The major proposed change for both pica and rumination disorder in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition is their relocation from their current section, titled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,”1 to the newly proposed section, “Feeding and Eating Disorders.”2
This change emphasizes that these disorders occur across the age range, including adulthood. Also, specifiers for severity and course have been suggested for each of these disorders, in keeping with DSM-5 format. Additional minor, but noteworthy, changes in phrasing that clarify ascertainment of diagnostic criteria are summarized in this paper.
The sine qua non of pica is the recurring ingestion of nonnutritive substances.1 Changes to phrasing of diagnostic criteria in DSM-5 are intended to guide clinicians in distinguishing eating behaviors that warrant a diagnosis of pica from behaviors that are developmentally normal, culturally supported or socially normative, or that support a diagnosis of a different mental disorder.
Our recommended changes indicate that consumption of products that are regarded as foods or beverages, even if they are without nutritional value (eg, diet soda and other “zero calorie” products), would not be consistent with pica. Two years is our suggested minimum age for a pica diagnosis; at younger ages, mouthing different kinds of objects is considered developmentally normal. Consumption of substances consistent with local cultural practices or social norms would not warrant a pica diagnosis.
Lastly, we recommend that a pica diagnosis would be given in the context of another mental disorder or medical condition only if the behavior requires additional, rather than independent, clinical attention, since clinical management of pica eating and the other disorder or condition would likely be integrated.
Individuals with pica may consume an eclectic variety of substances, including mud, pottery, clay, and laundry starch. Pica eating of numerous other substances, such as paper, tissues, wood, plastic straws, soap, cloth, carpet, hair, string, wool, paint, gum, metal, pebbles, chalk, charcoal, coal, and ash, has also been reported.
Substances consumed may vary with age or availability. Persistent consumption of food starches, such as cornstarch and uncooked pasta or rice, does not meet the diagnostic criterion for non-nutritive substances.
Likewise, persistent consumption of ice does not satisfy pica criteria since it is a food. However, if not regarded as food within local norms, consumption of freezer frost, also widely reported, would potentially meet criteria for pica.
In addition to heterogeneity of substances consumed, pica’s associated behavioral features can differ considerably among individuals (eg, its compulsive nature and relationship to emotional arousal or need for oral stimulation). Many individuals with pica display a compulsion to eat particular substances and may describe a craving or strong urge to consume the substance due to its taste or consistency.3 In some younger patients, as well as those with neuro-developmental or learning disorders, some clinicians regard pica as a form of self-soothing behavior, engaged in when arousal reaches a particular level.
Available evidence suggests that the prevalence of pica eating varies widely across diverse social and clinical contexts and appears to be higher among select populations that include pregnant women, children,4,5 adults with iron deficiency,6 and institutionalized persons.7 However, the prevalence of pica, the disorder, in these special populations is largely unknown since published studies generally omit key data essential for ascertaining the diagnosis, such as the behavior’s persistence, duration, and relativity to local social norms.
Available data suggest that pica eating — and by extension, pica — is rare in healthy children older than 2 years in the US.8 However, a study reported that 33.9% of Detroit children in treatment for sickle cell anemia had pica eating.9…