An Update on Pica: Prevalence, Contributing Causes, and Treatment

By Barton J. Blinder, MD, PhD and Christina Salama | May 1, 2008

Dr Blinder is clinical professor and past director of eating disorders research in the department of psychiatry and human behavior, School of Medicine, University of California, Irvine. Ms Salama is a research assistant, School of Social Sciences, University of California, Irvine. They report that they have no conflicts of interest concerning the subject matter of this article.

In a psychoeducation treatment approach recommended by Lourie,⁴⁵mothers are instructed about the danger of pica that could result in lead poisoning in their children. Social workers can provide a social support system for mothers by meeting the mothers' dependency needs and helping them to be more available to their children. Strategies of prohibiting pica are taught to mothers so that they can spend more time with their children and interrupt pica behavior. Furthermore, the ability to identify families at high risk for pica could function as a primary prevention.⁹To prevent lead poisoning in children, renovation of substandard housing and systematic screening of children in high-risk areas are imperative.^15,46
Pharmacological treatment with SSRIs and atypical neuroleptics has also been reported. On the basis of the proposition that decreased dopamine(Drug information on dopamine) transmission resulting from both iron deficiency and the administration of neuroleptics may be a critical determinant of pica, a pharmacological approach that increases dopaminergic transmission (bromocriptine, methylphenidate(Drug information on methylphenidate)) may be worthy of investigation in a subgroup of patients in whom pica is both refractory and hazardous.⁴⁷

Jakab⁴⁸ reported that thioridazine(Drug information on thioridazine) reduced pica as well as a number of other problematic behaviors, such as aggression in hospitalized mentally handicapped patients. However, Danford and Huber¹⁰ noted an increased pica incidence (39%) in a subgroup of institutionalized mentally handicapped patients who received neuroleptic medication, in contrast to a 25% incidence of pica in a medication-free group.

Conclusions
Pica is a complex disorder with varying prognoses among patients. Epidemiological surveys in different settings and age groups (urban, rural, youth, adults) indicate a greater prevalence of pica than expected by sporadic individual clinical reports. The adverse medical, surgical, and developmental consequences mean that early recognition and prevention are imperative.

Further research is needed to clarify the normal psychobiology and developmental progression of food selection, the intricate role of sociocultural influences, and the significance of appetite and ingestive disturbances in neuropsychiatric disorders. Special focus should be given to the high incidence of pica in the mentally handicapped and to the role of iron deficiency (the single most prevalent nutritional deficiency in world population studies) in causing and perpetuating eating disorders.

Education, prevention, and informed behavioral interventions are the mainstay of treatment. Advances in understanding the neurobiology of food selection may yield better nutritional and pharmacological approaches in the future.

Acknowledgements—The authors are grateful for the contributions to this article of Kim Jimenez, Jee Eun Kim, and Monica Salama.

Pages: 1 2 3 4

Evidenced-based References
• Gravestock S. Eating disorders in adults with intellectual disability. J Intellect Disabil Res. 2000;44:625-637.
• McAdam DB, Sherman JA, Sheldon JB, Napolitano DA. Behavioral interventions to reduce the pica of persons with developmental disabilities. Behav Modif. 2004;28:45-72.

References
1. Cooper M. Pica. Springfield, IL: Charles Thomas; 1957.
2. Vermeer DE, Frate DA. Geophagia in rural Mississippi: environmental and cultural contexts and nutritional implications. Am J Clin Nutr. 1979;32:2129-2135.
3. Singhi S, Singhi P, Adwani GB. Role of psychosocial stress in the cause of pica. Clin Pediatr (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 Behav Ther Exp Psychiatry. 1996;27:195-196.
6. Fishbain DA, Rotondo DJ. Foreign body ingestion associated with delusional beliefs. J Nerv Ment Dis. 1983;171:321-322.
7. Foulon C. Schizophrenia and eating disorders [in French]. Encephale. 2003;29:463-466.
8. Barltrop D. The prevalence of pica. Am J Dis Child. 1966;112:116-123.
9. Lourie RS, Layman EM, Millican FK. Why children eat things that are not food. Children. 1963;10:143-146.
10. Danford DE, Huber AM. Eating dysfunctions in an institutionalized mentally retarded population. Appetite. 1981;2:281-292.
11. Gravestock S. Eating disorders in adults with intellectual disability. J Intellect Disabil Res. 2000;44: 625-637.
12. Dumaguing NI, Singh I, Sethi M, Devanand DP. Pica in the geriatric mentally ill: unrelenting and potentially fatal. J Geriatr Psychiatry Neurol. 2003;16: 189-191.
13. Edwards CH. Clay and cornstarch eating women. J Am Diet Assoc. 1959;35:810-815.
14. Giudicelli J, Combes JC. Pica and iron deficiency in adolescents [in French]. Arch Fr Pediatr. 1992;49: 779-783.
15. Roberts JW, Dickey P. Exposure of children to pollutants in house dust and indoor air. Rev Environ Contam Toxicol. 1995;143:59-78.
16. Bateson EM, Lebroy T. Clay eating by aboriginals of the northern territory. Med J Aust. 1978;1(suppl 1): 1-3.
17. Eastwell HD. A pica epidemic: a price for sedentarism among Australian ex-hunter-gatherers. Psychiatry. 1979;42:264-273.
18. Derman O, Okstuz-Kanbur N, Yenicesy I, Klink E. Iron deficiency anemia in a group of Turkish adolescents: frequency and contributing factors. Int J Adolesc Med Health. 2005;17:179-186.
19. al-Kanhal MA, Bani IA. Food habits during pregnancy among Saudi women. Int J Vitam Nutr Res. 1995;65:206-210.
20. Richter CP. Self-selection of diets. Essays in Biology. Berkeley, CA: University of California Press; 1943.
21. Prasad AS, Halsted JA, Nadimi M. Syndrome of iron deficiency anemia, hepatosplenomegaly, hypo-gonadism, dwarfism and geophagia. Am J Med. 1961;31:532-546.
22. Mahaffey KR. Nutritional factors in lead poisoning. Nutr Rev. 1981;39:353-362.
23. Blinder BJ, Goodman SL, Henderson P. Pica: a critical review of diagnosis and treatment. In: Blinder BJ, Chaitin BF, Goldstein RS, eds. The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment. New York: PMA Publishing Corporation; 1988:331-344.
24. Rolls BR. Palatability and preference: basic studies. In: Blinder BJ, Chaitin BF, Goldstein RS, eds. The Eating Disorders: Medical and Psychological Bases of Diagnosis and Treatment. New York: PMA Publishing Corporation; 1988:101-120
25. Perry MC. Cautopyreiophagia. N Engl J Med. 1977;296:824.
26. Libnoch JA. Geomelophagia. An unusual pica in iron-deficiency anemia. Am J Med. 1984;76:A69.
27. Reynolds RD, Binder HJ, Miller MB, et al. Pagophagia and iron deficiency anemia. Ann Intern Med. 1968; 69:435-440.
28. Coltman CA Jr. Pagophagia and iron lack. JAMA. 1969;207:513-516.
29. Youdim MB. Brain iron metabolism: biochemical aspects in relation to dopaminergic neurotransmission. In: Lajitha A, ed. Handbook of Neurochemistry, Vol 10: Pathological Chemistry. New York: Plenum Press; 1985:731-755.
30. Blinder BJ, Goodman S, Youdim S. Iron, dopamine receptors and tardive dyskinesia. Am J Psychiatry. 1986;143:277-278.
31. Olynyk F, Sharpe DH. Mercury poisoning in paper pica. N Engl J Med. 1982;306:1056-1057.
32. Von Bonsdorff B. Pica: a hypothesis. Br J Haematol. 1977;35:476-467.
33. Youdim MB, Greene AR. Pica hypothesis. Br J Haematol. 1977;36:298.
34. Youdim MB, Ben Shachr D, Ashkenazi R, Yehuda S. Iron and dopamine receptor function: molecular pharmacology. In: Mandell P, DeFeudis FV, eds. CNS Receptors: From Molecular Pharmacology to Behavior. New York: Raven Press; 1983:309-322.
35. Leming PD, Reed DC, Martelo OJ. Magnesium carbonate pica: an unusual case of iron deficiency. Ann Intern Med. 1981;94:660.
36. Roselle HA. Association of laundry starch and clay ingestion with anemia in New York City. Arch Intern Med. 1970;125:57-61.
37. Cavdar AO, Arcasoy A, Cin S, et al. Geophagia in Turkey: iron and zinc deficiency. Prog Clin Biol Res. 1983;129:71-79.
38. Ackerman L. Surgical Pathology. St Louis: CV Mosby Co; 1981.
39. Sabouraud S, Testud F, Descotes J, et al. Lead poisoning following ingestion of pieces of lead roofing plates: pica-like behavior in an adult. Clin Toxicol (Phila). 2008;46:267-269.
40. Ellis C. Eating disorders. http://www.emedicine. com/ped/topic1798.htm. Accessed April 2, 2008.
41. Decker CJ. Pica in the mentally handicapped: a 15-year surgical perspective. Can J Surg. 1993;36: 551-554
42. Anderson JE, Akmal M, Kittur DS. Surgical complications of pica: report of a case of intestinal obstruction and a review of the literature. Am Surg. 1991;57:663-667.
43. Snowdon CT. A nutritional basis for lead pica. Physiol Beh. 1977;18:885-893.
44. Albin JB. The treatment of pica (scavenging) behavior in the retarded: a critical analysis and implications for research. Mental Retard. 1977;15:14-17.
45. Lourie RS. Pica and poisoning. Am J Orthopsychiatry. 1977;41:697-699.
46. Chisolm JJ. Management of increased lead absorption in children: illustrative cases. In: Chisolm JJ, O'Hara DM, eds. Lead Absorption in Children: Management, Clinical and Environmental Aspects. Baltimore and Munich: Urbin and Schwarzenber; 1982: 171-188.
47. Brahm NC, Farmer KC, Brown RC. Pica episode reduction following initiation of bupropion in a developmentally disabled adult. Ann Pharmacother. 2006;40: 2075-2076.
48. Jakab I. Short term effect of thioridazine tablets versus suspension on emotionally disturbed retarded children. J Clin Psychopharm. 1984;4:210-215.
49. Avila E, Schrader P, Belliappa, Faro S. Pica with paradichlorobenzene mothball ingestion associated with toxic leukoencephalopathy. J Neuroimaging. 2006;16:78-81.
50. Grotegut CA, Dandolu V, Katari S, et al. Baking soda pica: a case of hypokalemic metabolic alkalosis and rhabdomyolysis in pregnancy. Obstet Gynecol. 2006;107:484-486.
51. Chiu B, Ciaccio C, West MA. Intestinal obstruction from furniture cushion foam bezoar. Surgery. 2005; 138:956-958.
52. Trivedi TH, Daga GL, Yeolekar ME. Geophagia leading to hypokalemic quadriparesis in a postpartum patient. J Assoc Physicians India. 2005;53:205-207.
53. Frey AS, McKee M, King RA, Martin A. Hair apparent: Rapunzel syndrome. Am J Psychiatry. 2005;162: 242-248.
54. Kupiec TC, Goldenring JM, Raj V. A non-fatal case of sodium toxicity. J Anal Toxicol. 2004;28:526-528.
55. Bothwell DN, Mair EA, Cable BB. Chronic ingestion of zinc-based penny. Pediatrics. 2003;111:689-691.
56. Fernandez J, Gonzales Garcia ME, et al. Egg shells intake as a form of pica [in Spanish]. Med Clin (Barc). 2003;121:758.
57. Lopez LB, de Portela ML, Soler CR. Nutrient intake in women with pagophagia and other forms of pica during pregnancy [in Spanish]. Nutr Hosp. 2007;22: 641-647.
58. Pillmann F. Ingestion of metals and factitious disorders. Impulse control disorder presenting on a background of situational conflicts [in German]. Psychiatr Prax. 2000;27:99-100.
59. Harvey PW, Dexter PB, Darnton-Hill I. The impact of consuming iron from non-food sources on iron status in developing countries. Public Health Nutr. 2000; 3:375-383.
60. McAlinden MG, Potts SR. Sponge bezoar: a rare cause of abdominal pain. Ulster Med J. 1999;68:36-37.
61. Boris NW, Hagino OR, Steiner GP. Case study: hypersomnolence and precocious puberty in a child with pica and chronic lead intoxication. J Am Acad Child Adolesc Psychiatry. 1996;35:1050-1054.
62. Nordlander NB. Did Dracula suffer of pellagra or pica? [in Swedish]. Lakartidningen. 1998;95:2100-2101.
63. Karp JG, Whitman L, Convit A. Intentional ingestion of foreign objects by male prison inmates. Hosp Community Psychiatry. 1991;42:533-535.
64. Marinella MA. "Tomatophagia" and iron-deficiency anemia. N Engl J Med. 1999;341:60-61.
65. Chan JT, Liu CF, Housholder G. Dental fluorosis caused by toothpaste ingestion: a case report. J Gt Houst Dent Soc. 1996;67:18-19.
66. Grigsby RK, Thyer BA, Waller RJ, Johnston GA Jr. Chalk eating in middle Georgia: a culture-bound syndrome of pica? South Med J. 1999;92:190-192.
67. Barnes C, Monagle P, McNamara J. Velcroholism. J Paediatr Child Health. 2003;39:392.
68. Ferreri SJ, Tamm L, Wier KG. Using food aversion to decrease severe pica by a child with autism. Behav Modif. 2006;30:456-471.
69. McAdam DB, Sherman JA, Sheldon JB, Napolitano DA. Behavioral interventions to reduce the pica of persons with developmental disabilities. Behav Modif. 2004;28:45-72.
70. Piazza CC, Roane HS, Keeny KM, et al. Varying response effort in the treatment of pica maintained by automatic reinforcement. Appl Behav Anal. 2002;35: 233-246.
71. Hagopian LP, Adelinis JD. Response blocking with and without redirection for the treatment of pica. J Appl Behav Anal. 2001;34:527-530.
72. LeBlanc LA, Piazza CC, Krug MA. Comparing methods for maintaining the safety of a child with pica. Res Dev Disabil. 1997;18:215-220.
73. Johnson CR, Hunt FM, Siebert MJ. Discrimination training in the treatment of pica and food scavenging. Behav Modif. 1994;18:214-229.
74. Fisher WW, Piazza CC, Bowman LG, et al. A preliminary evaluation of empirically derived consequences for the treatment of pica. J Appl Behav Anal. 1994;27:447-457.
75. Bhatia MS, Gupta R. Pica responding to SSRI: an OCD spectrum disorder? World J Biol Psychiatry. 2007 May 11;1-3 [Epub ahead of print].
76. Pace GM. The effects of a vitamin supplement on the pica of a child with severe mental retardation. J Appl Behav Anal. 2000;33:619-622.
77. Lerner AJ. Treatment of pica behavior with olanzapine. CNS Spectr. 2008;13:19.
78. Overall KL. Use of clomipramine to treat ritualistic stereotypic motor behavior in three dogs. J Am Vet Med Assoc. 1994;205:1733-1741.
79. de La Blanchardière A, Contamin E. Pica. Anomalies in mother-child relations [in French]. Presse Med. 1994;23:1708-1709.

FROM PHYSICIANS PRACTICE

Primary Care Can't Thrive Without Nurse Practitioners
Courtney H. Lyder, ND, May 17, 2013
With a projected shortfall of primary-care physicians, it's time for alternate solutions to patient care. Nurse practitioners are one logical remedy.

VWhat Physicians Can Learn from the Allscripts EHR Lawsuit
Marisa Torrieri, May 16, 2013
Lawsuit prompts question: What should physicians do to ensure they end up with a great EHR instead of buyer’s remorse?

Eight Ways ICD-9 Will Still Matter to Medical Practices
Brenda Edwards, CPC, May 15, 2013
What should your medical practice do with your ICD-9-CM book after October 1, 2014? Keep it.

Seven Ways Technology Can Speed Up Patient Collections
Cheyenne Brinson, May 15, 2013
Failing to adopt widely available billing and collections technology can cost medical practices big. Here's how to do it right.

Four Reasons Private Medical Practice is Becoming Extinct
Carol Stryker, May 15, 2013
It’s becoming increasingly difficult for private medical practices to thrive. Here’s what’s driving the trend toward consolidation.

An Update on Pica: Prevalence, Contributing Causes, and Treatment

Join the Conversation