Patient is eating garbage

[whopper]

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I've encountered a first as an attending that I didn't encounter as a resident. Not much documentation on this type of behavior in the medical books, so I figured I'd present it here to teach the students & residents, but also to get some feedback that could teach me.

I got a patient that is eating garbage. He's schizophrenic, of low intelligence & years of homelessness. He had attempted to eat paper while I was doing my H&P on him. However despite the attempt at eating paper, he does go for edible food items in garbage.

OK, so I was thinking perhaps PICA.
http://en.wikipedia.org/wiki/Pica_(disorder)

The patient however does not show any signs of a microcytic anemia (which would point to an iron deficiency which is often times associated with PICA) and for that reason the IM doctor doesn't advise doing more labs in that area.

Another theoretical cause of PICA is a mineral deficiency. I noticed that the IM doc (at our institution is usually the person who orders the multivitamin-not me) hadn't order the multivitamin, so I did it. I figure after several days of MVI tx, that should fix the PICA if its being caused by a mineral deficiency.

Well there's no improvement so far, and the fact that I allowed the patient to eat much more than the dietician advised didn't seem to improve the garbage eating behavior. I'm not exactly certain how long replacing the deficieny minerals would take to improve PICA, if indeed this is what the guy has.

So right now I'm planning on waiting about 1 more week (he's been on a MVI for a week now) to see if his garbage eating behavior will decrease.

Verbal redirection & education is not going anywhere for now. He's still grossly psychotic despite being on Risperdal 4 BID. I just upped it from 3 BID which he was on for 2 weeks.

One of the psyche nurses told me he has a theory that homeless people develop a reward seeking type of behavior with garbage--e.g. if they see food in the garbage, they get a rush. This makes sense since finding food is generally accepted as a rewarding behavior, especially if you're homeless & without it. He thinks the guy is so used to being homeless that there's an actual behavior here that will be difficult to extinguish. If that's the case naltrexone therapy may help here. I am though not going to consider such a therapy for now. I would however if he continued his garbage eating behavior even after his psychosis cleared up and had been on the MVI for weeks with no improvement.

Anyone have any opinions on this area they'd like to mention?

 

[Faebinder]

Sounds like the patient... in his mind.. he never stopped being homeless when he is in the hospital. If the atypical antipsychotics are not reducing this behavior then it's a learned mindset and this will be difficult without a major change in the patient's lifestyle... like garuanteeing his living location and income sufficient to survive as a none homeless person, rebuilding his ego with behavior therapy...

It's a sad product of the society.

 

[Chrismander]

Any chance of dementia or something organic after years of homelessness, poor medical care, and ingesting god knows what? Maybe it's not an addiction or a psychologically inability to let go of eating garbage, as much as plain old confusion...
What's his MOCA or MMSE?

 

[whopper]

Haven't done an MMSE, though if its dementia-the guy's in his 50s. While it can occur at that age--that's just very rare, and he's not exhibiting the typical dementia symptoms. E.g. he's been dx'd with Schizophrenia for decades & is showing consistent psychotic sx with the Scz, though I never saw any past records of the guy mentioning he'd eat garbage.

We also don't have a dementia history on record or anything we can get from the guy like a long & gradual increase in memory & cognitition problems.

Dementia could though explain why his garbage eating behavior hasn't improved with antipsychotic therapy, though there's also a lot of other theories at this point that can too.

If I pursued a dementia outlook on this guy (vs Schizophrenia) the only red flag for it would be that he's eating garbage. That type of behavior isn't exactly common in dementia either.

I doubt its dementia because demented people if they were to perform some odd behavior as a result of their dementia wouldn't do something as cognitively engaging as actively seeking food in garbage. That requires the person approach the garbage can, & actively try to sort something out of there that is edible. Behaviors that require redirection from demented patients are often of a sort that are on the lower cognitive level such as screaming, throwing things, & saying things that don't make sense.

 

[Solideliquid]

Lace that garbage with Clozapine.

 

[blabbyblab]

Maybe it's the homelessness + increased appetite due to antipsychotic/lack of food + psychosis that lead to the learned behavior you describe. Is he still actively psychotic? How are his negative symptoms? Is he overweight? Does he have diabetes? Has he had an adequate trial on a weight neutral antipsychotic? Any chance of getting him into a long term care facility?

 

[whopper]

He's already in a long term care facility.

Still actively psychotic. The Risperdal at 3 BID has caused some benefit. He is more logical, more cooperative & directable. His language was incomprehensible. Now its semi-comprehensible. He's still though very bad & needs much more improvement.

Negative sx are very strong: flat affect pretty much all the time. Slow to respond. Slow movements. He has little if any positive symptoms.

The antipsychotic increasing his hunger issue has come to mind. However I've never had a patient who started searching through garbage due to hunger from an antipsychotic.

He's underweight. So underweight that he has some temporal wasting. You can see the bony cleft in his skull. That's another reason why I allowed him to eat much more than the dietician allowed. He's on a regular diet + 2 cans of Ensure + 2 snacks a day (yogurt or fruit & a sandwich).

No diabetes.

I tried Risperdal & not one of the other more metabolically neutral meds because he has a strong history of noncompliance & I want to put him on Consta. He is also in a forensic unit. He has a history of committing minor crimes such as trespassing due to his psychotic illness. While its not anything dangerous, this is something simply more than innocent & non-harmful psychosis. His activity could get him harming himself. He might for example tresspass onto someone's property who might harm him.

I have also considered that perhaps putting him on a med that can increase hunger might make him eat more & cure him of any nutritional deficiency that could be causing him to have PICA.

 

[blabbyblab]

He does sound like a good candidate for Consta. The only other thing I can think of is perhaps an OCD component to his illness.

 

[maybepsych]

Very interesting, thanks for posting. Unfortunately, I don't have anything intelligent to add.

 

[strangeglove]

Maybe this is a compulsive behavior, a la trichotillomania. Not that they work all that well for that disorder, but perhaps an SSRI might be of some use, along with some CBT (assuming he's cognitively up for it)?

 

[whopper]

Not at the point where CBT would do any good. His psychosis is too strong. My hope is I can get this guy's psychosis cleared up. If he's still attempting to eat garbage, I can then at least talk to him about why he's doing it, and go from there.

But I'm not going to engage in any med therapy at this point other than to attempt to treat his psychosis. I'll settle for behavioral redirection to keep him from eating garbage. Yeah it could be an OCD component, it could be a reward component, but I'd want more solid reasoning before I'd introduce another med.

 

[Anasazi23]

All these theories are interesting. But I'll stick with horses on this one. He sounds like a severely psychotic, perhaps treatment-resistant, regressed and primitive psychotic.

Keep the antipsychotic, increase it, change it, or add another.

 

[Therapist4Chnge]

It sounds like you've covered your bases. Outside of some very basic behavioral therapy stuff, I don't think you can do much else if his psychosis is still so persistent. Would you consider him MR or just below average....as MR + Pica is much more common prevalence-wise.

 

[whopper]

Previous records don't support MR as a diagnosis. Also, I haven't seen garbage eating as something associated with MR. He was only reported to have low intelligence. I don't know if any formal testing was done to exactly define between low intelligence, borderline, and mental ******ation.

 

[Therapist4Chnge]

Previous records don't support MR as a diagnosis. Also, I haven't seen garbage eating as something associated with MR. He was only reported to have low intelligence. I don't know if any formal testing was done to exactly define between low intelligence, borderline, and mental ******ation.

The garage eating (edible items) is much more of a conditioned/learned behavior. In shelters you often see the behavior continue in spite of having enough available food. It takes consistent redirection and behavioral management to help them re-adjust; similar issues happen with showering.

 

[zenman]

The garage eating (edible items) is much more of a conditioned/learned behavior.

You mean "garbage" eating don't you? Garage eating, while working on your car/bike is ok.

Has anyone tried wiring the garbage cans where the guy lives? Zhssssst!

 

[masterofnone]

Ect?

 

[whopper]

The garage eating (edible items) is much more of a conditioned/learned behavior. In shelters you often see the behavior continue in spite of having enough available food. It takes consistent redirection and behavioral management to help them re-adjust; similar issues happen with showering.

That's what that one nurse I mentioned told me. However this is something I've read little about in the psyche books & have seen little of in residency, and we get a lot of homeless people in the residency I'm from.

A reason why I bring it up. Its a learning experience for me that I'd like to share with the forum.

 

[dianamd]

Interesting case!

Just to clarify, with the exception of the paper-eating-during-H&P incident, he only eats EDIBLE things out of the garbage?

In that case, I would think this is a very sad, learned behavior, and is not going to change.

If he is eating non-edible things from the garbage, I would really consider increasing the meds -- although I am not trained in psychopharm so it is just a general idea. If a patient is at risk of eating something dangerous, you gotta consider more medication if he is showing improvement at the 4 BID dose.

I do not think there is any element of dementia, unless the guy has the ApoE4 gene or some genetic syndrome. Otherwise, just because the guy is homeless and treats himself badly, poor medical care, whatever -- I don't think those things cause dementia in a patient his age. You could do a CT/MRI to look for signs of dementia or organic disorder.

However, if he's only eating edible things out of the garbage, I don't think that habit is going to change. Frankly, it might be more gross than dangerous to the patient!

 

[illusenjester]

I have also considered that perhaps putting him on a med that can increase hunger might make him eat more & cure him of any nutritional deficiency that could be causing him to have PICA.

How is that going to help? If he's going to be hungrier wouldn't that make him more liable to go garbage digging for food/unedibles even more?
x0x0 illy

 

[Faebinder]

Mini Mental him Whopp... lets see what you come out with. This is probably just a negative symptom.

Heh, how are they keeping him from eating garbage? one to one?

Now that zenman is trying to become a psych NP will we see him posting more shaman stuff here?😱

 

[whopper]

How is that going to help? If he's going to be hungrier wouldn't that make him more liable to go garbage digging for food/unedibles even more?

PICA is a disorder where the person eats strange things such as dirt, paper, or chew on ice, what have you. Its not well understood. The theory is that it is caused by an iron or mineral deficiency. When that deficiency is corrected the PICA often goes away. The theory is that the deficiency causes a dysregulation in the parts of the brain that govern what we choose to eat. However some argue that its really not dysregulation because sometimes the items that are ingested (such as dirt) will have the minerals that the person is deficient in. It might actually be a beneficial evolutionary mechanism.

However in this modern world, PICA is causing people to eat items not available in nature such as paper, plastic, nails that are downright dangerous.

Actually this is a good disorder for you Illusenjester that shows how Psychiatry operates. Does PICA exist? Yes. Actually several women suffer from it during menstruation. Several women get an urge to chew on ice when they're losing blood from menstruating becuae it causes a short term iron deficiency.

& Studies show that when the deficiency is corrected--the desire goes down.

One of the reasons why its not better understood than that is because it'd require invasive lab testing such as drilling holes into people's brains to figure out why it happens. That type of research cannot be done without violating human rights. Besides- simply getting the person nutritious food & a vitamin can solve the problem.

As for my strategy-if giving the patient a medication to stimulate his hunger would make him eat more, and we are providing him with nutritious food (ensure, a regular diet, vitamins, fruits & vegetables etc),--then if he had a mineral deficiency--that would be corrected. In PICA the problem is not hunger, its the desire to eat items which are inedible or edible but not exactly something that should be eaten.

Right now, I'm not sure if its his psychosis, PICA or a learned reward behavior that's causing him to eat paper & garbage. In the spirit of avoiding polypharmacy, I'm not going to throw a medication at him that might not be needed until I eliminate through process of elimination what could be the other causes. I'm working on clearing his psychosis first.

I increased his Risperdal as I mentioned this Friday. However @ 4mg BID, this is getting to a dosage that I'm considering on the strong side. Risperdal is one of the few antipsychotic meds where its maximum reccomended dosage from the manufacturer is often times not achieved before a psychiatrist gives up on it. If I have to go to over 5 BID, I'm going to consider switching his medication. I'm keeping with risperdal for now because I want to get him to Consta.

By the way, aside from the paper, he seems to be pulling out only edible items from the garbage.

 

[billypilgrim37]

How about possibly sticking with the risperdal, but adding a more innocuous histaminergic agent to boost his appetite? I would almost wonder if some higher dose phenergan dosing would give you the same "side effect" you're looking for, while allowing you to stick with your AP of choice.

Maybe even some marinol?

And thanks for posting this, whopper. This is one of the most interesting threads we've had in quite a while.

 

[whopper]

Heh, how are they keeping him from eating garbage?

Well, the garbage cans are all in the public areas. They can be easily monitored by staff. There are those mini-trash baskets in their rooms but he's not eating garbage from there because his basket is pretty much empty because he's not putting anything in them.

He's not allowed to go into the other patients' rooms either, so that eliminates the possibility that he's eating their garbage.

Marinol? Nope. About 3 months ago, there was a article in the AJP showing that exposure to cannabis can accelerate the onset of schizophrenia. There is also evidence pointing out that the paranoia caused by cannabis may be associated with the same brain mechanisms that are involved in the paranoia aspect of psychosis.

http://www.schizophrenia.com/prevention/streetdrugs.html

While this new data doesn't follow the typical dopamine/serotonin model of psychosis (which are old models), nonetheless we know enough today to know that the pharmacological effects of cannabis probably do something that schizophrenia also does & are in some way adversely connected.

So no to the marinol. Besides, that'd just be a little too much of a red flag. Me ordering marinol to a non-cancer patient on a forensic unit? No way.

Risperdal isn't exactly like Zyprexa with the weight gain, in CATIE it actually lowered some factors for metabolic disease, though it did cause weight gain. Risperdal is still my first choice antipsychotic. Per CATIE it only only topped by 2 other meds and I got the Consta option. If I eventually get to a dose of Risperdal and there is not enough benefit, I'll go to Zyprexa next, which as we all know causes a lot more weight gain than Risperdal. I wouldn't be choosing it for that reason, but for the reason that CATIE showed it to be more efficacious than Risperdal.

He's eating all the food we're giving him, so I don't see a need to stimulate his appetite further.

 

[Therapist4Chnge]

How is that going to help? If he's going to be hungrier wouldn't that make him more liable to go garbage digging for food/unedibles even more?
x0x0 illy

Increasing his appetite and providing him more food (adding a snack, Ensure/Boost, etc), increases the opportunity for behavior mod....think of it like being able to do more repetitions of an exercise during your weekly workout. Though the current hypothesis is that the garbage (not garage 😀 ) eating is behaviorally reinforced, maybe it is instead tied into the psychosis, which can also be helped with the meds. The iron deficiency hypothesis also can be addressed by increased food intake.

I'm curious how verbal/responsive he is to inquiry, as some spec. questions could really help the differential and give whopper a better idea of what is going on.

Btw...*thumbs up* for not jumping on the polypharmacy bandwagon in this case, that often seems to be the next step for many, even though there usually isn't a good reason and/or efficacy behind the decision.

 

[billypilgrim37]

I'm sure you're well aware of the methodological flaws of the marijuana=>schizophrenia research, but that's one of the more brazen articles I've seen which has glossed over these flaws. First, the attributable risk statistic they throw up so much, the "cannabis use accounts for 8-13% of all schizophrenia" is fundamentally unsound, because an attributable risk calculation de facto requires that causality is already established. Or at least its validity depends on the likelihood of causality.

It's a much more complicated version of "correlation=/causation". You simply can't validly report that statistic. It doesn't mean anything except that "If cannabis caused schizophrenia, then X percent of schizophrenia would be attributed to cannabis."

Just like you could calculate "If having more churches caused you to have more whorehouses in a city, then X% of the whorehouses would be attributed to the presence of the churches." As you can see, the latter statistic doesn't add anything the to the fundamental argument. It simply quantifies an unreality. We all know that bigger cities have both more churches and more whorehouses, and one doesn't predicate the other.

We can measure the size of cities, so the logic is clear. What we don't do a good job of is measuring genetic and social predisposition to schizophrenia and genetic predisposition to rewarding marijuana use. The fact that the article is fairly clear that increased risk is present for a variety of street drugs further supports that the causal arrow goes in the other direction.

If cannabis doesn't cause schizophrenia, the AR is simply a statistical artifact with no meaning.

It's sort of like saying Sarah Palin is ready to be president. She might be, but we don't have much evidence to justify it 😉

Your reasoning of course still justifies your avoidance of marinol, because, sure, you've established a theoretical risk, and you obviously have sound clinical judgment. But the risk is just that, theoretical.

That said, did you have any thoughts about the histaminergic agents?

Personal disclosure: I have never smoked pot, because by the time I was old enough to realize that there was no reason for me not to smoke pot (other than legal ones), I was too old to risk getting caught buying or smoking pot. If I knew what I know now back in high school, I would have had a much better time of things.

 

[whopper]

Agree with you. Correlation doesn't mean causation.

However in the AJP, which I didn't reference, and nuts I'm looking in pubmed right now & can't find it (I believe it was in the May or June issue of American Journal of Psychiatry, you know the respected green journal), did a study putting 2 groups of subjects, both with several risk factors for schizophrenia, and the group that used cannabis got it significantly earlier.

However this doesn't prove causation. It could be that another factor about cannabis users increases their risk for schizophrenia, but not necessarily the cannabis, (maybe watching bad Cheech & Chong movies & saying "hey man" a lot can do it? ).

You are right to point out what you did, and in hindsight, I did overstate the relationship. What I mentioned is more theory & not fact.

we know enough today to know that the pharmacological effects of cannabis probably do something that schizophrenia also does & are in some way adversely connected.

Anyways, I appreciate the marinol suggestion but there's too many red flags with using it on this guy--minus the speculative schizophrenia & cannabis link.

 

[billypilgrim37]

It could be that another factor about cannabis users increases their risk for schizophrenia, but not necessarily the cannabis, (maybe watching bad Cheech & Chong movies & saying "hey man" a lot can do it? ).

Dude, you call the IRB, I'll call NIH, and we can hijack DS and OPD's Netflix accounts for our materials...

 

[OldPsychDoc]

Dude, you call the IRB, I'll call NIH, and we can hijack DS and OPD's Netflix accounts for our materials...

Get your own account, stoner!

(anyway, I use blockbuster online...😳)


Back on topic: hate to go all psychologist on you--but do you have adequate nursing support to put this guy on some kind of behavior plan? Like rewards for not going in the garbage can, loss of privileges when he does, etc.?

 

[Therapist4Chnge]

Back on topic: hate to go all psychologist on you--but do you have adequate nursing support to put this guy on some kind of behavior plan? Like rewards for not going in the garbage can, loss of privileges when he does, etc.?

Definitely a great idea to get buy-in from the nurses, since they will be around the patient the most.....but it may be a hard sell.

 

[Spiderwoman]

It may be a good idea to check him for intestinal parasites! That could cause PICA which is not responding to good diet.

 

[illusenjester]

Now that I think on it...I wonder if concentration camp victims had PICA.
x0x0 illy

 

[zenman]

Now that zenman is trying to become a psych NP will we see him posting more shaman stuff here?😱

Nope, you don't want to know...😀

I just check out the interesting links, but this one looks like trash.

 

[whopper]

Well, since I put the guy on Risperdal 4 BID, I haven't seen the guy better. I could actually understand what he was saying today. He actually smiled a few times at me today. I discussed with him that I'd like to switch him to Risperdal Consta & he said he didn't want it & actually was understanding what I was expressing to him, and said he didn't like needles & would stick with pills.

So I guess I'll stay away from the Consta.

This also pretty much effectively throws out the dementia theory. Antipsychotics may reduce some of the agitated sx of dementia but they don't improve cognition.

I have discussed with the treatment team about the garbage issue. The staff tells me he tends to target a main garbage can in the communal area on the unit which is smack in sight of the nurses station. We got that thing under surveillance & got a plan to keep him from trying to get food from it.

Since the guy is actually seemingly able to think logically now, I brought up him eating garbage. He said he didn't know what I was talking about. So now I don't know if this is denial, too embaressed to admit to his garbage seeking behavior, or not being able to remember his mindset while psychotic (which I see in a lot of patients--when they clear up, they don't remember the way they acted when psychotic. Geez, I wish I could video tape them when they first come in, & show the patient, but since my unit is a forensic unit they don't allow that.)

I also discussed with the IM doc that if the garbage seeking behavior doesn't improve, I want to order some serum mineral level tests.

Well, his psychosis, while there still is some residual symptoms, is improved to the point where if his garbage seeking behavior were to stop, I'd feel confident it was the psychosis. One of course could argue that the vitamins & diet may have coincidentally stopped Pica about the same time the psychosis cleared.

If the garbage seeking behavior improves, I'll order some tests to rule of a mineral deficiency. If they're not significant, I'll chalk it up to learned behavior that'll require behavior modification as a treatment.

Another thing I noticed that may be of relevance. The staff I got on my unit--which is in Cincinnati OH have told me almost all the patients they see that have been homeless for an extended period of time have this problem. While I was a resident in South Jersey, most of the homeless were from Atlantic City & garbage seeking behavior was rarely, if ever observed in those patients. I was wondering why this was. I'm thinking perhaps Atlantic City had a better organized soup kitchen & rescue mission than Cincinnati. This however is just my speculation.

 

[kugel]

I realize I'm late to this thread, so sorry if this is all for naught.
How's the patient doing now?

If it's still going on, seems to me you still have nothing to lose for putting him on a reward schedule for staying out of the trash.

You know the routine:
Big poster board in his room with a star put on for every day he avoids digging in the trash, and a reward per week that is reflective of the number of stars. Little ritual every day in which someone brings him the star, congratulates him for earning it, and makes a big deal of putting on his board. Let him identify some reinforcers (ice cream, picking a movie, etc) and rate them as good, better, best, and provide those in response to 3 stars, 5 stars, 7 stars per week. Even if he doesn't remember the garbage-picking behavior, this may still have an effect.

 

[Therapist4Chnge]

A Token Economy System (described above) is definitely a good behavioral intervention, which can be used with a range of populations as long as it is explained in such a way that the person understands the parameters.

Thanks for bumping this, I initially forgot about this case and now I am also curious as to the outcome.

 

[whopper]

Guy was doing well. I stabilized him on Risperdal. He stopped eating garbage after his psychosis cleared up.

 

[Faebinder]

Guy was doing well. I stabilized him on Risperdal. He stopped eating garbage after his psychosis cleared up.

Kick ass DUDE!!!!

ERrr... how much risperdal?

 

[Anasazi23]

Horses people.

:bows:

 

[whopper]

Risperdal 4mg Q BID.

The guy for someone his age & being thin required a high dose of Risperdal. I only raised his Risperdal about 2mg per week after I hit 2mg BID because I didn't want to overmedicate him. He showed slight improvement, then bam! hit 4mg BID & he was acting fine.

 

[masterofmonkeys]

awesome. Thanks for the update.

 

[Solideliquid]

Kick ass DUDE!!!!

ERrr... how much risperdal?

Well, when Risperdal came out wasn't the high dose like 16mg daily?

Some people do benefit from higher doses. Keeping people on higher doses (like 8-10mg daily) for ten years may be problematic however if it keeps the guy from complete disorganization, then....

 

[whopper]

Most of the atypicals have a maximum dosage which IMHO is not adequate. Risperdal is one of the few exceptions.

We have several psychotic patients in the forensic facility I work at that don't respond to the manufacturer's maximum reccomended dosage. E.g. people who respond to Zyprexa 40 mg a day, but not 20mg.

However Risperdal--if its not working by 10mg a day, I haven't seen many patients respond to higher doses than that.

The good thing with working at the place I'm at is that the institution has created a database on dosing meds above their manufacturer's maximum reccomended dosage. You got to sometimes-because where I'm at, these people are very sick.