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Pica is the eating or craving of things that are not food. It can be a disorder in itself or a sign of other cultural or medical phenomena. The ingested or craved substance may be biological, natural or manmade. The term was drawn directly from the medieval Latin word for
magpie Magpies are birds of the Corvidae family. Like other members of their family, they are widely considered to be intelligent creatures. The Eurasian magpie, for instance, is thought to rank among the world's most intelligent creatures, and is on ...
, a bird subject to much folklore regarding its opportunistic feeding behaviors. According to the '' Diagnostic and Statistical Manual of Mental Disorders, 5th Edition'' (DSM-5), pica as a standalone
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
must persist for more than one month at an age when eating such objects is considered developmentally inappropriate, not part of culturally sanctioned practice, and sufficiently severe to warrant clinical attention. Pica may lead to intoxication in children, which can result in an impairment of both physical and mental development. In addition, it can cause surgical emergencies to address intestinal obstructions, as well as more subtle symptoms such as nutritional deficiencies and parasitosis. Pica has been linked to other mental disorders. Stressors such as psychological trauma, maternal deprivation, family issues, parental neglect, pregnancy, and a disorganized family structure are risk factors for pica. Pica is most commonly seen in pregnant women, small children, and people who may have developmental disabilities such as
autism The autism spectrum, often referred to as just autism or in the context of a professional diagnosis autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental condition (or conditions) characterized by difficulti ...
. Children eating painted
plaster Plaster is a building material used for the protective or decorative coating of walls and ceilings and for moulding and casting decorative elements. In English, "plaster" usually means a material used for the interiors of buildings, while "re ...
containing
lead Lead is a chemical element with the symbol Pb (from the Latin ) and atomic number 82. It is a heavy metal that is denser than most common materials. Lead is soft and malleable, and also has a relatively low melting point. When freshly cut, ...
may develop brain damage from
lead poisoning Lead poisoning, also known as plumbism and saturnism, is a type of metal poisoning caused by lead in the body. The brain is the most sensitive. Symptoms may include abdominal pain, constipation, headaches, irritability, memory problems, infertil ...
. A similar risk exists from eating soil near roads that existed before the phase-out of
tetraethyllead Tetraethyllead (commonly styled tetraethyl lead), abbreviated TEL, is an organolead compound with the formula Pb( C2H5)4. It is a fuel additive, first being mixed with gasoline beginning in the 1920s as a patented octane rating booster that ...
or that were sprayed with oil (to settle dust) contaminated by toxic PCBs or
dioxin Dioxin may refer to: * 1,2-Dioxin or 1,4-Dioxin, two unsaturated heterocyclic 6-membered rings where two carbon atoms have been replaced by oxygen atoms, giving the molecular formula C4H4O2 * Dibenzo-1,4-dioxin, the parent compound also known ...
. In addition to poisoning, a much greater risk exists of gastrointestinal obstruction or tearing in the
stomach The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...
. Another risk of eating soil is the ingestion of animal feces and accompanying
parasites Parasitism is a close relationship between species, where one organism, the parasite, lives on or inside another organism, the host, causing it some harm, and is adapted structurally to this way of life. The entomologist E. O. Wilson ha ...
. Pica can also be found in animals such as dogs and cats.


Signs and symptoms

Pica is the consumption of substances with no significant nutritional value such as soap,
drywall Drywall (also called plasterboard, dry lining, wallboard, sheet rock, gypsum board, buster board, custard board, and gypsum panel) is a panel made of calcium sulfate dihydrate (gypsum), with or without additives, typically extruded between thic ...
, or paint. Subtypes are characterized by the substance eaten: This pattern of eating should last at least one month to meet the time diagnostic criterion of pica.Pica
New York Times Health Guide


Complications

Complications may occur due to the substance consumed. For example, lead poisoning may result from the ingestion of paint or paint-soaked
plaster Plaster is a building material used for the protective or decorative coating of walls and ceilings and for moulding and casting decorative elements. In English, "plaster" usually means a material used for the interiors of buildings, while "re ...
,
hairball A hairball is a small collection of hair or fur formed in the stomach of animals, and uncommonly in humans, that is occasionally vomited up when it becomes too big. Hairballs are primarily a tight elongated cylinder of packed fur, but may inclu ...
s may cause intestinal obstruction and ''
Toxoplasma ''Toxoplasma gondii'' () is an obligate intracellular parasitic protozoan (specifically an apicomplexan) that causes toxoplasmosis. Found worldwide, ''T. gondii'' is capable of infecting virtually all warm-blooded animals, but felids, such as ...
'' or '' Toxocara'' infections may follow ingestion of feces or soil.Spitzer, Robert L. ''Diagnostic and Statistical Manual of Mental Disorders: (DSM III)''. Cambridge: Univ. of Cambridge, 1986. Print.


Causes

Pica is currently recognized as a mental disorder by the ''
Diagnostic and Statistical Manual of Mental Disorders The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langu ...
'' (DSM-5). According to the DSM-5, mineral deficiencies are occasionally associated with pica, but biological abnormalities are rarely found. People practicing forms of pica, such as
geophagy Geophagia (), also known as geophagy (), is the intentional practice of eating earth or soil-like substances such as clay, chalk, or termite mounds. It is a behavioural adaptation that occurs in many non-human animals and has been documented in ...
, pagophagy, and amylophagy, are more likely to be anemic or to have low
hemoglobin Hemoglobin (haemoglobin BrE) (from the Greek word αἷμα, ''haîma'' 'blood' + Latin ''globus'' 'ball, sphere' + ''-in'') (), abbreviated Hb or Hgb, is the iron-containing oxygen-transport metalloprotein present in red blood cells (erythroc ...
concentration in their blood, lower levels of red blood cells ( hematocrit), or lower plasma zinc levels. Specifically, practicing geophagy is more likely to be associated with anemia or low hemoglobin. Practicing pagophagy and amylophagy is more highly associated with anemia. Additionally, children and pregnant women may be more likely to have anemia or low hemoglobin relative to the general population. Mental health conditions such as obsessive-compulsive disorder (OCD) and
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social w ...
have been proposed as causes of pica. 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. Sensory, physiological, cultural, and psychosocial perspectives have also been used to explain the causation of pica. Pica may be a cultural practice not associated with a deficiency or disorder. Ingestion of
kaolin Kaolinite ( ) is a clay mineral, with the chemical composition Al2 Si2 O5( OH)4. It is an important industrial mineral. It is a layered silicate mineral, with one tetrahedral sheet of silica () linked through oxygen atoms to one octahedra ...
(white clay) among
African-American African Americans (also referred to as Black Americans and Afro-Americans) are an ethnic group consisting of Americans with partial or total ancestry from sub-Saharan Africa. The term "African American" generally denotes descendants of ensl ...
women in the US state of
Georgia Georgia most commonly refers to: * Georgia (country), a country in the Caucasus region of Eurasia * Georgia (U.S. state), a state in the Southeast United States Georgia may also refer to: Places Historical states and entities * Related to the ...
shows the
practice Practice or practise may refer to: Education and learning * Practice (learning method), a method of learning by repetition * Phantom practice, phenomenon in which a person's abilities continue to improve, even without practicing * Practice-based ...
there to be a DSM-4 "
culture-bound syndrome In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or cu ...
" 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 acid Tannic acid is a specific form of tannin, a type of polyphenol. Its weak acidity ( pKa around 6) is due to the numerous phenol groups in the structure. The chemical formula for commercial tannic acid is often given as C76H52O46, which corresp ...
s.


Diagnosis

No single test confirms pica, but because pica can occur in people who have lower than normal nutrient levels and poor nutrition (malnutrition), the health care provider should test blood levels of iron and zinc. Hemoglobin can also be checked to test for
anemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, t ...
. 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 patient has been eating contaminated soil or animal waste.


DSM-5

The DSM-5 posits four criteria that must be met for a person to be diagnosed with pica: #Person must have been eating non-nutritive nonfoods for at least one month. #This eating must be considered abnormal for the person's stage of development. #Eating these substances cannot be associated with a cultural practice that is considered normal in the social context of the individual. #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.


Differential diagnosis

In individuals with
autism The autism spectrum, often referred to as just autism or in the context of a professional diagnosis autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental condition (or conditions) characterized by difficulti ...
,
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social w ...
, 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.


Treatment

Treatment for pica may vary by patient and suspected cause (e.g., child, developmentally disabled, pregnant, or psychogenic) and may emphasize
psychosocial The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...
, environmental and family-guidance approaches; iron deficiency may be treatable through iron supplements or through dietary changes. An initial approach often involves screening for, and if necessary, treating any mineral deficiencies or other comorbid conditions. For pica that appears to be of psychogenic cause, therapy and medication such as
SSRIs Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs increase the extracellu ...
have been used successfully. However, previous reports have cautioned against the use of medication until all non-psychogenic causes have been ruled out. 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. Behavior-based treatment options for pica can be useful for individuals who have a developmental disability or mental illness. Behavioral treatments have been shown to reduce pica severity by 80% in people with intellectual disabilities. These treatments may involve using
positive reinforcement In behavioral psychology, reinforcement is a consequence applied that will strengthen an organism's future behavior whenever that behavior is preceded by a specific antecedent stimulus. This strengthening effect may be measured as a higher fr ...
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. Treatment techniques include:


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, thus leading to the
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
recordings of pica among at-risk groups being in the range of 8% to 65% depending on the study. 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%). 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. Two studies of adults with
intellectual disabilities Intellectual disability (ID), also known as general learning disability in the United Kingdom and formerly mental retardation,Rosa's Law, Pub. L. 111-256124 Stat. 2643(2010). is a generalized neurodevelopmental disorder characterized by signifi ...
living in
institutions Institutions are humanly devised structures of rules and norms that shape and constrain individual behavior. All definitions of institutions generally entail that there is a level of persistence and continuity. Laws, rules, social conventions a ...
found that 21.8% and 25.8% of these groups had pica. Prevalence rates for children are unknown. 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. In institutionalized children with mental disabilities, pica occurs in 10–33%.


History

The condition currently known as pica was first described by
Hippocrates Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history o ...
. The term pica originates in the
Latin Latin (, or , ) is a classical language belonging to the Italic languages, Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through ...
word for
magpie Magpies are birds of the Corvidae family. Like other members of their family, they are widely considered to be intelligent creatures. The Eurasian magpie, for instance, is thought to rank among the world's most intelligent creatures, and is on ...
, ''pīca'', a bird famed for its unusual eating behaviors and believed to eat almost anything. The Latin may have been a translation of a Greek word meaning both 'magpie, jay' and 'pregnancy craving, craving for strange food'. In 13th-century Latin work, pica was referenced by the Greeks and Romans; however, it was not addressed in medical texts until 1563. In the southern United States in the 1800s, geophagia was a common practice among the slave population. Geophagia is a form of pica in which the person consumes earthly substances such as
clay Clay is a type of fine-grained natural soil material containing clay minerals (hydrous aluminium phyllosilicates, e.g. kaolin, Al2 Si2 O5( OH)4). Clays develop plasticity when wet, due to a molecular film of water surrounding the clay pa ...
, and is particularly prevalent to augment a mineral-deficient diet. 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. 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. Research on
eating disorder An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
s 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. Prior to the elimination of the category of "feeding disorders in infancy and early childhood", which is where pica was classified, from the DSM-5, pica was primarily diagnosed in children. However, since the removal of the category, psychiatrists have started to diagnose pica in people of all ages.


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 Grout is a dense fluid which hardens to fill gaps or used as reinforcement in existing structures. Grout is generally a mixture of water, cement and sand, and is employed in pressure grouting, embedding rebar in masonry walls, connecting sect ...
,
concrete Concrete is a composite material composed of fine and coarse aggregate bonded together with a fluid cement (cement paste) that hardens (cures) over time. Concrete is the second-most-used substance in the world after water, and is the most wid ...
dust, and
sand Sand is a granular material composed of finely divided mineral particles. Sand has various compositions but is defined by its grain size. Sand grains are smaller than gravel and coarser than silt. Sand can also refer to a textural class ...
. Dogs exhibiting this form of pica should be tested for anemia with a
complete blood count A complete blood count (CBC), also known as a full blood count (FBC), is a set of medical laboratory tests that provide information about the cells in a person's blood. The CBC indicates the counts of white blood cells, red blood cells and ...
or at least hematocrit levels. Although several theories have been proposed by experts to explain pica in animals, insufficient evidence exists to prove or disprove any of them.


See also

* Michel Lotito, Frenchman known for his ability to eat and digest metal, nicknamed Monsieur Mangetout ('Mr. Eat-All') * Animal psychopathology#Pica * ''Swallow'', a 2019 film about a young woman who, emotionally stifled in her marriage and domestic life, develops an impulse to consume inedible objects.


References


Further reading

*


External links

{{Authority control Mental disorders diagnosed in childhood Eating behaviors Eating disorders Dog diseases