Remember the maiden told to “let down your hair” so the prince could climb up to reach her? Yup, there’s more to that.

The girl with the long hair from the Grimm Brothers’ 1812 fairy tale inspired the name for a syndrome. Because the fairy tale and the clinical cases documented in a 1968 paper shared traits—the patient’s unusually long hair and the rarity of the occurrence—the condition was dubbed Rapunzel syndrome. Even though the first trichobezoar case was documented in 1779, medical professionals didn't describe the disorder until 1889.

For ages, people have recognized undigested masses in the stomachs of animals and humans as bezoars (accumulations of foreign material in the stomach). However, this discovery has increased in frequency. Despite the prevalence of information, Rapunzel syndrome is still quite rare and is considered to be a form of obsessive-compulsive disorder (OCD).

Researchers have recorded 24 cases in the literature, with a mean age of 10.8 years. Among these cases, there is one male patient and 23 female patients. Patients often report symptoms such as nausea, vomiting, and discomfort in the abdomen, as well as indicators of blockage.

The disorder is not only a medical concern but can cause death in extreme situations, such as in young girls who have eaten excessive amounts of their hair. Trichotillomania includes hair pulling without being fatal but can cause bald spots. It is not unusual for surgical removal of the hairballs to be necessary because this hair may cause intestinal blockages.

As a symptom of trichotillomania, the individual may bite their nails, chew their lips, or pick at their skin, scalp, eyebrows or other areas of their body. Though tweezers or other implements can be used, people typically remove hair by hand.

Some people have rituals around selecting hair and pulling it; for instance, after combing one’s hands through the hair, the individual may look for coarse hair toward the front of the hairline. Some people, after having their hair plucked, may examine it closely and then eat some of it.

Hair loss in household items, such as clothing or blankets, as well as in dogs or dolls, can indicate something more severe in terms of psychopathology. Because hair is a non-nutritive substance, we might also think of this as a form of pica.

Engaging in hair-pulling in private is common, and an episode can last from a few seconds to hours. Usually, individuals with this disorder attempt to hide it from others, but the signs may become evident once the balding patches, skin scabs, and chewed-down nails are obvious.

Causes of the Disorder

Trichotillomania typically begins in adolescence, between the ages of 10 and 13, and continues far into late adolescence, but it can last a lifetime. Most times, babies’ hair loss is minimal and resolves without medical intervention.

Genetics may influence the development of trichotillomania. Having a close family member who suffers from the disorder might increase the risk of developing it.

Some people have trichotillomania as a reaction to extremely stressful events or situations; others find that boredom, solitude, and privacy make them more likely to pull their hair out. The exact cause, however, is not clear.

The complex nature of trichotillomania necessitates a multi-pronged approach to prevention, diagnosis, and therapy. Primary care physicians, dermatologists, psychiatrists, and licensed clinical psychologists may see the patient. Therapy methods and possibly medication will be part of the treatment plan. Treatments for trichotillomania that are presently under research include habit reversal training and cognitive-behavioral therapy (CBT).

Although the disorder primarily affects adolescent females, adults may also engage in this behavior in stressful situations. I have observed adult female healthcare professionals playing with their hair. Although I did not see any active hair pulling, there was hair twisting and manipulation that was not intended for styling purposes. This may make it clearer that the behavior is not constant but may be episodic and persist into adulthood, where behavior modification may be effective.