Trichotillomania and excoriation disorder — structured clinical viva

This is co-occurring trichotillomania and excoriation disorder within the OCRD/BFRB spectrum, not “failed OCD” unless multi-theme OCD is separately demonstrated. Supportive talk is not HRT; fluoxetine 20 mg is not an adequate BFRB pharmacologic trial and does not replace behaviour therapy. Meta-analytic data favour behaviour therapy over SRI for core hair-pulling.[4][6]

First-line plan: engage with specialised HRT (awareness, competing response, stimulus control), with ACT-enhanced or ComB packages where available. Pharmacologically, discuss adult NAC (Grant 2009 TTM; Grant 2016 SPD) toward 1200–2400 mg/day oral if she wants medication with better BFRB-specific RCT support than low-dose SSRI alone. If she asks about children/family members, cite Bloch 2013 paediatric NAC null — do not oversell NAC in youth.[1][2][3]

Olanzapine demand. There is a small positive RCT (Van Ameringen 2010), but metabolic adverse effects make it a specialist later option, not a preferred first medication over HRT and NAC discussion.[5][6]

Trichophagia. Explicitly assess abdominal symptoms and arrange urgent medical review if obstruction features; educate about trichobezoar risk even if currently asymptomatic.[6]