There is a growing literature on the psychosocial implications of hair loss or alopecia. It is not surprising that hair loss distresses people, as hair – particularly but not solely for women – is a vital aspect of identity. We know that alopecia can result in emotional stress, reduced self-esteem, fear and anxiety can all impact alopecia patients’ psychosocial state, social interactions and daily activities (Hunt & McHale, 2004, 2005a & b).
Many of the papers discussed here are available on or via the web, depending on your access to the key databases. Papers, particularly the more up-to-date ones, are often available from the author of the paper. Addresses can be found on the paper itself.
Key types of alopecia
Alopecia areata is a chronic inflammatory disease that attacks the hair follicles causing round or oval patches of non-scarring hair loss. There are several main types: alopecia areata refers to mild patchy hair loss on the scalp; alopecia totalis to the loss of all scalp hair; and alopecia universalis to the loss of all scalp and body hair. Androgenetic alopecia is known as male or female pattern baldness.
Alopecia is an unpredictable condition and patients may experience numerous remissions and exacerbations. Although complete resolution often occurs, the disorder may also become chronic and unresponsive to treatment (Picardi et al., 2003). In approximately 20% of cases, hair loss recurs or becomes permanent. Alopecia can occur at any age, but often begins during childhood, with approximately 60% of patients developing the disease prior to age 20. Alopecia areata occurs in both men and women; with some studies showing a slight predominance in females. The estimated lifetime risk of alopecia areata is 1.7% (Hunt & McHale, 2004), indicating that approximately 1 million people in the UK suffer with alopecia at some point in their life. However, these figures may be under representations of actual incidence as many people with alopecia, particularly in milder forms, may not present to the medical community (Hunt & McHale, 2004).
Alopecia areata is an autoimmune disorder that arises as a combination of environmental and genetic influences (Hunt & McHale, 2007). Psychosomatic factors such as emotional stress and personality may also play a role (e.g. Van Moffaert, 1992). York et al. (1998) compared stress in the lives of 25 women who have experienced recent, unexplained hair loss with that of 25 women with no hair loss, and found that women who experience high stress are 11 times more likely to experience hair loss.
Androgenetic alopecia (AGA) in men, also known as male pattern baldness, is the most common type of hair loss in men, with: 12% for men ages 18–29 years, 38% of men in their 30s, 45% of men in their 40s, 52% of men in their 50s, and 65% to 70% for men over 60 years old. The pattern of hair loss varies, but it typically begins with a receding hairline, followed by loss at the vertex. The balding areas may merge, leaving only a ring of hair around the scalp.
AGA in women, also known as female pattern baldness, is less common than AGA in males and affects less than 10% of pre-menopausal women (Rushton, 2002). Among women, the pattern is more one of diffuse thinning across most of the scalp, usually with the perseveration of the frontal hairline. There is also often a reduction in hair density, but the hair that remains is usually normal in appearance.
Psychological Impact of Hair Loss
Hair loss can have a variety of negative repercussions for an individual’s psychological well-being and quality of life. A recent systematic review of 19 studies, representing a total of 1271 participants, concluded that “upon review of the evidence, it is apparent that alopecia areata causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and/or self-confidence,” (Tucker, 2009, p. 142).
For many cancer patients, losing their hair is traumatic (Richer & Ezer, 2002; Rosman, 2004). Indeed, some women described it as harder than losing a breast (e.g. Freedman, 1994). Women have reported that alopecia is a visible reminder of the disease which confronts the patients with the seriousness of cancer (Rosman, 2004). Some patients also reported that their hair loss negatively affected their social activities and interactions, and negatively influenced their willingness to continue working (Maunsell, Brisson, Dubois, Lauzier & Fraser, 1999). Changes in self-perception and self-esteem, and decreases in sensuality and sexuality were also felt to be related to the hair loss (Freedman, 1994).
Carpenter and Brockopp (1994) found that 73% of women with cancer reported a decrease in self-esteem after alopecia, regardless of the degree of their hair loss. Similarly, studies comparing cancer patients with and without alopecia found that those with alopecia have poorer body images and poorer self-concepts than before their hair loss (Baxley et al., 1984; Beard, 1986).
Hair loss may be more threatening for women, perhaps because women’s hair is regarded as an indicator of personality, attractiveness, sexuality and femininity. As a result, men’s experiences have largely been ignored, though in a study of both male and female experiences of chemotherapy-induced alopecia, Hilton et al. (2007) found that men appear to have as much difficulty as women in adjusting to hair loss.
Psychosocial Well-Being and AGA
Much of the literature on the psychosocial impact of AGA has focused on men, yet the impact may again be more pronounced in women than men, partially because of societal pressure for physical attractiveness, the greater investment of women in their appearance, and the lower prevalence in women, hence the impression of deviating from normal. In a study of women with AGA, Girman et al. (1999) found that participants were most bothered by an inability to style their hair, dissatisfaction with their appearance, concern about their hair loss continuing, and concern about others noticing their hair loss. Emotional aspects of hair loss also ranked highly, including self-consciousness, jealousy, embarrassment, and feeling powerless to stop the hair loss. In other studies of women with AGA, personality disorders, depression, anxiety, greater dissatisfaction with life, and negative feelings about their body image have all been shown to be associated with AGA (e.g. Cash, Price & Savin, 1993; Maffei, Fossati, Rinaldi & Riva, 1994; van der Donk et al., 1991). Similarly, low self-esteem, reduced self-confidence and insecurity are commonly accepted as associated with AGA in women (e.g. Cash et al., 1993). Van der Donk et al. (1994) found that 72% of women with AGA reported that their hair loss affected their self-esteem in a negative way, and this was expressed in terms of decreased self-confidence, uncertainty, shame and feelings of interiority. Feeling uncomfortable around others and avoiding going out are not uncommon amongst women with AGA, and some have even suggested that these social problems may extend to marital or sexual problems (Eckert, 1976).
Hair loss in males is also associated with depression, low self-esteem, neuroticism, introversion and feelings of unattractiveness, independent of age; and in the case of self-esteem, introversion and feelings of unattractiveness, the effect is especially pronounced in younger males (Wells, Willmoth & Russell, 1995). Most affected men cope well with androgenetic alopecia, without detriment to their psychosocial function. The most distressed balding men are those with more extensive hair loss, those who have a very early onset, and those that deem their balding as progressive (Cash, 1992).
Psychosocial Well-Being and Alopecia Areata
The experience of alopecia areata is psychologically distressing, causes intense emotional suffering and can lead to personal, social and work-related problems (Hunt & McHale, 2005). People with alopecia are also at higher risk for developing psychiatric disorders, including serious depressive episode, anxiety disorder, social phobia, or paranoid disorder (Koo et al 1994).
Chaudhury et al. (2001) studied fifty outpatients with alopecia areata and an equal number of age and sex matched controls without any physical or psychiatric disorders, and found that the patients with alopecia were significantly more anxious and depressed, and reported significantly more stressful life events compared to controls. The prevalence of psychiatric disorders was also significantly higher in alopecia areata patients (26%) than in controls (2%).
Discrimination against people with hair loss
The negative effects of hair loss are often trivialised or ignored by unaffected people, and the presence of baldness in males, is often regarded as a subject of mirth or derision, in a way which would be unthinkable with respect to other aspects of a persons’ appearance. Balding men with androgenetic alopecia often report frequent teasing by peers about their condition (Cash, 1999). Such teasing was reported by 45% of men with modest hair loss and by 79% of men with more extensive baldness (Cash, 1992). Whilst some men will regard such teasing as benign, others may feel it is far from being a laughing matter, and may find this teasing stressful or taken as “evidence of flawed social worth” (Cash, 1999, p. 399).
Individuals with chemotherapy-induced alopecia often report feelings that their appearance evokes hostile, impertinent and judgemental responses from others. Both men and women voiced worries about being perceived as aggressive, threatening or a ‘skinhead,’ where a lack of hair was perceived of as a lifestyle choice or to mark membership of a subculture (Hilton et al., 2007).
Many individuals make judgements about another’s personality based on their hair. Changes in the stimulus person’s hair produced changes in ratings of their appearance and personality. Improved make-up and hairstyle resulted in ratings of greater caring, warmth, sincerity, reliability, poise, and organisation. Similarly, bald or balding men are generally rated less favourably on dimensions such as physical attractiveness, self-assertiveness, social attractiveness, personal likeability and life success (e.g. Cash, 1990). Although first impressions may be overcome in light of subsequent interactions, it seems that men experiencing hair loss may be at something of a disadvantage in their initial interactions with others (Wells et al, 1995).
There is currently no proven cure for alopecia areata. In some cases, the hair will grow back naturally, but in other cases it does not. The effectiveness of treatments depends on the severity of the condition, the area of the body most affected and the age of the person being treated. The lack of efficacy of most treatments is likely to impact on psychological outcome, and hence lead to a need for psychological therapy.
Psychological treatment can positively affect how the patient adapts to his or her alopecia and perhaps can even lead to a better dermatological evolution of the alopecia. Psychological treatments may help patients by offering them hope and support to help them cope with the months of treatment that are often required. It may also be necessary to help patients adapt to the disappointment of unsuccessful treatment regimens, and adapt to a lifetime of baldness. Given the large and ever-increasing body of evidence demonstrating the profound negative impact of hair loss on psychological well-being, it is paramount that GPs and dermatologists offer relevant treatment not just for hair loss but for the accompanying psychological distress. There is very little research using randomized control trials that has examined the effectiveness of psychological treatments aimed at enabling people with alopecia to cope with the psychological consequences of the disorder.
Using a support group for people with alopecia may reduce psychological difficulties and help individuals cope better with the disorder. More generic psychological therapies for body-image issues may be suitable for use with patients with alopecia. For example, Cash (1997) developed a self-help workbook for body image improvement, regardless of the source of the body-image discontent. Empirical evidence attests to the effectiveness of this self-directed treatment (e.g. Grant & Cash, 1995).
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