1 Theoretical background

The term trichotillomania refers to the recurrent practice of extracting one’s own hair, along with the attempts to decrease this practice. This behavior may be associated with feelings of gratification, pleasure, or even relief as the hair is pulled from the scalp, eyelashes, eyebrows, or pubic area [1, 4]. Specific emotional states such as anxiety and boredom have also been associated with trichotillomania [1], and comorbidity with depression is not uncommon [10].

Trichophagia, which refers to the consumption of hair, occurs in 20–30% of people who are diagnosed with trichotillomania [9]. Trichophagia can lead to trichobezoars, which are physical obstructions caused by collection of hair in the intestinal tract. Trichobezoars are often associated with anemia, abdominal pain, nausea and vomiting, and can lead to bowel obstruction [1]. In more rare instances, a trichobezoar may extend into the small intestines and/or beyond, which is referred to as “Rapunzel syndrome” [7].

There is little research concerning the presentation of trichotillomania in African American culture. This is an area worthy of attention because of the unique physical, cultural, and historical aspects of African American hair and its styling. One study written by Angela Neal-Barnett and colleagues studies the relationship between anxiety, culture, and trichotillomania in a sample of professional African American females [11]. The study found a near-significant relationship between trichotillomania and both generalized anxiety and obsessive-compulsive disorder, suggesting a pattern of comorbidity possibly unique to the African American community that could be researched further. The study also notably brings attention to the physical properties of black hair and how these properties are commonly associated with messages that may affect self-perception, whether they are positive or negative. A study of the phenomenology of hair-pulling in a community sample underscored the role of poor self-perception in motivating the behavior [6]. For African-American patients, these self-perceptions are even more relevant in a broader cultural milieu that traditionally prizes European standards of beauty. While the increased use of hair extensions and weaves by many African Americans can be viewed as a byproduct of assimilation, for many it also serves to protect the unique style and texture of their hair [14].

This report will describe the case of an African-American female who initially presented with symptoms of small bowel obstruction, later revealed to be the result of ingestion of material from her weave hair extensions. The case report will also discuss the cultural considerations necessary when discussing hair with patients of thisethnic background. There has been a lack of attention to trichotillomania in the African-American community, especially in patients who turn to an unconventional source of hair that is not their own, such as weaves.

2 Case presentation

A 23-year-old African American female with a history of trichotillomania and trichophagia was seen by the psychiatry consult team while admitted to the hospital for treatment of abdominal pain due to a small bowel obstruction. She was ultimately treated with a laparotomy for removal of a trichobezoar. The patient reported that she had been consuming human hair from her weave, a type of hair extension, in order to relieve symptoms of stress-induced anxiety. She reported cravings for a duration of around 6 months during her pregnancy. The frequency of these cravings was about 3 times per week, and she typically ingested only one strand of hair at a time though occasionally consumed more. The cravings ceased after the delivery of her child and had not returned since. The patient also had a previous case of similar trichophagia and trichotillomania leading to abdominal pain at age 13. During both episodes of trichophagia and trichotillomania, symptoms came about when she was nervous, and the behavior helped relieve anxiety. This patient reported that she experienced some worry every day but denied any muscle tension, fatigue, concentration, restlessness, or sleep disturbance. She screened negative for Major Depressive Disorder, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, or psychosis. She did not have any other history of psychiatric diagnoses, medication, or therapy. The patient smoked cigarettes before her pregnancy but stopped when she became pregnant, and she also denied any use of alcohol or illicit substances. This patient was previously diagnosed with chronic anemia leading to low iron for which she took supplements. Her medical record indicated previous diagnosis with von Willebrand disease, but she was asymptomatic, and the disease was never confirmed.

On the mental status exam, the patient was alert, calm, cooperative, and appeared comfortable in her hospital bed. She was dressed in a hospital gown, was well groomed, and appeared well nourished. She appeared her stated age. She described her mood as "fine,” and her affect was congruent. She appeared relaxed and was friendly. She spoke in a normal rhythm with appropriate volume, and she was easy to understand. She had a coherent, linear, and goal-oriented thought process. She showed no signs of delusions, hallucinations, suicidal ideation, or homicidal ideation. She did not have any difficulty sustaining attention throughout the interview and performed well on serial-sevens subtractions. Her memory of recent events was intact. She had no gross abnormalities in intelligence or cognition, easily describing abstract similarities between word pairs such as table:chair and bus:bicycle. She showed good insight about her behavior as a response to states of anxiety and showed good judgment in her decisions.

This patient was discharged with conversative management of her small bowel obstruction but developed worsening abdominal pain and nausea overnight, leading to a return to the hospital. Endoscopy confirmed a gastric trichobezoar, which could not be removed endoscopically due to its size. A laparotomy was performed to remove the bezoar (Fig. 1). She was returned to the hospital floor postoperatively and kept on nasogastric tube decompression until bowel function normalized. Her diet was advanced as tolerated until she was again consuming a regular diet. Bowel movements resumed. Having met all postoperative milestones, she was discharged home. Seen during her recuperation from surgery, her mental status exam was unchanged from the previous visit and did not show any abnormalities.

Fig. 1 
figure 1

A photograph of the 13.0 × 6.5 cm × 5.0 cm gastric trichobezoar extracted after an exploratory laparotomy and anterior gastrotomy. Hair extracted from the patient’s weave and fragments of food are visible

Full size image

3 Discussion and conclusions

Trichotillomania in African-American females is a topic seldom encountered in the psychiatric and psychological literature [11]. In an older study by Angela Neal-Barnett et al., researchers interviewed African-American hair-care professionals and chronic hair-pulling customers [12]. They found chronic hair pulling was the primary cause of 29 out of 80 customers’ hair loss, and all customers that hair-care professionals identified as hair pullers were women [12]. Of these 29 individuals, 21 admitted to trichophagia, and 3 customers noted these behaviors had been ongoing since childhood [12]. This suggests that there are many women that suffer from trichotillomania/trichophagia and go untreated. A unique finding about our patient is that the hair extraction was not from a part of the patient’s own body, but from a weave made of human hair. She did not report feeling any sensations, either emotional or physical, when pulling the hair from the weave. The consumption of the hair is what brought relief from her feelings of anxiety, which had been exacerbated by her recent pregnancy and relationship issues. A previous episode of this behavior at the age of 13 had likewise relieved stress, described by the patient as related to expectations of high academic performance from her mother.

To fully appreciate the cultural presence of the weave in African-American society, an understanding of why many African-American people wear weaves is important. Black hair's role in shaping black identity in America can be traced at least as far back as the early 1900s, when straight, long hair and lighter skin was more favored within both white and African-American communities [14]. Advertisements for hair products began to proliferate, all promoting an idealized version of straight Black hair that eventually became associated with higher chances at employment and success [3]. In addition, part of what drove this shift toward straight hair was the economic appeal of a growing market of Black consumers as thousands migrated into northern cities throughout the first half of the twentieth century. White-owned companies such as Plough and Ozonized Ox Marrow marketed their products by "promising a cure for the curse of kinky hair” [3]. By the early 1990s, the weave industry, which produces a stylized form of synthetic or real human hair, was importing 1.3 million pounds of human hair valued at $28.6 million from countries like India, China, and Indonesia [3].

Enthusiasm for untreated Black hair has grown in recent years, with some opting for the “big chop” and allowing untreated hair to grow out [2]. All the same, the weave is unlikely to stop being an important hair style for many Black women. It has been compared to a “veil,” providing a sense of safety in spaces where Black hair is deemed “inappropriate” while still allowing a degree of self-expression [15]. Their popularity may also be partly explained by the expense and discomfort of the heat and chemical hair-straightening treatments frequently endured by past generations of Black women [13].

Most of the current literature about trichotillomania concerns its presentation in the White population. It is important to keep in mind that some Black patients have grown up in a societal environment where non-natural methods of attending to Black hair have been promoted, which, as aforementioned, can lead to a presentation of generalized anxiety and trichotillomania at least in part due to self-perception related to the differences in the physical properties of black hair [11]. Bringing more awareness to trichotillomania in the Black population can help patients better understand their diagnosis.

In terms of possible treatments for trichotillomania, there is a wide range of therapy available, including cognitive behavioral therapy, habit reversal training, and acceptance and commitment therapy. Other treatment options that may be effective include supportive counseling, support groups, hypnosis, medications and combined approaches [10]. In regard to pharmacological treatments, data on SSRIs remain controversial. Behavioral therapy appears to provide more long-term benefit when compared to fluoxetine [5]. There is some data on TCAs such as clomipramine, but their side effect profile may confer more risks than benefits. Other pharmacological treatments that have been investigated include a-acetylcysteine, olanzapine, naltrexone, topiramate, modafinil, and cannabinoid agonists like dronabinol; however, more research is needed to confirm their efficacy [5].

There is not a large amount of literature supporting one treatment approach over another, with fewer than 20 randomized controlled trials available to guide treatment choice and implementation [8]. Cognitive behavioral therapy has shown to be helpful for treatment following acute presentation, although relapse appears to be a problem. SSRIs generally do not appear to be efficacious in reducing trichotillomania [10].