Clinical Case Studies

Volume 7 Number 1
February 2008 3-11
© 2008 Sage Publications
10.1177/1534650106298917
The Girl Who Ate Her http://ccs.sagepub.com
hosted at

House—Pica as an http://online.sagepub.com

Obsessive-Compulsive Disorder
A Case Report
Yonas Baheretibeb
Addis Ababa University, Ethiopia
Samuel Law
Clare Pain
University of Toronto, Canada

This report concerns the interesting clinical phenomenology of a 17-year-old Ethiopian female
student with a long-standing history of ingesting nonnutritive materials. She was initially non-
selective, but later began more exclusively consuming mud obtained from a wall in front of
her house. She suffered from a feeding and eating disorder known as pica. Currently, there is
no clearly established etiology for pica. This patient’s particular psychopathology—recurrent,
unwanted, intrusive images and thoughts of the mud wall and of eating the mud; feelings of
distress and anxiousness that were not relieved unless she consumed mud; and significant
effects on her daily life from her uncontrollable need to return home to eat mud from her
wall—suggests an ego-dystonic, obsessive thought-distress-consumption-relief pattern that is
consistent with obsessive-compulsive disorder. This case may contribute to the etiological
understanding that some forms of pica may be part of the obsessive-compulsive spectrum
disorders.

Keywords: obsessive-compulsive disorder; obsessive-compulsive spectrum disorders; pica;

Ethiopia

1 Theoretical and Research Basis

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines pica as a
form of feeding and eating disorders of infancy or early childhood, characterized by “the
persistent eating of nonnutritive substance for a period of at least one month; [the behavior]
is inappropriate to the developmental level, . . . not part of a culturally sanctioned practice,
and . . . sufficiently severe enough to warrant independent clinical attention.” (American
Psychiatric Association, 1994, p. 96).
More specifically, when observed during the second year of life or earlier, pica is con-
sidered developmentally normal; beyond that, there is excellent cross-cultural agreement that
it is inappropriate (Castiglia, 1993). Although pica occasionally extends into adolescence,

Authors’ Note: Please address correspondence to Dr. Samuel Law, 17th floor, Cardinal Carter Wing, 30 Bond
Street, Toronto, Ontario, Canada, M5B 1W8; e-mail: laws@smh.toronto.on.ca.

3
4 Clinical Case Studies

it is rarely observed in adults who are not mentally disabled (Rose, Porcerelli, & Neale,
2000). Among the different substances—coins, pins, paint, paper, body products, glass, and
so forth—consumed as part of pica, geophagia (earth eating) is the most common. It is par-
ticularly found in those who live in poverty, in the tropics, and in tribe-oriented societies
(Robinson, Tolan, & Golding-Beecher, 1990). For adults, pica is most frequently observed in
pregnant woman; al-Kanhal and Banil (1995) studied 321 pregnant Saudi Arabian women
and found an 8.8% incidence of pica, particularly geophagia and pagophagia (ice eating).
Clinical presentation of pica is highly variable and is associated with the specific nature
of the ingested substance. Gastrointestinal tract complications associated with pica are
most common, ranging from mild or moderate symptoms of constipation to obstructions
caused by bezoar formation and the presence of indigestible materials to life-threatening
conditions such as hemorrhages secondary to perforations or ulcerations and soil-borne
parasitic infections (e.g., toxocariasis, toxoplasmosis, ascaris, and trichuriasis; Rose et al.,
2000). Robinson et al. (1990) studied 108 children with pica and found a 70% rate of
intestinal parasites. Other serious complications include lead poisoning, hypokalemia,
hyperkalemia, phosphorus intoxication, and mercury poisoning, depending on the sub-
stance ingested (Rose et al., 2000). Reluctance to report pica on the part of the patient often
further complicates diagnosis and effective treatment
Some forms of pica are linked to iron deficiency anemia, zinc deficiency, sickle cell ane-
mia, and family history of pica (Federman, Kirsner, & Federman, 1997; Ivascu et al., 2001;
Singhi, Ravishanker, Singhi, & Nath, 2003). However, the cause of pica behavior has
largely eluded researchers (see Lacey, 1990; Parry-Jones & Parry-Jones, 1992; Sayetta,
1986, for reviews). Sayetta (1986) described several theoretical views on etiology, includ-
ing nutritional, sensory, physiologic, neuropsychiatric, cultural, and psychosocial perspec-
tives. The DSM-IV, consistent with its atheoretical stance, only gives some epidemiological
accounts that pica is frequently associated with developmental delays, poverty, neglect, and
lack of parental supervision, and does not make any suggestion of the etiology or catego-
rize pica under any specific category or spectrum of disorders.
When clinicians see older children and adolescents with pica who do not have develop-
mental delays and who do not have any clear risk factors, psychosocial and psychological
factors are typically suspected. Recent literature on pica has raised the possibility that some
forms of it may fit under the umbrella of obsessive-compulsive spectrum disorders (OCSD;
Hollander, 1998). The category OCSD includes a large range of related disorders with some
overlap in important diagnostic, etiologic, and treatment arenas. All OCSD share some
characteristics along the lines of having intrusive, repetitive thoughts and/or repetitive
behaviors. All OCSD can be subdivided into one of three subgroups: (a) preoccupation or
obsession with specific bodily sensation or appearance (e.g., body dysmorphic disorder,
eating disorders, and hypochondriasis); (b) selected neurological disorders affecting the
basal ganglia that result in repetitive behavior (e.g., Tourette’s syndrome, Sydenham’s
chorea, torticollis); and (c) impulse control disorders, characterized by impulsivity, aggression,
and risk-seeking behaviors (e.g., trichotillomania, kleptomania, pyromania, pathological
gambling, and self-injurious behavior; du Toit, van Kradenburg, Niehaus, & Stein, 2001;
Hollander, 1998; Hollander & Wong, 1995; O’Sullivan, Mansueto, Lerner, & Miguel,
2000). Furthermore, these OCSD share other characteristics with obsessive-compulsive
disorder (OCD) itself, including features such as age of onset, clinical course, family history,
 Baheretibeb et al. / Girl Who Ate Her House 5

and response to selective serotonin reuptake inhibitors and behavioral therapy (Stein, 2000).
To this end, there is some evidence, although very limited, to support the possibility that
pica can present as OCD itself. Stein, Bouwer, and van Heerden (1996) reported five cases
of pica and found two had compulsions and met diagnostic criteria for OCD, and two had
impulse control disorders. Gundogar, Demir, and Eren (2003) reported three cases of pica
patients and found two of them had impulse control disorders and one had OCD.
Because pica remains a relatively little understood phenomenon in terms of its etiology
and treatment approaches, further case studies can add to the limited literature and con-
tribute to the theory that some forms of pica may be OCD, particularly those with no con-
current developmental delay.

2 Case Presentation
Bira (not her real name) is a 17-year-old female high school student from Addis Ababa,
the capital city of Ethiopia. She came to the medical outpatient department of an urban gen-
eral hospital in some distress, complaining of severe abdominal distension, constipation,
and abdominal cramping and pain. She informed the clinician that she had been ingesting
mud on a daily basis since her early childhood. Physical examination revealed multiple
scratch marks in the oral mucosa (related to injuries from the straw in the mud) but no other
remarkable findings and no surgical indications; vital signs were normal. Laboratory tests
showed normal electrolytes, hemoglobin, hematocrit, and white blood count with differen-
tials. There was no sickle cell anemia. Her stool examinations revealed multiple parasites,
which were later treated. She was referred to psychiatry for follow-up.

3 Presenting Complaints
The first author performed a psychiatric interview of Bira as an outpatient and gathered col-
lateral information from her mother. The interview was conducted in the Amharic language.
Like many other children in her neighborhood, Bira started ingesting nonfood items such as
soil or anything on the floor in early childhood. After the age of 2, her eating of nonnutritive
materials did not decline as it did in other children. Instead, it worsened, and her mother could
not stop her. There had been daily ingestion of some mud or soil, her preferred substance, for
as long as Bira could remember. In the last 5 years, Bira’s ingestion of mud worsened in terms
of frequency and amount —at least once a day, sometimes three times on weekends—and she
started eating mud only from the wall at her home. During the year prior to her seeking help,
the amount and the frequency again increased—a typical single ingestion was around 250 g of
mud; about 8 sq m of the mud wall had been consumed at the time of assessment.

4 History
Bira reported that in the last few years, she had been aware that these ingestions were
related to her increasingly frequent thoughts and images of the mud wall and of her eating
6 Clinical Case Studies

the mud. These thoughts and images were distracting and intrusive. They were frequent, at
least hourly, lasting at least a few minutes each time, at times longer when her mind was
unfocused on other matters. She described the thoughts and images as intense, and she
attempted to resist and distract herself but was not successful; after some time, she gave up
trying. During a school day, when she was away from home, the intrusiveness of thoughts
and images was slightly better, but they intensified as the last bell at school sounded. For a
period of time, she came to dread the end of school. On the way home from school, she was
aware that she usually was more restless and anxious. When she arrived home, she would
feel compelled to walk to the wall, tear a part of the wall, ingest it “greedily,” and then even-
tually calm down somewhat and ingest more slowly. She would stop ingesting after she got
some “relief” from the intrusive thoughts and images. She would brush her teeth and go to
her room after eating. Following that, she typically had some abdominal discomfort or dis-
tension, and that would be the time when she felt “regretful” of the ingestion. She had been
consistently very “embarrassed” by her behavior and had wanted help to decrease or stop
the ingestion but did not know how to obtain help. Combined, she would spend more than
2 hr per day thinking about and eating mud. For her long-standing abdominal health
problems, she took different herbal laxatives and had visited different Ethiopian traditional
healers, who treated her with prayers and holy waters and advised her to simply stop eat-
ing mud (Kloos et al., 1987). She had tried but became less hopeful and more frustrated
after each failure. She did not abuse any laxative, and there was no history of eating disor-
der or body image distortion issues. Her weight, height, food intake, and nutritional status
were all within normal limits. Despite Bira’s long-term ability to cope with her condition
and her relative freedom from comorbidity, she was beginning to experience increasing
amounts of distress that she could no longer cope with. This realization motivated her to
seek treatment.

5 Assessment
General psychiatric screening showed she had somewhat dysphoric, but largely stable
mood, no remarkable neurovegetative abnormalities, no psychotic features, no substance
abuse, and no gross difficulties in terms of personality and social functioning. She had
anxiety induced by the thoughts and images of mud and mud eating. Beyond that, there was
no generalized anxiety. There were no signs of attentional or hyperactive difficulties. There
was no history of serious medical illness except the multiple parasitosis and abdominal dis-
tension. Her father died of physical illness when she was young, and she grew up with her
mother. There was no family history of pica, developmental delays, eating disorders, sub-
stance abuse, or major anxiety disorders. In particular, there was no OCD or OCSD.
Developmental history showed that the patient was carried to full term; the pregnancy,
labor, delivery, and postpartum were uncomplicated. She had no gross dysmorphic features
and appeared normal in intelligence. She was immunized on time. She reached all devel-
opmental milestones within appropriate times. She started school at age 5 and was an aver-
age student throughout, with no difficulty socializing with her peer groups. There was no
history of childhood trauma or peer victimization. She started menarche at age 13, and
menses were regular. She had many friends but had not been involved in love affairs.
 Baheretibeb et al. / Girl Who Ate Her House 7

Baseline mental status showed no suicidal or self-injurious ideas or impulses in the past or
at the time of assessment. She wanted help for her presenting problem, knowing that her
behavior was abnormal but she could not change it herself. She harbored some hope in
Western medicine after her own efforts and the traditional healers had failed.
Based on the DSM-IV, Bira was diagnosed with pica, given her obvious age-inappropriate
ingestion of mud on a chronic basis. Given the particular phenomenology of her pica pre-
sentation, she was further diagnosed with OCD. For assessment, the first author relied on
DSM-IV; there was no access to a standard assessment instrument, such as the Yale-Brown
Obsessive Compulsive Scale for documentation at the time. The clinical impression of
Bira’s OCD was that it was moderately severe.
Of note is that our patient resides in Ethiopia and has engaged in persistent eating of mud
throughout her life. To our knowledge and in our local understanding, this practice is not part
of our patient’s culturally sanctioned practice, and her suffering was publicly acknowledged.

6 Case Conceptualization
There is no doubt that Bira has pica. Although being parsimonious in terms of diagnosis is
a virtuous principle, one also needs to attend to the impressive phenomenological fit and con-
sider the additional OCD diagnosis. The hallmark features of OCD are clearly present: The
mud wall and mud eating were persistent thoughts and images that were experienced as ego-
dystonic, intrusive, and inappropriate. Efforts to ignore and suppress these obsessions failed,
leaving her with marked anxiety and distress, leading to compulsive behavioral strategies to
prevent and reduce anxiety and distress. Her obsession and compulsions were increasingly
distressing and time-consuming and were disruptive to her school and adolescent life.
We are also aware that the formulation of the OCD diagnosis for Bira illustrates some of
the typical ambiguous issues involved in diagnosing OCD. To distinguish it from an
impulse control disorder, it is critical to recognize that the patient did not derive pleasure
or gratification through her mud-eating compulsion. Eating mud did bring her relief, but
there was little thrill in the actual mud-eating behavior, and she was evidently and consis-
tently regretful and wanted to get effective help. Another issue is that when compared to
others with OCD, the patient may come across as less severely ill and somewhat indiffer-
ent to her illness, given her lack of effort to persistently obtain treatment. This impression
may be attributed to her relatively young age and immaturity, as even though she may have
recognized mud eating as unhealthy and unreasonable, after repeated efforts and failure to
resist the compulsion, she may have yielded to and accepted the tension-relieving compul-
sion over time. The DSM-IV diagnosis of OCD recognizes that some sufferers do not per-
sistently experience a wish to resist the compulsion and may have simply incorporated the
compulsion into their daily routine. This seems to describe our patient’s situation well; the
early onset and long period of pica behavior would have resulted in some desensitization
and habituation of the behaviors, so there appears to be relatively less urgency in her pre-
sentation and her help seeking.
Furthermore, we conceptualized that Bira’s pica likely started out as a relatively benign
childhood maladaptive habit, but OCD may have played a role in perpetuating it. As she
grew older and pica became less socially acceptable, what kept Bira continuing to eat mud
8 Clinical Case Studies

is puzzling. It is possible that she was vulnerable to develop OCD to begin with, and her
ongoing pica conveniently provided the content of her OCD illness. It is notable that she
did not have the usual OCD risk factors, such as genetic predisposition, mood disorders,
other anxiety problems, or environmental stressors like trauma (Lochner et al., 2002) or
peer victimization (Storch et al., 2005). In any event, it is of note that there are diagnostic
complexities, and the concept of OCSD appears to be a generally useful overarching con-
cept for the understanding of this and possible other pica cases. With that, the treatment
options of using psychotherapy and pharmacotherapy for pica are also valuable. Finally, it
is possible that a subset of pica can manifest as OCD, and this subset may be best repre-
sented in the nondevelopmentally delayed population.
As it stands, there is no prevalent agreement on the etiology of pica. Most of pica suf-
ferers in Bira’s age group are those with developmental delays, and the proven treatment
approach is that of behavioral modification. This approach, using techniques such as dif-
ferential reinforcement of other behaviors, noncontingent attention, and overcorrection to
help the clients, has had some success, but it is limited by its lack of acceptability in clients
and the need for close monitoring and a contained, structured environment (McAdam,
Sherman, Sheldon, & Napolitano, 2004). For the nondevelopmentally delayed population,
these techniques are further limited in usefulness.
On the other hand, it is known that behavioral approaches in general are beneficial.
Schwartz, Stoessel, Baxter, Martin, and Phelps (1996) have demonstrated, using brain-
imaging techniques, that behavioral therapy for OCD can have direct brain chemistry
changes. Although Bira had attempted to correct herself of the mud-eating behavior over
the years and failed, the clinic would be in the position to teach her behavioral approaches
that might be more effective. Once taught, she might be able to use them on her own, and
she could feel more effective. On the other hand, we were also aware of the limits on
resources for proper behavioral treatment in Addis Ababa.

7 Course of Treatment and Assessment of Progress

Bira and her mother were seen at the clinic together and given psychoeducation in their
native language on the conditions of pica and OCD. Given the limited resources of the
clinic (there were eight practicing psychiatrists for 70 million Ethiopian people), the most
practical treatment modality was pharmacotherapy. Bira and her mother agreed to medica-
tion after the reasons and side effect profile were explained. She was started on 75 mg daily
of clomipramine (serotonin specific reuptake inhibitors are costly and rarely available in
Ethiopia at this time). She was seen weekly for assessment using clinical interview and
impression as the primary tool. During these sessions, which typically lasted 5 to 10 min,
she was encouraged to use a thought diary and “thought-stopping” techniques, as informed
by the cognitive-behavioral model, to monitor and relieve her obsessive thoughts and mud
ingestion; however, Bira was very forthcoming in reporting that she did not use any of the
techniques and was simply happy to take the pill instead.
By the end of the 4th week, Bira started to notice improvement in terms of having less
obsessiveness and less anxiety induced by the obsessive thoughts and images, and she was
able to delay and decrease the amount of mud ingested. She attributed the improvement
 Baheretibeb et al. / Girl Who Ate Her House 9

mainly to the medication. She liked the simplicity of taking medication. She enjoyed
spending more time with friends as she was freed from her consuming thoughts and com-
pulsions. After 3 more months, she reported complete stoppage of pica, with only occa-
sional unwanted thoughts and images of eating mud, which were under control. She was
very pleased and proud of her change.

8 Complicating Factors/Follow-Up
Because of the distance to the clinic, the limited clinical time available, and the modest
expense involved, Bira stopped coming to the clinic and stopped medication after the 4th
month. Six months after that, she relapsed in terms of having more obsessions, and she
restarted eating mud. The first author made a special home visit after the news of the relapse
and found her eating mud at home. Her mother reported that she was disappointed by Bira’s
relapse but not overly surprised as she had seen previous failures in their treatment-seeking
experiences. While the mother was busy looking after her house chores, the first author
advised and asked Bira directly to resume follow-up and medication, and Bira agreed. At
the time of the writing of the case report, Bira was being treated with clomipramine again
and was reportedly symptom free.

9 Treatment Implications of the Case

In terms of treatment, our patient showed good response to pharmacotherapy with
serotonin-enhancing medication (clomipramine). At an observational level, the outcome
lends some support to the diagnostic formulation in terms of OCD and is in keeping with
the treatment outcome as reported in the limited literature for similar cases (Gundogar et
al., 2003; Stein et al., 1996). Use of serotonergic treatment shows promise, at least for some
forms of pica patients, but more research is needed to see if pica patients at large can ben-
efit from the same (Richter, Summerfeldt, Antony, & Swinson, 2003). Related to this is our
belief that pica found in nondevelopmentally delayed, adult populations should include
OCD or OCSD as differential diagnoses, and these cases may be different from the majority
of pica cases typically found in the developmentally delayed population. However, further
research is needed.
It is also interesting that pharmacological treatment alone seemed to work for a stretch
of time for this patient. It is possible that more sustained improvement could be achieved if
more behaviorally based therapy, in conjunction with medication or independent of it, were
feasible with this patient. There are encouraging results in the field of behavioral treatments.
For example, research shows that habit-reversal approaches—such as awareness training,
self-monitoring, relaxation training, competing (healthier) response training, and contingency
management—can significantly help those with anxiety, obsession, and compulsion/
impulse-control-related problems such as OCD and trichotillomania, like those of this
patient. (Diefenbach, Reitman, & Williamson, 2000; Luselli, 1996; Wilhelm, Deckersbach,
Coffey, Bohne, & Baer, 2003). More specifically, some authors have argued that there is a
possible etiological link between OCD and pica, and that treatment for pica involving a
10 Clinical Case Studies

behavioral approach would be superior, given its general success with OCD (Zeitlin &
Polivy, 1995). In summary, if possible, behavioral approaches should be applied.

10 Recommendations to Clinicians and Students

This case report has obvious limitations, mostly owing to it being a phenomenological
discussion of a case. This case being from a developing country like Ethiopia is of interest
as it illustrates the universality of the basic phenomenology of both pica and OCD.
Furthermore, treating OCD in a resource-limited, developing-world setting does present
challenges, but it renders an accurate diagnosis ever more important. Considering OCD or
OCSD as part of the conceptualization of pica may be potentially useful.

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Yonas Baheretibeb, MD, was the first-ever chief resident of the Residency in Psychiatry training program and is
currently staff psychiatrist at the Department of Psychiatry, Addis Ababa University, Ethiopia. He has distinguished
himself in clinical and research work in anxiety and mood disorders and social and community psychiatry.

Samuel Law, MD, is an assistant professor in the Cultural, Community, and Health Studies Program in the
Department of Psychiatry, University of Toronto, Canada. He focuses his work on transcultural psychiatry and
community-based mental health services with an international perspective.

Clare Pain, MD, is an associate professor in the Department of Psychiatry, University of Toronto, Canada. She
is an internationally recognized expert in anxiety disorders, particularly posttraumatic stress disorder, and a pio-
neer in international educational collaboration projects such as the Residency in Psychiatry training program in
Addis Ababa, Ethiopia.