What are the guidelines for managing agitation and trichotillomania?

Management of Agitation and Trichotillomania

Agitation Management

Address reversible causes first through non-pharmacological interventions, then use benzodiazepines or antipsychotics for acute agitation, while trichotillomania requires habit reversal training as first-line therapy with N-acetylcysteine as the primary pharmacological option.

Initial Assessment and Non-Pharmacological Approach

Always begin by identifying and treating reversible causes before considering medications. 1, 2

• Explore patient concerns and anxieties, ensure effective communication and orientation (explaining where the person is, who they are, and your role) 1
• Treat specific medical conditions: hypoxia, urinary retention, constipation, pain, infections, dehydration, and electrolyte disturbances 2
• Provide adequate lighting and explain to caregivers how they can help 1, 2
• Implement verbal de-escalation: respect personal space, use calm demeanor, designate one staff member to interact, use simple language, and set clear limits 2, 3

Pharmacological Management for Acute Agitation

For patients able to swallow:

• Lorazepam 0.5-1 mg orally four times daily as needed (maximum 4 mg/24 hours) is the benzodiazepine of choice 1
• Reduce to 0.25-0.5 mg in elderly or debilitated patients (maximum 2 mg/24 hours) 1, 2
• Oral tablets can be used sublingually 1

For delirium with agitation (able to swallow):

• Haloperidol 0.5-1 mg orally at night and every 2 hours when required 1, 2, 4
• Increase in 0.5-1 mg increments as needed (maximum 10 mg daily, or 5 mg daily in elderly) 1
• Consider higher starting dose (1.5-3 mg) if severely distressed or causing immediate danger 1
• Add benzodiazepine if agitation persists despite adequate haloperidol 1, 4

For patients unable to swallow:

• Midazolam 2.5-5 mg subcutaneously every 2-4 hours as needed 1
• If needed frequently (>twice daily), consider subcutaneous infusion starting with midazolam 10 mg over 24 hours 1
• Reduce to 5 mg over 24 hours if eGFR <30 mL/min 1

Special Populations

Elderly patients on comfort measures:

• Haloperidol remains first-line at 0.5-1 mg orally, maximum 5 mg daily 4
• Alternative antipsychotics: risperidone 0.5-1 mg twice daily, olanzapine 2.5-15 mg daily, or quetiapine 50-100 mg twice daily 4
• Lorazepam 0.25-0.5 mg in elderly (maximum 2 mg/24 hours) 4

Hospitalized older adults:

• Multicomponent nonpharmacologic interventions are first-line; reserve antipsychotics ONLY for severe distress with hallucinations/delusions or imminent harm 2
• The ABCDEF bundle (Assessment of pain, Both spontaneous awakening/breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement) reduces mortality 2
• Discontinue antipsychotics immediately once agitation resolves 2

Critical Care Setting

• IV opioids are first-line for non-neuropathic pain in critically ill patients 1
• Pain should be routinely monitored using Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) 1
• Preemptive analgesia and/or nonpharmacologic interventions before painful procedures 1

Emergency Department Management

For undifferentiated acute agitation:

• Use benzodiazepine (lorazepam or midazolam) OR conventional antipsychotic (droperidol or haloperidol) as monotherapy 1
• If rapid sedation required, consider droperidol instead of haloperidol 1
• Combination of parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy 1

For cooperative agitated patients:

• Combination of oral lorazepam and oral risperidone is effective 1

Common Pitfalls to Avoid

• Never fail to identify and treat underlying medical causes before medicating 2
• Avoid high doses in elderly without appropriate dose adjustments 2
• Do not neglect non-pharmacological approaches before initiating medications 2
• Avoid physical restraints, which worsen delirium and outcomes 2
• Do not continue antipsychotics after agitation resolves 2

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Trichotillomania Management

First-Line Behavioral Treatment

Habit reversal training (HRT) and stimulus control are first-line treatments for all severity levels, particularly when pulling is performed with lowered awareness. 5

• HRT is most effective when pulling occurs with lowered awareness/intention 5
• Stimulus control techniques should be implemented alongside HRT 5

Augmentation Strategies for Emotional Triggers

When negative emotions trigger pulling:

• Acceptance and commitment therapy (ACT) can augment HRT/stimulus control 5
• Dialectical behavior therapy (DBT) is effective for emotion-driven pulling 5

Pharmacological Management

N-acetylcysteine (NAC) should be considered for all severity levels given its moderate efficacy and low side effect profile. 5

For treatment-resistant cases or significant comorbidities:

• Selective serotonin reuptake inhibitors (SSRIs) should be considered after behavioral/NAC treatment failure 5
• No FDA-approved pharmacologic treatments currently exist for trichotillomania 5

Pediatric Considerations

• Mean age of onset is 11.3 years (range 8-13 years) 6
• Triggers include psychosocial stressors: separation from attachment figures, hospitalization, birth of sibling, sibling rivalry, moving, or school performance problems 6
• Cognitive behavioral therapy is first-line in children 6
• Mild topical steroids (hydrocortisone butyrate 0.1% solution) and methionine capsules may be used adjunctively 6
• Psychopharmacologic therapy should be reserved for cases not responding to behavioral interventions 6

Diagnostic Confirmation

• Trichoscopy and skin biopsy confirm diagnosis 6
• Histology shows increased catagen/telogen hairs, pigment casts, empty anagen follicles, and perifollicular hemorrhage 6
• Screen for trichophagia (hair ingestion), present in 5-30% of adults but less common in children 6

Monitoring for Complications

• Watch for secondary bacterial infections with regional lymphadenopathy 6
• Screen for trichobezoar if trichophagia present: pallor, nausea, vomiting, anorexia, weight loss 6
• Consider radiologic examination and gastroscopy if trichobezoar suspected 6