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Rapunzel Syndrome: The Astonishing Truth About a Rare Psychological Condition

Trichophagia is a hair-eating disorder that may occur as a symptom of another condition known as trichotillomania, a hair-pulling disorder. We take a closer look at the symptoms of trichophagia and ways of helping people overcome the habit. 

Trichotillomania, also referred to as a hair-pulling disorder, is a compulsive psychological disorder in which a person has irresistible and recurrent urges to pull hair from their eyebrows, scalp, or other areas of their body. It may result in considerable hair loss.

An individual with trichotillomania may also suffer from trichophagia, which is the chewing and swallowing of the hair they pull out. Eating the pulled hair is a hazardous behavior. This may lead to the formation of a hairball (trichobezoar) that can potentially block the person’s intestinal tract gut and, if left untreated, risks becoming a life-threatening emergency needing surgery.

Bezoars form through the consolidation of existing internal and foreign materials in the gastrointestinal tract. Trichobezoars are made of hair-like fibers that form following hair eating. They generally form in the stomach and occur before the opening of the stomach, in the duodenum or small intestine. However, some trichobezoars may travel via the rear end of the stomach into the small intestine (duodenum, jejunum, and ileum) and even the large intestine (colon) in a medical condition referred to as Rapunzel syndrome. The latter is named after the princess in the Grimms’ Fairy Tales, who let her long golden hair down from her tower prison so her lover could climb up.

Most trichobezoars may not be identified due to their nonspecific presentation or lack of symptoms in their early stages.

Trichophagia is a rare condition, and it is often difficult to diagnose due to a general lack of symptoms. It is only when the condition is severe that symptoms present. There may be no symptoms, or they may occur as a combination of symptoms. Some symptoms of trichophagia are:

  • Pain in the abdomen or belly
  • Dizziness and faintness
  • Fatigue
  • Nausea
  • Vomiting
  • Chest discomfort
  • Change in the color of the stool (it may become dark green or black,  indicating bleeding from the gut)
  • Weight loss
  • Constipation or diarrhea
  • Loss of appetite

Complications from a large obstructing or eroding bezoar include:

  • Ulceration in the stomach
  • Obstructive jaundice
  • Gastric emphysema or the accumulation of gas within the stomach wall
  • Acute pancreatitis 
  • Perforation of the stomach

What causes trichotillomania or hair-pulling disorder remains unclear; however, similar to many complex conditions or disorders, it may result from an association of environmental and genetic factors.

Some psychiatric disorders, such as mental health conditions, abuse, pica, obsessive-compulsive disorder, depression, and anorexia nervosa, may also be associated with the hair-eating disorder, trichophagia.

Some therapies that may help in treating trichotillomania are as follows:

  • Habit reversal training: this behavioral therapy is the main treatment for the condition. The person with trichotillomania learns to recognize the situations when they are more likely to pull their hair and to substitute this behavior with other behaviors. For instance, they may clench their fists to help stop the urge to pull the hair or redirect their hand from their hair to their ear. The therapist may also use other therapies in combination with habit reversal training.
  • Cognitive therapy: cognitive therapy may help in identifying and examining distorted beliefs that a person may have related to the pulling of hair.
  • Commitment and acceptance therapy: with this therapy, a person may learn to accept their urges to pull their hair without acting upon them.

Therapies, which help in treating other mental health conditions that often occur with trichotillomania, including anxiety, substance abuse, or depression, may also form an integral part of trichophagia treatment.

Although the Food and Drug Administration hasn’t approved any medicines specifically to treat trichophagia, some medicines may help in controlling certain symptoms of hair eating. For instance, the physician may recommend taking an antidepressant. Some of the other medicines that, according to research, may provide some benefits include N-acetylcysteine (an amino acid, which influences neurotransmitters associated with mood) and an uncommon antipsychotic. 

Discuss treatment options with your physician as they will advise you on the balance between the possible advantages of the medicines and their possible side effects.

The surgical treatment of a trichobezoar depends on its eventual location and size. The surgeon may remove small trichobezoars endoscopically. Large symptomatic trichobezoars, particularly when associated with Rapunzel syndrome, should be surgically removed, preferably using a minimally invasive approach if possible.

Trichotillomania, or hair-pulling disorder, is a compulsive psychological condition that may be associated with other underlying mental disorders such as anxiety and depression. Trichophagia, or hair-eating disorder, is a rare symptom of trichotillomania and is often difficult to diagnose due to its general lack of symptoms.  

Rapunzel syndrome is a rare compulsive psychological disorder that must be considered while diagnosing patients with psychiatric comorbidity and a history of trichotillomania or trichophagia. The doctor may diagnose Rapunzel syndrome by imaging studies, and one of the accurate and direct diagnostic methods is endoscopy. The human gastrointestinal tract is unable to digest human hair, and trichobezoars generally need to be removed surgically. Patients usually also require psychiatric evaluation and treatment due to the association with impulse control disorders, especially trichotillomania. A long-term and regular follow-up, along with psychiatric consultation, is recommended.

If you aren’t able to stop pulling your hair or if you feel ashamed or embarrassed by the way you appear due to your hair pulling, you should discuss the issue with your doctor. Trichotillomania isn’t only a bad habit but a psychological disorder, and the intervention of a health professional is often required to break the habit. 

https://www.bfrb.org/storage/documents/Trichophagia_2017.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2757434/

https://www.mayoclinic.org/diseases-conditions/trichotillomania/symptoms-causes/syc-20355188

https://www.mayoclinic.org/diseases-conditions/trichotillomania/diagnosis-treatment/drc-20355193

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109030/

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