Pica | |
---|---|
Stomach contents of a psychiatric patient with pica: 1,446 items, including "457 nails, 42 screws, safety pins, spoon tops, and salt and pepper shaker tops". | |
Pronunciation | |
Specialty | Psychiatry |
Duration | life |
Causes | |
Deaths | 86/3993 |
Pica is the eating or craving of things that are not food. [2] It is classified as an eating disorder but can also be the result of an existing mental disorder. [3] The ingested or craved substance may be biological, natural or manmade. The term was drawn directly from the medieval Latin word for magpie, a bird subject to much folklore regarding its opportunistic feeding behaviors. [4]
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), pica as a standalone eating disorder must persist for more than one month at an age when eating such objects is considered developmentally inappropriate, not part of culturally sanctioned practice, and sufficiently severe to warrant clinical attention. Pica may lead to intoxication in children, which can result in an impairment of both physical and mental development. [5] In addition, it can cause surgical emergencies to address intestinal obstructions, as well as more subtle symptoms such as nutritional deficiencies and parasitosis. [5] Pica has been linked to other mental disorders. Stressors such as psychological trauma, maternal deprivation, family issues, parental neglect, pregnancy, and a disorganized family structure are risk factors for pica. [5] [6]
Pica is most commonly seen in pregnant women, [7] small children, and people who may have developmental disabilities such as autism. [8] Children eating painted plaster containing lead may develop brain damage from lead poisoning. A similar risk exists from eating soil near roads that existed before the phase-out of tetraethyllead or that were sprayed with oil (to settle dust) contaminated by toxic PCBs or dioxin. In addition to poisoning, a much greater risk exists of gastrointestinal obstruction or tearing in the stomach. Another risk of eating soil is the ingestion of animal feces and accompanying parasites. Cases of severe bacterial infections occurrence (leptospirosis) in patients diagnosed with pica have also been reported. [9] Pica can also be found in animals such as dogs [10] and cats. [11]
Pica is the consumption of substances with no significant nutritional value such as soap, plaster, or paint. Subtypes are characterized by the substance eaten: [12]
This pattern of eating should last at least one month to meet the time diagnostic criterion of pica. [20]
Complications may occur due to the substance consumed. For example, lead poisoning may result from the ingestion of paint or paint-soaked plaster, [21] hairballs may cause intestinal obstruction and Toxoplasma or Toxocara infections may follow ingestion of feces or soil. [22]
Pica is currently recognized as a mental disorder by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). According to the DSM-5, mineral deficiencies are occasionally associated with pica, but biological abnormalities are rarely found. [3] People practicing forms of pica, such as geophagy, pagophagy, and amylophagy, are more likely to be anemic or to have low hemoglobin concentration in their blood, lower levels of red blood cells (hematocrit), or lower plasma zinc levels. [23] Specifically, practicing geophagy is more likely to be associated with anemia or low hemoglobin. [23] Practicing pagophagy and amylophagy is more highly associated with anemia. [23] Additionally, children and pregnant women may be more likely to have anemia or low hemoglobin relative to the general population. [23] Mental health conditions such as obsessive–compulsive disorder (OCD) and schizophrenia have been proposed as causes of pica. [24] More recently, cases of pica have been tied to the obsessive–compulsive spectrum, and a move has arisen to consider OCD in the cause of pica. [25] Sensory, physiological, cultural, and psychosocial perspectives have also been used to explain the causation of pica. [26] [27] [28] [29] [30] [31]
Pica may be a cultural practice not associated with a deficiency or disorder. Ingestion of kaolin (white clay) among African American women in the US state of Georgia shows the practice there to be a DSM-4 "culture-bound syndrome" and "not selectively associated with other psychopathology". [32] Similar kaolin ingestion is also widespread in parts of Africa. [33] Such practices may stem from purported health benefits, such as the ability of clay to absorb plant toxins and protect against toxic alkaloids and tannic acids. [34]
No single test confirms pica, but because pica can occur in people who have lower than normal nutrient levels and poor nutrition (malnutrition), the health care provider should test blood levels of iron and zinc. Hemoglobin can also be checked to test for anemia. Lead levels should always be checked in children who may have eaten paint or objects covered in lead-paint dust. The healthcare provider should test for infection if the patient has been eating contaminated soil or animal waste. [20]
The DSM-5 posits four criteria that must be met for a person to be diagnosed with pica: [3]
In individuals with autism, schizophrenia, and certain physical disorders (such as Kleine–Levin syndrome), non-nutritive substances may be eaten. In such instances, pica should only be noted as an additional diagnosis if the eating behaviour is sufficiently persistent and severe to warrant additional clinical attention. [3]
Treatment for pica may vary by patient and suspected cause (e.g., child, developmentally disabled, pregnant, or psychogenic) and may emphasize psychosocial, environmental and family-guidance approaches; iron deficiency may be treatable through iron supplements or through dietary changes. An initial approach often involves screening for, and if necessary, treating any mineral deficiencies or other comorbid conditions. [8] For pica that appears to be of psychogenic cause, therapy and medication such as SSRIs have been used successfully. [35] However, previous reports have cautioned against the use of medication until all non-psychogenic causes have been ruled out. [36]
Looking back at the different causes of pica related to assessment, the clinician tries to develop a treatment. First, there is pica as a result of social attention. A strategy might be used of ignoring the person's behavior or giving them the least possible attention. If their pica is a result of obtaining a favorite item, a strategy may be used where the person is able to receive the item or activity without eating inedible items. The individual's communication skills should increase so that they can relate what they want to another person without engaging in this behavior. If pica is a way for a person to escape an activity or situation, the reason why the person wants to escape the activity should be examined and the person should be moved to a new situation. If pica is motivated by sensory feedback, an alternative method of feeling that sensation should be provided. Other nonmedication techniques might include other ways for oral stimulation such as gum. Foods such as popcorn have also been found helpful. These things can be placed in a "pica box" that should be easily accessible to the individual when they feel like engaging in pica. [5]
Behavior-based treatment options for pica can be useful for individuals who have a developmental disability or mental illness. Behavioral treatments have been shown to reduce pica severity by 80% in people with intellectual disabilities. [37] These treatments may involve using positive reinforcement normal behavior. Many use aversion therapy, where the patient learns through positive reinforcement which foods are good and which ones they should not eat. Often, treatment is similar to the treatment of obsessive–compulsive or addictive disorders (such as exposure therapy). In some cases, treatment is as simple as addressing the fact they have this disorder and why they may have it. A recent study classified nine such classes of behavioral intervention: Success with treatment is generally high and generally fades with age, but it varies depending on the cause of the disorder. Developmental causes tend to have a lower success rate. [38]
Treatment techniques include: [5]
The prevalence of pica is difficult to establish because of differences in definition and the reluctance of patients to admit to abnormal cravings and ingestion, [5] thus leading to the prevalence recordings of pica among at-risk groups being in the range of 8% to 65% depending on the study. [7] Based on compiled self-report and interview data of pregnant and postpartum women, pica is most prevalent geographically in Africa, with an estimated prevalence of 44.8%, followed by North and South America (23.0%) and Eurasia (17.5%). [39] Factors associated with Pica in this population were determined to be anemia and low levels of education, both of which are associated with low socioeconomic backgrounds. [39] Two studies of adults with intellectual disabilities living in institutions found that 21.8% [40] and 25.8% [41] of these groups had pica. [42]
Prevalence rates for children are unknown. [42] [43] Young children commonly place non-nutritious material into their mouths. This activity occurs in 75% of 12-month-old infants, and 15% of two- to three-year-old children. [43]
In institutionalized children with mental disabilities, pica occurs in 10–33%. [43]
The condition currently known as pica was first described by Hippocrates. [44]
The term pica originates in the Latin word for magpie, pīca, [4] [45] a bird famed for its unusual eating behaviors and believed to eat almost anything. [46] The Latin may have been a translation of a Greek word meaning both 'magpie, jay' and 'pregnancy craving, craving for strange food'. [47] [48] In 13th-century Latin work,[ clarification needed ] pica was referenced by the Greeks and Romans;[ when? ] however, it was not addressed in medical texts until 1563. [8]
In the southern United States in the 1800s, geophagia was a common practice among the slave population. [8] Geophagia is a form of pica in which the person consumes earthly substances such as clay, and is particularly prevalent to augment a mineral-deficient diet. [49] Noteworthy is the fact that kaolin was consumed by West Africans enslaved in the Southeastern United States, particularly the Georgia belt, due to the antidiarrheal qualities in the treatment of dysentery and other abdominal ailments. [50] The practice of consuming kaolin rocks was thereafter studied scientifically, the results of which led to the subsequent pharmaceutical commercialization of kaolinite, the clay mineral contained in kaolin. Kaolinite became the active ingredient in antidiarrheal drugs such as Kaopectate, although it was replaced by attapulgite in the 1980s and by bismuth subsalicylate starting in 2004. [51]
Research on eating disorders from the 16th to the 20th centuries suggests that during that time in history, pica was regarded more as a symptom of other disorders rather than its own specific disorder. Even today, what could be classified as pica behavior is a normative practice in some cultures as part of their beliefs, healing methods, or religious ceremonies. [8]
Prior to the elimination of the category of "feeding disorders in infancy and early childhood", which is where pica was classified, from the DSM-5, pica was primarily diagnosed in children. [44] However, since the removal of the category, psychiatrists have started to diagnose pica in people of all ages. [44]
Unlike in humans, pica in dogs or cats may be a sign of immune-mediated hemolytic anemia, especially when it involves eating substances such as tile grout, concrete dust, and sand. Dogs exhibiting this form of pica should be tested for anemia with a complete blood count or at least hematocrit levels. [52] [53] Although several hypotheses have been proposed by experts to explain pica in animals, insufficient evidence exists to prove or disprove any of them. [10]
Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention. Also, the depressive episodes will be approximately 2 weeks long.
A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.
Anemia or anaemia is a blood disorder in which the blood has a reduced ability to carry oxygen. This can be due to a lower than normal number of red blood cells, a reduction in the amount of hemoglobin available for oxygen transport, or abnormalities in hemoglobin that impair its function. The name is derived from Ancient Greek ἀν- (an-) 'not', and αἷμα (haima) 'blood'. When anemia comes on slowly, the symptoms are often vague, such as tiredness, weakness, shortness of breath, headaches, and a reduced ability to exercise. When anemia is acute, symptoms may include confusion, feeling like one is going to pass out, loss of consciousness, and increased thirst. Anemia must be significant before a person becomes noticeably pale. Additional symptoms may occur depending on the underlying cause. Anemia can be temporary or long term and can range from mild to severe.
Geophagia, also known as geophagy, is the intentional practice of eating earth or soil-like substances such as clay, chalk, or termite mounds. It is a behavioural adaptation that occurs in many non-human animals and has been documented in more than 100 primate species. Geophagy in non-human primates is primarily used for protection from parasites, to provide mineral supplements and to help metabolize toxic compounds from leaves. Geophagy also occurs in humans and is most commonly reported among children and pregnant women.
Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person who is exposed to alcohol during gestation, as a result of their mother drinking alcohol during pregnancy. The several forms of the condition are: fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND), and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE). Other terms used are fetal alcohol effects (FAE), partial fetal alcohol effects (PFAE), alcohol-related birth defects (ARBD), and static encephalopathy, but these terms have fallen out of favor and are no longer considered part of the spectrum.
Pagophagia is the compulsive consumption of ice or iced drinks. It is a form of the disorder known as pica, which in Latin refers to a magpie that eats everything indiscriminately. Its medical definition refers to the persistent consumption of nonnutritive substances for over a period of at least one month. However, different studies have included alternative definitions including "daily consumption of 2-11 full glasses of ice (480-2640g)" or "the purposeful ingestion of at least one ordinary tray of ice daily for a period in excess of two months." Pagophagia has been shown to be associated with iron-deficiency anemia and responsive to iron supplementation, leading some investigators to postulate that some forms of pica may be the result of nutritional deficiency.
Developmental disability is a diverse group of chronic conditions, comprising mental or physical impairments that arise before adulthood. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, especially in "language, mobility, learning, self-help, and independent living". Developmental disabilities can be detected early on and persist throughout an individual's lifespan. Developmental disability that affects all areas of a child's development is sometimes referred to as global developmental delay.
Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness". This behavior is usually targeted toward peers, parents, teachers, and other authority figures, including law enforcement officials. Unlike conduct disorder (CD), those with ODD do not generally show patterns of aggression towards random people, violence against animals, destruction of property, theft, or deceit. One-half of children with ODD also fulfill the diagnostic criteria for ADHD.
Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation as there is with typical vomiting, and the regurgitated food is undigested. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities . It is increasingly being diagnosed in a greater number of otherwise healthy adolescents and adults, though there is a lack of awareness of the condition by doctors, patients, and the general public.
Osteophagy is the practice in which animals, usually herbivores, consume bones. Most vegetation around the world lacks sufficient amounts of phosphate. Phosphorus is an essential mineral for all animals, as it plays a major role in the formation of the skeletal system, and is necessary for many biological processes including: energy metabolism, protein synthesis, cell signaling, and lactation. Phosphate deficiencies can cause physiological side effects, especially pertaining to the reproductive system, as well as side effects of delayed growth and failure to regenerate new bone. The importance of having sufficient amounts of phosphorus further resides in the physiological importance of maintaining a proper phosphorus to calcium ratio. Having a Ca:P ratio of 2:1 is important for the absorption of these minerals, as deviations from this optimal ratio can inhibit their absorption. Dietary calcium and phosphorus ratio, along with vitamin D, regulates bone mineralization and turnover by affecting calcium and phosphorus transport and absorption in the intestine.
A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".
Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.
Animal psychopathology is the study of mental or behavioral disorders in non-human animals.
Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).
Intellectual disability (ID), also known as general learning disability and mental retardation, is a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning that is first apparent during childhood. Children with intellectual disabilities typically have an intelligence quotient (IQ) below 70 and deficits in at least two adaptive behaviors that affect everyday, general living. According to the DSM-5, intellectual functions include reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. Deficits in these functions must be confirmed by clinical evaluation and individualized standard IQ testing. On the other hand, adaptive behaviors include the social, developmental, and practical skills people learn to perform tasks in their everyday lives. Deficits in adaptive functioning often compromises an individual's independence and ability to meet their social responsibility.
Mental disorders diagnosed in childhood can be neurodevelopmental, emotional, or behavioral disorders. These disorders negatively impact the mental and social wellbeing of a child, and children with these disorders require support from their families and schools. Childhood mental disorders often persist into adulthood. These disorders are usually first diagnosed in infancy, childhood, or adolescence, as laid out in the DSM-5 and in the ICD-11.
Substance use disorder (SUD) is the persistent use of drugs despite the substantial harm and adverse consequences to one's own self and others, as a result of their use. In perspective, the effects of the wrong use of substances that are capable of causing harm to the user or others, have been extensively described in different studies using a variety of terms such as substance use problems, problematic drugs or alcohol use, and substance use disorder. The National Institute of Mental Health (NIMH) states that "Substance use disorder (SUD) is a treatable mental disorder that affects a person's brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications. Symptoms can be moderate to severe, with addiction being the most severe form of SUD". Substance use disorders (SUD) are considered to be a serious mental illness that fluctuates with the age that symptoms first start appearing in an individual, the time during which it exists and the type of substance that is used. It is not uncommon for those who have SUD to also have other mental health disorders. Substance use disorders are characterized by an array of mental/emotional, physical, and behavioral problems such as chronic guilt; an inability to reduce or stop consuming the substance(s) despite repeated attempts; operating vehicles while intoxicated; and physiological withdrawal symptoms. Drug classes that are commonly involved in SUD include: alcohol (alcoholism); cannabis; opioids; stimulants such as nicotine, cocaine and amphetamines; benzodiazepines; barbiturates; and other substances.
Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.
Autism, formally called autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental disorder marked by deficits in reciprocal social communication and the presence of restricted and repetitive patterns of behavior. Other common signs include difficulties with social interaction, verbal and nonverbal communication, along with perseverative interests, stereotypic body movements, rigid routines, and hyper- or hyporeactivity to sensory input. Autism is clinically regarded as a spectrum disorder, meaning that it can manifest very differently in each person. For example, some are nonspeaking, while others have proficient spoken language. Because of this, there is wide variation in the support needs of people across the autism spectrum.
Externalizing disorders are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual's environment, which cause impairment or interference in life functioning. In contrast to individuals with internalizing disorders who internalize their maladaptive emotions and cognitions, such feelings and thoughts are externalized in behavior in individuals with externalizing disorders. Externalizing disorders are often specifically referred to as disruptive behavior disorders or conduct problems which occur in childhood. Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders. Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.
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