A Pica Case Associated with Suicide-Bereavement Ġntihar Yası

Atay 39 ______Case report / Olgu sunumu

A pica case associated with suicide-bereavement

Ġnci Meltem ATAY1 ______

ABSTRACT

Pica is defined as the consumption of non-edible substances for at least one month. Although there are reports about the causes of pica emphasizing nutritional deficiencies and psychosocial stress, the etiology and treatment approaches still remain unclear. In this case, a patient with pica accompanied by serious psychiatric and medical comorbidities which occur after witnessing a suicide, during adolescence is described firstly in the literature. (Anatolian Journal of Psychiatry 2014; 15(Suppl.1):S39-S42)

Key words: Pica, suicide-bereavement, depression, posttraumatic stress disorder

Ġntihar yası ile iliĢkili bir pika olgusu

ÖZET

Pika, yenilemeyen maddelerin en az bir ay süreyle tüketilmesi olarak tanımlanmaktadır. Pikanın nedenleri hakkın- da besin yetersizliklerini ve psikososyal etkenleri vurgulayan çalışmalar olmasına rağmen, etiyoloji ve tedavi yaklaşımları halen belirsizdir. Bu olguda, ergenliğinde bir intihara tanıklık sonrası ortaya çıkan, ciddi psikiyatrik ve tıbbi komorbiditelerin eşlik ettiği bir pika olgusu literatürde ilk kez tanımlanmıştır. (Anadolu Psikiyatri Derg 2014; 15(Ek sayı.1):S39-S42)

Anahtar sözcükler: Pika, intihar yası, depresyon, travma sonrası stres bozukluğu ______

INTRODUCTION those as important risk factors.7-10

Suicide is a serious trauma in every age group. Pica is defined as the ingestion of non-nutritive Studies about psychiatric morbidities in adoles- substances for a period of at least one month, 1 cents after a peer’s suicide, have shown that which is not occurring as a cultural practice. complicated grief (CG) is common in response Although the etiology of pica still remains un- to a peer’s suicide, and is found associated with clear, there are reports accusing iron, calcium 2,3 suicidal ideation, depression and posttraumatic or zinc deficiencies. Also, in literature pica is 11,12 stress disorder (PTSD). CG related to be- reported as an obsessive-compulsive spectrum reavement, which is proposed to classify differ- disorder or even as an impulse control disor- 4,5 ent from depression, anxiety, and PTSD is der. Finally, in DSM 5, pica is included in the characterized by preoccupation with the de- section of ‘eating and feeding disorders’ without 6 ceased, avoidance, disbelief, numbness, de- an age limitation. However, in many reports, tachment, irritability, anger, and also found pica is found associated with high levels of related with long term somatic and psychiatric stress, anxiety and depression emphasizing ______

1 Assist.Prof.Dr., Suleyman Demirel University, Medical School, Department of Psychiatry, Isparta, Turkey YazıĢma adresi / Address for correspondence: Yrd.Doç.Dr. Ġnci Meltem ATAY, Süleyman Demirel Üniversitesi Tıp Fakültesi Psikiyatri ABD, Isparta/Türkiye E-mail: [email protected] GeliĢ tarihi: 04.01.2014, Kabul tarihi: 26.02.2014 doi: 10.5455/apd.149941 Anadolu Psikiyatri Derg 2014; 15(Ek sayı.1):S39-S42

40 A Pica case associated with suicide-bereavement ______comorbidity and suicide ideation.12-14 CASE

Although many psychiatric disorders related to T, an 18-year-old male, brought to the ortho- CG were determined before, pica was not re- pedics clinic of a university hospital with hip ported in literature. In this regard, we discussed pain, by his parents and hospitalized with a pre- a case of pica characterized with lithophagia liminary diagnosis as avascular necrosis. After and serious medical/psychiatric comorbidities, the observation of aseptic necrosis with ‘the which had developed after witnessing his aunt’s intestines filled with stones’ in the anterior- suicide. posterior X-ray examination incidentally, general surgery and psychiatry consultations were requested (Image 1).

Image 1. Anteroposterior view of hip and intestines of the patient

After initiating laxative treatment by general and poor self-esteem since two years. Symp- surgery and planning the clinical follow-up by toms were progressive and, he had suicidal orthopedics, the patient admitted to the out- ideation, recently. The information about the patient clinics of psychiatry. In psychiatric ex- patient was also cross-checked by his mother. amination, he disclosed that since four years, She confirmed that all symptoms had begun i.e. since he had witnessed his aunt’s suicide by after suicide. She reported a close relationship hanging, he episodically had an irresistible de- between her sister and son, before the suicide. sire to consume rocks and pebbles. The patient The patient’s personality was introvert that he had intrusive memories, flash-backs and night- mostly had difficulties in expressing his emo- mares about his aunt are hanging vision. He tions and in relationships with peers. There was still was having trouble accepting the death of not any psychotic symptom described in the his aunt. His school performance deteriorated story and the level of his intelligence was within steadily, and therefore he had to leave school. the normal range consistent with his sociocul- He had low mood, loss of interest in daily acti- tural status. There was no other family history vities, hopelessness, worthlessness, irritability, of a psychiatric disorder except his aunt’s sui- impulsivity, disturbed sleep, decreased appetite cide. Anatolian Journal of Psychiatry 2014; 15(Suppl.1):S39-S42

Atay 41 ______

In the routine investigations, he had anemia response to both pica and PTSD symptoms that his hemoglobin was 9.0 g/dl. All other were congruent with the findings, that clinicians routines and trace elements were normal. The should be aware of this comorbidity. scores of Beck Depression Inventory and Although it’s difficult to suggest a definite rela- Inventory of Complicated Grief were 44 and 45, 15,16 tionship between this traumatic event and pica respectively. According to DSM-IV-TR, the in our case, the onset of pica during suicide- patient was diagnosed as depression and pica. bereavement is remarkable. Melhem et al. re- He had complicated grief and posttraumatic ported that adolescents might experience a symptomatology, as well. traumatic grief reaction after exposure to a His symptoms were still remaining after peer’s suicide.11 CG was found associated with controlling the anemia that fluoxetine 20 mg/day a fivefold increased risk of suicidal ideation after with supportive therapy initiated. Within a week, controlling for depression and was found depressive symptoms had decreased. He was related to the onset and prolonged course of interviewed for two-week intervals. After three depression and PTSD in adolescents whose months his mood was completely improved, his peers died by suicide.11 Our patient had multi- complicated grief and posttraumatic symptom- ple medical and psychiatric morbidity that he atology were subsided. He was not ingesting had CG, posttraumatic stress disorder symp- rocks and pebbles for the past four weeks and toms and major depression including suicide indicated that thoughts of eating rocks and ideation with a serious pica. Therefore, pebbles were not disturbing him anymore. The clinicians should be alert to the occurrence of treatment continued and he is still being traumatic grief reactions in adolescents and followed-up. should investigate all different clinical presenta- tions as in our case and further studies are DISCUSSION needed to elucidate all comorbidities in complicated grief for better treatment approaches. The most important feature of this case was the development of pica after witnessing a rela- CONCLUSION tive’s suicide, which was experienced during adolescence. There are reports about pica that This case presents some important points: aggravate with stressful situations.10,17 But to Firstly, witnessing a suicide is a serious trau- our knowledge the onset of pica related with matic event in childhood and adolescence that suicide was not reported before. may be characterized with different clinical manifestations. Our patient has much comor- In our case, pica was accompanied with bidity which may be associated with clinical posttraumatic stress disorder symptomatology. severity. Secondly, the possible relation with Although pica was not described with PTSD, suicide in this case, highlights the importance of there are many reports about eating disorders 18-20 psychosocial aspect of the disorder in terms of associated with PTSD. Also, Mitchell et al. the etiology of pica again. And finally, exposing indicated the common features of PTSD and to suicide may cause different eating disorders eating disorders, such as cognitive disturb- like Pica that future longitudinal studies inves- ances, emotion dysregulation, dissociation, and tigating the effects of witnessing a suicide impulsivity and reported the effectiveness of 21 would be helpful for preventing both psychiatric cognitive processing therapy in those patients. and clinical complications. The clinical features of our case and treatment

REFERENCES

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Anadolu Psikiyatri Derg 2014; 15(Ek sayı.1):S39-S42

42 A Pica case associated with suicide-bereavement ______

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Anatolian Journal of Psychiatry 2014; 15(Suppl.1):S39-S42