HISTORICAL OVERVIEW

Stedman's defines pica as "a perverted appetite for substances not fit as food or of no nutritional value." The first description of pica behavior was made by Galen in the second century. The term "pica" was first applied in the sixteenth century by a French physician, using the Latin word for magpie, a bird thought to have odd feeding habits. Medical dictionaries of the 17th century frequently mentioned the observed association of pica with pregnancy and "chlorosis" (an irondeficiency anemia in young girls sometimes characterized by a greenish skin color). Parry-Jones and Parry-Jones recently performed an exhaustive survey of historical references to pica. They noted a sampling of 18th- and 19th-century descriptions of pica taken from French, German, and British sources that continued to link pica with either chlorosis or pregnancy. Other 19th-century references commented on an increased incidence in black-slave populations in the southern United States, sometimes reaching "epidemic proportions." Particularly relevant to the case presented next is the report of extensive dirt eating noted in populations of the West Indies. Pica in the mentally ill was frequently documented in 19th-century mental hospital records, which described how "epileptic, paretic, senile and maniacal cases" could be subject to "an active perversion of the appetite for food which leads the patient to devour even the most disgusting substances." The early part of this century saw increasing concerns regarding pica in pediatric populations, especially as knowledge of medical complications of certain forms of pica became clear (e.g., lead poisoning from eating lead-based paint chips).

EPIDEMIOLOGY
There have been few studies of the epidemiology of pica; of these, the more detailed investigations have focused on pediatric populations. Results of these studies have estimated an overall prevalence of childhood pica as high as 32%, with a predominance in children under three and an increased prevalence in African American children. In general, pica tends to decrease with age. It has been estimated that up to 20% of pregnant women have a history of pica. One study reported finding pica in 58% of the patients presenting with iron-deficiency anemia secondary to gastrointestinal blood loss. Pica has been estimated to occur in up to 25% of institutionalized mentally retarded patients; one study of autistic patients reported a pica frequency as high as 60%.

DIAGNOSIS
DSM-IV restricts the diagnosis of pica to behavior that is inappropriate to a child's developmental level or not part of a culturally sanctioned practice. Pica may occur as a sign of other mental disorders (e.g., associated with delusions in schizophrenia), but is then only considered to warrant independent diagnostic attention if the eating behavior is especially severe. A major obstacle to both the diagnosis of pica in a particular patient as well as documentation of accurate prevalence rates is that patients rarely present complaining of pica, and often guard against revealing it at all. Rather, complications of pica, like diarrhea or weight loss, are what usually prompt patients to seek medical attention. Findings at initial evaluation can include anemia, iron deficiency, hypertension, hyperkalemia, and elevated liver-function tests.