Published online: 2021-12-31

THIEME
Review Article 411

Psychology of Hair Loss Patients and Importance

of Counseling
Lakshyajit Dhami1

1 Vasudhan Cosmetic & Plastic Surgery Centre, Mumbai, Maharashtra, Address for correspondence Lakshyajit Dhami, MS, MCh (Plastic
India Surgery), Vasudhan Cosmetic & Plastic Surgery Centre, Mumbai,
Maharashtra 400092, India (e-mail: [email protected]).
Indian J Plast Surg 2021;54:411–415.

Abstract Androgenetic alopecia (AGA) is highly prevalent in society, affecting both men and
women. More than the sociological meaning of hair loss, it has become a very
important part of self-identity or “body image.” A psychological concept of body
image refers to one’s thoughts, feelings, perceptions, and behavioral changes related
to one’s physical looks. In spite of alopecia’s common occurrence, it often leads to
psychological disturbance and distress. Hair thinning and perceived hair loss also has a
very important negative impact on the psyche of the individual. The common
emotional aspects associated are self-consciousness, embarrassment, frustration,
Keywords and jealousy. Knowledge of these effects among the clinicians managing hair loss
► hair loss patients is beneficial. The clinician must make an active effort to identify the borderline
► hair transplant group of patients with body dysmorphic syndrome so as to manage them with
► counseling psychotherapeutic medication for their hair loss prior to hair transplantation. This
► psychology article aims to provide important information and an understanding of how the
► body dysmorphic psychology gets affected due to hair loss, particularly AGA and its management to the
disorder practicing hair transplant surgeons.

Introduction The term “bad hair day” is an evidence to the psychologi-

cal importance of hair. A person suffering from hair loss may
Scalp hair has greater social and psychological significance as experience a “bad hair day” every day. A patient with hair
compared with its biological importance to mankind. Hair loss goes through multiple feelings and emotions due to
has no significant function in humans except providing some personal and social pressure. Hair loss may cause psycholog-
cranial padding and protection from the Sun’s rays.1 Beyond ical stress out of proportion to the problem. This is worsened
its sociological meaning, hair can become an essential part of by excessive advertisement of hair treatments and camou-
self-identity or “body image.” Scalp hair always makes a flage techniques in movies, on television, newspapers, and
statement. A head full of hair is perceived as a sign of gender, social media.
youthfulness, vigor, and status. Scalp hair is a unique part of
the human body that can be altered and restyled as per one’s
The Impact of Hair Loss
desire. It can be colored, cut, and curled in a short period of
time. In contrast, any transformation in other body parts Loss of hair at an early age due to nonscarring androgenic
would need substantial efforts and time, involve artificial alopecia (AGA) or pattern hair loss (PHL), results in a person
adornments, or entail various surgical procedures. feeling physically and socially less attractive, less virile, and

DOI https://doi.org/ © 2021. Association of Plastic Surgeons of India. All rights reserved.
10.1055/s-0041-1741037. This is an open access article published by Thieme under the terms of the
ISSN 0970-0358. Creative Commons Attribution-NonDerivative-NonCommercial-License,
permitting copying and reproduction so long as the original work is given
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412 Psychology of Hair Loss Patient and Importance of Counseling Dhami

less likeable leading to low self-esteem. The severity of these members. This condition is primarily an obsessive compul-
symptoms will be directly related to the severity of AGA. sive psychiatric disorder. Although it can easily be diagnosed
The psychological stress is felt more in women as com- by the history and patient examination, patients usually
pared with men. The hair is the crowning beauty and pride avoid reporting their problem due to shame and fear of
for a woman. She believes this adds to her feminity and being mocked or being labeled as a lunatic. The surgeon
attractiveness. Any sign can be traumatic to a woman’s self- should therefore approach the behavior in a nonincriminat-
esteem and identity, especially when affected at a younger ing or noncondescending manner and should be extra careful
age. Hair loss also is perceived as early aging for older woman while referring these patients to the psychiatrist.
making them feel loss of sexual attraction and virility to their
mate.
Disorders Associated with Hair Loss
Women face increased societal pressure as compared
with men due to reduced cosmetic acceptance. Hence, bald- Scarring alopecia is a pathological condition characterized by
ness will affect them more negatively and worsen their life loss of hair as a result of fibrosis of the follicular structure.
situation. Whatever may be the underlying reason, the psychological
The difference between emotions and psychology related effect of scarring alopecia is usually more than nonscarring
to hair loss is that emotions are what a patient feels or alopecia.
experiences, and psychology is how the doctor perceives Hair loss-related mental disorders can be broadly divided
these emotions. The patient may feel sad or dejected but in to:
diagnosing him of depression is the doctor’s job. Adjustment disorder, which may depend on the severity of
The emotions as a result of hair loss are sometimes so hair loss, and personality disorder, which is psychopatholog-
overwhelming that it starts affecting the patient’s daily ical and may be hypochondriacal or body dysmorphic disor-
routine life. It may lead to limiting social activities, avoiding der (BDD).
family occasions, and spending enormous amount of time Patient with hypochondriac disorder becomes preoccu-
and money on hair grooming. This behavioral impact is pied and obsessed with the fear of serious illness, even when
noticed not only in men but in women too. Studies by they do not have any abnormality, due to wrong interpreta-
Hunt and McHale have shown that around 40% of women tion of normal body functions. Medical investigations to rule
with alopecia have had marital problems and around 63% out any pathology and counseling also do not relieve their
claimed to have career-related issues.2 symptoms. Psychologic pseudo-effluvium is classic example
The same grade of alopecia may elicit a different psycho- of this disorder, which usually affects at middle age and
logical response in different individuals. Some will have a continues till old age.
physiologically normal response, some may have a border-
line psychosomatic disorder, while some may precipitate the
Body Dysmorphic Disorder
underlying psychiatric disorder. Clinical studies have shown
that 20 to 48% of patients presenting for cosmetic surgery BDD is a mental health disorder in which a patient cannot stop
may have a psychiatric diagnosis too.3 thinking about one or more perceived defects or flaws in their
Some of the mild to severe symptoms of associated appearance—a flaw that appears minor or cannot be seen by
psychological problems with hair loss are: anxiety, anger, others. It usually starts during adolescence with 16 years old as
depression, embarrassment, decreased confidence, reduc- an average age of diagnosis.5 Like many other mental health
tion in work and sexual performance, social withdrawal, conditions, BDD may result from a combination of causes such
and suicidal tendencies. These are similar to those usually as genetic predisposition, abuse or bullying during childhood,
seen with chronic and severe life-threatening diseases. low self-esteem, fear of being alone or isolated, and perfec-
Alopecia areata is a chronic disease, in contrast to PHL, tionism or competing with others. If a person’s unhappiness
with an incidence of 2.1%. It starts all of a sudden and causes with body part increases to the level that it starts to affect the
hair loss with sharp and circular borders.4 Although the exact daily routine or causes significant emotional disturbances,
etiopathology is largely unknown; the factors known to play they are diagnosed with BDD.6 These patients have difference
some role in its development are: genetic, immunological, in visual processing. They tend to see themselves differently
environmental, infectious, or psychological. Alopecia areata from how other people look at them. The common signs and
and its significant effect on the quality of life in relation to symptoms of BDD are:
psychological factors has been studied in more details.4
Alopecia areata patients as compared with other individuals • Excessive concern for physical appearance.
are also reported to be more commonly affected with social • Person has obsessive compulsive behavior like either
and family problems and they have reduced capacity to cope looking at self again and again or totally avoids looking
with events. at self and try to keep the body part covered with makeup
Trichotillomania is a disorder that involves impulsive, of clothing.
recurrent, and irresistible urges to pull out hair from scalp, • Keep thinking, worrying, and asking about their concern
eyebrows, and other body part. It is a disorder, characterized throughout the day.
by chronic hair pulling and leads to a negative effect on the • Avoid social gathering, public places, schools, or
quality of life not only of the patient but also their family workplace.

Indian Journal of Plastic Surgery Vol. 54 No. 4/2021 © 2021. Association of Plastic Surgeons of India. All rights reserved.
 Psychology of Hair Loss Patient and Importance of Counseling Dhami 413

• Emotional distress and suicidal tendencies. Table 1 Questionnaire to identify or rule out body dysmorphic
• History of previous cosmetic procedures and unsatisfied disorder (BDD)7
with it.
• History of previously visiting several doctors for the Sr. Question Score
correction of same defect. No.
• Patient who has come with the same problem earlier, 1 How often do you deliberately check your feature(s)?
without ever deciding about treatment. Not accidentally catch sight of it. Please include
looking at your feature in a mirror or other reflective
• Coming for consultation with detailed description of some
surfaces like a shop window or mobile or looking at it
celebrity’s appearance (more often with their photos) and directly or feeling it with your fingers.
asking for results to match it and occasionally coming
A About 40 times or more a day 8
with a detailed procedure plan for the surgeon to carry it
out. B About 20 to 40 times a day 6
• Patient who is looking for surgical results without any C About 10 to 20 times a day 4
side effects or scarring. D About 5 to 10 times a day 2
E Never check 0
Despite very high prevalence of psychological ailment
among patients seeking treatment for hair loss, some of 2 To what extent do you feel your feature(s) are cur-
rently ugly, unattractive or ‘not right’?
these remain undiagnosed and/or are untreated in a clinical
practice. The clinician being aware of these problems is the A Very ugly or “not right” 8
first step in their management. B Markedly unattractive 6
Most of the patients who seek treatment for hair loss have C Moderately unattractive 4
an underlying emotion or a motive and this is purely a
D Slightly unattractive 2
physiological reason to look better, so far as their perceived
self-image is concerned. Their behavior, obsession, desire, E Not at all unattractive 0
and demands are based with this goal in mind. If this patient 3 To what extent does your feature(s) currently cause
has realistic expectations and is self-motivated, the hair you a lot of distress?
transplant procedure will benefit the patient, not only A Not at all distressing 0
physically but also emotionally. While a small group of B Slightly distressing 2
patients who have psychological or psychosomatic causes
C Moderately distressing 4
will neither be happy or satisfied nor benefit in any way with
the best possible surgical outcome. They need to be coun- D Markedly distressing 6
seled and treated for these ailments before undertaking their E Extremely distressing 8
hair transplant surgery. 4 How often does your feature(s) currently lead you to
avoid situations or activities?

Questionnaire to Identify or Rule Out Body A Always avoid 8

Dysmorphic Disorder7 B Avoid about ¾ of the time 6

A general questionnaire (►Table 1) which the patients are C Avoid about half of the time 4
requested to fill themselves and the clinician later analyzes it D Avoid about ¼ of the time 2
during consultation, if need be with the help of the patient’s E Never avoid 0
relative.
5 To what extent does your feature(s) currently preoc-
Please note that the questions in ►Table 1 are intended to cupy you? That is, you think about it a lot and it is hard
screen for BDD and not diagnose it. The answers indicated can to stop thinking about it?
suggest that BDD may be present and evaluation by a psychia- A Not at all preoccupied 0
trist is recommended to determine the accurate diagnosis and
B Slightly preoccupied 2
its management. The surgeon should work in a formalized
collaboration with a psychiatrist so that it is easier for the C Moderately preoccupied 4
patient to accept psychiatric evaluation and therapy without D Very preoccupied 6
much resistance. They may be required to be treated with E Extremely preoccupied 8
psychopharmacological and behavioral therapy, if indicated. If
6 If you have a partner, to what extent does your feature
they are left undiagnosed and untreated and are still operated (s) currently have an effect on your relationship with
upon, there is a very high chance that these patients may not be an existing partner? (e.g., affectionate feelings,
satisfied. They may even sue the doctor or become aggressive number of arguments, enjoying activities together). If
or violent and physically harm the doctor. you do not have a partner, to what extent does your
feature(s) currently have an effect on dating or de-
It is of primary importance to be able to identify border-
veloping a relationship?
line BDD patients or mild cases of obsessive compulsive
disorder (OCD), as the patients at either end of this scale A Not at all 0
will be easily identifiable by any hair transplant surgeon (Continued)

Indian Journal of Plastic Surgery Vol. 54 No. 4/2021 © 2021. Association of Plastic Surgeons of India. All rights reserved.
414 Psychology of Hair Loss Patient and Importance of Counseling Dhami

Table 1 (Continued) to the patient. Only after the patient has an insight, will he be
willing to accept the change. Such patients should never be
Sr. Question Score accepted for surgery in the first visit. There was a study
No. conducted which shows that hair loss patients who display
B Slightly 2 BDD-like concerns, benefit significantly in their personal and
C Moderately 4 social life and also in work performance after hair
transplantation.8
D Markedly 6
Cognitive behavioral approaches and medications have
E Extremely 8
been found to be effective treatment for BDD in controlled
7 To what extent does your feature(s) currently interfere studies. Hair restoration surgery shall only be considered
with your ability to work or study, or your role as a after the effective BDD treatment.6
homemaker? (Please rate this even if you are not
working or studying: we are interested in your ability
to work or study.) Counseling of Hair Loss Patient
A Not at all 0
During consultation it is important to make the patient
B Slightly 2 understand that:
C Moderately 4
• Not every type of hair loss can be treated.
D Markedly 6
• The medical line of treatment may or may not be able to
E Very seriously: I can’t work 8 partially restore some hair loss that happened as a result
8 To what extent does your feature(s) currently interfere of AGA, but the treatment is more likely to prevent further
with your social life? (with other people, e.g., parties, hair loss.
pubs, clubs, outings, visits, home entertainment). • It may take 3 to 6 months before you see the results from
A Not at all 0 these treatments.
B Slightly 2 • No one line of treatment will work for everybody, not even
in two patients with a similar type of hair loss.
C Moderately 4
• Sometimes hair loss is stubborn and may require trying
D Markedly 6 different modalities including hair transplant surgery,
E Very severely 8 before finding the one that may work.
9 To what extent, do you feel your appearance is the • AGA/male and female PHL seen at an early age and treated
most important aspect of who you are? by hair transplantation would need a long-term medical
A Not at all 0 line of treatment to prevent hair loss and more likely will
need multiple sessions over a period of time, in case of
B Slightly 2
age-related progressive hair loss.
C Moderately 4 • Even after successful hair transplantation, the full growth
D Mostly 6 may take 6 months to 1 year, during which period the
E Totally 8 patient may need to use concealers.
• In patients with progressive or advanced hair loss with
Note: A general questionnaire which the patients are requested to fill restricted donor hair, there may be a need to use an
themselves and the clinician later analyzes it during consultation, if need
adjuvant concealer along with hair transplantation.
be with the help of the patient’s relative.
Scores analysis: • In patients with severe PHL and inadequate donor area the
• Higher scores reflect greater distress and interference in patient’s life only remedy that may help would be a hair patch or a wig
and the likelihood of a diagnosis of BDD. or the patient may accept and maintain a shaved look.
• If the score is 40 or more, it is recommended that patient seek an
assessment, as he/she is likely to have BDD.
• If the score is between 30 and 40, patient may still have BDD and will
Conclusion
still benefit from an assessment. An ideal case to perform a successful hair transplant proce-
• It is unlikely to have BDD if the score is below 30.
dure is the one with no obvious psychopathology, clearly
• It is advisable repeat the questionnaire at any time during treatment
to see if there are any changes in the symptoms. defined areas of dissatisfaction, realistic expectations, and
the one who is self-motivated.

without any psychiatric expertise or experience. Borderline Conflict of Interest

cases or mild cases of OCD or BDD may also benefit with None declared.
surgical procedures or a combination of psychiatric and hair
transplant treatments. Such patients may refuse to get
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Indian Journal of Plastic Surgery Vol. 54 No. 4/2021 © 2021. Association of Plastic Surgeons of India. All rights reserved.