Category Archives: Research

Medications

Medications for Body-Focused Repetitive Behaviors

 

by Jon E. Grant, MD, JD, MPH, Scientific Advisory Board Chair
Professor of Psychiatry and Behavioral Neuroscience, University of Chicago

If you are considering taking medication for BFRBs, please understand that no drug is currently approved by the Food and Drug Administration for these behaviors, that there is limited research on the use of medications for these behaviors, and that the medications often have side effects. Having said that, many individuals benefit from medications. They may find a reduction in their urges, an increased ability to resist their behaviors, and/or less obsessional thinking about their hair or skin. In most cases, medications appear most helpful when used in combination with ongoing behavior therapy.

Individuals who pull their hair or pick their skin should receive a thorough physical examination to rule out potential medical problems, such as skin disorders. In addition, individuals who eat their hair should inform their doctors of this behavior as it may lead to serious health problems.

Because no single treatment will work for everyone, a complete psychiatric assessment will aid in identifying which medication may be helpful. This assessment should include information about the BFRB (for example, does the person find the behavior pleasurable, does the individual pull or pick because they feel depressed, etc.), other mental health problems of the individual (including drug and alcohol problems), current medications and allergies, any previous trials of medication, and psychiatric problems within the family.

Women who choose to take medication either during pregnancy or during the period when they will be breast-feeding should discuss carefully the side effects of all medications (including the risks of possible birth defects) with their physician.

Clomipramine (Anafranil)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Other Antidepressants
Naltrexone (Revia)
Neuroleptics
Lithium
Other Agents/ Supplements
General Considerations
Considerations for Children and Adolescents

Clomipramine (Anafranil)

The first study for trichotillomania found that clomipramine (Anafranil), a medication affecting the brain neurotransmitters serotonin and norepinephrine, was beneficial in treating hair pulling in a small number of adults. Clomipramine has both antidepressant and anti-obsessional properties. Therefore, this may be a potentially beneficial medication for those who have trichotillomania in addition to depression or obsessive compulsive disorder (OCD). Clomipramine is approved for pediatric OCD and therefore could be used in children with both OCD and trichotillomania. There have been no studies examining the use of clomipramine in skin picking, but given its benefits in hair pulling, this is also considered a potentially beneficial option for picking as well.

Clomipramine, however, may result in multiple side effects such as dry mouth, constipation, blurred vision, sexual dysfunction and weight gain. In addition, clomipramine may cause fine tremor and muscle twitching. Starting at a low dose such as 25 mg at night and slowly titrating the dose over several weeks to 150 to 250 mg/day reduces the likelihood of side effects. Clomipramine should not be used if a patient has a history of cardiac conduction disturbance or a central nervous system illness that might compromise memory. At 300 mg/day, clomipramine can cause seizures in about 2% of subjects. Clomipramine should not be used with medications such as fluoxetine or paroxetine that inhibit P450 isozymes, for they inhibit clomipramine hepatic metabolism, cause elevated serum clomipramine, and desmethylated clomipramine levels. If it becomes necessary to use these medications in combination, clomipramine levels should be monitored frequently by blood tests and by performing periodic EKGs on the person.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Several studies have examined SSRIs in treating trichotillomania and skin picking. The SSRIs include: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil). These medications are FDA-approved for the treatment of depression or OCD or both.

Only fluoxetine (Prozac) has been rigorously studied in hair pulling and skin picking. Although the results have looked somewhat promising for using fluoxetine in skin picking, the results for trichotillomania have been largely no better than for a placebo. The other SSRIs have been used in smaller, less controlled studied and have demonstrated some limited benefits in some studies and no benefits in other studies. Individuals may report a range of improvement from dramatic reduction in behavior to no change. In general, the improvement is modest but may only last several months. These medications may be helpful in individuals with pulling or picking who also suffer from anxiety, depression or OCD.

Although the SSRIs are generally well tolerated, they may produce gastrointestinal distress, sedation, mild anxiety, headache, constipation, increased urinary frequency, weight gain, and sexual dysfunction. Fluvoxamine (Luvox) is a potent P450 1A2 inhibitor, and drug-drug interactions should be considered before it is prescribed. Given paroxetine’s (Paxil’s) relatively short half-life, the potential for flu-like SSRI discontinuation symptoms exist, particularly with abrupt cessation of high dosages of the drug. As with other anti-depressants, warnings exist for the potential association between SSRIs and suicidal thoughts and behaviors.

Other Antidepressants

Other antidepressants have been tried in the treatment of trichotillomania and skin picking. Although the data are sparse, case reports discuss the possible benefits from a range of antidepressants – amitriptyline (Elavil), imipramine (Tofranil), venlafaxine (Effexor), and doxepin (Sinequan). These medications have shown benefit for the treatment of depression and anxiety, but given the limited data for their use in trichotillomania and skin picking, these medications should not be considered first-line treatment.

Naltrexone (Revia)

Naltrexone, an opioid antagonist, is approved by the FDA for the treatment of alcohol dependence and opiate dependence. Naltrexone has been examined in two controlled studies of trichotillomania and demonstrated some potential benefit in one and none in the other. Because naltrexone reduces urges to engage in pleasurable behaviors, it may be best for those individuals who pull or pick due to strong urges and find the behavior pleasurable. It should also be considered in individuals with trichotillomania or skin picking who suffer from alcoholism, and possibly in individuals with a family history of alcohol use disorders.

Although generally well tolerated, naltrexone may cause nausea, insomnia, muscle aches, and headaches. Liver enzyme elevations are possible, especially in patients taking non-steroidal anti-inflammatory drugs, and therefore liver enzymes should be frequently monitored.

Neuroleptics

Dopamine-blocking neuroleptics have also been examined in the treatment of trichotillomania and skin picking. The rationale for their use is due to a possible link between repetitive behaviors and tic disorders such as Tourette’s disorder. A controlled study of olanzapine (Zyprexa) found that the medication was significantly more effective than a placebo in reducing hair pulling. Other neuroleptics – risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify) – may also be beneficial but there have been no controlled studies of these medications.

Neuroleptics may result in a range of side effects: extrapyramidal side effects (Parkinson-like tremor, rigidity, bradykinesia), akathesia, dysphoria, sedation, tardive dyskinesia, weight gain, and development of diabetes and high cholesterol.

Lithium

Lithium, a medication approved for the treatment of bipolar disorder, has shown some benefit in individuals with trichotillomania in uncontrolled studies. Lithium may be beneficial to those who are generally impulsive or have considerable emotional instability. Lithium may be an attractive medication option for individuals with trichotillomania or skin picking who also suffer from bipolar disorder.

Lithium can produce significant side effects. Common side effects of lithium include nausea, loss of appetite, mild diarrhea, dizziness, hand tremors, weight gain, hypothyroidism (low levels of thyroid hormone), increased white blood cell count, acne, and skin rashes. Individuals should tell their doctor immediately if they develop lack of coordination, muscle weakness, slurred speech, nausea, vomiting, diarrhea, confusion, or an increase in tremors or shaking. These symptoms may be a sign of having too much lithium in the body, which requires medical attention. With long-term use of lithium, kidney damage may also occur, but it is rare. In order to minimize risk, your healthcare provider will periodically measure kidney function and lithium levels with a simple blood test.

Other Agents

A variety of other medications have shown early promise in the treatment of trichotillomania and skin picking.

Medications that affect the neurotransmitter, glutamate, may be beneficial. Glutamate appears to have a role in the area of the brain involved in compulsive, repetitive behaviors. These medications include lamotrigine (lamictal) (FDA-approved for bipolar disorder), riluzole (Rilutek) (FDA-approved for ALS), and the amino acid N-Acetyl Cysteine. These medications, however, are not all alike and the studies suggest there may be important differences. One study of lamotrigine in skin picking found that it was not more beneficial than placebo. Although studies of riluzole have not been performed in trichotillomania or skin picking, a study in OCD found that it was no different from placebo. N-actetyle cysteine, however, was studied in trichotillomania and in adults appeared to be very promising although the study in children was no productive. N-acetyl cysteine may be beneficial alone or in combination with an SSRI (link to NAC article).

Inositol, a B-vitamin and an isomer of glucose, has also been used in the treatment of trichotillomania and skin picking. A controlled study has demonstrated improvement in OCD using inositol, but controlled studies are lacking for hair pulling and picking (link to inositol article)

General Considerations

A reasonable medication strategy is to employ a systematic trial of a specific medication while monitoring side effects. The choice of which agent to use can be based on known side effects, co-occurring disorders such as depression or OCD or alcoholism, or what has possibly worked for family members. Rating scales can be used to assess the degree of hair pulling or skin picking as well as global measure of improvement. The dose of the medication should be built up over time until complete benefit is obtained or to the maximum or best-tolerated dose. An appropriate period of time should be allowed (8-12 weeks or longer) before deciding whether a benefit has been achieved. If the benefit is only partial, the medication can either be changed or another medication can be added. Always consult your physician before abruptly stopping a medication. Also, individuals should be informed that medications appear most helpful when used in combination with ongoing behavior therapy.

Considerations for Children and Adolescents

In the case of adolescents, the general recommendation is first to use behavioral therapies before considering medication and then only use medication in severe cases. Many medications may cause suicidal thoughts in children and adolescents and therefore medications must be used very cautiously in this population and suicidal thinking should be monitored frequently.

Panic Attacks & Anxiety Linked to Vitamin Deficiencies

With approximately 40 million adults across the United States experiencing anxiety each year, scientists and researchers have dedicated their careers to trying to better understand this condition. Despite this work, we are still somewhat unclear on what actually causes this condition to occur.

Characterized by feelings of nervousness and restlessness, increased heart rate, hyperventilation, sweating, trembling, difficulty concentrating and uncontrolled worry, it has the ability to impact every area of one’s life. There are many theories regarding the root cause of the condition, including genetics, brain chemistry, environmental factors or other medical factors and/or disease, however, nothing has been proven definitively. Instead, the scientific community continues to explore these leads further in the hope of an answer.

One small study out of Japan may provide an important insight into the connection between nutritional deficiencies and mental health, revealing that low levels of vitamin B6 and iron may actually trigger the chemical changes in the brain responsible for panic attacks, hyperventilation and other forms of anxiety.

The research team analyzed the nutritional levels of 21 participants with varying levels of anxiety, panic attacks, and hyperventilation episodes. While some experienced minor attacks, manageable at home, others were severe enough to result in emergency room visits. They tested these participants for a number of different nutritional deficiencies or abnormalities in the hope of identifying a pattern. At the same time, they ran a similar set of tests on a control group of 20 people, comparing the two.

The data showed that those who were experiencing anxiety were found to have lower levels of B6 and Iron than those in the healthy group. Why is this important? One of the most accepted theories regarding the development of anxiety is that it is caused by a chemical imbalance in the brain, with serotonin seen as a key player. This is due to the fact that serotonin is one of the ‘happiness hormones’, responsible for triggering the reward and pleasure centers of the brain.

Serotonin is synthesized from the amino acid tryptophan, and both iron and vitamin B6 play an important role in this process. Therefore, an absence of these nutrients can, ultimately cause a decrease of serotonin levels. In fact, many of today’s antidepressant drugs work on this same theory, by boosting serotonin levels in order to regulate mental health.

The study’s authors wrote, “These results suggest that low serum concentrations of vitamin B6 and iron are involved in PA (panic attacks) and HVA (hyperventilation). Further studies are needed to clarify the mechanisms involved in such differences.”

Improving Dopamine Levels

What Is Dopamine?

Dopamine is the brain chemical that allows us to have feelings of bliss, pleasure, euphoria, drive, motivation, focus, and concentration. But let’s start at the beginning: Your brain actually communicates with itself. That is, you have an intricately linked system of nerve cells called neurons that “communicate” with each other via specialized receptor sites.

Dopamine is a chemical (neurotransmitter) that is used by the nerves to send “messages.” When a nerve releases dopamine, it crosses a very small gap called a synapse and then attaches to a dopamine receptor on the next nerve. Therefore, when dopamine levels are depleted in the brain, the nerve impulses, or “messages,” cannot be transmitted properly and can impair brain functions: behavior, mood, cognition, attention, learning, movement, and sleep.

How Do I Know Whether I Have Dopamine Deficiency?

When there is a dopamine deficiency, emotions cannot be correctly regulated. Mental impulses that mitigate intense feelings of sadness are inhibited; therefore, the most common low dopamine symptoms are the same signs associated with clinical depression (and more specifically, major depressive disorder):

14 Dopamine Deficiency Symptoms

1 Lack of interest in life

2 Decreased motivation

3 Procrastination

4 Inability to feel pleasure

5 Altered sleep patterns

6 Restless leg syndrome

7 Fatigue

8 Mood swings

9 Excessive feelings of hopelessness or guilt

10 Poor memory

11 Inability to focus/impaired concentration

12 Impulsive or self-destructive behaviors

13 Addictions to caffeine or other stimulants

14 Weight gain

Extreme dopamine deficiency, as in the case of Parkinson’s disease, causes a permanent and degenerative diminishing of motor skills, including muscle rigidity and tremors.

7 Ways to Treat Dopamine Deficiency

With that background in mind, consider the following dopamine-boosting tactics you can take to increase dopamine.

1. Decrease your sugar intake. Sugar alters brain chemistry by disrupting dopamine levels, which is one reason why people often experience a “sugar high” shortly after eating sweets. Just as alcohol and drugs can deplete dopamine levels, sugar does the same. In fact, sugar stimulates the exact same euphoric pathway targeted by alcohol and drug use–that is, the decreased dopamine levels lead to actual sugar addictions.

Whether initiated by alcohol, cocaine, or sugar, the compulsive behavior addiction is the same—an undeniable desire for dopamine. Limiting sugar intake will help fight this addictive dopamine depletion-sugar craving cycle. If you struggle with a sweet tooth, you can take chromium picolinate supplements to help decrease your sugar cravings.[1,2]

2. Take tyrosine. When your brain cells need to “manufacture” neurotransmitters for proper mood regulation, they use amino acids as the essential raw material. Amino acids are the building blocks of protein; there are 20 different amino acids that make up the protein our body needs.

The brain uses the amino acid l-phenylalanine as the source (precursor) for the production of dopamine. Phenylalanine is one of the “essential” amino acids; that is, the body cannot make it on its own so we have to get it from the foods we eat or from supplements. Once the body receives phenylalanine, it can convert it to tyrosine, which in turn is used to synthesize dopamine. So the way to increase central nervous system neurotransmitter levels is to provide proper amounts of the amino acid precursor.

Bananas, especially ripe bananas, are an exceptional food for regulating dopamine because they have a high concentration of tyrosine. Other foods that increase dopamine through the conversion of phenylalanine to tyrosine include almonds, apples, watermelons, cherries, yogurt, beans, eggs and meats.

It is important to note that dopamine foods alone generally do not have the therapeutic amino acid levels necessary to boost dopamine levels for someone experiencing major depressive disorder. To boost your levels of dopamine, dopamine rich foods may not be adequate. Tyrosine supplementation may help.

3. Decrease caffeine intake. Even though coffee gives you the energy boost you need, just like sugar, it only offers temporary relief and may actually be doing more harm than good. After experiencing the initial kick caffeine offers, dopamine levels in the body decrease. So, go for a cup of decaf or at least minimize consumption of coffee to counter dopamine deficiency.[5]

4. Set a routine schedule. One easy way to boost dopamine is to get in a healthy routine and stick to it. Your routine should include adequate time for work and rest. Ideally, your 24-hour day should include seven to eight hours of sleep per night in combination with periods of physical activity.

Under-sleeping and/or over-sleeping combined with lack of regular exercise can drain the brain of dopamine. Why? Proper sleep gives the brain time to recuperate from the day and recharge its stores of neurotransmitters.

5. Get consistent exercise. Regular physical activity increases blood circulation to influence the presence of many different hormones within the brain, affecting dopamine levels.

6. Decrease stress levels. High stress levels are also strongly correlated with dopamine deficiency. Stress can be caused by two sources: poor adrenal function and chronic daily life stressors. While we can’t always control our circumstances, there are “stress safeguards” you can utilize to help you deal with the day-in and day-out anxieties.

Remember, if stress is not handled properly, it can be devastating to your health. So, establish an ongoing plan that enables you to deal with stress effectively.

7. Correct a magnesium deficiency. Magnesium deficiency can cause decreased levels of dopamine, and natural health experts estimate over half of the US population to be deficient in this relaxation mineral. If you’ve been eating a diet heavy in junk foods or processed foods, you probably have a magnesium deficiency! Common symptoms include food cravings (salt or carbs), constipation, high blood pressure, rapid heartbeat or palpitations, muscle pains and spasms, fatigue, headaches, and depression symptoms such as mood swings, anxiety and irritability.

There are blood and urine tests that your doctor can perform to see if you have a magnesium deficiency. However, these tests may not always be accurate since most of the body’s magnesium stays in the cells, rather than in the bloodstream or the urine.

There is one lab test called a sublingual epithelial test that is more effective because it checks for magnesium in the cells, where most of it is present. To perform this test, your doctor will scrape under your tongue with a tongue depressor to obtain epithelial cells, which are then sent to a lab for analysis. Schedule this test with your doctor or start increasing your intake of magnesium.[6]

Dopamine

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Dopamine is the compound that fuels our drive and motivation. It increases attention, improves cognitive function, and stimulates our creativity. It makes us more social and extroverted and helps us form romantic and parental bonds. However, dopamine, when too high, can also have its drawbacks.

CONTENTS

Cutting-Edge Solutions For a Better Life
— Read on www.selfhacked.com/blog/ways-to-increase-and-decrease-dopamine

What is Trichotillomania?

A great overview of trichotillomania provided by the Trichotillomania Learning Center (TLC)

http://www.bfrb.org/learn-about-bfrbs/trichotillomania

 

What is Trichotillomania?

For an in-depth of overview of treatment guidelines and considerations for trichotillomania, download our free booklet, Experts Consensus Treatment Guidelines

Trichotillomania (trick-o-till-o-may-nee-uh) (TTM or “trich”), also known as Hair Pulling Disorder, is characterized by the repetitive pulling out of one’s hair. Trichotillomania is one of a group of behaviors known as Body-Focused Repetitive Behaviors (BFRBs), self-grooming behaviors in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the body.

Research indicates that about 1 or 2 in 50 people experience trichotillomania in their lifetime. It usually begins in late childhood/early puberty. In childhood, it occurs about equally in boys and girls. By adulthood, 80-90% of reported cases are women. Hair pulling varies greatly in its severity, location on the body, and response to treatment. Without treatment, trichotillomania tends to be a chronic condition; that may come and go throughout a lifetime.

Signs & Symptoms

Trichotillomania is currently classified as an “Obsessive Compulsive and Related Disorder” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

The DSM-5 diagnostic criteria include:

Recurrent hair pulling, resulting in hair loss

Repeated attempts to decrease or stop the behavior

Clinically significant distress or impairment in social, occupational, or other area of functioning

Not due to substance abuse or a medical condition (e.g., dermatological condition)

Not better accounted for by another psychiatric disorder

Hair pulling may occur across a variety of settings and both sedentary and active activities. There are times when pulling occurs in a goal-directed manner and also in an automatic manner in which the individual is less aware. Many individuals report noticeable sensations before, during, and after pulling.  A wide range of emotions, spanning from boredom to anxiety, frustration, and depression can affect hair pulling, as can thoughts, beliefs, and values.

Although the severity of hair pulling varies widely, many people with trichotillomania have noticeable hair loss, which they attempt to camouflage. Thinning or bald spots on the head may be covered with hairstyles, scarves, wigs, or makeup. Those with missing eyelashes, eyebrows, or body hair, may attempt to camouflage with makeup, clothing, or other means of concealing affected areas.

Due to shame and embarrassment, individuals not only try to cover up the effects of trichotillomania, but may avoid activities and social situations which may lead them to feel vulnerable to being “discovered” (such as windy weather, going to the beach, swimming, doctor’s visits, hair salon appointments, childhood sleepovers, readying for bed in a lighted area, and intimacy).

Impact and Effects

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Hair pulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.

Physical effects such as pruritus, tissue damage, infection, and repetitive motion injuries to the muscles or joints are not uncommon. Those who ingest the pulled hair or parts thereof may experience gastrointestinal distress or develop a trichobezoar (hairball in the intestines or stomach), which could lead to gastrointestinal blockage and require surgical removal. Although trichobezoars are rare, they are a serious risk for those who ingest hair.

Keep reading

What causes BFRBs?

How are body-focused repetitive behaviors treated?

Read our Experts Consensus Treatment Guidelines

Does Bipolar Disorder Run in Families? — The Bipolar Writer

I can trace Bipolar disorder in my family in at least three generations on my family tree. Two of my great aunts, a second cousin, first cousin on one side, and a first cousin on the Rhee side. My sister also suffer with bipolar 2 and trichotillomania just like me.

It’s interesting looking at my own tree, it feels like walking through a forest. Every tree is little bit different but they share parts of the same family. I have no idea if that made sense. I […]

via Does Bipolar Disorder Run in Families? — The Bipolar Writer

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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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.

*Updated 3/17/18

I started taking NAC (N-acetylcysteine) about five years ago and have noticed a decrease in my urge to pull when I take it 5-6 days per week. I have gone though periods where I did not take it or did not take enough that I notice any benefit.

Currently, I take 2-600mg 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

Steps to Recovery

The Path to Recovery: An Overview and Reminder

I believe the path to hair pulling and skin picking recovery includes the following steps:

1) Learn to accept & love yourself whether you’re pulling or not If you withhold self-acceptance until you have complete recovery you create a battle ground within yourself. (Read Radical Acceptance by Tara Brach.) This is NOT the same as giving up, or accepting the pulling will never change. This is accepting yourself, regardless of whether you are still pulling or picking; not making your self love conditional.

2) Keep a calendar and rate each day from 0 to 10, 0 being 0 pulling or picking, 10 being your worst day. This will be your “scale” so that you can see improvement, even if you can’t see it on your head, face or body. If one month has 9s, 8s and 7s, and the next has 8s, 6s and 4s, you may not see a physical change yet, but you are on your way. This helps when you have a bad day. My blog at HelpForHairPullers.blogspot.com will expand on this.

3) People always ask, Is there a substitute for pulling or picking? Something I can do with my hands? I say, the real substitute is something you do with your MIND. If you usually go go go all day, and then suddenly sit down to watch a movie, get on the computer, read, and find yourself pulling or picking, then pulling is aiding you in the transition from doing to not-doing. Instead of trying to fight the pulling, you want to adopt a nightly ritual that will help the body release stress Before you sit down to read, watch TV, et al. I suggest before you sit down with a book or TV, SIT for FIVE minutes and either do a relaxation exercise (inhale relaxation, exhale stress, tension & tightness) or do a mindfulness meditation for five minutes. Your mind & body then get a chance to make the transition into a state of relaxation. Your urges will begin to lessen as you do this since you’ve already addressed one of the reasons you have urges.

4) Bring awareness to your conscious mind: I once worked with a 60-ish woman who had a severe cuticle picking problem. It was so bad her hands were bloody and nicked, and she was deeply ashamed. I asked her if she did this all day or at specific times. Oh it’s always the same, she said. I sit down at 5pm for an hour before my husband comes home and read the paper and have a glass of wine. That’s when I pull. So I asked her, Do you think about it before you sit down? Do you bring to mind the fact that this a dangerous time for you? She said she did not. “I guess I don’t want to think about it because I’m always hoping that I won’t do it.” When I asked her if there was ever a time in the past 35 years that she didn’t pick, she said no. I explained that what she called “hope,” I called denial. I urged her to simply acknowledge to herself before she sat down that this was a danger time for her, and it was important to be aware. This often is not always enough to make a change, but for this woman, acknowledging to herself before hand that this was a dangerous time for her allowed her to stop picking entirely.   For other people it is one small piece in the bigger puzzle of trich and CSP recovery.

5) Until you understand & accept that recovery is a gradual process, you are unlikely to be able to recover long term. Pullers and pickers often proudly tell me they are perfectionists. Here’s the problem. If you are perfectionist, you are, by definition, a failure. Humans are not perfect, cannot be. So if you set a standard for yourself that is unattainable, you will always feel bad about yourself. The reason I suggest using a daily number (#2 above) is because recovery is generally a two steps forward, one step back kind of thing. The reason it’s so tough to recover from these disorders is that it’s quite common to have a “bad day” after having several good ones. And it’s just as common to think to yourself, “Oh boy, I ruined everything. Here I was doing well, and now I’ve messed it up. I guess I’ll NEVER recover, so I MIGHT AS WELL JUST PULL (or pick). That voice–the one that tells you that you’ll “never” recover? That’s the trich or CSP addiction talking. Think about it. If you tell yourself that you’ll “never recover,” you’re free to pull or pick! If you are a perfectionist about this, you are saying that either you suddenly stop and stay stopped 100% or you are a failure. Since that’s unlikely to happen, you in fact have now made it impossible to recover. What if, in order to get to zero, you have to achieve less and less pulling first? You might say, I did so well for three weeks, and I “ruined” everything all in one day. NOPE, not true, that’s impossible in fact. If you pulled very little or none for three weeks, and had one bad day, that means 21 of 22 days were good or even great. This is a huge improvement. And yes, I understand that you pulled out a bunch of hair and picked a bunch of skin. However, you didn’t “ruin” your progress. The more days you have where you pull less, the faster overall you’ll grow back your hair or heal up your skin.

6) Change your short-term goal. If your goal is to have your hair back or to have your skin clear, that’s always six months in the future. Your short term goal must be to feel good about yourself for improving and to validate yourself for any gains made, including gains made in awareness and self-talk, as opposed to lessening of the behavior. If you often say, I was so “good” for a while; now I’ve “messed” things up again. I have so little hair, or my skin is so messed up, “what’s the point” in trying to stop now. I look terrible anyway (and I’ll probably just pull or pick tomorrow). Here’s the POINT: You will feel better about yourself later if you pull even a little bit less right now. And if you don’t, you can learn to celebrate small victories.  You have to admit you will probably feel bad if you continue to pick or to pull. So at the very least you are avoiding that. The POINT is, recovery is gradual. The hair and the clear skin come later: the small steps happen now. The POINT is, taking any step, however small, is a step toward recovery.  This is a great point! The POINT is, Hey, even though I tried to tell myself that my hair is so messed up I might as well pull, I did NOT pull. Each day that goes on, and that you pull a little less, is another day that you can remind yourself, hey, I’m doing this. I’m making small steps these will add up. Good for ME! And every day you are able to pull or pick the smallest bit less, you are closer to the long term goals around hair or skin.

Changing the way you look at this so you understand it is not your fault that you have trich (but like any other disorder you could have, it’s your responsibility to yourself to address it), encouraging and supporting yourself as you recover, becoming more mindful, taking five minutes before those transition times to relax your body and mind, keeping track of the days with a single number (so you can look back and see that, hey, overall the numbers are getting lower), and accepting yourself no matter what, these are all important pieces on the path to recovery. Everyone can get there. Congratulations. You are on the path.

I blog about my personal struggle with trichotillomania and bipolar disorder. I also discuss helpful strategies, reflections, and treatments.

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