Pica is an eating disorder in which people intentionally eat non-food items that contain no nutritional value.11 Pica involves consuming such things as dirt, chalk, hair, and clay. Some people eat non-food items due to mineral deficiencies such as iron or zinc while others are thought to engage in this behavior due to a compulsive drive such as those with obsessive-compulsive disorder (OCD).
If this behavior continues beyond a month’s time, a diagnosis of Pica may be considered by a medical or mental health professional.
What Is Pica?
Pica gets its name from a species of bird that are routinely observed putting all kinds of items in their beaks, from food wrappers to shiny objects.14 This is an apt description of this eating disorder due to the correlation of the behavior of those with pica and that of the magpie who collects random objects. Young children ingest all kinds of nonfood items such as paper, dirt, glue, erasers, cloth, chalk and hair. This can result in nutritional deficits from lack of actual food, medical issues from intestinal blockages, or even more severe complications depending upon the items ingested.
This is not the same as children who suck on their hair as a self-soothing technique or chew on pencils out of boredom in the classroom. Pregnant women tend to chew on ice a great deal during pregnancy, but they can also consume much of the same items that children eat during episodes of pica. The unborn baby and mother can be endangered depending upon the items eaten.
Pica is most common among pregnant women and young children.14 Although pica occurs equally in female and male children, it is rare to see pica in adolescent and adult males.6 It is also seen in other populations such as those with intellectual disabilities, autism, OCD, trichotillomania (hair pulling), and schizophrenia.1
Common nonfood items that are eaten by those with pica include, but are not limited to the following items:
- Animal droppings/feces
- Batteries
- Chalk
- Cigarette ashes/butts
- Clay/dirt/rocks/pebbles
- Cloth/string
- Erasers
- Glue
- Hair
- Ice
- Magnets
- Paper clips/metal
- Soap
- Toys
Symptoms of Pica
In all those suffering with pica, the consumption of non-food items is present. There are several categories of items consumed. These include:14
- Geophagy (earth): clay, dirt, rocks
- Amylophagy (raw starch): raw potatoes, rice, flour, corn starch, baby powder
- Pagophagia (ice) ranging from cups to pounds a day
The symptoms in pica are usually related to the actual nonfood items that the individual consumes and the physical consequences that may result. Infections may result from consuming toxic substances. A person may become bloated and constipated as a result of consuming clay. Dental issues may result from eating ice and other hard substances.
Common symptoms of Pica include:
- Abdominal pain
- Nausea, vomiting
- Bloating
- Fatigue
- Poor nutrition
- Cravings
- Mineral deficiencies (iron, zinc)
- Lead toxicity
Causes and Risk Factors of Pica
There are many hypotheses regarding the causes of pica, but no firm data supports these theories.6 There are both psychosocial and biochemical causes. One potential reason that individuals consume nonfood items is that they suffer from a nutritional deficiency such as a low level of iron, zinc or calcium.
It is unclear, though, whether the lack of nutrients led to the consumption of clay, for instance, or whether eating nonfood items caused nutritional deficits. Ingestion of dirt or clay may be considered culturally acceptable in some areas. While this practice can still lead to medical complications, it is not considered to be an eating disorder under those circumstances.6
Pica is different from other eating disorders such as anorexia and bulimia in that it is not related to a disturbance of body image or a desire to become thin. The individual suffering from pica is more driven by compulsions such as in obsessive-compulsive disorder, for example. Lack of supervision in some families can lead to children consuming nonfood items. This is not always the case. Children may also turn to pica as a source of comfort in traumatic, neglectful or stressful situations.
Risk factors for Pica include:1,11
- Stress
- Pregnancy
- Nutritional deficiencies
- Co-occurring disorders
- Family psychopathology
- Cultural factors (some groups in the US and Africa are known to eat clay)
- Low socioeconomic status
- Learned behaviors
- Parental neglect
- Maternal deprivation
- Emotional trauma
Complications of Pica
Individuals can experience significant medical impairment as a result of consuming the nonfood items. Poisoning or infections are possible along with intestinal blockages and tears of the esophagus depending upon what items are ingested.
The following are common complications related to various substances consumed:1
- Clay or dirt consumption can lead to constipation, toxicity and nutritional deficiencies. Consuming dirt can also lead to infections or parasites.
- Eating large amounts of ice can lead to dental problems and iron deficiencies
- Consuming large amounts of starch can also lead to iron deficiencies. In some cases, pica can lead to high blood sugar and even obesity.
- Other substances frequently consumed pose risks as well such as lead poisoning from paint, mercury poisoning from paper, burns from batteries, arsenic, fluoride and many others.
- Intestinal blockages
- Nutritional deprivation
Diagnosing Pica
Children under the age of two are known to put objects into their mouths in order to explore their environments. This is not indicative of pica. Pica is not diagnosed in children under the age of two for this reason. Pica is found in children with intellectual disabilities and autism more than in children without these conditions.6 It is important to note that while most individuals do consume nonfood items or foods with little to no nutritional value at some point in their lives, most of the time these incidences do not constitute a diagnosable eating disorder.
Young children often chew on or even eat items such as crayons or even pet food that is easily accessible. When this behavior is considered developmentally appropriate, it is not diagnostic in nature. Adolescents and adults often consume foods and beverages that are of little to no nutritional value such as energy drinks, soda or candy. These examples do not qualify for an eating disorder diagnosis absent of other symptoms.
There are no specific tests to diagnose pica, so it is critical to be forthcoming with medical and mental health providers about the nonfood items being ingested. Diagnosis is dependent upon self-reporting of the patient. There are a few tests that physicians may order depending upon the nonfood items a patient has ingested. Blood tests to rule out lead poisoning and x-rays to determine whether a patient may have a bowel obstruction are a few examples of tests that a physician may perform in an individual with pica.6
Individuals are referred to a therapist if a primary care physician suspects an eating disorder for confirmation of a diagnosis and specialized treatment. Therapists and psychiatrists diagnose eating disorders based upon a set of industry accepted diagnostic criteria found in the
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).
The DSM-V describes pica as having the following diagnostic features:2
- A 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 behavior is not part of a culturally supported or socially normative practice
- If the eating behavior occurs in the context of another mental disorder (e.g. intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia), or medical condition (pregnancy), it is sufficiently severe to warrant additional clinical attention.
Treatment of Pica
A medical exam is needed at the onset of treatment for anyone suspected of having pica. It is important to conduct lab work that will check for deficiencies and toxicities due to nonfood items ingested. Your physician will address any medical complications related to consumption of nonfood items and related physical conditions resulting from the disorder. Then the individual will be referred to a mental health professional to address the pica and any other co-occurring conditions such as anxiety or impulse control disorders.
Treatment for the individual dealing with pica will include a multi-disciplinary approach with a team of professionals that includes a primary care physician, a therapist, a registered dietitian, and possibly a psychiatrist. These individuals may also require appointments with a dentist if the nonfood items they have been eating have damaged their teeth. The most common approaches to treating pica are behavior modification, nutritional counseling, medical monitoring and treatment, and in some cases medication for co-occurring medical or psychological conditions.
Therapy
In young children, it is crucial that their family is involved in treatment as they are crucial in providing a safe environment for the child so that nonfood items are no longer accessible for consumption. Adults may also involve family or friends in their treatment. Common types of therapies for treating pica include:
Behavioral Therapy4
Behavioral therapy is a term used to describe techniques used to change maladaptive behaviors. The goal is to reinforce desirable behaviors and eliminate unwanted ones. Behavioral therapy is focused on the problem. The goal is to teach people new behaviors to minimize or eliminate the issue. Children and their family members may use rewards such as stickers on a sticker chart to reinforce positive choices throughout the week regarding their food choices.
Nutrition Counseling
A registered dietitian with a specialty in eating disorders will provide nutrition counseling to the individual with pica. This may also include their family, especially in the case of the younger clients. The dietitian will educate the client and family about nutritional deficits in the client’s diet, how to meet their dietary needs, and how to determine the difference between edible and non-edible food items. The dietitian will work closely with the primary care physician to monitor lab work to ensure medical stability.
Family Therapy
Family therapy is designed to assist the entire family to learn about the disorder that is impacting the individual as well as everyone else. The family therapist will assist all involved to learn to cope with the stress as well as to develop coping skills needed to manage the condition within their household.
Family therapy may be conducted by a Licensed Marriage & Family Therapist (LMFT) and Licensed Professional Counselor (LPC) or a Licensed Psychologist (PhD, PsyD). Family therapy sessions provide a safe environment for families to discuss their feelings about dealing with a disorder that can be stressful and frightening for all involved. The family therapist will assist families to communicate better, problem-solve, and work together more effectively.
Psychoeducation5
Psychoeducation is designed to assist families to better understand and cope with pica within their households through providing information about the disorder and how to manage it. This will be provided to families by the therapist, psychiatrist, and the registered dietitian as it pertains to their portion of the patient’s treatment. It is important that both the individual diagnosed with pica and those they live with are given information about the condition and ideas about how to support and protect the individual. This is true of any co-occurring disorder that the patient is dealing with as well.
Medication
There are not any specific medications used to treat pica at this time. It is thought that antipsychotic medications, commonly used to treat schizophrenia and mood disorders, might help to reduce urges to consume nonfood items in pica. Some evidence suggests that the medications may provide treatment alternatives in individuals with pica that is resistant to behavioral intervention.6 The medications will likely have a larger role in treating any coexisting mental health disorders than in treating the pica.
Lifestyle Changes
In addition to the formal treatment a person receives for pica such as medical care, therapy and medication, there are lifestyle changes that can be helpful as well.
Some lifestyle changes that can help manage this eating disorder and related conditions include:
- Spending time with family and friends to increase support and accountability
- Making sure to get adequate sleep to reduce stress and anxiety
- Ensuring that the environment is safe for yourself and loved ones. Your home should be free of the nonfood items that the individual suffering from pica has been consuming
- Discovering alternative activities to distract oneself from consuming nonfood items
Intended Treatment Outcome & Timeline
The course of the disorder and treatment will vary depending upon whether there are co-occurring issues to resolve. The level of family involvement will also have an impact on the level of success a patient will experience. Most children do outgrow pica as indicated by the incidence in children decreasing with age.1
The following is a timeline of what treatment looks like for those dealing with pica:
Evaluation
A clinical history will be taken by the first professional to encounter a patient suspected of having pica (primary care practitioner, therapist, dentist, OB/GYN). Medical tests conducted to rule-out complications related to consumption of nonfood items.
Labs & X-rays check for:
- Anemia
- Intestinal blockages
- Toxicity
- Infections/parasites
Diagnosis of Pica
Diagnosis of co-occurring disorders (if applicable):
- OCD
- Anxiety
- Schizophrenia
- Autism
- Intellectual disability
Referral to appropriate professional:
- Primary care practitioner
- Therapist
- Family Therapist
- Psychiatrist
- Registered dietician
- Dentist
Treatment
The treatment plan for Pica will typically take place in this order:
- Correction of medical complications related to pica such as:
- Malnutrition
- Mineral/Nutrient deficiencies
- Safety plan development
- Behavioral interventions
- Medications (if indicated)
- Resolution of disorder
How to Get Help for Pica
Treatment for pica should begin with a physical examination to rule-out any medical complications related to consumption of nonfood items. A referral will be made to a mental health professional such as a Licensed Professional Counselor (LPC) or a Psychologist (PhD) to address the behavioral aspects of the disorder. A psychiatrist may also be consulted, especially if co-occurring disorders are present.
The cost for the treatment of pica is dependent upon the length of time needed and the number and qualifications of professionals required. Eating disorders require treatment from many professionals collaborating with one another to provide specialized care. Many commercial insurance plans will cover the costs of the medical treatment associated with pica while therapy and nutritional counseling may be more expensive due to out-of-pocket expenses.
Most individuals will be treated for pica at the outpatient level meaning they will not require hospitalization as with other eating disorders. Outpatient therapy appointments vary from state to state and the qualifications of the provider seen. The national average for a 50- minute counseling session is $90.13 The cost for nutritional counseling is also variable and is not always covered by commercial insurance.
How to get Help for a Loved One
There are online resources available if you suspect that you or a loved one is suffering with pica. Those with any eating disorder are encouraged to schedule an appointment with their primary care physician or locate a therapist through their insurance carrier. Pica is a severe eating disorder, so a good place to start is with an eating disorder specialist. When searching for specialists, one credential to look for is a therapist who is a Certified Eating Disorders Specialists (CEDS). These therapists are certified by the International Association of Eating Disorders Professionals (IAEDP) due to their highly specialized training and years of experience in the field of eating disorders.
Pica Statistics
Among individuals with intellectual disabilities, pica is the most common eating disorder. In this population, as the severity of the disability increases, the risk for and the severity of pica increases.6 Pica occurs in children, those with intellectual disabilities and pregnant women at higher rates than in the general population. Pica occasionally extends into adolescence, but rarely is it seen in adults who are not mentally disabled. Among those with intellectual disabilities, it is most common between the ages of 10-20 years.6
Other significant statistics regarding pica include:
- Children with intellectual disabilities and autism are more likely to have pica than those without these conditions6
- One study reported that 12.3% of children had engaged in pica behaviors during their lives
- A meta-analysis of studies of the prevalence of pica during pregnancy estimated that 27.8% of pregnant women reported experiencing pica
- The incidence of pica in children decreases with age with the rate over the age of 12 being only 10%1
- Up to 89% of those with Autism exhibit nutritional concerns including pica
- Worldwide, 25%-33% of all pica cases involve small children
- 10% to 15% of all pica cases are individuals with learning disabilities
- A small percentage of patients have iron deficiency anemia9
For Further Reading
The following are helpful resources for anyone impacted by Pica:
