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Pica and obsessive–compulsive spectrum disorders
Abstract
The concept of a spectrum of obsessive-compulsive related disorders may have clinical and research heuristic value in the approach to disorders similar to obsessive-compulsive disorder (OCD) in respect of phenomenology and psychobiology. Like other repetitive and ritualistic behaviours, pica may be postulated to fall at times on this spectrum.
Five cases of pica seen at our clinics are presented here in order to test this hypothesis. Phenomenology, neurobiology (where available) and pharmacotherapy data are provided in order to consider a possible relationship with OCD and OCD spectrum disorders.
In 2 of the cases, pica appeared to be a compulsion and patients had additional symptoms which met diagnostic criteria for OCD. In 2 of the cases, the clinical picture and neurobiological data were reminiscent of an impulse control disorder. Four of the 5 patients responded to treatment with a serotonin re-uptake inhibitor (SRI).
These results are consistent with a hypothesis that at least some cases of pica may usefully be conceptualised as lying within a compulsive-impulsive spectrum of symptoms and disorders.
... Pica is classically opined to be part of an eating disorder; however, there has been an undercurrent to reclassify pica as an OCD, but there is no absolute consensus in the scientific community regarding this classification. [3,4] Pica has been described as sequelae of psychosis due to its state of disorganization which may include symptoms such as disordered thinking, behavior, and emotions; however, temporo-causal relation between the two has not been reported in the context of exacerbation of pica before psychosis. Here, we describe a case of worsening pica as an indicator of impending psychotic disorder. ...
... [7] Although pica is a common finding seen alongside many psychiatric disorders, there has been a rising voice in academia to reclassify pica alongside the obsessive-compulsive spectrum pertaining to the presence of repetitive nature and response to SSRI. [4,8] In the present report, the patient did not respond to SSRI at an optimum dose which also supports the notion of pica not being of obsessive origin. We found a temporal relation between geophagy and psychosis where exacerbation of pica preceded psychosis on both occasions of the psychotic episode and improved on treatment with antipsychotics. ...
Pica is a sustained, compulsive eating behavior of nonedible substances. Pica has been described as sequelae of psychosis due to its state of disorganization; however, temporal and causal relationship between the two has not been reported in the context of exacerbation of pica before psychosis. Various causes of pica have been identified including malnutrition, iron-deficiency anemia, zinc deficiency, intellectual disability, and obsessive and impulse control disorders. Here, we describe a case of worsening pica which preceded exacerbation of psychosis in an 18-year-old female which was managed with antipsychotics along with complete remission of psychosis and improvement in the severity of pica. The present case highlights the association between psychosis and pica. There has been a rising voice in academia to reclassify pica alongside obsessive–compulsive disorder (OCD) with no absolute consensus. In conclusion, our findings suggest that the exacerbation of pica preceded psychosis and can be construed as an indicator for an upcoming psychotic episode or as a prodromal aspect of psychosis and may be useful for early identification and initiation of treatment in cases of relapsing psychosis.
... For example, pica has been conceptualized as a potential compulsive behavior (Bhatia & Gupta, 2009;Stein et al., 1996). Case studies found treatment for OCD led to a reduction in pica behavior (Bhatia & Gupta, 2009;Hergüner et al., 2008), but to our knowledge no study has investigated the prevalence of pica among children with OCD, nor whether children with pica are more likely to have OCD. ...
Objective: Pica is the persistent eating of non-nutritive, nonfood substances and is associated with serious medical consequences. There has been a lack of research into the psychiatric comorbidities of pica, despite being important for informing clinical care. The current study examines psychiatric comorbidities of pica in childhood and the longitudinal relationship between childhood pica and adolescent eating disorders. Methods: We analyzed data from the Avon Longitudinal Study of Parents and Children study. Pica and psychopathology, assessed with the Development and Well-Being Assessment and the Strengths and Difficulties Questionnaire, were assessed at about 7- and 10-years of age, reported eating disorders (ED) at 14-, 16-, and 18-years of age. We conducted linear and logistic regression models, adjusting for covariates, to identify concurrent psychiatric comorbidities, as well as risk for later EDs. Results . Pica was associated with increased odds of any psychiatric disorder and behavioral disorders in early childhood [OR = 7.30, p < .001 and OR = 5.65, p < .001, respectively] and mid-childhood [OR = 5.75, p < .001 and OR = 10.66, p < .001, respectively], and greater concurrent hyperactivity, conduct problems, peer problems, prosocial and emotional difficulties ( p <.01 across analyses). We did not find evidence pica presence increased odds for concurrent emotional disorders nor for later ED risk. Discussion : The association between pica and psychiatric and behavioral disorders, indicates a likely shared aetiology. Our findings provide insight into the psychiatric characteristics of children with pica and highlight they may require complex behavioral support beyond their eating difficulties. [250]
Public Significance (for IJED)
This study investigated the relationship between pica (the eating of non-food substances) and mental health conditions in childhood. We found that in childhood, pica was associated with increased odds of having behavioral disorders (e.g., ADHD and conduct disorder) and mental disorder (e.g., anxiety or ADHD) but not emotional disorders (e.g., OCD and depression). Our findings suggest children with pica may require complex behavioral support beyond their eating difficulties.
... [1] Different forms of pica as a dimension of obsessivecompulsive disorder have also been described in the literature. [8,13,14] As mentioned in case 3, pagophagia appeared in a female patient as a relatively acceptable obsessive-compulsive phenomenon in response to mounting stress. The case responded to both an SSRI and iron supplementation. ...
Pica, in the form of ingestion of various non-food items like clay, chalks, etc., is commonly reported in Indian settings, but its other variant, pagophagia (ice eating), gets attention rarely. This case series is about three female patients who presented in psychiatry outpatient clinics with various mental health issues and ice eating habits. A diagnosis of iron deficiency anemia was common among all three cases, and they were managed with oral iron supplementation along with appropriate psychiatric treatments. Pagophagia is an important clinical presentation to be looked for in the changing Indian society.
... [6] However, in chronically psychotic patients, aberrant feeding habits and poor functional status may also result in nutritional deficits and pica. [7] While some authors speculate that it could be a sign of the highly comorbid obsessive-compulsive disorder and schizophrenia known as pica, [8,9] others contend that pica may be brought on by antipsychotic medicines. [10] Pica in schizophrenia patients has been documented in the literature dating back to Bleuler, who linked aberrant eating patterns to delusional beliefs. ...
Pica is the prolonged, compulsive consumption of inedible objects. Pica is sometimes attributed to an iron deficiency, and it gets better with iron supplements. Typical kind of pica is geophagy or eating clay. Apart from nutritional deficiencies, it is also seen in psychiatric disorders such as obsessive–compulsive disorder. Pica is thought to be a rare, autonomous, and separate habit in the context of schizophrenia, which is frequently ignored in the diagnosis and may lead to consequences such as intestinal obstruction, electrolyte imbalances, and heavy metal toxicity. Here, we are going to discuss a case of a 25-year-old female. She came with complaints of pain abdomen and undergone routine X-ray abdomen which showed ingested three nails. She was admitted under general surgery care. After the evacuation of nails, she undergone psychiatric evaluation. She has faint memory of nail ingestion but discussed stressful interpersonal relationship with her husband and managed on antidepressant medication. Her pica was probably due to interpersonal conflict with her husband few days ago. Her anxiety and sadness improved significantly with the tablet escitalopram and etizolam. In this case, we are trying to understand the psychopathology of pica, other than medical and known psychiatric causes.
... Of note, pica occurred comorbidly with another ED in 1.2% (24.1% of those with pica) of the participants. Case studies of pica from South Africa identified overlap between pica and obsessive compulsive disorder (OCD) and speculated that pica may fit on the OCD spectrum of disorders, involving compulsive or impulsive consumption of non-nutritive substances (Stein et al., 1996;Szabo et al., 1995b). Another case study from Sudan described a man who presented with a bezoar related to eating multiple types of non-nutritive substances (stones, cloth, roofing material) who was diagnosed with OCD (Al-Mendalawi, 2014). ...
There is a dearth of research regarding eating disorders (EDs) in Africa. The first reports of EDs in Africa emerged in the 1970s and 1980s. Recent systematic reviews on the prevalence of EDs did not include any studies from Africa. The few studies undertaken suggest that the prevalence of anorexia nervosa (AN) and bulimia nervosa (BN) is lower in Africa than globally, and that women with AN-related pathology may present atypically, with less weight concern. Although few studies have evaluated binge-eating disorder (BED) in Africa, studies in other settings have found higher rates in black individuals compared to other ethnicities, emphasizing that BED should be further investigated in Africa. Furthermore, in certain African settings BED may be linked to a larger body size ideal suggesting the pathways leading to BED may be different in some African settings. Pica may be challenging to diagnose in Africa, due to common practices, such a geophagy, and more work is needed to disentangle pica from cultural practices. High rates of ED-related pathology have been reported in Africa, although evidence is largely from self-report instruments. Factors associated with ED pathology in Africa include female sex, ethnicity, socio-economic status, body mass index (BMI), Western media exposure, acculturation, urbanization, and trauma. Furthermore, studies suggest EDs may present atypically in some African settings and that the pathways to EDs may also be somewhat different, such as through cultural and religious rituals. Similar to other settings, high comorbidity is demonstrated with other psychiatric disorders, and EDs contribute to significant disability. There is a clear need for more research regarding EDs in Africa, particularly larger epidemiological studies, and qualitative research to understand how EDs may present differently in African settings.
There is little evidence for psychopharmacotherapy in pica. A few studies reported some benefit from the use of SSRIs, atypical antipsychotics and methylphenidate. That said, evidence to deploy these agents remains, at large, flimsy. Here, despite scarcity, we review available literature and draw some generalities that can inform decision-making on clinical grounds.
Pica, the urge to consume items generally not considered food, such as dirt, raw starch, and ice, are particularly common among pregnant women. However, the biology of pica in pregnancy is not well understood. Therefore, this study aimed to assess how pica relates to endocrine stress and immune biomarkers in a cohort of pregnant Latina women in Southern California. Thirty‐four women completed a structured pica questionnaire. Maternal urinary cortisol and plasma cytokine levels were measured between 21 and 31 weeks' gestation. Associations between pica during pregnancy and biomarkers were assessed using linear regression models adjusting for gestational age. Twelve (35.3%) of the pregnant women reported pica (geophagy and amylophagy) during pregnancy. In multivariate models, those who engaged in pica had higher levels of cortisol ( β : 0.37, 95% CI: 0.01, 0.073) and lower levels of IL‐1β ( β : −0.06, 95% CI: −0.11, −0.02), IL‐8 ( β : −0.30, 95% CI: −0.56, −0.05), IL‐21 ( β : −0.35, 95% CI: −0.63, −0.08), and type‐1 inflammation composite ( β : −0.29, 95% CI: −0.44, −0.14) than women who did not engage in pica. These results suggest that biological stress and immune response differ for women with pica compared to those without. This study suggests novel physiological covariates of pica during pregnancy. Further research is needed to better understand the mechanisms and temporality underlying the observed associations between pica and endocrine and immune biomarkers.
Intentional foreign body ingestions (FBIs) are commonly seen in adult patients with intellectual disabilities, substance use, severe psychiatric conditions, or external motivations, but these cases are rarely reported in the psychiatric literature. We present the case of a patient with an extensive history of FBIs and suicide attempts and a multitude of psychiatric diagnoses including borderline personality disorder, major depressive disorder, posttraumatic stress disorder from significant abuse in foster care, obsessive-compulsive disorder, and pica. During the single hospitalization described in this report, she had multiple incidents of self-harm, aggression, and 9 FBIs. A multidisciplinary team involving psychiatry, emergency medicine, gastroenterology, surgery, internal medicine, nursing, social work, behavioral health technicians, case management, chaplain, the legal department, police officers, and hospital maintenance was necessary for care coordination. Interventions included 8 endoscopies and an abdominal surgery to retrieve swallowed foreign bodies, pain management, psychopharmacological and psychotherapeutic interventions for agitation, and environmental precautions to minimize the risk of ingestion. Ultimately, to prevent further trauma and limit additional opportunities for FBI, a collaborative decision was made with the patient to discharge her to her home with outpatient psychologist and psychiatrist support. This case describes the complexities of hospital management of a patient with intentional recurrent FBI, highlighting the importance of a critical assessment of risk versus benefit for prolonging hospitalization. Development of practical management protocols and risk assessments for continued hospitalization is necessary for patients with recurrent intentional FBIs.
Feeding disorders and eating disorders (FEEDs) are serious mental and behavioural disorders in adults with intellectual disabilities (ID) and autistic spectrum disorders (ASD). FEEDs are often chronic, complex and associated with significant underweight, overweight or obesity. FEEDs are also associated with considerable physical ill health and psychiatric comorbidity. The DC-LD concept of FEEDs is then outlined. The possible personal psychological meanings of the ‘mainstream’ EDs (anorexia nervosa, bulimia nervosa and binge eating disorder) in adults with ID and ASD are considered. The prevalence of such ‘mainstream EDs’ have increased in recent decades. The caregiver and service delivery burdens of FEEDs such as pica, regurgitation/rumination disorder and food faddiness/refusal (ARFID) are high. The diagnosis and conceptualization of FEEDs in adults with ID and ASD using the DC-LD 2000, DSM 5 2005 and evolving ICD-11 2015 classification systems are evaluated. The 2005 Eating Disorders in Adults with Learning Disabilities (EDALD) clinical research data are summarized to outline the prevalence, types and aetiological associations of FEEDs in a selected mostly community ID service user sample (n = 214). Lessons learnt from the EDALD clinical research methodology and data are discussed to support evidence based multi-level and multi-professional screening, clinical assessment and management. Finally future clinical, research and service development directions are suggested for FEEDs in adults with ID and ASD.
Obsessive-compulsive disorder (OCD) has been shown to be highly prevalent in both developing and developed countries. Nevertheless, data on OCD in blacks, and black South Africans in particular, are limited.
Records of patients presenting with OCD at a tertiary hospital serving a predominantly black population were reviewed. Patient data, including demographic Information, presenting symptoms and clinical course, were collated.
Six black South Africans had presented with OCD in the previous year. Phenomenology and psychopharmacology of the disorder were largely reminiscent of those previously reported in the International literature.
Not surprisingly, black South Africans may suffer from OCD. Nevertheless, it is likely that such patients do not present for treatment or are underdiagnosed. Future rigorous epidemiological research on OCD in South Africa is necessary.
In DSM-III-R, pica, with anorexia nervosa, bulimia nervosa and rumination disorder of infancy, is accorded the status of a separate eating disorder. However, in the Draft of ICD-10, only anorexia nervosa and bulimia nervosa are listed under eating disorders. Pica in children, and feeding disorder in infancy and childhood, are incorporated with enuresis, encopresis, and feeding, movement and speech disorders in a separate "heterogeneous group of disorders". Extensive research on the history and terminology of eating disorders from the 16th to the 20th century suggests that, historically, pica was regarded as a symptom of other disorders rather than a separate entity. This paper aimed to locate and assess chronologically significant definitions and accounts of pica, to provide a fuller clinical description of a condition which, despite its current relevance, has received little detailed historical examination, and to give some consideration to the multiple aetiological theories which have been put forward. The historical findings are related to the descriptive criteria for pica in DSM-III-R and Draft ICD-10.
An association between recurrent motor and phonic tics and obsessive-compulsive behaviors has been noted since Tourette's Syndrome (TS) was first described. Obsessive-compulsive disorder (OCD) until recently was considered a rare disorder with poor prognosis. Currently, OCD is considered among the most common psychiatric diagnoses, and new treatments have spurred the development of considerable clinical, epidemiological, genetic, and biological research. Recent studies suggest a high rate of obsessive-compulsive symptoms in Tourette's Syndrome patients. A high rate of OCD among relatives of TS probands, both with and without OCD symptoms, suggest that some forms of OCD may represent an alternative expression of factors responsible for TS and/or chronic motor tics. Areas of conceptual controversy in the differentiation of tics, impulsions, and compulsions are discussed, confusing aspects of differential diagnosis are explored, and the relationship of diagnostic issues to clinical and familial studies are highlighted. There is considerable evidence for neuropsychiatric abnormalities in both OCD and TS; however, no studies have directly compared both disorders with similar methodological design. While studies of neurotransmitter function have primarily implicated dopaminergic dysfunction in TS and serotonergic function in OCD, other systems may be involved in each disorder, and neurotransmitter systems may be tightly linked, such that alterations of one system will affect other systems. This article reviews and discusses some of the conceptual and methodological issues associated with clinical, familial, neuropsychiatric and biological studies attempting to elucidate the association among tics, obsessive-compulsive disorder, and Tourette's Syndrome.
Coprophagia is seen, though uncommonly, in psychiatric hospitals among adult patients with diffuse brain disease and in individuals with subaverage intelligence. We describe here a case of coprophagia in an adult with normal cognitive functioning. Thorough assessment revealed that this coprophagia was a manifestation of obsessive-compulsive disorder. The problem behavior responded to a behavioral treatment program comprising exposure and response prevention.
Clinical impulsivity has been characterized in both dimensional and categorical terms. Whereas DSM-III-R classifies personality disorders characterized by impulsivity and impulse control disorders as discrete entities, impulsive symptoms and traits can also be conceived in terms of an underlying behavioral dimension. The authors review research on impulsivity and the impulse control disorders from a biological perspective. In particular, they critically review evidence that the serotonin neurotransmitter system mediates symptoms and traits of impulsive personality disorders and the impulse control disorders.
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