An atypical eating disorder with Crohn's disease in a fifteen-year-old male: a case study.

Holaday, Margot ; Smith, Karen E. ; Robertson, Shay 等

Typically, counseling or school psychology training programs include required courses in psychological theories, research design, statistical methods, therapeutic interventions, developmental issues, assessment procedures, and abnormal psychology. Electives are usually designed to expand on a specific topic related to required courses. What is missing from most of these programs is a course designed to alert future school and counseling psychologists and therapists to medical problems that might cause, or complicate, psychological difficulties. This article demonstrates that a medical disorder, Crohn's disease, might lead to or exacerbate an eating disorder.

In the following case study, the patient was initially evaluated by a pediatrician who noted vague gastrointestinal symptoms with inconclusive test results. Because of the patient's phobic-like behavior toward eating, he was referred to Pediatric Psychology to determine whether some or all of his physical problems were due to emotional sources. After interviews with the patient and his mother, an atypical eating disorder was diagnosed and an intervention implemented that was successful in encouraging him to eat. Yet his rate of weight gain was discouragingly slow. After six months of psychological therapy with nutritional monitoring and an increase in food intake, further medical testing revealed Crohn's disease. A collaborative process was possible because the patient was seen in a teaching hospital where all services were available and members of several disciplines worked as a team. If communication between team members had not been coordinated, the patient's psychological problems might have been further compromised and there might have been a longer delay in the diagnosis of Crohn's disease. The authors believe that counselors or psychologists who do not work in medical settings would benefit from developing a network of resources for consultations.

Crohn's Disease

Physical symptoms of Crohn's disease (a chronic inflammatory bowel disease) in children and adolescents are variable and may include the following: crampy abdominal pain, diarrhea, fever, growth failure, anorexia, chronic malaise, perianal lesions, blood in the stool, arthritis, finger clubbing, iron deficiency anemia, intermittent constipation, poor appetite, delayed puberty, nonspecific fatigue, and a sensation of having a full stomach after ingesting minimal amounts of food (Nelson, Vaughn, & Mccoy, 1969; Lagercrantz, Nelson, Berman, & Vaughn, 1963, 1976). When only a few of the symptoms are displayed, Crohn's disease may be difficult to diagnose in young people.

This disease is more common among some family groups and Jewish persons, and occurs more often in first-born children than their siblings (Nelson, Berman, & Vaughn 1983; Steinhausen & Kies, 1982). Up to 60% of patients may display psychological problems including anxiety, fearfulness, sensitivity, shyness, social withdrawal, relationship problems, and conduct disorders (Steinhausen & Kies, 1982). Children with Crohn's disease may cry more easily than their peers, be emotionally labile, have a negative view of the world, and adapt poorly to new situations (Nelson, Vaughn, & McCoy, 1969). There is no cure for this disease and the "natural history . . . is one of almost inevitable recurrence even when overt lesions are removed" (Brooke, Cave, Gurry, & King, 1977, p. 77). The diagnosis is made by a physician and is managed through psychological support, medication, surgery, and diet (Lagercrantz, 1976).

Eating Disorders

In diagnosing eating disorders, most practitioners refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III R) (1987). In this case, deliberate purging or bingeing behaviors were not reported, so a diagnosis of bulemia nervosa was not considered. The criteria for a diagnosis of anorexia nervosa were reviewed. They are: Refusal to maintain body weight over minimal normal weight for age and height ... leading to body weight 15% below that expected; intense fear of gaining weight or becoming fat, even though underweight; disturbance in the way in which one's body weight, size, or shape is experienced ... and in females, primary or secondary amenorrhea (DSM-III-R, 1987, p. 67). Ninety-five percent of individuals diagnosed with anorexia are young females (DSM-III-R, 1987). If a patient or client has some of the symptoms but does not meet the full criteria for an anorexic or bulimic disorder, a diagnosis of Eating Disorder, Not Otherwise Specified, may be given (DSM-III-R, 1987).

Individuals with anorexia nervosa usually are members of dysfunctional families with poor patterns of interaction, restricted affective expression, poorly defined roles, and strained marital relations, which cause problems in individuation for the patient (Humphrey, 1988). Strober (1986) summarizes the personality of females with anorexia as follows: "obsessional in character; introverted; emotionally reserved and socially insecure; self-denying; deferential to others, ... with limited autonomy, and overly rigid and stereotyped in thinking". In addition, Bruch (1986) describes persons with anorexia as coming primarily from educated and prosperous homes, not experiencing a loss of interest in food or loss of appetite, but displaying an obsessive focus on food.

Case Study

Presenting problem.The patient was a 15-year-old high school freshman referred to a pediatric endocrinologist at a tertiary care hospital for evaluation of short stature and delayed puberty. According to his medical history, he had always been shorter than most of his peers, and had not grown at all in the last 13 months. An extensive review of systems revealed him to have recurrent episodes of abdominal pain that occasionally woke him at night, poor appetite, and fatigue. His past medical and family histories were negative for chronic illnesses and endocrine disorders. Dietary and psychosocial histories (described in detail below) were significant for phobic-like behaviors toward eating.

Physical examination revealed his height to be 4[prime] 9 1/2[double prime] and his weight 70.8 pounds (both measurements are average for an 11-year-old boy). Except for short stature and pubertal delay, his general examination was unremarkable. Specifically, his abdominal and rectal exams were normal. A blood count revealed an anemia which was consistent with either iron deficiency or chronic illness. Although the possibility of a chronic bowel disorder was considered, a more extensive medical evaluation was deferred until he could first be evaluated by the Pediatric Psychology Service for his unusual eating behaviors.

Background Information and First Session

The following information was obtained in an initial diagnostic interview session in Pediatric Psychology following the medical evaluation. The patient's mother was unwed when he was born and she and her son lived with her uncle until he was four years old. At that time, the mother discovered that her son was being sexually abused by her uncle (anal penetration), and they moved. This incident was not reported to authorities because the mother explained that she also had been molested when she was a child and she "got over it." She thought her son could do the same without professional intervention. When he was in the seventh grade, this early abuse was briefly discussed with a male school counselor.

When the patient was seven years old, his mother married the man who later adopted him. At the time of interview, the patient lived with his mother, adopted father, and half brothers, aged one and four years. The family income was very low, even though both parents were employed. Both parents were overweight. The patient reported that he got along well with his younger brothers, but noted that when he lived alone with his mother, he received more personal attention from her.

The patient repeated first grade, earned average grades during elementary school, but did poorly in middle school. He reported that he told lies, stole things, and never did his homework. He was presently in his first year of high school and was doing very well academically because, as he explained, he needed good grades in order to continue his after-school activity as a sports trainer for the varsity athletic teams. The patient reported that although he had always been somewhat shorter than his friends, he remained the size of a normal 10-year-old while his peers had grown much taller and were more physically developed. The patient described his repertoire of humorous responses to the teasing he endured from other high school students, who did not believe he was the same age as they were.

The patient reported that about a year and a half before, he hated himself, believed that he was ugly and fat, and began restricting his food intake. His mother argued that he was actually so thin that when he did eat and his stomach filled, he thought he was fat and so "he starved himself." He did not feel hungry or want to eat, and his doctors insisted that the parents do everything they could to encourage him. As time passed, the more the patient refused to eat, the more his parents urged, prodded, and punished him for excessive chewing, slow eating behaviors, and resistance to certain types of food. Mealtimes at home became very strained for both the patient and his parents.

The patient reported that he had always been a slow eater, but remembered a time when he was about seven years old that he choked on a piece of meat and panicked. When his mother could not dislodge the food, his father ran into the house and twice performed the Heimlich maneuver. According to the patient, his father "saved his life." After that, he was even more careful about chewing his food and not swallowing until it was a very smooth consistency. He claimed, "I even chew Jello!" Eating a meal often took more than an hour, so he was able to consume very little during the 30-minute school lunch periods. Being constantly urged to eat or chew his food faster caused the patient to experience feelings of anxiety, and he was often nauseated. To relieve this tension, both the patient and his mother were told separately that eating, at least until the next session, must be the patient's responsibility and that beth parents should refrain from making any comments about food. Because the patient lived so far from the hospital, sessions were scheduled bimonthly.

In reviewing his initial diet history, the dietition concluded that the patient ate less than would be appropriate for a four-year-old. When she talked about eating high calorie foods with him and his mother, she noted that the patient seemed to withdraw and avoid eye contact, but he had been interacting well when other topics were discussed. He argued that he wanted to grow taller, but would not endorse an agreement to gain weight. He was asked to keep a detailed diet history and record the length of time it took him to finish a meal.

The first visit with the family revealed that they were relaxed and congenial. All five appeared to enjoy each other's company and there was good communication between them. They paid attention to each other, smiled easily, and were spontaneous in their interactions. Both parents were willing to do whatever they could to help their son. They reported no problems at home between any of them with the exception of tension during mealtimes when both parents were so concerned about the patient's eating habits. They reported that they had tried very hard not to remind the patient to eat, and the patient reported that he had actually eaten more.

Later Sessions

By the third visit, the patient was well aware of being more relaxed and eating more because his parents were no longer "bugging" him all the time. By the fourth visit, the patient had gained a total of 3.4 pounds in (two months), and was making milkshakes for snacks. For the first time, he reported that he experienced hunger and ate "all the time," but he "forgot" to record his diet history. His friends were making positive comments about his willingness to eat during school lunch times and at football games. He began talking about setting a goal of gaining 10 pounds and growing two inches by the end of the school year.

Over the next several sessions, the patient increased his motivation to grow, and still hoped for signs of puberty. He would run into the hospital and head straight for the scale to see if he had gained weight. But after five months and in spite of his increased caloric intake he was disappointed that he had gained only seven pounds and grown only a half inch. At the next session, the patient had gained nothing, despite a diet history that revealed a more than adequate caloric intake for weight gain. Both the patient and his mother were seen separately and were asked if there were problems that had not been discussed; none were reported. A Rorschach administered at the next session revealed that although he was depressed and had low self-esteem, those feelings appeared more acute than chronic, and seemed related to the frustration of trying so hard to gain weight without success.

Due to the changes in eating behavior without associated weight increase, the patient was admitted to the hospital for further medical evaluation. It was at that time that the diagnosis of Crohn's disease was made. By the end of a week, he had gained almost two pounds by drinking a high calorie liquid supplement five times a day in addition to his regular meals. Both the patient and his mother were relieved to find that there was a medical cause of his inability to grow, even though they understood the chronicity and seriousness of the disease. The patient was promised that injections of male hormones would be used to promote his sexual development as soon as possible. Psychological support was to continue.

DISCUSSION

When the patient was first seen, a diagnosis of anorexia nervosa was considered because he met criteria described in the DSM-III-R. He had a restricted food intake; he refused to endorse a weight gain contract despite being seriously underweight for his age; he expressed a fear of becoming obese; and he had a history of experiencing his stomach as fat when he did eat a meal. Yet, he did not display most of the personality traits described by Bruch (1986) or Strober (1986), and his family dynamics did not appear pathological or dysfunctional. A diagnosis of Eating Disorder NOS (DSM-III-R, 1987) was made.

Several hypotheses were considered to conceptualize the patient's eating problem, including: a conditioned fear of choking; a power/control struggle between himself and his parents over their efforts to get him to eat; a wish to remain a child like his two toddler brothers; a fear of developing sexually as a consequence of abuse in the past; or a fear of becoming overweight like both his parents. Fear of choking was given consideration since he had experienced an episode of choking on a piece of meat and had altered his eating behavior as a result. This might also explain why it took him so long to chew and swallow his food, yet the patient did not purposely select foods that were initially of a soft texture. He ate dried deer meat, fried chicken, and other foods that required effort and time to chew. Fear of developing mature sexual features (present in many persons with anexoria) did not seem plausible because one thing the patient wanted was for puberty to progress. His fear of becoming fat was overcome when his doctors told him that he could not begin hormone shots until he had more body weight, and that he would not grow taller unless he gained weight first.

Two working hypotheses were chosen to guide therapy: power/control issues, because both the patient and his parents were most vocal about the tension and arguments surrounding mealtimes, and a conditioned fear of choking, because of the time it took him to chew and swallow his food. As soon as his parents were asked to say nothing about food, the patient relaxed and increased his food intake. Within a month he had expressed the desire to grow taller and develop sexually. At first his parents were somewhat uneasy about relinquishing control over eating because they thought they were following doctors' orders in insisting that their son eat more. Had the patient not demonstrated, within a few weeks that he would eat more when left alone, his parents might have felt guilty, and reverted to their previous behavior.

Sessions quickly developed into celebrations of small increments of weight gain, reinforcement of eating snacks, monitoring of diet histories, and encouragement for the weeks to come. Summaries of psychology clinic visits with the psychology intern and the dietition were entered into medical records which were reviewed by the patient's physicians. After the patient had failed to show an increase in growth over six months, and a Rorschach had revealed increasing depression, he was hospitalized for further medical testing and diagnosed as having Crohn's disease.

Several issues are important in this case. First, the patient had developed a pattern of eating avoidance to the degree that he no longer cared about eating and had suppressed his appetite. Many of his behaviors and attitudes were similar to those described as criteria for a diagnosis of anorexia nervosa. His eating patterns appeared to be altered by an episode of choking, and finally, his medical presentation was clouded by psychological concerns. If Crohn's disease had been diagnosed during the first visit, the patient may have been very resistant to the diet plan which required him to ingest over 3,000 calories a day, and he might have been very distressed to learn about the seriousness and chronicity of the disease. Instead, he had gradually added more and more food to his diet on his own, and had reversed his attitude toward eating in order to gain weight and to grow. When he was finally told about Crohn's disease and what he had to do to control it, he seemed relieved and eager to try almost anything his doctors suggested.

IMPLICATIONS FOR PRACTITIONERS

The purpose of this article is to point out the need for additional training for those from traditional school and counseling psychology programs, and to demonstrate the importance of a team approach or consultation in complex cases. This already complex case might have been further complicated by other problems. What might have happened if this patient had not had medical and psychological resources available to him? If he had been a female, or had been a child of a dysfunctional family, or had not been responsive to the intervention, or had conduct problems, what might the outcome have been? Imagine being in a situation where medical advice or monitoring was not available and both the therapist and the patient continued to experience feelings of failure. Would the patient begin to blame himself? What would have happened if his parents had believed they should continue their intensive monitoring of food intake because the patient's health was in jeopardy? What would have happened if the physician had not referred the patient for psychological assessment and intervention?

The patient had been seen by his personal pediatrician all of his life and then had been referred to a tertiary care hospital for a more complete examination, yet the disease, often difficult to recognize in children and adolescents, was not diagnosed until six months later. Thus, until there was medical confirmation of his symptoms or problems, the underlying message perceived by the patient and his family was that his underdevelopment was the family's responsibility. Even though he knew that he had increased his eating and was determined to grow, he became more and more depressed when his efforts were unrewarded. This depression makes even more sense when one considers his fears that the medical staff and his parents might lose faith in him and suspect that he was not really eating what he claimed. School practitioners have not been trained to be aware of medical complications that may be causes or consequences of psychological problems, yet in reality, they are responsible for helping many children who fit that description during a school year. Diabetes, epilepsy, sickle-cell anemia, eczema, muscular dystrophy, and neurological problems, to name a few, are all medical problems that exacerbate emotional and behavioral difficulties. There are three possible solutions to this difficulty: first, establishing a network of medical colleagues would provide a means for consultations when there are physical symptoms. Second, building a personal library that includes books written for medical readers is strongly recommended. Too often, professional libraries are limited by too narrow a focus. A specific example is Brownell and Foreyt's, The Handbook of Eating Disorders (1986), frequently used by psychologists. It does not contain a reference to Crohn's disease, since it was not written to address medical disorders. Finally, a course in medical awareness of children's disorders would be invaluable in assisting practitioners to recognize symptoms that need to be assessed by a physician. A collaborative psychological/medical approach is always needed when both physical and emotional problems are displayed.

REFERENCES

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.). Washington, DC: Author.

Brownell, K. D., & Foreyt, J. P. (Eds.). (1986). Handbook of Eating Disorders: Physiology, psychology, and treatment of obesity, anorexia, and bulimia. New York: Basic Books.

Brooke, B. N., Cave, D. R., Gurry, J. F., & King, D. W. (1977). Crohn's disease: Aetiology, clinical manifestations and management. New York: Oxford University Press.

Bruch, H. (1986). Anorexia nervosa: The therapeutic task. In K. D. Brownell, & J. P. Foreyt (Eds.), Handbook of eating disorders: Physiology, psychology, and treatment of obesity, anorexia, and bulimia (pp. 328-332). New York: Basic Books.

Humphrey, L. L. (1988). Relationships within subtypes of anorexic, bulimic, and normal families, Journal of the American Academy of Child and Adolescent Psychiatry, 27(5), 544-551.

Lagercrantz R. (1976). Crohn's disease in children and adolescents. In I. T. Wetermen, A. S. Pena, & C. C. Booth (Eds.), The management of Crohn's disease (pp. 37-40). Amsterdam-Oxford: Excerpta Medica.

Nelson, W. E., Behrman, R., & Vaugham, V. C., III. (Eds.). (1983). Nelson textbook of pediatrics (12th ed.). Philadelphia: W. B. Saunders.

Nelson, W. E., Vaughan, V., C., III, & McCay, R. J. (Eds.). (1969). Textbook of pediatrics (9th ed.). Philadelphia: W. B. Saunders.

Steinhausen, H. C., & Kies, H. (1982). Comparative studies of ulcerative colitis and Crohn's disease in children and adolescents. Journal of Child Psychology and Psychiatry, 23(1), 33-42.

Stober, M. (1986.). Anorexia nervosa: History and psychological concepts. In K. D. Brownell, & J. P. Foreyt (Eds.), Handbook of eating disorders: Physiology, psychology of obesity, anorexia, and bulimia (pp. 231-246). New York: Basic Books.

Weterman, I. T., Pena, A. S., & Booth, C. C. (1976). The management of Crohn's disease. Amsterdam-Oxford: Excerpta Medica.

Karen E. Smith, Ph.D. is Associate Professor, Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas.

Shay Robertson, R.D., L.D., is Coordinator of Food Service, Devereaux Hospital, League City, Texas.

John Dallas, M.D., is Assistant Professor, Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas.