Comorbid bulimia and pica disorders tend to work together to accomplish a similar task: weight loss/control. Eating non-nutritive substances occupies space in the stomach, creating a sense of satiety without taking in calories. Therefore, this behavior acts as a substitute for binging in the patient with bulimia.14
One study identified eight themes associated with pica during pregnancy: keeping practices secret, singularity of the experience, extravagant means for obtaining the craved substance, fears for the effects on the fetus, yielding or not yielding to the cravings, use of the substances as medication, pica and lack of food intake, and sensory experiences other than taste.2 All eight of these themes were present in Ms. A.
Evaluation: Needing more and more
By her third pregnancy, Ms. A’s obsession with powder started to take hold. She found it easier to conceal the purging from her partner, so she began purging more often (twice daily) to offset her cravings for the baby powder. Purging was a last resort for the patient and her only means of off-setting her desire for the powder, which relieved her urge to vomit. She ate baby powder throughout the day, even awaking two to three times at night to ingest a few spoonfuls.
Until she presented to us, Ms. A had followed a daily ritual. At 10:30 a.m., when the local drug store opens, she superficially tested the consistency of a certain brand of powder available on the shelves. She then purchased one case (six 14-ounce containers) of powder, went home and sampled each container, and rated them in quality from 1 to 6, with 1 being the bottle of powder she ate that day. The next morning, regardless of how many cases of powder were piled in her closet, she went to the drug store and repeated the process.
Ms. A felt comfortable eating the talc-based powder in her apartment and her mother’s house. She kept some baby powder in her desk at work, but she regularly took an hour-long lunch break to drive back to her apartment and satisfy her craving. She also carried powder in the car, tasting it while driving.
When asked how the powder made her feel, Ms. A replied: “Powder is like nothing else. It makes me feel content and at ease.” Whenever she was irritated, or if the children were frustrating her, she would take a spoonful of powder.
In the beginning, she consumed approximately one 14-ounce bottle per month. When she presented 28 weeks pregnant with her third child, she could not imagine life without baby powder. A spoonful satisfied her for only 5 to 10 minutes before she would desire more. No other substance quelled the cravings. She had tried edible substitutes such as confectioners sugar, cornstarch, and ice chips, but nothing offered the satisfaction she got from powder.
When she is unable to ingest powder, she develops a headache, begins to sweat, gets extremely anxious and irritable, cries profusely, and becomes depressed. If she is abstinent more than 2 days she is unable to sleep and becomes preoccupied with the powder. If powder is not available, she binges and induces vomiting to stifle her craving.
In the hospital she craved powder 2 days after it was removed from her access. She became extremely anxious and distressed. She then ordered as much food as possible so she could purge and forget about the powder.
How would you explain the patient’s psychopathological attraction to baby powder?
Commentary
Patients with pica typically express satisfaction from consuming non-nutrient substances (Box 2). Ms. A’s motive for eating the powder stemmed from what she perceived as its soothing properties.
Other reported cases have alluded to the sensation generated by the texture of soil or chalk in the mouth. Some of these patients also described the importance of the soil’s taste—i.e., particle size—as being second to its texture.12 The desire to experience a certain texture, color, odor, and taste are important components in pica cravings.10
COMMON OBJECTS OF PICA
| Object | Specific disorder |
|---|---|
| Burnt matches | Cautopyreiophagia |
| Earth (chalk, clay, dirt) | Geophagia |
| Feces | Coprophagia |
| Hair | Tricophagia |
| Ice | Pagophagia |
| Laundry starch, cornstarch | Amylophagia |
| Lead paint chips | Plumbophagia |
| Raw potatoes | Geomelophagia |
| Stones | Lithophagia |
Other known objects of pica—Ashes, baking soda, balloons, carrots, celery, chewing gum, cigarette butts, cloth, coal, coca leaf, coffee grounds/beans, cotton balls, concrete, crayons, croutons, detergent, grass, hard candy, insects, lavatory fresheners, latex gloves, licorice, lint, metal, milk, newsprint, oats, oyster shells, paper, parsley, plant leaves, pencil erasers, plastic, popcorn, powder puffs, salt, soap, string, thread, toilet tissue, tomato seeds, twigs, vinegar, wood.
Pica appears to meet the individual’s need for mental relaxation and sensory pleasure15 in much the same way that alcohol or drug abusers satisfy their intense desire for euphoria and relaxation. Scientists theorize that alcohol and drug abuse may be exacerbated by or result from a neurochemical imbalance. A similar hypothesis may explain this “variant” in pica patients.