Pica and Rumination Disorder in DSM-5

The major proposed change for both pica and rumination disorder in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition is their relocation from their current section, titled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,"¹ to the newly proposed section, "Feeding and Eating Disorders."²

This change emphasizes that these disorders occur across the age range, including adulthood. Also, specifiers for severity and course have been suggested for each of these disorders, in keeping with DSM-5 format. Additional minor, but noteworthy, changes in phrasing that clarify ascertainment of diagnostic criteria are summarized in this paper.

Pica

Proposed Diagnostic Criteria for Pica

The sine qua non of pica is the recurring ingestion of nonnutritive substances.¹ Changes to phrasing of diagnostic criteria in DSM-5 are intended to guide clinicians in distinguishing eating behaviors that warrant a diagnosis of pica from behaviors that are developmentally normal, culturally supported or socially normative, or that support a diagnosis of a different mental disorder.

Our recommended changes indicate that consumption of products that are regarded as foods or beverages, even if they are without nutritional value (eg, diet soda and other "zero calorie" products), would not be consistent with pica. Two years is our suggested minimum age for a pica diagnosis; at younger ages, mouthing different kinds of objects is considered developmentally normal. Consumption of substances consistent with local cultural practices or social norms would not warrant a pica diagnosis.

Lastly, we recommend that a pica diagnosis would be given in the context of another mental disorder or medical condition only if the behavior requires additional, rather than independent, clinical attention, since clinical management of pica eating and the other disorder or condition would likely be integrated.

Clinical Presentation

Individuals with pica may consume an eclectic variety of substances, including mud, pottery, clay, and laundry starch. Pica eating of numerous other substances, such as paper, tissues, wood, plastic straws, soap, cloth, carpet, hair, string, wool, paint, gum, metal, pebbles, chalk, charcoal, coal, and ash, has also been reported.

Substances consumed may vary with age or availability. Persistent consumption of food starches, such as cornstarch and uncooked pasta or rice, does not meet the diagnostic criterion for non-nutritive substances.

Likewise, persistent consumption of ice does not satisfy...