**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 selfconfidence, 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.

**Keywords:** alopecia, hair disorders, psychodermatology, psychotrichology, psychiatric management, psychiatric symptoms

### **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

#### *Alopecia Management – An Update*

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

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

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 stressinduced psychiatric disorders such as major depressive disorder, generalized anxiety disorder and phobias, and they also occur comorbidly in patients with alopecia [15].
