1. Kaolin Specific Pica: A Culture-Bound Syndrome R. Kevin Grigsby, DSW Senior Director, AAMC Organizational Leadership Development

2. What is Pica? Derived from Latin for the magpie (bird) Will eat anything Persistent ingestion of non-nutritive substances Examples Pagophagia – ice Cautopyreiophagia - burnt matches Coprophagia – feces

3. Is pica common? Pica of pregnancy is common Steak, ice cream, salted peanuts Cravings for ice, baking soda, flour, cornstarch, and others May be olfactory Odor of bleach, pine oil, gasoline, cleanser, nail polish remover, crushed concrete Very little is known about “Why?”

4. Women’s experience of pica 8 themes Keeping practices secret Singularity of experience Obtaining the substance Fear of effects on fetus Yielding to the craving Use of substances as medication Pica and food intake Sensory experience beyond taste

5. Olfactory pica Changes in the sense of smell during pregnancy Both positive and negative reported Types of craving may differ from phagia May chew and remove – no swallow Escalation in use during pregnancy Occasional prior to pregnancy

6. What is culture? The integrated pattern of human behavior that includes actions, assumptions, values, reasoning, and communication of a racial, religious, ethnic, or social group “The way we do things around here”

7. Culture-Bound Syndrome Patterns of aberrant behavior and troubling experience that are: Recurrent Locality specific May be population specific, as well

8. Culture-Bound Syndrome: Examples Amok Dissociative outbursts with violence Koro Sudden, intense fear that genitalia is being withdrawn into the body Latah Hypersensitivity to sudden fright or startle resulting in a trance-like state

9. What is kaolin? A naturally occurring clay used in manufacturing textiles and ceramics Multi-billion dollar business in the southeastern United States The “main ingredient” in medication used to treat diarrhea

10. The influence of culture People are largely the same in their basic human needs. People differ in the conditioned and preferred ways of meeting those needs. Culture influences the conditioned and preferred ways of meeting human needs.

11. ADDRESSING Culture A helpful mnemonic to help with cultural responsiveness Age/generational influences Developmental and acquired Disabilities Religion/spirituality Ethnicity Social economic status (SES) Sexual orientation Indigenous heritage National origin Gender

12. Obstacles or barriers to recognizing cultural factors Defensiveness Fear Ignorance Pain Theoretical dogmatism Ethnocentrism

13. What do you need to do to be culturally responsive? Engage in ongoing cultural self- assessment Engage the “other” in the process Ask that person to teach you Demonstrate Humility Understanding Critical thinking

14. Concerns about geophagia Low prestige Classified as a psychiatric disorder Potential transmission of parasites Constipation; bowel obstruction Kaolin specific Interferes with iron absorption Anemia

15. Positive aspects of geophagia Stops cravings of pregnancy May protect women from anemia in iron poor areas In Peru, a low prevalence of anemia is found where geophagia is common Ingestion of a gray clay known as metalillo 1 gram provides 10 times the RDA for an adult Luis Benavente, Project Hope (correspondence)

16. Incidence and prevalence? Unknown

17. A culture-bound syndrome... Black women Southeastern USA as origin Introduced by family or friends Introduced during pregnancy Not associated with psychopathology Not forthcoming in discussions with health professionals

18. References(1) Best White Dirt. Accessed November 29, 2010 http://bestwhitedirt.com/index.html http://bestwhitedirt.com/index.html Blinder BJ, Goodman SL, Henderson P. Pica: a critical review of diagnosis and treatment. In Blinder BJ, Chaitlin R, Goldstein R. (Eds.) The Eating Disorders, pp. 331-344. PMA Publishing Corp., 1988. Bronstein ES, Dollar J. "Pica in Pregnancy," Journal of the Medical Association of Georgia 63, no. 8 (1974): 332-35. Callahan GN. Eating dirt. Emerg Infect Dis. August 2003. http://www.cdc.gov/ncidod/eid/vol9no8/03-0033.htm accessed November 29, 2010. http://www.cdc.gov/ncidod/eid/vol9no8/03-0033.htm accessed November 29 Cooksey NR. Pica and olfactory craving of pregnancy: how deep are the secrets? Birth 22(3): 129-137, 1995. Grigsby RK, Thyer BA, Waller RJ, Johnston GA. Chalk eating in middle Georgia: a culture bound syndrome of pica? Southern Medical Journal, 92(2): 190-192, 1999.

19. References (continued 2) Grigsby RK. Clay Eating. The New Georgia Encyclopedia (Athens, Georgia). Georgia Humanities Council and the University of Georgia Press http://www.georgiaencyclopedia.org/nge/Article.jsp?id=h-2669 February 3, 2004.http://www.georgiaencyclopedia.org/nge/Article.jsp?id=h-2669 Johnston GA. "Geophagia (kaolin ingestion) Complicated by Colon Rupture: A Case Report, Macon, Georgia," Journal of Abdominal Surgery (fall 1997): 8-9. Lacey EP. Broadening the perspective of pica: a literature review. Public Health Reports, 105(1): 29-35, 1990. Lallanilla M. Eating Dirt: It might be good for you. http://abcnews.go.com/Health/Story?id=1167623&page=1 accessed November 29, 2010. http://abcnews.go.com/Health/Story?id=1167623&page=1

20. References (continued 3) Smith EN. Digging up a dirty habit. SouthCoast Today. http://archive.southcoasttoday.com/daily/04-99/04-20- 99/b02he033.htm accessed November 29, 2010. http://archive.southcoasttoday.com/daily/04-99/04-20- 99/b02he033.htm accessed November 29 Smulian JC, Motiwala S, Sigman RK. "Pica in a Rural Obstetric Population," Southern Medical Journal 88, no. 12 (1995): 1236-40. Von Garnier C, Stunitz H, Decker M, Battegay E, Zeller A. Pica an refractory iron deficiency anaemia: a case report. Journal of Medical Case Reports. 2(324), 2008. http://www.jmedicalcasereports.com/content/2/1/324 accessed November 29, 2010. http://www.jmedicalcasereports.com/content/2/1/324