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Pica, the developmentally and culturally-inappropriate eating of non-nutritive and non-food substances, is most often documented in people with developmental disabilities and children, frequently in institutional and residential settings. To date, there are no randomized clinical trials on pica-specific treatments, and very little literature is available regarding the characteristics or treatment of pica in adults with no intellectual or social deficits, and co-morbid disorders. This case study addresses this gap, and involves a highly educated 30 year-old American woman with foam rubber pica and burned match consumption (cautopyreiophagia) behaviors, along with co-morbid depressive, anxiety, and obsessive-compulsive symptoms, who received treatment in a general intensive outpatient program for adults in a large urban community psychiatry setting. The case study describes how the Biosocial Theory and Transtheoretical Model of Health Behavior Change were used to conceptualize this woman’s symptoms and guide a treatment team of clinicians who did not specialize in pica. Providers in non-specialty clinic settings would benefit from reflecting on ways to adapt evidence-based techniques to the treatment of uncommon symptoms.

Cognitive loss brings up crucial questions of autonomy and capacity to make one’s decisions. Capacity refers to an assessment of whether a person can make a particular medical, legal, or financial decision, and is commonly assessed in medical settings. Competency, on the other hand, is a global assessment of decision-making abilities and is a legal, not medical, assessment. Most persons with mild cognitive impairment (MCI) retain capacity to make decisions. As their cognitive deficits progress, this capacity may be lost, impacting their global competency. This chapter reviews the process of assessing capacity in older persons in outpatient settings. It incorporates information from chapters 1-3 regarding the routine office evaluation of cognitive impairment and adds assessments targeting capacity.