Food refusal after an incident of choking: a posttraumatic eating disorder

Medical and psychiatric differential diagnoses of pediatric globus sensation: A case study with review discussion

Globus hystericus, also known as globus pharyngeus or globus sensation, is characterized by the physical sensation of a mass in one's throat. Globus sensation is more common in adults and reported more rarely in children. Adult patients with globus sensation score higher on neuroticism, introversion, anxiety, and depression. However, not all patients with globus sensation have psychiatric abnormalities. Thus, it is important to share an atypical presentation in children and highlight the necessity of ruling out other organic causes. The present case study elucidates the process of ruling out medical etiologies of globus sensation in a young girl with anxiety and food aversion. We provide a review discussion of the differential diagnoses, both medical and psychiatric, of globus sensation in the pediatric population reported in past literature. The case study and review of pediatric globus sensation shows that the symptom can be associated with a wide array of psychological and medical diagnoses. The medical differential diagnoses of globus sensation include the gastroenteric system, laryngeal system, cardiovascular system, and nervous system. We encourage critical analysis of other potential diagnoses, given each patient's unique history and physical presentation.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

Sudden Onset of Refusal to Eat on Waking After a Nightmare in a 6-Year-Old Girl

Bridgette is a 6-year-old girl, who presented with sudden onset of refusal to eat or drink. The only precipitating event was a nightmare the previous night. She described a dream in which her mother and maternal aunt, dressed as witches, and father and maternal uncle, appearing as bats, wanted to kill her by making her eat and drink from a cauldron. Bridgette stated, "I can't eat anymore, I'm afraid of dying." Bridgette's eating pattern and behavior were described as previously normal. Motor, social, and language milestones were also normal. Her parents reported that she occasionally refused nonpreferred foods, and they believed that her food intake had decreased at age 4 years. She was a full-term infant without perinatal problems and breast fed until 8 months. Her medical history was significant for strabismus surgery, before 6 months. Her mental health history revealed mildly depressed mood and irritability related to teasing at school after her strabismus surgery. Her parents described her as "always looking for attention." Her teachers reported that she had normal intelligenceand described her behavior as shy, slightly withdrawn, and distrustful. Social history revealed an only child of married parents without marital or work-related problems. Bridgette went to her maternal grandmother's home after school and during school holidays.Her parents pleaded with her to eat, but she refused. She was evaluated at urgent care where her physical examination was described as normal. Her body mass index was above the 97th percentile (3 SD above the mean). The parents were described as fearful and despairing. Laboratory tests included a complete blood count with differential, an electroencephalogram, and a computed tomography scan, all of which were normal. Intravenous fluids were administered on the day of presentation and the following day. She continued to refuse to eat or drink, and after 2 days, she was hospitalized for nasogastric tube feeding.

Parental perceptions of childhood feeding problems

Previous research suggests that parental report of children's feeding corresponds with their child's nutritional intake (Cooke et al., 2006; Ekstein et al., 2010). The current study aimed to determine whether there is a relationship between parental report of children's feeding problems and their child's nutritional intake in a non-clinical population and, in addition, to establish whether parental anxiety (Cooke et al., 2003) can predict whether parental report of feeding problems correspond with the child's intake. Sixty-one parents of children aged two to seven years completed the parent report measure; the Behavioural Paediatric Feeding Assessment Scale as well as a food diary detailing their child's intake, which was analysed using CompEAT nutritional software. They also completed the anxiety subscale of the Hospital Anxiety and Depression Scale. Previous findings of an association between parent report of feeding problems and child's intake (Cooke et al., 2006) were not replicated. However, an association was found between parents' anxiety and their reports of feeding problems. Parental anxiety was also found to independently predict whether parent report of feeding problems matched the child's intake. Findings highlight the importance of a multifactorial approach to understanding childhood feeding difficulties. This requires replication with a clinical sample.

The Effects of a Brief Behavioral Intervention on Food Refusal in a Child With a Fear of Choking

This study examined the effects of an exposure-based behavioral treatment on food refusal in a 4-year-old girl who developed a fear of choking after an acute choking episode. Prior to treatment, the child had stopped eating almost all solid foods for 3 months and was primarily consuming a chocolate-flavored pediatric formula. Treatment occurred across the span of 2 weeks and took place at a pediatric feeding program. At the end of treatment, the child accepted over 30 new foods and was no longer dependent on a pediatric formula to meet her nutritional needs.

The scientific legacy of Little Hans and Little Albert: future directions for research on specific phobias in youth

We review issues associated with the phenomenology, etiology, assessment, and treatment of specific phobias in children and adolescents and provide suggestions for future research and clinical practice. In doing so, we highlight the early case studies of Little Hans and Little Albert and the advances that have been made following the publication of these seminal cases. In recent years, we have witnessed a deeper understanding of the etiology of specific phobias and developed a rich array of evidence-based assessments and treatments with which to address specific phobias in youth. Although much has been accomplished in this area of inquiry, we also note that much remains to be done before we can advance more fully our understanding, assessment, and treatment of specific phobias in youth. It will be important for future work to build more firmly on these developments and to better determine the moderators and mediators of change with our evidence-based treatments and to more vigorously pursue their dissemination in real-word settings.

Posttraumatic Stress Disorder in Children and Adolescents

In recent years researchers and clinicians have paid increasing attention to posttraumatic stress disorder (PTSD) in children and adolescents. Issues of definition and evaluation are discussed and studies of children subsequent to natural disasters, accident, war, sexual abuse and human-made traumas are reviewed. Issues relating to treatment and “debriefing” are also discussed.

A case of choking phobia: towards a conceptual approach

Choking phobia, also known as phagophobia or swallowing phobia is an uncommon clinical entity that has been underappreciated and is included in the new DSM-5 and upcoming ICD-11 diagnostic category of avoidant/restrictive food intake disorder. Phenomenologically distinct from other eating disorders, it is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Its prevalence and long-term course on the general population still needs to be determined, probably reflecting years of indefiniteness regarding its nosology and by the absence of a clear set of diagnostic criteria. We present a clinical case of choking phobia in a 32-year-old male patient after an episode of choke when eating chicken. An early diagnosis and distinction from other eating disorders is important for proper treatment and fundamental for prognosis. We also make a thorough revision on literature in clinical features, differential diagnosis and treatment approaches, suggesting a conceptual approach for choking phobia as a clinical spectrum settled by different degrees of phobic subtypes, which may depend on a varied number of clinical variables.

Sudden onset of refusal to eat on waking after a nightmare in a 6-year-old girl

Bridgette is a 6-year-old girl, who presented with sudden onset of refusal to eat or drink. The only precipitating event was a nightmare the previous night. She described a dream in which her mother and maternal aunt, dressed as witches, and father and maternal uncle, appearing as bats, wanted to kill her by making her eat and drink from a cauldron. Bridgette stated, "I can't eat anymore, I'm afraid of dying." Bridgette's eating pattern and behavior were described as previously normal. Motor, social, and language milestones were also normal. Her parents reported that she occasionally refused nonpreferred foods, and they believed that her food intake had decreased at age 4 years. She was a full-term infant without perinatal problems and breast fed until 8 months. Her medical history was significant for strabismus surgery, before 6 months. Her mental health history revealed mildly depressed mood and irritability related to teasing at school after her strabismus surgery. Her parents described her as "always looking for attention." Her teachers reported that she had normal intelligence and described her behavior as shy, slightly withdrawn, and distrustful. Social history revealed an only child of married parents without marital or work-related problems. Bridgette went to her maternal grandmother's home after school and during school holidays.Her parents pleaded with her to eat, but she refused. She was evaluated at urgent care where her physical examination was described as normal. Her body mass index was above the 97th percentile (3 SD above the mean). The parents were described as fearful and despairing. Laboratory tests included a complete blood count with differential, an electroencephalogram, and a computed tomography scan, all of which were normal. Intravenous fluids were administered on the day of presentation and the following day. She continued to refuse to eat or drink, and after 2 days, she was hospitalized for nasogastric tube feeding.

Brief, Intensive Behavioral Treatment of Food Refusal Secondary to Emetophobia

Emetophobia, a fear of vomiting, has been reported in both adults and children but is not well documented. This study describes the treatment of an 8-year-old girl who developed emetophobia and food refusal after an acute illness. The intervention consisted of an exposure-based treatment conducted over 7 days at a feeding program. The girl was discharged consuming all of her nutrition by mouth, and her gastrostomy tube feedings were eliminated.

Phagophobia: Behavioral Treatment of a Complex Case Involving Fear of Fear

Phagophobia is the avoidance of swallowing foods, liquids, or pills, usually based on a fear of choking. Since the first reported case study in behavior therapy, cases reported in the cognitive-behavioral literature reveal that ostensibly different approaches have yielded similarly positive outcomes. A limited number of fundamental behavioral mechanisms appear to underlie the various manifestations of swallowing phobias. These may account for effectiveness of different cognitive-behavioral treatment protocols. This article describes a new case of phagophobia in an adult male client, revealing some of the variables that need to be considered in assessment and treatment. As the case described contained elements of body dysmorphic disorder, fear of choking, social anxiety, and fear of fear, it demonstrates subtleties of treatment design and the importance of adhering to sound behavioral principles and the value of a sophisticated functional analysis.

Cognitive Therapy in a Case of Choking Phobia

A 68-year old female with a phobia of choking on fluids was treated first with exposure in vivo and then with cognitive therapy. The exposure increased her water drinking to some extent, but the cognitive change was negligible. However, the cognitive therapy led to a dramatic change in the catastrophical misinterpretations and a fourfold increase in her water consumption. The effects of treatment were maintained at a 1-year follow-up.

Fluoxetine in posttraumatic eating disorder in two-year-old twins

Feeding disorders of infancy or early childhood are relatively uncommon in the pediatric population. In posttraumatic eating disorder, the infant demonstrates food refusal after a traumatic event or repeated traumatic events to the oropharynx or esophagus. We present case reports of 24-month-old twin girls, A and B, who presented to our clinic with food refusal and fear of feeding. Several invasive gastrointestinal procedures were performed when they were 3 months old, and they started to refuse all solid food and some liquids soon after hospitalization. Fluoxetine 0.3 mg/kg per day (5 mg/day) was started to target their anxiety and fear about feeding. In the second month of weekly follow up, the children began to be fed without a nasogastric catheter. A significant decrease in anxiety and fear was observed during feeding. Although the use of serotonin-selective reuptake inhibitors (SSRIs) in preschool children is controversial due to the lack of empirical data in this age group, we observed clinical improvements in anxiety in these two cases. Furthermore, fluoxetine was well tolerated and no side effects were observed.

[Infantile anorexia: from birth to childhood]

Young child's anorexia (0-4 years) may have organic or psychological origin, when parents-child relationships are concerned. The most complex and earliest forms often have unspecified aetiology. Psychopathological classifications, which emphasize the mother-child relationships, are essential reference marks. But there is now a consensus in the definitions: the diagnosis of infantile anorexia requires criteria of acute or chronic malnutrition. We mainly distinguish anorexia by early disorder of homeostasis, anorexia resulting from serious disorder of attachment, anorexia by disorder of mother-child interactions, and finally early and complex anorexia, mixing an organic vulnerability and a bonding trouble, which can be secondary. Treatments differ according to the selected aetiology. Even if the origin is not mainly the fact of a relational mother-child dysfunction, parents-child's relations require a support to avoid aggravation by interactive vicious circles (force feeding). More than other diseases of early childhood, feeding disorders require a good knowledge of the working hypotheses both in the field of the paediatrics and the child psychiatry.

Use of low-dose selective serotonin reuptake inhibitors for severe, refractory choking phobia in childhood

Difficulty swallowing solids and/or liquids accompanied by intense anxiety that results in restricted eating patterns or complete avoidance of eating may not have an easily identified underlying medical cause. This type of "eating disorder," which has also been described as "choking phobia," may occur in the absence of body image distortion, fear of becoming fat, or the desire to be thinner. The primary complaint in these children may be physical discomfort accompanied by high anxiety. Negative consequences can be severe and include social withdrawal, family distress, and deleterious effects on the child's physical health. Prompt recognition in the pediatric setting is, therefore, critical to avoid escalation of symptoms and treatment delays. Three pediatric cases of severe choking phobia refractory to prior intervention are presented in which rapid and sustained improvement followed low-dose therapy with a selective serotonin reuptake inhibitor (SSRI). Possible predictors of response to low-dose SSRI treatment in children with choking phobia and future avenues for investigation are explored.

[Choking phobia in childhood: a differential diagnosis with anorexia nervosa]

INTRODUCTION

Choking phobia has been rarely described in the literature and its prevalence has not yet been determined. Because of its clinical picture (female predominance, avoidance or refusal of certain foodstuffs, secondary weight loss, associated obsessive-compulsive symptoms), it is often misdiagnosed as anorexia nervosa.

CASE REPORT

The authors describe the case of an 11-year-old girl, hospitalised for anorexia, who actually had choking phobia. Following a long history of anxiety disorders (including separation anxiety, social phobia, obsessive-compulsive disorder), the choking phobia had been triggered by a traumatic choking episode occurred in her grandfather. The disorder was successfully treated by cognitive-behavioural techniques associated with an antidepressant therapy.

CONCLUSION

This typical case questions the relationships between choking phobia and the other anxiety disorders of childhood and adolescence. According to data from the literature, the authors conclude that choking phobia may be regarded as a non developmental specific phobia, whose occurrence is facilitated by the presence of pre-existing anxiety disorders. The disorder is usually improved by cognitive-behavioural treatment.

A multiple-baseline evaluation of the treatment of food phobia in a young boy

A multiple-baseline design was used to evaluate the effectiveness of a behavioral treatment program using modeling, graduated exposure, and contingency management to treat food phobia in a 4-year-old boy. In addition, a treatment component involving time-out and re-introduction of the initial request to consume the target food was added to reduce vomiting behavior that developed during the course of treatment. The volume and range of foods consumed by the participant increased, and observer-rated anxiety and vomiting decreased over the course of treatment. The results of this controlled evaluation suggest that this treatment program was responsible for the observed changes, which were maintained at 6-month follow-up.

Feeding disorders in infants and toddlers: diagnosis and treatment

Each of the six feeding disorders described presents with specific symptoms, has a different origin, and responds to different interventions. Consequently, it is important to establish an accurate diagnosis and use the appropriate intervention for the specific feeding disorder. As the study by Benoit et al [7] demonstrates, an intervention that may be helpful for one feeding disorder can be completely ineffective for another.

Observation of feeding in the diagnosis of posttraumatic feeding disorder of infancy

OBJECTIVES

To delineate diagnostic criteria for posttraumatic feeding disorder (PTFD) of infancy and to differentiate PTFD from infantile anorexia (IA) via observation of feeding interactions.

METHOD

Three groups of infants (aged 6-32 months) participated: PTFD (n = 30), IA (n = 30), and healthy eater controls (n = 30). The three groups were matched with regard to age, gender, ethnicity, and socioeconomic status. Child psychiatrists used infants' medical and feeding histories and observed 20-minute mother-infant feeding interactions to determine diagnoses and group placement. Feeding interactions were also videotaped, and two raters assessed infants' resistance to feeding situations and to swallowing, as well as specific qualities of mother-infant feeding interactions.

RESULTS

Overall, the clinical groups (PTFD and IA) demonstrated more problematic feeding interactions than did the control group. However, the PTFD group exhibited more resistance during feeding interactions than did the other two groups. In particular, the PTFD group displayed the most resistance to swallowing food.

CONCLUSIONS

Infants' medical and feeding histories, as well as observations of feeding, are important to making the diagnosis of PTFD and differentiating it from other feeding disorders. Implications for treatment of PTFD are discussed.

Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial

OBJECTIVE

To determine whether behavior therapy was more effective than nutritional therapy in obviating the need for enteral feeding in infants with resistance to feeding.

STUDY DESIGN

Sixty-four children aged 4 to 36 months who were tube fed for at least 1 month and had resistance to feeding were randomly assigned to either behavioral or nutritional interventions (32 per group). For 7 consecutive weeks subjects and their primary feeders attended a weekly clinic with 1 of 2 dietitians followed by 4 follow-up visits. The nutritional intervention provided structured schedules and routines to stimulate the hunger/satiety cycle. The behavioral intervention provided the same schedules and routines plus behavioral therapy (extinction). The primary outcome measure was the proportion of successes, defined as infants no longer requiring tube feeding at the third follow-up visit in each group (4(1/2) months after start of trial). The decision to discontinue tube feeding was made by an independent observer who used criteria defined before the study commencement.

RESULTS

Fifteen (47%) of 32 subjects in the behavioral group versus none in the nutritional group were successes (P <.001).

CONCLUSION

Behavior therapy is more efficacious in eliminating the need for tube feeding than nutritional counseling alone.

Young girls' emerging dietary restraint and disinhibition are related to parental control in child feeding

This research investigated the origins of dietary restraint and disinhibition in young girls by considering how parents' control in child feeding and their daughters' perceptions of these practices relate to girls' dietary restraint and disinhibition. Participants were 197 5-year-old girls (4.6-6.4 years) and their parents. Parental pressure and restriction were measured using the Child Feeding Questionnaire. Girls' perceptions of parental pressure and restriction were measured using the Kid's Child Feeding Questionnaire, and their restraint and emotional and external disinhibition were measured using an age-appropriate version of the Dutch Eating Behavior Questionnaire. Logistic regression was used to determine associations among parental control in feeding, daughters' perceptions of control, and daughters' dietary restraint and disinhibition. The results indicated that one-third of 5-year-olds reported moderate levels of dietary restraint, about 25% of the sample showed evidence of emotional disinhibition, and nearly 75% reported externally disinhibited eating in the presence of palatable foods. Daughters' dietary restraint and emotional disinhibition were related to their perceptions of parental pressure to eat more, while their external disinhibition was related to their perceptions of having restrictions placed on their eating. This research reveals that pressure in child feeding is associated with the emergence of dietary restraint and disinhibition among young girls, eating styles characterized by a lack of responsiveness to internal hunger and satiety cues.

Diagnosing infantile anorexia: the observation of mother-infant interactions

OBJECTIVE

This study has three objectives: (1) to delineate the diagnostic criteria for infantile anorexia, including the onset of persistent food refusal during the infant's transition to spoon- and self-feeding, acute and/or chronic malnutrition, parental concern about the infant's poor food intake, and mother-infant conflict, talk, and distraction during feeding; (2) to determine the interrater agreement of child psychiatrists when diagnosing infantile anorexia based on these criteria; and (3) to describe the use of the Feeding Scale as a diagnostic tool.

METHOD

One hundred two toddlers, ranging in age from 12 to 37 months, were assessed by two child psychiatrists and assigned the diagnosis of infantile anorexia, picky eater, or good eater. In addition, observers who were masked to the toddler's diagnosis rated mother-infant interactions with the Feeding Scale to permit objective evaluation of those interactions.

RESULTS

Two child psychiatrists were able to assign toddlers to infantile anorexia, picky eating, and healthy, good eating groups with a high level of agreement. The objective scale for rating mother-infant interactions showed a high level of agreement between two masked raters and a good level of agreement between masked raters and the child psychiatrists' diagnostic assessment.

CONCLUSIONS

Infantile anorexia can be diagnosed with high reliability by child psychiatrists. Evaluation of mother-infant interactions is a useful diagnostic tool.

Classifying complex pediatric feeding disorders

BACKGROUND

This study defines the multiple characteristics associated with complex pediatric feeding problems and determines the relative frequency of each classification in a population referred to an interdisciplinary feeding team.

METHODS

The written reports from team evaluations on 103 children (64 males, 39 females; age range 4 months to 17 years) were reviewed. Prematurity and/or presence of developmental delay was coded. Identified factors related to current feeding problems were coded according to five categories: structural abnormalities, neurological conditions, behavioral issues, cardiorespiratory problems, metabolic dysfunction.

RESULTS

Interrater reliability for the classification coding was 88%. Thirty-eight percent of the children had a history of pre- maturity and 74% were reported to have evidence of developmental delay. The following five categories or combinations were coded most frequently: structural-neurological-behavioral (30%), neurological-behavioral (27%), behavioral (12%), structural-behavioral (9%), and structural-neurological (8%). Overall, behavioral issues were coded more often (85%) than neurological conditions (73%), structural abnormalities (57%), cardiorespiratory problems (7%), or metabolic dysfunction (5%).

CONCLUSIONS

Data analysis using this classification system revealed that the majority of children in this sample had a behavioral component to their complex feeding problem, regardless of concurrent physical factors. These findings suggest that complex pediatric feeding problems are biobehavioral conditions in which biological and behavioral aspects mutually interact, and both need to be addressed to achieve normal feeding.

Behavioral treatment of conversion disorder in adolescence. A case example of Globus Hystericus

The present single case study evaluated the efficacy of a cognitive-behavioral intervention for the treatment of a patient diagnosed with globus hystericus, a conversion disorder characterized by a perceived lump in the throat. The patient was a non-mentally retarded 12-year-old female who refused to swallow solids because she thought that her throat muscles would involuntarily constrict and result in choking. She lost approximately .5 lbs. per week during the 6 months prior to treatment. Improvements in weight gain were demonstrated consequent to the implementation of behavior therapy, with weight gain being particularly pronounced after contingency contracting was added to therapy. Weight gain was maintained at 1, 6, and 10 months posttreatment.

Interview data on severe behavioural eating difficulties in young children

Interview data from parents of 201 children under age 7 years with severe feeding and eating difficulties were analysed to describe features in the child's and parents' experiences that may have contributed to the development of the eating problem. Prematurity and low birth weight, distress during feeding in the first six months of life, and regular or frequent vomiting were common findings in the histories of the children. Aversive experiences during feeding may be the basis for early childhood eating difficulties.

Choking phobia: a review of the literature

Choking phobia is characterized by fear and avoidance of swallowing food, fluids, or pills. Most individuals with this phobia suddenly acquire their fear after an episode of choking on food. Fear of choking appears to occur somewhat more often in females than in males, and has a variable age of onset ranging from childhood to old age. Its prevalence is unknown. Choking phobia appears responsive to antipanic medication and to certain cognitive and behavioral therapies.

Atypical eating disorders

Some patients with eating disorders have neither anorexia nervosa (A.N.) nor bulimia. Cases which do not rigorously meet the DSM-III-R criteria for anorexia nervosa or for bulimia are usually defined as "eating disorders N.O.S." Among them are patients with pathological characteristics very closely related to the above-mentioned categories. Others, however, although affected by an eating disorder, present a quite different clinical picture from either A.N. or bulimia. In a study of 80 eating disorder cases, only 45 met the strict definition of A.N. or bulimia. The other 35 were diagnosed as atypical eating disorders and are the focus of this presentation. 29 were classified as Eating Disorders N.O.S. and 6 as obesity. Co-morbidity, gender and age data, and clinical vignettes are presented.

Assessment and treatment of food aversion in a four year old boy: a multidimensional approach

Eating and mealtime problems are common in childhood. They are often stressful not only to the child, but to the entire family. In this case report we describe a multidimensional approach to the assessment and treatment of food aversion in a four year old boy. The integration of psychodynamic, systemic and behavioural concepts in the assessment and treatment is described. In addition we report on preliminary findings from the Children's Eating Behaviour Inventory, a new instrument under development, intended to assess eating and mealtime problems in children.