What is the most likely psychiatric condition in a patient with unexplained hair loss and severe abdominal pain with constipation?

Trichobezoar Secondary to Trichotillomania

The most likely psychiatric condition in this patient presenting with unexplained hair loss and severe abdominal pain with constipation is trichobezoar, which results from the compulsive hair-pulling disorder trichotillomania combined with trichophagia (hair ingestion).

Clinical Reasoning

The combination of unexplained hair loss with severe abdominal pain and constipation creates a highly specific clinical picture that points directly to trichobezoar:

Hair Loss Pattern

• Trichotillomania causes incomplete, patchy alopecia with hairs of variable length, distinguishing it from alopecia areata where hair loss is complete in affected patches 1
• The hair loss results from repetitive self-pulling behavior, often triggered by psychosocial stressors such as sibling rivalry, family conflict, or school performance issues 2
• Broken hairs remain firmly anchored in the scalp (still in anagen phase), unlike the "exclamation mark" hairs of alopecia areata 1

Gastrointestinal Manifestations

• Trichobezoar presents with epigastric/abdominal pain, constipation, early satiety, nausea, vomiting, and weight loss 3, 4
• Human hair is resistant to digestion and peristalsis, accumulating over time in gastric folds to form a compact mass 4, 5
• Approximately 5-30% of patients with trichotillomania engage in trichophagia (hair ingestion), though this is less frequent in children than adults 2
• The condition can cause gastric outlet obstruction, ulcers, perforation, and when hair extends through the small bowel to the cecum, it is termed Rapunzel syndrome 5

Demographic and Psychiatric Profile

• The typical patient is a female (disease almost exclusively affects females) in the preadolescent to young adult age range, with peak onset at 8-13 years (average 11.3 years) 2, 4
• Prevalence in children and adolescents is estimated at less than 1% 2
• Patients are often sensitive, anxious, withdrawn, with body dissatisfaction and low self-esteem 2

Diagnostic Approach

Clinical Examination

• Look for incomplete alopecia without inflammation, desquamation, or scarring, with hairs of variable length 2
• Negative hair pull test along edges of alopecia distinguishes from alopecia areata 2
• Palpate for an abdominal mass - trichobezoars often present as a firm, mobile (side-to-side but not up-down), oval-shaped mass in the epigastrium or left hypochondrium 4

Confirmatory Testing

• Endoscopy is the gold standard for diagnosis, revealing a hair ball occupying the gastric cavity 4
• CT scan shows a large oval mass with interspersed gas 4
• Barium swallow can establish diagnosis 5
• Skin biopsy of scalp (if needed) shows increased catagen/telogen hairs, pigment casts, empty anagen follicles, and perifollicular hemorrhage 2

Critical Pitfalls to Avoid

• Do not delay radiologic examination and gastroscopy when trichophagia is suspected, as complications include perforation, obstruction, intussusception, pancreatitis, and anemia 5
• Do not assume absence of visible trichotillomania excludes trichobezoar - many patients conceal their hair-pulling behavior and signs may not be obvious 6
• Do not confuse with alopecia areata - the latter shows complete hair loss in patches, positive hair pull test, and "exclamation mark" hairs on dermoscopy 1
• Recognize that patients often pull hair when alone in relaxed surroundings (bedroom, bathroom), and parents may not witness the behavior 2

Management Strategy

Immediate Surgical Intervention

• Laparotomy is the primary treatment modality as endoscopic removal is usually unsuccessful for large trichobezoars 4, 5
• Surgery is required emergently when obstruction or other complications are present 3

Psychiatric Treatment

• All patients require psychiatric consultation and long-term follow-up to prevent recurrence 4
• Cognitive behavioral therapy is first-line psychological treatment 2
• Consider psychopharmacologic therapy if behavioral interventions are insufficient 2
• Address underlying psychosocial stressors including family dynamics, sibling rivalry, and school performance issues 2

Dermatologic Support

• Mild shampoo, topical corticosteroids (hydrocortisone butyrate 0.1% solution), and methionine supplementation can support scalp health during recovery 2

The medical and psychiatric sequelae of trichotillomania should not be underestimated - early diagnosis and treatment is of utmost importance to save the patient's life and prevent recurrence 3.