Treatment of Recurrent Rapunzel Syndrome and Trichotillomania: Case Report and Literature Review Guy C. Jones, M.D., Karl Coutinho, M.D. Devashish Anjaria, M.D., Najeeb Hussain, M.D. Rashesh Dholakia, M.D., M.P.H. Background: Trichotillomania (obsession with one’s hair) was first described in the literature over 100 years ago and was recognized by the American Psychiatric Association as a distinct disorder in 1987. Objective: The authors discuss a rare presentation of a case of recurrent Ra- punzel syndrome in a 37-year-old woman. Method: The authors present a biopsychosocial treat- ment plan for a therapeutic approach. Results: This patient was unique for her relatively ad- vanced age at onset, the recurrent nature, association with pancreatitis, and the consumption of artificial hair extensions, rather than her own hair. This patient presented with small-bowel ob- struction requiring laparotomy. After surgery, she was evaluated by the psychiatric service; after discharge, she removed her hair extensions, continued to take her prescribed medication, at- tended a psychiatric program, and was monitored by family and friends. Conclusion: There are no definitive guidelines for treating trichotillomania. In this case, quetiapine, hair-extension re- moval, family involvement, and regular follow-up helped with the initial cessation of her hair consumption. Antidepressant treatment helped control the obsession while behavioral therapy and family involvement provided the means for habit-reversal training. (Psychosomatics 2010; 51:443– 446) T richotillomania was first described in the literature over 100 years ago by the French dermatologist Hal- lopeau, 1 and it was recognized by the American Psychi- atric Association as a distinct disorder in 1987. 2 The dis- order is far more common in girls than boys, and its age at onset is bimodal, typically beginning in either early child- hood or adolescence. 3 Among those who suffer from tricho- tillomania, most patients are embarrassed and secretive about the condition, but may exhibit certain stereotypic move- ments, such as nail-biting, knuckle-cracking, touching or playing with pulled hair, and hair-eating (trichophagia). 4,5 Controlled studies have shown that serotonergic drugs such as fluoxetine, clomipramine, sertraline, and venlafax- ine have reduced hair-pulling behavior. 6–8 Other studies, however, have shown no significant improvement in symptoms between use of fluoxetine and placebo; 9,10 and habit-reversal therapy has also been shown to reduce tri- chotillomania symptoms, and a combination of pharmaco- logical and behavioral treatment has been shown to be superior to either modality alone. 11 About 30% of patients suffering from trichotillomania will engage in trichophagia, or eating their hair, and, of these, about 1% will go on to eat their hair to an extent where surgical removal is required. 12 Rapunzel syndrome, named for a fictional character from a folktale about a girl with long hair, 13 is characterized by the very rare case of Received August 31, 2009; revised October 23, 2009; accepted Novem- ber 2, 2009. From the Univ. of Medicine and Dentistry, New Jersey Medical School, Newark, NJ. Send correspondence and reprint requests to Guy C. Jones, M.D., 707 Martin Luther King Dr., 311E, Cincinnati OH 45220. e-mail: guycjones@gmail.com © 2010 The Academy of Psychosomatic Medicine 443 Psychosomatics 51:5, September-October 2010 http://psy.psychiatryonline.org