Trichotillomania and excoriation disorder — assessment and management (MEQ)

(i) Definition and nosology. Trichotillomania: recurrent hair pulling causing hair loss, repeated attempts to decrease/stop, clinically significant distress/impairment, not better explained by another condition. Excoriation disorder: recurrent skin picking causing lesions with the same stop-attempt and impairment structure. Both are OCRD body-focused repetitive behaviours in DSM-5-TR (with OCD, BDD, hoarding), not primary impulse-control or anxiety-disorder chapter diagnoses.^[6]

(ii) Differentials. Alopecia areata: smooth patches, exclamation-mark hairs, no pulling rituals; here irregular varying-length broken hairs favour TTM. OCD: multi-theme obsessions/compulsions; sertraline labelled “OCD” without multi-theme content may have been a mislabel — BFRB can co-occur with OCD but is not the same. BDD: picking driven by perceived appearance defect belief; screen but co-existing facial picking here fits SPD/BFRB without proving primary BDD.^[6]

(iii) Assessment and risks. Chronology; sites (scalp, brow, face); hours/day; automatic (lecture watching, low awareness) versus focused styles; rituals; trichophagia (she swallows roots — ask GI symptoms, early satiety, pain); infection/scarring; shame/camouflage; mood/suicide risk (PHQ-9 11 needs full risk review); MGH-HPS/SPS concept for tracking; dermatology liaison already useful. Trichobezoar risk makes trichophagia a red flag even if currently mild GI symptoms are absent — educate and reassess.^[6]

(iv) Psychological first-line. Specialist habit reversal training: awareness training (self-monitoring during lectures), competing response (e.g. fist clench/needle-free competing motor hold ~1 minute), stimulus control (fidget tools, posture/environment redesign), social support. Modern packages: ACT-enhanced HRT or ComB individualising sensory/cognitive/affective/motor/place triggers. Not generic counselling alone. Meta-analyses favour behaviour therapy over SRI for core TTM.^[4][5]

(v) Pharmacotherapy and next steps. Sertraline 50 mg for 6 weeks is not an adequate BFRB plan and was not paired with HRT. Discuss adult NAC often 1200–2400 mg/day oral (Grant 2009 TTM; Grant 2016 SPD positive RCTs), GI tolerability, product quality; do not cite paediatric Bloch 2013 as positive evidence if treating youth later. SSRIs may help comorbid depression/anxiety or true OCD. Clomipramine/olanzapine are specialist later options (metabolic cost for olanzapine). Safety-net trichophagia/infection; arrange true HRT; review measurement and risk.^[1][2][3][6]