Psychotic pica, nicotinism, and complicated myocardial infarction

The authors report a case of a schizophrenic patient who repeatedly consumed a wide variety of inedible materials, including significant quantities of tobacco. The phenomenology of this behavior, as well as its psychiatric and medical complications are discussed. It is probable that chronic nicotinism contributed to this patient's refractoriness to psychiatric treatment and to his eventual cardiovascular crisis. The occurrence of pica as a manifestation of severe psychopathology was vividly described by the early pioneers of neuropsychiatry, but has received little attention in recent psychiatric literature. This is in marked contrast to the syndrome of psychogenic water intoxication which continues to be reported frequently. The majority of descriptions of pica have dealt with its occurrence in children, in pregnant women, and as a societal practice in certain cultures studied from a medico-anthropologic point of view. The toxic organic brain syndrome caused by chronic ingestion of nicotine-containing products has also been neglected in psychiatric publications. Descriptions of the neuropsychiatric complications of subacute and chronic nicotinism have been restricted to textbooks of toxicology, where greater emphasis has been given to the acute effects of large quantities of nicotine, often in forms other than tobacco. The following case illustrates the near-fatal practice of tobacco pica in a psychotic patient and dramatically demonstrates the systemic and central nervous system effects of nicotinism.