Xylophagia: a meta-synthesis of the literature

Publication Date28 November 2019
AuthorFahad Riaz Choudhry,Khadeeja Munawar,Bushra Akram,Yaser Mohammed Al-Worafi,Faizah Safina Bakrin,Li Ying Tey,Sabrina Anne Jacob,Goh Bey Hing,Tahir Mehmood Khan,Lee Learn Han,Anila Kamal
SubjectHealth & social care,Mental health
Xylophagia: a meta-synthesis of the
Fahad Riaz Choudhry, Khadeeja Munawar, Bushra Akram, Yaser Mohammed Al-Worafi,
Faizah Safina Bakrin, Li Ying Tey, Sabrina Anne Jacob, Goh Bey Hing, Tahir Mehmood Khan,
Lee Learn Han and Anila Kamal
Purpose The purpose of this paper is to provide an insight into xylophagia, its treatment, intervention
options, etiological causes and possible relationship with other diseases.
Design/methodology/approach A systematic search was performed across four scientific databases
(i.e. Ovid Medline, Embase via Ovid, PubMed and ProQuest). All of the qualitative studies reporting on
xylophagia from the inception of databases until August 2019 have been included. The quality of included
studies was assessed through a ten-item checklist given by Kmet et al. (2004).
Findings A total of 18 studies were included, and five primary themes emerged after analysis:
precipitation/onset of xylophagia, co-morbid psychiatric or medical illnesses, assessmentand investigation
modes to confirm diagnosis, outcomes of xylophagia and treatment options comprising medical care,
psychological care, counseling and duration of recovery. There were 16 females and 9 males in included
studies. The mean ages and standard deviations of males and females were 29.25(12.17) years and
32.81(11.92), respec tively. The mean duration and sta ndard deviation of paper pica were 4.8 0(4.27) years.
Research limitations/im plications Despite the limitation that this meta-synthesis is based
upon findings from case studies, results show that standardized medication regimens for treating
xylophagia are still not av ailable or are unknown. There is a dire need for fur ther research in order to better
understand the disorder. The healthcare professionals need to use reciprocal, mutually constituent
influence of biological and sociocultural factors in order to screen, diagnose and manage complex
psychological probl ems like xylophagia.
Originality/value The findings advance our understanding of the positive effects of patients and family
members undergoing counseling or cognitive behavior therapy in reducing stress and enhancing coping skills
thus, avoiding self-damaging behaviors.
Keywords Qualitative research, Quality of care, Health services, Health policy, Pica, Xylophagia,
Psychotherapy, Cognitive behaviour therapy
Paper type Literature review
Key points
1. This review provides an insight into xylophagia, its treatment and intervention options,
possible etiological causes, postulated relationships with other diseases and highlights its
inclusion in differentials of a medico-legal physician.
2. This paper highlights factors that lead to precipitation/onset of xylophagia, the co-morbid
psychiatric or medical illnesses, various assessment and investigation modes to confirm the
diagnosis of xylophagia, the outcomes of xylophagia and various treatment options
comprising medical care, psychological care, counseling and duration of recovery.
3. This review includes xylophagia studies from various countries and shows that xylophagia is
multifaceted and underdiagnosed.
4. There were females and males in included studies indicating its prevalence across gender.
5. This review suggests a need for biopsychosocial integration in diagnosing and treating
eating disorders.
Received 21 January 2019
Revised 23 August 2019
Accepted 23 August 2019
This research received no specific
grant from any funding agency in
the public, commercial or not-for-
profit sectors. All authors have no
conflict of interest.
(Information about the authors
can be found at the end of
this article.)
DOI 10.1108/MHRJ-01-2019-0005 VOL. 24 NO. 4 2019, pp. 275-297, © Emerald Publishing Limited, ISSN 1361-9322
PAG E 2 7 5
The simple act of eating has a certain cost to pay as food has been shown to be the cause of
millions of deaths globally due to various mechanisms. The consumptions of hundreds of
microbial, chemical and physical agents can result in illness and have various lethal outcomes
(Acheson, 1999; Jacob et al., 1990; Parakh et al., 2016; Dalal et al., 2013; Barros et al., 1991).
The forensic pathologists frequently come across cases of death by food and occasional and
culturally specific cases of death due to intentional or unintentional intake of pathogens, poisons,
and foodstuffs (Byard, 2017).
Xylophagia is described as the consumption of substances made up of wood such as paper,
pencils, boxes, toothpicks, matches and tree barks, with paper ingestion being the most
frequently reported type (Gowda et al., 2014; Moore and Sears, 1994). It is a form of pica, where
a person has a developmentally inappropriate compulsive yearning for and eats non-nutritive
substances (Blinder and Salama, 2008). Pica is explained in the field of medicine as an unnatural
appetite that initiates a craving for unhealthy substances. Other kinds of pica comprise
lithophagia (stone eating), geophagia (dirt eating), ice (pagophagia), gravel, paint flakes, clay, hair
(trichophagia) and laundry starch (amylophagia) (Byard, 2014; Parry-Jones and Parry-Jones,
1992; Loots and du Toit-Prinsloo, 2016). There has been much ambiguity in classification of this
disorder, with the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-V )
classifying it as an eating disorder in persons who fulfill the following criteria: persistent eating of
non-nutritive substances for a period of at least one month, the consumption of non-nutritive
substance that is inappropriate to the developmental level of an individual, eating behavior that is
not culturally supported or socially practiced, or the behavior is severe enough to call for
independent clinical attention if it occurs along with another mental disorder or medical condition
(APA, 2013). Others, however, have suggested that it is on the obsessive-compulsive disorder
(OCD) spectrum, given both the obsessive and compulsive features observed in patients (Bhatia
and Gupta, 2009; Gundogar et al., 2003; Hergüner et al., 2008).
A variety of factors are involved in the etiology of pica, such as genetic, biological and particularly
sociocultural and nutria-physiological aspects (Rose et al., 2000; Levine and Smolak, 2014).
Likewise, a past study has suggested the integration of sociocultural and biopsychiatric factors
in etiology and management of eating disorders (Levine and Smolak, 2014). A study conducted
on pregnant women in Mexico found that between approximately 30 and 50 percent of the
women consumed dirt, ashes, and clay, believing that failure to do so would lead to miscarriage
(Simpson et al., 2000). A large part of the literature also attributes it to iron deficiency, although
there remains some controversy as to whether it is a cause instead of an outcome of iron
deficiency (Kettaneh et al., 2005; Gupta et al., 2007). Other research studies have highlighted the
role of social and religious customs, where pica is considered culturally acceptable and is, thus,
not viewed as pathological (Blinder and Salama, 2008). This ambiguity has then resulted in
confusion as to how this condition should be treated. A review paper highlighting the forensic
implications of pica (Byard, 2014) shows that various fatal mechanisms result in the death of a
person with pica. In case of suspicion of pica in persons who are institutionalized or have
developmental delay, post-mortem examinations should cautiously analyze the possible side
effects of eating non-food substances (Byard, 2014). Authors highlight the presence of minimal
presenting symptoms and signs due to a variety of reasons.
In children aged between 18 and 36 months, an incidence of pica greater than 50 percent is
considered normal, and this is thought to decrease with age (Blinder and Salama, 2008). Among
institutionalized patients, prevalence rates range from 4 to 26 percent (Walker and Roberts,
2001), and it was noted that from 1999 to 2009, hospitalization rates due to pica increased by
more than 90 percent (Zhao and Encinosa, 2011). The intake of foreign bodies is commonly
observed in children and certain susceptible adult populations such as alcoholics, the elderly with
dentures, prisoners and individuals with psychiatric problems (Yamaguchi et al., 2014; Zouros
et al., 2014; Cangir et al., 2002; Velitchkov et al., 1996).
In most of the cases, the autopsy results reveal accidental intake of foreign bodies (e.g. meat or
bones). In rare cases, the autopsy results reveal non-food components (e.g. teeth, glass
fragments, dental crowns, batteries or small toys) (Sreetharan et al., 2004), and suicidal intent
VOL. 24 NO. 4 2019

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