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 just as 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). In an even smaller subset of people with trichotillomania, their trichophagia can become so severe that they develop a hair ball.[5]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 complicaiton whereby the hair ball extends past the stomach and can cause blockages of gastrointestinal system.[6]

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

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 ones 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 ones own hair, and thus any symptoms of trichotillomania could be predictive of trichophagia and must be ruled out. Rarely, person's with trichophagia do not exclusively have trichotillomania, and instead will eat the hair of others.[7][8]

Trichotillomania can be categorized as either "automatic", where the hair pulling is so habitual it is almost unconscious, or "focussed" where the pulling is more deliberate, with the focussed behavior thought to be more common among those who also have trichophagia.[9] 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.[7] 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.[10] 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).[7][6]

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%.[8] Trichophagia can present at any age, with childhood cases typically being of a more habitual nature, while in adulthood it is associated with underlying psychopathologies. 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.[11] Highest prevalence is in young adults.[7]

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 do to additional shame for men, or the ease of shaving and hiding their underlying trichotillomania.[8] Trichophagia in men, while more rarely reported, is often more severe.[1]

Diagnosis

Diagnosis of trichophagia can be difficult, as the behavior is easy to hide, and because of shame, individuals rarely admit they have trichophagia. Any patient who has confirmed trichotillomania should be screened for trichophagia.[7]

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.[5][12][13][14] In some cases, surgery may be required to remove the mass;[15] a trichobezoar weighing 4.5 kilograms (9.9 lb) was removed from the stomach of an 18-year-old woman with trichophagia.[16]

History

Trichophagia is most often covered in the medical literature only "as a rare symptom of trichotillomania." In the 18th century French doctor M. Baudamant described the condition in a 16-year-old boy.[1]

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.”

References
  1. 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). Paris. 11779 (2): 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. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Cisoń H, Kuś A, Popowicz E, Szyca M, Reich A (September 2018). "Trichotillomania and Trichophagia: Modern Diagnostic and Therapeutic Methods". Dermatology and Therapy. 8 (3): 389–398. doi:10.1007/s13555-018-0256-z. PMC 6109030. PMID 30099694.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
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