A unique case of pica of adult onset with interesting psychosexual aspects.

Pica has been considered as the ingestion of inedible substances or atypical food combinations. Pica has been reported widely in pediatric age group and often found to be co existing with obsessive compulsive or major depressive disorder. Reports of pica in elderly age group are relatively uncommon and rarely does it have an adult onset. In this article we present a case of adult onset pica. A young lady with unusual sensation in her abdomen was found to consume iron nails over years and there was history of dyspareunia since her marriage three months back. On query it was known that the lady is having same sex relationship over years. There unique conglomeration of cultural, psychodynamic and physiological determinants which together is responsible for this unusual habit of this lady. Moreover the onset of the disease at a late age and different psychodynamic issues make the case all the more interesting. Whether the pica is an eating disorder or obsessive compulsive disorder is still controversial. Pica has been mentioned in Diagnostic and Statistical Manual IV TR. The present case report warrants the need to look into this entity more closely with regards to its occurrence and etiology.

INTRODUCTION

Pica has been considered as the ingestion of inedible substances or atypical food combinations.[1] Pica was first described by Galen dating back to 2nd century. The term ‘pica’ actually refers to the Latin word for magpie, a bird thought to have odd feeding habits. Pica has been found to be linked with pregnancy over years.[2] Incidence of pica has also been linked to iron and zinc deficiency.[3] Whether the pica is an eating disorder or obsessive compulsive disorder is still controversial.[4]

CASE REPORT

The patient was a 27 year old young Indian lady living in the Baruipur with no previous psychiatric or medical history. The patient was referred from surgery OPD and was brought in by her parents. Patient complained of an unusual sensation in her abdomen for the last 3 months while her parents gave a history of habitual consumption of nails for the same duration. The patient was a single child to her parents and she was living in the Suburbs since her birth. She had attended public schools and had completed her graduation on arts from a college in Kolkata. She was currently unemployed. The patient had married 3 months back. The marriage was arranged by her parents. Soon after her marriage, she expressed sexual aversion with history of dyspareunia. Within a month of her marriage, she found it extremely difficult to live in her in-laws house and preferred to stay at her parental home, although her parents repeatedly insisted her to go back to her in-laws residence. She described her mood to be ‘depressed’ and also admitted that for the last 3 months, she was having a sense of hopelessness and worthlessness over her future days. It is then that she started consuming nails and found her sadness ‘vanished’. She temporarily enjoyed the gritty and spiky sensation of nails along her throat, but at night she used to have a vague abdominal sensation which she described to be ‘funny’.

According to her mother, she did not want to go back to live with her husband. On close interviewing of the patient, initially her response to same- sex relationship was guarded but later it was found that she was actually having such a relationship with another lady of her age for the past 3 years. She also accepted that she used to consume glass piece occasionally since last 3 years but never disclosed them to anyone. The patient did not have any history of intestinal obstruction in the past. She had once had an X-ray of her abdomen done 2 years back due to complaints of low back pain which was inconclusive; perhaps glass beads which are radiolucent were missed. No further investigation was done.

Obsessive Compulsive disorder was ruled out during the interview. The patient was decently dressed in a pastel shade Salwar with a boyish cut hairstyle. On mental state examination, there were no psychotic features, delusions or hallucinations. On interviewing the husband, it was known they had never had any sexual intercourse since marriage. There was no premarital heterosexual exposure either. There was no history of substance abuse.

On routine examination, possibility of Iron Deficiency anemia, Serum Ferritin abnormality and Zinc deficiencies were ruled out. Pregnancy tests in both blood and urine were found to be inconclusive. X ray of abdomen showed multiple radio opaque pointed objects in her gut (ingested iron nails). Possibility of Lead poisoning was also excluded. The patient was found have normal Liver Function Parameters, and Serum Electrolyte levels.

The patient had been nurtured in an overprotected environment by her parents in her early childhood days. However immediately following her high school, she had to take many responsibilities of the family all of a sudden because of loss of job of her father. She mostly had friends of same sex. She was more bonded to her mother and in the elderly, often avoided her father because he was alcoholic. She did respond well to Fluoxetine (SSRI). She was followed up in psychiatric outpatient department later showing significant improvement.

DISCUSSION

The cultural, psychodynamic, and physiological aspect of this case is a unique one. The patient's initial experimentation with ingestion of glass beads, though in a very remote sense, may be culture based considering the fact that the practice of ingesting such beads and sharp metallic objects has been reported.[5]

There are a few dynamic issues to this case as well. Considering the fact that the patient was initially nurtured in an overprotected environment by her parents and suddenly being exposed to a comparatively hostile situation where she found a discouraging picture of the members of the opposite sex from that of her alcoholic father, the patient's inclination toward same-sex relationship can be explained.[6] Psychologically, the inclination of the patient toward same sex relationship and her unfamiliarity and uneasiness with the members of the opposite sex led to marital dissatisfaction. Also, since the patient had to take many burdens of her family at an age which may be considered quite an early one considering the Indian standards and her socioeconomic profile, this probably has caused her to resort to some, harsh robust means like ‘ingestion of nails’ which may have been an act to depict her ‘bravery’ whenever she felt an essence of hopelessness and failure in her real life. The patient in discussion was not pregnant, iron deficient, or anemic. Her intelligent quotient as measured by Wechsler's adult intelligence scale had been found to be 98 which fall in normal age. As in most cases of pica, she initially did not come with a complaint of pica. Rather, she had reported to the hospital with complaints of unusual sensation in her abdomen.

CONCLUSION

The present case presented a unique conglomeration of cultural, psychodynamic, and physiological determinants which together contributed to the expression of pica in comparison with previous reports and reviews.[78] However, an interesting fact in this case is the age of the patient which is quite unusual for pica to occur.[910] This perhaps necessitates further research in dealing with the epidemiology and other aspects of this quite rare but interesting disease entity.