Onset of Obsessive Compulsive Disorder in Pregnancy with Pica as the Sole Manifestation
A 26-year-old female presented to the dental Outpatient Department (OPD) with complaints of toothache. The dentist found that her teeth were abraded with irregular surfaces. She had the habit of eating uncooked rice and wheat for the last one-and-a-half years, hence, she was referred to the Psychiatry OPD. This habit started during fourth month of her pregnancy. She had an intense and irresistible urge to eat these substances despite being aware of their non-edible nature.\nEvery attempt of resistance was leading to a feeling of restlessness and anxiety, which resolved only after eating. Initially she was expecting it to subside within few months after delivery like earlier pregnancies, but it persisted with similar intensity. She never ate any other non-edible substance. Her choice between rice and wheat was determined by their availability and there was no preference for either. She always had abdominal discomfort because of her eating patterns. During the last six months she was subjected to multiple religious practices by faith healers, for treatment of the said supernatural illness, but without any result. Pregnancy was reported as uneventful except for swelling of the lower limbs. She delivered a healthy male baby vaginally at home. No other precipitating factor or stress was found.\nThere was no history of any other abnormal behavior or irrelevant talks, although wasting of time due to her eating habit resulted in inadequate care of the children. There was no history of other repetitive action, ritual or mental repetitions.\nShe had revealed a similar habit during her previous pregnancies four and six years prior. Every time it started during the third or fourth month and resolved spontaneously two-to-three months after delivery. Both the earlier pregnancies were uneventful and she delivered healthy male and female babies, respectively. There was no past history of psychiatric illness, medical illness, or substance abuse. She and her husband were farmers, living with their three children. Her paternal grandmother had a habit of excessive washing and cleaning. The patient was an illiterate tribal, unable to understand Hindi or English. All communications were mediated by her husband who understood Hindi with some difficulty. On mental status examination she had a depressed mood, in addition to preoccupation with ideas of eating raw rice or wheat. She acknowledged that these repetitive, irresistible thoughts were her own, but she could not describe any reason for her habit, except intense urges for it. No other obsession or compulsion was found. She was considered as a case of OCD presenting as pica. All routine investigations including hemoglobin level were normal. The serum micronutrient assay was not done, as it was not available at our center, it being a new medical institute. Behavior therapy was not considered because of the patient's language problem and reluctance of her husband. She was started on fluoxetine 20 mg once a day along with alprazolam 0.25 mg per day. After one month she reported mild mood lifting, although the craving and subsequent eating was unchanged. Fluoxetine was increased to 40 mg per day and alprazolam stopped. Significant improvement was noted in her eating habits and depression after taking 40 mg / day for two months. She was maintained on the same dose for six months, after which she was lost to follow-up.