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Trichotillomania: NAC, GABA, tryptophan, inositol and zinc?

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This recent paper reports on a case study with NAC – Trichotillomania: a good response to treatment with N-acetylcysteine

Trichotillomania is considered a behavioral disorder and is characterized by the recurring habit of pulling one’s hair, resulting in secondary alopecia. It affects 1% of the adult population, and 2 to 4.4% of psychiatric patients meet the diagnostic criteria. It can occur at any age and is more prevalent in adolescents and females. Its occurrence in childhood is not uncommon and tends to have a more favorable clinical course.

The scalp, eyebrows and eyelashes are the most commonly affected sites. Glutamate modulating agents, such as N-acetylcysteine, have been shown to be a promising treatment. N-acetylcysteine acts by reducing oxidative stress and normalizing glutaminergic transmission. In this paper, we report a case of trichotillomania with an excellent response to N-acetylcysteine.

In this case report an 11 year-old male student had been pulling his hair out for 6 months. He had a relationship problem with this father and also suffered from asthma and dermatitis. He was started on NAC:

Treatment with N-acetylcysteine was initiated ​​(1200 mg/day for three months). The patient’s outlook improved dramatically, but complete remission was not achieved. We chose to increase the dosage to 1800 mg/day, which resulted in almost complete regrowth.

[From: Trichotillomania: a good response to treatment with N-acetylcysteine]

In this paper from 2009, N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study, it is reported that

  • Fifty individuals with trichotillomania (45 women and 5 men) received 1200-2400 mg/day of N-acetylcysteine or placebo over a 12-week period.
  • 56% percent of patients experienced “much or very much improved” hair-pulling symptoms with N-acetylcysteine use compared with 16% using the placebo, and the improvements were first noted after 9 weeks of supplementation.
  • Those in the N-acetylcysteine group did not experience any adverse events.

As you can see, the results with NAC are excellent but it can take 9 weeks and more before results are seen. For this reason, I would always also assess for low serotonin and low GABA and do trials of tryptophan or 5-HTP for low serotonin and GABA for low GABA. With any compulsive and obsessive behaviors I always consider inositol too and we may add this once the ideal dose of tryptophan has been found.

What is my rationale for recommending GABA, tryptophan, 5-HTP and/or inositol?

  • Since NAC works on reducing oxidative stress and normalizing glutaminergic transmission, GABA may help too and will certainly help to ease any physical anxiety that is being experienced
  • “Recommended first-line therapy for this psychiatric condition is administration of SSRIs” even though their efficacy is not yet proven in children – for this reason I’d recommend tryptophan or 5-HTP
  • Also “according to the psychiatric definition, these patients pull their hair because the act is gratifying and reduces tension, anger, depression and anxiety” (these are all signs of low serotonin and another reason to consider tryptophan or 5-HTP)
  • Because they offer relief right away, within 1-5 minutes

A complete nutritional and functional medicine work-up would be part of the plan too – to address the asthma and dermatitis (in the first paper above) and any other symptoms the person is experiencing and may be a contributing factor.

I’d expect the 56% of improved patients (in the second study above) to go to a much higher percent with all of the above approaches.

When I shared these papers on Facebook I was asked this question from someone who pulls out her eyelashes:

I pull my mascara off what is left of my eyelashes every night. I try my hardest not to do it but I find it impossible once I’ve touched my lashes. I’m about to start taking GABA and I was thinking about taking NAC. Would it be a bad idea to take both these amino acids?

This is my feedback: I always like to do one thing at a time and (as mentioned above) I would do the amino acid questionnaire and a trial of tryptophan and GABA first if the scores are high, and then look at adding NAC. If there are still some obsessive tendencies I would consider adding inositol. I am not aware of any issues with using all of these nutrients at once.

Someone else asked this:

Wouldn’t you deal with the psychological cause of it too – at the same time?

My response: Yes absolutely – if there is a psychological cause. But be aware that sometimes it’s purely nutritional or biochemical.

Another person shared that she only exhibits these behaviors when she’s stressed. Of course, the nutrients mentioned above, plus dietary changes, adrenal support, improving gut health and everything that I educate about, are important for reducing stress.

I also received some success stories. Here is one of them:

I’ve struggled with trichotillomania and dermatillomania (skin picking) for years and years. I underwent hypnosis that was extremely effective. When I added in zinc (after reading your book) the urge is almost completely gone. Thank you!

Keep in mind that zinc is a co-factor for making serotonin and GABA, is important for overall adrenal support and stress reduction, is needed for glutathione production and works as an antioxidant. I’d actually love to see these studies repeated with zinc alone.

And then I received this message from someone else:

I’m messaging you my answer about NAC because it’s slightly embarrassing I’ve always had terrible acne and always have picked at it obsessively and could not stop until I was given some supplements for PCOS which happened to contain NAC. To my surprise I lost the compulsion to pick at my skin, something I had never thought possible!

How wonderful for both of them! I always appreciate feedback like this and have to say nothing is too embarrassing to share (especially if it helps someone else).

Have you used NAC with success – with trichotillomania or dermatillomania (skin-picking) or even nail-biting? Or some other compulsive behavior?

What about GABA or inositol or tryptophan or zinc (or something else) for the same purpose and/or for additional emotional and stress-reducing support?

Magnolia officinalis and Phellodendron amurense (Relora®) lowers cortisol and reduces stress and anxiety

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magnolia

I recently blogged about the Seriphos reformulation: Seriphos has been reformulated – what do I use to lower high cortisol? and promised to share additional products that could provide similar benefits. When someone in my community shared that she uses Relora® with success I started to look at the research and I am very encouraged.

This 2013 study: Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects

assessed salivary cortisol exposure and psychological mood state in 56 subjects (35 men and 21 women) screened for moderate stress and supplemented with a standardized/patented MP [Magnolia bark extract and Phellodendron bark extract] combination (Relora®, Next Pharmaceuticals) or placebo for 4 weeks.

After 4 weeks of supplementation (500 mg /day, with 250 mg at breakfast and 250mg at dinner) these were the results seen in the Relora® group (compared to the placebo group):

  • salivary cortisol exposure was significantly lower (18%)
  • lower overall stress (11%)
  • lower tension (13%)
  • less depression (20%)
  • less anger (42%)
  • less fatigue (31%),
  • less confusion (27%)
  • and significantly better mood state parameters (11%) and vigor (18%)

relora-effect-chart (table from Effect of Magnolia officinalis and Phellodendron amurense (Relora®) on cortisol and psychological mood state in moderately stressed subjects)

Each of the components in Relora® have been shown to be beneficial for controlling stress and anxiety, with the combination proving to be even more effective:

Extracts of Magnolia officinalis bark and its active constituent, honokiol, have been studied in animal models with comparable anxiolytic activity to diazepam (a benzodiazepine anxiolytic used to treat anxiety), but without associated side effects such as sedation.

Berberine, a constituent of the Phellodendron extract, has also demonstrated a significant anxiolytic effect in rodent stress studies.

The combination of magnolia plus phellodendron appears to be even more effective in controlling stress/anxiety compared to either herb used separately.

The study concluded that:

daily supplementation with a combination of Magnolia bark extract and Phellodendron bark extract (Relora®) reduces cortisol exposure and perceived daily stress, while improving a variety of mood state parameters, including lower fatigue and higher vigor.

These results suggest an effective natural approach to modulating the detrimental health effects of chronic stress in moderately stressed adults.

An added bonus is that there were no adverse events or side effects reported.

I’d like to note that the study does report that it was funded by the manufacturer of Relora® (Next Pharmaceuticals) and conducted by SupplementWatch.

A related study, also funded by the manufacturer: Effect of a proprietary Magnolia and Phellodendron extract on stress levels in healthy women: a pilot, double-blind, placebo-controlled clinical trial indicated that

Relora may offer some relief for premenopausal women experiencing mild transitory anxiety.

In this study, the participants used 250mg Relora® 3 times daily for 6 weeks and although mild anxiety was reduced, no changes were observed in cortisol levels. Clearly more research is needed and as with any nutrient, there will be the fact that you may benefit from it and someone else may not.

I’m encouraged enough by the research to begin recommending this product for high cortisol and the anxiety caused by the high cortisol. This will of course be done in conjunction with all the other approaches I use: real whole food, quality animal protein, eat to control blood sugar, no gluten/sugar/caffeine, addressing gut health, using GABA/tryptophan and the other amino acids as needed and addressing low levels of zinc, vitamin B6, vitamin D, iron if necessary. Additional adrenal support would include extra vitamin C and pantothenic acid, a B complex and possibly rhodiola.

Have you used Relora® with success either personally or with clients/patients? Has it lowered salivary cortisol levels? Has it helped with stress and anxiety?

If you had been using Seriphos to help lower high cortisol and reduce stress and anxiety, and decide to use Relora® please let us know how effective it is for you.

Update November 18, 2016: I emailed Interplexus asking if they will be bringing back the original Seriphos formula and received this message from them:

Yes, the information is correct we will be returning the previous formula of Seriphos and are expecting to have it late November, unfortunately we do not have a completion date as of yet so the estimated time frame is not a guarantee. It will be the same formula as before and we will also manufacture a Phosphatidylserine standalone product in the future. If you have further questions or concerns feel free to contact, and you’re also welcome to check on the status of Seriphos periodically.

Update January 20, 2017: Seriphos Original Formula is back and you can read more about it here 

 

Tryptophan for PMS: premenstrual dysphoria, mood swings, tension, and irritability

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tryptophan for pms

In a study published in 1999, A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria, tryptophan was found to reduce symptoms of PMS when used in the luteal phase or second half of the cycle (i.e. after ovulation):

37 patients with premenstrual dysphoric disorder were treated with L-tryptophan 6 g per day, and 34 were given placebo. The treatments were administered under double-blind conditions for 17 days, from the time of ovulation to the third day of menstruation, during three consecutive menstrual cycles.

They looked at dysphoria, which is defined as a state of unease or generalized dissatisfaction with life, plus mood swings, tension (and anxiety), and irritability and they found a 34.5% reduction of symptoms with tryptophan compared to 10.4% with placebo.

The paper concludes:

that these results suggest that increasing serotonin synthesis during the late luteal phase of the menstrual cycle has a beneficial effect in patients with premenstrual dysphoric disorder.

Let me share what I see with the women with PMS that I work with:

  • This is very typical when I’m working with someone with PMS and anxiety and other mood symptoms. It typically takes 2 to 3 cycles for an amino acid like tryptophan to have an impact on PMS itself. But it does typically start to work right away on the less severe anxiety and mood symptoms that may also be a factor during the rest of the month.
  • I don’t start with 6g per day of the tryptophan but rather have each person do the amino acid questionnaire, review the precautions and do a trial of tryptophan, increasing as needed to find the optimal amount for their needs (you can read more about this here on anxiety and the amino acid overview
  • We often find that adding GABA helps too, as this supports progesterone production
  • Many anxious women I work with also have pyroluria or signs of low zinc and low vitamin B6 and adding these nutrients, together with evening primrose oil, provide additional hormonal support (and help with the social anxiety).
  • Other factors to consider with PMS: low total cholesterol (as cholesterol is needed to make hormones), gluten issues, adrenal function and blood sugar control, gut health and the microbiome, and liver support
  • And finally, we can’t forget diet and need to switch to eating a real whole foods diet free from sugar, gluten and caffeine. Coffee and chocolate in the second half of the cycle can be especially problematic for many women

Together with the tryptophan and the above approaches (if needed as we are all so different), it’s not unreasonable to get the reduction of symptoms from 34.5% (as seen with the tryptophan) down to 100%. It breaks my heart when I hear women think they have to live with PMS symptoms when they don’t have to!

Have you used tryptophan for PMS? Do you take it all month or just in the 2nd half of your cycle? What about other changes that have helped: GABA or liver support or quitting caffeine? Or something else?  Please share.

GABA, the calming amino acid: products and results

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gaba

GABA (gamma-aminobutyric acid) is a calming amino acid that when taken orally works to relax, calm, ease anxiety and social anxiety, quiet the mind, help with sleeping better, reduce neck tension, remove uneasiness and worry, and give hope.

Even though we have recent research that it does work we still hear the naysayers saying “why bother to take GABA, it just doesn’t work unless you have a leaky blood brain barrier.”  

The blog post from last week – GABA, the calming amino acid: expert opinions generated so much interest and feedback, so I’m sharing some of this feedback so you can hear first-hand from people who have tried various GABA products. I’ve corrected typos but what follows is their actual feedback.

As you’ll see, it does work extremely well for many people. You’ll also see that there are many different products that work well. I’m sharing all of them even though I have my favorites.

There are some people that don’t benefit from it.   I share some questions below and you may want to go through these if GABA doesn’t work for you.

Here is the feedback for many of the products that were mentioned. It starts with products I like/recommend and have experience with.

Allergy Research 200mg of Zen product contains 500mg GABA and 200mg Theanine 200 mg per 2 capsules. Dee likes the instant calm and compared how it worked as well as Xanax had worked for her in the past:

I have taken Xanax in the past for panic attacks. My functional medicine doctor suggested this product as I wanted a natural product. I was amazed how it works just like the Xanax did – instant calm feeling within 10 mins of taking 2 capsules. I use them as needed when I am having heightened stress and anxiety.

I’ve had a number of clients who really liked this GABA/theanine combination. This product together with Nutritional Fundamentals GABA-T SAP, also a GABA/theanine combination, comes highly recommended by me. They both contain a small amount of GABA, the theanine works really well with the GABA and the capsules, when opened on to the tongue, are pleasant tasting.

Source Naturals GABA Calm was only mentioned once which surprised me! Together with GABA/theanine combination products above, it’s the GABA product I use most with my clients because it’s sublingual, easy to take, great tasting and works so exceptionally well. It contains GABA, taurine and glycine, and a small amount of magnesium and tyrosine.   The tyrosine means this product cannot be used if you have melanoma, high blood pressure or bipolar disorder. You can see all the amino acid precautions here.  

Country Life GABA Relaxer contains GABA, taurine, glycine, inositol, niacin and vitamin B6. Melissa shares how much it helped her:

After my first panic attack I thankfully found Julia Ross’s work. I began taking 250 mg GABA every night. That really helped! Now a few years later I don’t need it every day, and I take a half pill during my cycle anxiety – more like uneasiness and over worried now, just as needed. I then heard you speak Trudy and share more info, bought your book, and put into place supportive lifestyle changes, and I have my life back. GABA is a great supplement for some of us!

I really like this product and used it when I worked with Julia Ross in her clinic. It was also a product I personally used when my anxiety and panic attacks started. I used this at night and GABA Calm in the day.

Seeking Health GABA 500mg was mentioned by a few people. Sherie said she loves it and takes it 2-4 times a day (she also takes theanine). This is what she shares:

It helps lower my overall anxious feeling all day (anxiety for no reason). I just started increasing the dose slightly and am beginning to take it a few times a day to help with social anxiety. I have lifelong problem of severe blushing and sweating from social anxiety and need that to stop.

I asked her if she’s looked into pyroluria and she said hadn’t but said it fits her to a T so this would be the next thing for her to address. It’s seldom just one underlying cause and the great thing is that the zinc, vitamin B6 and evening primrose oil of the pyroluria protocol help us make more GABA (and other brain chemicals).

I’d like to add that 500mg can be a high amount for many anxious individuals so it’s not something I typically start with. I like to have my clients start on either Source Naturals GABA Calm (which has 125mg of GABA) or one of the GABA/theanine combination products that have around 200mg GABA, and increase as needed.

I recommend GABA over pharmaGABA because over the years I’ve simply found more people seem to do better on GABA. But clearly, pharmaGABA does work for some individuals.

Thorne PharmaGABA-100 contains 100mg pharmaGABA and Cheryl shares how this product works great for her:

I usually only take it at night only when I know I need it, to quiet my mind and relax my body so I can sleep better. I need it less now because I am following MTHFR and adrenal fatigue supplement protocols and diet.

PharmaGABA Stress Relax from Natural Factors is another pharmaGABA product and Gina chewed two 100mg tablets and said this is how they helped:

It changed my life in minutes! Take it every day now. No more hopelessness!

April also finds that the Natural Factors pharmaGABA works great for her:

I take 100mg a day for about a week and then take time off until I feel I need it again or I feel I have too much. I know if I take too much, I get spacey, unmotivated, depressed even. Helps a ton with head/neck tension and anxiety.

I just want to add that this product does contain sugar (3.5 g with 300mg pharmaGABA) and fruit flavors (which sensitive folks may have an issue with) so this one would not be high on my list of recommendations. But if it’s the only one that works for you then go for it!

Quicksilver GABA is a liquid that contains GABA, theanine and sunflower lecithin, and is promoted as being a very effective form of delivery. Candy shares:

It is a liquid that I keep in the fridge. I squirt and leave it under my tongue for a couple minutes. It has been helpful.

I look forward to hearing if you or your clients have found this to be superior to other forms. I’d like add that it’s not suitable for children and alcoholics due to the ethanol.

A few other products were mentioned (neither of which I’ve had feedback on until now):

  • Source Naturals Theanine Serine which has GABA, theanine, taurine, magnesium and holy basil.
  • Pure Tranquility from Pure Encapsulations contains GABA, theanine and glycine. One person was suspicious that it was triggering migraines. I wonder if it could be related to one of the other ingredients like the natural apple flavor, potassium sorbate or purified stevia extract?

GABA won’t work for everyone and a few people said GABA didn’t work at all.

Karen appreciated me dispelling the blood-brain-barrier-GABA myth and pointing out that phenibut is not GABA. But GABA didn’t work for her and she shared this:

I have tried GABA, my mother swears by it and my husband uses it. It has a calming effect on me, but I like holy basil better.

I checked with her and she hasn’t tried it sublingually, which I find to be more effective for most of my clients. This could be something like Source Naturals GABA Calm or one of the GABA /theanine combination products opened on to tongue and held there for 1-2 minutes.

GABA also didn’t work for Sheri and she said:

I’m one of those folks for whom it seems to do nothing. Zip. I have found some relief using niacinamide, however.

Dr. Jonathan Prousky really likes niacinamide for anxiety and I find it helps a lot with my clients who have runaway thoughts and paranoia.

If GABA doesn’t work for you that’s fine, not everything works for everyone. But if you really feel GABA should work for you or feel you need additional support for your anxiety then I wouldn’t give up and ask these questions:

  1. do you have an underactive thyroid (amino acids may not be as effective)
  2. did you take it sublingually (it’s often more effective taken this way)
  3. did you take it away from protein (it needs to be taken this way)
  4. how much did you take (amounts can vary by person)
  5. do you have low GABA symptoms/physical anxiety (it will only work if you do) or
  6. are you taking a benzodiazepine (for some people on benzos many supplements don’t work or are just too much for them)

Here is the facebook post if you’d like to read the whole discussion.  I’d like to thank everyone who contributed to this great discussion!

I’ll cover phenibut (which is not GABA) in a future blog post. It’s always a hot topic and is not something I recommend but more on that next time.  

A heads up that I’ve shared links to the products that were mentioned so you can check them out. Some of the links are from Emerson, the online distributer I use. If you’d like to order from them you can find out how to set up an account here.

Now I’d love to hear from you. Have you used any of these GABA products (or had your clients use them) with good results? How much did you/they use and what were the results?

If GABA doesn’t help do you say “yes” to any of the 6 above questions?