INDIAN PSYCHOSOCIAL FOUNDATION
 
   INDIAN PSYCHOSOCIAL FOUNDATION
         
IJPS >
IJPS April 2011
IJPS October 2011
IJPS April 2012
IJPS October 2012
IJPS April 2013
IJPS October 2013
IJPS Apirl 2014
IJPS October 2014
IJPS Apirl 2015
IJPS Apirl 2016
IJPS October 2016
IJPS Apirl 2017
 
 
 
AN UPDATE ON PICA: PREVALENCE, CONTRIBUTING FACTORS AND TREATMENT

AN UPDATE ON PICA: PREVALENCE, CONTRIBUTING FACTORS AND TREATMENT

 Netranee Anju Ramdinny-Purryag

Consutant psychiatrist Mauritious

Abstract

Pica is more commonly seen in women and children; particularly it is seen in pregnant women. But it affects found of small children and those with developmental disabilites such as autism. This is a habit of non eating thinks like eating painted, plaster, lead, clay, eating dirt near road, oil etc. the result of these non eating things  brain damage, gastro-intestinal obstruction from led poisning, tetraethyllead and dioxin. Pica is currently recognized as a mental disorder by DSM –IV.  However, it is also correlated with cultural practice not associated with a deficiency or disorder. Kaolin white dirt) among African-American women in the US state of Georgia shows the practice there to be a DSM-IV "culture bound syndrom" and "not selectively associated with other psychopathology". Similar kaolin ingestion is also widespread in parts of Africa. Such practices may stem from health benefits such as the ability of clay to absorb plant toxins and protect against toxic alkaloids and tannic acids.

Key Words:PICA: Prevalence And Treatment

Introduction


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 following table:

Geophagia: Dirt or Clay eating

Chthnophagia: Dirt eating (archaic)

Lithophagia: stone or gravel eating

Amylophagia: starch eating

Pagophagia: ice eating

Geomelophagia: potato eating

Cautopyreiophagia: burned match eating

Trichophagia: hair eating                 


Classification under DSM-V

Pica, as per DSM V falls under the classification of Feeding & Eating Disorders.

Contributing Causes

Pica is most commonly seen in children and pregnant women.

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

Prevalence

The prevalence of pica is unclear because of differences in definition and the reluctance of patients to admit to abnormal cravings.

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 anaemia.7

When associated with iron deficiency, most physicians believe that pica is an effect of iron deficiency rather than a cause.

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

In Turkey, 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

Mechanisms

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 with pica.

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 ganglia dysfunction.19

Diagnostic Clinical Features (DSM-V) 20

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.

Diagnosis

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 following:

• 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

1. Hypokalaemia

2.Mercury & Lead Poisoning

3.Intestinal Obstruction

4. Dental Caries

5. Trichobezoar

Rapunzel Syndrome

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

Differential Diagnosis

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 primary diagnosis.

2. Factitious 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.

3. Non-suicidal 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.

Treatment

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.

Behaviour Modification

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 disabled patient

Participant was a 34 yrs old male with profound mental disability & resided in a residential facility for individuals with developmental disabilities in Austin, Texas.

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 pica.

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.


References


1.        kushner RF, Gleason B, Shanta-Retelny V: Reemergence of pica following gastric bypass surgery for obesity: a new presentation of an old problem. J Am Diet Assoc 2004;104: 1393-1397.

2.        Tisman G: Resinphagia. N Engl J Med 1970; 283(11): 602.

3.        Singhi S, Singhi P, Adwani GB. Role of psychosocial stress in the cause of pica.ClinPediatr (Phil) 1981; 20:783-785.

4.        Jawed SH, Krishnan VH, Prasher VP, Corbett JA. Worsening of pica as a symptom of depressive illness in a person with severe mental handicap. Br J Psychiatry 1993;162:835-837.

5.        Luiselli JK. Pica as obsessive-compulsive disorder. J BehavTherExp Psychiatry 1996;27:195-196.

6.        Fishbain DA, Rotondo DJ. Foreign body ingestion associated with delusional beliefs. J NervMent Dis 1983;171:321-322.

7.        Barker D: Toothwear as a result of pica. Br. Dent J 2005; 199:271-273.

8.        BarltropD.The prevalence of pica.Am J Dis Child. 1966;112:116-123.

9.        Danford DE, Huber AM. Eating dysfunctions in an institutionalized mentally retarded population. Appetite 1981;2:281-292.

10.     Gravestock S. Eating disorders in adults with intellectual disability. J Intellect Disabil Res 2000;44: 625-637.

11.     Dumaguing NI, Singh I, Sethi M, Devanand DP. Pica in the geriatric mentally ill: unrelentingand potentially fatal. J Geriatr Psychiatry Neurol. 2003;16: 189-191.

12.     Edwards CH. Clay and cornstarch eating women. J Am Diet Assoc1959;35:810-815.

13.     Kanhal MA, Bani IA. Food habits during pregnancy among Saudi women. Int J VitamNutr Res 1995;65:206-210.

14.     Blinder BJ, Goodman S, Youdim S. Iron, dopamine receptors and tardive dyskinesia. Am JPsychiatry 1986;143:277-278.

15.     Perry MC. Cautopyreiophagia. N Engl J Med 1977;296:824.

16.     Libnoch JA. Geomelophagia.An unusual pica in iron-deficiency anemia. Am J Med1984;76:A69.

17.     Olynyk F, Sharpe DH. Mercury poisoning in paper pica. N Engl J Med 1982;306:1056-1057.

18.     Leming PD, Reed DC, Martelo OJ. Magnesium carbonate pica: an unusual case of iron deficiency. Ann Intern Med. 1981;94:660.

19.     Huang JH, Lee WK. Olanzapine-associated pica in a schizophrenia patient. Psychiatry and Clinical Neurosciences 2010; 64: 442–44.

20.     APA. Feeding and Eating Disorders.Diagnostic and Statistical Manual of Mental Disorders-Edition 5: 329-331.

21.     Sah DE, Koo J, Price VH. Trichotillomania. Derma tolTher2008; 21(1):13-21.

22.     Chamberlain SR, Menzies L, Sahakian BJ, Fineberg NA. "Lifting the veil on trichotillomania".Am J Psychiatry2007; 164 (4): 568–74.

23.     Roberts JW, Dickey P. Exposure of children to pollutants in house dust and indoor air. Rev Environ ContamToxicol.1995;143:59-78.

24.     Lourie RS. Pica and poisoning.Am J Orthopsychiatry. 1977;41:697-699.

25.     Brahm NC, Farmer KC, Brown RC. Pica episode reduction following initiation of bupropion in a developmentally disabled adult. Ann Pharmacother. 2006;40: 2075-2076.

26.     Jakab I. Short term effect of thioridazine tablets versus suspension on emotionally disturbed retarded children. J ClinPsychopharm. 1984;4:210-215.

27.     Danford DE, Huber AM. Eating dysfunctions in an institutionalized mentally retarded population. Appetite. 1981;2:281-292.

28.     Bhatia MS, Gupta R.Pica responding to SSRI: an OCD spectrum disorder? World Journal Biol Psychiatry 2009; 10:936-38.