The Behavior of Eating Glass, With Radiological Findings: A Case of Pica

To the Editor: Pica is the persistent and compulsive ingestion of nonnutritive substances; it includes eating disorders with unusual cravings. Etiologies of consuming common and bizarre substances range from mineral deficiencies and helminthic infestations to cultural preferences. Recently, pica has been associated with obsessive-compulsive (OCD) spectrum disorders.^1,2

The purpose of this letter is to present a patient with the behavior of eating glass, in whom lesions in the sylvian fissure and corpus callosum were determined as a result of the radiological examination and cranial MRI.

Although there are a limited number of epidemiological studies and likely underreporting made by embarrassed patients, pica is observed in all ages, races, genders, and geographic regions. In addition to those with brain damage, epilepsy, mental retardation, psychosis, or dementia, lower socioeconomic groups, young children, pregnant women, or breastfeeding mothers with increased nutritional demands are at higher risk.^3,4

Finding pica in an elderly age-group is relatively uncommon, and it rarely has an adult onset. This article presents a case of adult-onset pica with radiological findings.

Case Report

A 32-year-old, primary school graduate, unemployed male patient applied to our polyclinic with the complaint of having the habit of eating glass for approximately 10 years. The patient, who had not made a psychiatric application before, has had an increasing craving for eating glass recently and had to make an application for treatment, since he was having difficulty with quitting. According to the anamnesis received, we learned that the patient, who has no feature in his premorbid life, has had the complaint for nearly 10 years; he constantly keeps glass pieces in his mouth during the day, chews and swallows them, feels restlessness and irritability whenever he does not have them, and embarks on a quest; this behavior of quest gradually increases with this craving. Also, he stated that the amount of glass eaten has showed an increase over time. There was no history of consuming alcohol or any other substance.

As a result of the psychometric examination; IQ was determined to be 86 (“dull normal”). It was determined that the patient had some anxiety periods during the day, which showed fluctuations and could not be associated with any reason. He stated that the eating of glass generally increased in these periods, and he felt relief. Suspicion, obsessions, and control compulsions were identified in the patient. He stated that he was never sure of some of his behaviors that were displayed during the day, had to examine constantly, and felt relief after at least three checks. This situation had been lasting for approximately 10 years; he did not make any application for treatment before and felt uncomfortable with his checks recently. Also, he also stated that he had excessive nervousness, as well as sudden, occasional, and repetitive tantrums and some impulsive behaviors such as harming things, or hitting his hand or head on the wall, which had increased, especially in recent times. The patient indicated that he could not prevent these behaviors, felt regret after these, but also felt relief in that moment. His psychomotor activity had increased. There was no delirium in the content of the thought and showed normal flow or speed of thought during the mental assessment. There was no perceptual defect. As a result of the physical examination, complete blood cell count performed on the patient, liver and kidney functions, thyroid hormone tests, iron and iron-binding capacity, vitamin B₁₂, folic acid, and zinc levels were normal. The Mini-Mental exam conducted on the patient was normal, as well.

As a result of the radiological imaging, which was performed in an attempt to exclude organic reasons, and cranial MRI, dilution on the corpus callosum, dilation on the sylvian fissure depths and convexity of sulcus, and a minimal asymmetry and abnormal dilation on the third ventricle and lateral ventricles were determined.

Discussion

Pica is considered as the ingestion of inedible substances or atypical food combinations.⁵ In DSM-III-R, pica, with anorexia nervosa, bulimia nervosa, and rumination disorder of infancy, is accorded the status of a separate eating disorder. However, in the Draft of ICD-10, only anorexia nervosa and bulimia nervosa are listed under eating disorders. Comprehensive study conducted on the history and terminology of eating disorders between the 16th and the 20th century suggests that, historically, pica was regarded as a symptom of other disorders, rather than a separate entity.² Pica has been found to be associated with pregnancy over the years.⁶ Incidence of pica has also been related to iron and zinc deficiency.⁷ Whether or not pica is an eating disorder or obsessive-compulsive disorder is still controversial.⁸

Association of pica, iron deficiency anemia (IDA), and celiac disease (CD) has been reported in the literature. Reporting of pica in elderly age-groups is relatively uncommon, and it rarely has an adult onset. Bhattacharjee et al. reported on a patient eating glass beads and hard-edged metal objects.⁹ In a case published by Chakraborty et al., on the other hand, there is a woman eating iron nails.¹⁰ In this case, the patient stated that she also used to eat glass pieces for a certain period before. A case, which was published by Choure et al. in 2005, with the use of “baking soda,” stated that it made her/him feel better, and therefore s/he could not quit using it (baking soda). Authors interpreted this condition to possibly be a weak impulse-control issue or compulsive behavior. Similarly, in their five-series case presentations, Stein et al. reported that pica was considered as a compulsion in two cases, and the cases were diagnosed with OCD, and both of the cases had concomitant impulse-control disorder.¹¹ Gupta et al. reported a case of eating sponge, which was assessed on the obsessive-compulsive spectrum.¹² In our case, the presence of obsessive and compulsive indications makes us think that the behavior of eating glass could also be on this spectrum. Similarly, Ceschin et al. reported pica containing impulsive and compulsive characteristics in a case with MS.¹³ In our case, the presence of obsessions and the existence of impulsive behaviors make us think that the behavior of eating glass could also be within this scope. On the other hand, the fact that the patient experiences cravings, the amount being used has showed an increase in the course of time, and he embarks on a “quest” when he cannot access makes us think that it is a kind of addiction. Some authors emphasize the similarities with the obsessive-compulsive spectrum disorders, whereas others propose an interpretation of pica as an addiction or as an impulsive behavior.¹³

Although element deficiencies are implicated in the etiology of pica, its relation with brain damage or lesions has not been revealed. During the cranial examination of the patient, a dilution was determined on the corpus callosum. There are studies in literature investigating the association of corpus callosum and psychiatric diseases. It is especially among the diseases whose association with OCD has been studied. Park et al. found out that thickness of corpus callosum was greater in patients with OCD.¹⁴ Saito et al., on the other hand, reported that there was a decrease in fractional anisotropy of corpus callosum in patients with OCD.¹⁵ Also, Liu et al. stated that there was a relationship between impulsivity and the corpus callosum in alcohol addicts, and they indicated a low presence of anisotropy in patients with high impulsivity.¹⁶ The fact that a dilution was determined on corpus callosum and there are obsessive and impulsive symptoms in our case supports the literature. The fact that there are compulsions and impulsive behaviors in our case makes us think that the behavior of eating glass could also be a compulsion. Future studies are required on whether the pica is on the obsessive or impulsive spectrum or it is an addiction.