Pica

Reviewed by Amy Baker Dennis, PhD, FAED

Pica is an eating disorder that involves eating items that are not typically thought of as food and that do not contain significant nutritional value, such as hair, dirt, and paint chips.1

Diagnostic Criteria


Accoring to the DSM-5 TR:1

  • There are no laboratory tests for pica. Instead, the diagnosis is made from a clinical history of the patient.
  • Diagnosing pica should be accompanied by tests for anemia, potential intestinal blockages, and toxic side effects of substances consumed (i.e., lead in paint, bacteria or parasites from dirt).

Warning Signs and Symptoms of Pica


The following are common signs of pica:1

  • The persistent eating, over a period of at least one month, of substances that are not food and do not provide nutritional value.
  • The ingestion of the substance(s) is not a part of culturally supported or socially normative practice (e.g., some cultures promote eating clay as part of a medicinal practice).
  • Typical substances ingested tend to vary with age and availability. They may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch, or ice.
  • The eating of these substances must be developmentally inappropriate. In children under two years of age, mouthing objects—or putting small objects in their mouth—is a normal part of development, allowing the child to explore their senses. Mouthing may sometimes result in ingestion. In order to exclude developmentally normal mouthing, children under two years of age should not be diagnosed with pica.
  • Generally, those with pica are not averse to ingesting food.

Risk Factors2


  • Pica often occurs with other mental health disorders associated with impaired functioning (e.g., intellectual disability, autism spectrum disorder, schizophrenia).
  • There is limited understanding of what causes pica, however iron-deficiency anemia and malnutrition are thought to be two of the most common causes of pica, followed by pregnancy. In these individuals, pica is a sign that the body is trying to correct a significant nutrient deficiency. Treating this deficiency with medication or vitamins often resolves the problems.
  • A medical professional should assess if the behavior is sufficiently severe to warrant independent clinical attention (e.g., some people may eat nonfood items during pregnancy, but their doctor may determine that their actions do not indicate the need for separate clinical care).
  • Lack of supervision in children or child neglect.
  • Family history of Pica.

Health Consequences of Pica


Pica can lead to serious health consequences such as:2,3,4,5

  • Poisoning, the most common type being lead poisoning, which can present with neurological symptoms such as irritability, lethargy, headaches, the loss of control of bodily movements (ataxia), seizures, cranial nerve paralysis, pressure in the brain which causes the optic nerve to swell (papilledema), brain damage (encephalopathy), coma, and death. Even lower levels of lead poisoning can lead to neurological damage such as impaired memory, decreased IQ and behavioral problems like ADHD.
  • Infection or parasitic infestations which can manifest with signs of fever, malaise, coughing, visual problems, inflammation of the heart (myocardium), and inflammation of the brain (encephalitis)
  • Gastrointestinal complications such as constipation, intestinal obstruction, ulcers, or perforations.
  • Dental issues such as severe damage to the teeth or abrasions to the gums.

Learn more about health consequences here.

Additional Information


  • It is unclear how many people are affected by pica. Since PICA was first formally recognized as an eating disorder in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013, there is limited research on the disorder. Due to this lack of research, prevalence rates of the disorder are varied. One study found that approximately 1.1% of adults experience recurrent PICA behaviors and another study found that 5% of youth aged 7 to 14 years experience recurrent PICA behaviors.6,7
  • The prevalence of PICA varies between countries and is higher in developing countries. This is likely due to increased food insecurity in developing countries and resulting malnutrition which is thought to be a contributing factor to the development of pica.8
  • Pica can affect children, adolescents, and adults of any genders.3
  • Those who are pregnant and craving nonfood items should only be diagnosed with pica when their cravings lead to ingesting nonfood items, and the ingestion of those items poses a potential medical risk (either due to the quantity or type of item being ingested). A meta-analysis study found that worldwide, 27.8% of pregnant women exhibit Pica behaviors, with increasing prevalence in developing countries with higher rates of anemia and lower levels of education.9
  • Pica can be associated with intellectual disability, schizophrenia, autism spectrum disorder, pregnancy, trichotillomania (hair pulling disorder), and excoriation (skin picking) disorder, obsessive compulsive disorder, and sickle cell disease.2,3,10,11
  • A recent study has also found that Pica can be associated with depression, anxiety, other eating disorder behaviors and less positive body image.2

Treatment Considerations2,3,12,13


The first-line treatment for pica involves testing for mineral or nutrient deficiencies and correcting those. In many cases, concerning eating behaviors disappear as deficiencies are corrected. If the behaviors aren’t caused by malnutrition or don’t stop after nutritional treatment, a variety of behavioral interventions are available.

Scientists in the autism community have developed several different effective interventions for those with developmental disabilities, including redirecting the person’s attention away from the desired object and rewarding them for discarding or setting down the non-food item.

Since pica can have serious health consequences early detection and treatment is important. Treatment providers specializing in pica are limited so if you or a loved one is exhibiting any concerning behaviors associated with pica consult with a primary care doctor or pediatrician as soon as possible. If you or your loved one has ingested anything that could be harmful seek immediate medical attention, call 911, or call poison control at: 1‑800‑222‑1222.

Learn more about treatment here.

Learn more about finding treatment providers in your area here.

Sources


[1]American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

[2] Al Nasser, Y., Muco, E., & Alsaad, A. J. (2022). Pica. In StatPearls. StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK532242/. Accessed on 8/2/23.

[3] McNaughten, B., Bourke, T., & Thompson, A. (2017). Fifteen-minute consultation: the child with pica. Archives of disease in childhood. Education and practice edition, 102(5), 226–229. https://doi.org/10.1136/archdischild-2016-312121

[4] Mourato Nunes, I., Pedroso, A. I., Irimia, M., & Ramos, A. (2017). Pica, constipation and cardiorespiratory arrest. BMJ case reports, 2017, bcr2017221066. https://doi.org/10.1136/bcr-2017-221066

[5]  The Pew Charitable Trusts. (2017, August 30). 10 policies to prevent and respond to childhood lead exposure. Health Impact Project. Available at: https://www.pewtrusts.org/en/research-and-analysis/reports/2017/08/10-policies-to-prevent-and-resp

[6] Hartmann, A. S., Zenger, M., Glaesmer, H., Strauß, B., Brähler, E., de Zwaan, M., & Hilbert, A. (2022). Prevalence of pica and rumination behaviours in adults and associations with eating disorder and general psychopathology: findings form a population-based study. Epidemiology and psychiatric sciences, 31, e40. https://doi.org/10.1017/S2045796022000208

[7] Hartmann, A. S., Poulain, T., Vogel, M., Hiemisch, A., Kiess, W., & Hilbert, A. (2018). 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. European child & adolescent psychiatry, 27(11), 1499–1508. https://doi.org/10.1007/s00787-018-1153-9 

[8] Ahmed, M. A., Al-Nafeesah, A., AlEed, A., & Adam, I. (2023). Prevalence and associated factors of symptoms of pica among adolescent schoolchildren in northern Sudan: a cross-sectional study. Journal of eating disorders, 11(1), 49. https://doi.org/10.1186/s40337-023-00777-0

[9] Fawcett, E. J., Fawcett, J. M., & Mazmanian, D. (2016). A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 133(3), 277–283. https://doi.org/10.1016/j.ijgo.2015.10.012

[10]Khosravi M. (2021). Pica behaviors in schizophrenia: a call for further research. Journal of eating disorders, 9(1), 117. https://doi.org/10.1186/s40337-021-00472-y

[11] Clark, O. M., & Williams, R. (2020). Pica behaviors in pediatric patients with sickle cell disease: a scoping review protocol. JBI evidence synthesis, 18(9), 2018–2024. https://doi.org/10.11124/JBISRIR-D-19-00241

[12] Liu, H., Burns, R. T., Spencer, B. R., Page, G. P., Mast, A. E., & NHLBI Recipient Epidemiology Donor Evaluation Study (REDS)-III. (2021). Demographic, clinical, and biochemical predictors of pica in a large cohort of blood donors. Transfusion, 61(7), 2090–2098. https://doi.org/10.1111/trf.16409

[13] Call, N. A., Simmons, C. A., Mevers, J. E., & Alvarez, J. P. (2015). Clinical Outcomes of Behavioral Treatments for Pica in Children with Developmental Disabilities. Journal of autism and developmental disorders, 45(7), 2105–2114. https://doi.org/10.1007/s10803-015-2375-z