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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
A pining for dining: A brief overview of Gourmand Syndrome
In 2005, an article in the May 8th issue of the New York Times magazine reported the case of an unnamed European political journalist who had a stroke that caused some damage to the right frontal lobe in his brain. The journalist made a full recovery but experienced an unexpected side effect – he developed an unusual passion for gourmet food (that he didn’t have prior to his stroke). He capitalized on his strange new behaviour and became a food columnist. Similarly, a 2011 article in the Huffington Post reported the story of Kevin Pearce, a snowboarder who sustained right hemispheric brain damage following an accident that nearly killed him. Waking up from a coma he developed a craving for basil pesto (something that he never did prior to his accident). Both of these cases are examples of a rare disorder that has been named Gourmand Syndrome, a strange behaviour first written about (clinically and academically) in the mid-1990s. Gourmand Syndrome basically comprises individuals becoming totally preoccupied and obsessed with food and ‘fine dining’.
This rare (and benign) condition only seems to occur in people who have sustained brain injuries involving the right frontal lobe and was first described (and named) by neuropsychologist Dr. Marianne Regard and neurologist Dr. Theodor Landis in a 1997 issue of the journal Neurology (one of only two empirical papers on the topic). The authors noted that hyper-orality is part of other conditions such as the Kluver-Bucy syndrome that occurs in patients with bilateral mesial temporal lesions (and which I examined in a previous blog).
Regard and Landid described the cases of two individuals who both had partial damage to the right anterior cerebral hemisphere of the brain. The first case was the political journalist briefly mentioned at the start of this article. He became totally preoccupied with gourmet food and continued after he had been discharged from hospital. The second case that Regard and Landis wrote about was a businessman who (following a stroke) also developed a passion for gourmet food. However, his preoccupation with gourmet food was part of a wider disturbance of impulse control as he also made repeated sexual advances towards the female nursing staff at the hospital he was in. (Interestingly, a later 2003 study by Regard and Landis on 21 pathological gamblers – and published in the journal Cognitive and Behavioral Neuropsychology – reported that 38% of them [n=8] were reported to have Gourmand Syndrome, again suggesting that these impulsive behaviours are highly inter-linked).
Having named this type of behaviour as Gourmand Sydrome, Regard and Landis then conducted a prospective study examining the frequency and the clinical and anatomical correlates of the syndrome. Over a three-year period, and using a self-constructed checklist, they carried out 723 neuropsychological examinations of patients with known (or strongly suspected) cerebral lesions. The specific criteria for Gourmand syndrome were: (i) the presence of a significant change in a person’s eating habits (i.e. preoccupation with the preparation and eating of fine-quality food), (ii) the onset of which was associated with a single cerebral lesion in the absence of other medical or social conditions, and (iii) previous eating disorders; or other neurological or psychiatric illness. A total of 36 people fulfilled the criteria for Gourmand Syndrome (5%).
Of those identified fulfilling the three criteria, 94% of them (n=34) appeared to have right hemisphere damage in the brain (in particular, the right anterior part of the brain involving basal ganglia, cortical areas, and limbic structures). Most of the individuals’ symptoms were caused by tumours (although there were other causes including focal seizures, head trauma [with focal concussion], haemorrhage, and cerebrovascular accidents). The authors concluded that:
“Most patients with the ‘gourmand syndrome’ had clinical and anatomical evidence of a unilateral right-sided lesion, mainly involving anterior cortico-limbicregions. The strong clinical-anatomical correlation suggests that gourmand eating can represent a neurological sign of diagnostic value. The eating behavior does not correspond to any known category of eating disorders. At most, it could be classified as a benign, non-disabling form of hyperphagia, but with a specific preference for fine food”
A later case study of Gourmand Syndrome by Dr. Mary Kurian and her Swiss colleagues was published in the journal Epilepsy and Behavior. They reported the case of a 10-year-old boy with epilepsy (and who had hemispheric brain damage (i.e., “right temporoparietal hemorrhagic lesion”). As with previous adult cases, he developed Gourmand Syndrome and experienced a significant change in his eating habits, or as the authors put it, an “abnormal preoccupation with the preparation and eating of fine-quality food…without any previous history of eating disorders or psychiatric illness”. More specifically, the boy’s parent’s noticed that he began to avoid eating at fast-food restaurants and would only eat or cook the finest foods. The authors argued that their case study confirmed previous observations relating to the importance of the right cerebral hemisphere in disturbed eating habits, not just in Gourmand Syndrome but eating disorders such as anorexia and obesity.
Both of the published empirical papers noted that Gourmand Syndrome includes an obsessive component along with other behavioural consequences typically associated with addiction (e.g., cravings, preoccupation, salience, etc.). They also notes that one-third of the 36 patients identified in their prospective study had symptoms of mania (e.g., aggression, diminished impulse control, disinhibition, affective lability). In recent a review of Gourmand Syndrome by trainee psychiatrist Alexandros Chatziagorakis in the Neuropsychiatry News concluded that:
“Owing to the rarity of further articles and reports of Gourmand syndrome, its diagnostic significance is yet to be proven. It would be worth using Regard [and] Landis’ checklist during neuropsychological assessment of neurological patients to establish its frequency and its clinical and anatomical correlates. At the same time, it would be worth performing a psychiatric assessment to determine whether Gourmand syndrome presents in the context of an already defined psychiatric syndrome such as mania. This will tell us whether Gourmand syndrome has indeed a diagnostic value as a neurological or even neuropsychiatric sign”.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
Chatziagorakis, A. (2012). Gourmand Syndrome. Neuropsychiatry News, 5 (Spring), 23-24.
Holt, T. (2005). Of two minds. New York Times (Magazine), May 8. Located at: http://www.communicationcache.com/uploads/1/0/8/8/10887248/the_way_we_live_now_-_of_two_minds.pdf
Huffington Post (2011). The Gourmand Syndrome: Brain Damage Can Trigger Food Obsession, Huffington Post, October 9. Located at: http://www.huffingtonpost.com/2011/07/11/the-gourmand-syndrome-food-obsession_n_894629.html
Kurian, M., Schmitt-Mechelke, T., Korff, C., Delavelle, J., Landis, T. & Seeck, M. (2008). “Gourmand syndrome” in a child with pharmacoresistant epilepsy. Epilepsy and Behavior, 13, 413-415.
Regard, M., Knoch, D., Gütling, E. & Landis, T (2003). Brain damage and addictive behavior: A neuropsychological and electroencephalogram investigation with pathologic gamblers. Cognitive and Behavioral Psychology, 16, 47-53.
Regard, M. & Landis, T (1997). ‘Gourmand syndrome’: Eating passion associated with right anterior lesions. Neurology, 48, 1185-1190.
Uher, R. & Treasure, J. (2005). Brain lesions and eating disorders. Journal of Neurology, Neurosurgery and Psychiatry, 76, 852–7.
Pica boom? A beginner’s guide to pica
Pica is an eating disorder that has been documented in the psychological literature for hundreds of years and refers to a behaviour in which individuals eat non-nutritive items or substances (such as coal, hair and wood). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines pica as “the persistent eating of nonnutritive substances for a period of at least one month, without an association with an aversion to food”. Therefore, one-off instances of eating non-nutritious items would not constitute pica. Children who occasionally eat items like crayons are rarely diagnosed as having pica. Pica comes from a Latin word for the magpie bird (known for its strange eating behaviours).
The prevalence rates of pica depend on which patient populations have been studied. Prevalence estimates are also skewed by the fact that many people suffering from pica are embarrassed about the behaviour and may not tell anyone and/or seek medial treatment. However, it is well established that pica is more prevalent in children, pregnant women, adults from lower socioeconomic classes, and children with developmental disabilities (such as autism). The incidence of pica is also higher amongst those suffering from family-related stress. Although pica can be a symptom of anaemia (i.e., iron deficiency) and other chemical imbalances, research has shown it is actually more common among those who have normal iron levels.
Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied. For instance, studies have reported pica prevalence rates of:
- 0.02% in Danish pregnant women
- 8% in US black pregnant women (pagophagia)
- 9% in Saudi Arabian pregnant women
- 26.5% in Tanzanian pregnant women (geophagia)
- 31% of Californian Mexican pregnant women
- 44% of Mexican pregnant women
- 50% of Nigerian pregnant women
- 74% in Kenyan pregnant women
- 44% in French anaemic patients (vs. 9% matched controls)
- 64% in Turkish anaemic patients (vs. 17% controls)
- 22%-26% in mentally retarded adults
- 34% in sickle cell disease patients
The Danish figure from a study led by Dr Tina Mikkelsen (University of Southern Denmark) is likely to be the most accurate as it was carried out on a sample of 100,000 pregnant Danish women and only 14 of the total sample reported that they had pica. The authors concluded that in privileged populations, pica is more a myth than a reality.
Despite increased research in the area, there has been no definitive explanation as to why some people consume such substances as hair (trichophagia), ice (pagophagia – which I briefly examined in a previous blog), soil/clay (geophagia), wood (xylophagia), stones (lithophagia), glass (hyalophagia), plumbophagia (lead paint chips), or laundry (uncooked) starch (amylophagia). Dr. Ella Lacey (Southern Illinois University) also listed many other non-food substances that pica sufferers may eat that don’t have specific names such as those people who eat paper, balloons, grass, soap, cotton wool, and cigarette butts. Pica is a widespread practice throughout Africa and India. It has also been reported in Australia, Canada, Israel, Iran, Uganda, Jamaica and various European countries. A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature. They also noted that:
- Geophagics frequently eat other non-food stuffs.
- Those who eat more manufactured substances say they use them as a replacement for earth, either because the desired soil is unavailable or socially unacceptable
- Bar the eating of ice, most pica substances are absorptive in the dry state and all easily absorb moisture.
- Pica substances are typically craved with great intensity or ‘‘devouring passion’’
A variety of conditions are known to cause some types of pica including mineral deficiencies, hookworm infection (parasitic infection in the small intestine), coeliac disease (an autoimmune disorder of the small intestine) and Kleine-Levin Syndrome (also known as Sleeping Beauty Syndrome, a neurological disorder characterized by recurring periods of excessive amounts of sleeping and eating). Interestingly, there are culture-specific cases where pica is not related to psychopathological disorders or deficiencies. For instance, black women in Georgia (USA) are known to eat kaolin (white dirt that is actually a clay mineral) – a so-called “culture-bound syndrome” (i.e., a recognizable combination of psychiatric and somatic symptoms that are only within a specific culture or society).
Some pica type disorders may be part of a wider psychiatric condition (such as schizophrenia) and/or may be part of a sexual paraphilia such as the small numbers of people who engage in coprophagia (eating faces) as part of coprophilia and people who engage in urophagia (drinking urine) as part of urophilia. If the primary focus for eating the item or substance was sexual, it would be more likely diagnosed as a sexual paraphila rather than pica. However, many of those with pica claim to love the taste, texture and/or smell of the things they eat. Some studies have suggested an association between pica and addictive behaviors. Others suggest pica is on the obsessive-compulsive disorder (OCD) spectrum of diseases. For instance, a study based on pica case studies by Dr Dan Stein and colleagues (a the University of Stellenbosch, South Africa) came to the conclusion that (based on their case studies), pica may be a symptom of OCD, and that pica may be phenomenologically reminiscent of an impulse control disorder.
For many people, pica is not dangerous but for some there may be complications including (i) parasitic infections (such as geophagics eating soil or copraphagics eating faeces), (ii) internal bodily obstruction (e.g., such as tricophagics getting hair stuck in their intestines), (iii) toxic reactions (e.g., such as autistic children getting lead poisoning from eating painted plaster), (iv) excessive caloric intake (such as that occurring with starch cravings), (v) dental injuries and infections, and (vi) nutritional deficiencies.
As Dr. Lacey concluded: “Pica appears to be a complex behavior that requires deliberate study rather than application of ex post facto single cause theories. Although such theories may motivate any given study of pica, it should be apparent that any single cause model will likely offer only a limited explanation of such diverse practices as have been described in the literature through case reports,’ research studies, and literature ‘reviews of various clinical and applied disciplines”
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Further reading
al-Kanhal, M.A., & Bani, I.A. (1995). Food habits during pregnancy among Saudi women. International Journal for Vitamin and Nutrition Research, 65, 206-210.
Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.
Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.
Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemade, U.J. et al (1994). Pica in an urban environment. Journal of Nutrition, 124(6 Suppl): 954S-962S.
Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188
Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.
López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.
Mikkelson, T.B., Andersen, A.M. & Olsen, S.F. (2006). Pica in pregnancy in a privileged population: myth or reality. Acta Obstetricia et Gynecologica Scandinavica, 85, 1265-1266.
Ngozi, P.O. (2008). Pica practices of pregnant women in Nairobi, Kenya. East African Medical Journal, 85(2), 72-79.
Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.
Rose, E.A., Porcerelli, J.H, & Anne Neale, A.V. (2000). Pica: Common but commonly missed. Journal of the American Board of Family Practice, 13, 353-358.
Simpson, E., Mull, J.D., Longley, E., & East, J. (2000). Pica during pregnancy in low-income women born in Mexico. Western Journal of Medicine, 173, 20-24.
Smulian, J.C., Motiwala, S. & Sigman, R.K. (1995). Pica in a rural obstetric population. Southern Medical Journal, 88, 1236–1240.
Stein, D.J., Bouwer, C. & van Heerden, B. (1996). Pica and the obsessive- compulsive spectrum disorders. South African Medical Journal, 86, 1586-1592.
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.
drmarkgriffiths 