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

Trichotillomania with trichotillophagia, Progressive Psychosis-Like Symptoms and Disinhibition, Following Suspected Frontal Traumatic Brain Injury: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Trichotillomania with trichotillophagia, Progressive Psychosis-Like Symptoms and Disinhibition, Following Suspected Frontal Traumatic Brain Injury: A Case Report Ammu Thulaseedharan, Mostafa Abulmagd, Noura Alabrach This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8833582/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract 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. Trichotillomania Trichophagia Traumatic brain injury TBI Frontal lobe injury Obsessive–compulsive and related disorders OCRD Personality change Pyschosis Introduction Trichotillomania (TTM), also known as hair-pulling disorder, is classified in the DSM-5 within the group of obsessive–compulsive and related disorders (OCRDs). It is characterized by recurrent urges to pull out one’s hair, resulting in noticeable hair loss and often significant distress or functional impairment. Epidemiological studies estimate a lifetime prevalence between 1–2%, and comorbid psychiatric conditions such as anxiety and depression are frequently reported. ( 1 ) The neurobiological basis of TTM is increasingly understood as involving dysfunction in cortico–striato–thalamo–cortical (CSTC) circuits. Neuroimaging and network studies highlight abnormal connectivity in frontal and striatal regions, implicating disrupted inhibitory control and habit regulation in the pathophysiology of hair-pulling behavior ( 2 ). This aligns with broader OCRD frameworks, where compulsive behaviors are maintained by maladaptive reinforcement loops.( 1 ) Traumatic brain injury (TBI) is widely recognized as a risk factor for diverse psychiatric outcomes, including depression, psychosis, and obsessive–compulsive spectrum symptoms. Post-TBI sequelae often reflect the site of injury, with frontal lobe involvement particularly associated with disinhibition, impulsivity, and compulsive behaviors ( 3 , 4 ). Notably, the regions most frequently implicated in TBI are the frontotemporal paralimbic areas and associated neocortical sites ( 5 ). Beyond mood and psychotic syndromes, personality changes after acquired brain injury may further complicate recovery and contribute to the emergence of novel psychiatric syndromes.( 2 ) This report presents the case of a young male who developed trichotillomania and progressive behavioral changes after a motor vehicle accident with suspected frontal lobe trauma. His presentation illustrates the complex interplay between TBI, personality change, and obsessive–compulsive spectrum pathology, underscoring the need for multidisciplinary psychiatric evaluation and the importance of a Bio-Psycho-Social approach of management. Case Presentation A 28-year-old single Pakistani male, multilingual (Arabic, Persian, Belushi, Urdu), unemployed, and living with his family, was brought to the emergency department by his sister and brother-in-law due to progressive behavioral abnormalities. Collateral history revealed a motor vehicle accident approximately five years earlier, with reported frontal lobe injury, although no medical records were available. Following the accident, the patient developed irritability and aggression towards family members, episodes of property damage, and marked disinhibition. He exhibited poor personal hygiene, occasional fecal smearing, and sleep disturbance. He reported perceptual abnormalities, including talking to unseen others, visual images, and suspiciousness of being followed or harmed. Grandiose religious delusions were described, including claims of being God and demands that family members pray to him. Self-harm behavior occurred in the context of delusional beliefs, including breaking a glass window and injuring his hand. A distinctive feature was the emergence of trichotillomania with trichophagia. The patient was repeatedly observed pulling beard hair, chewing and partially swallowing it, resulting in a localized patch of alopecia. On admission, he was distractible, irritable, and engaged in hallucinatory behavior, limiting cooperation. Urine toxicology was negative for all substances. Laboratory testing showed mildly elevated TSH (5.8 mIU/L), borderline low vitamin B12, lymphocytosis, and dyslipidemia. CT brain revealed no acute pathology. Abdominal ultrasound demonstrated hepatomegaly with fatty liver and a 4 mm gallbladder polyp. He was started on psychotropic medication aimed at controlling aggression, stabilizing mood, and improving sleep. His regimen included risperidone 2 mg at night, quetiapine 100 mg at night, fluvoxamine 50 mg at night, and promethazine 50 mg at night. These medications were selected for their combined sedative and antipsychotic effects, with fluvoxamine intended to target obsessive–compulsive features. Despite initial partial improvement and repeated psychoeducation sessions with the family, they insisted on discharging him prematurely. He left against medical advice (LAMA) after only eight days of admission, even before the recommended diagnostic work-up with planned MRI brain and EEG could be completed. Discussion This case highlights the uncommon presentation of trichotillomania (TTM) following traumatic brain injury (TBI). While post-TBI psychiatric sequelae often include depression, irritability, and psychosis-like symptoms ( 1 , 4 ), compulsive hair-pulling with trichophagia is rarely documented. The uniqueness of this case lies in the convergence of aggression, personality change, psychotic features, and TTM, suggesting that disruption of frontal–striatal systems may have facilitated both disinhibition and compulsive behaviors. Epidemiological studies in US estimate that TTM has a lifetime prevelence estimate of 2.5%, with frequent comorbidities such as anxiety and depression ( 6 , 7 ). Neurobiological models point to cortico–striato–thalamo–cortical (CSTC) dysfunction, and frontal and striatal regions, which has been supported by structural connectivity studies showing abnormal network integration in TTM patients ( 7 , 8 ). These findings parallel broader OCRD research, where maladaptive reinforcement loops maintain compulsive behaviors ( 9 ). Importantly, personality changes are also common after acquired brain injury, with increases in neuroticism and decreases in extraversion linked to poorer emotional outcomes, which also relates to poorer response to rehabilitation ( 2 ) highlighting how TBI-related personality changes may interact with vulnerability to compulsive syndromes. Case-based evidence reinforces this link. A Turkish case described a young woman who developed TTM localized to the site of frontal gliosis after trauma, underscoring a direct neuroanatomical contribution to compulsive pulling ( 10 ). Similarly, an earlier case report documented trichotillomania arising after trauma, again localized to the affected region. ( 9 ) These accounts, together with our patient, suggest that neurological insult may act as both a biological trigger and a contextual stressor for the onset of hair-pulling behaviors The clinical course of our patient was complicated by a short inpatient stay of only eight days, during which he was discharged against medical advice despite partial improvement. This limited the opportunity to complete recommended investigations such as MRI and EEG, which are crucial for assessing existence of traumatic brain injury, or epileptiform activity and link it to behavioral disturbances. His complex presentation illustrates the overlapping features of post-traumatic psychiatric syndromes, which often mimic primary psychotic or obsessive–compulsive disorders. ( 2 , 4 ) Management of TTM in the context of TBI requires caution and integration. SSRIs remain the most widely studied pharmacological treatment, with fluvoxamine frequently trialed for obsessive–compulsive symptoms ( 9 ). Atypical antipsychotics, such as risperidone and quetiapine, may be useful for agitation and psychosis but must be used judiciously in TBI due to cognitive and motor side effects ( 4 ). Our patient received low-dose risperidone, quetiapine -with a future plan to keep one antipsychotic coverage-, and fluvoxamine, that showed early partial benefit. Beyond medication, behavioral approaches such as habit reversal training (HRT) and cognitive–behavioral therapy (CBT) have demonstrated efficacy for TTM. However, these require sustained engagement, which was limited in this case by early discharge. Taken together, this case underscores the need for a bio-psycho-social, multidisciplinary approach. Integration of psychiatry, neurology, neuropsychology, and rehabilitation is essential for accurate diagnosis and comprehensive treatment planning. Family psychoeducation plays a central role, as premature discharge can compromise both diagnostic clarity and therapeutic benefit. Recognizing TTM as a potential, though rare, sequela of TBI expands awareness of post-traumatic psychiatric syndromes and emphasizes the importance of holistic management strategies that address biological vulnerability, psychological stressors, and social context simultaneously. Conclusion This case underscores the complex challenges of diagnosing and managing trichotillomania (TTM) in the aftermath of traumatic brain injury (TBI). The coexistence of compulsive hair-pulling with trichophagia, psychosis-like symptoms, and personality change illustrates how TBI can blur the boundaries between primary psychiatric disorders and neurobehavioral sequelae of brain injury. Effective management required cautious pharmacological intervention, combined with psychoeducation and planned behavioral therapies, though early discharge limited their implementation. This report highlights the need for clinicians to maintain awareness of TTM as a potential, though rare, post-TBI manifestation and emphasizes the importance of a comprehensive bio–psycho–social approach that integrates psychiatric, neurological, and rehabilitative perspectives to ensure accurate diagnosis and optimal outcomes. Declarations Ethics approval and consent to participate The report has been exempted from ethical approval by the Research Ethics Committee, Ministry of Health and Prevention, UAE Consent for publication Obtained by means of an informed consent form signed by legal guardians of the individual. Competing interests The authors declare no competing interests. Funding None Acknowledgements None Corresponding author Correspondence to Noura Alabrach, ( [email protected] ) Conflict of Interests: ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: References Howlett JR, Nelson LD, Stein MB. Mental Health Consequences of Traumatic Brain Injury. Biol Psychiatry. 2022 Mar;91(5):413–20. Svensson F, Much A, Exner C. Personality changes after acquired brain injury and their effects on rehabilitation outcomes. Neuropsychol Rehabil. 2023 Feb 7;33(2):305–24. Anghinah R, Freire FR, Coelho F, Lacerda JR, Schmidt MT, Calado VTG, et al. BPSD following traumatic brain injury. Dement Neuropsychol. 2013 Sep;7(3):269–77. Arciniegas DB, Harris SN, Brousseau KM. Psychosis following traumatic brain injury. Int Rev Psychiatry. 2003 Nov;15(4):328–40. Koliatsos VE, Rao V. The Behavioral Neuroscience of Traumatic Brain Injury. Psychiatr Clin North Am. 2020 Jun;43(2):305–30. Özten E, Hızlı Sayar G, Kağan G, Işık S, Karamustafalıoğlu O, Eryilmaz G. The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatr Dis Treat. 2015 May;1203. Roos A, Fouche JP, Stein DJ, Lochner C. Structural brain network connectivity in trichotillomania (hair-pulling disorder). Brain Imaging Behav. 2023 Aug;17(4):395–402. Grados MA. Obsessive-compulsive disorder after traumatic brain injury. Int Rev Psychiatry. 2003 Nov;15(4):350–8. Nuss MA, Carlisle D, Hall M, Yerneni SC, Kovach R. Trichotillomania: a review and case report. Cutis. 2003 Sep;72(3):191–6. Health Science University, Adana City Research and Training Hospital, Department of Psychiatry, Adana, Turkey, Kocamer Şahin Ş, Gönültaş U, Gaziantep University, Faculty of Medicine, Department of Psychiatry, Turkey, Demir B, Gaziantep University, Faculty of Medicine, Department of Psychiatry, Turkey. TRICOTILLLOMANIA SECONDARY TO TRAUMATIC BRAIN INJURY. Psychiatr Danub. 2023 Oct 23;35(3):430–2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 27 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers invited by journal 19 Feb, 2026 Editor assigned by journal 12 Feb, 2026 Submission checks completed at journal 12 Feb, 2026 First submitted to journal 09 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8833582","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":594649732,"identity":"1fb67ce7-c1ca-4edd-84d5-a8cf56c980bf","order_by":0,"name":"Ammu Thulaseedharan","email":"","orcid":"","institution":"Al Amal Psychiatric Hospital, Emirates Health Services","correspondingAuthor":false,"prefix":"","firstName":"Ammu","middleName":"","lastName":"Thulaseedharan","suffix":""},{"id":594649738,"identity":"b29d432b-b065-45f1-8572-4a5432fc8608","order_by":1,"name":"Mostafa Abulmagd","email":"","orcid":"","institution":"Al Amal Psychiatric Hospital, Emirates Health Services","correspondingAuthor":false,"prefix":"","firstName":"Mostafa","middleName":"","lastName":"Abulmagd","suffix":""},{"id":594649746,"identity":"f954dabc-6517-4316-8d74-9b2b382bac4c","order_by":2,"name":"Noura Alabrach","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBADGQYJIMnYYAMkmRsYGA4Q1sID1ZLGwMDGSJqWw4S1mLP3mH34wWDHwz+79+GHnzvOyxncb2x88OEMgzy/GHZ9lj1njGf2MCTzSNw5bizZe+a2scExxmbDGTcYDGfOTsCqxeBGjjHQVcw8DDfSGKQZ224nbjjG2CbN84EhweA2bi2MfxjqeeRvpDH/Zmw7R5wWoBWHeQxupLEBbTkA1XIDj5Yzx4qZZQyO8xjeOcZm2duWbCx5LBHolzMSuP1yvHkz45uKajm5223MN3622cnxHT588MGHYzby/NLYtUA1YgpJ4FE+CkbBKBgFo4AQAABtpl2DuGDhbAAAAABJRU5ErkJggg==","orcid":"","institution":"Al Amal Psychiatric Hospital, Emirates Health Services","correspondingAuthor":true,"prefix":"","firstName":"Noura","middleName":"","lastName":"Alabrach","suffix":""}],"badges":[],"createdAt":"2026-02-09 18:38:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8833582/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8833582/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103325130,"identity":"69495241-7b42-4f67-9dd7-9b89a126f190","added_by":"auto","created_at":"2026-02-24 12:42:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":332919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8833582/v1/9fea9a42-c3da-454e-a98f-944a683fcd67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trichotillomania with trichotillophagia, Progressive Psychosis-Like Symptoms and Disinhibition, Following Suspected Frontal Traumatic Brain Injury: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTrichotillomania (TTM), also known as hair-pulling disorder, is classified in the DSM-5 within the group of obsessive\u0026ndash;compulsive and related disorders (OCRDs). It is characterized by recurrent urges to pull out one\u0026rsquo;s hair, resulting in noticeable hair loss and often significant distress or functional impairment. Epidemiological studies estimate a lifetime prevalence between 1\u0026ndash;2%, and comorbid psychiatric conditions such as anxiety and depression are frequently reported. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe neurobiological basis of TTM is increasingly understood as involving dysfunction in cortico\u0026ndash;striato\u0026ndash;thalamo\u0026ndash;cortical (CSTC) circuits. Neuroimaging and network studies highlight abnormal connectivity in frontal and striatal regions, implicating disrupted inhibitory control and habit regulation in the pathophysiology of hair-pulling behavior (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This aligns with broader OCRD frameworks, where compulsive behaviors are maintained by maladaptive reinforcement loops.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTraumatic brain injury (TBI) is widely recognized as a risk factor for diverse psychiatric outcomes, including depression, psychosis, and obsessive\u0026ndash;compulsive spectrum symptoms. Post-TBI sequelae often reflect the site of injury, with frontal lobe involvement particularly associated with disinhibition, impulsivity, and compulsive behaviors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Notably, the regions most frequently implicated in TBI are the frontotemporal paralimbic areas and associated neocortical sites (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Beyond mood and psychotic syndromes, personality changes after acquired brain injury may further complicate recovery and contribute to the emergence of novel psychiatric syndromes.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis report presents the case of a young male who developed trichotillomania and progressive behavioral changes after a motor vehicle accident with suspected frontal lobe trauma. His presentation illustrates the complex interplay between TBI, personality change, and obsessive\u0026ndash;compulsive spectrum pathology, underscoring the need for multidisciplinary psychiatric evaluation and the importance of a Bio-Psycho-Social approach of management.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 28-year-old single Pakistani male, multilingual (Arabic, Persian, Belushi, Urdu), unemployed, and living with his family, was brought to the emergency department by his sister and brother-in-law due to progressive behavioral abnormalities. Collateral history revealed a motor vehicle accident approximately five years earlier, with reported frontal lobe injury, although no medical records were available.\u003c/p\u003e \u003cp\u003eFollowing the accident, the patient developed irritability and aggression towards family members, episodes of property damage, and marked disinhibition. He exhibited poor personal hygiene, occasional fecal smearing, and sleep disturbance. He reported perceptual abnormalities, including talking to unseen others, visual images, and suspiciousness of being followed or harmed. Grandiose religious delusions were described, including claims of being God and demands that family members pray to him. Self-harm behavior occurred in the context of delusional beliefs, including breaking a glass window and injuring his hand.\u003c/p\u003e \u003cp\u003eA distinctive feature was the emergence of trichotillomania with trichophagia. The patient was repeatedly observed pulling beard hair, chewing and partially swallowing it, resulting in a localized patch of alopecia.\u003c/p\u003e \u003cp\u003eOn admission, he was distractible, irritable, and engaged in hallucinatory behavior, limiting cooperation. Urine toxicology was negative for all substances. Laboratory testing showed mildly elevated TSH (5.8 mIU/L), borderline low vitamin B12, lymphocytosis, and dyslipidemia. CT brain revealed no acute pathology. Abdominal ultrasound demonstrated hepatomegaly with fatty liver and a 4 mm gallbladder polyp.\u003c/p\u003e \u003cp\u003eHe was started on psychotropic medication aimed at controlling aggression, stabilizing mood, and improving sleep. His regimen included risperidone 2 mg at night, quetiapine 100 mg at night, fluvoxamine 50 mg at night, and promethazine 50 mg at night. These medications were selected for their combined sedative and antipsychotic effects, with fluvoxamine intended to target obsessive\u0026ndash;compulsive features. Despite initial partial improvement and repeated psychoeducation sessions with the family, they insisted on discharging him prematurely. He left against medical advice (LAMA) after only eight days of admission, even before the recommended diagnostic work-up with planned MRI brain and EEG could be completed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case highlights the uncommon presentation of trichotillomania (TTM) following traumatic brain injury (TBI). While post-TBI psychiatric sequelae often include depression, irritability, and psychosis-like symptoms (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), compulsive hair-pulling with trichophagia is rarely documented. The uniqueness of this case lies in the convergence of aggression, personality change, psychotic features, and TTM, suggesting that disruption of frontal\u0026ndash;striatal systems may have facilitated both disinhibition and compulsive behaviors.\u003c/p\u003e \u003cp\u003eEpidemiological studies in US estimate that TTM has a lifetime prevelence estimate of 2.5%, with frequent comorbidities such as anxiety and depression (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Neurobiological models point to cortico\u0026ndash;striato\u0026ndash;thalamo\u0026ndash;cortical (CSTC) dysfunction, and frontal and striatal regions, which has been supported by structural connectivity studies showing abnormal network integration in TTM patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These findings parallel broader OCRD research, where maladaptive reinforcement loops maintain compulsive behaviors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Importantly, personality changes are also common after acquired brain injury, with increases in neuroticism and decreases in extraversion linked to poorer emotional outcomes, which also relates to poorer response to rehabilitation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) highlighting how TBI-related personality changes may interact with vulnerability to compulsive syndromes.\u003c/p\u003e \u003cp\u003eCase-based evidence reinforces this link. A Turkish case described a young woman who developed TTM localized to the site of frontal gliosis after trauma, underscoring a direct neuroanatomical contribution to compulsive pulling (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, an earlier case report documented trichotillomania arising after trauma, again localized to the affected region. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) These accounts, together with our patient, suggest that neurological insult may act as both a biological trigger and a contextual stressor for the onset of hair-pulling behaviors\u003c/p\u003e \u003cp\u003eThe clinical course of our patient was complicated by a short inpatient stay of only eight days, during which he was discharged against medical advice despite partial improvement. This limited the opportunity to complete recommended investigations such as MRI and EEG, which are crucial for assessing existence of traumatic brain injury, or epileptiform activity and link it to behavioral disturbances. His complex presentation illustrates the overlapping features of post-traumatic psychiatric syndromes, which often mimic primary psychotic or obsessive\u0026ndash;compulsive disorders. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eManagement of TTM in the context of TBI requires caution and integration. SSRIs remain the most widely studied pharmacological treatment, with fluvoxamine frequently trialed for obsessive\u0026ndash;compulsive symptoms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Atypical antipsychotics, such as risperidone and quetiapine, may be useful for agitation and psychosis but must be used judiciously in TBI due to cognitive and motor side effects (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Our patient received low-dose risperidone, quetiapine -with a future plan to keep one antipsychotic coverage-, and fluvoxamine, that showed early partial benefit. Beyond medication, behavioral approaches such as habit reversal training (HRT) and cognitive\u0026ndash;behavioral therapy (CBT) have demonstrated efficacy for TTM. However, these require sustained engagement, which was limited in this case by early discharge.\u003c/p\u003e \u003cp\u003eTaken together, this case underscores the need for a bio-psycho-social, multidisciplinary approach. Integration of psychiatry, neurology, neuropsychology, and rehabilitation is essential for accurate diagnosis and comprehensive treatment planning. Family psychoeducation plays a central role, as premature discharge can compromise both diagnostic clarity and therapeutic benefit. Recognizing TTM as a potential, though rare, sequela of TBI expands awareness of post-traumatic psychiatric syndromes and emphasizes the importance of holistic management strategies that address biological vulnerability, psychological stressors, and social context simultaneously.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the complex challenges of diagnosing and managing trichotillomania (TTM) in the aftermath of traumatic brain injury (TBI). The coexistence of compulsive hair-pulling with trichophagia, psychosis-like symptoms, and personality change illustrates how TBI can blur the boundaries between primary psychiatric disorders and neurobehavioral sequelae of brain injury. Effective management required cautious pharmacological intervention, combined with psychoeducation and planned behavioral therapies, though early discharge limited their implementation. This report highlights the need for clinicians to maintain awareness of TTM as a potential, though rare, post-TBI manifestation and emphasizes the importance of a comprehensive bio\u0026ndash;psycho\u0026ndash;social approach that integrates psychiatric, neurological, and rehabilitative perspectives to ensure accurate diagnosis and optimal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe report has been exempted from ethical approval by the Research Ethics Committee, Ministry of Health and Prevention, UAE\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eObtained by means of an informed consent form signed by legal guardians of the individual.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Noura Alabrach, ([email protected])\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflict of Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e☐ \u0026nbsp;The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHowlett JR, Nelson LD, Stein MB. Mental Health Consequences of Traumatic Brain Injury. Biol Psychiatry. 2022 Mar;91(5):413\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eSvensson F, Much A, Exner C. Personality changes after acquired brain injury and their effects on rehabilitation outcomes. Neuropsychol Rehabil. 2023 Feb 7;33(2):305\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eAnghinah R, Freire FR, Coelho F, Lacerda JR, Schmidt MT, Calado VTG, et al. BPSD following traumatic brain injury. Dement Neuropsychol. 2013 Sep;7(3):269\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eArciniegas DB, Harris SN, Brousseau KM. Psychosis following traumatic brain injury. Int Rev Psychiatry. 2003 Nov;15(4):328\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eKoliatsos VE, Rao V. The Behavioral Neuroscience of Traumatic Brain Injury. Psychiatr Clin North Am. 2020 Jun;43(2):305\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zten E, Hızlı Sayar G, Kağan G, Işık S, Karamustafalıoğlu O, Eryilmaz G. The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatr Dis Treat. 2015 May;1203. \u003c/li\u003e\n\u003cli\u003eRoos A, Fouche JP, Stein DJ, Lochner C. Structural brain network connectivity in trichotillomania (hair-pulling disorder). Brain Imaging Behav. 2023 Aug;17(4):395\u0026ndash;402. \u003c/li\u003e\n\u003cli\u003eGrados MA. Obsessive-compulsive disorder after traumatic brain injury. Int Rev Psychiatry. 2003 Nov;15(4):350\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eNuss MA, Carlisle D, Hall M, Yerneni SC, Kovach R. Trichotillomania: a review and case report. Cutis. 2003 Sep;72(3):191\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eHealth Science University, Adana City Research and Training Hospital, Department of Psychiatry, Adana, Turkey, Kocamer Şahin Ş, G\u0026ouml;n\u0026uuml;ltaş U, Gaziantep University, Faculty of Medicine, Department of Psychiatry, Turkey, Demir B, Gaziantep University, Faculty of Medicine, Department of Psychiatry, Turkey. TRICOTILLLOMANIA SECONDARY TO TRAUMATIC BRAIN INJURY. Psychiatr Danub. 2023 Oct 23;35(3):430\u0026ndash;2. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Trichotillomania, Trichophagia, Traumatic brain injury, TBI, Frontal lobe injury, Obsessive–compulsive and related disorders, OCRD, Personality change, Pyschosis","lastPublishedDoi":"10.21203/rs.3.rs-8833582/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8833582/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTrichotillomania (TTM), or hair-pulling disorder, is an obsessive\u0026ndash;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\u0026ndash;compulsive spectrum symptoms, particularly when frontal systems are involved.\u003c/p\u003e \u003cp\u003eWe 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.\u003c/p\u003e \u003cp\u003eThis 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\u0026ndash;psycho\u0026ndash;social, multidisciplinary approach that integrates psychiatric, neurological, and rehabilitative care to optimize outcomes.\u003c/p\u003e","manuscriptTitle":"Trichotillomania with trichotillophagia, Progressive Psychosis-Like Symptoms and Disinhibition, Following Suspected Frontal Traumatic Brain Injury: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 12:40:19","doi":"10.21203/rs.3.rs-8833582/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-27T23:20:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324119226776215116966350526342182407605","date":"2026-02-20T20:39:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T11:08:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-12T12:46:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-12T12:43:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Current Psychiatry","date":"2026-02-09T18:20:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"950ca06f-2e08-44f8-afa0-d8496fde228f","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T12:40:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 12:40:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8833582","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8833582","identity":"rs-8833582","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}