Treatment of Pica
Behavioral interventions using applied behavior analysis (ABA) represent the most empirically supported treatment for pica, with demonstrated efficacy in reducing pica behavior by at least 90% in the majority of cases. 1, 2
Primary Treatment Approach: Behavioral Interventions
Applied behavior analysis should be the first-line treatment for pica, as it has the most robust empirical support among all available interventions. 2 The behavioral approach involves:
- Functional assessment to identify the motivating operations that trigger pica behavior 1
- Disruption techniques to interrupt the occurrence of pica 1
- Reinforcement of adaptive alternatives to replace the pica behavior with appropriate behaviors 1
- Positive behavioral procedures are now preferred over aversive techniques, with most clinicians moving away from punishment-based approaches 2
Recent evidence demonstrates that behavioral treatment reduced pica by at least 90% in 30 of 33 consecutively treated patients, with maintained improvements when extended to novel settings and implementers in 26 of 29 cases. 1
Environmental and Institutional Management
Comprehensive environmental controls are essential, particularly for patients with developmental disabilities or psychiatric conditions:
- Restrict access to non-food items through environmental modifications 3
- Implement supervised eating routines with scrupulous maintenance of meal schedules to reduce anxiety and seeking behaviors 3
- Educate caregivers and family members that providing access to pica substances undermines treatment and the patient's well-being 3
- Supportive institutional care with restoration of self-confidence may serve as an indicator of care quality 4
Medical Evaluation and Monitoring
Screen for iron deficiency anemia, though correction alone typically does not resolve pica behavior. 4 Only 2 of 23 patients in one study had iron deficiency, and iron replacement did not improve pica symptoms. 4
Obtain abdominal X-rays for any gastrointestinal symptoms in patients with known or suspected pica, as anamnesis is often difficult and complications are common. 4
Pharmacological Considerations
Consider selective serotonin reuptake inhibitors (SSRIs) if pica appears related to obsessive-compulsive features, as the compulsive nature of the behavior (anxiety when prevented, relief after ingestion) suggests potential benefit from OCD-specific therapy. 4
Neuroleptic therapy may provide transient improvement, particularly in patients with delirious features, though results are often limited. 4
Cognitive and Psychotherapeutic Approaches
Cognitive-behavioral therapy may be beneficial when pica is conceptualized as an acquired behavior that could respond to behavioral modification techniques. 4
Address underlying psychopathology, as pica is frequently associated with severe mental impairment (48%), dysharmonic development (26%), autistic disorders, and schizophrenia. 4
Critical Safety Considerations
Monitor for life-threatening complications, which occur frequently despite treatment:
- Gastrointestinal obstructions from gastroliths or impaction are the most common surgical complications 4, 5
- Respiratory complications rank second in frequency 4
- Infectious complications particularly with geophagia (soil eating) and coprophagia, leading to intestinal parasitosis 4
- Toxic exposures including lead poisoning (paint), mercury poisoning (paper), phosphorus poisoning (matches), and naphthalene poisoning (air fresheners) 5
Maintain high clinical suspicion for complications, as the mortality rate can be significant and complications may be severe even with appropriate treatment. 4
Special Populations
For patients with Prader-Willi syndrome, pica (eating spoiled food, animal chow, decorative food-like items, garbage) occurs as part of hyperphagia and requires the same environmental controls used for general food-seeking behaviors. 3
Referral to psychiatry or specialist psychology is indicated when pica occurs in the context of severe psychiatric illness or eating disorders. 3