Pica is defined as persistent conscious ingestion of largely non-nutritive substances. It is classified as a separate disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). According to DSM-IV criteria, these actions are considered pica if they are persistent for more than 1 month in a person more than 18–24 months of age and are sufficiently severe enough to warrant clinical attention. Depending on the substance consumed varied types of disorders such as geophagy (consumption of soil, clay or chalk); coprophagy (consumption of faeces); hyalophagia (consumption of glass); pagophagia (pathological consumption of ice) and others have been identified as pica. Geophagy and pagophagia are implicated as the most common forms of pica[¹, ²]. Pica is seen more commonly in women as compared to men[³]. It has been linked with various mineral deficiencies, most commonly iron and usually it is suggested that the substance consumed has the mineral that the patient is deficient in[⁴]. In adults it is more commonly observed among pregnant women and patients with mental disorders[⁵]. The increasing evidence of pica being linked with the psychiatric disorders might have three important implications. First, the psychiatric disorders such as schizophrenia and major depressive disorder might cause mental instability so much so as to induce behaviour like pica. Second, disorders such as obsessive-compulsive disorder (OCD) may manifest in the form of pica. In support of the same, a recent case report has reported the successful treatment of pica using selective serotonin reuptake inhibitors (SSRIs), medications that are most commonly used in the treatment of OCD[⁶]. Third, it is also possible that the psychological distress produced as a result of primary pica might chronically result in disorders such as depression or even in some cases, psychosis. We report herein a case of an apparently healthy young lady with pica who committed suicide by hanging herself.

A 23-year-old unmarried woman was living with her parents and two siblings. She had an apparently healthy relationship with all the members of the family. She was average in her studies and was pursuing a course in computers. She was apparently healthy and had no diagnosed medical or psychiatric disorder except that nearly 7 years ago her father noticed that she was into the habit of consuming soil from the flower pot. Later her family members noticed that she also consumed pencils and chalks. According to her family she had no signs of clinical depression or history suggestive of any psychiatric disorder. Often she would be confronted by her family members because of pica which would leave her deeply distressed. A day before suicide, her elder brother caught her eating soil from a flower pot. She was confronted by her brother and mother, after which she appeared to be unusually upset, though the details of the conversation are unknown.

On the fateful day, she did not come out of her room and her bedroom was locked from inside. After a few hours the door was forcibly opened when it was discovered that her body was hanging from a ceiling fan with a dupatta (a long scarf that is a part of women's dress in most parts of India). She was immediately taken to the hospital where she was declared brought dead. A suicide note was discovered in which she had expressed love as well as apology towards her family members. She had also mentioned that barring her best friend no one else could understand her feelings.

On autopsy, a reddish brown ligature mark was found in the middle of the neck. The ligature mark was incomplete posteriorly and was running obliquely, upwards and backwards. On dissection of the neck, underlying soft tissue showed no extravasation of blood. The thyrohyoid complex, neck muscles and blood vessels were intact. Tracheal mucosa was found to be congested. Stomach was found to contain partially digested food. Most of the internal organs were congested. It was also found that the gall bladder was shrunken and was adherent to the liver. Microscopic examination of gastrointestinal tract, liver, gall bladder, and pancreas were unremarkable and were not suggestive of any pathology. Cause of death was estimated to be asphyxia due to be ante-mortem hanging.

Pica is a relatively common disorder that is largely underreported primarily because in most cases the patients are reluctant towards admitting their craving for nonnutritious substances. Hence, its prevalence shows a lot of variations from one report to other[⁷]. Also, even if discovered, it is not considered as a disorder and often no specific therapy is undertaken. Usually the patients of pica seek medical attention because of the associated complications. Geophagy is strongly associated with iron deficiency anaemia. High concentrations of elemental lead that occur in the soil are found to be associated with the sideroblastic anaemia. Also, the parasitic infestation from the soil could lead to the development of anaemia[⁸, ⁹]. However, in the case discussed above there were no signs of anaemia. Though geophagy is the most common form of pica, however there have been case reports of patients eating substances that are acutely hazardous to the body such as sponge, fire crackers, metallic objects such as iron nails and even talcum powder and have resulted in various complications like intestinal obstruction, perforation and interstitial lung disease[¹⁰, ¹¹, ¹²-¹³]. In many of such cases the patient's mental condition is not well and it becomes really difficult to assess whether the patient had a primary pica disorder or suicidal ideation due to other underlying disorders[¹⁰].

In the above-discussed case, chronic build up of distress drove the woman to her disastrous end. In the suicide note, she expressed her resentment towards her family because of their inability to understand her problems and how she felt about them. This case classically illustrates plead of the patients suffering from pica towards quitting their behaviour and their shear helplessness in this regard. It points towards the utmost need for the specific behaviour therapies along with the need to look for appropriate pharmacologic treatment in the management of this common disorder.

In conclusion, pica cannot and should not be ignored because it can have potentially dangerous complications. But at the same time, the patients should not be confronted and their helplessness to cease their behaviour should be acknowledged. Therefore, the appropriate step for a patient having pica must be to seek the medical consultation as soon as possible.

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