Humans tend to fear things that they don't understand and that are unknown. Mental illnesses and suicide are taboo topics that nobody wants to discuss. Neither topic lends itself to a clear cause-and-effect relationship, and suicide generally has the added layer of twisted roles i.e., the perpetrator and victim being the same - who do you really blame and whom do you sympathize with?  Most of us only get glimpses of such topics from movies or news, which are sometimes exaggerated or miss out on important details to maintain the privacy of individuals involved.     

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The intention of putting this out is to help anyone - spouse, parents, family, or friends coping with similar mental health challenges or the loss of a loved one to suicide. I sincerely hope that all of what I'm sharing helps to make some sense of the chaos in this anomic situation and provides some relief to the silent sufferers. 

 

Onwards..

My wife took her own life a few months ago and the whole world turned upside down for me and our families. While trying to find answers for this sudden and extremely unfortunate mishap, I am undergoing a journey full of pain and life learnings.

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She had informed me that she had a condition called Pica since she was 13-14 year old.

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Pica is an eating and mental disorder wherein the affected person ingests inedible items like soil, chalk, nails, paper and other such objects. Pica usually falls on the OCD spectrum and is categorized in the Manual of Mental disorders DSM IV. There have been many case studies reported wherein varied causes of Pica are observed but the primary factor seems to be early childhood mental trauma. Low iron and vitamin levels are also observed as symptoms. Depending upon the duration for which Pica remains untreated and if the coping/ compulsive behavior of ingesting inedible items is removed without medical supervision, it could even lead to suicidal tendencies. The compulsive coping behavior cannot be wished away through willpower/ positivity alone. The patients may be unable to articulate what exactly is the condition that is troubling them and may innocuously state that they like the taste, smell or other characteristics of the inedible items. Furthermore, due to the stigma, lack of understanding and embarrassment surrounding the topic, the patient may choose to avoid or maybe unable to articulate the physical and mental sensations immediately before or while engaging in Pica behavior.

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Whenever she was caught giving in to Pica's behavior, she showed helplessness to avoid the behavior. She also liked the smell of petrol, fresh paint and smoke/ smell of cigarettes. Upon her parents taking her for a diagnosis to a doctor in the initial few years, she was prescribed supplements (iron and other vitamins) and eating green leafy vegetables and fruits. The Pica behavior used to stop intermittently and whenever the stress increased due to familial matters or academics or otherwise, she resorted to extreme Pica behavior. Due to this, she even experienced difficulty in passing stool sometimes. This condition of my wife was divulged by her parents to some of her relatives too for discussing solutions for Pica but was mostly taken in a lighter vein during family gatherings, which further discouraged her from openly discussing her problem to avoid embarrassment. 

 

She had confided in me about her Pica affliction a few months before we got married. Frankly, I didn't think too much about it as she seemed so sorted otherwise. And, who was I to question her, when I was hardly perfect myself. Post our marriage, no abnormality in her behavior generally was observed by me since the Pica behavior is usually resorted in a private setting like a study room, restroom etc. In contrast to indulgence in other addictions like alcohol, which has relatively more social acceptability and needs more space with elaborate arrangements. But, Pica's behavior can be resorted to quickly on the pretext of going to the toilet or working alone in a room with the door latched, which cannot be usually doubted. It also does not involve a lot of effort - the affected person can source pins, hair, paper, soil, and other objects easily which are usually available at home. The only way to notice the behavior is if someone saw her during her Pica behavior or when she honestly replied upon being questioned about her Pica behavior. During our ~ decade-long relationship, she was only found once by me giving in to Pica behavior and she seemed to be more perturbed about being caught rather than giving in to Pica compulsive behavior.

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Since my wife was doing well from a career, family and financial standpoint, we both wanted to proceed with planning our baby as she reached her late 20’s. Based on extensive online research, it was found that her Pica had a co-morbid condition of Celiac disease, which is an autoimmune disease. 

 

In Celiac disease, the affected person has a sensitivity to gluten, the protein found in wheat grain. Celiac disease can be confirmed by conducting certain medical tests [1) Tissue TransGlutaminase Antibody IgA and ii) Gliadin-IgG Antibodies De-amidated (DGP) Serum] and/ or biopsy. Depending upon the duration for which the Celiac disease is left untreated and if the gluten protein is not removed from diet, it could even lead to cancer in the intestine due to constant inflammation from gluten. Celiac also has some common symptoms with Pica i.e. decrease in iron and vitamins in the body. Your medical consultant could even remove dairy products from the diet initially to double-check for dairy allergens too. 

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At this point, we were euphoric about having been able to find the connection between Pica and Celiac. The Celiac diagnosis helped to explain the severely adverse biomarkers. This led us to believe that the real culprit was Celiac (physical disease) and not Pica (mental illness). However, it was wrongly assumed by us that it was a purely physiological disorder and due to selective bias, the references and indications of mental illness were completely ignored/ missed.

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There have been some bidirectional studies that hypothesize that patients who have autoimmune disorders are at an increased risk for having psychiatric conditions, such as anxiety and depression, and vice versa. However, I’ve not found anything conclusive to confirm the chain of morbidity or independent existence of morbidities or some combination of it i.e. Celiac leads to Pica Or Pica leads to Celiac Or something else.

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This led us to consult an expert who had prior experience with Pica and Celiac. The expert prescribed that we may not plan a kid most likely for the next year till the initial biomarkers of my wife (iron, hemoglobin, CRP serum) do not become normalized. Fortunately, within the next 6 months, the biomarkers became normal and my wife was able to avoid the Pica behavior completely while she was on a very strict Celiac diet during this period. After the go-ahead from the expert, we started trying for a baby. Even the highly regarded expert (and I who used to stay 24X7 at home due to WFH) did not have any inkling of Pica or Celiac being connected to mental illnesses in my wife’s situation, as she did not show abnormality in any way.

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But the insidious nature of mental illnesses manifests cunningly. Within the next 2 months (almost after 14 years of Pica onset), on a very normal working day, my wife died by suicide due to normal work and life stress which was exponentially exacerbated in her mind due to cognitive distortion. This may have occurred due to a major anxiety episode and unbearable psychache, finally resulting in taking her own life.

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Nobody knows how many, if any, suicide attempts were made before the one that took her life. Due to some adverse experience at some point in her life, it may have been residing as trauma and anxiety in her body (for further such insights, read the brilliant book - The Body Keeps the Score by Dr. Kolk). This trauma described above/ anxieties flared up dangerously out of control, whenever she faced normal stresses of life. Strangely all this was a mental experience along with Pica's compulsive coping behavior and erupted only when she was stressed and alone.

 

I did not observe any substantially adverse or abnormal tendencies, except a few emotional bouts which were dismissed as normal behavior. However, there were regular observations of legs being crossed while sleeping which was later confirmed as Restless Legs Syndrome (RLS) due to iron deficiency and constant dreams of demons and snakes which was dismissed mutually by us as nothing to be concerned about. Also, I was able to recall a condition that involuntarily occurred 4-5 times for not more than 10-15 seconds at a time sporadically towards the last few months before my wife's death called Oculogyric Crisis (OGC).

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OGC is characterized by a prolonged involuntary upward deviation of the eyes accompanied by blinking of eyes and usually occurs due to caffeine, and stress and indicates dopamine deficiency.

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On sharing such a fact with her, she seemed unaware and quite surprised that OGC had occurred without her conscious knowledge. She also confessed that nobody had told her about it until then, except me and another schoolmate during her school time. It was mutually termed incorrectly as something not to be taken seriously or worried about.

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Given that my wife was highly functional at her job and generally in life, we considered only the Pica behavior to be an abnormality. The materiality of the affliction was ignored from the standpoint of aggregation of multiple contributory factors. The unfortunate accumulation of aggravating factors which may have cumulatively contributed to my wife's death were:

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i)      Frustration towards life due to restricted diet in Celiac (have heard exact utterances like some of these from her)
ii)     Pica (Undiagnosed mental illness - most likely OCD and Pica as compulsive coping behavior)

iii)    Celiac

iv)    2nd wave Covid cases and lockdown uncertainty - anomic conditions

v)     OGC recurrence

vi)    Restless legs syndrome 

vii)   Dreams of demons and snakes

viii)  Work stress due to deadlines and new untrained staff

ix)    Unable to exercise due to work and home commitments

x)     Very late night working during busy periods

xi)    Erratic sleep schedule and sleep deprivation

xii)   Heavy caffeine (coffee) intake in her last 1.5 months​

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Even though I've titled this page as 'Our Story' but who knows something like this is playing out in others' lives too. We, as individuals and our problems are not as unique as we like to think of them to be. 

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Tags: Pica, Celiac, Sprue, OCD, Obsessive Compulsive Disorder, RLS, Restless Legs Syndrome, OGC, Oculogyric Crisis, Soil eating, Paper eating, Xylophagia, Chalk eating, mental illness, mental health, suicide, die by suicide, Grief

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