Tag Archives: Inositol

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.

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.”

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)

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.

Life Happens

Looking over my progress this last month, I see what I expected to see.  I waited to tally the days because I knew I did not meet my goal.  I’ve been afraid to admit this and that is in part what has kept me from posting.  After listening to a good sermon this morning, I finally talked some sense into myself.  Well, God talked some sense into me and I just listened…

When I started this war against my ttm I knew it would be hard and I knew there would be ups and downs.  I need to stay focused on progress not perfection.  Although this past month was not perfect or better than the month before (which was my goal), it was still much better than any other month in at least a year.  I have to keep that in perspective.

Now I am not a fan of excuses, so I hope that not how this next sections comes across.  There are some factors that contributed to my ‘less successful month’.  From a research standpoint, I think it is important to consider all of the variables.

I learned that I was pregnant in September.  It was a big surprise as my husband and I thought our family was complete. I had my tubes blocked using Essure in February and was assured by 3 doctors and a CT scan that I could no longer have children.

Although shocked, I quickly embraced this precious baby.  I know God allowed this pregnancy for a reason and am thankful for this blessing.  I do not understand, but I am trusting God.

After learning that I was pregnant, I stopped taking all of my prescription medications for depression.  I also lowered the amount of NAC and inositol as recommended by my OB. By the end of September I had to stop taking all of my supplements and extra vitamins I had been using to help fights my urges.  I simply couldn’t stomach them with the intensity of my morning sickness.

The urge to pull my hair returned about a week after I lowered my dose of inositol and NAC. The urge has intensified since completely stopping these supplements.

Overall, my urge is still more manageable .  I think this is in part due to the John Kender diet I am still following.  I notice a direct correlation in increased urge if I eat anything I shouldn’t.  So I am trying to stick to the diet, but its hard because there is so little I can eat without feeling sick.  Also these hormone really do cause cravings.  I should start to feel better from the morning sickness soon (if this pregnancy is like my last 3).  Once I feel well enough I am going to begin inositol again.

My Inositol Trial

I am participating in an inositol trial with some members of my trich support group.  It is very informal and we are sharing our methods and results.  The conversation relating to this trial is on the daily strength trichotillomania support group.  This is a great support group that I recommend joining.  Being able to talk with others who understand what I am going through has been so helpful.

After doing a lot of research I found that it was generally agreed that a large dose was needed in order for it to be effective with trich. I worked my way up and now take 18g each 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 (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. The first few days it did give me gas, but that went away. In addition to inositiol I take 2400mg of NAC which I started several months ago and did not see much progress with that alone, therefore I added the 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 "

Inositol and Trichotillomania

Hi everyone, here’s some info I copied from an article specifically about inositol usage 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:

It cannot be taken together with Lithium, as it seems to block its action.
The chief side effects of inositol are gas and diarrhea. Some people get this for the first few days and then it clears up. Some of those taking it never have this side effect, and some only get it when they take more than a particular amount.
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 hair pulling, etc.
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 you mix it continuously for about 2 minutes, and if it is allowed to stand for about 10 minutes after mixing it, it seems to dissolve better. If it still doesn’t dissolve well (not all brands do), stir it up and drink it quickly before it settles.
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.
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.”

The full article is here: http://www.trich.org/treatment/article-inositol-penzel.html