Lifetime
Prevalence of Psychiatric Disorders Patients With Alopecia Areata
Eduardo A. Cob,
in
Michael K. Popkin, Allan L. Callies, Nancy J. Dessert, and Maria K. Hordinsky
Thirty-one patients with alopecia areata were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DE). Overall, 74% had one or more lifetime psychiatric diagnoses. Particularly noteworthy were the high lifetime prevalence rates of major depression (39%) and generalized anxiety disorder (39%). In addition, patients reported increased rates of psychiatric disorders in first-degree relatives: anxiety disorders (58%), affective disorders (35%), and substance use disorders (35%). Patients with patchy alopecia areata were more likely to have a diagnosis of generalized anxiety disorder. No relationships were found between major depression and any variable characterizing alopecia areata history. Possible interrelationships between psychiatric disorders and alopecia areata are discussed. The study suggests that patients with alopecia areata are at increased riskfor psychiatric disorders, and calls attention to the need for psychiatric assessment in this population. Copyright 0 1991 by W.B. Saunders Company
A
LOPECIA AREATA has been noted to account for 2% of dermatology clinic visits, with incidence figures ranging up to 3.5%.l Its clinical presentation can vary from a single patch of nonscarring hair loss, to multiple patches or total hair loss.’ Loss of all scalp hair (alopecia totalis) occurs in 5% to 10% of cases, and sites other than the scalp (eyelashes, beard, pubic or general body hair) may be affected in 10% of patients.’ Alopecia universalis involves the loss of all scalp and body hair. Patches of hair loss in alopecia areata are typically circumscribed, with smooth skin. Breakage of the shaft of hair leads to typical “exclamation-mark hairs,” often present around the margins of the patch. Prognosis is variable, with 20% to 30% of patients failing to recover from the original episode, and with complete recovery for 10 to 15 years in one third of cases.’ Various immunologic changes have been noted in this condition, and a variety of diseases with presumed immunologic pathogenesis have been linked with alopecia areata.’ A positive family history has been described in 6% to 20% of cases. Other factors associated with alopecia areata, and often debated in the literature, include endocrine factors, physical trauma, infections, and psychological determinants.’ The role of psychological factors in alopecia areata has long been a subject of debate, with various investigators reporting contradictory findings regarding the rates of psychopathology in patients with this condition, as well as the role of psychological events or stress in the onset of symptoms.1.3.’In a report of 55 cases, Irwin reported that 63% suffered from a severe psychoneurosis, while 14% were free of psychiatric problems.4 Greenberg’ reported on 44 consecutive adult or adolescent patients, noting the presence of psychopathology in 93% of patients: psychoneurotic (73%), borderline psychotic (9%), schizophrenic (9%), and From the Departments of Psychiatry, Medicine, and Dermarology (M.K.H.), University of Minnesota, Minneapolis, MN. Address reprint requests to Eduardo A. CoGn, M.D., Box 393 Mayo Building, University of Minnesota Hospital, 420 Delaware St SE, Minneapolis. MN 55455. Copyright 0 1991 by W.B. Saunders Company OOIO-440X/9113203-0009$03.OOiO Comprehensive
Psychiatry, Vol. 32, No. 3 (May/June),
1991: pp 245-251
245
246
COLON ET AL
involutional psychosis (2%). Diagnoses were based on clinical interviews and Rorschach tests (12 patients). Muller and Winkelmann reported on 736 cases of alopecia areata seen over a lo-year period, and described the presence of “psychoneuroses, personality disorders, or neurotic behavioral traits of a severe nature” in 17% of adults and 22% of children, They noted that this instability had often been present for many years before the onset of alopecia areata. Macalpine3 assessed the degree of psychiatric disturbance in 125 unselected patients without using specific diagnoses: 67% demonstrated no abnormality, 22% showed a mild psychiatric disturbance, and 11% were felt to have a severe psychiatric disturbance qualifying for the label “psychosis.” She noted no correspondence between onset of alopecia areata and onset of psychiatric symptoms. A larger proportion of patients with alopecia totalis or universalis were mildly disturbed, and the author concluded that this may be reactive, or a chance occurrence. More recently, Cipriani et a1.7administered Kellner’s Symptom Questionnaire to 48 patients with alopecia areata and compared them with patients with male pattern baldness and with patients with fungal infections. No differences were found with regard to neurotic symptoms, anxiety, depression, somatization, or hostility. Other investigatorss” have provided case histories focusing on the psychological impact of events preceding the onset of alopecia areata and the psychodynamic meaning of the patients’ hair loss. The above reports are largely limited by the absence of clear diagnostic criteria, potential biases of those performing the clinical evaluations, sample size, lack of uniformity in assessment, and absence of epidemiologic comparison groups. The role of stressful events in the onset of alopecia areata has also been the focus of attention and controversy.3 Anderson” described mental shock or acute anxiety as the most common precipitating cause in a series of 114 patients. In his series, Irwin indicated that 23% of patients fell into a “traumatic group,” precipitated by emotional distress.3 In reviewing the multiple reports supporting this association, Macalpine3 noted that six of her patients (4.8%) gave histories of mental or emotional trauma leading to the onset of alopecia areata, while noting that some actually had not reported preexisting lesions nor previous episodes, and had no recurrence when they experienced subsequent significant stressors. Additionally, she stated that many previous episodes of exposure to stress had not resulted in onset of illness, and concluded that there is no evidence for the role of stress in the onset of symptoms. Reinhold” evaluated 52 patients with alopecia areata and 27 patients with chronic urticaria. All of her patients described being unhappy or having stressful lives, and she noted that alopecia areata may have been precipitated by a major new stress in six cases and a minor new stress in nine cases. In 27 cases, no acute crisis was identified, while four patients had psychological disturbances but no stress, three had a depressive illness, and three had other psychosomatic illnesses. Although providing examples, no specific criteria for these classifications are delineated. More recently, Perini et a1.l’ examined 48 patients with onset of alopecia areata within the previous 6 months, using Paykel’s Interview for recent life events. They compared the frequency of reported significant life events in these patients with those reported by patients with common baldness and fungal infections. The patients with alopecia areata reported significantly more frequent life events than the control groups, including
PSYCHIATRIC
DISORDERS
IN ALOPECIA
AREATA
247
uncontrolled events, socially undesired events, and exits. The authors acknowledged the potential for biased recall, although they felt that limiting the sample to patients with onset within 6 months decreased the likelihood of this possibility. The possible impact of mood changes, or the bias introduced by preexisting beliefs or information regarding pathogenesis of alopecia areata were not discussed. In our study, we evaluated a consecutive series of patients with patchy and extensive alopecia areata using a structured interview and clinical characteristics of the patients in order to clarify the nature and prevalence of psychiatric disorders in this population. METHOD Patients who presented to the outpatient dermatology clinic during a 30-month interval (April 1985 to October 1987) for participation in a drug treatment study of alopecia areata were eligible for
inclusion in our study. Those whose willingness to participate was not prompted by their need for acute psychiatric intervention were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DIS) and a semistructured interview designed to elicit information regarding personal and familial psychiatric history, alopecia areata history, and personal perceptions regarding the etiology of their alopecia areata and its emotional impact. Alopecia areata history was characterized by several variables: age at onset, duration (age at first episode of alopecia areata to current age), form (patchy, totalis, universalis), and number of episodes. Psychiatric diagnoses were examined for significant relationships (P < .05) with the variables characterizing alopecia areata history using chi-square tests and t tests. Relationships between the onset of psychiatric disorders (as identified by the DIS) and the onset of alopecia areata were also examined.
RESULTS
Thirty-six patients agreed to participate in the study; five were excluded as they were judged to be primarily seeking psychiatric intervention. The median age of the resultant 31 study subjects was 35 years, with a range of 17 to 59 years; 22 (71%) were female and nine (29%) were male. The history of alopecia for the study subjects is summarized in Table 1. Of the 31 subjects, 23 (74%) had one or more lifetime psychiatric diagnoses identified by the DIS (Table 2). Of particular note were the high lifetime Table 1. Characteristics Age at onset (Yr) Median Range Duration (Yr) Median Range
of Alopecia Areata History (N = 31)
21 2-50 14 0.5-31
No. of episodes Median Range Single Multiple
2 l-6 12 (39%) 19 (61%)
Form* Patchy Totalis Universalis
23 (74%) 7 (23%) 13 (42%)
*Categories are not mutually exclusive; some patients with multiple episodes of alopecia had multiple forms.
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Table 2. Lifetime Prevalence Rates of Psychiatric Disorders in Patients With Alopecia Areata (N = 31) Diagnosis
Lifetime Prevalence
Any DIS diagnosis Major depression Generalized anxiety disorder Tobacco use disorder Psychosexual dysfunction Phobic disorder Alcohol or drug abuse/dependence Dysthymic disorder Antisocial personality disorder Panic disorder Bipolar disorder Posttraumatic stress disorder Obsessive-compulsive disorder Bulimia Pathological gambling
23 12 12 11 8 7 7 5 4 4 2 1 1 1 1
(74%) (39%) (39%) (35%) (26%) (23%) (23%) (16%) (13%) (13%) (6%) (3%) (3%) (3%) (3%)
NOTE. Categories are not mutually exclusive.
prevalence rates of major depression (39%) and generalized anxiety disorder (39%). Previous psychiatric treatment was reported by 12 (39%) of the subjects, with two subjects reporting a previous psychiatric hospitalization. Subjects reported high rates of psychiatric disorders among their first-degree relatives. Of the 31 subjects, 18 (58%) had at least one first-degree relative with an anxiety disorder, 11 (35%) reported an affective disorder, and 11 (35%) reported substance use disorders. Diagnoses are specified in Table 3. No lifetime psychiatric diagnosis was found to be significantly related to the age at onset of alopecia areata, although the sample size for some diagnostic categories was small. The seven subjects having a lifetime diagnosis of phobic disorder tended to have earlier mean age at onset of alopecia areata than those without phobic disorder (age, 13.6 v 24.7; t = 1.92, df = 29, P = .064). Similarly, the four cases with a lifetime diagnosis of antisocial personality disorder tended to Table 3. Subject Report of Psychiatric History in First-Degree Diagnosis Any anxiety disorder Phobic disorder Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Atypical anxiety disorder Posttraumatic stress disorder Any mood disorder Major depression Dysthymic disorder Alcohol or drug abuse/dependence Organic mental disorder-dementia Organic mood syndrome Antisocial personality disorder NOTE. Categories are not mutually exclusive.
Relatives (N = 31) Rate 18 10 7 4 4 2 1 11 9 2 11 2 2 1
(58%) (32%) (23%) (13%) (13%) (6%) (3%) (35%) (29%) (6%) (35%) (6%) (6%) (3%)
PSYCHIATRIC
DISORDERS
IN ALOPECIA
249
AREATA
have earlier mean age at onset than their counterparts
(age, 10.5 v 23.9; t = 1.85,
df = 29, P = .074).
With regard to the duration of alopecia areata (age at onset to current age), the four subjects having a lifetime diagnosis of panic disorder had a shorter mean duration than those without panic disorder (4.8 v 15.2 years; t = 2.05, df = 29, P = .050). No significant relationships were found between lifetime psychiatric diagnoses and the number of episodes of alopecia areata. A significant relationship was found between a lifetime diagnosis of generalized anxiety disorder and the form of alopecia areata. Of the 23 subjects who had one or more episodes of patchy alopecia areata, 12 (52%) had a lifetime diagnosis of generalized anxiety disorder compared with 0 of the eight subjects who never had an episode of patchy alopecia areata (x” = 4.79, df = 1, P = .029). Subjects who had one or more episodes of alopecia universalis tended to be less likely to have a lifetime diagnosis of generalized anxiety disorder than those who never had an episode of alopecia universalis (15% v 56%, respectively), although the difference was not statistically significant (x2 = 3.58, df = 1, P = .059). No significant relationship was found between a lifetime diagnosis of major depression and any of the variables characterizing alopecia areata history. Of the 12 patients having a lifetime diagnosis of major depression, six had onset of depression before the onset of alopecia areata (range, 2 to 29 years earlier), five had onset after the onset of alopecia (range, 10 to 29 years later), and one had onset coincident with the onset of alopecia areata. Of the 12 patients having a lifetime diagnosis of generalized anxiety disorder, five had onset of the anxiety disorder before the onset of alopecia areata (range, 7 to 29 years earlier), five had onset after the onset of alopecia areata (range, 1 to 29 years later), and two had onset coincident with the onset of alopecia areata. Of the seven patients having a lifetime diagnosis of phobic disorder, four had onset of a phobia before the onset of alopecia areata (range, 2 to 23 years earlier), and three had onset after the onset of alopecia areata (range, 7 to 8 years later). Similar patterns held for the remaining diagnostic categories. Table 4 summarizes patients’ perceptions regarding the etiology of their alopecia areata. Almost 50% of patients identified stress or depression as causing their etiology, although examination of the temporal relationship behveen psychiatric disorders and alopecia areata (presented above) found few cases of coincident onset. Of the 31 subjects, 23 (74%) reported that they had no significant difficulty in coping with their alopecia areata, although 16 (52%) said it had affected their personality or relationships with others. Twelve patients (39%) Table 4. Patients’ Perceptions
Regarding Etiology of Their Alopecia Areata (N = 31)
Stress Depression Medical illness Medications Hormonal Genetic Quitting smoking No identified reason NOTE. Percentages do not total 100% due to rounding.
12 (39%) 3 (10%) 2 (7%) 2 (7%) 2 (7%) 1 (3%) 1 (3%) 8 (26%)
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reported disliking their hair or wishing it was different before their initial hair loss, while eight patients (26%) reported that their hair had held special meaning to them in terms of their self-image or attractiveness to others. Twenty patients (65%) reported currently wearing a wig. Of these 20, 15 (75%) reported being satisfied with the wig. Eleven (55%) stated that the wig was similar in appearance to their hair before its loss. DISCUSSION
In our sample of patients with alopecia areata, 74% were noted to have a lifetime psychiatric diagnosis, with high prevalence rates of major depression and generalized anxiety disorder. Previous investigators have noted high rates of psychopathology without the use of formal diagnostic criteria,4-6’10and focused on the etiologic or reactive nature of these psychiatric disorders. The almost equal distribution of onset of psychiatric disorders before and after the emergence of alopecia areata does not support either of these assumptions. However, these high prevalence rates underscore the need for assessment and recognition of psychiatric disorders in this population. The reports of high rates of anxiety and mood and substance use disorders in first-degree relatives of patients with alopecia areata is striking. This raises questions about an increased risk for alopecia in patients with positive family (and personal) history of these disorders. The nature of this association remains speculative. It is possible that immunologic and neuroendocrine changes associated with these disorders may predispose or facilitate the development of alopecia areata or its course. Of interest is the report by most of the patients (74%) that they had no significant difficulty coping with their alopecia (although we excluded subjects presenting with acute emotional distress), and three fourths of the subjects wearing wigs indicated that they were satisfied with it. This may relate to the median duration of illness of 14 years in our subjects. Although the sample size is too small for generalization of findings, the apparent association between earlier age of onset of alopecia and the diagnoses of phobic disorders and antisocial personality disorders is interesting. Perhaps the onset of alopecia at an earlier age results in the emergence of more avoidant behaviors or alternatively, higher rates of “acting out” or risk-taking behavior. The latter phenomenon has been noted in the literature with regard to behavioral complications of hemophilia.‘3314 Examination of the distribution of psychiatric diagnoses in relation to onset of alopecia in larger samples would provide further indications of the long-term behavioral responses to an illness with potentially significant alterations in physical appearance. The association between patchy alopecia and generalized anxiety disorder is also of interest. In some patients the loss of patches of hair may generate a sense of apprehension regarding the potential course or progression to more generalized forms of alopecia, which becomes reinforced by recurring episodes. It is also possible that generalized anxiety disorder may lead to physiologic changes that predispose to the emergence or recurrence of patchy alopecia. Alternatively, a common pathophysiologic substrate may exist, leading to the emergence of both disorders.
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IN ALOPECIA
AREATA
251
As in previous reports, we found that a significant number of patients attributed the onset of their alopecia to stress or depression. In general, onset of formal psychiatric diagnosis did not appear to relate to onset of alopecia. However, this does not preclude a possible association with psychological distress. It has been noted that exposure to various stressful environmental stimuli can result in alterations in immune functioning,“.16 the physiologic consequences of which are not clear. Although a number of immunologic alterations have been noted in patients with alopecia areata, the underlying abnormalities have been characterized as variable and inconsistent.* In addition, patient reports of stressful events as correlated with onset of illness can be clouded by misattribution or even minimizing the existence of patches of alopecia before the stressful event.3 The role of stressful events can perhaps best be elucidated in a prospective study of patients with recurrent illness. It has been noted that alopecia areata represents a heterogeneous illness, with variable course and likely variable etiologies.’ In this context, establishing correlations between specific psychiatric disorders and alopecia areata becomes confounded. As the etiologies of this disorder become further elucidated, we may be in a better position to ascertain possible pathophysiologic correlations. However, the findings of high prevalence rates of psychiatric disorders should warrant attention to the presence of these disorders and the provision of assessment and intervention. REFERENCES 1. Ebling FTG, Dawber R, Rook A: The Hair, in Rook A, Wilkinson DS, Ebling FTG, et al (eds): Textbook of Dermatology. Boston, MA, Blackwell Scientific, 1986, pp 1985-1992 2. Rietschel RL: Alopecia areata: skin manifestations of an immunocutaneous endocrinologic syndrome. Immunol Allergy Clin North Am 9:543-547, 1989 3. Macalpine I: Is alopecia areata psychosomatic?-A psychiatric study. Br J Dermatol70:117-131, 1958 4. Irwin D: Skin diseases in which psychosomatic factors are of particular importance: II. Abnormal skin manifestations-Alopecia, in Wittkower E, Russell B (eds): Emotional Factors in Skin Disease. New York, NY, Hoeber, 1953, pp 176-189 5. Greenberg SI: Alopecia areata: A psychiatric survey. Arch Dermatol72:454-457,1955 6. Mueller SA, Winkelmann RK: Alopecia areata: An evaluation of 736 patients. Arch Dermatol 88:290-297, 1963 7. Cipriani R, Veller-Fornasa C, Peserico A: Symptom questionnaire for alopecia areata. G Ital Dermatol Venereol 118:281-282, 1988 8. Mehlman RD, Griesemer RD: Alopecia areata in the very young. Am J Psychiatry 125:605-614, 1968 9. Cohen IH, Lichtenberg JD: Alopecia areata. Arch Gen Psychiatry 17:608-614, 1967 10. Anderson I: Alopecia areata: A clinical study. Br Med J 2:1250-1252, 1950 11. Reinhold M: Relationship of stress to the development of symptoms in alopecia areata and chronic urticaria. Br Med J 1:846-849, 1960 12. Perini GI, Veller-Fornasa C, Cipriani R, et al: Life events and alopecia areata. Psychother Psychosom 41:48-52,1984 13. Jonas DL: Psychiatric aspects of hemophilia. Mt Sinai J Med 44:457-463, 1977 14. Agle D: Psychological factors in hemophilia-The concept of self-care. Ann NY Acad Sci 240:221-225, 1975 15. Tecoma E, Huey L: Psychic distress and the immune response. Life Sci 36:1799-1812,1985 16. Stein M, Keller AE, Schleifer SJ: Stress and immunomodulation: The role of depression and neuroendocrine function. J Immunol 135:827s-833s, 1985
Prevalence of Psychiatric Disorders Patients With Alopecia Areata
Eduardo A. Cob,
in
Michael K. Popkin, Allan L. Callies, Nancy J. Dessert, and Maria K. Hordinsky
Thirty-one patients with alopecia areata were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DE). Overall, 74% had one or more lifetime psychiatric diagnoses. Particularly noteworthy were the high lifetime prevalence rates of major depression (39%) and generalized anxiety disorder (39%). In addition, patients reported increased rates of psychiatric disorders in first-degree relatives: anxiety disorders (58%), affective disorders (35%), and substance use disorders (35%). Patients with patchy alopecia areata were more likely to have a diagnosis of generalized anxiety disorder. No relationships were found between major depression and any variable characterizing alopecia areata history. Possible interrelationships between psychiatric disorders and alopecia areata are discussed. The study suggests that patients with alopecia areata are at increased riskfor psychiatric disorders, and calls attention to the need for psychiatric assessment in this population. Copyright 0 1991 by W.B. Saunders Company
A
LOPECIA AREATA has been noted to account for 2% of dermatology clinic visits, with incidence figures ranging up to 3.5%.l Its clinical presentation can vary from a single patch of nonscarring hair loss, to multiple patches or total hair loss.’ Loss of all scalp hair (alopecia totalis) occurs in 5% to 10% of cases, and sites other than the scalp (eyelashes, beard, pubic or general body hair) may be affected in 10% of patients.’ Alopecia universalis involves the loss of all scalp and body hair. Patches of hair loss in alopecia areata are typically circumscribed, with smooth skin. Breakage of the shaft of hair leads to typical “exclamation-mark hairs,” often present around the margins of the patch. Prognosis is variable, with 20% to 30% of patients failing to recover from the original episode, and with complete recovery for 10 to 15 years in one third of cases.’ Various immunologic changes have been noted in this condition, and a variety of diseases with presumed immunologic pathogenesis have been linked with alopecia areata.’ A positive family history has been described in 6% to 20% of cases. Other factors associated with alopecia areata, and often debated in the literature, include endocrine factors, physical trauma, infections, and psychological determinants.’ The role of psychological factors in alopecia areata has long been a subject of debate, with various investigators reporting contradictory findings regarding the rates of psychopathology in patients with this condition, as well as the role of psychological events or stress in the onset of symptoms.1.3.’In a report of 55 cases, Irwin reported that 63% suffered from a severe psychoneurosis, while 14% were free of psychiatric problems.4 Greenberg’ reported on 44 consecutive adult or adolescent patients, noting the presence of psychopathology in 93% of patients: psychoneurotic (73%), borderline psychotic (9%), schizophrenic (9%), and From the Departments of Psychiatry, Medicine, and Dermarology (M.K.H.), University of Minnesota, Minneapolis, MN. Address reprint requests to Eduardo A. CoGn, M.D., Box 393 Mayo Building, University of Minnesota Hospital, 420 Delaware St SE, Minneapolis. MN 55455. Copyright 0 1991 by W.B. Saunders Company OOIO-440X/9113203-0009$03.OOiO Comprehensive
Psychiatry, Vol. 32, No. 3 (May/June),
1991: pp 245-251
245
246
COLON ET AL
involutional psychosis (2%). Diagnoses were based on clinical interviews and Rorschach tests (12 patients). Muller and Winkelmann reported on 736 cases of alopecia areata seen over a lo-year period, and described the presence of “psychoneuroses, personality disorders, or neurotic behavioral traits of a severe nature” in 17% of adults and 22% of children, They noted that this instability had often been present for many years before the onset of alopecia areata. Macalpine3 assessed the degree of psychiatric disturbance in 125 unselected patients without using specific diagnoses: 67% demonstrated no abnormality, 22% showed a mild psychiatric disturbance, and 11% were felt to have a severe psychiatric disturbance qualifying for the label “psychosis.” She noted no correspondence between onset of alopecia areata and onset of psychiatric symptoms. A larger proportion of patients with alopecia totalis or universalis were mildly disturbed, and the author concluded that this may be reactive, or a chance occurrence. More recently, Cipriani et a1.7administered Kellner’s Symptom Questionnaire to 48 patients with alopecia areata and compared them with patients with male pattern baldness and with patients with fungal infections. No differences were found with regard to neurotic symptoms, anxiety, depression, somatization, or hostility. Other investigatorss” have provided case histories focusing on the psychological impact of events preceding the onset of alopecia areata and the psychodynamic meaning of the patients’ hair loss. The above reports are largely limited by the absence of clear diagnostic criteria, potential biases of those performing the clinical evaluations, sample size, lack of uniformity in assessment, and absence of epidemiologic comparison groups. The role of stressful events in the onset of alopecia areata has also been the focus of attention and controversy.3 Anderson” described mental shock or acute anxiety as the most common precipitating cause in a series of 114 patients. In his series, Irwin indicated that 23% of patients fell into a “traumatic group,” precipitated by emotional distress.3 In reviewing the multiple reports supporting this association, Macalpine3 noted that six of her patients (4.8%) gave histories of mental or emotional trauma leading to the onset of alopecia areata, while noting that some actually had not reported preexisting lesions nor previous episodes, and had no recurrence when they experienced subsequent significant stressors. Additionally, she stated that many previous episodes of exposure to stress had not resulted in onset of illness, and concluded that there is no evidence for the role of stress in the onset of symptoms. Reinhold” evaluated 52 patients with alopecia areata and 27 patients with chronic urticaria. All of her patients described being unhappy or having stressful lives, and she noted that alopecia areata may have been precipitated by a major new stress in six cases and a minor new stress in nine cases. In 27 cases, no acute crisis was identified, while four patients had psychological disturbances but no stress, three had a depressive illness, and three had other psychosomatic illnesses. Although providing examples, no specific criteria for these classifications are delineated. More recently, Perini et a1.l’ examined 48 patients with onset of alopecia areata within the previous 6 months, using Paykel’s Interview for recent life events. They compared the frequency of reported significant life events in these patients with those reported by patients with common baldness and fungal infections. The patients with alopecia areata reported significantly more frequent life events than the control groups, including
PSYCHIATRIC
DISORDERS
IN ALOPECIA
AREATA
247
uncontrolled events, socially undesired events, and exits. The authors acknowledged the potential for biased recall, although they felt that limiting the sample to patients with onset within 6 months decreased the likelihood of this possibility. The possible impact of mood changes, or the bias introduced by preexisting beliefs or information regarding pathogenesis of alopecia areata were not discussed. In our study, we evaluated a consecutive series of patients with patchy and extensive alopecia areata using a structured interview and clinical characteristics of the patients in order to clarify the nature and prevalence of psychiatric disorders in this population. METHOD Patients who presented to the outpatient dermatology clinic during a 30-month interval (April 1985 to October 1987) for participation in a drug treatment study of alopecia areata were eligible for
inclusion in our study. Those whose willingness to participate was not prompted by their need for acute psychiatric intervention were administered a structured psychiatric interview (the Diagnostic Interview Schedule; DIS) and a semistructured interview designed to elicit information regarding personal and familial psychiatric history, alopecia areata history, and personal perceptions regarding the etiology of their alopecia areata and its emotional impact. Alopecia areata history was characterized by several variables: age at onset, duration (age at first episode of alopecia areata to current age), form (patchy, totalis, universalis), and number of episodes. Psychiatric diagnoses were examined for significant relationships (P < .05) with the variables characterizing alopecia areata history using chi-square tests and t tests. Relationships between the onset of psychiatric disorders (as identified by the DIS) and the onset of alopecia areata were also examined.
RESULTS
Thirty-six patients agreed to participate in the study; five were excluded as they were judged to be primarily seeking psychiatric intervention. The median age of the resultant 31 study subjects was 35 years, with a range of 17 to 59 years; 22 (71%) were female and nine (29%) were male. The history of alopecia for the study subjects is summarized in Table 1. Of the 31 subjects, 23 (74%) had one or more lifetime psychiatric diagnoses identified by the DIS (Table 2). Of particular note were the high lifetime Table 1. Characteristics Age at onset (Yr) Median Range Duration (Yr) Median Range
of Alopecia Areata History (N = 31)
21 2-50 14 0.5-31
No. of episodes Median Range Single Multiple
2 l-6 12 (39%) 19 (61%)
Form* Patchy Totalis Universalis
23 (74%) 7 (23%) 13 (42%)
*Categories are not mutually exclusive; some patients with multiple episodes of alopecia had multiple forms.
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Table 2. Lifetime Prevalence Rates of Psychiatric Disorders in Patients With Alopecia Areata (N = 31) Diagnosis
Lifetime Prevalence
Any DIS diagnosis Major depression Generalized anxiety disorder Tobacco use disorder Psychosexual dysfunction Phobic disorder Alcohol or drug abuse/dependence Dysthymic disorder Antisocial personality disorder Panic disorder Bipolar disorder Posttraumatic stress disorder Obsessive-compulsive disorder Bulimia Pathological gambling
23 12 12 11 8 7 7 5 4 4 2 1 1 1 1
(74%) (39%) (39%) (35%) (26%) (23%) (23%) (16%) (13%) (13%) (6%) (3%) (3%) (3%) (3%)
NOTE. Categories are not mutually exclusive.
prevalence rates of major depression (39%) and generalized anxiety disorder (39%). Previous psychiatric treatment was reported by 12 (39%) of the subjects, with two subjects reporting a previous psychiatric hospitalization. Subjects reported high rates of psychiatric disorders among their first-degree relatives. Of the 31 subjects, 18 (58%) had at least one first-degree relative with an anxiety disorder, 11 (35%) reported an affective disorder, and 11 (35%) reported substance use disorders. Diagnoses are specified in Table 3. No lifetime psychiatric diagnosis was found to be significantly related to the age at onset of alopecia areata, although the sample size for some diagnostic categories was small. The seven subjects having a lifetime diagnosis of phobic disorder tended to have earlier mean age at onset of alopecia areata than those without phobic disorder (age, 13.6 v 24.7; t = 1.92, df = 29, P = .064). Similarly, the four cases with a lifetime diagnosis of antisocial personality disorder tended to Table 3. Subject Report of Psychiatric History in First-Degree Diagnosis Any anxiety disorder Phobic disorder Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Atypical anxiety disorder Posttraumatic stress disorder Any mood disorder Major depression Dysthymic disorder Alcohol or drug abuse/dependence Organic mental disorder-dementia Organic mood syndrome Antisocial personality disorder NOTE. Categories are not mutually exclusive.
Relatives (N = 31) Rate 18 10 7 4 4 2 1 11 9 2 11 2 2 1
(58%) (32%) (23%) (13%) (13%) (6%) (3%) (35%) (29%) (6%) (35%) (6%) (6%) (3%)
PSYCHIATRIC
DISORDERS
IN ALOPECIA
249
AREATA
have earlier mean age at onset than their counterparts
(age, 10.5 v 23.9; t = 1.85,
df = 29, P = .074).
With regard to the duration of alopecia areata (age at onset to current age), the four subjects having a lifetime diagnosis of panic disorder had a shorter mean duration than those without panic disorder (4.8 v 15.2 years; t = 2.05, df = 29, P = .050). No significant relationships were found between lifetime psychiatric diagnoses and the number of episodes of alopecia areata. A significant relationship was found between a lifetime diagnosis of generalized anxiety disorder and the form of alopecia areata. Of the 23 subjects who had one or more episodes of patchy alopecia areata, 12 (52%) had a lifetime diagnosis of generalized anxiety disorder compared with 0 of the eight subjects who never had an episode of patchy alopecia areata (x” = 4.79, df = 1, P = .029). Subjects who had one or more episodes of alopecia universalis tended to be less likely to have a lifetime diagnosis of generalized anxiety disorder than those who never had an episode of alopecia universalis (15% v 56%, respectively), although the difference was not statistically significant (x2 = 3.58, df = 1, P = .059). No significant relationship was found between a lifetime diagnosis of major depression and any of the variables characterizing alopecia areata history. Of the 12 patients having a lifetime diagnosis of major depression, six had onset of depression before the onset of alopecia areata (range, 2 to 29 years earlier), five had onset after the onset of alopecia (range, 10 to 29 years later), and one had onset coincident with the onset of alopecia areata. Of the 12 patients having a lifetime diagnosis of generalized anxiety disorder, five had onset of the anxiety disorder before the onset of alopecia areata (range, 7 to 29 years earlier), five had onset after the onset of alopecia areata (range, 1 to 29 years later), and two had onset coincident with the onset of alopecia areata. Of the seven patients having a lifetime diagnosis of phobic disorder, four had onset of a phobia before the onset of alopecia areata (range, 2 to 23 years earlier), and three had onset after the onset of alopecia areata (range, 7 to 8 years later). Similar patterns held for the remaining diagnostic categories. Table 4 summarizes patients’ perceptions regarding the etiology of their alopecia areata. Almost 50% of patients identified stress or depression as causing their etiology, although examination of the temporal relationship behveen psychiatric disorders and alopecia areata (presented above) found few cases of coincident onset. Of the 31 subjects, 23 (74%) reported that they had no significant difficulty in coping with their alopecia areata, although 16 (52%) said it had affected their personality or relationships with others. Twelve patients (39%) Table 4. Patients’ Perceptions
Regarding Etiology of Their Alopecia Areata (N = 31)
Stress Depression Medical illness Medications Hormonal Genetic Quitting smoking No identified reason NOTE. Percentages do not total 100% due to rounding.
12 (39%) 3 (10%) 2 (7%) 2 (7%) 2 (7%) 1 (3%) 1 (3%) 8 (26%)
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reported disliking their hair or wishing it was different before their initial hair loss, while eight patients (26%) reported that their hair had held special meaning to them in terms of their self-image or attractiveness to others. Twenty patients (65%) reported currently wearing a wig. Of these 20, 15 (75%) reported being satisfied with the wig. Eleven (55%) stated that the wig was similar in appearance to their hair before its loss. DISCUSSION
In our sample of patients with alopecia areata, 74% were noted to have a lifetime psychiatric diagnosis, with high prevalence rates of major depression and generalized anxiety disorder. Previous investigators have noted high rates of psychopathology without the use of formal diagnostic criteria,4-6’10and focused on the etiologic or reactive nature of these psychiatric disorders. The almost equal distribution of onset of psychiatric disorders before and after the emergence of alopecia areata does not support either of these assumptions. However, these high prevalence rates underscore the need for assessment and recognition of psychiatric disorders in this population. The reports of high rates of anxiety and mood and substance use disorders in first-degree relatives of patients with alopecia areata is striking. This raises questions about an increased risk for alopecia in patients with positive family (and personal) history of these disorders. The nature of this association remains speculative. It is possible that immunologic and neuroendocrine changes associated with these disorders may predispose or facilitate the development of alopecia areata or its course. Of interest is the report by most of the patients (74%) that they had no significant difficulty coping with their alopecia (although we excluded subjects presenting with acute emotional distress), and three fourths of the subjects wearing wigs indicated that they were satisfied with it. This may relate to the median duration of illness of 14 years in our subjects. Although the sample size is too small for generalization of findings, the apparent association between earlier age of onset of alopecia and the diagnoses of phobic disorders and antisocial personality disorders is interesting. Perhaps the onset of alopecia at an earlier age results in the emergence of more avoidant behaviors or alternatively, higher rates of “acting out” or risk-taking behavior. The latter phenomenon has been noted in the literature with regard to behavioral complications of hemophilia.‘3314 Examination of the distribution of psychiatric diagnoses in relation to onset of alopecia in larger samples would provide further indications of the long-term behavioral responses to an illness with potentially significant alterations in physical appearance. The association between patchy alopecia and generalized anxiety disorder is also of interest. In some patients the loss of patches of hair may generate a sense of apprehension regarding the potential course or progression to more generalized forms of alopecia, which becomes reinforced by recurring episodes. It is also possible that generalized anxiety disorder may lead to physiologic changes that predispose to the emergence or recurrence of patchy alopecia. Alternatively, a common pathophysiologic substrate may exist, leading to the emergence of both disorders.
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DISORDERS
IN ALOPECIA
AREATA
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As in previous reports, we found that a significant number of patients attributed the onset of their alopecia to stress or depression. In general, onset of formal psychiatric diagnosis did not appear to relate to onset of alopecia. However, this does not preclude a possible association with psychological distress. It has been noted that exposure to various stressful environmental stimuli can result in alterations in immune functioning,“.16 the physiologic consequences of which are not clear. Although a number of immunologic alterations have been noted in patients with alopecia areata, the underlying abnormalities have been characterized as variable and inconsistent.* In addition, patient reports of stressful events as correlated with onset of illness can be clouded by misattribution or even minimizing the existence of patches of alopecia before the stressful event.3 The role of stressful events can perhaps best be elucidated in a prospective study of patients with recurrent illness. It has been noted that alopecia areata represents a heterogeneous illness, with variable course and likely variable etiologies.’ In this context, establishing correlations between specific psychiatric disorders and alopecia areata becomes confounded. As the etiologies of this disorder become further elucidated, we may be in a better position to ascertain possible pathophysiologic correlations. However, the findings of high prevalence rates of psychiatric disorders should warrant attention to the presence of these disorders and the provision of assessment and intervention. REFERENCES 1. Ebling FTG, Dawber R, Rook A: The Hair, in Rook A, Wilkinson DS, Ebling FTG, et al (eds): Textbook of Dermatology. Boston, MA, Blackwell Scientific, 1986, pp 1985-1992 2. Rietschel RL: Alopecia areata: skin manifestations of an immunocutaneous endocrinologic syndrome. Immunol Allergy Clin North Am 9:543-547, 1989 3. Macalpine I: Is alopecia areata psychosomatic?-A psychiatric study. Br J Dermatol70:117-131, 1958 4. Irwin D: Skin diseases in which psychosomatic factors are of particular importance: II. Abnormal skin manifestations-Alopecia, in Wittkower E, Russell B (eds): Emotional Factors in Skin Disease. New York, NY, Hoeber, 1953, pp 176-189 5. Greenberg SI: Alopecia areata: A psychiatric survey. Arch Dermatol72:454-457,1955 6. Mueller SA, Winkelmann RK: Alopecia areata: An evaluation of 736 patients. Arch Dermatol 88:290-297, 1963 7. Cipriani R, Veller-Fornasa C, Peserico A: Symptom questionnaire for alopecia areata. G Ital Dermatol Venereol 118:281-282, 1988 8. Mehlman RD, Griesemer RD: Alopecia areata in the very young. Am J Psychiatry 125:605-614, 1968 9. Cohen IH, Lichtenberg JD: Alopecia areata. Arch Gen Psychiatry 17:608-614, 1967 10. Anderson I: Alopecia areata: A clinical study. Br Med J 2:1250-1252, 1950 11. Reinhold M: Relationship of stress to the development of symptoms in alopecia areata and chronic urticaria. Br Med J 1:846-849, 1960 12. Perini GI, Veller-Fornasa C, Cipriani R, et al: Life events and alopecia areata. Psychother Psychosom 41:48-52,1984 13. Jonas DL: Psychiatric aspects of hemophilia. Mt Sinai J Med 44:457-463, 1977 14. Agle D: Psychological factors in hemophilia-The concept of self-care. Ann NY Acad Sci 240:221-225, 1975 15. Tecoma E, Huey L: Psychic distress and the immune response. Life Sci 36:1799-1812,1985 16. Stein M, Keller AE, Schleifer SJ: Stress and immunomodulation: The role of depression and neuroendocrine function. J Immunol 135:827s-833s, 1985
