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Ademir Carvalho Leite Junior, Fabiana Padovez, Laura Bovcon, Marcos Terra,
Miguel Cisterna, Rita de Cassia Alves Santos, Sheila Barnabé
Clínica Dr Ademir Jr, CAECI, Cabello & Salud, Academia Brasileira de Tricologia,
Universidade Anhembi Morumbi, Asociación Argentina de Tricologia(AATri), IJEP
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TOATES F. Stress Cenceptual and Biological Aspects. John Wiley & Sons, NY, 1999.
OLIVEIRA MT. Cabelos: da etologia ao imaginário. Revista Brasileira de Psicanalise. 2007;3(41):135-151.
PETERS EMJ, et al. Probing effects of Stresse Mediators on the Human Hair Follicle. Am J Pathol. 2007;171(6):1872-1886.
PETERS EMJ, ARCK PC, PAUS R. Hair Growth Inhibition by Psycoemotional Stress: A Mouse Model for Neural Mechanisms in Hair Growth Control. Exp Dermatol. 2006;15(1):1-13.
SILVA MN, SILVA RN, SOARES, GMT. Influência das Dermatoses no Psiquismo de Pacientes Dermatológicos. Med Cutan Iber Lat Am. 2011;39(5):209-210.
DE KONIG EB, PASSCHIER J, DEKKER FW. Psychological problems with hair loss in general practice and the treatment policies of general practitioner. Psychol Rep. 1990; 67:775-8
HADSHIEW IM et al. Burden of hair loss: Stress and the underestimated psychological impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol. 2004;123:455-57
VAN DER DONK J et al. Psychological characteristics of women with androgenetic alopecia: a controlled study. Br J Dermatol. 1991; 125(3):248-52.
CASH TF. The psychology of hair loss and the implications for patient care. Clin Dermatol. 2001; 19:161-166
HARRISON S, SINCLAIR R. Telogen effluvium. Clin Exp Dermatol. 2002; 27:393-99
SINCLAIR R. Chronic telogen effluvium or early androgenetica alopecia? Int J Dermatol. 2004;43:842-843
ITO N. et al. Human hair follicles display a functional equivalent of the hypothalamic-pituitary-adrenal axis and synthesize cortisol. FASEB. 2005;19(10):1332-1334.
RAMOT YUVAL, et al. Endocrine controls of keratin expression. BioEssays. 2009;31(4):389-399.
PAUS R. Frontiers in the (Neuro-)endocrine Controls of Hair Growth. JID – Symposium Proceedings. 2007:12-22.
PETERS EMJ, et al. Neurogenic Inflammation in Stress-Induced Termination of Murine Hair Growth Is Promoted by Nerve Growth Factor. Am J Pathol. 2004;165(1):259–271.
SLOMINSKI ANDRZEJ ET AL. Corticotrpoin Realising Hormone and Proopiomelanocortin Involvement in the Cutaneous Response to Stress. Physiological Reviews. 2000;(80):979-1020
TABORDA, M. L. V. V.; WEBER, M. B.; FREITAS, E. S. Avaliação da prevalência de sofrimento psíquico em pacientes com dermatoses do espectro dos transtornos psicocutâneos. Anais Brasileiros de Dermatologia. São Paulo: v. 80, n.4, p. 351-354, 2005.
Hair loss as an expression of stress -
Psychosomatic Concepts applied to
Trichology
Introduction:
The original concept of stress was introduced by the researcher Hans Selye in 1956. He performed
researches with animals which, after being submitted to stressing stimuli, always responded in a
regular and specific way.
Selye has suggested the word stress to define the syndrome produced by several aversive agents,
and he has also described the complete stress occurrence as General Adaptation Syndrome, that
happens in three successive stages: alarm, resistance and exhaustion.
In its turn, regardless if it is of physical, psychological or social nature, stress is a term that comprises
a number of physiological responses which, if overintense or overlasting, end up causing body
imbalances, often with damaging effects.
According to Cohen & Williamson (1988), there are three ways of measuring stress.
The first is the presence of specific stressing agents; the second comprises the physical and
physiological stress symptoms, and the third, regardless of stressing agents, measures up the global
perception of individual stress.
The stress sources change, but the damages it causes, be they physical or psychological, are
numerous and extensive. Most people somehow somatize stress, giving rise to Psychosomatic
manifestations.
Psychosomatics demands a multidisciplinary team working, respecting each other’s limitations and
flexibility. Exchanging information among themselves, aiming the individual in the present time and
offering a glimpse of his or her future so that they can build it up themselves, so that we are mere
facilitator agents because, deep down, the individual has got something that is singular to them.
Several schock organs break out from stress induced somatization and the skin is certainly one of
them, and it suffers in many ways under such circumstance.
The Neuroendocrine-Immunological System
Very significant laboratory experiments were made between 1970 and 1990, trying to prove the
connection between the Central Nervous System and the Immunological System. During those two
decades, it was detected cell depopulation in the thymus in rats, through induced lesions in the
hypothalamus. It was also shown that damaging lesions in the dorsal hypothalamus caused
suppression of the antibody response. All of these conclusions suggested that the hypothalamus
would be some kind of integration basis between the nervous and the immunological systems in
stress response.
From 1990 on, it was also observed that modifications in the pituitary gland could determine
immunological modifications as well, once the gland removal or even its pharmacological blockade
prevented the immune response in the laboratory animal.
The immune response to stress occurs through a joint action of the nervous system, the endocrine
system and the immunological system. Some disease related to any of those systems may emerge,
in case the stress condition is too intense or long-lasting.
An increase in corticosteroid hormones levels, secreted by the adrenal glands (cortisone), is an early
alteration that can be observed during stress periods.
Apparently, those levels are inversely proportional to the effectiveness of adaptation mechanisms,
that is, levels are not very high in cases that show proper adaptation mechanisms, but in depressive
people - therefore with severe adaptation troubles - the levels are higher.
The adrenal gland seems to play a roughly selective role in stress. In aggressive states, while its
central portion (cortex) produces cortisol, its medulla also takes some part, liberating norepinephrine
(noradrenaline).
During stressing situations, such as tension and anxiety, medullary liberation privileges epinephrine
(adrenaline).
Mello Filho has reviewed a 1976 experiment, by which he could detect an increase in 17 hydroxy-
corticoids, catecholamines (epinephrine and norepinephrine), thyroid stimulating hormone (TSH) and
growth hormone (GH) levels in monkeys submitted to stress, while there was a decrease of sex
hormones secretion. This situation was reversed as the animal recovered.
Catecholamines (adrenaline and noradrenaline) affect immune responses, be it by physiological
response, for instance as in spleen contraction, or by cell stimulus through specific (adrenergic)
receptors in the cellular membrane.
What is certain is that catecholamine increase inhibits antibody response and that its liberation may
be conditioned to neuropsychological factors. In a classic study, the immune function suppression
was experimentally developed by the use of a immuno-suppressor (ciclofosfamide), associated to a
beverage that contained a substance that had a very particular and strong taste (saccharine). Such
suppression could be achieved when only the beverage with saccharine was administered, thus
depicting an immune suppression caused by a biological conditioning, once saccharine is not an
immuno-suppressor agent.
Therefore, as we have seen so far, the immune system cells are under a complex influence web of
both the nervous and endocrine systems. Its mediators (neurotransmitters and various hormones)
synergistically interact with other lymphocytic products, from macrophags to inflammatory products,
in order to regulate its actions.
Therefore, the immune system seems to explain the interactions between psychosocial phenomena
to which people are submitted to, and major human pathology fields, such as auto-immune (self-
aggression), infectious and neoplasic disturbs. Furthermore, there are hundreds of experiments that
testify the major influence of emotions on the Immune System.
Every meaningful change demands that the body adapts itself and, in turn, this adaptation plays a
decisive role in stress pathogenesis. As human beings go through changes, we use our adaptive
energy reserves and, we thus can, under some circumstances, weaken our physical and mental
resistance, giving rise to countless psychophysiological diseases which origin can be interpreted as a
result of excessive emotional stress.
P282
Her compulsion to cut her hair was controlled by the he introduction of the medications and medical
supervision, and they also led to a meaningful improvement of her depressive condition.
In the monthly follow-up, the patient shows a good development of her psychic picture and no
recurrence of her hair cutting compulsion.
The case discussion with the psychiatrist suggested the trichotomy on the top of head by the patient
could be interpreted as a variant of trichotillomania, once the patient stated that she felt a huge
impulse of cutting her hair closely to the scalp, and also described a relaxing sensation and anxiety
decrease after doing it.
Trichotillomania is a type of hair loss, caused by the repetitive tracting or twisting of hairs until the
complete fiber breakage. Patients suffer from an impulsive disorder which is hard to control and has
unclear causes.
Trichotillomania usually affects around 4% of the population and women are up to four times more
affected than men.
The detection and early treatment beginning decrease the risks of thinning of hair and cicatricial
alopecia caused by the traction that occurs in more severe and long lasting cases.
Stress promotes a negative evolution of the condition, as well as depression and anxiety.
Serotonin re-uptake inhibitors and naltrexone have proved to be effective in symptom reduction.
Behavior and psychoterapies are also good proposed alternatives to control the clinical picture.
The Hair Follicle Inervation and the Impact of Stress on Hair.
PETERS, ARCK and PAUS studies have confirmed the hair follicle is the most nerve supplied skin
structure. Apparently, this is very important for the hair follicle to be a shock organ under stressing
situations.
In the experimental model studied and described by the forementioned authors, psychoemotional
stress showed to be a hair growth interruption motivator and, consequently, a hair fall motivator after
the follicles were exposed to chemical stress mediators, secreted by perifollicular nerve terminations.
Researches indicate that stress can favor the Substance P and Nerve Growth Factor release by the
perifollicular nerve terminations, and this factor would interfere on the hair bulb proliferation of matrix
cell process, cause chemotaxis of the immune system cells that end up triggering a perifollicular
neurogenic inflammation and inducing hair follicle cells apoptosis, as well as the follicle’s loss of
immune privilege.
Adrenal hormones and hair fall
There are several studies that prove the activity of systemic stress modulators related to the
hypothalamic-pituitary-adrenal axis (Corticotropin-releasing hormone - CRH, proopiomelanocortin
peptides and glucocorticoid hormones), as hair growth inhibiting agents.
In a study performed in 2005, Ito and associates have presented evidences that, besides being
hypothalamic-pituiraty-adrenal axis targets, hair follicles are also their regulating agents through the
feedback system and can even produce cortisol in response to CRH stimulation.
They then concluded that hair follicles may represent a functional equivalent to the hypothalamic-
pituiraty-adrenal axis.
This could suggest that, under stressing events, in addition to receiving hypothalamic-pituiraty-
adrenal axis stimuli to reduce its activity by inducing the anticipation of the catagen stage, the hair
follicle could also promote the self-regulation of its activities, once it is sensitive to CRH, which
induces the catagen stage by itself, as well as responding to this hormone by producing cortisol
which, in turn, inhibits the follicle proliferative activity.
Hair losses and the reduction in quality of life
Hair losses can occur due to countless situations. In general, any hair loss picture that results in a
decrease of hair volume, be it light or severe, can lead to anxiety or depressive states, thus reducing
the person’s quality of life, as shown by Van der Donk’s research with women who suffered from
androgenetic alopecia, in 1991.
The study compared two groups of women; one with androgenetic alopecia, and the other with no
hair problems whatsoever. In this study, women with alopecia have attributed a lot of social and
psychic changes to their condition of reduced hair.
Several other evaluations show that the many diverse types of hair loss and alopecias are usually
limiting factors for those who suffer from such problems, and can even be compared to severe
chronic diseases. Once stress is one of the hair fall outbreak and maintenance factors, some cases
tend to become chronic, due to the stress and concern caused by the hair fall itself, thus generating a
vicious cycle that is very difficult to break.
The possibility of making an accurate and early diagnosis of hair losses and alopecias by any
ethiology favors a proper intervention, allows therapeutical precision and a larger possibility of hair
maintenance and of recovering the lost hairs. When making the proper diagnosis of alopecias, one
expects to prevent psychosocial impairments related to them, thus keeping the patient’s quality of life
and contributing to their health
Final Comments and Conclusion
It seems hair fall is a problem that affects an increasing number of people. This statistical increase of
the problem’s acute or chronic cases seems to be related to modern life style, and specially to
personal conflicts we develop from our relationship with our environment, with the society we live in
and our personal history.
Through the understanding of disease forming mechanisms, and due to a better understanding
provided by researches in the neuroscience and psychoneuroendocrine immunology fields, health
sciences can explain phenomena that involve the presence of stress in daily events, with the
emergence of psychosomatic manifestations.
Psychosomatics perspective seems to be a reality that explains such phenomena in most of the
cases, specially those of telogen effluvium and alopecia areata.
OBS: This display content was taken from a course conclusion monograph for the
postgraduation course on Psychosomatics, presented by its authors to the Instituto
Junguiano de Estudo e Pesquisa – IJEP, in December, 2012.
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