Psychology of a Hair Loss Patient

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Psychology of a Hair Loss Patient

“Ugly is a field without grass, a plant without leaves, or a head without hair.”

-Ovid “The Silent Woman”

KEY NOTE:

·        Hair loss may have extreme psychological effects due to the current societal pressure

·        Not all hair loss patients are to be operated, since nowadays patients demand surgery but may not need one

·        It is important to give time to counselling of the patient to identify any underlying psychological disorder

·        If the patient has a psychiatric disorder, it is advisable to counsel the patient and encourage them to take a psychiatrist opinion before going ahead with the surgery, to avoid any unnecessary hassle or legal complications.

 

 

INTRODUCTION

Hairloss can be traumatising in a society that perceives hair as a sign of youthfulness, vigour and success. This worsens when loss of hair starts at an early age, resulting in patients feeling physically and socially less attractive, less virile, less likable and having low self-esteem. In search for a remedy and quick fix, this societal pressure leads to an increase in the demand for hair transplant surgeries. This is worsened by excessive advertising of hair transplant and camouflage techniques on television, newspapers and social media sites. Women with acute telogen effluvium or active scarring alopecia approach for surgery as a cure. Similarly patients, who don’t need surgery or are not the right candidates, have started demanding for a hair transplant.  Multiple online marketing sites and forums have started rating surgeons and have support groups for hair loss patients. It is not uncommon to get patients with grade 6 alopecia, coming with their past photos or pictures of movie stars and asking for hairlines like them. Frequently, we also get a patient who quotes a study on stem cells under trial and asks, ‘Doctor, can you do this for me?’ Hence with the current scenario, each patient approaches with a different psychology and emotion.

In one third patients these emotions are so over-whelming that they start affecting the patient’s daily lifestyle, such aslimiting their social activities, avoiding family occasions and spending enormous amount of time and money on hair grooming. This behavioural impact is noticed not only in men but in women too. Surveys have shown that around 40% of women with alopecia have had marital problems, and around 63% claimed to have career related problems.1 The same grade of alopecia may initiate a different psychological response in different patients, some are regarded as physiologically normal responses while some are borderline psychosomatic disorders and rarely a typical case of an underlying psychological disorder may be encountered.To prove this further, clinical studies have also shown that 20-48 % of patients presenting for cosmetic surgery may have a psychiatric diagnosis too.2Such patients need to be treated psychologically too along with their hair treatments, to get satisfying results. Hence evaluation of psychology of a patient suffering from hair loss, should play a major part in the training of an hair transplant surgeon to avoid dire consequences. It is the physician’s responsibility to segregate such patients, counsel them, and in most cases refer them or rarely themselves become the psychotherapist.

CURRENT SCENARIO

More than 3 lakh hair restoration surgeries have been done in 2014 itself, as per the International Society of Hair Restoration Surgery 2015 Practice Census Results data.3Since multiple surgeons in our country are not members of ISHRS, hence the actual number of surgeries may be much higher. Several factors have lead to this changing trend and increasing demand in hair transplant surgeries.

Table 1

  • Increased longevity
  • Changing trends and attitudes
  • Media hype
  • Increased awareness
  • Increased affordability
  • Demand for longer lasting drastic results
  • Hassel free one time treatment option

Paradoxically, coinciding with the demand for procedures there is an increasing fear of side effects and  demand for simpler and safer procedures. Often in the same patient one sees obsessive urge for procedure and also a paranoid fear of side effect- the twin demands of providing “ guaranteed efficacy with absolutely no side effects” is one of the challenges of hair transplant surgery.

DISEASE VS DESIRE:

As a result trichology is changing from disease oriented speciality to a desire satisfyingspeciality, where a patient demands a procedure for a perceived problem. This has led to a debate as to whether such patients are indeed patients or should they be termed as clients.

The difference between a patient and a client is given below:

PATIENT CLIENT
Has a disease Has a desire
Mostly needs medical treatment ; occasional surgical treatment Mostly needs a procedural treatment
Fear of  consequences of disease, fear of infection, fear of progression of alopecia Well aware; often has read well; knows often what treatment is needed
Accepts treatments willingly Wants options- safe options
Easier to counsel about side effects Paranoid about side effects
Respectful towards doctor; doctor is dominant Demands an equal relationship
Easier to handle if there is a side effect Demanding; can be aggressive, more likely for a medico legal situation

 

Being a successful hair transplant surgeon is always a multifaceted job. It involves being a director, an organizer, a marketing salesman and an entrepreneur. If one patient has a bad experience while undergoing a hair transplant, he not only gives the doctor a bad reputation but also discourages other patients from thinking about a hair restoration surgery. Hence making sure the patient has a pleasant experience and understanding their feelings at every step is a crucial part of this job.

TABLE 2

Characteristics of of a good hair transplant surgeon are as follows:

  • Emphasis on treatment
  • Emphasis on comfort
  •  Emphasis on results
  • Emphasis on safety
  • Emphasis on patient satisfaction
  • Emphasis on a joyful experience

ASSESSMENT OF PSYCHOLOGY OF A HAIR LOSS PATIENT

In 1818, Heinroth described the term ‘Psychosomatic’ referring to the influence, the mind has on the body. The easiest way for a physician of a non-psychiatric background to assess the psychology or thinking of the patient is via a good doctor-patient relationship. This is easier said than done. Despite the best medical education and training, good communication and interpersonal skills come naturally to health-care providers or with great experience and observation. Only a doctor with good communication skills will be able to segregate the cases that need psychotherapy.

Most important thing while evaluating a patient’s psychology is to give the patient time. Minimum 15 minutes per consultation are a must.4 It is often worthwhile to give the patient a questionnaire to fill . A counsellor or a junior doctor can also screen the patient first.

Following points give a stepwise guideline on evaluating a patient’s psychology when he enters an aesthetic clinic.

  1. GENERAL OBSERVATION: Assessment of the patient should start from the minute the patient enters the clinic. Subtle signs like, who is accompanying the patient? Is the patient’s dressing sense loud or subtle? Is the patient maintaining eye-contact? Who is talking more during the visit, the patient or the accompanying person? Does the patient’s tone seem over-excited or monotonous? Continuously fidgeting with their hair or looking at the mirror frequently?

Being anxious, nervous and self-conscious is a normal feeling while visiting a doctor and hence it is important to make the patient feel comfortable during his visit.

  1. CLINICAL OBSERVATION: Notice if the patient has exaggerated frown lines or glabellar lines, indicating stress. Any sign of a past cosmetic procedure carried out? Early signs of aging? Any sign of depression, such as hesitation marks?
  2. AMBIENCE: To make the patient comfortable, greet the patient with their name and get them seated comfortably. This helps in relieving the initial anxiety too. Notice if the patient is quite most of the time or talkative, reluctance in mentioning the complaints or over-zealous and demanding.
  3. QUESTIONING: Ask the patient what are his concerns- what is bothering; how much is it bothering. The reason behind getting the surgery? If anyone else told them to get the surgery? For how long have they wanted to get this surgery?

Asking open-ended questions helps in allowing the patient to talk more and open up.

Ask details about the expectations? To understand his expectations, ask, what and how much would satisfy him? Is there any minimum that he expects? Show him photos of what results can achieve and then ask will he be happy if such results are achieved?

  1. SCIENTIFIC HISTORY : History of any sleep disturbances, alcohol consumption or smoking, appetite loss, weight gain, give a hint about the physical and mental well-being. Family history regarding relations may be asked indirectly, such as recent divorce or marriage, which gives a hint on interpersonal relationships. The patients work type tells about their job satisfaction. Any hesitation to answer a question may also indicate a stress factor and should be noted.5

 

TYPES OF EMOTIONS IN ALOPECIA:

The difference between emotions and psychology is that, emotions are what a patient feels or experiences and psychology is how the doctor perceives these emotions. The patient may feel sad and rejected but diagnosing him of depression is the doctor’s job.

  1. DENIAL: Few patients are in denial about their hair loss. This is seen in men who usually comb their hair over the bald patch to create illusion of a full hairy head. A female having a receding hairline will usually change her hairstyle and start keeping a fringe. Such patients usually approach a doctor late and suffer due to poor treatment choices
  2. PANIC- Anxiety and panic are some of the common feelings seen in younger patients suffering from hair loss. The fear of looking old and unattractive and the inability to style hair are especially higher in women. Women are used to styling hair, curling them, straightening them and when they are unable to do it due to the excessive hair thinning; they have trouble dealing with it.
  3. DISSATISFACTION WITH APPEARANCE: Living with alopecia can be difficult in a culture that views hair as a sign of youth and good health. Feeling of a low self-esteem can be seen with any grade of alopecia but is more common with men profound alopecia.5This study also showed that this effect was seen more in younger males comparatively.
  4. REJECTION- Majority of the people suffering from higher grades of alopecia have suffered from social teasing and humiliation. Those who cannot deal with it usually start avoiding social functions. This may cause introversion and shyness, in extreme cases it may result in depression.6
  5. FIXATION- Alopecia leads to obsession in few patients. They get fixed about their loss and it can lead to an obsessive compulsive disorder in severe case. Continuously fidgeting with their hair and looking in the mirror for long hours are few of the hints pointing toward fixation.

 

UNDERSTANDING THE PSYCHOLOGY BEHIND THE EMOTION:

Not all patients have an underlying psychological issue. However all patients do have an underlying emotion or motive behind getting a hair transplant surgery. A survey done by the ISHRS 2015 practise consensus, showed that apart from having low density of hair, there were multiple reasons why female patients ask for a hair transplant. (Table1)3

Table 1: Aside from “wanting more hair,” what was the main reason women were seeking hair restoration in 2014? (n=233)

65% of the women in the study felt the reason for getting the surgery was psychological.  Rarely we encounter patients with psychosomatic causes asking for a surgery. These are the patients that need to be segregated.

 

  1. .

Psychosomatic causes: One-third of the patients visiting a dermatologist have associated emotional and psychosomatic factors,only treating the physical aspect in these patients is not going to yield any results, the psychosomatic factor needs to be resolved too.7Most common presentation of these factors seen in a hair transplant centre is in cases of body dysmorphic disorder (BDD) and depression.

 

BDD is considered a type of obsessive compulsive disorder and has been discussed in detail in another chapter in this textbook.8

The following table gives a list of screening questions to be asked during history taking:

Screening questions in to indentify patients with psychological disorder

If the answer to these five questions is “yes”, it is highly likely that the patient has BDD, and elective aesthetic surgery should not be performed

1.Do you believe that your alopecia is abnormal for your age?
2.Have you ever been very concerned about your appearance?
3.Do you often and carefully view yourself in the mirror? How much time do you spend doing so?
4.Do you attempt to hide your hair loss with your caps, scarfs, or camouflage?
5.Does your preoccupation with appearance have affected your life in the areas of your profession, social contacts, and partnerships? Have you neglected normal activities because of the defect?

 

After the screening, underlying psychosomatic cause can be confirmed via a simple tool-The Visual Analogue Scale (VAS). The doctor and patient independently rate disfigurement and record severity on the optical VAS using values between 0 and 10 (with 0 meaning “no disfigurement” and 10 meaning “most severe disfigurement”). When a discrepancy of more than 4 points on the VAS occurs, body dysmorphic disorder is highly suspicious.

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INTERVENTION AND DECISION TO DO THE PROCEDURE:

An ideal case to perform a procedure is the one with no obvious psychopathology, clearly defined areas of dissatisfaction, realistic expectations and who is self-motivated. Contradictorily, aesthetics procedures should be avoided in patients with major depression, signs of self-mutilation, troubled or agitated on day of surgery or on psychotics.9Depending on the assessment of the patient, if the physician feels there are no psychosomatic factors behind the patient’s demand for the surgery, he should go ahead. Borderline cases or mild cases of obsessive compulsive disorder or BDD also benefit with cosmetic procedures or a combination of psychiatric and cosmetic treatment.4Patients with psychological disorders believe they have a ‘defective appearance’ and despite doing a surgery they will feel it still looks defective, hence are always dissatisfied. They usually have a tendency to get multiple surgeries. Such patients also refuse to get psychiatric help initially. Counselling and communication skills are of utmost importance at stance instances. It is the dermatologist’s responsibility to act like a psychotherapist and explain the complexity of the condition to the patient. Only once the patient has insight, will he be willing to accept change. The doctor should work in a formalized collaboration with a psychiatrist, so it is easier for the patient to open up to psychiatric therapy without much resistance.10Occasionally a dermatologist may also have to prescribe selective serotonin reuptake inhibitors, such as fluoxetine , Sertraline orEscitalopram  in case the patient is extremely reluctant to visit a psychiatrist.

Doing a procedure on a patient with BDD may have dire consequences too, as patients may occasionally turn violent. There are 2 cases of murder of surgeons by patients showing symptoms of BDD.11Surveys have shown that 29% of aesthetic surgeons have been threatened legally by BDD patients.12

Warning signs for when not to do procedures

It is important for a dermatologist, not just to know when to do or how to do, but also when not to do. Following tips can be of help in identifying such patients:

1.      A patient who is obsessively concerned

2.      2. A patient who wants 100% guarantee

3.      A patient who wants absolutely safety

4.      A patient who demands multiple procedures

5.      A patient who says: I want to look like that person or that film star

6.      A patient who has visited several doctors for the same indication previously

7.      A patient who comes for the same problem repeatedly without ever deciding

 

Here are some personal examples of patients encountered by the author, to explain such patients in a practical aspect:

  1. A young girl was brought by the father for hair loss demanding hair transplantation, but was found to have a heedful of hairs and attempts to convince her otherwise failed. A biopsy was done, a trichoscan was done to show that everything was normal, but she refused to agree. One day she was brought in an ‘emergency’ to show that she had lost 90% of hairs, when she was found to have full head. At this stage a psychiatric component was suspected and she was asked to be shown to the psychiatrist. Father who was a doctor agreed, only to come back a week later, asking that the drugs prescribed by psychiatrist be given on a dermatologist’s prescription so that they don’t appear psychiatric. After checking with a psychiatrist, a prescription was given, but this request was repeated multiple times, till finally the author refused to give any further prescriptions till a psychiatrist gives his opinion. The psychiatrist intervened and gave a final diagnosis of schizophrenia – and the father knew it all along- only refused to accept it.

 

  1. A patient who was obsessed about donor scar after hair transplantation (Strip Surgery). He kept calling and questioning about the scar. Eventually patient was not considered a good candidate due to unrealistic expectations.
  2. A man approached to consult for a hair transplant for his brother suffering from alopecia, as his brother was obsessed about his hair loss and had quit his job as a driver since past 5 months due to alopecia.

CONCLUSION:

Tips for practice

Establish rapport with the patient- understand his indications  but also reasons for indications

Be empathetic; spend time with the patient-avoid doctor’s ego

Know when to do, how to, but also when not to do

Learn to say no

Always under promise but over deliver

If there is a side effect, be prepared for an aggressive reaction

 

Only a psychologically fit patient will be satisfied by a surgery. The doctor should not only be trained in aesthetics but also in psychotherapy and should know basics of pharmacology behind psychology. The judgement of taking a decision in such patients depends purely on the physicians knowledge and experience in dealing with psychological conditions.

References:

  1. Hunt, N., McHaleS. (2005a). Clinical review: The psychological impact of alopecia. British Medical Journal, 331, 951–953.
  2. Napoleon, A. The presentation of personalities in plastic surgery. Ann. Plast. Surg. 31: 193, 1993.
  3. International Society of Hair Restoration Surgery:2015 Practice Census Results. July 2015
  4. Poot, F., Sampogna, F. and Onnis, L. (2007), Basic knowledge in psychodermatology. Journal of the European Academy of Dermatology and Venereology, 21: 227–234. doi: 10.1111/j.1468-3083.2006.01910
  5. Girman CJ, Rhodes T, Lilly FR, etal. Effects of self-perceived hair loss in a community sample of men. Dermatology. 1998;197:223-229.
  6. Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on quality of life. J EurAcadDermatolVenereol. 2001;15:137–9
  7. Gupta MA, Gupta AK. Psychodermatology: an update.J Am AcadDermatol 1996;34:1030–46
  8. Phillips, K. A., McElroy, S. L., Hudson, J. I., et al. Body dysmorphic disorder: An obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? J. Clin. Psychiatry 56: 41, 1995
  9. Elsaie ML. Psychological approach in cosmetic dermatology for optimum patient satisfaction. Indian Journal of Dermatology. 2010;55(2):127-129. doi:10.4103/0019-5154.62733.
  10. Koblenzer CS. Psychocutaneous disease. Orlando(FL)7 Grune& Stratton; 1987
  11. Yazel, L. The serial-surgery murder. Glamour May: 108,1999.
  12. Sarwer, D. B. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a survey ofAmerican Society for Aesthetic Plastic Surgery members. Aesthetic Surg. J. 22: 531, 2002

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