General Hospital Psychiatry 35 (2013) 439–441

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Recurrent trichobezoar due to trichophagia: a case report

İsmet Kırpınar, M.D. a,⁎, Tuğba Kocacenk, M.D. a, Emel Koçer, M.D. a, Naim Memmi, M.D. b

a Psychiatry Department, Bezmiâlem Vakif University, İstanbul, Turkeyb General Surgery Department, Bezmiâlem Vakif University, İstanbul, Turkey

⁎ Corresponding author. Tel.: +90 212 453 17 08, +90212 533 23 26.

E-mail address: ikirpinar@yahoo.com (İ. Kırpınar).

0163-8343/$ – see front matter © 2013 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.genhosppsych.2013.01.013

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 15 June 2012Revised 24 January 2013Accepted 26 January 2013

Keywords:TrichotillomaniaTrichophagiaRapunzel syndromeCase

Objective: Trichobezoar, a hair ball in the gastrointestinal tract, is usually the result of the urge to pull outone's own hair (trichotillomania) and swallow it (trichophagia). It is almost exclusively seen in youngfemales and may cause serious medical complications. This case report will describe an adult female patientwith recurrent trichobezoars.Method: Data for this case report was collected from peer-reviewed literature and treatment encounters bythe consultation–liaison psychiatry unit; subsequent to obtaining informed consent.Results: The personality characteristics, familial structure and domestic stress found in this case mirror theliterature. We initiated behavioral interventions including habit reversal training and patient education incombination with pharmacologic therapy with clomipramine.

Conclusion: Left untreated, trichophagia can cause a life-threatening emergency, requiring surgery.Recurrence of tichobezoars can be anticipated when the underlying emotional disorder is notaddressed using multimodal management including psychiatric evaluation and treatment combinedwith surgical procedures.

© 2013 Elsevier Inc. All rights reserved.

1. Introduction

A bezoar is a ball of swallowed foreignmaterials that collects in thegastrointestinal tract of animals and humans. In humans, bezoars canbe made of hair, vegetable or fruit fiber, milk curd or any indigestiblematerial. Trichobezoars may arise from eating one's own hair(trichophagia) or other indigestible fibers [1–4] and are the seriouscomplications of trichotillomania (TTM), which are mostly seen inchildren and adolescents [5–7].

Although the trichobezoars are generally confined within thestomach, sometimes, they may extend into the ileocecal valve. Thiscondition is known as Rapunzel syndrome [5,7,8]. Trichobezoars canblock the intestinal tract and, if left untreated, can be a life-threatening emergency requiring surgery.

This case report will present an adult female patient with recurrenttrichobezoar due to TTM and the psychiatric considerations.

2. Case report

Mrs. A, a 34-year-old housewife, was referred to the Gastroenter-ologic Surgery Clinic for epigastric pain. She had been complainingabout dyspepsia and vomiting during the past year. A diagnostic

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gastroscopy revealed a large filling defect in the stomach. Routinehematologic, biochemical tests, chest X-ray and electrocardiographywere within normal limits. A computed tomography scan of the upperdigestive tract showed a solid stomach density, which confirmed thediagnosis of bezoar. Surgical intervention by gastrostomy removed asolid, mass trichobezoar that completely filled the stomach (Fig. 1).She was discharged on Day 4 postop with referral to the consultation–liaison psychiatric unit.

Mrs. A was born in a little village as the youngest of five sisters.Her father was a poor, silent miner. Her mother was a proud,meticulous, perfectionist housewife who maintained the family farm.The stubborn grandmother took care of her from infancy. There wasno psychiatric family history, but the family environment hadlimited emotional or intellectual stimulation. Mrs. A had enuresisuntil 10 years of age. She also began nail biting and hair swallowingduring childhood. At 11 years old, she began complaining ofabdominal pain and nausea. The family took her to a hospitalwhere a bezoar was surgically removed; after which, the hairswallowing stopped.

Upon completing primary schooling, Mrs. A quit studying to helpwith household chores and farming. At 20 years old, she wasmarried to a poor laborer who she never met until her weddingday; violent abuse began within a few days. She resumed pullingand swallowing her hair within 3 months of marriage. Even thoughshe divorced and took their baby back to her parent's home after 2years, the trichophagia continued for the next 5 years. Thereafter,Mrs. A married again. Her second husband, though with low salary,was father of two children. In the third year of that marriage, she

Fig. 1. Extraction of the trichobezoar and the extracted material.

440 İ. Kırpınar et al. / General Hospital Psychiatry 35 (2013) 439–441

resumed the trichophagia in response to frequent disputes with himover their children.

Intake evaluation revealed observable hair loss, which Mrs. Acharacterized as providing escape from unpleasant feelings or thoughtsespecially those related to familial, marital and financial problems. Sherecalled increasing tension immediately before hair pulling and asensation of relief during and after completing the act. She reportedfeeling guilty after swallowing her hair but felt powerless to stop. Shemet all Diagnostic and Statistical Manual of Mental Disorders, FourthEdition, Text Revision (DSM-IV-TR) criteria for TTM. Her BeckDepression Inventory score was 21, the Yale–Brown Obsessive–Compulsive Scale score was 7 and the Beck Anxiety Inventory scorewas 13. She had obsessive–compulsive and depressive symptoms butdid not meet the criteria for any other psychiatric disorder.

Treatment consisted mainly of behavioral therapy. Pharmacother-apy consisted of clomipramine, 25 mg/day, titrated up to 75 mg/day.After 4 months of treatment, the patient reported she had no furtherepisodes of pulling and swallowing her hair. Her postoperativerecovery was uncomplicated. Mrs. A provided informed consent forpublication of her case.

3. Conclusion

Recurrence of trichobezoar is well described in terms of surgicaldiagnostic procedures, but there are only scarce reports in psychiatricliterature [8–10]. In our case, the adult female patient with TTM had aprevious trichobezoar removal 20 years earlier. She did not receiveany psychiatric intervention after her first surgical operation, eventhough an initial consultation was made. Similar outcomes werereported in cases of discontinuation or absence of psychiatrictreatment [9,10].

Previous studies have suggested that 5 to 30% of the patients withTTM engage in trichophagia [2,11–13], while 1 to 37.5% of these willdevelop a trichobezoar [2,4,13]. TTM subjects with and withouttrichophagia are similar with respect to a majority of demographicand clinical variables [11]. TTM is classified as an impulse controldisorder inDSM-IV-TR, but some researchers classify it as an obsessive–compulsive spectrum disorder. However, in comparison with obsessivecompulsive disorder (OCD), TTM has a younger peak age at onset,lower rates of comorbidity and is more common among females[14–16]. Our patient reported a history of obsessive–compulsive symp-toms but did not meet the criteria for an OCD diagnosis.

Although an empirically supported etiological mechanism oftrichophagia has not been established [1], earlier reports offerbiological or psychoanalytical explanations [17–19]. Behavioraltheories emphasize modeling and conditioning as factors thatestablish and maintain hair pulling as a habit [1]. Hair pulling isused as an adaptive response to stress, and the behavior is reinforcedby the relief or pleasure obtained. Some behavioral interventions ashabit-reversal therapy are derived from this theoretical explanation

[20–24]. In our case, common triggers were anxiety, boredom andexternal cues (poverty, children). Mrs. A. engaged in hair pulling as adistraction from domestic stress and the avoidance of noxiousaffective states, reinforcing the maladaptive behavior over time. Weused habit-reversal therapy and stimulus control training for Mrs. A.

Antidepressants and antipsychotics are commonly used drugs forTTM, having the evidence for efficacy [2,3,6,18,25,26]. Dual treatmentwith behavioral therapy and an serotonin selective reuptake in-hibitors may provide advantages over monotherapy in somecases [27]. N-acetylcysteine has emerged as a useful agent in alarge double-blind study and significantly reduced the TTM com-pared to the placebo [28]. We prescribed clomipramine, shown to beeffective in TTM [29] to address the patient's anxiety.

In conclusion, if left untreated, trichophagia can cause life-threatening emergencies, requiring surgery. Therefore, cliniciansshould carefully consider the importance of psychiatric evaluationand treatment in combination with surgical procedures.

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