Trichophagia

Template:Infobox medical condition (new) Trichophagia is a form of disordered eating in which persons with the disorder suck on, chew, swallow, or otherwise eat hair.<ref name="Grant2">Template:Cite journal Citing Template:Cite journal</ref> The term is derived from ancient Greek θρίξ, Template:Lang ("hair") and φαγεῖν, Template:Lang ("to eat").<ref>Template:Cite web</ref> 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.<ref>Template:Cite web</ref> It is considered a chronic psychiatric disorder of impulse control.<ref>Template:Cite journal</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">Template:Cite journalTemplate:Dead linkTemplate:Cbignore</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">Template:Cite journal</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>Template:Cite web</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">Template:Cite journal</ref><ref name="Gawłowska-Sawosz_2016">Template:Cite journal</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>Template:Cite journal</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">Template:Cite journal</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">Template:Cite journal</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>Template:Cite journal</ref> It is important for physicians to recognize and treat these secondary symptoms in order to relieve hair-pulling and eating behaviors.<ref>Template:Cite journal</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>Template:Cite journal</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>Template:Cite journal</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">Template:Cite journal</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>Template:Cite journal</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>Template:Cite journal</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>Template:Cite journal</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>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> In some cases, surgery may be required to remove the mass.<ref name="Gorter">Template:Cite journal</ref> In one case, a trichobezoar weighing Template:Convert was removed from the stomach of an 18-year-old woman with trichophagia.<ref name="Levy">Template:Cite journal</ref>

History

Trichophagia and trichobezoars have been documented by physicians for centuries, even long before a medical definition was established for trichotillomania.<ref>Template:Cite journal</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>Template:Cite journal</ref>

In media

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."

External links

• The TLC Foundation for Body-Focused Repetitive Behaviors