Can Skimping on Sleep Make Trichotillomania Worse?

As you read through the numerous articles and research on this blog you will quickly see that we have found that imbalances with certain neurotransmitters (which are brain chemicals that control most of the body’s functions) can lead to a great many disorders, including trichotillomania and the urge to pull, depression, anxiety, compulsive and/or obsessive thoughts and behaviors, food cravings, binging behavior, addictions, migraines and many others, including sleep disturbances. Therefore, it would not be surprising to find a relationship between these seemingly varied imbalances.

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Trichotillomania and Food Cravings

Many people that suffer from trichotillomania also experience other symptoms of neurotransmitter imbalance, which can include any of the following:

In particular, we have been seeing a lot of people suffering from trichotillomania that also have insatiable cravings for sweets and/or simple carbohydrates, including breads, cookies, candy, chips, pastries and similar foods. Most people that have this combination of sugar cravings and trichotillomania don’t realize they are connected, and they often feel helpless on both accounts. However, I am here to tell you that not only are they related, they can both be resolved using the same techniques.

Balanced Amino Acid Therapy

Both the urge to pull and cravings for sugar and sweets are regulated by your brain chemistry. The chemical messengers responsible for this regulation are called neurotransmitters, which include serotonin and dopamine. Imbalances in your neurotransmitter function will cause miscommunication, which often leads to symptoms including the urge to pull, cravings and any number of the conditions listed above. However, restoring proper neurotransmitter balance will improve communication and alleviate these conditions.

One of the keys to establishing proper neurotransmitter function is the employment of balanced amino acid therapy. This means that a health care professional trained in the proper use of amino acids will help you determine exactly the right mix of amino acids and cofactors you need in order to establish optimal neurotransmitter function. Once this occurs, not only will your urge to pull disappear, your cravings will also be substantially reduced or eliminated altogether. This occurs because you are addressing the root cause of your problems, and by digging down to the root, you can manage a whole host of symptoms due to neurotransmitter imbalance.

The Importance of Using Balanced Amino Acids

I have been many emails asking how to achieve proper neurotransmitter balance using amino acid therapy. It seems that many people are attempting to take their own mixture of amino acids in an attempt to alleviate their urges to pull. This trial-and-error method is bound to fail in most cases and can lead to greater imbalances. This is because taking amino acids that are not properly balanced for each individual will cause depletion of competing systems over time.

Amino Acid Synthesis

I believe the reason for so much confusion comes from the fact that the synthesis of monoamine neurotransmitters, including serotonin, dopamine, norepinephrine and epinephrine, seems so straightforward:

From an intuitive standpoint, taking 5-HTP would seem to be the perfect way to increase serotonin and taking L-tyrosine or L-dopa would seem the ideal way to increase levels of dopamine. Unfortunately, this is one instance where the simple answer doesn’t play out in practice.

Synthesis Interactions

A thorough review of peer-reviewed literature shows several interactions occur in the actual synthesis of neurotransmitters from amino acids:

As you can see, giving only 5-HTP, L-dopa, L-tyrosine or L-tryptophan can deplete the monoamine neurotransmitters along with their amino acids, making the overall situation worse. Based on this data, the odds of a person obtaining the correct balance of amino acids to achieve proper neurotransmitter function are virtually zero. Once more, the probability of a person using trial-and-error to try and establish proper neurotransmitter function causing further imbalance is incredibly high. This highlights the need for professional guidance in regards to establishing the optimal amino acid dosing for each person.

Professional Guidance

Although resolving this situation isn’t as easy as it seems, a solution does exist. The science of amino acid therapy has grown by leaps and bounds over the past six years, due in large part to the work of Marty Hinz, MD and his staff at NeuroResearch, Inc. Dr. Hinz’s work has shown that with proper training, achieving optimal neurotransmitter function is possible using properly balanced amino acid therapy along with functional testing as needed. We have been using this approach for almost a decade with tremendous success and can help you achieve the resolution you are looking for.

Amino Acid Therapy and RepleteExtra

A large minority of people (~30%) using properly balanced amino acid therapy will achieve a complete resolution of symptoms using only NeuroReplete and CysReplete at the proper dosage. However, many others will require the addition of other formulas to increase the amounts of serotonin, dopamine or both in the system. One of the formulas often used in this process is RepleteExtra.

RepleteExtra was formulated to be used in addition to NeuroReplete when it is desired to increase both serotonin and dopamine in a balanced manner. RepleteExtra contains only L-tyrosine, 5-HTP and folic acid. It does not contain the basic cofactors (vitamins and minerals) that are found in NeuroReplete, highlighting the need to use these products in combination with one another.

By providing L-tyrosine and 5-HTP in a balanced ratio, RepleteExtra works with NeuroReplete to increase the levels of dopamine and serotonin, respectively, in a balanced fashion. Using clinical experience and functional testing when needed, a trained health care professional can help a large number of people (~80%) achieve a complete resolution of symptoms using only these formulas in the proper dosage. If testing indicates the need for additional cofactors, other formulas such as TyrosineReplete, D5 Mucuna or 5-HTP may be employed. We will explore each of these formulas in other posts.

A Very Trichy Case

Many of the testimonials and case studies I write about are about very fast results where people suddenly have a complete elimination of the urge to pull within days or weeks of starting balanced amino acid therapy. Truth-be-told, most cases of trichotillomania do resolve within a relatively short period of time, so these case histories and testimonials are representative of what we typically see at the clinic. However, we do have a few cases where things aren’t quite so cut and dry; in these instances, it can take months to get the amino acid dosing right. This obviously requires incredible dedication on the part of the client, as well as their family, as this case history illustrates.

Jenna came to us after her mom had been searching the internet for three years trying to find a solution for her daughter. Jenna had started pulling the hair out of her sheep-skin blanket before progressing to pulling out her eyebrows and then from her head. By the time we spoke with Jenna’s mom, the right side of her head was bald and she didn’t have any eyelashes or eyebrows.

In addition, Jenna had been diagnosed with obsessive compulsive disorder (OCD), with the onset of symptoms occurring when she was just six years old. Her mother stated that she had a period of several years when she did exhibit any OCD symptoms, but that about three years ago, she started constantly washing her hands (to the point that her hands cracked and bled), “straightening things”, developing extensive bedtime rituals and became very worried about contamination and germs. Jenna had been on Prozac for about a year when we first spoke. Both she and her mom were desperate.

We began by attempting to balance out Jenna’s neurotransmitter levels as we always do. However, it became obvious quite quickly that this was not working, so we ran some testing to help guide her care. Jenna’s body was requiring incredibly high levels of amino acids to show any kind of change and the testing was extremely valuable to help make sure we were on the right track.

It took 12 tests and 10 months until she got the result she was looking for. The dedication and support exhibited by Jenna and her parents was incredible over this time period, especially considering that Jenna did not experience any relief of symptoms for the first 10 months we worked together. However, her diligence, and her parents dedication paid off. Like flipping a switch, everything changed.

I spoke with Jenna recently and she told me it was suddenly “easy to control my trich and OCD” and that she “didn’t need reassurance as much”. She was sleeping well, eating normally and doing well in school. Her mom was ecstatic. She said both she and Jenna were realizing most of the repetitive actions were now only habits versus being due to OCD or anxiety and that Ana was now able to differentiate between them and stop when she wanted to. This was a HUGE improvement according to her mom; “We have a life again, and we have our daughter back!” said mom. Now, Jenna’s work is awareness; becoming aware of when she is doing something mindlessly and asking herself if she wants to continue. Now she has control.

Everybody wants instant gratification – and why wouldn’t we? Getting something for less or little effort is always preferable, especially when we are talking about ending what could be a debilitating condition such as trich or OCD. However, when things don’t happen right away and our resolve is tested, then we find out how badly we want a solution. In this instance, desperation was the key to sticking with the program until we achieved the desired result. This means preparing for the long-haul knowing that a resolution will come when we determine exactly what your body needs to achieve balance. We will help you reach your goals, but it is your resolve and dedication that will matter most if and when the going gets tough or the journey grows long.

Trichotillomania Diagnostic Criteria

I have had many questions on this blog as well as several others that I regularly comment on regarding whether or not a person ‘has trich’. We have reviewed this information before, but it is worth restating here.

From a clinical perspective, the diagnostic criteria used by clinicians to officially diagnose trichotillomania comes from the Diagnostic and Statistical Manual of Mental Disorders, 4^th edition, better known as the DSM-IV, that is published by the American Psychiatric Association. The DSM-IV diagnostic criteria for trichotillomania are:

(1)    Recurrent pulling out one’s hair resulting in noticeable hair loss

(2)    An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior

(3)    Pleasure, gratification, or relief when pulling out the hair

(4)    The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g. a dermatological (skin) condition)

(5)    The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Only a licensed mental health professional can make a diagnosis of trichotillomania. However, in layman’s terms it is likely that you have trich if you (1) pull out hair anywhere on your body and/or have an intense urge to do so, (2) have anxiety or tension before you pull or if you try to resist pulling along with some form of pleasure or relief after you pull, (3) do not have some other condition that causes you to pull and (4) find that puling or the urge to pull is negatively impacting your life.

In addition, it is often beneficial to differentiate between two distinct types of pulling – “focused” hair pulling and “automatic” hair pulling. Focused pulling involves conscious pulling, often in reaction to an unpleasant sensory, emotional or mental state. This type of pulling is best illustrated in a person that tends to have an intense urge to pull during or after stressful situations, when they are emotionally upset or when triggered by other environmental factors. Focused pulling is very hard to stop, as the underlying urge is very strong.

Automatic pulling, in contrast, involves habitual pulling that often occurs outside of your conscious awareness. Automatic pulling is when somebody pulls and doesn’t even realize they are doing it, such as while driving, while doing homework, or while talking on the phone. Normally, a person that is pulling automatically can stop once the behavior is brought to their conscious attention. However, sometimes when this occurs, the urge to pull kicks in and it becomes focused pulling.

If you think you may have trichotillomania, you should speak with your doctor about options. However, we have found the best approach incorporates properly balancing your neurotransmitter function using balanced amino acid therapy. You can find much more information about this approach on this blog.

A Novel Way to Improve Trichotillomania

We talk a lot about using amino acid therapy to help correct underlying neurotransmitter imbalances to help people overcome trichotillomania and other disorders related to neurotransmitter imbalance, such as depression, anxiety, OCD, ADD/ADHD, migraines, obesity, fibromyalgia and insomnia. However, recent research has shown that you may be able to fine-tune your neurotransmitter levels by using the right combination of probiotics.

Probiotics – good for your (brain) health

Probiotics are the “good” bacteria that normally reside in your gut. It is known that if  these bacteria become imbalanced in some way (due to illness, improper diet or toxin exposure), a condition called “dysbiosis” results, which can have many dire consequences including decreased immunity, improper immune function, food allergies, inflammation, indigestion and numerous other physical disorders. However, until recently it was not known that these bacteria can also generate neurotransmitters that can also affect your brain, impacting your mental and emotional states.

Researchers at Texas Tech University Health Sciences Center found that the following bacteria can produce neurotransmitters in the gut:

This could mean that the microbial balance in your gut could be a key player in improving and maintaining your neurotransmitter levels, and therefore alleviating the urge to pull. It also provides more scientific evidence for something that we routinely see in the clinic – that many people with gastrointestinal disorders develop or have one or more disorders related to neurotransmitter imbalance and that correctly the underlying gastrointestinal disorder is imperative to long-term recovery. Think of it like this – the gastrointestinal disorder (like IBS, Crohn’s disease, food allergies or Celiac’s disease) is like a hole in a bucket, causing neurotransmitter levels to decline (or become imbalanced). In order to fill the bucket back up (using amino acid therapy) over time, you have to first fix the whole.

Certain gastrointestinal disorders create neurotransmitter imbalances through inflammatory, immune or genetic influences. This research provides another potential way to explain, and address, the resulting neurotransmitter dysfunction. Obviously, more research needs to be done to define just how this can be useful in real life, but for now, it seems logical that anyone that suffers from trich or other disorders associated with neurotransmitter imbalance must heal any underlying gut issues while restoring proper neurotransmitter balance using amino acid therapy to achieve long term success.

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.

Trichotillomania Help – Denise’s Story

Denise came to us to try and stop her hair pulling and eliminate the need for a medication she was given (Zoloft) for trichotillomania. She said, “I have always pulled my hair, even as a kid but it was very minor then. I have mostly puled some eye brows and eye lashes occasionally. In the 1990’s hair pulling was confined to the top of my head and there was a small bald spot. Since I moved to Houston in 1997, my hair pulling has become extreme and I now wear a wig all the time; I was prescribed Zoloft for trichotillomania at that time. My hair pulling is mostly at home and is minimal at work.” Denise was now 64 years old.

“I don’t even think about hair pulling.”

We started Denise on amino acid therapy, but she didn’t feel great right off the bat; in fact, she said, “I felt ‘foggy’ at first, but that cleared up. I always felt a little off after taking the amino acids, so I spread them out more throughout the day.” Her hair pulling had improved at this point, but was not eliminated so we adjusted her dosing.

Denise said she “instantly felt so much better – like somebody flipped a switch. I’m more motivated and have a lot more energy. I haven’t felt this good in decades!” She wanted to try and eliminate the Zoloft at this time, so we consulted with her prescribing physician and they came up with a tapering plan.

As Denise continued to taper off the Zoloft, she experienced waves of nausea and occasional depression. We checked her vitamin D levels and found them to be extremely low; once we added in the appropriate amount of vitamin D, the depression disappeared. She also noted that she would occasionally pull her hair out of habit, but that the urges were gone. Denise said, “I don’t pull if I don’t want to.” We recommended she seek out behavior therapy assistance to help her establish new habits instead of pulling.

Once she completed the taper off the Zoloft, the nausea subsided and she said, “I feel darn good – I have forgotten about pulling my hair! I don’t even think about hair pulling!” She continued to have a lot of energy and felt very focused. She also noticed that her appetite had decreased and that her sleep was improving. Most important to Denise, her hair was now growing back and she had absolutely no desire to pull it out, even when she was under stress.

Denise’s story exhibits many facets associated with amino acid therapy. It often takes some individualized tweaking to help restore proper neurotransmitter status; this could mean adjusting the dosing schedule or the amounts of certain amino acids. It usually means adapting the dosing schedule to accommodate each person’s needs.

In addition, as we continued to work with Denise, we also uncovered some other imbalances that we then needed to correct; this too is common. It is a rare occurrence that a single deficiency or imbalance is responsible for the totality of a person’s symptoms. However, by addressing each imbalance as it surfaces, we can continue to peel away the proverbial onion until we’ve gotten to and addressed the appropriate issues. At that time, just like with Denise, many aspects of one’s health will improve; and they will stop pulling their hair.

SAMe and Neurotransmitter Depletion

I recently had a client ask me whether or not she should take S-adenosyl-methionine (SAMe) as a trich treatment. SAMe is a sulfur amino acid that functions as a one carbon methyl donor in chemical reactions. I knew that SAM-e was often recommended for depression but I hadn’t heard of it in regards to trich.

A literature search provided some unexpected results. Several research articles showed that long term use of SAMe causes depletion of serotonin, dopamine and norepinephrine, which can exacerbate symptoms of depression (and presumably other disorders related to neurotransmitter imbalance) over time. One of the studies even found that this depletion led to the development of Parkinson’s-like disease symptoms.

These are very interesting observations, as it appears that although SAMe is often recommended for symptoms of depression and other disorders relating to imbalanced neurotransmitter levels, long term use depletes the very neurotransmitters that are implicated with those diseases.

I obviously told my client that I would not advise that she use SAMe as a trich treatment. However, that if she chose to use it, she would need to take additional amino acid precursors at the same time in order to prevent further depletion of serotonin, dopamine and norepinephrine. This meant more pills and more money; she gratefully declined.

Sources:

1)      Striatal dopamine depletion, tremors, and hypokinesia following the intracranial injection of S-adenosylmethionine: a possible role of hypermethylation in parkinsonism. http://www.ncbi.nlm.nih.gov/pubmed/8748929

2)      Depletion of nigrostriatal and forebrain tyrosine hydroxylase by S-adenosylmethionine: a model that may explain the occurrence of depression in Parkinson’s disease. http://www.ncbi.nlm.nih.gov/pubmed/9247319

3)      Parkinson’s disease-like effects of S-adenosyl-L-methionine: effects of L-dopa. http://www.ncbi.nlm.nih.gov/pubmed/1359575