Trichotillomania is described as the recurrent pulling out of one’s own hair, leading to alone is and marked impairment. It is included under the OCD type disorders in the DSM-V. The other disorders now in that category include body dysmorphic disorder, hoarding disorder, excoriation disorder, and OCD. The lifetime prevalence is estimated at around .6% with a  F:M ratio of 4:1. The typical age of onset is between 10-13 years. The pulling can be automatic or focused. Over 20% of patients also experience trichophagia. Only 1/3 of patients with the disorder seek treatment. The disease is highly comorbidies with other psychiatric disorders, particularly those in the. OCD spectrum. Stimulants can make the pulling worse. It is also associated with rare variations in the SAPAP3 gene and does show a familial pattern. Treatments include psychotherapy, usually behavioral using habit reversal techniques (self monitoring, awareness training, competing response training, and stimulus control procedures) and pharmacotherapy (clomping mine, antipsychotic medications, and glutamate rigs agents). Among the glutamatergic agents, N-acetyl cysteine (NAC) has demonstrated benefit in a double blind PC trial…at a dosage of 200 mg. twice a day. Other agents worth noting include  olanzapine.  SSRIS have not yet shown to be that effective, adn fluvoxamine may be the drug of choice. 

Ketamine is a non competitive, N-methylfolate-D-aspartame glutamate receptor antagonist that is approved as an anesthetic agent. Recent studies have shown a rapid onset (2-24 hours post infusion) of antidepressant effect. This effect is short lived, with range of effect form 3-17 days. Studies have found twice weekly dosing to be sufficient over a 4-6  week period. The dose was .5mg/kg. Side effects included headache, dizziness, and nausea as well as acute transient psychotomimetic and dissociative symptoms which resolved within 2 hours. At this time, however studies over efficacy for longer time periods is needed. 

Now strategy for the treatment of treatment resistant depression has been the addition of anti-inflammatory agents, including COX-2 inhibitors, aspirin, and NSAIDS. Statins, used primarily for their lipid lowering properties also have direct anti-inflammatory effects. FIndings: concomitant use of an SSRi and a station was associated with a decreased risk for both psychiatric and general medical hospital contacts.  It was also NOT associated with increases in mortality. Over 870,000 patients were included in the study.