Knives and razor blades aren't things that most people would dream of swallowing -- but some doctors see patients who do just that.
A new study out of Rhode Island Hospital looked at 33 adult patients who together were responsible for 305 instances of medical intervention because of intentionally consuming foreign objects -- most commonly pens, batteries, knives and razor blades.
The bizarre cases were as expensive as they were shocking; treating patients for the swallowed objects cost the hospital more than $2 million, for which most of the payment came from Medicare and Medicaid.
The results were published in the journal Clinical Gastroenterology and Hepatology.
"After some suspicion, we were able to document these incidences, and we've learned how to deal with this with a minimum amount of disruption," said Dr. Steven Moss, a gastroenterologist at Rhode Island Hospital and lead author of the study. Moss is also a professor of Medicine at Brown University.
For the average person, it is very difficult to understand why someone would want to ingest such risky materials.
Dr. Donald Malone, director of the Center for Behavioral Health at Cleveland Clinic, said the reasons are complicated. Sometimes, it can be blamed upon developmental delays, mental retardation or autistic spectrum disorders. Sometimes, the reason might be impulsive behaviors without the rational thought process that prevents most people from doing the same thing.
For others, the reason might be is self-injury. With that self-harm comes attention, and some people want that attention whether it is in a positive or negative form.
Hard to Prevent Intentional Ingestion
Regardless of the motive, Malone said, prevention is difficult.
"There's not a whole you can do," Malone said. "You can't tie somebody down 24 hours a day so they don't swallow or ingest things."
While the incidents can be dangerous, doctors say that, in most instances, patients are not trying to end their lives.
"In most cases, foreign body ingestion does not represent a frank suicide attempt," said a statement by Dr. Colin Harrington, a psychiatrist at Rhode Island Hospital and co-author of the study.
Dr. Pamela Cantor, a lecturer of Psychology at Cambridge Hospital's Department of Psychiatry, specifically treats children and teenagers with self-destructive and violent behaviors. She, too, is familiar with the cases of ingestion and said parents should not confuse them with suicide attempts.
"It is important to know the difference between suicidal behaviors and self-harm," said Cantor. "Suicidal behavior is one with intention to die or call attention to their pain. Self-injury is an attempt to reduce anxiety, or it could be used as an attempt to draw attention to their psychological pain."
A Tough Concept to Swallow
About 11 percent of the patients in the study came from prisons, and nearly 80 percent of the patients suffered from psychiatric illnesses like mood disorders, anxiety, substance abuse and psychotic or impulsive disorders.
Fortunately, the majority of foreign objects can be retrieved successfully through endoscopic extraction, in which a special camera snakes down the patient's esophagus or stomach and removes the foreign object.
Moss said that most patients who have endoscopic surgery are given "soft" or conscious sedation. Many of the patients who swallow objects need to be given general anesthesia because they are on psychiatric medications that could interfere with the ability to sedate them. The general anesthesia adds significant cost and means booking added time for an operating room.
For Some Intentional Ingestion Patients, Options Exist
Dr. H. Steven Moffic, a professor of Psychiatry at the Medical College of Wisconsin who has written or contributed to 500 publications and presentations relating to psychiatry, said there are treatment options for certain patients.
"As far as psychotherapy goes, probably cognitive-behavioral psychotherapy is the best because it can alter how one thinks about things negatively or inappropriately," said Moffic.
But Moffic said the difficulty in treating the person doing the ingestion is two-fold.
"Those who do it for attention or secondary gain might not want to get better," Moffic said. "[And] some of the underlying disorders are among the most difficult to treat, especially the personality traits or disorders of a borderline, sociopathic, or narcissistic nature."
The Prison Difference
Moffic has done extensive psychiatry work and research in prisons. For prisoners, the reasons behind ingesting objects can be different.
"Often, the reason is to hide what is swallowed and then to actually try to retrieve it when defecating, with the assumption that the object will not be altered," said Moffic.
"In prison, medical and psychiatric treatment is provided when this is done," said Moffic. "Most important is that there is not much other positive reinforcement for the behavior, as the inmate is, in fact, punished by being put into a segregation unit for a long period of time."
Moffic said that such a reprimand discourages repeat behavior in individuals and the prison population as a whole. Outside of prison, such discouragement generally is not conveyed.
But outside or inside, it can be a wearisome process for health care professionals.
"Our numbers are similar to those at Rhode Island Hospital," said Malone. "It isn't something we see often, but when it does happen, it can be frustrating. We're used to people wanting to get better, so it can take a toll on caregivers."