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Healing after Harvey

Written by:

Hannah Sommer Garza, PhD, Rosie Polifroni, PhD, & Tyson Reuter, PhD

Healing after a natural disaster is difficult. There’s no sugar-coating that fact. Hurricane and Tropical Storm Harvey was considered the largest natural disaster in the history of the United States, and it hit us right here in the Texas coast. Even though the storm itself has passed, it will take time and significant effort for the people impacted to heal. Many people who were impacted by Harvey have likely experienced a range of feelings–fear, concern, numbness, anger, sadness, grief, and maybe even feelings of appreciation and hope. It may be difficult to truly know how to move forward emotionally.

Thankfully, research shows that humans are incredibly resilient beings even in the face of disaster. The vast majority of people impacted directly by Harvey will recover. That is not to say that the recovery will happen overnight. This was a huge natural disaster, and temporary disruption is to be expected. However, there are some things you can do to propel yourself forward in the process of healing. In particular, start with your go-to stress management and coping strategies that have helped you manage difficult times in the past. Below, we’ve included some research-supported suggestions for coping that we hope will help you to move forward with healing after Harvey.

Give Yourself Time

Being distressed after a natural disaster is normal and to be expected. Allow yourself time to grieve and to process what has happened, and anticipate that this will be a difficult time in your life. Remember that it is the norm to bounce back within a few months of the event.

Seek Social Support

Get support from people who understand what you’re going through and who are willing to lend a hand (or an ear) to help you get through this difficult time.

Benefits of Seeking Social Support. There are three huge emotional benefits to getting connected with your community in response to a natural disaster. First, you will see that you are not alone. Humans are social creatures, and we are hard-wired to be connected with others. Knowing that you are not alone, even when going through hard times, can ease the struggles as you heal. Second, by talking with other Harvey survivors, you may pick up some helpful coping strategies that they have been using to get through these tough times. Third, research tells us that individual resilience, which is the capacity of a person to bounce back from adversity, is dependent on a larger systems-level resilience (i.e., community). In particular, social connection helps to build emotional resilience following disaster (Boon, 2014). As Houston residents, we’ve seen first-hand the awesome, selfless, and inspiring spirit of this city to support one another following Harvey. Get connected with your neighbors and other parts of your community as you heal.

How to Get Support. The most natural instinct for so many who will begin to grieve following Harvey, will be to withdraw and isolate, which, in turn, will lead to further anxiety and significant depression. Instead of withdrawing, consider reaching out. Reach out to family members, romantic partners, friends, neighbors, church or temple staff, others who have lost their homes too, and seek mental health support. If you are asking questions like, “why me?”, “why our home?”, “what do we do next?”; know that you are not alone. On the other end of the phone, across the street, at a shelter, at your church, at your work place, and even at your child’s school, is someone who wants to help you. All you have to do is reach out. Reach out for that support that is waiting. Reach out once, twice, ten times. You are not a burden. Your network of those who want to help you will provide immeasurable comfort, if you let them.

How to Give Support. Let’s also take a moment and speak to those of you who know friends, family members, and even acquaintances, that have lost everything and who may be finding it hard to reach out and ask for help. You are on the front lines of helping and giving. Don’t be afraid to make a phone call, send a text, or stop by. You are not bothering anyone. In fact, you are helping more than you may ever know. You are offering continued hope for someone who is grieving. It is easy to offer help right after a tragedy, but as you go back to your ‘normal’ lives and schedules, don’t forget those who are not as fortunate to be able to do the same. Remember them in two weeks, one month, three months, even six months from now. When you reach out, don’t just ask, “what can I do to help?”, be specific. Ask what they need for dinner. Ask if they need help with dropping or picking up their children from school. Ask if they need to borrow one of your vehicles. Ask if you can do their laundry. Ask what they need from the grocery store. Instead of answering a general question with “we’re ok”, they will be able to tell you what their continued needs are without feeling like a burden to others.

Examine Your Mindset

If you’re ruminating on the difficulty and pain caused by Harvey without being able to take steps forward, this may be a sign that you’re getting stuck. Start to challenge your thinking so you can move toward your goals.

Avoid seeing the problems as insurmountable. It can be easy to feel overwhelmed with the logistical steps needed to move forward after Harvey. If you find that you’re getting stuck because the problems seem too large to handle, take a step back and re-evaluate. Set realistic goals for yourself. Also try breaking each goal into small, digestible pieces that do not feel as overwhelming. For instance, submitting an insurance claim for flood damage can be a huge undertaking…but there are ways to make it feel less overwhelming. Break the task into smaller components–call your insurance company to find out their process for submitting a claim, separate items to be photographed into small groups, photograph items within each group, complete your claim forms, etc. If you find that you get stuck on a task, ask yourself, “what is the smallest step I can take today to move toward this goal?”

Notice how challenging avoidance helps you to feel better.  As you start to build momentum toward solving the tasks ahead of you, your sense of accomplishment will increase. Research shows that engaging in activities that give you a sense of accomplishment boosts mood and counteracts feelings of depression or sadness.

Take a news break. Oftentimes, the media covers the worst case scenarios, which can skew your mindset on what’s really happening for you. If you find that watching the news is making you feel worse or is keeping you from taking steps forward, take a break from it. Either focus your energy on taking care of yourself or on solving a problem ahead of you. Those are actions that will help you to feel better.

Accept the circumstances that cannot be changed. Not every problem is solvable. There are likely circumstances that have occurred due to Harvey that don’t have clear solutions. For instance, you may have lost special photographs or prized possessions as a result of the flood damage. Items like these are not exactly replaceable, and that is truly painful. Acknowledge that pain and grieve what was lost. Ultimately, allow yourself space to heal and focus on what you can control.

Be Kind to Yourself

This is a difficult time, and it is especially important to focus on taking care of yourself.

Look for opportunities of self-discovery.  Connect with your values and what is really meaningful to you in your life. Oftentimes, significant life events cause people to examine their lives in new ways and to get more connected with what really matters to them. Take this time to learn more about yourself. Perhaps you are passionate about your environment or community, or you want to reconnect with friends and family, or maybe you want to enroll in a course or training on an area of interest. Get connected with what really matters to you.

Be self-compassionate. Dealing with the aftermath of Harvey is difficult and stressful. Be kind to yourself by acknowledging how hard it is and by comforting yourself. Try treating yourself as you would treat a close friend or loved one going through a hard time. Let yourself know that “you’re doing the best you can” or “today was difficult, but you’ll get through this challenge.” Check out this website for some guided meditations, self-compassion exercises, and information on self-compassion from its leading researcher (**link http://selfcompassion.org/**).

Get engaged in healthy coping behaviors. Although it may be difficult right now, try to focus on eating a balanced diet, drinking water, exercising, regulating sleep, and doing meditation or other relaxation techniques known to help manage stress. Also think about using other healthy coping strategies that have worked for you in the past, because those are most likely to benefit you now. Avoid drinking alcohol or doing drugs to cope, because they are depressants and can de-motivate you for taking steps toward meaningful goals.

Develop or re-engage in a routine. Your routine has been disrupted due to Harvey. Do your best to move forward by creating some routine structure to your day. Our brains love predictability and structure, so create that for yourself. Try to wake up and go to sleep at a regular time each day. Establish certain things you want to do on a daily or weekly basis. Ideally, include some healthy coping strategies (i.e. taking steps toward goals, taking care of yourself, doing things you like to do) as part of your routine.

Get Support from Professionals

If your emotional reaction to Harvey is above and beyond what would be expected OR your symptoms of distress last longer than 6 months, getting help from a professional is likely warranted. Look into options for support groups or individual therapy in your community. If you’re interested in joining a support group, try to find one that is facilitated by psychologists or other trained professionals. Similarly, if you’re interested in individual therapy, try to find psychologists or trained professionals who use evidence-based approaches in their work. Recommended approaches include cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), solution-focused therapy, and problem-solving therapy. Depending on your symptoms and areas of concern, it may also be helpful to find a therapist specializing in grief and loss or trauma. You can find psychologists near you by contacting the Texas Psychological Association: http://www.texaspsyc.org/.

Ways to Seek (or Provide) Support through Organizations

In addition to these coping strategies, numerous organizations throughout the greater Houston area are available to provide resources and help move Houstonians toward regrowth. Research also shows that helping others can have a profound impact on health and happiness (Dunn et al., 2008; Post, 2005). The following are a few of the resources available, whether seeking support for yourself and family, or providing it for others.

To find a shelter, call 800-RED-CROSS or visit: www.redcross.org/shelter

For food assistance, contact the Houston Food Bank at 832-369-9390 or visit: www.houstonfoodbank.org/services/if-you-need-food

To find family and friends or to register yourself as safe, visit the American Red Cross at: www.safeandwell.communityos.org/cms/

To report a missing child, contact the National Emergency Child Locator Center at: 1-866-908-9570

To search for a lost pet, contact the Houston SPCA at: http://www.houstonspca.org/harvey/

To apply for disaster assistance, call 1-800-621-3362 or visit: www.disasterassistance.gov

To donate to the Hurricane Harvey Relief Fund, established by Mayor Sylvester Turner, text HARVEY2017 to 91999 or visit: https://ghcf.org/hurricane-relief/

Finally, if you are unsure where to donate, the following website is an excellent resource as it rates charities based on transparency, accountability, financial health, and overall effectiveness at distributing donations: https://www.charitynavigator.org/

Coming Together with Hope and Healing

This is a difficult time right now, and it will take time and effort to heal. We’ve provided some evidence-based suggestions for moving forward with the healing process. All in all, focus on what you can control, seek out support, and continue to take steps toward solving problems and taking care of yourself. Evaluate what’s working and what’s not working so you can continue to work toward your ultimate goals. This is a time for connection and growth. This is a time for healing and hope.

Resources

This article was adapted from American Psychological Association (APA) and Texas Psychological Association (TPA) disaster relief resources: http://www.apa.org/helpcenter/

Other Resources

Boon, H. J. (2014). Disaster Resilience in a Flood-Impacted Rural Australian Town. Natural Hazards, 71(1), 683-701.

Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319(5870), 1687-1688.

Post, S. G. (2005). Altruism, happiness, and health: It’s good to be good. International Journal of Behavioral Medicine, 12(2), 66-77.

Common Myths and Misconceptions about Trichotillomania: Part 2 Functions of Pulling and Treatment

By Hannah Sommer Garza, Ph.D.

Welcome back to the second part of our two-part series on myths and misconceptions about trichotillomania from a trichotillomania treatment provider. If you missed Part 1, check out our previous post (http://psychologyhoustonpc.com/2017/08/03/common-myths-and-misconceptions-about-trichotillomania-part-1-what-is-it-who-gets-it-and-why/ ) on myths about what trichotillomania is, who experiences it, and why. Today’s post will focus on misconceptions about reasons for pulling behaviors and how trichotillomania is treated. The hope with this two-part series is to dispel some common myths and misconceptions about trichotillomania, to pass along up-to-date information, and to reduce stigma associated with the lack of awareness about trichotillomania and trichotillomania treatment.

As a reminder of some of the basics, trichotillomania is also known as hair-pulling disorder, TTM, or “trich.” It involves the recurrent pulling out of one’s own hair despite attempts to stop pulling. It is considered a Body-Focused Repetitive Behavior (BFRB), similar to other behaviors like skin-picking and nail-biting. Now let’s keep dispelling some of these pesky myths.

Myth:  People with Trichotillomania are Pulling to Get Attention

This couldn’t be further from the truth. Often due to feelings of shame and embarrassment, many individuals with trichotillomania go to great lengths to hide their trich from others. In reality, the majority of people with trichotillomania attempt to REDUCE attention they receive related to their trich, not get more of it. Furthermore, research has shown that pulling can occur outside the individual’s awareness (also known as “automatic” pulling). It is not being used as some sort of manipulative strategy to get attention from others.

Myth:  Trichotillomania is a form of self-harm

The big take-home here is that it’s all about function. For individuals with trichotillomania, the intention of the pulling is NOT to hurt oneself. In contrast, that is the intention for self-harm. The injuries or damage caused by hair-pulling are merely a result of pulling and not the goal of pulling. Furthermore, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) distinctly categorizes self-harm as separate from trichotillomania, using language like “the behavior is not better explained by another mental disorder or medical condition (e.g. trichotillomania).” Trichotillomania is specifically mentioned in the DSM-5 as a rule-out for self-harm, implying that they are distinct from each other.

Functions of trichotillomania pulling are usually sensory related (e.g. seeing a hair out of place, or feeling discomfort with a coarse hair), emotionally related (e.g. pulling more when feeling nervous, bored, or stressed), and/or cognitively related (e.g. “I will just pull one more” or “pulling this eyebrow hair will ‘fix’ my brows”). The function of NSSI pulling is to harm oneself.

Myth:  People with Trichotillomania can “Just Stop”

This myth always reminds me of a comedy sketch with Bob Newhart called “Stop It” (https://www.youtube.com/watch?v=Ow0lr63y4Mw). It’s a parody of a therapy session, where the provider’s treatment for the patient’s concern (not trich-related) is to “just stop it.” As you can imagine, it’s over the top, not very therapeutic, and has no impact on helping the patient to “stop” her unwanted concern. All silliness aside, I imagine that this is what many people with trichotillomania experience when people tell them to “just stop” pulling. It’s just not helpful.

Many factors can influence pulling to make it a difficult behavior to change. Researchers suspect a genetic component, as many BFRBs cluster together within families. Overriding genetics is no easy task without evidence-based techniques for doing so. Additionally, people with trichotillomania often describe an enjoyable/soothing/calming sensation that occurs during pulling. I often think of it as similar to eating chips and queso (my great diet weakness). I may be very consciously aware that I am breaking my diet as I continue to reach for chip after chip after chip after chip…but boy do they taste good in the moment! The long-term effects of pulling are very difficult to keep in mind when the body is experiencing immediate “rewards” while pulling. Trichotillomania treatment involves the patient and therapist working together to identify targeted ways to prevent and manage urges for pulling. It takes a lot of work to change a behavior like pulling, and saying that the person can “just stop” is extremely invalidating.

Myth:  Once with Trich, Always with Trich

Trichotillomania is a Body-Focused Repetitive Behavior (BFRB; http://bfrb.org/ ). Other common BFRBs include skin-picking (excoriation), nail-biting (onychophagia), and knuckle-cracking. Evidence suggests that it is not uncommon for individuals to change target BFRBs throughout development or to engage in multiple BFRBs simultaneously. For instance, someone may start pulling eyebrows as a child, then focus more on chronic skin-picking during adolescence and early adulthood, and may even shift back to trichotillomania during adulthood. Researchers are actively attempting to unveil reasons for these shifts.

Approximately 23% of people with trichotillomania have a relapsing and remitting course of symptoms with at least one period of complete symptom remission, according to a retrospective report study (Meunier, Tolin, Diefenbach, & Brady, 2005).

Another way trichotillomania can change for a person is through trichotillomania treatment. Will a flip be switched and the urges disappear? Unlikely. This is why learning skills in treatment for how to prevent and manage pulling urges is a powerful way to change pulling behaviors.

Myth:  All Treatments are Created Equal

The Trichotillomania Learning Center’s Scientific Advisory Board, a panel of expert clinicians and researchers, have identified specific behavioral treatments (http://bfrb.org/storage/documents/Expert_Consensus_Treatment_Guidelines_2016w.pdf ) that have evidence for treating trichotillomania. Specifically, Cognitive Behavioral Therapy (CBT) and its related therapies are recommended.

CBT is a type of therapy that involves an identification of problematic thoughts, feelings, and behaviors, and a focused training in how to make them more helpful. For more information on CBT, check out our former blog post (http://psychologyhoustonpc.com/2016/06/01/all-therapy-is-not-created-equal/ ). Several treatments fall within the umbrella of CBT treatments, including Habit Reversal Therapy (HRT), Comprehensive Behavioral Treatment (ComB), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT).

If you or a loved one are seeking treatment for trichotillomania, be on the lookout for words like “cognitive behavioral therapy (CBT),” “behavior therapy,” “habit reversal,” “third wave treatments,” “dialectical behavior therapy (DBT),” or “acceptance and commitment therapy (ACT).” The provider should also be familiar with body-focused repetitive behaviors and the Trichotillomania Learning Center. If they’re not using some language like this, then they may not be best trained to provide trichotillomania treatment.

Although the main treatment for trichotillomania is CBT, medication can also be helpful. There is no one medication that works for everyone with trichotillomania, but some medications have been found to reduce symptoms for some people. Medications are often used to relieve emotional symptoms that may be related to pulling for some people. Selective Serotonin-Reuptake Inhibitors (SSRIs) are often used to address symptoms of anxiety and depression that may be associated with pulling. There is preliminary support for N-Acetylcysteine (NAC), an amino acid working on the glutamate system (http://jamanetwork.com/journals/jamapsychiatry/fullarticle/483113) to reduce trichotillomania symptoms. Over 50% of individuals in the cited trial found significant improvement in trichotillomania symptoms over the course of 12-week NAC treatment. However, to date, no medication has been approved by the Food and Drug Administration (FDA) for the treatment of trichotillomania or other BFRBs. Scientists are working to better understand trichotillomania and to enhance its treatments. Check out this website (https://www.bfrb.org/research-programs-news/bpm) if you’re interested in learning more about the research initiative.

Other treatments do not have enough research support to be currently recommended by trichotillomania experts as stand-alone treatments. This includes approaches such as hypnosis, diets, massage, acupuncture, and electric stimulation.

Conclusions

I’m hopeful that this two-part blog series on myths and misconceptions about trichotillomania has been helpful, and that you can help to spread the truth about trichotillomania and its treatment. The unfortunate truth is that there is still a lot that we don’t know about trichotillomania and its successful treatment. If you’re at all interested in learning more about the research initiative or even getting involved in a study near you, I encourage you to check out the website linked above. For more information about trichotillomania, you can also check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs (http://bfrb.org/).

Resources

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.

Grant, J. E., Odlaug, B. L., & Won Kim, S. (2009). N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania:  A Double-blind, Placebo-Controlled Study. JAMA Psychiatry, 66(7), 756-763.

Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.

Meunier, S. A., Tolin, D. F., Diefenbach, G. J., & Brady, R. E. (2005, November). Severity and course of hair pulling symptoms across the lifespan. Paper presented at the Annual Meeting of the Association for Behavioral and Cognitive Therapies, Washington, DC.

Woods, D. W. & Houghton, D. C. (2014). Diagnosis, Evaluation, and Management of Trichotillomania. Psychiatric Clinics of North America, 37(3), 301-317.

Common Myths and Misconceptions about Trichotillomania: Part 1 What is it? Who Gets it, and Why?

Written by Hannah Sommer Garza, Ph.D.

As a trichotillomania (trick-o-till-o-may-nee-uh; TTM or “trich”) treatment provider, I have come across many myths and misconceptions about trichotillomania (hair-pulling disorder) from new clients, family members of new clients, other people in my social network, and even other medical and psychological treatment providers. “That’s where people believe there are bugs in their hair, so they pull to get them out, right?” I’m telling you, I feel like I’ve heard it all!

While I happily dispel myths and provide more accurate information in those situations, I have come to realize how little most people know about trichotillomania in general. I also think that the existence of these misconceptions can lead to individuals with trich feeling stigmatized at home, with friends, at school/work, and with their doctors/hairstylists/coaches (fill in the blank). I’m hopeful that by sharing up-to-date information, we can decrease stigma associated with trichotillomania and the pursuit of trichotillomania treatment. I believe that knowledge is power, and I hope that this post gives more power to individuals with trichotillomania.

What is Trichotillomania?

Trichotillomania, also known as hair-pulling disorder, is the repetitive pulling out of one’s hair. Pulling sites vary from one individual to the next with trich, and they can be from anywhere on the body where hair exists (e.g. scalp, eyebrows, eyelashes, arms, legs, pubic area, chest, stomach). Trichotillomania is considered a diagnostic mental health disorder, and it is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an Obsessive-Compulsive and Related Disorder. Trich is also considered a body-focused repetitive behavior (BFRB)  http://www.bfrb.org/learn-about-bfrbs alongside excoriation (skin-picking), and onychophagia (nail-biting).

According to the DSM-5, diagnostic criteria for Trichotillomania are:

  1. Recurrent pulling out of one’s hair, resulting in hair loss

  2. Repeated attempts to decrease or stop pulling

  3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

  4. The hair pulling or hair loss is not attributable to another medical condition (e.g. a dermatological condition)

  5. The hair pulling is not better explained by the symptoms of another mental disorder

Now that we’ve covered the basics, let’s get to the myths and misconceptions.

Myth:  Trichotillomania is Rare

Nope. Research shows that about 1 or 2 in 50 people have trichotillomania at some point during their lifetime. That means that of the approximate 325 million people in the United States (according to the U.S. Census Bureau), around 6.5 million to 13 million (MILLION!) people will meet diagnostic criteria for trichotillomania at some point during their lifetime. As an anecdote, since talking openly with family and friends about treating trichotillomania and other BFRBs, I have had people come out of the woodwork to tell me that they have trich, have a relative with trich, or know someone with trich. It’s a lot more common than you might think.

One reason trichotillomania may seem to be a rare problem is that many individuals with trich feel shame, embarrassment, or other undesirable emotions related to disclosing their trich to others. Social and cultural messages about hair, beauty, and mental strength can contribute to this too. Many individuals with trichotillomania go through great lengths to hide it, and may do so by wearing makeup, hairpins, hats, headwraps, or other concealing clothing. It is also common for individuals with trichotillomania to avoid doing certain activities that may lead to them being “discovered” such as attending sleepovers, going outside on a windy day, going swimming, going to the hair salon, etc. Taken together, the pressure to stay silent about trich due to stigma and people’s savvy with concealment make trichotillomania seem more rare than it really is.

Myth:  Only Girls Have Trichotillomania

Boys can definitely have trichotillomania. In fact, rates of trichotillomania are similar for boys and girls during childhood. They become much more skewed toward girls (80-90% of cases) in adulthood. It is suspected that women/girls are much more likely to seek professional help for trichotillomania compared to men/boys. A study found similar rates between men and women in the community (i.e. not treatment-seeking) and higher rates of women with trichotillomania in clinical settings (i.e. treatment-seeking). One theory is that men are better able to conceal their trichotillomania by shaving their face or head. In the U.S., people may not think twice about seeing a man with a shaved head, but a woman with a shaved head may get all kinds of odd looks or questions. “Do you have cancer?” Thus, societal norms about hair and hair loss may influence women to seek treatment more compared to men. The jury is still out, though, and more research is needed to give us a definitive answer about reasons for gender differences seen in epidemiological studies. Regardless of differences in rates, studies generally show that trichotillomania presentation is similar for men and women and response to treatment is similar for men and women.

Myth:  Trichotillomania is the Result of Trauma

There is no clear evidence to support this myth. About 50% of people with trichotillomania report some sort of negative event or trauma occurring in their lives around the time they started pulling…BUT those events include common occurrences such as changing schools, moving to a new city, or parents divorcing. The other 50% deny experiencing ANY negative events when they started pulling. If trichotillomania was truly the result of trauma, trauma would be reported in much higher numbers. Additionally, many people experience negative events throughout their lives and do not go on to develop trichotillomania. Similarly, many people have trichotillomania without previously experiencing significant negative events. Ultimately, the research shows that there’s just not a clear link of trauma predicting trichotillomania. The causes of trichotillomania are still being researched, but the explanation appears to be much more complicated than one root cause. Furthermore, research suggests that there may be a related genetic component. Many BFRBs and Obsessive-Compulsive Related Disorders and sub-clinical features of these issues tend to cluster together within families.

Myth:  Trichotillomania is OCD

I hear this one a lot, so let’s set the record straight. Trichotillomania is in the Obsessive-Compulsive and Related Disorder section of DSM-5 because there are some noteworthy similarities among disorders in that section. The main similarities are that both people with trich and those with OCD report having compulsive urges and repetitive behaviors. Otherwise, contextual and functional subtleties differentiate the two.

OCD obsessions are intrusive thoughts or images that are distressing. “Obsessions” about pulling in trichotillomania are more likely to be associated with focused pulling, or purposeful pulling within the individual’s awareness. For instance, thoughts associated with urges like “this kinky hair needs to go” or “I will only pull one more” may precede pulling behaviors. These “obsessions” in trichotillomania would only relate to hair-pulling. If someone has “obsessions” about hair pulling AND another topic (e.g. germs), then it is possible that they meet diagnostic criteria for both trichotillomania and OCD. Studies have found approximately 6.5%-10.7% of individuals with trichotillomania to have a comorbid diagnosis of OCD.

An OCD compulsion is a repetitive mental act or behavior used in response to an obsession. For example, washing one’s hands extensively or repetitively (compulsion) in response to the fear of becoming ill (obsession). For these reasons, it is understandable why many people might get confused that repeated attempts to pull out one’s own hair is a “compulsion.” However, there are some noteworthy differences. With trichotillomania, there is an element of sensory self-soothing. Many people with trichotillomania report having an enjoyable feeling or feeling of relief during pulling (and often feelings of regret after pulling). In contrast, people with OCD are distressed by their obsessions and compulsions. Ultimately, it is important to understand the content of “obsessions” and the functions of pulling behaviors and other possible “compulsions” to differentiate between trichotillomania and OCD.

Conclusion

Researchers continue to explore features of trichotillomania in order to clarify some of the existing myths and misconceptions, and to find the best ways to treat trichotillomania and other BFRBs. There is a major multi-state study trying to do just that. If you’re interested in learning more or getting involved with the research initiative, check out the BPM Research Initiative  http://bfrb.org/research-programs-news/bpm.

Now that you know a little more of the truth about trichotillomania, you can help to spread the word and spread the knowledge. Let’s work together to reduce trichotillomania stigma. Look for our next post on more myths and misconceptions about trichotillomania, especially related to the reasons for pulling and treatment/recovery options. For more information about trichotillomania, check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs http://bfrb.org/ .

Resources

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.

Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.

Mouton-Odum, S., Goldfinger Golomb, R. (2013). A Parent Guide to Hair Pulling Disorder:  Effective Parenting Strategies for Children with Trichotillomania. Goldum Publishing.

Grief After a Violent Death

I recently attended the 10th Biennial Bereavement Conference presented by Baylor Scott & White Health Care System.  The conference was titled “Coping with Bereavement Complications,” and among the invited speakers was Dr. Edward K. Rynearson, M.D. who presented on the treatment of traumatic grief after violent death.

On a yearly basis in the U.S., violent deaths (suicide, homicide, and most accidental deaths) total between 180,000 to 200,000 and comprise about 5 to 7% of total deaths.

In 2014 for example, about 2.6 million people died in the U.S.  Of these, about 130,000 deaths were caused by unintentional injures from accidents (4th leading cause of death), 42,000 suicides (10th leading cause of death), and about 16,000 homicides.  In 2014 then, about 198,000 deaths, or about 7% of all deaths, were unnatural, sudden, violent, and in many cases, preventable.

These types of violent losses give rise to a grief process that is more likely to be complicated.  To be bereaved by such a loss is to feel helpless, powerless, and to question “why” this happened. It is also to feel deep pain over the thought that our loved one died in such a horrific manner, alone, without our presence nearby. This is to say that there are some unique dimensions to grief after the loss of a loved one to a violent death.  Violent dying defies reason.  One can’t make meaningful sense out of it by thinking about it over and over again.  This is a death that never should have happened, and mourners are likely to be plagued by intense, highly disturbing visual imagery of what they imagine happened to their loved one.

To get a sense of the scope and intensity of the pain of these types of losses, 30 to 50% of mourners will experience depression or significant anxiety in the first year after such a loss.  Those at highest risk are mothers who have lost a child (a full 30% of whom will display PTSD symptoms a full five years after the loss).  Excruciating suffering is normal (for a time) after such a loss.

A particular form of grief therapy is helpful to many bereaved people in such a situation.  Initially, interventions are designed to assist in the reduction of acute distress.  In this phase, attention is paid to creating coping strategies to manage one’s own emotional and body-focused expressions of distress (i.e., self-regulation).  After self-regulatory skills are more readily available to a person, the narrative of the person who died, their relationship to the bereaved, and the manner of dying is processed, including commemorating the person for whom they were while they were alive.  Over time, the focus shifts to reengaging in life in ways that are personally meaningful.

Medications may be helpful for the depressive features and anxiety, but they will not help much with the grief component underlying the distress.

Despite the shock, horror, agony, despair, and utter shattering that occurs in individuals and families after the death of a loved one to a violent death, experience teaches that one can (and most likely will) prevail in the long run.

Dr. Rynearson’s website vdbs.org: Violent Death Bereavement Society has a tremendous amount of valuable information, including research findings and grief and bereavement resources.

Holding Steady in an Uncertain World

With the recent events that have taken place in this country it is hard to imagine how and when these acts of violence will cease. It can be difficult to feel safe and calm when the world is painting a different picture. National events like those in Baton Rouge and Dallas can cause anxiety for both children and adults. Are we safe? When will the violence stop? When will the next tragedy happen? Where will it happen? These are all questions many of us have asked ourselves over the past couple of weeks. If your thoughts are racing with questions like these, know that you are not alone.  In times of stress in our country it is important to take a step back and remind ourselves that we are all responsible for our own actions and choices, and we must remain calm and steadfast when external situations make us feel out of control.

So, what can you do? Don’t worry, if you are concerned about the state of the world, or struggling with anxiety in general, there are steps you can take to overcome it. First things first, you are safe. You are likely reading this blog from your home, office, or on your smart phone while running errands. One of the best things you can do to create stability in your life is to maintain your routine. Maintaining your everyday routine will allow you to feel a sense of control in an ever changing world. Along the same lines, it is also important to separate out the things you can control from those you cannot. If you can focus on the specific difficulties in your life that you can control, you usually end up feeling much better about everything else. The interesting thing about anxiety is that once you let go of wanting to control everything and just focus on living, your anxiety will decrease. If your anxiety about the state of our country still feels intense—take action! Write a letter to your local congressman or state senator, engage in a random act of kindness the next time you are at Starbucks, or take some baked goods to your local police station or firefighters. Once you do something productive and proactive you will notice that you will begin to feel better. Your act of kindness will also help others to feel better. And last but not least, spend some time with your family and loved ones. They will remind you of not only what is important in your life, but also that people do love each other.

Dr. Rosie

To cope or not to cope…

When you think of “coping” with a problem, how do you define that term?  Here are three definitions of “cope.” (1) To deal with and attempt to overcome problems and difficulties, (2) To deal effectively with something difficult, (3) To deal successfully with a difficult situation.  Notice that in each of these definitions of coping, it is not simply enough to “deal with” a problem; the key is to do so in such a way as to “overcome” it “effectively” or “successfully.”

When you become aware of a problem in your life, what do you do?  The problem might be a troubling present situation, or may be one that is coming, perhaps just around the corner.  Viktor Frankl, a famous doctor, writer and concentration camp survivor, teaches us that there are some situations in which there is absolutely nothing we can do to alter a painful external situation (e.g., being in a concentration camp, being held hostage, etc.), and that in such a situation, one can still exert the “last of the human freedoms,” to alter one’s attitude toward one’s situation and one’s suffering.  However, in most situations, we can most certainly make decisions and act in ways to make our problems dissipate or resolve.

Yet how many times do we find ourselves doing counterproductive things?  We want for the situation to get better and to feel better, but we hesitate to do what is required of us in that situation.  We make the mistakes of being in denial, avoiding, procrastinating, etc. While these avoidance techniques may help you to (temporarily) feel better, what they are also doing is allowing the problem to fester and perhaps get worse.

So, we need to get clear on what exactly the problem is, its’ scope and dimensions, and to do that we need to face it.  After all, how can we solve a problem if we won’t allow ourselves to understand it.  The goal is to figure out a solution, a way forward, to devise a plan, and then to execute the required steps to get there.  So, ask yourself when you come across a situation that is a challenge or problem, “Do I want to solve this, or, not?”  It seems to me that it is far preferable to do all that one can do to alter the actual situation so that the problem is successfully managed.   We can all learn to cope better by sharpening our problem-solving skills, but remember, the most important idea here is that one must first be willing to face and directly confront our problems.  If you will allow yourself do this, you are already on the road to coping better.

Cheers,

Steve Bailley, PhD

All Therapy Is Not Created Equal

Ask anyone on the street what they imagine when they hear the words “therapy” or “psychologist” and you’ll likely hear something along the lines of lying on a long couch, talking about the past, and some form of analysis, whether it be your dreams, childhood, unconscious, or relationship with your mother.

When new patients come in for therapy, they often do not know what to expect. And they often come in with these preconceptions. However, when it comes to mental health treatment, there is a significant amount of variety, from level of training (masters, doctorate) to type of provider (counselor, social worker, physician, psychologist) to treatment approach (psychoanalysis, cognitive behavioral therapy).

We know from research that the single most important factor associated with treatment success is the strength of relationship between patient and therapist, something called therapeutic alliance. However, therapeutic alliance by itself is only one piece of the puzzle, as there are a number of other factors also associated with treatment success. One of these factors is treatment approach, also called theoretical orientation. This refers to how a therapist generally understands and explains a patient’s symptoms or difficulties, and importantly, guides how the therapist will provide treatment.

Cognitive behavioral therapy (CBT) is a treatment approach that assumes emotions, thoughts, and behaviors are connected and influence one other. Patients typically come in for therapy because of unpleasant or painful emotions, such as anger, depression, anxiety, or worry. But the problem is this: Telling someone, including ourselves, not to feel a certain way has little or no effect. Just think of the last time you were angry and someone asked you to calm down, or feeling depressed and told you to cheer up.

Put simply, we can’t change the way we feel just by choosing to feel differently. However, we can change the way we think and we can change the way we behave. And because these are related to our emotions, we can target how we feel.

For example, say your friend is feeling depressed. Simply telling them “don’t be sad” wouldn’t have much success. But suppose your friend is also having thoughts such as “I can’t seem to do anything right,” “things will never get better,” or “I’m a failure.” And suppose they’re isolating themselves, not exercising, or socializing with friends or family. It’s no surprise these patterns would make your friend’s depression worse.

A cognitive behavioral therapist would challenge these thoughts: Is it really true you can’t do anything right? What evidence do you have that nothing will get better? Have things ever been difficult in the past and actually did get better? And what does being a failure even mean? Living under I-10 addicted to heroin? The therapist would also target the behaviors maintaining depression. In-between sessions, they would assign homework to increase more adaptive behaviors, perhaps call one friend each day, walk/run around the block three times this week, or engage in activities they used to find pleasurable.

The take home message is this: Our thoughts and behaviors are not written in stone. They are malleable. Changeable. And behaviors can be learned. Unlearned. Relearned. And it is this very process of change that lies at the core of cognitive-behavioral therapy, and why it is so often successful.

Tyson Reuter, Ph.D.

New Beginnings

Change is hard, but beautiful. After 17 years of being in the same office practicing psychology, we are moving. Not only will we have a new location, but we also have a new practice. Psychology Houston, PC was a concept to bring evidence-based treatment to Houston in a cohesive and direct way. All of us in the practice specialize in treating people with diverse backgrounds and issues utilizing state of the art treatment that has been proven to work in research studies. Treatment is effective, but conducted in a way that really focuses on the therapeutic relationship. In the end, it doesn’t matter what treatment you are doing, if your client does not feel safe, trust in the therapist, and comfortable in the relationship, the treatment will likely not work. So as I packed up my office yesterday I felt sad, but excited for this new beginning. Change is hard and creates many questions and fears about the unknown. As I teach my clients, I am focusing on embracing the unknown, going boldly into the future, curious about how things will unfold over the years to come. Thanks to everyone who has contributed to this move and to all of my clients who have supported my practice over the years, to you all I am truly grateful.

Suzanne Mouton-Odum, Ph.D.