Pagophagia

Pagophagia (pronounced pag-off-faghia)

(1) The excessive and constant eating of ice, often as part of extreme dieting.

(2) A craving to eat ice, sometimes associated with iron-deficiency anemia.

Pre 900: A compound word, the construct being págo(s) + -phagia.  Págos is from the Byzantine Greek, the perfective stem of ἔφαγον (éphagon) (I ate; I devoured), singular first-person aorist active indicative form (by suppletion) of ἐσθίω (esthíō) (I eat; I devour).  Phagia is from the Ancient Greek πάγος- (phag-) (stiff mass; frost; ice) from pēnunai, (to stick, stiffen), from the primitive Indo-European root pag.  It was used also in a derogatory, figurative sense to describe a cold, unfriendly person (in the sense of one metaphorically cold like ice).

Ice, diet and the DSM

Pagophagia (the excessive consumption of ice or iced drinks), is often regarded as a recent phenomenon and a novel manifestation of pica (a disorder characterized by craving and appetite for non-edible substances, such as ice, clay, chalk, dirt, or sand and named for the jay or magpie (pīca in Latin), based on the idea the birds will eat almost anything) but in texts from Classical Greece are warnings in the writings of both the physician Hippocrates (circa 460–circa 370 BC) and the polymath Aristotle (384–322 BC) concerning the dangers of the excessive intake of cold or iced water.  The cause of the death of Theophilus (Byzantine (Eastern Roman) Emperor 829-842) was officially dysentery but, based on the original texts of Byzantine historians and chroniclers of the era, modern researchers speculate the cause of death may have been related to Theophilus' pagophagia (snow eating), a long-time habit he indulged to relieve the symptoms of gastric inflammation.  In the medical literature, from the sixteenth century on, there are discussions and illustrative case histories about the detrimental effect of immoderate usage of cold water, ice and snow, frequently in the context of eating disorders, another range of conditions with a long history.

A noted feature of the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5 (2013)), was the more systematic approach taken to eating disorders, variable definitional criteria being defined for the range of behaviours within that general rubric.  What may have appeared strange was including the ice-eaters within the psychological disorder Pica which is characterized by the manifestation of appetite for non-nutritive substances including sharp objects (acuphagia), purified starch (amylophagia), burnt matches (cautopyreiophagia), dust (coniophagia), feces (coprophagia), sick (emetophagia), raw potatoes (geomelophagia), soil, clay or chalk (geophagia), glass (hyalophagia), stones (lithophagia), metal (metallophagia), musus (mucophagia), ice (pagophagia), lead (plumbophagia), hair, wool, and other fibres (trichophagia), urine (urophagia), blood (hematophagia (sometimes called vampirism)) and wood or derivates such as paper & cardboard (xylophagia).  DSM-5 also codified the criteria for behaviour to be classified pica.  They must (1) last beyond one (1) month beyond an age in infancy when eating such objects is not unusual, (2) not be culturally sanctioned practice and (3), in quantity or consequence, be of sufficient severity to demand clinical intervention.  Interestingly, when the text revision of DSM-5 (DSM-5-TR, 2022) was released, the sentence “individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa” was added to the description of the atypical anorexia nervosa example to clarify that the presence of physiological consequences during presentation does not mean that the diagnosis is the (typical) anorexia.

However, it must be remembered the DSM is a tool for the clinician and, while it can be a useful source document for the lay-reader, there are other publications better suited to those self-diagnosing or informally assessing others.  An individual for whom the only symptom of pica is abnormally high and persistent ice consumption doesn’t of necessity need to be subject to the treatment regime imposed on more undiscriminating consumers.

The pro-ana community does recommend the eating of ice, not merely as a food substitute but because the body needs to burn energy both to melt the ice and subsequently restore the body to its correcting operating temperature.  With frozen water, this effect is greatest in negative calorie terms but the discount effect applies even to iced confections.  If a frozen confection is listed as containing a calorie content of 100 (25 grams of carbohydrate @ 4 calories per gram), this does not include the energy the body expends to melt the ice and the net consumption is actually around 72 calories.

All things in moderation: Lindsay Lohan enjoying ice-cream and (an allegedly virgin) iced mojito, Monaco 2015.

Pro-ana does NOT however approve of frozen confections, the preferred one litre of frozen water containing zero calories yet demanding of the body a burn of around 160 calories to process, the energy equivalent of running one mile (1.6 km).  The practical upper limit per day appears to be between 3-5 litres (.8-1.3 gallons) depending on the individual and it’s speculated a daily intake much over eight litres may approach toxicity, essentially because the localized symptoms would be similar to hypothermia and some organs fail optimally to work when body temperature drops too much.  Paradoxically, pro-ana also notes, ice shouldn’t be eaten when one is too hot.  After running, the body actually exerts energy through the active effort of dissipating excess heat and if one were to ingest large amounts of ice as one was cooling off, some of the heat generated would be neutralized by the coolness of the ice, minimizing some of the energy burning benefits.  There’s also the need to avoid dental damage; pro-ana recommending it be allowed to melt in the mouth or consumed as shaved ice.

Autophagia

Autophagia (pronounced aw-tuh-fey-juh or aw-tuh-fey-jee-uh)

(1) In cytology, the process of self-digestion by a cell through the action of enzymes originating within the same cell (the controlled digestion of damaged organelles within a cell which is often a defensive and/or self-preservation measure and associated with the maintenance of bodily nutrition by the metabolic breakdown of some bodily tissues).

(2) In cytology, a type of programmed cell death accomplished through self-digestion (known also as apoptosis and associated with the maintenance of bodily nutrition by the metabolic breakdown of some bodily tissues).

(3) In psychiatry, self-consumption; the act of eating oneself.

The construct was auto- + -phagia.  The auto-prefix was a learned borrowing from Ancient Greek αὐτο- (auto-) (self-) (reflexive, regarding or to oneself (and most familiar in forms like autobiography)), from αὐτός (autós) (himself/herself/oneself), from either a construct of (1) the primitive Indo-European hew (again) + to- (that) or (2) the Ancient Greek reflexes of those words, αὖ (aû) (back, again, other) +‎ τόν (tón) (the) and related to Phrygian αυτος (autos), the existence of alternatives suggesting there may have been a common innovation.  Phagia was from the Ancient Greek -φαγία (-phagía) (and related to -φαγος (-phagos) (eater)), the suffix corresponding to φαγεῖν (phageîn) (to eat), the infinitive of ἔφαγον (éphagon) (I eat), which serves as aorist (A verb paradigm found in certain languages, usually an unmarked form or one that expresses the perfective or aorist aspect) for the defective verb ἐσθίω (esthíō) (I eat).  The alternative spelling is autophagal and the synonyms (sometimes used in non-specialist contexts) are self-consumption & auto-cannibalism.  Autophagia, autophagophore, autophagosome & autophagy are nouns, autophagically is an adverb, autophagocytotic is an adjective and autophagic is an adjective (and a non-standard noun); the noun plural is autophagies.

In cytology (in biology, the study of cells), autophagy is one aspect of evolutionary development, a self-preservation and life-extending mechanism in which damaged or dysfunctional parts of a cell are removed and used for cellular repair.  Internally, it’s thus beneficial, the removal or recycling of debris both efficient and (by this stage of evolutionary development) essential, most obviously because it removes toxins and “effectively “creates” younger cells from the old; it can thus be thought an anti-aging mechanism.  It something which has also interested cancer researchers because all cancers (as the word and the parameters of the disease(s) are defined) start from some sort of cell-defect and the speculation is it might be possible to in some way adapt the autophagic process, re-purposing it to identify and remove suspect cells.

In psychiatry, autophagia refers to the act of eating oneself which is sometimes described as self-consumption or the even more evocative auto-cannibalism.  Perhaps surprisingly, the behavior is not explicitly mentioned in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) which of course means there are no published diagnostic criteria nor recommendations for treatments.  The DSM’s editors note there are a number of reasons why a specific behavior may not be included in the manual notably (1) the lack of substantial empirical evidence or research, (2) the rarity of cases and (3) the material to hand being unsuitable (in terms of volume or quality) for the development of practical tools for clinicians to diagnose and treat a disorders.

It would be flippant to suggest autophagia might have been included when the revisions in the fifth edition of the DSM (DSM-5 (2013)) included a more systematic approach taken to eating disorders and as well as variable definitional criteria being defined for the range of behaviours within that general rubric, just about every other form of “unusual” consumption was listed including sharp objects (acuphagia), purified starch (amylophagia), burnt matches (cautopyreiophagia), dust (coniophagia), feces (coprophagia), sick (emetophagia), raw potatoes (geomelophagia), soil, clay or chalk (geophagia), glass (hyalophagia), stones (lithophagia), metal (metallophagia), musus (mucophagia), ice (pagophagia), lead (plumbophagia), hair, wool, and other fibres (trichophagia), urine (urophagia), blood (hematophagia (sometimes called vampirism)) and wood or derivates such as paper & cardboard (xylophagia).  The DSM-5 also codified the criteria for behaviour to be classified pica (a disorder characterized by craving and appetite for non-edible substances, such as ice, clay, chalk, dirt, or sand and named for the jay or magpie (pīca in Latin), based on the idea the birds will eat almost anything): they must (1) last beyond one (1) month beyond an age in infancy when eating such objects is not unusual, (2) not be culturally sanctioned practice and (3), in quantity or consequence, be of sufficient severity to demand clinical intervention.  However, pica encompassed only “non-nutritive substances” which of course one’s own body parts are not.

Finger food: Severed fingers are a popular menu item for Halloween parties; kids think they're great.  For those who like detail, those emulating nail polish seem to be following Dior shades 742 (top right) and 999 (bottom right). 

In the profession, autophagia seems to be regarded not as a progression from those who eat their fingernails or hair but something with more in common with the cutters.  Cutters are the best known example of self-harmers, the diagnosis of which is described in DSM as non-suicidal self-injury (NSSI).  NSSI is defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned; it includes behaviors such as cutting, burning, biting and scratching skin.  Behaviorally, it’s highly clustered with instances especially prevalent during adolescence and the majority of cases being female although there is some evidence the instances among males may be under-reported.  It’s a behavior which has long interested and perplexed the profession because as something which involves deliberate and intentional injury to body tissue in the absence of suicidal intent (1) it runs counter to the fundamental human instinct to avoid injury and (2) as defined the injuries are never sufficiently serious to risk death, a well-understood reason for self-harm.  Historically, such behaviors tended to be viewed as self-mutilation and were thought a form of attenuated suicide but in recent decades more attention has been devoted to the syndrome, beginning in the 1980s at a time when self-harm was regarded as a symptom of borderline personality disorder (BPD) (personality disorders first entered DSM when DSM-III was published in 1980), distinguished by suicidal behavior, gestures, threats or acts of self-mutilation.  Clinicians however advanced the argument the condition should be thought a separate syndrome (deliberate self-harm syndrome (DSHS)), based on case studies which identified (1) a patient’s inability to resist the impulse to injure themselves, (2) a raised sense of tension prior to the act and (3) an experience of release or at least partial relief after the act.  That a small number of patients were noted as repeatedly self-harming was noted and it was suggested that a diagnosis called repetitive self-mutilation syndrome (RSMS) should be added to the DSM.  Important points associated with RSMS were (1) an absence of conscious suicidal intent, (2) the patient’s perpetually negative affective/cognitive which was (temporarily) relieved only after an act of self-harm and (3) a preoccupation with and repetitiveness of the behavior.  Accordingly, NSSI Disorder was added to the DSM-5 (2013) and noted as a condition in need of further study.

However, although there would seem some relationship to cutting, it’s obviously a different behavior to eat one’s body parts and the feeling seems to be that autophagia involves a quest for pain and that suggests some overlap with other conditions and it certainly belongs in the sub category of self-injurious behavior (SIB).  The literature is said to be sparse and the analysis seems not to have been extensive but the behavior has been noted in those diagnosed with a variety of conditions including personality disorders, anxiety disorders, obsessive compulsive disorder, schizophrenia and bipolar disorder.  The last two have been of particular interest because the act of biting off and eating some body part (most typically fingers) has been associated with the experience of hallucinations and patients have been recorded as saying the pain of the injury “makes the voices stop”.  Importantly, autophagia has a threshold and while in some senses can be thought a spectrum condition (in terms of frequency & severity), behaviors such as biting (and even consuming) the loose skin on the lips (morsicatio buccarum) or the ragged edges of skin which manifest after nail biting (onychophagia) are common and few proceed to autophagia and clinicians note neurological reasons may also be involved.    

Lindsay Lohan with bread on the syndicated Rachael Ray Show, April 2019.

Autophagia and related words should not be confused with the adjective artophagous (bread-eating).  The construct was the Artos +‎ -phagous.  Artos was from the Ancient Greek ἄρτος (ártos) (bread), of pre-Greek origin.  Phagous was from the Latin -phagus, from the Ancient Greek -φάγος (-phágos) (eating) from φαγεῖν (phageîn) (to eat).  Apparently, in the writings of the more self-consciously erudite, the word artophagous, which enjoyed some currency in the nineteenth century, was still in occasional use as late as the 1920s but most lexicographers now either ignore it or list it as archaic or obsolete.  It’s an example of a word which has effectively been driven extinct even though the practice it describes (the eating of bread) remains as widespread and popular as ever.  Linguistically, this is not uncommon in English and is analogous with the famous remark by Sheikh Ahmed Zaki Yamani (1930–2021; Saudi Arabian Minister of Petroleum and Mineral Resources 1962-1986): “The Stone Age came to an end not for a lack of stones, and the Oil Age will end, but not for a lack of oil” (the first part of that paraphrased usually as the punchier “the Stone Age did not end because the world ran out of rocks”).