8.7 Pica

Pica: Overview and Characteristics

Pica is a psychological disorder that is distinguished by an appetite for non-nutritive substances—items that do not provide nutritional value. Common substances consumed by individuals with pica include:

  • Ice
  • Soap
  • Hair
  • Paper
  • Metal
  • Soil
  • Stones
  • Glass
  • Chalk
    The term 'pica' is derived from the Latin word for magpie, "picave," which is a bird known for its indiscriminate eating habits.

Types of Cravings Associated with Pica

Individuals with pica may exhibit cravings for various substances, including but not limited to:

  • Acuphagia: Craving sharp objects
  • Amylophagia: Craving starch
  • Cautopyreiophagia: Craving burnt matches
  • Coniophagia: Craving dust
  • Coprophagia: Craving feces
  • Emetophagia: Craving vomit
  • Geomelophagia: Craving raw potatoes
  • Geophagia: Craving earth, soil, or clay
  • Hyalophagia: Craving glass
  • Lithophagia: Craving stones
  • Mucophagia: Craving mucus
  • Pagophagia: Craving ice
  • Plumbophagia: Craving lead
  • Trichophagia: Craving hair, wool, and other fibers
  • Urophagia: Craving urine
  • Hematophagia: Craving blood (vampirism)
  • Xylophagia: Craving wood or wood derivatives

Figure 1: Consuming non-nutritional substances like rocks can lead to surgical emergencies.

Implications of Pica

Pica is often viewed as a significant disorder that calls for clinical attention due to its potential consequences, which can include:

  • Intoxication in children leading to impaired physical and mental development.
  • Surgical emergencies necessitated by intestinal obstructions.
  • Nutritional deficiencies and the occurrence of parasitosis (infection or infestation with parasites).

Related Stressors and Vulnerable Populations

Pica has been linked to various mental and emotional disorders. Stressors correlated with the onset of pica include:

  • Emotional trauma
  • Maternal deprivation
  • Family issues
  • Parental neglect
  • Pregnancy
  • Disorganized family structures

Pica is most frequently diagnosed among:

  • Pregnant women
  • Small children
  • Children with iron and zinc deficiencies
  • Malnourished children
  • Individuals with intellectual disabilities
Health Risks

Children consuming painted plaster—especially those containing lead—or soil near roads may be at risk of lead poisoning and subsequent brain damage. Risks associated with pica also include:

  • Gastrointestinal obstruction or tearing of the stomach
  • Ingestion of animal feces and related parasites
  • Pica can also be observed in animals, including dogs and cats.

Associations with Nutritional Deficiencies

Pica behaviors such as geophagy, pagophagy, and amylophagy are often associated with:

  • Anemia, resulting in low hemoglobin concentration
  • Lower levels of red blood cells (hematocrit)
  • Decrease in plasma zinc levels
    Research indicates:
  • Geophagy: Most tied to anemia and low hemoglobin levels.
  • Pagophagy and Amylophagy: Also strongly correlated with anemia.
  • Young children and pregnant women are more likely to exhibit anemia relative to the general population.

Psychological Aspects and Diagnosis of Pica

Recently, pica has been recognized as potentially linked to the obsessive-compulsive spectrum, prompting consideration of Obsessive-Compulsive Disorder (OCD) as a potential causal factor.

Diagnosis:
No singular diagnostic test confirms pica; however, the following steps are recommended:

  • Assess blood levels of iron and zinc due to their association with malnutrition.
  • Check hemoglobin levels to evaluate for anemia.
  • Evaluate lead levels, especially in children suspected of ingesting lead-painted materials or objects.
  • Screen for infections if there is a history of consuming contaminated soil or animal waste.
DSM-5 Diagnostic Criteria for Pica

The DSM-5 outlines four criteria essential for diagnosing an individual with pica:

  1. The individual has been eating non-nutritive, non-food items for at least one month.
  2. This behavior is considered abnormal for the person's developmental stage.
  3. The consumption of these items is not in line with cultural practice recognized within the individual's social context.
  4. The behavior must not occur exclusively during the course of another mental disorder (e.g., autism spectrum disorder).

Epidemiology of Pica

Establishing accurate prevalence rates for pica is challenging due to varying definitions and patients' reluctance to disclose their behavior. Available data on at-risk populations estimates the prevalence of pica ranges from 8% to 65%, depending on individual studies.

Geographically, pica is most prevalent in:

  • Africa: 44.8%
  • North and South America: 23.0%
  • Eurasia: 17.5%
    Associated factors with pica prevalence include anemia and low educational levels, generally observed in lower socioeconomic groups.

Among adults with intellectual disabilities in institutions, studies have reported pica occurrence rates of 21.8% to 25.8%.

Pica in Children

Prevalence rates in children are not well documented. However, it is observed that:

  • 75% of 12-month-old infants commonly place non-nutritious objects in their mouths.
  • 15% of children aged two to three years exhibit similar behaviors.
    In institutional settings, the prevalence of pica among children with mental retardation ranges from 10% to 33%.

Treatment Approaches for Pica

Treatment for pica varies depending on patient circumstances and the suspected underlying cause (e.g., developmental issues, pregnancy-related, or psychogenic). The following focus areas are common in managing pica:

  • Psychosocial interventions
  • Environmental modifications
  • Family guidance strategies
  • Addressing iron deficiency through supplementation and dietary adjustments

Initial Approach:

  • Screening for, and if necessary, addressing any mineral deficiencies or co-occurring medical conditions.
    For psychogenic causes, therapeutic interventions and medications such as SSRIs may be utilized. However, it is advised to rule out all non-psychogenic causes before considering pharmacological treatments.

Behavioral Treatment Options

Behavior-based treatments for pica have been shown to effectively reduce pica severity, particularly in individuals with intellectual disabilities, by up to 80%.
Common techniques include:

  • Positive reinforcement to encourage healthy eating behaviors
  • Aversion therapy to promote understanding of acceptable versus unacceptable food choices
General Treatment Methods:
  1. Unconditional reinforcement (attention, food, or toys) not dependent on attempting pica
  2. Differential reinforcement for not attempting pica versus consequences for attempting
  3. Discrimination training with negative consequences for trying to eat inedible objects
  4. Visual screening exercises with eyes covered post-attempt
  5. Aversive stimuli (taste, smell, or physical sensations) when pica is attempted
  6. Self-protection devices to prevent the incorrect placement of objects in the mouth
  7. Behavior management such as time-out after attempts
  8. Overcorrection or punishment following pica attempts
  9. Negative practice (presenting inedible objects to the mouth without ingestion)

Case Study: Skyler

[Details of a specific case study were to be provided in subsequent segments but are not included here.]