Trichophagia

{{Infobox medical condition (new) | name = Trichophagia | synonyms = | image = | caption = | pronounce = tricho-phag-ia | field = Psychiatry | symptoms = nausea, vomiting, abdominal pain, and hair loss | complications = Trichobezoar, Rapunzel syndrome | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = }} '''Trichophagia''' is a form of disordered eating in which persons with the disorder suck on, chew, swallow, or otherwise eat hair.<ref name="Grant2">{{cite journal | vauthors = Grant JE, Odlaug BL | title = Clinical characteristics of trichotillomania with trichophagia | journal = Comprehensive Psychiatry | volume = 49 | issue = 6 | pages = 579–584 | year = 2008 | pmid = 18970906 | pmc = 2605948 | doi = 10.1016/j.comppsych.2008.05.002 }} Citing {{cite journal | vauthors = Baudamant M |year=1777 |title=Description de deux masses de cheveux trouvee dans l'estomac et les intestines d'un jeune garcon age de seize ans |trans-title=Description of two masses of hair found in the stomach and intestines of a sixteen-year-old boy |journal=Hist Soc Roy Med |volume=11779 |issue=2 |pages=262–63 |language=fr |place=Paris}}</ref> The term is derived from ancient Greek θρίξ, {{lang|grc-Latn|thrix}} ("hair") and φαγεῖν, {{lang|grc-Latn|phagein}} ("to eat").<ref>{{Cite web |title=Trichophagia {{!}} TrichStop.com |url=https://www.trichstop.com/info/related/trichophagia |access-date=2023-09-17 |website=www.trichstop.com}}</ref> Tricho-{{em|phagy}} refers only to the chewing of hair, whereas tricho-{{em|phagia}} is ingestion of hair, but many texts refer to both habits as just trichophagia.<ref>{{Cite web |title=APA Dictionary of Psychology |url=https://dictionary.apa.org/ |access-date=2023-10-06 |website=dictionary.apa.org |language=en}}</ref> It is considered a chronic psychiatric disorder of impulse control.<ref>{{cite journal | vauthors = Diefenbach GJ, Reitman D, Williamson DA | title = Trichotillomania: a challenge to research and practice | journal = Clinical Psychology Review | volume = 20 | issue = 3 | pages = 289–309 | date = April 2000 | pmid = 10779896 | doi = 10.1016/S0272-7358(98)00083-X }}</ref> Trichophagia belongs to a subset of pica disorders and is often associated with trichotillomania, the compulsive pulling out of ones own hair.<ref name="Grant2" /> 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.<ref name="Gawłowska-Sawosz_2016" /> In an even smaller subset of people with trichotillomania, their trichophagia can become so severe that they develop a hairball.<ref name="Sah2">{{cite journal | vauthors = Sah DE, Koo J, Price VH | title = Trichotillomania | journal = Dermatologic Therapy | volume = 21 | issue = 1 | pages = 13–21 | year = 2008 | pmid = 18318881 | doi = 10.1111/j.1529-8019.2008.00165.x | doi-access = free }}{{dead link|date=February 2019|bot=medic}}{{cbignore|bot=medic}}</ref> 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.<ref name="Taşkın_2022">{{cite journal | vauthors = Taşkın HE, Erginöz E, Çavuş GH | title = Trichophagia as a cause of acute appendicitis in a patient with bipolar disorder | journal = Ulusal Travma ve Acil Cerrahi Dergisi = Turkish Journal of Trauma & Emergency Surgery | volume = 28 | issue = 4 | pages = 554–556 | date = April 2022 | pmid = 35485504 | doi = 10.14744/tjtes.2022.34808 | pmc = 10521004 }}</ref>

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.<ref>{{cite web|url=https://catattitudes.com/cats-eat-fur/ |title=Why do Cats Eat Their Own Fur? - Cat Attitudes |work=Cat Attitudes |date=14 September 2021 }}</ref>

==Signs and symptoms== 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.<ref name="Snorrason_2021">{{Cite journal | vauthors = Snorrason I, Ricketts EJ, Stein AT, Björgvinsson T |date=2021-10-01 |title=Trichophagia and trichobezoar in trichotillomania: A narrative mini-review with clinical recommendations |journal=Journal of Obsessive-Compulsive and Related Disorders |volume=31 |article-number=100680 |doi=10.1016/j.jocrd.2021.100680 |issn=2211-3649}}</ref><ref name="Gawłowska-Sawosz_2016">{{cite journal | vauthors = Gawłowska-Sawosz M, Wolski M, Kamiński A, Albrecht P, Wolańczyk T | title = Trichotillomania and trichophagia - diagnosis, treatment, prevention. The attempt to establish guidelines of treatment in Poland | journal = Psychiatria Polska | volume = 50 | issue = 1 | pages = 127–143 | date = 2016 | pmid = 27086333 | doi = 10.12740/PP/59513 | doi-access = free }}</ref>

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.<ref>{{cite journal | vauthors = Melo DF, Lima CD, Piraccini BM, Tosti A | title = Trichotillomania: What Do We Know So Far? | journal = Skin Appendage Disorders | volume = 8 | issue = 1 | pages = 1–7 | date = January 2022 | pmid = 35118122 | doi = 10.1159/000518191 | pmc = 8787581 }}</ref> 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.<ref name="Snorrason_2021" /> 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.<ref name="Cisoń-2018">{{Cite journal |last1=Cisoń |first1=Hanna |last2=Kuś |first2=Aleksandra |last3=Popowicz |first3=Ewa |last4=Szyca |first4=Marta |last5=Reich |first5=Adam |date=September 2018 |title=Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods |journal=Dermatology and Therapy |language=en |volume=8 |issue=3 |pages=389–398 |doi=10.1007/s13555-018-0256-z |pmid=30099694 |issn=2193-8210 |pmc=6109030}}</ref> 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).<ref name="Snorrason_2021" /><ref name="Taşkın_2022" />

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.<ref name="Sabra-2023">{{Cite journal |last1=Sabra |first1=Mohammad A. Abu |last2=Al Kalaldeh |first2=Mahmoud |last3=Alnaeem |first3=Mohammad M. |last4=Zyoud |first4=Amr H. |date=2023-11-22 |title=The Efficacy of Using Psychotherapy Interventions to Minimize Symptoms of Trichotillomania and Trichophagia: A Scoping Review |url=https://link.springer.com/10.1007/s10879-023-09604-8 |journal=Journal of Contemporary Psychotherapy |volume=54 |issue=2 |pages=143–154 |language=en |doi=10.1007/s10879-023-09604-8 |s2cid=265390790 |issn=0022-0116|url-access=subscription }}</ref> 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.<ref>{{Cite journal |last1=Woods |first1=Douglas W. |last2=Flessner |first2=Christopher A. |last3=Franklin |first3=Martin E. |last4=Keuthen |first4=Nancy J. |last5=Goodwin |first5=Renee D. |last6=Stein |first6=Dan J. |last7=Walther |first7=Michael R. |last8=Trichotillomania Learning Center-Scientific Advisory Board |date=2006-12-15 |title=The Trichotillomania Impact Project (TIP): Exploring Phenomenology, Functional Impairment, and Treatment Utilization |url=https://www.psychiatrist.com/jcp/trichotillomania-impact-project-tip-exploring-phenomenology |journal=The Journal of Clinical Psychiatry |volume=67 |issue=12 |pages=1877–1888 |doi=10.4088/JCP.v67n1207 |pmid=17194265 |issn=0160-6689|url-access=subscription }}</ref> It is important for physicians to recognize and treat these secondary symptoms in order to relieve hair-pulling and eating behaviors.<ref>{{Cite journal |last1=Grant |first1=Jon E. |last2=Chamberlain |first2=Samuel R. |date=September 2016 |title=Trichotillomania |journal=American Journal of Psychiatry |language=en |volume=173 |issue=9 |pages=868–874 |doi=10.1176/appi.ajp.2016.15111432 |issn=0002-953X|doi-access=free |pmid=27581696 |pmc=5328413 }}</ref>

== Epidemiology == 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%.<ref name="Gawłowska-Sawosz_2016" /> Its prevalence among patients with trichotillomania is estimated to be around 37.5%, with 33% developing trichobezoars.<ref>{{Cite journal |last=Kumar |first=Bharat |date=April 2011 |title=The Mind-Body Connection: An Integrated Approach to the Diagnosis of Colonic Trichobezoar |url=http://journals.sagepub.com/doi/10.2190/PM.41.3.e |journal=The International Journal of Psychiatry in Medicine |language=en |volume=41 |issue=3 |pages=263–270 |doi=10.2190/PM.41.3.e |pmid=22073765 |s2cid=7000634 |issn=0091-2174|url-access=subscription }}</ref> 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.<ref name="Gawłowska-Sawosz_2016" /> 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.<ref>{{cite journal | vauthors = Sehgal VN, Srivastava G | title = Trichotillomania +/- trichobezoar: revisited | journal = Journal of the European Academy of Dermatology and Venereology | volume = 20 | issue = 8 | pages = 911–915 | date = September 2006 | pmid = 16922936 | doi = 10.1111/j.1468-3083.2006.01590.x | s2cid = 2640995 }}</ref> Highest prevalence is in young adults.<ref name="Snorrason_2021" />

Many of the prevalence rates are thought to be underestimates due to stigma and inconsistent definitions of trichophagia.<ref name="Grant2" /> 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.<ref name="Gawłowska-Sawosz_2016" /> Trichophagia in men, while more rarely reported, is often more severe.<ref name="Grant2" />

== Etiology == 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.<ref name="Gawłowska-Sawosz_2016" /> 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.<ref name="Zhang-2022" />

== Comorbid Psychopathologies == When assessing patients with trichophagia, common comorbid psychopathologies are anxiety disorders, eating disorders, depressive disorders, and addiction.<ref name="Gawłowska-Sawosz_2016" /> More comorbid psychopathologies are associated with more severe symptoms of trichotillomania and trichophagia.<ref name="Zhang-2022">{{Cite journal |last1=Zhang |first1=James |last2=Grant |first2=Jon E. |date=November 2022 |title=Significance of family history in understanding and subtyping trichotillomania |journal=Comprehensive Psychiatry |language=en |volume=119 |article-number=152349 |doi=10.1016/j.comppsych.2022.152349|doi-access=free |pmid=36215772 }}</ref> 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.<ref>{{Cite journal |last1=Lochner |first1=Christine |last2=Keuthen |first2=Nancy J. |last3=Curley |first3=Erin E. |last4=Tung |first4=Esther S. |last5=Redden |first5=Sarah A. |last6=Ricketts |first6=Emily J. |last7=Bauer |first7=Christopher C. |last8=Woods |first8=Douglas W. |last9=Grant |first9=Jon E. |last10=Stein |first10=Dan J. |date=December 2019 |title=Comorbidity in trichotillomania (hair-pulling disorder): A cluster analytical approach |journal=Brain and Behavior |language=en |volume=9 |issue=12 |pages=e01456 |doi=10.1002/brb3.1456 |issn=2162-3279|doi-access=free |pmid=31692297 |pmc=6908854 }}</ref> 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.<ref>{{Cite journal |last1=Woods |first1=Douglas W. |last2=Fuqua |first2=R. Wayne |last3=Outman |first3=Ryan C. |date=1999-03-01 |title=Evaluating the Social Acceptability of Persons with Habit Disorders: The Effects of Topography, Frequency, and Gender Manipulation |journal=Journal of Psychopathology and Behavioral Assessment |language=en |volume=21 |issue=1 |pages=1–18 |doi=10.1023/A:1022839609859 |s2cid=141846379 |issn=1573-3505}}</ref>

== Diagnosis == 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.<ref name="Snorrason_2021" /> Often, individuals only seek medical help after they have developed gastrointestinal problems caused by a trichobezoar.<ref name="Gawłowska-Sawosz_2016" /> Any patient who has confirmed trichotillomania should be screened for trichophagia.<ref name="Snorrason_2021" /> 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.<ref name="Gawłowska-Sawosz_2016" />

== Treatment == 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.<ref name="Cisoń-2018"/><ref>{{Cite journal |last1=Wolski |first1=Marek |last2=Gawłowska-Sawosz |first2=Marta |last3=Gogolewski |first3=Michał |last4=Wolańczyk |first4=Tomasz |last5=Albrecht |first5=Piotr |last6=Kamiński |first6=Andrzej |date=2016-02-28 |title=Trichotillomania, trichophagia, trichobezoar – summary of three cases. Endoscopic follow up scheme in trichotillomania |journal=Psychiatria Polska |volume=50 |issue=1 |pages=145–152 |doi=10.12740/pp/43636 |issn=0033-2674|doi-access=free |pmid=27086334 }}</ref><ref name="Sabra-2023" /> 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.<ref name="Cisoń-2018" /> Evidence for efficacy has been found in studies using non-SSRIS, including N-acetylcysteine and olanzapine.<ref name="Cisoń-2018" />

==Prognosis== 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.<ref name="Sah2" /><ref>{{cite journal | vauthors = Ventura DE, Herbella FA, Schettini ST, Delmonte C | title = Rapunzel syndrome with a fatal outcome in a neglected child | journal = Journal of Pediatric Surgery | volume = 40 | issue = 10 | pages = 1665–1667 | date = October 2005 | pmid = 16227005 | doi = 10.1016/j.jpedsurg.2005.06.038 }}</ref><ref>{{cite journal | vauthors = Pul N, Pul M | title = The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report | journal = European Journal of Pediatrics | volume = 155 | issue = 1 | pages = 18–19 | date = January 1996 | pmid = 8750804 | doi = 10.1007/bf02115620 | s2cid = 20876626 }}</ref><ref>{{cite journal | vauthors = Matejů E, Duchanová S, Kovac P, Moravanský N, Spitz DJ | title = Fatal case of Rapunzel syndrome in neglected child | journal = Forensic Science International | volume = 190 | issue = 1–3 | pages = e5–e7 | date = September 2009 | pmid = 19505779 | doi = 10.1016/j.forsciint.2009.05.008 }}</ref> In some cases, surgery may be required to remove the mass.<ref name="Gorter">{{cite journal | vauthors = Gorter RR, Kneepkens CM, Mattens EC, Aronson DC, Heij HA | title = Management of trichobezoar: case report and literature review | journal = Pediatric Surgery International | volume = 26 | issue = 5 | pages = 457–463 | date = May 2010 | pmid = 20213124 | pmc = 2856853 | doi = 10.1007/s00383-010-2570-0 }}</ref> In one case, a trichobezoar weighing {{convert|4.5|kg|lb}} was removed from the stomach of an 18-year-old woman with trichophagia.<ref name="Levy">{{cite journal | vauthors = Levy RM, Komanduri S | title = Images in clinical medicine. Trichobezoar | journal = The New England Journal of Medicine | volume = 357 | issue = 21 | pages = e23 | date = November 2007 | pmid = 18032760 | doi = 10.1056/NEJMicm067796 }}</ref>

==History== Trichophagia and trichobezoars have been documented by physicians for centuries, even long before a medical definition was established for trichotillomania.<ref>{{Cite journal |last1=Bouwer |first1=Colin |last2=Stein |first2=Dan J. |date=1998 |title=Trichobezoars in Trichotillomania: Case Report and Literature Overview |url=http://journals.lww.com/00006842-199809000-00025 |journal=Psychosomatic Medicine |language=en |volume=60 |issue=5 |pages=658–660 |doi=10.1097/00006842-199809000-00025 |pmid=9773774 |s2cid=40366370 |issn=0033-3174|url-access=subscription }}</ref> 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."<ref name="Grant2" />

Despite its appearance in medical literature over the centuries, little research was conducted on trichophagia until the past decade.<ref name="Sabra-2023" /> 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.<ref>{{Cite journal |last1=Patel |first1=Akshar |last2=Kim |first2=Alex |last3=Loomis |first3=James Grant |last4=Okwara |first4=Tracey |last5=Miller |first5=Michael |date=2022-12-13 |title=An unusual case of trichotillomania and trichophagia associated with authentic hair extension as seen in a young African-American female adult |journal=Discover Psychology |language=en |volume=2 |issue=1 |page=46 |doi=10.1007/s44202-022-00053-3 |issn=2731-4537|doi-access=free }}</ref>

==In media== Trichophagia is mentioned in the ''1000 Ways to Die'' episode "[https://www.imdb.com/title/tt1714211/ 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 == {{reflist}}

== External links == {{Medical resources | DiseasesDB = | ICD10 = F98.4 (ILDS F98.420) | ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = }} *[http://bfrb.org The TLC Foundation for Body-Focused Repetitive Behaviors]

Category:Body-focused repetitive behavior Category:Eating behaviors Category:Hair diseases Category:Hair removal Category:Human hair Category:Pica (disorder)