Pregnant women often develop taste aversions for items that are potentially harmful to the developing fetus, such as alcohol and coffee. Expectant mothers may develop utter disgust and provocation of nausea toward items they enjoyed while not gravid. Aversions to foods and other items during pregnancy might be the consequence of homeostatic factors that have evolved as general feto-protective mechanisms.16,17 The metabolic changes that accompany the gravid state might alter olfactory and taste sensitivity.17
If a pregnancy-related change in chemical balance can cause taste aversion, certainly a similar situation could evolve into pica. In laboratory rats, intraventricular injection of exogenous neuropeptide Y, a hormone with documented CNS activity, caused taste aversions and elicited geophagia.18
Ms. A’s ingestion of baby powder itself did not harm the fetus. Stephen Emery, MD, director of perinatal ultrasound at the Cleveland Clinic, notes that talc is inert and the powder’s perfumes probably are benign. He adds, however, that because the powder often has replaced real food, Ms. A placed her unborn child at risk via malnourishment.
Further evaluation: A ‘pleasant’ appearance
Ms. A’s medical history revealed chronic asthma since childhood and gastroesophageal reflux disease. According to her social history, she is dating the father of her expectant child. She has been smoking one pack of cigarettes per day for 2 years but says she does not drink alcohol and has never abused illicit drugs.
Her lab values were as follows (with normal ranges in parentheses): blood urea, 4 mg/dl (9-23); serum iron, 69 mg/dl (42-135); calcium 8.7 mg/dl (8.5-10.5); magnesium, 1.6 mg/dl (1.8-2.4); phosphate, 2.4 mg/dl (2.7-4.6); hemoglobin, 10.0 g/dl (12.0-14.0); hematocrit, 31.1% (37.0-47.0); mean corpuscular volume, 86.4 fl (81-99).
Ms. A appeared well-nourished, appropriately dressed, and well-groomed during our examination. She was alert, oriented and cooperative, and held a pleasant conversation with good eye contact. Her mood was depressed and anxious, and her affect was congruent. Speech was normal in rate, tone, and volume. Her thoughts were well organized and goal-directed. She denied suicidal ideation but had thoughts of harming her fetus. She denied any perceptual disturbances. No intellectual impairment was evident, and her insight and judgment were preserved.
What is the psychiatric diagnosis for this patient? Also, in your view, how likely is she to harm her fetus or her two children? How would you assess and manage that risk?
Commentary
The physiologic cause of pica may be metabolic disturbances in iron, zinc, calcium, potassium, lead, and magnesium.10,19-22 Ice pica typically is associated with iron deficiency and low hemoglobin levels,14,20,23,24 although other forms of pica have been linked to iron deficiency.12,25 Some studies show iron deficiency in nearly half of patients who display ice pica;20,26 correcting the iron deficiency relieves the cravings for the desired substances.7,14 Scientists are split as to whether pica results in the deficiency of certain minerals or whether mineral deficiencies cause pica. Mineral deficiencies may alter appetite-regulating brain enzymes that can lead to these cravings.7,10,11,23
Ms. A’s laboratory values demonstrated decreased hemoglobin, hematocrit, and magnesium levels. Magnesium replacement did not change her eating behavior. Her mild anemia may simply have been an effect of pregnancy.
Treatment: Confronting comorbid depression
Ms. A’s diagnosis was pica, bulimia nervosa-purging type, with comorbid depressive disorder NOS.
She was placed on the selective serotonin reuptake inhibitor sertraline, 12.5 mg/d. The dosage was increased gradually to 50 mg qd. Supportive psychotherapy was provided during the patient’s hospital course.
After her discharge, cognitive therapy was initiated. Ms. A was asked to keep a journal utilizing the “triple column technique,” through which she described a situation in one column, explained the symptoms or unwanted behaviors and emotions evoked by that situation in the second, and wrote down her thoughts in the third.
Ms. A was monitored for signs and symptoms of postpartum depression. After this careful assessment, in which two psychiatrists and the ob/gyn team participated, we concluded that the patient’s transient thoughts of harming her fetus had fully resolved.
Ms. A was educated about nutrition and healthy exercise, as well as birth control options. We also asked to see her as an outpatient.
In the ensuing months, Ms. A reported moderate depressive symptoms but described a significant decrease in her craving for, and consumption of, powder. She continued follow-up treatment with her physician at the women’s care center. Ms. A decided to stop taking sertraline after 2 months because she felt it was not helping her depression and was causing fatigue.
When we followed up after 6 months, Ms. A reported that she and her baby were doing well. She told us that her powder cravings had decreased markedly.