Patients with repeated deliberate foreign body ingestion (DFBI) are among the most challenging we see. In any given room, there’s bound to be some small object that can be swallowed. So how can we reduce the likelihood of foreign body ingestion in these patients?
Published On: 11/8/2021
Duration: 14 minutes, 32 seconds
Related Article: “Deliberate Foreign Body Ingestions,” The Carlat Hospital Psychiatry Report, January 2021
Victoria Hendrick, MD, and Adrienne Grzenda, MD, PhD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity
Dr. Hendrick: Patients with repeated deliberate foreign body ingestion (DFBI) are among the most challenging we see. In any given room, there’s bound to be some small object that can be swallowed. So how can we reduce the likelihood of foreign body ingestion in these patients? A previous issue from The Carlat Hospital Psychiatry Report included a Clinical Update about the dangers of recurrent DFBI, and how to mitigate the consequences of this complicated condition. This Clinical Update was written by Dr. Adrienne Grzenda, who’s a Clinical Assistant Professor of Psychiatry & Biobehavioral Sciences at UCLA David Geffen School of Medicine and UCLA-Olive View Medical Center. In this podcast, Dr. Grzenda and I will break down what motivates patients to swallow foreign objects and which objects are most commonly swallowed, as well as how to manage patients with recurrent DFBI.
Welcome to The Carlat Psychiatry Podcast
This is a special episode from The Carlat Hospital Psychiatry Report.
I’m Dr. Victoria Hendrick, the Editor-in-Chief of The Carlat Hospital Psychiatry Report, and a clinical professor at the David Geffen School of Medicine at UCLA. I’m also the director of inpatient psychiatry at Olive View -- UCLA Medical Center.
Let’s start our conversation on patients with DFBI with an overview of the condition, and which objects are most commonly swallowed.
Dr. Grzenda: So, pens, toothbrushes, and batteries are among the most commonly ingested items. However, the range of objects deliberately swallowed is vast. For instance, patients may swallow objects that will cause severe injuries such as sharp objects, including knives and razor blades, batteries, or packages of narcotics, or they may swallow objects that will have more benign consequences like small, blunt, non-toxic objects.
Dr. Hendrick: Yeah, and because the toxicity, sharpness, and size of these deliberately swallowed objects vary greatly, you’re likely to see a plethora of different symptoms between each DFBI case. Some patients experience no symptoms, while others present with dysphagia, drooling, emesis, gastrointestinal bleeding, pharyngeal or abdominal pain, and respiratory distress.
Dr. Grzenda: Complications, including perforation, impaction, and bleeding depend on the type, size, and location of the ingested object.
Dr. Hendrick: Foreign bodies with corrosive properties, such as button batteries, can be particularly harmful as they can result in necrosis and fistulas.
Dr. Grzenda: But, fortunately, 80%-90% of swallowed foreign bodies pass spontaneously through the gastrointestinal tract. Another 10%-20% will require intervention via endoscopy and less than 1% require surgery.
Dr. Hendrick: Well, if 80-90% of swallowed foreign objects pass spontaneously, then why is DFBI so costly?
Dr. Grzenda: DFBI is costly and resource-intensive, in part because of these patients’ extremely high rate of repeated swallowing attempts: over 80% of DFBI presentations occur in patients with prior ingestions. A retrospective analysis of 305 cases of DFBI found that they involved only 33 patients and generated over $2 million in costs in a single year.
Dr. Hendrick: So why do patients swallow foreign objects, and why do they do it recurrently?
Dr. Grzenda: In most cases, DFBI patients are not suicidal: they have no greater risk of lifetime suicidal thoughts or actions compared to patients with other types of non-suicidal self-injurious behaviors.
Dr. Hendrick: Individuals with DFBI fall into four diagnostic categories: malingering, borderline personality disorder, psychosis, and pica.
DFBI patients who fall under the malingering category tend to ingest foreign bodies that are likely to cause serious bodily harm. A 2020 retrospective case series study in Northern China investigated the differences in age, types, gender, location, and management of foreign body ingestion between two separate groups: Group A consisted of patients who intentionally ingested a foreign body and Group B included those who accidentally ingested a foreign object. Out of the 90 total patients in Group A, about 86% were prisoners, 2% were suspects, and 12% suffered from a psychiatric disorder. The ratio of males to females in Group A was 79 males to 11 females. In contrast, Group B consisted of 1020 individuals with an almost equal number of males and females, none of which were prisoners, suspects, or had a history of psychiatric disorders.
Dr. Grzenda: And here’s what sets malingering apart from the other categories of DFBI, the types of foreign bodies they choose to ingest. This study revealed that the majority of the foreign bodies intentionally ingested by individuals in Group A were metallic objects, which made up about 55% of the Group A cases. And there were no cases of food-related foreign bodies in Group A, while almost all of the cases in Group B, approximately 91%, involved accidental ingestion of food-related foreign bodies.
Dr. Hendrick: This study highlights that DFBI cases associated with malingering often occur in institutionalized settings, like jails. Moreover, the motivation behind malingering DFBI is typically aimed at reaping a secondary gain. Which is why incarcerated individuals who swallow foreign objects are more likely to select highly injurious items, like sharp metallic objects, which require transfers to hospitals and prolonged treatment.
Dr. Grzenda: The next diagnostic DFBI category is borderline personality disorder or BPD. In DFBI patients with BPD, the swallowing behaviors resemble other forms of self-injury (e.g., cutting, burning) in their triggers and intent, such as escape from distress. But these swallowing behaviors differ from other self-injurious behaviors in one important way.
Dr. Hendrick: For instance, compared to cutting, where the severity of the injury is immediately evident, suspicion of DFBI triggers an often-prolonged series of assessments and treatment.
Another diagnostic category is psychosis.
Dr. Grzenda: In a 1996 retrospective study involving 542 patients, ages 15 to 82, with a total of 1203 foreign body ingestion events, almost a quarter of all patients included in the study had a history of psychosis. Delusions/command hallucinations can prompt swallowing behavior. Additionally, patients with psychosis-related DFBI are most likely to ingest large numbers of small objects, sometimes numbering in the hundreds.
As a side note, the majority of DFBI patients in this study, about 70%, were also jail inmates at the time of foreign body ingestion.
Dr. Hendrick: The last category of DFBI is pica, which is the repeated consumption of non-nutritive substances, such as dirt and paint. Pica is most often diagnosed in children, pregnant women, and those with iron-deficiency.
Dr. Grzenda: In adulthood, pica primarily occurs in cases of severe intellectual disability, autism spectrum disorder, and schizophrenia. Pica is classified as voluntary when patients eat what is readily available, and as involuntary when it is driven by compulsions or egodystonic intrusive thoughts.
Dr. Hendrick: Involuntary pica demonstrates strong overlap with obsessive-compulsive disorder. Attempting to resist the compulsion results in significant anxiety and distress.
Now that we’ve reviewed the DFBI diagnostic categories, let’s move on to management of DFBI patients, and when emergent surgical removal of a foreign body is warranted.
Dr. Hendrick: Your patient has swallowed a foreign body. What do you do next?
Dr. Grzenda: Current guidelines recommend emergent removal in less than 6 hours after ingestion of sharp objects, like knives and razor blades, batteries, packages of narcotics, or any objects that may result in the obstruction or perforation of the esophagus.
Dr. Hendrick: Surgical management of DFBI will depend on the characteristics of the swallowed object, time since ingestion, current location in the GI tract, and presence of complications. Non-contrast CT is better than x-ray in evaluating for ingested objects; if the ingested object is radiolucent, x-rays are of no use.
Dr. Grzenda: For sharp objects that have already progressed to the stomach or duodenum or objects greater than 6cm in length and/or greater than 2.5cm in diameter, removal by endoscopy is recommended within 24 hours. Blunt objects with rounded edges (e.g., coins, buttons), smaller than 2.5cm in diameter, and/or smaller than 6cm in length can be removed non-emergently in an outpatient clinic.
Dr. Hendrick: While small, blunt, non-toxic objects observed in the small intestine can be monitored to ensure uncomplicated, spontaneous passage. Once objects reach the stomach, most will pass within 4–6 days. Seek surgical consultation if the object fails to progress after 72 hours or the patient develops symptoms of perforation, obstruction, or peritonitis.
Dr. Grzenda: General management of DFBI for inpatient and institutionalized settings focuses on reducing the frequency and potential lethality of ingestions. We can minimize swallowing incidents by monitoring patients closely and minimizing their access to swallowable items, such as utensils, pens, combs, toothbrushes.
Furthermore, there are specific management principles that vary between each of the DFBI subtypes.
Dr. Hendrick: For DFBI due to malingering, minimize the secondary gain, meaning that patient transfers for hospital treatment should be kept as brief as possible.
Dr. Grzenda: When personality disorders are the underlying cause, target the impulsivity with the use of mood stabilizers, naltrexone, or clonidine. Also, dialectical behavioral therapy and cognitive behavior therapy can be helpful too.
Dr. Hendrick: Like for other self-injurious behaviors in patients with BPD, inpatient admissions after a swallowing incident can be counter-productive, fostering an exacerbation of symptoms. Unless there are additional indications, like the presence of psychotic symptoms or suicidal ideation, swallowing incidents alone do not justify psychiatric admission.
Dr. Grzenda: For DFBI rooted in delusional beliefs or driven by command hallucinations, treat the underlying psychosis. SSRIs appear effective for DFBI due to pica or OCD, especially fluoxetine.
Dr. Hendrick: DFBI patients require a multidisciplinary approach involving surgery, medicine and psychiatry. Frustration with the patient may lead to animosity between services due to the perception that psychiatry is not “doing enough” to prevent repeated behaviors.
Dr. Grzenda: Consultant-liaison providers can assist the treatment team or caregivers to (1) recognize countertransference forces at play, (2) provide education on the limited efficacy of pharmacologic and behavioral treatments, (3) help with limit setting to lessen reinforcement of maladaptive behaviors, and (4) help foster realistic expectations regarding recurrence. At present, we know little about the long-term prognosis for patients with recurrent DFBI.
Dr. Hendrick: Overall, patients with recurrent deliberate foreign body ingestions are among the most difficult to treat. It’s important that you identify the specific DFBI subtype associated with your patient so that you can choose the most effective treatment possible. Also, you should minimize psychiatric admissions as these can be counterproductive. And don’t forget to collaborate closely with a gastroenterologist.
DFBI can be potentially life-threatening, and managing patients with recurrent DFBI is definitely not an easy task. Nevertheless, by following these tips, you’ll be able to improve the clinical outcomes for your DFBI patients and reduce the rate of DFBI recurrence amongst them as well.
Dr. Hendrick: This Clinical Update is available for subscribers to read in The Carlat Hospital Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
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