JOURNAL OF ADOLESCENT HEALTH 1992;13:400-402
CONFERENCE PROCEEDINGS
Atypical Eating Disorders EDITH
MITRANY,
M.D.
Some patients with eating disorders have neither anorexia nervosa (A.N.1 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 abovementfoned 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.
introduction Eating disorders, as listed in DSM-III-R (1) include anorexia, bulimia, pica, rumination disorder of infancy and Eating Disorders Not Otherwise Specified (N.O.S.). The previous edition of DSM-III (2) de-
fined this latter subclass as atypical eating disorder, i.e., a residual category for eating disorders that cannot be adequately classified in any of the pre+us categories. As to obesity, it is regarded (1) as a “physical disorder not associated with any distinct psychological or behavioral syndrome.” It is suggested to code it as Psychological Factors Affecting Physical Condition “when there is evidence that
From the Child and Adolescent Psychosomatic r-In& SheIH1Medical Center, Tel Hashomer, Israel. Address reprint requests to: Edith Mitrany, M.D,, Chaim-Sheba Medicul Center, Child and Adolescent Psychosomulic Department, Sackb School of Medicine, Tel Hashomer 52621, Israel. This pper wll~ presented at the 5th Congress of the International eGL$ fir Adolescent Health, \uly 3-6, 1991, Montreux, Munusc&t accepted October 31, 1991.
400 1@34-139x/92l83.00
psychological factors are of importance in the etiology or course of a particular case of obesity”. In this paper, we look more closely at the atypical eating disorders. We propose to include obesity because, more often than not, there are psychological factors involved with defense organization, object relations, and behavioral patterns, which are similar to those seen in other eating disorders. In this study, out of a cohort of 122 inpatients of a Child and Adolescent Psychosomatic Unit, 80 were diagnosed with eating disorders (Tables 1 and 2). Mean age was 15 years. There were 3 males and 32 females. A total of 35 cases were defined as atypical eating disorders; 20 of the patients resembled those with A.N. but were missing at least one of the four diagnostic criteria listed in DSM-III-R. Only 2 were bulimia-like; and, in 2 cases, there was a combination of bulimia and A.N. features; 6 patients presented symptoms of food restriction or refusal, vomiting with weight loss, or a combination of vomiting and subsequent alimentary restriction. The co-morbidity, using the DSM-III-R clnssification, was represented as follows: One each of schizophreniform disorder, anxiety disorder, depressive neurosis, oppositional defiant disorder, and borderline personality disorder; two each of conversion disorder, schizoaffective disorder, adjustment disorder; and ten of personality disorder N.O.S. In 3 cases, no additional diagnosis had been given. Over a period of 4 years, 6 obese patients have been admitted to the unit.
Clinical Vignettes Patient 3 History and Treatment. M.B. is an 11-yr-old female who choked on a piece of food 2 yr prior to admission. Since that incident, she refused any solid food.
0 Society pubkkd
for Adolescent Medicine, 1992
by Ekvier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
July 1992
ATYPlCAL EATING DISORDERS
Table 1. Subcategories of Eating Disorders in 80 Cases Total Anorexia Bulimia
n 80 39 6
100.00 48.75 7.5
Eating disorder NOS. Obesity
29 6
36.2 7.5
401
Table 2. Age and Gender Data of Patients .P
9/l ._
._
Total sample size Male Female
8; 9
Age at admission (mean)
15 yr
71
NOS., not otherwise specified.
apy, and psychotherapy process. In addition, she resumed bcdwetting, expressed various fears, and complained of frightening dreams. Two attempts at psychotherai?y proved to be of no avail. Shortly before admission, psychosomatic complaints were noted together with sadness, irritability, school failure, and social withdrawal. M.B. is the oldest of three children. Her developmcnt was rana!von~Culexcept 603”l%r~:.Sof separation anxiety when she entered kmdergarten and then again in first grade. She was described as very sweet and quiet, helpful at home with house chores and in the care of her younger siblings. At admission, body weight was 29 kg. (target weight, 35 kg). M.B. was clinically depressed and anxious, particularly about separating from parents and at meals. M.B. entered intensive psychotherapy and also received intragastric feeding (for 1 week). As soon as she was willing to swallow solids, chlorimipramine was administered. MB. resumed normal eating about 1 month after admission. At that point, the sad affect was temporarily replaced by an aggressive, hypomanic mood. At the end of hospitalization (3 mo), M.B. ate normally, and she showed no signs of depression. Discussion. The refusal to ingest solid food following a traumatic event suggests the possibility of a post-traumatic stress disorder. The accompanying depression is either an associated feature of the former or a disorder in its own right. Psychotherapy uncovered that M.B. harbored unconscious aggressive, cannibalistic wishes directed toward a weak mother who apparently failed to provide the child with adequate gratifications as well as toward her younger brothers who further deprived her of mother’s care. These wishes led to her guiltridden (over-) reaction after choking on a piece of meat. In the hospital setting, M.B. could eventually separate eating food from devouring the primary objects. She also became able to displace aggression to substitute objects and realize that these objects could survive her aggression. Antidepressive drugs, milieu ther-
helped consolidate
this
Patient 2 historyand Treatment.L.R. is a 12-yr-old boy who was admitted to the Psychosomatic Unit on an emergency basis on account of solid and liquid food refusal of 1 wk duration. There was no identifiable stressor responsible for this condition. R&y&&ion and pediatric evaluation were performed in another hospital. On admission, L.R. looked calm and even indifferent to his condition. He could not provide any explanation for his refusal to eat or drink and did not seem disturbed in the least by having to be fed via intragastric tube. Within a few days, he volunteered to introduce the tube himself which he continued to do for the following 3 mo, time during which he neither ate, nor drank, nor deplored his predicament. In psychotherapy he mostly remained aloof and detached. Occasional fantasy productions dealt with sadistic themes such as betrayal and murder. His interpersonal relations with the other children in the ward were tainted by subtle aggression (mostly verbal in the form of offending and cynical remarks, occasional competitive outdoing and outsmarting, etc.). There was something mechanical, inhuman about this boy. He could astonish the staff by his mysterioubli gaining access to all forbidden areas, such as locked offices and file cabinets, or his eavesdropping on private conversations, etc. He could gaze without blinking and seldom displayed any empathic feelings toward people with the exception of his depressed mother, toward whom he showed compassion and sorrow. In the fourth month of hospitalization, after numerous and futile attempts (psychotherapy, hypnosis, narcoanalysis, etc.) geared to both understand and cease the food refusal, the intragastric feeding was discontinued, and a closely monitored fasting period was allowed; 5 days: later, in a rather theatrical way, L.R. resumed eating “as if nothing ever happened.” The following 6 wk were not less dramatic. L.R. became increasingly restless and ag-
402
MITRANY
gressive, occasionally uncontrollable, and evidently fearful of the loss of control. Following this, he sunk into a depressive mood not unlike his mother’s. Only now, for the first time s&e admission and possibly for the first time altogether, was L.R. able to express feelings of helplessness, fear, and despair. His condition gradually improved. Owing to this improvement, his parents insisted on a discharge which was definitely premature. Discussion.. L.R. suffered from a conversion disorder. His total abstinence from eating and drinking over a period of 3 mo seems to have been rooted in a desperate attempt of L.R. to control stressful external situations as well as his inner overwhelming feelings. He displaced onto eating an effort to overcome emerging sexual and aggressive preadolescent urges. At the same time, he postponed or provoked emotional upheavals in his already unstable parents, both on the brink of psychosis. His character defenses, isolation and distancing, were well served by the symptom; renunciation of the symptom induced an upsurge of aggression, first directed to the outside and then turned against the self.
Conclusions Atypical eating disorders confront the clinician with a variety of psychopathologies gravitating around preoccupation with body weight, food, and eating. While in need of consistency insofar as physiological and nutritive tasks are concerned, one cannot develop a single psychodynamic model applicable to all these disorders. The obese patients are the most difficult to treat, although their personality, on the
JOURNAL OF ADOLESCENT HEALTH b 01.13, No. 5
whole, and their defense organization seem better integrated than those of patients with bulimia for instance. Food refusal after an incident of choking has been described by Chatoor (3) in 5 preadolescent children and related-as in this presentation-to a post-traumatic stress disorder. We could not find in the literature a case similar to the 12-yr-old boy who totally refrained from active eating and drinking for over 3 months, while not opposing passive alimentation. Here, the act of eating (incorporation) is the locus of symbolization rather than the effect of food on the body as seen in anorectic restricters. Among the atypical eating disorder cases were oppositional defiant ones who embraced nonconformist behavior for the sake of resisting and provoking authority and norms, and psychotic (schizoaffective) patients who refused food on account of delusional beliefs (such as the food was being poisoned). These were diagnosed and treated as eating disorders because the disturbed eating pattern was the major presenting symptom, to a degree where it endangered not only mental but also bodily health. A.N. and bulimia-like patients, who were essentially similar in their psychological profile to their DSM-III-R counterparts, were in the majority in this cluster.
References American Psychiatric Association. Diagnostic and Statistic Manual of Mental Disorders, 3rd ed. revised. Washington, DC: American Psychiatric Association, 1987. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association, 1980. Chatoor I. Food refusal after an incident of choking: A posttraumatic eating disorder. J Am Acad Child Psychiatry 1988; 27:105-10.
CONFERENCE PROCEEDINGS
Atypical Eating Disorders EDITH
MITRANY,
M.D.
Some patients with eating disorders have neither anorexia nervosa (A.N.1 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 abovementfoned 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.
introduction Eating disorders, as listed in DSM-III-R (1) include anorexia, bulimia, pica, rumination disorder of infancy and Eating Disorders Not Otherwise Specified (N.O.S.). The previous edition of DSM-III (2) de-
fined this latter subclass as atypical eating disorder, i.e., a residual category for eating disorders that cannot be adequately classified in any of the pre+us categories. As to obesity, it is regarded (1) as a “physical disorder not associated with any distinct psychological or behavioral syndrome.” It is suggested to code it as Psychological Factors Affecting Physical Condition “when there is evidence that
From the Child and Adolescent Psychosomatic r-In& SheIH1Medical Center, Tel Hashomer, Israel. Address reprint requests to: Edith Mitrany, M.D,, Chaim-Sheba Medicul Center, Child and Adolescent Psychosomulic Department, Sackb School of Medicine, Tel Hashomer 52621, Israel. This pper wll~ presented at the 5th Congress of the International eGL$ fir Adolescent Health, \uly 3-6, 1991, Montreux, Munusc&t accepted October 31, 1991.
400 1@34-139x/92l83.00
psychological factors are of importance in the etiology or course of a particular case of obesity”. In this paper, we look more closely at the atypical eating disorders. We propose to include obesity because, more often than not, there are psychological factors involved with defense organization, object relations, and behavioral patterns, which are similar to those seen in other eating disorders. In this study, out of a cohort of 122 inpatients of a Child and Adolescent Psychosomatic Unit, 80 were diagnosed with eating disorders (Tables 1 and 2). Mean age was 15 years. There were 3 males and 32 females. A total of 35 cases were defined as atypical eating disorders; 20 of the patients resembled those with A.N. but were missing at least one of the four diagnostic criteria listed in DSM-III-R. Only 2 were bulimia-like; and, in 2 cases, there was a combination of bulimia and A.N. features; 6 patients presented symptoms of food restriction or refusal, vomiting with weight loss, or a combination of vomiting and subsequent alimentary restriction. The co-morbidity, using the DSM-III-R clnssification, was represented as follows: One each of schizophreniform disorder, anxiety disorder, depressive neurosis, oppositional defiant disorder, and borderline personality disorder; two each of conversion disorder, schizoaffective disorder, adjustment disorder; and ten of personality disorder N.O.S. In 3 cases, no additional diagnosis had been given. Over a period of 4 years, 6 obese patients have been admitted to the unit.
Clinical Vignettes Patient 3 History and Treatment. M.B. is an 11-yr-old female who choked on a piece of food 2 yr prior to admission. Since that incident, she refused any solid food.
0 Society pubkkd
for Adolescent Medicine, 1992
by Ekvier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
July 1992
ATYPlCAL EATING DISORDERS
Table 1. Subcategories of Eating Disorders in 80 Cases Total Anorexia Bulimia
n 80 39 6
100.00 48.75 7.5
Eating disorder NOS. Obesity
29 6
36.2 7.5
401
Table 2. Age and Gender Data of Patients .P
9/l ._
._
Total sample size Male Female
8; 9
Age at admission (mean)
15 yr
71
NOS., not otherwise specified.
apy, and psychotherapy process. In addition, she resumed bcdwetting, expressed various fears, and complained of frightening dreams. Two attempts at psychotherai?y proved to be of no avail. Shortly before admission, psychosomatic complaints were noted together with sadness, irritability, school failure, and social withdrawal. M.B. is the oldest of three children. Her developmcnt was rana!von~Culexcept 603”l%r~:.Sof separation anxiety when she entered kmdergarten and then again in first grade. She was described as very sweet and quiet, helpful at home with house chores and in the care of her younger siblings. At admission, body weight was 29 kg. (target weight, 35 kg). M.B. was clinically depressed and anxious, particularly about separating from parents and at meals. M.B. entered intensive psychotherapy and also received intragastric feeding (for 1 week). As soon as she was willing to swallow solids, chlorimipramine was administered. MB. resumed normal eating about 1 month after admission. At that point, the sad affect was temporarily replaced by an aggressive, hypomanic mood. At the end of hospitalization (3 mo), M.B. ate normally, and she showed no signs of depression. Discussion. The refusal to ingest solid food following a traumatic event suggests the possibility of a post-traumatic stress disorder. The accompanying depression is either an associated feature of the former or a disorder in its own right. Psychotherapy uncovered that M.B. harbored unconscious aggressive, cannibalistic wishes directed toward a weak mother who apparently failed to provide the child with adequate gratifications as well as toward her younger brothers who further deprived her of mother’s care. These wishes led to her guiltridden (over-) reaction after choking on a piece of meat. In the hospital setting, M.B. could eventually separate eating food from devouring the primary objects. She also became able to displace aggression to substitute objects and realize that these objects could survive her aggression. Antidepressive drugs, milieu ther-
helped consolidate
this
Patient 2 historyand Treatment.L.R. is a 12-yr-old boy who was admitted to the Psychosomatic Unit on an emergency basis on account of solid and liquid food refusal of 1 wk duration. There was no identifiable stressor responsible for this condition. R&y&&ion and pediatric evaluation were performed in another hospital. On admission, L.R. looked calm and even indifferent to his condition. He could not provide any explanation for his refusal to eat or drink and did not seem disturbed in the least by having to be fed via intragastric tube. Within a few days, he volunteered to introduce the tube himself which he continued to do for the following 3 mo, time during which he neither ate, nor drank, nor deplored his predicament. In psychotherapy he mostly remained aloof and detached. Occasional fantasy productions dealt with sadistic themes such as betrayal and murder. His interpersonal relations with the other children in the ward were tainted by subtle aggression (mostly verbal in the form of offending and cynical remarks, occasional competitive outdoing and outsmarting, etc.). There was something mechanical, inhuman about this boy. He could astonish the staff by his mysterioubli gaining access to all forbidden areas, such as locked offices and file cabinets, or his eavesdropping on private conversations, etc. He could gaze without blinking and seldom displayed any empathic feelings toward people with the exception of his depressed mother, toward whom he showed compassion and sorrow. In the fourth month of hospitalization, after numerous and futile attempts (psychotherapy, hypnosis, narcoanalysis, etc.) geared to both understand and cease the food refusal, the intragastric feeding was discontinued, and a closely monitored fasting period was allowed; 5 days: later, in a rather theatrical way, L.R. resumed eating “as if nothing ever happened.” The following 6 wk were not less dramatic. L.R. became increasingly restless and ag-
402
MITRANY
gressive, occasionally uncontrollable, and evidently fearful of the loss of control. Following this, he sunk into a depressive mood not unlike his mother’s. Only now, for the first time s&e admission and possibly for the first time altogether, was L.R. able to express feelings of helplessness, fear, and despair. His condition gradually improved. Owing to this improvement, his parents insisted on a discharge which was definitely premature. Discussion.. L.R. suffered from a conversion disorder. His total abstinence from eating and drinking over a period of 3 mo seems to have been rooted in a desperate attempt of L.R. to control stressful external situations as well as his inner overwhelming feelings. He displaced onto eating an effort to overcome emerging sexual and aggressive preadolescent urges. At the same time, he postponed or provoked emotional upheavals in his already unstable parents, both on the brink of psychosis. His character defenses, isolation and distancing, were well served by the symptom; renunciation of the symptom induced an upsurge of aggression, first directed to the outside and then turned against the self.
Conclusions Atypical eating disorders confront the clinician with a variety of psychopathologies gravitating around preoccupation with body weight, food, and eating. While in need of consistency insofar as physiological and nutritive tasks are concerned, one cannot develop a single psychodynamic model applicable to all these disorders. The obese patients are the most difficult to treat, although their personality, on the
JOURNAL OF ADOLESCENT HEALTH b 01.13, No. 5
whole, and their defense organization seem better integrated than those of patients with bulimia for instance. Food refusal after an incident of choking has been described by Chatoor (3) in 5 preadolescent children and related-as in this presentation-to a post-traumatic stress disorder. We could not find in the literature a case similar to the 12-yr-old boy who totally refrained from active eating and drinking for over 3 months, while not opposing passive alimentation. Here, the act of eating (incorporation) is the locus of symbolization rather than the effect of food on the body as seen in anorectic restricters. Among the atypical eating disorder cases were oppositional defiant ones who embraced nonconformist behavior for the sake of resisting and provoking authority and norms, and psychotic (schizoaffective) patients who refused food on account of delusional beliefs (such as the food was being poisoned). These were diagnosed and treated as eating disorders because the disturbed eating pattern was the major presenting symptom, to a degree where it endangered not only mental but also bodily health. A.N. and bulimia-like patients, who were essentially similar in their psychological profile to their DSM-III-R counterparts, were in the majority in this cluster.
References American Psychiatric Association. Diagnostic and Statistic Manual of Mental Disorders, 3rd ed. revised. Washington, DC: American Psychiatric Association, 1987. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association, 1980. Chatoor I. Food refusal after an incident of choking: A posttraumatic eating disorder. J Am Acad Child Psychiatry 1988; 27:105-10.
