N-Acetylcysteine for Excoriation (Skin Picking) Disorder, Trichotillomania (Hair Pulling), and Obsessive Compulsive Disorder

Skin picking disorder is a disabling condition which consists of repeated picking of the skin leading to noticeable skin damage. It affects up to 5% of the population and no medication seems to be effective for the treatment of this disorder.

In a study published in the 3/23/2016 online issue of JAMA Psychiatry, Grant and colleagues report a decrease in skin-picking symptoms in a randomized double-blind 12-week study comparing 31 patients on placebo with 35 patients on N-acetylcysteine in a dosing range of 1200-3000 mg daily. N-acetylcysteine was well tolerated. Side effects were mild and included nausea (14% of participants]), dry mouth (3%), constipation (6%), and dizziness (3%). In a previous study, the same group found that N-acetylcysteine is also effective for the treatment of tricholamania, a condition characterized by a compulsive urge to pull out one’s hair resulting in hair loss, balding, and distress. Afshar and colleagues reported the effectiveness of N-acetylcysteine as an add-on treatment for refractory obsessive-compulsive disorder (OCD) treated with selective-serotonin-reuptake-inhibitor antidepressants.

N-acetylcysteine is an amino acid available without prescription. The authors hypothesize that N-acetylcysteine decreases compulsive behaviors by increasing extracellular levels of glutamate in the nucleus accumbens. Because skin-picking, trichotillomania, and OCD are chronic conditions, a treatment longer than 12 weeks may be necessary. Cognitive Behavioral Therapy (CBT) is also beneficial and should be combined with N-acetylcysteine.

Genetic Testing to Determine Responses and Side Effects to Psychotropic Medications

Genetic testing as an additional measure to determine responses and side effects to psychotropic medications is now available in my private practice. The Genecept Assay is a simple, non-invasive, buccal test developped by Genomind. It analyzes ten genes shown to have implications for response to treatments used in depression, bipolar disorder, schizophrenia, anxiety disorders, OCD and ADHD. The analyzed genes target major hepatic enzymes and key neurotransmitter pathways including serotonin, dopamine and glutamate.

 

For more information or to schedule an appointment, call (917) 251-6498. 

Is adding an atypical antipsychotic effective in OCD patients not responding to SSRI antidepressants?

In the November 2014 issue of BMC Psychiatry, David Veale and colleagues from King’s College in London conducted a meta-analysis of the clinical effectiveness of adding atypical anti-psychotics (aripiprazole, olanzapine, quetiapine, or risperidone) to Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants (e.g., fluoxetine, fluvoxamine, citalopram) in treatment-resistant patients with Obsessive Compulsive Disorder (OCD) . They found limited evidence for using a low dose of risperidone or aripiprazole and no evidence for using olanzapine or quetiapine. They suggest considering other augmentation strategies such as combining the SSRI antidepressant with cognitive-behavioral therapy or clomipramine.

Cognitive-Behavioral Therapy and Risperidone in Obsessive-Compulsive Disorder

In a video, Dr. Helen Blair Simpson discusses her study published in JAMA Psychiatry comparing Exposure and Ritual Prevention Cognitive-Behavioral Therapy (CBT), risperidone, and placebo in OCD patients treated with selective serotonin reuptake inhibitor antidepressants (SSRI’s).  CBT had better outcomes than risperidone and placebo. Dr. Simpson suggests discontinuing antipsychotic medications in SSRI-treated OCD patients who do not improve after four weeks.