Pica behaviors in a German community-based online adolescent and adult sample: an examination of substances, triggers, and associated pathology.

PURPOSE: To examine self-reported pica substances, situational triggers for, and associated psychosocial burden of pica eating in adolescents and adults in a Western European population. METHODS: A total of 78 individuals aged 16 years and over, who indicated consuming a substance that in their opinion is not considered as food, participated in an online survey. Two questionnaires assessed eating disorder and general psychopathology, and a third asked about the substances consumed, duration and frequency of consumption, triggers for consumption, emotions thereafter, and interest in treatment. RESULTS: The most frequently reported substances included foods in an uncooked or non-edible form, body parts/fluids, grass, leaves, paper, and earth-like substances, with 54 (69.23%) participants reporting a substance that would qualify as pica substance according to DSM-5. The main triggers for consumption were taste of the substance/indulgence, boredom, curiosity, and release of internal tension. The most common emotion after consumption was relief. Pica eating frequency was not significantly related to eating disorder and general psychopathology (both p > 0.05). A total of 24 individuals considered their pica eating as disruptive, of whom only eight declared an interest in treatment. CONCLUSIONS: The kind of substances consumed is in line with the previous reports in other populations. Pica eating does not seem to be associated with significant psychosocial burden; only a subgroup indicated that they experience it as disruptive and expressed interest in treatment. Nevertheless, for these individuals, triggers for pica eating and emotions thereafter might provide first hints for the development of interventions. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22.

OBJECTIVE: Avoidant/restrictive food intake disorder (ARFID), pica, and rumination disorder (RD) were added to the revised DSM-5 Feeding and Eating Disorders chapter in 2013. We developed a structured interview-the Pica, ARFID, and Rumination Disorder Interview (PARDI)-to assess the presence and severity of these diagnoses for evaluation and treatment planning in clinical and research settings. Here, we describe the development of the PARDI and provide a preliminary report on feasibility, acceptability, reliability, and validity in relation to ARFID. METHOD: We created an initial item pool from existing measures of similar constructs and clinical experience. The PARDI includes items assessing the level of endorsement and overall severity of common ARFID features organized into profiles (i.e., sensory sensitivity, lack of interest in eating, and fear of aversive consequences) and algorithms for diagnosing ARFID, pica, and RD. We collected initial psychometric data from participants (10-22 years) with ARFID (n = 39), clinically significant avoidant/restrictive eating (n = 8), and healthy controls (n = 10). RESULTS: On average, the PARDI took 39 min to complete and was acceptable to participants. All subscales achieved internal consistency greater ≥0.77, and inter-rater reliability for the ARFID diagnosis was moderate (κ = 0.75). Individuals with ARFID scored significantly higher than healthy controls on ARFID severity and ARFID profiles. DISCUSSION: The PARDI appears acceptable to respondents and preliminary evidence of reliability and validity has been demonstrated in an initial sample. Larger-scale validation studies are currently underway. The PARDI is freely available to clinicians and researchers.

Investigating the association between stress. Anxiety and geophagy among pregnant women in mwanza, Tanzania.

Geophagy, the craving and intentional consumption of soil, is common especially among pregnant women in some low- and middle-income settings. Soils may contain a variety of non-nutritive components such as heavy metals and microbes or substances that interfere with gastrointestinal absorptive processes, posing health risks to pregnant women. Several hypotheses regarding the practice have been proposed but very few have examined the role of maternal stress. The practice of geophagy may help to alleviate stress or anxiety during gestation from perceived dietary or other pregnancy-related concerns. In this study, we evaluated several measures of maternal stress (general anxiety, Pregnancy-Related Anxiety Scores (10-item revised), and Perceived Stress Scores) and other covariates in relation to geophagic behaviour in early pregnancy in 227 women (12-19 weeks gestation) recruited from two hospitals in the Nyamagana district of Mwanza City, Tanzania. Geophagy was reported by 24.7% of the pregnant women. Using LASSO regression, self-reported treatment of nausea or vomiting during pregnancy (adjusted OR = 3.12, 95%CI: 1.43 to 6.83), paternal education level (adjusted OR = 2.79, 95%CI: 1.32 to 5.87 for primary or lower education level), antenatal hospital site (adjusted OR = 3.71, 95%CI: 1.78 to 7.75), prescription drug use prior to pregnancy (adjusted OR = 1.76, 95%CI: 0.87 to 3.56) and general anxiety (feeling worried, tense or anxious in the past four weeks) (adjusted OR = 1.81, 95%CI: 0.88 to 3.72) were associated with geophagic behaviour. Given that relatively little has been done to examine geophagy in relation to the public health risk it may pose to pregnant women, these findings suggest the need for further investigations regarding maternal stress.

Prevalence of pica and rumination behaviors in German children aged 7-14 and their associations with feeding, eating, and general psychopathology: a population-based study.

Despite potentially severe medical consequences of pica and rumination disorder (RD), little is known about their prevalence and association with other psychopathology in childhood. As a part of a larger population-based study, 804 children aged 7-14 years and their parents were asked about their experience of pica and RD behaviors, and associated eating, feeding and general psychopathology. A total of 12.31 and 11.49% of the participants reported having engaged in pica or RD behaviors, respectively, at least once. Recurring pica or RD behaviors had been experienced by 4.98 and 1.49% of the participants, respectively. The behaviors showed a significant but small correlation with one another (r = 0.28, p < 0.01). Correlations with symptoms of avoidant/restrictive food intake disorder (ARFID) were significant but small (pica: r = 0.18, RD: r = 0.27, both p < 0.01). Prevalence rates of recurring pica behavior were significantly increased if recurring RD was present (58.33%), and also vice versa (17.50%). The prevalence rates of recurrent pica and RD behaviors were also increased in the presence of an ARFID diagnosis (both behaviors 12.0%). However, correlations with restraint and eating, weight, and shape concern were non-significant (all p > 0.05). Additionally, RD behavior was positively correlated with emotional and conduct problems (r = 0.15 and 0.22, both p < 0.01), and both behaviors were negatively correlated with prosocial behavior (r = -  0.10 and - 0.09, both p < 0.05). Our findings underscore the clinical significance of pica and RD behaviors. More research is warranted on both disorders and their association and relation with ARFID to deepen the understanding of their presentation and to ascertain diagnostic validity.

A Fatal Outcome of Pica Syndrome: An Unusual Case of Delayed Mortality.

We present the case of a 42-year-old man, with a medical history of schizophrenic psychosis, who was found dead on the floor of his bedroom. At the autopsy, a bottle lid with a notched edge was found in the lower pharynx, partially obstructing the larynx and thus keeping the epiglottis in an open position. Airway obstruction was caused by edema and inflammation of the surrounding tissue. After removal of the foreign body, the tissue of the larynx was left with an impression of the bottle lid. The adjacent mucosa was swollen, hyperemic, partly necrotic, and covered with fibrin deposits. Also, foreign bodies were found in the stomach. The histological analysis of the hypopharynx showed severe nonspecific inflammation and necrosis of epithelium. The cause of death was a complication of subacute laryngeal obstruction caused by a foreign body.

Role of lateral septum glucagon-like peptide 1 receptors in food intake.

Hindbrain glucagon-like peptide 1 (GLP-1) neurons project to numerous forebrain areas, including the lateral septum (LS). Using a fluorescently labeled GLP-1 receptor (GLP-1R) agonist, Exendin 4 (Ex4), we demonstrated GLP-1 receptor binding throughout the rat LS. We examined the feeding effects of Ex4 and the GLP-1R antagonist Exendin (9-39) (Ex9) at doses subthreshold for effect when delivered to the lateral ventricle. Intra-LS Ex4 suppressed overnight chow and high-fat diet (HFD) intake, and Ex9 increased chow and HFD intake relative to vehicle. During 2-h tests, intra-LS Ex9 significantly increased 0.25 M sucrose and 4% corn oil. Ex4 can cause nausea, but intra-LS administration of Ex4 did not induce pica. Furthermore, intra-LS Ex4 had no effect on anxiety-like behavior in the elevated plus maze. We investigated the role of LS GLP-1R in motivation for food by examining operant responding for sucrose on a progressive ratio (PR) schedule, with and without a nutrient preload to maximize GLP-1 neuron activation. The preload strongly suppressed PR responding, but blockade of GLP-1R in the intermediate subdivision of the LS did not affect motivation for sucrose under either load condition. The ability of the nutrient load to suppress subsequent chow intake was significantly attenuated by intermediate LS Ex9 treatment. By contrast, blockade of GLP-1R in the dorsal subdivision of the LS increased both PR responding and overnight chow intake. Together, these studies suggest that endogenous activity of GLP-1R in the LS influence feeding, and dLS GLP-1Rs, in particular, play a role in motivation.

Interpreting habits in a new place: Migrants' descriptions of geophagia during pregnancy.

BACKGROUND AND INTRODUCTION: Previous studies of soil eating, or geophagia, among pregnant women in sub-Saharan Africa indicate the practice is widespread. Various explanations have been explored to explain the global phenomenon of soil eating, with the most compelling explanation focused on clay's ability to prevent or treat intestinal infection. The urban South African context for clay eating is not well understood. This paper explores clay consumption amongst pregnant migrants who are nationals of countries where clay consumption may be common. METHODS: I conducted in-depth interviews with a purposively selected group of Somali, Congolese, and Zimbabwean women (n = 23). Interviews included questions broadly related to maternal and infant nutrition. In addition, I conducted nine focus group discussions (n = 48) with adult Somali, Congolese (DRC), and Zimbabwean men (N = 3) and women (N = 6), segregated by country of origin and gender. This paper focuses specifically on responses related to geophagia. RESULTS: While Somali women did not report consuming clay or charcoal, Congolese and Zimbabwean participants self-reported commonly consuming clay during pregnancy, and at times also when not pregnant. Despite having heard public health messaging that discouraged the practice, participants largely did not describe this consumption in terms of health, but rather in terms of craving and habit. Participants described continued consumption of clay in South Africa, and the only reason for ceasing consumption was in cases of severe constipation. DISCUSSION: The widespread consumption of clay soil by Congolese and Zimbabwean women during pregnancy may be a mechanism through which identity was reasserted and reproduced in a foreign country. Participants' emphasis on clay consumption seemed related to the absence or expense of other craved foods, and perhaps also to feelings of loss in Cape Town.

Pica and Eating Attitudes: A Study of High-Risk Pregnancies.

OBJECTIVE: To describe and determine the association between the occurrence of pica and eating attitudes in women with high-risk pregnancies and to determine the prevalence of pica during pregnancy. METHODS: A cross-sectional and prospective 24-month study was conducted with 913 women with high-risk pregnancies. Structured interviews were carried out and the Eating Attitudes Test was applied. RESULTS: Pica was diagnosed in 5.7 % of the pregnant women, and its most commonly practiced type was geophagia (57.7 %). The association between pica and signs related to the eating attitudes: "to be considered too thin by others" (p < 0.02), and "to spend too much time thinking about food" (p = 0.05); and the association between pica and the risk of both anorexia nervosa and bulimia nervosa (p < 0.01) were statistically significant. CONCLUSIONS: The absence of validated instruments in the literature for assessing pica reinforces the difficulty of investigating this practice and the need for further studies. Moreover, additional efforts need to focus in the improvement of screening for other eating disorders with obstetric consequences associated with pica and be incorporated into the routine of healthcare professionals.

Pica and rumination behavior among individuals seeking treatment for eating disorders or obesity.

OBJECTIVE: Pica and rumination disorder (RD)-formerly classified within DSM-IV Feeding and Eating Disorders of Infancy or Early Childhood-are now classified within DSM-5 Feeding and Eating Disorders. Though pica and RD have been studied in select populations (e.g., pregnant women, intellectually disabled persons), their typical features and overall prevalence remain unknown. This study examined the clinical characteristics and frequency of DSM-5 pica and RD among individuals seeking treatment for eating disorders and obesity. METHOD: We conducted structured interviews with adolescent and young adult females from a residential eating disorder center (N = 149), and adult males and females with overweight or obesity from an outpatient weight-loss clinic (N = 100). RESULTS: Several participants reported ingesting non-nutritive substances (e.g., ice) for weight-control purposes. However, only 1.3% (n = 2; 95% CI: .06% to 5.1%) at the residential eating disorder center and 0% at the weight-loss clinic met DSM-5 criteria for pica, consuming gum and plastic. Although no eating disorder participants were eligible for an RD diagnosis due to DSM-5 trumping rules, 7.4% (n = 11; 95% CI: 4.0% to 12.9%) endorsed rumination behavior under varying degrees of volitional control. At the weight-loss clinic, 2.0% (n = 2; 95% CI: 0.1% to 7.4%) had RD. DISCUSSION: DSM-5 pica and RD were rare in our sample of individuals seeking treatment for eating disorders and obesity, but related behaviors were more common. The wide range of pica and rumination presentations highlights the challenges of differential diagnosis with other forms of disordered eating.

A Rare Case of Ileocolic Obstruction Due to Lithophagia Associated with Cervical Oesophageal Perforation.

Lithophagia is a rare syndrome characterized by a repetitive ingestion of stones and pebbles. We herein report a case of a 61-year old mentally retarded man, with a past surgical history of multiple laparotomies for stone ingestion, presenting with cervical oesophagus perforation due to a large butterfly screw and massive impaction of 89 stones and other foreign bodies in the caecum, with consequent mechanical bowel obstruction.

[Recurrent voluntary ingestion of metallic objects in prison by a female patient]. / Ingestion volontaire d'objets métalliques à répétition chez une patiente en milieu carcéral.

INTRODUCTION: Recurrent and intentional ingestion of metallic objects is a rare but important phenomenon. It has attracted great interest among mental health professionals over the last decades. However, this issue is rarely reported in the literature. A deep exploration of its clinical and specific psychopathological aspects remains limited. CASE REPORT: We report the case of a 32-year-old female patient, who was sentenced to 20 years in prison for homicide against her cousin, the daughter of an uncle who had raped her when she was 14. This affair was hushed by the patient's family and the patient was submitted to several acts of abuse by her family. Following her incarceration, she repeatedly ingested metallic objects requiring repeated admissions in a department of surgery for endoscopic extractions or surgical interventions. She impulsively ingested more than 30 times various metallic objects such as wire, razor blades, spoons, etc., under the pressure of impulsiveness and massive anxiety. Voluntary metal ingestions, associated with iterative self-mutilation behaviors, took place within the framework of a borderline personality disorder, the incarceration and the conditions of imprisonment playing a role in initiating and retaining the behavior. CONCLUSION: Through this case report, we examine the specific psychiatric aspects of intentional ingestion of metallic objects in order to better understand this behavior.

Pica during pregnancy among Mexican-born women: a formative study.

Although pica, the craving and purposive consumption of non-food substances, is common among many populations, especially during pregnancy, the health consequences are not well understood. Further, very little is known about pica among Mexican populations in the United States and Mexico. Therefore, we conducted formative research to understand pica in this understudied population. Our objectives were to identify the frequency and types of pica behaviours, to understand perceived aetiologies and consequences of pica and to ascertain if the behaviour was common enough to warrant a larger study. We held nine focus group discussions (three in the Salinas Valley, California; six in Xoxocotla, Morelos, Mexico) with 76 Mexican-born women who were currently pregnant or had delivered within the past 2 years. Earth, adobe, bean stones and ice were the most commonly reported pica substances. Twenty-eight of the 76 participants (37%) reported ever engaging in pica; 22 participants (29%) reported doing so during pregnancy. The proportion of women reporting pica in the United States and Mexico was 43% and 34%, respectively. Women attributed pica to the overwhelming organoleptic appeal of pica substances (especially smell and texture) and to micronutrient deficiencies. Perceived consequences of unfulfilled pica cravings were birthmarks or fetal loss; fulfilled pica cravings were also thought to be generally harmful to the mother or child, with several women specifying toxic lead, pesticides or 'worms'. In sum, pica among Mexican women is common enough to warrant a larger epidemiologic study of its sociodemographic correlates and physiological consequences.

A CASE OF PICA FOLLOWING A PARAMILITARY PRE-EMPLOYMENT ORIENTATION CAMP.

BACKGROUND: Pica is an unusual craving for and ingestion of either edible or inedible substances first observed in pregnant women but has been reported in all groups of people. Pica poses a significant health risk that often requires medical attention but the awareness of pica among physicians seems to be have reduced. METHOD: We report a case study of a young lady who presented with anaemia (pcv = 21%) and craving for sand. Laboratory investigations carried outwere in keepingwith iron deficiency anaemia. CONCLUSION: It is therefore postulated that pica may actually be a sign of iron deficiency anaemia.

Homicide or suicide? Xylophagia: a possible explanation for extraordinary autopsy findings.

Determining the cause of death and differentiating self-inflicted injuries from non-self-inflicted injuries is a primary goal in legal medicine. Especially with unidentified decedents, autopsy findings alone are often not sufficient; there is no knowledge of pre-existing conditions and only circumstantial evidence is available from the scene of death. In our case, radiological, histological, and toxicological examinations provided an explanatory model for extraordinary autopsy findings consistent with pica, a rare eating disorder. In cases of pica, variable and potentially lethal complications emerge, depending on the type and amount of material ingested. Our case is of an apparently uncontrolled intake of wooden objects (xylophagia). The resulting mechanical damage to the gastrointestinal tract and subsequent soft tissue damage supports that this behavioral disorder is not only of medical concern, but also identifies it as a mental disease with medico-legal relevance.

A test of three hypotheses of pica and amylophagy among pregnant women in Tamil Nadu, India.

OBJECTIVES: Pica has been studied in India and elsewhere for more than 100 years, yet no compelling and empirically well-supported explanation for it has emerged. Amylophagy, sometimes considered a type of pica and sometimes studied separately, is less frequently investigated and also lacks a convincing explanation. This study used a biocultural approach to test three hypotheses of pica and amylophagy: protection, hunger/nutrition, and psychological distress. METHODS: The research took place in Tamil Nadu, India. In study 1, a cultural investigation was carried out among nonpregnant, adult women (n = 54) to determine nonfood substances that are consumed in this region and perceptions of health consequences. Next, using the substances identified in Study 1, three hypotheses of pica and amylophagy were tested in a cross-sectional study of pregnant women (Study 2, n = 95). Logistic regression analysis was used to analyze the presence or absence of engaging in pica and amylophagy. A series of bivariate analyses were used to examine the variation in amount and frequency of consumption. RESULTS: Study 1 revealed that cultural attitudes strongly shape the selection of nonfood substances. In Study 2, the presence or absence of pica was not predicted by any of the variables included in the study, whereas the frequency and amount of consumption of pica substances were primarily explained by the psychological distress and hunger/nutrition hypotheses. Both the presence or absence of amylophagy as well as the frequency and amount of consumption were best explained by the protection hypothesis. CONCLUSIONS: This research provided partial support for the protection and hunger/nutrition hypotheses for amylophagy, and also provided some evidence for the role of psychological distress and hunger or nutrition in pica.

A pica case confused with renal and bladder stones.

Pica is considered as an eating-nutritional disorder in childhood and is generally analysed within obsessive-compulsive disorders. A 15-year-old female patient was admitted to the urology clinic with nausea, vomiting, and stomach-ache. A 23 x 23 mm opacity was identified in left T-11-12 level in direct urinary graph. Full abdomen ultrasonography was reported to be normal. Later, it was learned that the patient had the habit of eating stone. The patient was diagnosed with obsessive-compulsive disorder following psychiatric consultation, and appropriate treatment was given.

A huge abdominal mass revealing a depressive syndrome.

Trichobezoar is a rare condition that occurs mostly in young women with psychiatric disorders such as trichotillomania and trichophagia. We report the case of a giant gastric trichobezoar in a 21-year-old woman who presented with chronic abdominal pain, vomiting and weight loss. Abdominal examination revealed a large epigastric mass. Endoscopic and imaging findings were highly suggestive of a gastric trichobezoar. Surgical extraction of the huge hair mass was successfully performed through an open gastrotomy. Postoperatively, history of a neglected chronic depression with suicidal ideation was diagnosed. Consequently, the patient was referred to the psychiatric department for mental healthcare, to prevent trichobezoar recurrences.

Pica, Autism, and Other Disabilities.

BACKGROUND AND OBJECTIVES: Pica, the repeated ingestion of nonfood items, can be life-threatening. Although case reports describe pica in children with autism spectrum disorder (ASD) or intellectual disability (ID), there has been little systematic study of pica prevalence. We assessed pica in children 30 to 68 months of age (median = 55.4 months) with and without ASD. METHODS: Our sample from the Study to Explore Early Development, a multisite case-control study, included children with ASD (n = 1426), children with other developmental disabilities (DDs) (n = 1735), and general population-based controls (POPs) (n = 1578). We subdivided the ASD group according to whether children had ID and the DD group according to whether they had ID and/or some ASD characteristics. Standardized developmental assessments and/or questionnaires were used to define final study groups, subgroups, and pica. We examined pica prevalence in each group and compared ASD and DD groups and subgroups to the POP group using prevalence ratios adjusted for sociodemographic factors. RESULTS: Compared with the prevalence of pica among POPs (3.5%), pica was higher in children with ASD (23.2%) and DD (8.4%), and in the following subgroups: ASD with ID (28.1%), ASD without ID (14.0%), DD with ID (9.7%), DD with ASD characteristics (12.0%), and DD with both ID and ASD characteristics (26.3%); however, pica prevalence was not elevated in children with DD with neither ID nor ASD characteristics (3.2%). Between-group differences remained after adjustment (adjusted prevalence ratio range 1.9-8.0, all P <.05). CONCLUSIONS: Pica may be common in young children with ASD, ASD characteristics, and ID. These findings inform the specialized health care needs of these children.