A Review of Alopecia and its Psychological Consequences
The term alopecia simply means baldness or hair loss. It has a strange etymology. Derived from the Greek word alopex, which means fox, it was originally used to refer to a disease in foxes that caused them to lose their fur. Nowadays, it is an overarching term for a range of hair-loss disorders, the most common of which is alopecia areata, which causes people to lose their hair in small patches (areata comes from area, which in Latin meant a vacant space).
In general, hair-loss disorders are neither physically painful nor permanently scarring, but they can have significant psychological consequences, leading to social anxiety, depression, and even post-traumatic stress disorder. In this post, we look at the causes, symptoms, and ramifications of hair-loss disorders, and we consider their importance from a medico-legal perspective.
The causes and symptoms of alopecia areata
Alopecia areata was diagnosed as early as 1763, when the term was used by Sauvages de Lacroix to describe patchy hair loss in humans. Despite the long history of the diagnosis, though, doctors and researchers are still not exactly sure what causes it.
The most common theory is that it is an autoimmune disorder that causes a person’s cells to mistake their hair follicles for harmful, foreign objects. The cells respond by attacking those hair follicles, ultimately forcing them out. Why the cells should make this mistake, though, is unclear; there seem to be a range of environmental and genetic factors at stake. On the one hand, for example, researchers have shown that stress affects hair growth, so it seems likely that increased levels of stress in a person’s environment would contribute to alopecia. On the other hand, though, studies have also shown that alopecia can be caused by a malfunctioning of the central immune system. This system is regulated by specific genes, and when these do not work properly, the system can end up attacking the body and its hair. In all cases, alopecia can lead to hair loss on both the head and the rest of the body.
Although the mechanism that underlies alopecia is not exactly clear, there are two forms of the disorder that have clearly identifiable causes:
Chemotherapy-induced alopecia. Chemotherapy, which is used to treat cancer, aims to remove any cells in the body that are developing and dividing rapidly. Since hair follicle cells are some of the fastest-growing cells in the body, chemotherapy often affects them as well. This is why chemotherapy often causes hair loss, which can either take the form of alopecia areata, general hair thinning, or hair loss all over the body (alopecia universalis). The combination of alopecia with the other side effects of chemotherapy can cause people significant pain and distress, negatively affecting their mental health and their overall quality of life. Fortunately, chemotherapy-induced alopecia is rarely permanent, so people who recover from the treatment generally see their hair grow back.
Telogen effluvium. Another form of alopecia with a readily identifiable cause is telogen effluvium, which was first identified by the American dermatologist Albert Kligman in 1961. It is a very rapid and acute form of hair loss, which typically comes on after a psychologically traumatic or stressful event. Like alopecia areata, it is not physically painful and does not cause scarring. It typically occurs between three and four months after the triggering event and lasts for around six months. As telogen effluvium is connected to a specific event, treating the patient for the precipitating cause is often the best approach. Doctors will typically help patients to recognize the underlying trauma and to see their hair loss as a natural response. Once the precipitating event has been identified and the stress has been eased, the hair typically grows back.
The psychological consequences of alopecia
The research into the psychological consequences of alopecia is not definitive, but several studies have shown that people who experience hair loss are more likely to suffer from mental disorders than the general population. Psychological disorders that are associated with alopecia include depression, anxiety, social phobia, paranoia, body image disorder, and post-traumatic stress.
There are both psychological and social reasons for these effects. On a psychological level, it is important to recognize that a person’s hair is often closely tied to their identity. Like their face, a person’s hair tends to be clearly visible, so it affects both how they recognize themselves and how they are recognized by others. Unsurprisingly, therefore, a person whose hair suddenly and unexpectedly changes may experience significant psychological distress. The same is true, incidentally, for people who suffer physical damage to their face, as we discussed in our post on facial injuries and disfigurements.
As well as affecting people’s self-image, alopecia can also cause individuals to experience a sense of loss. People with alopecia can sometimes become obsessed with the way they used to look, grieving over what happened to their appearance. As a result, some researchers have argued that dealing with alopecia can be like learning to cope with a bereavement.
Another problem with alopecia is that it is difficult to predict and relapse is very common. This can make it hard for patients to accept their lack of hair as a permanent aspect of their identity. It can also cause people to feel like they are on an emotional rollercoaster, experiencing joy at regaining their hair before suddenly losing it all over again. For this reason, alopecia patients can feel like they do not have control over their body, which only exacerbates their sense of anxiety.
All of these problems are exacerbated by social factors since hair has lots of symbolic connotations in modern society. For example, hair loss is associated with getting older, so having a full head of hair is generally thought to be a sign of youthful exuberance. People who experience premature hair loss or alopecia, therefore, may be concerned that they have lost their youth and may become socially isolated as a result.
Alopecia and women
These kinds of social factors generally have more of an impact on women than on men. This is likely due to the unrealistic beauty standards created by celebrities advertising hair and cosmetic products aimed at women. While there are hair products marketed at men, the vast majority of them target women, which makes the stigma around hair loss even worse for women than it is for men.
Moreover, studies have shown that hair is typically thought to be more essential to a woman’s identity than a man’s. As a recent review of the effects of telogen effluvium put it, “femininity, sexuality, attractiveness, and personality are symbolically linked to a woman’s hair, more so than for a man.” Relatedly, a comparative analysis of 96 women and 60 men found that while hair loss was undeniably stressful for both genders, it was “substantially more distressing for women.”
Specifically, women with alopecia often report a deterioration in their self-esteem. In a comparison of cancer patients who did and did not develop alopecia, those with alopecia were found to respond more negatively to their bodies. Their sense of self deteriorated after the alopecia emerged, suggesting a strong correlation between hair loss and self-esteem issues.
Finally, these psychological consequences can have a broader effect on women’s quality of life. Around 40% of women with alopecia report having problems in their marriage, and almost two thirds of them experience difficulties in their careers. This creates a vicious cycle of anxiety and withdrawal that can be hard to break.
Treating alopecia
As mentioned, there is no recognized cure for alopecia. While some medications can prove useful in combating milder forms of the disease, they are generally ineffective at treating severe cases. As a result, psychiatric treatment becomes particularly important. In fact, one of the most important aims for treatment for an alopecia patient is to help them come to terms with their hair loss and stop searching for a cure. Given the unpredictability of the disorder, remaining focused on a cure can leave patients struggling to overcome their anxiety.
That said, the specific form that the psychiatric treatment takes will vary on a case-by-case basis. If the alopecia is associated with a traumatic incident, for example, then the methods used to treat post-traumatic stress disorder may prove useful. On the other hand, treating stress-induced alopecia generally involves introducing lifestyle changes or developing stress management techniques.
One study has shown that group support can benefit patients with alopecia. As part of this study, the patients organized a support group that featured medical professionals as guest speakers. Sharing information and experiences with other people in the group helped the patients to de-stigmatize hair loss. It also allowed them to be informed about cosmetic interventions like changing their appearance with wigs, tattoos, and more.
In general, however, the research into treatment for alopecia remains fairly limited. There has been little investigation, for example, into the importance of family support for people with alopecia, nor has there been much study of how different treatments affect different demographics.
Alopecia in medico-legal settings
From a medico-legal perspective, the psychological consequences of alopecia may be relevant in cases relating to personal injury or work-induced stress. If a person experiences hair loss as a result of negligence (say, for example, while receiving a treatment at the hairdressers), and this proves to be psychologically damaging, then they may be able to make a claim for compensation. Similarly, if a person developed alopecia from working in a stressful work environment over an extended period of time, then they might be able to make a claim against their employer. However, as we discussed in our post on psychological injury claims for work-induced stress, the burden of proof in these cases is generally very high.
The most likely way in which alopecia would be relevant to a workplace injury claim would be as a symptom of ongoing psychological damage. This was relevant, for example, in a case from 2006 (McMullan v Coleraine Football and Sports Club Ltd) that involved an employee of a football club who fell from a crane while putting up advertising boards. The employee sustained significant physical injuries, as well as long-term psychological symptoms. He became socially isolated and exhibited signs of depression and stress. The stress also caused him to develop alopecia, which further affected his mood and made him unwilling to leave the house. As a result, his alopecia later became a contributing factor in the claim he made against his company; he argued that his hair loss had been caused and exacerbated by the mental health problems that he sustained from his injury.
Summary
In conclusion, while alopecia is a physical disorder, its most damaging effects are undoubtedly psychological. Given the very important role that hair plays in a person’s identity, hair loss caused by alopecia or telogen effluvium can be very damaging to their sense of self. People with alopecia, particularly women, can become socially isolated; they are more at risk of certain psychological disorders than the general population. For this reason, it is important for mental health professionals to take a nuanced response to treating alopecia, varying their treatment depending on the individual in question and the specific nature of the disorder. For the foreseeable future, it seems unlikely that we will find a medical treatment for alopecia, so it should continue to be treated as a disorder with significant and damaging psychological sequelae.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.