Category Archives: Expert Advice

A Beginner’s Guide to Treating Trichotillomania

Clinical Psychologist

I often tell my colleagues that trichotillomania (hair pulling disorder) represents the wild west of psychological disorders. Unfortunately, it remains one of the least researched and most misunderstood disorders in the DSM. Additionally, there is a lot of pseudoscience, snake oil, and plain old quackery on the internet about the best way to treat it.

In this article, I will highlight what we do know about scientifically supported treatments for trichotillomania. As a disclaimer, this is only an introduction to treating trichotillomania and is not intended to formally train clinicians. Lastly, I will not be reviewing medical treatments for trichotillomania (you can learn more about those here).

Historical Treatments

hands.jpg

Photo by Gregory Parker

The first scientifically based treatment for trichotillomania was Habit Reversal Training (HRT) (Azrin, Nunn, & Frantz, 1980; Duke, Keeley, Geffken, & Storch, 2010). During HRT, individuals become more aware of their hair pulling behavior and practice interrupting the behavior by engaging in incompatible behaviors. For example, people who use their hands to pull from their scalp might practice reaching down towards one’s knees. While HRT has been effective in the treatment of tics and Tourette’s Disorder, it doesn’t work for everyone who has trichotillomania and also has a high rate of relapse. Why? As I described in a previous article, trichotillomania is a very heterogeneous disorder and affects each person differently. A “one size fits all” treatment just won’t work for trichotillomania.

Modern Treatments

Recently, researchers have developed more comprehensive approaches to treating trichotillomania. Dr. Charles Mansueto pioneered the Comprehensive Behavioral Model (ComB) for trichotillomania (Mansueto, Stemberger, Thomas, & Golomb, 1997). In ComB, clinicians first understand the function of hair pulling. Does it relieve stress? Does it end boredom? Does it reduce anger and frustration? Next, clinicians identify the main types of hair pulling. Some individuals pull for sensory stimulation (trying to find the hair that feels just right), others due to specific thoughts (I have to get rid of all the grey hairs), etc. Lastly, clinicians create treatments that address all aspects of trichotillomania including emotional regulation (learning more adaptive ways of dealing with stress, anger, boredom), physical habits (using HRT and objects to stop motor behavior), and environmental interventions (covering mirrors, getting rid of tweezers).

While research is underway to evaluate Mansueto’s ComB model, other researchers have found support for this approach to treating trichotillomania. In a recent pilot study, Dr. Nancy Keuthen and her colleagues found that Dialectical Behavior Therapy (DBT) was effective at reducing trichotillomania symptoms for at least 3 months (Keuthen et al., 2010). DBT is a form of cognitive behavior therapy that focuses on learning new ways of regulating one’s emotions. Additionally, in a review of all published scientific treatment studies on trichotillomania, Dr. Michael Walther and his colleagues concluded that behavior therapy (HRT), emotional regulation, and acceptance together represent the most promising treatment for trichotillomania (Walther, Ricketts, Conelea, & Woods, 2010). Furthermore, Dr. Martin Franklin and his colleagues have demonstrated that this comprehensive approach to behavior therapy not only works for adults, but it can help children as young as 7 (Franklin, Edson, & Freeman, 2010).

So what does this all mean? To the best of our scientific knowledge, effective trichotillomania treatment includes three things:

  1. An increased awareness of when, where, and why hair pulling occurs.
  2. An effort to control or change hair pulling behavior.
  3. Emotional regulation training to find alternative ways of dealing with negative feelings.

Here’s how I use these scientific findings to treat trichotillomania.

Increasing Awareness

Photo by Wim Mulder

Before creating a treatment plan, I collaborate with my clients to understand the unique patterns of their hair pulling. This usually includes a 1-2 week record of all hair pulling episodes. I ask each client to record the following information after each hair pulling episode:

  • What part of the body was the hair pulled from?
  • Where was the person when they pulled their hair?
  • What time was it when the person pulled their hair?
  • Was an instrument (e.g. tweezers) used to help pull hair?
  • What was the person doing while they pulled their hair?
  • What was the person feeling before, during, and after the hair pulling?
  • What was the person thinking before, during, and after the hair pulling?
  • Was anyone else present during the hair pulling?
  • What did the person do with their hair after they pulled it? (Sidenote: You’ll want to look out for individuals who swallow their hair, this could lead to a potentially lethal condition known as a trichobezoar and will need immediate medical attention).

Changing Hair Pulling Behavior & Emotional Regulation

Photo by Aimee Quiggle

A key component of Dr. Manysueto’s ComB model is the SCAMP Intervention. SCAMP stands for Sensory, Cognitive, Affective, Motor, and Place. Once my client and I have a firm understanding of the hair pulling behavior, I use the SCAMP Intervention to create a customized treatment plan.

Sensory: For individuals who seek sensory activation on their scalp, we might use brushes, combs, pens, massages, or ice to ease sensations. For hands, individuals can get manicures, use lotions, or file their nails. For the face, bath oils, baths, facial scrubs, or a loofah could be used.

Cognitive: Often specific thoughts can lead to hair pulling. Common thoughts include, “My hair has to look perfect”, “I need to get rid of that blemish”, “I’ll just pull a little”, “I’ve already pulled once, so why try holding back?” Here, individuals practice thinking in more realistic way (e.g. “It’s okay to be imperfect”, “The best way to fix it is to let it heal”, and “A slip-up is not a failure, any progress is helpful”).

Affective: When specific emotions lead one to pull their hair, the best way to address this problem is learn more effective ways of regulating your nervous system. To become more relaxed, individuals can use diaphragmatic (belly) breathing, progressive muscle relaxation, practice meditation, listen to white noise, use a heating pad, drink a warm beverage, take a slow relaxing walk, use an eye/face gel mask, or take a long bath. To address intensity and pain, individuals can stick their fingers in frozen ice cream, put their face in a bowl of ice water, suck on a lemon, snap a rubber band on your wrist, take a cold shower, go for a fast run, or chew a large wad of gum. To deal with boredom, individuals can learn about a topic of interest on the internet, write in a journal, draw, play a musical instrument, read a book, paint, take photographs, do a crossword puzzle, and garden.

Motor: In addition to HRT, physical barriers can often help reduce hair pulling. For example, rubber fingers, band-aids, sleep masks, head wraps, glasses, hats, gloves, thumb braces, and tape can all be used to create barriers to hair pulling. Also, changing the condition of your hair and hands can help (e.g. wetting hair, placing Vaseline on your eyelids/brows, wearing false nails, using hand lotion). Objects such as loud bracelets, elbow braces, and perfume can increase awareness of hair pulling. Fiddling toys can sometimes provide alternatives to hair pulling (e.g. koosh balls, silly putty, clay, knitting). For oral rituals, chewing gum, eating sunflower seeds, chewing raw pasta, chewing a toothpick, and eating gummy bears can help.

Place: Comprehensive interventions should also target the environment in which hair pulling takes place. Individuals can try changing light levels, covering mirrors, getting rid of tweezers (or placing them in the freezer), using sticky notes, keeping certain doors open (to decrease privacy), rearranging furniture, and sitting in different positions.

Monitoring Progress and Revising Treatment

As a client and clinician begin treatment, it’s important to keep a daily log of the hair pulling episodes and the attempted interventions. Some interventions will work right away, others will need to be fine tuned, and some will lose their effectiveness over time. The client and clinician must work together, constantly monitoring and reevaluating the treatment until a plan is developed that fits the needs of the client. This process could take weeks or months. Additionally, since trichotillomania changes as we age, treatments that worked at one phase of life may not work in another.

Advice for Treatment Seekers and Treatment Providers

As you can tell, treating trichotillomania is a complex and long process. It takes a lot of time, courage, and motivation on the part of the individual and a lot of training and experience on the part of the clinician. If you are someone who is suffering from trichotillomania, make sure that your clinician is using scientifically supported treatments. Ask them about the type of treatment they are using. If you don’t hear anything about increasing awareness, changing behaviors, or emotional regulation, their treatment may not be based on science. If they start using personal testimonials and wild theories to backup their treatment, or say their treatment cannot be evaluated by science, run away – they’re probably selling you snake oil.

I recommend using the Trichotillomania Learning Center’s list of health care providers to find individuals trained in scientifically supported treatments. If you are a health care provider wanting to learn more about these treatments, I highly recommend attending a Trichotillomania Learning Center Professional Training Institute and browsing through their clinical resources.

References:

Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair-pulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13-20.

Duke, D., Keeley, M., Geffken, G., & Storch, E. (2010). Trichotillomania: a current review. Clinical Psychology Review, 30, 181-193.

Franklin, M. E., Edson, A. L., & Freeman, J. B. (2010). Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child and Adolescent Psychiatry and Mental Health, 4, 18.

Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., et al. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27(10), 953-959.

Mansueto, C. S., Townsley-Stemberger, R. M., McCombs-Thomas, A., & Goldfinger-Golomb, R. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17, 567-577.

Walther, M. R., Ricketts, E. J., Conelea, C. A., & Woods, D. W. (2010). Recent Advances in the Understanding and Treatment of Trichotillomania. Journal of Cognitive Psychotherapy, 24(1), 46-64.

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Peace

Reflections on Skin Picking and Hair Pulling - OCD Center of Los Angeles

Reflections on
Skin Picking and Hair Pulling

__________________________

Peace is not something you wish for; it’s something you make, something you do, something you are.

~ Robert Fulghum

__________________________

Peace

It’s quite natural to crave a feeling of peace. This is true whether you are experiencing a significant mental health issue, coping with a personal crisis such as a divorce or the death of loved one, or just trying to effectively manage the vicissitudes of every day life.

If you suffer with Skin Picking Disorder or Trichotillomania, peace is likely something you have been “wishing” for throughout your struggle. Of course, it would be wonderful if a feeling of peace would descend upon us just by wishing for it. But in reality, peace requires action. If you are committed to finding peace, you must wholeheartedly agree to do the work involved in attaining it.

In many ways, peace is a function of conscious acceptance in that it requires us to choose to accept reality as it is, rather than as we would like it to be. Of course, this may not be easy – sometimes the urge to pick or pull may be so powerful that it feels almost impossible to peacefully accept. Some with Skin Picking Disorder or Trichotillomania describe their urges as being like a loud sound that simply can’t be ignored – as if someone has turned the volume of the urge up so high that it is the only thing they can pay attention to.

In order to move through and past this extremely distracting urge, the first thing you must do is to fully accept its existence. If you spend your time attempting to control or avoid your picking and pulling urges, all you are doing is spending time engaging with something you cannot control.

Once you have accepted the presence of your loud and annoying urges to pick or pull, you can choose to engage in other activities. When you do this, you will notice the volume of your urges decreases because they are no longer front and center. They will still be there, but they will not be all-consuming. By choosing the action of doing something other than engaging with the urge, you take an enormous step forward in your recovery.

Choosing to act differently in response to your urges may at first feel quite difficult. But keep in mind that peace is not just wishing or hoping – peace is “something you do”. It is something that requires repeated practice. And with effort and commitment, it eventually becomes “something you are”.

__________________________

1) In what ways are you accepting, or not accepting, of your unwanted urges to pick or pull?

2) What actions might you take to further develop a peaceful, accepting relationship with your urges?

3) What are some activities that you find peaceful, and how can you implement them in your daily life?

__________________________

Weekly Tip: This week, try to be mindful of your thoughts, feelings, and actions at those times when you are able to accept and move through an urge without giving in to it. Notice if there is a sense of peace after you accept an urge rather than trying to control it. Practice this approach in order to develop a consistent, new pattern of responding to your urges with acceptance, action…and peace.

__________________________

For a free subscription to “Reflections”, please click here.

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD, Skin Picking Disorder, Trichotillomania, and related conditions. We offer the following services:

  • Individual Therapy
  • Low-Fee Group Therapy
  • Online Therapy
  • Phone Therapy
  • Home Visits
  • Intensive Outpatient Program
We treat adults, adolescents, and children, and offer services six days a week, including evenings and Saturdays. For more information, please contact one of our client coordinators at (310) 824-5200 (ext. 4), or click here to email us.
__________________________

OCD Center of Los Angeles
http://ocdla.com

(310) 824-5200

Written by
Kelley Franke, MA
and Tom Corboy, MFT

© 2016 OCD Center of Los Angeles

We will never share, rent or sell your personal information to third parties.

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Inositol

Studies show that Inositol helps many Trichotillomania suffers. I find that it reduces the urge to pull, which helps with my focused pulling. The Inositol also increases my awareness, which decreases my unfocused pulling.

Leading Trichotillomania specialist Dr. Penzel’s wrote, Inositol and OCD. He recommends the following regimen to begin Inositol: 

(1 teaspoon=2 grams, and be sure to use a measuring spoon) for an adult:

Week 1 – 1 teaspoon/2x per day
Week 2 – 1 teaspoon/3x per day
Week 3 – 1.5 teaspoons/3x per day
Week 4 – 2 teaspoons/3x per day
Week 5 – 2.5 teaspoons/3x per day
Week 6 – 3 teaspoons/3x per day

Following this regimen, I worked my way up and now take 18g each day. I do this by mixing 3 teaspoons (1 tablespoon) of inositol in water 3 times a day. I have found the Jarrow brand powder (shown above) to dissolve well. It is available on amazon for reasonable price. I mix it with warm water as it dissolves better that way. You can add it to fruit juice or other sweetened drink. I simply mix the powder with ~3oz of warm water and drink plain as it has a mild sweet taste that I actually like. In addition to Inositol, l I take 1800mg of  NAC, which I started several months before the Inositol. I did not see much progress with that alone, therefore I added the Inositol. If you are considering both supplements, choose one to start with, otherwise you will not know which is helping and or causing side effects.

I have taken Inositol on and off for 2 years. When I first started the recommended regimen over 6 weeks, I noticed many GI side effects. When I unexpectedly became pregnant a couple months later, I had to lower my dose because it increased my nausea. That did not help so I discontinued the Inositol until my morning sickness passed. Reassured by my OB that Inositol is safe while pregnant and breastfeeding, I slowly reintroduced the Inositol. I only took 1-2 because it aggravated epigastric pain I had while pregnant. The lower dose helped a bit, but not nearly as well as the recommended 3 TBSP. Now that I am back to 3 TBSP per day (which I take in one large dose at night to help my insomnia), I am definitely feeling the benefits. It decreases my urges and makes me more aware of pulling.

Here’s more details information I copied from the article about Inositol use for trich sufferers, written by trich specialist Fred Penzel:

“Obviously, before you run out and try anything new, you should always consult your physician. If your physician recommends trying this, you might also want to mention the following information to him or her:

  1. It cannot be taken together with Lithium, as it seems to block its action.
  2. The chief side effects of inositol are gas and diarrhea. Some people get this for the first few days and then it clears up. Many of those taking it never have this side effect, and some only get it when they take more than a particular amount.
  3. I have heard reports that caffeine lowers inositol levels in the body, so if you are a heavy coffee drinker, you might consider cutting down or eliminating this from your diet. Actually, stimulants such as caffeine can sometimes contribute to anxiety, jitteriness, etc.
  4. It should be purchased in powdered form, and taken dissolved in water or fruit juice. It has a sweet taste, and is chemically related to sugar. If it is allowed to stand for about 10 minutes after mixing it, it seems to dissolve better. Vigorous mixing for a few minutes also helps. If it still doesn’t dissolve well (not all brands do), stir it up and drink it quickly before it settles. The use of powder is recommended, as the larger doses required could require taking as many as 36, 500 mg. capsules per day.
  5. Inositol is a water-soluble vitamin, so although the doses appear to be large, it will not build up to toxic levels in the body. Whatever the body doesn’t use is excreted. The average person normally takes in about 1 gram of inositol each day via the food they eat. There are no reports of any harm associated with the long-term use of inositol. Some of our patients have been taking it as long as eight years now, with no problems.6. It can be built up according to the following schedule (1 teaspoon=2 grams, and be

sure to use a measuring spoon) for an adult:

  • Week 1 – 1 teaspoon/2x per day
  • Week 2 – 1 teaspoon/3x per day
  • Week 3 – 1.5 teaspoons/3x per day
  • Week 4 – 2 teaspoons/3x per day
  • Week 5 – 2.5 teaspoons/3x per day
  • Week 6 – 3 teaspoons/3x per day

A child can be built up to 3 teaspoons per day over the same six-week period. Dosages for adolescents can be adjusted according to weight. In either case, it is best to allow side effects to be the guide. If they begin to occur, it is not considered wise to increase the dosage unless they subside.

Once a person has reached either the maximum dosage, or the greatest amount they are able to tolerate, it is best to try staying six weeks at that level to see if there is any noticeable improvement. If there is none by the end of that time, it should probably be discontinued. As with any treatment, those who are absolutely positive that it will help are only setting themselves up, and may wind up more than disappointed. Everything works for someone, but nothing works for everyone.”

Habits

habits-wordle1

__________________________

Chains of habit are too light to be felt until they are too heavy to be broken.

~ Warren Buffett

__________________________

Habits

We all have habits. In fact, many habits, such as putting on your seatbelt or brushing your teeth, are beneficial. But those suffering with Skin Picking Disorder and Trichotillomania have habits that are anything but beneficial.

All habits – good or bad – include three components:

  • A cue, which triggers the habitual behavior to start.
  • The behavior itself, such as picking or pulling.
  • A reward, which “reinforces” the behavior, thus leading you to repeat it in the future.

This is called a “habit loop” and it is a crucial principle in understanding these conditions.

Habit Reversal Training (HRT) is one of the most important strategies used in changing your behavior and breaking habit loops. The first step in HRT, as discussed here in previous installments, is building awareness of your picking and pulling. Once a trigger is identified, it can act as a warning sign that you are about to engage in a destructive behavior.

Using HRT, you learn to instead use a competing response to the trigger, rather than picking or pulling. This competing response should ideally be something that actively engages your hands, and which can be done easily in most situations. The immediate goal is to make picking or pulling more difficult, or even burdensome. Some examples of competing responses include squeezing a stress ball, knitting, writing, or painting. Basically, anything that keeps your hands away from your skin and hair!

By introducing this alternative behavior as a replacement for your habitual behavior, you interrupt the reinforcement, start the process of breaking the habit loop, and begin developing a new, non-damaging habit in its place. Additionally, some people use habit blockers such as gloves, to act as a further impediment to their picking and pulling.

It may take some time to find what works for you, and some things might work better than others depending on the given situation. As a result, you may at first find it difficult to consistently implement HRT, and may grow frustrated with yourself. But with repeated practice, you can learn to replace a destructive habit with one that is neutral or even positive. While HRT is seldom a solution in itself, it is a critical component of a long-term process of challenging these destructive, habitual behaviors.

__________________________

1) Create a list of the situations that often trigger you to pick or pull.

2) Create a list of different competing responses you might use this week when you feel the urge to pick or pull. (Hint: The TLC Foundation for BFRBs website at www.bfrb.org sells many inexpensive “fidgets” that can keep your hands busy.)

3) Keep a log of which competing responses work and don’t work for you this week, and try to come up with alternatives for those times that the competing behavior you try is not helpful.

__________________________

Weekly Tip: Remember that when you first start using competing responses, you might feel frustrated because you are using it so often, or because HRT is simply not working in that moment. This is a normal reaction, and it is important to keep trying new ways to break the habit loop. You might find that you will have to try several replacement behaviors, or to repeat the replacement behaviors numerous times before you start to experience success in breaking your habit loop.

__________________________

OCD Center of Los Angeles
http://ocdla.com

(310) 824-5200

Written by
Kelley Franke, BA and Tom Corboy, MFT

© 2016 OCD Center of Los Angeles

Treating the Whole Person: Part 2

Treating the Whole Person: A Personal User’s Guide, Part Two

Renae M. Reinardy, PsyD.,LP
Lakeside Center for Behavioral Change, PC
Fargo, ND

Reprinted from InTouch Issue 64, Winter 2012
© The TLC Foundation for Body-Focused Repetitive Behaviors. 2016. All Rights Reserved

As we bring in the New Year many people have the goal of making a significant change in their life. If you struggle with a body focused repetitive behavior (BFRB), that goal might be increased control over picking or pulling. In Part One of the Personal User’s Guide, we discussed how building a healthy foundation through nutrition, exercise and sleep are important to good health and decreased urges. We also looked at the balance of how we live our life in comparison to how we would like to spend our time and energy. Spirituality was also briefly discussed as a tool to improve our experience. Any one of these areas could be the focus for changes in the coming year. Do not overwhelm yourself, narrow your goals to what makes sense to you. The purpose of the Personal User’s Guide is to serve as a self-guiding compass. It is not a final destination, but a process of change.

Here are some other things to consider in planning your route in your personal change process. And, please pull out your notes from Part One.

My Mind

We are all actors in our internal soap operas. Our thoughts are incredibly powerful, yet we tend to just accept our internal script without much editing. Cognitive behavioral therapists encourage the process of cognitive restructuring. This involves identifying, challenging and replacing thoughts that are not true or helpful to us. It is good to look inside of your mind to make any helpful editorial changes to your internal script about BFRBs. Thoughts can involve perceptions of self control, permission-giving thoughts, perfectionism, and/or social judgments to name a few. Just like a soap opera, there tends to be many areas of dialog that can use some editing to more accurately reflect reality.

Identify: What is a thought that often comes up about your picking or pulling? How much do you believe it?
  • Is this thought true?
  • Is it helpful?
  • Is there another way of thinking about it that would be p helpful?Edited thought: What is my new self-care script about picking or pulling that is more positive, realistic, or takes a problem solving approach?

The script that we rehearse is the life that we choose to live. In addition to identifying, challenging and replacing toxic thoughts, it is also good to practice mindfulness. Mindfulness involves awareness of ourselves and how our mind functions. It is turning off autopilot. There is quite a bit of information out there on the benefits of mindfulness training. I would encourage you to practice a mindfulness activity daily. One thing at a time, being aware of ourselves and our activity in that moment. This also helps to improve awareness of BFRBs and can be a good substitute if your picking or pulling puts you into a “trance-like” state.

My Emotional Triggers

Emotional triggers are very common in picking and pulling behavior. It is good to understand what emotions your BFRBs are trying to regulate. Do you pull when you are bored? Tired? Frustrated? Unsure? Angry? Excited? Intolerant of less than perfect skin or hair?

Most common emotional triggers:

  • What sparks your emotions?
  • What do you do to cope with emotions?
  • What can you do to cope with emotions?

Once you are aware of your emotional triggers, you can start to learn and practice some adaptive emotional coping skills. For example, if you notice strong picking or pulling urges when you are frustrated, it may be helpful to learn a relaxation exercise such as controlled breathing or progressive muscle relaxation. Most cognitive behavioral therapists can help you identify which skills would be best for you to regulate trigger emotions.

Other Triggers

This article has already discussed some of the cognitive (thought-related) and emotional triggers of BFRBs, but it is important to look at other factors that may also influence your behavior. It is common for people to have certain locations that become conditioned as situational triggers (i.e., pulling in the car, picking when washing your face before bed, etc.). Sensory triggers are the fascinating experiences that people have when they pick or pull. It can be a tpingly scalp, the coarse feeling of a hair, a bump on the skin, or the pop of a blemish. There can be much satisfaction in these sensory cues, so it is important to understand if they are a factor for you, and what substitutes can be used to satisfy these sensory experiences.

Situational triggers:

Sensory triggers:

Other triggers:

My Strategies

In this section, take a few minutes to focus on one or two strategies/goals in each area. If it is overwhelming, break it down and focus on one area at a time. Once that becomes more of a habit add another to your daily routine. Remember to be flexible; there are often twists and turns in any journey.
There are a number of strategies that can be used; it may be helpful to review some of the resources on the “Resource Library” tab on The TLC Foundation for Body-Focused Repetitive Behaviors’ website,www.bfrb.org, for some additional inspiration.

My Body: Diet, Exercise, Sleep

How will you meet physical needs to promote overall well-being?
Example: Decrease soda consumption to 2 cans per week

My Life:

How will you create a better match between the “ideal” and the “real?”
Example: Check work email no more than 2x per week at home

My Spirit:

What steps will you take to connect to something outside of yourself?
Example: Practice walking meditation twice per week

My Mind:

How will you edit your internal script?
Example: Challenge permission-giving thoughts like, “I will start tomorrow” with “Trich is getting restless, now is the time to use a strategy before I even start pulling”

My Emotions:

What are some different ways you can cope with emotions
Example: Practice breathing exercise when mind is racing before bed

My Other Triggers: Sensory, Situational, Habits

Example: Meet sensory needs by using fiddle toy while on computer

Example: Modify situation trigger by practicing quick in and out of bathroom without lingering

Example: Make picking or pulling more difficult by wearing a rubber fingertip

As you practice these new patterns you will find that they will become stronger and the BFRBs will decrease in the frequency and intensity of urges. It is important to remember that it is still a part of you, but it can go into “hibernation.” Monitor how you are doing and evaluate which strategies work best for you in getting and keeping your picking or pulling under control by giving your body and mind what it needs in other ways.

My Story
What is the direction you have decided to take on this journey?

 

 

Many good wishes on your path.

Dr. Renae Reinardy is the founder of the Lakeside Center for Behavioral Change in Fargo, ND. Prior to opening her own practice, Dr. Reinardy worked as a psychologist at the Behavior Therapy Center of Greater Washington in Silver Spring, Maryland. Dr. Reinardy specializes in the treatment of hair pulling and skin picking disorders, obsessive compulsive disorder, compulsive hoarding, and related conditions. She has been an adjunct professor at the doctoral level and has presented numerous times at national conferences and at local meetings and trainings, including The TLC Foundation for Body-Focused Repetitive Behaviors’ Annual Conferences and Retreats. Dr. Reinardy has been interviewed on Good Morning America, the Joy Behar Show, Dateline NBC, and A&E’s Hoarders. For more information, visit www.lakesidecenter.org.

 

 

 

 

 

 

Treating the Whole Person

imageTreating the Whole Person:

A Personal User’s Guide

By Renae M. Reinardy, PsyD., LP

There are many different ways for us to understand our experiences in life. I have not found it helpful for clients to be overly harsh or punishing in their efforts to produce the changes they want to make. Rather, it is good practice to take a comprehensive, wise and compassionate approach toward getting unstuck on the path to change. Everyone’s path is different, so I want to offer a few tips that might help you to write your own Personal User’s Guide. This includes taking care of your mind, body and spirit in a comprehensive manner, which I will briefly outline in this article. Please have a pen and paper handy for taking notes as we go along.

Before reading on, take a few minutes to write down what your pulling or picking means to you. Questions to help you start include: How did this journey start, what directions has it taken you in, what have you gained and what do you feel like you have lost, what works, what doesn’t, when did the behavior start, and what function does it serve?

The way that I conceptualize BFRBs is that they are like a friend who is trying really hard to make a person feel better, but they do not offer the best advice. Pulling and picking are often ways for one’s body to sort out sensory, emotional, cognitive, spiritual, and physical deregulation. This friend may offer some quick relief or distraction from these experiences, but often there are no lasting gains. Rather, it can lead to a vicious cycle of behavior which can feel out of control.

Somewhere along the way, many people lose track of what they need and have stopped listening to their inner core. Instead, they tried to quiet it with distracting and impermanent forms of relief or pleasure. Let’s look at a few components of the Personal User’s Guide to see if it is helpful in hearing one’s self better.

One of the first things that I work on with my clients is the “pillars of health”. This is learning how to take care of one’s body through proper nutrition, sleep, exercise and general self-care. Again, if a person has any deregulation in their body, there is a good chance that the BFRBs will pick up on that imbalance and try to fix the problem. Let’s try in a new way, by looking at what might be contributing to the problem in the first place. Please ask yourself to honestly answer the following questions:
Nutrition: What do I eat?

List some typical items you consume on a daily basis for the following meals:
Breakfast
Lunch
Dinner
Snacks
Caffeine
Vitamins:
Exercise: How and when do you exercise?

Sleep: What time do you wrap up your day?

How long does it take to fall asleep?
Do you wake up at night?
What time do I wake up in the morning?
Well, how does it look?

If you are like most of us, at least some improvement can be made in how we care for our bodies. Perhaps there are one or two things from the lists above you’ve always wanted to change, or believe if you COULD change, it would help with your BFRB management. Can you identify one small difference you could make to begin?

Over the past few years, there has been more research to support the role of nutrition in BFRBs, including sugar intake, and dietary supplements. Some people have had great success with the supplements N-acetylcysteine (NAC) and/orInositol (B- vitamin) decreasing urges to pick or pull. Work with your healthcare provider to determine if these might be appropriate for you. I have also found that my clients experience great benefit when sugar intake is reduced.

In our typical diet, we are often starving for good nutrients. Our diet must contain 5 essential items to be truly healthy: carbohydrates, proteins (1/5 of our calories), fats, water and minerals. Amino acids are the building blocks of protein which plays a role in every cellular function of the body. Out of 20 amino acids present in the body, 9 are essential, meaning that they must come from diet. Clinical nutritionists have found that deficiencies in B1, B2, B6, folate, B12, C, magnesium and zinc are related to a number of mental health conditions. Since many people do not get what they need from their diet, vitamin supplements are often needed in addition to dietary changes. Be sure to get a good natural vitamin that your doctor approves.

The “E” word. Research has proven the mental health benefits of exercise. It is believed that exercise stimulates the production of endorphins—the feel good hormone. Serotonin, dopamine, and norepinephrine are also released during exercise. (Do these sound familiar? Yep, these are same chemicals that are targeted with many psychotropic medications.) Other benefits of exercise include improved blood flow, increased brain function, increased oxygen, and removal of toxins through breathing and sweat. Time to dust off those shoes with the laces. Start gradually and set realistic goals. For example, if you’d like to exercise more, maybe start with just ten minutes of exercise every day. Ten minutes of walking at a faster pace, ten minutes of jogging, ten minutes on the treadmill or the elliptical….then when that gets easy, add five more minutes. Before you know it, you are exercising for an hour. Talk to your doctor if you have any medical conditions that would restrict exercise.

Sleep is another thing we all know is important, yet is one of the first things to go in our busy schedules. The average adult needs 7-9 hours of sleep each night. Research suggests that people who do not get adequate sleep tend to live shorter lives than those who do. Chronic sleep deprivation also leads to increased risk of obesity, diabetes and heart disease. When we sleep, we produce extra protein molecules to help us fight off infection, stress and toxins by helping the immune system mend our bodies. Take good care of your body and your body will take good care of you. Again, remember that picking and pulling serve a function. If any of these areas are out of whack, you may notice urges on the rise in attempts to self regulate.

Take the time to evaluate your pillars of health. When we rush things, they tend not to be effective. In working with my clients, I’ve found that focusing on the pillars of health can be a big factor in getting someone unstuck when a traditional behavioral and cognitive plan are not enough.
How I Live My Life

Another piece of the Personal User’s Guide that I want to cover in Part One is how we live our life. So many times people plow through the day, just to work toward another goal—the weekend, a long-awaited vacation, or milestones such as graduation, retirement, etc. Yikes! There is often quite a bit of time spent waiting for something good to happen!

Draw two circles in your notebook. Label one circle “real Life” and the other circle “Ideal Life.” In each circle complete a pie chart: one on how you spend your typical day and the other on how you would like to spend your day.

How do they compare? Is there anything that you can take from your ideal and build into your everyday/real life? It is important to take time now to spoil yourself a bit—listen to music, get and receive hugs, sing, pet an animal, smile, pray, make good wishes for others, take a nap, get a massage, acknowledge yourself and your accomplishments, or try to find a quiet place to rejuvenate. We often cannot live every moment in the ideal, but it is good to not get stuck in long patterns of unfulfillment.

Can you think of a few ways you can incorporate goals from your ideal life into your real life? Write them in your notebook.

Okay, one more thing to think about in Part One of your Personal User’s Guide: Spirituality.

Pretty big topic and I am not talking about religion, although that can fall into this category. Focusing on one’s spirituality involves developing an inner life to experience greater connectedness through practices such as prayer, meditation and contemplation. These practices help us to experience a more comprehensive sense of self and the interrelatedness to others, nature and/or religious experiences. Recent research has shown the medical and emotional benefits of these practices including a more complex range of brain activity, stress relief, decreased heart rate, improved lung capacity, and decreased anxiety, to name a few. Please take a few moments and think of how you might summarize your spiritual life.
My Spirit: Take some notes on the following questions

What gives me inner strength and connectedness to things outside of myself ?
How can I build on this?

In Part Two of the Personal User’s Guide, we will discuss emotions, thoughts, and behavioral strategies that can help give your body what it needs. By learning and listening to ourselves it is possible to improve one’s overall well-being and decrease undesirable behaviors and patterns. In the meantime, best wishes in reinforcing or changing any experiences that you may have realized in completing.

This is part 1 of a two-part article. Read part 2, here >>

Dr. Renae Reinardy is the founder of the Lakeside Center for Behavioral Change in Fargo, ND. Prior to opening her own practice, Dr. Reinardy worked as a psychologist at the Behavior Therapy Center of Greater Washington in Silver Spring, Maryland. Dr. Reinardy specializes in the treatment of hair pulling and skin picking disorders, obsessive compulsive disorder, compulsive hoarding, and related conditions. She has been an adjunct professor at the doctoral level and has presented numerous times at national conferences and at local meetings and trainings, including The TLC Foundation for Body-Focused Repetitive Behaviors’ Annual Conferences and Retreats. Dr. Reinardy has been interviewed on Good Morning America, the Joy Behar Show, Dateline NBC, and A&E’s Hoarders. For more information, visit http://www.lakesidecenter.org.

 

 

How Long Does it Take to Break a Habit?

image.jpegYes Trich is more than a ‘bad habit’. However, it is an unwanted behavior that I believe can be unlearned or changed.

My goal is to break this ‘habit’. I have been working at this since beginning this blog 2 years ago. Yes, I tried to stop pulling before that, but my mindset changed. I was willing to do everything I could, including changing my mindset.

Before a bad habit or unwanted behavior can be changed or stopped, I believe you need to change your thinking. Your thinking rules everything you do. This is why cognitive therapy is effective. The fist step of changing your thinking is to accept that you have a real disorder that causes you to pull your hair. It is not a lack of will power or discipline that keeps you in the cycle of hair pulling and self-loathing that often directly follows pulling. Click here for more information about Commitment and Acceptance Therapy.

Once you have changed your thinking, you can focus more on the unwanted behavior (hair pulling or any behavior). Cognitive Behavioral Therapy follows this approach (CBT).

According to The OCD Center of Los Angeles:

“The most effective treatment for Trichotillomania is a combination of various types of Cognitive-Behavioral Therapy (CBT). Perhaps the most important of these is called Habit Reversal Training (HRT). HRT is based on the principle that hair pulling is a conditioned response to specific situations and events, and that the individual with Trichotillomania is frequently unaware of these triggers. HRT challenges Trichotillomania in a two-fold process. First, the individual with Trichotillomania learns how to become more consciously aware of situations and events that trigger hair-pulling episodes. Second, the individual learns to utilize alternative behaviors in response to these situations and events.

Other Cognitive-Behavior Therapy techniques can be used as adjuncts to HRT in the treatment of Trichotillomania. Among these are Stimulus Control techniques and Cognitive Restructuring. Stimulus Control techniques involve utilizing specific physical items as “habit blockers” to restrict the ability to pull hair, while Cognitive Restructuring helps an individual with Trichotillomania learn to think differently in response to the urge to pull their hair.
Skin Picking and Hair Pulling – Reflections

One of the most effective CBT developments for the treatment of Trichotillomania is Mindfulness Based Cognitive Behavioral Therapy. The primary goal of Mindfulness-Based CBT is to learn to non-judgmentally accept uncomfortable psychological experiences. From a mindfulness perspective, much of our psychological distress is the result of trying to control and eliminate the discomfort of unwanted thoughts, feelings, sensations, and urges. In other words, our discomfort is not the problem – our attempt to control and eliminate our discomfort is the problem. For those with Trichotillomania, the ultimate goal of mindfulness is to develop the ability to more willingly experience their uncomfortable thoughts, feelings, sensations, and urges, without pulling their hair. To learn more about Mindfulness Based CBT for the treatment of Trichotillomania, click here.

Here’s how long it takes to break a habit, according to science
*You’re gonna need more than will power.
SIGNE DEAN 24 SEP 2015

From daily tooth-brushing to the 11am coffee, we all have dozens of habits that get us through our daily routine. Some are great – weekly gym visits are often encouraged – others not so much, like smoking a pack a day, or dialling the number of the pizza place way too often. Because we recognise our habits as useful or detrimental behaviours, we often strive to shape them accordingly.

There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.
However, according to a 2009 study, the time it takes to form a habit really isn’t that clear-cut. Researchers from University College London examined the new habits of 96 people over the space of 12 weeks, and found that the average time it takes for a new habit to stick is actually 66 days; furthermore, individual times varied from 18 to a whopping 254 days.

The take-away message here is that if you want to develop a new behaviour, it will take at least two months, and you shouldn’t despair if three weeks doesn’t do the trick – for most people that’s simply not enough. Stick with it for longer, and you’ll end up with a habit you can keep without thinking.

But what about trying to break an unwanted habit?

It turns out the two – habit forming and breaking – can be quite closely linked. As psychologist Timothy Pychyl explains to Alison Nastasi at Hopes and Fears, they’re two sides of the same coin: “Breaking a habit really means establishing a new habit, a new pre-potent response. The old habit or pattern of responding is still there (a pattern of neuron responses in the brain), but it is less dominant (less potent).”

From daily tooth-brushing to the 11am coffee, we all have dozens of habits that get us through our daily routine. Some are great – weekly gym visits are often encouraged – others not so much, like smoking a pack a day, or dialling the number of the pizza place way too often. Because we recognise our habits as useful or detrimental behaviours, we often strive to shape them accordingly.

There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.
However, according to a 2009 study, the time it takes to form a habit really isn’t that clear-cut. Researchers from University College London examined the new habits of 96 people over the space of 12 weeks, and found that the average time it takes for a new habit to stick is actually 66 days; furthermore, individual times varied from 18 to a whopping 254 days.

The take-away message here is that if you want to develop a new behaviour, it will take at least two months, and you shouldn’t despair if three weeks doesn’t do the trick – for most people that’s simply not enough. Stick with it for longer, and you’ll end up with a habit you can keep without thinking.

But what about trying to break an unwanted habit?

It turns out the two – habit forming and breaking – can be quite closely linked. As psychologist Timothy Pychyl explains to Alison Nastasi at Hopes and Fears, they’re two sides of the same coin: “Breaking a habit really means establishing a new habit, a new pre-potent response. The old habit or pattern of responding is still there (a pattern of neuron responses in the brain), but it is less dominant (less potent).”

“It’s much easier to start doing something new than to stop doing something habitual without a replacement behaviour,” says neuroscientist Elliot Berkman. “That’s one reason why smoking cessation aids such as nicotine gum or inhalers tend to be more effective than the nicotine patch.”

Experts agree that there’s no typical time frame for breaking a habit, and the right recipe is going to be a mix of personality, motivation, circumstances, and the habit in question. “People who want to kick their habit for reasons that are aligned with their personal values will change their behaviour faster than people who are doing it for external reasons such as pressure from others,” says Berkman.

According to psychology professor Susan Krauss Whitbourne, sometimes a habit can be broken quickly: “In extreme cases, the habit can be broken instantly, such as if you happen to become violently ill when you inhale cigarette smoke or nearly get hit by a bus when texting and walking.” But in most cases it’s going to take longer than that, and you should probably allow for at least two months.

To successfully break a habit, you need to think of your strongest motivation, which will drive you along. Think of a ‘replacement behaviour’ for the habit, but make sure it’s a positive one – replacing smoking with snacking is a common trap, for example. And be patient. The longer you’ve had a habit, the longer it will take to get rid of it.

“Longtime habits are literally entrenched at the neural level, so they are powerful determinants of behavior,” explains Berkman. “The good news is that people are nearly always capable of doing something else when they’re made aware of the habit and are sufficiently motivated to change.”

So stay strong, you can do it.

 

 

 

NAC for Trichotillomania

Research shows that nutritional supplements may help mental health including trichotillomania. Lately I have focused on inositol and NAC as I have heard about these supplements in many trichotillomania communities with varied success.

I started taking NAC (N-acetylcysteine) about two years ago and have noticed a decrease in my urge to pull when I take it 5-6 days per week. I take2-600mg capsules in the morning and 2-600mg capsules in the evening, giving me a total of 2400mg of NAC. Doses between 1200-3600mg may be helpful according to this article,  N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania

I recently added inositol to increase the benefits of NAC.  It is generally agreed that a large dose is needed for inositol to be effective with trich. I worked my way up to 18g per day. I do this by mixing 3 teaspoons or 1 tablespoon of inositol in water 3 times a day. I have found the Jarrow brand powder dissolves best. It is available on amazon for a reasonable price. I mix it with warm water as it dissolves better that way. You can add it to fruit juice or other sweetened drinks.  I simply mix the powder with ~3 oz. of warm water and drink it plain as it has a mild sweet taste that I actually like.

 

NAC and Trichotillomania

By Fred Penzel, Ph.D.

**Please note the following: This advice is purely informational, and not in any way meant to be a substitute for treatment by a licensed physician. Do not try this, or anything else, without first consulting your physician. If your M.D. has not heard about it, refer them to the following article and let them decide:

Jon E. Grant, JD, MD, MPH; Brian L. Odlaug, BA; Suck Won Kim, MD, N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania: A Double-blind, Placebo-Controlled Study. Arch Gen Psychiatry/ VOL 66 (NO. 7), JULY 2009.

 

Over the years, it has become apparent that prescription medications, as remedies for trichotillomania (TTM), have proved to be somewhat of a disappointment. These meds have been employed since the early 1990’s, and although they may be seen to work occasionally for some individuals, research indicates that their overall effectiveness is not great for the majority of sufferers. When they do appear to work, it is most likely that they are actually helping with coexisting problems such as depression and anxiety that are impacting the pulling, but not directly causing it. The discovery of a new compound with a greater level of direct effectiveness would be considered a blessing to sufferers. If this compound were also an over-the-counter remedy, it would be even better.

This very thing was confirmed in 2009 with the publication of an article by Grant, Odlaug, and Kim in The Archives of General Psychiatry, titled “N-acetylcysteine, A Glutamate Modulator, In the Treatment of Trichotillomania.”This study, which lasted 12 weeks, investigated the use of the amino acid N-acetylcysteine (NAC) in 50 patients with TTM, and found that 56% of them were rated as improved or very much improved. A much smaller previous pilot study had also found positive results.

So what is this compound? NAC is a both a pharmaceutical drug and a nutritional supplement used primarily to treat Cystic Fibrosis, and also to treat individuals suffering from acetaminophen overdoses. In the former case, it thins mucus, making it easier for patients to cough it up, and in the latter case, has liver detoxifying effects. It has also been said to aid in the treatment of cocaine addiction. Some practitioners out there are also exploring the use of NAC in the treatment of OCD, although whether it is effective or not, is still unproven.

What exactly is NAC? NAC is a natural sulfur-containing amino acid that is a breakdown product of the amino acid L-cysteine, and is in turn broken down by the body and converted to a powerful antioxidant known as glutathione.Antioxidants can repair oxidative stress in the body. Oxidative stress occurs when cell metabolism produces an increased level of oxidants known as free radicals that tip the balance between themselves and antioxidants in the body.These free radicals can cause the breakdown of cells, damaging proteins, genes, and cell membranes. Substances known as antioxidants act by neutralizing free radicals, and some are produced naturally by the body. Some have theorized that hair-pulling may be the result of the effects of oxidative stress within the brain, and that NAC can help reverse this.

NAC is also what is known as a chelating agent. That is, it hastens the excretion of heavy metals such as lead, mercury and arsenic from the body by binding to them. While this is of course, a positive benefit of taking it, it also causes the body to excrete copper, zinc and other essential minerals when used over time. Some research says this effect may be minimal, but others have suggested that it is necessary to take supplements containing copper, zinc, and other vital minerals when using NAC. Until this is settled, it is advisable to take a daily multivitamin plus minerals along with the NAC. It is often recommended to take extra vitamin C, itself an antioxidant, along with NAC, as it can also assist in raising glutathione levels. The amount of vitamin C one should take has been said to be in the range of 500 mg. per day.

As far as taking NAC itself for a BFRB, we have been using the following approach:

1. Start by taking one, 600 mg. capsule of NAC daily for the first two weeks along with a daily multivitamin plus minerals, in addition to 500 mg. of vitamin C. You will most likely not see any changes on this dosage.

2. If the NAC appears to be well tolerated, increase it to 1, 600 mg. capsule, 2x per day. Again, wait two to three weeks to see if there is any reduction in pulling activity.

3. If there are no changes, or only minimal changes in pulling, increase to 1 capsule, 3x per day, and again wait two to three weeks to see if there is any noticeable result.

4. If there is only little or no change, you can then increase to 4, 600 mg. capsules per day, and wait another two to three weeks. Take 2 capsules for one of the three daily doses, to make a daily total of four.

5. If there is still little or no change, you can increase up to what is the maximum of 5, 600 mg. capsules per day. A total of 3,000 mg. is the maximum you should take as a daily dose. Take 2 capsules for two of the three daily doses, to make a daily total of five.

6. If after 4 weeks at the maximum dosage there is still no result, then it is likely that it is not working, and can then be discontinued.

As with all medications and supplements, there are no sure things. It is ultimately all trial-and-error. We hope that NAC will help, but just keep in mind that it will not necessarily work for everyone. Remember that it was shown to be effective for about 56 percent of the subjects in the original research study.

NOTE: There are some very important precautions that should be observed when taking NAC.

1. It should be noted that there are some individuals who suffer from cystinuria, a genetic disorder that causes cysteine to build up in their urine. If levels of cysteine molecules become high enough, they clump together to form kidney stones. It is therefore recommended that those with this problem not take NAC.

 

2. In addition, NAC supplementation might increase the side effects associated with nitroglycerin and isosorbide, two medications commonly used to treat angina.

 

3. Using NAC at the same time as the hypertension drugs ACE-inhibitors might cause blood pressure to drop too low. It might also excessively strengthen the actions of immunosuppressant drugs.

 

How N-Acetylcysteine (N-A-C) Cured My Depression and Anxiety

The maternal side of my family contains a history of severe mental illness. My maternal grandmother suffered from schizophrenia and died in a mental ward. My mother has been institutionalized repeatedly, suffering from a decades long battle with bipolar disorder.

My younger brother is a legitimate sociopath. He is not merely “dark triad.” He has actual antisocial personality disorder. He has no feelings of empathy or kindness or decency. Lacking the vision to rob banks or become a drug kingpin, he is currently free after spending 10 years in prison for shooting his one-armed drug dealer.

In other words, there’s some funny business in my DNA.

I used to get depressed and feel anxious. I never had full-on panic attacks, but I would have severe anxiety that would leave my brain spinning. My skin would break out in rashes.

I conquered this anxiety through two means, as anxiety and other mental illnesses have two components – physical and psychological.

The psychological components of anxiety come from society and the brain washing. That is where state controlreframing techniques, and other Mindset Training comes into play.

The physical components of anxiety and depression come from a variety of sources – poor nutrition, lack of sunlight, excessive oxidative stress, high cortisol, and heavy metal poisoning.

glutathione

N-Acetylcysteine (N-A-C) has been clinically proven to help treat symptoms of anxiety and depression.

N-Acetylcysteine is a powerful nootropic with still many unstudied benefits. N-A-C has been used by visionary doctors to help treat intractable depression and anxiety.

Why haven’t you heard about the magical effects of N-A-C? Simple. Go on Amazon and see how much a bottle of N-A-C costs.

My mom was on a $1,500 a month cocktail of drugs. No one would listen when I suggested they buy a $15 bottle of N-A-C. But the science is there.

See, N-acetyl cysteine for depressive symptoms in bipolar disorder–a double-blind randomized placebo-controlled trial(“NAC appears a safe and effective augmentation strategy for depressive symptoms in bipolar disorder.”) (PubMed.)

See also, N-acetyl cysteine as a glutathione precursor for schizophrenia–a double-blind, randomized, placebo-controlled trial. (“These data suggest that adjunctive NAC has potential as a safe and moderately effective augmentation strategy for chronic schizophrenia.”) (PubMed.)

N-A-C depression anxiety

Why does N-A-C help treat depression?

Acetylcysteine is a glutathione precursor. That is, acetylcysteine is converted into glutathione.

Glutathione is an antioxidant that used by your liver to detox your body. Emergency rooms give high doses of NAC to patients that have overdosed with Tylenol.

Resources:

  • The Wahls Protocol: How I Beat Progressive MS Using Paleo Principles and Functional Medicine (Amazon).
  • Smash Chronic Fatigue: A Concise, Science-Based Guide to Help Your Body Heal, and Banish Fatigue Forever (Amazon).

Could mental illness be caused by toxins that your liver is unable to clear from your body, due to a glutathione deficiency?

That is not so far fetched, and in fact the cutting-edge of mental health research is on the role toxins and oxidative stress play in mental illness.

See, The efficacy of adjunctive N-acetylcysteine in major depressive disorder: a double-blind, randomized, placebo-controlled trial (“These data implicate the pathways influenced by NAC in depression pathogenesis, principally oxidative and inflammatory stress and glutamate, although definitive confirmation remains necessary.”) (PubMed.)

See also, The Glutathione System: A New Drug Target in Neuroimmune Disorders (“Glutathione depletion and concomitant increase in oxidative and neurological stress and mitochondrial dysfunctions play a role in the pathophysiology of diverse neuroimmune disorders, including depression, myalgic encephalomyelitis/chronic fatigue syndrome and Parkinson’s disease, suggesting that depleted GSH is an integral part of these diseases.” (PudMed.)

Do you know what else boosts glutathione?

Carrot orange pomegranate juice

How much N-A-C should you take?

That would be medical advice, which I don’t give. However, participants in the studies usually used between 1 and 2 grams daily.

Why take N-A-C instead of glutathione?

If N-A-C is a precursor, wouldn’t it make more sense to take glutathione directly? That seems intuitively correct. There is some evidence to suggest that N-A-C is more bioavailable than glutathione.

I personally use N-A-C because that was the compound studied. How much glutathione would one need to take to get the same benefits that one can obtain from 1 to 2 grams of N-A-C? As I don’t know, I went with N-A-C.

You are of course free to try both for yourself to see what works best.

What brand of N-A-C is best?

As the supplement industry is unregulated, I generally prefer to use use two brands of supplements – Life Extension Foundation and Jarrow.

I personally use Jarrow’s form of N-A-C Sustain, which is time released. (Amazon).

For more information on oxidative stress, nutrition, and various maladies, watch this video.

Minding Your Mitochondria

Change Your Thinking to Change Your Behavior

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Change Your Thinking, Change Your Behavior

 By Claudia Miles

I have been sharing my view that hair pulling & skin picking are most like “addictions” for many years.  I was not taken seriously by other professionals at first, but in recent years I’ve seen the term used more and more when other professionals talk about Body-Focused Repetitive Disorder (BFRD).  In fact, TTM & Dermatillomaia fit the criteria of addiction quite well. Think about the way we respond to an addiction like substance abuse (food, drink, drugs). We develop a craving, we try to talk ourselves out of it by saying: You don’t really want to drink again, you’ll lose your job. Don’t eat that whole box of cookies, you’ll feel sick and diagusted. Don’t keep pulling your hair out, there won’t be any way to cover it up.

The addict in you rebels against this kind of feedback. You want to do it, and all the consequences you are thinking about happen in the long term. You feel bad NOW. Gaining weight or losing hair happens later. You just want to feel better. So finally you  say, “Screw it. I don’t care about the consequences,” and we block out the fact that we missed work last time we drank, lost custody of our kids, took any number of actions that cause us shame, pain, financial loss or worse. You say, “I don’t care, I had a bad day and I’m going to do it.” Or “It doesn’t matter, I already ruined my hair, I’m already almost bald, That is how we give yourselves permission to pick or pull.

1) (Screw it.) It’s hopeless.
2) I don’t care
3) It doesn’t matter anyway.

And by convincing ourselves for just a few minutes that those lies are true, we rebel against what we really want. We pretend that we “don’t care” about pulling, that we’ve done so much damage it doesn’t matter if we pull or not, and finally we feel so hopeless about the idea of stopping forever, we don’t see the point in stopping NOW. (It’s quite similar to the process of procrastination which is often connected to BFRD behaviors: Denial, Delay (now we’ve waited so long it will never get done), Hopelessness)

Rather than trying to “FORCE” yourself to stop, the key is to understand and change the pattern of addictive thoughts. It doesn’t matter whether you are a picker who is aware that you are about to pick or a puller who has already pulled for ten minutes before you become aware of what you are doing. There will be a moment when you ARE aware of what you are doing and think to yourself: “I don’t care!” This thought comes in response to earlier thoughts like, You “shouldn’t” be doing this OR I can’t believe I’m doing this again. We think “I don’t care!” as a way to tell our inner bully to shut up, leave us alone & let us pull. Because let’s face it, pulling & picking are made less pleasurable when we simultaneously are attempting to shame ourselves for engaging in the behaviors.  (And SHAME does not help one bit, of course.)  So we say to ourselves by way of making the shame stop: I DON’T CARE! (In other words, leave me alone, Bully, I want to pull!)

The problem is we have dis-identified with the real reason we want to stop these behaviors, which is not that they are morally wrong or that we “shouldn’t” do them. Rather, it upsets us *THAT* we do them. And it is crucial to acknowledge that, but at the same time, not shame ourselves.

Here’s what I mean. See if you can become aware when you start to think to yourself: I don’t care! Once you do, apply what Mindfulness practice teaches us is the “observer” within and “note” the thought.

You: I don’t care
The Observer (You): Ah, there’s that addictive thought. Telling me I don’t care. Giving me permission to pull.

The problem is, you DO care. You care very much. If you didn’t, you sure as heck wouldn’t be reading this blog. You just want to forget that fact for a moment, an hour, two hours, so you can go to that familiar (and comforting) sense of “Numbness.”.  So what I’m asking you to do here is this: DO NOT bully or shame yourself into stopping. (What are you DOING?! What’s wrong with you?! You’re “pathetic”!) But DO acknowledge that the behavior is causing you pain. The example I give to my clients is this: Imagine an alcoholic who is living in a one room apt. after having lost his (or her) share of custody with his kids. He has to get sober and stay sober for 6 mos to get the issue revisited. Six months seems like FOREVER. So every night, to numb the pain of not seeing his children, he pulls out a bottle of whisky. He may say, You moron, what are you doing? But he feels compelled to continue. So he takes the pictures of his kids and turns them around. Puts them away. It’s too painful to look at his kids. He’s already “blown it” he thinks.

Now I would tell that guy, Go ahead and drink. But do NOT put away the pics of your kids. At the same time, you don’t get to berate yourself for doing something you feel so compelled to do despite all it has cost you. What you do is this: You look at your kids and think to yourself, wow, this drinking has cost me a lot. And it’s not because I don’t care about my kids cause I do! How powerful this addiction must be if it makes me ignore what truly matters. Now this makes the drinking FAR less enjoyable & shifts this man’s thinking from “I’m shit. I’m a loser.” to “This is a serious problem & it’s costing a lot.” That latter voice we can call the “Supportive Friend.” The friend you can be to yourself. The friend who wants to HELP you, not SHAME you.  It’s a completely different way of relating to the self.

Here’s how it translates for sufferers of TTM or Dermatillomania:

Your Inner Bully (You): Stop pulling you pathetic loser!
BFRB* Addict (You): I had a lousy day. I just don’t CARE right now!
NEW-Observer (You): Ah, there’s the inner addict trying to convince me I don’t care.
NEW-Supportive Friend (You): You know what? That’s not true. I DO care. I care very much.  It causes me  emotional pain to do this. It makes me feel bad about myself. I just want to acknowledge that.

Now at this point, I am not saying that you can (or should) instantly stop. Not at all. I am suggesting that you go ahead and pull or pick, while simultaneously acknowledging that you DO care.   Not that you’re an idiot or weak or pathetic. Rather, that you are a human being who’s desire or urge to do this is so strong that it eclipses the fact that the behavior causes you so much pain. Now that’s a HARD spot to be in, and until you can empathize with yourself, you remain stuck in a cycle of Blame, Shame, Addictive Thought, Numbness, More Shame, Emptiness, Self-Hatred.

Please note that I am suggesting you tell yourself that you DO care, NOT because of hair loss or scarring but because you will feel bad about yourself. That’s very important. We all know how long it takes for hair to grow back or skin to heal. It takes so long it’s hard to feel motivated. That’s why it is crucial you motivate yourself based on how you feel about yourself. That can become your immediate payoff. And when you consider the crippling shame and self-hatred that appears sometime after a pulling or picking session, perhaps you can see that there is another kind of cost to this besides hair loss and skin scars.  And when that can be replaced by actively telling yourself that you made an effort (even if the effort at first is just changing your thoughts), you will become a real support to yourself, a cheerleader, a caring friend and more able to continue on the path of recovery. A bully, a critic, a shaming, finger-wagging inner “bad parent” WILL NOT HELP YOU. That kind of thinking will tear down any efforts you make toward your goal. That kind of thinking SUPPORTS the addiction. And you do not deserve it, as one day you will surely know.

As I said for the “I don’t care” thought, the same goes for “It doesn’t matter,” and “It’s hopeless.” The thought “It doesn’t matter” is generally linked with the fact that you’ve done so much “damage” that it doesn’t matter if you do a little more. It’s the same irrational thinking behind, “I went off my diet and ate some cake! I ‘ruined’ everything. Well, I may as well eat everything in the house.” Because that makes sense, right? You ate an extra 500 calories so you may as well eat 5,000.

First of all, even when you break it down literally, I can tell you that it DOES matter. In the practical physical world, even though you may not see the difference right away, any lessened amount of pulling, (55 minutes and not an hour, 3 hours and not 4) is PROGRESS. And progress is what will help you reach your goal. But going back to my earlier point, it’s about shifting the focus in this moment away from what your hair or skin looks like and acknowledging that the shame and anger toward the self you feel is hurtful. It not only doesn’t help you pull less, it absolutely causes you to pull more. Please hear this: All attempts to attack, shame or SCARE you into less pulling or picking, whether done by you or someone else, do the OPPOSITE. Every “I can’t believe you’re doing that!” “Stop it, you’re making a mess of your face!” “Why can’t you.. STOP doing that??!!” and “What’s WRONG with you!!” will push you FURTHER from your goal. Please stop and think about that. You don’t want to “let yourself off the hook.” You falsely believe that loving yourself or, yes, accepting yourself, even while you are still pulling means you are “giving up” and just accepting this is how it is. That’s just plain wrong! Just like you love your kids even if you don’t love the behavior, just like you accept them (vs. rejecting them) when they make mistakes, so too you must accept yourself. Accepting and loving yourself NO MATTER WHAT is the ONLY way you’ll recover.

So you see, it does matter. New dialogue:

Inner Bully (You): Stop pulling! Stop picking! You’re pathetic.
BFRB* Addict (You): I’ve already messed up my hair (skin) so much it doesn’t matter anyway.
NEW- Observer (You): Ah, there’s the addict trying to snow me into believing it doesn’t matter.
NEW-Supportive Friend (You): You know what, it DOES matter. It matters because how you feel about yourself matters. It matters because  it’s about small steps, and even if your skin or hair won’t shift right away, it will eventually if you take those small steps. And it MATTERS because this pulling or picking makes you feel like shit, and recovery only happens a moment at a time.

That same point must be made when recovery feels hopeless. One can imagine that that’s very much how someone who has 100 or more lbs to lose might feel. Because no matter what one does, change doesn’t come overnight. Also, you cannot stop pulling “FOREVER” all at once. You can only improve a little in each moment. Those moments will add up, and believe me, they can become a total cessation of pulling or picking, or a nearly total cessation of pulling or picking over time. But any efforts you do make must be made for TODAY only. Forever feels too big. Forever feels hopeless. Today (or even “right now”) need not feel hopeless. You will be able to DO today. And it’s ok if you can’t quite do that right now.

Changing the dialogue is the first step. Working on self-acceptance and self-love, letting go of negative reinforcement and focusing on positive reinforcement, that must be done before any other efforts are made.

And, NO, you won’t have to fight the urges forever. If you change your thinking and change your relationship with yourself so you can support yourself and love yourself through the process, the urges will start to subside. Just like with any addiction, the urges and the desire takes time to subside, and once in a while may show up out of the blue. That’s why you’ll need that “Supportive Friend” with you. The part of you that encourages you and believes in you, just as you do for your friends who aren’t you. Imagine if you could be as helpful to yourself as you are to others.

With practice, you will see that making just a little progress on this (which is all you CAN do) will eventually get you where you want to go. Just like a person who needs to lose 100 lbs. Yes, they won’t be where they want to be after a day or a week of progress toward healthy eating. But they will have taken a step. And it’s one step, then another, then another, and then maybe a step or two back. That’s how it goes. If you can find a way to accept that, if you can find a way to encourage yourself based on “progress not perfection” (AA), you CAN recover. If you continue to believe that it’s all at once or nothing, Your inner addict wants you to believe this so you will give in and pull or pick. Your inner bully wants to tell you it’s hopeless. But your inner Supportive Friend knows the truth. It’s one day at a time, one moment at a time, one breath at a time. It’s taking one small step and focusing only on what you can do, not what you cannot. THAT, I can tell you, is one of the most important things to know about the journey of recovery from BFRB*s. The second is, You CAN do it!

*BFRB = Body-Focused Repetitive Behaviors

Struggles

Reflections on Skin Picking and Hair Pulling - OCD Center of Los Angeles

Reflections on
Skin Picking and Hair Pulling

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Suffering usually relates to wanting things to be different from the way they are.

~ Allan Lokos

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Suffering

Everybody suffers. But much of our psychological suffering occurs as a result of our beliefs about how we think life “should”be, or how we would ideally like it to be. Often, it is our over-attachment to these beliefs that turns normal, everyday pain and discomfort into true suffering.

If you have Skin Picking Disorder or Trichotillomania, you may suffer needlessly as a result of this type of over-attachment to certain beliefs. An unwanted blemish or hair (or event or feeling) is not as you wish it would be, which leads to distress, which in turn leads to a picking or pulling episode. This not only worsens the physical consequences of these conditions, but leads to more psychological suffering in the form of hours (or days) of self-loathing during which you spend a great deal of time negatively evaluating yourself and your behavior.

Common negative thoughts might include “I should have been able to overcome the urge to pick or pull”, or “I look so ugly”, or “I am inadequate” or “I am hopeless”. Over time, and with much repetition, these types of thoughts become internalized into an overall negative belief system you have about yourself, which only increases your suffering.

The long-term goal of recovery is to develop more psychological flexibility by making room for all of the imperfections of real life, thus lessening the emotional suffering you experience. Life will never be 100% free of pain and suffering.  In fact, life is full of unavoidable pain, such as the pain we experience with serious illness or injury, or the death of a loved one. However, much of our psychological pain is self-created by thoughts and beliefs that are unhelpful, and which ultimately lead to picking and pulling setbacks.

If you do not measure up to what you think is acceptable, you may ultimately inhibit and prolong your recovery. Alternatively, by accepting all of life, including your imperfections, you will reduce your suffering, and move further down the road of recovery.

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1) How often do you get stuck in the trap of judging yourself and your picking and pulling behavior, and not allowing room for imperfection?

2) What specific thoughts do you have after a setback that might increase your suffering?

3) What thoughts might be more helpful in promoting your long-term recovery?

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Weekly Tip: When you experience negative self-talk, notice how this increases your suffering, and choose instead to fully accept yourself, including your imperfections.

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For a free subscription to “Reflections”, please click here.

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD, Skin Picking Disorder, Trichotillomania, and related conditions. We offer the following services:

  • Individual Therapy
  • Low-Fee Group Therapy
  • Online Therapy
  • Phone Therapy
  • Home Visits
  • Intensive Outpatient Program
We treat adults, adolescents, and children, and offer services six days a week, including evenings and Saturdays. For more information, please contact one of our client coordinators at (310) 824-5200 (ext. 4), or click here to email us.
__________________________

OCD Center of Los Angeles
http://ocdla.com

(310) 824-5200

Written by
Kelley Franke, BA and Tom Corboy, MFT

© 2016 OCD Center of Los Angeles

We will never share, rent or sell your personal information to third parties.

OCD Center of Los Angeles: 11620 Wilshire Blvd. #890, Los Angeles, California, 90025, United States

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