Progress in Neuro-Psychopharmacology & Biological Psychiatry 32 (2008) 2010–2011
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Progress in Neuro-Psychopharmacology & Biological
Psychiatry
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Letter to the Editor (Case report)
Is Pica an eating disorder or an obsessive–compulsive
spectrum disorder?
1. Introduction
Pica is classified in Diagnostic and Statistical Manual of Mental
Disorders (DSM) under the Feeding and Eating Disorders of Infancy
and Early Childhood, and defined as the persistent eating of non-
nutritive substances for a period of at least one month in a
developmentally inappropriate and culturally unacceptable manner
(APA, 1994). Although there is no clearly established etiology for Pica,
its association with a number of conditions is reported; most
commonly pregnancy, iron deficiency and psychosocial problems. It
is also seen frequently in individuals with psychiatric disorders
including psychosis, autism and intellectual disability. Moreover an
association between Pica and obsessive–compulsive spectrum dis-
order (OCSD) is described by some authors (Bhatia and Gupta, 2007;
Gundogar et al., 2003; Stein et al., 1996; Szabo et al., 1995). We here
report a child who had Pica and treated with fluoxetine successfully.
2. Case
A 10-year-old boy who had ingested foreign materials (carpet and
cloth fibers) for more than 5 years was referred to our out-patient
clinic by his pediatrician. He was admitted to the pediatric clinic for
several times because of abdominal pain. Iron deficiency anemia
was detected according to his laboratory investigations (Hemoglobin
(Hb) = 10.6 g/dl; Hematocrit (Hct) = 33.9%; Mean Corpuscular Volume
(MCV) = 70.6 fl; Iron (Fe) = 20 mg/dl; Ferritin = 7.2 ng/ml) and he was
kept on 6 mg/kg per day of iron supplementation for three months.
Although his serum level of iron and full blood count were within
normal limits (Hb = 12.6 g/dl; Hct = 37%; MCV = 72.8 fl) at the time of
referral to child psychiatry, his Pica behavior was still continuing.
He described his eating behavior as a strong, irresistible urge
which he could not resist. Although he did not want to eat, he felt
unable to overcome this urge. He was collecting fibers to his pocket
and consuming them secretly both at home and at school. He reported
the sense of tension before eating, followed by a relief afterwards. In
his psychiatric assessment he had compulsive behaviors including
repeating, controlling, ordering and frequently asking questions. His
psychometric testing revealed a normal intelligence level. He had
diagnoses of Obsessive–Compulsive Disorder (OCD) and Pica accord-
ing to DSM-IV criteria (APA, 1994). His score on the Children's Yale–
Brown Obsessive–Compulsive Scale (CY-BOCS; Scahill et al., 1997) was
19 (11 on the Compulsions; 8 on the Obsessions Severity Scale).
His mother, father and sister were assessed by Structured Clinical
Interview for DSM-IV Axis-I Disorders (SCID-I)/Clinical Version (First
et al., 1997). His mother (37-years-old) was diagnosed of Generalized
Anxiety Disorder, his father (47-years-old) of OCD and his sister (17-
years-old) of Conversion Disorder. His sister also had Pica, namely
geophagia, when she was 3-years-old and remitted spontaneously
two years later. In his family history his aunt had OCD.
0278-5846/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pnpbp.2008.09.011
The patient was started on fluoxetine 10 mg/day and the dose was
increased up to 30 mg/day within three weeks. His Pica and
compulsive behaviors decreased gradually within 6 weeks. His score
on the CY-BOCS was 7 in his 8th week visit. We ceased medication
after 9 months. In his follow up at one year he did not demonstrate any
symptom, and his full blood count was within normal range
(Hb = 14.3 g/dl; Hct = 41.8%; MCV = 80.3 fl).
3. Discussion
We have described a pediatric case of Pica who did not respond to
iron therapy but his symptoms resolved with fluoxetine treatment.
Here, we plan to discuss the possible relationship between Pica and
OCSD.
The literature classifies Pica simply into two main groups; 1) volun-
tary (eating in response to what is available) which is seen frequently in
cases with mental retardation, autistic disorder and schizophrenia, and
2) involuntary (eating in response to a compulsion or addiction) as
reported in OCD and other eating disorders (Lacey, 1990). Like
compulsive eating (rumination and bulimia), Pica involves an urge to
eat non-nutritive substances and may serve the function of self-soothing
and relief of tension. In our case, Pica was described as repetitive,
intrusive and egodystonic. Attempts to resist increased his level of
anxiety and distress which was then relieved by ingestion of the fibers.
Several disorders such as trichotillomania and kleptomania have
been suggested to fall within the obsessive–compulsive spectrum on the
basis of shared clinical and phenomenological features including age of
onset, course of illness, family history and responsiveness to Selective
Serotonin Re-uptake Inhibitors (SSRIs) (Cohen et al., 1997). The positive
response of some cases to SSRIs has led to view Pica as a form of OCSD
(Bhatia and Gupta, 2007; Gundogar et al., 2003; Stein et al., 1996).
Compulsive behaviors of the case, improvement with fluoxetine, and
OCD and Pica in his family history support the hypothesis that Pica may
be related to OCSD. As his Pica behavior resolved gradually, slow
response to fluoxetine could be explained by obsessive traits of the case.
Although Pica is often considered as a manifestation of iron
deficiency, it remains controversial whether it is a consequence rather
than a cause of iron deficiency (Gupta et al., 2007). The reported case
had iron deficiency anemia however after the iron supplementation
and correction of anemia his Pica did not resolve. Additionally his Pica
behavior ceased following the fluoxetine treatment.
Psychopharmacologic therapy of Pica has not been well documen-
ted in the literature. Treatment with SSRIs including fluoxetine
(Choure et al., 2006; Gundogar et al., 2003), sertraline (Gundogar
et al., 2003) and escitalopram (Bhatia and Gupta, 2007) has been
shown to reduce Pica intensity. Their positive effect is attributed to
their anti-anxiety and anti-obsessive properties.
4. Conclusion
This report suggests that Pica, at least in some cases, may be part of
OCSD and may improve with SSRIs. As children are referred rarely to
 Letter to the Editor (Case report) 2011

the psychiatry services for Pica, we suggest psychiatric assessment Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK. Children's
Yale–Brown obsessive compulsive scale: reliability and validity. J Am Acad Child
especially when iron deficiency anemia and Pica are resistant to iron Adolesc Psychiatry 1997;36:844–52.
therapy or when there are not any underlying medical conditions and/ Stein DJ, Bouwer C, Van Heerden B. Pica and obsessive–compulsive spectrum disorders.
or compulsive behaviors and family history of OCD are evident. S Afr Med J 1996;86:1589–92.
Szabo CP, Van Rooy W, Allwood CW. Pica — is it a variant of obsessive–compulsive
Although a single-case report limits the generality of the results, disorder? A case report. S Afr Med J 1995;85:1390–1.
further research is needed to declare a possible relationship between
Pica and OCSD. Sabri Hergüner
Bakırköy State Hospital for Mental Health and Neurological Disorders,
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