PRESENTED BY-MONALISA BAIRAGI

(M.PHIL. 2 ND YEAR TRAINEE)

CHAIRED BY- DR. PRASANTA KR. ROY CASE
(ASSISTANT PROFESSOR, HEAD OF THE
DEPARTMENT) CONFERENCE
INSTITUTE OF PSYCHIATRY. COE - KOLKATA
PURPOSE OF THE PRESENTATION

 Psychotherapeutic formulation
Session wise management
CASE HISTORY
SOCIODEMOGRAPHIC DETAILS: -

NAME: A.P

SEX: Female

AGE: 26 Years

ADDRESS: Arambag

MARIATAL STATUS: Unmarried

MOTHER TONGUE: Bengali

EDUCATION: M. Sc in Geography

OCCUPATION: Not working

RELIGION: Hindu

RESIDENCE: Suburban

FAMILY TYPE: Nuclear

FAMILY SIZE: Adult 3

INCOME SOURCES: Father

FAMILY INCOME: 15000/ month

REFERRAL: -

FOR: Intervention

BY: Department of Psychiatry, Institute of Psychiatry, Kolkata

 INFORMANT: -

Name of informant: S.P

Relationship with the client: Mother

Duration of relationship with client: since birth

Information provided was adequate, reliable.

PRESENTING COMPLAINTS:

According to informant and client: -

1. Repetitively plucking of hair for last 12 years

2. Sense of relief after pulling hair
3. Increased anxiety for last 4 years
4. Disturbed sleep
5. Low mood for last 8 months
HISTORY OF PRESENT ILLNESS:

Onset: Insidious

Course: Continuous

Progress: Fluctuating

Precipitating factor: Nil identifiable

The client was apparently well 12 years ago. She started to pull her hair when she was in class VIII and was
first observed by her elder sister. She informed the other family members and the client was scolded for that.
For few days she stopped this behaviour but again started when she was alone in her room. She reported that
initially her family members did not observe it but when significant amount of hair was lost, her mother and
elder sister started scolding her. Client reported that she used to engage in this behaviour during her study
time and before going to bed for sleep. After 2 years when her sister left home for higher studies, her hair
pulling behaviour increased. The client reported that she wanted to study in science stream and to continue
her higher studies in Kolkata like her elder sister. She took science after her 10th board exams but she started
to suffering from jaundice and family member forced her to take humanities as she might not be able to do
well in science. Finally, she took humanities in her higher secondary education and her hair pulling
behaviour gradually increased.
Family members forced her to study Sanskrit in graduation level at her nearest college due to her father’s
poor financial condition and they did not allow her to come to Kolkata. During that time, she reported
that she felt discriminated again and started experiencing distress about her career. Finally, the client came
to Kolkata to continue her study after a long argument with family members. She completed her
graduation in geography (H) while staying at a hostel for 3 years. Her hair pulling behaviour had relatively
reduced and she sought treatment from a dermatologist. She was prescribed some hair growth medicine
and shampoo, following which she had further reduction in her hair pulling behaviour. She also reported
that she became friendly with a food delivery boy in her hostel during that time with whom she was in
contact even when she returned home after her graduation. Her elder sister caught her during a
conversation and did not trust her, and hence, informed the parents. Her phone also got taken away though
she denied romantic relationship with that boy. This led to arguments and feelings of anger and sadness in
the client. Her hair pulling behaviour increased and she blamed her elder sister for her illness.
However, she had to stay with her sister in Bali, Howrah during her postgraduation studies and had frequent
arguments over minor things. According to the client, her elder sister always tried to dominate and criticize her.
This led to further increase in her hair pulling behaviour. After completing her postgraduation, her mother began
comparing the client to her elder sister and pressurized her into finding a job. However, she faced repeated failures
in competitive exams and experienced feelings of anxiety upon hearing her mother say that she will not get job.
Her hair pulling behaviour has been continuing for last 4 years and her anxiety increased gradually. According to
the client, her elder sister continues to interfere in her life matters repeatedly. She also reported low mood and
difficulties in falling asleep since the last 8 months. She reported that her sleep was decreased for 4 hours and
during this time she engaged with mobile phone. However, there was no physical tiredness due to insufficient
sleep after waking up. She was referred to psychiatric department upon consulting with a dermatologist in
February 2021.
Biological functioning

Sleep: Decreased

Appetite: Unchanged

Sexual interest & activity: Unchanged

Energy: Unchanged
 Negative history

History suggestive of-

1. No significant head injury.

2. No hair loss due to skin disease.
3. No primary skin infection leading to itching sensation.
4. No perception without stimuli.
5. No false, firm, unshakable belief that is not shared by others in her community
6. No periods of elevated or depressed mood.
7. No excessive free-floating anxiety.
8. No anxiety evoked by certain well-defined situations or objects.
9. No repetitive, persistent, unwanted, ideas, images or acts and rituals.
10. No sudden rapid non rhythmic motor movements.
TREATMENT HISTORY: -

The client’s first visit to the Institute of Psychiatry was on 10. 02.2021. She has been prescribed –

❑ Fluoxetine (SSRI) tab 20 mg (2-0-0)

❑ Olanzapine (Anti-psychotics) tab 5 mg (0-0-1)

❑ Mirtazapine (Anti-depressant) tab 15mg (0-0-1)

✓ Compliance – Good Side effects- None reported

✓ Outcome –Slight (30%) improvement in target symptoms reported

PAST ILLNESS:

 Medical-Jaundice (2011)

Psychiatric- None
 FAMILY HISTORY:

62 years

52 years

28 years

Consanguinity: Absent
Family interaction pattern:

● Communication: Direct, adequate, clear, verbal

● Leadership: Father is the nominal head and mother is the functional head

● Decision making: Democratic but decision about clients mostly taken by her elder sister.

● Role: Clearly delineated and agreed upon roles. Each role performed by all family member and client.

● Family rituals: Taking dinner together

● Cohesiveness: Present but not adequate

● Family burden: financial

● Expressed emotion: critical comments from sister

Family history of psychiatric/physical illness:

● The client’s maternal Grandmother has excessive washing and cleaning behaviour

● Impression- provisional diagnosis is OCD

PERSONAL HISTORY:
Birth & developmental history:
● Type of birth: Full term normal vaginal delivery at hospital with immediate birth cry
● Birth complication: None reported
● Milestones: Developmental milestones were age appropriately attained
Childhood Disorders- None significant
Parents & home atmosphere in childhood & adolescence: The client reported that she shared a congenial
relationship with both parents and they were supportive during the client’s childhood. However, her grandfather
discriminated between her and her elder sister since he wanted a boy grandchild. She did not receive any expression
of affection from him. When her parents gave her toys, her sister broke them. According to the client, her elder
sister was jealous, attention-seeking, and often tried to dominate her. The client’s mother reported that she was often
unavailable to care for the client in her infancy since she had lots of responsibility in her joint family. The client’s
father reported not being able to fulfil the demands of both daughters due to financial difficulties, and hence, the
elder sister received most of the privileges.
Home atmosphere: congenial
 Scholastic & extracurricular activities:

● Highest grade completed: M.SC

● Academic performance: Average

● Peer relationship – she has few good friends.

● Any disciplinary problems – None reported

● Hobbies, Interests and extracurricular activities – Drawing and cooking

Interpersonal relations & social activities:

The client interacts well with her peers as well as those younger and older to her. She also likes to
attend social gatherings but takes time to get comfortable with the situation. She does not take initiation
to make new friends.
 Occupational history: Not Applicable

Menstrual history

Menarche- 13 years age

Duration- 5 days

Periods- Regular

None physical/ psychological symptoms reported

Sexual history:

Knowledge –Knowledge acquired from peers at the age of 12

Attitude towards sex- Positive.

No history of sexual engagement including masturbation

No history of sexual abuse and sexual deviance was reported

 Habits and addiction:

● Sleep pattern – she used to Sleep around 8 hours at night, But Sleep disturbance reported currently.

● Food Habits – Non - Vegetarian.

● Substance Use – No use of substance reported

Legal history

● None reported.
 Premorbid Temperament

● Activity level- moderate

● Rhythmicity-regular

● Distractibility-not distractable

● Approach/withdrawal- shy

● Adaptability- can adjust well in new situation

● Attention span and persistence- adequate and persistent

● Intensity of reaction- appropriate

● Threshold of responsiveness- adequate

● Quality of mood- cheerful

● IMPRESSION: Easy temperament (Thomas and chess, 1977)

 MENTAL STATUS EXAMINATION:

Consciousness: Conscious and alert

General appearance & behaviour:

● Appearance: Well kempt and tidy

● Body build: Age-appropriate

● Hair: Well-groomed

● Contact with the surroundings: Present

● Eye contact: maintained

● Rapport: Easily established

● Attitude towards examiner: Cooperative

● Motor behaviour: within normal limits

 Speech:

● Intensity - Audible

● Reaction Time to stimulus – Normal reaction time

● Speed – Normal

● Prosody/Tempo - Normal fluctuations

● Ease of speech – Spontaneous

● Productivity/Volume - Normal

● Relevant to the context/situation

● Coherent

● Goal directed

Volition: Within normal limits.

Cognitive functions:

Orientation: Well oriented towards time, place, person, date, day, month and year.

Attention & concentration: Easily aroused and sustained.

Test-Serial Seven Subtraction test was given. 100, 93,86,79,72, 65

Memory:

Remote memory

Personal– Name of primary school in Std IV – Hatbasantapur Primary school

Date of Birth- 18.05.1995

Impersonal – Prime Minister of India – Narendra Modi

Name of 3 consecutive chief Minister of West Bengal – Jyoti Basu, Buddhadeb Bhattacharya and Mamata
Banerjee
 Recent memory –

“kaal raat e ki kheyehchilen” – bhaat, dal, dimer jhol

“aaj shokal e ki bhabe ele” – bus e kore

Immediate memory – DF – 7, DB – 5 WR – 4/4

Impression – Intact recent, remote and immediate memory

Abstraction:
Similarities –
First and last – 2to e position

Liberty and justice – 2to e rights Impression - Conceptual level of abstraction

Proverbs –

Nacchte naa jaanle uthon baka – “aami jei kaaj ta jaani na, orr dosh dicche onno keu ke”

Ulobone mukto chorano- ojoggo lok ke jokhon valo kichu peye jay
 General Intelligence

Information

1. Who discovered Kolkata: Job Charnock

2. Which Indian economist got Noble prize: Amartya Sen

Calculation

1. How many inches in 2 and ½ feet – andaaj e bolchi 24-inch hobe;

2. If 7 pens costs 2 Rs each and you give 50rs to the shopkeeper how much will you get back – Rs. 36

Comprehension

1. Why does the Government impose tax – Desh er unnoti er jonne, bibhinno nirman er jonne

2. Why marriages should be registered – So that it is justifiably under the law and if any problems occur,
then the law can take the adequate course
 Vocabulary

1. Ambassador- person representing your country in foreign land

2. Auspicious – Prosperous

Impression – Average level of intelligence

Judgement – Test, Personal and Social Judgements were intact

Lobe functions: Intact (Able to do the clock drawing and alternate pattern drawing tests)
 Affect

 Subjective – kichuta tension hoche

 Objective – Anxious

 Depth – Normal

 Range – Adequate

 Stability – Stable

 Appropriate to the situation

 Communicable

 Reactivity to stimulus – Normal

 Thought

1. Stream: Normal

2. Form: normal

3. Possession: Normal

4. Content: pre-occupation of hair plucking urges

Perception – No abnormality could be elicited

Insight – Grade VI level of Insight (Emotional Insight)

Sample Talk – ami age jantam na eta manishik rog tai eto din treatment koraini. Ami ageo dermatologist er kache
giyechilm tara age bujhte parle eto din e onek ta sustho hoy jete partam. Last time jokhon dermatologist bollo eta
psychiatric problem tar por thekei ami treatment start korechi. 8 months asudh kheye kichuta symptoms
komeche. Baki treatment tao continue korte chai.
DIAGNOSTIC FORMULATION:

Index client A.P a 26 years old, Bengali speaking, Hindu female, with education up to Master’s, currently
preparing for Govt job, belonging to a middle socioeconomic status, hailing from a suburban nuclear family
background came with complaints of repetitively plucking of hair and sense of relief after pulling hair for
last 12 years, increased anxiety for last 4 years and disturbed sleep, low mood for last 8 months with nil
identifiable precipitating factors, with insidious onset, continuous course and fluctuating progress, with
decreased sleep, treatment history suggestive of SSRI, Antidepressant and Antipsychotic for last 6 months
with slight improvement , family history suggestive of undiagnosed OCD in maternal grandmother, critical
comments from elder sister, personal history reveals insecure attachment in childhood, discriminating
attitude of grandfather, dominated by elder sister with easy temperament ; Mental Status Examination
reveals well kempt tidy appearance, age appropriate body build, presence of eye contact, easily established
rapport, cooperative attitude, normal motor behaviour, with audible, relevant, coherent, spontaneous, goal
directed speech, intact orientation, easily aroused and sustained attention, intact memory with conceptual
level of abstraction, average general intelligence with intact judgement, anxious, stable, reactive,
communicable objective affect, with pre-occupation of hair plucking urges in thought content with grade VI
level of insight leads to the……….
PROVISIONAL DIAGNOSIS
ICD 10
F63.3 Trichotillomania

Points in favour Point against

Recurrent impulse to pull hair resulting in None

noticeable hair loss.

Tendency to pull hair when anxious.

Sense of relief after plucking hair.

DSM V
312.39 Trichotillomania (Hair pulling Disorder)

Points in favour: Point Against:

Recurrent Pulling out of one’s hair, resulting in hair None
loss.
Repeated attempts to decrease or stop hair pulling.

The hair pulling causes clinically significant distress

or impairment in social, occupational or other
important areas of functioning.

The hair pulling or hair loss is not attributable to

another medical condition. (e.g., a dermatological
condition)

The hair pulling is not better explained by the

symptoms of another mental disorder (e.g.,
attempts to improve a perceived defect or flaw in
appearance in body dysmorphic disorder)
FINAL DIAGNOSIS
The provisional diagnosis was taken as the Final Diagnosis for further management, considering the points in favor and
points against the same.
.
PROGNOSTIC FACTORS
Good Prognostic Factors Poor Prognostic Factors
● Female ● Adolescent onset

● Good educational background  Financial burden

● Average level of intellectual  Choric nature of illness

functioning

● Grade VI level of insight  Critical comments of sister

● Easy temperament  Family history of psychiatric illness

● Absence of comorbid disorder  Unknown precipitating factor

● Supportive parents
● Good compliance to medication
PSYCHOPATHOLOGY FORMULATION
MANAGEMENT PLAN:

LOCUS OF THERAPY: Outpatient hospital based set up with one individual.

FOCUS OF THERAPY:

Short term goals:

● Engagement in the therapeutic session

● To inform and educate the client regarding the illness

● Decreasing autonomic symptoms and anxiety

● Awareness through self-monitoring

● Developing competing response

 Long terms goals:

● Relapse prevention

● To enhance coping skills

● To improve overall adjustment

MODUS OF THERAPY PROCESS:

Behaviour Therapy
RATIONAL FOR BEHAVIOR THERAPY:

The client faces difficulty in the reduction of anxiety as the client cannot pull the hair, relaxation will be
introduced as counter-conditioning to anxiety and for better compliance in treatment. Distressing
behaviours such as anxiety is often caused by maladaptive learning that triggers undesirable autonomic arousal.
Relaxation training will thus serve as a self-control procedure that will help the client develop a set of
response to modify autonomic arousal. Progressive muscle relaxation, involving successive flexing and
relaxing of voluntary muscle, will thus help in the reduction of anxiety.

Habit Reversal consists of two main components. The first is awareness Training, in which individual take the
time to get some very specific observations of one’s hair pulling habit: when they do it, where they do it, which
hand, which fingers, and so on. The most important outcome of this training is to develop a very good
awareness of the early warning signs (internal and external) that one is about to start pulling. When one
notice a warning sign, this serves as a signal for them to reply with the second part of Habit Reversal, an
incompatible or competing response. A competing response would be some action that makes it hard, or
impossible, to pull your hair.
INTERVENTION: THERAPY PROCESS:

Session 1: Agenda: Clarification of history, psycho-education, sleep hygiene, baseline assessment for therapeutic
purpose, engagement and introduction to therapy.

 In the first session the history was clarified, mental status examination was done and a provisional diagnosis was
reached at.
 She was then given information and education regarding her illness, its course, prognosis, common comorbid
conditions and possible causal factors in the development of pulling hair, how the therapy would go about and
help her to cope with her problems. She was informed about what to expect from therapy as well. Role of anxiety
and stress was emphasized.
 Moreover, it was emphasized by the therapist that it was a collaborative approach and that active participation on
the part of the client was expected and that it would lead to better progress in therapy. The role of homework
assignments and the necessity of performing them was also explained. Medication compliance was also discussed
with the client.
 Sleep hygiene explained.
 Base line assessment done for monitoring the effectiveness of therapy. BDI- 15 (mild subjective distress);BAI-23
(moderate levels of subjective anxiety) Massachusetts General Hospital Hairpulling- 15
SESSION 2: Agenda: Jacobson progressive relaxation training introduced.

 The session initiated with the feedback from informant and the client about the previous session. Since
the subjective anxiety of the client was quite high, progressive Muscular Relaxation was planned.
 She was explained that the relaxation exercise would serve as a method of modifying autonomic arousal
which occurs during anxious states. She was informed how tension affects the body and how by reducing
the tension in the body the mind also becomes less tensed.
 The client was explained that physiological arousal is governed by the autonomic nervous system which
has two branches: the sympathetic and the parasympathetic. The sympathetic branch increases arousal
when the organism is under threat and the parasympathetic restores the body to its resting state. These
actions enable the survival of organisms. It was explained that the relaxation response aims to counteract
the effects of sympathetic activity by prompting the action of the parasympathetic nervous system as
there is a reciprocal nature to their actions.
 It was discussed which muscle groups would be involved in the training and the method for tensing and
subsequently relaxing them was demonstrated by the therapist.
 She was then asked to follow the instructions of the therapist and relaxation training was started. The
client was asked to made a comfortable posture with closed eyes and the muscle groups were made to
tense and relax gradually one by one. The client was given the instruction to become aware of the two
competing states of tension and relaxation and to be able to discriminate between them. Tension was
maintained for 8 to 10 seconds followed by relaxation for 20-25 seconds.
Homework assigned: After explaining the exercise, the client was emphasized and encouraged about
practicing progressive muscle relaxation regularly and how it would improve with practice was
emphasized.

Feedback from the client: - after the training of relaxation, the client was asked if she had faced any
problems in performing the steps. She denied facing any such difficulty and said she felt quite calm after
the exercise.

Therapist reflection: - considering the motivation level and cooperative attitude of the client, the therapist
was hopeful of positive outcomes of the therapy process.
SESSION 3
Agenda: Functional analysis of problematic behaviour, introduction to self-monitoring task, Reassessment
of anxiety, depression and hair pulling scale.
 JPMR was reviewed, the client reported that she was performing the exercise regularly. The therapist
asked the client to demonstrate the exercise during session. It was found that the client was following
the procedure correctly. She was appreciated for this and was asked to continue it twice daily.
 Functional analysis of plucking of hair was done with the help of client.
 With the help of client, preliminary measures of frequency, duration and intensity of plucking behaviour
was obtained.

Behaviour Duration Intensity

(on 10- Frequency
point
scale)
Plucking 15 7 4-5
of hair minutes times/day
 Related to antecedents-

1. Are there circumstances in which plucking of hair particularly occurs?

Only home, mostly while alone in bedroom or dining room

2. Are there circumstances in which plucking of hair never occurs?

Other than home, all other possible situation public place, relatives’ home

3. Does the behaviour only (more often) during particular activities?

While studying, argument with sister, thinking about job

4. Is there any internal cues associated with it(specify)?

Visual- none Tactile- tickling sensation over scalp

Affective- mostly during the time over stressed Cognitive- none

5. Does the behaviour more likely occur in specific period of time?

Mostly occurs during evening and night time.

Related to behaviour-
1. Preferable body site of plucking hair? Mostly scalp
2. Specific procedure for plucking of hair procedure?
Wandering one hand over the skin and searching for the right hair which can get maximum stimulation after
plucking
3. Any instrument required?
Plucking mostly done by the pull of index finger and thumb of right.
4. Fate of plucked hair?
Discarding it immediately by throwing away.
Related to consequences-

1. Any positive consequences? Relief from short term reduction of anxiety

2. Any negative consequences? Losses of hair and sadness
Reassessment done beck depression scale, beck anxiety inventory and general hospital hair pulling scale. In
all domains the scores slightly decreased.

BDI= 13, BAI=16, hair pulling scale=12

 The client was introduced with self-monitoring task of her hair pulling behaviour. Self-monitoring
requires that client to record her urges to pull hair, including the frequency, duration and situations in
which the urges occur.

Homework assigned- self-monitoring task given and continuing JPMR.

Feedback from the client: - client gave positive feedback about the session. She showed satisfaction
with sessions and slightly relief from her problem

Therapist’s reflection: - client properly following the skills, which she learned from therapy session. It
was a positive hope for better outcomes of the therapy.
 SESSION 4 Agenda: - Self-monitoring task assessed and diaphragmatic breathing introduced.

 Review of the previous session with self-monitoring task. She was maintaining the self-monitoring log for 1
week.

 Awareness training taught to the client on the basis of her self-monitoring log. The purpose of awareness
training was to get the client to recognize and react to episodes of the pulling or antecedent stimuli. Awareness
training involves describing the pulling, describing the sensations and behaviours that precede the pulling.

 Diaphragmatic breathing exercise introduced and asked to practice when she become aware about her urge.
The following instruction was given and demonstrated once.

Spend a few moments running through a sequence of pleasant imagery…. Then, as your mind relaxes
turn your attention to your breathing… lay one hand lightly over the abdomen (solar plexus). Focus your
attention on this area. Start the exercise with a breath out… a naturally occurring breath out. Notice a slight
sinking of the area under your hand. Next, allow air to flow into the lungs, noticing the slight swelling which
takes place under your hand. Then as the air is expelled, notice the area under the hand shrinking back again.
Allow the breathing to take place naturally.
 SESSION 5

Agenda: Reassessment, teaching the competing response

 Previous session was reviewed from the client. She reported that she can identify the cue when the urge came
in her mind multiple times after getting awareness training from previous session. She reported she practiced
diaphragmatic relaxation when she became aware. She can also control her urge after practicing relaxation.

 In this session focused on teaching the “competing response” which is acquiring of a muscle tensing activity
which is somewhat opposite to, and incompatible with hair pulling. She was taught to make a clenched fist
with the hand she uses to pull hair, to bend the arm at the elbow 90, and to press the arm and hand firmly
against her side at waist level. She was then instructed that whenever she gets the urge to pull, she was to
relax herself, do diaphragmatic breathing for 60 seconds, and the competing response for 60seconds.

 BAI=9, BDI=10, HAIR PULLING SCALE=9

Measures of frequency, duration and intensity of plucking behaviour was obtained.

Behaviour Duration Intensity Frequency

(on 10-
point
scale)
Plucking 5 minutes 4 2 times/day
of hair

Homework assigned- Asked the client to practice the strategies those are teach throughout the session and
advise to continue relaxation training.
Feedback from the client: - client was happy and proud of the improvement she made. Initially client was
little confused about competing response then again clarified from the therapist.
Therapist’s reflection: - the client is giving the genuine efforts and she was further got motivated by the
marked improvement. However, the therapist was apprehensive whether the competing response will work with
the client or not.
 SESSION 6 Agenda: - Replacement behaviour introduced; postural variation explained, discuss about study skills.

 Previous session was reviewed. Clients reports that she had been practicing relaxation training and maintain the self-
monitoring log regularly. She can also practice competing response most of the time. In few situations when she
studies, she cannot aware of her urge and competing response was difficult to follow. Awareness training phases
were re-discussed with the client.

 Replacement behaviours including cue-controlled relaxation and postural variations such as not holding her head
during study time. It was recommended to increase the distance between her hands and head at all times and hold a
pen in whichever hand was idle while she was studying.

 It was also evident from self-monitoring log that plucking occurs mostly during the time of studying. It was felt by
the therapist to initiate with habit skill training to deal with her problems of procrastination to study and time
management.

 Feedback from the client: - client reported that time management skills will be really helpful to her as she can
cover the syllabus in a systematic way and it make her less distressed.
SESSION 7

Agenda: - Reassessment, previous strategies monitored, termination planned

 Previous session reviewed. She made a study schedule to prepare job entrance. She would follow it. After
managing her time, she also observed her urges to pulling hair was significantly decreased. Client also report
she is practicing relaxation regularly and it helps her a lot to manage her stress during study time. Her
concentration and productivity were also increased.

 BDI=2, BAI=4, HAIR PULLING BEHAVIOUR=4

 All the techniques including JPMR, diaphragmatic breathing, self-monitoring, awareness training, competing
response are discussed with the client briefly and asked to use the strategies for better improvement.
Termination of main session was done after discussion with the client. Booster session planned once in a
month for relapse prevention.

 Feedback of the client:- She reported feeling very motivated by the therapy session and by seeing how well
she could change her problematic behaviour. At the same time, she expressed concern being able to do so
without the therapist’s help.
OVERALL THERAPIST REFLECTION

The session went satisfactorily and the therapist was pleased that the problem behaviours had decreased, to the
extent that both the client and her mother did not have any presenting complaints. She was also happy to see
that the client was taking active interest and asking questions when having doubts and queries.

OUTCOME OF THE THERAPY

The therapy was conducted over 7 sessions so far and it yielded an improvement in the client’s overall
performance. There was a reduction in client’s general level of anxiety experience. Over 5 sessions there was
significant decrease of hair pulling behaviour in the client.

FUTURE PLAN

● To enhance coping skills

● Focus on any associated cognitive symptoms

● Relapse Prevention