Achalasia mistakenly diagnosed as eating disorder and prompting prolonged psychiatric hospitalization

Psychopathological aspects of dysphagia: a systematic review on correlations with eating disorders and other psychiatric conditions

BACKGROUND

The effect of psychopathology on swallowing ability tends to be an overlooked issue in the assessment of dysphagic patients, possibly overshadowed by the given prominence to organic pathologies and the difficulties on the management of these patients. In addition, it should also be kept in mind that a great number of psychotropic drugs can affect swallowing adding problematic clinical issues in this area. Despite this, assessment of dysphagia should be considered as an extremely important issue, due to its impact on basic symptomatology, course of illness and quality of life.

OBJECTIVE

This review aims to be an overview of relevant data on psychopathology associated with dysphagia and impairment of swallowing function.

MATERIALS AND METHODS

An extensive bibliographic search was carried out in different medical databases (PubMed and Psycharticles) to comprehensively identify the most relevant publications available on dysphagia in eating disorders published until December 2020, according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) method. Research articles, either theoretical or empirical-based, published in peer-reviewed journals and in English language, were included. Case reports were also considered in the analysis when it was appropriate for completeness purposes. Titles and abstracts were reviewed according to the eligibility criteria.

RESULTS

In total, 260 published studies were identified and 40 were finally selected after removal of duplicates and relevance. Primarily we investigated the correlation between dysphagia and eating disorders, analysing the complex relationship between the two conditions. Then we provided an overview of the assessment of dysphagic symptoms in other psychiatric syndromes.

LIMITS

No exclusion criteria or statistical methods were applied nor was an assessment of study-level or outcome-level bias applicable for our purpose. The topic is vast and research bias could not be excluded; moreover, data available are heterogeneous and lacking systematic approach.

CONCLUSIONS

With this review, the authors want to provide an overview of the most considerable and clinically useful information about the topic, focusing on some key points to disentangle psychiatric components from the complexity of patient with dysphagia. It should be a relevant concern for all clinicians and should be always thoroughly assessed, considered its frequency in clinical practice and its implications in every kind of patients' morbidity, mortality and quality of life. Special attention should be paid to mentally ill patients, who might display complex and multiple comorbidities, as well as consequences of abnormal eating behaviours, occasionally exacerbated by psychotropic medications. More systematic studies are needed, while it seems clear that a multidisciplinary approach is pivotal in the assessment and management of dysphagic patients.

LEVEL OF EVIDENCE

Level I (evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies).

Achalasia and megaesophagus misdiagnosed as anorexia nervosa

A 40-year-old woman initially considered as suffering from anorexia nervosa was later diagnosed as having achalasia and megaesophagus.

Pregnancy delusion hinders the diagnosis of achalasia in a patient with life-threatening emaciation

Abnormal eating behaviour among psychiatric patients is associated with several psychiatric conditions, but may also be caused by a comorbid physical condition. Clinical assessment of a psychiatric patient is often challenging, which contributes to an increased rate of undiagnosed medical conditions and an increased mortality rate. We present the clinical case of a 46-year-old woman with a long-term delusion of triplet pregnancy, and recurrent vomiting. She experienced intense weight loss and eventually faced a life-threatening situation due to achalasia, which was incidentally discovered on a chest X-ray during her second psychiatric hospitalization, after several other tests, including upper digestive endoscopy, returned normal results. After a successful laparoscopic Heller's myotomy, her digestive symptoms greatly improved. This report illustrates the difficulty of establishing clinical-surgical diagnoses in psychotic patients, as some delusions seem to explain clinical complaints, masking and delaying the diagnosis of comorbid conditions.

Is it an eating disorder or achalasia or both? A literature review and diagnostic challenges

INTRODUCTION

Achalasia is a rare oesophageal motility disorder characterized by physical, behavioural and psychosocial features that are strikingly similar to eating disorders (ED).

METHOD

A literature search of PubMed and Google Scholar identified 36 cases of achalasia from 11 countries misdiagnosed as ED between 1980 and 2013.

RESULTS

On average, the typical misdiagnosed case was an 18-year-old female with an average weight loss of 16.2 kg. Vomiting behaviour in achalasia was distinguished by occurring after both solids and liquids, occurring in public, and worsening at night or while lying down, and was associated with pain relief. Manometric investigations of oesophageal functioning in clinical ED samples are few and have shown little evidence of dysmotility.

DISCUSSION

Achalasia and ED share numerous clinical features including weight loss and vomiting. Pain associated with swallowing difficulties may lead to an increasingly restricted pattern of eating and food avoidance. Increased awareness of achalasia in ED treatment settings can help facilitate detection of achalasia, thereby reducing treatment delay.

Achalasia mistaken as eating disorders: report of two children and review of the literature

Eating disorders are commonly considered diagnoses in young women who present with unexplained weight loss and vomiting. Our objective was to report the increased awareness of eating disorders and that it is likewise important to recognize that organic pathology (achalasia) can cause symptoms that may mimic an eating disorder and lead to misdiagnosis. Two case reports are presented and a review of the existing literature is provided. In the first patient, initial diagnosis of nonclassified eating disorder based on a pubertal conflict was made, and 3.5 years later diagnosis of primary achalasia was established. Atypical bulimia nervosa was initially suspected in the other case, but diagnosis of achalasia was established at an early stage of evaluation. The exclusion of organic disease must be a priority, even if a psychotherapeutic intervention may be needed in the global care of eating disorder patients. Esophageal achalasia should be considered in anyone presenting with difficulty swallowing or dysphagia, even if other features suggest anorexia nervosa or bulimia nervosa.

Gastric adenocarcinoma mistakenly diagnosed as an eating disorder: case report

OBJECTIVE

A number of organic conditions may mimic the symptoms of an eating disorder, however, gastric outlet obstruction mimicking anorexia nervosa has rarely been reported.

METHOD

We report the case of a 51-year-old female admitted to an eating disorders unit with an initial diagnosis of anorexia nervosa.

RESULTS

The patient's upper gastrointestinal symptoms and weight loss were found to be secondary to gastric outlet obstruction from a gastric adenocarcinoma. Coincidental psychosocial stressors and past psychiatric history, among other factors, had confounded the diagnosis.

DISCUSSION

Organic causes of weight loss and upper gastrointestinal symptoms need to be fully excluded prior to making the diagnosis of an eating disorder, particularly when there are atypical features in the presentation.

Should non-fat-phobic anorexia nervosa be included in DSM-V?

OBJECTIVE

Cross-cultural data suggest that rationales for food refusal vary in anorexia nervosa (AN), and a variant, termed non-fat-phobic AN (NFP-AN), has been described. This review evaluates whether data support modification of the requirement for intense fear of weight gain to meet AN criterion B in DSM-V.

METHOD

We performed a systematic search of the Medline and PsychInfo literature and evaluated the relevant publications by Robins and Guze's (Am J Psychiatry 126, 983-987, 1970) criteria as a standard for diagnostic validity. We also performed a meta-analysis comparing the severity of eating pathology in AN to (a) NFP-AN and (b) AN with low drive for thinness (low-DT-AN).

RESULTS

A modest literature indicates that NFP-AN has wide geographic distribution and occurs in both Western and non-Western populations alongside cases of typical AN. Aggregating across eligible studies, patients with NFP-AN or low-DT-AN score at least 2/3 of a standard deviation lower on measures of eating pathology than patients with conventional AN. Transcultural comparison of drive for thinness suggests significantly lower norms in non-Western cultures.

DISCUSSION

NFP-AN occurs with wide distribution. Further research is necessary on the course and outcomes of NFP-AN to characterize its congruence with, or distinction from, conventional AN. We discuss several options for including a description of NFP-AN in DSM-V.

Vomiting and feeling fat--coincidence of achalasia and bulimia nervosa

OBJECTIVE

In clinical practice it is often difficult to distinguish between organic and psychological vomiting.

METHOD

We present a case of a 34-year-old woman with an 18-month history of vomiting with the initial diagnosis of bulimia nervosa (BN). However, the patient showed an unusual vomiting behavior. Therefore, further somatic diagnostic procedures were carried out leading to the additional diagnosis of achalasia. After successful interventional and surgical treatment for achalasia, further psychotherapeutic interventions were necessary because of worsening of the BN symptoms. A certain disturbed eating behavior seemed to persist at 3-year follow-up, while the medical condition had improved.

CONCLUSION

It needs to be emphasized that careful diagnostic steps are indispensable to distinguish between psychological vomiting and organic vomiting. In case of two separate diseases a suitable treatment regime for each is required.

Psychological or organic vomiting

The near-fatal occurrence of achalasia in a patient with pre-existing bulimia nervosa is described. The case emphasizes the critical importance of being alert to the development of new pathology in individuals with chronic symptoms, especially in the presence of psychological illness. It also raises the possibility of an additional mechanism by which achalasia could be initiated.

Achalasia mimicking prepubertal anorexia nervosa

A 9-year-old girl presents for continuing weight loss of 10 kg over the course of 1 year. Medical history showed three episodes of pneumonia requiring hospital admission in the 6 months before presentation and 4 months of weekly psychotherapy for anorexia nervosa. A thorough history of eating behavior and a review of systems revealed not only typical aspects of prepubertal anorexia nervosa but also vomiting at night while asleep, difficulty drinking liquids, epigastric pain, and a frequent experience of "a lump in the throat"; these symptoms were not suggestive of a diagnosis of anorexia nervosa but rather of esophageal achalasia. The patient was transferred to the Department of Pediatrics, and a diagnosis of esophageal achalasia was made by chest x-ray and barium swallow. After dilatation and botulinum toxin application, the patient regained weight easily and was discharged in stable condition. In this case, esophageal achalasia mimicked prepubertal anorexia nervosa.