One day at the park John, Carl, and Terry are digging in the dirt. John finds a small rock and starts to snicker. A minute later he turns to Terry and says, “I dare you to eat this pebble. I will give you $5 for doing it.” Terry seems uneasy, but he takes the rock and looks at it for a couple of seconds while John and Carl quietly snicker at the idea. Does Terry do the dare
Later when John, Carl, and Terry part ways to go home, Terry looks around to make sure they are both gone. He pulls the pebble out of his pocket, analyzing its every corner before popping it in his mouth. He swallows slowly, knowing that the craving that was tugging at his thoughts at the park was finally subsiding. What might be a silly dare to John and Carl is an everyday reality to Terry, who has a box filled with small rocks and pebbles under his bed that he eats from whenever no one is around.
The thought of eating pebbles at all may make many of us a bit squeamish, but Terry does not flinch for a second. The truth about Terry is that he has pica, an eating disorder defined by the American Psychiatric Association’s 5th edition of the Diagnostic and Statistic Manual (DSM-V) as “the eating of one or more non-nutritive, non-food substances on a persistent basis over a period of at least one month” with respect to age and availability of the desired non-nutritive, non-food substance or substances. (American Psychiatric Association, 2013). Some of the more typical substances ingested might include paper, soap, hair, gum, chalk, or, in Terry’s case, pebbles. For individuals to be clinically diagnosed with pica, the eating of these non-nutritive, non-food substances “must be developmentally inappropriate” and “not part of a culturally supported or socially normative practice” (American Psychiatric Association, 2013).
Terry does not see a problem with eating pebbles, and neither do his parents because they do not even know that Terry eats them out of the box under his bed. But Terry is not alone. 43-year-old mother of two Heather drinks the paint of one paint marker a day, which is equivalent to three gallons of paint per week. Featured on TLC’s My Strange Addiction, Heather admits to us that she has been “addicted to drinking paint” for more than two years and knows that the behavior is not “normal.” Afraid of what others will think when she begins to seek help, Heather starts by telling her best friend, who at first is shocked but supportive of her and suggests she get tests run by a doctor who specializes in internal medicine. In this three-minute YouTube video of the TLC episode, the doctor reports to Heather that her kidney function is “a little bit abnormal” because of her ingestion of paint, which contains more than half a dozen lethal chemicals such as xylene that could cause pulmonary hemorrhage in the lungs, seizures, and even death.
The remaining issue with both Terry’s and Heather’s cases is that they have not been clinically diagnosed to have pica even though they meet all criteria for the eating disorder. If eating pebbles and drinking paint regularly can raise concerns about the physical and mental health of Terry and Heather, then what is the barrier for diagnosis and treatment?
The prevalence of pica is currently unknown since the eating disorder often goes unreported (Dennis & Ekern 2014), but what is known is that diagnosis is most common among vulnerable populations such as pregnant women and mentally and developmentally delayed children. The root of pica is also unknown, but based on previous medical reports, a frequent reason for pica-related behavior is anemia or the absence or lack of important minerals (iron or zinc). Given pebbles, paint, and other unusual items that might be consumed, pica is viewed as extremely dangerous to the individual. Moreover, long-term ingestion may cause unprecedented complications, such as poisoning from toxic substances similar to those contained in the paint Heather ingested; brain damage, which, in younger children, often translates into learning disabilities and other mental conditions; and organ failure or death in the most extreme cases. Terry is at risk for permanent dental damage if he continues to hide eat pebbles during a time when his baby teeth are falling out for his mature teeth to settle, and he may also experience constipation or blockages in the digestive tract (including the intestines and bowels), perforations in the lining of the intestines if the edges of the rocks are too sharp, and potentially vicious bacterial infections from dirt coating the rocks he finds (Dennis & Ekern 2014).
Pica is more than just a “strange addiction,” as implied by the stories that appear on My Strange Addiction. According to the DSM-V, the eating of non-nutritive, non-food substances can also be “an associated feature of other mental disorders” that include intellectual development disorder (IDD), autism spectrum disorder (ASD), and schizophrenia. When pica is induced by another mental disorder such as schizophrenia, the consequences can be even more baffling. AB, a 75-year-old lady with a 40-year history of schizophrenia and a 20-year history of pica, was found to have almost 216 dollars’ worth of loose change in her stomach. While her physical examination was reported as normal by Beecroft et al. (1998), one of her laboratory tests revealed depressed levels of zinc, and a CT scan of her head showed lesions in her temporal lobe or damage in the area of her brain responsible for speech function.
Another case discussed by Huang et al. (2010) described a 35-year-old man with schizophrenia who had no medical or surgical diseases, eating disorders, drug abuse history, or other psychiatric history, but once he started taking olanzapine (an antipsychotic drug), he exhibited pica by uncontrollably and unexplainably eating garbage, sand, and pebbles. While his pica only persisted for three weeks, Harada et al. (2006) reported that a patient with schizophrenia, Mr. A, suffered from medication-refractory coprophagia, or the eating of one’s own feces as induced by antipsychotic drug side effects. The extreme nature of this situation should be enough to warrant immediate medical attention, but even still, pica continues to be underdiagnosed and undertreated despite the detrimental effects of errant feeding behavior.
If individuals, young or old, show clear signs and symptoms of pica, how do they get the treatment they need? A typical medical evaluation for pica includes blood tests for possible anemia, toxins, and other substances in the blood, and X-rays to reveal items or blockages in the intestinal tract (Dennis & Ekern 2014). In addition, the clinician may check medical history, examine physical wellness, and refer undiagnosed individuals like Heather and Terry to psychiatric specialists for better help.
Sometimes people with pica like the taste, texture, or smell of the items they consume, but many of the items or substances ingested have grave medical and cognitive consequences. In the end, pica is more than just “strange” or “disgusting,” as portrayed by reality television shows like My Strange Addiction that often stigmatize individuals who consume non-nutritive, non-food substances by terming them “freak-shows” or “attention-seekers.” As a society, we should not isolate people with pica; we should steer them away from eating behaviors that can jeopardize their lives.
American Psychiatric Association. (2013). Feeding and Eating Disorders. Pica. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm10
Beecroft, N., Bach, L., Tunstall, N., & Howard, R. (1998). An unusual case of pica. International Journal of Geriatric Psychiatry, (Volume 13, Issue 9), 638-641.
Dennis, K., Ekern, J. (2014). Pica: A lesser known, highly disturbing eating disorder. Eating Disorder Hope. Retrieved from https://www.eatingdisorderhope.com/information/eating-disorder/pica-a-lesser-known-highly-disturbing-eating-disorder
Harada, K.I., Yamamoto, K., Saito, T. (2006). Effective treatment of coprophagia in a patient with schizophrenia with the novel atypical antipsychotic drug perospirone. Pharmacopsychiatry, (Volume 39, Issue 11), p.113.
Huang, J.H., Shiah, I.S., Lee, W.K., Tzang, R.F., Chang, K.J. (2010). Olanzapine-associated pica in a schizophrenia patient. Psychiatry and Clinical Neurosciences, (Volume 64), p. 444.