Pica is an unusual craving for and ingestion of
either edible or inedible substances. The condition has been described in
medical journals for centuries.1 One of the first cases of pica was
noted in 6th century AD and was observed in a pregnant woman.1 Since
then, many cases of pica have been reported where patients have acknowledged
ingesting ice cubes, clay, dried pasta, chalk, starch, paste, kayexalate resin,
tomatoes, lemons, cigarette butts, hair, lead and laundry starch.2
Pica is a medical term which comes from the latin
word Magpie or Pica-Pica, a bird that by folklore incessantly gathers objects
to satiate its curiosity.
Glossary of terms
Many terms have been coined to describe certain
picas. These terms have in common a Greek root for the material ingested
followed by phagia, for eating. An exemplary glossary is provided in the
Dirt or Clay eating
Dirt eating (archaic)
stone or gravel eating
burned match eating
Trichophagia: hair eating
Classification under DSM-V
Pica, as per DSM V falls under the classification
of Feeding & Eating Disorders.
Pica is most commonly seen in children and pregnant
In some populations, the eating of earth or other
seemingly nonnutritive substances is believed to be of spiritual, medicinal or
other social value, or may be culturally supported or a socially normative
practice. Such behaviours do not warrant a diagnosis of pica.
Neglect and lack of supervision can increase the
risk for pica.
Pica occurs in both males and females. It can occur
in females during pregnancy; however little is known about the course of pica
in the postpartum period.
Pica is often seen in mentally or developmentally
disabled persons. Several recent studies suggest significant psychiatric
comorbidity as a determinant of pica.3,4 Kraeplin was the first to
document an extraordinary array of inedible materials consumed by psychotic
patients and felt that this behaviour might be a vegetative sign of psychosis,
"a perversion of the appetite." Delusional schizophrenic patients may
ingest glass, pins, or various other nonnutritive items, and driven
nonnutritive eating has been seen in disorganized schizophrenic patients.5,6
The prevalence of pica is unclear because of
differences in definition and the reluctance of patients to admit to abnormal
Although pica is most prominent in individuals with
developmental disabilities, it has been observed in men and women of all ages
and ethnicity, but is more prevalent among the lower socioeconomic classes.
Worldwide, 25% to 33% of all pica cases involve
small children; 20% are pregnant women; and 10% to 15% are individuals with
learning disabilities. A small percentage of patients have iron deficiency
When associated with iron deficiency, most
physicians believe that pica is an effect of iron deficiency rather than a
1. An incidence of pica greater than 50% is
considered normal in children 18 to 36 months old. Pica is thought to decrease
with age; one study showed that 10% of children older than 12 years engage in
pica.8 Persistence of excessive hand to mouth movements observed in
pica is abnormal in children older than 36 months old.
2. In the developmentally disabled, there are
changes in incidence of pica with age, IQ, medication, and manifestations of
behaviour and appetite.
3. An increased incidence of pica has been found to
occur in patients with CNS congenital anomalies and associated medical
problems, such as diabetes, deafness and seizures.9
4. The incidence of pica has also been found to be increased
in patients taking neuroleptics, which may be related to diminished
postsynaptic dopamine receptor changes.10,11
5. Demographic studies reveal that pica has been
associated with diets that are low in iron, zinc and calcium compared with a
balanced controlled diet.12
6. Ethnic differences occur in pica.
Pica is endemic among sedentary aborigines in Australia,
where clay has been eaten as a fertility food.12
young women were encouraged to eat clay to enhance their fertility. Similar
ideas shared in black culture encouraged pregnant females, both in Africa and
later in the US,
to eat various types of clay to enhance childbearing.13
In medieval times, girls ate unusual foods on St
Valentine’s Day to make them dream of their future husband.
However contemporary health education and
availability of medical care have diminished these practices.
Statistics for pica in BSMHCC
1) Pica is need determined behaviour and this
theory is supported by studies of food selection in young infants.14
2) Studies of food selection by Rolls suggest 2
adaptive mechanisms in the control of eating:
(1) Sensory specific satiety in which a person's
perception of a specific food as pleasant decreases with increasing intake of
that food, while other foods not eaten increase in pleasantness as a function
of time since last eaten.
(2) Neophobia, the avoidance of food not in a
person's current food repertoire.
Sensory specific satiety leads to increased variety
of food and neophobia ensures against eating possibly dangerous or non
nutritive foods. Perhaps both mechanisms are impaired or inoperative in persons
3) Pica has been associated with occult Fe
deficiency, which resulted in the sudden appearance of eating non-nutritive
objects such as match heads15 and raw potatoes.16
Iron deficiency has been reported to be linked to
decreased CNS neurotransmission which causes food and non food pica.
Appetite regulation is believed to result from Fe
dependent CNS neurochemical processes.17
However, on the other hand, some study findings
suggest that pica may be a cause of Fe deficiency in which the non-nutritive
substances (eg clay, starch) interferes with the dietary intake or absorption
of iron. 18
Further research on the neurobiological basis of
pica is clearly desirable.
There is one report of a schizophrenic patient who
developed pica during the course of treatment with olanzapine. The mechanism of
pica development in this case could have been due to the mechanism of blockade
of olanzapine on the 5- HT2a receptors, resulting in an increase of dopamine
release in the midbrain and frontal cortex, and further causing corticobasal
Diagnostic Clinical Features
A person suffering from pica must show persistent
eating of nonnutritive, nonfood substances over a period of at least 1 month.
The eating of nonnutritive, nonfood substances is
inappropriate to the developmental level of the individual.
The eating behaviour is not part of a culturally
supported or socially normative practice.
If the eating disorder occurs in the context of
another mental disorder (eg intellectual disability, autism spectrum disorder,
schizophrenia or medical condition including pregnancy, it is sufficiently
severe to warrant additional clinical attention.
Pica is often diagnosed in a hospital emergency
room, when the child or adolescent develops symptoms of lead poisoning, bowel
perforation, or other medical complications caused by the nonfood items that
have been swallowed. Laboratory studies may be used to assess these
complications. The choice of imaging or laboratory studies depends on the
characteristics of the ingested materials and the resultant medical problems.
The examining doctor may order a variety of imaging
studies in order to identify the ingested materials and treat the
gastrointestinal complications of pica. These imaging studies may include the
• abdominal x rays
• barium examinations of the upper and lower
gastrointestinal (GI) tracts
• upper GI endoscopy to diagnose the formation of
bezoars (solid masses formed in the stomach) or to identify associated injuries
to the digestive tract
Films and studies may be repeated at regular
intervals to track changes in the location of ingested materials.
Complications of Pica
2.Mercury & Lead Poisoning
4. Dental Caries
The Rapunzel syndrome is an extremely rare
intestinal condition in humans resulting from eating hair (trichophagia).21
The syndrome is named after the long-haired girl Rapunzel in the fairy
tale by the Brothers Grimm. Trichophagia is sometimes associated with the
hair-pulling disorder trichotillomania.22
1. Anorexia Nervosa. Pica can usually be
distinguished from the other feeding and eating disorders by the consumption of
nonnutritive, nonfood substances. It is important to note however, that some
presentations of anorexia nervosa include ingestion of nonnutritive, nonfood
substances, such as paper tissues, as a means of attempting to control
appetite. In such cases, when the eating of nonnutritive, nonfood substances is
primarily used as a means of weight control, anorexia nervosa should be the
Disorder Some individuals with factitious disorder may
intentionally ingest foreign objects as part of the pattern of falsification of
physical symptoms. In such instances, there is an element of deception that is
consistent with deliberate induction of injury or disease.
self injury & nonsuicidal self injury behaviours in personality disorders Some individuals may swallow potentially harmful items (eg pins,
needles, knives) in the context of maladaptive behaviour patterns associated
with personality disorders or non-suicidal self-injury.
4. Pica may also occur during the course of other
mental disorders such as autism spectrum disorder and schizophrenia and in
Kleine Levin Syndrome. In such instances, an additional diagnosis of pica
should be given only if the eating behaviour is sufficiently persistent and
severe to warrant additional clinical attention.
Kleine-Levin syndrome (KLS) is a rare sleep
disorder characterized by persistent episodic hypersomnia and cognitive or mood
changes. Many patients also experience hyperphagia, hypersexuality and other
symptoms. Patients generally experience recurrent episodes of the condition for
more than a decade. Viral etiology is the triggering factor.
As of 2002, there is no standard treatment for
pica. Currently, the most effective strategies are based on behaviour
modification , but even these treatments have achieved limited success.
Several behavioural techniques have been used to
diminish pica behavior in developmentally disabled patients in a residential
setting. One paradigm of treatment consists of sensory reinforcement , verbal
reprimand & reward.
Behaviour Modification Techniques in a mentally
Participant was a 34 yrs old male with profound
mental disability & resided in a residential facility for individuals with
developmental disabilities in Austin,
A. He was engaged in a number of sensory
stimulating activities eg rocking or use of a neck massager.
Edible objects (Snacks & Juice) were scattered
around & when he engaged in pica, he was verbally reprimanded by (No!).
After verbal reprimand, patient was physically
redirected to participate in a sensory stimulation activity.
B. He was engaged in a number of sensory
stimulating activities at the end of which he was given edible objects. As time
passed, he was given edible objects at increasing intervals, with praise at the
end of each sensory stimulus. At the end, he was not given any edible objects.
Prevention by education
Example: To prevent lead poisoning in children,
renovation of substandard housing & systematic screening of children in
high risk areas are imperative.23
In a psychoeducation treatment approach recommended
by Lourie24, mothers are instructed about the danger of pica that
could result in lead poisoning in their children.
3. Pharmacological Treatment
Pharmacological treatment with dopaminergic agents,
Iron, SSRIs and atypical antipsychotics has also been reported.
(a) Dopaminergic agents such as bromocriptine &
methylphenidate may be the pharmacological approach in subgroups of patients in
whom pica is both refractory and hazardous.25 With antipsychotics,
dopamine transmission is decreased & pica behaviour explained.
(b) Iron deficiency also is a critical determinant
of decreased dopamine transmission & hence also the indication of iron in
the treatment of pica.
(c) SSRIs have proved efficient in few cases of
I refer here to the case of an adult female patient
who developed an impulsive craving for chalks which she would ingest in only
stressful conditions. The thought of eating chalk was ego dystonic and it kept
on hammering her mind until she ate it. She was diagnosed as having MDD with
relational problems and pica. She was prescribed escitalopram with clonazepam
and she was asked to ventilate her feelings during stressful situations. Her
depression improved within 3 weeks, with remarkable improvement in pica
symptoms. It was also concluded from this narrative that stress may induce pica
and that the thoughts involved have compulsive characters which may induce pica.
In addition, appropriate management of stress may help to alleviate the
symptoms of pica.26,27,28
(d) Few reports also show the efficacy of
antipsychotics in pica.
For example, In one case report, an autistic adult
with severe pica responded dramatically to olanzapine.
In another case report, a 42 years old woman with
severe mental retardation, autism and seizure disorder who had a long standing
history of pica responded dramatically to 2.5 mg olanzapine/day. The response
was maintained over a period of 36 months.
(e) Lead poisoning resulting from pica may be
treated by chelating medications, which are drugs that remove lead or other
heavy metals from the bloodstream. The two medications most often given for
lead poisoning are dimercaprol, which is also known as BAL or British
Anti-Lewisite and edetate calcium disodium (EDTA).
(f) In some cases, surgery may be required to
remove metal objects from the patient's digestive tract or to repair tissue
injuries. It is particularly important to remove any objects made of lead
(fishing weights, lead shot, pieces of printer's type, etc.) as quickly as
possible because of the danger of lead poisoning.
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