EMPIRICAL ARTICLE

Pica and Rumination Behavior among Individuals

Seeking Treatment for Eating Disorders or Obesity

Charlotte B. Delaney, BA1,2 Abstract

Kamryn T. Eddy, PhD2,3
Andrea S. Hartmann, PhD4
Anne E. Becker, MD, PhD2,3,5
Helen B. Murray, BA2
Jennifer J. Thomas, PhD2,3*
Objective: Pica and rumination disorder
(RD)—formerly classified within DSM-IV
Feeding and Eating Disorders of Infancy
or Early Childhood—are now classified
within DSM-5 Feeding and Eating Disor-
ders. Though pica and RD have been
studied in select populations (e.g., preg-
nant women, intellectually disabled per-
sons), their typical features and overall
prevalence remain unknown. This study
examined the clinical characteristics and
frequency of DSM-5 pica and RD among
individuals seeking treatment for eating
disorders and obesity.
Method: We conducted structured inter-
views with adolescent and young adult
females from a residential eating disorder
center (N 5 149), and adult males and
5.1%) at the residential eating disorder
center and 0% at the weight-loss clinic
met DSM-5 criteria for pica, consuming
gum and plastic. Although no eating dis-
order participants were eligible for an RD
diagnosis due to DSM-5 trumping rules,
7.4% (n 5 11; 95% CI: 4.0% to 12.9%)
endorsed rumination behavior under
varying degrees of volitional control. At
the weight-loss clinic, 2.0% (n 5 2; 95%
CI: 0.1% to 7.4%) had RD.
Discussion: DSM-5 pica and RD were
rare in our sample of individuals seeking
treatment for eating disorders and obe-
sity, but related behaviors were more
common. The wide range of pica and
rumination presentations highlights the
challenges of differential diagnosis with
other forms of disordered eating. VC 2014

females with overweight or obesity from Wiley Periodicals, Inc.

an outpatient weight-loss clinic
(N 5 100). Keywords: pica; rumination; DSM-5;
eating disorder; feeding disorder
Results: Several participants reported
ingesting non-nutritive substances (e.g., (Int J Eat Disord 2014; 00:000–000)
ice) for weight-control purposes. How-
ever, only 1.3% (n 5 2; 95% CI: .06% to

Introduction
The previous and fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-
Accepted 11 March 2014 IV) classified pica and rumination disorder (RD)
Disclosure: The authors disclosed no proprietary or commercial
under Feeding and Eating Disorders of Infancy or
interest in any product mentioned or concept discussed in this
article. Early Childhood.1 DSM-5 recently combined these
Previous Presentation: These data were included in a poster conditions with the better-studied disorders of
presentation at the 2013 Eating Disorder Research Society meet-
anorexia nervosa (AN), bulimia nervosa (BN), and
ing in Bethesda, MD.
Supported by Office of Medical Student Research of the Albert binge eating disorder (BED) to comprise the uni-
Einstein College of Medicine and Hilda and Preston Davis tary category of Feeding and Eating Disorders.2
Foundation.
Though pica has gained some notoriety due to sen-
*Correspondence to: Jennifer J. Thomas, Ph.D., Eating Disorders
Clinical and Research Program, Massachusetts General Hospital, 2 sationalized depictions on television shows such as
Longfellow Place, Suite 200 Boston, MA 02114. My Strange Addiction,3 both pica and RD remain
E-mail: jjthomas@mgh.harvard.edu
1 inadequately understood and frequently go unde-
Albert Einstein College of Medicine, Yeshiva University, Bronx,
New York tected in clinical settings.4,5
2
Eating Disorders Clinical and Research Program, Massachu-
setts General Hospital, Boston, Massachusetts
3
Department of Psychiatry, Harvard Medical School, Boston, Pica
Massachusetts
4
Insititute for Psychology, University of Osnabr€
uck, Germany Pica is the recurrent consumption of
5
Department of Global Health and Social Medicine, Harvard “nonnutritive, nonfood” items,2 such as dirt, chalk,
Medical School, Boston, Massachusetts or paper. The word “nonfood” was added to DSM-5
Published online 00 Month 2014 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22279 to exclude substances with minimal nutritional
VC 2014 Wiley Periodicals, Inc. value, such as low-calorie foods, which may be

International Journal of Eating Disorders 00:00 00–00 2014 1

DELANEY ET AL.
consumed in excess as a means of weight manage-
ment. To meet DSM-5 criteria, these behaviors
must last longer than one month, be developmen-
tally inappropriate, and not be part of a culturally
normative practice. If pica eating occurs during the
course of another mental or physical condition,
such as autism spectrum disorder or pregnancy, it
must be severe enough to require additional clini-
cal care.
According to DSM-5, “the prevalence of pica is
unclear” in the general population (p. 330).2
Indeed, prevalence estimates are difficult to ascer-
tain due, in part, to the inconsistent operationaliza-
tion of pica across studies. For example, some
studies have counted cases in which items with
some nutritional value, including cornstarch or
uncooked rice, are consumed,4,6 and some have
included the ingestion of ice, typically considered a
food, whereas others have estimated prevalence
using cases that meet the more strict “nonnutritive,
nonfood” definition. Other studies have reported
occurrence of pica eating, without describing the
recurrence or duration of the behavior. Addition-
ally, many studies have reported cross-sectional
data and focused on select demographic strata,
finding relatively high rates of pica behavior. These
high-prevalence groups have included pregnant
women (up to 77%),7 individuals with intellectual
disabilities (15%),6 children in sub-Saharan Africa
(up to 74%),8 and persons with iron-deficiency
anemia (61% ice pica, 24% other pica).9 Challenges
to ascertaining pica prevalence in clinical settings
include shame about the behavior,5 or, in contrast,
viewing the behavior as normal.10 Furthermore,
clinicians may not inquire about pica eating in the
absence of physical signs. Case reports provide
examples in which covert pica was not revealed
until serious medical consequences arose; poten-
tial complications of pica include heavy metal tox-
icity:6,11 gastrointestinal obstruction;6,11 parasitic
infection;12 or dental problems such as caries, ero-
sion or abrasion, loss of vertical dimension of
occlusion, and cracked teeth.11–13
Rumination Disorder
RD is the recurrent, effortless regurgitation of
food, which is subsequently rechewed, reswal-
lowed, or spit out. The behavior is not due to a
medical condition, such as gastroesophageal reflux
disorder (GERD), and occurs without nausea or
retching. When it presents comorbidly with
another mental disorder, rumination behavior
must be severe enough to require additional clini-
cal care. A formal DSM-5 diagnosis cannot be con-
2 International Journal of Eating Disorders 00:00 00–00 2014
ferred if rumination symptoms present exclusively
in the context of AN, BN, BED, or avoidant restric-
tive food intake disorder (ARFID). However, DSM-5
does not provide specific guidelines about whether
other specified feeding or eating disorder (OSFED)
or unspecified feeding or eating disorder (UFED)
would trump RD in a patient who presents with
both problems.2
Similar to pica, DSM-5 characterizes RD preva-
lence in the community as “inconclusive” (p. 333).2
Whereas there are few epidemiologic data address-
ing prevalence, the dearth of information may also
be partially attributable to non-disclosure of symp-
toms.14 This is illustrated in a case study where a
patient, who finally sought treatment for BN after
13 years of rumination behavior, described rumina-
tion as “the biggest secret I ever had.”15 Moreover,
the symptoms can resemble or overlap with those
of GERD, gastroparesis, and BN; and RD may not
routinely be considered when a patient presents
with recurrent vomiting or regurgitation.5,16Alth-
ough the overall prevalence is unknown, available
evidence supports that RD is more common
among infants, children (5%),17 and persons with
developmental disabilities (5–10%).18 In addition
to its associated psychological distress, rumination
can also cause medical complications such as mal-
nutrition,11 significant weight loss,16 electrolyte
disturbances,16,19 and dental complications includ-
ing caries, erosion, and halitosis.11,16
Comorbidity Between Pica, RD, and Eating
Disorders
According to DSM-5 trumping rules, a pica diag-
nosis can be made in the presence of another eat-
ing disorder under some circumstances. However,
if motivation for eating the nonfood item is driven
by another eating disorder (e.g., desire to suppress
hunger in AN) a diagnosis of pica would not be
made.2 As early as the 19th century, physicians
reported young women eating nonfood items such
as paper, thread, chalk, and vinegar as a way to
control their shape and weight.4 Anecdotal evi-
dence suggest that this pattern has persisted: for-
mer editor of Vogue Australia, Kirstie Clements,
described models eating tissues to stay thin,20 and
Janice Celeste, mother of a fashion model, wrote in
her book: “I’ve seen some life-threatening meas-
ures models have gone through to lose weight . . . I
personally know of one model who dipped cotton
balls in orange juice and consumed it to feel full.
Later it came out that she had anorexia.”21 Multiple
case reports describe ice pica eating among indi-
viduals with AN,22,23 and another documents a
 DSM-5 PICA AND RUMINATION DISORDER

TABLE 1. Characteristics of the residential eating disorder treatment center (N 5 149) and outpatient weight-loss
clinic (N 5 100) samples
Residential Eating Disorder Outpatient Weight-
Treatment Center Loss Clinic
Gender Female n (%) 149 (100%) 72 (72.0%)
Male – 28 (28.0%)
Age Mean (SD) 18.1 (2.7) 45.8 (12.0)
Race White 141 (94.6%) 81 (81.0%)
Asian 6 (4.0%) 2 (2.0%)
African American 4 (2.7%) 12 (12.0%)
American Indian/Alaskan Native 2 (1.3%) 2 (2.0%)
Ethnicity Hispanic or Latino 6 (4.0%) 10 (10.0%)
Not Hispanic or Latino 143 (96.0%) 90 (90.0%)
DSM-5 Eating Disorder Diagnosis AN 69 (46.3%) –
BN 29 (19.4%) 2 (2.0%)
ARFID 4 (2.7%) –
BED – 9 (9.0%)
OSFED 47 (31.5%) 21 (21.0%)
None – 68 (68.0%)

AN: anorexia nervosa; ARFID: avoidant/restrictive food intake disorder; BED: binge eating disorder; BN: bulimia nervosa; OSFED: other specified feeding
or eating disorder.
Note: Race percentages do not add up to 100% because some participants self-identified with multiple races, and others declined to answer the
question.

woman with BN who replaced bingeing and vomit-
ing with the ingestion of baby powder.23 Although
these cases highlight the potential for phenomeno-
logical overlap between pica eating and other eat-
ing disorders, all preclude a formal DSM-5 pica
diagnosis because the pica eating was motivated
by weight control.
Unlike pica, an RD diagnosis cannot be given in
the presence of another DSM-5 eating disorder.
Nevertheless, rumination behavior has been docu-
mented among individuals with eating disor-
ders.10,19,25 In a sample of 35 women with BN, 20%
reported rumination behavior.10 In another sample
of eight patients presenting with rumination
behavior, five met criteria for eating disorders,25
while other case studies have highlighted presenta-
tions of rumination behavior comorbid with AN19
and binge eating.26 Case reports on patients with
BN have included their description of rumination
as an independent weight control measure—both
as a “step above the vomiting,”27 and a way to
enjoy food without purging or gaining weight.19
In summary, available data from case reports
and case series suggest that pica and rumination
behavior are observable clinical phenomena that
sometimes co-occur with other forms of disordered
eating. However, their exact prevalence is unknown
outside of highly specialized populations. Further-
more, no studies to date have evaluated the preva-
lence of pica and RD—in any population—using
newly revised DSM-5 criteria. Therefore, the pres-
ent study sought to describe the clinical character-
istics and frequency of pica, RD, and related
behaviors in two distinct groups at high risk for
feeding problems: individuals seeking treatment
for either an eating disorder or overweight/obesity.
We selected these two populations to maximize the
opportunity to identify and describe these rela-
tively rare behaviors, laying the groundwork for
larger-scale epidemiological inquiry. A second aim
of this study was to highlight the challenges inher-
ent to differential diagnosis of pica and RD with
other eating disorders.
Method
Participants
We recruited participants from two clinical settings in
New England: a residential treatment facility for adoles-
cent and young adult females with eating disorders; and
an outpatient clinic for male and female adolescents and
adults seeking weight-loss treatment.
Residential Eating Disorder Treatment Center. At the
residential eating disorders treatment center, consecutive
patients admitted between July 2011 and October 2012
(N 5 164) were invited to participate in a field trial of the
DSM-5 criteria for feeding and eating disorders. Of those,
150 enrolled in the study, reflecting a 91.4% response
rate. Of the 150, all but one fully completed study inter-
views, leaving an analytic sample of 149. Demographic
characteristics are presented in Table 1.
Outpatient Weight-Loss Clinic. At the outpatient
weight-loss clinic, consecutive patients who presented
for treatment of overweight or obesity between October
2011 and January 2012, and who completed an intake
evaluation with one of two participating psychologists,

International Journal of Eating Disorders 00:00 00–00 2014 3

DELANEY ET AL.
were invited to take part the study. (All new patients
receive a mental health evaluation as part of routine care
at the weight-loss clinic. The two participating psycholo-
gists conducted evaluations with 80% of total clinic
patients during the recruitment period, with the remain-
der of new patients seen by part-time clinicians or train-
ees who did not recruit participants for the research
study.) Out of 147 patients approached, 100 (68.0%)
enrolled and completed interviews. See Table 1 for
demographics.
Each study participant provided informed consent (or,
if under 18, assent and parental consent). Participants
were compensated $40 upon completion of the inter-
views. The Partners Human Research Committee
approved all study procedures.
Assessment of Feeding and Eating Disorders
We assessed the presence of any DSM-5 feeding or eat-
ing disorder with a structured clinical interview, adminis-
tered either in person (at the residential eating disorder
treatment center) or via telephone (at the outpatient
weight loss clinic). Study interviewers comprised three
clinical psychologists, a clinical psychology doctoral stu-
dent, and a clinical psychology intern, all with graduate-
level training in eating disorders.
Eating Disorder Assessment. Because no structured
interviews for DSM-5 feeding and eating disorders were
available in the public domain at the time the study was
conducted, we assessed individual symptoms using
extant interviews keyed to DSM-IV criteria. We then
asked additional questions querying DSM-5 criteria from
the diagnostic checklist for DSM-5 feeding and eating
disorders developed by B. Timothy Walsh M.D., Chair of
the DSM-5 Work Group. At the residential eating disor-
ders center, we assessed eating disorder psychopathol-
ogy with the Eating Disorder Examination interview
version 16.0.27 In a convenience subsample of 16 cases
who were double-coded based on an audio-recording of
the original interview, the two raters conferred the same
eating disorder diagnosis in 93.8% of cases (inter-rater
reliability j 5 0.92). At the outpatient weight-loss clinic,
we assessed the current presence of eating disorder
symptoms with the Structured Clinical Interview for
DSM-IV.28 In a randomly selected subsample of 20 cases
who were double-coded, the two raters conferred the
same diagnosis in 95% of cases (inter-rater reliability
j 5 0.87).
Assessment of Pica and RD. We used Walsh’s DSM-5
checklist to confer pica and RD diagnoses. Because the
instrument is an investigator-based checklist that does
not contain standardized probe questions, we used a
gateway question for pica similar to an item in an exist-
ing child interview (i.e., the Diagnostic Interview Sched-
ule for Children30). To query for pica, we asked, “Over
4 International Journal of Eating Disorders 00:00 00–00 2014
the past month, have you eaten anything that other peo-
ple might not consider food, such as paper, chalk, or
large quantities of ice?” [We included ice in the query
because previous studies had done so, and DSM-5, which
contained the revised “non-food” wording, had not yet
been published.] For RD, we asked, “Over the past
month, have you had the experience of regurgitating
food, i.e., bringing it back up into your mouth, and then
either chewing it again, swallowing it again, or spitting it
out?” If a participant endorsed either of these behaviors,
the interviewer asked additional open-ended questions
(e.g., regarding frequency, duration, and motivations for
pica and rumination behavior) to ascertain whether the
participant met the remaining criteria from the DSM-5
checklist. Interviewers recorded responses in real time
during interviews, including yes/no responses to pica
and rumination gateway questions. Digital recordings of
participants who responded affirmatively were subse-
quently transcribed verbatim. Once final DSM-5 criteria
were published in May 2013, two investigators (CBL, JJT)
reviewed the transcripts to confer final DSM-5 pica and
RD diagnoses. For discrepant cases, two additional inves-
tigators (AEB, ASH) determined the final diagnosis.
We determined caseness by applying a conservative
interpretation of DSM-5 criteria that excluded pagophagia
(ice consumption). In addition, observations that could
not establish duration or recurrence criteria either
because of explicit or indeterminate responses were
assigned as noncases for the purpose of frequency esti-
mates. We later undertook a sensitivity analyses that iden-
tified any pica or rumination behavior that did not meet
DSM-5 criteria. Under “any pica behavior,” we included
participants who (1) met behavioral criteria but with a
“non-pica” substance, such as ice; (2) engaged in pica eat-
ing, but with either short duration, sporadic frequency, or
unclear information regarding timing of behavior; or (3)
engaged in pica eating (of either a pica or non-pica sub-
stance) where the primary motive was judged to be appe-
tite suppression. Similarly, under “any rumination
behavior,” we included participants who (1) met behav-
ioral criteria, but in the presence of a comorbid eating dis-
order, therefore excluding an RD diagnosis; or (2) engaged
in rumination behavior in which the timing, frequency, or
voluntary/involuntary nature of the behavior was unclear.
For the purposes of this study, we made the a priori
decision to let OSFED/UFED trump RD in our sample of
eating disorder patients, because the residential program
from which we recruited did not specifically offer treat-
ment for pica or RD, suggesting that OSFED/UFED symp-
toms were the primary reason for seeking care. To allow
for straightforward comparison across samples, we
applied the same trumping scheme to weight-loss clinic
participants.

Results
Clinical Characteristics and Frequency of Pica
Table 2 summarizes participant narrative and
investigator-assessed descriptive data used to
ascertain pica eating in both the residential eating
disorder and weight-loss samples. Applying DSM-5
criteria, 1.3% (n 5 2; 95% CI: .06% to 5.1%) of par-
ticipants at the residential eating disorder treat-
ment center had pica. In one case the pica
substance was gum (i.e., “I used to eat a pack of
gum in an hour as a snack”), and, in the other, plas-
tic (i.e., “[I eat] little cocktail swords”). We did not
identify any case of pica at the outpatient weight-
loss clinic.
As a sensitivity test and means to encompass the
broad phenomenologic range of pica eating
reported by study participants, we also identified
cases with similarities to pica eating but not meet-
ing DSM-5 criteria. This group included partici-
pants who consumed non-pica substances such as
still-frozen foods, uncooked pasta, or entire cups of
ice; did not provide sufficient frequency/duration
data; or engaged in pica-like eating for the purpose
of weight control. For example, one participant at
the residential eating disorder center who repeat-
edly consumed ice cubes explained that, “I needed
to chew on something and I didn’t want to eat.”
Interestingly, another participant in this group
reported negative consequences from her persis-
tent ice consumption (i.e., “I’ve had a few cavities. I
actually broke one tooth in the back of my
mouth”). Those endorsing any pica behavior com-
prised 7.4% (n 5 11, 95% CI: 4.0–12.9%) of partici-
pants at the residential eating disorder treatment
center and 4.0% (n 5 4, 95% CI: 1.2–10.2%) at the
outpatient weight loss clinic.
At the residential eating disorder treatment cen-
ter, the comorbid eating disorder diagnoses of par-
ticipants reporting any pica eating included AN-
restricting type (n 5 2, 18.2%), AN-binge-eating/
purging type (n 5 1, 9.1%), BN (n 5 4, 36.3%), and
OSFED (n 5 4, 36.4%). At the outpatient weight loss
clinic, two participants with pica behaviors had no
comorbid eating disorder, while one participant
had BED, and one had OSFED; this 50% eating dis-
order prevalence in the subset with pica eating
compared with 32% overall eating disorder preva-
lence at the weight-loss clinic.
Clinical Characteristics and Frequency of RD
Table 3 depicts qualitative descriptions of rumi-
nation behavior in both the residential eating dis-
order and weight-loss samples. Four participants at
International Journal of Eating Disorders 00:00 00–00 2014
DSM-5 PICA AND RUMINATION DISORDER
the residential treatment center met all criteria for
RD, but were ineligible for a formal diagnosis
because of DSM-5 trumping rules. Since none of
the residential eating disorder participants was eli-
gible to receive an RD diagnosis, a priori, no cases
were identified. At the weight loss clinic, 2.0%
(n 5 2, 95% CI: 0.1–7.4%) met criteria for RD. Both
participants described the behavior as volitional
and reported that it was more likely to occur after
consuming specific foods (e.g., red meat, pizza).
Furthermore, one weight-loss participant
explained that his decision whether to spit or re-
chew the regurgitated food depended on taste
selectively: “If it’s a good slice of pizza, I’m not
going to waste it. But if it was spinach to begin
with, of course I’m going to spit it out.”
In addition to DSM-5 RD, we also identified
rumination behavior in the narrative data that did
not meet DSM-5 criteria. These individuals exhib-
ited behavior that had not occurred within the past
month, was very infrequent, or could not unequiv-
ocally be distinguished from involuntary/physio-
logic processes (e.g., reflux; see Table 3). For
example, whereas one residential participant
described her habitual regurgitation as “very vol-
untary,” other participants viewed their own rumi-
nation behavior as “not on purpose” and “out of
my control.” The frequency of any rumination
behavior was 7.4% (n 5 11; 95% CI: 4.0–12.9%) at
the residential treatment center, but we identified
no additional cases at the weight-loss clinic using
this broader definition.
Like pica, rumination behavior appeared across
the spectrum of eating disorder diagnoses in the
residential treatment sample including AN-
restricting type (n 5 2, 18.2%), AN-binge-eating/
purging type (n 5 2, 18.2%), BN (n 5 3, 27.2%), and
OSFED (n 5 4, 36.4%). Neither participant from the
outpatient weight loss clinic with RD had a comor-
bid eating disorder.
Discussion
To our knowledge, we report the first data on clini-
cal characteristics and frequency of either pica or
RD ascertained with the newly revised DSM-5 crite-
ria. Bona fide pica substances in our sample
included gum and plastic, but ice consumption not
meeting DSM-5 criteria for pica was much more
common. RD was typically linked to specific foods
(e.g., meat or pizza), and participants who engaged
in any rumination behavior differed in whether
they viewed the behavior as entirely volitional. Our
findings support a low frequency of DSM-5 pica
5
DELANEY ET AL.

TABLE 2. The range of pica behavior among individuals seeking treatment for eating (N 5 149) and weight (N 5 100)
disorders
Participant Description of
Clinical Setting Sex Age BMI DSM-5 ED Behavior
DSM-5 pica
Residential ED F 15 14.8 AN-R “I have these weird habits . . .
I drink vinegar . . . and
pickle juice. I like the sour-
ness. And [I eat] little cock-
tail swords . . . sometimes I
swallow them, which I
shouldn’t. It’s pica.”
Residential ED F 17 24.8 BN “Since I was a little kid, I
always ate my gum . . . I
actually have gotten scared
of swallowing it . . . I don’t
do it as much anymore,
but I used to eat a pack of
gum in an hour as a
snack.”
Any pica behavior
Outpatient Weight Loss F 48 39.7 – “I put ice in a cup and I eat it
all the time . . . I always
have a cup of ice with me
. . . I don’t know what it is,
but if I don’t keep my
mouth moist, then I lose
my voice. So that’s why I
eat it.”
Outpatient Weight Loss F 22 44.9 OSFED “I seek ice . . . If I’m getting it
from my house, we have
the big cubed ice, so I’ll eat
like 5 or 6 of those. But if
it’s the little one from
stores, it’s like a whole cup
full . . . I do it on my own.”
Outpatient Weight Loss F 50 37.2 BED “I eat ice constantly . . . I take
glasses of ice and chew it
. . . I’ve wondered if it’s a
condition. I do it in front of
people, I do it when I’m
alone, I do it all the time.”
Residential ED F 16 20.2 OSFED “I have a habit of eating stuff
that’s supposed to be
cooked when it’s not
cooked. Like frozen meals.
I’ll eat frozen French fries
. . . I was at a friend’s house
. . . he was going to cook
them, and I just ate all of
them.”
Outpatient Weight Loss F 39 39.9 – “I do eat pasta noodles
uncooked . . . Usually it’s
like angel hair, just like a
snack. When I’m cooking
pasta, and I’ll just grab
some, munch on them . . .
It’s just kind of a habit I’ve
developed as a kid. I don’t
know if other people find it
weird, but it doesn’t bother
me . . . I did eat paper, tis-
sue paper . . . from the age
of 2 to 5.”
Residential ED F 15 16.7 AN-R “Ice by itself. Probably 5 ice
cubes, usually . . . so I
wouldn’t get hungry.”
Residential ED F 16 19.2 OSFED “Whenever I walk by the
freezer, I grab an ice cube
DSM-5 Criteria
Meets duration criterion
(about 1 month)
Persistent behavior (at least
13/week)
Pica substance (plastic)
Meets duration criterion
Persistent behavior (20 pieces
in past month)
Pica substance (gum, i.e., not
intended to be swallowed)
Meets duration criterion (5
years)
Persistent behavior (6 cups/
day)
Not pica substance
No data on duration; long-
standing behavior implied
Persistent behavior (1 cup,
53/week)
Not pica substance
No data on duration; long-
standing behavior implied
Persistent behavior (8 glasses/
day)
Not pica substance
Meets duration criterion (but
no data before the past
month)
Not pica substance
Meets duration criterion
Behavior in context of cooking
pasta, no data on other
times
Not pica substance
Possible past paper pica
Meets duration criterion (but
no data before past month)
Shape and weight rationale
Not a pica substance
Meets duration criterion
Persistent behavior (6x/day)

6 International Journal of Eating Disorders 00:00 00–00 2014

 DSM-5 PICA AND RUMINATION DISORDER

TABLE 2. Continued
Participant Description of
Clinical Setting Sex Age BMI DSM-5 ED Behavior DSM-5 Criteria
and chew on it, but I’ve Shape and weight rationale
been doing that for a really Not a pica substance
long time. My mom used to
tell me when I was younger
. . . if I was going to munch
on something in front of
the TV, chew on ice chips,
so I got used to that.”
Residential ED F 18 22.5 BN “I eat ice . . . I’d get a cup Meets duration criterion (but
from the freezer and eat it no data before past month)
instead of food.” Persistent behavior (73/
month)
Shape and weight rationale
Not a pica substance

Residential ED F 18 23.9 BN “Chewing ice cubes . . . I’d Meets duration criterion

take them purposefully, Persistent behavior (1 cup,
because I needed to chew 23/week)
on something and I didn’t Shape and weight rationale
want to eat . . .” Not a pica substance

Residential ED F 21 23.3 BN “I would compensate a lot of Meets duration criterion (but

the time with . . . a lot of no data before past month)
ice . . . I would go a couple Persistent behavior (23/day)
times a day and fill up just Shape and weight rationale
a large cup of ice.” Not a pica substance

Residential ED F 21 23.4 OSFED “Occasionally I suck on ice
cubes and spit them out or
chew them up. When I’m
restricting fluids, having an
ice cube is like a binge.”
Meets duration criterion (but
no data before past month)
Persistent behavior (1 cube,
13/day)
Shape and weight rationale
Not a pica substance

Residential ED F 21 23.7 OSFED “I eat ice a lot. I’ve been chew-
ing ice since middle school.
I just like it . . . I’ve had a
few cavities. I actually
broke one tooth in the
back of my mouth . . . I
think I do it as a behavior,
like if I’m eating ice it’s like
I’m eating real food.”
Residential ED F 23 17.2 AN-BP “I’ve eaten ice cubes . . . just
ice cubes in a cup. I heard
that if you have ice cubes
and it’s really cold so it
burns more calories.”
Meets duration criterion
Persistent behavior (33/week)
Shape and weight rationale
Not a pica substance
Possible past pica: medical
complication (tooth)
Meets duration criterion
Persistent behavior (1 cup,
13/week)
Shape and weight rationale
Not a pica substance

AN-BP: anorexia nervosa-binge-eating/purging type; AN-R: anorexia nervosa-restricting type; BED: binge eating disorder; BMI: body mass index; BN: buli-
mia nervosa; ED: eating disorder; OSFED: other specified feeding or eating disorder

and RD in two treatment-seeking populations, for
eating disorders and overweight/obesity, respec-
tively. Although we were able to estimate the point
prevalence in each of our relatively small samples,
the wide confidence intervals highlight the approx-
imate nature of these estimates. At the residential
eating disorders center, the endorsement of any
pica behavior was significantly more common than
cases meeting full DSM-5 criteria, and several par-
ticipants endorsed rumination behavior in contrast
with none eligible for a diagnosis of RD. Thus the
potential clinical utility of allowing a comorbid RD
diagnosis alongside another eating disorder in
future versions of DSM is worthy of further study.
Although based on two specialized populations
at high risk for feeding problems, our estimated
frequency for both pica and RD was substantially
lower than previous studies examining psychiatric
populations. These more conservative estimates
are consistent with the stricter definitions of pica
and RD in DSM-5 compared with DSM-IV, in par-
ticular the addition of the “non-food” requirement

International Journal of Eating Disorders 00:00 00–00 2014 7

DELANEY ET AL.

TABLE 3. The range of rumination behavior among individuals seeking treatment for eating (N 5 149) and weight
(N 5 100) disorders
Participant Description of
Clinical Setting Sex Age BMI DSM-5 ED Behavior DSM-5 Criteria
DSM-5 RD
Outpatient Weight Loss F 40 53.6 – “I have that all the time with Meets duration criterion (over
meat . . . it always kinda 12 years)
comes back up, and my Regular behavior (at least 13/
husband’s like, ‘what the month, when eating red
hell are you chewing?’ [I meat)
have] acid reflux . . . to me Distinct from reflux (no associ-
they seem two independ- ated pain/bile/acid taste)
ent things, because the
reflux, it tends to be like
heartburn that backs up
when you eat anything . . .
they seem kind of
unrelated.”
Outpatient Weight Loss M 43 26.9 – “[That happens] on a daily No data on duration; long-
basis . . . If it tasted good standing behavior implied
coming back up, it’ll taste Regular behavior (daily)
even better going back Motivation involves taste and
down . . . If it’s a good slice food selectivity
of pizza, I’m not going to Distinct from reflux (no associ-
waste it. But if it was spin- ated pain/bile/acid taste)
ach to begin with, of course
I’m going to spit it out . . . I
mean, you just try not to
think about what you’re
doing, of course . . . Just
chewing it again can’t be
that bad, you know what I
mean?”
Any rumination behavior
Residential ED F 16 26.0 BN “I do that a lot actually. I’ll, Meets duration criterion (5
like, chew it again . . . It’s years)
just kind of like a habit . . . Regular behavior (25% of
It’s not like I’m throwing meals)
up. It’s like right after I Shape and weight rationale
swallow it or right after I Distinct from vomiting
eat. I feel like it’s as if I’m
eating more, but I’m not.
It’s kind of a way to not eat
as much, I think . . .”
Residential ED F 17 16.6 AN-R “Yeah, it’s weird, no one’s Meets duration criterion (3
ever asked me that. Some- months)
times I swallow the food Regular behavior (100% of
after I chew it, but then I meals)
felt like I didn’t chew it
enough, so it comes back
up and I chew it again and
then I swallow it. Happens
all the time.”
Residential ED F 19 17.6 AN-BP “It would affect what I chose Participant previously diag-
to eat . . . things that are nosed with RD
very fibrous and would Meets duration criterion
hold together for a while, Regular behavior (100% of
those are the things that I meals)
would ruminate because Motivation involves taste and
you could chew them and food selectivity
they would come up well
. . . It’s very voluntary, but
sometimes I’ll be anxious
and it will just happen
involuntarily.”
Residential ED F 19 24.6 BN “That’s pretty much how it Meets duration criterion (3
goes. Maybe that’s hap- years)
pened a couple times. It’s Regular behavior (23/month)
just funny that you brought Mix of voluntary and
it up because no one ever involuntary

8 International Journal of Eating Disorders 00:00 00–00 2014

 DSM-5 PICA AND RUMINATION DISORDER
TABLE 3. Continued
Participant Description of
Clinical Setting Sex Age BMI DSM-5 ED Behavior
says anything about that,
but I know people who do
it, for sure.”
Residential ED F 13 17.2 OSFED “That’s happened a lot lately
. . . I eat a lot, and when I
eat quickly, it just like
comes back and I just swal-
low it back down . . . It’s
sort of out of my control, I
mean, I’m not trying to do
it . . . It makes me worried
that my body doesn’t want
it.”
Residential ED F 15 14.8 AN-R “Just when I drink a lot of
water or liquid, usually I
burp and it just comes
back up sometimes. But I
don’t have, like, reflux or
anything . . . Sometimes
with food, but mostly
water.”
Residential ED F 15 20.9 OSFED “I have acid reflux, so it hap-
pens a lot . . . it’s painful
probably 1=4 of the time . . .
if it’s a time when I’m purg-
ing, I purge it up. Some-
times I’ll just swallow it
back down.”
Residential ED F 16 19.3 OSFED “When I make myself throw
up, it’s not actually real
projectile vomiting. It’s like
little bits come up at a
time. And that’s like if I’m
trying to fight against my
eating disorder, then I’ll
swallow it . . . Not purpose-
fully. . .it just comes up . . .
it’s been so normal to just
regurgitate food and spit it
out, so now it just kind of
happens.”
Residential ED F 17 15.2 AN-BP “I’ve done that with Cheezits
because I think it tastes
good. That’s kind of gross,
but. . .”
Residential ED F 18 24.6 BN “That happens to me not on
purpose, but I just have to
swallow it again . . . it’s not
like I’m contracting any
muscles on purpose or any-
thing, it just comes up . . .
It makes me want to
purge.”
Residential ED F 20 22.3 OSFED “I burp up food a lot . . . I usu-
ally don’t tell people that,
because that’s just gross. I
typically try to swallow it
back down, like definitely
when I’m around people,
because that’s just awk-
ward. But like, sometimes
it just comes up and I can’t
stop it.”
AN-BP: anorexia nervosa-binge-eating/purging type; AN-R: anorexia nervosa-restricting type; BMI: body mass index; BN: bulimia nervosa; ED: eating
disorder; OSFED: other specified feeding or eating disorder.
International Journal of Eating Disorders 00:00 00–00 2014
DSM-5 Criteria
Meets duration criterion
Regular behavior (2–33/
week)
Voluntary/involuntary nature
of behavior is unclear
Meets duration criterion (2
months)
Regular behavior (daily)
Voluntary/involuntary nature
of behavior is unclear
Possible, (but unclear) shape
and weight rationale; liq-
uid only
Meets duration criterion
Regular behavior (several
times after 100% of meals)
Voluntary/physiologic (reflux)
nature of behavior is
unclear
Meets duration criterion
Regular behavior (103/
month)
Voluntary/involuntary nature
of behavior is unclear
Distinct from vomiting
Possible past rumination
(behavior stopped 7–8
months ago)
No data on duration or
frequency
Motivation involves taste and
food selectivity
Meets duration criterion
Regular behavior (almost
every meal)
Voluntary/involuntary nature
of behavior is unclear
No data on duration
Regular behavior (multiple
times/day)
Voluntary/physiologic (reflux)
nature of behavior is
unclear
9
DELANEY ET AL.
that excludes ice as a pica substance. Pica and RD
have been documented at high rates among indi-
viduals with other psychiatric disorders including
intellectual disability,6,16,18 autism,16,18 demen-
tia,6,18 schizophrenia,6,18 and depression.16 The
exact nature of the overlapping phenomenology is
unclear, though hypotheses include shared neuro-
logical pathology (brain volume loss, temporal lobe
lesion, and neurotransmitter abnormalities),6
learned behavior (maintained by oral stimula-
tion),5,6,14 and coping mechanism (symptoms
beginning post-stressor).16 Another possible reason
for our lower pica and RD frequency was that par-
ticipants who were excluded from a formal RD
diagnosis through DSM-5 trumping rules repre-
sented more than one third (36.4%) of those report-
ing rumination behavior in the residential eating
disorder sample. Furthermore, we evaluated pica
and RD among consecutive treatment seekers for
eating disorders or obesity, rather than in a case
series specifically selected to highlight the comor-
bidity among these clinical presentations.
To promote detection and treatment, direct and
non-judgmental queries for pica and RD may be
especially important in light of the secrecy and
stigma attached to these behaviors.31 For example,
one participant who later endorsed regurgitating
and rechewing food after every meal for the past
three months spontaneously commented in
response to the first rumination probe: “It’s weird,
no one’s ever asked me that.” Another who
endorsed multiple daily episodes of rumination
explained, “I usually don’t tell people . . . because
that’s just gross.” Several participants spontane-
ously referenced television shows like My Strange
Addiction as their only source of information about
pica. One participant said she realized she had pica
after watching a woman on television eat laundry
detergent, and another participant who denied
pica behavior spontaneously commented that he
wasn’t “like those freaks on A&E.” These negative
reactions are especially notable given that our sam-
ple specifically comprised participants who already
self-identified as having problematic feeding and
eating behaviors.
A secondary aim of the present study was to
identify the challenges associated with differential
diagnosis of DSM-5 feeding and eating problems,
to highlight directions for future research. While in
pediatric populations the Diagnostic Interview
Schedule for Children (DISC)30 can be used to eval-
uate pica and the Rome III Diagnostic Question-
naire for the Pediatric Functional GI Disorders32
can be used to diagnose RD, no published assess-
ment evaluates either disorder in adults. Given that
10
DSM-5 has taken a lifespan perspective indicating
that feeding and eating problems can occur in both
children and adults, the addition of standardized
probes for pica and rumination behavior to adult
psychiatric interviews would be a helpful first step
toward clinical detection. For example, DSM-5
diagnostic criteria for both pica and RD contain a
duration criterion (greater than one month), but
lack frequency specifications. For some cases in
our own sample, it was unclear whether a behavior
was frequent enough to qualify as “regular” or
“persistent.” Similarly, optimal follow-up questions
clarifying rumination would also assist assessors in
ascertaining the voluntary versus involuntary
nature of the behavior. For example, several partici-
pants in our sample echoed those in past studies
and described motivations related to taste and
food selectivity,14,25 or to shape and weight,25,27
both of which suggest some degree of volitional
control. The overlap of symptoms between the two
conditions can render differential diagnosis chal-
lenging, but the picture becomes even more com-
plicated when patients themselves cannot
distinguish voluntary behavior from physiologic
phenomena. It may be helpful to explore not only
detailed physical sensations (such as pain or acid
taste), but also the emotional experience of the
patient.
Lastly, our study findings support that motiva-
tion for pica eating is a critical aspect of differential
diagnosis that would need to be included in any
standardized assessment. While not meeting full
DSM-5 criteria, several individuals in our sample
engaged in pica eating with items not considered
“nonnutritive, nonfood substances.” Some investi-
gators have previously proposed that eating large
quantities of raw vegetables, vinegar, or frozen or
rotten food could be considered pica,4,6 despite
their exclusion in DSM-5 by the criterion requiring
that ingested substances be non-food. Excessive
ice consumption, or pagophagia, was the most fre-
quently consumed item in our sample (67% and
75% of all pica behavior at the residential eating
disorder treatment center and the outpatient
weight loss clinic, respectively), and in several pre-
vious studies.7,9 It is notable that eight of 11 partici-
pants who engaged in ice eating did so to avoid
eating food, and so could not be diagnosed with
pica for that reason. Even so, we observed that the
pica eating was associated with additional clinical
morbidity (a broken tooth) for one such participant
(Table 2). For individuals whose pica and rumina-
tion behaviors are distressing or associated with
medical morbidity, additional therapeutic inter-
vention may be warranted.
International Journal of Eating Disorders 00:00 00–00 2014

The results of this study should be interpreted in
light of its limitations. A primary limitation is that
we did not include a measure of the distress and
impairment specifically associated with pica or
rumination behavior. The presence of these condi-
tions in DSM-5 implies a degree of impairment
that has not yet been thoroughly investigated and
may require further study before additional resour-
ces are targeted toward detection and treatment.
Moreover, the sample subset endorsing pica and
rumination behaviors was too small to analyze
whether certain feeding disorder symptoms were
particularly likely to co-occur with specific eating
disorder symptoms, as hypothesized by previous
investigators.10,25 In contrast to the high response
rate from the residential treatment center (91.4%),
the response rate at the weight-loss clinic was con-
siderably lower (68.0%), which limits the conclu-
sions that can be drawn. This discrepancy, in
addition to the differences in demographics and
interview methodologies between the two sites
(i.e., in-person vs. telephone interviews) may have
differentially impacted frequency estimates for
each population. Furthermore, results from our
sample have uncertain generalizability to nonclini-
cal samples or other treatment-seeking samples.
In conclusion, DSM-5 pica and RD were rare
among individuals seeking treatment for eating
and weight disorders, but pica and rumination
behavior were relatively more common. The chal-
lenges of differential diagnosis suggest that future
research using a consistent operationalization of
these behaviors would be useful in understanding
the burden of disease imposed by pica and RD in
both clinical and research settings.
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