Trichotillomania with trichotillophagia, Progressive Psychosis-Like Symptoms and Disinhibition, Following Suspected Frontal Traumatic Brain Injury: A Case Report

Trichotillomania (TTM), or hair-pulling disorder, is an obsessive–compulsive and related disorder characterized by recurrent hair-pulling resulting in hair loss, distress, and functional impairment. Although most cases emerge in adolescence, secondary forms can develop in the context of neurological illness or trauma. Traumatic brain injury (TBI) is widely recognized as a risk factor for psychiatric outcomes, including depression, psychosis, and obsessive–compulsive spectrum symptoms, particularly when frontal systems are involved. We describe the case of a 28-year-old male who presented to our emergency department with severe behavioral disturbances, including aggression, irritability, psychotic-like experiences, and compulsive hair-pulling with trichophagia. His family reported a motor vehicle accident with suspected frontal lobe injury five years earlier. During admission, he displayed distractibility, hallucinatory behavior, poor hygiene, and localized alopecia due to beard-hair pulling. Investigations revealed unremarkable CT brain findings, subclinical hypothyroidism, and fatty liver. He was started on risperidone 2 mg, quetiapine 100 mg, fluvoxamine 50 mg, and promethazine 50 mg at night, with partial symptomatic improvement. However, despite psychoeducation, the family insisted on discharge against medical advice after only eight days, before recommended MRI and EEG could be completed. This case illustrates the rare emergence of TTM following TBI and highlights the diagnostic challenges posed by overlapping features of psychosis, personality change, and compulsive behavior. It emphasizes the importance of considering TTM as a potential post-traumatic syndrome and the need for a comprehensive bio–psycho–social, multidisciplinary approach that integrates psychiatric, neurological, and rehabilitative care to optimize outcomes.