Pica: Everything You Need To Know About The Non-Nutritive Eating Disorder

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When you hear the words “feeding and eating disorders”, it’s highly likely that you automatically think about anorexia nervosa, bulimia nervosa, or binge-eating disorder. 

Another feeding and eating disorder that’s less commonly spoken about – but is equally important –  is pica syndrome. 

Pica disorder – an eating disorder most commonly observed in children – describes eating items that are not typically thought of as food and that do not contain any noticeable nutritional value¹American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.: DSM 5. Virginia: American Psychiatric Association.

Items that are commonly eaten among people with pica syndrome include:

• Hair 
• Dirt
• Stones
• Ice
• Paint chips
• Mud 
• Pottery
• Clay
• Soap
• Straws
• Wool
• Pebbles 
• Chalk 

Pica was officially recognized in the “Feeding and Eating Disorders” category in the latest Diagnostic and Statistical Manuel for Mental Disorders. 

Let’s take a closer look at the specific signs and symptoms of pica syndrome 

Signs, Symptoms, and Features of Pica 

• Over a time-frame of at least one month, there is a persistent eating of substances that are not food and do not provide nutritional value.
• Eating these substances cannot be associated with a cultural practice that is considered normal in the social context of the individual (e.g., some cultures promote eating clay as part of a medicinal practice)
• The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects—or putting small objects in their mouth—is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with pica.
• Generally, those with pica are not averse to ingesting food.
• 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 non-foods should only be considered pica if it is dangerous and requires extra medical investigation on top of what they are already receiving for their pre-existing condition

Pica Prevalence 

Rates of pica varies widely across diverse social and clinical contexts and appears to be higher among select populations that include pregnant women, children, and adults with iron deficiencies. 

Although it is very difficult to obtain accurate data on the prevalence of pica, some key statistics include:

• 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%)²Fawcett, 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.
• Around 25% of adults with an intellectual disability suffered from pica ³Danford DE, Huber AM (1982). “Pica among mentally retarded adults”. American Journal of Mental Deficiency. 87 (2): 141–6.
• In institutionalized children with mental retardation, pica occurs in 10–33%⁴Chatoor, 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. 360.
• Around 8% of US. pregnant women may engage in pica eating Rainville AJ. Pica practices of pregnant women are associated with lower maternal hemoglobin level at delivery⁵J Am Diet Assoc. 1998;98(3):293-296..
• Only 1.3% of people seeking treatment for an eating disorder exhibit pica-like behaviors⁶Delaney, C. B., Eddy, K. T., Hartmann, A. S., Becker, A. E., Murray, H. B., & Thomas, J. J. (2015). Pica and rumination behavior among individuals seeking treatment for eating disorders or obesity. International Journal of Eating Disorders, 48(2), 238-248..

Complications

There are a whole range of different medical and psychological complications associated with pica eating and pica syndrome⁷Hartmann, A. S., & Jurilj, V. (2017). Pica. In Handbook of DSM-5 Disorders in Children and Adolescents (pp. 319-332). Springer, Cham.; 

Medical and Physical Complications

• Certain items, such as paint chips, may contain lead or other toxic substances and eating them can lead to poisoning, increasing the child’s risk of complications including learning disabilities and brain damage.
• Eating non-food objects can interfere with eating healthy, nutrient rich foods, which can lead to nutritional deficiencies (e.g., iron deficiency)
• Eating objects that cannot be digested can cause constipation or blockages in the digestive tract, as well as tears in the lining of the esophagus or intestines. 
• Bacteria or parasites from dirt or other objects can cause serious infections.
• Broken or damaged teeth
• Bloody stool
• Lead poisoning 

Psychological Complications

There are many other psychological problems that are associated with pica eating and pica syndrome. These include:

• Schizophrenia 
• Obsessive-compulsive disorder
• Autism 
• Skin-picking disorder
• Hair-pulling disorder 

What Causes Pica Disorder?

Unfortunately, the causes of pica are not well-understood. 

However, we do know that there is no one single cause of pica syndrome; rather, it’s likely caused by a multitude of different factors. 

There is some evidence to suggest that certain mental health disorders that are characterized by impaired intellectual functioning (e.g., intellectual disability, autism spectrum disorder, schizophrenia) are associated with onset of pica.

Other risk factors for pica syndrome include iron-deficiency anemia, malnutrition, pregnancy, and cultural norms that view certain nonfood substances as sacred or as having healing properties⁸Hartmann, A. S., Poulain, T., Vogel, M., Hiemisch, A., Kiess, W., & Hilbert, A. (2018). Prevalence of pica and rumination behaviors in German children aged 7–14 and their associations with feeding, eating, and general psychopathology: A population-based study. European child & adolescent psychiatry, 27(11), 1499-1508..

Treatment for Pica Disorder

High quality studies evaluating different treatment approaches for pica are lacking. 

It is proposed that, generally speaking, treatment options differ based on the severity of the disorder and the presence of comorbid conditions.

Therefore, it is important for treatment providers to conduct a thorough history and physical examination to determine whether their maladaptive behavior patterns are explained by a medical condition (e.g., iron deficiency), environmental factors (e.g., limited food availability) and/or culturally sanctioned norms (e.g., fasting for religious purposes)

If these patterns are explained by such factors, then simple non-psychological interventions may, like iron supplements, may be enough to address pica. 

Behavioral interventions are also effective for pica.

Depending on the severity of the condition, behavioral treatment varies from brief outpatient to intensive inpatient therapy and includes “traditional habit reversal protocols”

Some behavioral strategies used to help with pica include: 

• Functional assessment to identify reinforcement contingencies,
• Self-monitoring to increase awareness of eating behavior and antecedents
• Relaxation strategies to reduce physiological arousal
• Distraction
• Systemic desensitization
• Positive reinforcement 

Have any questions about Pica? Let me know in the comments below.