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Dementic insertion of different objects

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The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions.

Dementia Foreign object insertion resulting...

Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article. Have you ever had to evaluate and manage a patient with polyembolokoilamania inserting a foreign body into 1 body orifice or more? Have you wondered why he or she did it and been surprised by your reactions to their behavior?

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If you have, then the following case vignette and discussion should prove useful with your approach to and management of patients who insert foreign bodies into themselves. Although insertion of foreign bodies into bodily orifices is not uncommon, relatively little has been written about its predisposing factors, its complications, or its management.

Care required is often collaborative, involving primary care physicians who oversee the patient's caresurgeons who assess the need for surgical removal or management of its complications, eg, perforated viscerainfectious disease specialists re: In addition, such individuals and their behaviors evoke intense emotional reactions eg, disgust, anger, embarrassment, fear that threaten to interfere with medical care eg, via avoidance, a lack of compassion or empathy, hostility.

Psychiatric consultation may facilitate a greater understanding of the patient Dementic insertion of different objects his or her dilemma so that timely treatment and effective care can be initiated. Mr A, a year-old man, brought himself to the emergency department ED when he was unable to remove a flower vase from his rectum. On several occasions he had inserted the same vase and had removed it without difficulty.

Unfortunately, this time it had penetrated so far that he could not grip the edge and remove it. Months earlier, he had inserted a hanger into his rectum to remove the vase; this procedure led to rectal perforation that required an exploratory laparotomy and repair.

In the ED, examination Dementic insertion of different objects that the mouth of the glass was palpable and intact at the anal verge. A kidneys, ureter, bladder radiograph confirmed the presence of an Since it could not be removed under conscious sedation at the bedside, Mr A was sent to the operating room for an exploratory laparotomy and foreign body removal.

LESSONS LEARNED AT THE INTERFACE...

He denied that foreign body insertion was ever an intentional self-injurious act. He identified himself as a heterosexual; however, he had never had genital intercourse. He denied any active neurovegetative symptoms of depression but acknowledged that he had a bout of depression as a teenager. He also reported having social anxiety that improved dramatically with use of fluoxetine. Mr A denied substance use or abuse or having been the victim of abuse or trauma.

His medical history included asthma, glaucoma, scoliosis, a congenital deformity of his right arm, and an exploratory laparotomy for rectal perforation following insertion of a hanger.

His vital signs were stable. On mental status examination, he was awake, alert, oriented, comfortable sitting up on the stretcherand cognitively intact. His right arm had marked malformations proximal and distal, including his hand and fingers. There was no evidence of a thought disorder. His laboratory values were notable only for a white blood cell count of Individuals who insert foreign objects into their Dementic insertion of different objects bodily orifices span disparate backgrounds, ages, and lifestyles.

Children under the age of 20 years commonly swallow foreign bodies, accounting for approximately 80, cases each year; most of these are accidental ingestions in children between the age of 6 months and 4 years. In adolescents, intentional foreign body insertion often reflects risk-taking, Dementic insertion of different objects, or poor judgment while under the influence of drugs or alcohol or as a manifestation of psychological abnormalities.

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While the list of objects that patients insert into their orifices is long and sundry, most are common household Dementic insertion of different objects eg, beans, dried peas, popcorn kernels, hearing-aid batteries, raisins, beads, coins, chicken bones, fish bones, pebbles, plastic toys, pins, keys, buckshot, round stones, marbles, nails, rings, batteries, ball bearings, screws, staples, washers, pendants, springs, crayons, toothbrushes, vases, razor blades, soda cans and bottles, silverware, hinges, telephone cable, and guitar picks.

Once past the esophagus, the majority of swallowed foreign bodies pass through the alimentary canal without sequelae. The properties of involved objects often determine the complications associated with ingestion.

CASE VIGNETTE

Long, thin objects especially if more than 1 object has been ingested 68 tend to have more difficulty traversing the GI tract and are more likely to become entrapped.

Objects wider than 2 cm tend to lodge in the stomach and do not pass the pylorus ; objects longer than 5 cm tend to get caught in the duodenal sweep. Although most foreign bodies fail to cause significant anorectal injuries, complications can arise from their insertion or removal, or from the content they introduce. The complications of foreign bodies inserted into the penis Dementic insertion of different objects generally evident; most affected individuals seek care for relief of pain eg, from testicular torsion or scarring of the penis or inability to void.

Complications of genitourinary GU foreign body insertion include acute cystitis, dysuria, urinary frequency, hematuria, and strangury.

Some patients experience tears of the urethra, with periurethral abscesses, fistulas, and urethral diverticula. Complications of foreign bodies inserted into subcutaneous tissue are largely dependent on the type of object used along with the location of injury.

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Objects inserted into abdominal tissue carry the risk of stomach or bowel perforation, while insertion into the extremities may result in abscess formation or nerve injury; these may result in permanent functional impairment. Establishing the motivation for foreign object insertion is crucial to successful patient management Table 1.

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This may be facilitated by eliciting the patient's description of the psychological circumstances mental state preceding the insertion, by comparing the intended and actual effects of the insertion, and by taking a general psychiatric and developmental history.

Sexual gratification is commonly reported by patients and accepted by clinicians as the reason for autoerotic or consensual sexual acts involving the insertion of foreign objects into the erogenous zones of the urethra, 232428 — 30 vagina, 31 or rectum. Psychoanalysts have long observed that psychosexual energy libido can become invested in actions that do not lead directly to orgasm, such that some behaviors may be primarily reinforced by a compelling emotional payoff that has become layered upon a secondary outcome of orgasm, or occurs in the absence Dementic insertion of different objects orgasm.

A deeper understanding of the patient's situation may also distinguish between nonpathologic sexual preferences and the paraphilic disorders.

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When a patient's sexual history reveals a pattern of recurrent behaviors, fantasies, or urges involving nonhuman objects that causes significant distress or functional impairment, a paraphilic disorder fetishism may be diagnosed.

Nonsuicidal self-injurious behavior serving an emotional regulatory function is strongly associated with borderline personality disorder BPD. Such behavior can take the form of foreign body insertion eg, 76 needles and hair pins self-inserted under the skin of a woman's arms, head, and neck, which required surgical excision, 36 or straightened paper clips inserted into the forearm Suicide attempts by foreign body insertion usually involve oral ingestion of toxic solids eg, batteries or sharp objects such as pins.

Psychosis with or without mood disturbance can lead to foreign Dementic insertion of different objects insertion either directly in response to a delusional belief or command hallucination or indirectly via impaired judgment.

Depressive disorder with psychotic features has been reported in association with more bizarre insertions eg, ingestion of 50 pins 41 and insertion of needles through the chest wall Recurrent depressive illness without psychosis has also been diagnosed in some insertions leading to hospital attention.

Factitious disorder marked by the deliberate production of physical or psychiatric symptoms or signs to obtain the sick role 49 has been manifest by rectal Dementic insertion of different objects of a glass bottle neck 50 in the context of similar presentations for feigned or simulated illness, peregrination wandering or travelingand pseudologia fantastica pathological lying ; endoscopic retrieval detected that the object had been packed with paper, likely by the patient to afford himself some protection from internal trauma.

One illustrative example of malingering and social contagion 51 involved 6 males 3 met criteria for antisocial personality disorder and 3 for BPD living in a maximum-security hospital who copied each other's urethral self-insertion technique in a deliberate attempt to control hospital staff.

All 6 inserters reported that their behavior released tension, while the initial inserter reported a sadistic fantasy during insertion in which he imagined the damage being inflicted to the urethras of other people. Cognitive disorders may lead to foreign object insertion or influence its course. In one case series of 17 men who presented with urethral insertion, substance intoxication was detected in 6 men.

Finally, foreign bodies may be inserted for reasons not inherently psychopathological. These include nonpathologic sexual preference; exploratory misadventures occurring in children as isolated acts driven by simple curiosity 54 — Dementic insertion of different objects ; insertions by other people during sexual assaults or pranks 58 — 61 eg, a man's friends inserted tennis wire into his urethra at a stag party and another man's roofing colleagues forced cylindrical rolls of tar into his urethra to have fun at his expense ; drug concealment or smuggling 6263 ; and misguided attempts at contraception, Dementic insertion of different objects, or self-treatment of anal or urinary symptoms.

Although case reports of foreign body insertion are not uncommon, only a few large reviews on the subject exist; most were written before How people insert, embed, or ingest foreign bodies depends largely on the type of objects used, and the anatomic location of the object's placement. Upper GI tract foreign body ingestions are more common in those who are either young, have comorbid drug or alcohol use histories, have psychiatric illness, or are prisoners. Intentionally ingested items were typically common household items eg, pens, plastic spoons, toothbrushes, or pencilswhereas accidentally ingested items were often food impactions, bones, or coins.