6B84 - Pica: Complete Guide to Coding and Clinical Diagnosis

1. Introduction

Pica is an eating disorder characterized by persistent consumption of non-nutritive and non-food substances, representing a significant clinical challenge that affects individuals of diverse age groups and socioeconomic contexts. This atypical eating behavior goes beyond normal childhood curiosity, manifesting as an established pattern of ingestion of materials such as dirt, clay, chalk, paper, metal, plastic, hair, or raw food ingredients in excessive amounts.

The clinical importance of Pica lies in its potential serious medical complications, including intestinal obstruction, gastrointestinal perforation, heavy metal intoxication, parasitic infections, nutritional deficiencies, and infections. The disorder may occur in isolation or associated with other medical and psychiatric conditions, such as intellectual disability, autism spectrum disorder, schizophrenia, pregnancy, and nutritional deficiencies, particularly of iron and zinc.

The exact prevalence of Pica remains uncertain due to underreporting, shame associated with the behavior, and cultural variations in the acceptance of certain eating practices. Studies suggest higher frequency in young children, pregnant women, individuals with intellectual disability, and institutionalized persons. In mental health settings, the prevalence may be considerably elevated.

Correct coding of Pica is critical for multiple aspects of healthcare. It enables appropriate epidemiological tracking, facilitates research on effective treatments, ensures appropriate reimbursement of services, enables resource planning in health systems, and ensures continuity of care among different professionals and institutions. The transition to ICD-11 offers greater diagnostic specificity and alignment with contemporary clinical criteria.

2. Correct ICD-11 Code

Code: 6B84

Description: Pica

Parent category: Feeding and eating disorders

Complete official definition: Pica is characterized by the regular consumption of non-nutritive substances, such as non-food objects and materials (for example, clay, soil, chalk, plaster, plastic, metal, and paper) or raw food ingredients (for example, large amounts of salt or cornmeal), in a persistent or severe manner sufficient to require clinical attention, by an individual who has reached a developmental age at which one would expect them to distinguish between edible and non-edible substances (approximately 2 years).

The behavior must cause harm to health, impairment of functioning, or significant risk due to the frequency, amount, or nature of the substances or objects ingested. This code applies when the behavior is not part of a culturally sanctioned practice or socially normative behavior within the individual's context.

It is fundamental to understand that diagnosis requires that the behavior be inappropriate for the individual's developmental level. Children under two years of age naturally explore their environment by putting objects in their mouth as part of normal development, not characterizing Pica. The persistence of the behavior beyond this developmental phase, especially when it causes adverse health consequences, justifies clinical attention and appropriate coding.

3. When to Use This Code

Code 6B84 should be used in specific clinical scenarios where diagnostic criteria are clearly present:

Scenario 1: Child with persistent ingestion of non-food substances A 5-year-old patient presents with an 8-month history of daily ingestion of garden soil and pieces of school chalk. Parents report that the behavior occurs multiple times per day, despite supervision and redirection. The child developed iron deficiency anemia and was diagnosed with intestinal parasitosis. Psychological evaluation rules out significant intellectual disability. This case meets the criteria: developmentally appropriate age, persistence of behavior, non-nutritive substances, and adverse health consequences.

Scenario 2: Pregnant woman with geophagia A woman in the second trimester of pregnancy seeks care reporting intense desire and regular consumption of dry clay for 3 months. She consumes approximately 30 grams daily, describing temporary relief after ingestion. Laboratory tests reveal anemia and low serum iron levels. The behavior is not culturally accepted in her community and causes social embarrassment. The coding 6B84 is appropriate considering persistence, non-nutritive substance, health impact, and functional impairment.

Scenario 3: Adolescent with trichotillophagia A 14-year-old patient presents with a 2-year history of pulling out and ingesting their own hair. Developed a trichobezoar (hairball) in the stomach, confirmed by endoscopy, requiring surgical intervention. The behavior persists despite previous counseling and is associated with significant psychological distress. The presence of serious medical complication, persistence, and developmental age justify the use of code 6B84.

Scenario 4: Adult with intellectual disability and pagophagia A 28-year-old individual with moderate intellectual disability, residing in a long-term care facility, presents with persistent behavior of chewing and excessively ingesting ice (more than 10 cups daily). Developed severe dental erosion and iron deficiency. The behavior interferes with daily activities and social interactions. Despite intellectual disability, the specific Pica behavior requires separate coding.

Scenario 5: Child with ingestion of paper and plastic A 7-year-old patient with a 6-month history of tearing and ingesting paper from notebooks, books, and plastic packaging. Presented with an episode of partial intestinal obstruction requiring hospitalization. Psychiatric evaluation rules out other primary eating disorders. Parents report that the behavior occurs mainly in situations of anxiety, but is present regularly. Significant health risk and persistence justify code 6B84.

Scenario 6: Psychiatric patient with ingestion of metal objects A 35-year-old adult with a history of psychotic disorder presents with recurrent behavior of ingesting small metal objects (coins, clips, nails) during exacerbations and periods of partial remission. Multiple hospitalizations for gastrointestinal complications. The behavior persists regardless of psychotic state, characterizing Pica as an additional diagnosis to the primary psychiatric disorder.

4. When NOT to Use This Code

There are specific situations where code 6B84 should not be applied, even when there is ingestion of unconventional substances:

Normal oral exploration in childhood: Children under 2 years of age who put objects in their mouth as part of normal development should not receive this code. Sensory exploration is expected in this age group and does not constitute an eating disorder.

Culturally sanctioned practices: Some cultures have traditional practices that involve consumption of specific substances (such as certain types of clay for medicinal or ritual purposes). When the behavior is culturally accepted, normative, and does not cause harm to health, code 6B84 does not apply.

Accidental ingestion: Isolated cases of unintentional ingestion of non-food substances do not characterize Pica. The diagnosis requires a persistent and intentional pattern of consumption.

Other primary eating disorders: When ingestion of non-nutritive substances occurs exclusively in the context of another eating disorder (such as excessive ice consumption only during periods of food restriction in anorexia nervosa), the primary disorder should be coded as a priority.

Factitious disorder or malingering: Individuals who ingest non-food substances intentionally to produce medical symptoms with the objective of assuming the role of a sick person (factitious disorder) or obtaining external gains (malingering) require different coding.

Substance intoxication: Recreational use or dependence on psychoactive substances does not constitute Pica, even when there is ingestion of unconventional materials. These cases require codes from the substance use disorder category.

Self-injurious behavior: When object ingestion occurs primarily with self-injurious intent in the context of personality disorders or suicidal crises, other diagnostic codes are more appropriate.

5. Step-by-Step Coding Process

Step 1: Assess diagnostic criteria

The first step requires systematic confirmation of the essential criteria for Pica diagnosis. Conduct a detailed clinical interview with the patient and, when appropriate, with family members or caregivers. Investigate the specific type of substances consumed, frequency of the behavior, duration of symptoms, and contexts in which it occurs.

Confirm that the individual has reached appropriate developmental age (approximately 2 years or older). Assess overall cognitive development to establish whether there is expected capacity to distinguish edible from non-edible substances. Document specific examples of the behavior, including direct testimonies when possible.

Identify adverse health consequences, which may include gastrointestinal complications, nutritional deficiencies, intoxications, parasitic infections, or dental damage. Perform appropriate physical examinations and laboratory tests: complete blood count, iron profile, zinc levels, renal and hepatic function, abdominal radiographs when indicated.

Assess functional impairment resulting from the behavior: interference with daily activities, social isolation, need for constant supervision, academic or occupational impairment. Use standardized instruments when available, such as structured interviews for eating disorders adapted for Pica.

Step 2: Verify specifiers

Although code 6B84 does not have formal subtypes in ICD-11, document specific characteristics that inform therapeutic planning. Record the predominant type of substance consumed (geophagia for soil/clay, pagophagia for ice, trichotillophagia for hair, etc.), as different substances present distinct risks.

Assess severity considering daily frequency of the behavior, amount consumed, associated medical risk, and degree of functional impairment. Document symptom duration, differentiating acute cases (less than 3 months) from chronic cases (3 months or more), although both may justify the diagnosis if sufficiently severe.

Identify relevant contextual factors: presence of psychosocial stressors, medical comorbidities (especially anemia, nutritional deficiencies), psychiatric comorbidities (intellectual disability, autism spectrum disorder, schizophrenia), and special situations such as pregnancy.

Step 3: Differentiate from other codes

6B80 - Anorexia nervosa: Characterized by significant dietary restriction leading to low body weight, intense fear of weight gain, and disturbance in body image perception. The fundamental difference is that in anorexia nervosa the focus is on restriction of normal foods and weight control, whereas in Pica the central behavior is ingestion of non-nutritive substances. Patients with anorexia may occasionally consume non-food substances, but when this behavior is prominent and persistent, both codes may be applied.

6B81 - Bulimia nervosa: Involves recurrent episodes of binge eating followed by inappropriate compensatory behaviors (vomiting, laxative use, excessive exercise). The essential distinction is that bulimia involves excessive consumption of conventional foods followed by purging, whereas Pica involves non-food substances without the characteristic binge-purge pattern.

6B82 - Binge eating disorder: Characterized by recurrent episodes of ingestion of large quantities of conventional foods with a sense of loss of control, without regular compensatory behaviors. It differs from Pica by the nature of foods consumed (normal foods versus non-nutritive substances) and by the episodic versus persistent pattern of consumption.

Step 4: Required documentation

Prepare complete clinical documentation including: detailed description of Pica behavior (types of substances, frequency, duration), age of symptom onset, triggering or maintaining contexts, observed or potential medical consequences, results of relevant physical examinations and laboratory tests.

Record assessment of cognitive and functional development, history of previous interventions and their responses, presence of medical and psychiatric comorbidities, relevant cultural and social factors, and current risk assessment (intestinal obstruction, intoxication, nutritional deficiencies).

Document the diagnostic reasoning explaining why the criteria for Pica were met, how other differential diagnoses were excluded, and justification for additional codes when applicable. Include comprehensive therapeutic plan and recommendations for continued monitoring.

6. Complete Practical Example

Clinical Case:

Marina, 6 years old, is brought to pediatric consultation by her parents due to concerning eating behavior. Approximately 10 months ago, she began eating small quantities of school chalk. Initially, her parents attributed the behavior to childhood curiosity and provided simple guidance. However, the behavior intensified progressively.

Currently, Marina consumes chalk, garden soil, and occasionally small pieces of paper daily. Her parents estimate that she ingests approximately 5-6 pieces of chalk per day and handfuls of soil when she has the opportunity. The behavior occurs both at home and at school, causing embarrassment and concern among teachers. Marina hides the behavior from adults when possible, but siblings report observing her frequently.

In recent weeks, Marina has presented with intermittent abdominal pain and constipation. Physical examination reveals cutaneous-mucosal pallor and slightly distended abdomen. Complete blood count demonstrates microcytic anemia (hemoglobin 9.5 g/dL), low ferritin (8 ng/mL), and stool parasitological examination positive for Ascaris lumbricoides. Abdominal radiography shows radiopaque material dispersed throughout the gastrointestinal tract, consistent with chalk.

Psychological evaluation rules out intellectual disability, with cognitive development appropriate for age. There is no evidence of autism spectrum disorder or other primary psychiatric disorders. Family history reveals that the mother presented with similar behavior during a previous pregnancy, consuming excessive ice.

Step-by-Step Coding:

Criteria Analysis:

Appropriate developmental age: Marina is 6 years old, well above the minimum 2 years expected to distinguish edible substances
Regular consumption of non-nutritive substances: chalk, soil, and paper consumed daily
Persistence: behavior present for 10 months with progressive intensification
Adverse consequences: iron deficiency anemia, intestinal parasitosis, abdominal pain, constipation
Functional impairment: social embarrassment, need for increased supervision, school concerns
Exclusion of culturally sanctioned practices: the behavior is not accepted or normative in the family's cultural context

Code chosen: 6B84 - Pica

Complete Justification: Marina's case fully meets the diagnostic criteria for Pica according to ICD-11. The child presents with persistent and regular consumption of multiple non-nutritive substances (chalk, soil, paper) for a period exceeding 10 months, with significant daily frequency. Her age (6 years) is well established in the developmental phase in which discrimination between edible and non-edible substances is expected.

The behavior resulted in documented medical consequences, including iron deficiency anemia and intestinal parasitosis, in addition to gastrointestinal symptoms (abdominal pain, constipation) and radiological evidence of non-food material in the digestive tract. There is also manifest functional impairment evidenced by social embarrassment and need for intensified supervision.

Psychological evaluation excluded intellectual disability and other developmental disorders that could alternatively explain the behavior. There is no evidence that the behavior is culturally sanctioned or part of traditional family practices.

Applicable complementary codes:

Code for iron deficiency anemia (medical consequence of Pica)
Code for intestinal parasitosis (Ascaris lumbricoides)
Codes for gastrointestinal symptoms if separate documentation is necessary for therapeutic planning

The case requires a multidisciplinary approach including treatment of anemia and parasitosis, behavioral interventions for Pica, family education, and continuous medical monitoring to prevent additional complications.

7. Related Codes and Differentiation

Within the Same Category:

6B80: Anorexia nervosa

When to use vs. 6B84: Use 6B80 when the clinical presentation is dominated by intentional food restriction with the goal of weight control, intense fear of gaining weight, and disturbance in the perception of body shape, resulting in significantly low weight. Use 6B84 when the central behavior is the ingestion of non-nutritive substances without primary focus on weight control.
Main difference: Anorexia nervosa involves restriction of normal foods with central concern about weight and body shape; Pica involves active consumption of non-food substances without necessarily having concern about weight. Both codes may coexist when both patterns are present in a prominent manner.

6B81: Bulimia nervosa

When to use vs. 6B84: Apply 6B81 when there are recurrent episodes of binge eating (consumption of large quantities of conventional foods) followed by compensatory behaviors such as self-induced vomiting or laxative use. Use 6B84 when the pattern is persistent consumption of non-nutritive substances.
Main difference: Bulimia involves a binge-purge cycle with normal foods; Pica involves regular consumption of non-food substances. The temporal pattern also differs: bulimia has discrete episodes of binge eating, while Pica typically presents a more constant pattern of consumption.

6B82: Binge eating disorder

When to use vs. 6B84: Use 6B82 when there are recurrent episodes of ingestion of large quantities of conventional foods with a sense of loss of control, without regular compensatory behaviors. Use 6B84 for consumption of non-nutritive substances.
Main difference: Binge eating disorder involves episodes of excessive consumption of normal foods with loss of control; Pica involves non-food substances consumed in a more regular manner. The nature of the substances consumed is the fundamental differentiator.

Differential Diagnoses:

Autism spectrum disorder: Individuals with autism may present with repetitive behaviors including putting objects in the mouth or ingesting non-food substances. Differentiate by the presence of central autism criteria (deficits in social communication, restricted and repetitive patterns of behavior). When Pica is present in a prominent manner in an individual with autism, both diagnoses should be coded.

Intellectual disability: People with intellectual disability may present with Pica at higher frequency. The distinction is based on assessing whether the Pica behavior is disproportionately severe in relation to the overall level of cognitive functioning. Both diagnoses may coexist.

Psychotic disorders: Schizophrenia and other psychotic disorders may present with bizarre behaviors including ingestion of non-food substances, often related to delusions. When Pica persists independently of the psychotic state or is sufficiently prominent, code both.

8. Differences with ICD-10

In ICD-10, Pica was coded as F98.3 (Pica of childhood and early childhood) when it occurred in children, or F50.8 (Other eating disorders) when in adults. This artificial division created challenges in coding and epidemiological tracking throughout the lifespan.

ICD-11 unifies the coding of Pica under the single code 6B84, regardless of the patient's age. This change reflects the recognition that Pica represents the same clinical phenomenon across different age groups, with variations in the substances consumed and risk factors, but not in the fundamental nature of the disorder.

Another significant change is greater specificity in diagnostic criteria. ICD-11 explicitly emphasizes that the behavior must cause harm to health, functional impairment or significant risk, and that it must be inappropriate for the developmental level. This clarification helps distinguish Pica from normal exploratory behaviors in childhood and cultural practices.

ICD-11 also better integrates Pica within the category of eating disorders, recognizing its relationship with other disorders in this category while maintaining its distinct diagnostic identity. The practical impact of these changes includes better continuity of care throughout the lifespan, greater consistency in epidemiological research, and increased clarity in diagnostic criteria, reducing ambiguity in clinical coding.

9. Frequently Asked Questions

How is Pica diagnosed? The diagnosis is primarily clinical, based on a detailed history obtained from the patient and collateral informants (family members, caregivers, teachers). The clinician should specifically investigate consumption of non-food substances, frequency, duration, and consequences. Physical examination may reveal signs of complications (pallor suggesting anemia, abdominal distension). Complementary tests are important to identify medical consequences: complete blood count to detect anemia, iron and zinc levels, parasitological stool examination, radiographs when obstruction or foreign bodies are suspected. Psychological evaluation may be necessary to rule out intellectual disability or other developmental disorders.

Is treatment available in public health systems? Treatment for Pica is generally available in public health systems through pediatrics, psychiatry, and psychology services. The approach is typically multidisciplinary, including medical management of complications, behavioral interventions, cognitive-behavioral therapy when appropriate, and family support. Behavioral interventions such as differential reinforcement, redirection, and environmental modification are often effective. Treatment of underlying conditions (anemia, nutritional deficiencies) is essential. The availability of specialized services may vary geographically, but the basic components of treatment are generally accessible.

How long does treatment last? The duration of treatment varies considerably depending on severity, chronicity, presence of comorbidities, and response to interventions. Mild cases with early intervention may respond within weeks to a few months. Chronic cases or those associated with conditions such as intellectual disability may require prolonged management, sometimes years. Treatment generally involves an initial intensive phase (2-6 months) with structured behavioral interventions and correction of nutritional deficiencies, followed by a maintenance phase with less frequent monitoring. Relapses are possible, especially during periods of stress, requiring resumption of interventions. The prognosis is generally favorable with appropriate treatment, especially when initiated early.

Can this code be used in medical certificates? Yes, code 6B84 can be used in medical certificates when clinically appropriate and necessary to justify absences, special accommodations, or treatment needs. In pediatric contexts, it can justify school accommodations or need for increased supervision. For adults, it can support the need for occupational adjustments or temporary leave when there are serious medical complications. Documentation should focus on functional limitations and specific therapeutic needs, respecting confidentiality and providing only information necessary for the purpose of the certificate.

Does Pica always indicate a serious psychiatric problem? Not necessarily. Although Pica is classified as an eating disorder, its severity and psychiatric implications vary widely. Many cases, especially in children, respond well to simple behavioral interventions without indicating serious underlying psychopathology. However, Pica can be associated with psychiatric conditions (intellectual disability, autism, schizophrenia) or medical conditions (anemia, nutritional deficiencies). Comprehensive evaluation is always necessary to identify contributing factors and comorbidities. The presence of Pica warrants clinical attention due to medical risks, regardless of whether or not there is serious underlying psychiatric disorder.

Do nutritional deficiencies cause Pica or are they a consequence? The relationship between nutritional deficiencies and Pica is complex and bidirectional. Iron and zinc deficiencies may precede and potentially contribute to the development of Pica, particularly pagophagia (ice consumption) and geophagia (soil consumption). Simultaneously, Pica can cause or worsen nutritional deficiencies through multiple mechanisms: the substances consumed can interfere with nutrient absorption, cause intestinal damage, or simply replace nutritious foods in the diet. Treatment of identified deficiencies is an essential component of management, often resulting in improvement of Pica behavior. However, nutritional correction alone does not always completely resolve the disorder, especially in chronic cases or those with significant psychological factors.

Do children with Pica always have developmental problems? No. Although Pica is more common in children with intellectual disability, autism spectrum disorder, or developmental delays, many children with typical development also present with the disorder. Risk factors in children with normal development include neglect, environmental deprivation, family stress, anxiety, and nutritional deficiencies. Each case requires individualized evaluation of cognitive and adaptive development. The presence of Pica in a child with normal development generally has a more favorable prognosis with appropriate interventions.

Is there specific medication to treat Pica? There is no medication specifically approved for the treatment of Pica. Pharmacological management, when used, is generally directed at comorbid conditions (treatment of underlying psychotic disorder, anxiety management) or supplementation of nutritional deficiencies (iron, zinc). Some studies suggest that iron supplementation may reduce Pica behaviors even in individuals without frank anemia. Selective serotonin reuptake inhibitors have occasionally been reported as useful in refractory cases, but evidence is limited. The primary therapeutic approach remains behavioral interventions, environmental modification, and treatment of underlying conditions.

Conclusion:

Appropriate coding of Pica using ICD-11 code 6B84 is fundamental to ensure accurate diagnosis, appropriate treatment, and consistent documentation of this potentially serious eating disorder. Clear understanding of diagnostic criteria, differentiation from other eating disorders, and recognition of multiple clinical presentations enable healthcare professionals to effectively identify and manage cases of Pica. The multidisciplinary approach, combining medical, behavioral, and nutritional interventions, offers the best prospects for recovery for individuals affected by this complex disorder.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-03

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