Trich and meds - Dr. Carol Novak

Info supplied by Pamela

Here are the notes from a session at this year's TLC retreat on
meds and their use in treating TTM. These notes from the session were
originally written by Doctor Novak who is experienced with treating
TTM'ers, (with possible typing errors by writer) 

Please note she doesn't suggest staying on a med forever if it isn't
helping with the pulling. Also note, she does suggest having a very
clear idea of what the purpose is of the med. So at the very least,
anyone can print this out and share it with their doctor - and ASK


Carol E. Novak, M.D.
Regions Behavioral Health
2345 Ariel St. N.
Maplewood, MN 55109 

Medications have a role 
in the treatment of trichotillomania, although for most people
medications alone are not enough in the long run. No medication has
been adequately studied for the long-term treatment of
trichotillomania and information is being gained through clinical
experience and further research. Medication has been
"over-sold" as a treatment for trichotillomania. There is no one
classification of medication that is distinctly successful in treating
trichotillomania to a significant degree, to a significant percentage
of people -- or with long-term success, anyhow. A multitude of
medications have helped a small percentage of hair-pullers, but none
of them are predictably more effective than the others in most
individual cases. This sets trichotillomania apart from other
neuro-biological disorders psychiatrists commonly treat such as
depression and obsessive-compulsive disorder. Medications are not a
specific Rx for trichotillomania. While it is possible there is a
specific abnormality in the biochemical state of the nervous system of
hair pullers, it's unlikely -- and in any case we haven't found it

When medications are helpful in reducing pulling, patients
usually describe either a reduced urge to pull, more awareness of
their pulling, or a new ability to resist the urges. These effects can
make behavior therapy more approachable and easier. Occasionally
someone will report that on medication he or she enjoys a complete
cessation of the desire and habit of hair pulling altogether.
Erroneous preconceptions about trichotillomania may
lead to poor medication management. The most common is that
trichotillomania is biologically related to obsessive-compulsive
disorder (OCD). There is little evidence for this, and more for it's
not being closely related. Because of the superficial similarities
between trichotillomania and OCD, the specific anti-obsessional
medications, serotonin re-uptake inhibitors (SSRIs), have been most
frequently tried in the treatment of trichotillomania. As of today
only a few well-designed research studies have been performed using
SSRIs for trichotillomania and they have been contradictory as to
whether there is any measurable effect. What we see clinically is that
some patients' hair pulling gets better, some get worse, and some are
unaffected by the medication. There may be a remarkable, immediate
response that may fade over weeks or months. This may even be a
"placebo" response that would be the same as to a sugar pill. As a
whole, these medications are safe, and are worth trying as some
patients receive long-term benefit. 

No other type of
medication has been carefully studied for treatment of
Trichotillomania in a scientific manner. There are always case reports
and letters to the editor about the success of one medication or
another in one or two patients, but since no one reports failure to
respond to a medication in that manner, these reports cannot give a
balanced view. 

There are a number of mistakes commonly made by psychiatrists in treating trichotillomania.
For example: 

* No attempt is made to treat the condition with behavioral therapy
first, even when the hair puller is otherwise psychiatrically healthy.
 Unless the patient is unwilling or unable to undergo behavioral
therapy, this should be done before considering medications. 

* Too high an expectation is placed on medications, particularly SSRIs,
in the treatment of trichotillomania. This creates multiple problems,
for example: - -Doses are pushed higher and augmentation strategies
are stressed, creating needless side effects - -Four or five similar
medications in the same category are tried before deciding to try
something else which wastes time, energy, and hope. - -Since hair
pullers have usually experienced hopelessness about ever recovering,
they tend to feel more profoundly discouraged than ever if a
confidently-promoted treatment fails. - -The psychiatrist gets
frustrated and conveys to their patient that their trichotillomania is
too difficult to treat, creating more hopelessness and shame. 

* No criteria is set for whether the medication is helpful, so the
right questions are not asked, such as: Is it helping a co-existing
anxiety or depressive disorder? Is it helping to reduce frenzied
urges, or allowing more awareness of behavior? Any of these effects
alone may be enough to make the medication worthwhile taking if
behavioral therapy can then be used with greater success. It is
important for both doctor and patient not to focus just on the amount
of hair that's being pulled. 

* Medications are not tried long enough or at the proper dose. Some of
the medications require a trial of at least eight to twelve weeks at
the therapeutic dose or maximum dose tolerated to know if it is going
to work for an individual patient. If it is not helping, it should be
discontinued. If it is only partially helpful, another medication may
be added to it. This should be done with careful supervision by a
psychiatrist as there are potential medication interactions.

The "try-it-and-see-if-it-works" approach is generally what must take
place. Which medication to try first depends on potential risks or
side effects, history of effectiveness for trichotillomania, and other
symptoms or disorders a hair puller may be experiencing. As there is
no specific medication treatment for trichotillomania, a rational
approach is to treat any co-existing conditions and see if hair
pulling improves. 

Examples of medications used for other conditions that have also helped reduce hair pulling in
some pullers are as follows: 

* Obsessive-compulsive disorder - serotonin re-uptake inhibitors such as fluoxetine (Prozac),
clomipramine (Anafranil), paroxetine (Paxil), citalopram,(Celexa),
fluvoxamine (Luvox), or sertraline (Zoloft). Some cases respond to
monoamine-oxidase inhibitors (Nardil or Parnate). 

* Depression - serotonin re-uptake inhibitors (see examples above), venlafaxine (Effexor),
buproprion (Wellbutrin), nefazodone (Serzone) or tricyclic
antidepressants (e.g. Elavil, Norpramin), and monoamine-oxidase
inhibitors (e.g. Nardil, Parnate). 

* Generalized anxiety disorder - benzodiazepines (e.g., Valium, Klonopin, Xanax),
hydroxyzine (Vistaril), or buspirone (Buspar). 

* Attention deficit-hyperactivity disorder - amphetamines (e.g. Ritalin, Cylert,
Adderall) or clonidine. 

* Tourette syndrome - neuroleptics 
(e.g. Risperdal, Zyprexa, Geodon). 

* Bipolar disorder, - lithium (Lithobid, Eskalith), valproate (Depakote), or other
anti-seizure medications (Lamictal, Neurontin, Topamax). Blood tests
must be performed at intervals when using lithium and valproate. Blood
levels on the high end of the therapeutic range are generally
required, in my experience. 

* Alcoholism - naltrexone (ReVia) is sometimes effective - seems to take the enjoyment out of

Miscellaneous aspects of medication use in treating trichotillomania: 

Certain medications
may make hair pulling worse in certain individuals, just like
caffeine. Anything likely to increase physical tension may exacerbate
the symptoms. This includes SSRIs, amphetamines, and thyroid
medications -- especially when started too rapidly. Failure to warn
patients of this possibility may impair the doctor-patient

* Topical medications to treat skin itching, tingling roughness, flaking or scabbing may be
helpful as all these conditions may trigger pulling. Over-the-counter
preparations such as peppermint or tar shampoo or others (e.g. Nioxin,
Scalpasin, Sea Breeze facial astringent) useful in some cases by
reducing itching or providing a tingling sensation. Eye ointments can
be soothing. Doxepin cream (Zonalon) has been helpful for itchy
eyelids. Betamethasone valerate (Luxiq), fluincinolone 0.2% solution 

* Some medications may be helpful in a temporary or situational manner. For example,
medications such as trazodone (Desyrel) may be used to help promote
rapid onset of sleep in the hair puller who pulls as they are trying
to fall asleep. Cyclical use of SSRIs premenstrually may alleviate
worsening of pulling associated with PMS. Tranquilizers such as
diazepam (Valium) or alprazolam (Xanax) can be used for intermittent
tension or emotional crises.