Psychosomatics 39:465-469, October 1998
© 1998 The Academy of Psychiatric Medicine
Adult Pica
A Clinical Nexus of Physiology and Psychodynamics
Martin Goldstein, M.D.
Received March 20, 1997; revised September 16, 1997; accepted November 6, 1997. From the Department of Psychiatry, New York Hospital–Cornell Medical Center, New York. Address reprint requests to Dr. Goldstein, Payne Whitney Clinic, New York Hospital–Cornell Medical Center, 525 East 68th St., Baker Tower 16, New York, NY 10021.
Key Words: Pica • Eating • Psychodynamics
Rebecca only liked to eat the damp earth of the courtyard...It was obvious that her parents, or whoever raised her, had scolded her for that habit because she did it secretively and with a feeling of guilt, trying to put away supplies so that she could eat when no one was looking...1
—From "One Hundred Years of Solitude," by Gabriel Garcia Marquez
The bizarre phenomenon known as pica has long attracted clinical attention. Despite varied speculations about its etiology, a definitive explanation has never been formulated. Following a brief historical review, a case is presented that exemplifies several cultural, psychodynamic, and physiologic aspects of pica that, considered together, suggest a possible etiologic account for this strange behavior.
HISTORICAL OVERVIEW
Stedman's defines pica as "a perverted appetite for substances not fit as food or of no nutritional value."2 The first description of pica behavior was made by Galen in the second century. The term "pica" was first applied in the sixteenth century by a French physician, using the Latin word for magpie, a bird thought to have odd feeding habits.3 Medical dictionaries of the 17th century frequently mentioned the observed association of pica with pregnancy and "chlorosis" (an iron-deficiency anemia in young girls sometimes characterized by a greenish skin color).4
Parry-Jones and Parry-Jones recently performed an exhaustive survey of historical references to pica.4 They noted a sampling of 18th- and 19th-century descriptions of pica taken from French, German, and British sources that continued to link pica with either chlorosis or pregnancy.4 Other 19th-century references commented on an increased incidence in black-slave populations in the southern United States, sometimes reaching "epidemic proportions." Particularly relevant to the case presented next is the report of extensive dirt eating noted in populations of the West Indies.5
Pica in the mentally ill was frequently documented in 19th-century mental hospital records,4 which described how "epileptic, paretic, senile and maniacal cases" could be subject to "an active perversion of the appetite for food which leads the patient to devour even the most disgusting substances."6
The early part of this century saw increasing concerns regarding pica in pediatric populations, especially as knowledge of medical complications of certain forms of pica became clear (e.g., lead poisoning from eating lead-based paint chips).
CONTEMPORARY FORMULATIONS
Although several clinical features have long been associated with pica, no clear etiologic mechanism has been found to explain any specific form of pica, nor has any single theory been formulated to link varying manifestations.7
Cultural factors involving pica include societal beliefs attributing therapeutic and/or magical qualities to certain substances (clay in particular has figured prominently in the history of culturally related pica).3 Nutritional theories frequently hypothesize mineral deficiencies (e.g., iron or zinc) as somehow producing cravings for dirt. Iron-deficiency anemia remains the most common context in which pica is found in adult populations. Supporting theories causally connecting mineral deficiency and pica is anecdotal evidence that pica often stops following the administration of iron or zinc. However, it remains unclear whether mineral deficiencies are a cause or a consequence of pica: clay eating has been causally linked to iron and zinc deficiencies (clay has mineral-absorbing qualities, thereby interfering with gastrointestinal mineral absorption).8
Psychodynamic accounts of the etiology of pica have focused on poorly characterized inadequacies of the parent–child relationship.3 Supporting such theories are comparative studies documenting a high frequency of parental emotional deprivation among children with pica.8
Evidence suggesting a possible hereditary component of pica includes an increased incidence of pica in first-degree relatives of index cases.3 Features suggesting complicated and possibly multifactorial determinants of pica include 1) an increased incidence of obesity and drug addiction among parents of pica patients and 2) a childhood history of pica is frequently but not always found in adults with pica.3
EPIDEMIOLOGY
There have been few studies of the epidemiology of pica; of these, the more detailed investigations have focused on pediatric populations. Results of these studies have estimated an overall prevalence of childhood pica as high as 32%,9 with a predominance in children under three and an increased prevalence in African American children.3 In general, pica tends to decrease with age.3
It has been estimated that up to 20% of pregnant women have a history of pica. One study reported finding pica in 58% of the patients presenting with iron-deficiency anemia secondary to gastrointestinal blood loss.3
Pica has been estimated to occur in up to 25% of institutionalized mentally retarded patients; one study of autistic patients reported a pica frequency as high as 60%.3
DIAGNOSIS
DSM-IV restricts the diagnosis of pica to behavior that is inappropriate to a child's developmental level or not part of a culturally sanctioned practice.10 Pica may occur as a sign of other mental disorders (e.g., associated with delusions in schizophrenia), but is then only considered to warrant independent diagnostic attention if the eating behavior is especially severe.10
A major obstacle to both the diagnosis of pica in a particular patient as well as documentation of accurate prevalence rates is that patients rarely present complaining of pica, and often guard against revealing it at all. Rather, complications of pica, like diarrhea or weight loss, are what usually prompt patients to seek medical attention. Findings at initial evaluation can include anemia, iron deficiency, hypertension, hyperkalemia, and elevated liver-function tests.3
The following case of pica in an adult patient represents an amalgam of cultural, dynamic, and possibly physiologic features that appear to intricately combine to a clinical nexus manifested by eating dirt.
Case Report
The patient was a 33-year-old, African American woman with no formal psychiatric history but a medical history significant for noninsulin-dependent diabetes, a poorly characterized seizure disorder, recurrent headaches, and a complicated obstetric history, including two spontaneous abortions and an ectopic pregnancy. She was admitted to the medicine service via the emergency room, where she had presented complaining of vague abdominal complaints, increasing abdominal girth, weight gain, and episodic nausea and vomiting of several months' duration. Substance abuse history included occasional alcohol and intranasal cocaine. There was no significant family psychiatric history.
The patient was born in the West Indies; she had one twin (identical?) sister, and one older brother. The patient emigrated with her family to the United States at the age of two. She attended public schools through graduation from high school and later attended some college. She had been steadily employed as a cosmetics technician.
The patient had had seven pregnancies. Of these, only three resulted in live births; the other pregnancies ended in two miscarriages, one ectopic pregnancy, and one elective abortion. Never married, she was living with the father of her two younger children at the time of her admission. Sexual history was significant for multiple prior heterosexual partners (each of her pregnancies, except the last two, was conceived by a different sexual partner), as well as an ongoing lesbian relationship (the only homosexual relationship she had ever had). However, it was doubtful that she had a genuinely bisexual orientation: her sexual fantasies were solely of men. When queried about the physical nature of her homosexual relationship, she described it as consisting more of "holding and hugging" than actual sexual interaction. The patient was at her most guarded when discussing this relationship, emphasizing the taboos about homosexuality existing within the culture in which she was raised. She consequently kept this relationship secret, believing that her family (especially her parents) would condemn her for doing something "dirty" (her word).
The patient's physical examination was significant only for mild, diffuse abdominal tenderness. Laboratory data were remarkable for eosinophilia (70% eosinophils with a normal white blood cell count) and an elevated IgE (immunoglobulin E) titer of 4,294 (normal < 187). All other routine lab data were within normal limits (including normal hemoglobin/hematocrit levels and normal iron studies). Pregnancy and HIV (human immunodeficiency virus) testing were negative.
On presentation, the patient was neatly but extravagantly dressed and made-up: false eyelashes, two-tone nail polish on extremely long, artificial fingernails, and wearing multiple, large gold rings, necklaces, and earrings. Her attitude was reluctantly cooperative, initially quite guarded, and suspicious of the purpose of the psychiatric evaluation. Affect was significant for occasional contextually inappropriate smirking and intermittent giggling (e.g., when discussing pica). She described her mood as "I think I've been depressed." Thought content was remarkable for generalized suspiciousness, sometimes approaching paranoia regarding her medical and psychiatric evaluation (e.g., "you don't have a tape recorder in that briefcase, do you?"). Thought processes were notable for occasional tangentiality. She denied any history of hallucinations.
The patient recalled first eating dirt as a child, but soon stopped, careful to keep the behavior hidden from her parents for fear of their punishing her "for doing something so dirty." At age 19, she experienced her first miscarriage. After the burial service, the patient described taking a handful of dirt from the grave and ingesting it. There were brief recrudescences of pica following the burial of the next stillborn, as well as during subsequent pregnancies. Except for these episodes, pica behavior was quiescent until about 9 months prior to admission, when the patient began instructing her 9-year-old-son and 11-year-old daughter to collect dirt from a neighbor's flower garden. Although her children knew why they were collecting the dirt, the patient was careful not to ingest the dirt in front of them.
The patient gave a sensorially detailed account of her experience of eating dirt: she would grab a handful from the plastic toy pail in which her children had collected it, hold it for a moment, look at it, smell it, and feel it with her fingers. She would then thrust the entire handful into her mouth, progressively swallowing it. She especially enjoyed the "gritty feeling" in the back of her throat.
The patient denied ever experiencing any significant immediate adverse effects from eating dirt, and she did not associate her current abdominal complaints with her pica. Her only attribution for her current symptomatology was "I think there's something going on here," pointing to her lower abdomen, and nodding her head yes when asked if she meant her uterus. She was unable to attribute either the recurrence of her pica behavior 9 months prior to admission, nor its continuation ("a few times a week") since then, to any specific cause. However, she did describe how her "boyfriend" (how she referred to the man with whom she lived and the father of two of her children) had "stopped paying attention to me sexually," beginning about a year prior to admission. This was followed by an intensification of the patient's lesbian relationship.
The patient's attitude became increasingly entitled and demanding as her hospitalization progressed, frequently requiring significant coaxing to comply with routine procedures (e.g., blood tests). Although her white blood cell differential gradually improved (down to 54% eosinophils), the etiology of her hematologic abnormality (dirt-related parasitosis?), as well as her abdominal complaints, remained unclear. Further diagnostic tests (e.g., bone marrow biopsy) were planned, but the patient eventually demanded to be discharged. Given the patient's clinically stable condition, her demands for discharge were accommodated. An outpatient psychiatric referral was offered but quickly rejected.
Discussion
Two questions psychiatrists ask when confronted with a new symptom presentation are "why this?" and "why now?" Let us consider the cultural, psychodynamic, and physiologic aspects of this case in turn to try to answer "why pica now?" for this patient's presentation.
The patient's early experimentation with dirt-eating as a child may be considered, at least partially, to be culturally based: as described earlier, the West Indies is among the places that pica has been observed with some regularity.
The dynamic issues in this case are striking. Two themes were strongly suggested in the way this patient related her personal history: shame and loss. She was ashamed to tell her parents about eating dirt as a child, lest they think that she was being "dirty." Later, the patient concealed her lesbian relationship, again because she feared her family (especially her parents) would believe her to be "doing something dirty" and consequently reject her.
But more than any other feeling state, the patient related a terrible sense of loss when discussing her miscarriages. The context of the initial adult appearance of the patient's pica and her explanation of it are telling: she took a handful of dirt from the grave of her fetus and ate it, feeling "like maybe I could put some of it back in me." The notion of replacement of a lost object (a kind of concrete introjection) is compelling.
The patient's prior pica episodes were consistent with epidemiologic data associating pica with pregnancy. Although mechanistically unexplained, the occurrence of pica during pregnancy might be accounted for by the same causes of pica associated with iron-deficiency anemia, given the tendency to develop physiologic anemia during pregnancy (i.e., normal red blood-cell mass distributed in an expanded plasma volume), and the high prevalence of iron deficiency among women of child-bearing age. An etiology for the patient's eosinophilia was never ascertained; speculation about what components of the dirt she had been ingesting (including parasitic elements) continued at the time of discharge.
So why was this patient presenting with pica? She was neither pregnant nor iron-deficient. Nor was she anemic. As in most cases of pica, the patient did not present complaining of pica, but instead came to the hospital reporting vague abdominal complaints. Reviewing the chronology of the history of the present illness, as given by the patient, suggests a possible answer.
About a year and a half prior to admission, her boyfriend stopped paying sexual attention to her. A few months later, the patient re-activated her relationship with a former lesbian partner. Soon thereafter, about 9 months prior to admission, the patient started eating dirt again. A few months prior to admission, the patient told her parents for the first time about her habit of eating dirt, but she concealed from them her habit of sleeping with a woman, which, again, she believed they would consider "dirty." The sequence of psychological events accounting for this patient's presentation of pica might therefore have been as follows: loss of love object (boyfriend), prompting resumption and intensification of the homosexual relationship, a primarily nurturing relationship but one nevertheless engendering feelings of shame, resulting in patient simultaneously experiencing fear of loss of boyfriend and risk of parental condemnation—a presumably intolerable combination of shame and potential loss in the context of heightened need. Pica is her solution: regression to a prior behavior that was culturally sanctioned (or less culturally condemned), earlier associated with the notion of replacement, and providing a behavior she could share with her family that was "dirty," thereby providing a sort of substitutive "sin" to confess to her parents that did not carry the higher risk of rejection associated with homosexuality. The answer to the question "why now?" with respect to her hospital presentation may be provided by the following: pica was something this patient had long associated with pregnancy, a condition the patient had experienced in conjunction with almost every romantic partner with whom she had previously become involved. That the patient was presenting 9 months (according to her own chronology) following the resumption of pica, with complaints of increasing abdominal girth (unsubstantiated on exam), weight gain (also unsubstantiated), vague abdominal complaints associated with episodic nausea and vomiting, and with her sole attribution being "something going on in my uterus," would strongly suggest that the idea of pregnancy was somewhere on the mind of this patient.
Conclusion
A unified theory accounting for the diverse manifestations of pica has been elusive. In the case presented, cultural, psychodynamic, and possibly physiologic determinants seem to have combined, albeit quite intricately, to contribute to the expression of pica. Until a satisfactory mechanism for the genesis of pica is found, it would seem prudent for a physician, upon being presented with a case involving adult pica, to investigate the cultural context and intrapsychic meaning of the behavior to the patient (if any) and include this information with pathophysiologic data in formulating an explanation for the occurrence of pica in an individual patient.
REFERENCES
-
Marquez GG: One Hundred Years of Solitude. New York, Harper & Row, 1991
-
Stedman's Medical Dictionary, 26th Edition. Baltimore, MD, Williams & Wilkins, 1995
-
Garfunkel PE: Feeding and eating disorders of infancy and early childhood, in Comprehensive Textbook of Psychiatry, edited by Kaplan HI, Sadock BJ. Baltimore, MD, Williams & Wilkins, 1995, pp. 2321–2324
-
Parry-Jones B, Parry-Jones WL: Pica: symptoms or eating disorder? A historical assessment. Br J Psychiatry 1992; 160:341–354[Abstract/Free Full Text]
-
Gould GM, Pyle WL: Anomalies and Curiosities of Medicine. London, UK, Rebman Publishing Co., 1898
-
Kellogg TH: A Textbook of Mental Diseases. London, UK, Churchill, 1897
-
Isselbacher KJ, Braunwald E, Wilson JD, et al: Harrison's Principles of Internal Medicine, 3rd Edition. New York, McGraw-Hill, 1994
-
Blinder BJ, Goodman SL, Henderson P: Pica: a critical review of diagnosis and treatment, in The Eating Disorders—Medical and Psychological Basis for Diagnosis and Treatment, edited by Blinder BJ, Chaitlin BF, Goldstein R, et al. New York, PMA, 1988, p. 331
-
Benoit D: Phenomenology and treatment of failure to thrive. Child Adolesc Psychiatry Clinic North Am 1993; 2:61–73
-
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
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