Appendix: response to Trüeb

This appendix accompanies the article: Response to Dr. Ralph Trüeb’s writings on post-finasteride syndrome.

• Table of competing interests
• Recycled text
• Errors

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Recycled text

In his recent article “Ignorism,” Dr. Ralph Trüeb weighs in on self-plagiarism.¹ Meanwhile, there are numerous examples of text reused across his own articles and other works. Seven are provided below. The first is a nearly verbatim copy of over 300 words of text.

1. The physician’s role is to help the patient figure out what he really wants and then to use the power of persuasion to show the patient the way there. At length, the way a physician phrases his recommendations can powerfully sway a patient’s choice and have an influence on the treatment outcome. Ultimately, the physician’s choice has to be consistent with the patient’s philosophy of living.

2. The physician’s role is to help the patient figure out what he really wants and then to use the power of persuasion to show the patient the way there. At length, the way a physician phrases his recommendations can powerfully sway a patient’s choice and have an influence on the treatment outcome. Finally, the physician’s choice has to be consistent with the patient’s philosophy of living.

3. The physician’s role is to help the patient figure out what he really wants and then to use the power of persuasion to show the patient the way there. At length, the way a physician phrases his recommendations can powerfully sway a patient’s choice and have influence on the treatment outcome, both in terms of efficacy and of tolerability.

(1) Rezende et al, 2018²; (2) Trüeb et al, 2019³; (3) Trüeb 2022.⁴

1. The physician should be careful not to be judgmental or to scold because this may rapidly close down communication. Sometimes the difficult patient gains therapeutic benefit just from venting concerns in a safe environment with a caring physician.

2. …[I]t is important never to be judgemental or scolding because this may rapidly close down communication. The patient gains therapeutic benefit just from venting concerns in a safe environment with a caring physician.

3. The symptomatic patient gains therapeutic benefit already from venting concerns in a safe environment with a caring physician. The physician should be careful not to be judgmental, ridiculing, or scolding because this may rapidly close down communication and potentially aggravate the situation.

(1) Trüeb, 2015⁵; (2) Trüeb 2013⁶; (3) Rezende et al, 2018.²

1. Furthermore, Maffei et al. found the prevalence of personality disorders in patients with male pattern hair loss to be significantly higher than in the general population, with three distinct personality profiles:

• Suspicious, with grandiose sense of self-importance, obsessive, and socially withdrawn
• Impulsive, identity disordered, and socially maladjusted
• Dramatic, emotional, and dependent.

Specifically, patients with personality disorders tend to experience more distress from hair loss than nondisordered patients, […]. Ultimately, these patients tend to be more difficult to handle with respect to the treatment of their hair loss:

• Patient compliance issues are a problem in patients with paranoid, avoidant, or passive-aggressive (negativistic) personality disorders
• Nocebo reactions are more frequent in patients with paranoid, passive-aggressive (negativistic), or histrionic personality disorders
• Overvalued ideas are typical for patients with histrionic or narcissistic personality disorders.

2. Maffei et al. found the prevalence of personality disorders in subjects with male pattern hair loss to be significantly higher than in the general population, with three distinct personality profiles:

• Suspicious, with grandiose sense of self-importance, obsessive, and socially withdrawn.
• Impulsive, identity disordered, and socially maladjusted.
• Dramatic, emotional, and dependent.

Patients with personality disorders tend to be more difficult to handle with respect to treatment of their hair loss: nocebo reactions in particular are more frequent in patients with paranoid, passive-aggressive (negativistic), or histrionic personality disorders, while overvalued ideas are typical for patients with histrionic or narcissistic personality disorders.

(1) Rezende et al, 2018²; (2) Trüeb et al, 2019.³

1. Attention must be focused rather on the treatment of associated specific psychopathological disorders and related sexual symptoms with appropriate psychotherapy and specific psychotropic agents depending on the type of the underlying mental disorder (depressive, delusional, or somatoform disorder).

2. Attention must be focused rather on the associated psychopathological disorder with appropriate psychotherapy and specific psychotropic agents depending on the underlying mental disorder (depressive, delusional, or somatoform disorder).

(1) Trüeb et al, 2019³; (2) Trüeb et al, 2021.⁷

1. Specifically, patients with personality disorders tend to experience more distress from hair loss than nondisordered patients, since these individuals lack a secure sense of self and effective coping skills, and therefore may be particularly vulnerable to the adverse effects of pattern hair loss.

2. However, patients with personality disorders tend to experience more distress from alopecia than non-disordered patients, since these individuals lack a secure sense of self and effective coping skills, and therefore may be especially vulnerable to the adverse effects of both alopecia and the media coverage on finasteride and adverse effects.

(1) Rezende et al, 2018²; (2) Trüeb et al, 2021.⁷

1. In our opinion, PFS demonstrates some analogies to such controversial “mystery syndromes” as amalgam illness, multiple chemical sensitivity, Morgellons disease, and Koro for the following reasons: patients complain of symptoms that cannot be adequately explained biologically, and the frequency of consultations for the conditions parallels the respective media coverage, which points to a high degree of suggestibility.

2. …the PFS demonstrates some striking analogies to other mystery syndromes, such as amalgam illness, multiple chemical sensitivity, Morgellons disease, and Koro, in which the alleged symptoms cannot be explained biologically and the frequency of consultations for the respective condition strikingly parallels the media coverage, which points to a high degree of suggestibility.

(1) Trüeb et al, 2019³; (2) Trüeb, 2022.⁸

Errors

Effects on fertility. Trüeb et al, 2022⁴ notes (emphasis added): “there have been case reports of a negative effect of oral finasteride on men with pre-existing decreased fertility.” They cite two case reports describing three patients. Only one patient was described as having infertility prior to using finasteride.^9,10

Risk of male breast cancer. Trüeb et al, 2022⁴ states: “the respective studies also support the view that exposure to finasteride is not associated materially with male breast cancer risk.” One of the two papers cited made no mention of this topic.¹¹

References

1. Trüeb RM. Ignorism. Int J Trichology. 2023. DOI • PubMed
2. Rezende HD, Gavazzoni Dias MFR, Trüeb RM. A comment on the post-finasteride syndrome. Int J Trichology. 2018. DOI • PubMed
3. Trüeb RM, Régnier A, Rezende HD, Gavazzoni Dias MFR. Post-finasteride syndrome: an induced delusional disorder with the potential of a mass psychogenic illness? Skin Appendage Disord. 2019. DOI • PubMed
4. Trüeb RM, Luu NC, Gavazzoni Dias MFR, Rezende HD. How to deal with the issues of fertility, malignancies, and the postfinasteride syndrome while prescribing finasteride for male pattern hair loss. Skin Appendage Disord. 2022. DOI • PubMed
5. Trüeb RM. Psychopathological Disorders. In: The Difficult Hair Loss Patient: Guide to Successful Management of Alopecia and Related Conditions. Cham, Switzerland: Springer International Publishing Switzerland; 2015. Via Springer
6. Trüeb RM. The difficult hair loss patient: a particular challenge. Int J Trichology. 2013. DOI • PubMed
7. Trüeb RM, Gavazzoni Dias MFR, Rezende HD. Suicidality and psychological adverse events in patients treated with finasteride. Skin Appendage Disord. 2021. DOI • PubMed
8. Trüeb RM. Psychiatric comorbidity related to the therapy of male androgenetic alopecia independent of the 5-alpha reductase pathway. Skin Appendage Disord. 2022. DOI • PubMed
9. Ricci G, Martinelli M, Luppi S, Lo Bello L, De Santis M, Skerk K, et al. Finasteride and fertility: case report and review of the literature. J Drugs Dermatol. 2012. DOI • PubMed
10. Liu KE, Binsaleh S, Lo KC, Jarvi K. Propecia-induced spermatogenic failure: a report of two cases. Fertil Steril. 2008. DOI • PubMed
11. Basaria S, Jasuja R, Huang G, et al. Characteristics of men who report persistent sexual symptoms after finasteride use for hair loss. J Clin Endocrinol Metab. 2016. DOI • PubMed