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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.
... While some authors postulate that it might be a symptom of obsessive-compulsive disorder, which is highly comorbid with schizophrenia [8,9], Others suggest that pica may be induced by antipsychotic medications [10]. Demonstration of pica in patients with schizophrenia goes back in literature as far as Bleuler, who attributed abnormal eating behaviors to delusional ideas [11]. ...
Although pica is commonly associated with nutritional deficiencies, it is also observed in psychiatric disorders such as obsessive-compulsive disorder and less commonly in schizophrenia. We describe a case of pica in a 34-year-old male with decompensated schizophrenia. Emergency medical services brought the patient from a state facility as he was scavenging and eating foreign objects. Upon initial evaluation, no notable nutritional deficiencies were noted. After surgical removal of foreign objects, he was started on antipsychotics. His pica was determined to be due to his active psychosis involving delusions, disorganized thought processes, and loosening of associations. His psychosis improved on paliperidone intramuscular injection and oral olanzapine, which coincided with reduction and resolution of pica. Our case highlights the need to understand further the exact psychopathology of pica that may not be limited to nutritional deficiencies.
... Furthermore, some previous authors proposed that pica should be classified as an obsessive-compulsive spectrum disorder (Gundogar et al., 2003;Gupta et al., 2007;Stein et al., 1996). Given that obsessive-compulsive symptoms appears to occur frequently among patients with schizophrenia, Kar et al. (2015) suggested that a substantial overlap might exist among schizophrenia, obsessivecompulsive disorder and pica. ...
Aim
We aimed to further elucidate the under-researched, underdiagnosed and misunderstood comorbid pica in the context of psychosis.
Method
We report a case of teen-onset plastophagia in an antipsychotic-naïve girl at ultra-high risk (UHR) for psychosis.
Results
HA is a 17-year-old unmarried girl who had a history of good premorbid functioning, no personal psychiatric history and an uncle with schizophrenia. She was referred to our psychiatry department with the complaint of having the habit of eating plastic for about 2 years. A thorough clinical history revealed that she developed, since more than a year, difficulty in school and interpersonal functioning. After clinical evaluation, a diagnosis of UHR with major depressive disorder, iron deficiency anaemia and pica was made.
Conclusion
We draw attention to the possibility of an overlap between the pathogenesis of pica and psychosis, and we highlight the importance of early diagnosis and management of both pica and UHR since they can lead to serious medical and mental consequences.
... Pikası olan okul öncesi dönemi çocuklarda demir eksik liği, anemi ve bağırsak parazitleri sıklığım tespit amacıyla 1-6 yaşları arasında (ortalama yaş 29 Although an important association was found between pica and iron deficiency (3,4,7,8), it is controversy whether iron deficiency causes pica or the dietary irregularities engendered by the pica produce iron deficiency (1,4). Pica may be one of the important causes of lead poisoning (9-11), tox ocariasis (12,13), poor growth (3,14), intestinal ob struction and perforation (15,16), intestinal para-sitic infection (3,17,18) and anemia (1,3,4,19,20). ...
... The occurrence of Pica is shrouded by lots of speculations ranging from nutritional, physiological and psycho-social theories, 17 some have even speculated that Pica is indeed a form of OCDs (obsessive-compulsive Disorder). 26 Also observed in this study is the predominance of Pica among women with family history, here it was noticed that 26.7% (Table 4) of the women that had pica during the study period had a friend or a family history of Pica, this was also the findings of Johnson and Derrick were pica was commoner among women that had family history in a culturally exposed communities. 27 This finding further supports the observation made by Simpson et al. in 2000 that a family history of pica and its presence during childhood is a risk factor for pica in pregnancy. ...
One of the unusual symptoms observed among pregnant women is the aversion for non-food substances like sand, clay and ice. Pica is a form of eating disorder characterised by these symptoms. It occurs commonly in children and among pregnant women. This study aims to determine the prevalence and associated factors for Pica among booked patients in our institution. A prospective study was conducted among pregnant women at booking aged 11-45 years at the ATB University teaching Hospital Bauchi between 1st February to 31st of July 2019. All pregnant women who gave their consent were interviewed using a pretested questionnaire. The biodata, risk factors for Pica, occurrence in childhood and other social habits were recorded. The result showed a prevalence rate of pica at 38.9% with a craving for ice (18.7%), sand (14.7%) and others (55.11%). Pica was observed more in the day time (afternoon and evening) and most women having pica had a low level of education. Even though the prevalence of Pica appeared low in our environment, adequate counselling and appropriate treatment of women with this condition should be given more priority.
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.
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.
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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