Pica vs. Avoidant/Restrictive Food Intake Disorder
Both are sometimes grouped together simply as 'atypical eating' in casual discussion, obscuring that they involve opposite behaviors -- consuming nonfood items versus avoiding actual food.
Learn
Core explanation
Core concept
Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month, inappropriate to the developmental level of the individual, not part of a culturally supported or socially normative practice, and severe enough to warrant independent clinical attention if occurring alongside another mental disorder or medical condition.
Plain-language explanation
Pica involves a persistent pattern of eating things that aren't food and have no nutritional value — such as paper, soap, cloth, hair, chalk, or dirt — that continues for at least a month and isn't developmentally normal (like a toddler briefly mouthing a non-food item) or part of a culturally sanctioned practice. A September 2024 DSM-5-TR text/coding update added a distinct adult-specific code, reflecting that Pica is diagnosable at any age, not just in children.
Developmental considerations
Diagnosable at any age; the September 2024 DSM-5-TR update added a distinct adult-specific ICD-10-CM code reflecting that Pica occurs across the lifespan, including in pregnancy, and is not exclusively a childhood presentation.
Functional impact
Medical risks can be significant and depend on the substance ingested — ranging from dental damage and intestinal obstruction/perforation to poisoning (e.g., from ingesting lead-containing materials) and parasitic infection — making medical evaluation and monitoring an essential part of management alongside behavioral treatment.
Associated features
More common in individuals with intellectual disability, autism spectrum disorder, and in the context of pregnancy; nutritional deficiencies (e.g., iron or zinc deficiency) are sometimes identified as a contributing or co-occurring factor and should be evaluated.
Cultural considerations
Some cultures have traditional, socially sanctioned practices of consuming particular nonfood substances (such as specific clays), which DSM-5-TR explicitly excludes from the diagnosis; careful inquiry into the social and cultural context of the behavior is essential before applying the Pica diagnosis.
Common misconception
A common misconception is that Pica is only a childhood disorder. The September 2024 update specifically added an adult-specific code, and Pica is recognized as diagnosable at any age, including during pregnancy, where cravings for nonfood substances can occur.
Reconsider this formulation
If the ingestion of a nonfood substance is a recognized, socially sanctioned practice within the individual's culture, or reflects normal mouthing behavior in a very young child, reconsider whether the Pica criteria are actually met before applying the diagnosis.
Example fictional case
A 6-year-old repeatedly eats paint chips, paper, and small amounts of dirt over several months, unrelated to any recognized cultural practice and well beyond typical toddler mouthing behavior, prompting medical evaluation for possible lead exposure alongside a Pica diagnosis.
Quick recall
Know
Pica is the persistent, developmentally inappropriate, non-culturally-sanctioned eating of nonfood substances for at least 1 month, diagnosable at any age including adulthood and pregnancy, and carrying real medical risk depending on the substance involved.
Notice
In a case, notice whether the substance is genuinely nonnutritive/nonfood (Pica) rather than restriction or avoidance of actual food (ARFID), and whether the behavior is developmentally inappropriate and outside any recognized cultural practice.
Distinguish
Distinguish from Avoidant/Restrictive Food Intake Disorder by what's being consumed (nonfood substances in Pica vs. avoidance/restriction of actual food in ARFID) — the two describe fundamentally different eating behaviors.
References
Recognize
Spot the pattern
Recognition pattern
Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month; eating behavior inappropriate to the developmental level of the individual; eating behavior not part of a culturally supported or socially normative practice; if occurring in the context of another mental disorder or medical condition (including pregnancy), severe enough to warrant independent clinical attention.
What to notice
- Persistent eating of nonnutritive, nonfood substances for at least 1 month
- Inappropriate to developmental level
- Not part of a culturally supported or socially normative practice
- Diagnosable at any age, including adulthood and pregnancy (2024 update added an adult-specific code)
Distinguish
Differential reasoning
Distinguish
Distinguish from Avoidant/Restrictive Food Intake Disorder by what's being consumed (nonfood substances in Pica vs. avoidance/restriction of actual food in ARFID) — the two describe fundamentally different eating behaviors.
Differential considerations
Avoidant/Restrictive Food Intake Disorder involves avoidance or restriction of actual food due to sensory characteristics, lack of interest, or fear of aversive consequences, not the eating of nonfood substances — the two involve fundamentally different eating behaviors and are not diagnostically overlapping. Developmentally normal mouthing of objects in very young children, and culturally supported practices (e.g., certain traditional consumption of clay in some cultures and regions), are explicitly excluded and must be distinguished from clinically significant Pica.
Commonly confused conditions
Related comparisons
Pica vs. Other Specified / Unspecified Feeding or Eating Disorder
Clinicians sometimes reach for the residual category prematurely when a nonfood-ingestion pattern looks slightly atypical, without first checking whether it in fact satisfies Pica's actual criteria (which do not require any particular substance, frequency beyond 'persistent,' or specific medical harm).
Pica vs. Rumination Disorder
Both are sometimes lumped together simply as 'unusual eating behaviors in children,' but they involve entirely different physical acts and different downstream medical risks -- Pica's danger is largely about ingested substance toxicity/obstruction, while Rumination Disorder's danger is largely about nutritional loss from repeated regurgitation.
Reason
Work through the logic
Reasoning prompts
- Has the substance's medical risk (e.g., toxicity, obstruction potential) been assessed and addressed alongside the behavioral diagnosis?
- Is the ingestion behavior outside any recognized cultural practice and inappropriate for the individual's developmental level?
Clarifying questions to ask
- Is the person consuming nonfood substances, or avoiding/restricting actual food?
- What specific mechanism (sensory sensitivity, low interest, fear of aversive consequences) appears to be driving restriction, if ARFID is being considered?
- Has the medical risk specific to the substance (if Pica) or nutritional status (if ARFID) been assessed?
- Has the nonfood ingestion persisted for at least a month, and is it inappropriate to the person's developmental level?
- Have Pica and the chapter's other specific disorders been considered and ruled out?
- Is there a clear substance or behavior pattern, or is the presentation genuinely atypical or mixed?
- Is the person ingesting nonfood substances, or regurgitating and re-processing food already swallowed?
- Has a gastrointestinal medical cause of any regurgitation been ruled out?
- Is the behavior culturally supported or socially normative in this person's context?
Apply
Put it to use
Case Lab
Not Food
Recognize Pica's core pattern of eating nonfood substances, distinguished from ARFID's avoidance or restriction of actual food.
Retrieve
Recall it cold
Practice questions
2 question(s) reference this disorder. Practice Pica →
Master