Treatments for Trichotillomania – What Works and What Doesn’t

A search of the internet for ‘treatments of trichotillomania’ brings back over 335,000 results. This can make the search for a viable treatment option very difficult, if not downright impossible.  However, upon closer investigation, you will find that there are really only a few treatments for trichotillomania that have any scientific evidence behind them, although even within this select group of therapies, results are highly individualized.

Treatments for Trichotillomania

Cognitive Behavioral Therapy (CBT): Cognitive behavior therapy attempts to alter behavior by identifying environmental factors that trigger hair pulling and then helping a person learn skills to interrupt and redirect their responses to those triggers. Used over time, the new behavior replaces the old (i.e., pulling). CBT should be performed by a therapist trained in this method, ideally with experience in the treatment of trichotillomania. Certain methods of CBT such as Habit-Reversal Training and the Comprehensive Model for Behavioral Treatment of Trichotillomania have shown to be the most successful CBT treatments for trichotillomania, so be sure to ask your provider if they use or have been trained in these therapies.

Medications: many medications have been tried as a treatment for trichotillomania. Unfortunately, the results have been disappointing (see other posts on this site for more information on drug treatments for trichotillomania). That said, some people do benefit from drug therapies, either alone or in conjunction with cognitive-behavior therapy or amino acid therapy. The effect, however, is almost always temporary because drug therapies cannot address the underlying cause of trichotillomania in most people. In addition, the use of medications for the treatment of trichotillomania in children or adolescents brings additional concerns. Very few drug trials involve children and to date there have been no studies of the use of medication for the treatment of trichotillomania in children.  Due to the limited evidence supporting these medications effectiveness, as well as concerns about the long-term effects of medications on the developing brain, several groups, including the Trichotillomania Learning Center’s Scientific Advisory Board have advised that “for most children and adolescents with trichotillomania, medications should not be used as a treatment of first choice.”

Amino acid therapy: Amino acid therapy involves providing the body the nutrients it needs to optimize neurotransmitter balance in the body. One of the main underlying causes of trichotillomania for many people is an imbalance in one or more neurotransmitters. The ONLY way to correct this for the long term is to supply the body the amino acids and co-factors it needs to restore proper neurotransmitter balance, which will eliminate the urge to pull, allowing you to stop pulling.  Once the urge to pull is gone, other therapies, like Cognitive Behavior Therapy are much more effective as a treatment for trichotillomania in order to address any remaining behavioral and/or habitual triggers to pull.

It can be a confusing and frustrating experience for people searching for treatments for trichotillomania. However, after looking at the scientific and clinical evidence, only two have shown reproducible results – cognitive behavioral therapy and amino acid therapy – for people with trichotillomania.

Trichotillomania Cures

I am often asked if our approach ‘cures’ trichotillomania. The simple answer is ‘it depends’.

The word ‘cure’ or ‘curing’ are used and strictly protected as medical terms, only to be used by medical doctors and other health care professionals that are licensed to practice medicine. Judging by the number of law suits against integrative, complementary and alternative practitioners who have mistakenly used this term in regards to what they do, I’d say that it is strictly enforced. As I am a naturopathic doctor and do not practice medicine, I am not entitled to use the terms ‘cure’, ‘cures’ or ‘curing’ in relation to what I do or to describe the effects that what I recommend may have on or for a person.

Interestingly, the general public often use these terms without recourse. I even had one client look up the word ‘cure’ and forward me the definition: ‘A cure or remission is the end of a medical condition’, so they stated that because we helped them eliminate the urge to pull their hair out, we helped them ‘cure’ their trichotillomania and should therefore be listed in any list of ‘trichotillomania cures’.

While I am glad this person feels better, this discussion brought up a couple additional points that are important to keep in mind (not only for a person considering amino acid therapy, but also for me as a complementary health care practitioner). In addition to the above discussion about the use of the words ‘cure’, ‘cures’ and ‘curing’, we are not specifically addressing any medical condition(s), including trichotillomania using amino acid therapy. What we are doing is looking for and addressing fundamental root imbalances in body or brain chemistry and addressing them using natural methods if at all possible. These imbalances can manifest themselves in conditions that are diagnosed by medical professionals as trichotillomania. However, they can also manifest themselves in other ways that prompt people to seek medical help; these diagnoses can include depression, anxiety, OCD, ADD, ADHD, insomnia, migraines, fibromyalgia and numerous other sets of symptoms labeled as ‘diseases’ by the medical profession.

We don’t concern ourselves nearly as much with what a group of symptoms is called by the medical profession as we do with figuring out what imbalances created these symptoms and addressing those underlying imbalances. By addressing the underlying imbalances, our clients often see a reversal of many previously diagnosed medical conditions, not just the one(s) they are seeking us out for. That is why when you read the many testimonials and background information about amino acid therapy throughout this site, you see that many, many conditions can be corrected through the proper use of amino acid therapy. We cannot say amino acid therapy ‘cures’ trichotillomania or any other diagnosed medical condition as I am not a medical doctor; I am a naturopath.

But what really matters is that by finding and addressing the underlying neurotransmitter imbalances that a person with trichotillomania has, they can eliminate the urge to pull. If they want to find out if they are ‘cured’ or if this ‘cures’ trichotillomania, they just need to ask their medical doctor if no longer having the urge to pull means that they are ‘cured’.

Stephanie’s Story

We just did a post on Stephanie’s story with trich and how amino acid therapy helped her ‘beat trich’ in her words. I wanted to follow up with a couple points regarding Stephanie’s story to point out a few things that we see often when working with people with trich.

First, many people see results in just a month or two, just as Stephanie did. In fact, about 80% of people can completely eliminate the urge to pull in that time frame. For those 20% that don’t, additional testing is used to help them eliminate the urge to pull.

Second, once we find the right dose of amino acids that a person needs, they need to take them about 6-9 months before we can start tapering the dose without the recurrence of symptoms. If a person misses a dose or multiple doses, the urge to pull will often return within a few days and will persist until a person gets back on the recommended supplements for about 3-5 days. This means that the person continues to need the amino acids to eliminate the urge to pull.

Third, eliminating the urge to pull does not mean that a person automatically stops pulling. We’ve talked in other posts about the difference between the urge to pull (the compulsion) and the behavior of pulling. Once the urge is gone, a person can still find themselves pulling when they get triggered by certain events (the most common one is stress). When this happens, they may find their hands playing with or pulling their hair before they even realize what is happening. The difference is that once they become conscious of it, a person on the proper dose of amino acids and stop pulling and not think about it anymore. This is where other therapies, such as stress reduction, exercise and Cognitive Behavioral therapies can be a big help.

Fourth, exercise, lifestyle and dietary recommendations can often decrease the need for amino acids. If a person addresses the day-to-day reasons for neurotransmitter imbalance, they can often substantially reduce the amount of amino acids they need over time to eliminate the urge to pull.

And finally, just like Stephanie, many people can reduce and eliminate the need for the amino acids and still have no urge to pull. Most of the time, these people have taken the amino acids as recommended for at least 6-9 months and have incorporated other strategies to help deal with the behavioral and environmental component of pulling (we help guide them through this process as well). This provides them the life skills that they need to function as they want to without the need for the amino acids. This doesn’t always happen, but it happens a great deal of the time, and it’s so wonderful to see the confidence, the pride and the relief in the people that ‘beat trich’ as Stephanie did.

Image: scottchan / FreeDigitalPhotos.net

Urge, Drug, and Supplement Free!

The following is a compelling story from one of our clients:

“I was diagnosed with trich in 1^st grade and I’ve pulled every 1-3 days since then. By the time I found Dr. Oler I was 17 years old and had pulled out all my eyebrows, eyelashes and about 50% of the hair on my head. My dad’s a doctor, so I’ve tried pretty much every possible medical treatment and drug for trich out there. They didn’t help me get rid of the urge and I usually felt awful when I took them.

Within a month of starting the amino acid therapy my urge to pull was completely gone! It was great! And unbelievable! Dr. Oler told me to continue my current dosing for 2 months and follow up. Over those 2 months, I pulled a couple times, but it wasn’t an urge; it felt more like the hairs weren’t growing right and I just pulled those and left everything else alone. My eyelashes, eyebrows and hair on my head all started growing back. During this time, I stopped taking the amino acids a couple times, but noticed the urge to pull increased, so I went back to Dr. Oler’s recommendations.

After 2 more months, all my hair was grown back and I wasn’t having any urges anymore. However, I forgot to take my supplements with me when I went away from Christmas and New Years and the urges came back BIG TIME and I pulled everything out again in about 5 days. As soon as I got home, I started the supplements again and didn’t have any urge to pull after about 5 days.

I continued at this dose for 6 months. I wasn’t pulling, my energy levels were great, I slept well, my cravings were gone and I started playing rugby again. I also noticed that my focus, concentration and memory had improved and I was doing better in my classes. I was very content.

After a couple more months, Dr. Oler recommended that we start to decrease the amino acids, as by this time, my neurotransmitter stores should be back to where they belong. I was apprehensive, but reassured that I could always go back to taking what I was currently taking and get the same results within a few days even if the urge to pull returned. I had a little bit of an increased urge to pull after changing the dose, but it only lasted a few days and it wasn’t too bad, but no urges after that.

We continued to decrease the amino acid dosing over time, adjusting as needed if I had an increased urge to pull or stress triggered me to pull. I also started learning some other ways to manage stress, like deep breathing, taking a quick walk around the block and aerobic exercise which helped.

It’s now been two years since I started working with Dr. Oler and I (1) don’t have any urges to pull, (2) am no longer taking medications for trich, and (3) haven’t taken any of the amino acid supplements for over 3 months. All my hair is grown back and I have absolutely no urge to pull anymore unless there is a lot of stress in my life. Even then, I can get through it without pulling very much. I am very content where I am at. Thank you for helping me beat trich!”

-Stephanie, 08/02/11

Image: Graeme Weatherston / FreeDigitalPhotos.net

Trichotillomania in Children

Trichotillomania, or ‘trich’, often shows its first signs in childhood. In fact, we see trichotillomania in children as much as in adults, and the majority of the adults we work with had their first symptoms of trich as children.

It is not uncommon for trichotillomania in children to start right around puberty. I haven’t seen any data to give concrete rationale why this is, however, it would not be a stretch to say that there are obviously a lot of hormonal changes going on during this period as well as elevated stress due to social pressures, body changes and self-awareness. These coupled together could cause or exacerbate the neurotransmitter changes that often lead to trichotillomania in children and the urge to pull.

However, it is interesting that we see many children, mostly girls, that exhibit trichotillomania symptoms well before puberty. We have a large number of girls that are between 7-11 years old that have been diagnosed with trichotillomania or have been referred to us by their parents after they have done their own searching on the internet to try and determine what is happening with their kids.

The great news is that children often respond very quickly with amino acid therapy. In fact, we’ve only had a couple cases where amino acid therapy hasn’t completely eliminated the urge to pull in these kids.

For parents, seeing their kids pulling, or the effects of their pulling – such as missing eyebrows or eyelashes, bald spots on their head or other part of their bodies or bald spots on pets – can be a traumatic experience. However, it is often not until the parent sees the shame or despair in their child’s eyes when they talk about pulling or not being able to stop or help themselves that the true tragedy of this condition hits home.

Trichotillomania in children is reversible with amino acid therapy. Once your child experiences this relief, you will be able to look into your child’s eyes and see not shame, fear or despair, but the joy of being a kid free from the burden of trich.

No Urge to Pull After 24 Years

I had a follow up the other day with a client that came to us with trich. She had been pulling since she was 13 years old (she was now 37) and had tried numerous techniques and treatments over those 24 years to stop pulling, including numerous medications. Here is her story and experience with amino acid therapy.

“I started pulling when I was 13 years old. At first it was more of a nervous habit, but pretty soon, I couldn’t help myself. I lived with it until I was an adult, then I began trying medications; none of them helped, and many of them made my symptoms worse or made me feel horrible. Over this time, I also started to developed terrible anxiety which got worse and worse with each pregnancy (she has 3 kids).  I also started to gain weight. The worst part is that I am starting to see signs of trich in my kids.

When I first started working with Dr. Chad, I immediately started to feel better, with some decrease in anxiety and a substantial increase in energy. I also started to work with my doctor to decrease the Wellbutrin that I was taking by 50%. The trich wasn’t doing so great, as I still had urges, but I didn’t pull.

Dr. Chad adjusted the amino acid therapy and within 3 weeks my urge to pull was gone, my anxiety was doing really well and my appetite had gone down, so I was starting to lose weight. I was also able to completely get off my Wellbutrin with no increase in symptoms. Now I am going to try and get off the amitriptyline that I am taking for anxiety as well.

I am so grateful to Dr. Chad for helping me get my life back. I can now enjoy my time with my kids because I’m not so stressed out and not thinking constantly about pulling. I’ve started to go out socially again and it feels wonderful. Thank you Dr. Chad for all you do and for helping me get rid of trich!”

Margaret’s story goes to show that no matter how long you may have suffered from trich, you can still get your life back and eliminate the urge to pull. Now we are working with Margaret’s kids to help them eliminate the urge to pull and stop the trich before it starts.

Trich – Two Kinds of Pulling

We spend a lot of time on this blog talking about the ins and outs of amino acid therapy as an effective solution to the underlying neurotransmitter imbalance(s) that often lead to trich. However, there is also a behavioral component that cannot be overlooked and must also be addressed. Most people experience both the ‘urge’ to pull and develop a ‘habit’ of pulling.

For instance, many people pull at certain times of day or under certain situations, such as while driving, while studying or when watching TV. They may not even notice that they are doing it. The key is what happens when they do notice – can they tell themselves to stop and move on without giving it another thought? Or do they then have to constantly think about it in an internal struggle not to begin pulling again?

When the underlying neurotransmitter imbalances have been addressed, the urge to pull disappears. However, the habit remains. The good news is that once the urge is gone, when a person catches themselves pulling, they can take a look at the situation and make a decision to stop pulling – and then let it go. Because the urge is gone, they no longer need to bother with any thought of pulling. If they catch themselves pulling again out of habit, they simply correct the behavior. This is in stark contrast to someone that has to continually battle with themselves to not pull their hair out.

Once the urge is gone, behavior modification therapies often are an incredible help. These can be as simple as sitting on ones hands or keeping the hands busy to help break those habitual patterns, or involve more in-depth therapy, such as cognitive behavior therapy (CBT). Many of our clients who had tried CBT in the past with little success report outstanding results once their neurotransmitter levels are balanced.

Differentiating between the urge and habit is important. Habits can be changed with time and attention. Urges require that the underlying biochemical imbalance be corrected.

To find a Cognitive Behavioral Therapist, visit the National Association of Cognitive-Behavioral Therapists website or the Trichotillomania Learning Centers Resource page.

Trichotillomania and Stress

Here is a story that sounds so familiar that I wanted to share it:
Trichotillomania Story

In it, Michelle explains that her pulling started after a severe amount of stress and that she often pulls more when she is stressed out. This is very, very common as stress is one of the key reasons neurotransmitter imbalances develop (see our latest post on 2 Major Causes of Neurotransmitter Imbalance).

Even though you can rebalance your neurotransmitter levels through proper amino acid therapy, properly addressing chronic stress involves a lot more than taking pills. As Michelle points out, she feels she could deal with this much better with a strong support network; this is, in fact, exactly what we have found in our clinic as well. Luckily, that support network can be made up of not only people you can see day-to-day, but also those who you can interact with via social networks and online forums. The key is to feel and be connected – to others and often to whatever higher power you believe in.

Outside of staying connected and feeling supported, many people need to implement specific daily strategies to help them management stress. This may include psychotherapy, EMDR, meditation, yoga, deep breathing, exercise and any number of other daily or regular therapies to help them lessen the impact stress has on their lives.

It may not seem easy, but getting the pieces in place certainly raises the potential for eliminating the urge to pull. Once more, it also sets the stage for long term health and healing on many levels.

Neurotransmitter testing – what does it measure and how does it help? Part II

Now that you have a better understanding of what we are looking for, you can quickly see that it takes a very specialized laboratory to do these measurements; it also helps you to see why the interpretation of the results isn’t quite so straightforward.  We have used and done tests on several laboratories across the country and we have only found one that produced consistently reliable results, and that laboratory was DBS Labs (www.labdbs.com). This is the lab we use and the only one that is qualified to run these OCT Assay Interpretations.

The good news is that we have found that the vast majority of people (~80-85%) have a complete resolution of symptoms before any kind of lab testing is necessary. This means that majority of people will have their symptoms go away (i.e., eliminate the urge to pull) within about 3-4 weeks with proper guidance and weekly follow ups. Even if a person doesn’t see a complete resolution of symptoms in this time frame, a urine test can help guide the way to reach the goal.

A health care provider has to take many hours of training to even begin to interpret the results from these tests, and then have the experience of reviewing and working with hundreds of clients before they can say they understand what they are doing. This is because it is not a simple matter of ‘is the number too high or too low’. The client’s clinical symptoms and changes in those symptoms must be coupled with the OCT functional assessment to determine the proper next steps. That is why it can take years for a health care provider that has had the proper training to become proficient at using these tests properly. Again, that is assuming they have been properly trained in the first place; currently there is only one seminar that covers this peer-reviewed information; it is a 37.5 hour seminar and has continuing education for MDs, DOs and NDs (you can learn more about it at www.neurosupport.com).

If this all sounds overwhelming and to ‘geeky’ just know this: most people will experience a complete resolution of symptoms without the need for any kind of testing. If you do need a test to help determine the proper amino acid dosing, we have worked with thousands of clients over the past decade and evaluated hundreds and hundreds of OCT Assay Interpretations (i.e., Neurotransmitter tests) to help people eliminate their symptoms. That is why we can help over 86% of people with trich eliminate the urge to pull and over 98% of people with other neurotransmitter-related disorders achieve a complete resolution of their symptoms.

If you’d like more information or really get into the science of this, here’s a place to find more detailed information:  http://www.neuroassist.com/OCT-functional-status%20determinatino.htm.

Neurotransmitter testing – what does it measure and how does it help? Part I

I am often asked what tests are available to help determine if a person’s neurotransmitter levels are imbalanced. There is a lot of misleading and inaccurate information out there, so I will try and summarize what testing procedures we use, what is being tested and how those test results are useful to help us determine how to optimize your amino acid dosing over the next two posts.

First, let’s clear up some misconceptions. Peer-reviewed research has shown that the following statements are FALSE:

• Doing a urine test prior to taking any amino acids is an accurate assessment of neurotransmitter levels in the body – this is completely false. Research shows absolutely no correlation between urinary test results and amino acid needs if a person is not already taking a known amount of amino acids (more on this below).
• Urinary neurotransmitter levels are indicative of brain (central nervous system) neurotransmitter levels – again false. The amount of measured neurotransmitters in the urine is indicative of the neurotransmitters formed and excreted by the kidneys, not what is present in the rest of the body. However, as you will soon find out, it does provide valuable information about how to properly dose amino acids to eliminate your symptoms.
• All neurotransmitter tests are the same – false. There is great variety in not only what is tested, but the accuracy and reproducibility of the tests and therefore, the utility of the results.
• Neurotransmitter test results are easy to interpret and use – unfortunately, this too is false. Because it is not a straightforward measurement, proper analysis of the results takes hours of training and extensive clinical experience.

Let’s expound upon these myths and talk about what is actually going on.

For urinary testing to be accurate, a person must be taking some known amount of amino acids; this puts the body into what is called a ‘competitive inhibition state’. This is similar to measuring a person’s glycemic response by giving them a set amount of glucose and then taking blood samples at timed intervals. If you don’t give them a known amount of glucose and take the measurement at set times, the results are misleading and worthless. Likewise, in order for neurotransmitter testing to be accurate, a person must be taking a set amount of amino acids and take the urine sample at a specified time.

Some of the confusion also comes from using the term ‘neurotransmitter test’. Many labs test the metabolites (break-down products) of neurotransmitters in the urine and say that these are indicative of levels throughout the body, including the brain. Research has shown this not to be the case, so what is actually going on?

This test should really be called Organic Cation Transporter (OCT) Functional Status Determination (or something like it), as this is more descriptive as to what is actually occurring. Simply said, there are mechanisms called transporters that direct (or transport) neurotransmitters formed in the kidneys either into the bloodstream or out into the urine. These transporters act differently in every person, but we can affect how these transporters work by giving a person amino acids in a balanced manner.

By giving the body the right amount and balance of amino acids, we can help these transporters work better and restore a person’s neurotransmitter levels to a level where they function properly, that is, don’t experience any symptoms. This works because the OCT transporters in the kidneys act exactly like the OCT transporters in the brain (and liver and intestines, etc.). Therefore, although the actual numbers given on the test are not direct measures of the body’s neurotransmitter levels, they do provide the clinician (properly trained in amino acid therapy) a means to determine the status of these OCT transporters so that they can help them function properly throughout the body. When this happens, any symptoms associated with neurotransmitter imbalance – like trichotillomania, depression, anxiety, OCD, attention deficit, Parkinson’s disease, insomnia, fibromyalgia, panic attacks, dementia and a host of other disorders – disappear.

We call the test a ‘Neurotransmitter Test’ or ‘Neuroregulatory profile’ because it is an easier concept for our clients to understand; however, as I point out above, it is technically incorrect.

The next post will reveal the difference between laboratory measurements, what labs we have found provide accurate, actionable results and how these results can help us determine your optimal amino acid dose.