Tag Archives: medication

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.

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

Undermethylation & Trich – what it means for you

Trichotillomania sufferers are believed to be undermethylated.

Undermethylated people tend to be depleted in these 3 neurotransmitters- serotonin, dopamine, and norepinephrine, which all greatly affects one’s mental health.

Most people with depression, oppositional defiant disorder, OCD, bipolar disorder, trichotillomania, or schizophrenia exhibit a genetic abnormality in methylation….. which appears to be central to their illness.

Trichotillomania treatment includes(1) aggressive doses of l-methionine, calcium, magnesium, along with augmenting nutrients zinc, B-6, Inositol, Vitamin A & C and (2) strict avoidance of folic acid, choline, DMAE, and copper supplements.

Aggressive methylation therapy can be very successful, but usually involves a very slow response. Typically, treatment requires about 2 months before the patient before any progress is evident and 6-12 months are required for all of the benefits to be attained.

One way to speed up the process of recovery is to use SAMe supplements in the beginning. Undermethylated patients usually report nice progress after the first week or two. SAMe is quite expensive, and can be gradually replaced by methionine after a couple of months.

Adults typically require 2,000 – 3,000 mg/day of methionine for several months to see good results. Also, augmenting nutrients such as calcium, magnesium, B-6, and zinc are essential.

Undermethylation

Most undermethylated persons in the general population tend to be high-achievers and have good mental health.  These people tend to be our doctors, lawyers, corporate executives, professional athletes and scientists who strive for high career accomplishment.  Undermethylation is also more prevalent in college populations and in affluent neighborhoods.

Many individuals diagnosed with mental illnesses have severe undermethylation which is associated with low serotonin activity.  They have a genetic tendency to be very depressed in calcium, magnesium, methionine, and Vitamin B-6 and may have excessive levels of folic acid in nuclei of brain cells.  Undermethylated persons benefit from biomedical therapy to directly correct the underlying problem using methionine, calcium, magnesium, amongst others.

Decide for yourself if you fit into this chemical biotype.  Here is a list of factors associated with undermethylation – 

•  obsessive/compulsive tendencies

•  history of perfectionism

•  seasonal inhalant allergies

•  low tolerance for pain

•  prior diagnosis of OCD or ODD

•  ritualistic behaviors

•  very strong willed

•  slenderness

•  history of competitiveness in sports

•  calm demeanor, but high inner tension

•  frequent headaches

•  family history of high accomplishment

•  delusions (thought disorder)

•  self-motivated during school years

•  poor concentration endurance

•  social isolation

•  addictiveness

•  phobias

•  good response to antihistamines

•  high fluidity (tears, saliva, etc.)

•  good response to SSRI’s

•  very high libido

•  diagnosis of delusional disorder

http://www.mensahmedical.com/resourcecenter/undermethylation.html