Hard to swallow: a systematic review of deliberate foreign body ingestion
Introduction
As many as 1500 people die annually in the United States as a result of foreign body ingestion (FBI) [1], most of which is thought to occur accidentally [2]. Patient groups at risk of FBI include those intoxicated, those undergoing dental surgery, the visually impaired, young children and infants, and those with bulimia nervosa who accidentally swallow an object that is used to induce vomiting. Conversely, according to a review by Palta et al., deliberate FBI (DFBI) occurs in up to 92% of all adult FBI presentations. Eighty-five percent of these patients have a prior psychiatric diagnosis, and 84% of DFBI presentations occur in patients with prior ingestions [3]. DFBI incurs substantial health consequences. Although it has been estimated that 90% of foreign objects will eventually pass spontaneously per rectum [4], the risk of injury is serious, and treatments such as endoscopy and/or surgical removal are frequently necessary [5]. Literature on the acute medical and surgical management of FBI is widely available [5], [6]; however, there is a relative paucity of literature regarding efficacious long-term psychiatric and psychological management of these patients.
The most recent review on this topic, by Gitlin et al., included four etiologic categories [psychosis, malingering, pica and borderline personality disorder (BPD)] [7]. Pica, where repeated eating of nonnutritive substances occurs in cognitively impaired individuals or as a food replacement in those with normal cognition, is not considered further in this paper as there is ample literature on this diagnostic entity [8], [9]. Diagnostically, it may be challenging to distinguish pica from obsessive–compulsive disorder (OCD). We surmise that, in physically healthy, nonpregnant and cognitively intact adults, this type of behavior and the psychological relief it provides are best understood as an obsessive–compulsive spectrum disorder. In addition, we will not address the other nonpsychiatric group of smugglers who hide drugs in their gastrointestinal tracts. Gitlin et al. identified treatment of the underlying psychiatric diagnosis in DFBI as crucial and suggested specific management strategies applicable to patients with BPD, including the use of naltrexone, clonidine and dialectical behavior therapy (DBT) [7]. We will focus on both identified evidence-based approaches as well as broad management strategies for use in the consultation–liaison setting. Managing these patients is complex given the demands of integrating care across the relevant disciplines in the context of countertransferential feelings evoked by these behaviors. Moreover, the majority of evidence regarding management is taken from single case reports. Larger studies and clinical trials are, unfortunately, absent. Alternatively, extrapolating evidence from research related to other forms of self-injurious behaviors may not be applicable to DFBI; therefore, reducing the risk of reoccurrence is particularly challenging.
In addition to the emotional and physical consequences of this behavior to the patient, these presentations are expensive for our heath care system [3], [10]. Based on the Ontario Health Insurance Plan schedule of benefits for 2009 and the Ontario Case Costing Initiative (2007–2008), as well as costs related to security personnel involvement with these patients, we estimate that, in Ontario, the average cost per hospital visit, including emergency department (ED) care, day surgery and inpatient admissions, for treatment of DFBI is approximately ⁎$2305.00 (CAD). Similarly, a 2010 retrospective cost analysis of DFBI by Huang and others estimated an average cost of ⁎$6616.63 (USD) per DFBI presentation [11]. By comparison, in 2007, according to the Organization for Economic Co-operation and Development (OECD), which compares government health expenditure and services data from more than 30 countries, the per capita (per year) health expenditure in Canada was ⁎$4139.30 (CAD) [12]. Given that many of these patients have monthly or weekly visits to the ED related to swallowing behavior, it is apparent that the costs of DFBI incurred by Canada's health care system are strikingly disproportionate to other medical and psychiatric presentations.
To illustrate the relevant issues surrounding DFBI in mental illness, we first identify some broad management principles that can be applied in most presentations. Next, four cases related to the most frequent psychiatric diagnoses are presented. A review of the literature related to the psychiatric management and strategies to reduce reoccurrence for each of the diagnostic groups (psychosis, OCD, malingering and BPD) is discussed. Gaps in the literature and areas for further development are also addressed.
Section snippets
Method
A comprehensive literature search was conducted on PubMed for articles published between January 1966 and April 2011. The search strategy was limited to English-language studies on humans and used the keywords “foreign body ingestion OR atypical swallowing behavior OR foreign object ingestion OR pica”. The term “pica” was included in order to capture articles that discussed both pica and DFBI. The search strategy yielded 2432 primary articles. Each citation and abstract were reviewed by the
General management principles
The first general management principle of DFBI in mentally ill patients is to establish a safe environment, which may necessitate the removal of certain proximal objects (including batteries within devices, call bells, and medical or surgical instruments), constant observation and limit setting.
Secondly, the medical or surgical consequences of this episode should be managed emergently when batteries, narcotics packages, or long or sharp objects were ingested. Any patient with symptoms of pain,
Case reports and diagnostically specific management principles
Examples are drawn from cases that presented to EDs in Canada, the United States and Ethiopia. As the case reports are brief and contain no identifying data, consent was not sought from the patients.
Conclusion
As demonstrated in this review, DFBI in a psychiatric population typically presents in the context of psychosis, malingering, OCD or personality disorders. Given the differential and varied treatment implications, a thorough psychiatric history is crucial, and consulting psychiatrists must be prudent with their diagnoses and when evaluating and explaining underlying psychopathological reasons for this behavior. Hesitation on the part of the patient to report this self-injurious behavior due to
References (25)
- et al.
Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion
Gastrointest Endosc
(2009) - et al.
Diagnosis and management of ingested foreign bodies: a ten-year experience
Ann Emerg Med
(1984) - et al.
Guideline for the management of ingested foreign bodies
Gastrointest Endosc
(2002) - et al.
Foreign-body ingestion in patients with personality disorders
Psychosomatics
(2007) Adult pica: a clinical nexus of physiology and psychodynamics
Psychosomatics
(1998)- et al.
Intentional swallowing of foreign bodies is a recurrent and costly problem that rarely causes endoscopy complications
Clin Gastroenterol Hep
(2010) - et al.
Treatment of scavenging behavior (coprophagy and pica) by overcorrection
Behav Res Ther
(1975) - et al.
Foreign body ingestion in the emergency department: case reports and review of treatment
J Emerg Med
(1998) - et al.
Baking-soda pica in an adolescent patient
Psychosomatics
(2006) - et al.
Is pica in the spectrum of obsessive–compulsive disorders?
Gen Hosp Psychiatry
(2003)