Explain TTM, HRT and NAC to a patient — CASC communication station

Station brief

Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the outpatient clinic. [4]

Candidate instructions. Explain trichotillomania/skin-picking as treatable neurobehavioural BFRBs (not vanity or weak will), outline habit reversal training, discuss possible adult NAC, address partner criticism, safety-net trichophagia/infection, and check understanding. The examiner plays the patient. [3][4]

Candidate scenario

Your patient meets criteria for trichotillomania with co-occurring mild excoriation. You plan referral for HRT-based behaviour therapy and discussion of N-acetylcysteine often building toward 1200 mg twice daily oral (within 1200–2400 mg/day) if she chooses medication after medical review. She fears therapy will force her to sit with urges forever and believes only a “strong psychiatric drug like olanzapine” will work. Her partner currently grabs her hand and criticises bald patches. She sometimes swallows hair. [1][2][5]

Marking domains

• Empathy, structure, and shame-sensitive agenda-setting
• Accurate plain-language BFRB model (urge/habit loop, not character flaw)
• Clear HRT explanation (awareness, competing response, stimulus control, homework)
• Medication discussion: adult NAC evidence concept, delayed benefit over weeks, side-effects
• Explicit message that olanzapine is not first-line due to metabolic risks
• Partner advice without blame (support skills practice; stop shaming)
• Safety-net for trichophagia, infection, mood worsening
• Checks understanding / teach-back [1][3][4]