Abstract
To the Editor:
P
Herein, we present a 12-year-old male patient who developed severe food refusal after a choking experience. He was resistant to behavioral therapy. Lorazepam, a benzodiazepine with acute anxiolytic effect, resulted in dramatic improvement.
Case Report
A 12-year-old male patient was admitted to hospital for severe refusal to drink or to eat any food, after a choking episode while eating nuts that had occurred 5 days before. He described something stuck in his oropharynx, and was continiously displaying a stereotypic swallowing movement. Past history was unremarkable. Family history revealed a conflicting relationship between the parents, but they were reluctant to give detailed information. Physical examination together with fiberendoscopic evaluation of the throat was unremarkable. Broncoscopic and upper gastrointestinal endoscopic examinations were all normal as well. Psychiatric assesment revealed that the patient was afraid of choking and dying when feeding, and that he diplayed severe anxiety when food presented to his mouth. Behavioral therapy (gradual desensitization method) was started. The patient did not respond to this approach and at the end of first week lorazepam (Ativan p.o.) was added to the treatment regimen. Clinical response was dramatic, and resulted in full restoration of oral feeding within 48 hours. Lorazepam was withdrawn during the clinical course, and the patient was discharged. Clinical symptoms and signs did not relapse.
Discussion
PTFD is first described by Chatoor et al. (1988) in latency-age children refusing to eat any solids after they had experienced a choking episode and severe gagging. PTFD was later described in infants and toddlers as well (Chatoor 1991). The children are generally preoccupied with the fear of choking and dying. They display intense anxiety, and sometimes panic when food is introduced into the mouth. It can occur at any age, from infancy to adulthood. A standard treatment for this condition has not been described. Therefore, each child with a PTFD needs to be assessed individually to determine which treatment is most appropriate for the child and the family.
Behavioral therapies, such as extinction, manipulation of hunger, and contingency management, have been used with variable success in infants and young children (Linscheid 2006). However, these therapies are difficult to apply to older children and adolescents. In the present case, a gradual desensitization method (Chatoor 2009) had been tried, but it had been unsuccesful in an acute setting. Children with PTFD feel intense anxiety when positioned for feeding and presented with feeding utensils and food. Sometimes, they may refuse all foods and liquids and require acute intervention to prevent dehydration and starvation. In the present case, the fear of eating seemed to override any awareness of hunger. The patient was displaying intense anxiety when presented with food because he was afraid of dying of suffocation when eating or drinking.
Low dose selective serotonine reuptake inhibitors (SSRIs) have been reported in the treatment of PTFD (Banerjee et al. 2005; Çelik et al. 2007) Banerjee et al. (2005) described three children 7–12 years of age, diagnosed with choking phobia, who were refractory to behavioral interventions and displayed rapid and sustained response to a low dose SSRI. Çelik et al. (2007) described 24-month-old twins with PTFD who had previously undergone multiple gastrointestinal procedures. They were refusing all solid food and some fluids, and were tube dependent. At the age of 2 years, they were started on fluoxetine. In the 2nd month, a significant decrease in anxiety and fear was observed during feeding and the children began to be fed without a nasogastric catheter. Our patient was still refusing even sips of water at the end of the 1st week of behavioral therapy. We did not choose SSRIs, because they do not have an acute effect, and their onset of action usually starts after 2 weeks of therapy. Benzodiazepines have been found to be efficacious in the treatment of anxiety, generally leading to a reduction of emotional and somatic symptoms within minutes to hours, depending upon the specific medication (Hoffman and Mathew 2008). This medication class has the advantage of a rapid onset of action, and when used alone, carries an extremely low risk of acute toxicity, but its use is limited by its potential for abuse and lack of antidepressant properties. Atkins et al. (1994) described a 7-year-old boy with functional dysphagia treated using a successful multimodal approach, including behavioral, family, and play therapy with alprazolam augmentation. The patient showed minimal response to early interventions, but rapidly improved with the prescription of alprazolam before meals. Therefore, we decided to start on lorazepam, a benzodiazepine with a short half-life and acute anxiolytic effect. The response was rapid. The patient tolerated all liquids and solid foods within 48 hours without any adverse effects from lorazepam. Subsequently in the treatment course, lorazepam was successfully withdrawn without any relaps of symptoms.
To our knowledge, this is the first case of PTFD in children that was succesfully managed with lorazepam. In older children and adolescents with PTFD who are resistant to behavioral and/or SSRI therapy, lorazepam can be tried for control of symptoms and signs in an acute setting. However, controlled trials are needed to determine the possible effects of behavioral therapy and placebo before appreciating the aforementioned role of lorazepam in the treatment of PTFD.
Footnotes
Acknowledgment
We thank Susan Delacroix for English editing.
Disclosures
No competing financial interests exist.