nonfood substances, such as paper tissues, as a means of attempting to control appetite. In
such cases, when the eating of nonnutritive,  nonfood substances is primarily used as a
means of weight control, anorexia ne rvosa should be the primary diagnosis. 
Factitious disorder. Some individuals with factitious disorder may intentionally ingest
foreign objects as part of the pattern of fals ification of physical symptoms. In such in-
stances, there is an element of deception that is consistent with deliberate induction of in-
jury or disease. 
Nonsuicidal self-injury and nonsuicidal self -injury behaviors in personality disorders.
Some individuals may swallow potentially harm ful items (e.g., pins, needles, knives) in
the context of maladaptive be havior patterns associated with personality disorders or
nonsuicidal self-injury. 
Comorbidity
Disorders most commonly comorb id with pica are autism spectrum disorder and intellec-
tual disability (intellectual deve lopmental disorder), and, to a lesser degree, schizophrenia
and obsessive-compulsive disorder. Pica can be associated with trichotillomania (hair-
pulling disorder) and exco riation (skin-picking) disorder. In comorbid presentations, the
hair or skin is typically ingested. Pica can al so be associated with av oidant/restrictive food
intake disorder, particularly in individuals with a strong sensory component to their pre-
sentation. When an individual is known to  have pica, assessment should include con-
sideration of the possibility of gastrointestinal complications, poisoning, infection, and
nutritional deficiency.