Understanding Pica (Eating Disorder)

Pica is characterized by the continued consumption of nonfood substances, such as dirt, chalk, paper, or ice. This behavior is not culturally or socially acceptable and occurs despite the individual's efforts to stop or control it. Nutritional deficiencies, such as iron deficiency anemia, are common in people with pica, and ingesting nonfood substances may be an attempt to correct these deficiencies.

Pica can have serious health consequences, depending on the substances ingested.

• For example, lead-based paint or soil consumption can result in lead poisoning, which can cause developmental delays, learning difficulties, and other health problems.
• Ingesting sharp or abrasive substances, such as metal or glass, can cause injury to the digestive tract.
• By contrast, ingesting large amounts of nonfood substances can cause intestinal obstruction or perforation.

Pica is most observed in children, pregnant women, and individuals with developmental disabilities, such as autism or intellectual disability. However, it can occur in people of any age or background. The exact causes of pica are poorly understood, but several factors are thought to contribute to its development.

In children, pica is more common between the ages of two and three, and it tends to resolve on its own by the age of four or five. In pregnant women, pica is often associated with iron deficiency anemia, which is common during pregnancy. People with developmental disabilities are also at a higher risk of pica due to difficulties with impulse control or communication. Some researchers have suggested that pica may be related to underlying mental health conditions, such as obsessive-compulsive disorder, schizophrenia, or depression. Additionally, environmental factors, such as poverty or exposure to toxins, may play a role in the development of pica.

Nutritional Deficiencies

Pica is often associated with nutritional deficiencies, particularly deficiencies in iron, zinc, and calcium.

Some of the specific nutritional deficiencies that can lead to pica include:

• Iron deficiency anemia: Iron deficiency is a common cause of pica, particularly in pregnant women and young children. Iron is necessary to produce hemoglobin—a protein in red blood cells that carries oxygen to the body's tissues. When the body is deficient in iron, it can lead to anemia, which can cause fatigue, weakness, and other symptoms. People with iron deficiency anemia may crave nonfood substances such as ice, dirt, or clay.
• Zinc deficiency: Zinc is an essential mineral for the immune system, wound healing, and normal growth and development. Zinc deficiency can cause various symptoms, including diarrhea, hair loss, and skin rashes. People with zinc deficiency may crave nonfood substances such as soil, sand, or chalk.
• Calcium deficiency: Calcium is a mineral that is essential for bone health, muscle function, and nerve function. Calcium deficiency can lead to a range of symptoms, including muscle cramps, osteoporosis, and dental problems. People with calcium deficiency may crave nonfood substances such as paper or chalk.

Mental Health Conditions

Pica is often associated with mental health conditions that involve obsessive-compulsive behaviors, schizophrenia, anxiety, developmental disorders, or intellectual disabilities.

Some of the specific mental health conditions that can lead to pica include:

• Obsessive-compulsive disorder (OCD)
  • OCD is a mental health condition characterized by intrusive thoughts or images (obsessions) and repetitive behaviors or mental acts (compulsions). In some cases, the compulsive behaviors associated with OCD may involve eating nonfood substances, such as hair, dirt, or paper.
• Intellectual or developmental disabilities
  • People with intellectual or developmental disabilities may engage in pica behaviors due to a lack of understanding of what is considered edible or non-edible or to explore their environment.
• Schizophrenia
  • Schizophrenia is a mental health condition that affects perception, thinking, and behavior. In some cases, individuals with schizophrenia may engage in pica behaviors because of delusions or hallucinations.
• Anxiety disorders
  • Anxiety disorders, such as generalized anxiety disorder or post-traumatic stress disorder, can cause intense feelings of stress or fear, leading to pica behaviors as a way of coping with these emotions.

Developmental Disorders

Pica is often associated with developmental disorders that affect cognitive, social, or behavioral development.

Some of the specific developmental disorders that can lead to pica include:

• Autism spectrum disorder (ASD)
  • ASD is a developmental disorder that affects communication, social interaction, and behavior. Some individuals with ASD may engage in pica behaviors, such as eating nonfood substances, as a form of self-stimulation or sensory seeking.
• Attention-deficit/hyperactivity disorder (ADHD)
  • ADHD is a developmental disorder that affects attention, hyperactivity, and impulsivity. Some individuals with ADHD may engage in pica behaviors as a way of managing hyperactivity or as a form of sensory stimulation.
• Prader-Willi syndrome
  • Prader-Willi syndrome is a rare genetic disorder that affects growth, development, and metabolism. People with Prader-Willi syndrome may engage in pica behaviors due to a constant feeling of hunger or a lack of satiety signals.

Pica can also be influenced by cultural and social factors. The types of nonfood items that people with pica crave may vary based on cultural beliefs and practices. For example, in some cultures, clay or soil may be consumed for medicinal purposes, whereas in others, it may be viewed as a taboo or a sign of mental illness. Social factors, such as poverty or lack of access to nutritious food, may also contribute to pica behaviors.

Some examples of how cultural and social factors can influence pica include:

• Cultural practices
  • In some cultures, certain nonfood items are believed to have medicinal properties and may be consumed for their perceived health benefits. For example, in some parts of Africa and South Asia, clay is consumed to alleviate digestive problems, whereas, in the Caribbean, charcoal is used to alleviate stomach issues.
• Poverty and lack of access to nutritious food
  • People who are living in poverty or do not have access to nutritious food may be more likely to engage in pica behaviors as a way of satisfying their hunger or nutritional needs. This is particularly common in developing countries where malnutrition is prevalent.
• Family or peer influences
  • Individuals with a close relative with pica may also engage in pica behaviors as a way of copying family members.
• Sensory seeking or avoidance
  • Some individuals with pica may engage in these behaviors to seek or avoid certain sensory experiences. For example, they may enjoy the taste or texture of certain nonfood items or try to avoid unpleasant sensory experiences associated with food.

People with pica can ingest a wide variety of nonfood substances. Substances that are ingested can vary depending on cultural, environmental, and personal factors.

Some of the most common objects ingested by people with pica include:

• Dirt or soil
• Clay
• Ice
• Chalk
• Paint
• Paper
• Hair
• Small metal objects such as coins
• Soap
• Plastic

Pica can cause serious health issues depending on the type and amount of substance ingested.

Some of the physical symptoms that can occur because of pica include:

• Gastrointestinal problems: Ingesting nonfood substances can cause gastrointestinal problems, such as nausea, vomiting, constipation, or diarrhea.
• Tooth damage: Eating hard or abrasive substances, such as metal or stones, can cause damage to the teeth or lead to tooth decay.
• Poisoning: Ingesting toxic substances, such as lead or mercury, can lead to poisoning, which can cause a range of symptoms, including seizures, developmental delays, and cognitive impairment.
• Infections: Eating substances contaminated with bacteria or other pathogens can lead to infections, such as gastrointestinal infections or parasitic infections.
• Bowel problems: Eating nonfood substances can cause bowel problems, such as blockages or perforations, requiring medical intervention.
• Nutritional deficiencies: Consuming nonfood substances can interfere with the absorption of nutrients from food, leading to nutritional deficiencies, such as iron deficiency anemia.
• Abdominal pain: Ingesting nonfood substances can cause abdominal pain, which can be a sign of digestive tract irritation or injury.
• Damage to the mouth or throat: Swallowing sharp or abrasive substances, such as metal or glass, can cause damage to the mouth or throat.

What are pica-like behaviors?

Pica is a condition often associated with psychological factors, such as stress, anxiety, or obsessive-compulsive disorder (OCD).

In addition to physical symptoms, pica can cause a range of psychological symptoms, including:

• Cravings or urges: People with pica often experience strong cravings or urges to eat nonfood substances, which can be challenging to resist.
• Anxiety: The inability to satisfy cravings or the fear of harm from ingesting nonfood substances can lead to anxiety in people with pica.
• Shame or embarrassment: The social stigma associated with pica can lead to feelings of shame or embarrassment in people with the condition.
• Depression: The psychological distress associated with pica can lead to depression, particularly if the condition is not treated.
• Guilt: People with pica may feel guilty about their behavior, particularly if they are aware of the potential health risks associated with ingesting nonfood substances.
• Obsessive thoughts: Pica is often associated with OCD, which can cause intrusive thoughts about ingesting nonfood substances.
• Compulsive behavior: People with pica may engage in compulsive behaviors, such as hoarding or collecting nonfood substances, and ingesting them.
• Low self-esteem: The social stigma associated with pica can lead to low self-esteem in people with this condition, particularly if they feel judged or misunderstood by others.

The doctor takes down thorough medical history, including details of previous medical conditions, and recent changes in appetite or eating habits.

A physical examination is conducted to check for any signs of damage or blockages in the digestive tract caused by ingesting nonfood items.

A mental health professional, such as a psychologist or psychiatrist, will conduct a psychological evaluation to assess any underlying mental health conditions that may be contributing to pica behaviors and even take a history of any previous mental health conditions, trauma, or abuse and any current stressors or life events.

The doctor or mental health professional will check if the individual meets the diagnostic criteria for pica as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). According to DSM-5, to be diagnosed with pica, an individual must have persistent cravings and consumption of nonfood substances for at least one month, and the behavior must be considered inappropriate to the individual's developmental level.

Treatment for pica usually involves a combination of medical and behavioral interventions. The underlying causes of the behavior should be identified and treated, such as addressing nutritional deficiencies or providing therapy for underlying mental health conditions. 

Behavioral interventions, such as cognitive-behavioral therapy, can help individuals learn alternative coping strategies to reduce the urge to consume nonfood substances. In severe cases, medication may also be prescribed to reduce the individual's cravings for nonfood substances.

Treatment for pica may include the following:

• Behavioral therapy
  • This type of therapy aims to identify and modify the behaviors that lead to pica. Behavioral therapy can be effective in children and adults with mild-to-moderate pica. The therapy may involve reinforcement of positive behaviors, such as eating nutritious food while discouraging pica behaviors.
  • A behavioral therapist may also work with the individual to identify triggers that lead to pica and develop coping strategies to manage those triggers.
• Nutritional counseling
  • Nutritional counseling can help individuals with pica establish healthy eating habits and ensure they meet their nutritional needs. A registered dietitian can work with the individual to develop a meal plan that includes a variety of nutrient-rich foods that can help reduce cravings for nonfood items.
• Medication
  • In some cases, medication may be prescribed to treat underlying mental health conditions contributing to pica, such as obsessive-compulsive disorder (OCD) or autism spectrum disorder. Medication may also be prescribed to treat any medical conditions associated with pica, such as anemia or iron deficiency.
• Family therapy
  • Family therapy can be effective in treating pica behaviors in children and adolescents. A family therapist can work with the entire family to develop strategies for managing the behavior, establishing consistent routines, and addressing any underlying family dynamics contributing to the behavior.
• Environmental interventions
  • This may involve making changes to the individual's environment to reduce access to nonfood items. For example, parents may need to secure cabinets or drawers containing nonfood items or place childproof locks on trash cans.
• Safety monitoring
  • Individuals with severe pica may require constant supervision to ensure their safety. This may involve monitoring the individual's behavior, ensuring that nonfood items are not accessible, and providing appropriate care if an emergency arises.

Preventive strategies for pica can help reduce the risk of the condition or help manage the behavior.

Here are some common preventive strategies for pica:

• Address underlying mental health conditions
  • Pica is often associated with underlying mental health conditions, such as OCD, anxiety, or developmental disorders. Addressing these conditions through therapy, medication or other interventions can help reduce the risk of pica.
• Ensure adequate nutrition
  • Nutritional deficiencies can contribute to the development of pica, so it is important to ensure that individuals receive adequate nutrition through a balanced diet or nutritional supplements if needed.
• Environmental modifications
  • Making changes to the individual's environment can help prevent access to nonfood items that may be ingested. This can include locking cabinets and drawers containing nonfood items, securing trash cans, and supervising children or individuals with developmental disorders who may be at a high risk of pica.
• Educational interventions
  • Educating individuals about the dangers of ingesting nonfood items and the importance of seeking help for pica behaviors can be an effective preventive strategy. This can include providing educational materials, conducting workshops or training sessions, and involving families and caregivers in the educational process.
• Supervision and monitoring
  • This can help prevent individuals from engaging in pica behaviors. This may include frequent check-ins, setting up a schedule for meals and snacks, and providing appropriate care and support if pica behaviors occur.
• Positive reinforcement
  • Providing positive reinforcement for appropriate behaviors, such as eating healthy foods, can help reduce the risk of pica. This can include verbal praise, rewards, or other forms of positive reinforcement.

What foods satisfy pica cravings?

Although certain foods may help reduce cravings for nonfood items in some individuals with pica, there is no one-size-fits-all approach to addressing pica behaviors. Nutritional counseling and individualized meal planning with a registered dietitian can help ensure that individuals with pica are meeting their nutritional needs and addressing their specific food cravings.

Here are some foods that may help satisfy pica cravings for certain individuals:

• Ice: Chewing on ice can help satisfy cravings for crunchy or chewy nonfood items. Excessive consumption of ice can lead to dental problems, so it's important to practice moderation.
• Gum or mints: Chewing gum or sucking on mints can help reduce cravings for nonfood items with strong flavors or aromas.
• Crunchy fruits and vegetables: Crispy, crunchy fruits, and vegetables, such as apples, carrots, and celery, can help satisfy cravings for crunchy or fibrous nonfood items.
• Protein-rich foods: Meats, fish, beans, and nuts can help address cravings for certain minerals or nutrients that may be lacking in the individual's diet.
• Nutrient-dense snacks: Cheese, yogurt, or hummus with vegetables can help provide the individual with a satisfying snack that also meets their nutritional needs.