Category Archives: Research

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.

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

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.

What Causes the Urge to Pull

Here is another great blog post from Trichotillomania therapist and 20 year pull-free trichster, Claudia Miles (my role model).

As a psychotherapist who’s worked with hundreds of hair pullers, and as someone who personally suffered from daily hair pulling until I was 27 and has been pull free for 20 years, I know all too well the pain, shame and despair that pullers experience. I also know firsthand the frustration and hopelessness of trying *everything* to stop with no success. Or worse, having short-lived success–a day, a week, maybe even a month–and suddenly without warning you find yourself pulling again.

Maybe you pull your head hair, or your brows or lashes, or other body hair. My clients tend to be equally divided in that nearly half pull head hair and nearly half pull brows and/or lashes, a small number pull both, and the remainder pull from various areas on the body.

For those who don’t have Trich, also known as a “body focused repetitive disorder” (BFRD, and don’t understand it, but are close to someone who does, their own frustration and sadness about their child’s, friend’s, sibling’s or partner’s suffering may lead them to make constant suggestions (have you tried __ or ___), say to you, “Stop pulling, Honey,” if they see you do it, or try to “convince” you to stop by “reminding” you: “But Honey you have such pretty
hair..” “You don’t want to be bald, do you?” “Remember how upset you were about your lashes when you went to that dinner party, school dance, work, saw yourself in a picture, your friend asked you about it?”

As if you don’t already more desperately want to stop than anyone else could ever imagine. What’s hard to explain even to yourself is why you keep doing it, or why you do it at all. Why stopping seems so impossible when the behavior itself makes no sense. It just seems “crazy” or “gross” or you may feel “weak” and “pathetic”.

What others don’t know, and what you may not know, is that for people with Trich, hair pulling is a self-soothing mechanism (not an attempt to cause harm to yourself), and it feels pleasurable. It’s not an addiction to pain. The other even more important thing is that you are being prompted to pull by a physical urge that can best be compared to an itch. When people have an itch, they tend to respond to it without thinking or even being aware they are doing so. That’s why, if you have poison oak or chicken pox, you may not want to scratch, the doc may even say not to scratch, but the moment your attention is diverted (you’re watching TV or you’re on the phone), you “find yourself scratching.” And at that point, the need to “complete or finish” scratching is extremely compelling, even if you don’t want to. This comparison may help your spouse or parent or even you yourself to understand a little better what it is that causes you to start pulling in any particular moment. Either a physical or neurological urge occurs in a split second, as if you had an itch, and without conscious awareness you respond automatically. That’s why you may not have any idea of a precipitating factor.

Now, if it were that simple, it might well be easier to treat. But it’s important for pullers and their families to understand that this is not a willful behavior. Most people know what it’s like to respond to an itch and begin scratching, sometimes for a minute or more, before you realize what you’re doing. And most people also understand that, once you start scratching, poison oak for example, the craving to do so can overtake you, even though you know you shouldn’t. Most folks also know that, when at its itchiest, you may find yourself scratching, stop doing so, tell yourself, OK, I’m not going to scratch anymore, go back to
your movie, and find yourself scratching again and again. Imagine if this urge was daily and constant. Imagine if it resulted in hair loss. Yet no matter what you did, you would suddenly and repeatedly “find” yourself doing it. That’s, in short, what is happening to pullers. And because it as relieving to someone with Trich as it is for anyone to scratch an itch, you continue the behavior even when you’re aware. It is extremely important to understand that you (the puller) are not “crazy.” And anyone who experienced these urges, which occur in a microseconds, would respond the same way.

There are however, two other factors that come into play. I believe these urges have a cause that goes beyond that physical urge, and that are psyche comes to play a part in the constancy and intensity of these urges. Most people describe hair pulling as occurring in or even causing a “trance-like” state. This trance-like state kind of numbs one out emotionally, just like using a substance of some kind and also much like eating excessive amounts of carbs and sugar. This is why lots of people who have issues with weight may be engaging in what is called “emotional eating.” One may crave carbs and sugar in a way that feels like “regular” hunger. You may feel like you have to have a muffin or donut or cookie or hunk of sourdough bread. Yet underneath that craving, outside your present awareness, it may be fear or loneliness or shame that in a sense causes those cravings to happen. And once fulfilled, the emptiness or loneliness or shame is covered up.. Numbed out. So people tend to think that “their only problem is overeating.” Otherwise everything is fine. And this is exactly the same for hair pullers. The act of pulling numbs the longing or dis-ease, so it’s easy to believe that if I could just stop pulling, everything would be fine.

I work with people to get beneath this fallacy, generally dealing with issues like perfectionism, a lack of self love and self acceptance, or rather, a self-acceptance that is conditional. If they make a mistake, don’t finish their endless to do lists, aren’t thin enough, productive enough, accomplished enough or smart enough (which they rarely if ever think they are), they see themselves as unworthy, “lazy,” weak or just not good enough- And self love or acceptance is undeserved. That’s why many clients I see who have Trich and who generally also have this overly harsh, critical, perfectionistic attitude toward themselves tend to seek external validation since they are unable to give it to themselves. And this causes a pattern of people pleasing behaviors that also lead to living an inauthentic life, a life where one is not true to one’s self (since others’ opinions of their lives tend to be more important than their own.

Once my clients are able to access some of the painful feelings beneath the urges, and begin to experience greater self-acceptance and self love, two things happen: They begin to lead lives that are more authentic and true to themselves, and their urges to pull begin to diminish. And using mindfulness and learning to embrace gradual reduction rather than instant total cessation of pulling, they are able to slowly let go of some, most or all of tbeir hair pulling.

 

BFRB (Body-Focused Repetitive Behavior)

BFRB for short, is an umbrella term for a group of repetitive self-grooming behaviours in which an individual damages* their appearance or causes physical injury through pulling, picking, biting or scraping of the hair, skin or nails. BFRBs are also considered impulse control disorders as part of the OCD Spectrum. Over time these conditions can cause very significant distress, which can affect work, social and daily activities.

BFRBs affect 2-5% of the Canadian population, or approximately 2 million adults and children.

 *These behaviours are NOT a form of self-harm.

Why are they not considered self-harm?

BFRBs are not considered self-harm because the intent of the behaviour is not to harm oneself, but rather to fix, correct or otherwise make better some aspect of physical appearance (for example, get rid of a blemish, or a hair that doesn’t seem to belong). BFRBs are also a coping mechanism for overwhelming emotions, but once again the intent is not to cause damage. When it comes to BFRBs, the physical damage done is just a by-product of the behaviour.


Common Types of BFRBs

 

Hair-Pulling Disorder (Trichotillomania/ Trich/ TTM) – The compulsive urge to pull out hair from various parts of the body resulting in noticeable hair loss. Areas where pulling usually occur include scalp, eyelashes, eyebrows, arms, legs, and pubic area.

Skin-Picking Disorder (Dermatillomania/Excoriation Disorder/ Derm) – The compulsive urge to pick at one’s skin resulting in noticeable damage (sores, scabs, infections). Common areas include: face, head, cuticles, back, arms and legs, hands and feet.

TrichophagiaCoinciding with Trichotillomania, Trichophagia is the compulsive urge to eat or ingest the hair that has been pulled. In extreme cases, this can lead to a hair ball called a trichobezoar, which can cause significant health problems. Removal of the hair ball is usually done through surgery.

Onychophagia – Compulsive nail/cuticle biting. The severity and extent of damage to the skin is variable, but can lead to infections, pain in the fingers and torn skin around the fingernails. Some signs include short nails, skin damage around nails, bleeding skin around nails, callouses.

Rhinotillexomania – Compulsive nose picking. Not to be confused with people picking thier nose from time to time for strictly hygienic purposes. Compulsive nose picking causes a greater risk of infection/damage to the lining of the nose.

Other BFRBs include:

  • Trichotemnomania (compulsive hair cutting/shaving)
  • Dermatophagia (compulsive skin biting ie. around nails, lips & inside of cheeks)
  • Scab Eating Disorder (comparable to the way someone with trichotillomania may digest the hair after pulling it out)

Who is affected and when does it typically develop?

Most BFRBs begin in early puberty/adolescence and many continue into adulthood. In childhood both males and females are affected equally, but in adulthood more females are seemingly affected. Anyone can be affected by a BFRB.

Why do I pull or pick?

Research indicates these behaviours are possibly related to genetics/ environmental causes, but there is no concrete answer yet as to why people begin these behaviours. The symptoms are not personality traits or something that a person can just “snap out of” or stop.

I think my child has a BFRB, what should I do?

First and foremost, be there to support your child and NEVER punish them for the behaviour. Although it may seem like a good deterrent, BFRBs are a group of disorders, not just bad behaviour that can be solved by punishment. Keep in mind that your child very likely doesn’t want to pick or pull, and is probably ashamed of the behaviour. They probably want to stop just as badly as you want them to.

Knowledge is power! Educate yourself about BFRBs and if you take your child to the doctor for the behaviour(s), bring some printed materials/ information along with you. It will take some effort, but find what’s best for your child as they deal with their BFRB(s).

Trichotillomania Research, Clinical Research into BFRBs

 

BFRBs are categorized under Obsessive Compulsive related Disorders in DSM-V. BFRB for short, is an umbrella term for a group of repetitive self-grooming behaviours in which an individual damages* their appearance or causes physical injury through pulling, picking, biting or scraping of the hair, skin or nails. BFRBs are also considered impulse control disorders as part of the OCD Spectrum. Over time these conditions can cause very significant distress, which can affect work, social and daily activities.

Many people find NAC helpful to reduce their BFRBs. Ideally a full nutritional program should be utilized.  This would begin with a food journal to analyze the effects of various foods and supplements.  Looking at the rate of urge and pulling days and weeks after particular foods will help you see patterns of increased pulling following consumption of certain ‘bad’ or ‘triggering’ foods.

The John Kender Diet is a helpful launching point for this analyses.  Although that diet plan sets a good foundations, each trichter is unique and his or her food triggers may vary.  In addition, various supplements may help some trichters, while not helping others.  Most commonly, NAC and inositol have shown a correlation with reduced urges and hair pulling.  Also there is a milder correlation between Luvox and some other prescription medications.  Personally, I have found Zoloft and Anafranil helpful with my pulling.  The Zoloft mildly decreases my urge to pull. Moreover, it reduces my overall anxiety, which is a major contributing factor to my pulling.

Laboratory mice are helping researchers from Stanford University School of Medicine who have developed the study of specific nutritional supplements to prevent skin picking and hair pulling. The mice have been supplemented with NAC and glutathione, leading to decreased BFRBs.

NAC is necessary for the natural formation of glutathione. Glutathione is one of the methods used by the brain to regulate cortisol. Cortisol is often described as a stress hormone, but its role in life is far more complex. Cortisol wakes people up in the morning and lowers to allow for sleep at night. Many people with trichotillomania experience a reversed effect, feeling extremely low in energy on waking and only beginning to wake up by the time most people go to bed. Another effect of cortisol is to lower histamine levels, thereby reducing inflammation both in the body and brain.

The role of enhanced emotion in trichotillomania is evident in certain brain areas, and the reward centre of the brain reveals a connection with dopamine. An MRI-based human study by Grachev investigated only twenty right-handed females aged 28-30, ten were trichsters while ten were not. Two areas of the neocortex were significantly reduced in volume, but there was no overall loss of volume, indicating that the tricster brains may have developed differently, possibly in a compensatory manner. Additional studies have also revealed increased grey matter in the amygdale hippocampus area of the brain, which plays a vast role in emotional processing (Aldridge et al, 1993).

Increased cortical thickness has also recently been revealed in people with trichotillomania and their close relatives, possibly causing response inhibition. (Odlaug et al, 2014)

References

Aldridge JW,. Berridge KC, Herman M, Zimmer L, Research report neuronal coding, Psychological Sciences, 4 (1993).

Christenson GA, Popkin MK, Mackenzie TB & Realmuto GM, Lithium treatment of chronic hairpulling, Journal of Clinical Psychiatry, 52 (1991).

Grachev ID, MRI-based morphometric topographic parcellation of human neocortex in trichotillomania, Psychiatry and Clinical Neuroscience, 51(1997).

Odlaug BL, Chamberlain SR, Derbyshire KL, Leppink EW, Grant JE, Impaired response inhibition and excess cortical thickness as candidate endophenotypes for trichotillomania, Journal of Psychiatric Research, 59 (2014).

If you are interested in carrying out a research project and would like any help or involvement from us; please contact us. We are always happy to help improve knowledge of trichotillomania in any way we can.

John Kender Diet: ‘Bad’Foods Trigger Urge to Pull

I figure who better to explain the John Kender diet then John Kender himself..so here he gives an excellent overview of his findings.  Michael Grant also presents his extensive knowledge on good and bad skin products that affect trichotillomania, much like good foods.

Here’s some info about hair pulling, particularly about nutrition, skin care, and yeast. This compilation was originally created in July 1997, and should be accompanied by an updated article, “A Theory of Trichotillomania”, written in August 2008, which focuses more on the possible chemicals involved. Please write me if you have not received it.

As of July 2012, more than 600 people (including more than 100 children or adolescents) have been reported to me via email as obtaining from “good” to”total” relief, from at least one week to over eight years, using some or all of these techniques. I have used them since July 1992, and (except for experiments with new things and an occasional deliberate dietary lapse) I have been pull-free for that time. I have also received several reports that skin-picking and even nail-biting are also responsive to these methods, and that five dogs have stopped their compulsive paw-licking similarly.

Thank you,

John Kender

TRICH, FOOD, AND SKIN CARE

(Submitted to the TLC newsletter “InTouch” in August 1999, so references to dates and times have to be adjusted somewhat.)

by John R. Kender and Michael J. Grant

In this letter, we outline some observations about several simple at-home procedures that have proven to be helpful to many pullers. These procedures involve various foods and skin care practices. We guess that for many people, hairpulling is aggravated by a particular biological cause that these practices help to address. At the end of this letter, we list postal and email addresses where you can get more detailed information about our ideas and methods.

1) Who We Are and What We Have Done

Let’s first introduce ourselves. One of us, John, is a university professor who pulled eyebrows for 30 years, but is currently enjoying a more than seven year remission which he attributes to dietary control. For the past four years, John has run the TTM remailer program, a private internet email exchange about trich, which has about 400 subscribers and participants. John has spoken at two TLC retreats about his experiments with nutrition and its effect on trich.

The other of us, Mike, is the father of a hairpuller. He and his daughter, Terri, have experimented with several skin and hair treatment approaches to hairpulling. Mike started and is an active contributor to an email support group for PoPs (Parents of Pullers) on the internet. Mike has attended several TLC retreats, at which he has demonstrated on multiple volunteers his various scalp care procedures, which use only non-prescription preparations.

The two of us, in our combined 12 years of experimentation, have observed that for many people some of the trich experience is directly affected by diet and by skin condition. By continuing to use the internet to gather the experiences of other hairpullers, and by combining these with our own experimentation, we have become convinced that for many people it is possible to achieve significant amounts of relief and control by taking some straight forward measures with regard to nutrition and skin care procedures.

Although our observations have not yet been medically verified and our guesses as to their biological roots remain unproven, in the past four years we have gathered reports of significant improvement from an encouragingly large number of people.

We aren’t selling anything–there is really nothing to sell–and we realize that what we have noted does not work for all forms of trich. But we offer them to the readers of InTouch, who can try them for themselves as they see fit. Please be aware that we are not medical doctors and that anyone considering these approaches should check with their doctor first.

We will describe first some nutritional means, then some skin and hair care means, and then suggest a possible explanation for why these two seemingly unrelated approaches may both be ways of attacking a common biological cause. If anyone then wishes further information, we list where we can be reached.

2) Nutrition and TTM (John writes)

Seven years ago, by keeping careful records of what I ate, I noticed that certain foods tended to increase my urges to pull. By avoiding those foods, I began what is now a seven year remission: no urges, and no hairpulling. Numerous experiments, some even with my dog who had a problem with compulsive paw licking, confirmed that some foods were “bad”, meaning that they increased hairpulling urges and sometimes increased an itchy “this hair is out of place”feeling. I wrote in a previous issue of InTouch four years ago about some of these experiments.

Since then, based in part on written and email reports from other pullers, the list of “good” and “bad” foods and of other food-related techniques has been refined, and there is now a better understanding of the strengths and weaknesses of this approach. As of the Summer of 1999, over 100 people, including about a dozen children and adolescents, and several dogs, have reported or have been reported as obtaining from “good” to “total” relief, for a week to years, using some or all of these techniques. More than two dozen of these pullers report from two months to three years’ worth of benefit. At the same time, the number of people reporting increased urges and hairpulling after eating “bad” foods has been so numerous (on the order of several hundred) that I have stopped keeping track of them, even electronically. On the other hand, we have received a few reports of earnest attempts at dietary control measures that have failed, most of them appearing to be from lash pullers.

According to several polls we have taken on the TTM remailer list, we have gathered the following information. About one-half of pullers who responded to the polls do experience strong hairpulling reactions to one or more of sugar, caffeine, cola and/or chocolate, egg yolks, legumes (peanuts, mostly), or fatty fish (tuna, mostly). First preceded by an growing internal feeling of agitation, the hairpulling urges begin increasing a few hours after eating sugar or caffeine, or about one to two days after eating the others. The increased urges usually peak after about twice that amount of time. Often these urges, particularly the ones due to egg yolk and legumes, take as much as a week to fully subside down to their usual level. Although stress aggravates such food-related pulling, it is not necessary for it: after “bad” foods, people report they pull regardless of their mental state.

The polls have indicated, however, that scalp and/or body pullers seem to differ somewhat from lash and/or brow pullers. Scalp and/or body pullers seem to be food-sensitive to the extent that their hairpulling is worse during Premenstrual Syndrome (“PMS”)–which tends to be experienced as increased depression–and to the extent that they “trance out” while hairpulling. Lash and/or brow pullers, however, seem less food-sensitive and more business-like in their hairpulling. Their PMS tends to be experienced as irritation, and their hairpulling is more focused; further, their hairpulling may be more related to the eating and drinking of vitamin-D enriched dairy products. But both kinds of pullers in general tend to be far more likely than average to have allergies, to have sweet tooths, and to have an unexpectedly extensive experience of being around furry pets. Most surprisingly, the polls indicate that pullers tend to have an unusually high number of “trichy” dogs and cats.

If people are interested in seeing if their hairpulling is food-related, there is a simple test: they should simply eat as many peanut M&Ms or Reese’s peanut butter cups as they can stand at one sitting (sugar! chocolate! legumes!),washing them down with Coca-Cola (cola! caffeine! more sugar! or aspartame, which is just as bad!). Alternatively, especially for children, it could be peanut butter and jelly sandwiches with chocolate milk. If in two days there is a noticeable increase in hairpulling urges, then they could consider abstaining from “bad” foods. Unfortunately, it appears to take from 30 to 40 days to purge the gut and skin of their bad effects fully, and it also seems to take several attempts and about a year of trying for most pullers to get there. People report that avoiding sugar and caffeine, which act more quickly, is the most rewarding way to start.

The “bad” food list given above reflects the worst experiences of many people, but it is not complete. The full list is available on written request (it’s too long to explain here). It includes, among other things, concentrated natural sugars, tomato seeds, soy products, yams, MSG, and ibuprofen. However, there are a few “good” foods, which partially counteract the “bad” ones. They include garlic, most acidic fruits, dry red wine, unsweetened yogurt, and a chemical family called gluconates.

Additionally, certain hair care products and certain skin creams carry chemicals that appear to be similar to those involved with the “bad” foods. In particular, food-sensitive pullers report that hair conditioners with stearyl alcohol or other fatty alcohols should be avoided. Similarly, there have been reported a few “good” food-related chemicals that can be applied to the skin and hair to stop them from itching, among them alpha hydroxy acids (“AHA”s, sometimes called “fruit acids”), and a home-made hair rinse made from a mixture of acetic and boric acids (essentially, dilute vinegar and eyewash). We have a theory as to what may hold these unusual collections of “good” and “bad” foods and chemicals together, which we will briefly explain below.

3) Skin and Hair Care and TTM (Mike writes)

My continuing interest in the relationship of certain types of scalp conditions and TTM has been an outgrowth of my daughter Terri’s experience which began more than five years ago. At the time Terri was diagnosed withTTM, she had already been under a dermatologist’s care. She had what was thought to be spontaneous hair loss due to alopecia areata, as well as due to an inflammatory condition of the scalp that had progressed to the point of forming sores which she would want to pick at due to their intense itching. The condition of Terri’s scalp was thought to be a medical consequence of her primary impulse control disorder.

In the years that have followed, through Terri’s experience as well as my own participation with children and adults in the TTM community, I discovered a group of hairpullers who share the same scalp symptoms. Further, observing these scalp conditions over time, I have noticed that in many instances the scalp conditions preceded, not followed, the hairpulling. The pulling appeared to be triggered by the inflammatory process, much like the scratching behavior most of us have in response to conditions such as mosquito bite,poison ivy, or athlete’s foot. I speculated that it might be possible in some instances to reduce or eliminate the hairpulling behavior simply by alleviating the inflammatory trigger.

The opportunity came when Terri consented to have her head shaved for medical reasons to help resolve her on-going scalp problems. Her urge to pull seemed to disappear literally overnight, an observation agreed with by the medical professionals attending her. The conventional explanation was that this had removed a significant trigger and prevented the self-reinforcement of pulling behavior. But the conventional explanation did not explain the suddenness with which the urge seem to be extinguished, nor the experimental result that the relief only came when the scalp was wet-shaved with a blade, and not with a surgical clipper which cut the hair to virtually the same length. At the same time, the razor shave was observed to relieve the inflammation, whereas the clipper shave noticeably exacerbated the redness and itching.

After reading an abstract John posted to the remailer describing a protocol for treating a particular inflammatory process possibly related to a biological cause, I noted that there were some similarities between the article’s treatment and what Terri was receiving in the head shave. The article’s treatment soaked the scalp with a soapy lather beneath hot water-saturated towels. This was exactly the preparation done prior to using the razor. As an experiment, we did the soak but didn’t use the razor. Terri experienced nearly the same degree of relief as if her head had been actually shaved, and it alleviated the inflammation of her scalp as well. This strongly suggested it was not the cutting of the hair that provided the relief–the clipper did that without good effect–but rather it was the preparation regimen itself. We also noted with some interest that letting her scalp get some sun also helped; in fact, an accidental sunburn gave about four days free of itching.

On the possibility we were dealing with a dermatological disorder, a receptive dermatologist prescribed the antifungal shampoo Nizoral, then available only by prescription. And based on the article, we substituted Cuticura soap, which is similar to the liquid barber’s soap we were using, but which also contains an antiseptic. Over time, we found that the optimal regimen was to alternate the Cuticura with the Nizoral shampoo on a daily basis. It appears that the two are good compliments to one another. Cuticura is anti-bacterial, Nizoral is anti-fungal. Cuticura is a soap which is milder but leaves a residue which can build up. Nizoral is a detergent which removes the residue and prevents the build-up.

Some other preparations we tried were pure aloe vera gel, benzoyl peroxide, and camphor. Terri’s barber suggested the aloe vera gel as a skin conditioner to soothe and protect her scalp after shaving. She also tried a lanolin-based product, but that resulted in intense itching within 30 minutes of being applied to Terri’s scalp, whereas the aloe vera gel seemed to help reduce what itching there was. The benzoyl peroxide worked well for an intense itching area where there was inflammation and a distinct raised area on the skin, but it was very drying to the scalp and it bleached the emerging hair. (Along the way, I discovered that benzoyl peroxide also stopped, within a week, one of my own year-long bouts with skin picking.) But with further experimentation we found that camphor spirit topically applied would alleviate itching for several hours without adverse effects. Camphor is also contained in Sea Breeze astringent, which we found useful and mild enough for general routine application.

What I believe to be a significant discovery happened while Terri was having her head shaved on a regular basis. To alleviate the “shine” which my daughter did not like, the barber applied to her scalp a mineral clay masque, made principally from bentonite, to help absorb the excess oils. As the water evaporated from the clay, contrasting dark areas would appear in proportion to the amount of oil that had been absorbed. (We later found a formal clinical study in which bentonite clay was also used to collect skin oils from patients.) An astonishing phenomenon slowly began to appear. Terri only pulls from highly selective areas that have an intense itch-like sensation. After shaving her head with the straight razor, these areas could no longer be distinguished from the rest of her head. But the contrasting dark areas of the clay masque exactly outlined those “hot spot” areas which were otherwise indistinguishable on her scalp–even when they were examined by an experienced dermatologist under magnification. I believe this to be a physical demonstration of the correlation between hot spots and excess sebum, present even six months after the cessation of all pulling.

In an attempt to replicate the observations I made with Terri, as well as to do a preliminary investigation of a possible biological cause, I made up kits with various over-the-counter preparations and skin care products for some of my email TTM friends. Included were the Cuticura soap, as well as several other types of soaps we had used. Also included were a triple antibiotic, a mild steroid anti-inflammatory (hydrocortisone), an antihistamine (diphenhydramine), as well as an anti-yeast product (miconazole nitrate). Only general cautions were provided, together with the instructions to try all the products and decide which ones worked the best. At least half of those who received the kits were not associated with John’s remailer, and had not heard of any possible search for a biological connection with TTM.

The antiseptic Cuticura was by far the preferred cleansing agent over very similar soaps without the antiseptic. Sea Breeze astringent for general overall application, and camphor spirit for intense hot spots, were also widely reported as being helpful. The antibiotic ointment seemed to have no effect, nor did the antihistamine ointment, but the surprisingly effective agent, widely and independently reported to alleviate the itch and pulling urge, was the antifungal miconazole nitrate 2% cream.

At this point, I can recommend a specific program for shampooing, massaging, and treating the hair, skin, and scalp. The full program is available on written request (it’s too long to explain here). We have a theory as to what may hold these unusual collections of “good” and “bad” skin treatments together, and what may relate them to the “good” and “bad” foods and chemicals, which we will briefly explain below.

I have had the privilege of demonstrating these techniques at the last two TLC Retreats, and I would like to thank those individuals who participated. They helped to advance our understanding and to make this letter possible. I would also like to thank Jo Ann, our family barber, and most of all, my daughter Terri, for her patience, understanding, and courage.

4) A Possible Theory of Some TTM (both of us)

Putting all these observations together, we guess that some people pull because of a local skin irritation caused by chemicals released into skin grease by a skin micro-organism. Specifically, we guess that some (about 60% of) hairpulling is aggravated or caused by a local allergic reaction to the enzymes and/or fatty alcohols produced by a normally innocuous skin yeast, Malassezia. Nearly everyone has this skin yeast, particularly in hair follicles of the lashes, brows, and scalp. But what may make pullers different is that their immune system reacts more strongly to its presence. From this perspective, hairpulling is like sneezing: the body is attempting to rid itself of an allergy-causing irritant.

What ties the “bad” things together is that the “bad” foods are all scientifically known to encourage the growth of this yeast, and the “bad” chemicals are scientifically known to cause allergic reactions. Oppositely, the “good” things are known to kill or inhibit either the yeast, the yeast enzymes, or the yeast-produced chemicals in various ways.

There are more details to this theory, which are available on written request. For example, common sugar is a powerful yeast food, for all yeasts (including the different yeast which is known to cause vaginal yeast infections), but fructose, a somewhat different sugar which does not seem to bother pullers, is not a good yeast food at all. Foods rich in sterols, whether they are the cholesterols in animal foods such as egg yolks, vitamin D-related sterols in milk or tuna, or the phytosterols in plant foods such legumes, are believed by researchers to be growth signals to the specific skin yeast we suspect. Similarly, there are links between the other foods and chemicals to this yeast’s life cycle and health. One of us, Mike, has even grown a colony of Malassezia, and has found that its most preferred food is the oil from freshly ground peanuts.

Further, the irritancy of conditioners containing fatty alcohols, the “hot spots” of pulling, the slow migration of hot spots over the skin, their localized overproduction of skin grease, the relief people experience from the grease-removing clay masks, the effectiveness of anti-bacterial and anti-fungal shampoos, and the soothing action of the extended grease- expressing hot-towel scalp massages: these all appear consistent with the idea of a localized allergic response to an infecting organism. Seen this way, the

hot towels, high pH soaps, and blade shaving may be removing both the organism and the grease it feeds on, something an electric razor misses. Even the gradual recurrence of the itch after four days or so fits with what is known about the time necessary for yeast growth. Further, the propylene glycol base for the helpful aloe vera gel is a known yeast killer (as is sunlight and as is benzoyl peroxide), whereas the troublesome lanolin is a complex of growth-stimulating sterols and irritating fatty alcohols.

We think the theory helps explain why hairpulling is worse premenstrually: the increased progesterone, a sterol, is a known yeast growth stimulant. And why hairpulling usually doesn’t hurt and is often done in a trance: this skin yeast is known scientifically to make a chemical called hexanol that has anesthetic properties. (And besides, people with other skin yeast infections scratch like crazy, sometimes drawing blood, but finding it pleasant.) And why hairpulling usually starts in early adolescence: this is when the sebaceous glands start to produce the grease this yeast needs. And why hairpulling is chronic: this yeast, in general, is hard to control, and other disorders related to it are chronic; in any case, most allergies are unfortunately chronic, too.

We think the theory may help explain the “fat roots” that hairpullers seem to go hunting for: skin micro-organisms are able to turn soft grease into a harder wax-like plug that is easy for exploring fingers to recognize. (We have found that non-pullers get them, too, but it doesn’t seem to drive them nuts.) We think the theory may help explain why such very large doses of serotonin-specific reuptake inhibitors (“SSRI”s, like Prozac) are found to be necessary for TTM: it may be that the SSRIs act like chemotherapy, stressing the human body, but fatally overloading critical yeast digestive processes (technically, the “cytochrome P450 enzymes”, which the human body also uses to dispose of SSRIs). We even speculate that hairpulling and furry pets seem to go together because, perhaps, the microorganisms involved can be shared between people and dogs and cats; some people have in fact have found some relief from lash pulling by simply making sure to regularly wash their hands and eyelids.

5) For Further Information

If you have access to the Internet, a good place to explore these food and skin care observations is by joining the TTM remailer (send email to jrk@cs.columbia.edu), or by viewing Amanda’s website (at jly2.com/ttm). The authors can be reached at jrk@cs.columbia.edu or TTMParents@aol.com.

6) An Important Final Disclaimer

Please note that the two of us are simply reporting what we have observed and thought. We are not offering medical advice. We cannot guarantee results, or even the safety of any these procedures. It is important that you check with your doctor first before you experiment. And, please, let us know of your results, so that we can keep all these things safe, and share them with other hairpullers.

The Benefits of Breathing

When anxiety hits or something bad happens, you’ve all been told to “take a deep breathe”, or “just breathe”.  Purposeful breathing seems to have wide reaching benefits for mental and physical well being.

When my anxiety was at its worst and I was having panic attacks almost daily, my therapist explained the benefits of deep breathing. I was skeptical at best. How was something as simple as breathing going to make any difference, after all I breathed all day long.

I agreed to try the deep breathing because it wouldn’t hurt. I was shocked to find it actually helped.The more I did it, the more I grew to view it as a coping skill.

The most profound difference in my anxiety and panic attacks came from ‘simple’ strategies: walk away, count to 10, and deep breathing. I continue incorporating these strategies into my life even now that my anxiety is much milder and my panic attacks are for the most part gone.  

Being a research junky, I wanted to know why something as simple as breathing was so helpful. I also looked into different breathing exercises.

Here are a few articles I found most informative and helpful:

 The Art of Living Blog: Benefits of Deep Breathing and How to Breathe

Harvard Health Publications: Relaxtion Techniques: Breath Control Help Quell Errant Stress Response

13 Health Benefits of Deep Breathing

NPR: Just Breathe: Body has a Built in Stress Reliever

 

High Doses of EPA for Depression, Anxiety, and Bipolar Disorder

I have been researching the use of omega 3’s in the treatment of depression, anxiety, and bipolar disorder.  The current studies agree that high doses of EPA work well to treat mood disorders.  DHA is another omega 3 and works better for cognition and fetal/infant development.  Studies show that supplementing with only EPA or higher doses of EPA than DHA work best for mood disorder.

I just had a baby and have been taking 1 gram of DHA throughout my pregnancy. I will continue this dose until I am done breatfeeding.  I have also been taking 500 mg of EPA.   Now I am increasing my EPA dose to 2 grams.  I am hoping this will help with postpartum depression, which I had badly with my 3 previous children. I will keep you posted as to my progress with this increase.  Here is some helpful information about EPA for depression, suggested doses, and relevant studies.

High Doses of Omega 3 EPA and Depresion

Omega 3 Fatty Acids