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Bog standard: A brief look at toilet tissue eating

In previous blogs I have looked at pica (i.e., the eating of non-nutritive items or substances) and subtypes of pica such as geophagia (eating of soil, mud, clay, etc.), pagophagia (eating of ice), acuphagia (eating of metal), and coprophagia (eating of faeces). It wasn’t until I started to research on specific sub-types of pica, that I discovered how many different types of non-food substances had been identified in the academic and clinical literature. For instance, Dr. V.J. Louw and colleagues provided a long list in a 2007 issue of the South African Medical Journal including cravings for the heads of burnt matches (cautopyreiophagia), cigarettes and cigarette ashes, paper, starch (amylophagia), crayons, cardboard, stones (lithophagia), mothballs, hair (trichophagia), egg shells, foam rubber, aspirin, coins, vinyl gloves, popcorn (arabositophagia), and baking powder. Most of these are generally thought to be harmless but as Louw and colleagues note, a wide range of medical problems have been documented:

“These include abdominal problems (sometimes necessitating surgery), hypokalaemia, hyperkalaemia, dental injury, napthalene poisoning (in pica for toilet air-freshener blocks), phosphorus poisoning (in pica for burnt matches), peritoneal mesothelioma (geophagia of asbestos-rich soil), mercury poisoning (in paper pica), lead poisoning (in dried paint pica and geophagia), and a pre-eclampsia-like syndrome (baking powder pica)”.

In the clinical literature, the eating of paper has been occasionally documented (although anecdotal evidence suggests this is fairly common and I remember doing it myself as a child). A recent review paper on pica by Dr. Silvestre Frenk and colleagues in the Mexican journal Boletín Médico del Hospital Infantil de México highlighted dozens of pica-subtypes and created many new names for various pica sub-types. They proposed that people who eat paper display ‘papirophagia’ (in fact if you type ‘papirphagia’ into Google, you only get one hit – the paper by Silvestre and colleagues – although this blog may make it two!). Eating paper is not thought to be particularly harmful although I did find a case of mercury poisoning because of ‘paper pica’ (as the authors – Dr. F. Olynk and Dr. D. Sharpe – called it) in a 1982 issue of the New England Journal of Medicine.

One sub-type of papirophagia is the eating of toilet paper. As far as I am aware, there is only one case study in the literature and this was published back in 1981, Dr. J. Chisholm Jr. and Dr. H. Martín in the Journal of the National Medical Association. They described the case of a 37-year old black woman with an “unusually bizarre craving” for toilet tissue paper. The authors reported that:

“[The] woman was referred for evaluation of disturbed smell and loss of taste for over one year. These were associated with chronic fatigue and listlessness. During this same period of time, she rather embarrassedly admitted to an overwhelming desire to eat toilet tissue. Frequently, she would awaken at night and dash to her bathroom to eat toilet tissue. No other type(s) of pica were admitted. In addition, she gave a long history of menorrhagia and frequently passed vaginal blood clots during her menses. Her libido was normal and there was no history of poor wound healing, skin or mucous membrane lesions, or intestinal symptoms. Her dietary history suggested a high carbohydrate diet, and due to a mild exogenous obesity she intermittently resorted to a vegan-like diet that included beans and various seeds”

A variety of medical tests were carried out and she was diagnosed with combined iron and zinc deficiency. She was treated with iron and zinc tablets and within a week, both her taste and smell had returned, and her energy levels greatly improved. Zinc deficiencies can lead to a wide variety of clinical disorders including loss of small and taste, anorexia, dwarfism (i.e., growth retardation), impaired wound healing, and geophagia. The woman’s (sometimes) vegan diet may have been to blame for her zinc deficiency as the authors noted that:

Although vegetables contain zinc, vegans should be made aware that zinc from plant sources is not readily absorbed because naturally occurring phytates, particularly high in beans and seeds, reduce zinc gastrointestinal absorption. Carbohydrates are very poor sources of zinc. Chronic iron deficiency secondary to chronic menorrhagia accounts well for the anemia, fatigue, and unusual pica for toilet tissue noted in this patient”.

Paper pica has occasionally been mentioned in other academic papers although details have typically been limited. For instance, a 1995 paper in the journal Birth by Dr. N.R. Cooksey on three cases of pica in pregnancy reported that one of the women chewed non-perfumed blue toilet paper during the first trimester of her pregnancy (and was forced by her mother to stop). There was also a 2003 paper published by Dr. Dumaguing in the Journal of Geriatric Psychiatry and Neurology examining pica in mentally ill geriatrics. One of the cases mentioned was a 76-year old patient that not only ingested their medication (an emollient cream for arthritis) but was also recorded eating toilet paper, napkins, Styrofoam cups, crayons, and other patients’ medications.

A more recent 2008 paper by Dr. Sera Young and her colleagues in the journal PLoS ONE, critically reviewed procedures and guidelines for interviews and sample collection in relation to pica substances. In describing the protocols involved, they referred to paper pica in the questions that should be asked:

“What is the local name, brand name, or type of pica substance desired or consumed? This will help others to know if this substance has already been studied and assist interested researchers in obtaining subsequent samples at a later date. Furthermore, different manufactured products may contain different materials, e.g. Crayola chalkboard chalk contains slightly different ingredients from other brands. Similarly, the consequences of toilet tissue paper consumption are different from those of eating pages of a novel; information would be lost if the substance was simply described as paper. For these reasons, the substance consumed should be described in as much detail and as accurately as possible”.

Personally (and based on anecdotal evidence), I think that papirophagia is not overly rare (especially among children – although I admit this may be more out of curiosity that craving) but the clinical literature suggests that it is a fairly rare disorder found amongst distinct sub-groups (pregnant women, the mentally ill). Given the fact that for most people eating paper would not cause any problems, this would provide the main reason why so few cases end up seeking medical, clinical, and/or psychological help.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chisholm Jr, J. C., & Martín, H. I. (1981). Hypozincemia, ageusia, dysosmia, and toilet tissue pica. Journal of the National Medical Association, 73(2), 163-164.

Cooksey, N.R. (1995). Pica and olfactory craving of pregnancy: How deep are the secrets? Birth, 22, 129-137.

Dumaguing, N.I., Singh, I., Sethi, M., & Devanand, D.P. (2003). Pica in the geriatric mentally ill: unrelenting and potentially fatal. Journal of Geriatric Psychiatry and Neurology, 16, 189-191.

Frenk, S., Faure, M.A., Nieto, S. & Olivares, Z. (2013). Pica. Boletín Médico del Hospital Infantil de México, 70(1), 55-61

Louw, V.J., Du Preez, P., Malan, A., Van Deventer, L., Van Wyk, D., & Joubert, G. (2007). Pica and food craving in adults with iron deficiency in Bloemfontein, South Africa. South African Medical Journal, 97, 1069-1071.

Olynyk, F., & Sharpe, D. H. (1982). Mercury poisoning in paper pica. The New England Journal of Medicine, 306, 1056 -1057.

Young, S.L., Wilson, M.J., Miller, D., Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE, 3(9), e3147. doi:10.1371/journal.pone.0003147

Metal defectives: A brief look at metal eating and acuphagia

In a previous blog I briefly examined pica (an eating behaviour in which individuals eat non-nutritive items or substances such as coal, hair and wood). One thing I was surprised to find out was how many different sub-types of pica there are. For instance, a 2005 review of pica by Dr. L.N. Stiegler in an autism journal listed (in alphabetical order) acuphagia (eating sharp objects), amylophagia (laundry starch), coprophagia (faeces), cautopyreiophagia (burnt matches), foliophagia (leaves, grass), geophagia (sand, clay, dirt), lignophagia (wood, bark, twigs), lithophagia (stones, pebbles), pagophagia (ice, freezer frost), plumbophagia (lead items), tobaccophagia (cigarettes, butts), and trichophagia (hair). Today’s blog examines acuphagia and metal eating (which doesn’t appear to have specific sub-name). Here are a few interesting media stories that caught my eye:

  • Case 1: “Serbian pensioner Branko Crnogorac was rushed to hospital after he attempted to eat a bicycle within three days as part of a bet made by friends.The stuntman, who has already consumed 25,000 light bulbs, 12,000 forks and thousands of vinyl records in a glittering 60-year career, was in a severe condition when doctors attended to him. ‘I almost died,’ said Mr Crnogorac. ’Doctors at the same time found two kilograms of assorted ironware in my stomach, including two gold rings. ‘So after 20 years of eating everything, I’ve realised my digestive system is not as strong as it used to be, so I’ve decided to retire.’ Crnogorac’s obsessive object eating began after a friend recommended he eat sand to calm down an acidic stomach ache. From then on Mr Crnogorac resolved to eat any object in sight. Mr Crnogorac has also managed to eat 2,000 spoons and 2,600 plates”.
  • Case 2: “Doctors in a coastal town in northwestern Peru have rescued the innards of a 38-year-old man by removing 17 metal objects – among them nails, a watch clasp and a knife – that he ate. Luis Zarate was taken to the regional hospital of Trujillo earlier this week by his family after complaining of sharp stomach pains. Doctors took X-rays of his chest that showed his insides littered with screws. ‘There were 17 strange objects found at the level of his stomach and colon’, said Dr. Julio Acevedo, one of the surgeons who operated on Zarate. The black-and-white scans showed Zarate’s skeleton interlaced with things like bolts, barbed-wire and pens. ‘The objects had caused the stomach to expand’ said Acevedo. Doctors said Zarate was mentally ill but it was not clear why he ate the metal”.
  • Case 3: A 40-year-old Ethiopian man is recovering in hospital after surgeons in Addis Ababa removed 222 metallic objects from his stomach.Gazehegn Debebe was admitted to Tibebu General Hospital last week after complaining of continuous vomiting.After intensive investigation, doctors opened his stomach to find an assortment of 15 cm nails, door keys, hair pins, coins and even watch batteries.Doctors at the hospital say it’s incredible that Gazahegn’s stomach could contain all these objects…‘He must have been eating these objects for at least two years, as the wall of his stomach had thickened to accommodate all the inedible objects’ said Dr Samuel.Some of the nails found were 15 cm in length…It is unclear why Gazehegn was eating nails and other objects, but his family say he has a history of mental illness”.
  • Case 4: “47-year old Englishman Allison Johnson [was an] alcoholic burglar with a compulsion to eat silverware, Johnson has had 30 operations to remove strange things from his stomach. In 1992, he had eight forks and the metal sections of a mop head lodged in his body. He has been repeatedly jailed and then released, each time going immediately to a restaurant and ordering lavishly. Unable to pay, he would then tell the owner to call the police, and eat cutlery until they arrived. Johnson’s lawyer said of his client, ‘He finds it hard to eat and obviously has difficulty going to the lavatory”.

After reading these news stories, it got me wondering what academic research had been carried out on people that voluntarily eat metal objects (irrespective of whether the person is mentally ill).One of the earliest papers that I came across was a case study by Dr. K.M. Hambridge and Dr. A. Silverman published in a 1973 issue of the Archives of Disease in Childhood. They described the case of a 2-year-old girl had a 6-month history of pica, that resulted in ‘metal-eating’. She had a poor appetite generally and was diagnosed with a zinc deficiency. When she was one-and-a-half-years old she began to eat small metallic objects (such as keys, the metal trim on carpets, and bits of aluminium foil). She was treated with a dietary zinc supplement and within 3 days, her pica disappeared completely. Papers and other anecdotal evidence from parents demonstrates children eating metallic objects is well documented, although acuphagia in children appears to be very rare (and is potentially fatal). In a 2003 book chapter in the book Child Psychopathology, Dr. L.G. Klinger and colleagues reported that acuphagia has been documented in autistic children, and that this may be possibly due to sensory disturbances.

Acuphagia and metal eating appears to be rarer in adult populations although a number of case studies from around the world have been published over the last decade. For instance, a 2007 paper by Dr. D. Halliday and Dr. F. Iroegbu reported the case of a 22-year old adult Nigerian male (Mr. C.O.) that turned up at hospital complaining of “persistent vomiting after meals, cough, weakness, inability to walk and swelling of the legs and face”. The initial diagnosis was ‘kwashiorkor’ (protein calorie malnutrition) but following an X-ray, the doctors discovered there were metallic objects in his upper abdomen. Following a surgical procedure, a total of 497 metallic objects weighing 1.84 kilograms were found in his stomach (and what was most remarkable was that his stomach was completely in tact). This included 303 two-inch nails, 145 coins, 25 office pins, six razor blades, and 18 sowing needles.Mr. C.O. was referred for psychiatric consultation but denied he had swallowed all the metallic objects (and no-one close to him had ever seen him ingest any metallic objects). Halliday and Iroegbu concluded that in their part of the world, magical arts (i.e., juju) is widely practiced and believed, and that this was the most likely explanation for his illness, triggered by a number of other factors including poverty, isolation, neglect and loneliness.

In 2008, another case was reported in the Indian Journal of Surgery by Dr. P. Kariholu and his colleagues. However, they debated whether their case was acuphagia and/or hyalophagia (the eating of glass materials – a subtype not actually listed in Stiegler’s classification above). In this particular case, a young 20-year old woman presented for treatment with an impacted mass of 18 bangles broken into 55 glass bangle pieces (each measuring 2cm to 7cm) in the stomach as well as few in her small and large bowel. The bangles were successfully removed via surgery.

A short 2007 article in The Medicine Forum by Dr. Saurabh Bansal described the case of a 29-year old male with a history of acuphagia who needed treatment after “accidentally” swallowing a pen. The patient underwent an esophagogastroduodenoscopy (EGD) to remove the pen, and left the hospital six hours after the EGD. Ten days later, the same man returned to the hospital with hematemesis (i.e., vomiting blood). This time he had swallowed a knife and after emergency treatment was sent to the psychiatric facility. Unfortunately no information was provided in relation to the man’s psychiatric assessment.

Most recently, a 2010 paper by Dr. B.T. te Wildt and colleagues in a psychiatric journal reported a case of acuphagia as a disorder of impulse control. They reported the case of a 41-year-old man with intellectual disabilities who required medical treatment after having swallowing around 20 sharp objects. He had also swallowed a glove. The patient claimed that the swallowing of the objects was done to alleviate tension and stress. The authors also wrote that the man’s “aberrant behavior also seemed to serve as a means to exert pressure on psychosocial workers. Other deviations included the pushing of sharp objects under the skin and multiple paraphiliae. As a child, the patient suffered from early psychological and physical traumatization. Both parents were allegedly physically abusive alcoholics”.

Although very few cases of acuphagia have been reported in the medical literature (particularly in adults), most of these suggest that those displaying the symptoms have psychological and/or psychiatric disorders that may be accompanied by some form of learning disability (except – of course – if the behaviour is part of an ‘entertainment’ act).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bansal, S. (2007). Acuphagia. The Medicine Forum, 9, Article 23. Available at: http://jdc.jefferson.edu/tmf/vol9/iss1/23

Halliday, D., & Iroegbu, F. (2007). Case report ‘Acuphagia’ – An adult Nigerian who ingested 497 sharp metallic objects. Editorial Advisory Board, 4(2), 54-59.

Hambidge, K.M., & Silverman, A. (1973). Pica with rapid improvement after dietary zinc supplementation. Archives of Disease in Childhood, 48, 567-568.

Kariholu, P. L., Jakareddy, R., Hemanth Kumar, M., Paramesh, K. N., & Pavankumar, N. P. (2008). Pica – A case of acuphagia or hyalophagia?. Indian Journal of Surgery, 70(3), 144-146.

Klinger, L.G., Dawson, G., & Renner, P. (2003). Autistic disorder. In: E.J. Mash & R.A. Barkley (Eds.), Child Psychopathology, 2nd Edition (pp. 409-454). New York: Guilford Press.

Stiegler, L.N. (2005). Understanding pica behavior: A review for clinical and education professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-38.

te Wildt, B. T., Tettenborn, C., Schneider, U., Ohlmeier, M. D., Zedler, M., Zakhalev, R. & Krueger, M. (2010). Swallowing foreign bodies as an example of impulse control disorder in a patient with intellectual disabilities: a case report. Psychiatry (Edgmont), 7(9), 34