Elsevier

General Hospital Psychiatry

Volume 33, Issue 5, September–October 2011, Pages 518-524
General Hospital Psychiatry

Hard to swallow: a systematic review of deliberate foreign body ingestion

https://doi.org/10.1016/j.genhosppsych.2011.06.011Get rights and content

Abstract

Objective

Deliberate foreign body ingestion (DFBI) is often impulsively driven, repetitive and refractory to intervention and frequently necessitates multiple medical interventions. As such, the frustrations among health care providers are great, and the financial toll on health care is significant. Nevertheless, the literature on DFBI is sparse, and suggestions for treatment planning and management are limited. The authors sought to investigate and uncover efficacious treatments and strategies for preventing reoccurrence in DFBI. We build on earlier work by offering both broad and diagnosis-specific management strategies.

Method

A literature review was performed addressing the presentation, management and prevention of reoccurrences of DFBI. Four cases of DFBI are presented illustrating those psychiatric diagnoses (psychosis, malingering, obsessive–compulsive disorder and borderline personality disorder) most frequently encountered in hospital practice. Both broad and specific treatment approaches are presented.

Results

Patients engaging in DFBI are best managed through a multidisciplinary approach, following acute medical management. Successful strategies for the prevention of reoccurrences of DFBI are inconclusive.

Conclusion

Understanding the function of this behavior is critical in developing treatment for patients who engage in these dangerous, potentially life-threatening, self-injurious behaviors. An amalgam of medical, pharmacological and cognitive–behavioral interventions is recommended, as is additional research.

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

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