Foreign-Body Ingestion in Patients With Personality Disorders

Received September 29, 2005; revised February 10, 2006; accepted February 17, 2006. From the Dept. of Psychiatry, Brigham and Women’s Hospital, Boston, MA. Send correspondence and reprint requests to David F. Gitlin, M.D. e-mail: dgitlin@partners.org Copyright 2007 The Academy of Psychosomatic Medicine The medical care of patients who engage in repeated acts of deliberate self-harm can prove costly, both economically and in terms of the morale of their careproviders. Accordingly, there has been a wealth of discussion in both the psychiatric and medical literature regarding the diagnostic, treatment, and fiscal questions that arise in caring for patients with severe personality disorders who cut, burn, or otherwise mutilate themselves. Much of that discussion has focused on psychiatric patients with personality disorders, particularly borderline and narcissistic personality disorders. In stark contrast, the literature offers comparatively little discussion of the unique problems inherent in treating patients who harm themselves by deliberately ingesting foreign bodies. In this article, we will review what is known about deliberate foreign-body ingestion, present several illustrative cases, and discuss some of the clinical problems they pose, with a particular focus on this behavior in patients with personality disorders. There are many unique challenges in treating patients who engage in deliberate foreign-body ingestion as a method of self-harm. Whereas other forms of mutilation may be dangerous to patients and distressing to their treaters, foreign-body ingestion carries a sense of insidiousness in the lack of outward evidence that harm has been done and in the latent risk of further injury even after a diagnosis has been made. This danger persists until an ingested object is either passed or removed. Furthermore, although a patient’s environment can be controlled for objects used for cutting or burning, it is nearly impossible to prevent access to all potentially ingestible objects. The existing literature consists almost entirely of case reports detailing the medical and surgical aspects of this phenomenon, and scant reference is made to the psychiatric care of such patients. It seems unlikely that the repeated ingestion of foreign bodies would not elicit psychiatric consultation, and it is thus surprising that psychological investigation of this phenomenon is so limited. Review of previous case reports in the psychiatric literature reveals that the population engaging in this behavior seems to separate into four distinct diagnostic subgroups: 1) malingering; 2) psychosis; 3) pica; and 4) personality disorders. We will briefly review the first three subgroups, and then focus the remaining discussion on patients with personality disorders.