My wife and I recently became vegetarians.  Well, she started using the word “vegetarian” to describe already never eating meat.  For me it required more of a lifestyle change.  I grew up on a small beef cattle farm, so I was used to the idea that you could grow meat the same way you grow vegetables.  Throughout my life it always felt as if meat was how one defined the difference between a “snack” and a “meal”.  So as part health experiment and part social consciousness attempt, I have given up meat for the time being.

At first I felt like I was denying myself something purely enjoyable.  I’m used to it, I like it, so why don’t I just do it?  Saying, “I want to change” or “I’m not happy with the consequences” doesn’t seem to be much comfort.  However, nearly 4 months into this experiment, I now get what can only be described as a “resistor’s high” – an addictive satisfaction derived from choosing not to eat meat.

The other night I had dinner at someone’s house and literally had to stare down an absolutely gorgeous pork chop fresh off the grill.  It appeared to be taunting me as I ate the otherwise perfectly delicious pasta and veggie sides, but I made a conscious effort to reserve analyzing the situation until after dinner.  As it turns out, it felt great not to have eaten the pork chop because it felt great to have committed to a choice.  I even get a similar buzz from locating and ordering the vegetarian options on restaurant menus.  So what is this phenomenon?

When you do something for a long time without putting much thought into it, you begin to adopt it as part of your worldview.  I live in a world where meat is something to be eaten every day.  So not eating meat every day seems like a different world.  Similarly, people who grow up engaging in body-focused repetitive behaviors like Trichotillomania (compulsive hair pulling) and Dermatillomania (compulsive skin picking) often fail to identify these behaviors as problematic until the consequences are impossible to ignore.  They live in a world where hair gets pulled and skin gets picked.  If you pull and/or pick every day, and it feels good, how do you find the strength to stop only because you know you should?

Trichotillomania (TTM) and Compulsive Skin-Picking (CSP) function as both behavioral addictions and Obsessive-Compulsive Spectrum Disorders.  As an addiction, a behavior is repeated for a reward, but the reward becomes increasingly difficult to obtain and the behavior continues to be repeated to excess.  The good feeling that comes from picking one’s skin or pulling one’s hair is soon followed by a sense of shame and helplessness as the brain prepares itself to motivate for the next fix.

Viewed from the perspective of obsessive-compulsive spectrum disorders, both TTM and CSP sufferers have distorted thoughts about their ability to experience and  resist uncomfortable urges.  The desire to engage in the addictive behavior is made greater by the fear that feeling and resisting the urge will be overwhelming and unmanageable.  Perhaps as a more familiar analogy, a compulsive hand washer may intellectually understand when washing is unnecessary, but feels that the anxiety produced by not washing is too painful to be tolerated.

Treatment for TTM and CSP follows two parallel Cognitive Behavioral Therapy (CBT) protocols to address both the obsessional urge and the behavioral addiction:

• Habit Reversal Training (HRT) uses a straight-forward pragmatic approach of blocking the addictive behavior with non-destructive alternatives.  This could involve anything from making picking too difficult by wearing gloves, to covering mirrors to aid in resisting checking, to occupying the hands with a competing stimulus (such as a stress ball or piece of string).  HRT also involves strategies for helping the individual with TTM or CSP become more aware of the behavior when it might otherwise be performed absent-mindedly.

• Mindfulness-Based Cognitive Behavioral Therapy uses a combination of mindfulness, cognitive restructuring, and behavioral conditioning:

~ Mindfulness – learning to acknowledge that sensations, feelings, and thoughts about pulling and picking are inevitable, normal occurrences that do not intrinsically mean you have to pull or pick;

~ Cognitive Restructuring – identifying the thoughts, feelings, and sensations that precede the behavior and challenging the distorted thoughts that make the behavior more difficult to resist;

~ Behavioral Modification – while treatment for TTM and CSP typically does not involve exposure the way it does in the treatment of Obsessive Compulsive Disorder (OCD) and other OC spectrum disorders, it does involve practicing the ability to tolerate the anxiety that comes from experiencing and resisting an urge.

Finding your personal “resistor’s high” will likely mean employing all of the above techniques simultaneously.  To learn to love the feeling of not picking and pulling, you need to experience it for extended periods.  People tend not to enjoy training for marathons, but they do appear to enjoy completing them.  The early work toward overcoming TTM and CSP involves regular confrontation with discomfort, and faith that your resitor’s high will come in time.

By using HRT to interfere with your ability to pull or pick, mindfulness to accept your urges as they are, and cognitive restructuring to address your  distorted beliefs about your ability to resist those urges, you can then practice absorbing and digesting the urge.  Taking the urge in and letting it wash over you becomes increasingly rewarding when paired with resisting the urge over time.  In the end, the behavioral addiction can be replaced by fascination with one’s own ability to emerge victorious from inner struggles.

•Jon Hershfield, MA, is a psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions, including Trichotillomania and Compulsive Skin Picking.  He can be contacted jon@ocdla.com.

Fortunately, researchers are starting to learn more about the origin of the disorder and possible treatments.  One recent study conducted at the University of Minnesota School of Medicine in Minneapolis has uncovered a promising potential avenue for future treatment of this condition.

The research, published in the Archives of General Psychiatry (July 7, 2009), found that an amino acid, N-Acetylcysteine, was successful in significantly reducing Trichotillomania symptoms in study participants.  Fifty-six percent of those participating in the study were “much or very much improved” after a nine week course of taking 1,200 to 2,400 milligrams of N-Acetylcysteine per day, compared to only 16% of participants in the control group taking a daily placebo.  And those frustrated by expense of most psychiatric medications will be happy to know that N-acetylcysteine can be readily purchased at most health food and vitamin stores.

On a different front, a 2006 study done at Duke University in North Carolina identified two gene mutations that appear to be linked to the development of Trichotillomania.  The research team at Duke focused on 44 families in which at least one person had Trichotillomania.  They found that these two gene mutations were present in those family members with Trichotillomania, while the gene mutations were not present in other family members who did not have the condition.

These two studies auger well for those suffering with Trichotillomania, and by extension, those with similar impulse control conditions such as Dermatillomania (compulsive skin picking), and Onychophagia (compulsive nail biting).  And though a “cure” is likely years off, it seems safe to say that researchers are starting to unravel the complex web of interacting factors that appear to be involved in these conditions.

•Maria Cervantes, LCSW, is a Licensed Clinical Social Worker at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions.  She can be contacted maria@ocdla.com.