Hair is considered a sign of youthfulness and beauty. Healthy hair reflects the physical well-being of a person. Patients feel physically and socially less attractive if they have a loss of hair at an early age. Underlying pathophysiology may be different in different cases of alopecia but the final outcome is in the form of emotional and psychological disturbances.
Studies have shown dermatological diseases and psychological problems are interrelated. Psychological/psychiatric disorders have been detected at rates up to 60% in dermatology patients treated as inpatients and 30% in those treated as outpatients. Hair loss is a major concern for most people due to its psychological impact on them.
Alopecia can affect women and men of all ages. Hair, as such, has no significant function in humans. However, the role of hair in physical appearance cannot be overlooked. Therefore, hair loss can cause several psychological problems such as depression, anxiety, anger, fatigue, decrease in confidence level, embarrassment, lower self-regard, less sexual activity, decrease in work performance, social withdrawal, and suicidal tendencies. Surveys have shown that around 40% of women with alopecia have had marital problems, and around 63% claimed to have career-related problems. Recent studies have shown the stress level experienced by patients with alopecia to be at a level similar to many severe, chronic, and life-threatening diseases.
With the same pattern and degree of hair loss, different patients may have different psychological responses that vary from physiologically normal responses to exaggerated abnormal response. Sometimes a typical case of the subclinical psychological disorder may become manifested clinically because of hair loss. Clinical studies have also shown that 20-48% of patients presenting for cosmetic surgery may have a psychiatric diagnosis too. So evaluation of the patient suffering from hair loss from a psychological point of view is equally important to avoid subsequent consequences. Such patients may need counseling and treatment for their psychological disorder also along with hair treatment.
As per the 2017 ISHRS practice Census result data more than 0.6 million hair restoration surgeries were performed in the year 2016 with a maximum in the age group 26 to 35 years old (47.5%), approximately a 50% increase in the volume since 2014. So, the demand for hair restoration surgery is increasing day by day. Increased awareness along with the desire for a better look may be the cause. It may also be due to improved results with the availability of body hair grafts along with scalp hair grafts.
Hair transplant surgeons should be able to differentiate between a patient with hair loss who needs treatment/surgery and a patient who insists on treatment/surgery without indication. Psychological assessment of the patient while doing consultation is an art, it needs good communication skills. Giving time for each patient is also important. A minimum of 15 minutes per consultation is a must. Patient satisfaction and success of treatment depend on the quality of communication between patient and doctor. Improper communication is the main cause of patient dissatisfaction even after providing quality treatment to them. In the case of an anxious depressed and negativistic patient, try not to be judgmental or scolding otherwise patient will never open up with their problems. We as hair restoration surgeons need to include the following skills in our consultation
Careful listening to and understanding of complaints,
Informing the patient on all aspects:
investigations needed diagnosis, treatment, and duration of treatment and finally the prognosis.
During this process, we have to convince the patient and motivate him/her about treatment. We need to document and compare the results of treatment in a few months by global photography as further motivation to continue treatment.
The most common mental disorder related to hair loss is adjustment disorder. These are in the form of anxiety, depressed mood, somatic and/or sexual dysfunction, and feeling of guilt and/or obsession. This disorder depends on the acuity and severity of hair loss.
Other psychopathological disorders are somatoform disorders(hypochondria and body dysmorphic disorder) and personality disorder (anxious, negativistic, dramatic, and insecure). These are more challenging to treat.
A patient with the hypochondriacal disorder is excessively obsessed with normal bodily functions even though they do not have any abnormality. For, example, they believe any daily shedding of hair means they are going bald. Due to wrong interpretation of normal body functions, these patients become preoccupied with the fear of serious illness. Medical investigations and counseling also do not relieve them from fear of serious illness. The stress level of such patients affects their normal social and personal work to the level that becomes clinically significant. This disorder usually develops in middle age men/women and then tends to run a chronic course. It is also seen in older ages.
In psychogenic pseudo-effluvium (imaginary hair loss), patients fear that they are going bald without any sign of hair loss. Depressive disorder and body dysmorphic disorder are usually associated with psychogenic pseudo-effluvium.
In BDD patients become preoccupied with a non-existent or insignificant cosmetic defect. Patients consult different physicians for the same defect and are never satisfied with any prescribed treatment. This preoccupation causes distress that is clinically significant and affects social or personal life. This disorder is more common in teens and late adolescence. Patients with body dysmorphic disorder are arguably the most difficult patients for dermatologists.
Common Signs And Symptoms of BDD
Everybody wants to look good but they may not be satisfied with their appearance and feel conscious about that. The most important parts of body which contribute to the appearance of a person are face and head. Hence, usually, the main areas of concern are hair, shape of nose, ear, lips, eyebrows, beard, and mustaches. If unhappiness with a body part increases to the level that it starts affecting their daily routine or causes significant emotional disturbances, the person is diagnosed with BDD.
A patient suffering from BDD thinks that there is some significant defect in their appearance even when no such defect exists. This is probably because people with BDD have differences in visual processing – they tend to see themselves differently than other people do. We should suspect a patient has BDD if the following signs and symptoms are present-
Excessive concern for physical appearance.
Obsessive-compulsive behaviour such as looking at the mirror repeatedly to make sure that they look good. Some patients have opposite reaction that is they avoid looking at the mirror and try to keep their body parts covered either by some cloth or makeup.
Frequently asking, thinking or worrying about their concerns throughout the day.
There may be a history of previous cosmetic procedures with which the patient is not satisfied and visited different cosmetic surgeons for the correction of the same defect.
They may come with detailed descriptions of a celebrity’s physical appearance to match that look and may instruct the surgeon on how to perform the procedure.
Avoiding social gatherings, public places, workplaces, schools, etc.
Emotional distress such as lack of confidence, feeling low, depression, anxiety, and suicidal tendencies.