Category Archives: Treatment

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.

Increase Dopamine

What Is Dopamine?

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.

What Does Dopamine Do?

The most important dopamine pathway in the brain controls reward-motivated behavior.

Most types of rewards, such as new experiences or accomplishment, can increase dopamine levels in the brain. In addition, most addictive drugs and behavioral addictions can increase dopamine.

In addition, dopamine has many other important roles in humans, including movement, memory, attention, learning, sleep, and mood.

Dysfunctions of the dopamine system contribute to Parkinson’s disease, schizophrenia, restless legs syndrome, and attention-deficit hyperactivity disorder (ADHD).

The Dopamine Diet: An Ideal Diet to Increase Dopamine

The following diet will be optimal for increasing dopamine:

Our bodies produce dopamine from the amino acid tyrosine. In turn, tyrosine can be produced from phenylalanine.

Bananas especially contain high dopamine and L-dopa levels [5, 6].

Bananas especially contain high dopamine and L-dopa levels [5, 6].

Saturated fats can suppress dopamine. Equivalent intake of monounsaturated fats (from olive oil) protects against dopamine decreasing [7].

Green tea increases dopamine in rats [8, 9], including its constituents Theanine and Caffeine.

Caffeine’s performance-enhancing effects are accomplished via dopamine. Caffeine maintains a higher dopamine concentration especially in those brain areas linked with attention [10].

You want to consume cholesterol-rich foods because cholesterol is a precursor to Pregnenolone, which increases dopamine in animals [11, 12].Saturated fats can suppress dopamine. Equivalent intake of monounsaturated fats (from olive oil) protects against dopamine decreasing.

Green tea increases dopamine in rats, including its constituents Theanine and Caffeine.

Caffeine’s performance-enhancing effects are accomplished via dopamine. Caffeine maintains a higher dopamine concentration especially in those brain areas linked with attention.

You want to consume cholesterol-rich foods because cholesterol is a precursor to Pregnenolone, which increases dopamine in animals.

Magnesium has antidepressant effects that can partially be tied to increasing dopamine activity in the brain [13].

Curcumin, found in the spice turmeric, increases dopamine concentration in the brain [14, 15, 16], by inhibiting MAO-mediated dopamine break down [17].

Resistant starch is a type of soluble fiber that increases butyrate. Butyrate may increase dopamine levels [18, 19].

Folate is needed for the production of dopamine (and serotonin). When your body is low in folate, it cannot produce dopamine and other monoamines efficiently, which may result in depression [20, 21].

Nutritional or brewer’s yeast is rich in uridine. Uridine-5′-monophosphate increases dopamine levels in the rat brain [22].

Seafood, which contains DHA, can increase dopamine levels in the brain [23, 24, 25].

Oregano increases dopamine levels by decreasing dopamine break down and reuptake [26].

Both tyrosine and phenylalanine are found in protein-rich foods [27]:

  • Chicken and Turkey
  • Fish
  • Almonds
  • Avocados
  • Bananas
  • Pumpkin and Sesame seeds
  • Dairy: Milk, Cheese, Yogurt, Cottage cheese
  • Legumes: Soy, Lima beans, Peanuts

Lifestyle to Increase Dopamine

1) Sun/Being outside/Bright Light increases dopamine

Bright light can improve our mood. This may partially be due to dopamine.

A study shows that light may increase dopamine, and thereby improve mood in women with mild seasonal mood disorder [28].

Light also stimulates the release of dopamine in the retina, and this is beneficial for maintaining good vision [29].

2) Exercise

Exercise increases dopamine [30, 31].

A study in women showed that exercise decreases COMT activity, thereby increasing dopamine in women (in the prefrontal cortex) [32]. COMT is the enzyme that breaks down dopamine.

3) Meditation

Meditation increases dopamine release [33, 34].

However, the effects seem to be transient unless meditation is done regularly.

A study shows that long-term meditation practice is needed to induce stable changes in baseline dopamine (striatum) [35].

4) Yoga

3 months of practicing yogaincreased dopamine levels in men (in blood/circulating levels) [36].

The study revealed that yogic practices might help in the prevention of age-related degeneration….in healthy males.

5) Touch

Pleasurable physical contact can increase dopamine.

In rats, it was shown that stroking increases dopamine release (nucleus accumbens) [37].

Tickling, as a form of play behavior in adolescent rats, also increases dopamine release (nucleus accumbens) [38].

In early life, stimulation from touching improves spatial working memory in rats, possibly by improving dopamine function [39].

6) Massage therapy increases dopamine

Massage therapy increases dopamine, with a 31% increase of urinary dopamine in people [40].

Massage increased dopamine levels in pregnant women with depression [41] and in adolescents with bulimia [42].

7) Music

Parts of the brain release dopamine when listening to pleasurable music (striatum, nucleus accumbens) [43, 44, 45, 46].

Not just listening, but creating and performing music also produce dopamine [47].

Food to Increase Dopamine

8) Tyrosine- and phenylalanine-rich food

Our bodies produce dopamine from the amino acid tyrosine. In turn, tyrosine can be produced from phenylalanine [4]. Both tyrosine and phenylalanine are found in protein-rich foods [27]: chicken, turkey, fish, peanuts, almonds, avocados, bananas, milk, cheese, yogurt, cottage cheese, lima beans, pumpkin seeds, sesame seeds, and soy.

Bananas especially contain high dopamine and L-dopa levels [5, 6].

9) Unsaturated fat

Saturated fats can suppress dopamine. Equivalent intake of monounsaturated fats protects against dopamine decreasing [7].

Supplements That Increase Dopamine

10) Tyrosine

dopamine_production increase dopamine

Tyrosine supplementation increases dopamine levels in the brain [48, 49, 50].

A study shows that tyrosine supplementation effectively enhances cognitive performance, particularly in short-term stressful and/or cognitively demanding situations when dopamine is temporarily depleted [51, 48].

11) Green Tea

Green tea increases dopamine in rats (in blood, stress model) [8, 9].

Theanine, one of the major amino acid components in green tea, increases dopamine in animals [52, 53, 54].

12) Caffeine

Caffeine increases dopamine release (striatum, nucleus accumbens) [55, 56].

Caffeine’s performance-enhancing effects are accomplished via dopamine. Caffeine maintains a higher dopamine concentration especially in those brain areas linked with attention [10].

13) Pregnenolone

Pregnenolone sulfate increases dopamine in animals (striatum, nucleus accumbens) [11, 12].

14) Magnesium

Magnesium has antidepressant effects that can partially be tied to increasing dopamine activity in the brain [13].

15) St. John’s Wort

A number of studies have shown that St. John’s Wort, an herbal anti-depressant, increases dopamine content in the brain (nucleus accumbens, striatum) [57, 58, 59, 60, 61].

16) Gingko

Gingko biloba increases dopamine and dopamine neuron activity (PVN, VTA, Nucleus Accumbens) [62, 63, 64]. This increase in dopamine may partially explain the improvement of cognitive function observed with Gingko supplementation.

17) Curcumin

Curcumin increases dopamine concentration in the brain [14, 15, 16], by inhibiting MAO-mediated dopamine break down [17].

18) Butyrate

Butyrate may increase dopamine levels in animals in response to toxic injuries (striatum) [18, 19]. You can get butyrate in the diet by consuming soluble fibers found in fruits and vegetables or ghee.

19) Folate

Folate is found in leafy greens/vegetables and is needed for the production/synthesis of dopamine (and serotonin). When your body is low in folate, it cannot produce dopamine and other neurotransmitters (monoamines) efficiently, which may result in depression [20, 21].

20) Huperzine A

Huperzine A is a substance that is known to increase acetylcholine, but it also increases dopamine levels 129% above baseline in rats (cortex) [65].

This substance may help with treating drug addiction [66].

21) SAM-e

S-Adenosyl-l-methionine (SAM-e) is an over-the-counter dietary supplement commonly used to treat depression. SAMe helps in the production of dopamine and other monoamines, causing elevations in dopamine levels [67].

22) Shilajit

Shilajit is a naturally occurring biomass found in the Himalayas. In traditional Indian medical practice to be useful in the treatment of nervous disorders, epilepsy and as an antistress agent.

Shilajit increases the levels of neuronal dopamine in the brain, which has an anxiety suppressing action [68].

23) Uridine

Uridine-5′-monophosphate increases dopamine levels in the rat brain when the neurons are activated (striatum) [22]. Uridine is found very concentrated in nutritional and brewer’s yeast, meat and fish.

24) Fish Oil

Seafood/Fish Oil/DHA can increase dopamine levels in the brain in rats (striatum). Dopamine levels were also 40% greater in the frontal cortex of rats fed fish oil. DHA treatment led to an 89% rise in tyrosine-hydroxylase terminals within the striatum in lesioned animals [23, 24, 25].

25) Ginseng

Ginseng components can increase levels of dopamine in the brain and have beneficial effects on attention, cognitive processing, sensorimotor function and auditory reaction time in healthy subjects [69].

However, ginseng can also blunt dopamine release in response to other stimulants such as nicotineand cocaine [70, 71].

26) Danshen

Red sage, also known as danshen (Salvia miltiorrhiza), may increase dopamine in cells (striatum) [72].

27) Resveratrol

Resveratrol can increase dopamine levels in the brain in animals (frontal cortex, striatum). Resveratrol treatment in old rats increased dopamine by 53% (striatum) [73, 74].

28) Oregano

Oregano extract increases dopamine levels by decreasing dopamine break down and reuptake in animals [26].

29) Carvacrol

Carvacrol, present in the essential oil of many plants including oregano and thyme oils, acts as an antidepressant by activating the dopamine system in mice [75].

At low concentrations (what’s in oregano and supplements), carvacrol increases dopamine. However, in high concentrations, it may decrease dopamine levels [76].

30) Clary sage

Clary sage (Salvia sclarea) oil increases dopamine activity in rats, which contribute to its anti-depressant effects [77].

31) Bacopa

Bacopa (Bacopa monnieri) extract can increase dopamine in rats (in the cortex and hippocampus) and have a nootropic effect [78, 79].

32) Mucuna pruriens

Mucuna pruriens has a high concentration of L-Dopa (4 – 7%), which is a precursor of dopamine [80].

Mucuna pruriens, an ayurvedic plant, was shown to increase dopamine in mice [81, 82].

33) Catuaba

The Brazilian medical plant catuaba (Trichilia catigua), increases dopamine release and may have dopamine-mediated antidepressant effects [83].

The herbal product containing this plant, catuama, has similar effects [84].

34) Rosemary

Rosemary (Rosmarinus officinalis) increases brain dopamine levels [85].

35) Kava

Higher doses of kava (Piper methysticum) increase levels of dopamine in rats (nucleus accumbens). Individual compounds isolated from kava can both increase or decrease dopamine concentration [86, 87].

However, in a couple of cases, blocked dopamine function has also been observed [88].

36) Lactobacillus plantarum

The probiotic Lactobacillus plantarum can increase dopamine in the brain in mice (striatum), and could potentially improve anxiety-like behaviors and psychiatric disorders [89, 90].

35) Fresh Cut Grass/Essential Oils

Hexanal is a “green” odor compound found in plants that may increase dopamine in rats (striatum) [91, 92]. Increasing dopamine is a potential mechanism in which green odors, such as fresh cut grass and plant essential oils, may improve mood and attention.

36-41) Flowering Quince, Psoralea corylifolia, Mycoleptodonoides aitchisonii, Blue trumpet vinePrickly nightshade, Gardenia jasminoides

Flowering quince, the fruit of Chaenomeles speciosa used in Chinese traditional medicine, increases dopamine levels by inhibiting the dopamine transporter (DAT) [93].

Psoralea corylifolia fruit/seed extract and its components increase dopamine [94, 95]. This plant is used both in Ayurveda and Chinese traditional medicine.

The edible mushroom Mycoleptodonoides aitchisoniiincreases dopamine [96].

Blue trumpet vine (Thunbergia laurifolia) is a Thai herbal medicine used to treat drug addiction. It works by increasing dopamine [97, 98].

Prickly nightshade (Solanum torvum) increases dopamine and shows antidepressant activity [99].

Gardenia jasminoides can increase dopamine by inhibiting MAO-A and B [100].

Hormones that Increase Dopamine:

42) Estrogen

Estrogen may increase dopamine. Women act more impulsively in the early as opposed to the late phase of the menstrual cycle [101].

In rats, estrogen-induced improvements in recognition memory were shown to be due, in part, to increased dopamine [102].

However, dopamine’s relationship to cognitive performance is not linear – dopamine function follows an ‘inverted U-shaped’ curve, where optimal dopamine results in maximal function and both insufficient or excessive levels lead to dysfunction [103]. That is why too much estrogen is not beneficial.

43) Ghrelin

Ghrelin stimulates dopamine release in rats (amygdala, nucleus accumbens, VTA, prefrontal cortex) [104, 105].

Dopamine Drugs/Agonists

44) Nicotine

Nicotine “hi-jacks” the reward circuitry in the brain by increasing dopamine release (striatum, VTA, amygdala, nucleus accumbens, prefrontal cortex) [106, 107104].

45) L-dopa

dopamine_production2 increase dopamine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967375/

L-dopa is made from tyrosine, and then converted into dopamine. Basically, it is the precursor of dopamine [108].

46) Bromantane

Bromantane increases the amount of dopamine in the brain by increasing its synthesis from tyrosine (increases Tyrosine Hydroxylase, AAAD) [109, 110].

Enhancement of dopamine is observed in the hypothalamus, striatum, ventral tegmental area, nucleus accumbens, and other regions [111112113].

By increasing dopamine, Bromantane increases alertness and wakefulness [114] and improves short-term memory, motivation, planning abilities, and attention [110].

47) Tianeptine

Tianeptine increases the release of dopamine in rats (nucleus accumbens > striatum) [115].

48) Phenibut

Phenibut is a nootropic drug that stimulates dopamine receptors [116].

49) Alcohol

Dopamine release may contribute to the rewarding effects of alcoholand may thereby play a role in promoting alcohol consumption (nucleus accumbens) [117].

50) Methylphenidate/Amphetamines

Amphetamine exerts rewarding and reinforcing effects by elevating dopamine and prolonging dopamine receptor signaling [118].

Methylphenidate works in the treatment of ADHD by increasing levels of dopamine in children’s brains.

Previous research has shown that some people with attention deficit hyperactivity disorder may have too many dopamine transporters, which results in low levels of dopamine in the brain.

The drug seems to raise levels of dopamine by blocking the activity of dopamine transporters, which remove dopamine once it has been released [119].

51) Modafinil

Modafinil seems to inhibit the reuptake of dopamine by dopamine transporter, thereby increasing the concentration in humans [120, 121].

52) Deprenyl

Deprenyl (Selegiline) increases dopamine by blocking MAO-B, an enzyme that breaks down dopamine [122].

53) MDMA

MDMA/Ecstasy increases dopamine [123].

54) Cocaine

Cocaine inhibits the dopamine transporter responsible for dopamine recycling, thereby increasing the levels [124].

Ways to Decrease Dopamine

Drugs and Supplements that Decrease Dopamine

1) Anti-psychotics

In cases of schizophrenia, you can use anti-psychotic drugs to lower dopamine signaling by blocking the receptors [125].

2) Melatonin

Melatonin suppresses dopamine activity [126].

3) Lithium

Lithium impairs dopamine release [127, 128].

4) Manganese

Long-term manganese decreases dopamine release in the brain [129, 130].

A study showed that manganese exposure, even within the safety limit, decreased dopamineproduction in primates [131].

5) Liriodenine

Liriodenine inhibits dopamine production and decreases dopamine levels [132].

6) Salvinorin A

Derived from the plant Salvia divinorum, Salvinorin A decreases dopamine [133].

7) 5-HTP

Serotonin shares the same conversion and breakdown enzymes with dopamine.

Long-term supplementation with 5-HTP, the immediate precursor of serotonin, can cause dopamine depletion, which can worsen neurological and psychiatric diseases [134].

Conditions That Decrease Dopamine

1) Inflammation

Inflammation decreases dopamine [135]. That’s why we feel less motivated and more sluggish when we are sick [135].

2) Maternal Deprivation

Maternal deprivation of rat pups leads lower dopamine levels. However, these pups reared in isolation have higher levels in response to stress [136].

3) Diet High in Saturated Fats

Saturated fats can suppress dopamine [7, 137].

4) Chronic Sugar Intake

Sugar acutely increases dopamine, which, over time, leads to a reduced number of D2 receptors and possibly a reduction in dopamine itself, leading to desensitization. These effects would not be due to the acute effects of sugar, but rather would occur over weeks to months with chronically elevated and intermittent sugar ingestion [138].

5) Iron Deficiency

Iron is a cofactor for tyrosine hydroxylase, a key enzyme in dopamine production [139]. Iron-deficient rats have reduced brain dopamine levels [139].

Low brain iron stores may contribute to ADHD symptoms because low iron levels in the brain can alter the activity of dopamine [140].

Weaning rats fed an iron-deficient diet showed decreased physical activity and increased anxiety-like behavior with a reduction of brain dopamine receptors [141].

However, some studies indicate iron deficiency has the exact opposite effect [142].

Just Keep Swimming

It’s been a while since I checked in and talked about my pulling. Perseverance though this uphill battle is not easy. Everyday I need to make a conscious effort to resist the urge to pull. Some days are good and I barely pull, while other days it seems I can’t stop. I still hope to be pull free one day, but accept where I am and see this as a process. It’s so engrained in my being that I don’t even know what life is like without pulling. I’ve had short remission periods, but never more than a few months.

I refuse to give up or become complacent. If I didn’t try I’d have way less hair so in a way I’m making progress. My recovery includes acceptance of my current situation and faith that it will change through awareness, commitment, helpful behaviors, following my rules (see below) a positive attitude, balance, mood stabilization, barriers, the John Kender diet, and supplements.

I had given up on the supplements because of some stomach issues which have resolved. I’m going to try my regimen of NAC, inositol, and the John kender diet again. I’ll also resume charting my pulling as that has always helped with my awareness. I’ll be checking in periodically with updates on my current supplements and pulling progress. I’ll use my daily score of 0-10 to rate my pulling. I’m going to post my supplement plan and rating system for anyone looking to follow it. These two tools have helped me most over my 25 years of battling trich.

The John Kender Diet

Basically , it’s a nutritional and skin care approach. First, try not eating sugar, caffeine, and chocolate. Have some dry red wine or uncaffinated tea instead. These should have an effect in about two or three days. Then, avoid peanuts, chickpeas beans, egg yolks, tuna, and waxes. These should have an effect in about 10 days. Take magnesium gluconate, and take borage oil. Use Shampoos with selenium (Selsun) or Nizoral. Keep a food diary to help you track your own particular triggers. Keep your hair and hands clean. Wash your lashes with baby shampoo hot compresses. Watch out for pet fur.   Apply fresh cut ginger, or miconazole nitrate cream, or propylene glycol/aloe vera/rubbing alcohol, or eyewash/vinegar. Use Sea Breeze or Band-Aid Anti-Itch gel for emergency hot spot care.

 Treatments: Supplements

NAC

I take NAC (N-acetylcysteine) 3- 600mg capsules of NAC (N-acetylcysteinen) in the morning and 3-600mg capsules in the evening, giving me a total of 3600mg of NAC. Doses between 1200-3600mg may be helpful according to this article.

Inositol

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.

Rules:

#1 Where Bandaides or other barriers whenever possible, if not wearing them use fiddle toy /keep hands below neck and BE AWARE.

#2 Avoid mirrors. Don’ t stand close, do makeup quickly, avoid touch ups or unnecessary glances.

#3 Keep hands off of face. Don’t touch hair or eyes. Use only one finger or utensil if need to itch or touch eye/head and don’t linger. BE AWARE.

#4 Change activity when triggered before pulling begins.

#5 When stressed find way to take a break and relax (at least 1 minute deep breathing break).

Rating my Progress

Good Days 0-3

0=no pulling

1=0-5 hairs

2= 5-10

3 = 10-20

Bad Days

4=20-30

5=30-50

6=50-70

7=70-100

8=100+

9=too many/couldn’t count

7 Strategies to Outsmart the Sun: Staying Clear of Summer Mania

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The changing seasons effect my moods in a noticeable pattern. Very often winter or even fall bring on depression which last though the spring. I slowly climb out of depression only to land in a hypomanic state, which often begins in the springs and worsens in the summer.

Once again, spring brought on a hypomanic episode that worsened in the summer. Stress, changing schedules, change in sunlight and activities all bring on these mood swings. I just read this blog about fighting summer mania. Here’s to a balanced life. Now I’m going to sleep because I know sleep and a consistent schedule are an important part of my self care. ☀️ 🏖🧜🏻‍♀️💦💛

While you can’t change the seasonal shift to longer days, you can make subtle lifestyle changes, such as regulating sleep, to sidestep summer mania.

Photo: Merlas/Getty Images

By Brittany Sibley

The days are longer and the sun is shining the brightest in a while. For a person diagnosed with Bipolar I in 2006, the mere transition to long, luminous days and shorter nights causes more anxiety and nervousness than usual.

The change of seasons has caused me plenty of manic episodes in the past. I have since learned seven solid solutions and tips to help combat the symptoms of seasonal changes. These tips help in staying clear of an inpatient hospital visit during what most consider the best months of the year. I hope they are as effective for you as they have been for me.

1. Sleep

It has been essential for me to always get enough rest. However, with Daylight Saving Time and longer, shinier days, an additional burst in energy is never too far away. Although it almost always feels wonderful, and causes you to want to get more done, stay out longer, possibly accomplish a few more things in 24 hours…DON’T!

While the feeling of more energy is real and feels great, falling away from your regular sleep regimen is never a good idea, especially when the season of mania approaches. In fact, one should definitely keep the regular sleeping hours and if anything changes, let the hours increase, and not the opposite.

2. Eat Healthy

Eating healthy and making healthy eating decisions regularly is something I still struggle with. Yet I have experienced the benefits of eating salad instead of a deep dish pizza several times. You are what you eat! Eating more veggies, fruit, and lean meats instead of processed foods regularly, and especially during manic season, makes a difference. You will feel a difference in your skin, your mood, and even your waistline.

3. Take Deep Breaths

Taking deep breaths when stressed, tired, upset, angry, unfocused or even irritated helps. Try deeply inhaling through your nose and exhaling through your mouth in sets of 3. This is also a good tool because it requires nothing but reminding yourself to do so in times of sudden distress.

4. Pray/Meditate

Take time out of your day, (first thing in the morning works best for me), and remind yourself of who you are besides your diagnoses.

Remember that you are loved and worthy of all the great things that day has in store for you.

 

Since I am a Christian, it helps me to remind myself that I am never alone because the Holy Spirit, who my Savior promised to send when he left, is with me no matter how lonely I may feel.

5. Take Breaks

The sudden burst of energy one may experience from the sunnier days and more exposure to the sun in general can trigger the want to complete more tasks—and this can be alright, as long as you remember to take breaks.

It helps to remember that this new energy feels good, but is coming from an unbalanced source.

 

Doing too much in 24 hours with little time to break or rest can cause the onset of a manic episode.

6. Watch Alcohol Intake

5 years ago in 2013, I had an inpatient hospital visit that can be directly attributed to the large intake of hard alcohol consumed two nights before. I simply drank way too much that night.

With spring and summer come more festivals, barbecues, beaches, and let’s admit it—booze.

Monitoring alcohol intake during these seasons is a must! If you still are not sure when you have had enough, take it slow. Yes it can be a bit lame being the responsible one at the party, but I promise, your freedom will thank you later.

7. Cover Bedroom Windows Heavily

The day before Daylight Saving Time, try covering your bedroom window with a dark-colored blanket. The blanket will work as a shield to the bright rays of sun in the morning.

Although longer, sunnier days are always welcome, adjusting to the initial change while having a mental health condition can be traumatic.

The dark blanket helps ensure your sleeping pattern is not interrupted so blatantly. It also allows your body to tell you when it has had enough sleep.

I hope these seven tips are as helpful for you as they have been for me over the past several springs and summers.

Let’s do our best to have a safe, healthy and stable summer while enjoying the sunnier days and moonlit nights. Remember, mental health is just as important as physical health. Until next time…Happy Summer!

Learn more:

Ask The Doctor: Summer Mania

Watch Out for Summer Mania

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

Thank You God for These Hands

Thank you God for these able hands that shoveled many feet of snow. My poor van was almost lost for good, but with help from my wonderful husband we saved her.

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Now I rest. I’m thankful for this ‘Mommy break’. I gave myself a manicure. I am happy even though they are short. I broke four nails in the process of shoveling and putting outside clothes on and off four kids about a hundred times.

A little me time and pampering goes a long way. It was a much needed 30 minute break while my three big kids played outside and baby Rachel napped. Thank you God for moments of rest and peace. #simplepleasures #girlygirl

ACT Therapy: Acceptance

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ACCEPTANCE: allowing urges, emotions, thoughts and feelings to occur without attempts to control them.

Acceptance does NOT mean a hopeless acceptance of the fact you have trichotillomania.

ACT is an acceptance-based, behaviorally oriented therapy.  It was first proposed by Hayes et. al. (1999), but I believe Dr. Woods is the first to study treating ttm with ACT.

ACT Therapy � TLC Retreat Notes
Credit Sue Price notes – TLC Conference Session

TLC Retreat Session September 2002
Acceptance and Commitment Therapy
Douglas Woods, Ph.D.

Why work on acceptance? Dr.Woods conducted an online study which showed that pullers who are less accepting of private events tend to have stronger urges to pull and more severe pulling. [I found the concept of “private events” confusing at first. From what I can tell, it’s anything that happens inside you that you experience privately. As he said: thoughts, feelings, emotions, urges].

People follow rules not experience. He cited a study where people played a slot machine that was rigged to never pay off for the player. The people who were told that the machine WOULD pay off eventually, played longer than the people who were not told anything. The point is, people follow rules over their experience.

Where this fits in with trich: the rule is, “if you feel bad, get rid of it.” This is what society teaches us. This works well in many situations (if the kids are too noisy, send them outside; if someone is tailgating you, change lanes, etc.).  But this does not work with private events such as feelings. Trying to just get rid of bad feelings, urges, etc. does not work long term. But we keep doing this anyway because that’s the rule we’ve been taught.

ACT breaks down rules by emphasizing experiential exercises over verbal rules. The idea is that the person accepts that while the rule they’ve been taught is “get rid of it”, their experience shows that this has not worked, and then they can learn a willingness to experience those private events. [Side note: the addiction book that I’ve found so helpful makes similar points: that our society teaches us that feeling bad is intolerable, to be avoided, and if you feel bad you must do something to stop feeling bad RIGHT AWAY. This is the kind of thinking that fosters addiction, and changing this way of thinking and being willing to FEEL bad is a major part of combating addiction.]

Steps to Acceptance

1. Creative Hopelessness

Focuses on getting the person to see that attempts to stop, alter or avoid private events such as thoughts, emotions or feelings have been unsuccessful. Pulling is often another way to avoid or control private events. He asked us to think about an uncomfortable private event that we’re dealing with right now. He asked how we tried to deal with it. The common answers people gave were: avoided thinking about it, distracting themselves from it, and denial. We confirmed that none of these things work long term in dealing with the private event. It comes back.

2. Willingness

Focuses on getting the participant to be willing to experience negative or uncomfortable private events. If trying to control private events is the problem, willingness to experience uncomfortable feelings may be a solution.

– Willingness is not the same as “wanting”. He had a “Joe the Bum” metaphor (acknowledging that “bum” is not PC.) Say you are having a party that all your neighbors are invited to, and everyone is having a great time. Then Joe the Bum shows up. You don’t want him there, nobody likes him, he’s dirty, he’s smelly. But if you spend your time trying to physically keep him out, you won’t be enjoying your party. But if you are WILLING to accept that he’s there and not fight it, even though you don’t WANT him there, you can still enjoy your party.

– Willingness is all or nothing

3. Diffusion

He said that even if urges etc. are not originally language-based, they become so because WE are language-based. (There was a lot of clinical stuff he went over making this point.) We need to understand language for what it is, and that words are powerful only because we let them be. This step is about de-literalizing private events. We did two exercises to illustrate this.

First he asked us what we associate with the word “milk”. We said white, cold, frothy, things like that. Then he has us say, out loud,”milkmilkmilkmilkmilkmilkmilk. . .” over and over. (Try it, it’s physically not easy to keep this up!) Picture an entire room of us saying it over and over, and he had us keep it up for what seemed like forever. When he finally stopped us, he said, “I bet you’re not thinking of that white frothy stuff anymore.”

The idea is that “milk” made us think of the white frothy stuff, but only because of what WE associate with that word. By repeating the word over and over, we de-literalized it. It became just a word, the letters m-i-l-k. Similarly, an urge that’s felt as “I need to pull” can be de-literalized by repeating “I need to pull I need to pull I need to pull” until they are just words, not something that must be acted on. Those words don’t have power unless we give it to them.

The second exercise is to imagine you are watching a parade and a band is marching by. Imagine that your thoughts, whatever’s bothering you, are written up on cards that the band members are carrying. And just watch those “thoughts on cards” go past you.  Acknowledge them but separate yourself from them.

4. Understanding the Self

Who are “you?” Who is your “self?”

– Conceptualized Self: who do we say we are? What do we stand for? How do we see ourselves? (we typically think of this as our only self, and defend it)

– Knowing Self: the “self” that is experiencing events as they are occurring

– Observing Self: the “self” that has always been and always will be. He made an analogy to a chessboard: I am the board, not the game that is happening on it. Whatever happens on the board does not have to affect me.

5. Valuing

– You have the ability to choose your behavior. You must choose to move in your valued direction.

– What do you value? What do you want your life to stand for?

– Need to make psychological room for private events while you move your life in the valued direction.

[I think an example of what he means by the last item is: a valued direction for me, is not pulling. By trying to move my life in that valued direction, I will have uncomfortable private events and I need to accept this and be ready for this.

He also said:

-Committed Action Invites Obstacles (disguised as private events)

– The Journey in the Valued Direction involves fear and action. So I take it as, anything I do to move my life in a direction I value(trich-related or not) can bring up private events that will be uncomfortable. He is saying “choose to move in your valued direction” while experiencing these private events.]

**The idea is to combine acceptance techniques with other behavior therapy procedures. A clinical study showed this is effective, based on five different measures of pretreatment and post treatment hair pulling.

For more info, this book is very helpful:

Trichotillomania: An ACT-enhanced Behavior Therapy Approach Therapist Guide (Treatments That Work), March 31, 2008, by Douglas W Woods and Michael P Twohig

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

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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.

Newer:Update From the Fall 2010 APAGS Committee MeetingOlder:Ask Congress to Strengthen the Graduate Psychology Education Program

Inositol

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

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

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

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

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

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

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

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

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

sure to use a measuring spoon) for an adult:

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

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

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

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

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