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 “overcontrol- ling” 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’d ever seen: a weird type of beehive combed over from the left. It was just horrible. I asked her why she did that to her hair, and she just said she liked it that way. After she’d been home a few days, she literally let her hair down, and when she tilted her head back once, right before she quickly brushed the hair back over, I saw it—her scalp! A horrifying, huge bald spot. I asked her what was wrong. “Are you sick?” But she just got really serious and said she didn’t want to talk about it. Then she left the room.
Later, she admitted that she had started pulling her hair out. She said she didn’t know why she did it, but she was going into therapy, for that and for a lot of other things. She explained that it was somehow connected to the eyelash thing from years ago, and I thought. “Of course, it all makes sense now.” This is really strange, but she told me that it wasn’t my problem, and I should just let her try to work on it herself. After that, once she was back at school, whenever I would ask her on the phone how she was doing with the hair problem, she would mumble a short answer like “Fine.” Sometimes she wouldn’t come home at all on vacations. But I guess now that she’s a senior, she’s made things right and put it all behind her. She was home just last month and she certainly seemed to have a full head of lovely blond hair. We had a great visit and she’s looking forward to graduating. And guess who’s the starting guard on the girls’ basketball team?
What defense mechanisms did Suzanne and her mother seem to use in order to cope with her eyelash problem and, later, her hair- pulling problem? How did such mechanisms help Suzanne? How did they hurt her?
The individual in Case 20: The Case of Suzanne would receive a diagnosis of trichotillomania (hair-pulling disorder).
Trichotillomania (Hair-Pulling Disorder)
1. Individuals repeatedly pull out their hair.
2. Despite attempts to stop, individuals are unable to stop this practice.
3. Significant distress or impairment. (Based on APA, 2013.)
1. Trichotillomania is listed as one of the obsessive-compulsive and related dis- orders in the DSM-5, a group of disorders marked by excessive preoccupations and rituals (APA, 2013).
2. Some clinicians believe that the disorder is actually a form of obsessive- compulsive disorder, because the hair-pulling, like the compulsions found in obsessive-compulsive disorder, is compulsive in nature, feels involuntary, and is recognized as senseless (Grant, Odlaug, & Potenza, 2007).
3. Contrasts between trichotillomania and the compulsions of obsessive- compulsive disorder: Compulsions are most often performed in response to obsessions, performed in a rigid or even ritualistic way, aimed at preventing some dreaded event, done with full awareness by the patient, and span beyond a single behavior (Grant, Odlaug, & Potenza, 2007).
4. Research on trichotillomania and its treatments is very limited.
5. The disorder often first appears during early adolescence at the onset of puberty (AP