Why Do People Lose Their Hair?

Physical versus Psychological Factors

This entry is in process, started 2/19/2022

Today, I’ve decided to take on a small, but annoyingly persistent issue: Hair Loss.

Why do people lose their hair? What are the implications of hair loss? Should I be afraid of it? Is it telling me something about myself and my future?

Some time ago, I saw Roger, an older male, for 7 sessions. He was not a typical client, in fact, his stated occupation, an FBI Agent, precluded it. Roger was worried. I use the name, Roger, because, I never knew his name. It was a pseudonym, Roger, and he told me so. I didn’t know his address, his phone number, his email. He paid my fee in cash (bills) and I hand-wrote a receipt. I assume that he was who he said he was. He fit the profile, trim, looked good every session, nearly perfect in dress with a dark blue blazer, white shirt, jeans, dark shoes, dark socks. When he left, he walked out of the lot and I never did know where he parked a car, if he parked it at all.

Everything about him was obvious, also mysterious. He was perplexing, partly because all he wanted to talk about was his early pattern baldness which disturbed him. It was almost like he was angry with his body, a controlled anger, at what he perceived as his body’s inability to give him exactly what he wanted. What he wanted was silver/black consistent hair for the duration of his life. He also saw hair loss as a marker of stress (possibly weakness), but said, for the most part, he led a stress free life, no partner, no children, not connected to his parents or family, no stress at work (even though he was a stated FBI agent). He was, I believe, a USA Citizen, but I wasn’t sure. When I asked a question, for him, out of bounds, he politely told me he’d rather not discuss it, so we moved to something else. He was well informed. I think he read the New York Times, The Economist, and the Washington Post cover to cover, daily, although I don’t think he would risk a subscription, so he probably just bought them at a news stand. I never saw a cell phone, and, in fact, he said he had access to a cell phone, but never carried one. He described himself as, efficient. Which again, was odd, because I can’t think of anyone else who would introduce themselves as an “efficient person.” His mannerisms were controlled. He would sit there, hands on his lap, move slightly, but for the most part, sit still. I watch for small things, pupil-dilation, eye movements, tightening of facial muscles, for example, and he did none of these. He had clearly trained himself to be opaque.

I saw him for 7 sessions, we talked about a number of things, he liked to talk, about current events, his opinions. But, as we agreed, at session #7, he thanked me for the time, didn’t say whether it was helpful or not, and ended. I never saw him again. He was a difficult client because of these characteristics, but intriguing all the same. I would say that he was the most opaque individual I’ve ever met, personally or professionally.

All except for this hair loss concern. I should note he hid it well. It wasn’t until the third session that he showed it to me and describe how he hid it from others. He was clearly protective of what he perceived as a personal flaw.

Hair Loss is a Big Worry

I’ve not met any other “Rogers,” but I have heard a lot of people who complain about hair loss. It is usually for two reasons: 1. The person has had a serious illness and a visible consequence of that illness (or the treatment of the illness) has been hair loss. 2. The person is experiencing some kind of chronic and progressive stressful state, and hair loss occurs while the stress is increasing. I don’t think it matters what age a person is because young or old, hair loss can cause one to feel disrupted and uncertain.

One of the most disturbing symptoms is when hair falls out while combing it. This makes sense, because you start combing your hair and you notice the hair in the comb and you keep combing and the hair keeps showing up and pretty soon you think all your hair is falling out and you think that if you keep combing you will soon show pattern baldness and eventually you will be bald. For both men and women the symptoms are similar. People apologize for hair loss like worrying about it is silly, or juvenile, or petty, but they still bring it up. Why? Because it’s bothersome and threatening.

Across all people who experience hair loss two big questions arise:

1. Doctor, Why is this happening to me? and 2. Tell me what to do to make it stop.

What Causes Hair Loss?

I could write pages and pages on this topic because we know a lot about the causes of hair loss. From a biological, genetic, physiological perspective, there are theories about hair loss, and strong evidence to back up physiological formulations about Why hair loss occurs. I briefly review prominent physical/biological reasons or theories below:

• Hereditary Hair Loss

  The genetic marker Androgenetic Alopecia for male pattern baldness (MPB) accounts for over 95 percent of all hair loss in men. Evidence: In one genomic and health study in the UK of 52,000 men, two samples were identified. A sample of 40,000 people and a target sample of 12,000 men. The samples differed on genetic variants that separated those with no hair loss from those with severe hair loss. An genetic algorithm was generated to predict who would develop MPB. Approximately 14 percent of the participants with a below-median algorithm score had severe MPB, and 39 percent had no hair loss. By contrast, 58 percent of those in the top 10 percent on the genetic algorithm had moderate to severe MPB. As far as genetics is concerned, this study is almost confirmatory of a genetic marker for MPB.

• Alopecia Areata Aging

  Alopecia a medical term for being bald. Areata means patchy. This patchy baldness develops anywhere, the scalp, beard area, eyebrows, eyelashes, armpits, inside the nose, or ears. Signs of hair loss can be caused by almost anything, but the biggest culprit is aging whether you are genetically at risk or not. Gradual thinning of the hair on your head, Bald spot that grows slowly, Receding hairline more visible with each year, Widening part, Thinner ponytail. People experience burning or stinging before hair loss in a specific area. Redness, swelling, and sores that may itch or leak, or may be a consequence (or risk factor) for process baldness.

• Cancer Treatment

  Chemotherapy for cancer or any disease may cause hair loss all over your body. This is probably because the drugs damage hair follicles. Whether this is permanent or temporary depends on the drug. Sometimes your eyelash, eyebrow, armpit, pubic and other body hair also falls out. Some chemotherapy drugs are more likely than others to cause hair loss, and different doses can cause anything from thinning to complete baldness.

• Hormonal Imbalance

  androgenic alopecia, also called androgenetic is a term that describes male or female pattern hair loss due to hormonal imbalance. This can occur naturally as in androgenic hair loss at the onset of puberty. High testosterone, High cortisol, High or low thyroid hormone are all hormonal culprits for hair loss.

  Cortisol due to stress can cause telogen effluvium, sending all hairs into the resting phase, followed by shedding. This is also seen after delivering a baby, surgery, or rapid weight loss, as the body views these as stressful events.

• Conditions of the Scalp

  Conditions of the scalp can lead to hair loss in two ways. 1. Hair falls out from the affected area and is unable to grow new hair until the condition is treated and remediated. 2. Scalp conditions itch. Excessive scratching can cause hair to break, fall out, and cause irreversible damage to the hair follicle. Four infections are prominent in the Western world. Ringworm (fungal infection), Scalp Psoriasis (poor immune function), Seborrheic Dermatitis (Danddruff), Lichen Planus (skin plaque)

• Medications

  Drugs cause hair loss by interfering with the normal cycle of scalp hair growth. During the anagen phase, which lasts for two to seven years, the hair grows. During the telogen phase, which lasts about three months, the hair rests. At the end of the telogen phase, the hair falls out and is replaced by new hair. Medications can lead to two types of hair loss: telogen effluvium and anagen effluvium. Among the medications that affect hair loss, antidepressants, birth control pills, cholesterol lowering drugs, mood stabilizers, NSAIDs, steroids, and on and on. Almost every medication a person takes has at least one hair-loss side effect.

• Sexually Transmitted Disease and its Treatment

  Gonorrhoea and herpes show symptoms such as sores and fatigue These infections don’t directly cause hair loss. Chlamydia isn’t known to cause hair loss – however, a common treatment for chlamydia is the drug azithromycin, a macrolide antibiotic that works by killing the bacteria that cause the condition by depleting both your vitamin B and haemoglobin – leading to hair loss. In Syphilis, if early symptoms are missed, then the infection can progress into secondary syphilis which is likely to lead to swollen lymph nodes, reddish brown rashes, fevers – and hair loss.

• Thyroid Disease

  Severe and prolonged hypothyroidism and hyperthyroidism can cause loss of hair. The loss is diffuse and involves the entire scalp rather than discrete areas. The hair appears uniformly sparse. Regrowth is usual with successful treatment of the thyroid disorder, though it will take several months.

• Nutrient Deficiencies

  Iron deficiency is a a major cause of hair loss. Iron helps red blood cells carry oxygen throughout the bloodstream. Without iron, blood cells cannot deliver enough oxygen to the body, resulting in symptoms like hair loss, brittle nails, and fatigue. When vitamin D is low, the hair may thin or stop growing. Zinc deficiency can cause similar hair loss to iron and may also damage any remaining hair, causing it to break. Selenium deficiency may disrupt thyroid functioning, which can cause hypothyroidism and hair loss.

• Poison

  If you are exposed to arsenic, thallium, mercury, and lithium, you will certainly experience hair loss. If you ingest a large amount of warfarin, which is found in rat poisons, it can also cause hair loss. Taking large amounts of vitamin A or too much selenium is also toxic and will cause hair loss.

I point out these physical reasons because hair loss is susceptible to all kinds of situations, circumstances, lifestyle choices, diets, and the like. So, while there may also be psychological reasons for hair loss, it is important to look at the physical features of your way of life and your habits to see if your lifestyle choices or your situation is playing a role in this disturbing pattern of bodily change.

Another factor in hair loss is, of course psychological or emotional. What emotional features of your life and world are impacting your hair loss? I explore a few below.

The Psychology of Hair Loss

Discussing the psychological concerns of hair loss involve how hair loss impacts the individual experiencing the loss versus what is causing the loss per se. Of course, if the hair loss is connected to a stressful event or a trauma, then a focus might be dealing with the trauma and then the hair loss as a consequence. This clear up hair loss, for example, once a trauma is dealt with.

Almost everyone would agree that the experience of hair loss is traumatic, especially for some people. It can be associated with intense emotional suffering, and can even lead to social, work and relationship problems. Hair loss can become an obsession in and of itself. So it is a big issue in the psychological literature and psychological treatments have been investigated to address this human concern.

Trichotillomania or TTM

There are also conditions, Trichotillomania (trik-o-til-o-MAY-nee-uh) or TTM, also called hair-pulling disorder that is a bona-fide mental disorder. It involves recurrent, irresistible urges to pull out hair from your scalp, eyebrows or other areas of your body, despite trying to stop. Hair pulling from the scalp often leaves patchy bald spots, which causes significant distress and can interfere with social or work functioning. Those experiencing trichotillomania may go to great lengths to disguise this form of hair loss. Guilt and shame are also attached to this form of hair loss. For some, trichotillomania may be mild and manageable without help. For others, the compulsive urge to pull hair can become overwhelming. Some treatment options have helped many people reduce their hair pulling or are able to stop it entirely. This might involve the administration of certain classes of psychoactive medications. Serotonergic Reuptake Inhibitors (SSRI’s) and clomipramine are considered standard in the treatment of TTM. In addition, family members of TTM patients are often affected by obsessive-compulsive spectrum disorders. With these persons, other drugs may used including lamotrigine, olanzapine, N-Acetylcysteine, inositol, and even naltrexone. Of course, it gets even more complicated because one of the side effects of SSRI’s is hair loss.

NOTE: Some people have asked me if the SSRI (Prozac) is a successful treatment for TTM because so many people experience TTM as an obsessive-compulsive behavior that co-occurs with depression and a high percentage of the U.S. population are taking some dosage of Prozac (or Sertraline). The answer to this is probably NO. Why? Because Prozac is an SSRI. The answer is confusing. For some reason, some SSRI’s (Prozac being one) don’t seem to block the obsessive TTM behavior. The fact is that study after study conducted to determine why this is the case has produced mixed results. This underscores, again, how confusing drug treatment is for psychological disorders. I will return to TTM when I discuss treatments that work for hair loss that is primarily psychological.

Study after study indicates that psychiatric disorders are more common in people with hair loss as the only complaint, including than in the general population of people with and without hair loss worry. Therefore, hair loss could be a risk factor for a more comprehensive mental health condition such as chronic depression, anxiety disorder, social phobia, or even paranoid disorder. The experience described by a typical person who suffers from verified hair loss (seeing hair falling out in the wash basin) is a sense of loss. From this viewpoint hair loss sufferers might be thought of as grieving for normal hair growth.

Most of the research shows that people with hair loss report lower self esteem, poorer quality of life, and poorer body image. Those who lose eyebrows and eyelashes may also have problems with identity and it has been speculated that because eyebrows are so integral to the distinguishing characteristic of the face, this is a particularly acute problem, serious enough to ask about it separately from hair loss in general.

Hair loss may be viewed as a form of personal fragility or abnormality and as a failure to conform to the norms of physical appearance in society, which has the potential to separate a person from his or her own estimation of self-worth. People can have serious problems with self esteem. Stressful life events are a confound to this general self-esteem issue, because it might be viewed that hair loss is temporarily impacted by a trauma or an unwanted circumstance, and then the focus is ridding oneself of the unwanted circumstance and situation with the hope that normal hair growth will re-occur.

Case Study (Taken from the Internet, BMJ. 2005 Oct 22; 331(7522): 951–953.)

A 27 year old man lost his hair after his best friend was killed. This immediately added to his distress and was exacerbated by his partner also experiencing problems because of the alopecia. She could no longer bear to look at him. When he was first sent to a dermatologist he went in wearing a cap. He had only recently lost all his hair, and the thought of being seen in public with no hair was unbearable. He was very self conscious, and his problem was not the alopecia, but coping with his new appearance. The dermatologist, a traditional doctor in his 50s and a white coat, greeted him curtly and ripped off his hat without permission, exposing his hairless head in a way he was not ready for. This was the point at which he realised that “doctors were not going to help him.”

As a practicing psychologist, the topic of hair loss comes up frequently enough that I generally ask about it when I am first trying to get to know an individual and build a trusting relationship with that person. If I discover that a person is concerned about hair loss, I generally acknowledge it as a problem, but I am cautious not to jump in and make too much of a fuss about it unless the person wants to talk more about the issue. Forcing or coercing a person to talk about something this personal is not a good strategy, but I do log the issue and I record it in my notes each time it comes up. If after I’ve seen the person a few times and the issue keeps coming up, initiated by the client, I will generally probe more to understand the magnitude of the issue from the client’s point of view in an attempt to understand what kinds of theories the person has about this phenomenon. Sometimes, I can use hair loss as a consequence of a changing psychological condition; that is, if it is of great concern to begin with and then the concern fades over time, it could be a secondary marker that the person is feeling better about him or herself.

How to Treat Psychological Hair Loss

I will write more on this entry, last note 2/20/2022