Category Archives: NAC

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.

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

NAC for Trichotillomania

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

*Updated 3/17/18

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

Currently, I take 2-600mg capsules in the morning and 2-600mg capsules in the evening, giving me a total of 2400mg of NAC. Doses between 1200-3600mg may be helpful according to this article,  N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania

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

 

NAC and Trichotillomania

By Fred Penzel, Ph.D.

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

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

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

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

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

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

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

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

glutathione

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

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

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

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

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

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

N-A-C depression anxiety

Why does N-A-C help treat depression?

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

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

Resources:

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

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

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

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

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

Do you know what else boosts glutathione?

Carrot orange pomegranate juice

How much N-A-C should you take?

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

Why take N-A-C instead of glutathione?

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

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

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

What brand of N-A-C is best?

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

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

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

Minding Your Mitochondria

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.

My Trich Supplements: Update

A.M. on Empty Stomach

NAC:1800mg

Methionine: 1000mg

Probiotic:10 strains, 25 billion organisms

After Breakfast (about 1-2 hours after AM dose)

B6 100 mg (5,000% daily value)

Biotin 10,000mcg

Mid-Day on Empty Stomach
C 500mg (helps absorb the minerals)

+

Magnesium 400mg of elemental magnesium

(100% daily value)

(I use Doctor’s Best Brand which is formed from 2,000mg magnesium glycinate/lysinate chelate. This is a more readily absorbed form of magnesium with less side effects than the more commonly sold magnesium oxide.)

or

Zinc 50mg (333% daily value)

(I alternate every other day, as these minerals should not be taken together as they hinder the absorption of one another as with other minerals such as iron.)

With Dinner
Multi-Vitamin

DHA 1000mg /EPA 500mg

Bedtime (With or Without Food)

Inositol Powder- 12 grams (2 tablespoons in warm water)

Epsom salt baths 2-3x /week

(magnesium is readily absorbed through the skin, by adding 1-2 cups of Epsom salts to a warm, not hot bath – about 98 degrees is best for absorption)

NAC Benefits

I am a huge fan of NAC as it has helped myself and many others with trichotillomania.  In addition, this amino acid is a powerful antioxidant that has been shown to:

  • enhance immune function
  • enhance respiratory tract function
  • assist detoxification by the liver

Research done at a university in Spain found that NAC improves immune function in postmenopausal women. The study concluded “NAC could contribute to maintenance of good health and quality of life in postmenopausal women by decreasing the probability of immune system related diseases, such as infections in aging.”

In an Italian study, researchers found that NAC 1,500 mg/day, reduced the development of flu symptoms by 75 percent and improved immunity among a group of seniors during an epidemic of H1N1 flu.

In the following article, Byron Richards further explains how NAC can help you fight the flu.

N-acetylcysteine (NAC) Improves

Immunity Against the Flu

Byron J. Richards,
Board Certified Clinical Nutritionist
N-acetylcysteine (NAC) is an important nutrient for respiratory health and immunity, including defense against the flu. The nutrient has been used longer than four decades to help break up and clear mucous from the airways. The latest research continues to show that it is a potent anti-viral compound warranting widespread use in the winter months to help ward off the common cold as well as the flu.

NAC has long been known as a flu-fighting nutrient based on a 1997 study of 262 older adults who participated in a double-blind randomized placebo-controlled study over a six-month period, some taking 600 mg of NAC twice daily or the others placebo. Individuals taking NAC were much less likely to have clinical influenza illness (29 percent of the NAC group compared to 51 percent of the placebo group. Flu that did occur in the NAC group was much less severe. Tests showed that cell-mediated immunity continually improved with NAC supplementation whereas it remained unchanged in the placebo group.

In modern times NAC has continued to impress. Those with compromised lung function are at very high risk for problems should they get a respiratory infection. In such patients NAC has been shown to reduce respiratory symptoms, reduce flu virus replication, and dramatically lower the inflammatory damage caused by viral infection. This means NAC is good nutritional support for any person who typically is susceptible to respiratory infection.

NAC was shown to be effective against the potentially pandemic H5N1 virus, demonstrating direct anti-viral properties and reduction of H5N1 replication. NAC also reduced the inflammatory signaling caused by H5N1, which is what leads to the cytokine storm that causes severe and potentially life threatening infection. The researchers concluded, “antioxidants like NAC represent a potential additional treatment option that could be considered in the case of an influenza A virus pandemic.”

As with any nutrient and an active infection, they do not replace proper medical care or treatment. Rather, they should be viewed as part of your support team to help prevent a problem or to help your body better cope should you get a bug so as to help reduce the severity as much as possible.

Clean Slate

https://ttmsupport.files.wordpress.com/2014/12/345ab-rewrite-your-future-quote-credits.jpg

I’m looking at December as a clean slate.  November was a tough month as I fell back into old patterns.  It started with just 1 hair and from there increased exponentially until my pulling was almost as bad as it had been in June.  Luckily I did not do any noticeable damage.

As I mentioned in my last post, I stopped taking NAC and inositol in September due to morning sickness.  I started taking both supplements again about a week ago.  Already I feel the difference.  My urge to pull has decreased and it is easier to fight the urge.

I remember this sensation from the last time I started these supplements.  I think my initial response to them was faster this time.  I wonder if this is because I have taken them recently.  It took about 2 months for the supplements to reach their full effect last time. I am expecting to see similar result this time around.

Stopping and restarting NAC and inositol has shown me how much they were helping. This has renewed my determination and faith that I can overcome trich.  I am off to a great start this December and plan to keep at it.

Amino Acid Therapy and Trichotillomania

Amino Acid Therapy and Trichotillomania

Amino acid therapy can be very effective at restoring proper neurotransmitter function and alleviating the insatiable urge to pull that some many people with trichotillomania experience. There are really two ways in which amino acids are used for people with trichotillomania. The first is to use n-acetyl cysteine, or NAC, which has been shown in clinical trials to reduce the urge to pull in about 56% of people that use NAC (see our post entitled N-acetylcysteine and Treatment of Trichotillomania for more information). NAC is thought to work by increasing the concentration of glutamate (an excitatory neurotransmitter) in a part of the brain that reduces compulsive behavior and hair pulling. Glutamate works in conjunction with GABA (an inhibitory neurotransmitter) to control many functions in the body. Thus, NAC provides a safe and moderately effective strategy to use amino acid therapy to decrease the urge to pull associated with trichotillomania.

However, we have found that a more effective way to implement amino acid therapy in regards to trichotillomania is to address the serotonin/dopamine system. By providing the brain the proper proportion of the necessary amino acid precursors and cofactors necessary to achieve optimal serotonin and dopamine function we have had an 86% success rate with eliminating the urge to pull, as opposed to just reducing the urge to pull.

This increased success rate is attributed to the fact that dopamine exhibits control over the release of glutamate and GABA in certain parts of the brain. Therefore, the imbalance between glutamate and GABA that leads to trichotillomania in most people is likely to be caused by an imbalance with dopamine and serotonin (as they are farther upstream). By optimizing serotonin and dopamine function, all the systems downstream, including glutamate and GABA normalize as well. When this happens, the urge to pull disappears.

Another key distinction between using NAC or this balanced amino acid approach is the ability to remain symptom free once the amino acid(s) have been discontinued. With NAC, the urge to pull often returns once the supplement is discontinued (this provides further evidence that NAC may not be addressing the root cause of the imbalance). However, with balanced amino acid therapy we have found that once optimized neurotransmitter function is established and maintained for a period of time, most people can reduce or eliminate the amino acids and remain symptom free utilizing dietary and lifestyle factors to maintain optimal neurotransmitter status. This means that it is very likely you won’t have to take these supplements forever and you can remain trichotillomania-free. This occurs because we are addressing the underlying root imbalance that seems to lead to the urge to pull for most people with trichotillomania. By correctly the underlying neurotransmitter imbalance with balanced amino acid therapy you effectively eliminate the problem, which allows you to stop pulling your hair out.

Source:

http://stoppullinghairout.com/blog/2011/12/15/amino-acid-therapy-and-trichotillomania/

How NAC Works

NAC is an Amino Acid supplement, (AKA: N-Acetylcysteine). Supplementation boosts Glutathione levels and Glutathione is an extremely important antioxidant! Cellular glutathione is the backbone of our antioxidant system and plays a crucial role in DNA Methylation. NAC works by increasing your cellular ability to detoxify. You can help this process along by decreasing your exposure to toxic foods and chemicals. Also, keep in mind that NAC is only one amino acid used in Amino Acid Protocols. It can be used more effectively if combined with other amino acids and nutrients. (NAC is not the only way to boost Glutathione. There are alternative methods for those who are pregnant/breast feeding or children that are too young for AA Protocols/NAC. You can boost Glutathione levels and regulate Methylation most effectively through diet change. Read Action Steps: http://kickthetrich.blogspot.com/2010/11/action-steps-to-overcoming-sensory.html and Contact Be Well, www.bewellnsb.com if you have questions).

Recent research from the Department of Psychiatry, University of Minnesota School of Medicine regarding NAC and Glutathione click here: http://www.ncbi.nlm.nih.gov/pubmed/19581567.
Conclusion: “This study, the first to our knowledge that examines the efficacy of a glutamatergic agent (production of glutathione) in the treatment of trichotillomania, found that N-acetylcysteine demonstrated statistically significant reductions in trichotillomania symptoms. No adverse events occurred in the N-acetylcysteine group, and N-acetylcysteine was well tolerated. Pharmacologic modulation of the glutamate system may prove to be useful in the control of a range of compulsive behaviors.” Go to http://www.pubmed.gov/ and type in N acetyl cysteine in the search box… other good articles available. Related research: http://www.ncbi.nlm.nih.gov/pubmed/11499335

If you have tried NAC before and did not experience any relief, the most common reasons for this are the following: (You should minimize this problem by using NAC or equivalent protocol under the supervision of a professional.) 1.) Remember that NAC is most effective when combined with other Amino Acids and Nutrients. 2.) Remember that it can take up to one month of consistent use for you to notice relief. (Could take up to two months if you are working against yourself and dosage may need to be increased.) 3.) Effective dose is usually between 500 – 1500 mg three times per day.
[FYI: I didn’t use NAC to stop Trich; I was already pull free when NAC came to my attention. As explained in the Action Steps post, I used personalized dietary controls including whey protein and physical exercise to achieve the same but better and Lasting Methylation Balance. I also included Cognitive Behavioral Therapy exercises in order to address every aspect of the problem. (Free CBT Program Here: http://moodgym.anu.edu.au/welcome/new/splash ) We now know that it is best to combine AA protocol/NAC with Lifestyle Changes and CBT. That is why I like the Designs for Health Detoxification Protocol. A modified version of their Protocol, (link here https://www.bewellnsb.com/DFH28DayDetox.pdf ), is used at Be Well. It combines the speed of relief NAC and other AA’s/Nutrients can provide with the lifestyle education needed to make the relief you experience permanent. Make the most of Amino Acid Supplementation! That is why NAC should be discussed with your Doctor or natural health expert. More info here http://www.alternativementalhealth.com/articles/walshMP.htm#Met on Methylation/Production of Glutathione. Links to additional Amino Acid Research at the bottom of this page. (ie: Carnitine, 5-HTP)Over methylation vs Undermethylation here: http://www.alternativementalhealth.com/articles/pfeiffer.htm]

I talk at length about Amino Acid Therapy Protocols in my Support Group and I do believe NAC and other Amino Acids to be very effective but I do not write much about AA Therapy protocols because I do not believe you should prescribe one to yourself. That said, most sources suggest that the effective dose for Amino Acids, like NAC, should start at 100mg three times per day and should be increased from there. Most people respond to daily doses of 500mg-1500mg three times per day. When taking NAC alone, it could take up to a month (two max depending on your “cellular state”) to notice the full effects. Amino acids are most effective when taken with water on an empty stomach, especially the larger amino acids. More info here about AA Therapy protocols, Chapter 4 of this book http://www.scribd.com/doc/56428903/Clean-and-Sober-Full-Text (free read).

Recent studies indicate that higher amounts of whey protein offers major benefits to health! Research supports whey protein as a complete way to boost Glutathione levels “long term”. I drink a whey protein based shake every morning that contains a mix of Amino Acids (including cysteine, the C in NAC) and whole food nutrients that is designed to maximize Glutathione levels.
More Info here: http://www.wellnessresources.com/studies/whey_boosts_production_of_key_glutathione_antioxidant/

More research on the importance of Increasing Glutathione Levels from the Journal of Biological Chemistry:  http://www.jbc.org/content/286/24/21865.long

If possible, you should find a Functional Medicine Doctor

(watch video and click here for more info http://www.bewellnsb.com/index.php?option=com_content&view=article&id=86&Itemid=99).

If this is not possible find a Counselor/Therapist that specilizes in Cognitive Behavioral Therapy and combines therapy with an Amino Acid based detoxification program. (I like this protocol and it is widely available https://www.bewellnsb.com/DFH28DayDetox.pdf ask the expert about possibly adding a product from the same company called CraveArrest, Inositol, and possibly additional NAC if needed.) Knowing what I know now, this is exactly where I would have started. This approach will bring you significant relief and if you make what you learn during the program a permanent part of your life, you could experience complete resolution.
[You might say, “I pull because of the stress in my life… How could an antioxidant supplement like NAC help in my case?
Effects of Chronic Stress on the Immune System include:
– Increased sympathetic (fight or flight) activity decreases cellular immunity
– Immune cells migrate to different parts of the body and can worsen autoimmune and allergic conditions
-Over time, the positive acute mobilization of immune cells in response to challenge is suppressed.
(Reference: McEwan BS. Protective and Damaging effects of stress mediators. New England Journal of Medicine. 1983;338(3):171-179)]

It’s all connected!! Treat the whole body not just one aspect!!
Read Action Steps and Be Empowered! http://kickthetrich.blogspot.com/2010/11/action-steps-to-overcoming-sensory.html

Watch the video below to learn the science behind why your cellular environment matters.

Watch PBS’s, “Science Nova” on Epigenetics!

Join the support group on Facebook!! https://www.facebook.com/#!/groups/kickthetrich/

Support Group Information and FAQ’s:

http://kickthetrich.blogspot.com/2011/06/support-group-information-and-faqs.html

FAQ’s and Other Info:

Why is Trich (and other Impulse Control Problems) so Enjoyable?

It’s enjoyable because, (for whatever reason), our brains have hooked the release of “feel good” neurotransmitters to the action of both pulling the hair and performing the post pull sensory activity… (All impulse control issues stem from the same type of neurotransmitter imbalance, I’m not sure why our physiology chooses different forms of expression.) We have basically adapted a way to mentally “Check Out” of our environment, but the result of this adaptation is devastating to the lives of almost all who suffer. Where Trauma is involved, therapy and CBT can really help us find the event or chain of events that we are escaping. (Maybe you already know or maybe it doesn’t feel like Trauma at all from your current perspective.) Maybe Your Cause is not trauma related at all; Maybe your body is trying to escape a Physiological State of Being (ie: state of health) or maybe you are trying to escape a combination of both “micro traumas” and the physiological state you’ve set for yourself over time. Find YOUR reason (or reasons) your mind/body has a need for this escape and you will be able to address it and overcome it. Physical Trauma, Emotional Trauma, Cellular Toxicity and/or Deficiency; all of these reduce immune system function; they suppress mitochondrial activity which depresses the cell’s ability to produce energy efficiently. All of these stressors hinder our ability to adapt to our environment. Some of us will experience relief with therapy alone but most of us need a much deeper evaluation. CBT and Therapy alone does not hold an answer for all those who suffer and medication on its best day functions as a band-aid and at worst screws up everything…

If I were to start all over again, I would ask my doctor to look into metabolic
testing, something like this http://www.bewellnsb.com/DHFMetabolicProfile.pdf
and if I were female I might have the need to ask the doctor to follow up with an expanded female hormone panel, something like this http://www.bewellnsb.com/diagnostechfemalehormonepanel.pdf
It’s all connected; we have to stop treating the parts and start addressing the whole. 😉
Join our “colsed” facebook group here: https://www.facebook.com/pages/Be-Well-A-Chiropractic-Wellness-Community/114241455256159#!/groups/kickthetrich/

Research:

Research regarding Inositol for treatment of Trichotillomania and Skin Picking specifically:  http://www.healthrising.com/stories/trich.htm more here: http://www.ocdrecoverycenters.com/about/prot_inositol.html

Inositol is a B-vit. and works by supporting all neurotransmitter activity in the brain. Effective dose of Inositol by itself has shown to be between 3 and 6 grams three times per day, (9 grams – 18 grams total in divided doses), which is a lot of inositol… Keep in mind when reading research that the point of research is to isolate the nutrient in question to see if it really has an effect on a particular condition. Unfortunately, this can result in extremely high doses; this is shown to be true in looking at both NAC and Inositol. In clinical settings, clinicians know that Nutrient Synergy is very important. When you combine nutrients like NAC and Inositol with other synergistic nutrients you can use less of any one particular substance.

Other Amino Acid Research:

5-HTP and Serotonin

Immune Response to Dietary Protein

L-Carnitine Reduces Fatigue

Carnitine for ADHD Symptoms

These are all helpful when used in protocol but you do not want to take all or any of this stuff on a long-term basis! Eat, Move and Think in ways that are genetically congruent! http://kickthetrich.blogspot.com/2011/01/wellness-and-prevention-paradigm.html

More on NAC from WebMD:
http://www.webmd.com/vitamins-supplements/ingredientmono-1018-N-ACETYL%20CYSTEINE.aspx?activeIngredientId=1018&activeIngredientName=N-ACETYL+CYSTEINE

More Research here:
http://www.futurescience.com/nac.html
What is Lifestyle Based Chiropractic and how can it Help?
http://kickthetrich.blogspot.com/2011/01/what-is-wellness-based-chiropractic-and.html

eHow.com:
“Glutathione is an important antioxidant. As a natural antioxidant produced by cells in the body, it provides protection from toxin damage and supports many essential biological functions. It is important to keep glutathione from becoming low, because low levels are associated with a variety of diseases. N-acetylcysteine (NAC) is derivative of the amino acid cysteine. NAC can be used to boost levels of glutathione, and this article will show how to boost glutathione with NAC supplementation”
Read more: How to Boost Glutathione With NAC | eHow.com http://www.ehow.com/how_5788474_boost-glutathione-nac.html#ixzz1BtUnJOet

Read Original Article: How N-Acetylcysteine Works

The Light

I can finally see the light at the end of this 20 year dark, dark tunnel.  After so many attempts to stop pulling, I have finally found something that reduces the urge.  I had learned many coping mechanism and preventative strategies, but the decreased urge makes this so much easier.  The combination of inositol, NAC, methanonine, and the John Kender diet are really helping. I have not had an urge to pull from my scalp (which is unheard of). I am also more aware of my pulling and feel like I have more control to stop myself from an urge or after an involuntary pull. I have not pulled from my scalp in nine days. In those nine days, I have pulled less from my lashes and brows with two minor episodes where I pulled a bit. It was easier for me to stop myself and stay strong for the rest of the day after those 2 slips. Normally, once I had started, it would’ve been an all day battle, but I was able to regain control. I feel hopeful for the first time in a long while that I can beat this.