Abstract
C
The onset of choking phobia is typically sudden, following an incident of choking. The children refuse to either drink liquids or eat any solid food, and in severe cases, refuse all oral feeding. It may cause weight loss, avoidance of public eating, social withdrawal, and anxiety and family distress during mealtimes. Choking phobia is more common in girls than in boys, and high comorbidity with other anxiety disorders, including separation anxiety disorder and obsessive-compulsive disorder (OCD) is reported (Okada et al. 2007; Lopes et al. 2014).
A standard treatment for choking phobia has not been described in the literature. Behavioral interventions, including systemic desensitization, are found as effective in a number of case studies (Okada et al. 2007; Lopes et al., 2014). There are several reports about the psychopharmacological treatment of choking phobia, including selective serotonin reuptake inhibitors (SSRIs) (Banerjee et al. 2005; Celik et al. 2007), risperidone (Berger-Gross et al. 2004), and benzodiazepines (Kardas et al. 2014). Here, we report a pediatric patient who began refusing food after a choking experience, and was treated successfully with mirtazapine.
Case Report
A 10-year-old girl was referred to the child and adolescent psychiatry outpatient clinic from the pediatric gastroenterology department because of her refusal to eat any solid foods. Her symptoms began after she had choked on her mother's ring when she was 4 years old. After this event, she became fearful and started refusing to consume and swallow any solid foods. During mealtimes she experienced great anxiety and distress. Because she was willing to eat only strained foods and liquids, her mother was liquidizing solid foods. On admission, the patient's weight was 26 kg and her weight-for-stature was below the 10th percentile. Although she had undergone repeated physical examinations and several diagnostic tests, they were all unremarkable.
At her psychiatric assessment, she was diagnosed with OCD and ARFID, and she had a past history of separation anxiety disorder according to DSM-5 criteria (American Psychiatric Association 2013). Family history was positive for OCD in her mother and grandmother. Initially, a behavioral approach (gradual desensitization) was introduced, but the patient did not respond because of her high anxiety level. Then we decided to try psychopharmacological treatment. Because of her difficulty swallowing pills, liquid preparation of fluoxetine 10 mg/day was initiated and the dose was increased up to 30 mg/day, gradually. There was no significant improvement in her symptoms during a 2 month period; moreover, her appetite decreased. We stopped fluoxetine, and a liquid form of mirtazapine 15 mg/day was introduced. The response was dramatic; within the first week she began eating solid foods, including toast, beef, and crackers. At her follow-up visit 2 weeks later, she reported feeling less anxious during mealtimes and was consuming entire meals without difficulty. According to her mother, her appetite increased, and she completely stopped refusing food. She received mirtazapine for 6 months and her weight increased to 34 kg (25–50 percentile). She tolerated the medication well, and did not report any side effects related to mirtazapine. After the discontinuation of mirtazapine, her complaints did not reemerge during the 6 month follow-up period.
Discussion
In this report, we described a pediatric patient with choking phobia who did not respond to behavioral intervention because of her intense anxiety, and who experienced a marked, rapid, and sustained improvement following mirtazapine administration. To our knowledge, this is the first report of successful treatment of choking phobia with mirtazapine.
Because of their effects on reducing anxiety, the use of antidepressants has been suggested in the treatment of choking phobia. Celik et al. (2007) reported 24-month-old twins who were tube dependent and refusing all solid foods and some fluids. They were started on fluoxetine, in the 2nd month a significant decrease in anxiety was observed during feeding, and they began to be fed without a nasogastric catheter. Banerjee et al. (2005) described three school-aged children with choking phobia who were refractory to behavioral interventions for their high level of anxiety. They displayed rapid and sustained response to SSRIs (sertraline and paroxetine) and their anxiety during mealtime reduced. However, the case we reported did not respond to either behavioral treatment or fluoxetine.
Mirtazapine, a noradrenergic and specific serotonergic antidepressant, acts to increase the release of both norepinephrine and serotonin via blockade of central presynaptic α2-adrenergic receptors. It also has antagonist actions at the postsynaptic serotonin 5-HT2 and 5-HT3 receptors, which contribute to its rapid-onset anxiolytic properties, beginning as early as the 1st week of treatment (Benjamin and Doraiswamy 2011). Increased appetite and weight gain are the most reported side effects, which may because of its potent antagonism at the serotonin 5-HT2c and histamine H1 receptors. After introduction of mirtazapine, our patient reported increased appetite, improved anxiety, and less fear, and she gained 8 kg during 6 months.
This report suggests that mirtazapine may be an effective and safe treatment alternative in children with choking phobia who are resistant to behavioral and/or SSRI therapy. In addition to stimulating appetite and promoting weight gain, mirtazapine may reduce the level of anxiety associated with solid food. Further research about the efficacy and safety of mirtazapine in this group is needed.
Footnotes
Disclosures
No competing financial interests exist.