Abstract
Pica, the developmentally and culturally-inappropriate eating of non-nutritive and non-food substances, is most often documented in people with developmental disabilities and children, frequently in institutional and residential settings. To date, there are no randomized clinical trials on pica-specific treatments, and very little literature is available regarding the characteristics or treatment of pica in adults with no intellectual or social deficits, and co-morbid disorders. This case study addresses this gap, and involves a highly educated 30 year-old American woman with foam rubber pica and burned match consumption (cautopyreiophagia) behaviors, along with co-morbid depressive, anxiety, and obsessive-compulsive symptoms, who received treatment in a general intensive outpatient program for adults in a large urban community psychiatry setting. The case study describes how the Biosocial Theory and Transtheoretical Model of Health Behavior Change were used to conceptualize this woman’s symptoms and guide a treatment team of clinicians who did not specialize in pica. Providers in non-specialty clinic settings would benefit from reflecting on ways to adapt evidence-based techniques to the treatment of uncommon symptoms.
1 Theoretical and Research Basis
Pica is classified as the developmentally and culturally-inappropriate eating of one or more non-nutritive, non-food substances, on a persistent basis over a period of at least 1 month (DSM V, American Psychiatric Association, 2013). Pica has previously been documented predominantly in children (Leung & Hon, 2019), adults with autism (Matson et al., 2013), intellectual disability (Ashworth et al., 2008; Williams & McAdam, 2012), obsessive-compulsive disorder (Baheretibe et al., 2008; Bhatia & Gupta, 2009; Gundogar et al., 2003), schizophrenia (Sinha & Mallick, 2010), pregnancy (Fawcett et al., 2016), other feeding disorders (Delaney et al., 2015), or non-psychiatric conditions (Hackworth & Williams, 2003; Miao et al., 2014). Shifting diagnostic criteria, misdiagnosis in the presence of other disorders, and difficulty in case identification related to the often-secretive nature of pica have made it difficult to establish a consensus on prevalence or etiology.
Even though pica can lead to serious complications, including bowel obstruction, hemorrhage, parasitic infections, poisoning, and dental problems (Johnson et al., 2005; Rose et al., 2000), relatively few psychiatric treatment guidelines exist for pica and there have been no randomized clinical treatment trials (Treasure et al., 2020). Existing literature on pica has primarily described people with intellectual disabilities in institutional and residential settings, and suggested treatment strategies have been strongly rooted in simple operant conditioning (Williams & McAdam, 2012). These strategies, however, may not be sufficient for adults with no social or intellectual deficits who seek mental healthcare in less restrictive treatment settings.
The present case study describes the unique presentation of a highly educated non-pregnant woman who ate burned matches (cautopyreiophagia
2 Case Introduction
Vera (alias) is a 30-year-old highly educated (she earned a master’s degree and completed some doctoral training), single black woman living in the United States who self-referred to an IOP within a large urban community mental health clinic. Her chief complaints included experiencing an exacerbation of depressive symptoms, avoidance of sitting on toilets, symptoms of general anxiety, and eating foam rubber. In the months leading up to admission, she had lost a fellowship when her co-workers learned that she urinated in cups, kept them in her room, and poured them into a sink/toilet every few days. Vera reported consuming two meals daily and denied significant medical issues due to non-nutritive object consumption (although she had a history of kidney stones). She denied binge and purge behaviors with nutritive foods. Her BMI was 39.1, she reported no history of extreme methods of weight loss, and she verbalized a desire to eat more healthfully.
3 Presenting Complaints
Vera presented to the IOP complaining of depressive symptoms, anxiety, avoidance behaviors, and eating of non-nutritive substances. Upon admission, she endorsed hypersomnia (regularly sleeping at least 10 hr per day, and sometimes sleeping the whole day), depressed mood (“Lately I have been feeling down, I feel like I lost community, my job, spirituality”), low motivation, “lethargic” energy level, critical self-talk (“I think to myself, I hate myself”), social isolation, anhedonia, and eating two regular meals per day. She denied suicidal and homicidal ideation, hallucinations, or manic symptoms. In the weeks leading up to admission, she reported “rising anxiety,” often relating to “bathroom germs,” and “an impending sense of failure and an antsy anxious feeling.” She reported that she had been avoiding sitting on toilet seats and instead would urinate in cups, eventually pouring the cups into sinks and toilets periodically.
Vera reported consuming approximately 15 two-to-three-inch hair curlers or the equivalent amount of rubber pillow foam daily. She described regularly going to convenience stores to buy hair curlers. She reported “liking the flavor” of foam rubber and feeling “soothed” and a sense of “satisfaction” afterwards. She often, but not exclusively, ate foam rubber after she had eaten a nutritive meal. During a brief period of abstinence from foam rubber, she reported experiencing cravings, including salivation and “struggling to fill the time.” She typically did not feel ill after eating foam rubber. She reported having a desire to stop foam rubber consumption because “you are not sure what you are putting in your system.”
Vera also reported eating burned match heads, sometimes as many as 200 daily, as recently as 1 month prior to the IOP admission. She would first light the matches, blow them out, and then eat the burned heads. She reported that they “tasted good” to her and would give her a similar feeling of satisfaction to that from consuming foam rubber. Vera would often eat burned match heads in her car. She reported that she began to eat these after she clogged the plumbing in her home due to defecating foam rubber. Despite consuming the match heads, Vera reported that she was “horrified by what was in them.”
4 History
Vera indicated that she had been dealing with mental health and behavioral issues since she was a child. She reported engaging in pica behaviors since she was about 4 years old, including eating foam from couches and erasers, and that her parents sent her to therapy for “destructive behaviors,” including furniture destruction. She ate foam daily during middle school, and her consumption increased to several times daily on a consistent basis as an adult. At the height of her consumption behaviors, she carried a supply of foam rubber in her car. Her longest period of abstinence from foam rubber consumption was 3 months. She reported that she abstained for 3 weeks after losing her fellowship, but resumed after returning to live with her mother. During these brief periods of abstinence, she experienced significant cravings for foam rubber. Vera reported eating burned match heads “every once in a while” throughout her history, but her consumption increased in the years and months leading up to her IOP admission (although she had abstained for the month prior to admission).
Vera reported that she had been experiencing anxiety and depression for at least the last 4 years prior to IOP admission. She reported that her worst period of depression had been four summers prior to admission, and was characterized by depressed mood, hypersomnia, and suicidal ideation. Around this time, during the last year of living in a seminary, she started to experience an “OCD fear of bathroom germs” and began urinating in containers on an intermittent basis. Shortly after this, she enrolled in a doctoral program in biblical studies for 1 year. After suffering a week of “panic attacks” and a “breakdown” involving “stress and isolation,” she dropped out of the program, moved out of state, and enrolled in and completed a master’s degree of ministry/Christian counseling. Around this time, Vera attended another IOP while she was still having “mini bursts” of panic.
After completing her master’s degree, Vera again moved out of state to take a job/fellowship related to ministry, which lasted for about 6 months. She left this position after pastors learned she was urinating in cups. She described the loss of this position as “traumatic,” and she subsequently went to live with her mother, which was her place of residence at the time of admission to the IOP.
5 Assessment
As assessed by licensed clinical social workers and a psychiatrist, Vera met DSM-V criteria for recurrent major depressive disorder without psychotic features, obsessive compulsive disorder, and pica. The Depression Anxiety Stress Scale (DASS-21) (Lovibond & Lovibond, 1995) was also used to determine symptom severity. Given that there was no standardized assessment measure specific to pica at the time of Vera’s treatment, her symptoms were determined through her verbal self-report. She was generally well-groomed, had appropriate eye contact, grossly normal muscle tone/strength, normal gait, normal prosody of speech, intact memory, and a generally linear and goal-oriented thought process. She was oriented to person, place and time, and general circumstances, and demonstrated no evidence of perceptual disturbances or delusional thought content. She denied any history of mania, substance use disorder, suicide attempts, or intentional non-suicidal self-injurious behaviors, such as cutting or burning. Depending on Vera’s mood (which could be labile, ranging from dysphoric to euthymic), her affect varied from full range to constricted.
Generally, Vera’s premorbid personality appeared to be outgoing, playful and, often, perfectionistic. Developmentally, she was born via C-section and without birth complications. Vera’s parents divorced when she was 8 years old, and she continued to have a particularly close relationship with her mother at the time of her IOP treatment. She reported enjoying school and being very academically-oriented. She identified as heterosexual, and denied any history of significant partnerships or children. She had no history of inpatient psychiatric hospitalizations or substance abuse treatment. She had no military history and denied any significant legal history. Vera’s extended family history was positive for substance use disorders and sexual trauma. To our knowledge, her pica and urination behaviors were not part of a sanctioned practice within her familial or cultural community and these behaviors were ego-dystonic.
6 Case Conceptualization
There are many etiological conceptualizations of pica behaviors, ranging from nutritional to cultural and/or psychological. In Vera’s particular case, pica behaviors appeared, at least in part, to be psychological in nature. The IOP treatment team hypothesized that her pica behaviors were related to her other psychiatric symptoms and utilized the Biosocial Theory (Linehan, 1993) to conceptualize her. Linehan’s theory, originally developed to understand patients diagnosed with Borderline Personality Disorder, but later applied to understand a wide range of disorders, posits that patients may have a deficit in emotion regulation ability which emerges from a transaction of two components: biological/genetic vulnerabilities and an invalidating environment. Regarding the former component, the theory asserts that a person’s biologically-influenced temperament results in increased sensitivity to their environments, strong internal and external emotional reactions, and slow rebound to their emotional baseline after strong reactions. Regarding the latter component, the theory holds that a person’s environments routinely communicate to the person that their internal and external reactions are inappropriate or unacceptable. This invalidation could manifest in a variety of ways, including an incongruous fit between a person’s temperament and their environment, direct invalidation of symptoms, a lack of skill teaching from the environment regarding how to cope with symptoms, and in some cases, the environment making attempts to remove stress or excessively overregulate the person’s emotions for them, leading to a belief that they are unable to tolerate their own distress (Wisniewski & Kelly, 2003).
Vera was conceptualized as having a likely biological vulnerability to emotional dysregulation, as evidenced by emotional and behavioral challenges dating back to at least 4 years-old, including destruction of furniture, depression, anxiety, and mood lability. Moreover, as an adult, she struggled at times with awareness and naming of her emotions, tolerating the intensity of her emotions leading to emotional avoidance, and feeling a sense of emotional dyscontrol. Vera’s temperament and reactions may not have fit, at least in her own perception, with her home environment. Vera described coming from a family environment where there was a strong emphasis on high achievement and academic success, creating significant emotional pressure which may have been difficult for Vera to tolerate effectively. Moreover, as her difficulties with academic success ensued (e.g., starting but needing to drop out of programs), and perhaps solidification of a belief that mental health symptoms are not consistent with success, Vera may have experienced cognitive dissonance and engaged in self-invalidation. This ultimately may have contributed to her needing to figure out ways to cope with these feelings, including through pica. Additionally, Vera may not have learned sufficient healthy emotion regulation skills as a function of inadvertent family attachment dynamics, stemming from events such as her family’s divorce. Her mother and primary caregiver, may have engaged in compensatory over-parenting, leading to an overreliance on her mother for emotional soothing at the expense of developing independent emotion regulation skills. In turn, this well-intentioned overparenting could have communicated to Vera the message that she was unable to cope with her emotions, resulting in increased stress and subsequent behaviors of overcontrol (e.g., eating, urinating) to deal with feelings of overreliance. As mentioned previously, Vera was living with her mother at the time of her treatment in the IOP and had a very close, perhaps at times enmeshed, relationship with her. In Vera’s work life, she may have also experienced invalidation of her symptoms, whether externally or self-driven by strong feelings of shame, after pastors found out about her urination behaviors. Vera’s reported secretiveness and shame about her pica behaviors also likely indicate external and/or self invalidation processes driven by self-judgmental cognitions.
Examining Vera through the lens of the Biosocial Theory helped to highlight the role her pica behaviors may have played in emotion regulation, not unlike the role substance use, compulsive behaviors, and binge eating might play in other disorders. On numerous occasions, she discussed the self-soothing power of her consumption behaviors to reduce psychological distress, akin to how someone experiencing addiction might utilize a substance to cope with uncomfortable thoughts, emotions, and body sensations. Illustrating the deeply rooted nature of Vera’s pica, she reported previous unsuccessful efforts to cut down on consumption, significant time spent to obtain foam/matches (e.g., regularly going to the store to buy hair curlers), cravings/urges (e.g., salivation), withdrawal-like experiences, increased frequency of use over time (perhaps a form of tolerance), and continued consumption despite negative consequences (e.g., clogged plumbing). Moreover, Vera’s pica could be viewed as compulsive emotion regulation strategies that she “needed” to engage in to neutralize her anxiety, like those demonstrated in obsessive-compulsive disorder. More specifically, her consumption behaviors were driven by ego-dystonic, persistent/repetitive urges, and resulted in a reduction of internal distress, which was sometimes related to thoughts of dyscontrol. Finally, not unlike the sense of emotional relief a person experiencing a binge-eating disorder might report following a binge, Vera’s pica might have served a similar emotion regulatory role. Vera reported consuming large amounts of matches and foam over a discreet period (e.g., a car ride), being on “autopilot” while eating, consuming foam and matches alone due to embarrassment, and feeling guilty afterward.
Conceptualizing Vera’s pica as an unhealthy emotion regulation strategy, the IOP team employed the Transtheoretical Model of Health Behavior Change (Prochaska & Velicer, 1997) to help identify which processes to target to reduce her pica behaviors. The model posits that behavior change often requires temporal progress through several stages, including precontemplation, contemplation, preparation, action, and maintenance. Moreover, experiential and behavioral change processes, self-efficacy, and decisional balance, are thought to be intervention targets to help move people through these stages. Upon admission to the IOP, Vera was staged as contemplative (e.g., recognizing a problem and considering behavior change) around her foam rubber consumption, and in early action (e.g., the implementation of behavior change within the last 6 months) for match consumption.
As such, the IOP planned to focus on numerous intervention targets. First, staff planned to target Vera’s decisional balance, her relative weighing of the pros and cons of changing or maintaining the status quo with her pica. Second, Vera’s self-efficacy, her confidence in her ability to change her pica behaviors or cope with emotional triggers without engaging in pica, was to be targeted through intensive DBT and CBT skill-building, as well as through medication interventions to reduce Vera’s need to use pica to cope with other psychiatric symptoms, such as anxiety and depression. In terms of internal or experiential change processes, the IOP planned to help Vera better understand the causes and consequences of her pica (consciousness raising), consider her self-image with and without pica (self-reevaluation), and consider how pica had affected her social environments (environmental reevaluation). For behavioral change processes, the program planned to provide Vera with a caring and nonjudgmental space (helping relationship) where she could receive verbal positive reinforcement for achieving behavior change (contingency management), learn healthier coping substitutes for pica (counterconditioning), and work on removing triggers for pica while increasing cues for healthier alternatives (stimulus control).
7 Course of Treatment and Assessment of Progress
Vera attended the IOP 5 days a week, 3 hr per day, for 14 weeks. This involved daily group psychotherapy, weekly individual counseling, and medication management. IOP staff included four licensed clinical social workers and a psychiatrist. Vera received 2 to 3 hr of highly structured group psychotherapy daily focused on learning and practicing skills rooted heavily in DBT and CBT. Each group focused on one core skills module (mindfulness, interpersonal effectiveness, emotion regulation, healthy thinking, or distress tolerance), each with 10 to 15 specific skills. Patients in the IOP received a coping skills manual which was used during group sessions and contained handouts reflecting skills content. On a weekly basis, patients in the IOP attended four mindfulness groups, two emotion regulation groups, two interpersonal effectiveness groups, three distress tolerance groups, and one coping skills review group. Each group module cycled continuously through its specific skills in an ordered fashion, with repetition purposefully built into the sequence to reiterate concepts. Groups were facilitated by the four clinical social workers. Groups consisted of between 8 and 12 patients at any given time who were admitted on a rolling basis and discharged from the IOP after an average of 6 to 8 weeks. Although the IOP patient population was diverse, it consisted of primarily white, unemployed, heterosexual, cis-identifying women with a psychiatric inpatient hospitalization history, significant trauma history, and a mood or anxiety disorder diagnosis. Many patients were referred to the IOP as a step-down from an inpatient level of care, while others were referred from an outpatient level of care for stabilization to prevent hospitalization. Once a week, Vera engaged in a 45 to 60 min individual counseling session with her assigned IOP clinical social worker. This time was used to assess Vera’s symptoms, engage in treatment planning, reinforce group skills, and deliver individualized interventions. Vera also met with the psychiatrist once a week for medication management.
Given the time-limited, programmatic nature of the IOP and an emphasis on effectively helping patients as efficiently as possible, the IOP followed a treatment philosophy implementing numerous psychological and psychopharmacological interventions in parallel, rather than individual interventions sequentially. As such, Vera simultaneously received scheduled group interventions focusing on building coping skills and interventions during individual sessions selected based on her verbalized needs, preferences, and readiness. Moreover, medication adjustments were driven by the Vera’s preference, improvement or worsening of depression, anxiety, and pica behaviors, improvement in her ability to access coping skills she was learning in therapy, and her tolerance for each medication and its side effects.
As part of a program initiative to routinely measure patient outcomes to help guide treatment, patients in the IOP completed the DASS-21 once per week using paper and pencil during a designated group. Vera’s DASS-21 responses were entered by IOP staff into an excel database that would visually graph them and her clinical social worker would share these results with her during individual counseling sessions to foster discussion. Vera’s foam rubber and match consumption, as well as urination behaviors, were verbally assessed at every individual counseling session and documented by her clinical social worker in session notes in as much detail about amount and frequency as she would offer.
Building on the Transtheoretical Model framework, several strategies were employed to help move Vera toward the action stage with both of her pica behaviors. Although research regarding the relationship between intellect and treatment success is limited, it has been suggested that people with higher intellectual capacity may benefit the most from the relational corrective experiences of therapy (Knekt et al., 2014). Vera did not initially demonstrate insight into the cause of her pica behaviors. However, targeting the change processes of helping relationship and contingency management, the clinical team worked to create a safe and non-judgmental space where she could feel comfortable discussing pica behaviors, engage in self-reflection around thinking and behavioral patterns contributing to her mood and anxiety symptoms, and receive positive reinforcement in the form of verbal validation and encouragement from staff when she engaged in open reflection and behavioral change.
Early on, staff engaged Vera in numerous change processes through insight building exercises, such as completing a decisional balance worksheet to better understand motivations to continue or reduce pica behaviors. Through consciousness raising, this exercise helped Vera explore the underlying emotional and physiological needs that she was trying to meet through pica behaviors. This exercise also activated self-reevaluation and environmental reevaluation processes by helping Vera to identify various motivators for change, such as experiencing dissonant emotions thinking of herself as reliant on pica, and negative environmental impacts, like clogging plumbing at her family’s residence, and losing employment. Generally, staff helped Vera understand how thoughts, emotions, and body sensations might be connected to her consumption behaviors. Throughout the whole admission, group therapy sought to build Vera’s self-efficacy coping with her emotions. For example, she engaged in regular mindfulness practice during group therapy, including awareness of body tension, mindful eating exercises, and noticing urges without acting on them. A large component of treatment also involved helping her identify distorted thoughts, as well as building self-soothing and grounding behaviors to help cope with intense emotions and sensations that typically resulted in unwanted behaviors. Later in treatment, in attempting to activate the counterconditioning and stimulus control change processes, staff worked with Vera to try portion-control of foam and to eat ice instead of foam or matches. The goal was to simultaneously incrementally reduce the amount of foam consumed and replace the behavior with a healthier alternative sharing certain features (e.g., oral, intense sensations). In addition to cognitive and behavioral methods, staff encouraged Vera to explore potential symbolic meanings of consumption behaviors.
At the time of admission, Vera’s psychotropic medications included escitalopram 20 mg daily and clonazepam 0.5 mg daily. She reported consistent medication compliance for 3 months prior to admission, but with no changes in anxiety or pica symptoms. Previous medication trials included sertraline, lamotrigine, aripiprazole, and quetiapine. The pharmacological treatment of pica often resembles that of obsessive-compulsive disorder: high dose antidepressants (specifically selective serotonin reuptake inhibitors and clomipramine) supplemented with neuroleptics. The IOP staff and Vera reviewed the utility of this treatment regimen. Given that she had not improved with her medication regimen of escitalopram and clonazepam, these were both tapered to discontinuation. Vera agreed to restart sertraline, as she had tolerated this previously. Sertraline was slowly titrated up to a high dose of 250 mg daily. Risperidone was added as an augmentation strategy. Both to provide her with a sense of control over when to take her medications and to determine the appropriate dose, Vera was initially instructed to take risperidone up to every 6 hr as needed for anxiety or distress. Vera tolerated risperidone and found it helpful. Over time, she was instructed to take a dose of risperidone at the same time every day, however she still had the option to take doses as needed for anxiety or distress. By the end of Vera’s IOP admission, her combined total daily dose of risperidone was 2 mg. Efforts to coordinate care with her primary care physician, in an effort to rule out non-psychiatric causes for her symptoms were, unfortunately, unsuccessful.
Upon discharge, Vera reported that treatment had helped her in several ways, including increased emotion regulation skills, decreased symptom-related distress, and stabilized bathroom and consumption behaviors. Figure 1(A) represents her report of changes in her pica and urination behaviors. During most of her admission, she regularly consumed both foam and matches. Approximately 2 weeks prior to discharge, these behaviors halted abruptly. At 8-week follow-up post discharge, she reported that she sustained her abstinence in consumption behaviors (her report on urination behaviors was not available).
Changes in behaviors and symptoms over the course of initial IOP admission: (A) Depicts self-reported changes in target behaviors; any line above the “No” line indicates that some amount of behavior was reported and a higher line indicates a higher amount/frequency of the behavior (patient was not always precise in her report and so graph shows approximation of relative changes) and (B) Depicts changes in depression, anxiety, and stress symptom scores (DASS-21).
Figure 1(B) depicts Vera’s scores on the Depression Anxiety Stress Scale (DASS-21) over the course of the admission, and at 8-week follow-up. Notably, at the 8-week post-discharge follow-up, she reported clinically significant improvements (Ronk et al., 2013) on the two subscales most relevant to her clinical profile: depression and stress (the items of the stress subscale appeared to be more meaningful than those of the anxiety subscale in capturing her irritability, agitation, and nervousness).
Figure 1 reveals a correlation between DASS-21 scores and consumption behaviors. In particular, approximately 4 weeks into treatment, Vera demonstrated a decrease in match consumption and what could be considered a compensatory increase in foam consumption. These changes tracked with increasing scores in stress and anxiety, illustrating the possible effect these behaviors had in alleviating psychological and physiological distress, similar to how engaging in maladaptive substance use or eating behaviors alleviates distress.
Table 1 provides several clues to the interventions that may have contributed to Vera moving into the action stage of the Transtheoretical Model for both of her pica behaviors. Notably, only at week 12 did both of Vera’s pica behaviors cease and sustain. By this point, she had been taking 200 mg of sertraline daily for 6 weeks; after this point, her dose was increased to 250 mg daily, and 2 mg of risperidone was added. Although it is difficult to isolate the precise impact of specific therapeutic interventions given the IOP’s multipronged parallel treatment approach, consistent with the Transtheoretical Model, the impact of some combination of interventions likely took time to accumulate and Vera’s readiness to change converted to behavioral change toward the end of her admission. Anecdotally, upon discharge, Vera verbally reported improved self-worth, coping self-efficacy, and mood, all of which were targeted with skill building in group and individual sessions, and signified improved emotion regulation. She reported that her improved coping ability was accompanied by an improved sense of hope for the future, which manifested around week 8 in increased planning for returning to school. Vera’s improved sense of hope, which, per her report, stemmed from an improved confidence in her ability to cope with stressors in healthier ways, along with a better understanding of her motivations to engage in pica, as explored through ongoing behavioral chain analyses and Motivational Interviewing techniques (Miller & Rollnick, 2002), likely increased her motivation to halt her pica behaviors.
Summary of Treatment Interventions over the Initial IOP Admission.
8 Complicating Factors
Vera’s treatment was complicated by the fact that she appeared to be experiencing symptoms of numerous co-occurring psychiatric disorders, making it challenging to know the precise etiology of these symptoms, and thus rendering the selection of specific treatment interventions less straightforward. Moreover, a clear understanding of Vera’s pica behaviors and their treatment was further complicated by a reliance on her self-report. Due to the IOP’s design to deliver multifaceted treatment interventions simultaneously in a time-limited fashion to effectively relieve psychiatric pain as quickly as possible, it is challenging to determine precisely which interventions ultimately led to Vera’s reduction in pica behaviors. Given Vera’s strong feelings of embarrassment around pica behaviors, one might worry about her comfort level in disclosing details. Nevertheless, Vera presented as motivated to work on her pica behaviors and the treatment team regularly checked in with her individually about her comfort discussing them, ideally creating a safe space to be open and honest.
9 Access and Barriers to Care
Vera had health insurance which allowed her the opportunity to attend the IOP daily for several weeks. Moreover, Vera was internally motivated and had significant support from family, both of which helped her to access treatment. Nevertheless, this IOP was neither a specialty program for pica, nor for other eating disorders. Furthermore, as mentioned above, efforts to coordinate care with her primary care physician to rule out non-psychiatric causes for her symptoms were unsuccessful.
10 Follow-Up
The IOP had the opportunity to work with Vera again about 3 years after her first admission (discussed above) when she self-referred for further assistance working on emotion dysregulation, anxiety, and depressive symptoms. Notably, for approximately 2 years following her first discharge from the IOP, Vera remained psychiatrically stable, reporting that she did not engage in pica or urination behaviors. During this time, she lived with family, did volunteer work while seeking employment, and engaged in outpatient mental health treatment.
About 2 years after her first IOP admission, Vera moved out of state, became employed as a youth pastor, and transferred her outpatient psychiatric care. Concurrent with significant stress related to her new job and her mental health provider switching her from risperidone to lurasidone, she began to re-engage in obsessions and compulsions related to urination and resumed pica behaviors. About a year later, Vera’s symptoms of depression and anxiety further exacerbated to the point that she felt a need to enroll in an exposure therapy program to target obsessions and compulsions related to contamination in the bathroom. By the end of this treatment course, Vera had successfully stopped urinating in cups. Upon returning to the present IOP for a second admission, however, she reported continuing to consume about six foam curlers per day. During this second admission, she attended the IOP for 14 weeks, focusing on continued skill-building around mood dysregulation, avoidance behaviors, and pica, with an emphasis on anxiety-related behaviors and cognitions. About 8 weeks into this second IOP admission, she stopped engaging in pica behaviors. She also maintained abstinence from urinating in cups throughout the duration of the admission. Of note, by the seventh week, Vera was taking an iron supplement that her primary care physician had prescribed for anemia. During this second admission, from program initiation to discharge, she reported reliable changes in depression (8–3) and stress (9–6) on the DASS-21, as well as an increase in DBT skills use (2.03–2.39), including emotion regulation skills, and a decrease in dysfunctional coping (1.52–1.24) on the DBT Ways of Coping Checklist (Neacsiu et al., 2010). At the time of her second IOP admission, she was prescribed sertraline 250 mg daily, lurasidone 40 mg daily, bupropion 150 mg daily, and alprazolam 0.5 mg daily as needed. Upon discharge, she was taking sertraline 250 mg daily, trazodone 50 mg daily, and clonazepam 1 mg daily.
11 Treatment Implications of the Case
The woman in this case study is unique and notable in several ways. She was highly educated, presented with strong cognitive skills, demonstrated significant social intelligence, and stood to gain from improved emotion regulation skills. We believe these traits allowed her to benefit from common evidence-based therapy modalities, such as CBT, DBT, mindfulness (Germer et al., 2005), Motivational Interviewing, and psychopharmacological interventions, namely high dose SSRIs combined with neuroleptics. Application of these treatment strategies in individual and group therapy settings may prove useful for similar pica case profiles.
Vera’s case illustrates the likely multifaceted etiology of pica behaviors. The fact that she was able to halt foam rubber and match consumption and maintain abstinence for an extended period (e.g., 2 years) through psychotherapy and medication interventions, as well as the way in which her other affective symptoms and significant environmental stressors appeared to correlate with these behaviors, point to a psychological conceptualization of pica. Adding further support to a psychological etiology of Vera’s pica is the fact that many of the other suspected causes of pica did not apply to her, including pregnancy, an intellectual deficit, and following cultural norms of eating nonfood substances. At the same time, as noted during a subsequent episode several years later, other physiological considerations, such as an iron supplement, may have also helped Vera halt pica behaviors. To emphasize the point about complex etiology, she was able to halt pica behaviors with and without iron supplementation. Understanding the way psychological, physiological, and environmental factors interact and impact a patient presenting with pica will likely help to guide treatment interventions.
12 Recommendations to Clinicians and Students
In resource-sparse environments where specialty clinics are not often available, the reality is that clinicians must increase their expertise in treating patients with uncommon symptoms. We recommend that clinicians build competency around both non-judgmental assessment and treatment of pica behaviors, understand its complex etiology, and tune in to its connection with emotion regulation. The perspectives above may be helpful in guiding the treatment of pica behaviors in individuals with no intellectual or social deficits, as well as co-morbid disorders. The current case presentation demonstrates the utility of applying evidenced-based treatments that are successful for the treatment of mood disorders, anxiety disorders, and obsessive-compulsive disorders (CBT, DBT, Motivational interviewing, and medications), for the treatment of pica behaviors in cognitively high functioning adults.
Footnotes
Acknowledgements
We would like to thank “Vera,” who is featured in this case study, for her hard work on her mental health, allowing us to tell her story, and for reviewing the case study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
