of a 16-year-old girl with depression, behavior disorder, and trichotillomania that may shed additional light on the possible relationship between trichotillomania and depression. J. was a 16-year-old girl who functioned quite well academically and socially until 2 years before an inpatient psychiatric hospitalization for evaluation and treatment of a serious behavior disorder. J. relates the onset of her problems to her sister's divorce from a tyrannical man who reminded her of her father. During the divorce, J. began pulling out hair from the top of her head and eyebrows. Her grades dropped precipitously, and she developed behavioral problems at home and at school. She became depressed , and complained of anhedonia, decreased concentration, anxiety, guilty ruminations, and low self-esteem. She had intermittent suicidal ideation and attempted suicide by superficially cutting her wrist with a razor. 1. became irritable, and criminal charges were filed after she assaulted a friend. A court-ordered outpatient therapy was unsuccessful, and she was hospitalized. Her developmental history was normal except for a mild speech articulation problem. Her past medical history revealed a mild sensorineural hearing loss. Her family psychiatric history was remarkable for depression, alcoholism, and panic disorder in her mother. A mental status examination revealed a somewhat masculine appearing girl with intact cognitive functioning , except for mildly impaired attention. Her judgment and abstracting ability were normal. Her affect was depressed and anxious but reactive and appropriate. There was no psychosis or suicidal/homicidal ideation. A thorough medical evaluation was normal. Inpatient treatment was multidisciplinary. She was treated with individual , family, and group psychotherapy. Her mood brightened spontaneously, and her trichotillomania improved but did not stop. Upon her discharge, she was euthymic , and the bald spot on her head was smaller, though still present. J. did reasonably well after her discharge; however, 6 months after her discharge she became depressed again. Her Hamilton Rating Scale for Depression (HRSD) was 15. Her trichotillomania worsened despite continued individual and family psychotherapy. The hair pulling was preceded by a sense of increasing tension that was relieved after pulling her hair. The bald spot on her head had grown in size to 8 em in diameter. An outpatient, cognitive-behavioral therapy was prescribed, but she did not cooperate . She began receiving fluoxetine 20 mg/p.o.! qAM. Over the next 4 weeks, her mood and school performance improved dramatically . Her HRSD fell to 1. Her trichotillomania improved transiently; however, she relapsed fully within 6 weeks of starting medications. Disappointed with its lack of efficacy, J. discontinued the fluoxetine on her own. She began receiving chlomipramine 150 mg/p.o .!qHS. She remained euthymic (HRSD -I), and after 2 weeks on the chlomipramine noted that she no longer had the urge to pull her hair. Two months after the chlomipramine was begun, her bald spot completely disappeared . This case report suggests that although depression and trichotillomania may coexist, at least in some individuals, the two disorders are separate entities. If this were not the case, J.'s trichotillomania would have improved concurrently with the improvement in her mood. Although this did occur initially , her trichotillomania never fully responded and worsened to baseline levels after several weeks on fluoxetine. The criticism could be leveled that the dose of fluoxetine was inadequate to treat the trichotillomania. In the treatment of obsessive-
156
compulsive disorder (OCD), fluoxetine is often effective only at higher doses. Her trichotillomania may well have improved on an increased dose of the fluoxetine; however, this does not detract from the fact that she was completely euthymic and still had severe symptoms of trichotillomania . Her account of her symptoms and response to the chlomipramine is telling and suggests that, in some cases, trichotillomania may be related neuropharmacologically to OCD. Additional research is necessary to delineate the relationship between affective disorders, OCD, and trichotillomania . Michael W. Naylor, M.D. Meg Grossman, M.S .W. University of Michigan Ann Arbor, Michigan REFERENCES
American Psychiatric Association (1981), Diagnostic and Statistical Manual of Mental Disorders. Third Edition. Revised . Washington, D.C .: American Psychiatric Association. Krishnan, K., Davidson, J. R. T. & Guajardo, .C. (1985), Trichotillomania: a review. Compr. Psychiatry, 26:123-128. Oguchi, T. & Miura, S. (1977), Trichotillomania: its psychological aspect. Compr. Psychiatry, 18:177-182. Weller, E. B., Weller, R. A. & Carr , S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old . J. Am. Acad. Child Adolesc. Psychiatry. 28:952-953.
T3 Levels in Anorexia Nervosa To the Editor: Changes in body weight play an essential role in the management of anorexia nervosa, and many behavioral treatment programs are based on "rewards" for weight gain. However , many patients with anorexia are most reluctant to be weighed. Even if they do agree , there is no guarantee that the weight recorded is correct, since patients often dissemble by drinking large volumes of water or by concealing heavy items in their loose clothing before being weighed. We have noticed that levels of triiodothyronine (T,) can provide an alternative measurement by which to assess body weight changes and nutritional status. We report here data on four patients with anorexia nervosa. While the usual thyroid tests-thyroxine (T.), thyroid stimulating hormone (TSH), and free thyroxine index (FTI)-were within normal limits irrespective of body weight, T, levels were invariably decreased and responded significantly to a change in body weight over a range of 30 to 40 kg. The respective average weight and T, values of our patients were as follows (mean ± SD): initially 33.0 ± 3.5 kg, 66.5 ± 16.4 ng/dl., later on 37.5 ± 5.0 kg, 109.3 ± 44.3 ng/ dl., and finally 42.6 ± 3.0 kg, 152.3 ± 42.6 ng/dL. The slopes of the responses in levels of T, to weight gain in the individual subjects were very similar. The regression equation for the combined data points is y = 8.9 x - 227 (r = 0.999, p < 0.001). Thus, for every 1 kg increase in body weight, T, levels can be expected to increase by approximately 9 ng/dL. T) is produced by the deiodination of T. in the peripheral tissues and is the active thyroid hormone . The conversion of T4 to T, is dependent on caloric balance (Portnoy et al., 1974). During hypocaloric feeding and weight loss, T4 is converted to the metabolically inactive rT), thereby conserving energy expenditure (Vagenakis et al., 1977). Patients with anorexia are euthyroid by conventional tests, such as the free thyroxine index, yet have low T, levels, so-called "euthyroid sick" (Moshang et al., 1975; Herzog and Copeland, 1985). Recently a hypothalamic-pituitary-thyroidal dysfunction was demonstrated in anorexia nervosa patients with low T) in addition to the characteristic impaired peripheral conversion of T. to T) (Kikohara et al., 1989).
J.Am.Acad. Child Adolesc. Psychiatry, 30:1. January 1991
LEITERS TO THE EDITOR
In the clinical management of patients with anorexia nervosa , it is very important to be able to assess nutritional status at reduced body weight in an often uncooperative patient. Serial measurements of T) levels appear to be a simple objective test for this purpose . Elliott M. Berry , M.D ., F.R .C .P . Yoseph Caraco , M.D. Dina Roth, M.D . Hadassah Universit y Hospital , Jerusalem
REFERENCES
Herzog, D. B. , Copeland , P. M. (1985), Eating disorders . N . Engl. J. Med., 313:295-303. Kikohara , K., Tarnal, H ., Takaichi, Y., Nakagawa, T. & Kumagai, L. F . (1989), Decreased thyroidal triiodothyronine secretion in patients with anorexia nervosa : influence of weight recovery. Am . J . Clin. Nutr.• 50:767-772 . Moshang, T . , Parks, J. S., Baker , L. , Vaidya, V. , Utiger , R. , Bongiovanni , A. M . & Snyder, P. J. (1975) , Low serum tri-iodothyronin in patients with anorexia nervosa . J. Clin. Endocrinol., Metab . 40:470-473.
Portnoy , G. 1., O'Brian , J. T., Vagenakis , A . G . , Rudolph , M ., Arky , R. , Ingbar, S. M. & Braverman, L. E . (1974), Abnormalities in triiodothyronine metabolism induced by starvation in man . J. Clin. Invest. 53:191-194. Vagenakis , A. G., Portnoy , G. 1., O'Brian, 1. T. (1977), Effect of starvation on the production and metabolism of thyrozine and triiodothyronine in euthyro id obese patients . J . Clin. Endocrinol . Metab. , 45:1305-1309.
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 ; tables and figures will not be published . They must be submitted in duplicate and typed doublespaced. All letters are subject to editing and shortening; the contents are 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 Journal. Please direct your letters to John F. McDermott, Jr., M.D ., Editor, Journal 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.
Erratum In the article, " A Follow-up Study of the Influence of Early Malnutrition on Development: Behavior at Home and at School," by Janina R. Galler, M.D. , and Frank Ramsey, F.R.C.P. , published in the March 1989 issue of the Journal (Vol. 28:254-261), Dr. Galler wishes to correct the acknowledgment by adding, "The authors wish to thank Dr. Patricia Salt and Ms: Debra Morley for their assistance in the data analysis."
J.Am .Acad. Child Adolesc. Psychiatry, 30:1 . January 1991
157
loss (American Psychiatric Association Press, 1987). It is accompanied by an increasing sense of tension immediately before pulling out the hair and of relief afterwards. Trichotillomania, a rare disorder seen most commonly in females, cuts across socioeconomic and cultural groups (Krishnan et al., 1985). It is often associated with anxiety, depression, and behavior disorders (Oguchi and Miura, 1977). Weller et al. (1989) recently reported the case of a 7-year-old girl with trichotillomania and depression who responded to imipramine pharmacotherapy. They postulated a relationship between depression and trichotillomania, though the nature of this relationship remains unclear. We present a case report of a 16-year-old girl with depression, behavior disorder, and trichotillomania that may shed additional light on the possible relationship between trichotillomania and depression. J. was a 16-year-old girl who functioned quite well academically and socially until 2 years before an inpatient psychiatric hospitalization for evaluation and treatment of a serious behavior disorder. J. relates the onset of her problems to her sister's divorce from a tyrannical man who reminded her of her father. During the divorce, J. began pulling out hair from the top of her head and eyebrows. Her grades dropped precipitously, and she developed behavioral problems at home and at school. She became depressed , and complained of anhedonia, decreased concentration, anxiety, guilty ruminations, and low self-esteem. She had intermittent suicidal ideation and attempted suicide by superficially cutting her wrist with a razor. 1. became irritable, and criminal charges were filed after she assaulted a friend. A court-ordered outpatient therapy was unsuccessful, and she was hospitalized. Her developmental history was normal except for a mild speech articulation problem. Her past medical history revealed a mild sensorineural hearing loss. Her family psychiatric history was remarkable for depression, alcoholism, and panic disorder in her mother. A mental status examination revealed a somewhat masculine appearing girl with intact cognitive functioning , except for mildly impaired attention. Her judgment and abstracting ability were normal. Her affect was depressed and anxious but reactive and appropriate. There was no psychosis or suicidal/homicidal ideation. A thorough medical evaluation was normal. Inpatient treatment was multidisciplinary. She was treated with individual , family, and group psychotherapy. Her mood brightened spontaneously, and her trichotillomania improved but did not stop. Upon her discharge, she was euthymic , and the bald spot on her head was smaller, though still present. J. did reasonably well after her discharge; however, 6 months after her discharge she became depressed again. Her Hamilton Rating Scale for Depression (HRSD) was 15. Her trichotillomania worsened despite continued individual and family psychotherapy. The hair pulling was preceded by a sense of increasing tension that was relieved after pulling her hair. The bald spot on her head had grown in size to 8 em in diameter. An outpatient, cognitive-behavioral therapy was prescribed, but she did not cooperate . She began receiving fluoxetine 20 mg/p.o.! qAM. Over the next 4 weeks, her mood and school performance improved dramatically . Her HRSD fell to 1. Her trichotillomania improved transiently; however, she relapsed fully within 6 weeks of starting medications. Disappointed with its lack of efficacy, J. discontinued the fluoxetine on her own. She began receiving chlomipramine 150 mg/p.o .!qHS. She remained euthymic (HRSD -I), and after 2 weeks on the chlomipramine noted that she no longer had the urge to pull her hair. Two months after the chlomipramine was begun, her bald spot completely disappeared . This case report suggests that although depression and trichotillomania may coexist, at least in some individuals, the two disorders are separate entities. If this were not the case, J.'s trichotillomania would have improved concurrently with the improvement in her mood. Although this did occur initially , her trichotillomania never fully responded and worsened to baseline levels after several weeks on fluoxetine. The criticism could be leveled that the dose of fluoxetine was inadequate to treat the trichotillomania. In the treatment of obsessive-
156
compulsive disorder (OCD), fluoxetine is often effective only at higher doses. Her trichotillomania may well have improved on an increased dose of the fluoxetine; however, this does not detract from the fact that she was completely euthymic and still had severe symptoms of trichotillomania . Her account of her symptoms and response to the chlomipramine is telling and suggests that, in some cases, trichotillomania may be related neuropharmacologically to OCD. Additional research is necessary to delineate the relationship between affective disorders, OCD, and trichotillomania . Michael W. Naylor, M.D. Meg Grossman, M.S .W. University of Michigan Ann Arbor, Michigan REFERENCES
American Psychiatric Association (1981), Diagnostic and Statistical Manual of Mental Disorders. Third Edition. Revised . Washington, D.C .: American Psychiatric Association. Krishnan, K., Davidson, J. R. T. & Guajardo, .C. (1985), Trichotillomania: a review. Compr. Psychiatry, 26:123-128. Oguchi, T. & Miura, S. (1977), Trichotillomania: its psychological aspect. Compr. Psychiatry, 18:177-182. Weller, E. B., Weller, R. A. & Carr , S. (1989), Imipramine treatment of trichotillomania and coexisting depression in a seven-year-old . J. Am. Acad. Child Adolesc. Psychiatry. 28:952-953.
T3 Levels in Anorexia Nervosa To the Editor: Changes in body weight play an essential role in the management of anorexia nervosa, and many behavioral treatment programs are based on "rewards" for weight gain. However , many patients with anorexia are most reluctant to be weighed. Even if they do agree , there is no guarantee that the weight recorded is correct, since patients often dissemble by drinking large volumes of water or by concealing heavy items in their loose clothing before being weighed. We have noticed that levels of triiodothyronine (T,) can provide an alternative measurement by which to assess body weight changes and nutritional status. We report here data on four patients with anorexia nervosa. While the usual thyroid tests-thyroxine (T.), thyroid stimulating hormone (TSH), and free thyroxine index (FTI)-were within normal limits irrespective of body weight, T, levels were invariably decreased and responded significantly to a change in body weight over a range of 30 to 40 kg. The respective average weight and T, values of our patients were as follows (mean ± SD): initially 33.0 ± 3.5 kg, 66.5 ± 16.4 ng/dl., later on 37.5 ± 5.0 kg, 109.3 ± 44.3 ng/ dl., and finally 42.6 ± 3.0 kg, 152.3 ± 42.6 ng/dL. The slopes of the responses in levels of T, to weight gain in the individual subjects were very similar. The regression equation for the combined data points is y = 8.9 x - 227 (r = 0.999, p < 0.001). Thus, for every 1 kg increase in body weight, T, levels can be expected to increase by approximately 9 ng/dL. T) is produced by the deiodination of T. in the peripheral tissues and is the active thyroid hormone . The conversion of T4 to T, is dependent on caloric balance (Portnoy et al., 1974). During hypocaloric feeding and weight loss, T4 is converted to the metabolically inactive rT), thereby conserving energy expenditure (Vagenakis et al., 1977). Patients with anorexia are euthyroid by conventional tests, such as the free thyroxine index, yet have low T, levels, so-called "euthyroid sick" (Moshang et al., 1975; Herzog and Copeland, 1985). Recently a hypothalamic-pituitary-thyroidal dysfunction was demonstrated in anorexia nervosa patients with low T) in addition to the characteristic impaired peripheral conversion of T. to T) (Kikohara et al., 1989).
J.Am.Acad. Child Adolesc. Psychiatry, 30:1. January 1991
LEITERS TO THE EDITOR
In the clinical management of patients with anorexia nervosa , it is very important to be able to assess nutritional status at reduced body weight in an often uncooperative patient. Serial measurements of T) levels appear to be a simple objective test for this purpose . Elliott M. Berry , M.D ., F.R .C .P . Yoseph Caraco , M.D. Dina Roth, M.D . Hadassah Universit y Hospital , Jerusalem
REFERENCES
Herzog, D. B. , Copeland , P. M. (1985), Eating disorders . N . Engl. J. Med., 313:295-303. Kikohara , K., Tarnal, H ., Takaichi, Y., Nakagawa, T. & Kumagai, L. F . (1989), Decreased thyroidal triiodothyronine secretion in patients with anorexia nervosa : influence of weight recovery. Am . J . Clin. Nutr.• 50:767-772 . Moshang, T . , Parks, J. S., Baker , L. , Vaidya, V. , Utiger , R. , Bongiovanni , A. M . & Snyder, P. J. (1975) , Low serum tri-iodothyronin in patients with anorexia nervosa . J. Clin. Endocrinol., Metab . 40:470-473.
Portnoy , G. 1., O'Brian , J. T., Vagenakis , A . G . , Rudolph , M ., Arky , R. , Ingbar, S. M. & Braverman, L. E . (1974), Abnormalities in triiodothyronine metabolism induced by starvation in man . J. Clin. Invest. 53:191-194. Vagenakis , A. G., Portnoy , G. 1., O'Brian, 1. T. (1977), Effect of starvation on the production and metabolism of thyrozine and triiodothyronine in euthyro id obese patients . J . Clin. Endocrinol . Metab. , 45:1305-1309.
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 ; tables and figures will not be published . They must be submitted in duplicate and typed doublespaced. All letters are subject to editing and shortening; the contents are 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 Journal. Please direct your letters to John F. McDermott, Jr., M.D ., Editor, Journal 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.
Erratum In the article, " A Follow-up Study of the Influence of Early Malnutrition on Development: Behavior at Home and at School," by Janina R. Galler, M.D. , and Frank Ramsey, F.R.C.P. , published in the March 1989 issue of the Journal (Vol. 28:254-261), Dr. Galler wishes to correct the acknowledgment by adding, "The authors wish to thank Dr. Patricia Salt and Ms: Debra Morley for their assistance in the data analysis."
J.Am .Acad. Child Adolesc. Psychiatry, 30:1 . January 1991
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