Treatment for hair pulling (trichotillomania) part 3

Coping with hair pulling

Because cure is not always possible, most individuals need to learn some method(s) to help cope with the disorder. The following steps may help coping with hair pulling:

- Write down on a piece of paper all situations
which lead to hair pulling. Most individuals
tend to pull hair while watching TV, reading,
driving, or when they are alone and frustrated.
Try and change the situation or environment to
reduce the hair pulling.
- Keep your self busy with activities that engage
your hands. For example, start knitting, drawing,
writing, painting or play a sport like tennis.
- If you pull hair at night or are not aware of
the situation, wear gloves.
- Join a support group because there are many
individuals with this problem. With these support
groups one can get advice, moral support and
treatment help. While support groups are not for
everyone, they can be helpful for advice.
- If you are bothered by your hair loss, buy a wig,
wear a hat, apply make-up or see a hair expert.
- One way to prevent hair pulling is to keep the
hair short.
- If you do tend to pull hair without being aware,
ask your family members or friends to alert you.
- Learn how to reduce stress
- Talk to your family, educate members in your home
or circle of friends about this disorder.

Trichotillomania is a distressing disorder without a good treatment that works in everyone. Because there is no cure for the disorder, one should learn how to cope with the condition. While the condition is embarrassing and filled with anguish, one should be aware that given time, many individuals will outgrow hair pulling. For those who continue to be tormented by this dreadful disorder, the first place to start is by going to see a health care professional who specializes in psychiatry.

Treatment for hair pulling (trichotillomania) part 2

What about medications?

The use of medications to treat Trichotillomania is empirical. Because so little is known about the disorder, no one really knows what the best medications are, when to start the pill and for how long the treatment should be continued. The most common class of medications used to treat Trichotillomania are the anti depressants. There are no clinical trials on effectiveness of these drugs, but anecdotal reports do indicate that some patients do improve over time. Some patients need to take the anti depressants for 3-9 months to see an improvement. Because of side effects, compliance with these drugs is poor. Many patients stop taking the drug after 2-4 months. The most common complications of these drugs include weight gain, loss of libido, fatigue, and dry mouth. The side effects do stop when the drug is discontinued. Most experts recommend drug therapy with CBT for the best results.

The unfortunate thing is that not all individuals respond to drugs or CBT therapy. Many individuals do relapse even when the treatment is initially successful. Because the disorder can create havoc in one’s life it is recommended that one see a health care worker for help. Even though present day treatments are not ideal, in some individuals, drugs or CBT can help one make a dramatic recovery.

Alternative medicine

Because conventional medicine has not been successful in treatment of many mental disorders, including trichotillomania, many patients have been turning to alternative health care. There are reports that some individuals do benefit from hypnotherapy. When this treatment is combined with drugs or CBT, the frequency of relapse is much less. Alone, hypnotherapy works in less than 5% of individuals. The treatment is prolonged and requires patience and commitment.

Another technique that has been reported to help individuals with Trichotillomania is biofeedback. In this therapy, one is taught how to control or change certain physical responses. For example, when one encounters a certain stress, headache or a frustrating situation, biofeedback can help reduce tension and erases the urge to pull hair. The technique can also help decrease anxiety and helps control negative behaviors like pulling hair. However, on its own biofeedback often fails to work. For the best results, it must be combined with drug therapy or CBT.

Treatment for hair pulling (trichotillomania)

Trichotillomania is a dreadful disorder and very little is known about it. For one thing, the disorder is associated with a lot of torment and internal turmoil. The most important aspect of this disorder is that the individual is not to be blamed for it. why Trichotillomania happens is not well understood and like most medical disorders bad luck or bad genes seem to part of the problem.

One reason why there is little known about Trichotillomania is because many individuals who have this disorder do not go and see their health care worker. Over the years, fear, embarrassment and lack of family support has driven these individuals into the closet. Medical professionals rarely come across individuals with Trichotillomania and most health care professionals have no idea how to treat it. Nevertheless, if one does seek help, there are some treatments that can improve the disorder. Two basic treatments are currently available for hair pulling.

Psychotherapy or cognitive behavior therapy (CBT) is an effective treatment for Trichotillomania. It is a slow process but helps one understand the disorder and brings awareness to the problem. Over time, some individuals learn not to pull their hair. The therapy centers around control of emotions, stress and trigger factors. The triggers and negative behaviors are then substituted for positive things. For example, if one used to pull hair, then now one will go for a swim, read a book or cook a meal. CBT requires commitment and patience. It is not a one shot deal because recovery can take 3-8 months. Frequently CBT also entails family involvement to help members understand the disorder and what they can do to help the affected individual. Over time, CBT can help diminish urges to pull hair and relieves strong impulses causing disruptive behavior.

Does CBT always work? No. CBT does work when treatment is sought out early. In normal people who have capacity to understand and comprehend, the results are good. Individuals who have other problems like drug abuse, alcoholism or personality disorders, CBT does not work well. From anecdotal reports, about 30-50 percent of individuals do benefit from this therapy.

Can thiamine help reverse or delay Alzheimer’s dementia? part 2

It has been observed that individuals who develop Wernicke’s Korsakoff syndrome have a deficiency of thiamine. The most common cause of this disorder is alcoholism. These individuals develop dementia, have memory loss, unsteady gait, and muscle weakness. When individuals with this disorder are treated with thiamine, the symptoms do dramatically reverse. Thus, there has been a recent trend to recommend thiamine to patients with Alzheimer’s dementia.

Thiamine is one of the Group B vitamins and known as B1. It is found in both plants and animals. Thiamine is vital for many metabolic functions in the body that use energy. Thiamine deficiency is quite rare but individuals who drink excess alcohol can develop deficiency of this amino acid.

Because lack of thiamine can cause dementia in Wernicke’s Korsakoff syndrome, it has been proposed that perhaps thiamine can also be used to reduce severity of Alzheimer’s disease. Almost every health food stores sells thiamine and this amino acid is widely hyped up as a cure for many dementias. Thiamine has been marketed heavily for treatment of many medical disorders including Alzheimer’s, but does it work?

Several years ago several controlled studies looked at the effects of thiamine on dementia. Thiamine was administered daily and compared with a sugar pill. The three studies from the 90s did not reveal any benefit of thiamine in patients with Alzheimer’s disease. The only positive observation was that thiamine had no side effects. Since then many anecdotal reports have been published and countless patient testimonials indicate that thiamine does not reverse or slow down dementia in patients with Alzheimer’s disease.

For the moment, thiamine cannot be recommended as a treatment for Alzheimer’s. For individuals who still believe in thiamine and would like to treat their family members with dementia, foods containing thiamine are much better than pills.

Capsules or pills containing thiamine have often been found to contain fake and counterfeit products Foods which are rich in thiamine include whole grains, rice, bran, brewer’s years and wheat germ. These foods are cheaper and also more nutritious than any pill.

Can thiamine help reverse or delay Alzheimer’s dementia?

Alzheimer’s is a devastating disorder that gradually results in memory impairment, disorganized thoughts, and poor reasoning. Over time, these cognitive impairments become so severe that there is a gradual decline in the individual’s usual level of functioning. Although all individuals have some degree of memory loss as part of aging, these cognitive changes generally do not interfere with level of function. In Alzheimer’s, the memory loss is much faster and associated with severe impairment in cognition. The disease progresses relentlessly and most individuals become incapable of independently looking after themselves. During the later stages of the disorder, depression, paranoia and delusions often accompany the illness and usually persists for long periods.

Today we have no cure for Alzheimer’s disease, but there are a few treatments available to alleviate some symptoms that are causing suffering.

The management of alzheimer's consists of use of medications and non-medications based treatments. The two different class of medications that have been approved by the FDA for treating Alzheimer’s include choline esterase inhibitors like Tacrine (Aricept) and partial glutamate antagonists. However, both class of drugs only work during early dementia and do not slow rate of progression of Alzheimer’s disease. Recently, there has been a surge in alternative care for patients with Alzheimer’s dementia.

What are options for treating PICA (eating crap)? Part 2

The role of Social worker

In toddlers and young children, pica behavior training must also bring about a positive appreciation of the environment and/or sensory stimulation. In young children with PICA, other issues that may need to be addressed are improvement of financial problems, schooling, social welfare, and prevention of isolation. One may also need to assess cultural beliefs and practices, educate both child and family, and teach about the harm of PICA. In children, it is vital that the surrounding environment be free of lead based paints, toys and furniture.

Medications

The majority of health care workers believe that PICA resolves spontaneously or can be improved with behavior treatment. Moreover, this is true in a number of individuals. However, there are many reports of adults with PICA who realize that their eating habits are troublesome. Many of these individuals have tried behavior therapy and have not improved. There are no approved drug regimens for PICA. In the literature, all drug therapy treatment for PICA is anecdotal and only isolated case reports exist. No one really knows what the ideal drugs are and how long to treat PICA.

However, based on case reports and effectiveness, the drugs with the best benefit for PICA are the atypical anti psychotics. Drugs like olanzapine, risperidone, or clozapine have shown to be more easily tolerated and produce relief in many cases.

Isolated reports do indicate that with time PICA does diminish and the drugs can be stopped. Some individuals required drug therapy for 3-9 months. The principal brain target of all antipsychotic drugs is the dopamine D2 receptor. One should be aware that a few mentally handicapped individuals who have been treated with anti psychotics have gone on to develop worsening of PICA. This may be due to ineffective dose, improper diagnosis or a combination of other emotional problems.

It is highly recommended that one follow up with a psychiatrist when using these drugs. The lowest dose of drug should be used. The effects of anti psychotics are not immediate and can take anywhere from 2-4 weeks to manifest. Other drugs which have been tried for treatment of PICA with some benefit include bromocriptine and methylphenidate.

At low dose, these drugs are fairly well tolerated and to avoid side effects one should not practice polypharmacy. Careful titration of dose with gradual increases can have a major impact on PICA

(http://www.psychiatrictimes.com/display/article/10168/1159376?pageNumber=4)

What are options for treating PICA (eating crap)?

Pica is an eating disorder typically characterized by the continual eating of nonnutritive substances for a period of at least 4 weeks at an age in which this behavior is developmentally inappropriate (e.g., >18-24 mo). Today, the definition of PICA has been expanded to include eating of nonnutritive substances.

Individuals who are diagnosed with pica have been reported to mouth and/or gulp down a wide variety of nonfood materials, including, but not limited to, clay, dirt, sand, stones, pebbles, hair, feces, lead, laundry starch, vinyl gloves, plastic, pencil erasers, ice, fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string, cigarette butts, wire, and burnt matches.

In the majority of cases of children who have been diagnosed with PICA, natural recovery occurs with time. Most children who have no mental problems simply grow out of the disorder. However, some children may need a multidisciplinary approach involving psychologists or social workers. The role of physician in early treatment stage is that of reassurance.

When spontaneous recovery does not take place, some type of treatment must be offered. Expansion of management plan must take into relation symptoms of pica and causative factors, as well as treatment of potential complications of the disorder.

The variety of behavioral strategies that have been proven to be effective in treating PICA include

- Antecedent treatment
- Distinction guidance between edible and
non-edible items
- Self-protection equipment that prevent
insertion of objects in the mouth
(mouth guards)
- Sensory strengthening of proper foods
- Differential strengthening of other or
unrelated behaviors, such as screening
(covering eyes briefly), or performing
exercise (or watching TV) is encouraged
- Conditional aversive oral taste (silver
acetate, lemon)
- Conditional aversive smell consciousness
(sulfur or ammonia),
- Conditional aversive physical awareness
(water spray, mild static shock therapy),
- Brief time out with physical restraint of
arms
- Correction of the environment
- Administer appropriate responses to
reinforce positive behavior

How can I improve my libido while taking an antidepressant? part 3

Some individuals prefer to use only an SSRI. However, almost all SSRI have the ability to induce sexual dysfunction. Recently Fluvoxamine (luvox) has been speculated to help individuals with sexual dysfunction. At present Luxol is used to treat OCD and does work well. The drug does maintain sexual function but it has two side effects of concern. When the drug is abruptly discontinued, it can cause withdrawal symptoms of dizziness, fatigue, nausea, vivid dreams, irritability, and headaches. The other problem is that luvox may increase the risk of suicide in young adults and children. Individuals who are depressed have been found to have worsening of depression and suicidal thoughts when taking Luvox. Therefore, at the moment, the drug is rarely prescribed without close supervision.

Some physicians do try an add a psychostimulant to the patient’s regimen to counter the sexual dysfunction. Addition of drugs like Ritalin or methyl phenidate have been shown to work, but often the side effects of anxiety and insomnia also dominate. Further, these drugs have ability to cause physical dependence and cause withdrawal reactions when the drugs are abruptly stopped.

The latest and perhaps the one with the least controversy are Viagra and Tadalafil. Since the availability of Viagra and related drugs, there have been a few studies to see if the sexual dysfunction can be reversed. There have been a few studies which showed that both tadalafil and sildenfail both slightly improved sexual function in individuals who took anti depressants. However, most of the studies included small numbers and long-term data are not available. Anecdotal reports indicate that while Viagra does work, the effects are not sustained in the long run. In any case, Viagra is perhaps the best option for individuals with sexual dysfunction which occurs with anti depressants. The few negatives about viagra are that it is expensive and fake/counterfeit products are common.

How can I improve my libido while taking an antidepressant? part 2

The other option for treatment of sexual dysfunction includes lowering dose of the anti depressant. This is often a tricky option as most antidepressants have a fine line between effectiveness and no effect. Lowering the dose may reduce sexual dysfunction but may also decrease effectiveness of the drug- most patients are reluctant to try this option.

The other option includes adding another medication to counter the sexual dysfunction or one can switch to another anti depressant with a lower incidence of side effects.

One of the alternative drugs, which has often been prescribed to counter sexual dysfunction is bupropion. Bupropion is an effective anti depressant and does not cause a change in sex drive or weight gain. Bupropion, also sold as Wellbutrin, is an atypical antidepressant that does work well. There are several studies which have shown that bupropion can reverse sexual dysfunction in normal healthy individuals. The improvements were observed in terms of arousal, orgasm, and overall sexual satisfaction. However, it was observed that sexual benefits usually were more prominent at a higher dose (300 mg). A lower dose (150 mg) was not much different compared to placebo

However, at high doses, bupropion often has many side effects including inability to sleep, anxiety, and intense headaches. Most people stop taking the drug because of headaches and mouth dryness.

Another drug recommended to counter the sexual dysfunction is to use selegeline. This anti parkinsonian drug when applied as a patch (6 mg) does work as an antidepressant and has minimal sexual side effects.

How can I improve my libido while taking an antidepressant?

A fairly high number of individuals who take anti depressant medications complain that they have decreased libido, lack of sexual desire, failure to achieve an erection or inability to ejaculate. The exact numbers of people who have sexual dysfunction from anti depressant medications is not known, but anecdotal reports suggest that the numbers are high.

The sexual dysfunction that occurs with anti depressants has been known for decades and is somewhat difficult to resolve. Almost every class of anti depressant drugs has been associated with sexual dysfunction and lowered sexual excitement. The sexual dysfunction generally occurs after the patient has been on the drug for a few months. In some cases, the sexual dysfunction improves with time, but in many cases, the problem only gets worse. These sexual side effects while not life threatening, seriously affect an individual’s lifestyle. Often the patients solve the problem by refusing to take their medication. This lack of compliance then leads to worsening of the mental health problem.

So how can this problem be resolved?

When an individual first complains of sexual dysfunction, a wait and see approach may be appropriate because some individuals will improve with time. The wait and see period should not be more than 2-4 months. If the patient has not improved by then, he/she is unlikely to improve.

PICA- eating crap part 2

Once the patient has recovered from surgery, a consultation is made with a psychiatrist to evaluate the individual. Close monitoring of the patient is necessary. Many individuals continue to persist with this bizarre eating habit even after surgery.

While pica is common in childhood and occasionally there may be just one episode, there are developmentally delayed children who do persist with this eating habit. The treatment of pica is behavior management.

Close supervision is required of children known to put things in their mouth. Unfortunately developmentally disturbed children fare well with psychotherapy and many require medications. Healthy adults generally recover spontaneously or with some type of behavior management.

PICA- eating crap

Pica is an exotic name for a mental disorder which is characterized by persistent eating of non food substances such as hair, paint, paper, soil, pencils, metal pins, etc. However, some individuals may eat foods like raw rice, excess salt or sugar, flour, etc. The disorder is quite common and is estimated to occur in 4-25% of the population. A fascinating observation is that the majority will continue to eat only one these non nutritive items during the course of the disorder. Of course, there are others who will eat multiple items.

Pica is most commonly observed in the 1st-3rd decade of life. It may occur early in children but is often mistaken for just children being foolish. To make a diagnosis of Pica, one must persist with these eating habits for more than one month at an age where such a habit would be considered developmentally unsuitable.

Most individuals who develop Pica are healthy individuals. Pica has often been reported during pregnancy where females suddenly develop a taste for bizarre items. The disorder is also seen in wide variety of mental disturbed individuals, esp. those with dementia and some types of schizophrenia.

The majority of healthy individuals eat the non nutritive substances secretly and often are brought to hospital with symptoms of bowel obstruction. Some children eat plaster from the walls and in the past, lead poisoning was a common emergency admission. A number of individuals require surgery because the foreign material may have either blocked the bowel or caused a perforation in the stomach. At surgery, the diagnosis of pica is usually made by the findings of hair, soil or plastic straws, etc.

Emsam; An Anti depressant which is applied as a patch. Part 2

Emsam patch is changed once daily at the same time. The patch does tend to get stick to the skin rather firmly and most people need to apply an adhesive remover or mineral oil to get it off. The new patch should always be rotated a new skin site. Once the patch is applied firm pressure with the palm should be applied for a few seconds to ensure proper contact with skin. Emsam comes in various doses and it is recommended that depressed patients start with the 6mg/24 hr formula. At this does level there are no dietary restrictions. However, if the higher doses of 9 and 12 mg are used every 24 hrs, dietary restrictions do apply.

So does Emsam work?

Several studies have shown that compared to placebo, Emsam is a superior anti depressant. At present Emsam is used to treat clinical depression and has even been found to be useful in patients who have failed to respond to other SSRI and tricyclic anti depressants. The most common side effect is at the application site and is redness caused by the adhesive tape. Other rare side effects include headache, lack of sleep, diarrhea dry mouth, and gastric upset. These side effects occur in less than 5-10 percent of individuals. There are a whole list of drugs which cannot be taken while taking Emsam and the list is no different when one takes the other anti depressants.

Emsam has been on the market for only 2 years to treat depression but the results indicate that it does help some individuals who have failed to respond to other anti depressants. So far it has remained a decent drug with not as many side effects as the tricyclics. Furthermore, weight gain has not been a problem with this agent. How long it will continue to work in depressed patients remains to be seen.

Emsam; An Anti depressant which is applied as a patch

Emsam was released a few years ago as transdermal patch for the treatment of depression. Emsam is Selegeline. Selegeline is a monoamine oxidase inhibitor (MAOI) used in the treatment of Parkinson’s disease and has been around for more than a decade. It was observed that many parkinsonian patients who were treated with selegeline had improved mood and spirits. Further work revealed that selegeline did improve mood in patients with depression.

Monoamine oxidase inhibitors have been used to treat depression for more than half a century and are some of the oldest drugs in the pharmacopeia. While the drugs are effective, the major problem with MAOI is that people have severe dietary restrictions otherwise complications can occur. However, with Emsam, the drug is delivered via the skin and the same type of dietary restrictions are not needed (esp at the low dose).

Emsam is slow absorbed through the skin and enters the brain where it works in depressed patients. The biggest advantage of Emsam is that because it does not go via the stomach and avoids the liver, it has a very low risk of inducing problems which were previously seen with older MAOI. The risk of high blood pressure with this formulation is less than 1 percent.

Emsam is usually applied as patch on the skin. When the 6 mg patch is applied every 24 hours there are no dietary restrictions. The drug is slowly absorbed through the skin continuously for 24 hours and this keeps level of Emsam fairly constant thought out the day.

IF I have bipolar, can I take antidepressant drugs?

As a rule anti depressants are almost never used to treat bipolar disorder. It is only the rare physician who treats bipolar with an antidepressant. The reason for the hesitancy in treating a bipolar patient who is depressed with a conventional anti depressant is that the drug may rapidly induce a state of mania with potential adverse outcomes, such as extreme paranoia, suicide or psychosis.

Further, not all anti depressants work in the same way and there is always a chance of harming the patient. For the above reasons most psychiatrists have been very hesitant in using the conventional anti depressant in individual with a bipolar disorder. The routine practice has been to use an anti depressant in combination with a mood stabilizer to prevent the sudden onset of mania. Some physicians only use a mood stabilizer alone or combine it with a anti psychotic (neuroleptic) drugs which is approved for use in bipolar depression.

At the moment there is no way of knowing which bipolar individual will react adversely to the anti depressant drugs. Most of the factors which determine the type of reaction are individually based. Individuals who continue to abuse drugs, or have had prior treatment failures with anti depressant, or those who have a rapid cycling form of bipolar disorder or those with a genetic alteration a certain gene (serotonin transporter gene) have a high risk of developing adverse reactions.

So far there are no rigid rules or guidelines as to when an anti depressants can be used in patients with bipolar disorder. In those individuals with bipolar disorder who continue to have prolonged episodes of depression, it is important to discuss this issue with your mental health counselor. One needs to develop a treatment plan to meet individual needs. If an anti depressant is started, one needs very close follow up to ensure that there are no untoward problems during the with mania phase.