Paper eating: An unusual obsessive-compulsive disorder dimension

Abstract

There is a lot of diversity in the medical realm; where unspecified sign and symptoms might confuse and force even experienced clinicians to commit mistakes. Paper eating is presently included in pica, but certain rare compulsions may mimic this and cause confusion for unsuspecting observers. We report a case of paper eating as a manifestation of compulsion in a 15-year-old girl, and reiterate that missing on rare presentations might cause the patient sufferings from inadvertent pharmacological treatment efforts.

Obsessive-compulsive disorder (OCD) is a chronic condition, often inflicting significant sufferings on the patients. In addition to its impact on multiple dimensions of quality of life[1] of the sufferer, OCD imposes major financial costs in the form of lost economic activities and treatment. With a lifetime prevalence of 1–3%, older adolescents are particularly prone to developing the disorder; males having an earlier age of onset.[2,3,4] Extended “obsessive-compulsive (OC) spectrum” disorders have over the past few years emerged as a unique and fascinating category of related conditions, and so have newer facets of OC-phenomenon.[5,6] In the present report, our patient demonstrated repeated “paper eating” as a manifestation of OCD.

CASE REPORT

A 15-year-old unmarried female student from urban area of Uttar Pradesh (India), living in a joint family, presented in the OPD with a history of eating papers for last 2–3 years. The symptoms were of insidious onset, continuous and were deteriorating in progress. There was a family history of eating papers in her brother, and our patient's initiation into this habit had been shaped by her brother's behavior. The symptom began when the patient started having a fear that something untoward was going to happen to her mother, and she attempted eating papers to help her get over these fears. Gradually, she developed the belief that if she did not perform this act, the mother would get killed. It became a regular affair in no time since her belief was easily vindicated. Initially, she would feel odd about this behavior and therefore would try to hide from family members and at school. She would eat from her copies inside bathroom or at other secluded places, and only ate papers which were blank. She avoided written over or printed pages since she felt the ink had made the pages dirty and eating them might cause her illness. She reports that though this did not give her pleasure, and she did not know exactly how this would prevent an accident with her mother; she felt it helped her to overcome a sense of “restlessness” which arose subsequent to these thoughts of loss she could not control otherwise. She had considered the fact many-a-times that the behavior might be odd and not “right” for her to do, but was unable to get rid of it.

The family members had noticed her brother's behavior in the meantime and had got him treated with fluvoxamine by a psychiatrist, with significant improvements over 1-year. Her brother's treatment made her aware that the behavior might constitute an illness, and she tried curbing down her own activity. Many a times did she try, but to no avail. She would become restless, anxious; have palpitation and headache; all of which would relieve after eating paper. Her personal and social life suffered for this, and her interaction with family members and friends became compromised. Gradually she also started eating papers in front of her family members because she could not bear the anxiety from abstinence. She ate 5–7 full-scape sheets per day now, up from 1 to 2 per week at the beginning. Her family members became cautious and worried about her habit and forced her to avoid eating papers. However, her visit to a psychiatrist was delayed as girls received lesser attention in her household.

While family's disapproval led her to hide the behavior from the acquaintances; she developed mild to moderate intensity headache, occurring 8–10 times/month with bilateral, constricting nature and without nausea/vomiting/photophobia/phonophobia; lasting 5–6 h at a time. For last 2–3 months she also started complaining of disturbed sleep, loss of appetite, loss of interest in pleasurable activities, decreased attention and concentration. There were associated feelings of sadness. There was nil other psychopathology elicited in her at interview.

During the initial assessment, she participated in a semi-structured interview using Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Our patient satisfied the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for OCD as a primary diagnosis. Patient's pretreatment Y-BOCS score of 24 was in the moderate range of severity, indicating significant distress and impairment associated with her OCD symptoms. The OCD diagnosis was based on the evidence that she experienced recurrent, intrusive, and persistent fears of harm to near and dear ones that cause marked distress and hence she was compelled to perform the act (compulsive eating of papers) to avoid the dreaded outcome. Her depression seemed secondary (rather than primary) to her behavior and stresses, evidenced by the course of illness and chronology of symptom-development. Her hemogram, serum electrolytes, and serum iron were within normal limits, stool examination findings were insignificant and magnetic resonance imaging did not reveal any intracranial pathology. Her electroencephalography was a normal awake record.

She was started on fluoxetine 20 mg/day, hiked to 40 mg/day after 1^st week and cognitive behavior therapy (CBT). The choice of medication, in this case, was made largely because of the prominent OCD symptoms, co-morbid depressive symptoms, and socioeconomic status; for all of which fluoxetine seems to be better. Most importantly, the patient was extremely motivated to engage in CBT and taking treatment. She openly welcomed the support and assistance of her therapist and of the treatment team overall. By the end of 4 weeks’ treatment, she started showing clinical improvement, and Y-BOCS score reduced to 16. Over 8 weeks’ follow-up, Y-BOCS had reduced to 10. Her peer and family interactions had also shown improvement.

DISCUSSION

DSM-5 defines pica as a form of feeding and eating disorder of infancy or early childhood, characterized by “the persistent eating of nonnutritive substance for a period of at least 1-month: Inappropriate to the developmental level, not part of a culturally sanctioned practice and sufficiently severe enough to warrant independent attention.” Some of the reported types of pica include eating earth, soil or clay (geophagia), ice (pagophagia), starch (amylophagia) and substances such as cigarette butts, ashes, hair, paint chips, and papers.[5] The behavior has been mentioned in relation to a number of psychiatric conditions such as mental retardation and schizophrenia.[7] Though numerous forms (yielding and controlling) and contents (dirt and contamination, inanimate and impersonal, sex, religion, and aggression) of compulsion have been described in literature;[6] pica as a possible manifestation of an underlying OC-phenomenon had been mentioned only sparsely, in spite of evidence of pharmacological and phenomenological similarities with the latter.[8,9] Authors have tried to ascertain the role of micro-nutrient deficiency as being a common mediator of pica and OC symptoms,[10] though such assertions remain largely anecdotal till date.

Our case describes paper eating as a possible OC-phenomenon, with all its phenomenological nuances. The patient had probably modeled this behavior on her brother and had designed this to ward off certain aversive (and magical) eventualities. Paper eating, in itself, is rare in literature, and this case demonstrates shaping of compulsions via psychosocial observation and their reinforcement and maintenance through “escape learning.” Through this report, we emphasize upon the kind of diversity in psychopathology a practicing psychiatrist is exposed to. Nonspecific sign and symptoms might confuse and force unsuspecting clinicians to commit mistakes; thus exposing patients to unnecessary treatments and pharmacological side effects.[11]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.