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Trichophagia (Rapunzel Syndrome): Symptoms, Health Risks, & Treatments

Published: January 25, 2023 Updated: January 25, 2023
Published: 01/25/2023 Updated: 01/25/2023
Headshot of Leslie Shapiro, LICSW
Written by:

Leslie Shapiro

LICSW
Headshot of Dr. Kristen Fuller, MD
Reviewed by:

Kristen Fuller

MD
  • What Is Trichophagia?Definition
  • Signs & Symptoms of TrichophagiaSigns
  • What Causes Rapunzel Syndrome to Develop?Causes
  • Health Risks & Complications of Rapunzel SyndromeComplications
  • Diagnosis & Treatment for TrichophagiaTreatment
  • How to Get Help for Rapunzel SyndromeGet Help
  • Final Thoughts on TrichophagiaConclusion
  • Additional ResourcesResources
Headshot of Leslie Shapiro, LICSW
Written by:

Leslie Shapiro

LICSW
Headshot of Dr. Kristen Fuller, MD
Reviewed by:

Kristen Fuller

MD

Trichophagia is a somatic symptom disorder in association with trichotillomania (hair pulling), that leads to eating hair. It can result in serious medical consequences and can even be fatal. People who eat hair over a long period of time may begin to have abdominal pain, nausea, vomiting, diarrhea, or constipation due to the accumulation of hair that develops into a hairball, medically referred to as a trichobezoar.

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What Is Trichophagia?

Trichophagia involves the act of eating hair. It is a psychiatric somatic symptom disorder that is mostly, though not exclusively, seen in females. Nicknamed Rapunzel syndrome, trichophagia can lead to serious, sometimes life-threatening medical problems that may require gastrointestinal surgery. This is likely due to the growth of a hairball that accumulates in the small intestine.

When the small intestine runs out of space, hair infiltrates surrounding areas. Symptoms do not occur until the GI tract (esophagus to rectum) becomes clogged with hair. The syndrome often goes undiagnosed or undertreated and is often misdiagnosed as a gastrointestinal problem.1

Who Gets Trichophagia?

Trichophagia is a type of body-focused repetitive behavior (BFRB) found mostly in females who started eating and pulling their hair during middle childhood or adolescence. In males, this disorder often begins at a younger age, during early to middle childhood.1 Children may eat their own hair, their dolls’ hairs, found hairs, or paint brush bristles.

Trichophagia & Trichotillomania

Trichotillomania is a somatic symptom disorder that is characterized by hair pulling. Hair can be pulled from anywhere it grows (e.g., eyebrows, eyelashes, pubic hair, etc.). Pulling hair from the head often creates noticeable patches, often resulting in the person wearing hats or wigs in an effort to try and hide or camouflage the bald spots. People may start avoiding going to work or socializing.

Approximately 20% of people with trichotillomania end up eating their hair after pulling it out.2 Trichophagia (hair eating) could be the last step in a series of ritualized hair pulling behaviors. Some people wind the pulled hair into a ball and swallow it whole, which is especially risky if they have long hair. However, not all hair pullers eat their hair and not all people who eat hair pull their hair out.

By association with trichotillomania, trichophagia is considered a body-focused repetitive behavior diagnosis. Other repetitive behaviors serve the same soothing purpose as hair pulling and eating.

Other Related Disorders

Other behaviors that often co-occur with trichotillomania, and their associated frequencies include:3

  • Skin picking (51%)
  • Nail biting (30%)
  • Lip/cheek biting (26%)
  • Nose picking (12%)

Signs & Symptoms of Trichophagia

Unfortunately, signs and symptoms of Rapunzel syndrome don’t typically manifest until there are physical symptoms of a hairball that has accumulated over years—if not decades. People with trichophagia may seek medical help due to symptoms like abdominal pain or swelling, nausea, and vomiting. Many patients deny any history of trichotillomania or trichophagia, even when they are specifically asked.4

Signs of trichophagia include:

  • Abdominal pain or swelling
  • A mass developed in the upper abdomen
  • Halitosis (bad breath)
  • Peritonitis (inflammation of the abdominal wall lining)
  • Nausea
  • Vomiting
  • Feeling full from eating small portions
  • Weight loss

What Causes Rapunzel Syndrome to Develop?

There is no definitive cause of Rapunzel syndrome, but there appears to be a neurobiological predisposition in those who perform the behaviors. Conditions such as intellectual disabilities, anemia, and iron deficiency have been found in people with trichophagia, but it’s unclear what role they play in its development.8,9

Nervous Emotions & Anxiety

Trichotillomania and trichophagia behaviors appear to have a calming effect. The behaviors are used as a way to regulate someone’s emotions and cope with stress, boredom, negative or uncomfortable feelings, anxiety, tension, loneliness, fatigue, or frustration. Other emotional factors identified as contributing to the behaviors are parental discord, grief, or other family problems.

Depression & Social Isolation

People often experience feelings of  guilt, shame, and embarrassment from pulling or eating their hair. This can lead to social isolation in fear of being negatively judged by others. Social isolation often leads to depression and erodes self-confidence, resulting in increased urges to self-soothe by pulling or eating hair.

There is often a buildup of tension that triggers the urge to eat hair that has been pulled from the body or other sources (i.e., others’ loose hairs). The urges can be consciously acted upon as part of a daily routine or without the person’s awareness, similar to a nervous habit. Longer episodes can lead to feelings of depersonalization, being in a trance-like state, and losing track of time.

Health Risks & Complications of Rapunzel Syndrome

There are several health consequences from eating hair. Due to its enzyme-resistant properties and smooth, slippery surface, human hair cannot be digested, which means that it’s stagnant in the gastrointestinal system. Consequently, hair accumulates between the gastric mucosal folds that lead to the formation of a hairball.5 On average, only 1% of patients with trichophagia develop hairballs.6

Trichobezoars were found to occur in 24% of females with trichotillomania and may be more complicated in people who have long hair.2

Potential health consequences from hairballs include:

  • Ulcers that perforate the stomach and spread bacteria
  • Infected or inflamed abdominal cavity (peritonitis)
  • Gastrointestinal bleeding due to mucosal erosion
  • Bowel obstruction

Can You Die From Rapunzel Syndrome?

Rapunzel syndrome can be fatal. While the prevalence of hairballs in humans is low, mortality rates may be as high as 30% if they remain untreated.7 It is unclear if this is an underrepresentation of how many deaths have actually been caused by trichophagia.

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Diagnosis & Treatment for Trichophagia

The diagnosis of trichophagia often only occurs after seeking medical attention for gastrointestinal pain or the presence of other related symptoms likely due to a hairball. Tests are performed by a gastrointestinal endoscopy, ultrasound, CT scan, or x-ray of the abdomen.

Surgery

Emergency surgery may be performed depending on the severity of the case.10 Surgical options include:

  • Laparotomy (open surgery)
  • Laparoscopy (localized abdominal surgery that breaks down and removes the hairball)
  • Endoscopy (nonsurgical procedure that inserts a tube down the throat to the esophagus)

Medication

Psychiatric medications have also been prescribed to treat the disorder, including N-acetylcysteine, naltrexone, topiramate, atypical neuroleptics, and selective serotonin-reuptake inhibitors.

Therapy

Psychological treatment is also recommended. It’s important to seek help from a therapist who specializes in treating trichotillomania and provides habit-reversal training. Along with treating behaviors, this type of training identifies the factors driving the behaviors and teaches skills that address emotional factors and stress management.

In habit-reversal therapy, patients learn to be aware of the internal and external cues as well as predictable and unpredictable situations that lead to hair pulling. They practice competing behaviors and movements such as keeping hands clasped, sitting on hands, or keeping hands busy by engaging in activities like knitting, crocheting, doing needlepoint, coloring, or other tasks that involve the hands.

Autogenic training is another behavioral treatment option geared toward stress reduction and improved body relaxation. It teaches relaxation techniques designed to reduce blood pressure, heartbeat, and body temperature.

Other cognitive behavioral therapy (CBT) strategies may include journaling, contingency planning for acting on urges, self-monitoring of symptomatic behaviors, thought-monitoring that precede and follow episodes, and restructuring cognitive distortions and automatic negative thoughts.

How to Get Help for Rapunzel Syndrome

When looking for a therapist, it is recommended that the person be licensed, such as a psychologist, social worker, or counselor. Professionals who provide exposure and response prevention often have the skills mentioned in the above section. Good therapists welcome and will provide answers about their background and training. You can find a therapist by asking for a referral from your primary care provider, or by using an online therapist directory, where you can sort by specialty and insurance coverage.

Here are some resources for getting help:

  • Trichstop
  • The TLC Foundation for Body-Focused Repetitive Behavior
  • NOCD

Final Thoughts on Trichophagia

Trichophagia is a serious psychological condition that can be successfully treated with CBT and medication. Help should be sought as soon as the problem is recognized in order to avoid developing hairballs that require surgery or compromise health. It is important for people to know that even if they are keeping their hair eating a secret, they are not alone.

Additional Resources

Education is just the first step on our path to improved mental health and emotional wellness. To help our readers take the next step in their journey, Choosing Therapy has partnered with leaders in mental health and wellness. Choosing Therapy may be compensated for marketing by the companies mentioned below.

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For Further Reading

  • Mental Health America
  • National Alliance on Mental Health
  • MentalHealth.gov

Trichophagia (Rapunzel Syndrome) Infographics

What Is Trichophagia? Signs and Symptoms of Trichophagia Diagnosis and Treatment for Trichophagia

10 sources

Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy.

  • Snorrason, I., Ricketts, E. J., Stein, A. T., & Björgvinsson, T. (2021). Trichophagia and trichobezoar in trichotillomania: A narrative mini-review with clinical recommendations. Journal of Obsessive-Compulsive and Related Disorders, 31, 100680. doi: https://doi.org/10.1016/j.jocrd.2021.100680

  • Grant, J. E., & Odlaug, B. L. (2008). Clinical characteristics of trichotillomania with trichophagia. Compr Psychiatry, 49(6), 579-584. doi:10.1016/j.comppsych.2008.05.002

  • Stein, D. J., Flessner, C. A., Franklin, M., Keuthen, N. J., Lochner, C., & Woods, D. W. (2008). Is trichotillomania a stereotypic movement disorder? An analysis of body-focused repetitive behaviors in people with hair-pulling. Annals of Clinical Psychiatry, 20(4), 194-198.

  • Naik, S., Gupta, V., Naik, S., Rangole, A., Chaudhary, A. K., Jain, P., & Sharma, A. K. (2007). Rapunzel Syndrome Reviewed and Redefined. Digestive Surgery, 24(3), 157-161. doi:10.1159/000102098

  • Iwamuro, M., Okada, H., Matsueda, K., Inaba, T., Kusumoto, C., Imagawa, A., & Yamamoto, K. (2015). Review of the diagnosis and management of gastrointestinal bezoars. World journal of gastrointestinal endoscopy, 7(4), 336-345. doi:10.4253/wjge.v7.i4.336

  • Prasad, A., Jain, A., Gupta, A., & Kamra, A. (2018). Trichobezoar: Ravenous for Hair. Euroasian journal of hepato-gastroenterology, 8(1), 97-98. doi:10.5005/jp-journals-10018-1271

  • Diefenbach, G. J., Reitman, D., & Williamson, D. A. (2000). Trichotillomania: a challenge to research and practice. Clinical Psychology Review, 20(3), 289-309.

  • Cannalire, G., Conti, L., Celoni, M., Grassi, C., Cella, A., Bensi, G., . . . Biasucci, G. (2018). Rapunzel  : an infrequent cause of severe iron deficiency anemia and abdominal pain presenting to the pediatric emergency department. BMC pediatrics, 18(1), 125-125. doi:10.1186/s12887-018-1097-8

  • Kalyoncu, T., Çıldır, D. A., & Özbaran, B. (2017). Trichotillomania in celiac disease patient refractory to iron replacement. Int J Adolesc Med Health, 31(4). doi:10.1515/ijamh-2017-0027

  • Phillips, M. R., Zaheer, S., & Drugas, G. T. (1998). Gastric trichobezoar: case report and literature review. Paper presented at the Mayo Clinic Proceedings.

update history

We regularly update the articles on ChoosingTherapy.com to ensure we continue to reflect scientific consensus on the topics we cover, to incorporate new research into our articles, and to better answer our audience’s questions. When our content undergoes a significant revision, we summarize the changes that were made and the date on which they occurred. We also record the authors and medical reviewers who contributed to previous versions of the article. Read more about our editorial policies here.

  • Originally Published: December 2, 2021
    Original Author: Leslie Shapiro, LICSW
    Original Reviewer: Kristen Fuller, MD

  • Updated: January 25, 2023
    Author: No Change
    Reviewer: No Change
    Primary Changes: Updated for readability and clarity. Reviewed and added relevant resources.

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Headshot of Leslie Shapiro, LICSW
Written by:

Leslie Shapiro

LICSW
Headshot of Dr. Kristen Fuller, MD
Reviewed by:

Kristen Fuller

MD
  • What Is Trichophagia?Definition
  • Signs & Symptoms of TrichophagiaSigns
  • What Causes Rapunzel Syndrome to Develop?Causes
  • Health Risks & Complications of Rapunzel SyndromeComplications
  • Diagnosis & Treatment for TrichophagiaTreatment
  • How to Get Help for Rapunzel SyndromeGet Help
  • Final Thoughts on TrichophagiaConclusion
  • Additional ResourcesResources
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