Trichotillomania And Ocd

There Are Similarities Between Trichotillomania and OCD

Obsessive-compulsive disorder (OCD) and trichotillomania are similar in a variety of ways, even though they are considered separate disorders.

Although the causes of trichotillomania, or "trich" (an abnormal desire to pull out one's hair), and OCD aren't completely understood, both can be treated with a variety of methods, including medications, therapy and even dietary changes.

The link between trichotillomania and OCD

"The link between OCD and trichotillomania is called a spectral one, meaning that many researchers and myself believe that OCD, trichotillomania and Tourette's syndrome are all related entities," says California psychotherapist William Shryer, D.C.S.W., L.C.S.W. Shryer is clinical director of Diablo Behavioral Healthcare and specializes in mood disorders, including OCD.

"In 2006, they [National Institute of Mental Health researchers] actually isolated a gene that they believe is partially responsible for a number of what has been called impulse-control disorders,' and these include skin picking, hair pulling, nail biting, eating disorders, and Tourette's syndrome," explains Shryer. "Recent research has shown some good response to an over-the-counter substance known as N-acetylcysteine. It is a glutamate-modulating amino acid that our body produces naturally. It is thought that there is a genetic inherited problem that leads those with this disorder to engage in the problematic behaviors."

The disorders may have similar symptoms; however, that doesn't mean the causes or treatment options are identical.

"Trichotillomania and OCD may seem similar because in both cases people engage in chronic repetitive behaviors," says Simon Rego, Psy.D., director of psychology training at Montefiore Medical Center and assistant professor of psychiatry and behavioral sciences at the Albert Einstein College of Medicine. "In addition, some people who are diagnosed with OCD have hair pulling as a symptom -- but it is usually due to a need to 'get things just right,' such as having their hair perfectly symmetrical or even. It's important to note, however, that not everyone with OCD engages in compulsive hair pulling and not everyone with trichotillomania has OCD. Most experts now agree that they are two distinct disorders -- with different treatment options."

Obsessions and rituals

While all of us feel a certain degree of anxiety and fear at times in our lives, normal reactions to these feelings are to protect ourselves, solve any real problems or simply shake off irrational thoughts. A person who is vulnerable to OCD is unable to process these thoughts properly. The brain cannot sort out what is truly dangerous and what is an irrational fear; therefore, a stream of anxiety and doubt often takes over and the person suffering from OCD begins to obsess.

With trichotillomania, the obsessive behavior is related to the hair -- hair pulling or twisting. With OCD, the rituals and obsessions sometimes include hair pulling but are extremely varied from case to case. While some people with OCD are centered on specific behavior -- such as hand washing, because of thoughts of germs and contamination -- other patients exhibit a number of different obsessions and compulsions.

"People with OCD can have obsessions and rituals connected to checking (locks, windows), contamination and washing (hands, clothes), counting, arranging things in a specific way, saving items of little or no value " says Rego.

"The types of rituals and obsessions that those so afflicted can demonstrate are as deep and wide as one can imagine," Shryer agrees. "From the more common hand washing to concern with blasphemy, to having to possess certain things to even writing and erasing [over and over], to concern about contracting an illness or causing others to become sick or injured. So as you see, the list is endless. Another rare and poorly conceptualized OCD spectrum is the 'myth of perceived ugliness,' or body dysmorphic disorder, where the afflicted believe that they have something wrong with their body, as in some defect. They will often not want to go out, believing that others will notice this defect. They are famous for going from plastic surgeon to plastic surgeon, trying to get them to fix the imagined defect. This is also an OCD spectrum disorder that, as with all disorders on the spectrum, generates significant anxiety for them."

Trich and OCD: Age and gender factors

Unfortunately, both children and adults can suffer from OCD and/or trich. "There is no evidence that I am aware of that either disorder is more prevalent in any age group or gender," says New Jersey-licensed psychologist Allen Weg, Ed.D. Weg is certified by both the Trichotillomania Learning Center and the Behavior Therapy Training Institute (BTTI) -- the therapy training arm of the International OCD Foundation. "Many more women report trich than men, but this is thought to be the case because it is more evident in women and men can hide their problem more easily, by such things as shaving their heads or keeping their hair very short. So, more women seek treatment for the disorder."

When does it all start? For most patients with either disorder, the answer is in childhood. "With both trichotillomania and OCD, the age of onset is typically either early childhood or young adulthood, and once present, the course appears to be chronic -- unless it is treated," says Rego.

"Many persons with OCD can trace the beginning of their symptoms to childhood," Weg elaborates. "But there also seems to be a burst of onset for many individuals around early adolescence, presumably in part due to hormone changes in the body, and in early college years, presumably because the disorder was under control until the demands of young adulthood and living outside the protective environment of the home made managing the symptoms less possible. Once in a great while we will see someone in our practice who had no symptoms of OCD until his 30s or later."

Uncovering the causes of trichotillomania and OCD

The causes of trichotillomania and OCD aren't clear or completely understood. Experts hold a variety of theories, including the conditions stemming from biology and/or the environment. These disorders may have genetic components, but to date the specific genes haven't yet been identified in research. Trich and OCD may also be the results of changes in body chemistry and brain functions.

Some research indicates that an insufficient amount of serotonin may contribute to the disorders. A percentage of OCD patients who are given selective serotonin reuptake inhibitors (SSRIs) experience fewer OCD symptoms. Serotonin plays a variety of essential roles in the body, in both the gut and the brain. A deficiency, therefore, can affect an individual both physically and mentally. Serotonin is a neurotransmitter found naturally in the body that is often dubbed a "mood hormone." It's primarily located in the body's gastrointestinal tract, central nervous system and platelets. Serotonin levels are affected by diet. Foods with high concentrations of serotonin include bananas, kiwis, pineapples, plantains, plums and tomatoes. Some experts also recommend consuming foods rich in tryptophan -- an amino acid key to serotonin production in the brain. Soybeans as well as other foods such as fish, tofu, turkey, brown rice, eggs, cheese, and nuts and seeds, especially peanuts and pumpkin and sesame seeds, are considered tryptophan-rich foods.

OCD and trichotillomania could be linked to one's environment in that these disorders may stem from behavioral habits that the person learns over time, such as compulsive hand washing as a learned response. The compulsion (the hand washing) relieves the anxiety associated with the obsession (contamination). Thus, a person suffering from OCD repeatedly carries out the compulsion to relieve the feelings of anxiety.

PANDAS

Although many patients become symptomatic over a long period of time, research has shown that some children experience sudden onset of OCD. In these cases, it has been discovered that there is a link to strep throat.

"There is a rather rare finding in children in that occasionally a child exposed to strep throat will develop a sudden and spontaneous obsessive compulsive disorder that can come on almost overnight," explains Shryer. "This has been labeled as PANDAS and stands for pediatric autoimmune neuropsychiatric disorders associated with Streptococcus. What a mouthful that is, and what is so interesting is that it's not the strep that is the culprit -- it is the antibodies that our bodies produce to fight the strep -- and that if strep isn't present, our own antibodies can attack a part of our brain and cause OCD symptoms. It isn't a huge reach to wonder if other toxins or chemicals could cause this; however, I am not aware of any studies as of yet that can substantiate this."

OCD and Trichotillomania: The connection to food

Not every person who suffers from trichotillomania is dealing with anxiety, stress, trauma or another mental disorder. A number of people, both old and young, who are dealing with trich are otherwise well-adjusted, happy individuals. So, why do they have an uncontrollable urge to pull out their hair? Could it be because of what they are eating?

While some psychologists believe that food and toxins don't play a role, others maintain that these factors can worsen -- if not cause -- disorders such as trich and OCD. We touched on the effect of serotonin levels through diet, but serotonin isn't the only factor that plays a role in these disorders.

"Poor diet can exacerbate symptoms sometimes," admitted Eric Hollander, M.D. "The dietary supplement NAC (N-acetylcysteine) can help." Hollander is a clinical professor of psychiatry and behavioral sciences and the director of the Autism and Obsessive Compulsive Spectrum Program at the Albert Einstein College of Medicine and Montefiore Medical Center.

"I have heard a few passing indications for certain diets, and that is that a diet higher in protein than sugars and carbohydrates has shown some help," says Shryer. "As one would expect, staying away from caffeine and other drugs, especially any stimulants that could cause a rise in the anxiety level, would be beneficial for this diagnostic category."

Could it be more than that? Could diet and the toxins in your food play a role in actually causing the disorder?

GAPS

GAPS (Gut and Psychology Syndrome) is a condition that establishes a connection between the functions of the digestive system and the brain. The term was coined by Natasha Campbell-McBride, M.D. (who in addition to being a doctor also has master's degrees in medical sciences in neurology and human nutrition) in her 2004 book Gut and Psychology Syndrome: Natural Treatment for Autism, ADHD/ADD, Dyslexia, Dyspraxia, Depression and Schizophrenia. Campbell-McBride had worked with thousands of patients (both children and adults) with neurological and psychiatric conditions, including autistic spectrum disorders, attention-deficit/hyperactivity disorder and attention-deficit disorder (ADHD/ADD), schizophrenia, dyslexia, dyspraxia, depression, obsessive-compulsive disorder, bipolar disorder and other neuropsychological and psychiatric problems.

Campbell-McBride believes that GAPS conditions are digestive disorders and that therefore through detoxification, lifestyle changes and a proper diet, the digestive tract can be healed so that it stops being the primary source of toxins in the body and starts becoming the source of nourishment it was intended to be.

"As more than 90 percent of everything toxic floating in our blood (and getting into the brain) comes from the gut," explains the GAPS website, "healing it will drop the level of toxicity in the body dramatically."

For comprehensive information about GAPS, how it develops and how to treat it effectively with a sound nutritional diet, start with www.gaps.me or www.gapsdiet.com.

The GAPS diet has as its basis the Specific Carbohydrate Diet (SCD), created by pediatrician Sidney Valentine Haas, M.D. Campbell-McBride took the diet several steps further, creating a full protocol for healing digestive disorders and subsequent behavioral, emotional, mental and psychological issues. The GAPS diet isn't simple, but to reverse the damage done by the toxins in your body, it can't be. The detoxification and diet consist of several stages and include avoiding starches and sugar for at least two years.

We reached out to Campbell-McBride for her thoughts on GAPS and its relation to OCD and trichotillomania.

"Any obsessive behavior and anxiety is a GAPS condition, in my opinion. When you examine the person and get a full picture, you find that they have many other obsessions and addictions, particularly to foods that harm them. Many people in this group suffer from various digestive problems, so they are clearly GAPS people. Many OCD patients don't have digestive symptoms, but when I put them on the GAPS program, they get better, which means that their GI tract was compensating for abnormalities."

OCD and Trich: Traditional treatment options

A majority of psychologists, psychiatrists and other specialists agree about the similarities but make a distinction when it comes to treatment methods. In addition to dietary changes, a psychologist may recommend a combination of therapy and/or medications.

"The use of the over-the-counter supplement known as NAC, or N-acetylcysteine, seems to help just about as well as the family known as SSRIs," explains Shryer. "The nonmedical treatment approaches for OCD are a combination of cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP). For trichotillomania, habit reversal training (HRT) along with CBT is the most agreed-upon treatment approach."

"Cognitive-behavioral therapy is not used in identically the same way for the two disorders," Weg elaborates. "In OCD, the focus is on exposure and response prevention, or facing fears, one level at a time, becoming desensitized to these fears and thus learning to live more normally without the anxiety that OCD generates. In trich, the focus is much more on managing the disorder through a series of interventions that are aimed at controlling the habit, helping people find different outlets for their urges to fiddle with something, and learning other ways to self-stimulate, manage their emotions better, deal with the tendency to be perfectionistic, and control the environmental triggers better."

"In the case of trichotillomania, habit reversal training has a lot of research support, particularly when paired with a newer talk therapy called acceptance and commitment therapy," Rego explains. "In terms of medications, currently there are none that are FDA approved for trichotillomania. Many doctors try the medications that are used for OCD, with varying degrees of success."

Dangers of misdiagnosis

If you are suffering from OCD or trichotillomania, it's imperative that you seek consultation and treatment from someone who specializes in these types of disorders.

"It is essential that those with any impulse-control disorder or with OCD receive treatment with someone excellently trained in CBT/ERP and HRT," cautions Shryer. "These disorders are also very frequently misdiagnosed as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and others, with grave consequences for the patients misdiagnosed. New research into treatments is looking into several new approaches, and one that will no doubt be highly controversial is the use of something called an opioid antagonist -- a medication used to treat drug addiction, which, if you think about it, may be a type of impulse-control disorder like trichotillomania. The drug being explored is something called naltrexone and has been used for years for opiate dependence."

The outlook for people with trichotillomania and OCD

Can OCD and trichotillomania be cured? That's up for debate. "They can be significantly improved, but we often don't say cured," says Hollander. "This can be an improvement in frequency, severity and time of symptoms, and this can result in improvement of level of functioning and disability, and quality of life."

The outlook is promising for both conditions, but most experts agree that there's much more research to be done.

"Some people stop completely with treatment," says Rego. "Others do not respond at all. One important thing to remember is that, to a degree, having some symptoms of either of these disorders is perfectly normal! So rather than think of these as things you either have or do not have, it is better to think of them as being along a dimension. In other words, it is perfectly normal to pull [hair] sometimes, and it is perfectly normal to have the occasional obsessive thought or do an occasional ritual. It is only when these symptoms begin to take a lot of time, cause distress, or interfere with social, home, or work/school functioning that they are considered disorders."

Don't let OCD or trich define you

Shryer warns about how these conditions can evolve throughout a patient's life. "OCD and the related disorders are chameleons, as they change and morph over time. Most people with these disorders initially hide them, as they are embarrassed to let others know. In families, a child with OCD often has the entire family wrapped up in their OCD, with begging for reassurance or having the whole house have to be just so to keep the child with OCD from having a meltdown. OCD and its related disorders are highly treatable when proper help is found. Currently, research has shown that from the time symptoms first are evident to the initiation of proper treatment and diagnosis, some 14 years passes by. I always wonder how much significant development in a child is affected by this long wait."

If you believe that you, your child or someone else close to you is suffering from OCD or trichotillomania, the first step is to seek out a professional with expertise in the specific field. Even though the exact causes of the disorders aren't completely known and despite the fact that it's impossible to guarantee a symptom-free life following treatment, OCD and trich are conditions that are becoming increasingly more treatable and manageable. Whether through medication, therapy or change in diet, millions of people have already found answers to these two disorders.

by: Kori Ellis

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