celiac disease ( cd ) , an inflammatory disorder of the upper small intestines , is characterized by intestinal villous atrophy and crypt hyperplasia and is caused by an abnormal immune reaction to wheat gliadin .
it may be associated with different symptoms and signs , depending on the degree of intestinal involvement .
the damage to the intestine makes it difficult for the body to absorb nutrients , especially fat , calcium , iron , and folate .
this often results in diarrhea , abdominal distension , generalized malnutrition and failure to thrive , or subclinical deficiencies along with isolated nutrient deficiencies such as anemia , aphthous ulcer , bone pain , etc .
the prevalence of cd is high in saudi patients ( 4% )   when compared to the prevalence rates reported from the usa and europe ( i.e. , 3% )   and is comparable to the rates reported from other tropical countries .
moreover , a high prevalence of serological markers of cd has been reported among patients with autoimmune thyroid disease .
osteomalacia and iron deficiency anemia were common clinical presentations of adult cd in saudi arabia . hence , the presence of either one of these presentations in a female patient should raise the possibility of cd .
trichotillomania has been classified as an obsessive - compulsive and related disorder ( dsm-5 ) that is characterized by recurrent body - focused repetitive behavior ( hair pulling ) and repeated attempts to decrease or stop the behavior .
it may result in impairment in important areas of functioning , such as relationships , social functioning , etc . .
in addition , it is 7 times more prevalent in children ( peak prevalence observed between 417 years of age ) than in adults .
hair pulling in early childhood ( < 5 years of age ) can be regarded as a distinct clinical entity that tends to be self - limiting without the need for intervention .
however , pathological hair pulling has been observed in 1.5% of adult males and 3.4% adult females .
trichotillomania is typically confined to one or two sites , frequently affecting the scalp , but it can also involve the eyelashes , eyebrows , pubic hair , body hair , and facial hair [ 8 , 9 ] .
the patients tend to be highly secretive about the condition and regard their behavior as shameful .
many hair pullers exhibit additional stereotypic movements such as nail biting , knuckle cracking , touching or playing with pulled hair , and hair eating ( trichophagia ) .
insufficient data exist on the association of cd with various neurological disorders , including certain common and  soft neurological conditions such as headache , learning disorders , attention deficit hyperactivity disorder , and tic disorders , in children , adolescents , and young adults . to the best of our knowledge ,
there are only four articles that have reported on the association between cd and trichobezoars [ 11 , 12 , 13 , 14 ] .
a 22-year - old saudi female university student presented with cd and complaints of an uncontrollable , irresistible , and repetitive urge to pull her scalp hair .
this condition started 15 years ago with the pulling of hair on the legs and then shifted to scalp hair 2 years ago after a year of no hair pulling .
the hair pulling had currently become distressing , problematic , and  out of control. in addition , there was a significant deterioration in her academic performance and social adjustment .
the patient engaged in hair pulling on a daily basis for 13 h irrespective of whether she was relaxed ( like watching tv ) or under stress ( like preparing for exams ) . however , when she was anxious during her exams or when assigned a project ( with minor changes in sleep and appetite ) , her hair pulling behavior increased . immediately before pulling her hair , she felt a mounting tension , which was relieved with the successful pulling out of a hair root .
she carefully examined the hair root but did not ingest them . if the hair root remained intact and instead the hair shaft was broken , she repetitively pulled the hairs until successful . she felt guilty and embarrassed by her hair pulling behavior and wore a head scarf most of the time to cover the bald patches of 12 cm on her scalp .
the hair , particularly on the top of her head , was very thin , brittle and uneven .
two years ago , she was diagnosed with cd and had symptoms like digestive problems ( abdominal bloating , pain , and gas ) , skin eczema and psoriasis , iron deficiency anemia , and diarrhea .
she then started a gluten free diet and noticed a decrease in the frequency of symptoms and hair pulling .
the trichotillomania symptom severity scale showed that the patient had moderate symptoms ( 20 out 30 ) .
the hamilton anxiety rating scale showed mild anxiety and the hamilton rating scale of depression showed no depression in the patient .
trichotillomania is associated with significant social and functional impairment [ 5 , 6 ] . along with the cosmetic and psychosocial consequences ,
this disorder is also associated with certain medical complications , including infection , permanent loss of hair , repetitive stress injury , carpal tunnel syndrome , and gastrointestinal obstruction with bezoars as a result of trichophagia .
the patients actively disguise their symptoms to avoid disclosure , and clinicians should be vigilant when patients present with inappropriate or unusual head coverings .
in addition , the assessment of such disorders requires great clinical sensitivity as patients frequently regard their behavior as shameful .
studies have reported a history of psychiatric disorders in a high proportion of adults who were newly diagnosed with cd . in our case
this was further supported by the fact that her symptoms improved when she started a gluten - free diet .
screening for comorbid anxiety disorders , obsessive - compulsive and related disorders , and depression in patients with cd by general practitioners and gastroenterologists is recommended .
 trichotillomania is an underreported and underdiagnosed condition associated with significant impairments in social and functional relationships . 
 the connection between celiac disease and trichotillomania is not yet established clearly . 
 only a few cases of trichotillomania have been reported to date . here , we report the case of a 22-year - old saudi female , who presented with celiac disease and trichotillomania to the psychiatry clinic . 
 this is the first report of its kind in saudi arabia . by reporting this case 
 , i highlight the importance of psychiatric and comprehensive approaches in patients with celiac disease . 
Introduction
Case Presentation
Discussion
Conclusion
Ethics Statement
Disclosure Statement