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Bog standard: A brief look at toilet tissue eating

In previous blogs I have looked at pica (i.e., the eating of non-nutritive items or substances) and subtypes of pica such as geophagia (eating of soil, mud, clay, etc.), pagophagia (eating of ice), acuphagia (eating of metal), and coprophagia (eating of faeces). It wasn’t until I started to research on specific sub-types of pica, that I discovered how many different types of non-food substances had been identified in the academic and clinical literature. For instance, Dr. V.J. Louw and colleagues provided a long list in a 2007 issue of the South African Medical Journal including cravings for the heads of burnt matches (cautopyreiophagia), cigarettes and cigarette ashes, paper, starch (amylophagia), crayons, cardboard, stones (lithophagia), mothballs, hair (trichophagia), egg shells, foam rubber, aspirin, coins, vinyl gloves, popcorn (arabositophagia), and baking powder. Most of these are generally thought to be harmless but as Louw and colleagues note, a wide range of medical problems have been documented:

“These include abdominal problems (sometimes necessitating surgery), hypokalaemia, hyperkalaemia, dental injury, napthalene poisoning (in pica for toilet air-freshener blocks), phosphorus poisoning (in pica for burnt matches), peritoneal mesothelioma (geophagia of asbestos-rich soil), mercury poisoning (in paper pica), lead poisoning (in dried paint pica and geophagia), and a pre-eclampsia-like syndrome (baking powder pica)”.

In the clinical literature, the eating of paper has been occasionally documented (although anecdotal evidence suggests this is fairly common and I remember doing it myself as a child). A review paper on pica by Dr. Silvestre Frenk and colleagues in the Mexican journal Boletín Médico del Hospital Infantil de México highlighted dozens of pica-subtypes and created many new names for various pica sub-types. They proposed that people who eat paper display ‘papirophagia’ (in fact if you type ‘papirphagia’ into Google, you only get one hit – the paper by Silvestre and colleagues – although this blog may make it two!). Eating paper is not thought to be particularly harmful although I did find a case of mercury poisoning because of ‘paper pica’ (as the authors – Dr. F. Olynk and Dr. D. Sharpe – called it) in a 1982 issue of the New England Journal of Medicine.

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One sub-type of papirophagia is the eating of toilet paper. As far as I am aware, there is only one case study in the literature and this was published back in 1981, Dr. J. Chisholm Jr. and Dr. H. Martín in the Journal of the National Medical Association. They described the case of a 37-year old black woman with an “unusually bizarre craving” for toilet tissue paper. The authors reported that:

“[The] woman was referred for evaluation of disturbed smell and loss of taste for over one year. These were associated with chronic fatigue and listlessness. During this same period of time, she rather embarrassedly admitted to an overwhelming desire to eat toilet tissue. Frequently, she would awaken at night and dash to her bathroom to eat toilet tissue. No other type(s) of pica were admitted. In addition, she gave a long history of menorrhagia and frequently passed vaginal blood clots during her menses. Her libido was normal and there was no history of poor wound healing, skin or mucous membrane lesions, or intestinal symptoms. Her dietary history suggested a high carbohydrate diet, and due to a mild exogenous obesity she intermittently resorted to a vegan-like diet that included beans and various seeds”

A variety of medical tests were carried out and she was diagnosed with combined iron and zinc deficiency. She was treated with iron and zinc tablets and within a week, both her taste and smell had returned, and her energy levels greatly improved. Zinc deficiencies can lead to a wide variety of clinical disorders including loss of small and taste, anorexia, dwarfism (i.e., growth retardation), impaired wound healing, and geophagia. The woman’s (sometimes) vegan diet may have been to blame for her zinc deficiency as the authors noted that:

Although vegetables contain zinc, vegans should be made aware that zinc from plant sources is not readily absorbed because naturally occurring phytates, particularly high in beans and seeds, reduce zinc gastrointestinal absorption. Carbohydrates are very poor sources of zinc. Chronic iron deficiency secondary to chronic menorrhagia accounts well for the anemia, fatigue, and unusual pica for toilet tissue noted in this patient”.

Paper pica has occasionally been mentioned in other academic papers although details have typically been limited. For instance, a 1995 paper in the journal Birth by Dr. N.R. Cooksey on three cases of pica in pregnancy reported that one of the women chewed non-perfumed blue toilet paper during the first trimester of her pregnancy (and was forced by her mother to stop). There was also a 2003 paper published by Dr. Dumaguing in the Journal of Geriatric Psychiatry and Neurology examining pica in mentally ill geriatrics. One of the cases mentioned was a 76-year old patient that not only ingested their medication (an emollient cream for arthritis) but was also recorded eating toilet paper, napkins, Styrofoam cups, crayons, and other patients’ medications.

A more recent 2008 paper by Dr. Sera Young and her colleagues in the journal PLoS ONE, critically reviewed procedures and guidelines for interviews and sample collection in relation to pica substances. In describing the protocols involved, they referred to paper pica in the questions that should be asked:

“What is the local name, brand name, or type of pica substance desired or consumed? This will help others to know if this substance has already been studied and assist interested researchers in obtaining subsequent samples at a later date. Furthermore, different manufactured products may contain different materials, e.g. Crayola chalkboard chalk contains slightly different ingredients from other brands. Similarly, the consequences of toilet tissue paper consumption are different from those of eating pages of a novel; information would be lost if the substance was simply described as paper. For these reasons, the substance consumed should be described in as much detail and as accurately as possible”.

Personally (and based on anecdotal evidence), I think that papirophagia is not overly rare (especially among children – although I admit this may be more out of curiosity that craving) but the clinical literature suggests that it is a fairly rare disorder found amongst distinct sub-groups (pregnant women, the mentally ill). Given the fact that for most people eating paper would not cause any problems, this would provide the main reason why so few cases end up seeking medical, clinical, and/or psychological help.

Dr Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chisholm Jr, J. C., & Martín, H. I. (1981). Hypozincemia, ageusia, dysosmia, and toilet tissue pica. Journal of the National Medical Association, 73(2), 163-164.

Cooksey, N.R. (1995). Pica and olfactory craving of pregnancy: How deep are the secrets? Birth, 22, 129-137.

Dumaguing, N.I., Singh, I., Sethi, M., & Devanand, D.P. (2003). Pica in the geriatric mentally ill: unrelenting and potentially fatal. Journal of Geriatric Psychiatry and Neurology, 16, 189-191.

Frenk, S., Faure, M.A., Nieto, S. & Olivares, Z. (2013). Pica. Boletín Médico del Hospital Infantil de México, 70(1), 55-61

Louw, V.J., Du Preez, P., Malan, A., Van Deventer, L., Van Wyk, D., & Joubert, G. (2007). Pica and food craving in adults with iron deficiency in Bloemfontein, South Africa. South African Medical Journal, 97, 1069-1071.

Olynyk, F., & Sharpe, D. H. (1982). Mercury poisoning in paper pica. The New England Journal of Medicine, 306, 1056 -1057.

Young, S.L., Wilson, M.J., Miller, D., Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE, 3(9), e3147. doi:10.1371/journal.pone.0003147

Bog standard: A brief look at toilet tissue eating

In previous blogs I have looked at pica (i.e., the eating of non-nutritive items or substances) and subtypes of pica such as geophagia (eating of soil, mud, clay, etc.), pagophagia (eating of ice), acuphagia (eating of metal), and coprophagia (eating of faeces). It wasn’t until I started to research on specific sub-types of pica, that I discovered how many different types of non-food substances had been identified in the academic and clinical literature. For instance, Dr. V.J. Louw and colleagues provided a long list in a 2007 issue of the South African Medical Journal including cravings for the heads of burnt matches (cautopyreiophagia), cigarettes and cigarette ashes, paper, starch (amylophagia), crayons, cardboard, stones (lithophagia), mothballs, hair (trichophagia), egg shells, foam rubber, aspirin, coins, vinyl gloves, popcorn (arabositophagia), and baking powder. Most of these are generally thought to be harmless but as Louw and colleagues note, a wide range of medical problems have been documented:

“These include abdominal problems (sometimes necessitating surgery), hypokalaemia, hyperkalaemia, dental injury, napthalene poisoning (in pica for toilet air-freshener blocks), phosphorus poisoning (in pica for burnt matches), peritoneal mesothelioma (geophagia of asbestos-rich soil), mercury poisoning (in paper pica), lead poisoning (in dried paint pica and geophagia), and a pre-eclampsia-like syndrome (baking powder pica)”.

In the clinical literature, the eating of paper has been occasionally documented (although anecdotal evidence suggests this is fairly common and I remember doing it myself as a child). A recent review paper on pica by Dr. Silvestre Frenk and colleagues in the Mexican journal Boletín Médico del Hospital Infantil de México highlighted dozens of pica-subtypes and created many new names for various pica sub-types. They proposed that people who eat paper display ‘papirophagia’ (in fact if you type ‘papirphagia’ into Google, you only get one hit – the paper by Silvestre and colleagues – although this blog may make it two!). Eating paper is not thought to be particularly harmful although I did find a case of mercury poisoning because of ‘paper pica’ (as the authors – Dr. F. Olynk and Dr. D. Sharpe – called it) in a 1982 issue of the New England Journal of Medicine.

One sub-type of papirophagia is the eating of toilet paper. As far as I am aware, there is only one case study in the literature and this was published back in 1981, Dr. J. Chisholm Jr. and Dr. H. Martín in the Journal of the National Medical Association. They described the case of a 37-year old black woman with an “unusually bizarre craving” for toilet tissue paper. The authors reported that:

“[The] woman was referred for evaluation of disturbed smell and loss of taste for over one year. These were associated with chronic fatigue and listlessness. During this same period of time, she rather embarrassedly admitted to an overwhelming desire to eat toilet tissue. Frequently, she would awaken at night and dash to her bathroom to eat toilet tissue. No other type(s) of pica were admitted. In addition, she gave a long history of menorrhagia and frequently passed vaginal blood clots during her menses. Her libido was normal and there was no history of poor wound healing, skin or mucous membrane lesions, or intestinal symptoms. Her dietary history suggested a high carbohydrate diet, and due to a mild exogenous obesity she intermittently resorted to a vegan-like diet that included beans and various seeds”

A variety of medical tests were carried out and she was diagnosed with combined iron and zinc deficiency. She was treated with iron and zinc tablets and within a week, both her taste and smell had returned, and her energy levels greatly improved. Zinc deficiencies can lead to a wide variety of clinical disorders including loss of small and taste, anorexia, dwarfism (i.e., growth retardation), impaired wound healing, and geophagia. The woman’s (sometimes) vegan diet may have been to blame for her zinc deficiency as the authors noted that:

Although vegetables contain zinc, vegans should be made aware that zinc from plant sources is not readily absorbed because naturally occurring phytates, particularly high in beans and seeds, reduce zinc gastrointestinal absorption. Carbohydrates are very poor sources of zinc. Chronic iron deficiency secondary to chronic menorrhagia accounts well for the anemia, fatigue, and unusual pica for toilet tissue noted in this patient”.

Paper pica has occasionally been mentioned in other academic papers although details have typically been limited. For instance, a 1995 paper in the journal Birth by Dr. N.R. Cooksey on three cases of pica in pregnancy reported that one of the women chewed non-perfumed blue toilet paper during the first trimester of her pregnancy (and was forced by her mother to stop). There was also a 2003 paper published by Dr. Dumaguing in the Journal of Geriatric Psychiatry and Neurology examining pica in mentally ill geriatrics. One of the cases mentioned was a 76-year old patient that not only ingested their medication (an emollient cream for arthritis) but was also recorded eating toilet paper, napkins, Styrofoam cups, crayons, and other patients’ medications.

A more recent 2008 paper by Dr. Sera Young and her colleagues in the journal PLoS ONE, critically reviewed procedures and guidelines for interviews and sample collection in relation to pica substances. In describing the protocols involved, they referred to paper pica in the questions that should be asked:

“What is the local name, brand name, or type of pica substance desired or consumed? This will help others to know if this substance has already been studied and assist interested researchers in obtaining subsequent samples at a later date. Furthermore, different manufactured products may contain different materials, e.g. Crayola chalkboard chalk contains slightly different ingredients from other brands. Similarly, the consequences of toilet tissue paper consumption are different from those of eating pages of a novel; information would be lost if the substance was simply described as paper. For these reasons, the substance consumed should be described in as much detail and as accurately as possible”.

Personally (and based on anecdotal evidence), I think that papirophagia is not overly rare (especially among children – although I admit this may be more out of curiosity that craving) but the clinical literature suggests that it is a fairly rare disorder found amongst distinct sub-groups (pregnant women, the mentally ill). Given the fact that for most people eating paper would not cause any problems, this would provide the main reason why so few cases end up seeking medical, clinical, and/or psychological help.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chisholm Jr, J. C., & Martín, H. I. (1981). Hypozincemia, ageusia, dysosmia, and toilet tissue pica. Journal of the National Medical Association, 73(2), 163-164.

Cooksey, N.R. (1995). Pica and olfactory craving of pregnancy: How deep are the secrets? Birth, 22, 129-137.

Dumaguing, N.I., Singh, I., Sethi, M., & Devanand, D.P. (2003). Pica in the geriatric mentally ill: unrelenting and potentially fatal. Journal of Geriatric Psychiatry and Neurology, 16, 189-191.

Frenk, S., Faure, M.A., Nieto, S. & Olivares, Z. (2013). Pica. Boletín Médico del Hospital Infantil de México, 70(1), 55-61

Louw, V.J., Du Preez, P., Malan, A., Van Deventer, L., Van Wyk, D., & Joubert, G. (2007). Pica and food craving in adults with iron deficiency in Bloemfontein, South Africa. South African Medical Journal, 97, 1069-1071.

Olynyk, F., & Sharpe, D. H. (1982). Mercury poisoning in paper pica. The New England Journal of Medicine, 306, 1056 -1057.

Young, S.L., Wilson, M.J., Miller, D., Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS ONE, 3(9), e3147. doi:10.1371/journal.pone.0003147

That’ll do icily: A brief look at pagophagia

In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.

Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):

“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.

Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.

Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.

“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonalds-like cups and from the use of popular bottled water containers that have been frozen”.

There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.

Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:

“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”

However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.

de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.

Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.

Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located: http://www.jmedicalcasereports.com/content/4/1/86

Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.

Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961

Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.

Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.

Muddy daughters: A beginner’s guide to geophagia

In previous blogs I have looked at pica and some of the pica sub-variants including pagophagia (the eating of ice) and coprophagia (the eating of faeces). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Today’s blog takes a look at geophagia (the eating of earth, soil and/or clay). In a literature review published in the Journal of the Royal Society of Medicine by Dr Alexander Woywodt and Dr. Akos Kiss that geophagia has been regarded as a psychiatric disease, a culturally sanctioned practice and/or a sequel to poverty and famine. Geophagia is also a culturally sanctioned practice in some parts of the world. Woywodt and Kiss also stated that:

“[Geophagia] is not uncommon in southern parts of the United States5 as well as urban Africa. Fine red clay is often preferred. In particular, geophagia is observed during pregnancy or as a feature of iron-deficiency anaemia. Where poverty and famine are implicated, earth may serve as an appetite suppressant and filler; similarly, geophagia has been observed in anorexia nervosa. However, geophagia is often observed in the absence of hunger, and environmental and cultural contexts of the habit have been emphasized. Finally, geophagia is encountered in people with learning disability, particularly in the context of long-term institutionalization”.

The relationship between anaemia and pica (including geophagia) has been well documented. However, Woywodt and Kiss assert that it is still unclear whether anaemia prompts geophagia to compensate for iron deficiency or whether geophagia is the cause of anaemia. Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied although there are few reliable prevalence estimates of geophagia. One study of pregnant Tanzanian women found a prevalence rate of 26.5% (but this is – of course – a totally unrepresentative sample).

A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature although it did also report that geophagics frequently eat other non-food stuffs (particularly if the desired soil is unavailable or socially unacceptable). For many people, pica is not dangerous but for geophagia there may be complications including parasitic infections (from eating soil). Although eating soil and clay may be regarded as unappetizing (and perhaps bizarre) by most people, some authors have argued that eating soil can be nutritionally beneficial (which if that was the case, it wouldn’t technically be a form of pica).

While not being considered a social norm in Western society, eating soil or clay is said to be quite common among primitive or economically depressed peoples a way of augmenting a scanty and/or mineral-deficient diet. Having said that, the geophagia is most often confined to people suffering from chronic mental illness. Clay (as opposed to soil) consumption has been reported in India, Haiti, various parts of Africa (Cameroon, Gabon, Guinea), and even rural areas of the USA. Like soil consumption, clay consumption has also been associated with pregnant women and some women claim they eat it to eliminate nausea. The Wikipedia entry on geophagia noted:

“In Haiti, the poorest economy in the Western Hemisphere, geophagy is widespread. The clay mud is worked into what looks like pancakes or cookies, called ‘bon bons de terres’…The cookies have little or no nutritional value and are associated with various health problems”.

A study led by Dr. L.T. Glickman and colleagues, and published in a 1999 issue of the International Journal of Epidemiology, provided some data on geophagia by carrying out a study examining intestinal parasitism among children from three rural villages in Guinea (Africa). More specifically they examined the faecal stools of 266 randomly selected children (aged 1-18 years). The researchers found that 53% of children were infected by at least one type of soil-transmitted parasite. They also surveyed parents and reported that geophagia was reported by parents to occur in 57% of children aged 1-5 years, 53% of children aged 6-10 years, and 43%, of children aged 11-18 years. It was concluded that geophagia is an important risk factor for orally acquired parasitic infections in African children.

A small study carried out by Turkish researchers and published in a 1978 issue of Acta Haematologica carried out oral iron and zinc tolerance tests on 12 patients from Turkey and Iran aged between 8 and 21 years with iron deficiency anemia and geophagia. The research team reported decreased iron and zinc absorption in patients compared to control patients. They concluded that iron and zinc malabsorption may be an additional feature of the syndrome characterized by geophagia among those from Turkey and Iran. Finally, in their literature review on geophagia, Dr Woywodt and Dr Kiss concluded that:

“The causation is certainly multifactorial; and clearly the practice of earth-eating has existed since the first medical texts were written. The descriptions do not allow simple categorization as a psychiatric disease. Finally, geophagia is not confined to a particular cultural environment and is observed in the absence of hunger”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Arcasoy, A., Cavdar, A.O. & Babacan, E. (1978). Decreased iron and zinc absorption in Turkish children with iron deficiency and geophagia. Acta Haematologica, 60, 76-84.

Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.

Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.

Glickman, L.T., Camara, A.O., Glickman, N.W. & McCabe, G.P. (1999). Nematode intestinal parasites of children in rural Guinea, Africa: Prevalence and relationship to geophagia. International Journal of Epidemiology, 28, 169-174.

Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188

Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.

López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.

Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.

Rose, E.A., Porcerelli, J.H, & Anne Neale, A.V. (2000). Pica: Common but commonly missed. Journal of the American Board of Family Practice, 13, 353-358.

Stein, D.J., Bouwer, C. & van Heerden, B. (1996). Pica and the obsessive- compulsive spectrum disorders. South African Medical Journal, 86, 1586-1592.

Woywodt, A. & Kiss, A. (2002). Geophagia: the history of earth-eating. Journal of the Royal Society of Medicine, 95:143-146.

Young, S.L., Wilson, M.J., Miller, D., & Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One, 3(9), e3147.

Wikipedia (2012). Geophagy. Located at: http://en.wikipedia.org/wiki/Geophagy

Pica boom? A beginner’s guide to pica

Pica is an eating disorder that has been documented in the psychological literature for hundreds of years and refers to a behaviour in which individuals eat non-nutritive items or substances (such as coal, hair and wood). The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines pica as “the persistent eating of nonnutritive substances for a period of at least one month, without an association with an aversion to food”. Therefore, one-off instances of eating non-nutritious items would not constitute pica. Children who occasionally eat items like crayons are rarely diagnosed as having pica. Pica comes from a Latin word for the magpie bird (known for its strange eating behaviours).

The prevalence rates of pica depend on which patient populations have been studied. Prevalence estimates are also skewed by the fact that many people suffering from pica are embarrassed about the behaviour and may not tell anyone and/or seek medial treatment. However, it is well established that pica is more prevalent in children, pregnant women, adults from lower socioeconomic classes, and children with developmental disabilities (such as autism). The incidence of pica is also higher amongst those suffering from family-related stress. Although pica can be a symptom of anaemia (i.e., iron deficiency) and other chemical imbalances, research has shown it is actually more common among those who have normal iron levels.

Prevalence rates of pica have range anywhere between 0.02% and 74% depending on the study and population studied. For instance, studies have reported pica prevalence rates of:

  • 0.02% in Danish pregnant women
  • 8% in US black pregnant women (pagophagia)
  • 9% in Saudi Arabian pregnant women
  • 26.5% in Tanzanian pregnant women (geophagia)
  • 31% of Californian Mexican pregnant women
  • 44% of Mexican pregnant women
  • 50% of Nigerian pregnant women
  • 74% in Kenyan pregnant women
  • 44% in French anaemic patients (vs. 9% matched controls)
  • 64% in Turkish anaemic patients (vs. 17% controls)
  • 22%-26% in mentally retarded adults
  • 34% in sickle cell disease patients

The Danish figure from a study led by Dr Tina Mikkelsen (University of Southern Denmark) is likely to be the most accurate as it was carried out on a sample of 100,000 pregnant Danish women and only 14 of the total sample reported that they had pica. The authors concluded that in privileged populations, pica is more a myth than a reality.

Despite increased research in the area, there has been no definitive explanation as to why some people consume such substances as hair (trichophagia), ice (pagophagia – which I briefly examined in a previous blog), soil/clay (geophagia), wood (xylophagia), stones (lithophagia), glass (hyalophagia), plumbophagia (lead paint chips), or laundry (uncooked) starch (amylophagia). Dr. Ella Lacey (Southern Illinois University) also listed many other non-food substances that pica sufferers may eat that don’t have specific names such as those people who eat paper, balloons, grass, soap, cotton wool, and cigarette butts. Pica is a widespread practice throughout Africa and India. It has also been reported in Australia, Canada, Israel, Iran, Uganda, Jamaica and various European countries. A recent review on pica led by Dr Sera Young (University of California, USA) noted that geophagia is the most common type of pica described in the psychological and medical literature. They also noted that:

  • Geophagics frequently eat other non-food stuffs.
  • Those who eat more manufactured substances say they use them as a replacement for earth, either because the desired soil is unavailable or socially unacceptable
  • Bar the eating of ice, most pica substances are absorptive in the dry state and all easily absorb moisture.
  • Pica substances are typically craved with great intensity or ‘‘devouring passion’’

A variety of conditions are known to cause some types of pica including mineral deficiencies, hookworm infection (parasitic infection in the small intestine), coeliac disease (an autoimmune disorder of the small intestine) and Kleine-Levin Syndrome (also known as Sleeping Beauty Syndrome, a neurological disorder characterized by recurring periods of excessive amounts of sleeping and eating). Interestingly, there are culture-specific cases where pica is not related to psychopathological disorders or deficiencies. For instance, black women in Georgia (USA) are known to eat kaolin (white dirt that is actually a clay mineral) – a so-called “culture-bound syndrome” (i.e., a recognizable combination of psychiatric and somatic symptoms that are only within a specific culture or society).

Some pica type disorders may be part of a wider psychiatric condition (such as schizophrenia) and/or may be part of a sexual paraphilia such as the small numbers of people who engage in coprophagia (eating faces) as part of coprophilia and people who engage in urophagia (drinking urine) as part of urophilia. If the primary focus for eating the item or substance was sexual, it would be more likely diagnosed as a sexual paraphila rather than pica. However, many of those with pica claim to love the taste, texture and/or smell of the things they eat. Some studies have suggested an association between pica and addictive behaviors. Others suggest pica is on the obsessive-compulsive disorder (OCD) spectrum of diseases. For instance, a study based on pica case studies by Dr Dan Stein and colleagues (a the University of Stellenbosch, South Africa) came to the conclusion that (based on their case studies), pica may be a symptom of OCD, and that pica may be phenomenologically reminiscent of an impulse control disorder.

For many people, pica is not dangerous but for some there may be complications including (i) parasitic infections (such as geophagics eating soil or copraphagics eating faeces), (ii) internal bodily obstruction (e.g., such as tricophagics getting hair stuck in their intestines), (iii) toxic reactions (e.g., such as autistic children getting lead poisoning from eating painted plaster), (iv) excessive caloric intake (such as that occurring with starch cravings), (v) dental injuries and infections, and (vi) nutritional deficiencies.

As Dr. Lacey concluded: Pica appears to be a complex behavior that requires deliberate study rather than application of ex post facto single cause theories. Although such theories may motivate any given study of pica, it should be apparent that any single cause model will likely offer only a limited explanation of such diverse practices as have been described in the literature through case reports,’ research studies, and literature ‘reviews of various clinical and applied disciplines”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

al-Kanhal, M.A., & Bani, I.A. (1995). Food habits during pregnancy among Saudi women. International Journal for Vitamin and Nutrition Research, 65, 206-210.

Ashworth, M., Hirdes, J.P. & Martin, L. (2008). The social and recreational characteristics of adults with intellectual disability and pica living in institutions. Research in Developmental Disabilities, 30, 512-520.

Danford, D.E. & Huber, A.M. (1982). Pica among mentally retarded adults. American Journal of Mental Deficiency, 87, 141-146.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemade, U.J. et al (1994). Pica in an urban environment. Journal of Nutrition, 124(6 Suppl): 954S-962S.

Kettaneh, A., Eclache, V., Fain, O., Sontag, C., Uzan, M. Carbillon, Stirnemann, J. & Thomas, M. (2005). Pica and food craving in patients with iron-deficiency anemia: A case-control study in France. American Journal of Medicine, 118, 185-188

Lacey, E. (1990). Broadening the perspective of pica: Literature review. Public Health Reports, 105, 29-35.

López, L.B., Ortega Soler, C.R. & de Portela, M.L. (2004). Pica during pregnancy: A frequently underestimated problem. Archivos latinoamericanos de nutricion, 54, 17-24.

Mikkelson, T.B., Andersen, A.M. & Olsen, S.F. (2006). Pica in pregnancy in a privileged population: myth or reality. Acta Obstetricia et Gynecologica Scandinavica, 85, 1265-1266.

Ngozi, P.O. (2008). Pica practices of pregnant women in Nairobi, Kenya. East African Medical Journal, 85(2), 72-79.

Nyaruhucha, C.N. (2009). Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 11(1), 29–34.

Rose, E.A., Porcerelli, J.H, & Anne Neale, A.V. (2000). Pica: Common but commonly missed. Journal of the American Board of Family Practice, 13, 353-358.

Simpson, E., Mull, J.D., Longley, E., & East, J. (2000). Pica during pregnancy in low-income women born in Mexico. Western Journal of Medicine, 173, 20-24.

Smulian, J.C., Motiwala, S. & Sigman, R.K. (1995). Pica in a rural obstetric population. Southern Medical Journal, 88, 1236–1240.

Stein, D.J., Bouwer, C. & van Heerden, B. (1996). Pica and the obsessive- compulsive spectrum disorders. South African Medical Journal, 86, 1586-1592.

Young, S.L., Wilson, M.J., Miller, D., & Hillier, S. (2008). Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One, 3(9), e3147.

Each to their own: Five weird (non-sexual) addictions, compulsions and obsessions

On a recent rainy Sunday afternoon and out of sheer boredom I typed in the words ‘weird addictions’ into Google. There were a large number involving various sexual acts that I will leave for another blog. Today’s article briefly overviews what I found that didn’t involve sex along with a brief commentary on the extent to which these behaviours can really be said to be an addiction, compulsion or obsession.

Tanning addiction: Addiction to tanning – typically involving the repeated daily use of sun beds by women – is something that I have commented on a number of times in the British national media and relates to an apparent unhealthy dependence on tanning as a way of raising a person’s self-esteem. Back in the 1990s, the media often referred to this condition as “tanorexia”, and this term has now been taken up by some members of the academic research community. For instance, a study carried out in 2008 on 400 students and published in the American Journal of Health Behavior reported that 27% of the students were classified as “tanning dependent”. Personally, I am not convinced that this is a real dependence and/or addiction based on the empirical evidence to date, but I will look at this issue in more depth in a future blog.

‘BlackBerry’ addiction: There are countlessmedia reports of males in management and other professional occupations who are allegedly addicted to their Blackberry (or ‘Crackberry’ as the media often likes to term it). Symptoms include such things as (i) hearing a “phantom rings” and/or experiencing phantom vibrations, (ii) constantly checking e-mails and/or texts. Apparently, the content of emails and texts makes the person feel important and (like ‘tanorexia’) helps raise a person’s self esteem. Although I have often written and researched into ‘technological addictions’ I have yet to come across a case of genuine case of Blackberry addiction myself. If such an addiction does exist, there are also issues around whether the Blackberry is just a means to fuel particular addictive behaviour (e.g., texting) or whether people are addicted to the Blackberry itself.

Cosmetic surgery addiction:Again, there are many examples in the popular media of patients who allegedly have an addiction to plastic surgery.  There are certainly well documented cases of high profile individuals who have undergone countless operations in their desire to achieve (what they perceive to be) the perfect face and/or body (Michael Jackson, Cher, Jocelyn ‘Cat Woman’ Wildenstein, David Gest, Micky Rourke). Such people appear to be initially satisfied once they have had the procedure in question but then start to think “just one more (operation)”. Again, I am unconvinced that any of these high profile cases are “addicted” to plastic surgery but like ‘tanorexia’ there is certainly the desire to look good as a way of feeling good about themselves. However, there are cases of individuals who seek out constant plastic surgery because they suffer from Body Dysmorphic Disorder (BDD). BDD can affect sexes and typically manifests itself as a preoccupation with an imagined physical defect or an exaggerated concern about a minimal defect. This may lead the BDD sufferer to a cosmetic surgeon in an attempt to try to change or eliminate the perceived defect. The patient is never happy with the changes so it begins another cycle of surgery. The exact cause or causes of BDD is unknown, but most clinicians believe it to be a complex disorder with biopsychosocial underpinnings.

Addiction to chewing ice: On first glance, ice chewing might seem to be a completely made up behaviour yet compared to the other activities on this list, there is quite an established empirical literature. Ice eating is known in the scientific literature by the name of pagophagia and is a particular expression of the more general phenomenon of pica (an eating disorder whose name derives from the Latin word for magpie, a bird known for its peculiar eating behaviours). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Pica more often occurs in pregnant women, children, and adults of lower socioeconomic status. Other types of pica in addition to ice chewing include the eating of clay and soil (geophagia) and starch (amylophagia). Pagophagia is also closely associated with iron deficiency anemia. Empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. Some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships. Although there are some claims in the literature that pagophagia can be addictive, the more likely is that it may be a compulsion in extreme cases.

Compulsive lying: Telling lies is widespread yet there appears to be some empirical evidence that in extreme cases it can be chronic, compulsive and/or pathological. Often, compulsive lying may be an adjunct to other mental illnesses such as Munchausen’s Syndrome (where a person persistently seeks medical treatment for illnesses that do not exist) or pathological gambling (where persistent lying is needed to prevent others realizing there is a gambling problem). Other sufferers may include those with False Memory Syndrome where the person actually believes the lies that they tell. Writings relating to pathological lying first appeared in the psychiatric literature over 100 years ago and have been given names such as ‘pseudologia fantastica and ‘mythomania’. Pathological lying has been defined by Dr Charles Dike and his colleagues at Yale University as “falsification entirely disproportionate to any discernible end in view, may be extensive and very complicated, and may manifest over a period of years or even a lifetime”. It s thought to affect men and women equally with an onset in late adolescence. There are no reliable prevalence figures although one study estimated that one in a 1000 repeat juvenile offenders suffered from it.  A study published in the British Journal of Psychiatry reported differences in brain structure between pathological liars and control groups. Pathological liars showed a relatively widespread increase in white matter (approximately one-quarter to one-third more than controls) and suggested that this increase may predispose some individuals to pathological lying.

These five activities were just the tip of the iceberg. I also came across alleged addictions to heavy metal music, teeth whitening, body modification (piercing and tattoos), animal hoarding, and reading. They will have to wait for another time.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Chatterjee, A. (2007). Cosmetic neurology and cosmetic surgery: Parallels, predictions, and challenges.Cambridge Quarterly of Healthcare Ethics, 16, 129-137.

Dike, C.C., Baranoski, M. & Griffith, E.E. (2005). Pathological lying revisited. Journal of the American Academy of Psychiatry and the Law, 33, 342–349.

Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E.,  Jones, S. Laryea, H. &  Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.

Griffiths, M.D. (1995). Technological addictions. Clinical Psychology Forum, 76, 14-19.

Griffiths, M.D. (2008). Internet and video-game addiction. In C. Essau (Ed.), Adolescent Addiction: Epidemiology, Assessment and Treatment. pp.231-267.  San Diego: Elselvier.

Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.

Heckman, C.J., Egleston, B.L., Wilson, D.B. & Ingersoll, K.S. (2008). A preliminary investigation of the predictors of tanning dependence. American Journal of Health Behavior, 32, 451-464

Joshi, S. & Lalbeg, V.K. (2011). Texting mania – A social dilemma. International Journal of Research in Commerce, Economics, and Management, 1(3), 132-135.

King, B.H. & Ford, C.V. (1988). Pseudologia fantastica. Acta Psychiatrica Scandinavica, 77, 1-6

Kirchner, J.T (2001). Management of Pica: A Medical Enigma. American Family Physician, 63, 1177-1178.

Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.

Yang, Y., Raine, A., Narr, K., Lencz, T., LaCasse, L. Colleti, P., & Toga, A. (2007). Localisation of increased prefrontal white matter in pathological liars. British Journal of Psychiatry, 190, 174-175.