Pica

Essential (Required) Features:

• Regular consumption of non-nutritive substances, such as non-food objects and materials (e.g., clay, soil, chalk, plaster, plastic, metal and paper), or raw food ingredients (e.g., large quantities of salt or corn flour).
• The ingestion of non-nutritive substances is persistent or severe enough to require clinical attention. That is, the behaviour causes damage or significant risk to health or impairment in functioning due to the frequency, amount or nature of the substances or objects ingested.
• Based on age and level of intellectual functioning, the individual would be expected to distinguish between edible and non-edible substances. In typical development, this occurs at approximately 2 years of age.
• The symptoms or behaviours are not a manifestation of another medical condition (e.g., nutritional deficiency).

Boundary with Normality (Threshold):

• It is normal for infants and very young children to put non-food objects in their mouths as a means of sensory exploration. The diagnosis of Pica should not be applied to this phenomenon.
• Many pregnant women crave or eat non-nutritive substances (e.g., chalk or ice). In addition, the eating of non-nutritive substances is a culturally sanctioned practice among certain groups. A diagnosis of Pica should only be assigned to such behaviour if it is persistent or potentially dangerous enough to require specific clinical attention.

Course Features:

• Pica can be episodic and variable, or chronic and continuous. When variable, consumption of non-nutritive substances may be associated with increased levels of stress or anxiety.

Developmental Presentations:

• Onset of Pica can occur across the lifespan but is most commonly observed in childhood.

Culture-Related Features:

• In some cases, eating of non-nutritive substances may be a culturally sanctioned practice. In these cases, the consumption of the non-nutritive substance is thought to have some health, spiritual or social benefit. In parts of Africa and certain rural areas of the United States and India, for example, the eating of clay or earth (geophagia) can be a culturally accepted practice. Pica should not be diagnosed in such cases unless the quantities ingested are large enough to require clinical attention.

Sex- and/or Gender-related Features:

• The prevalence of Pica is similar among males and females.
• Although females can be diagnosed with Pica during pregnancy and the postpartum period, a diagnosis should only be assigned if consumption of non-nutritive substances is persistent or potentially dangerous enough to require specific clinical attention.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with nutritional deficiencies: Individuals who ingest non-nutritive substances as a symptom of specific nutritional deficiencies should not be diagnosed with Pica unless the behaviour persists after the deficiency is corrected. For example, anaemia caused by vitamin B-12, folate, or iron deficiency can be associated with a craving to eat dirt.
• Boundary with Disorders of Intellectual Development: The ingestion of non-nutritive substances is common in children or adults with Disorders of Intellectual Development. An additional diagnosis of Pica may be given, provided that the individual is able to distinguish between edible and non-edible substances, if the behaviour is persistent or potentially dangerous enough to require specific clinical attention.
• Boundary with Factitious Disorder and Malingering: Individuals with Factitious Disorder or who are malingering may swallow harmful substances or objects in order to present themselves as ill. For example, prisoners may swallow harmful substances or objects in order to be transferred to hospital or to a setting that is less harsh or less restrictive. Pica should not be diagnosed in such cases.
• Boundary with other Mental, Behavioural or Neurodevelopmental Disorders: Individuals with Anorexia Nervosa may eat non-nutritive substances (e.g., tissues, paper) in order to suppress hunger. In Trichotillomania (Hair Pulling Disorder) or Excoriation (Skin Picking) Disorder, individuals sometimes eat hair or skin that they pull or pick from the body. Eating of non-nutritive substances may also occur in other Mental, Behavioural or Neurodevelopmental Disorders such as Autism Spectrum Disorder and Schizophrenia. In all such cases, an additional diagnosis of Pica should be assigned only if the behaviour is persistent or severe enough to require clinical attention. That is, the behaviour causes damage to health, impairment in functioning, or significant risk due to the frequency, amount or nature of the substances or objects ingested.