**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 selfesteem 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

#### *Psychological Aspect of Alopecia DOI: http://dx.doi.org/10.5772/intechopen.106132*

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 [42–44]. 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].
