Sir,
Pica is a sustained, compulsive eating behavior of nonedible substances.[1] Iron deficiency is commonly associated with pica and it improves with iron supplementation.[12] Geophagy (eating of clay) is a common variant of pica. In the context of schizophrenia, pica is believed to be a rare, independent and discrete behavior,[3] which is often missed in the diagnosis and as a result, complications such as intestinal obstruction, electrolyte disturbances, and heavy metal poisoning may occur.[1]
In this case, for which informed consent was obtained, a 22-year-old, divorced, female of lower socioeconomic status presented to the psychiatry outpatients’ clinic with the complaints of increased irritability, aggressive and disruptive behavior, muttering, and smiling to herself, suspiciousness, hearing voices commenting and criticizing her and decreased sleep. These symptoms started 1-year prior, shortly after she was married. Just after her marriage, she had become suspicious of her husband and believed that he was not the same person she had married - she alleged that he was a stranger who had replaced her husband by changing his face. Her persistent suspiciousness toward her husband led to marital discord and divorce, 3 months before presentation. After the divorce, her symptoms increased in severity causing even more impairment. Often, she would run away from home and be missing for several days. Family members also reported that she was eating clay and pieces of brick for approximately 2 months prior to hospitalization. She was treated culturally by different faith healers prior to consultation in our outpatients’ department. The patient had a history of pulmonary tuberculosis 2 years ago for which she had received an appropriate course of anti-tubercular treatment. There was no other significant past medical or psychiatric illness. Personal and family histories were not contributory and she had no maladaptive personality traits premorbidly.
Physical examination revealed no significant abnormality other than pallor. On mental status examination, there was increased flow of speech with occasional irrelevance, inappropriate affect, persecutory delusions, a delusion of doubles (husband being replaced by a stranger), third person auditory hallucinations, and impaired judgment with absent insight. Her routine investigations, other than hemoglobin (Hb - 9.1 g%), were within the normal limits. There was reduced serum ferritin, and raised reticulocyte count, however the peripheral blood smear, red blood cell indices, renal function test, liver function test, serum protein, urine and stool microscopy and stool for occult blood tests were all within normal limits. After clinical evaluation, a diagnosis of paranoid schizophrenia with iron deficiency anemia and pica was made.
She was started on the antipsychotic risperidone and the dose was optimized to 6 mg/day. She also received trihexyphenidyl 2 mg/day and lorazepam 2 mg/day. In addition, she was treated with iron and folic acid supplementation. Over a period of 4 weeks, the pica completely resolved and her Hb level reached 10.4 g%. Her psychotic symptoms partially responded. On follow-up visits, risperidone was further increased to 8 mg/day and her psychopathology improved.
In the context of schizophrenia, the development of pica has various potential causes:
- Long standing malnutrition related to an underlying chronic psychotic illness
- Psychotropic induced compulsive eating behavior of inedible substances[4]
- Hematopoietic suppression resulting from
- Chronic psychotic illness
- Chronic use of psychotropics.
- A feature of disorganized behavior.
Pica is believed to be an obsessive-compulsive spectrum disorder[5] and obsessive-compulsive symptoms are also not uncommon in patients with schizophrenia. It seems that there exists substantial overlap among the three clinical entities – schizophrenia, obsessive-compulsive disorder, and pica.
In our case, laboratory findings were suggestive of iron deficiency anemia and the patient showed a good response to iron supplementation. Risk factors for iron deficiency in this patient were – female gender, low socioeconomic status, chronic psychotic illness, and a recent history of pulmonary tuberculosis. This case shows that pica can be a warning signal of underlying iron deficiency irrespective of other clinical associations.
1. Federman DG, Kirsner RS, Federman GS. Pica: Are you hungry for the facts? Conn Med. 1997;61:207–9
2. Moore DF Jr, Sears DA. Pica, iron deficiency, and the medical history Am J Med. 1994;97:390–3
3. Tracy JI, de Leon J, Qureshi G, McCann EM, McGrory A, Josiassen RC. Repetitive behaviors in schizophrenia: A single disturbance or discrete symptoms? Schizophr Res. 1996;20:221–9
4. Huang JH, Shiah IS, Lee WK, Tzang RF, Chang KJ. Olanzapine-associated pica in a schizophrenia patient Psychiatry Clin Neurosci. 2010;64:444
5. Stein DJ, Bouwer C, van Heerden B. Pica and the obsessive-compulsive spectrum disorders S Afr Med J. 1996;86(12 Suppl):1586–81591-2
