Thinning hair, and a heavy soul

My patient suddenly leaned forward, swung her hair up, and began to push it this way and that, determined to find and show me the partitions that her hair made when rested in a new equilibrium.

It was a warm Thursday afternoon and we were in dermatology clinic. This 20-something young professional had come to have her scalp examined. She’d noticed a sudden increase in the quantity of hair follicles that parted ways in the shower, after an ordinary brush, on her pillowcase, and she was worried that she had developed female-pattern hair loss.

As the medical student, I was ushered in first and alone, as usual, to talk to her and see what I could make of her symptoms. Seeing how she was knotting her fingers in anxiety, I decided on open-ended questions. What’s concerning you? What’s been different?

She began to recount her early symptoms, how she started to notice that when she braided her hair, it looked less thick. How a friend took a picture of her in the sun and it inadvertently illuminated a wide partition on her head. How she began to notice her tub needed more frequent dollops of Drano to clear the clots made by wet clumps of hair.

She reached into her bag and pulled out her iPhone.

“I don’t want you to think I’m just imaging this,” she said, “because I’ve been to my primary care doctor a few months ago and he told me that this was all psychosomatic from my anxiety and to take some Biotin pills if I was really concerned.”

She opened her camera app and began to show me a series of selfies, if you could call them that, of her scalp. She’d taken these at various diverse occasions — in the morning, after a shower, before going out, in a dressing room, in different sorts of lighting. Her scalp was frequently drawn and quartered, as she pushed it aside with her fingers to pull the areas of thinning into greater prominence. I scrolled through them, noting the time stamps above each cluster of photos. More recently, she had grown even more obsessive with documenting the progression of the hair loss, with numbers rising from single digits into double under each date.

I looked up to see that she was watching my face nervously.

“I believe you,” I said, and she visibly relaxed, but simultaneously scrunched her face and began to cry.

The same impulse that had driven her to track her alopecia was causing her grief now. Documenting the damage, I imagine, thrilled her in her validation but devastated her in its proof. I suspected that her primary care physician was not the first to casually dismiss her fears without even attempting to disprove them with a good listen and thorough exam. Now she was vindicated, but the implications of having her fears acknowledged were overwhelming.

I asked her if the hair loss was limiting her life in any way. She nodded fervently. She’d stopped going to the beach because she was afraid the wind would upend her careful setting every morning. She used to like getting caught in the rain, but now she feared it would expose her losses to the world. She was generally less spontaneous, more restrained. She had begun to obsess over it, watching how her friends were so carefree about their own fringes and feeling inordinately jealous and lonely in her affliction.

I listened to her, thinking about the ways in which I could relate. I had my own guilt/indulgence cycles, after all. The ways in which people, but more frequently, young women, choose to represent reality in a distorted manner, whether that be about their appearances or their circumstances, choose to exaggerate their deficiencies, in order to feel something like anguish, are a common enough societal phenomena.

Back in my attending’s office, I caught a title of dermatology textbook, Atlas of Dermatoses, upside down, and in attempting to interpret it lopsided, thought it read Atlas of Dreamatoses. How appropriate! I think many people, even with legitimate concerns, suffer more insistently than their peers when they languish in these dreamtoses, these preoccupations with their illnesses that prolong and exacerbate even genuine symptoms. Still, without being directly affected so, it’s impossible to judge.

The thing about playing doctor to a patient like this, with a complaint so universal and easily relatable, is that one must consciously assert these roles: doctor, patient. I restrained myself from trying to comfort her with examples from my own experiences, worrying that this would set us down a very long path of sharing neuroses with each other. I listened patiently, asked more follow-up questions that would get at the heart of a full differential, and performed a comprehensive exam. Thanked her for her patience with me and promised to relay my findings to my attending.

Eventually, we three, my attending, patient and I, decided that to perform a scalp biopsy. While it would have been reasonable to wait and see if the hair loss would temporize and perhaps improve, we felt that the patient would benefit from the peace of mind that would come with knowing, definitively, the nature of her condition.

The biopsy was scheduled for the following week.

Samyukta Mullangi is a medical student who writes at her self-titled site, Samyukta Mullangi. This article originally appeared in the Huffington Post.

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  • guest

    Hair loss in women is a significant disfiguring condition, given our society’s unhealthy emphasis on appearance, especially in females. Female physicians and medical students are frequently less impacted by these societal pressures–we tend to be relatively insulated from them due to the all-consuming nature of our studies/work. That does not mean that other women can do the same. I would hesitate to label as “neurotic” or “indulgent” the psychological impact that a female patient might experience as a result of hair loss.

    This excerpt from the American Hair Loss Association website might help with developing an empathic response…

    “Mistakenly thought to be a strictly male disease, women actually make up forty percent of American hair loss sufferers. Hair loss in women can be absolutely devastating for the sufferer’s self image and emotional well being.
    Unfortunately, society has forced women to suffer in silence. It is considered far more acceptable for men to go through the same hair loss process. Even more unfortunately, the medical community also treats the issue of women’s hair loss as if it were nonexistent. Since hair loss doesn’t appear to be life threatening, most physicians pay little attention to women’s complaints about hair loss and essentially tell their patients that “it’s no big deal”, and that “you’ll just have to live with it.”
    Of course what these physicians don’t seem to realize is that the psychological damage caused by hair loss and feeling unattractive can be just as devastating as any serious disease, and in fact, can take an emotional toll that directly affects physical health.
    The American Hair Loss Association recognizes that hair loss is women is a serious life altering condition that can no longer be ignored by the medical community and society as a whole.”

  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    Real (not imagined) hair loss can result from anxiety and stress. So it’s possible to believe the reality of this patient’s complaint, including the reality of its effect on her social functioning and self-image, while still including psychological factors (in addition to medical ones, of course) in the differential diagnosis. And whether it’s an etiological factor or not, her anxiety itself may warrant a mental health referral.

    • FEDUP MD

      Yes, I lost a tremendous amount of hair a few months into my intern year. Looking at photos, it was definitely not my imagination either and it was remarked upon by others. It grew back but I have had hair loss again twice after each childbirth. It has grown back every time but the first time was definitely scary, worrying it was permanent.

  • JR DNR

    I think you did the right thing. You believed the patient and didn’t dismiss the patient off hand. Especially since this patient has already been told her issues are “psychosomatic.” She’s obviously sensitive to such suggestions.

    If the tests do come back negative, this is my suggestion from a patient perspective. Let the patient know that even without a clear diagnosis, you want to do what can be done to help improve the symptoms and be supportive (even if it’s taking biotin!). If you have a develop a good relationship with the patient, and you really think what they need is counseling, then it can help to talk about working with someone to develop coping skills and the anxiety their symptoms are causing them. From a patient perspective, that is a supportive approach. “You’re symptoms are caused by anxiety” without any proof comes across as dismissive.

  • RenegadeRN

    My thoughts exactly! And what about a thyroid check?

    I lost about 1/3 of my hair in the 80′s to Graves’ disease, and treatment with Synthyroid only, prevented it from re- growing. Fast forward to today and a year on NP Thyroid- and it’s approximately 50% regrown! After all these years! I am SO thrilled. Even at 50 something, I value my hair and it’s contribution to my appearance and sense of well being.

  • Ladyimacbeth

    You handled this patient’s concerns with such respect and compassion. Patients will be lucky to have you as their physician.

  • Eric W Thompson

    I know men who are balding and go through unbelievable gyrations to hide or repair the condition. Since in most cases loss of hair does not threaten health it would be better to change societal attitudes.

    • FEDUP MD

      The challenge is that it is actually not that uncommon in women. While embarrassing in men, it is just that, and not considered essentially emasculating, however- just a sign of aging (which of course has its own stigma). Having had hair loss as a woman, though, there is the addition of the stigma of having a “masculine” problem which often shakes one’s identity as a feminine person to the core, in addition to the embarrassment about physical appearance and stigma of aging that women with thinning hair share with men. I draw a parallel to gynecomastia in men- a not uncommon problem, but one that often leads to problems of self-identity as men are “not supposed” to have this happen to them.

  • JR DNR

    Do you have a good physician who is checking your nutritional status? I’m just being checked for iron and vitamin D based on symptoms, and taking a general multivitamin to cover everything else.

    I never lost my hair, it just became thin. But that was my thought too – what if the hair loss in an underlying disease? I’ve been gluten free two years and my hair is finally thick again. My nails are improved but still have a lot of ridges to them.

    I was an unconventional presentation too – my first symptoms were nerve problems. They still come and go but I admit they are improved.

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