Pica A Very Common but Less Commonly Recognised Problem!

April  Jaya Srivastava

Dr. Jaya Srivastava disusses Pica, including causes, diagnostics and homeopathic remedies that may be indicated.

INTRODUCTION

Picais the desire for and eating of items that are not considered food, and doing so for more than a month. The material is often consumed in large quantities without regard for the health consequences.

The term Pica comes from the Latin for ‘magpie’, a bird that gathers objects to satisfy its curiosity.

April 2016 Jaya Srivastava

Magpies are frequently seen with all sorts of items in their beaks, from chewing gum wrappers to wire hangers. Due to this habit of having something in their beaks always, they were thought to be birds with a random appetite.  By similarity, the human condition of desiring non-food items was given the name “pica” in the sixth century.

CATEGORIZATION

The mental health professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (2000), which is abbreviated as DSM-IV-TR, classifies pica under the heading of “Feeding and Eating Disorders of Infancy or Early Childhood.”

CATEGORYMental and behavioural disorders
SYSTEMNervous system
ORGANBrain, Stomach, Gastro-intestinal tract
OTHER/COMMON NAMESGeophagy, geophagia
NAMES IN OTHER LANGUAGESPicacismo- Italian

Cicero- Spanish

ICD CLASSIFICATIONF50.8 – pica of adults

F98.3- pica of infancy and childhood

WORLD STATISTICSSince 1999, the in-patient stays due to PICA have sharply increased by 93%
INDIAN STATISTICSNot available due to under-reporting
MOST PREVALENT INIndia, Africa, Australia, America

DEFINITION

PICA is an eating disorder usually defined as the constant eating of non-nutritive substances for a period of at least 1 month at an age for which this behaviour is not suitable (e.g., above 18-24 months of age). Pica items are diverse, and therefore can be named accordingly. Names for specific types of pica generally have Greek origins. These terms have in common a Greek root for the material ingested followed by phagia, for “eating.”

For example:

Term                                     Desire for
Acuphagia                         Sharp objects
Amylophagia                     Laundry starch
Cautopyreiophagia           Burnt matches
Coprophagia                     Human feces, animal dung
Foliophagia                       Leaves, grass, acorns, pinecones
Geomelophagia                  Raw potatoes
Geophagia                          Dirt, sand, clay
Lignophagia                       Wood, bark, twigs
Lithophagia                        Rocks, gravel, pebbles
Pagophagia                         Ice, freezer frost
Plumbophagia                    Paint chips (lead)
Tobaccophagia                   Cigarette butts
Trichophagia                      Hair

 

But this is not all!

There are other types of pica behaviours which are not named, like:

 

     Items                          Desire for
Art supplies                    Crayons, chalk, glue, markers, pencils, pens
Ashes                              Cigarette
Building materials          Caulking, concrete, glass
Fibers                              Rope, carpet, cloth, pillow/toy stuffing, sponge
Home items                    Candles, charcoal, coffee grounds, mothballs
Insects                             Dead, live
Metal                               Bolts, coins, nails, nuts, rust, screws
Paper                               Books, disposable diapers, labels, toilet paper
Plastic                             Container lids, toy parts
Rubber                            Foam rubber, tubing, telephone cord
Sewing supplies              Pins, needles, buttons, thread
Toiletries                         Soap, deodorant, toilet bowl freshener, toothpaste

SYMPTOMS

April 2016 Jaya Srivastava.

  1. The person will have a habit of eating substances like clay, dirt, stones, pebbles, hair, faeces, lead, plastic, pencil, erasers, fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string, cigarette, wire and burnt matches etc.
  2. A person with history of PICA may present with complaints of:
  • Constipation
  • Diarrhoea
  • Chronic or acute, diffuse or focused abdominal pain
  • Nausea/ vomiting
  • Loss of appetite

The symptoms of pica vary with the item ingested.

  • Sand or soil is associated with gastric pain and occasional bleeding.
  • Chewing ice may cause abnormal wear on teeth.
  • Eating clay may cause constipation.
  • Swallowing metal objects may lead to bowel perforation.
  • Eating faecal material often leads to parasitic infectious diseases as toxocariasis.
  • Consuming lead can lead to kidney damage and mental retardation.
  1. On examination, there will be findings like :
  • Abdominal swelling and tightness
  • Pallor that is yellowness of skin
  • Iron deficiency anaemia which could be the cause of PICA
  1. Clinical presentation of PICA is variable and is associated with the specific nature of the resulting medical conditions and the indigested substances.
  2. Parasitic infestations are usually associated with PICA. Worm troubles are commonly seen in children with Pica.

CAUSES

  1. Mineral deficiency specially iron deficiency

Malnutrition is often diagnosed at the same time as pica. Eating clay has been associated with iron deficiency. In many cases, with the treatment of anaemia, the pica desires have stopped.

  1. Upsetting events

Stress has been found associated with development of such abnormal eating desires.  Some frequent reasons for the stress are as follows:

  • Maternal lack
  • Parental separation or neglect
  • Childhood violence
  • Poor parent-child relation
  1. Low socio-economic status

Eating paint is most common among children from families of low socioeconomic status. It is often associated with lack of parental supervision. Hunger also results in pica.

  1. Psychiatric causes

Pica is occasionally a feature of much more severe mental problems, including autism, schizophrenia, and developmental disorders. It is suggested that pica functions as a soothing behaviour. Among persons with mental retardation, pica has been explained as the result of an inability to tell the difference between food and non-food items.

  1. Cultural and religious practices

There are a number of places where earth is eaten or applied externally because of its supposed religious properties. There are stories of modern-day religious geophagy from around the world, in Christianity, Islam, Hinduism, and Voodoo. In some cultures ingestion of kaolin (white dirt) is a common practice, in order to achieve protection and health.

RISK FACTORS

Certainly, eating any indigestible thing can have risks. It affects

almost all aspects of life::

  • Family life is affected
  • Environmental danger
  • Pregnancy- it has harmful effects on the unborn baby and the pregnant lady also
  • Epilepsy- risk to epilepsy is increased
  • Brain damage- it causes harm to the brain
  • Mental retardation- brain damage may result in mental retardation
  • Pervasive developmental disorders- these are very common nowadays, like autism

TEST & DIAGNOSIS

Pica is often diagnosed in a hospital emergency room, when the child or adolescent develops symptoms of lead poisoning, bowel perforation, or other medical complications caused by the non-food items that have been swallowed. Otherwise this is one of least reported problems as a chief complaint. The choice of imaging or laboratory studies depends on the characteristics of the ingested materials and the resultant medical problems.

  1. Imaging studies

The examining doctor may order a variety of imaging studiesin order

to identify the ingested materials and treat the gastrointestinal

complications of pica. These imaging studies may include:

abdominal x rays

  • barium examinations of the upper and lower gastrointestinal (GI) tracts
  • upper GI endoscopies to diagnose the formation of bezoars (solid masses formed in the stomach) or to identify associated injuries to the digestive tract

Films and studies may be repeated at regular intervals to track changes in the location of ingested materials.

  1. Blood examination

All routine tests are compulsory. A complete blood count will reveal

anemia. Blood examination is recommended for:

  • Haemoglobin level to diagnose anaemia and its extent.
  • Screening for blood lead levels in children is advised. Lead levels should always be checked in children who may have eaten paint or objects covered in lead-paint dust to screen for lead poisoning.
  • The tests for infection if the person has been eating contaminated soil or animal waste are also essential.
  1. Stool examination

Stool examination may indicate presence of worms.

TREATMENT

The management of this disorder requires a multidisciplinary approach which involves the family, physician, nutritionist, psychologist and sometimes the social workers also. Behavioural strategies are also useful in the treatment.  The line of treatment has to be based on the underlying cause for the abnormal craving. Thus, Homeopathic prescribing is most suitable as it is based on individualization.  But, if it is not reported early, it leads to medical emergencies like severe bleeding or obstruction in the food tract and hospitalization is necessary.

HOMEOPATHIC TREATMENT

There are many Homeopathic medicines which have a promising scope in combating this disorder. Some of these are:

  1. Abies canadensis:
  • Peculiar cravings and chilly sensations most marked.
  • Great appetite, craving for meat, pickles, pickles, radishes, turnips, artichokes, coarse food. Tendency to eat far beyond capacity for digestion.
  • Especially for women with uterine displacements, probably due to defective nutrition and debility.
  • Burning and distention of stomach and abdomen with palpitation.
  • Constipation, with burning in rectum.
  1. Alumina:
  • Abnormal cravings for chalk, charcoal, dry food, tea-grounds.
  • Aversion to meat. Potatoes disagree. No desire to eat.
  • Colic, like painter’s colic. Left-sided abdominal complaints.
  • Subject to catarrh of the stomach, to ulceration of the stomach, to indigestion from the simplest food.
  • Stool hard, dry, and knotty with no desire. Constipation of infants and in women of very sedentary habit.
  • Persons with lack of vital heat, debility, sluggish functions, heaviness, numbness, staggering, and the characteristic constipation.
  • Confused as to personal identity. Hasty, hurried. Time passes slowly.
  1. Arsenicum album
  • Craves acids and coffee.
  • Craves for ice. Continual craving for fluids, drinks frequently but little at a time.
  • Ill effects from decayed food or animal matter.
  • Anemia and chlorosis. Reduces the refractive index of blood serum.
  • Gradual loss of weight from impaired nutrition.
  • Great anguish and restlessness. Changes place continually. Fears, of death, of being left alone. Suicidal.
  • Liver and spleen enlarged and painful.
  • Burning pain and pressure in rectum and anus. Stool small, offensive, dark, with much prostration. Dysentery dark, bloody, very offensive.
  1. Calcarea carbonica
  • Craving for indigestible things-chalk, coal, pencils; also for eggs, salt and sweets.
  • Aversion to meat, boiled things. Milk disagrees. Dislike for fats.
  • Loss of appetite when overworked.
  • Cramps in stomach; worse, pressure, cold water. Abdomen sensitive to slightest pressure.
  • Liver region painful when stooping. Cannot bear tight clothing around the waist.
  • Crawling and constriction in rectum. Stool large and hard.
  • The chief action is centered in the vegetative sphere, impaired nutrition being the keynote of its action, the glands, skin, and bones.
  • Children are late in learning to walk. Difficult and delayed dentition.
  • Children, who grow fat, are large-bellied, with large head, pale skin, chalky look. Calcarea patient is fat, fair, flabby and perspiring and cold, damp and sour.
  • Anemia of girls.
  1. Calcarea phosphorica
  • Craving for bacon, ham, salted or smoked meats.
  • Easy vomiting in children. Colic, soreness and burning around navel.
  • Bleeding after hard stool.
  • Anemic children who are peevish, flabby, have cold extremities and feeble digestion.
  • Complaints during teething; teeth develop slowly; rapid decay of teeth.
  • Scrofulosis, chlorosis and phthisis.
  1. Cina maritima
  • Desires many and different things. Craving for sweets.
  • Gets hungry soon after a meal. Hungry, digging, gnawing sensation.
  • Vomiting and diarrhea immediately after eating or drinking.
  • Twisting pain about the navel.
  • The person is hungry, cross with an irritability of temper, variable appetite, grinding teeth and even convulsions, with screams and violent jerking of the hands and feet.
  • Child very cross; does not want to be touched, or crossed, or carried.
  1. Cicuta virosa
  • Desire for unnatural things, like coal.
  • Indigestion, with insensibility, frothing at mouth.
  • Flatulence with anxiety and crossness. Rumbling in. Distended and painful. Colic with convulsions.
  • General action of the patient is violent, with frightful distortions. Delirium, with singing, dancing and funny gestures.
  • History of suppressed skin eruptions
  1. Ignatia amara
  • Averse to ordinary diet; longs for great variety of indigestible articles. Craving for acid things.
  • Sinking in stomach, relieved by taking a deep breath.
  • Rumbling in bowels. Weak feeling in upper abdomen.
  • Itching and stitching up the rectum. Stool passes with difficulty.
  • Especially adapted to the nervous temperament-women of sensitive, easily excited nature, dark, mild disposition, quick to perceive, rapid in execution.
  • Effects of grief and worry. Changeable mood; introspective; silently brooding.
  1. Medorrhinum
  • Craves stimulants, tobacco, sweets, green fruit, ice, sour things, oranges, ale, and salt.
  • Ravenous hunger even after eating. Unquenchable thirst.
  • Nausea after eating and after drinking water. Sour and bitter vomiting.
  • Gasping pain in liver and spleen. Rests more comfortably lying on abdomen.
  • Inactivity of rectum. Can pass stool only by leaning very far back.
  • Many uses in inherited complaints of children. Marasmas and emaciation of children with sycosis in genetic background.
  1. Natrum muriaticum
  • Craving for salt. Aversion to bread, to anything slimy, like oysters, fats.
  • Hungry, yet loose flesh. Unquenchable thirst.
  • Cutting pain in abdomen. Distended.
  • Constipation; stool dry, crumbling. Burning pains and stitching after stool.
  • The prolonged taking of excessive salt causes profound nutritive changes to take place in the system, and there arise not only the symptoms of salt retention as evidenced by dropsies and œdemas, but also an alteration in the blood causing a condition of anæmia and leucocytosis.
  • Emaciation most notable in neck.
  • Great debility; most weakness felt in the morning in bed.
  1. Nitric acidum
  • Longing for indigestible things-chalk, earth, etc.
  • Great hunger, with sweetish taste. Loves fat and salt.
  • Bowels constipated, with fissures in rectum. Great straining, but little passes.
  • Hemorrhages from bowels, profuse, bright. Hemorrhoids bleed easily.
  • All discharges very offensive, especially urine, feces, and perspiration.
  • Best suited to the dark complexioned and past middle life.
  • Irritable, hateful, vindictive, headstrong. Hopeless despair. Sensitive to noise, pain, touch, jar.
  1. Nux vomica
  • Craves for charcoal, pepper, chalk. Desire for stimulants. Loves fats and tolerates them well.
  • Dyspepsia from drinking strong coffee.
  • Sour taste and nausea in the morning, after eating.
  • Bruised soreness of abdominal walls. Flatulent distension, with spasmodic colic.
  • Constipation, with frequent ineffectual urging, incomplete and unsatisfactory; feeling as if part remained unexpelled.
  • Nux patients are easily chilled, avoid open air, etc.
  • Very irritable: sensitive to all impressions. Cannot bear noises, odors, light, etc. Does not want to be touched.
  1. Phosphorus
  • Bad effects of eating too much salt. Inflammation of stomach, with burning extending to throat and bowels.
  • Hunger soon after eating. Sour taste and sour eructations after every meal.
  • Pain in stomach; relieved by cold food, ices. Region of stomach painful to touch, or on walking.
  • Liver congested. Fatty degeneration. Large, yellow spots on abdomen.
  • Very fetid stools and flatus. Long, narrow, hard, like a dog’s. Difficult to expel. Desire for stool on lying on, left side.
  • Produces a picture of destructive metabolism. Tall, slender persons, narrow chest, with thin, transparent skin, weakened by loss of animal fluids, with great nervous debility, emaciation, amative tendencies.
  • Great lowness of spirits. Easily vexed. Fearfulness.
  1. Silicia terra
  • Craving for raw food, lime, sand.
  • Disgust for meat and warm food.
  • Want of appetite; thirst excessive. Sour eructations after eating.
  • Colic; cutting pain, with constipation; yellow hands and blue nails. Stool comes down with difficulty; when partly expelled, recedes again.
  • Imperfect assimilation and consequent defective nutrition.
  • Patient is cold, chilly, hugs the fire, wants plenty warm clothing, and hates drafts, hands and feet cold, worse in winter.
  • Lack of vital heat. Prostration of mind and body.
  • Nervous and excitable. Sensitive to all impressions.
  • Brain-fag. Obstinate, headstrong children. Abstracted. Fixed ideas.
  1. Staphisagria
  • Craving for tobacco. Desire for stimulants.
  • Canine hunger, even when stomach is full.
  • Colic after anger. Colic, with pelvic tenesmus.
  • Swollen abdomen in children, with much flatus.
  • Nervous affections with marked irritability, Child cries for many things, and refuses them when offered.
  • Impetuous, violent outbursts of passion, hypochondriacal, sad. Very sensitive.
  1. Sulphur
  • Craves raw food. Great desire for sweets. Milk disagrees.
  • Complete loss of, or excessive appetite.
  • Very weak and faint about11 am; must have something to eat.
  • Abdomen very sensitive to pressure; internal feeling of rawness and soreness. Movements as of something alive.
  • Chronic constipation. Frequent, unsuccessful desire; hard, knotty, insufficient. Child afraid on account of pain.
  • Dirty, filthy people, prone to skin affections. Aversion to being washed. Standing is worse position.
  • Individuals are nearly always irritable, depressed, thin and weak, even with good appetite.
  • Very forgetful. Difficult thinking. Religious melancholy.
  1. Tarentula hispanica
  • Craves raw food and sand.
  • Aversion to food; aversion to meat especially. Thirst for cold water.
  • Burning in the abdomen that extends down through the intestine. Liver is painful to touch and is swollen. Pain in both sides of the abdomen.
  • No desire for stool. With the stool there is much blood.
  • Emaciation well marked. Sensitiveness to cold.
  • Anxiety and restlessness.
  • Trembling and jerking convulsions.
  1. Veratrum album
  • Craves cold things, ice, and salt.
  • Coprophagia violent mania alternates with silence and refusal to talk.
  • VoraciousThirst for cold water, but is vomited as soon as swallowed. Averse to warm food.
  • Abdomen sensitive to pressure, swollen with terrible colic.
  • Gastric catarrh, great weakness, cold, sudden sinking.
  • Melancholy, with stupor and mania.
  • Delusions of impending misfortunes. Mania, with desire to cut and tear things

Other aids

  1. General behavioural strategies

Cognitive behavioural therapies are considered effective in the treatment of pica. This is typically demonstrated in children as learning negative associations with eating things that aren’t food and positive associations with healthy eating habits. In order to treat this common but mind-boggling disorder, each patient has to be individually assessed for his or her needs and possible causes.

Such strategies include the following:

  • Antecedent manipulation
  • Training in discrimination between edible and non-edible items
  • Self-protection devices that prohibit placement of objects in the mouth
  • Sensory reinforcement
  • Differential reinforcement of other or incompatible behaviours
  • Overcorrection

A behavioural assessment is required to identify individuals who swallow objects in response to hallucinations, delusions, or in reaction to mood or anxiety symptoms. Once there is reasonable certainty that there are no medical explanations for the PICA, an assessment of psychiatric symptoms should be conducted

Individuals with intellectual disabilities are more likely to have behavioural manifestations of psychiatric symptoms when they occur and are less likely to be able to verbalize in a sophisticated way about what they are experiencing.

  1. Nutritional supplementation.

Many times, the underlying cause for pica is related to some mineral deficiency. Then it is very important to include the food items enriched with that particular mineral in the daily diet and get a supplement (if required) as directed by the nutrition-advisor.

  1. Consultation with a Dentist

It is necessary in the cases of pica where there are dental manifestations (e.g., severe tooth abrasion, aberration, and surface tooth loss).

  1. Family education

It is important to tell the family about the condition of the affected member so that they could provide the necessary support and care in achieving the desired goal of perfect health of the patient. In case of abnormal cravings, family members can take care to abstain from all such triggering factors and avoid any stress to the patient.

  1. Surgery

In some cases, surgery may be required to remove metal objects from the patient’s digestive tract or to repair tissue injuries. It is particularly important to remove any objects made of lead (fishing weights, lead shot, pieces of printer’s type, etc.) as quickly as possible because of the danger of lead poisoning.

SIMILAR CONDITIONS

  • Anorexia nervosa- It is an eating disorder characterised by immoderate food restrictions, inappropriate eating habits or rituals and obsession with having a fear of weight gain which results in excessive weight loss and harmful to health.
  • Bulimia nervosa- It is an illness in which a person has regular episodes of overeating and feels a loss of control. People with bulimia generally eat large amounts of high calorie foods secretly.
  • Worm’s infection- This is known as the parasitic infection of intestines and is very common throughout the world. Children are particularly susceptible to the worms. There are over 100 different types of parasites that can live in human body. These parasites may cause many ill health conditions including diarrhoea and gastrointestinal upset.

RESOURCES

Books:

  • Craving Earth- Understanding Pica: The Urge to Eat Clay, Starch, Ice & Chalk by Sara L. Young, Columbia University Press, paperback edition, 2012
  • American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 4th ed, revised. Washington, DC: American Psychiatric Association, 2000.
  • Beers, Mark H., MD, and Robert Berkow, MD., editors. “Anemias.” In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
  • Beers, Mark H., MD, and Robert Berkow, MD., editors. “Malnutrition.” Section 1, Chapter 2 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
  • Pocket manual of homeopathic Materia Medica, 9th edition – William Boericke & O E Boericke
  • Boger Boenninghausen’ Characterstics Materia Medica and Repertory
  • Kent’s Repertory- James Tyler Kent

Web search:

  • http://www.pghomeopathy.com/home.asp
  • http://www.homeoint.org/cazalet/gibshotrem.htm
  • www.wikipedia.com
  • http://hoacuoidep.info/homeopathy-papers/homoeopathic-management-of-pica/

 

About the author

Jaya Srivastava

Jaya Srivastava

Dr. Jaya Srivastava (PGHom (UK), BHMS(India), DipN(UK)
obtained her Bachelor's Degree in Homeopathic Medicine and Surgery from the prestigious LBS Homeopathic College, India and a postgraduate diploma in Homeopathy from Hahnemann College of Homeopathy, London. She also holds DipN (UK): Diploma in Nutrition, Blackford Center for Nutrition, UK (2013), Certificate in Lifestyle Medicine for Stress Management –and Nutrition and Metabolic Syndrome, Harvard Medical School, Boston (2017).

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