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‘Uncommon manifestations of mental health conditions require customised treatment’

16 Jun 2021

  • Study highlights lack of guidelines on managing coprophagia associated with schizophrenia

By Ruwan Laknath Jayakody   Clinicians need to customise treatment plans to manage uncommon manifestations associated with mental health conditions, such as coprophagia in the case of schizophrenia, according to the underlying psychopathology and other clinical features, as presently, there is a lack of guidelines on how to manage the said condition, a case report noted. This advice was given in the case report on “Successful treatment of coprophagia in resistant schizophrenia”, authored by D. Jayakodi (attached to the Peradeniya Teaching Hospital’s Psychiatry Unit) and S.R. Perera (attached to the same unit and the Peradeniya University’s Medical Faculty’s Psychiatry Department) and published recently in the Sri Lanka Journal of Psychiatry.  The condition of coprophagia involves, as noted by H. Azizi, T. Khan, C. Canale, J. Kallikkadan, I. Leung, A. Khan, D. Rimawi, S. Williams, C.M. Obegolu, S. Paul, S. Chaudhry, C. Ojimba, K. Kodjo, O. Olayinka, O. Jegede, and A. Jolayemi in “The Pathophysiology and Management of Coprophagia: A Report of Two Cases and Literature Review”, the compulsive consumption of faeces. In addition to its rare association with schizophrenia (only a few cases have been reported, according to “Coprophagia in a schizophrenic patient: Case report” by S.K. Chaturvedi and “Coprophagia in an Eight-Year-Old Hospitalised Patient: A Case Report and Review of the Literature” by A. Bacewicz and K. Martin), psychiatric disorders including dementia, autism, and obsessive compulsive disorder too have an association with the same, as noted by K.A. Josephs, J.L. Whitwell, J.E. Parisi, and M.I. Lapid in “Coprophagia in neurologic disorders”. Coprophagia can result in serious complications. Therefore, even though there is no consensus regarding its management, Jayakodi and Perera noted that it is treated with interventions which are both pharmacological (through the use of atypical or second generation antipsychotics, mood stabilisers, and selective serotonin reuptake inhibitors as per Bacewicz and Martin, and “Coprophagia in an Elderly Man: A Case Report and Review of the Literature” by D.A. Beck and N.R. Frohberg) and behavioural (strategies based on behavioural theories and cognitive behavioural therapies as per “The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta analysis” by M.V.D. Gaag, L.R. Valmaggia, and F. Smit, and “The treatment of hallucinations in schizophrenia spectrum disorders” by I.E. Sommer, C.W. Slotema, Z.J. Daskalakis, E.M. Derks, J.D. Blom, and M.V.D. Gaag). Jayakodi and Perera presented a case of the successful management of coprophagia in a patient with resistant schizophrenia.   Case report The patient was a 32-year-old male from Gampola. He had been on treatment for schizophrenia for the past 15 years. Due to resistance posed by symptoms to other antipsychotics, for the past two months, he had been given a daily dose of an atypical or second-generation antipsychotic medication. He was admitted to the psychiatry ward due to a recent exacerbation of his symptoms. He reported that two persons known to him and based in Kelaniya were monitoring him and controlling his emotions and activities, through a device implanted underneath his scalp. He said that he had often heard the duo discussing him, making references to him in the third person. Coprophagia was noted during the first day of his recent admission, with the staff observing him to be defecating and consuming his faeces, multiple times during the day. When asked about this, he reported that he ate his own faeces in response to the voices which commanded him to do so. Though undisclosed, this behaviour had been taking place over the past three years. There are also, Jayakodi and Perera mention, case reports of secondary obsessive compulsive symptoms occurring in the course of schizophrenia, due to treatment with atypical or second generation antipsychotics; however, it is not applicable in this instance, as the patient exhibited the compulsive eating of faeces prior to being started on a particular atypical or second-generation antipsychotic medication and whilst being treated with other such antipsychotics. Although the voices never threatened him, he had felt compelled to carry out the command, as it caused him unbearable distress if he did not do so. He said that eating faeces gave him temporary relief from this distress. There was an urgent need, therefore, Jayakodi and Perera emphasised, to control his coprophagia, because the command auditory hallucination he was experiencing was causing him great distress and the only way he knew how to reduce this distress was by eating his faeces. Jayakodi and Perera observed that the symptom of coprophagia, in this instance, had a compulsive nature to it, although the thought was secondary to a command hallucination and not an obsession. He did not have any obsessions or compulsions at the onset of this symptom, nor during previous exacerbations. The dose of the same atypical or second-generation antipsychotic was gradually increased. He was also prescribed an antidepressant from a group of drugs called selective serotonin reuptake inhibitors in order to reduce his distress and the compulsive nature of the behaviour, and the dose was titrated. He also underwent cognitive behaviour therapy, where the therapist encouraged him to recognise the hallucination as a voice, while encouraging him not to take part in the action of ingesting faeces. According to Gaag et al. and Sommer et al., auditory hallucinations in schizophrenia have responded to cognitive behaviour therapy. Further, F. Schirmbeck and M. Zink note in “Clozapine (atypical or second-generation antipsychotic medication) induced obsessive compulsive symptoms in schizophrenia: A critical review” that cognitive behavioural therapy reduces catastrophic appraisals, which in turn reduces anxiety and distress, while enhancing new coping strategies. Following almost six weeks of hospital stay, which included 10 biweekly sessions of psychotherapy, together with the combination of the medicinal treatment, his coprophagia ceased and he appeared to have reduced anxiety and distress. He is currently being followed up as an outpatient. Although he continues to have some hallucinations, he is not distressed by them, and is able to distract himself with adaptive coping strategies. Jayakodi and Perera explained that the therapy could also have helped him gain some insight, which led to him avoiding the compulsion to eat his faeces.


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