**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 [91–94]. 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

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

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].
