Annals of Indian Psychiatry

CASE REPORT
Year
: 2017  |  Volume : 1  |  Issue : 2  |  Page : 124--126

Schizophrenia in a case of alopecia universalis


Deepa Sangolkar, Dhruv Parmar, Avinash De Sousa, Nilesh Shah, Sagar Karia 
 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Correspondence Address:
Avinash De Sousa
Carmel, 18, Street Francis Road, Off S.V. Road, Santacruz West, Mumbai  -  400  054, Maharashtra
India

Abstract

Alopecia universalis is characterized by total loss of hair from all over the body such as the scalp, eyebrows, and limbs. Alopecia areata has been known to coexist with psychiatric disorders such as anxiety disorders and depression, although reports with schizophrenia are rare. We present, herewith, a case of alopecia universalis seen to coexist with schizophrenia– a rare clinical picture.



How to cite this article:
Sangolkar D, Parmar D, De Sousa A, Shah N, Karia S. Schizophrenia in a case of alopecia universalis.Ann Indian Psychiatry 2017;1:124-126


How to cite this URL:
Sangolkar D, Parmar D, De Sousa A, Shah N, Karia S. Schizophrenia in a case of alopecia universalis. Ann Indian Psychiatry [serial online] 2017 [cited 2020 Jan 19 ];1:124-126
Available from: http://www.anip.co.in/text.asp?2017/1/2/124/220248


Full Text



 Introduction



Schizophrenia is one of the most common psychiatric disorders seen in clinical practice and is characterized by repeated delusions and hallucinations.[1] Alopecia areata is a skin condition characterized by patchy or total loss of hair from various hair growth areas of the body. Alopecia areata has been linked to various psychiatric conditions, and a huge psychiatric comorbidity is seen in the disorder.[2] Alopecia areata might be a psychosomatic disease precipitated by stressful life events. Stress theory research also implies that there is a role of psychoneuroimmunology in the pathogenesis of both alopecia areata and schizophrenia.[3] It has been suggested that it is a primary dermatologic disorder with psychiatric comorbidity or it may be considered as a primary psychiatric disorder with dermatologic problems.[4] Alopecia areata universalis is a condition where there is total hair loss from various hair growth areas of the body such as the scalp, eyebrows, armpits, pubic hair, and hands or feet.[5] Anxiety disorders have been reported in 30%–40% cases of alopecia areata while schizophrenia is rare.[6] Here, we present a case report of a patient with alopecia areata universalis that coexisted with schizophrenia.

 Case Report



A 30-year-old Muslim married female residing at Mumbai and educated till the 7th standard was brought by her mother to the psychiatry outpatient department with the chief complaints of angry assaultive behavior, hearing voices inaudible to others, refusal to eat food, and reduced interaction with others in social settings. The total duration of her illness was 8 years and the patient was well maintained on medication. The patient stopped all medications for the past 6 months and her symptoms aggravated for the past week before presentation. As per the mother, the patient was alright around 8 years back, when due to interpersonal stressors with her husband, the patient underwent a separation and later got divorced within a month of marriage. It was observed by her mother that the patient started showing altered behavior in the form of remaining withdrawn to self and not interacting with family members as before. She stopped doing the routine household work and would be sitting idle or sleeping most time of the day. Gradually, she began to show decreased self-care in the form of not bathing or changing clothes unless exhorted to do so. The patient would also talk irrelevantly and would say that she is talking to her father who had actually expired when she was young. She said that she was going to get married soon and was found making claims that she was married to a famous Bollywood actor and was carrying his child. On two occasions, the patient tried to run away from home for no apparent reasons. She started blaming her brothers for her failed marriage and all her hardships in life for which they were never responsible. She would claim that all the Muslims who had died for a noble cause have possessed her body and that they would send her messages through television. She also began to show decreased sleep and appetite.

She was then brought to our hospital for a psychiatry consultation and was diagnosed as schizophrenia and started on olanzapine 10 mg/day in divided doses. Later, aripiprazole was added for complains of withdrawn behavior at 10 mg/day. The patient followed up for 6 months and showed 100% improvement on regular treatment. She was remarried 5–6 years before the current episode, and it was noticed that whenever there were stressors in her life, her behavioral symptoms would recur and subside by adjusting the dose of her medication after consultation with the psychiatrist in our hospital. The patient stopped taking medications for 1 year due to complete remission of all her symptoms. Around a month back, the patient had come to mother's place for her father's death anniversary and developed cold, cough, and fever, and hence stayed back here. In this 1 month, the patient's husband did not enquire about her and neither tried to contact her nor replied her messages or received her phone calls. Due to these happenings, the patient became mentally upset. When he came to meet her on the request of elders in family, he refused to take the patient back home with him and escaped making some excuse. After this episode, the patient suddenly started shouting loudly, abusing her mother, and getting aggressive toward her. She was getting irritable on trivial matters and would throw things such as the television remote in anger and approach people in aggressive manner. Since the last 3 days, she started complaining of hearing voices that were inaudible to others all around the clock. They were male voices claiming to kill her, making crying sounds, and other scary sounds to frighten her. She complained of feeling fearful but would not attribute it to anyone particular. Since a day before presentation, the patient refused eating or drinking anything and was getting extremely aggressive toward the mother. Hence, she was brought to hospital. There were no symptoms suggestive of depression, bipolar disorder, obsessive-compulsive disorder, or any anxiety disorders. There was no history suggestive of significant head injury or epilepsy in the past.

It was noticed that the patient had a loss of total body hair for the past 10 years, which was suggestive of condition diagnosed as alopecia universalis [Figure 1] and [Figure 2]. She also had irregular menstrual cycles with primary infertility. She would need to take medications to stop the cycles when bleeding was excess, and there was a history of blood transfusion taken 2 years back due to severe anemia. The patient was the youngest of seven siblings and was presently in her 2nd marriage. She had no children. She had interpersonal stressors with her husband due to infertility problems. The patient's father had expired 18 years back due to cancer. There was no family history suggestive of psychiatric illness or substance use in her family. Her birth and developmental history were insignificant, and she was educated till the 7th standard and she had left studies due to monetary issues after her father's death. She was average in studies, able to handle money matters, and do household jobs well. She attained menarche at the age of 13 years and had irregular cycles every 3–4 months with cycles lasting for 20–25 days to 2 months at a time. The premorbid personality was sensitive, calm, and of an adjusting nature. On general examination, her vital parameters were normal and pallor in the nails was present.{Figure 1}{Figure 2}

On mental status examination (MSE), she was well built, well kempt, and sitting comfortably in the hospital chair, and her head was covered with dupatta. There was significant hair loss over the head, eyebrows, hands, and legs. On enquiring, the mother claimed complete hair loss all over the body except sparse hair on head. The patient was conscious, minimally cooperative, minimally communicative, and grossly oriented to time, place, and person. Eye-to-eye contact was ill maintained. Rapport was not established and attention was aroused. Passive attention was decreased and mood was conveyed to be fearful. The affect was mood congruent, stable, and appropriate to mood. Her speech output was less and no spontaneous speech was initiated. Delusions of persecution were present, and auditory hallucinations were reported in the form of male derogatory voices. She was not cooperative for intelligence and judgment testing, and further MSE was not conducted. Insight at the time of examination was Grade I.

The clinical impression formulated was one of schizophrenia, and the patient was started on oral olanzapine 10 mg/day in divided doses and haloperidol 5 mg twice a day with trihexyphenidyl 2 mg/day. The patient was admitted and administered intravenous fluids as she had not eaten. Her laboratory investigations were carried out and a dermatological reference for hair loss along with a gynecology opinion for menstrual and fertility problems was sought. The patient's hemoglobin was 7 g/dl with a hypochromic, microcytic, anisocytosis, and poikilocytosis anemia. She was started on iron tablets and hematinics for the same. On dermatological reference, she was diagnosed as alopecia areata universalis. She was given a blood transfusion for her anemia. The patient improved significantly from a psychiatric point of view within 1 week of restarting medications. Blood transfusion was done and the patient was discharged after initiating treatment from dermatology and gynecology (hormonal therapy). On subsequent follow-up after 15 days, the patient was well-maintained symptomatically on regular medications.

 Discussion



In the case discussed above, alopecia areata universalis existed before the start of schizophrenia in the patient. There were also significant life events and family factors that could have contributed to the psychiatric illness. The patient had received no treatment for the alopecia. There was a presence of infertility and menstrual irregularities. Alopecia areata has been linked in many studies to menstrual irregularities and infertility as a number of endocrine factors play a role in causation of the disorder.[7] These factors add to the psychopathology that may be seen in such cases. Psychiatric comorbidity may either coexist or add to the severity in alopecia in some cases. In our case, coexistence was the pattern noticed. It is vital from a consultation liaison perspective that dermatologists and psychiatrists work together in the management of disorders such as alopecia areata that may have significant psychopathology or coexistent psychiatric disorders.[8],[9] Schizophrenia, psychosis, and alopecia have been demonstrated to coexist together, but an inter-disorder pathological correlation is yet to be determined.[10] This case report is important as alopecia areata universalis may be seen in patients with schizophrenia. Drug-induced hair loss is also common with antipsychotic treatment, and it is important that clinicians know the differences between a patchy drug-induced hair loss and alopecia areata universalis. The present case report documents the presence of schizophrenia in an existing case of alopecia areata universalis – a phenomenon that is uncommonly seen in clinical practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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