What is the PICA disorder?

By Anushka Gupta

You have probably heard of anorexia nervosa as the most common eating disorder, but do you know what PICA is? According to NEDA (National Eating Disorders Association), it is “eating items that aren’t typically thought of as food and have no significant nutritional value”.1 It is hugely prevalent as it can affect a wide age range. In the United States alone up to 68% of pregnant women, 18.5% of children and 50% 18-36 months old children are currently affected by it – this doesn’t even include the rest of the world.2 This disorder is not widely known, and it may sound strange and uncommon however it must be made aware about especially due to the extremely harmful effects it has on people’s health. There could be even more people that have this, but do not report it, for example children hiding this behaviour from their parents or guardians. 

Causes

No one cause has been identified to explain this disorder. Instead, there are many theories that have been proposed. Naturally, babies have a tendency to put anything they find in their mouths but it is a given behaviour in this case since they are exploring the environment around them and developing their sense of taste.3 However, other behaviours and causes are abnormal arose from either mental health conditions or just the environment people are in. For example, some children do not have breakfast and eat paper or other items instead just to survive and to beat their hunger.4 

Another cause is a zinc, iron and calcium deficiency.5 Patients commonly tend to eat soil clay, ice, and laundry starch. The clay and the starch binds the iron in the individual’s gastrointestinal tract and exacerbates the deficiency.6Additionally, soil contains compounds that bounds both iron and zinc and further causes unusual abnormalities.7 A theory8 suggests that leptin and other appetite-regulating ‘brain enzymes’ trigger specific cravings and these are altered by the iron or zinc deficiency. Also, the physiological reasoning behind PICA that the theory explains is that eating the clay or starch removes or helps relieve nausea,  control diarrhoea, increase salivation, remove toxins or  even alter taste or odour perception during pregnancy  when women have odd cravings.9

Lastly, a high level of lead exposure can be associated as a cause of PICA.  This was a prevalent problem before the 1970s where children live for an extended time at old houses with lead paint. However, this is still quite prevalent nowadays where sources of lead can be found in some medication types and pottery. 10

Long term Effects 

Mainly, PICA has effects on teeth. This depends on what the individual is eating frequently since for example they are addicted to chewing bricks and stones, this can lead to the abrasion of the teeth.11 In a case report by Djemat et. Al12, there was report of attrition of teeth due to a habit of eating sand. Teeth attrition is dentrimental especially with effects of numbing nerves and increases the sensitivity of teeth as there is less protection. Another effect, which could be seen as more life-threatening, is a development of an additional eating disorder. In a case report13, a patient with depression and pregnancy got diagnosed with both bulimia and PICA. As  it is known, an eating disorder is already something hard to manage but having two at the same time requires careful, constant care by a doctor which can have major implications if the patient is financially disadvantvantaged or other ways where it is hard for them to get help properly. Other complications of PICA is malnutrition, intestinal obstruction and infection, anaemia, mercury poisoning, liver, kidney damage, constipation and abdominal problems.14

As PICA is classified as an eating disorder, the common consequences can also occur. The heart has less fuel to pump blood with and fewer cells, which increases the risk of heart failure as well as an abnormally low heart rate. The body also tries to conserve energy, because of the less energy it is getting from reduced food and thus reduces the individual’s metabolic rate. In the gastrointestinal system, gastroparesis occurs (slow digestion), stomach pains, bloating, and most threatening is when intestines are blocked from solid masses of undigested food. This is also associated with constipation, where it occurs due to laxative abuse which damages nerve endings and therefore leaves the body dependent on laxatives to have a bowel movement.15 In a neurological sense, the loss of protective lipid layering of neurons due to less fat in the body, so this can lead to numbness and tingling in hands and feets and other places. Linking back to the cardiovascular system, another effect is that if blood vessels cannot push enough blood to the brain, the individual is prone to dizziness or fainting, especially upon standing.16

Treatments – Is there a Cure? 

As mentioned, iron deficiency exacerbates PICA. Thus, a common treatment used is iron therapy or iron replacement therapy17 These are oral iron supplementation to provide the individual with their daily iron needs.18 Other treatments are purely behavioural, with seeing dietitians as well as therapists or psychiatrists to mend people’s addiction and help them guide their way to normal eating habits. A specific example of this is the ‘Overcorrection Method’.19 This is most useful for people who need to scavenge things in garbage bins (for example) and eat them, as the method’s purpose is to educate the person to accept responsibility for their behaviour, to allow them to practice the correct manner to fix it.  A case study20  exemplifies this – A 30-year-old woman named Dorris was institutionalised for 20 years as she regularly ate trash. The overcorrection method she went through frequently was: 1.  She was guided to a trash can by the trainer to spit/throw away the material she had 2. She went to the toilet where trainer gave her oral hygiene training where she was required to wash her hands and clean her fingernails for a set amount of time 3. The trainer instructed her to pick up trash around the ward and empty  trash cans. After day 15 of following the method, Dorris’s scavenging behaviour had reduced by 90% per cent and she had a larger appetite for normal meals.22 Therefore, the method did show good results, although this is just one example.

Conclusion 

PICA arises as unusual addictions to things in order to replace actual food, and normally people eat items that are easily found in their surroundings. There are a plethora of causes, long term effects, and treatments for this disorder but these vary among individuals. Currently, people have little to no awareness about this, however, we live in times where we are becoming more health conscious, more aware of our decisions about our diets, so it wouldn’t be surprising to see more circulation of information about this disorder. 

References:

  1. Advani S, Chachra S, Dhawan P, Kochhar G. Eating everything except food (PICA): A rare case report and review. Journal of International Society of Preventive and Community Dentistry. [Online] 2014;4(1): 1. Available from: doi:10.4103/2231-0762.127851
  1. Borgna-Pignatti C, Zanella S. Pica as a manifestation of iron deficiency. Expert Review of Hematology. [Online] 2016;9(11): 1075–1080. Available from: doi:10.1080/17474086.2016.1245136 
  1. Djemal S, Darbar UR, Hemmings KW. Case report: tooth wear associated with an unusual habit. The European Journal of Prosthodontics and Restorative Dentistry. 1998;6(1): 29–32.
  1. Dr. Karen Vieira. Pica Facts & Statistics. [Online] The Recovery Village Drug and Alcohol Rehab. Available from: https://www.therecoveryvillage.com/mental-health/pica/pica-statistics/%5D
  1. Health Consequences. Health Consequences. [Online] National Eating Disorders Association. Available from: https://www.nationaleatingdisorders.org/health-consequences 
  1. Johnson CD, Koh SH, Shynett B, Koh J, Johnson C. An uncommon dental presentation during pregnancy resulting from multiple eating disorders: pica and bulimia: case report. General Dentistry. 2006;54(3): 198–200.
  1. Pasricha S-R, Tye-Din J, Muckenthaler MU, Swinkels DW. Iron deficiency. The Lancet. [Online] 2021;397(10270): 233–248. Available from: doi:10.1016/s0140-6736(20)32594-0 
  1. Pica. Pica. [Online] National Eating Disorders Association. Available from: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/pica
  1. Roselle HA. Association of laundry starch and clay ingestion with anemia in New York City. Archives of Internal Medicine. 1970;125(1): 57–61
  1. Young SL, Wilson MJ, Miller D, Hillier S. Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE. [Online] 2008;3(9): e3147. Available from: doi:10.1371/journal.pone.0003147

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