Psychological Aspect of Alopecia

Abstract

Hair is one of the most important components of the individual’s appearance and self-perception, as an organ that has an important role in social and sexual communication in humans. Therefore, hair loss can have negative effects on self-confidence, body image and self-esteem. Trichopsychodermatology is a special field of psychodermatology that deals with the psychosocial causes and consequences of hair loss and hair diseases. Alopecia patients suffer from various mental disorders, especially anxiety and depression. Psychological stress and emotional difficulties act as triggers and accelerators in both trichotillomania, which is within the scope of primary psychiatric diseases, and hair diseases with different etiopathogenesis such as alopecia areata, telogen effluvium, cicatricial alopecia, androgenetic alopecia, anagen alopecia. Providing psychiatric diagnosis and treatment in a patient presenting with alopecia may also have a positive effect on the course of alopecia. In this section, the psychiatric approach to patients with alopecia is discussed. This situation, which is frequently observed by dermatologists in clinical practice, has actually been little studied in the literature.

1. Introduction

Hair is not only a beauty, but a mirror of health and youth, and also has a cultural, sociological and psychological significance. It was seen as a symbol of power and handsomeness in men, and a tool for beauty and attractiveness in women. Therefore, especially in diseases with hair loss, psychosocial effects such as significant self-image deterioration and loss of self-esteem occur. Hair diseases are one of the challenging areas of dermatology [1]. Especially in cases with chronic hair loss, the psychosocial problems experienced by the patients in the personal, social and professional areas are also added to the difficulties in treatment and complicates the patient management for the dermatologist. Although it is thought that there will be similar psychosocial difficulties in all hair loss, different degrees and serious results may occur in different hair diseases [2]. The stress and embarrassment experienced by patients with hair disease should not be ignored and should be taken into account when creating a treatment plan. Although hair loss is generally seen as a non-threatening cosmetic problem, its psychological effect can reach serious dimensions. In many cultures, hair is associated with one’s self or community identity. Hair is considered an indicator of beauty and health. This situation, which is frequently observed by dermatologists in clinical practice, has actually been little studied in the literature. Trichopsychodermatology is a special and new field of psychodermatology that deals with the relationship between stress and hair loss and the negative psychosocial consequences of hair loss. It focuses on the development of coping strategies and the application of necessary psychotherapeutic and pharmacological treatments [1].

2. General features in psychodermatology

Psychosomatic theory has an important place in elucidating the relationship between the skin and the spiritual phenomena that create the personality of the human being. The relationship between the skin and the soul is tried to be explained with a few links. First of all, the epidermis has the same embryological origin as the nervous system. It separates man from the outside world; It is a person’s showcase to the outside world. With these features, leather has a very special place in our individual existence. The skin is an important erogenous zone, and touch, heat and pain are also sources of erogenous pleasure. It is also the source of erotic rewards such as the mother’s touch and caress from infancy. If the urge to use the skin in the usual way is suppressed, repetitive tendencies that stimulate and oppose the skin can find an expression on the body through changes in the skin. It can also be a source of anxiety as it involuntarily transmits some of our emotional states such as shame and anger. In addition, the skin is the organ of expression of emotions and the outlet of anxiety [3]. According to psychosomatic theory; Any conflict situation that creates anxiety and injury on the basis of the integrity of the person can turn into a mental or physical illness based on this. As Cazzullo points out on the topic of skin diseases, “a superficialization mechanism from a conflict situation” is ignited. Similarly, Cormia stated that people with psychodermatological diseases could not cope with the difficult situations in their lives and that the use of autonomous mechanisms as a result of the tension and stress created by this strain could lead to skin diseases [4]. While explaining psychosomatic diseases, psychoanalysts did not only mention conflicts, but also included other factors such as personality and life events in their explanations. According to Dunbar and Alexander, there are specific personality traits for each psychosomatic disorder. In line with this idea, they created “personality profiles” and tried to establish a connection between these personality profiles and physical ailments. Alexander emphasizes the importance of the combined effect of conflicts and life events on the development of the disease. According to him, people whose defenses are weakened by the presence of unresolved psychological conflict experience discomfort in their weakest body parts in the face of certain life events [5]. The skin is the focus of stress-reducing behaviors due to its easy accessibility and its primary role in early bonding. Since the skin is the most prominent organ, skin lesions seen in people with low psychological insight and prone to somatization may be the only way to express emotional disturbances [6]. Herman Musaph, an Amsterdam-born psychiatrist, is considered one of the founders of psychodermatology. Musaph became head of the department of psychodermatology at the University of Amsterdam in 1953. Musaph’s knowledge and experience in psychoanalysis enabled him to examine and understand the role of psycho-emotional factors in skin patients in more detail and led to the emergence of studies especially on psoriasis, artifact dermatitis and pruritus. One of the best and comprehensive examples on this subject was “Itching and scratching, Psychodynamics in Dermatology” published in 1964. The European Society of Psychiatry and Dermatology was established in Vienna in 1993 [7]. Didier Anzieu, on the other hand, focused on the relationship between self psychology and the skin in his book “Skin-Ego” published in 1985, emphasizing the experiences of body contact and the functions of the skin in the early stages of the development of the child’s self [8]. The first attempts to classify psychodermatological diseases were made by Caroline Koblenzer, a dermatologist and psychoanalyst, in 1982 [9]. One of the widely accepted classifications today is the classifications proposed by Koo and Lee and the other by Harth et al. [10].

When evaluated from a neurobiological point of view, it is known that psychological and physical stress triggers the emergence of various skin and hair disorders. Hair cortisol analysis, which has been used in recent years, has been accepted as an effective method in evaluating disorders in the hypothalamus-pituitary-adrenal axis [11]. Hair cortisol concentrations vary according to both emotional and physical stress. Hair cortisol concentration has proven to be more reliable than blood, saliva, and urine cortisol measurements [12]. Since this technique shows chronic stress, which is the trigger of various skin and hair changes, hair cortisol measurements may be useful for future research [1]. Emotional stress can accelerate alopecia by causing local inflammation with the activation of type 2b corticotropin-releasing hormone receptors that are overexpressed around the hair follicle [13]. It has been reported that substance P is released from nerves in response to stress, and the same has been noted in hair follicles [14]. Similar neurobiological mechanisms are also detected in stress-induced psychiatric disorders such as major depressive disorder, generalized anxiety disorder and phobias, and they also occur comorbidly in patients with alopecia [15].

3. Psychosomatic scalp diseases

3.1 Alopecia areata

Alopecia areata is one of the common causes of hair loss. The lifetime incidence is 2.1% [16]. It has been shown that genetic, autoimmune and environmental factors may play a role in the etiology, but the cause is not known yet. It has been suggested that alopecia areata can be considered among the psychosomatic diseases triggered by stressful life events [17]. Alopecia areata, one of the non-scarring hair loss, is a common inflammatory hair disease and is clinically characterized by asymptomatic, ovarian-round hair loss areas. It is polygenetic and multifactorial and its etiopathogenesis is not clearly understood. Although not life-threatening, psychiatric outcomes are common in alopecia areata, especially in total and universal types where loss is severe. It is extremely important to detect possible emotional problems accompanying the disease. Because pharmacological treatments are ineffective, especially in severe forms, and psychotherapeutic approaches are needed [18, 19]. In a recent study, the association with psychiatric diseases was investigated and it was found that depression, anxiety and sleep disorders often accompanied the disease. In addition, it has been determined that both alopecia areata and psychiatric disorders mutually affect each other and lead to disease progression. The sense of identity is severely damaged, especially in women, and feelings of grief and pain emerge [19]. While sexual identity is damaged in women, social identity is damaged by loss of trust more in men. In addition, marital problems and occupational problems are pointed out in women with alopecia areata [20, 21]. It has been emphasized that stressful events increase with age and eventually lead to stress-related psychological disorders such as anxiety and OCD.

There are views that major depressive disorder (MDD) and alopecia areata share a common pathogenesis [22]. However, it is also suggested that there is a bidirectional relationship between the two diseases. According to these views, alopecia areata may initiate MDD or alopecia areata may be the result of MDD. On the other hand, depression and anxiety emerge as a risk as hair loss creates a negative self-image. There is a high risk of self-harming behaviors and suicide [23, 24]. Socialization problems, increased aggression, fear of ridicule and avoidance of friendships with peers in school-age children were noted [25]. The experiences of patients with Alopecia Areata are complex and highly personal. With the unpredictability of hair loss, life restrictions, cycles of hope and despair are seen. Interestingly, the presence of negative emotions and psychological stress is not parallel to the severity of the disease. Patients with mild Alopecia Areata are just as affected as those with severe hair loss. Although patients receiving psychotherapy have a different experience, positive results provide coping, acceptance and greater personal growth [26]. Although rarer, alexithymia, adjustment disorders, developmental disorders, and substance use-related disorders have been reported with Alopecia Areata. There are also some reports of attention deficit-hyperactivity [24, 27, 28].

3.2 Androgenetic alopecia

Androgenetic alopecia (AGA) is also known as male pattern hair loss. Genetic and hormonal factors are effective in development. It is most often seen in middle-aged white men. About 30% of men are affected by age 30, 50% by age 50, and 80% by age 70 [29]. One of the important topics in the discussion of hair loss has been the effects of hair loss on body image and social acceptability. In fact, various results have been obtained in studies on the psychological effects of androgenic alopecia, which is seen by many men as a part of the natural aging process. In a study conducted several decades ago by Cash, men stated that androgenic alopecia impairs body image and causes stress without significant loss in psychological functioning [30]. Although androgenetic alopecia can be seen by many men as a part of the natural aging process, it has been shown that especially young and single men are adversely affected by alopecia [30]. In a study investigating the effects of androgenetic alopecia on male psychology, men evaluated alopecia or hair loss as an event that disrupted their body image or caused stress. Men with alopecia stated that they were not completely satisfied with their appearance, they actually preferred to have more hair, and some of them questioned their social acceptability due to alopecia and they had to expend more energy to cope. As the severity of alopecia increases, these symptoms also increase [31]. It is reported that androgenetic alopecia, which usually starts in the early 20s, causes the person to compare himself with his peers and decreases his self-esteem over time. Such people can become obsessed with androgenetic alopecia and spend a lot of time and money on the treatment of alopecia [32, 33].

It has been shown that women with androgenic alopecia are affected more negatively than men psychologically. Psychological stress is usually more severe in women [34]. Hair is one of the most important components of physical appearance in women. One study compared 96 female and 60 male patients with androgenic alopecia and reported that 52% of women and 28% of men were extremely unhappy with androgenic alopecia. When female patients with androgenetic alopecia were compared with female patients with another dermatological disease, it was found that the androgenic alopecia group was more stressed, experienced more social anxiety, and had lower self-esteem [35]. Studies investigating anxiety, depression and personality traits associated with androgenetic alopecia in women have been conducted. It is especially seen in women with polycystic ovary syndrome (PCOS). In a study of 254 women with PCOS, androgenetic alopecia was detected in 56 women, and it was determined that these patients were more anxious about hair loss, but Beck depression scores were not higher than other PCOS patients [36]. The presence of psychiatric disorders in androgenic alopecia is actually an expected situation. In the treatment of comorbid conditions, an intervention for the etiology should be considered first, and hormonal regulation should be aimed first. In addition, necessary treatment should be arranged after psychiatric evaluation in symptomatic cases.

3.3 Telogen effluvium

Losses caused by disorders in the development cycle of the hair are called telogen effluvium (TE) or anagen effluvium (AE) according to the stage in which the hair is affected. Causes of TE include high fever, thyroid disorders, surgeries, accidents, some medications, postpartum period, severe emotional stress, heavy diets, eating disorders, vitamin and mineral deficiencies. Hair loss rate in TE cases is generally milder than AE and this rate is usually below 50% [37]. Acute or chronic stress can cause TE to develop, while TE itself can cause secondary stress. As a result, a vicious cycle can occur. Although it is a common condition, there are limited studies in the literature on the psychosocial effects of TE [38]. Indeed, a recent study showed a more than 400% increase in the incidence of TE after a few months in populations heavily affected by COVID-19 [39]. In patients with telogen effluvium, the negative emotions created by the loss and experienced by the patient take place on a wide scale. A wide variety of emotions can be experienced, such as shame, anger, humiliation, disgust, fear, sadness, anxiety, depression, frustration, body image damage, inadequacy and lack of confidence, feeling older and unhappy with their appearance, helplessness, social stress, and even fear [40].

3.4 Anagen effluvium/chemotherapy induced alopecia

Hair loss in the anagen phase, which is the growth phase of the hair, is called anagen effluvium. Unlike TE, intense loss is observed rapidly. It is also called chemotherapy alopecia because it often occurs after chemotherapy treatment [41]. Chemotherapy-induced alopecia (CIA) has various psychosocial effects that adversely affect quality of life such as anxiety, depression, low self-esteem and low self-image. Even the idea of patients developing alopecia after being diagnosed with cancer can cause severe fear and anxiety for patients. It has been shown that CIA is among the three main negative effects of the chemotherapy-induced distressing process, and the distressing process caused by alopecia is more evident in female patients [42, 43, 44]. When the studies in the literature were examined, it was determined that hair loss was considered as one of the most disturbing side effects of chemotherapy. In one study, it was shown that 8% of female cancer patients consider stopping chemotherapy to prevent hair loss [45]. The CIA is one of the main sources of stress for patients, as it is the most obvious reminder of the cure and death process for cancer patients [42]. The CIA’s effective coping strategies include referrals to mental health professionals, wigs, headscarves, and various haircuts. Patient education and planning are important tools for minimizing distress. Since this approach will prepare the cancer patient for alopecia, it may reduce the effects of alopecia-related emotional stress, anxiety and depression, as well as increase compliance with chemotherapy treatment [38, 42].

3.5 Cicatricial alopecia

Cicatricial alopecia is a type of alopecia characterized by inflammation that permanently destroys hair follicles and leads to fibrotic scarring. Scarred alopecia requires rapid diagnosis and multidisciplinary care due to its irreversible nature and severe psychosocial impact [46]. It has been determined that women with scarred alopecia have a lower quality of life and a heavier psychosocial burden than women with non-scarring alopecia. Psychiatric comorbid conditions such as low quality of life, anxiety, depression, loneliness, social isolation and low self-esteem are found in women with scarred alopecia [47]. In a study examining psychiatric comorbidities in female patients with cicatricial alopecia, a 10% prevalence of comorbid depressive or anxiety disorders was found [48]. The psychological impact of scarred alopecia has been reported to be equally severe in both sexes, but concerns about appearance are more pronounced in female patients. Esthetic concerns were found to be higher in young patients who felt old due to scarred alopecia [49]. In a study comparing female patients with and without scarring, it was shown that the quality of life of female patients with scarred alopecia was more affected, and accordingly anxiety and depression were more common [47]. It has been suggested that in scarred alopecia, patients spend too much time and effort to normalize their appearance, resulting in reduced success in friendship, work and school life [49]. The psychosocial burden of the disease is reduced by including psychological counseling and support groups in the care plan. Early diagnosis and treatment are important to prevent irreversible hair loss in scarred alopecia. The initiation of psychological support in the early period is also important in terms of a holistic treatment approach.

3.6 Trichotillomania

It is a disease that is characterized by the voluntary and involuntary pulling out of one’s own hair and hair and is basically included in the scope of primary psychiatric diseases. Due to its similarities with obsessive compulsive disorder, it has also been evaluated as one of the obsessive compulsive spectrum disorders [50]. Although it can be seen in different anatomical regions, one of the most affected areas is the scalp, pubic hair, and facial areas such as the eyebrows, eyelashes and beard. Although rare, one of the areas that are plucked is the nose hair [51]. Trichotillomania patients, on the one hand, relieve their stress and distress with hair pulling, on the other hand, experience a significant sense of shame, social isolation and deterioration in their quality of life. Psychological disorders such as low self-esteem, depression, anxiety etc. are characteristic of these patients [52]. Nail biting, thumb sucking, nose picking, masturbation, school problems and bad friendships may accompany in children. Comorbidity with major depressive disorder and anxiety disorders is quite common. In addition, increased rates of obsessive-compulsive disorder were detected both in patients with trichotillomania and in their relatives. Personality disorders in adults may be accompanied by conduct disorders in young people. The most common personality disorder is histrionic personality disorder with a rate of 26% [53]. Family studies have found an increased rate of hair pulling and obsessive compulsive disorder in first-degree relatives of trichotillomania cases [54].

4. Psychiatric symptoms and disorders comorbid with alopecia

4.1 Alopecia and depression

The presence of depressive symptoms in alopecia areata patients has been known for years. Colon et al. in their study, they predicted the lifetime prevalence of major depressive disorder as 39% in patients with alopecia areata [55]. Studies on this subject in the following years also suggest that the incidence of depression in alopecia has increased. Şahin et al., in their study with the beck depression inventory, compared the patients followed up with the diagnosis of alopecia areata and healthy volunteers; found the rate of depression to be 16.7% in healthy volunteers and 64.6% in patients with alopecia [56]. In the study of Arı et al., in which they compared the Beck depression, beck anxiety and alexithymia scale with patients with alopecia and healthy volunteers, no difference was found between the groups in terms of anxiety and alexithymia, but the depression scores of the alopecia group were found to be higher [57]. In another study conducted with the hospital anxiety depression scale, depression was found to be significantly higher than the control group with 38% [58]. The limitation of all these studies is that they are based on the use of scales rather than clinical interviews, but on the other hand, there seems to be an accumulation of knowledge that depressive symptoms are more common in patients with alopecia. It appears to be a risk group for major depressive disorder in children and adolescents with alopecia. In a study conducted with the evaluation of 5117 patients with alopecia areata in Taiwan, it was determined that alopecia areata, which started under the age of 20, poses a risk for major depressive disorder [24]. Although depression is thought to be more common in patients with alopecia, another point of view is the possibility that depression may exacerbate alopecia. In a case-control study conducted in Taiwan, patients with alopecia areata had higher rates of psychiatric disease; however, 50% of these people have been shown to have a psychiatric illness that precedes alopecia [24]. It has also been reported that a quarter of patients with alopecia areata experience stressful life events before the onset or exacerbation of the disease [59]. In another study, a significant relationship was shown between exacerbations in patients with alopecia areata and the patients’ perception of stress and state anxiety scores [60]. Studies have shown that imipramine, an antidepressant drug, and hypnotic approaches reduce depressive symptoms in alopecia areata and produce significant hair growth [61, 62]. There are other studies showing that the onset and exacerbations of alopecia areata may be associated with stressful life events. In fact, it is known that the stress response of the hypothalamopituitary axis (HPA) in the face of emotional stress can trigger not only alopecia, but also many other dermatological diseases (psoriasis, atopic dermatitis, urticaria, vitiligo, acne, etc.). There are studies that associate and investigate this link with common neuromediators associated with psychoneuroimmunological systems [63].

4.2 Alopecia and anxiety disorders

Many studies have shown that anxiety disorders are more common in alopecia areata. It is now accepted that visual lesions in the hair can have negative psychological consequences. In addition to the physical appearance of the disease, it has been shown that the chronic and poor course also causes anxiety. This can cause great concern, especially in women and young adults [62, 64]. In one study, generalized anxiety disorder was found in 39% of patients with alopecia areata. The same study reported that the frequency of anxiety disorders is higher in first-degree relatives of patients with alopecia [55]. Later, many studies have been conducted to support the knowledge that anxiety disorders are common in alopecia areata [17]. Onset at different ages in alopecia areta can also be a risk factor. Onset between the ages of 20 and 39 has been shown to be a risk factor for anxiety disorders [24]. In a study conducted in patients with refractory alopecia areata, hypnosis was used to improve psychiatric symptoms; It was determined that the severity of alopecia of the patients whose psychiatric symptoms improved, also decreased [62]. The most common anxiety disorder with alopecia areata is obsessive compulsive disorder [28].

4.3 Alopecia and schizophrenia

Schizophrenia is a serious psychiatric disorder with impaired ability to evaluate reality, hallucinations and delusions, disorganized thoughts and behaviors. In a case-control study conducted with 5117 patients in Taiwan, alopecia areata was found to be less common in schizophrenia, unlike other psychiatric diseases [24]. Case reports in this area are also limited. Years ago, Kubota et al. reported three cases of zotepine-induced alopecia areata, one schizophrenic and two bipolar, and the symptoms improved upon reduction or discontinuation of the zotepine dose [65]. In a recent case-control study of alopecia areata in the USA, the authors reported a higher incidence of schizophrenia and other psychotic disorders among patients with alopecia areata [27]. On the other hand, a large case-control study involving 5117 alopecia areata patients in Taiwan reported contrasting findings and showed a negative association between alopecia areata and schizophrenia [24]. A study conducted in Israel comparing 41,055 patients with alopecia areata to a control group found that schizophrenia was negatively associated with alopecia areata in both men and women [66]. It is not known how schizophrenia protects against alopecia areata. This area seems open to research.

4.4 Effects of alopecia on quality of life

Quality of life is a broad concept. It assesses whether it limits the patient’s ability to perform a normal role in their daily life, as well as the burden and outcomes of the treatments offered. It is defined as patients’ subjective perception of its impact on their physical, psychological, and social functioning [67]. Quality of life in diseases such as alopecia areata is a strong and important indicator of the disease on social relations, daily activities and psychosocial status [67]. The effectiveness of treatment in alopecia areata, the social and financial burden of the disease can be evaluated using quality of life indicators [68]. In a case-control prospective study involving 115 women with alopecia and 97 control patients of the same age, alopecia was found to significantly affect female sexual functioning, reducing desire, arousal, lubrication, orgasm, and satisfaction [69]. A meta-analysis of 2530 patients showed that alopecia significantly reduces patients’ quality of life [70]. As a result of studies using various quality of life tools, it has also been shown that alopecia has a detrimental effect on the quality of life of patients and that there is an improvement in quality of life with improvement in disease status [71, 72].

4.5 Alopecia and suicidal behavior

The relationship between suicide and alopecia is not completely clear. Although one report concluded that patients with alopecia areata did not show suicidal thoughts, another study found that 12.8% of patients with alopecia areata were at risk of committing suicide [73, 74]. In further support of the possible increased risk of suicide in patients with alopecia areata, a case series of suicides in 4 boys aged 14–17 years afflicted with alopecia areata within 1 year of diagnosis is presented [75].

4.6 Alopecia and personality profiles

Patients with alopecia areata have a characteristic personality profile with low novelty seeking, low reward dependence, and low self-transcendence [76]. More withdrawn, depressive, and aggressive features are found in approximately 40–50% of children with alopecia areata [77]. There are not many studies on the personality traits of these patients, and the incidence of personality disorders in this group has not been studied either. There is a study documenting high depression, psychosthenia, and social introversion subscales in the Minnesota Multidimensional Personality Inventory (MMPI) assessment in this group [78]. Carrizosa et al. used the Minnesota Multidimensional Personality Inventory to show that patients with alopecia areata expressed more depressed, hysterical, and anxious feelings than healthy subjects [79].

4.7 Alopecia and alexithymia

Alexithymia is a cognitive disorder related to the identification and expression of emotions. Its basic features can be listed as disorders in emotional awareness, social connectedness, and interpersonal relationships [80]. Although there are conflicting results, there are studies showing a relationship between skin diseases and alexithymia [81]. Features associated with alexithymia have also been found in individuals with alopecia areata. Alexithymia is seen at a higher rate in patients with alopecia areata than in the healthy group [82]. It will be useful to take alexithymia into account when evaluating the psychological state of the patient [83].

4.8 The effects of alopecia on self-image and self-esteem

Hair is important for individuals due to its cosmetic functions as well as its anatomical and physiological features. Hair loss can lead to low self-esteem and a negative self-image. It is known that hair loss in children significantly affects their social and psychological well-being, and children may experience significant psychological distress due to stigma, ridicule, bullying and peer pressure [84]. In a study conducted on female patients with a diagnosis of gynecological cancer, it was determined that 13% of the patients believed that they would be rejected by their spouses when hair loss occurred [85]. In a study conducted by Yin et al. between patients with and without cosmetic surgery, it was found that preoperative patients had lower self-esteem than the control group, and there was no significant difference in the self-esteem of the patients after surgery compared to the control group. As a result, it shows that plastic surgery can increase self-esteem and self-efficacy [86].

4.9 Alopecia and stigmatization

Physical appearance and attractiveness have a special importance in today’s social structure. Therefore, hair problems, which play an important role in physical attractiveness, can create significant psychological and social problems for people. One of these problems is stigma [87]. Stigma is the state of being humiliated, ostracized and ignored by the general society due to an illness. In other words, stigma means scar, stain, a sign of shame and humiliation that marks the person [88]. Hair diseases act as a stigma, as they cause significant changes in physical appearance. For this reason, stigma becomes an important psychological problem in patients with hair diseases [23]. In a study conducted by Temel et al., a statistically significant correlation was found between the Internalized Stigma Scale scores of patients due to alopecia areata and the scores measured by both the Dermatology Quality of Life Index and the General Health Questionnaire. In the study, internalized stigma scores of patients with alopecia areata were also found to be higher than those of patients with acne vulgaris and vitiligo [89]. In another study by Creadore et al., it was determined that as the severity of alopecia increased, the approval of each stigma item by the participating patients increased [90]. Medical and complementary treatments for alopecia, such as wigs, can alleviate the severity of stigma.

5. Alopecia and psychotropic drugs

It does not seem possible to say that psychotropic drugs are directly related to alopecia. There are case reports with citalopram, sertraline, venlefaxine and quetiapine [91, 92, 93, 94]. Psychotropic drugs are widely used in the research, development, production, measurement of clinical effects and use in the community, and side effect profiles are created. A direct relationship between alopecia and any antipsychotic or antidepressant drug has not been determined. Case reports remind us that individual responses should be considered. It is known that mood-stabilizing drugs such as lithium, valoproic acid and carbamazepine may be associated with hair loss [95]. It may be necessary to benefit from psychotropics in the treatment of comorbid psychiatric comorbidity in patients with alopecia as well as in the normal population. In a study comparing the use of 20 mg citalopram and triamcinolone with the use of only triamcinolone injections in patients with alopecia diagnosed with major depressive disorder, it was found that the use of citalopram significantly contributed to the improvement of alopecia symptoms as well as depression symptoms [96].

6. Psychiatric treatment approaches of alopecia

Data on the results of the use of psychopharmacology in the treatment of alopecia are very limited in the literature. The positive effect of imipramine, which is a tricyclic antidepressant, on alopecia has been demonstrated in a study in the literature [61]. The useful effects of citalopram and paroxetine were also demonstrated in one study [97, 98]. If there are psychiatric disorders or symptoms accompanying alopecia, some psychotherapy treatment methods can be used as well as psychopharmacological treatments. In dermatology, indications for psychotherapy include: worsening of disease-related symptoms under chronic or acute stress, increased secondary social avoidance and anxiety when a possible cause of body dysmorphic disorder is suspected, significant skin manipulation or self-harm is observed [99]. Some of these psychotherapy methods are cognitive behavioral therapy (CBT), habit reversal training (HRT), mindfulness therapies and hypnosis [99]. In a study conducted on patients with alopecia, it was shown that CBT has a positive effect on quality of life and depressive symptoms. In addition, it was determined that hair loss was less than the control group during the treatment [100]. Various psychotherapeutic techniques have been applied in the treatment of trichotillomania. However, HRT has been widely used with success, especially when combined with pharmacological therapy. HRT shares the basic principles of CBT but aims to reverse the positive reinforcement developed by patients with trichotillomania. By completing therapy, patients learn to effectively monitor and raise awareness of their hair-pulling behavior [101]. In a study conducted by applying mindfulness therapy, an improvement in quality of life and a decrease in psychiatric symptoms were found in patients with alopecia [102].

7. Conclusion

Hair is the most appearing and noticeable part of the body. It is a very important part for the psychologically healthy development of the individual from childhood to adulthood and even death. Alopecia is a disease that should be evaluated with its psychiatric dimensions. Having a diagnosis of alopecia at a young age, especially in children and adolescents, increases the risk in terms of psychiatric diseases. Mental disorders related to alopecia manifest themselves with many different psychiatric symptoms. However, many psychiatric disorders can also cause hair loss. The basis of psychosomatization of patients with alopecia who usually present to the dermatology outpatient clinic should be investigated and referred to a psychiatrist for appropriate psychotherapy or psychopharmacotherapy.