Psychosomatics 47:531-532, December 2006
doi: 10.1176/appi.psy.47.6.531
© 2006 Academy of Psychosomatic Medicine
Baking-Soda Pica in an Adolescent Patient
Jayant Choure, M.D.,
Kathleen Quinn, M.D., and
Kathleen Franco, M.D.
Received May 10, 2005; revised December 16, 2005; accepted December 20, 2005. From the Dept. of Psychology and Psychiatry, Cleveland Clinic Foundation, Cleveland, OH. Send correspondence and reprint requests to Dr. Franco, Dept. of Psychology and Psychiatry, Cleveland Clinic Foundation, Cleveland, OH. e-mail: francok{at}ccf.org
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INTRODUCTION
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Pica is the persistent, compulsive ingestion of non-nutritive substances, which includes eating disorders with unusual cravings. Etiologies of consumption of common and bizarre substances range from mineral deficiencies and helminthic infestations to cultural preferences. Recently, pica has been linked to obsessive-compulsive (OCD) spectrum disorders.1,2
Although there are few epidemiological studies and likely underreporting by embarrassed patients, pica exists in all ages, races, genders, and geographic regions. Lower socioeconomic groups, young children, pregnant women, or nursing mothers with increased nutritional demands are at higher risk, as well as those with brain damage, epilepsy, mental retardation, psychosis, or dementia.3–5
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Case Report
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A 13-year-old African American young woman, with known reactive airway disease, complained of trembling and shortness of breath. Her mother provided albuterol and fluticasone for her asthma, but increased "shakiness" led to an Emergency Department assessment. En route, the patient confessed that she had ingested an entire box of baking soda. On arrival, she had a metabolic alkalosis (pH of 7.51 and bicarbonate of 29). After treatment, her pH dropped to 7.4, with a bicarbonate of 20.
During examination, she acknowledged ingesting 2 handfuls of baking soda 3–4 times daily for the past 4 years. She initially consumed baking soda for indigestion and noticed that it made her "feel better generally" over time, unaware that it could negatively affect her health; she became "addicted," denying any side effects until the present episode. In retrospect, increased anger, irritability, depression, and crying episodes 4–5 times per week occurred concurrently with baking-soda ingestion. Also, she reported disturbed sleep, lack of interest, excessive guilt, and low energy. About the time the pica started, the patient had cut her wrist in a suicide attempt. She was not hospitalized or given medication, but briefly met with her school counselor, with some benefit. She had no history of panic attacks, obsessive-compulsive disorders, auditory or visual hallucinations, paranoid ideation, or anorexia, bingeing/purging, or definitive manic behavior. Medical history was significant only for asthma. Family history was unremarkable, and milestones were within normal limits.
During the assessment, psychomotor retardation was evident, but her cognitive skills were excellent and consistent with above-average IQ. The patient adamantly denied any suicidal ideation, although she met criteria for major depression. Physical examination and her laboratory studies, including complete blood count (CBC), basic metabolic panel, serum iron, zinc, and thyroid-stimulating hormone were within normal limits.
Fluoxetine 10 mg daily was prescribed, along with outpatient psychodynamic psychotherapy. Her depression and pica improved within 4 weeks of treatment, and she remains symptom-free after 2 years.
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Discussion
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We found no reports specifically reporting baking-soda pica or linking major depression to pica. Our patient did not have iron or zinc deficiencies known to alter appetite regulation.
Some patients practice pica to enjoy the taste, texture, or smell of the chosen item. Our patient described pleasure and a soothing sense of wellness. For hundreds of years, bicarbonate, in small amounts, has been used for "indigestion," but not in such large quantities.
Current neuropsychiatric theory connects particular brain lesions in laboratory animals with abnormal eating behaviors and pica. Pica—repetitive and ritualistic like OCD, may be associated with increased caudate volume during symptom presence.
Pica can appear as compulsive behavior to relieve tension or in response to poor impulse-control. Comorbid pica and OCD respond to serotonin-reuptake inhibitors, thus supporting the hypothesis that pica is a manifestation of OCD spectrum. Although our patient’s depression and pica remitted with fluoxetine, we did not have adequate criteria to diagnose OCD.
Psychosocial theory views pica as an infantile "hand-to-mouth" behavioral response to family stress, including child abuse, parental neglect, separation, or deprivation. An oral-fixation response, habit disorder, or addictive behavior may result from unresolved pica. For our patient, current family dysfunction was denied but could have been present 4 years earlier, when the behavior started.
Diagnosis is dependent upon patient reports, collateral observations, and a nonjudgmental attitude while interviewing. Physical examination, CBC with peripheral smear for anemia and eosinophilia, serum levels of iron, ferritin, lead, zinc, electrolytes, liver function tests, abdominal radiographs for intestinal obstruction, and stool for ova and parasites are recommended. The most important confirmatory test remains a patient’s truthfulness. Screenings for OCD, impulse-control disorders, and depression are important, and include brain imaging if neurologically indicated.
Potential complications of pica include dental injury, achlorhydria, malabsorption, constipation, gastrointestinal obstruction, necrotizing enterocolitis, perforation, peritonitis, or even death.6 Metabolic aberrations include lead or mercury poisoning, interference with bioavailability of minerals like iron or zinc, hyperkalemia from clay ingestion, hypoalbuminemia, and elevated serum copper levels.
The treatment must address etiology, correct metabolic deficiencies, and reduce heavy-metal toxicities. Psychotherapies, positive reinforcement of alternative behaviors, environmental enrichment with adult interaction, and, rarely, negative reinforcement can be of benefit.7 Serotonin-reuptake inhibitors may reduce pica associated with OCD and depression. Future research can elucidate roles of neurocircuitry, neurotransmitters, and environmental influences on this biopsychosocial disorder.
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REFERENCES
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- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Washington, DC, American Psychiatric Press, 1994, pp 95-96
- Parry-Jones B, Parry-Jones WL: Pica: symptom or eating disorder? a historical assessment. Br J Psychiatry 1992; 160:341–354[Abstract/Free Full Text]
- Moore DF Jr, Sears DA: Pica, iron deficiency, and the medical history. Am J Med 1994; 97:390–393[CrossRef][Medline]
- Rose EA, Porcerelli JH, Neale AV: Pica: common but commonly missed. J Am Board Fam Pract 2000; 13:353–358[Medline]
- von Bonsdorff B: Pica: a hypothesis. Br J Haematol 1977; 35:476–477[Medline]
- Hoyt RE: Popcorn, pica, and impaction. Am J Med 1997; 103:70[Medline]
- Stein DJ, Bouwer C, van Heerden B: Pica and the obsessive-compulsive spectrum disorders. S Afr Med J 1996; 86(suppl12):1586–1588,1591–1592
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INTRODUCTION
Case Report
