Wikipedia

Trichophagia

Trichophagia is a form of disordered eating in which persons with the disorder suck on, chew, swallow, or otherwise eat hair.[1] The term is derived from ancient Greek θρίξ, thrix ("hair") and φαγεῖν, phagein ("to eat").[2] Tricho-phagy refers only to the chewing of hair, whereas tricho-phagia is ingestion of hair, but many texts refer to both habits as just trichophagia.[3] It is considered a chronic psychiatric disorder of impulse control.[4] Trichophagia belongs to a subset of pica disorders and is often associated with trichotillomania, the compulsive pulling out of ones own hair.[1] People with trichotillomania often also have trichophagia, with estimates ranging from 48-58% having an oral habit such as biting or chewing (i.e. trichophagy), and 4-20% actually swallowing and ingesting their hair (true trichophagia). Extreme cases have been reported in which patients consume hair found in the surrounding environment, including other people's and animals' hair.[5] In an even smaller subset of people with trichotillomania, their trichophagia can become so severe that they develop a hairball.[6] Termed a trichobezoar, these masses can be benign, or cause significant health concerns and require emergency surgery to remove them. Rapunzel syndrome is a further complication whereby the hairball extends past the stomach and can cause blockages of gastrointestinal system.[7]

Trichophagia
Pronunciation
  • tricho-phag-ia
SpecialtyPsychiatry
Symptomsnausea, vomiting, abdominal pain, and hair loss
ComplicationsTrichobezoar, Rapunzel syndrome

Trichophagia occurs instinctively in many animal species and is not always a sign of a psychological disorder. Cats practice trichophagia as a form of regular grooming. [8]

Signs and symptoms

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Signs and symptoms of trichophagia are variable depending on the individual's behavior patterns. Trichophagia's loosest definition is the putting of hair in one's mouth, whether that be to chew it or suck on it, with the strictest definition being that the hair is swallowed and ingested. Trichophagia is most closely associated with trichotillomania, the pulling out of one's own hair, and thus any symptoms of trichotillomania could be predictive of trichophagia and must be ruled out. Rarely, persons with trichophagia do not exclusively have trichotillomania and instead will eat the hair of others.[9][5]

Trichotillomania can be categorized as either "automatic", where the hair pulling is so habitual it is almost unconscious, or "focused", where the pulling is more deliberate, with the focused behavior thought to be more common among those with trichophagia.[10] Once the hair has been pulled out, persons with trichophagia might rub the hair against their lips, roll the hairs around and inspect them, bite off and swallow the bulb of the hair, or ingest the entire hair shaft as well.[9] Typically, ingested hair remains asymptomatic and is not harmful. However, if trichophagia is severe or chronic, a large mass of undigested hair can accumulate in the stomach, resulting in a trichobezoar. This can be symptomatic, including nausea, vomiting, and abdominal pain.[11] Once the trichobezoar grows large enough, it can extend beyond the stomach and lead to bowel obstructions, ulcers, perforations, acute pancreatitis and appendicitis (this is called Rapunzel syndrome).[9][7]

Along with the physical harm caused by the pulling out and ingestion of hair, the unpleasant symptoms and social stigma surrounding trichophagia negatively affect the quality of life of sufferers, leading to shame, guilt, and impairment of social functioning.[12] In one study, it was found that a significant percentage of patients with trichotillomania used drugs and alcohol to cope with negative feelings relating to pulling behaviors, with most sufferers reporting symptoms of anxiety and depression.[13] It is important for physicians to recognize and treat these secondary symptoms in order to relieve hair-pulling and eating behaviors.[14]

Epidemiology

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Trichophagia is estimated to have a prevalence of 0.6% in the general population with the most restrictive definition of hair ingestion, but looser definitions which are inclusive of sucking and chewing without swallowing, can be as high as 3.2%.[5] Its prevalence among patients with trichotillomania is estimated to be around 37.5%, with 33% developing trichobezoars.[15] Trichophagia can present at any age, with childhood cases typically being more common and of a more habitual nature, while in adulthood it is associated with underlying psychopathologies and more severe symptoms.[5] Among childhood cases the distribution between males and females is equal. However, in adolescents and adults, trichophagia is increasingly common among females, with a distribution of cases of 15:1, female-to-male.[16] Highest prevalence is in young adults.[9]

Many of the prevalence rates are thought to be underestimates due to stigma and inconsistent definitions of trichophagia.[1] Moreover, the discrepancy between rates in women and men could be explained by underreporting in men, either due to additional shame for men or the ease of shaving and hiding their underlying trichotillomania.[5] Trichophagia in men, while more rarely reported, is often more severe.[1]

Etiology

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Several etiological causes for trichotillomania and trichophagia have been hypothesized, suggesting that symptoms may be caused by disordered emotional regulation, autostimulation mechanisms, a response to stressors, behavioral conditioning, or addiction.[5] Research has also shown that there is a genetic component to the disorders; trichotillomania patients are more likely to have relatives who suffer from obsessive-compulsive disorder, excoriation disorder, and major depressive disorder. Decreased distress tolerance and increased impulsivity were also found in trichotillomania patients with a family history of obsessive-compulsive disorder.[17]

Comorbid Psychopathologies

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When assessing patients with trichophagia, common comorbid psychopathologies are anxiety disorders, eating disorders, depressive disorders, and addiction.[5] More comorbid psychopathologies are associated with more severe symptoms of trichotillomania and trichophagia.[17] The association between trichotillomania, obsessive-compulsive disorder, and related body-focused repetitive behaviors has been of particular interest to researchers, with studies finding that those with both trichotillomania and obsessive-compulsive disorder have higher levels of anxiety and depression as opposed to those who only suffer from trichotillomania.[18] The commonality of comorbid psychopathologies in individuals with trichotillomania and trichophagia could be indirectly caused by the social rejection sufferers face due to their symptoms. Researchers suggest that bringing awareness of the disorders to the general population could help relieve the stigmas faced by patients.[19]

Diagnosis

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Diagnosis of trichophagia can be difficult, as the behavior is easy to hide, and because of shame, individuals rarely admit they have trichophagia, even if they have stopped engaging in its related behaviors.[9] Often, individuals only seek medical help after they have developed gastrointestinal problems caused by a trichobezoar.[5] Any patient who has confirmed trichotillomania should be screened for trichophagia.[9] Some symptoms, such as hair loss, can be caused by other somatic conditions, the presence of which needs to be excluded before a diagnosis of trichotillomania or trichophagia.[5]

Treatment

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Psychotherapy has been widely used in the treatment of trichotillomania and trichophagia, with evidence supporting cognitive behavioral therapy, habit-reversal training, and mindfulness-based cognitive therapy as being effective treatments.[11][20][12] The most commonly used clinical treatment is the prescription of selective serotonin uptake inhibitors (SSRIs), such as fluoxetine and clomipramine, but the effectiveness of this treatment has not been supported empirically.[11] Evidence for efficacy has been found in studies using non-SSRIS, including N-acetylcysteine and olanzapine.[11]

Prognosis

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Rapunzel syndrome, an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, and can be fatal if misdiagnosed.[6][21][22][23] In some cases, surgery may be required to remove the mass.[24] In one case, a trichobezoar weighing 4.5 kilograms (9.9 lb) was removed from the stomach of an 18-year-old woman with trichophagia.[25]

History

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Trichophagia and trichobezoars have been documented by physicians for centuries, even long before a medical definition was established for trichotillomania.[26] For example, in the 18th century, French doctor M. Baudamant described the condition in a 16-year-old boy. Trichophagia is most often covered in the medical literature only "as a rare symptom of trichotillomania."[1]

Despite its appearance in medical literature over the centuries, little research was conducted on trichophagia until the past decade.[12] Even now, most research focuses on Western cultures and European hair textures, with other groups with distinct hair textures, styles, and cultures, such as African Americans, often overlooked.[27]

In media

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Trichophagia is mentioned in the 1000 Ways to Die episode "Stupid Is As Stupid Dies" featuring a young woman who died from it. It is also mentioned in Grey's Anatomy season 9 episode 11 "The End Is the Beginning Is the End". As well as Season 3 episode 16 of The Resident, “Reverse Cinderella.”

References

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  1. ^ a b c d e Grant JE, Odlaug BL (2008). "Clinical characteristics of trichotillomania with trichophagia". Comprehensive Psychiatry. 49 (6): 579–584. doi:10.1016/j.comppsych.2008.05.002. PMC 2605948. PMID 18970906. Citing Baudamant M (1777). "Description de deux masses de cheveux trouvee dans l'estomac et les intestines d'un jeune garcon age de seize ans" [Description of two masses of hair found in the stomach and intestines of a sixteen-year-old boy]. Hist Soc Roy Med (in French). 11779 (2). Paris: 262–63.
  2. ^ "Trichophagia | TrichStop.com". www.trichstop.com. Retrieved 2023-09-17.
  3. ^ "APA Dictionary of Psychology". dictionary.apa.org. Retrieved 2023-10-06.
  4. ^ Diefenbach GJ, Reitman D, Williamson DA (April 2000). "Trichotillomania: a challenge to research and practice". Clinical Psychology Review. 20 (3): 289–309. doi:10.1016/S0272-7358(98)00083-X. PMID 10779896.
  5. ^ a b c d e f g h i Gawłowska-Sawosz M, Wolski M, Kamiński A, Albrecht P, Wolańczyk T (2016). "Trichotillomania and trichophagia - diagnosis, treatment, prevention. The attempt to establish guidelines of treatment in Poland". Psychiatria Polska. 50 (1): 127–143. doi:10.12740/PP/59513. PMID 27086333.
  6. ^ a b Sah DE, Koo J, Price VH (2008). "Trichotillomania". Dermatologic Therapy. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. PMID 18318881.[dead link]
  7. ^ a b Taşkın HE, Erginöz E, Çavuş GH (April 2022). "Trichophagia as a cause of acute appendicitis in a patient with bipolar disorder". Ulusal Travma ve Acil Cerrahi Dergisi = Turkish Journal of Trauma & Emergency Surgery. 28 (4): 554–556. doi:10.14744/tjtes.2022.34808. PMC 10521004. PMID 35485504.
  8. ^ "Why do Cats Eat Their Own Fur? - Cat Attitudes". 14 September 2021.
  9. ^ a b c d e f Snorrason I, Ricketts EJ, Stein AT, Björgvinsson T (2021-10-01). "Trichophagia and trichobezoar in trichotillomania: A narrative mini-review with clinical recommendations". Journal of Obsessive-Compulsive and Related Disorders. 31: 100680. doi:10.1016/j.jocrd.2021.100680. ISSN 2211-3649.
  10. ^ Melo DF, Lima CD, Piraccini BM, Tosti A (January 2022). "Trichotillomania: What Do We Know So Far?". Skin Appendage Disorders. 8 (1): 1–7. doi:10.1159/000518191. PMC 8787581. PMID 35118122.
  11. ^ a b c d Cisoń, Hanna; Kuś, Aleksandra; Popowicz, Ewa; Szyca, Marta; Reich, Adam (September 2018). "Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods". Dermatology and Therapy. 8 (3): 389–398. doi:10.1007/s13555-018-0256-z. ISSN 2193-8210. PMC 6109030. PMID 30099694.
  12. ^ a b c Sabra, Mohammad A. Abu; Al Kalaldeh, Mahmoud; Alnaeem, Mohammad M.; Zyoud, Amr H. (2023-11-22). "The Efficacy of Using Psychotherapy Interventions to Minimize Symptoms of Trichotillomania and Trichophagia: A Scoping Review". Journal of Contemporary Psychotherapy. 54 (2): 143–154. doi:10.1007/s10879-023-09604-8. ISSN 0022-0116. S2CID 265390790.
  13. ^ Woods, Douglas W.; Flessner, Christopher A.; Franklin, Martin E.; Keuthen, Nancy J.; Goodwin, Renee D.; Stein, Dan J.; Walther, Michael R.; Trichotillomania Learning Center-Scientific Advisory Board (2006-12-15). "The Trichotillomania Impact Project (TIP): Exploring Phenomenology, Functional Impairment, and Treatment Utilization". The Journal of Clinical Psychiatry. 67 (12): 1877–1888. doi:10.4088/JCP.v67n1207. ISSN 0160-6689. PMID 17194265.
  14. ^ Grant, Jon E.; Chamberlain, Samuel R. (September 2016). "Trichotillomania". American Journal of Psychiatry. 173 (9): 868–874. doi:10.1176/appi.ajp.2016.15111432. ISSN 0002-953X. PMC 5328413. PMID 27581696.
  15. ^ Kumar, Bharat (April 2011). "The Mind-Body Connection: An Integrated Approach to the Diagnosis of Colonic Trichobezoar". The International Journal of Psychiatry in Medicine. 41 (3): 263–270. doi:10.2190/PM.41.3.e. ISSN 0091-2174. PMID 22073765. S2CID 7000634.
  16. ^ Sehgal VN, Srivastava G (September 2006). "Trichotillomania +/- trichobezoar: revisited". Journal of the European Academy of Dermatology and Venereology. 20 (8): 911–915. doi:10.1111/j.1468-3083.2006.01590.x. PMID 16922936. S2CID 2640995.
  17. ^ a b Zhang, James; Grant, Jon E. (November 2022). "Significance of family history in understanding and subtyping trichotillomania". Comprehensive Psychiatry. 119: 152349. doi:10.1016/j.comppsych.2022.152349. PMID 36215772.
  18. ^ Lochner, Christine; Keuthen, Nancy J.; Curley, Erin E.; Tung, Esther S.; Redden, Sarah A.; Ricketts, Emily J.; Bauer, Christopher C.; Woods, Douglas W.; Grant, Jon E.; Stein, Dan J. (December 2019). "Comorbidity in trichotillomania (hair-pulling disorder): A cluster analytical approach". Brain and Behavior. 9 (12): e01456. doi:10.1002/brb3.1456. ISSN 2162-3279. PMC 6908854. PMID 31692297.
  19. ^ Woods, Douglas W.; Fuqua, R. Wayne; Outman, Ryan C. (1999-03-01). "Evaluating the Social Acceptability of Persons with Habit Disorders: The Effects of Topography, Frequency, and Gender Manipulation". Journal of Psychopathology and Behavioral Assessment. 21 (1): 1–18. doi:10.1023/A:1022839609859. ISSN 1573-3505. S2CID 141846379.
  20. ^ Wolski, Marek; Gawłowska-Sawosz, Marta; Gogolewski, Michał; Wolańczyk, Tomasz; Albrecht, Piotr; Kamiński, Andrzej (2016-02-28). "Trichotillomania, trichophagia, trichobezoar – summary of three cases. Endoscopic follow up scheme in trichotillomania". Psychiatria Polska. 50 (1): 145–152. doi:10.12740/pp/43636. ISSN 0033-2674. PMID 27086334.
  21. ^ Ventura DE, Herbella FA, Schettini ST, Delmonte C (October 2005). "Rapunzel syndrome with a fatal outcome in a neglected child". Journal of Pediatric Surgery. 40 (10): 1665–1667. doi:10.1016/j.jpedsurg.2005.06.038. PMID 16227005.
  22. ^ Pul N, Pul M (January 1996). "The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report". European Journal of Pediatrics. 155 (1): 18–19. doi:10.1007/bf02115620. PMID 8750804. S2CID 20876626.
  23. ^ Matejů E, Duchanová S, Kovac P, Moravanský N, Spitz DJ (September 2009). "Fatal case of Rapunzel syndrome in neglected child". Forensic Science International. 190 (1–3): e5–e7. doi:10.1016/j.forsciint.2009.05.008. PMID 19505779.
  24. ^ Gorter RR, Kneepkens CM, Mattens EC, Aronson DC, Heij HA (May 2010). "Management of trichobezoar: case report and literature review". Pediatric Surgery International. 26 (5): 457–463. doi:10.1007/s00383-010-2570-0. PMC 2856853. PMID 20213124.
  25. ^ Levy RM, Komanduri S (November 2007). "Images in clinical medicine. Trichobezoar". The New England Journal of Medicine. 357 (21): e23. doi:10.1056/NEJMicm067796. PMID 18032760.
  26. ^ Bouwer, Colin; Stein, Dan J. (1998). "Trichobezoars in Trichotillomania: Case Report and Literature Overview". Psychosomatic Medicine. 60 (5): 658–660. doi:10.1097/00006842-199809000-00025. ISSN 0033-3174. PMID 9773774. S2CID 40366370.
  27. ^ Patel, Akshar; Kim, Alex; Loomis, James Grant; Okwara, Tracey; Miller, Michael (2022-12-13). "An unusual case of trichotillomania and trichophagia associated with authentic hair extension as seen in a young African-American female adult". Discover Psychology. 2 (1): 46. doi:10.1007/s44202-022-00053-3. ISSN 2731-4537.
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