Successful management of trichotillomania in a patient with SSRI-induced hypersomnia: a case report

Trichotillomania is predominantly managed via serotonergic pharmacotherapy and behavioral interventions. However, options become scarce when patients exhibit extreme intolerance to first-line agents. Bupropion, a norepinephrine-dopamine reuptake inhibitor (NDRI), has been reported in a limited number of cases as a potential treatment option for hair-pulling disorders but remains infrequently used in clinical practice.

A 25-year-old female medical student with a 13-year history of severe, stress-triggered Trichotillomania developed debilitating hypersomnia (16-18 hours of sleep/day) during separate trials of fluoxetine and escitalopram. This adverse effect, also historically reported by her mother, forced abrupt drug cessation and caused severe academic decline during medical school. Following intolerance to two selective serotonin reuptake inhibitors (SSRIs), the patient was treated with a combination of bupropion and therapist-guided mindfulness-based behavioral therapy. Over the subsequent two months, she experienced marked improvement in hair-pulling behaviors without recurrence of hypersomnia. Clinical improvement was sustained throughout a 24-month follow-up period after discontinuation of bupropion while continuing intermittent self-directed mindfulness practice.

This case suggests that a combined treatment approach incorporating bupropion and mindfulness-based behavioral therapy may be associated with sustained improvement in trichotillomania when SSRIs are poorly tolerated. Although the individual contribution of each intervention cannot be determined from a single case, this report adds to the limited literature supporting further investigation of non-serotonergic pharmacological strategies in selected patients.