Trichophagia - The Hair Eating Disorder

What Is It?

Trichophagia is a compulsive disorder in which a person sucks, chews, or swallows hair. It belongs to the Pica family of disorders (eating non-food substances) and is most closely linked to Trichotillomania (TTM) - the compulsive urge to pull out one's own hair.

Prevalence: ~0.6% of the general population (strict definition: hair swallowing); up to 3.2% using broader definitions that include chewing/sucking without swallowing.
Gender: Trichotillomania (the associated hair-pulling disorder) affects women 10 times more commonly than men.
Age of onset: Can occur at any age, but often begins in childhood or adolescence.

The Trichophagia - Trichotillomania Connection

Most people with trichophagia also have trichotillomania. The typical pattern is:

Person compulsively pulls out their own hair (scalp, eyebrows, eyelashes)
Then puts the hair in their mouth to chew, suck, or swallow it
Some eat only the root tip of pulled hair - this specific variant is called trichorhizophagia

Two types of hair-pulling behavior exist:

Focused pulling - intentional, to relieve an urge, itch, or uncomfortable feeling (similar to a compulsion)
Automatic pulling - occurs without awareness, usually during sedentary activities (watching TV, reading)

DSM-5 Classification

Trichotillomania is classified under Obsessive-Compulsive and Related Disorders (OCRD) in DSM-5. The diagnostic criteria are:

Criterion	Description
A	Recurrent hair pulling resulting in hair loss
B	Repeated attempts to decrease or stop hair pulling
C	Clinically significant distress or functional impairment
D	Not caused by another medical/dermatological condition
E	Not better explained by another mental disorder (e.g., body dysmorphic disorder)

(Kaplan & Sadock's Comprehensive Textbook of Psychiatry)

Physical Complications: Trichobezoar & Rapunzel Syndrome

The most serious medical consequence is the formation of a trichobezoar - a mass of swallowed hair that accumulates in the stomach. Hair is not digested by gastric enzymes, so it builds up over time.

Rapunzel Syndrome is a rare, severe form where the trichobezoar grows so large that its "tail" extends from the stomach down into the small or large intestine - named after the fairy tale character.

Symptoms of a trichobezoar include:

Abdominal pain and bloating
Nausea and vomiting
Early satiety (feeling full quickly)
Abdominal mass that can be felt on examination
Bowel obstruction (in severe cases)
Weight loss

Treatment requires surgical or endoscopic removal of the hairball. Without treatment, it can be life-threatening. (Bailey and Love's Short Practice of Surgery; Andrews' Diseases of the Skin)

Brain & Neurobiology

The disorder involves dysregulation of cortico-striatal-thalamic-cortical (CSTC) circuits - the same circuits implicated in OCD. Neuroimaging studies have found:

Decreased putamen volume in TTM patients vs. healthy controls
Treatment response to clomipramine is inversely correlated with anterior cingulate and orbitofrontal metabolism
High baseline CSF 5-HIAA (serotonin metabolite) predicts better response to SSRIs

Psychiatric Comorbidities

People with trichophagia/TTM commonly have:

Major depression (most common mood comorbidity)
Generalized anxiety disorder (most common anxiety comorbidity)
OCD (family history of OCD is often reported)
Personality disorders - especially Cluster C (obsessive-compulsive 27%, avoidant 14%) and Cluster B (histrionic 26%, borderline 18%)
Schizophrenia (rarely, as in case reports)

Treatment

Treatment depends on age and severity:

Behavioral/Psychological

Habit Reversal Training (HRT) - the gold standard psychotherapy for TTM; teaches awareness of hair-pulling triggers and substitutes competing behaviors
Cognitive Behavioral Therapy (CBT) - addresses underlying thought patterns
Parental guidance - most effective for young preschool-age children

Medications

Drug Class	Examples	Notes
SSRIs (first-line)	Fluoxetine, sertraline, paroxetine, fluvoxamine	Better tolerated than TCAs
Tricyclic antidepressants	Clomipramine	Shown superior to desipramine in double-blind trials
Atypical antipsychotics	Olanzapine, risperidone, aripiprazole	Used alone or as SSRI augmentation
Mood stabilizers	Lithium, topiramate, lamotrigine	For comorbid mood disorders
Opioid antagonists	Naltrexone	May reduce positive reinforcement from hair-pulling
Glutamate modulator	N-acetylcysteine (NAC)	Shown effective in pediatric TTM

For Trichobezoar

Endoscopic removal (when possible)
Surgical removal for large bezoars or Rapunzel syndrome
Address the underlying trichophagia/TTM afterward to prevent recurrence

Key Takeaways

Trichophagia = hair eating; trichotillomania = hair pulling - they often go together
The most dangerous complication is a trichobezoar (stomach hairball), which can cause obstruction
It is classified as an OCD-related disorder in DSM-5
Treatment combines behavioral therapy (HRT/CBT) with medication (SSRIs are first-line)
Early treatment leads to better outcomes

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