Mrs A, a 25-year-old woman, came to our hospital because of repeated hair pulling behaviour. Her medical history was collected via a detailed inquiry. More than 10 years ago, the patient was sexually discriminated against by her family and had a bad relationship with her parents. She gradually became unhappy, experienced self-abasement and became nervous, after which she began to repeatedly and uncontrollably pull out her hair, which was more obvious when she was in a bad mood. She had received psychological therapy and drug therapy for many years, but the effects were not good. Nearly a year ago, the condition worsened; she was upset, unhappy and was crying often. Additionally, the hair pulling phenomenon worsened, and she even used nail clippers to pull out the hair follicles on her head, and she had to resort to constantly wearing a wig to cover up the local hair loss. Furthermore, patients encountering increased pressure will exhibit intermittent binge eating attacks, but no emetic, diuresis or diarrhoea behaviour, thus resulting in a significant increase in weight gain. The patient had an obvious impairment in social function and had changed jobs several times. The patient had been successively diagnosed with "obsessive-compulsive disorder", "depression" and "anxiety disorder" in the outpatient department of our hospital. Sertraline tablets (up to 200 mg/day) and vofloxamine tablets (150 mg/day) were used as the main treatments, but the efficacy was still not good.
On admission, the patient had normal vital signs and obesity (BMI: 28.23 kg/m2), and she was wearing a wig. The hair defects in the temporal and occipital regions were obvious, and the local hair follicles in the scalp were red and swollen with oozed blood (see attached figure 1., the local hair defect). After admission, the examination revealed the following: clear consciousness, orientation and complete contact cooperation, denials of auditory hallucinations, the existence of tinnitus, depression associated with anxiety, a low degree of self-evaluation, negative ideas (but no behaviour), emotional response coordination, no obvious body-like obstacles, hypoactivity, poor interest and a good insight. Laboratory and auxiliary tests revealed the following: TG, 5.06 mmol/L; and abdominal colour ultrasound, fatty liver. The psychological tests revealed the following: Y-BOCS, 18 points; HAMA-14:22 points; HAMD-17:18 points; and Eating Disorder Questionnaire (EDI), 245 points. EEG, ECG and head MRI scans showed no obvious abnormalities.
After admission on the basis of the original treatment, the patient was given a combined treatment with NAC, starting at 600 mg and titrated gradually to 1,200 mg (D4) and 1,800 mg (D9). During this period, the patient's anxiety and depression were significantly improved, the obsessive symptoms were alleviated, the hair plucking behaviour was significantly reduced and her binge eating was also significantly alleviated; subsequently, the patient was discharged from the hospital on day 11.
A follow-up 2 weeks after discharge showed that the patient's mood was stable, her anxiety was alleviated, no hair plucking behaviour was observed, her hair was thicker than before and inflammation was significantly improved. A follow-up 4 weeks after discharge showed an improvement of her obsessive symptoms, no episodes of binge eating and her normal occupation of teaching had resumed. A follow-up 14 weeks after discharge (16 weeks after treatment) showed no obvious obsessive-compulsive symptoms, no episodes of binge eating (BMI: 26.95 kg/m2) and good working and living conditions (drug dosages and scale evaluations used during treatment are shown in Table 1, and changes in local hair defects are shown in Figure 2, Figure 3 and Figure 4).