An Unusual Case of Pica* CAROL SOLYOM, Ph.D. I , LESLIE SOLYOM, M.D. 2 AND RICHARD FREEMAN, Ph.D. 3
This paper presents the case ofa 29 year old woman who compulsively ate rocks and pebbles, a habit developed in childhood. Extensive psychometric testing did not demonstrate phobias, obsessions, tendency to increased anxiety, depression or anorexic or bulimic disorder. The development of pica is partially explained by a childhood eating disorder, obsessive personality traits,culturalfactors and specific (personality induced) stresses. Stress-reducing measures were successful in eliminating the eating disorder.
considered compulsive and inappropriate. Children with pica have been found to experience significantly greater psychosocial stress than normal children (5). Stress factors significantly associated with pica include maternal deprivation, parental neglect, child beating, insufficient parent/child interaction, and disorganization of family setup. Traumatic weaning and undesirable feeding practices have been found to be significantly more frequent in children with pica (6). In this paper, an interesting case of pebble and rock eating pica is presented, for the following reasons: only two reports of adult pebble eating have been reported to date (7,8); pica has been associated with bulimia, sufferers of which may be food faddists (for example, popcorn, carrots) but do not attempt to eat inedible substances; the positive treatment outcome casts some light on variables affecting both pica and bulimia; and in this case, the habit had apparently continued from childhood.
P
ica is the Latin word for magpie, a bird known for its fickle appetite and its habit of eating almost anything. The term also refers to the ingestion of inedible substances. These include starch (amylophagia), ice (pagophagia), hair (trichophagia), and clay (geophagia). Etiological theories include psychological, cultural, nutritional, and pharmacological ones. Psychologically, pica is seen as a manifestation of oral fixation because of its association with thumbsucking (I), as a form of aggression (since it has been associated in children with temper tantrums), and as a compulsion (l). The last hypothesis has been formulated without attempting to verify the presence of criteria (for example, a subjective feeling of compulsiveness, recognition as being ego-alien and resisted) or other obsessive symptoms. The cultural theory (3) notes that certain religious rites and/or class habits favour the development of pica, such as those in Africa and among Blacks in the southern United States. Pica has been associated with nutritional deficiencies of iron, calcium, and zinc, but it is unclear whether the deficiencies cause the pica or are caused by it. Teabag, coffee grounds and cigarette-end picas in institutionalized mentally handicapped individuals have been explained by addictions to pharmacologically active substances (2). In many cases, etiological factors interact (2,4), and no single theory seems able to explain all types of pica (2). Women experience strong desires for various foods during pregnancy. When these desires lead to pica, the behaviour is
Case History The patient was a 29 year old blaster apprentice who suffered from an irresistible urge to eat pebbles and rocks. During an episode of pica, which would last two to three weeks, she would eat two cups of sand and pebbles or small rocks once or twice daily. In a single "bingeing" session, she would usually keep eating until she felt full, her stomach hurt, or she became nauseated. A pica-free period of two to three weeks would ensue, followed by another bout of pica. She described her pebble eating as being preceded by anxiety and a feeling of "being forced to do it." Sometimes she was able to resist for days, but would ultimately succumb to the urge. When she did resist, she felt tense until she started to eat rocks or pebbles again, and then she would eat an uncommonly large amount. She recognized this habit as being bizarre and ego-alien. Nevertheless, when she anticipated that she would be unable to find pebbles (for example, during the winter months when there was a thick blanket of snow), she would keep a bottle full of rocks on hand. During a bout of pica, filling her stomach was the most important thing. She would tolerate the pain of swallowing the sand, pebbles and rocks in order to fill her stomach. She had tried unsuccessfully to eat enough food to relieve the feeling of emptiness in her stomach. Her eating habits were otherwise normal. Her appetite was good, and she ate two or three meals a day. Her diet was well balanced, although she tended to eat more health and organic foods or, at times, follow a vegetarian-like diet, which never-
* Manuscript received March 1989; revised September 1989.
'Adjunct Professor of Psychology, University of British Columbia; University Hospital, Vancouver, British Columbia. 2Honourary Staff, University Hospital, Vancouver, British Columbia. 3Associate Professor of Psychology, Simon Fraser University, Vancouver, British Columbia.
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theless included some animal protein. She reported that she did not suffer from nausea, vomiting or heartburn. When she was anxious or frustrated, her pica worsened. She owed a great deal of money - debts incurred when she trained as a helicopter pilot. AnxIety was also brought on by such job hazards as driving in zero visibility, driving huge trucks (with tires twice her height), working with explosives, piloting solo, working with heavy equipment, and negotiating violent rapids. She also applied for a position as an astronaut, not knowing whether she would be accepted, thereby adding to her anxiety. Her weight was 140 pounds, which is within the standard range of 136 to 150 pounds for her height (5'8") on the Metropolitan Height and Weight Tables (9). Her other problem was constipation. She reported having small amounts of dark brown "rock-like" stools every four to five days, but occasionally not for ten days. On rare occasions, she noted a small amount of bright red blood on the stool and on the toilet tissue. She had taken laxatives to help initiate bowel movements daily for the previous three months (mineral oil with every meal, a natural fibre laxative and glycerine suppositories). She also complained of occasional, unpredictable peri-umbilical pain, which she described as a dull ache lasting two to three hours. Her best strategy was to go to sleep, since when she awakened, she would usually be pain-free. Shealso found that swimming was the only activity that tended to relieve the pain. There seemed to be no relationship between the pains and meals or bowel movements. Otherwise, GI enquiry was essentially negative. She did not suffer from anemia. She had no fears or phobias. Although she had obsessive personality traits - she was systematic, ambitious, competitive, doubtful, and a perfectionist - there was no obsessive neurosis. She had never been clinically depressed. There were no signs or symptoms of significant background anxiety or panic attacks. When she was anxious, she experienced nausea and tachycardia. She was living with her boyfriend, age 33, who was also a blaster, in rather primitive quarters in the bush in northern British Columbia. They had a good emotional and sexual relationship. A background enquiry revealed that she was born of Jewish parents in northern Canada and was the second of three siblings. She described her brother as celibate and "very strange"; he meditated four to five hours daily and belonged to an extreme vegetarian sect. Both he and a maternal uncle suffered from diabetes insipidus. She described her 15 year old sister as still "very much under mother's heavy hand" and somewhat shy. Her mother was described as a tyrant who kept the whole family under her thumb. She did not have any obsessive or phobic symptoms. Father was very friendly and energetic; at age 58, he apparently ran several miles a day. She had been a thin child, and reported that as early as age two or three, her mother forced her to eat scrambled eggs. She felt nauseated and wanted to vomit, but her mother screamed at her and clamped her hand over the child's mouth until she
swallowed the food. There were tremendous fights between her and her mother over meals. To avoid fighting with mother, she would claim that she was no longer hungry. Then to make sure that she was not hungry, she would eat pet food, grass, flowers - almost anything, including rubber and sand. She recalled fighting, at age four, with the neighbourhood dogs for their bones. On seeing her approach, the dogs would pick up their bones and run away. After starting school at age five, she would exchange her lunch, if it contained eggs, with a classmate for food she liked. Her mother had always tried to bribe her (for example, offering her chocolates if she would eat dinner). She was unhappy during her childhood and made several attempts to run away, finally succeeding at age 17.Since then, she has been on her own and has always held a job - usually in a traditionally male field. Table I presents her scores on a number of psychometric tests: the Leyton Obsessional Inventory (LOI)(IO), Beck Depression Inventory (BD!) (11), State Trait Anxiety Inventory (STAI)(l2), Fear Survey Schedule (FSS)(13), and Eating Attitude Test (EAT)(l4). None of her scores on the above tests was abnormal. In
LOI
Table I Psychometric Test Results Test Patient 4 • Symptom • Triat
BOI
STAI • State • Trait FSS EAT
5 0 25 27 6 16
Norm 11
7 10* 49 47 58 30 t
*a score of 10 or less on the BDI indicates an absence of depression t
a score of 30 or less on the EAT indicates an absence of an eating disorder
fact, herresults indicated that she was less obsessive, anxious, phobic, and depressed than the norms for a non psychiatric population. On the EATshe scored below the cut-off point for bulimics. Nevertheless, she answered "often" (much like a bulimic) to the followingstatements: "I am terrified of being overweight."; "I have gone on eating binges where I felt that I may not be able to stop."; "I cut my food into small pieces."; "I feel that food controls my life." She answered "very often" to the statement "I feel uncomfortable after eating sweets." Once the assessment was completed, a management program was outlined for her as follows: I. She should eliminate, or at least reduce, the frequency of stressful events which might lead to rock and pebble eating - give up her apprenticeship as a blaster, reduce the number of helicopter flights; 2. She should resolve two major stressors - her $20,000 debt and her application to the astronaut program; 3. In response to strong urges to eat pebbles, or worrying over gaining weight, she should eat something bulky and low in calories, such as watermelon or cantaloupe. If these were unavailable or did not eliminate the urges, she should substitute purified
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white sand (used to decorate gardens), pebblelike candies, or similar items; 4. She should eat a high-fibre diet with bran supplements. The dangerousness of her eating habits was also pointed out to her. At six months follow-up she reported a remarkable improvement. She had stopped all activities she considered stressful: piloting helicopters, blasting, studying, and even working in the kitchen. She withdrew her candidacy for the astronaut program. Her father was willing to help her renegotiate her loan. She participated more in physical activities such as skating and cross-country skiing. Nevertheless, during the first three weeks at home, she felt strong urges, "as if [she] had withdrawn from an addictive drug." She attributed her ability to continue to resist, and her ultimate improvement to the recognition that her behaviour was harmful and the understanding that she had developed this habit in childhood. At one year follow-up she reported continued success, with no recurrence of rock or pebble eating. At 18 months follow-up she reported running nine miles every second day, working 14 to 16 hours on alternate days, hiking five to six hours daily, and bingeing, but not vomiting, twice weekly. She stated, "I eat far too much to be comfortable and, in fact, the consequent inertia and bloatedness keeps me low afterwards [Le.prone and enervated]. So do guilt and self reproach.... [My habit] is not at all consistent with my otherwise healthy, positive and disciplined lifestyle."
Discussion Are we justified in calling this pebble eating a form of neurosis, in particular, a compulsive neurosis? If neurosis is defined as chronic maladaptive habits without a break with reality, our case certainly fits the definition. Is there a monosymptomatic form of obsessive-compulsive disorder? Trichotillomania cases may suffer only from compulsive hair pulling; among our approximately 350 patients with obsessive-compulsive disorder, two have suffered from only one type of chronic compulsion (for example, determining details about music played on the radio: the title, writer, singer, etc.). Perhaps a more important factor is that many bulimics have an obsessive personality and/or suffer from obsessive-compulsive disorder (15). Several contributing factors may be considered in our case: a domineering mother who brought up her children much like Portnoy's mother (16) (who kept a knife at his abdomen stating, "eat it or I'll kill you"); the development of an eating habit to avoid conflict with her mother and thus reduce the anxiety she felt upon being force-fed food she disliked; persistence of the habit into adolescence because it resolved an approach/avoidance conflict, to fill her stomach without gaining weight, in a culture that values slimness. Eating also gave rise to anxiety about weight (she had gone on binges during which she was afraid that she could not stop eating). In comparing this case of pica with more typical patients with problems of binge eating, it is obvious that in both, anxiety, dysphoric mood (17) and resistance may precede the
overeating of food and pebbles. There is also yielding to fear of being overweight, excessive exercising and obsessive personality traits. The pica patient, however, does not avoid eating regular meals or eating in public, unlike bulimics. Another important contribution of this case to the understanding of bulimia is the consumption of rocks and pebbles to achieve satisfaction. As long as pebbles made our patient feel satisfied by filling up her stomach, she would binge only occasionally. When she could not eat pebbles - a food substitute - she would eat excessive amounts of food. Since Pavlov's sham feeding experiments (18), it is assumed that among other factors gastric distention is a normal anxiety signal. Smith and Gibbs (19) considered gastric distention a necessary, but not the only, signal of satiety. This explanation is supported by the subsequent development of bulimia. A similar mechanism is implicated in at least some forms of pica, for example in malnourished children. In summary, a childhood habit formed under the exigencies of a domineering mother and further influenced by our culture's emphasis on slimness serves in adulthood the compulsive needs of a woman who is ambitious and a perfectionist.
References 1. Sayetta RB. Pica: an overview. Am Fam Physician 1986; 33: 181-185. 2. McLoughlin IJ. The picas. Br J Hosp Med 1987; 37: 286-290. 3. Danford DE. Pica and nutrition. Ann Rev Nutr 1982; 2: 303322. 4. Feldman MD. Pica: current perspectives. Psychosomatics 1986; 27: 519-523. 5. Singhi S, Singhi P, Adwant GB. The role of psychosocial stress in the cause of pica. Clin Paediatr 1981; 20: 783-785. 6. Pueschel SM, Cullen SM, Howard RB, et al. Pathogenic considerations of pica in lead poisoning. Int J Psych Med 1977; 8: 13-24. 7. Hawass NO, Alnozha MM, Kolawole T. Adult geophagia report of three cases with review of the literature. Trop Geogr Med 1987; 39: 191-195. 8. Robertson WD, Crabtree JB. Pebble ingestion: an unusual form of geophagia. South Med J 1977; 70: 776-792. 9. Whitney EN, Cataldo CB. Understanding normal and clinical nutrition. St. Paul MN: West Publishing, 1983. 10. Cooper J. The Leyton Obsessional Inventory. Psychol Med 1970; 1: 48-64. 11. Beck AJ, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571. 12. Spielberger CD, Gorsuch RL, Lushene RE. STAI manual. Palo Alto CA: Consulting Psychologists Press, 1970. 13. Wolpe J, Lang PJ. A fear survey schedule for use in behavior therapy. Behav Res Ther 1964; 2: 27. 14. Garner 0, Garfinkel P. The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychol Med 1979; 9: 273-279. 15. Solyom L, Thomas CD, Freeman RJ, et al. Anorexia nervosa: obsessive-compulsive disorder or phobia? A comparative study. In: Darby PL, Garfinkel PE, Garner OM, et al, eds. Anorexia nervosa: recent developments in research. New York: Alan R. Liss, Inc., 1983; 137-147. 16. Roth P. Portnoy's complaint. New York: Random House, 1969.
UNUSUAL CASE OF PICA
February, 1991
17. Davis R, Freeman R, Solyom L. Mood and food: an analysis of bulimic episodes. J Psych Res 1985; 919: 331-335. 18. Pavlov IP. The work of the digestive glands, second edition (translation by WH Thompson). London: Charles Griffin, 1910. 19. Smith GP, Gibbs J. Postprandial satiety. Progress in Psychobiology Physiological Psychology 1979; 8: 179-242.
Resume Le present article rapporte le cas d' une femme de 29 ans qui mangeait des pierres et des cailloux de facon compulsive
53
depuis l' enfance. Des evaluations psychometriques detaillees n' ont revete aucune phobie ou obsession, ni aucune tendance a l' anxiete, la depression, l' anorexie ou la boulimie. 'on attribue partiellement le developpement du pica, ou perversion du gout, a un trouble de l' alimentation survenu durant l' enfance, a certains traits caracteristiques d' une personnalite obsessive, a des parametres culturels et a des tensions specifiques (dues ala personnalite). Des mesures en vue de reduire le stress ont elimine le trouble de l' alimentation.
This paper presents the case ofa 29 year old woman who compulsively ate rocks and pebbles, a habit developed in childhood. Extensive psychometric testing did not demonstrate phobias, obsessions, tendency to increased anxiety, depression or anorexic or bulimic disorder. The development of pica is partially explained by a childhood eating disorder, obsessive personality traits,culturalfactors and specific (personality induced) stresses. Stress-reducing measures were successful in eliminating the eating disorder.
considered compulsive and inappropriate. Children with pica have been found to experience significantly greater psychosocial stress than normal children (5). Stress factors significantly associated with pica include maternal deprivation, parental neglect, child beating, insufficient parent/child interaction, and disorganization of family setup. Traumatic weaning and undesirable feeding practices have been found to be significantly more frequent in children with pica (6). In this paper, an interesting case of pebble and rock eating pica is presented, for the following reasons: only two reports of adult pebble eating have been reported to date (7,8); pica has been associated with bulimia, sufferers of which may be food faddists (for example, popcorn, carrots) but do not attempt to eat inedible substances; the positive treatment outcome casts some light on variables affecting both pica and bulimia; and in this case, the habit had apparently continued from childhood.
P
ica is the Latin word for magpie, a bird known for its fickle appetite and its habit of eating almost anything. The term also refers to the ingestion of inedible substances. These include starch (amylophagia), ice (pagophagia), hair (trichophagia), and clay (geophagia). Etiological theories include psychological, cultural, nutritional, and pharmacological ones. Psychologically, pica is seen as a manifestation of oral fixation because of its association with thumbsucking (I), as a form of aggression (since it has been associated in children with temper tantrums), and as a compulsion (l). The last hypothesis has been formulated without attempting to verify the presence of criteria (for example, a subjective feeling of compulsiveness, recognition as being ego-alien and resisted) or other obsessive symptoms. The cultural theory (3) notes that certain religious rites and/or class habits favour the development of pica, such as those in Africa and among Blacks in the southern United States. Pica has been associated with nutritional deficiencies of iron, calcium, and zinc, but it is unclear whether the deficiencies cause the pica or are caused by it. Teabag, coffee grounds and cigarette-end picas in institutionalized mentally handicapped individuals have been explained by addictions to pharmacologically active substances (2). In many cases, etiological factors interact (2,4), and no single theory seems able to explain all types of pica (2). Women experience strong desires for various foods during pregnancy. When these desires lead to pica, the behaviour is
Case History The patient was a 29 year old blaster apprentice who suffered from an irresistible urge to eat pebbles and rocks. During an episode of pica, which would last two to three weeks, she would eat two cups of sand and pebbles or small rocks once or twice daily. In a single "bingeing" session, she would usually keep eating until she felt full, her stomach hurt, or she became nauseated. A pica-free period of two to three weeks would ensue, followed by another bout of pica. She described her pebble eating as being preceded by anxiety and a feeling of "being forced to do it." Sometimes she was able to resist for days, but would ultimately succumb to the urge. When she did resist, she felt tense until she started to eat rocks or pebbles again, and then she would eat an uncommonly large amount. She recognized this habit as being bizarre and ego-alien. Nevertheless, when she anticipated that she would be unable to find pebbles (for example, during the winter months when there was a thick blanket of snow), she would keep a bottle full of rocks on hand. During a bout of pica, filling her stomach was the most important thing. She would tolerate the pain of swallowing the sand, pebbles and rocks in order to fill her stomach. She had tried unsuccessfully to eat enough food to relieve the feeling of emptiness in her stomach. Her eating habits were otherwise normal. Her appetite was good, and she ate two or three meals a day. Her diet was well balanced, although she tended to eat more health and organic foods or, at times, follow a vegetarian-like diet, which never-
* Manuscript received March 1989; revised September 1989.
'Adjunct Professor of Psychology, University of British Columbia; University Hospital, Vancouver, British Columbia. 2Honourary Staff, University Hospital, Vancouver, British Columbia. 3Associate Professor of Psychology, Simon Fraser University, Vancouver, British Columbia.
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UNUSUAL CASE OF PICA
theless included some animal protein. She reported that she did not suffer from nausea, vomiting or heartburn. When she was anxious or frustrated, her pica worsened. She owed a great deal of money - debts incurred when she trained as a helicopter pilot. AnxIety was also brought on by such job hazards as driving in zero visibility, driving huge trucks (with tires twice her height), working with explosives, piloting solo, working with heavy equipment, and negotiating violent rapids. She also applied for a position as an astronaut, not knowing whether she would be accepted, thereby adding to her anxiety. Her weight was 140 pounds, which is within the standard range of 136 to 150 pounds for her height (5'8") on the Metropolitan Height and Weight Tables (9). Her other problem was constipation. She reported having small amounts of dark brown "rock-like" stools every four to five days, but occasionally not for ten days. On rare occasions, she noted a small amount of bright red blood on the stool and on the toilet tissue. She had taken laxatives to help initiate bowel movements daily for the previous three months (mineral oil with every meal, a natural fibre laxative and glycerine suppositories). She also complained of occasional, unpredictable peri-umbilical pain, which she described as a dull ache lasting two to three hours. Her best strategy was to go to sleep, since when she awakened, she would usually be pain-free. Shealso found that swimming was the only activity that tended to relieve the pain. There seemed to be no relationship between the pains and meals or bowel movements. Otherwise, GI enquiry was essentially negative. She did not suffer from anemia. She had no fears or phobias. Although she had obsessive personality traits - she was systematic, ambitious, competitive, doubtful, and a perfectionist - there was no obsessive neurosis. She had never been clinically depressed. There were no signs or symptoms of significant background anxiety or panic attacks. When she was anxious, she experienced nausea and tachycardia. She was living with her boyfriend, age 33, who was also a blaster, in rather primitive quarters in the bush in northern British Columbia. They had a good emotional and sexual relationship. A background enquiry revealed that she was born of Jewish parents in northern Canada and was the second of three siblings. She described her brother as celibate and "very strange"; he meditated four to five hours daily and belonged to an extreme vegetarian sect. Both he and a maternal uncle suffered from diabetes insipidus. She described her 15 year old sister as still "very much under mother's heavy hand" and somewhat shy. Her mother was described as a tyrant who kept the whole family under her thumb. She did not have any obsessive or phobic symptoms. Father was very friendly and energetic; at age 58, he apparently ran several miles a day. She had been a thin child, and reported that as early as age two or three, her mother forced her to eat scrambled eggs. She felt nauseated and wanted to vomit, but her mother screamed at her and clamped her hand over the child's mouth until she
swallowed the food. There were tremendous fights between her and her mother over meals. To avoid fighting with mother, she would claim that she was no longer hungry. Then to make sure that she was not hungry, she would eat pet food, grass, flowers - almost anything, including rubber and sand. She recalled fighting, at age four, with the neighbourhood dogs for their bones. On seeing her approach, the dogs would pick up their bones and run away. After starting school at age five, she would exchange her lunch, if it contained eggs, with a classmate for food she liked. Her mother had always tried to bribe her (for example, offering her chocolates if she would eat dinner). She was unhappy during her childhood and made several attempts to run away, finally succeeding at age 17.Since then, she has been on her own and has always held a job - usually in a traditionally male field. Table I presents her scores on a number of psychometric tests: the Leyton Obsessional Inventory (LOI)(IO), Beck Depression Inventory (BD!) (11), State Trait Anxiety Inventory (STAI)(l2), Fear Survey Schedule (FSS)(13), and Eating Attitude Test (EAT)(l4). None of her scores on the above tests was abnormal. In
LOI
Table I Psychometric Test Results Test Patient 4 • Symptom • Triat
BOI
STAI • State • Trait FSS EAT
5 0 25 27 6 16
Norm 11
7 10* 49 47 58 30 t
*a score of 10 or less on the BDI indicates an absence of depression t
a score of 30 or less on the EAT indicates an absence of an eating disorder
fact, herresults indicated that she was less obsessive, anxious, phobic, and depressed than the norms for a non psychiatric population. On the EATshe scored below the cut-off point for bulimics. Nevertheless, she answered "often" (much like a bulimic) to the followingstatements: "I am terrified of being overweight."; "I have gone on eating binges where I felt that I may not be able to stop."; "I cut my food into small pieces."; "I feel that food controls my life." She answered "very often" to the statement "I feel uncomfortable after eating sweets." Once the assessment was completed, a management program was outlined for her as follows: I. She should eliminate, or at least reduce, the frequency of stressful events which might lead to rock and pebble eating - give up her apprenticeship as a blaster, reduce the number of helicopter flights; 2. She should resolve two major stressors - her $20,000 debt and her application to the astronaut program; 3. In response to strong urges to eat pebbles, or worrying over gaining weight, she should eat something bulky and low in calories, such as watermelon or cantaloupe. If these were unavailable or did not eliminate the urges, she should substitute purified
52
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CANADIAN JOURNAL OF PSYCHIATRY
white sand (used to decorate gardens), pebblelike candies, or similar items; 4. She should eat a high-fibre diet with bran supplements. The dangerousness of her eating habits was also pointed out to her. At six months follow-up she reported a remarkable improvement. She had stopped all activities she considered stressful: piloting helicopters, blasting, studying, and even working in the kitchen. She withdrew her candidacy for the astronaut program. Her father was willing to help her renegotiate her loan. She participated more in physical activities such as skating and cross-country skiing. Nevertheless, during the first three weeks at home, she felt strong urges, "as if [she] had withdrawn from an addictive drug." She attributed her ability to continue to resist, and her ultimate improvement to the recognition that her behaviour was harmful and the understanding that she had developed this habit in childhood. At one year follow-up she reported continued success, with no recurrence of rock or pebble eating. At 18 months follow-up she reported running nine miles every second day, working 14 to 16 hours on alternate days, hiking five to six hours daily, and bingeing, but not vomiting, twice weekly. She stated, "I eat far too much to be comfortable and, in fact, the consequent inertia and bloatedness keeps me low afterwards [Le.prone and enervated]. So do guilt and self reproach.... [My habit] is not at all consistent with my otherwise healthy, positive and disciplined lifestyle."
Discussion Are we justified in calling this pebble eating a form of neurosis, in particular, a compulsive neurosis? If neurosis is defined as chronic maladaptive habits without a break with reality, our case certainly fits the definition. Is there a monosymptomatic form of obsessive-compulsive disorder? Trichotillomania cases may suffer only from compulsive hair pulling; among our approximately 350 patients with obsessive-compulsive disorder, two have suffered from only one type of chronic compulsion (for example, determining details about music played on the radio: the title, writer, singer, etc.). Perhaps a more important factor is that many bulimics have an obsessive personality and/or suffer from obsessive-compulsive disorder (15). Several contributing factors may be considered in our case: a domineering mother who brought up her children much like Portnoy's mother (16) (who kept a knife at his abdomen stating, "eat it or I'll kill you"); the development of an eating habit to avoid conflict with her mother and thus reduce the anxiety she felt upon being force-fed food she disliked; persistence of the habit into adolescence because it resolved an approach/avoidance conflict, to fill her stomach without gaining weight, in a culture that values slimness. Eating also gave rise to anxiety about weight (she had gone on binges during which she was afraid that she could not stop eating). In comparing this case of pica with more typical patients with problems of binge eating, it is obvious that in both, anxiety, dysphoric mood (17) and resistance may precede the
overeating of food and pebbles. There is also yielding to fear of being overweight, excessive exercising and obsessive personality traits. The pica patient, however, does not avoid eating regular meals or eating in public, unlike bulimics. Another important contribution of this case to the understanding of bulimia is the consumption of rocks and pebbles to achieve satisfaction. As long as pebbles made our patient feel satisfied by filling up her stomach, she would binge only occasionally. When she could not eat pebbles - a food substitute - she would eat excessive amounts of food. Since Pavlov's sham feeding experiments (18), it is assumed that among other factors gastric distention is a normal anxiety signal. Smith and Gibbs (19) considered gastric distention a necessary, but not the only, signal of satiety. This explanation is supported by the subsequent development of bulimia. A similar mechanism is implicated in at least some forms of pica, for example in malnourished children. In summary, a childhood habit formed under the exigencies of a domineering mother and further influenced by our culture's emphasis on slimness serves in adulthood the compulsive needs of a woman who is ambitious and a perfectionist.
References 1. Sayetta RB. Pica: an overview. Am Fam Physician 1986; 33: 181-185. 2. McLoughlin IJ. The picas. Br J Hosp Med 1987; 37: 286-290. 3. Danford DE. Pica and nutrition. Ann Rev Nutr 1982; 2: 303322. 4. Feldman MD. Pica: current perspectives. Psychosomatics 1986; 27: 519-523. 5. Singhi S, Singhi P, Adwant GB. The role of psychosocial stress in the cause of pica. Clin Paediatr 1981; 20: 783-785. 6. Pueschel SM, Cullen SM, Howard RB, et al. Pathogenic considerations of pica in lead poisoning. Int J Psych Med 1977; 8: 13-24. 7. Hawass NO, Alnozha MM, Kolawole T. Adult geophagia report of three cases with review of the literature. Trop Geogr Med 1987; 39: 191-195. 8. Robertson WD, Crabtree JB. Pebble ingestion: an unusual form of geophagia. South Med J 1977; 70: 776-792. 9. Whitney EN, Cataldo CB. Understanding normal and clinical nutrition. St. Paul MN: West Publishing, 1983. 10. Cooper J. The Leyton Obsessional Inventory. Psychol Med 1970; 1: 48-64. 11. Beck AJ, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571. 12. Spielberger CD, Gorsuch RL, Lushene RE. STAI manual. Palo Alto CA: Consulting Psychologists Press, 1970. 13. Wolpe J, Lang PJ. A fear survey schedule for use in behavior therapy. Behav Res Ther 1964; 2: 27. 14. Garner 0, Garfinkel P. The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychol Med 1979; 9: 273-279. 15. Solyom L, Thomas CD, Freeman RJ, et al. Anorexia nervosa: obsessive-compulsive disorder or phobia? A comparative study. In: Darby PL, Garfinkel PE, Garner OM, et al, eds. Anorexia nervosa: recent developments in research. New York: Alan R. Liss, Inc., 1983; 137-147. 16. Roth P. Portnoy's complaint. New York: Random House, 1969.
UNUSUAL CASE OF PICA
February, 1991
17. Davis R, Freeman R, Solyom L. Mood and food: an analysis of bulimic episodes. J Psych Res 1985; 919: 331-335. 18. Pavlov IP. The work of the digestive glands, second edition (translation by WH Thompson). London: Charles Griffin, 1910. 19. Smith GP, Gibbs J. Postprandial satiety. Progress in Psychobiology Physiological Psychology 1979; 8: 179-242.
Resume Le present article rapporte le cas d' une femme de 29 ans qui mangeait des pierres et des cailloux de facon compulsive
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depuis l' enfance. Des evaluations psychometriques detaillees n' ont revete aucune phobie ou obsession, ni aucune tendance a l' anxiete, la depression, l' anorexie ou la boulimie. 'on attribue partiellement le developpement du pica, ou perversion du gout, a un trouble de l' alimentation survenu durant l' enfance, a certains traits caracteristiques d' une personnalite obsessive, a des parametres culturels et a des tensions specifiques (dues ala personnalite). Des mesures en vue de reduire le stress ont elimine le trouble de l' alimentation.
