Trichotillomania Disorder Assessment, Treatment, and Complications

Trichotillomania Disorder Assessment, Treatment, and Complications
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Case Formulation
Patient Case Study/History
Carol is a 20-year-old engaged Caucasian female working part-time as a clerk for a local logistics company. Her father referred her to an outpatient psychological services center after her hair-pulling behavior worsened and there were visible patches on her scalp. At the initial intake, Carol was in her second year in college and lived in an apartment with her workmate, with whom she got along relatively well. At information, Carol explained that her symptoms of hair pulling started when she was ten years old but became more severe after being diagnosed with severe depression. However, it was not until very recently that her father noticed her symptoms and encouraged her to see a therapist, even going ahead to make an appointment for her. Even though Carol was hesitant about seeing a clinician, she was very forthcoming in her responses. She maintained good rapport, as shown by the candid and friendly manner she answered questions.
Allison reported that her hair-pulling behavior started as an experiment and was focused on upper eyelashes. She remembered seeing her classmates making wishes with their loose eyelashes and eyebrows. Carol would also begin to pulling out her eyelashes and eyebrows to make wishes. She would pull short and stubby hairs, especially when her eyelashes or eyebrows were clumped together or sticking out. This pulling of hairs that were “out of line” would become a habit and continue with lowered awareness when watching a movie or seated at her desk studying. Carol confessed to experiencing calmness, pleasure, and satisfaction in these hair-pulling episodes. However, the passing away of her mother in a car accident was very harrowing for her, and she was diagnosed with severe depression. Carol reported that her hair-pulling behavior became more frequent after the traumatic event, and she started pulling out hair from her scalp.
This habit was more pronounced when she was stressed by life events, especially social situations, and academics. Carol reported suffering anxiety directly related to her hair-pulling behavior, namely, worrying that her father would notice her lack of eyebrow/eyelash hair and the shrinking scalp. She not only feared her father's reprimand but the embarrassment of her peers seeing the lack of eyebrow/eyelash hair along with the shrinking scalp and asking questions. Consequently, Carol wore false eyelashes and applied heavy makeup to ensure that others, especially her father, did not notice. Besides, she always wore a baseball cap to hide the patches of missing hair on her scalp. She refrained from all activities that would require removing the makeup, false eyelashes, and baseball cap, such as swimming. Carol also confessed to having a good relationship with her father and two younger siblings, with whom she assumed a parental figure after her mother's death.
Even though she tried several times to stop her hair pulling tendencies, she admitted that the daily stressors of academics, work, and social life impeded her ability to control the behavior. Carol reported that her social awkwardness around men led to a lack of relationship experience or any significant romantic relationship. She perceived that some of her workmates negatively assessed this inability, thereby stressing her and exacerbating the problem. Carol also hinted that she was having problems juggling her part-time job as a clerk and committing to her studies and that her hair-pulling behavior had taken a worse turn after securing the placement. She also reported that it was difficult for her to express her feelings with her supervisor. She would resort to pulling out her eyelashes, eyebrows, and hair from her scalp every time she was forced to go out of her way to please her demanding boss. Carol reported pulling out her hair in these instances to relieve the tension of not making known her feelings to others. This pattern of anxiety, distress, depression and avoidance became a negatively perpetuating cycle for Carol.
Assessment
After the intake interview entailing the patient's history and presenting problem, Carol was evaluated for trichotillomania (TTM), depression, anxiety, and stress using self-report measures throughout her treatment. The measures were given to assess her hair-pulling behavior and self-reported symptoms of depression, anxiety, and stress, over and above, her social relations at home, work, and school.
The first assessment tool was the DASS-21, a psychometrically verified 21-item self-report evaluation tool intended to determine patient's self-reported levels of depression, anxiety, and stress in the past week. Patients are required to answer several questions connected to the intrapsychic symptoms of depression, anxiety, and stress on a scale ranging from 0 (Never) to 3 (Almost Always) (Le et al., 2017). The scores are then summed for each category, and the sum score is multiplied by two. Resultant scores are typically ranged from average to highly severe. At intake, Carol reported depression, anxiety, and stress scores of 23, 17, and 28, respectively, indicating severe depression, anxiety, and stress symptoms.
The second assessment tool was the Massachusetts General Hospital Hair-Pulling Scale (MGH Hair-Pulling Scale): the MGH Hair-Pulling Scale is a psychometrically verified seven-item survey and a concise, self-report instrument for evaluating repetitive hair-pulling behavior. Patients indicate the degree to which they have experienced sensory urges to pull out their hair over the past week, the intensity of those urges, their ability to control the urges, the frequency of hair-pulling, their attempts at resisting hair-pulling, their control over hair-pulling, and the associated distress on a scale ranging from 0 (Never) to 4 (Often) (Keuthen et al., 1995). At intake, Carol reported a score of 24 (range 0 to 28), thereby demonstrating significant challenges with sensory urges to pull out her hair, control of those urges, perceived control of her hair-pulling behavior, and associated distress.
The third assessment tool was the OQ-45.2 self-report questionnaire administered several times throughout therapy to determine client progress. It consists of three measures: Symptom Distress, Interpersonal Relationships, and Social Role. The Interpersonal Relationships subscale evaluates challenges associated with isolation, conflicts with others, and married difficulties. Lastly, the Social Role subscale assesses the challenges related to the daily stressors of school, work, and home. Patients indicate the degree to which they have encountered challenges over the past week in the three aspects above on a 4-point scale ranging from 0 (Never) to 4 (Often) (Boswell et al., 2013). There is extensive normative data gathered using this assessment tool, and therefore patient scores can be compared against inpatient and outpatient averages to evaluate treatment efficiency.
The OQ-45.2 also includes several critical items that measure the degree of substance abuse, workplace violence, and suicidality and can help reveal specific issues that demand immediate attention by clinicians. At intake, Carol recorded an OQ-45.2 score of 89, which indicated symptoms of increased distress connected to intrapsychic symptoms of depression, anxiety, and stress; interpersonal relations; and performance of daily tasks at home, work, and school.
Treatment
Initial Phase
The treatment started by conceptualizing Carol's hair-pulling behavior using the antecedent-behavior-consequence (ABC) model. The patient e...