An unusual case of xylophagia (paper-eating).

Xylophagia is a condition involving the consumption of paper and form of eating disorder known as pica. Pica is an unusual craving for ingestion of either edible or inedible substances. Inhalants are volatile substances, which produce chemical vapors that can be inhaled to induce a psycho-active or mind altering effect. Although, pica is not linked to solvent abuse, here we report an adolescent case of paper-eating with solvent dependence.

Xylophagia is a condition involving the consumption of paper and form of eating disorder known as pica. People who suffer from this eating disorder usually consume substances like paper, pencils, tree barks or other items made of wood. The most popular form of xylophagia is the consumption of paper, but rare type of pica may be described in the literature. Pica is an unusual craving for and ingestion of either edible or inedible substances. The condition has been described in medical journals for centuries.[123] Incidence of pica has also been linked to iron deficiency, zinc deficiency and certain co-morbid conditions like Kleine-Levin syndrome, mental retardation and schizophrenia. It has been observed in men and women of all ages and ethnicity, but is more prevalent among the lower socioeconomic classes.[45] World-wide 25-33% of all pica cases involve small children, 20% are pregnant women, and 10-15% are individuals with learning disabilities. Solvents are volatile substances which produce chemical vapors that can be inhaled to induce a psycho-active or mind altering effect. They encompass a broad range of chemicals that may have different pharmacological effects and are found in hundreds of different products such as fuels, solvents, glue, propellants, adhesives and paint thinners. Although pica is not linked to solvent abuse here, we report an adolescent case of paper-eating with solvent dependence.

CASE REPORT

Ms. B, a 16-year-old unmarried girl, a student of 1st psychiatric urgent care, belonging to a Hindu lower socioeconomic strata family, with no past or family history of any psychiatric illness or substance abuse, was brought with a history of eating paper and inhaling substances like kerosene for 3 years. Her family members would chew betel nut, and she also started chewing betel nut regularly without her parents’ knowledge. When her family came to know about this, she was restricted and was advised against it.

At the same time when alone at school 1-day, she felt like eating notebook paper and got immense pleasure after it. An hour later she had another piece of paper and passed the whole day without having any adverse impact. Next day also without the knowledge of her classmates she ate three pieces of paper. Within a month, she developed a habit of eating 4-5 A4 size papers daily during school time. She had never tried to cut down on eating paper until she was brought to the hospital. Meanwhile, while transferring kerosene to another container she accidentally experienced the smell of kerosene and was inclined towards that smell. She felt good, and that led her to smell kerosene daily without her family's knowledge. She used to feel relaxed and detached from the surroundings after inhaling the kerosene for about 3-4 h. After 6 months of this practice she realized that if she misses inhaling the kerosene for even 1 or 2 days she will feel restless, having low mood at school, not interested in doing any household work and craving to inhale kerosene. In that frustration, she used to eat around 10 papers daily and run behind autos and other vehicles to inhale that smell. Her family noticed that she had academic problems, had poor concentration and was not helping in household works. She was frequently angry, argumentative, throwing things at parents and trying to harm herself.

After about 3 years family noticed her addiction practices and brought her for evaluation.

On examination she was well kempt, cooperative and rapport could be established. There was no mood, thought or perception abnormality. She had partial insight and was willing for the treatment. Cognitive functions, physical examination, investigations such as complete blood picture, urine routine and X-ray abdomen, liver function and serum electrolytes were normal. Possibility of lead poisoning was also excluded after peripheral blood smear examination.

She was diagnosed to have pica (xylophagia) with mental and behavior disorder due to use of volatile solvents. She was admitted and started with paroxetine 25 mg in 2 divided doses. To control her withdrawal symptoms clonazepam 0.5 mg was added. After 2 days her withdrawal symptoms were under control, baclofen 20 mg was added for control of craving and supplemental multi-vitamin injectable preparations.

Patient and family members were psycho-educated about the nature of the illness and harmful consequences of addiction. Cognitive behavior therapy (CBT) was employed for stress reduction, coping skills, challenge distressing thoughts and preventing damaging behaviors. After 6 sessions of CBT she started showing improvement in her motivation levels, compulsive behavior and role of psycho-therapy. During the 12 days of hospital stay she remained abstinent from eating paper and inhaling the kerosene, and was considered fit for discharge with an advice for follow-up and continued medications with CBT.

DISCUSSION

Pica is sometimes a culturally sanctioned practice and may not be pathological. Although pica is the most common eating disorder in individuals with developmental disabilities and children, in this case there was no history of childhood developmental disabilities.

Although the etiology of pica is unknown, more recent cases of pica have been tied to the obsession – compulsion spectrum disorder. Numerous hypotheses like psychosocial, biochemical, cultural, socioeconomic and psychodynamic factors explain this phenomenon.[6] Deficiencies in iron, calcium, zinc and nutrients (thiamine, niacin, Vitamins B and C) have been associated with pica in some children with malnutrition. Pica may be benign, or it may be associated with life-threatening complications.

The onset of inhalant use disorder is a major concern in adolescence as missed in routine enquiry. Most epidemiological studies do not include questions for eliciting solvent abuse, causing poor recognition of the magnitude of problem.[7] Inhalant abuse is becoming a public health problem in India due to lack of awareness among the general population as well as health professionals.[8] Inhalants are cheap, easily available, and not prohibited for procurement. They are capable of producing a rapid euphoria and use cannot be detected after a few hours due to their volatile nature, making it easier for the user to conceal.

The majority of the users stop using inhalants after a brief period of experimentation and only 4% go on to develop dependence. Treatment is generally supportive, and there are no standardized medication regimens or psycho-therapeutic recommendations till date for the treatment of xylophagia and pica. Residential care in a drug-free environment with family support, improving existing personal, social and environmental strengths may help.

Pica, in the context of other eating disorders, has received little attention in the past, and this is the first case of adult onset pica, without mental retardation, in the context of volatile solvent dependence reported in the literature.