Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Ms. F," 19-year-old college freshman, presenting with visible hair loss on her scalp and eyebrows, requesting help with 'a habit I can't stop.'

Chief Concern: "I've been pulling my hair out since I was 12. I have bald patches on my head and I've pulled out most of my eyebrows. I wear hats and use eyebrow pencil to hide it. I've tried to stop hundreds of times."

History of Present Illness: Ms. F reports onset of hair pulling at age 12 (7 years). She pulls hair from her scalp (primarily the crown and temporal regions) and eyebrows. She describes two pulling patterns: (1) 'automatic' pulling while studying, watching TV, or reading (she is not fully aware she is doing it until she notices hair in her hand), and (2) 'focused' pulling during stress or boredom (she deliberately searches for hairs that feel 'different' — coarser, kinked, or with a specific texture — and pulls them with satisfaction upon removal). She pulls 20-50 hairs per sitting, with multiple sittings daily. She has visible bald patches on her crown and sparse eyebrows. She examines the root of each pulled hair and sometimes runs the bulb along her lips (oral manipulation). She has tried to stop 'hundreds of times': wearing gloves, applying bandaids to fingertips, rubber bands on wrists. All strategies work for days then fail. She also picks at her cuticles and the skin around her fingernails (excoriation). She wears baseball caps and fills in her eyebrows with makeup daily. She avoids swimming, windy conditions, and situations where her hat might come off.

Past Psychiatric History: No prior treatment. Never disclosed to a clinician before this visit.

Family History: Mother: nail biting (lifelong). No other psychiatric history.

Mental Status Exam: Wearing baseball cap (removes reluctantly, revealing sparse hair on crown with 3 visible circular bald patches). Eyebrows drawn in with makeup (minimal natural hair evident). Cuticles ragged and bleeding. Affect embarrassed but earnest. No depression. No anxiety except situational (about appearance). No psychotic symptoms. Insight excellent.

Step 1: Trichotillomania DSM-5-TR Criteria

Criterion A: Recurrent pulling out of one's hair, resulting in hair loss.

Seven-year pattern of pulling hair from scalp and eyebrows. Visible bald patches and sparse eyebrows. MET.

Criterion B: Repeated attempts to decrease or stop hair pulling.

Reports 'hundreds' of failed cessation attempts. Behavioral strategies (gloves, bandaids, rubber bands) provide only temporary relief. MET.

Criterion C: Hair pulling causes clinically significant distress or impairment.

Wears hats daily, fills in eyebrows with makeup, avoids swimming and wind. Avoidance behaviors limit social and recreational activities. Significant distress about appearance. MET.

Criterion D: Not attributable to another medical condition (e.g., dermatological).

No alopecia areata or other dermatological conditions. Hair loss is clearly trauma-induced (irregular patches in accessible areas). MET.

Criterion E: Not better explained by another mental disorder.

Not related to OCD (no intrusive obsessive thought driving the behavior). Not related to BDD (not preoccupied with a perceived defect; she is distressed about the CONSEQUENCES of pulling, not a pre-existing appearance concern). Not stereotypic movement disorder. MET.

Step 2: Comorbid Excoriation and BFRBs

Ms. F also picks at her cuticles and periungual skin. This represents a second body-focused repetitive behavior (BFRB):

Excoriation Disorder comorbidity

Recurrent skin picking at cuticles/periungual skin causing tissue damage (ragged, bleeding cuticles). Repeated attempts to stop. Causes distress. Meets DSM-5-TR criteria for comorbid Excoriation (Skin-Picking) Disorder. COMORBID EXCORIATION PRESENT.

BFRB Cluster

Hair pulling and skin picking frequently co-occur as body-focused repetitive behaviors (BFRBs). Ms. F's mother's lifelong nail biting also represents a BFRB, suggesting a familial pattern. Treatment should address both behaviors simultaneously.

Diagnostic Formulation

Diagnostic Conclusion

Trichotillomania (F63.3) + Excoriation Disorder (L98.1): All 5 DSM-5-TR criteria for Trichotillomania met. Comorbid Excoriation Disorder. Seven-year duration with both automatic and focused pulling patterns. Functional impairment (social avoidance, appearance camouflage). Treatment: Habit Reversal Training (HRT) as first-line behavioral treatment — awareness training, competing response (fist clenching when urge to pull), stimulus control (identifying triggers). N-acetylcysteine (NAC) as augmentation. Consider clomipramine if behavioral intervention and NAC are insufficient.

Teaching Points

  • Trichotillomania involves two pulling patterns: 'automatic' (out of awareness, during low-attention activities) and 'focused' (deliberate, often in response to an urge or to find hairs with specific textures). Most patients engage in both patterns. Treatment must address both: stimulus control for automatic pulling, urge surfing and competing responses for focused pulling.
  • Habit Reversal Training (HRT) is the first-line behavioral treatment. The three core components are: (1) awareness training (recognizing urges and automatic pulling), (2) competing response training (substituting an incompatible behavior when the urge arises), and (3) social support (enlisting a support person to provide feedback).
  • N-acetylcysteine (NAC), a glutamate modulator, has demonstrated efficacy for trichotillomania in clinical trials. It represents a pharmacological option with a favorable side effect profile. Standard dosing is 1200-2400mg daily.
  • The oral manipulation pattern (examining the root, running the bulb along lips) is common in trichotillomania and can progress to trichophagia (ingesting hair), which carries the risk of trichobezoar (a hair ball in the GI tract requiring surgical removal). Clinicians should screen for hair ingestion.
  • Body-focused repetitive behaviors (hair pulling, skin picking, nail biting, cheek chewing) cluster in families. Ms. F's mother's nail biting suggests shared vulnerability. The cluster nature suggests a common underlying neurobiological mechanism related to grooming behavior regulation.