Pica (disorder)

Pica
Stomach contents of a person with pica: 1,446 items, including "453 nails, 42 screws, safety pins, spoon tops, and salt and pepper shaker tops."
Pronunciation
  • /ˈpaɪkə/ PY-kə[1]
SpecialtyPsychiatry
SymptomsAppetite for and eating of substances that are not food[2]
ComplicationsLead poisoning, gastrointestinal obstruction, low red blood cells[2]
Duration> 1 month[2]
Risk factorsPregnancy, iron deficiency, other mental disorders, poverty, emotional trauma[2]
PrognosisUsually good[3]
FrequencyRelatively common[2]

Pica is a disorder characterized by the appetite for and eating of substances that are not considered food.[2] Generally the craving are for a few specific items such as soil, raw potatoes, ice, hair, or paint.[4] Often few signs are present though abdominal pain may occasionally occur.[2] Pica may lead to lead poisoning, gastrointestinal obstruction, low red blood cells, or parasitic infections.[2]

Pica is associated with pregnancy, iron deficiency, other mental disorders, poverty, malnutrition, and emotional trauma.[2][5] A formal diagnosis requires behaviors to persist for at least a month and be inappropriate for a persons age and culture.[2] To make the diagnosis the person most also be at least two years old.[3]

In children who are otherwise normal, pica while generally resolve with education around what is appropriate to eat.[2] Counselling, including behavioral therapy, may also be useful.[2] If iron deficiency is present this should be treated.[2]

Pica effects up to 30% of children and pregnant women.[2] In children it occurs most frequently in those between 18 months and 6 years of age.[2] Described of pica date back more than 2,000 years to Hippocrates.[5][6] The term is named for the common magpie (Pica pica) which eats unusual objects.[2]

Signs and symptoms

Chalky stone composed of kaolinite with traces of quartz ingested by a person with pica

Pica is the consumption of substances with no significant nutritional value such as soil, soap, or ice.[7] Subtypes are characterized by the substance eaten:[8]

  • Sharp objects (acuphagia)
  • Purified starch such as corn starch (amylophagia[9][10])
  • Burnt matches (cautopyreiophagia)
  • Dust (coniophagia)
  • Feces (coprophagia)
  • Vomit (emetophagia)
  • raw potatoes (geomelophagia)[11][12]
  • Earth, soil, clay (geophagia)
  • Glass (hyalophagia)[13]
  • Stones (lithophagia)[14]
  • Mucus (mucophagia)
  • Ice (Pagophagia)
  • Lead (lumbophagia)
  • Hair, wool, and other fibers (trichophagia)
  • Urine (urophagia)
  • Blood (hematophagia vampirism)
  • Wood, or derivates of wood such as paper (xylophagia)

This pattern of eating must last at least one month to meet the diagnosis.[15]

Complications

Complications may occur due to the substance consumed. For example, lead poisoning may result from the ingestion of paint or paint-soaked plaster,[16] hairballs may cause intestinal obstruction and Toxoplasma or Toxocara infections may follow ingestion of feces or soil.[17]

Mineral deficiencies are occasionally associated with pica, but biological abnormalities are rarely found.[18] People that eat soil, ice, and starch, are more likely anemic or have low hemoglobin concentration in their blood, lower levels of red blood cells (hematocrit), or lower plasma zinc levels.[19] Specifically, eating soil is more likely to be associated with anemia or low hemoglobin.[19] While eat ice and starch is more highly associated with anemia.[19] Additionally, children and pregnant women may be more likely to have anemia or low hemoglobin.[19]

Causes

More recently, cases of pica have been tied to the obsessive–compulsive spectrum, and a move has arisen to consider OCD in the cause of pica.[20] Pica is recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM 4). Sensory, physiological, cultural, and psychosocial perspectives have also been used by some to explain the causation of pica. Mental-health conditions, such as obsessive-compulsive disorder (OCD) and schizophrenia, have been proposed as causes of pica.[21]

However, pica can also be a cultural practice not associated with a deficiency or disorder. Ingestion of kaolin (white clay) among African-American women in the US state of Georgia shows the practice there to be a DSM 4 "culture-bound syndrome" and "not selectively associated with other psychopathology".[22] Similar kaolin ingestion is also widespread in parts of Africa.[23]

Diagnosis

While lab test do not confirm pica, because pica can occur in people who have lower than normal nutrient levels and poor nutrition, the testing blood levels of iron and zinc may be recommended. Hemoglobin can also be checked to test for anemia. Lead levels should always be checked in children who may have eaten paint or objects covered in lead-paint dust. The healthcare provider should test for infection if the person has been eating contaminated soil or animal waste.[15]

DSM 5

The DSM-5 posits four criteria that must be met for a person to be diagnosed with pica:[18]

  1. Person must have been eating non-nutritive nonfoods for at least one month.[18]
  2. This eating must be considered abnormal for the person's stage of development.[18]
  3. Eating these substances cannot be associated with a cultural practice that is considered normal in the social context of the individual.[18]
  4. For people who currently have a medical condition (e.g.: pregnancy) or a mental disorder (e.g.: autism spectrum disorder), the action of eating non-nutritive nonfoods should only be considered pica if it is dangerous and requires extra medical investigation or treatment on top of what they are already receiving for their pre-existing condition.[18]

Differential diagnosis

In individuals with autism, schizophrenia, and certain physical disorders (such as Kleine-Levin syndrome), non-nutritive substances may be eaten. In such instances, pica should not be noted as an additional diagnosis.[17]

Treatment

Treatment for pica may vary and suspected cause (e.g., child, developmentally disabled, pregnant, or psychogenic) and may emphasize psychosocial, environmental and family-guidance approaches; iron deficiency may be treatable though iron supplement through dietary changes. An initial approach often involves screening for, and if necessary, treating any mineral deficiencies or other comorbid conditions.[5] Reports have cautioned against the use of medication until all non-psychogenic causes have been ruled out.[24]

Looking back at the different causes of pica related to assessment, the clinician tries to develop a treatment. First, there is pica as a result of social attention. A strategy might be used of ignoring the person's behavior or giving them the least possible attention. If their pica is a result of obtaining a favorite item, a strategy may be used where the person is able to receive the item or activity without eating inedible items. The individual's communication skills should increase so that they can relate what they want to another person without engaging in this behavior. If pica is a way for a person to escape an activity or situation, the reason why the person wants to escape the activity should be examined and the person should be moved to a new situation. If pica is motivated by sensory feedback, an alternative method of feeling that sensation should be provided. Other nonmedication techniques might include other ways for oral stimulation such as gum. Foods such as popcorn have also been found helpful. These things can be placed in a “pica box” that should be easily accessible to the individual when they feel like engaging in pica.[25]

Behavior-based treatment options can be useful for developmentally disabled and mentally ill individuals with pica. Behavioral treatments for pica have been shown to reduce pica severity by 80% in people with intellectual disabilities.[26] These may involve using positive reinforcement normal behavior. Many use aversion therapy, where the patient learns through positive reinforcement which foods are good and which ones they should not eat. Often, treatment is similar to the treatment of obsessive-compulsive or addictive disorders (such as exposure therapy). In some cases, treatment is as simple as addressing the fact they have this disorder and why they may have it. A recent study classified nine such classes of behavioral intervention: Success with treatment is generally high and generally fades with age, but it varies depending on the cause of the disorder. Developmental causes tend to have a lower success rate.[27]

Treatment techniques include:[25]

  • Presentation of attention, food, or toys, not contingent on pica being attempted
  • Differential reinforcement, with positive reinforcement if pica is not attempted and consequences if pica is attempted
  • Discrimination training between edible and inedible items, with negative consequences if pica is attempted
  • Visual screening, with eyes covered for a short time after pica is attempted
  • Aversive presentation, contingent on pica being attempted:
  1. oral taste (e.g., lemon)
  2. smell sensation (e.g., ammonia)
  3. physical sensation (e.g., water mist in face)
  • Physical restraint:
  1. Self-protection devices that prohibit placement of objects in the mouth
  2. Brief restraint contingent on pica being attempted
  3. Time-out contingent on pica being attempted
  4. Overcorrection, with attempted pica resulting in required washing of self, disposal of nonedible objects, and chore-based punishment
  5. Negative practice (inedible object held against patient's mouth without allowing ingestion)

Epidemiology

The prevalence of pica is difficult to establish because of differences in definition and the reluctance of patients to admit to abnormal cravings and ingestion,[25] thus leading to the prevalence recordings of pica among at-risk groups being in the range of 8% to 65% depending on the study.[7] Based on compiled self-report and interview data of pregnant and postpartum women, pica is most prevalent geographically in Africa, with an estimated prevalence of 44.8%, followed by North and South America (23.0%) and Eurasia (17.5%).[28] Factors associated with Pica in this population were determined to be anemia and low levels of education, both of which are associated with low socioeconomic backgrounds.[28] Two studies of adults with intellectual disability living in institutions found that 21.8%[29] and 25.8%[30] of these groups suffered from pica.[31]

Prevalence rates for children are unknown.[31][32] Young children commonly place non-nutritious material into their mouths. This activity occurs in 75% of 12-month-old infants, and 15% of two- to three-year-old children.[32]

In institutionalized children with mental retardation, pica occurs in 10–33%.[32]

History

The condition currently known as pica was first described by Hippocrates.[6] It was in the category of “feeding disorders in infancy and early childhood” before the DSM 5, as pica was primarily diagnosed in children.[6] Diagnosis in all ages is becoming more common.[6]

The term pica originates in the Latin word for magpie, picave,[33] a bird that is famed for its unusual eating behaviors, where it is known to eat almost anything.[34] In 13th-century Latin work, pica was referenced by the Greeks and Romans; however, it was not addressed in medical texts until 1563.[5]

In the southern United States in the 1800s, geophagia was a common practice among the slave population.[5] Geophagia is a form of pica in which the person consumes earthly substances such as clay, and is particularly prevalent to augment a mineral-deficient diet.[35] Noteworthy is the fact that kaolin was consumed by West Africans enslaved in the Southeastern United States, particularly the Georgia belt, due to the antidiarrheal qualities in the treatment of dysentery and other abdominal ailments.[36] The practice of consuming kaolin rocks was thereafter studied scientifically, the results of which led to the subsequent pharmaceutical commercialization of kaolinite, the clay mineral contained in kaolin. Kaolinite became the active ingredient in drugs such as Kaopectate and Pepto-Bismol, although the formulations have since found additional active ingredients to replace kaolinite. [37]

Research on eating disorders from the 16th to the 20th centuries suggests that during that time in history, pica was regarded more as a symptom of other disorders rather than its own specific disorder. Even today, what could be classified as pica behavior is a normative practice in some cultures as part of their beliefs, healing methods, or religious ceremonies.[5]

Other animals

Unlike in humans, pica in dogs or cats may be a sign of immune-mediated hemolytic anemia, especially when it involves eating substances such as tile grout, concrete dust, and sand. Dogs exhibiting this form of pica should be tested for anemia with a complete blood count or at least hematocrit levels.[38][39] Although several theories have been proposed by experts to explain pica in animals, insufficient evidence exists to prove or disprove any of them.[40] Pica can also be found in animals such as dogs[40] and cats.

References

  1. ↑ "Pica". Merriam-Webster. Archived from the original on April 23, 2020. Retrieved April 19, 2020.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Leung, AKC; Hon, KL (2019). "Pica: A Common Condition that is Commonly Missed - An Update Review". Current pediatric reviews. 15 (3): 164–169. doi:10.2174/1573396315666190313163530. PMID 30868957.
  3. 1 2 Al Nasser, Y; Muco, E; Alsaad, AJ (January 2020). "Pica". PMID 30335275. {{cite journal}}: Cite journal requires |journal= (help)
  4. ↑ Luby, Joan L., ed. (2009). Handbook of preschool mental health : development, disorders, and treatment. New York: Guilford Press. p. 129. ISBN 9781606233504. Archived from the original on 21 November 2020. Retrieved 3 June 2016.
  5. 1 2 3 4 5 6 Rose EA, Porcerelli JH, Neale AV (2000). "Pica: Common but commonly missed". The Journal of the American Board of Family Practice. 13 (5): 353–8. PMID 11001006.
  6. 1 2 3 4 Michalska, Aneta; Szejko, Natalia; Jakubczyk, Andrzej; Wojnar, Marcin (2016). "Nonspecific eating disorders - a subjective review". Psychiatria Polska. 50 (3): 497–507. doi:10.12740/PP/59217. ISSN 2391-5854. PMID 27556109.
  7. 1 2 López, LB; Ortega Soler, CR; de Portela, ML (March 2004). "Pica during pregnancy: a frequently underestimated problem". Archivos Latinoamericanos de Nutricion. 54 (1): 17–24. PMID 15332352.
  8. ↑ Peter Sturmey; Michel Hersen (2012). Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders. John Wiley & Sons. p. 304. ISBN 978-0-470-33544-4. Archived from the original on 2016-05-28. Retrieved 2015-02-12.
  9. ↑ Coleman AM (2015). A Dictionary of Psychology. Oxford University Press. p. 576. See Google books link. Archived 2016-04-17 at the Wayback Machine
  10. ↑ Sturmey P, Hersen M (2012). Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders. John Wiley & Sons. p. 304. See Google books link. Archived 2016-04-06 at the Wayback Machine
  11. ↑ Coleman AM (2015). A Dictionary of Psychology. Oxford University Press. p. 576. See Google books link. Archived 2016-04-17 at the Wayback Machine
  12. ↑ Johnson, BE; Stephens, RL (1982). "Geomelophagia. An unusual pica in iron-deficiency anemia". The American Journal of Medicine. 73 (6): 931–2. doi:10.1016/0002-9343(82)90802-6. PMID 7148884.
  13. ↑ Andrew M. Colman (2015). A Dictionary of Psychology. OUP Oxford. p. 576. ISBN 978-0-19-105784-7. Archived from the original on 2020-08-20. Retrieved 2015-02-17.
  14. ↑ Somalwar, Ashutosh; Keyur Kishor Dave (March 2011). "Lithophagia: Pebbles in and Pebbles out" (PDF). Journal of the Association of Physicians of India. 59: 170. PMID 21751627. Archived from the original (PDF) on 2012-05-31. Retrieved 2012-07-22.
  15. 1 2 Pica Archived 2013-05-27 at the Wayback Machine New York Times Health Guide
  16. ↑ "Mental Health and Pica". WebMD. Archived from the original on 2020-11-11. Retrieved 2019-03-16.
  17. 1 2 Spitzer, Robert L. Diagnostic and Statistical Manual of Mental Disorders: (DSM III). Cambridge: Univ. of Cambridge, 1986. Print.
  18. 1 2 3 4 5 6 "Feeding and Eating Disorders". Diagnostic and Statistical Manual of Mental Disorders. DSM Library. American Psychiatric Association. 2013-05-22. doi:10.1176/appi.books.9780890425596.dsm10. ISBN 978-0890425558.
  19. 1 2 3 4 Miao, Diana; Young, Sera L.; Golden, Christopher D. (January 2015). "A meta-analysis of pica and micronutrient status". American Journal of Human Biology. 27 (1): 84–93. doi:10.1002/ajhb.22598. ISSN 1520-6300. PMC 4270917. PMID 25156147.
  20. ↑ Hergüner S, Ozyildirim I, Tanidir C (2008). "Is Pica an eating disorder or an obsessive-compulsive spectrum disorder?". Progress in Neuro-Psychopharmacology & Biological Psychiatry. 32 (8): 2010–1. doi:10.1016/j.pnpbp.2008.09.011. PMID 18848964. S2CID 207408405. Archived from the original on 2020-11-21. Retrieved 2020-01-31.
  21. ↑ Gull WW (1874). "Anorexia nervosa (apepsia hysterica, anorexia hysterica)". Trans. Clin. Soc. Lond. 7: 22.
  22. ↑ R. Kevin Grigsby, et al. "Chalk Eating in Middle Georgia: a Culture-Bound Syndrome of Pica?" Archived 2012-09-22 at the Wayback Machine Southern Medical Journal. 92.2 (February 1999). pp.190-192.
  23. ↑ Franklin Kamtche. "Balengou : autour des mines." Archived 2011-07-15 at the Wayback Machine (Balengou : around the mines) Le Jour. 12 January 2010. Retrieved 1 March 2010. (in French)
  24. ↑ Fotoulaki M, Panagopoulou P, Efstratiou I, Nousia-Arvanitakis S (2007). "Pitfalls in the approach to pica". European Journal of Pediatrics. 166 (6): 623–4. doi:10.1007/s00431-006-0282-1. PMID 17008997. S2CID 1429977. Archived from the original on 2020-11-21. Retrieved 2020-01-31.
  25. 1 2 3 Blinder, Barton, J.; Salama, C. (May 2008). "An update on Pica: prevalence, contributing causes, and treatment". Psychiatric Times. 25 (6).
  26. ↑ Hagopian, Louis P.; Rooker, Griffin W.; Rolider, Natalie U. (2011). "Identifying empirically supported treatments for pica in individuals with intellectual disabilities". Research in Developmental Disabilities. 32 (6): 2114–2120. doi:10.1016/j.ridd.2011.07.042. PMID 21862281.
  27. ↑ McAdam, David B.; Sherman, James A.; Sheldon, Jan B.; Napolitano, Deborah A. (January 2004). "Behavioral interventions to reduce the pica of persons with developmental disabilities". Behavior Modification. 28 (1): 45–72. doi:10.1177/0145445503259219. ISSN 0145-4455. PMID 14710707. S2CID 12112249.
  28. 1 2 Fawcett, Emily J.; Fawcett, Jonathan M.; Mazmanian, Dwight (June 2016). "A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period". International Journal of Gynaecology and Obstetrics. 133 (3): 277–283. doi:10.1016/j.ijgo.2015.10.012. ISSN 1879-3479. PMID 26892693. S2CID 205265004.
  29. ↑ Ashworth M, Hirdes JP, Martin L (2009). "The social and recreational characteristics of adults with intellectual disability and pica living in institutions". Research in Developmental Disabilities. 30 (3): 512–20. doi:10.1016/j.ridd.2008.07.010. PMID 18789647.
  30. ↑ Danford DE, Huber AM (1982). "Pica among mentally retarded adults". American Journal of Mental Deficiency. 87 (2): 141–6. PMID 7124824.
  31. 1 2 Hartmann AS, Becker AE, Hamptom C, Bryant-Waugh R (November 2012). "Pica and Rumination Disorder in DSM-5". Psychiatric Annals. 42 (11): 426–30. doi:10.3928/00485713-20121105-09.
  32. 1 2 3 Chatoor, I (2009). "Chapter 44: Feeding and eating disorders of infancy and early childhood". In Sadock, BJ; Sadock, VA; Ruiz, P (eds.). Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed.). Lippincott, Williams & Wilkins. p. 3607. ISBN 9780781768993.
  33. ↑ T.E C. Jr. (October 1, 1969). "Origin of the word pica". Pediatrics. 44 (4): 548. Archived from the original on October 15, 2018. Retrieved December 6, 2014.
  34. ↑ Thyer, Bruce A.; Wodarski, John S (2007). Social work in mental health: an evidence-based approach. John Wiley and Sons. pp. 133. ISBN 978-0-471-69304-8.
  35. ↑ "geophagy". Merriam-Webster Dictionary. Archived from the original on 27 October 2014. Retrieved 27 October 2014.
  36. ↑ Martin, Anthony (2013). Life Traces of the Georgia Coast: Revealing the Unseen Lives of Plants and Animals. Indiana University Press. p. 43. ISBN 978-0-253-00602-8.
  37. ↑ Pray, W. Steven; Pray, Joshua J. (2005). "Diarrhea: Sweeping Changes in the OTC Market". US Pharmacist. 30 (1). Archived from the original on 2016-09-20. Retrieved 2017-03-24.
  38. ↑ Plunkett, Signe J. (2000). Emergency Procedures for the Small Animal Veterinarian. Elsevier Health Sciences. p. 11. ISBN 978-0-7020-2487-0.
  39. ↑ Feldman, Bernard F.; Joseph G. Zinkl; Nemi Chand Jain; Oscar William Schalm (2000). Schalm's Veterinary Hematology. Blackwell Publishing. p. 506. ISBN 978-0-683-30692-7.
  40. 1 2 "Pica: Why Pets Sometimes Eat Strange Objects". The Humane Society of the United States. Archived from the original on March 14, 2016. Retrieved 20 July 2019.

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