Pica DSM-5 307.52 (F98.3) (F50.8)

Pica DSM-5 307.52 (F98.3) (F50.8)

DSM-5 Category: Feeding and Eating Disorders

Introduction

Pica involves an individual persistently and compulsively eating nonfood substances that are nonnutritious. The act is considered developmentally inappropriate as non-discrimination between what one ingests orally is associated with young children. Pica in children over five years of age can be a sign of age-inappropriate behavior. Adults engaging in pica often have intellectual disabilities. Pica, formerly under a section for disorders with onset in childhood and adolescence, now falls under the eating disorders umbrella of “Feeding and Eating Disorders” in DSM-5. With the new classification, DSM-5 sought to address the over classification of eating disorders into a not otherwise specified category. Under DSM-5, there is no age specification for the onset of pica. Items eaten include earth, paper, chalk, feces, glass, paper and other nonfood items.

Pica is sometimes linked to obsessive-compulsive disorder and impulse disorder because of the persistent dieting on non-nutritious food. Like those with OCD, individuals with pica are conscious of their behavior even though it is unhealthy and illogical behavior.

Pica Symptoms

Individuals who engage in pica may experience some of the same symptoms as a malnourished anorexic. Symptoms may include mineral deficiency, unhealthy nails and hair, and weight loss. They are at higher risk of more serious health issues such as abdominal pain, and intestinal and colonic obstruction. Pica is often co-morbid with other mental disorders and may be seen in autism spectrum disorder, schizophrenia, anorexia nervosa and nonsuicidal self-injury. Individuals feigning a factitious disorder may ingest nonfood items in order to imitate the symptoms of a more serious disorder.

The criteria for pica under DSM-5 is as follows (APA, 2013):

  • Persistent eating of non-nutritive, nonfood substances for a period of at least one 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 occurring with another mental disorder, or during a medical condition, it is severe enough to warrant independent clinical attention.

 

Although a link is often made between pica and obsessive-compulsive disorder, at this time pica is not classified as a symptom or specifier of OCD, although it was suggested as part of the DSM-5 reclassifications. An example of pica linked to OCD is a pregnant woman with obsessive-compulsive disorder whose sole manifestation was pica. The subject ate uncooked rice during three pregnancies resulting in abdominal discomfort (Upadhyaya & Sharma, 2012). In pica, the compulsive behavior has been linked to low economic status. A Turkish research team has reported most cases of colonic obstruction to be related to pica. A typical example is a young girl from a poor family who suffered from constipation and colonic obstruction as a result of eating stones. The behavior of the child, who also suffers from an iron deficiency, was considered compulsive (Senol, Özdemir, Sahiner, & Özdemir, 2013).

Pica Risk Factors

The onset of pica is typically in childhood, although there is no age specification for developing the disorder. Pica is more common in areas of low economic status. Africa has a higher incidence of pica than western countries, for example. Some researchers have linked the odd cravings to nutritional deficiencies such as mineral deficiencies (Kumsar & Erol, 2013). Pregnant women experience pica, which may be part of pregnancy ‘cravings’ for different types of food.

Much of the research on pica has focused on its occurrence in those who have an intellectual disability. In fact, pica has a higher prevalence rate in individuals with intellectual disabilities than those with eating disorders (Karlsson, Råstam, & Wentz, 2013). Neglect and a lack of supervision are also risk factors, according to DSM-5. An abused child who is not adequately nourished may try and eat nonfood substances.

Pica may also be associated with a mental disorder or brain damage. Brain imaging has revealed brain abnormalities prior to the development of pica symptoms. In one study, recent damage to the hippocampal area preceded the onset of pica (Rohde, Claussen, Kuechenhoff, Seifritz, & Schuepbach, 2013). As noted, there is a strong association between pica and obsessive-compulsive disorder.

Culture as a risk factor is evident in several African countries where Pica is most common among African women and children. A Nigerian study provides some surprising statistics that point to the need for more research on therapeutic solutions. It reports incidences of pica of 25 % and 46% in Zambian adolescents and male children, respectively; and 8.1% and 8.8% in pregnant African-American women in the United States and pregnant women in Saudi Arabia, respectively. This study also makes a link between pica and iron and zinc deficiency (Ibrahim, 2013). However, if pica is of spiritual, medicinal or social value in a culture, then it does not qualify as pica under the DSM-5 criteria.

Pica demonstrates the anxiety-relief-anxiety behavior pattern of anxiety disorders. A typical example is the case study of an adult male with a low-to-normal IQ who eats glass when feeling a high level of anxiety. After eating the glass, he reports feeling relief (Kumsar & Erol, 2013).

An individual engaging in pica may suffer from nutritional deficiencies, get infections, and die from the practice. Intestinal and colonic obstruction and infection are experienced. Pica is most often brought to the attention of doctors due to abdominal complaints.

Pica Therapy

The classification of three new disorders under ‘Feeding and Eating Disorders’ in DSM-5 seeks to improve the clinical utility and thus treatment of eating disorders. Pica has not received a lot of research attention to date. Cognitive behavioral therapy (CBT) and family therapy are commonly used to treat eating disorders. One treatment focus of pica is on those with intellectual and development disabilities who engage in a higher rate of pica behavior. Applied behavior therapy (ABT) is one of the most effective therapies; it is commonly and successfully applied with those with intellectual disabilities and behavioral problems, including those with autism and other disorders. ABT teaches new behavior by rewarding and reinforcing positive behavior and punishing undesired behavior (Matson, Hattier, Belva, & Matson).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Ibrahim, A. (2013). Pica in children with tetralogy of Fallot: Report of two cases. Muller Journal of Medical Sciences and Research, 4(2), 122.

Karlsson, L., Råstam, M., & Wentz, E. (2013). The Swedish Eating Assessment for Autism spectrum disorders (SWEAA)—validation of a self-report questionnaire targeting eating disturbances within the autism spectrum. Research in developmental disabilities, 34(7), 2224-2233.

Matson, J. L., Hattier, M. A., Belva, B., & Matson, M. L. (2013). Pica in persons with developmental disabilities: Approaches to treatment. Research in developmental disabilities, 34(9), 2564-2571.

Rohde, J., Claussen, M. C., Kuechenhoff, B., Seifritz, E., & Schuepbach, D. (2013). Combined symptomatology of psychosis, pica syndrome, and hippocampal sclerosis: A case report. International Journal of Eating Disorders, 46(1), 89-91.

Senol, M., Özdemir, Z. Ü., Sahiner, I. T., & Özdemir, H. (2013). Intestinal Obstruction due to Colonic Lithobezoar: A Case Report and a Review of the Literature. Case reports in pediatrics, 2013.

Upadhyaya, S. K., & Sharma, A. (2012). Onset of obsessive compulsive disorder in pregnancy with pica as the sole manifestation. Indian journal of psychological medicine, 34(3), 276.


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