Expert answer:What are effective treatments for Trichotillomania
Expert answer:Psychological Treatment Plan It is recommended that students review the e-book The Complete Adult Psychotherapy Treatment Planner (Jongsma, Peterson, & Bruce, 2014) for additional assistance in completing this assignment. Clinical and counseling psychologists utilize treatment plans to document a client’s progress toward short- and long-term goals. The content within psychological treatment plans varies depending on the clinical setting. The clinician’s theoretical orientation, evidenced-based practices, and the client’s needs are taken into account when developing and implementing a treatment plan. Typically, the client’s presenting problem(s), behaviorally defined symptom(s), goals, objectives, and interventions determined by the clinician are included within a treatment plan. To understand the treatment planning process, students will assume the role of a clinical or counseling psychologist and develop a comprehensive treatment plan based on the same case study utilized for the Psychiatric Diagnosis assignment in PSY645. A minimum of five peer-reviewed resources must be used to support the recommendations made within the plan. The Psychological Treatment Plan must include the headings and content outlined below. Behaviorally Defined Symptoms Define the client’s presenting problem(s) and provide a diagnostic impression.Identify how the problem(s) is/are evidenced in the client’s behavior.List the client’s cognitive and behavioral symptoms. Long-Term Goal Generate a long-term treatment goal that represents the desired outcome for the client.This goal should be broad and does not need to be measureable. Short-Term Objectives Generate a minimum of three short-term objectives for attaining the long-term goal. Interventions Identify at least one intervention for achieving each of the short-term objectives.Compare a minimum of three evidence-based theoretical orientations from which appropriate interventions can be selected for the client.Explain the connection between the theoretical orientation and corresponding intervention selected.Provide a rationale for the integration of multiple theoretical orientations within this treatment plan.Identify two to three treatment modalities (e.g., individual, couple, family, group, etc.) that would be appropriate for use with the client. It is a best practice to include outside providers (e.g., psychiatrists, medical doctors, nutritionists, social workers, holistic practitioners, etc.) in the intervention planning process to build a support network that will assist the client in the achievement of treatment goals. Evaluation List the anticipated outcomes of each proposed treatment intervention based on scholarly literature.Be sure to take into account the individual’s strengths, weaknesses, external stressors, and cultural factors (e.g., gender, age, disability, race, ethnicity, religion, sexual orientation, socioeconomic status, etc.) in the evaluation.Provide an assessment of the efficacy of evidence-based intervention options. Ethics Analyze and describe potential ethical dilemmas that may arise while implementing this treatment plan.Cite specific ethical principles and any applicable law(s) for resolving the ethical dilemma(s). The Psychological Treatment Plan Must be 8 to 10 double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.)Links to an external site..Must include a separate title page with the following:Title of paperStudent’s nameCourse name and numberInstructor’s nameDate submittedMust use at least five peer-reviewed sources in addition to the course text.Must document all sources in APA style as outlined in the Ashford Writing Center.Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.
case_20.docx
cognitive_deficits.docx
impulse_control_disorder.docx
psychiatric_diagnosis.docx
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CASE 20: Case of Suzanne
This case is presented in the voices of Suzanne and her mother, Sherry. Through- out the case, you
will be asked to consider a number of issues and to arrive at various decisions, including diagnostic
and treatment decisions. Appendix C reveals Suzanne’s probable diagnosis, the DSM-5 criteria,
clinical information, and possible treatment directions.
Suzanne A Sign of things to Come I don’t know when I started doing it. I guess I’ve always hated
school and I’ve al- ways been really nervous about things. A lot of the time, even before college, I
used to play with my hair a lot and pull on it; the more nervous I became, the tighter I pulled. But I
didn’t think there was anything unusual about it. You know, everyone has nervous habits that they
turn to when they get stressed out, right? My parents were . . . let’s say “difficult.” They were always
making me feel like I
didn’t do well enough. “Couldn’t you have gotten an A? Couldn’t you play basketball or soccer?
Couldn’t you have won the game? What could you have done to prepare for the test better? What
can we learn from this? Why don’t you have a boyfriend? Maybe if you dressed differently? You
know, we just want you to be happy.” I guess this whole thing really started a long time ago. When I
was in seventh grade, I used to pluck out my eyelashes. I can’t remember how it started, but I
remember that it used to relax me when I was tense. I also got the idea in my head that my
eyelashes and my eyes were really irritated. I thought that maybe I had some dirt caught in there,
and it was stuck between my eyelashes. So I would loosen it and stop the irritation by pulling the
eyelash out. I actually re- member thinking that there were microscopic bacteria—like I had seen in
a science film—living on the end of the eyelash, wiggling around under my skin, and the bad
eyelashes needed to be pulled out. The little pain of pulling the lash out was something I actually
looked forward to, like when you have a hanging fingernail that hurts and you need to pull it out: a
second of pain and instant relief. Once I started noticing that I was doing it, I would be really
nervous right before I would pull it, and I would think that maybe I shouldn’t pull this one. Then,
when I was pulling it out, I imagined I could feel the irritating part coming out. After it was over, I felt
relieved, all the nervousness gone. I would look at the lash I had pulled, almost trying to see the
little bacteria wiggling like a worm on a fishhook. Soon, my eyelids were running out of hair, but no
one seemed to notice, so I thought it wasn’t a big deal. Maybe I wasn’t really plucking them all out, I
thought. Maybe I was just plucking out the bad ones, and the eyelashes now looked exactly the way
they were supposed to. Maybe, I thought, I’m just sensitive to the way it looks because I keep
thinking about it so much. Of course, I couldn’t help but notice that I wasn’t able to pluck any long
eyelashes anymore, only little stubby ones. Also, my eyelids were hurting all the time.
Many loving parents are described as being “over- concerned” about their children, or “overcontrolling” or “overinvolved.” Where do such pat- terns of behavior come from? What can parents do to
avoid crossing the line in their efforts to guide and protect their maturing children?
One night at dinner, my mom just turned to me after we’d been sitting to- gether the whole dinner,
and screamed out, “What happened to your eyelashes?” That was so embarrassing! I wanted my
parents to just go away. They wouldn’t understand why I had to do it. I just wanted to crawl into a
hole and die. I promised my mom that I would stop, but it was easier said than done. I’d catch
myself—or should I say Mom would catch me—doing it, reaching for the eye- lashes even when
there wasn’t anything there. Eventually, my embarrassment became so great that it helped me to
stop. Whenever I would reach for my eye- lashes, I was able to catch myself before I touched them.
My lashes grew back, and the eyelids weren’t as irritated all the time. After about 6 months, I didn’t
even have to think about it anymore. When I did think back on my behavior, I couldn’t believe that I
had plucked out every eyelash. It didn’t make sense anymore, and it seemed so unnatural. I was
glad I had stopped, but I didn’t want to think about it too much because I didn’t want to consider
the possibility that I wasn’t “normal.” After my victory over eyelash plucking, I found myself trying
to cope with school and other stresses in other ways. Throughout high school, I bit my nails and
often stayed up all night worrying myself to the point of tears, and walking around with a headache,
half asleep, during the day. During my junior and senior years, I was always concerned about
whether I would get into a good college. Then, after I was accepted, there were all these
preparations to make, while at the same time trying to finish my senior year in good standing. And
then I had to get ready to move away from home. All the while, in the back of my mind, I was
worried that there was something different about me from everyone else. I really didn’t get along
that well with most people; I just got too nervous around them, and relationships with boys never
seemed to go anywhere.
Suzanne entering the Big Leagues
Entering college is a major life stress that seems to trigger or exacerbate psychological difficulties
for many persons. Why might this be such a difficult period in life?
When I first got to college, I was really scared. I’d never been away from home for more than a
couple of weeks, and never so far from my parents. Even though I couldn’t wait to get away from
them, I didn’t know how I was going to get through life without them telling me how to do
everything and how to get by in the real world. My next-door neighbor in the dorm suite, Jon, was a
big help. He was from New York, so he was independent and sure of himself. He taught me how to
take care of things like bills and spending money, how to get through classes, and how to get food
for myself. It was really a lot of fun; we made a little family out of our suite. Jon and I spent tons of
time together and I was happy that I had wound up with him; it seemed like a stroke of luck. Then
one day he kissed me. Gosh, it seems so simple just to say it like that: “He kissed me.” But that was
how it happened. And I didn’t think twice; I just kissed him back, even though I had never really
kissed a boy before. Not like that. We moved on from there and had sex. I had always wondered
what that would be like. How would it feel? But it felt wonderful—so right, so natural. I was so very
happy with Jon, and I was feeling things that I had never felt for anyone. One day, after we had been
going together for about a month, Jon suddenly told me he thought we shouldn’t be doing what we
were doing anymore. He said it just like that, and just like that it was all over. He talked about
expanding our horizons, exploring other relationships, and other such things. None of it made much
sense or comforted me. I was totally devastated. And I was shocked by the suddenness with which
the relationship ended. That alone would have been enough to crush me, but there was more. Jon
wouldn’t even talk to me or hang out with me anymore. It was a nightmare. I knew he was having
girls come over and he was sleeping with them—each of them was a reminder of how undesir- able
I was, of my failure at love, of my loss. I felt terrible about myself because Jon didn’t love me like I
loved him, and terrible because I had loved him in the first place. I was so depressed that I started
failing two of my classes. I think it was around this time, about midway through that first semester,
that I first became aware that I was pulling my hair out. I say “first became aware,” because I have
no idea how long I’d actually been doing it. I just suddenly noticed, while in the middle of pulling my
hair one time, that there were already a few strands of blond hair on the floor. This time it wasn’t
my eyelashes, but actual hair from my scalp.
Everyone has certain habits that they exhibit when they are under stress. Only occasionally do such
habits blossom into a disorder such as Suzanne’s. Are there ways of distinguishing innocent bad
habits from signs of problems to come?
I realized immediately that the hair pulling was the same kind of thing that my eyelashes had been.
I didn’t feel so much the itchy, irritated feeling, but I would feel very uncomfortable. If I tried not to
do it, I’d get really nervous and tense. I’d get this cramped, tight feeling in my stomach, and I’d
worry that something bad was going to happen. By pulling out a hair, I would feel instant relief.
When the hair came out, the knot in my stomach would pass and my heart would stop pump- ing
so heavily. I could lean back in my chair or bed, and breathe much more easily. Unfortunately, this
feeling of relief wouldn’t last for long. In fact, as I said, the hair pulling would happen so often that I
usually didn’t know I was doing it—I would sometimes simply catch myself in the act. Recalling the
eyelash thing, I’d say to myself, “Remember that was just a phase. You didn’t have any trouble
stopping,” and I’d feel reassured. But of course I had had trouble stopping the eyelash plucking; it
had just faded from my memory. As I paid more attention to my hair pulling, I observed that I
tended to pull it from my right temple, on the side of my head, with my right hand. But I honestly
couldn’t be sure that that was the only hand I ever used. A month or two after I first noticed what I
was doing, I was in the shower and felt a little patch of skin exposed around my favorite plucking
spot. I think I was running the shampoo through my hair and I was rubbing it through my scalp.
Based on your reading of either the DSM-5 or your textbook, what disorder might Suzanne be
displaying? Which of her symptoms suggest this disorder?
When I felt the patch where there was less hair, I panicked immediately. I could feel my face turn
bright red, and I think I was more embarrassed than anything else, even though I was alone. I
thought, here I am doing this bizarre and per- verse thing that no one else does, and now I must
look like a freak. It occurred to me that everyone must know, and I just wanted to run and hide. In
those first few moments of shock, I started breathing heavily, and I silently promised myself that I
would never do this horrible thing again, that I was immature and stupid and disgusting, and I had
to stop. I rinsed out my hair, toweled it off, then, terri- fied, I moved to the mirror to see just how bad
I looked. Peeking from between squinted eyelids, I couldn’t see a difference at first. Then I opened
my eyes wide, and saw that there was definitely a bald patch, although not as bad as it had felt to
my fingers in the shower. Good, I thought, with a feeling of relief. It seems silly in retrospect, but I
re- member thinking that if I just combed my hair over a certain way, everything would look fine. It
relieved me enough that I went right back to my routine. Time and again, I’d catch myself plucking
hair from the same spot. Eventually, I could no longer pretend that I didn’t have a noticeable bald
patch. I invented newer, more elaborate hairstyles to cover it, while always thinking to myself, “Oh,
I’m never going to do this again,” or “I’m phasing it out.” The truth was I hadn’t slowed down a bit. It
was probably becoming apparent to the people around me that there was something peculiar going
on with my hair. But I kept on going.
Suzanne’s disorder is listed with the obsessive- compulsive and related disorders in the DSM-5,
but it is considered a separate disorder from obsessive-compulsive disorder. Yet some clinicians
believe that problems like hers are really a kind of compulsion. How are her symptoms similar to
those displayed by the individual in Case 2, Obsessive-Compulsive Disorder? How are they
different?
When I went home for the winter break, I was terrified. I didn’t want to risk my parents seeing this
ugly bald spot on their “perfect” little daughter. For the entire month before winter break, I kept
thinking, “Okay, stop pulling the hair. It needs to grow back.” Then I’d think, when the urge had its
grip on me, “Well, break is still 3 weeks away.” And so I’d pull out the hair. And pull. And pull. And 3
weeks became 2, and 2 became 1, and the problem was as bad as ever when I had to fly home. I bit
my nails the whole flight home, trying not to give in to the urge to pull my hair. I also didn’t want to
mess up the deceptive hairdo I had worked on so hard. Of course, there was Mom at the terminal
waiting area, screaming, “Oh, my God! What kind of a hairstyle is that? You look terrible!” I told her
to mind her own business and leave my hairdo alone. It was all I could do to stop her from touching
it. I was only kidding myself that I could keep this a secret for 4 weeks. Within 1 week, Mom noticed
the bald spot that I’d tried so hard to hide. In her typical way, she made me feel as if I had cut off an
arm, and I turned bright red and cried. I didn’t want to talk to her about it, both because she was
horrible and because I didn’t want to face it myself. So I left the room and said, “I won’t talk about
this now.” But I knew that the damage had been done, and later I went down and told her that, as
she could see, I had been pulling out my hair. I explained that I didn’t know why, but I was going
into therapy (to get her off my back) and I wanted to deal with it on my own. And then I refused to
discuss it further. I was surprised at how well I had handled my mother, but I knew that I had yet to
handle my hair problem. I went back to school, and continued to pull my hair out. My hair looked so
bad I wasn’t even trying to date. It wasn’t until 2 more years passed that I decided to actually try
the therapy that I’d told my mom about. I’ve been in counseling for 8 months now. I’ve come to
appreciate that I have a lot of anxiety issues and problems with myself and my parents, and that’s
probably why I do this—at least in part. At the same time, my therapist has explained that many
people have this disorder. I couldn’t believe that at first; I really thought I was the only one. I’m
going to graduate this coming spring, and I’m doing very well at school and in basketball. Mom and
Dad are so happy! I haven’t pulled any hair out in, I think, close to 4 months, and I’m not feeling the
urge much anymore, which is great. I feel better about the way I look. I’ve also started seeing a
really nice guy named Mark. It’s going great, although, after the disaster with Jon, I’m trying to take
it slow. All in all, things are pretty good, but I do wonder whether I am prone to pulling my hair. Will I
revert to this whenever I face a crisis? That worries me, and for now that’s why I am continuing to
attend therapy.
How might the treatment approaches used in Cases 2 and 5 be applied to Suzanne? Which aspects
of these approaches would not be appropriate for her? Should additional interventions be applied?
A Mother’s View “You’ve Got to Stop this”
I think Suzanne was about 13 when I first noticed the problem with her eyelashes. We were sitting
at the dinner table—this was about, oh, 8 years ago—and talking about her cheerleading practice.
She was excited that she’d been picked to be the top of the pyramid. Tom and I were also happy
about that. We’d been encouraging Suzie to try out for this cheerleading team because she had
seemed unhappy. Sometimes she’d cry, and when we’d ask her what was wrong, she’d say, “I don’t
know,’’ or “School is really hard.” Tom and I talked about it and thought she might want to get
involved in an extracurricular activity. We gently tried to get her to go out for a sport, like basketball,
which she was so good at, but she insisted she didn’t like playing sports. Finally, in desperation, I
suggested that since she really liked gymnastics, she might want to try cheerleading. Suzie loved
the idea. Apparently, she had thought about cheerleading, but she had been afraid to ask us if she
could be a part of the team. She was concerned that we’d be disappointed; she thought we might
look down on it compared with basketball, soccer, or field hockey. Can you imagine that? Anyway,
the eyelashes. . . . She was telling us about this pyramid thing at the table, and I wanted to give my
little girl a big hug. When I leaned in, I thought something looked peculiar about her face. At first, it
seemed like she looked really sad, and her eyes were bigger than usual. I hugged her and told her
that I was so proud of my little girl. Tom looked up from the paper and said he thought it was just
great.
Are the family, school, and social pressures described by Suzanne particularly unusual? Why might
they have led to dysfunction in Suzanne’s case, but not in the lives of other persons?
Later, during dessert, when I was passing out the ice cream, I looked at her again. We were talking
about her test the next day in social studies and how much studying she should do after dinner. At
one point, she looked up, and that’s when I noticed it. “What happened to your eyelashes?” I
exclaimed, before I could stop myself. Suzie tried to turn her head away and look outside the room,
in the opposite direction. She muttered, “I don’t know.” But I said, “Tom, look at this! She doesn’t
have any eyelashes.” He looked over, leaned in, and said, “You’re right, Sherry. What’s going on
here, Suze?” Suzie took a deep breath and just said she sometimes plucked her eyelashes out. She
didn’t know why she did it. She said she just did—they itched her, maybe. I figured it was some sort
of nervous habit, and I told her she had to stop. I told her it wasn’t normal. She got upset, but finally
promised she would try to stop doing it. I tried to give her some more incentive. “You’re so
beautiful,” I told her, “but you look terrible without your eyelashes. You could look so much better.
You’ve got to stop this, okay?”
On the surface, Suzanne and her mother had a close and loving relation- ship, but they also had
some serious problems in their interactions. What were some of these problems, and how might
they have contributed to Suzanne’s disorder?
For a while after that, I’d see her rubbing her eyelids where the lashes used to be. Tom and I tried to
help out by stopping her whenever we saw her playing with her eyelids or eyelashes. After a while,
and with some effort, it seemed to pay off. Her eyelashes eventually grew back, and she didn’t
seem to be plucking them anymore. Tom and I forgot all about it after a few years. When Suzanne
went off to college in Florida, the last thing on my mind was the way she had plucked out her
eyelashes at the age of 13. Tom and I had been hoping she would go to a good school, with a
strong girls’ basketball team, but she didn’t do very well on her SATs, and never did well enough in
basketball to interest the scouts from the big schools. Anyway, the school she went to was fine,
and we were proud that Suzie was going to college. She never called us when she first went away. I
guess it was the excitement of being somewhere new. Anyway, girls are like that at that age. When
we would call her to see how she was doing in her classes, she never seemed to want to talk—she
would talk very softly, say things were fine, and yes, she was making friends. She would then rush
off the phone; once, I was sure that she was holding back tears. When she came home for her first
winter break, she had the most ridiculous hairdo I’ …
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