The development of a trichobezoar is a rare and potentially life-threatening complication of trichotillomania, which is an impulse control disorder characterized by the persistent and excessive pulling of one’s own hair. The term “trichobezoar” derives from the Greek word for hair and the Arabic word “bazahr,” which means protection from poisoning. A bezoar is an aggregation within the gut of indigestible foreign matter, which is repeatedly ingested over a period of time. Bezoars can be broadly classified as trichobezoars (hair ball), phytobezoars (food ball), and miscellaneous (such as pharmacobezoar, a collection of drugs).1
The term “trichotillomania” was coined in 1889 by the French dermatologist, Hallopeau.2 According to the DSM-IV, the features of this condition are recurrent pulling out of one’s hair, resulting in noticeable hair loss and clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is also an associated increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, followed by pleasure, gratification, or relief when the act of pulling out the hair occurs. However, the disturbance should not be better accounted for by another mental disorder or caused by another medical condition. Currently, trichotillomania is classified as an impulse control disorder, but there is an ongoing debate about whether it would be better classified as an anxiety or obsessive-compulsive disorder.2,3
Prevalence estimates range from a point prevalence of 4% to a lifetime prevalence of 10% among the general population.2–4 Anonymous surveys among college students have revealed that 0.6% met the criteria for trichotillomania and another 2.5% met partial criteria.4 Onset is generally in the prepubertal years, peaking between ages 9 and 13 years. Although there is an equal prevalence between the genders in childhood, the diagnosis is more common in women in adulthood.
Clinical characteristics of alopecia caused by trichotillomania are hairs that are irregularly shaped with angular borders and of varying lengths, hair loss is sometimes biased to the side of handedness, and affected areas are never completely bald.2,4,5 The differential diagnosis includes but is not limited to alopecia areata, tinea capitis, traction alopecia, female pattern hair loss (androgenetic alopecia), and teloegen effluvium.4,5 Patients often pull hair from the scalp; however, pulling hairs from eyebrows and eyelashes has also been reported. Other areas of hair pulling include the pubic, perianal, nasal, ear, and abdominal areas.4
Of patients with trichotillomania, approximately one half practice associated oral behaviors such as touching or tickling their lips or nostrils with the hair, one third bite off the root of the hair, and 5% to 18% engage in trichophagy (as our patient did). Many patients report spending over 1 hour a day engaged in hair pulling, with 95% reporting episodes of bingeing (ie, pulling hair for several hours at a time).4
Hypotheses of etiology include biochemical dysfunction including serotonin deficiency, structural brain abnormalities that are based on MRI findings of abnormalities in the lenticulate gyrus, abnormal brain metabolism due to the finding of high glucose metabolic rates in the global, bilateral, cerebellar, and right superior parietal areas, or endogenous opiate activity.3,4
Trichotillomania with trichophagy can result in the rare, but potentially fatal complication of trichobezoar, as in our patient (Figures 2 and 3). Patients with trichobezoar often are asymptomatic but can present with anorexia due to early satiety, weight loss, anemia, gastrointestinal disturbances, and abdominal pain once the bezoar has progressed to a large size.1 Complications of trichobezoar can include Rapunzel syndrome, which involves extension of the trichobezoar throughout the intestine, perforation of the intestine, and peritonitits.1
Figure 2. Trichobezoar being removed from patient.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.
Figure 3. Trichobezoar after removal.Photo courtesy of Donald B. Shaul, MD. Reprinted with permission.
Pharmacologic treatment of tricho tillomania includes use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, venlafaxine, lithium, and naltrexone.3,7 Behavioral therapy with various treatment strategies, including habit reversal therapy, relaxation training, hypnosis, and elimination of comorbid behavior, have also been employed.3 Recent comparisons of pharmacotherapy and psychotherapy have demonstrated that habit reversal therapy is superior to treatment with clomipramine and that treatment with SSRIs was not more effective than treatment with placebo.7
Many patients with trichotillomania have difficulty finding providers of psychotherapy, social support, and cosmetic care. The Trichotillomania Learning Center has compiled lists that address these needs for patients and providers. This information can be accessed at their website: www.trich.org/index.asp.8