Trichotillomania: A Case Study PDF

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This is a case study of Lisa (not her real name), a patient diagnosed with trichotillomania. Trichotillomania is characterized by continual urges to pull out one’s own body hair in response to psychological distress...

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INTRODUCTION Trichotillomania is characterized by continual urges to pull out one’s own body hair in response to psychological distress (American Psychiatric Association, 2013). Azrin and Nunn (1973) suggest that hair pulling may be triggered by or accompanied by a number of emotional states like anxiety, boredom, stress or tension and reinforced by the relief or pleasure experienced by the hair pulling. Hair pulling from the face can result to a complete or partial removal of the eyebrows and eyelashes while hair pulling from the scalp can result in varying degrees of patches of hair loss (Hurley, 2018). In the case study “A Case Study on Behavioral Treatment of Trichotillomania” by Kurt D. Michael (2004), the main focused was finding a way to cure people with trichotillomania like Lisa (not her real name), a patient suffering from excessive hair pulling. During the initial evaluation, Lisa complained of chronic and significant hair pulling, associated hair loss, concealment of damage secondary to hair pulling, body image disturbance, depression, anxiety, and low self-esteem. Lisa undergo different sessions to be monitored and kept track of the number of hairs pulled and the number of hair-pulling events daily during the course of treatment. She also undergo behavioral treatment to identify antecedents and triggers to hair pulling as well as the consequences and implications. This behavioral treatment includes relaxation and alternative methods of tension reduction, development of competing yet constructive replacement behaviors, and self-reinforcement of adaptive alternative behaviors. Furthermore, based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2013), trichotillomania is reported to affect as much as 4% of the

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population with highest incidence in childhood and adolescence. Moreover, in the article released by the American Journal of Psychiatry (2007), it states that based on reports, females tend to outnumber males by 10 to 1 among adults and Lisa is one of those female who suffers from trichotillomania. The general purpose of analyzing this study is to evaluate the case of Lisa to further understand what are the causes that triggers to a person to have this hair pulling disorder. Also, to contribute to the growth and development in the field of psychology.

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BACKGROUND The case study at hand was produced by Kurt D. Michael, a professor of Psychology at Appalachian State University (ASU) and the former Director of Clinical Services at the ASU Institute for Health and Human Services. The study was conducted in the year 2004 and the main focused of it was the behavioral treatment of patient named Lisa, who was diagnosed to have a trichotillomania or hair pulling disorder. Lisa is the second among three children of her parents whom are both college graduates. She lived with her parents and two sisters until she enrolled in college. Her family life is filled with ups and downs and her revelation about being lesbian added to the fact that she's not supported by her family. She was only 9 years old when she saw her classmate pulling out his hair and afterwards she also tried hair pulling that makes her somewhat satisfied. Being hooked on the behavior, it became increasingly automatic after a few months even to the point where she became less aware of the behavior. Although her hair-pulling behavior continued through adolescence, she had difficulties with her body image and self-esteem as she was 12. Based on the article released by Mayo Clinic (2016) trichotillomania usually develops just before or during the early teens — most often between the ages of 10 and 13 years — and it's often a lifelong problem. Infants also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment. Kelly (2019) emphasized that trichotillomania can affect people of all ages; however, it appears to be much more common among children and adolescents than adults. In a very young children, less than 5 years old often pull their hair out unknowingly or even while they sleep. In the same way that thumb sucking stops spontaneously

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for most children, the majority of children who begin to pull their hair at this early age will stop on their own. On the other hand, the treatment of trichotillomania is often unnecessary for very young children as they usually grow out of it. However, for people with adolescent – onset trichotillomania, treatment may be necessary, especially if it is suspected that the individual is consuming their own hair, which can cause dangerous blockages in gastrointestinal system. Chamberlain et al. (2007) mentioned other habits such as nail biting, knuckle cracking, touching or playing with pulled hair, and hair swallowing (trichophagia) to be associated with this disorder. The medical complications that can arise from this disorder are: infection; permanent loss of hair; repetitive stress injury; iron-deficiency anaemia; carpal tunnel syndrome; and gastrointestinal obstruction by hairballs (trichobezoars), as a result of swallowing of hair (a condition known as trichophagia). The onset of hair pulling most often coincides with or follows, the onset of puberty. The course of the disease is chronic, though individuals can experience symptoms that wax and wane over time. There does appear to be a genetic component to trichotillomania. The disorder is more common among individuals with obsessive-compulsive disorder and their first-degree relatives than the general population. Moreover, Trichotillomania is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an impulse control psychiatric disorder within the group of conditions known as body-focused repetitive behaviors (BFRBs). Family history, genetics may play a role in the development of trichotillomania, and the disorder may occur in those who have a close relative with the disorder. Stephen Zucher (2006) from Duke Center for Human Genetics, says genetic mutations only account for a small fraction 4|Page

of trichotillomania cases. Furthermore, based on the study published in Molecular Psychiatry, the gene SLITRK1 that was also linked in to Tourette’s syndrome, a related impulse-control disorder was also present in some patients with trichotillomania. The gene was said to be interact with other genes and also, other factors are needed in order to trigger the trichotillomania and other psychiatric conditions. Cognitive behavioral techniques have demonstrated some efficacy in treating trichotillomania. Prominent among these is habit reversal therapy. Habit reversal therapy involves self-monitoring of behaviors, improving stress coping strategies, increasing social support and relaxation therapy. Hypnosis is also one way to get rid of such disorder. The Erickson approach of hypnosis helps the child to substitute hair pulling for a stroking behavior. Currently, there is limited evidence that medications such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) are effective in treating trichotillomania, so the FDA has not approved any medications for treating it.

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EVALUATION OF THE CASE The case study discussed the behavioral treatment of a 21- year old college women with a long standing history of chronic hair pulling. According to Lisa, she first pull her hair when she saw her male peer pull his hair out and says that is was cool to see the root of hair. Thereafter, Lisa tried pulling her hair and found it to be somewhat compelling. After a month, she became hooked on the behavior and became increasingly automatic to the point she became less aware of the behavior.

Lisa consult herself for treatment after two unsuccessful attempts to treat her condition via what was described as nonspecific supportive psychotherapy. During her previous therapy attempts to (a. a weak therapeutic alliance and b. her own self-described reluctance to modify maladaptive behavior), she attributed her limited success decreasing her hair pulling behavior. Her prior treatment occurred within the context of the prominent issues including alcohol abuse and family-of-origin conflicts. According to Lisa and a functional analysis of her TM, hair pulling reinforced in several ways. The most common antecedent events to hair pulling were anxiety and boredom, often associated with academic stress and external cues (e.g., being alone in her bedroom or bathroom). Based on the several narrative reviews of the extant literature of trichotillomania (TM), habit-reversal training (HRT) is the treatment with the most empirical support and remains to be one of the few treatments tested in a controlled trial. “In her first sessions, Lisa participated in a semi-structured clinical interview conducted by the Structured Clinical Interview for DSM. According to the data, she met Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR) criteria for TM, give her longstanding and

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significant history of hair pulling with associated hair loss and impairments in important areas of functioning (e.i. interpersonal, academic, occupational).” “After initial session, Lisa was instructed to self-monitor each hair pulling events using spreadsheet provided by the author to collect baseline data.” During the 11 days baseline period, she pulled out her hair follicles (range: 22-65 hair pulled) every day during the interval. A ratio of days when hair pulling occurred versus day when zero hairs were pulled was calculated over the course of therapy. Therefore, during the baseline phase, Lisa pulled hair on 100% of the days in the period. Moreover, she was also instructed to take a picture of the top of her scalp as another measure of her current state. The baseline pictures not only revealed significant hair loss on the top of her scalp but also skin damage, blemishes, and sores, likely associated with a longstanding pattern of TM. The pictures was used as a punishing and tangible reminder of the damage that she inflicted on her scalp over the course of several years of hair pulling. She was instructed to place the baseline picture in prominent hair-pulling locations (bedroom, bathroom, car) to disrupt her automatic behavioral cycle of hair pulling in environments where external cues for TM were prevalent. During the second session, Lisa permitted the author to visually inspect the affected areas of her scalp, she also indorsed subclinical levels of depression, general anxiety and body image disturbance but she did not meet DSM-ITVR criteria for obsessive-compulsive (anxiety) disorder (OCD). “During the 123 days (12 sessions) of the active treatment phase, Lisa pulled her hair on 37 of those days (range: 1-40 hairs pulled). Whereas she pulled hair on 100% of the days during 7|Page

the baseline assessment period, she pulled hair on 30% of the days during the active treatment period. Thus, Lisa reported a 70% reduction in the number of hair pulling days over the course treatment days over the course treatment (86/123 no hair pulling days). Moreover, based on a trend analysis, the average number of hairs pulled during each event was reduced. Lisa reported substantial improvements in depression and self-esteem. However, she still experience considerable difficulty managing her academic tension and general anxiety. Lisa’s report of body image disturbance remained relatively unchanged over the course of treatment. In this case, it is important to the field of Psychology that clinicians maintain a watchful eye for potential improvements to their procedures in hopes of providing better treatments for a substantial number of individuals who struggle with chronic hair pulling.

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PROPOSED SOLUTION OR CHANGES Research on treatment of trichotillomania is limited. However, some treatment options have helped many people to reduce their hair pulling and it may also be applied in different psychological disorders. The following solutions was from recent studies conducted from different psychological institution. 1. THERAPY 

Habit reversal training. This behavior therapy is the primary treatment for trichotillomania. It is a multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders. Habit Reversal Training is made up of five parts: a. Awareness training: brings attention to the behavior so the person can gain better self-

awareness. In this stage you will work to notice when you are performing the behavior, identify the earliest warning that a behavior is about to take place, and identify the situations where the behavior occurs. b. Competing response training: you will work with your therapist to come up with a different behavior to replace the old unwanted behavior and practice performing this new behavior. c. Motivation and compliance: you may make a list of all the problems that were caused by the behavior to remind you of the importance of sticking with it. Parents and friends may be asked to offer praise and encouragement for the person’s progress, support of family and friends can increase your chances of kicking an unwanted behavior.

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d. Relaxation training: habits or tics can be common when a person is under stress, it can be helpful to learn relaxation skills such as deep breathing, mental imaging, mindfulness, and progressive muscle to keep urges at bay. e. Generalization training: you will practice your new skills in a number of different situations so new behavior becomes automatic. 

Cognitive therapy. It is a treatment method that focuses on improving cognitive function (e.g. memory, attention, concentration, learning, planning). This therapy can help you identify and examine distorted beliefs you may have in relation to hair pulling.

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Acceptance and commitment therapy. This therapy can help you to learn to accept your hair-pulling urges without acting on them. Therapies that help with other mental health disorders often associated with

trichotillomania, such as depression, anxiety or substance abuse, can be an important part of treatment. 2. MEDICATIONS Although no medications are approved by the Food and Drug Administration specifically for the treatment of trichotillomania, some medications may help control certain symptoms. For example, your doctor may recommended an antidepressant, such as clomipramine (Anafranil). Other medications that research suggests may have some benefit include Nacetylcysteine, an amino acid that influences neurotransmitter related to mood, and alanzapine (Zyprexa), an atypical antipsychotic.

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Talk with your doctor about any medication that he or she suggests. The possible benefits of medications should always be balanced against possible side effects.

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CONCLUSION The study shown that Lisa was suffering from trichotillomania and it was triggered by different factors associated by different mental problems. It states that Lisa got to pull her hair when she was just in fourth grade and the fact that she was not supported by her parents regarding a number of issues, most notably her revelation about being lesbian added to her burden. Lisa consult herself for treatment after two unsuccessful attempts to treat her condition via what was described as nonspecific supportive psychotherapy. Thereafter, Lisa when to Kurt D. Michael and she was assessed and treated. Lisa’s primary reason for seeking treatment was to address something that seemed well beyond her control, despite her experience of significant impairments in daily functioning as well as prior unsuccessful treatment attempts. Lisa also reported that her self-awareness of the actual behavior varied, based on her mood state. For example, she said that during times of stress, her hair-pulling behavior was automatic and not subject to conscious cognitive processing of the event. Formative evaluation efforts were conducted throughout the intervention phase, and necessary adjustments and revisions were made to promote the best possible outcome for Lisa. Moreover, the content and focus of individual sessions often included the discussion and review of important contextual factors and interpersonal developments. Moreover based on the data obtained during the course of Lisa’s treatment, it appears that conceptualizing and treating TM from a behavioral perspective leads to some positive results. Moreover, as Silverman (1999) described, the context in which the treatment is conceptualized, taking into account the relevant individual factors of each case (e.g., family-of-origin issues, interpersonal difficulties), provides a full menu of potential correlates for the practitioner to consider during therapy. 12 | P a g e

The extent of the trichotillomania was measured during an 11-day baseline period (selfmonitoring, photographs) followed by 4 months of behavioral treatment including prominent components of habit-reversal training. The results of the intervention were suggestive of a substantial reduction in hair pulling incidents, hair re-growth in the affected parts of her scalp, and self-reported improvements in mood, anxiety, and self-esteem.

RECOMMENDATIONS

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The following are some steps to adopt to the given solutions that are presented. This will help not just to address what is reality about trichotillomania and other psychological problems but also to take a step in order to reach out people who are afraid and not able to have psychological treatments. A. To the Government -

The government must allocate funds to build a free psychological clinics in order for people to have psychological treatments. And also, programs like conducting seminars to every city or barangay will be a great help in increasing the awareness of people regarding different psychological problems.

B. To Educational Institutions -

Every School, Universities and Colleges must implement a strong curriculum that will help students to further understand the importance of having a healthy mind and also educational institutions must have a registered counselor and equipped clinical facility in case of emergencies.

C. To Family Members / Parents -

Every family members or parents must join in different seminars that is focusing on good parenting and also every family members must build a strong and good communication to their children. Every traumatic events will have a great impact in psychological state of a child, thus a good and strong parent-child relationship is a great way to nurture the physical, emotional and social development of the child.

D. To those people who have psychological problems

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If you feel there is something wrong with you, don’t be afraid to seek medical advice. Treatments that doctors will provide for you will be a great help in lessening or controlling what you have and it may help you to fully recover in a long run.

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