A Theory of Trichotillomania

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    * Malassezia Health Quest *

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TRICH, FOOD, AND SKIN CARE BY JR KENDER

Here’s some info about hairpulling, particularly about nutrition, skin care, and yeast. This compilation was orginially created in July 1997, and should be accompanied by an updated article, “A Theory of Trichotillomania”, written in August 2008, which focuses more on the possible chemicals involved. Please write me if you have not received it. As of July 2012, more than 600 people (including more than 100 children or adolescents) have been reported to me via email as obtaining from “good” to “total” relief, from at least one week to over eight years, using some or all of these techniques. I have used them since July 1992, and (except for experiments with new things and an occasional deliberate dietary lapse) I have been pull-free for that time. I have also received several reports that skin-picking and even nail-biting are also responsive to these methods, and that five dogs have stopped their compulsive paw-licking similarly. Also included is some info about the TTM mailer, if you haven’t heard of it. And, at the very end of this message, in a fine FAQ about TTM written by Geoff Dean, is some info about the TTM Parents group (if you are the parent of a puller), and some info about the TTM Teen group (if you are a teen). For some additional info on nutritional means of TTM control posted by people other than me who were interested in it, go to their web pages at: http://home.intekom.com/jly2 http://www.geocities.ws/ttmlarchive http://www.trichotillomania.co.uk/trichotillomania_research/diet.htm Please let me know if I can help you further. If you do try a nutritional approach to TTM, please let me know your results so that we all can learn more about this disorder. Thank you, John

RICH, FOOD, AND SKIN CARE (Submitted to the TLC newsletter “InTouch” in August 1999, so references to dates and times have to be adjusted somewhat.) by John R. Kender and Michael J. Grant In this letter, we outline some observations about several simple at-home procedures that have proven to be helpful to many pullers. These procedures involve various foods and skin care practices. We guess that for many people, hairpulling is aggravated by a particular biological cause that these practices help to address. At the end of this letter, we list postal and email addresses where you can get more detailed information about our ideas and methods. 1) Who We Are and What We Have Done Let’s first introduce ourselves. One of us, John, is a university professor who pulled eyebrows for 30 years, but is currently enjoying a more than seven year remission which he attributes to dietary control. For the past four years, John has run the TTM remailer program, a private internet email exchange about trich, which has about 400 subscribers and participants. John has spoken at two TLC retreats about his experiments with nutrition and its effect on trich. The other of us, Mike, is the father of a hairpuller. He and his daughter, Terri, have experimented with several skin and hair treatment approaches to hairpulling. Mike started and is an active contributor to an email support group for PoPs (Parents of Pullers) on the internet. Mike has attended several TLC retreats, at which he has demonstrated on multiple volunteers his various scalp care procedures, which use only non-prescription preparations. The two of us, in our combined 12 years of experimentation, have observed that for many people some of the trich experience is directly affected by diet and by skin condition. By continuing to use the internet to gather the experiences of other hairpullers, and by combining these with our own experimentation, we have become convinced that for many people it is possible to achieve significant amounts of relief and control by taking some straightforward measures with regard to nutrition and skin care procedures. Although our observations have not yet been medically verified and our guesses as to their biological roots remain unproven, in the past four years we have gathered reports of significant improvement from an encouragingly large number of people. We aren’t selling anything–there is really nothing to sell–and we realize that what we have noted does not work for all forms of trich. But we offer them to the readers of InTouch, who can try them for themselves as they see fit. Please be aware that we are not medical doctors and that anyone considering these approaches should check with their doctor first. We will describe first some nutritional means, then some skin and hair care means, and then suggest a possible explanation for why these two seemingly unrelated approaches may both be ways of attacking a common biological cause. If anyone then wishes further information, we list where we can be reached. 2) Nutrition and TTM (John writes) Seven years ago, by keeping careful records of what I ate, I noticed that certain foods tended to increase my urges to pull. By avoiding those foods, I began what is now a seven year remission: no urges, and no hairpulling. Numerous experiments, some even with my dog who had a problem with compulsive paw licking, confirmed that some foods were “bad”, meaning that they increased hairpulling urges and sometimes increased an itchy “this hair is out of place” feeling. I wrote in a previous issue of InTouch four years ago about some of these experiments. Since then, based in part on written and email reports from other pullers, the list of “good” and “bad” foods and of other food-related techniques has been refined, and there is now a better understanding of the strengths and weaknesses of this approach. As of the Summer of 1999, over 100 people, including about a dozen children and adolescents, and several dogs, have reported or have been reported as obtaining from “good” to “total” relief, for a week to years, using some or all of these techniques. More than two dozen of these pullers report from two months to three years’ worth of benefit. At the same time, the number of people reporting increased urges and hairpulling after eating “bad” foods has been so numerous (on the order of several hundred) that I have stopped keeping track of them, even electronically. On the other hand, we have received a few reports of earnest attempts at dietary control measures that have failed, most of them appearing to be from lash pullers. According to several polls we have taken on the TTM remailer list, we have gathered the following information. About one-half of pullers who reponded to the polls do experience strong hairpulling reactions to one or more of sugar, caffeine, cola and/or chocolate, egg yolks, legumes (peanuts, mostly), or fatty fish (tuna, mostly). First preceded by an growing internal feeling of agitation, the hairpulling urges begin increasing a few hours after eating sugar or caffeine, or about one to two days after eating the others. The increased urges usually peak after about twice that amount of time. Often these urges, particularly the ones due to egg yolk and legumes, take as much as a week to fully subside down to their usual level. Although stress aggravates such food-related pulling, it is not necessary for it: after “bad” foods, people report they pull regardless of their mental state. The polls have indicated, however, that scalp and/or body pullers seem to differ somewhat from lash and/or brow pullers. Scalp and/or body pullers seem to be food-sensitive to the extent that their hairpulling is worse during Premenstrual Syndrome (“PMS”)–which tends to be experienced as increased depression–and to the extent that they “trance out” while hairpulling. Lash and/or brow pullers, however, seem less food-sensitive and more business-like in their hairpulling. Their PMS tends to be experienced as irritation, and their hairpulling is more focused; further, their hairpulling may be more related to the eating and drinking of vitamin-D enriched dairy products. But both kinds of pullers in general tend to be far more likely than average to have allergies, to have sweet tooths, and to have an unexpectedly extensive experience of being around furry pets. Most surprisingly, the polls indicate that pullers tend to have an unusually high number of “trichy” dogs and cats. If people are interested in seeing if their hairpulling is food-related, there is a simple test: they should simply eat as many peanut M&Ms or Reese’s peanut butter cups as they can stand at one sitting (sugar! chocolate! legumes!), washing them down with Coca-Cola (cola! caffeine! more sugar! or aspartame, which is just as bad!). Alternatively, especially for children, it could be peanut butter and jelly sandwiches with chocolate milk. If in two days there is a noticeable increase in hairpulling urges, then they could consider abstaining from “bad” foods. Unfortunately, it appears to take from 30 to 40 days to purge the gut and skin of their bad effects fully, and it also seems to take several attempts and about a year of trying for most pullers to get there. People report that avoiding sugar and caffeine, which act more quickly, is the most rewarding way to start. The “bad” food list given above reflects the worst experiences of many people, but it is not complete. The full list is available on written request (it’s too long to explain here). It includes, among other things, concentrated natural sugars, tomato seeds, soy products, yams, MSG, and ibuprofen. However, there are a few “good” foods, which partially counteract the “bad” ones. They include garlic, most acidic fruits, dry red wine, unsweetened yogurt, and a chemical family called gluconates. Additionally, certain hair care products and certain skin creams carry chemicals that appear to be similar to those involved with the “bad” foods. In particular, food-sensitive pullers report that hair conditioners with stearyl alcohol or other fatty alcohols should be avoided. Similarly, there have been reported a few “good” food-related chemicals that can be applied to the skin and hair to stop them from itching, among them alpha hydroxy acids (“AHA”s, sometimes called “fruit acids”), and a home-made hair rinse made from a mixture of acetic and boric acids (essentially, dilute vinegar and eye wash). We have a theory as to what may hold these unusual collections of “good” and “bad” foods and chemicals together, which we will briefly explain below. 3) Skin and Hair Care and TTM (Mike writes) My continuing interest in the relationship of certain types of scalp conditions and TTM has been an outgrowth of my daughter Terri’s experience which began more than five years ago. At the time Terri was diagnosed with TTM, she had already been under a dermatologist’s care. She had what was thought to be spontaneous hair loss due to alopecia areata, as well as due to an inflammatory condition of the scalp that had progressed to the point of forming sores which she would want to pick at due to their intense itching. The condition of Terri’s scalp was thought to be a medical consequence of her primary impulse control disorder. In the years that have followed, through Terri’s experience as well as my own participation with children and adults in the TTM community, I discovered a group of hairpullers who share the same scalp symptoms. Further, observing these scalp conditions over time, I have noticed that in many instances the scalp conditions preceded, not followed, the hairpulling. The pulling appeared to be triggered by the inflammatory process, much like the scratching behavior most of us have in response to conditions such as mosquito bite, poison ivy, or athlete’s foot. I speculated that it might be possible in some instances to reduce or eliminate the hairpulling behavior simply by alleviating the inflammatory trigger. The opportunity came when Terri consented to have her head shaved for medical reasons to help resolve her on-going scalp problems. Her urge to pull seemed to disappear literally overnight, an observation agreed with by the medical professionals attending her. The conventional explanation was that this had removed a significant trigger and prevented the self-reinforcement of pulling behavior. But the conventional explanation did not explain the suddenness with which the urge seem to be extinguished, nor the experimental result that the relief only came when the scalp was wet-shaved with a blade, and not with a surgical clipper which cut the hair to virtually the same length. At the same time, the razor shave was observed to relieve the inflammation, whereas the clipper shave noticeably exacerbated the redness and itching. After reading an abstract John posted to the remailer describing a protocol for treating a particular inflammatory process possibly related to a biological cause, I noted that there were some similarities between the article’s treatment and what Terri was receiving in the head shave. The article’s treatment soaked the scalp with a soapy lather beneath hot water-saturated towels. This was exactly the preparation done prior to using the razor. As an experiment, we did the soak but didn’t use the razor. Terri experienced nearly the same degree of relief as if her head had been actually shaved, and it alleviated the inflammation of her scalp as well. This strongly suggested it was not the cutting of the hair that provided the relief–the clipper did that without good effect–but rather it was the preparation regimen itself. We also noted with some interest that letting her scalp get some sun also helped; in fact, an accidental sunburn gave about four days free of itching. On the possibility we were dealing with a dermatological disorder, a receptive dermatologist prescribed the antifungal shampoo Nizoral, then available only by prescription. And based on the article, we substituted Cuticura soap, which is similar to the liquid barber’s soap we were using, but which also contains an antiseptic. Over time, we found that the optimal regimen was to alternate the Cuticura with the Nizoral shampoo on a daily basis. It appears that the two are good compliments to one another. Cuticura is anti-bacterial, Nizoral is anti-fungal. Cuticura is a soap which is milder but leaves a residue which can build up. Nizoral is a detergent which removes the residue and prevents the build-up. Some other preparations we tried were pure aloe vera gel, benzoyl peroxide, and camphor. Terri’s barber suggested the aloe vera gel as a skin conditioner to soothe and protect her scalp after shaving. She also tried a lanolin-based product, but that resulted in intense itching within 30 minutes of being applied to Terri’s scalp, whereas the aloe vera gel seemed to help reduce what itching there was. The benzoyl peroxide worked well for an intense itching area where there was inflammation and a distinct raised area on the skin, but it was very drying to the scalp and it bleached the emerging hair. (Along the way, I discovered that benzoyl peroxide also stopped, within a week, one of my own year-long bouts with skin picking.) But with further experimentation we found that camphor spirit topically applied would alleviate itching for several hours without adverse effects. Camphor is also contained in Sea Breeze astringent, which we found useful and mild enough for general routine application. What I believe to be a significant discovery happened while Terri was having her head shaved on a regular basis. To alleviate the “shine” which my daughter did not like, the barber applied to her scalp a mineral clay masque, made principally from bentonite, to help absorb the excess oils. As the water evaporated from the clay, contrasting dark areas would appear in proportion to the amount of oil that had been absorbed. (We later found a formal clinical study in which bentonite clay was also used to collect skin oils from patients.) An astonishing phenomenon slowly began to appear. Terri only pulls from highly selective areas that have an intense itch-like sensation. After shaving her head with the straight razor, these areas could no longer be distinguished from the rest of her head. But the contrasting dark areas of the clay masque exactly outlined those “hot spot” areas which were otherwise indistinguishable on her scalp–even when they were examined by an experienced dermatologist under magnification. I believe this to be a physical demonstration of the correlation between hot spots and excess sebum, present even six months after the cessation of all pulling. In an attempt to replicate the observations I made with Terri, as well as to do a preliminary investigation of a possible biological cause, I made up kits with various over-the-counter preparations and skin care products for some of my email TTM friends. Included were the Cuticura soap, as well as several other types of soaps we had used. Also included were a triple antibiotic, a mild steroid anti-inflammatory (hydrocortisone), an antihistamine (diphenhydramine), as well as an anti-yeast product (miconazole nitrate). Only general cautions were provided, together with the instructions to try all the products and decide which ones worked the best. At least half of those who received the kits were not associated with John’s remailer, and had not heard of any possible search for a biological connection with TTM. The antiseptic Cuticura was by far the preferred cleansing agent over very similar soaps without the antiseptic. Sea Breeze astringent for general overall application, and camphor spirit for intense hot spots, were also widely reported as being helpful. The antibiotic ointment seemed to have no effect, nor did the antihistamine ointment, but the surprisingly effective agent, widely and independently reported to alleviate the itch and pulling urge, was the antifungal miconazole nitrate 2% cream. At this point, I can recommend a specific program for shampooing, massaging, and treating the hair, skin, and scalp. The full program is available on written request (it’s too long to explain here). We have a theory as to what may hold these unusual collections of “good” and “bad” skin treatments together, and what may relate them to the “good” and “bad” foods and chemicals, which we will briefly explain below. I have had the privilege of demonstrating these techniques at the last two TLC Retreats, and I would like to thank those individuals who participated. They helped to advance our understanding and to make this letter possible. I would also like to thank Jo Ann, our family barber, and most of all, my daughter Terri, for her patience, understanding, and courage. 4) A Possible Theory of Some TTM (both of us) Putting all these observations together, we guess that some people pull because of a local skin irritation caused by chemicals released into skin grease by a skin micro-organism. Specifically, we guess that some (about 60% of) hairpulling is aggravated or caused by a local allergic reaction to the enzymes and/or fatty alcohols produced by a normally innocuous skin yeast, Malassezia. Nearly everyone has this skin yeast, particularly in hair follicles of the lashes, brows, and scalp. But what may make pullers different is that their immune system reacts more strongly to its presence. From this perspective, hairpulling is like sneezing: the body is attempting to rid itself of an allergy-causing irritant. What ties the “bad” things together is that the “bad” foods are all scientifically known to encourage the growth of this yeast, and the “bad” chemicals are scientifically known to cause allergic reactions. Oppositely, the “good” things are known to kill or inhibit either the yeast, the yeast enzymes, or the yeast-produced chemicals in various ways. There are more details to this theory, which are available on written request. For example, common sugar is a powerful yeast food, for all yeasts (including the different yeast which is known to cause vaginal yeast infections), but fructose, a somewhat different sugar which does not seem to bother pullers, is not a good yeast food at all. Foods rich in sterols, whether they are the cholesterols in animal foods such as egg yolks, vitamin D-related sterols in milk or tuna, or the phytosterols in plant foods such legumes, are believed by researchers to be growth signals to the specific skin yeast we suspect. Similarly, there are links between the other foods and chemicals to this yeast’s life cycle and health. One of us, Mike, has even grown a colony of Malassezia, and has found that its most preferred food is the oil from freshly ground peanuts. Further, the irritancy of conditioners containing fatty alcohols, the “hot spots” of pulling, the slow migration of hot spots over the skin, their localized overproduction of skin grease, the relief people experience from the grease-removing clay masks, the effectiveness of anti-bacterial and anti-fungal shampoos, and the soothing action of the extended grease- expressing hot-towel scalp massages: these all appear consistent with the idea of a localized allergic response to an infecting organism. Seen this way, the hot towels, high pH soaps, and blade shaving may be removing both the organism and the grease it feeds on, something an electric razor misses. Even the gradual recurrence of the itch after four days or so fits with what is known about the time necessary for yeast growth. Further, the propylene glycol base for the helpful aloe vera gel is a known yeast killer (as is sunlight and as is benzoyl peroxide), whereas the troublesome lanolin is a complex of growth-stimulating sterols and irritating fatty alcohols. We think the theory helps explain why hairpulling is worse premenstrually: the increased progesterone, a sterol, is a known yeast growth stimulant. And why hairpulling usually doesn’t hurt and is often done in a trance: this skin yeast is known scientifically to make a chemical called hexanol that has anesthetic properties. (And besides, people with other skin yeast infections scratch like crazy, sometimes drawing blood, but finding it pleasant.) And why hairpulling usually starts in early adolescence: this is when the sebaceous glands start to produce the grease this yeast needs. And why hairpulling is chronic: this yeast, in general, is hard to control, and other disorders related to it are chronic; in any case, most allergies are unfortunately chronic, too. We think the theory may help explain the “fat roots” that hairpullers seem to go hunting for: skin micro-organisms are able to turn soft grease into a harder wax-like plug that is easy for exploring fingers to recognize. (We have found that non-pullers get them, too, but it doesn’t seem to drive them nuts.) We think the theory may help explain why such very large doses of serotonin-specific reuptake inhibitors (“SSRI”s, like Prozac) are found to be necessary for TTM: it may be that the SSRIs act like chemotherapy, stressing the human body, but fatally overloading critical yeast digestive processes (technically, the “cytochrome P450 enzymes”, which the human body also uses to dispose of SSRIs). We even speculate that hairpulling and furry pets seem to go together because, perhaps, the microorganisms involved can be shared between people and dogs and cats; some people have in fact have found some relief from lash pulling by simply making sure to regularly wash their hands and eyelids. 5) For Further Information If you have access to the Internet, a good place to explore these food and skin care observations is by joining the TTM remailer (send email to jrk@cs.columbia.edu), or by viewing Amanda’s website (at jly2.com/ttm). The authors can be reached at jrk@cs.columbia.edu or TTMParents@aol.com. Otherwise, send a self-addressed stamped envelope to either: John R. Kender M. J. Grant 169 Ames Ave. P.O. Box 2825 Leonia, NJ 07605 St. Louis, MO 63118 6) An Important Final Disclaimer Please note that the two of us are simply reporting what we have observed and thought. We are not offering medical advice. We cannot guarantee results, or even the safety of any these procedures. It is important that you check with your doctor first before you experiment. And, please, let us know of your results, so that we can keep all these things safe, and share them with other hairpullers.

HE YEAST HYPOTHESIS: PRACTICAL TECHNIQUES My guess at this point is that some pullers are sensitive, as are a small fraction of the population, to certain branched long chain fatty alcohols such as isostearyl alcohol, which are produced from waxes and fats by the skin yeast Malassezia. If so, then pulling can be managed in many ways: by inhibiting the yeast, by disabling the enzymes, or by avoiding the irritants their enzymes produce. Thus, here is a grand summary of things that might be helpful for pulling. In general, this list is based on the reported experience of many pullers, but items marked “possibly” have been reported infrequently. Please note that some things appear in more than one category; in general, those things tend to have a more pronounced effect. EXECUTIVE SUMMARY: Basically, it’s a nutritional and skin care approach. First, try not eating sugar, caffeine, and chocolate. Have some dry red wine or ginger tea instead. These should have an effect in about two or three days. Then, avoid peanuts, chickpeas, beans, egg yolks, tuna, and waxes. These should have an effect in about 10 days. Take choline bitartrate or magnesium gluconate, and take borage oil. Use Shampoos with selenium (Selsun) or IPBC (White Rain). Keep a food diary to help you track your own particular triggers. Keep your hair and hands clean. Wash your lashes with baby shampoo hot compresses. Watch out for pet fur. Apply fresh cut ginger, or miconazole nitrate cream, or propylene glycol/aloe vera/rubbing alcohol, or eyewash/vinegar. Use Sea Breeze or Band-Aid Anti-Itch gel for emergency hot spot care. EVEN SHORTER: Avoid sugar, caffeine, lecithin, wax; take borage oil and dry red wine; apply fresh cut ginger. 1) Minimizing yeasts Via energy supply Avoid eating sugars, even natural ones as in: honey, molasses, raisins, dates, fruit juices; avoid Splenda (sucralose); use pure fructose if necessary instead. Via resting stage signals Avoid drinking caffeine as in: coffee, cocoa, chocolate, soft drinks. Via nitrogen supply Avoid eating aginine, as in: nuts, legumes, seeds, especially sunflower seeds. Avoid eating asparagine/aspartate, as in: coffee, cocoa, chocolate, cola; legumes; tomato seeds; possibly seeds; possibly nuts; possibly whole grains, whole grain flours; possibly aspartame (Nutrasweet). Avoid eating glutamine/glutamate, as in: MSG, soy sauce. Avoid eating nitrites, as in: possibly preserved meats. Via growth signals Avoid eating sterols as in: egg yolk; butterfat; legumes, especially peanuts and garbanzos/chickpeas, but also beans, alfalfa sprouts, licorice, soy products (including “vegetable oil”; use olive oil instead); yams; dates; organ meats; crustaceans (shrimp, crab, lobster); oily fish such as tuna, herring, sardines, salmon, mackerel; hair roots; possibly (for lash or brow pullers) vitamin D enriched milk products. Avoid eating lecithins as in: brazil nuts, chocolate, whole corn (including popcorn), egg yolk, oily fish, lecithin, margarine, peanuts, sesame, soy, wheat germ; no-stick pan sprays like Pam. Avoid increasing blood cortisol as in: stress; possibly grapefruit. Avoid increasing blood progesterone as in: PMS. Take supplements to increase liver clearance of blood sterols as in: magnesium and vitamin B complex, possibly (for lash or brow pullers) additional B-6. Counter ethanol-induced growth by eating: inositol. Via chemical attack Eat allicins as in: garlic, possibly onions. Eat alpha hydroxy acids as in: whole fruits (not juices) of apple, grape, orange/lemon/lime, pineapple; fermented foods of cottage cheese, yogurt, kefir, sour cream, or sauerkraut, or hard sausages. Eat bromelains/papains as in: pineapple, kiwi, gingerroot, papaya, figs, guava. Eat beta-glucanases as in: ripening bananas Eat gamma-thionins and isothiocyanates as in: mustard, and possibly other mustard family vegetables like cabbage, Brussels sprouts, etc. Drink tannins as in: unsweetened tea, astringent red wine. Take “fruit acid” supplements as in: dry red wine, choline bitartrate, magnesium gluconate, “cream of tartar sauce” (see below)Via external (skin) environment Bleach, color, or relax the hair. Have long hot sudsy showers and shampoos, morning and dinnertime. Use non-pH-balanced antifungal shampoos like: Zincon. Use antifungal shampoos like: Nizoral. Use shampoos with the antifungal IPBC (iodopropynyl butylcarbamate) like: White Rain Classic Care Extra Body, or most Clairol Herbal Essences. Use high pH soaps like: castile, Cuticura; avoid Neutrogena. Use a low pH rinse like: 2% boric + 2% acetic (eye wash + vinegar, see below). Apply antibiotic chemicals like: Cuticura and ZNP soap; possibly (for very short term use only) terpenes, as in: Listerine, Vick’s Vap-O-Rub, tea tree oil, spirit of camphor, Band-Aid Anti-Itch. Apply antifungal chemicals like: Fresh cut ginger; aloe vera gel; miconazole nitrate (Micatin) cream, possibly mixed with Polysporin cream; propylene glycol homemade lotion (see below). Apply tannins as in: witch hazel. Apply ultraviolet light, local heat, and ozone as through: probably sunshine; probably high frequency generation (“violet ray”) machines. Via internal (gut) environment Eat acidophilus as in: capsules, unsweetened “live” yogurt, kefir, possibly buttermilk, sauerkraut, or kimchi. Probably avoid antacids. Via yeast reservoir control Avoid close contact with furry pets. Wash hands before touching hair or eyes, especially after touching pets. Wash eyelids with baby shampoo. Via mite vector control Use insecticidal shampoos like: Nix, Rid. 2) Minimizing yeast enzymes Via all above but also Via feeding signals Avoid taking medicines with ibuprofen. Via direct induction Avoid possibly drinking alcohol; avoid probably drinking gin. Via enzyme inhibition Eat possibly broccoli. Take gamma linolenic acid (GLA) as in: borage oil. Take possibly eicosapentaenoic acid (EPA) as in: fish oil (only if very fresh; rancid fish oil appears to be a trigger). Apply fresh ginger juice or drink ginger tea. Use shampoos with selenium sulfide like: Selsun Blue. Via chemical attack Use only olive oil in foods. Take gluconate supplements: preferably magnesium, but also calcium, ferrous, potassium, sodium, and/or zinc. Take tartrates: dry red wine, choline bitartrate, “cream of tartar sauce” (see below). Apply benzoyl peroxide. Via control of chemical reactions Apply ice cubes. 3) Minimizing fatty alcohol exposure Via all above but also Avoid waxes as in: lipstick, mascara, some candies and candy-coated gums Via skin exposure Wick them up by applying solvents like: rubbing alcohol, witch hazel; (for very short term use only) Sea Breeze Sensitive Skin. Avoid applying fatty alcohols, especially “-yl” alcohols (cetearyl, cetostearyl, cetyl stearyl, stearyl; possibly cetyl) as in: conditioners, deodorants, shaving creams, hand and body lotions that contain them. Via ingestion Take antioxidants as in: vitamin E. Avoid eating fatty alcohols as in: hair roots. * Propylene glycol recipe: 1 part PG, propylene glycol (available from pharmacies, about $8/pint) 1 part AV, pure aloe vera gel (make sure it has no other ingredients) 3 parts RA, rubbing alcohol (which comes as 70% isopropyl alcohol, 30% water) Apply twice a day with cotton ball. Stings but works quickly. Note: For areas around the eyes, people have found that much less alcohol is better, and use instead: 2 parts PG, 2 parts AV, 1 part RA. **”Cream of tartar sauce” recipe: 1/4 teaspoon cream of tartar 1/2 teaspoon (one packet) fructose (do not use regular sugar) 1 cup of water Starts to work in about 3 hours. Full effect by 8 hours. Note: This mixture is acidic, and overuse has caused throat and stomach irritation. Instead of cream of tartar, using lemon juice (as much as can be tolerated) also works, but less well. *** Acetic-boric (eyewash/vinegar) rinse recipe (and warnings): 1) WARNING! Check with your doctor first! These are my experiences only, and are not medical advice. Boric acid can be dangerous; read the label for precautions. Don’t use it if you have broken skin or may be pregnant. 2) To make it, I put 2 oz. of water in a cup, and add 1/2 teaspoon boric acid. The boric acid dissolves after being zapped in the microwave enough so that the water boils. I let it cool, then add 2 oz. of vinegar. Apple cider vinegar has a better smell than white vinegar, and rice vinegar probably has the least smell of all. This makes me 4 oz. of a 2% acetic acid plus 2% boric acid solution. I would increase or decrease quantities proportionately as needed to make more or less of it, but it does not appear that exact ratios are critical. 3) I apply it only to unbroken skin. (Although this does not apply to me, I won’t use it at all if I thought I was pregnant.) I let it sit for about five minutes, then I usually rinse it off. 4) I do this once a day for a week, then stop; I found that sufficient. Based on its supposed action, I would guess if there was going to be any effect, it should be evident by then, and it should continue for some days thereafter. 5) If you find the rinse useful and your doctor has approved, check again with your doctor to determine how often it would be safe for you to use it. 6) Again, WARNING! Check with your doctor first! These are my experiences only, and are not medical advice. Boric acid can be dangerous; read the label for precautions. Don’t use it if you have broken skin or may be pregnant.

SCALP AND HOT SPOT CARE by Michael J. Grant Much of the informal research John and I have done shows there is a positive correlation between the so-called hot spots some pullers experience and areas of increased activity of the sebaceous glands. I have been able to demonstrate in the limited number of trials I have been able to do that reduction of the excess oil in these areas significantly reduces the intensity of the urge to pull from these areas. Overactivity of the sebaceous glands has been long demonstrated by established medical research as the primary factor in skin conditions such as seborrhea, acne and acne like skin eruptions, not to mention sebaceous cysts or “wens”. The underlying cause, at least initially, for this overactivity is likely systemic. The sebaceous glands respond to gonadotropic, thyroid, and other hormones present in the blood. Adolescents develop oily skin due to high levels of testosterone and estrogen. It is also possible the sebaceous glands may also trigger off the hormones and other substances in the food we eat, which my explain John’s trigger food phenomenon. Aside from judicious dietary changes, dealing with the hot spots on a systemic level is best left to the medical professionals. Being a good state of overall health often lessens the incidence and severity of many disorders when they do occur. So it is good idea to do those things such as exercise, eating a healthy balanced diet, and seeing your doctor for checkups on a regular basis which maintain that state of overall wellness. The basic regimen I recommend for those trouble by hot spots, scalp sores, and other related conditions such as excessive dandruff or flaking is as follows: Step 1. Objective: Remove any possible sources of allergies or irritation. Action: Discontinue all regular shampoos, conditioners, etc. Rationale: Many of these products contain fragrances and proteins which are potential sources of allergic reactions. Hair sprays and mousses can clog pores and follicles and prevent normal aeration of the scalp. Step 2, A through F. Objective: Cleanse the scalp to remove excess oils and skin debris which can plug the follicles. Action: A) Saturate the hair and scalp with warm water gradually increasing the water temperature until as warm as tolerable. Rationale: The warm water softens and liquefies the sebum which facilitates washing it away. Increasing the temperature of the skin dilates the pores and increases blood circulation while promotes flushing out of the follicles. Action: B) Lather the hair with Cuticura soap by first applied a small amount of soap, massaging it into the hair, and adding more soap or water as need to produce a thick lather. (It may be more convenient to grate the Cuticura bar by means of a cheese grater.) Rationale: Cuticura soap contains an antiseptic and is anti-comedogenic. A lather help emulsify sebum to facilitate it being washed away. Grating the bar soap allows only that needed to have contact with the scalp preventing contamination of the bar. Action: C) Rinse the hair thoroughly with the same very warm water as before to remove all traces of the soap. Rationale: It is important to maintain the scalp at an elevated temperature to keep the sebum liquefied and to promote softening of skin cells at the scalp surface as they absorb water. Action: D) Relather the hair as before working up a thick lather. Massage the lather into the scalp using pressure on the fingertips (never fingernails) for a minimum of five to ten minutes, adding water or soap as need to maintain the lather. For those who know the four massage movements, these movements may used for two to three minutes each. Rationale: The mechanical action of massaging the scalp helps break up dried sebum and loosen shedding skin cells from the scalps surface. Further, it aids in helping work sebum beneath the the skin to the surface where it can be removed. Massaging also promotes blood circulation to aid in removing toxins and irritates in the scalp tissue, supplying antibodies to combat any infection as well as nutrients and oxygen to support the follicles hair producing cells. Massage can also stimulate the nerves of the scalp making them less sensitive and likely to itch. Action: E) Wrap the lathered head in a Turkish towel saturated with water as warm as tolerable. Replace the towel with another after 2 minutes. Allow last towel to remain until it feels tepid, but not cool or around 3 to 5 minutes. Rationale: This moist heat is aimed at further softening of surface skin cells and keeping the sebum beneath the skin the least viscous as possible to bring it to the surface of the scalp. The elevated temperature and high pH of the Cuticura forces water into hair and skin cells carrying with it the antiseptic contained in the soap. Action: F) Rinse the remaining soap from the hair with warm, not hot water. After all of the soap has been removed, gradually reduce the rinse water temperature over a period of two minutes until it is as cool as can be comfortably tolerated. Allow the hair to remain wet. Rationale: Reducing the water temperature closes off the pores and seals the moisture and antiseptic in the skin and hair cells, pores, and follicles. Cooling the skin reduces the activity of the sebaceous glands temporary reducing new oil secretion. The sensitivity of nerve sensors in the skin is also reduced to aid in itch reduction. The hair and scalp are allow to remain wet to keep the hair and skin cells saturated with water. Step 3. Objective: Reduce the sensitivity of scalp nerves to promote itch control. Close the pores and dissolve any remaining sebum left behind. Reduce the scalp temperature, leaving an additional antiseptic residual. Action: Generously apply Sea Breeze astringent to the scalp and massage in. Allow it to remain on scalp for a couple of minutes. Rationale: Sea Breeze contains alcohol which is a solvent to dissolve any dried sebum which had not been washed away. Through evaporation, the alcohol reduces the scalp temperature. Sea Breeze contains phenol, a topical anesthetic, as well as camphor, a potent counterirritant and itch suppressant. Sea Breeze contains an astringent to further promote closing of the pores and follicles. Sea Breeze leaves an antiseptic residual behind after it dries. Step 4. Objective: Seal the moisture into the hair and scalp. Provide additional protection against irritation and itching. Action: Apply a small amount of clear pure aloe vera gel onto the wet hair and work into scalp. Comb hair into place. Allow to dry naturally or with heatless drying setting. Rationale: Removing the sebum strips the hair and scalp of its natural vapor barrier. Without a vapor barrier, the moisture in the hair and scalp would quickly evaporate causing the skin and hair to dry out and become brittle and irritated. The aloe vera gel seals in the moisture while the hair and scalp are still saturated. The gel is non-greasy, hypo-allergenic, and does not promote comedos like natural sebum. It is not subject to bacterial attack as well. Aloe vera is naturally soothing to the skin and also help prevent itching. The aloe vera gel will appear to leave the hair stiff. This is not a problem. The stiffness completely disappears by simply running a comb through the hair. The aloe vera gel leaves no visible residual and coats the hair and scalp with a protective clear film that breaths. As a side benefit, the aloe vera gels acts like a styling gel keeping the hair in place eliminating the need for hairsprays and mousse. Allowing the gel to dry on the wet hair without combing after it dries leaves the hair with a wet mousse like look. Unlike mousse that gets that appearance with comedogenic oils and lacquers, the wet look of aloe vera comes from the actual health water held into the hair. – – – – So this is the basic protocol. The products needed are Cuticura soap, Sea Breeze astringent, and pure clear aloe vera gel. If you have a problem locating these in your area, send me an email. I never sell anything but have been known to send these things out without charge from time to time. If it is for a child or young adult, I always send out a kit upon request. There are modifications and enhancements for special circumstances. When the hair loss is severe and/or the person is shaving, a bentonite slurry clay masque substantially reduces even more oil as well as extracting excess fluids and toxin from the scalp. There are both prescription and over the counter topical medications that can be used to spot treat sores and particularly inflamed areas. I am always looking for an opportunity to demonstrate this and other techniques. I have wanted to do some training-a-trainer things, but have never been able to put something together. Perhaps if there is any interest at the Retreats, I can work something out. I also would be willing to travel within a couple of hundred radius of the St. Louis area if that would work out for anyone. If several people who were willing to be trainers could get together in one place, I would be willing to consider traveling a greater distance, particularly if any of these people were POPs. Take care. Mike (TTMParents@aol.com)

A FAVORITE QUOTATION I have copied below a paragraph from one of the many books I have researched in. Of all what I have ever read, it comes closest to what I believe is the sensible approach to dealing with pulling–or anything else, for that matter. – – – – From “The Essential Guide to Psychiatric Drugs”, by Jack O’Gorman, MD (Columbia University College of Physicians and Surgeons): A Final Note . . . If there is any overriding principle to this book, it is simply that the object of psychiatric treatment should always be to make the patient better. That may sound ridiculously obvious, but in fact will be challenged by many. Some feel the object of treatment is to make the patient understand more about him or herself, to be better able to ‘deal’ with complex emotions like anger and envy, or to follow societal rules and regulations better. I am not going to argue these points, because that would require another book. But I will bluntly assert that the object of psychiatric drug treatment has nothing to do with self-understanding or self-realization; it is a medical procedure intended to relieve symptoms and sometimes even cure disease. Thus, a patient can always ask himself a simple question when evaluating the usefulness and success of a drug treatment: Do I feel significantly better now than before I started taking the medicine?”

TTM: Trichotillomania Tele-Mailer Welcome to the Trichotillomania Tele-Mailer, an automatic mailing list for people involved with trichotillomania. Trichotillomania (“trich”, “TTM”) is an impulse control disorder of uncertain origin characterized by a recurrent urge to pull out one’s own hair. PLEASE SAVE THIS FILE FOR FUTURE REFERENCE! It would be a courtesy to the many existing list members if you would take the time to read this message in its entirety. It has five sections: a) basic information, b) general ground rules, c) general procedures, d) acknowledge- ments, and e) a Frequently Asked Questions document (“FAQ”). TTM A) BASIC INFORMATION This mailer will rebroadcast to all the list membership whatever you mail to: ttm@lists.cs.columbia.edu For more information on how to use this list, including where to read recent archives on-line, send a message with the subject “help” to: ttm-request@lists.cs.columbia.edu To subscribe to this list so that you receive individual copies of messages, much like regular email, send a message with the subject “subscribe” to: ttm-request@lists.cs.columbia.edu To subscribe to this list so that you receive batched messages, about a dozen at a time, send a message consisting of “subscribe digest” to: ttm-request@lists.cs.columbia.edu If you would prefer to converse with a human being, send your email to: ttm-owner@lists.cs.columbia.edu If you are interested in receiving a collection of documents concerning the control of TTM through nutritional and skin care methods, send an email to: ttm-owner@lists.cs.columbia.edu Please give the FAQ below a read, as it attempts to provide new list members with a running start on the discussions on the list. In general, the list membership is tolerant of “newbies” asking old questions, but will usually respond privately to such requests, saving the public list for newer issues. TTM B) GENERAL GROUND RULES Three design decisions in creating and maintaining this list may affect your comfort with it: 1) Because of the risk of spam and viruses, this list is moderated. Your mailings are rebroadcast to the list membership as soon as the moderator becomes aware of them and approves them. This may take anywhere from minutes to days, depending on the moderator’s schedule. 2) To provide some degree of discretion, only members of the list can see the mail addresses of other members, or retrieve old mailings from the archives. However, anyone who has heard about the list can join it. 3) Again for speed, and, more importantly, to help develop a sense of community, the list does not provide for anonymous joining or anonymous mailing. Those members wishing to preserve their anonymity can do so by using a service provider that allows pseudonyms for logon IDs. TTM C) GENERAL PROCEDURES Four items of procedure and policy that frequently come up are the following: 1) The amount of messages that you can expect to receive will vary widely. There are usually about 300 on the list. Some days there are no messages; on a few days there may be over five; in general, there are about two to five per week. For reasons that are not understood, the postings seem to go through cycles of about four weeks long, first with little activity, then with a lot of activity. If you aren’t getting any messages and you think the system is broken, send the list owner a private message. Or just wait a few days. 2) Civil interactions are presumed. The list owner tends to be a bit lenient, and is reluctant to interfere with discussions, noting that the list very often will police itself. However, if in the opinion of the list owner, a member persists in doing more harm than good (as evidenced by people sending private mail stating such, or by a rash of unsubscriptions), uncivil posters will be unsubscribed–usually, but not necessarily, after a warning. In the life the list, since April 1995, six such people have been forcibly removed. 3) The posting or forwarding of chain letters, commercial advertisements, virus warnings, pleas for locating abducted children, internet hoaxes, urban legends, etc., even if well-intentioned, is forbidden. Violators will be removed from the list immediately and without warning. Five such posters have been removed so far. If you have received an email that is not about TTM but it causes you concern–including email warnings about viruses–check first privately with the list owner before you attempt to post it to the mailer. 4) This is a plain text mailer only! Please do not post using HTML or base64. Such messages will be returned, and so will any messages longer than 5000 characters. TTM D) ACKNOWLEDGEMENTS This list is owned by John R. Kender, a professor of computer science at Columbia University in New York City, who became a hair puller at age 13, and who is currently enjoying a remission since July 1992 which he attributes to nutritional control and skin care measures. This automatic list was inspired by the courage and good cheer of both Christina Pearson, the director of the Trichotillomania Learning Center, and Bill Sweeney, who bravely started it by hand(!) as a college freshman in 1994. TTM E) GEOFF DEAN’S TRICH FAQ. [Comment: last updated Spring 2000] by Geoff H. Dean [JRK comment: with some additions and updates by JRK, in square brackets starting with “JRK” like this one, most recently in 2012. Original comments by Geoff are also in square brakets, but are just plain comments, like above.] Please find enclosed the latest version of the FAQ. The main section is essentially the same, but the resources and links section has been extensively revised. Thanks to everyone who has contributed. – – – – The following are the most Frequently Asked Questions by people new to the mailer. 1 – EXACTLY WHAT IS TRICHOTILLOMANIA? Trichotillomania is defined as recurrent pulling out of one’s hair, resulting in noticeable hair loss, which is not due to another medical condition. There is an increasing sense of tension immediately before pulling out the hair, or when attempting to resist the behavior, and there is pleasure, gratification, or relief when pulling out the hair. 2 – HOW MANY PEOPLE ARE AFFECTED? The true prevalence of Trichotillomania is unknown, since people are often ashamed of their behavior and are consequently reluctant to discuss it, even with their doctor. So it is difficult to get reliable statistics. Historically it was thought to be rare, but the condition is now better understood and more people are seeking help. More recent estimates range from 0.5 to 3.5% of the population, depending on the definition used, and the nature of the study. 3 – WHERE DO PEOPLE PULL FROM, AND WHAT OTHER THINGS DO THEY DO? Sufferers as a group pull hair from a wide range of body sites including the scalp, eyebrows, eyelashes, beard, pubic areas; and, less commonly, underarms, chest, ears, nose and general body hair. The sites pulled by particular people vary widely, and may be restricted to one or two sites. Associated behaviors include searching for hairs that stand out in some way; repetitive drawing of hair through the fingers, or over the lips, before or after pulling; picking of associated skin; careful examination of the hair or roots; compulsively playing with, or splitting the hair; biting off the roots, or the hair itself into segments. The behaviors are also specific to the particular person; some just pull eyebrows with tweezers, for example, and others just pull from their scalp. Some pull intensively from particular sites; others try to manage their appearance by pulling less intensively, but from a wider range of sites. Some people eat the roots or the whole hair. Since hair is not digested, but remains in the stomach, this condition is potentially dangerous and medical examination should be sought. 4 – WHAT ARE THE CAUSES, AND WHEN DOES IT FIRST START? There is no known single or obvious cause, and there may be several contributing factors, such as genetic predisposition, diet and stress. It is now commonly regarded as a medical illness, and it may be caused by a disruption in the system for communication between cells in the brain. People frequently start compulsive pulling at 12 to 13 years of age, although commonly at a much younger or older age. The onset may be associated with hormonal changes at puberty, although many people recall a significantly stressful event associated with the onset. 5 – WHY DOES PULLING COMFORT ME? AM I GOING CRAZY? During hair pulling episodes, the sufferer frequently pulls from zones of heightened sensitivity. It is generally not painful to pull from these areas, or the pain is mild and the pulling causes great relief, or even comfort. The pulling can quickly become compulsive, causing relief and comfort on the one hand, but anxiety and distress at the increasing hair loss on the other. Sufferers can quickly become greatly distressed at an apparent inability to control their own behavior, and the continual increase in damage to both their hair and self-esteem. Is it any surprise if some sufferers feel they might be going crazy, even though they are not? 6 – ARE THERE ASSOCIATED ILLNESSES OR CONDITIONS? There are apparent similarities with the symptoms of Obsessive Compulsive Disorder (OCD), but only a low minority of Trichotillomania sufferers have OCD as well; 15% in one study. Depression has been reported to occur in a majority of people. However it is not known if this is due to a direct biological link between the two conditions, or whether the depression is a consequence of the severe loss of morale and self-esteem brought on by the hair pulling. Other behaviors believed to be common include nail biting and skin picking. Procrastination has been reported as a symptom. This behavior of putting off tasks is very frustrating to family and friends, and may be disruptive of personal relationships. 7 – WHAT TREATMENTS AND SUPPORTS ARE THERE, AND WHAT SUCCESS DO THEY HAVE? Medications are easy to use, but, used in isolation, are reported to have limited long term effectiveness for the treatment of Trichotillomania itself. They have been reported as a useful adjunct to other treatments, and are often used to reduce the symptoms of associated depression. Behavior Therapy attempts to stop or control specific undesirable behaviors, or to replace them with new ones. Cognitive Therapy usually involves identifying the thoughts that make pulling more likely, and working on replacing them with new thought patterns. These are often combined and / or used in conjunction with specific medications. The treatments might include Group Therapy; training in life skills such as Assertion, Anger and Stress Management, Goal Setting and Problem Solving; and Relaxation Training. Programs are usually tailored to the needs of the individual and, where practicable, involve the family and supporting persons. Psychotherapy and Hypnosis have also had some reported success. Diet control has been widely claimed to contribute to easing or eliminating pulling behavior. It is recommended that all sufferers carefully consider the impact of diet, since some people have reported benefits from even simple changes. Skin care has been shown to be important for control of the condition in some people. A variety of effective and readily available products has been identified to relieve intense itching or other associated problems which are present with some people. Religion may become a powerful motivating force for healing in some people, particularly as an adjunct to other treatments. It can contribute to a sense of community; improved self-esteem; a strong sense of purpose, and focus on goals; and an easing of depression. A sense of community is a powerful force for healing with many people – to know that you are not alone; to discover after years, or even decades, that your condition is known to medicine; to share your thoughts and feelings; to feel understood and accepted; to see people, who share the same affliction, caring for one another. There are reports from sufferers that aspects of hygiene may be important for some people. Specifically, those who pull from eyebrows or lashes may benefit from avoiding furry pets and frequent washing of the hands and eye area with soap and water. We should also consider what we regard as success, as so eloquently stated by a parent, “Improvement tends to be incremental rather than total or complete, and must be viewed in a broad perspective [rather] than simply the reduction or cessation of the hair pulling behavior itself. Rarely can a given course or therapy be viewed in such absolutes as success or failure, but rather as a process of continuous improvement in all aspects of the child’s overall quality of life.” (M.J.Grant, TTM mailer, 5 Aug 99) 8 – HOW CAN I MEET OTHER SUFFERERS? There are two broad ways to interact with fellow sufferers: via support groups in your own locality, and via the various internet networks. There should be a Mental Health organization in your own area who can put you in contact with local support groups. In any case, the Trichotillomania Learning Center attempts to maintain a comprehensive listing of support groups. For those who have an internet connection, there are support groups using email which are knowledgeable, helpful and provide a safe environment for interaction and learning. Options for contacts include email networks (e.g. the TTM mailer); the Fairlite Bulletin board; online chat groups; private email with users met via these groups; and private web pages featuring contacts and links. Some groups organize, or facilitate activities, such as retreats, picnics, an International Day, and a bracelet symbolic of unity within the trich community. 9 – WHAT CAN I DO FOR SUFFERERS? The best way to help sufferers with Trichotillomania is to care about them, to try to understand them, and to help them to learn more about their condition, and how to manage it. Sufferers commonly express enormous relief to discover that they are not alone; to find that the condition has a name; and to be reassured that they are not weird or crazy. It can be a profound experience for a sufferer to describe their behavior and associated feelings to others people, and for this to be accepted. Parents of sufferers have often sought guidance about what is a helpful approach toward their children, and specific information and contacts are available for parents. 10 – WHERE CAN I FIND MORE INFORMATION? Please note that this is not intended to be a comprehensive list of information sources. Readers are referred to the pages below with the comment “resources and links”. BOOKS Dan Stein, Gary Christenson, Eric Hollander, “Trichotillomania”, 1999, American Psychiatric Press, 344 pages, ISBN: 0880487593, Price: US$45, Publisher phone in the US, (202) 682-6262. Also in online bookstores Jeffrey L. Anders, James W. Jefferson, “Trichotillomania – A Guide”, 45 pages, by the Madison Institute of Medicine, 1989, ISBN: 189080214X Price: $4.95. Postal address: Information Centers, Madison Institute of Medicine, P O Box 628365, Middleton, WI 53562-8365; or by phone in the US, on (608) 827-2470. This is online at http://www.trichotillomania.ab.ca/rwpeta/Aguide.html. Cheryn Salazar, “You Are Not Alone: Compulsive Hair Pulling, the Enemy Within”, 1995, Cheryn Intl., 262 pages, ISBN: 0965067009, Price: US$14.95, Web: http://www.cheryn.com/book.html. Also in online bookstores. Jack M. Gorman, M.D., “The Essential Guide to Psychiatric Drugs”, Revised edition December 1998, paperback, US$6.99, St Martins Mass Market Paper, 416 pages. In online bookstores. [Comment: Expert but non-technical information on psychiatric drugs] WEB RESOURCES TLC (Trichotillomania learning Center) http://www.trich.org/ trichster@aol.com [Comment: Key site for resources and information; non-profit, subscription] TTM Mailer library web site http://www.irishlace.net/trichlibrary/ [Comment: Aims to make available select material from the mailer] [JRK comment: Site expired sometime around 2011. Some of its content is avaialble at: http://www.geocities.ws/ttmlarchive%5D Parent Group You can subscribe by sending a message to: parents_ttm-subscribe@yahoogroups.com containing only the word subscribe. The group is also online at http://groups.yahoo.com/group/parents_ttm This will require a free registration. [Comment: An forum to share ideas, hopes and concerns with other parents of pullers] [JRK comment: Still exists, but inactive since June 2009] [JRK comment: YouTube has many teen-oriented videos. One good place to start: http://www.youtube.com/watch?v=CiBIXMBEqgE Online full text articles. http://mblcommunications.com/trichotillomania.html [Comment: Medical information about Trichotillomania – drug treatments; Behavior Therapy; Classification; Trichotillomania in Children and Adolescents; etc.] [JRK comment: website expired about 2006] [JRK addition: Use Pubmed: http://www.ncbi.nlm.nih.gov/pubmed/%5D JK Diet Pages http://jkdietpage.tripod.com http://soul4ce.home.texas.net [Comment: Information on dietary control of Trichotillomania] [JRK comment: not JRK’s own web pages, but web sites set up by some other people who have had success with nutritional approaches to TTM.] [JRK comment: both websites expired about 2011] Amanda’s Trich Web Guide http://www.jly2.com/ttm [Comment: Excellent private site, resources and links] [JRK comment: Site moved to http://www.home.intekom.com/jly2%5D Stephanie’s FAQ http://www.geocities.com/~modularforms/trich/FAQ.html [Comment: Excellent and extensive FAQ] [JRK comment: Site expired when Yahoo shut down Geocities in 2009] Open Directory Project http://search.dmoz.org/cgi-bin/search?search=trichotillomania [Comment: Useful links]

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