Buspirone Treatment of Anxiety in an Adolescent Female with Avoidant/Restrictive Food Intake Disorder

To the Editor:

Avoidant/Restrictive Food Intake Disorder (ARFID) is a newly formulated disorder described in the Feeding and Eating Disorders section of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (American Psychiatric Association 2013). ARFID replaced Feeding Disorder of Infancy and Early Childhood in the DSM-IV, and expanded the diagnosis into adolescence and adulthood (American Psychiatric Association 2000; Bryant-Waugh 2013; Moskowitz et al. 2014). Anxiety disorders are commonly seen in ARFID (Fisher et al. 2014; Nicely et al. 2014). This report describes the successful treatment of anxiety in an adolescent female with ARFID with buspirone.

Case Report

S., a 14-year-old female, presented to an initial psychiatric office visit with complaints of anxiety. For 1 year, the patient had experienced multiple episodes of epigastric abdominal pain and resultant vomiting and culminating in a presentation to an emergency room. During that time, S. had begun to restrict her food intake, due to fears of both abdominal pain and vomiting with eating, and for about 6 months her body mass index (BMI) fell from 23.2 kg/m² (84th percentile) to 20.3 kg/m² (58th percentile) at the time of her visit. The weight loss occurred in the context of various anxiety-inducing social stressors at school. S. reported anxious thoughts, various body aches, nausea, and panic attacks, and occasionally induced vomiting to relieve anxiety. S. also reported recent episodes of nonsuicidal self-injury with scratching near the onset of her weight loss, but had no clear major depressive symptoms. About 5 months into her weight loss, S. was diagnosed with ARFID by an eating disorder specialist. Her symptoms included a cyclical pattern of fearfulness of vomiting and then food restriction due to that fear. S. did not have poor body image or any symptoms of bulimia nervosa or anorexia nervosa. S. also had a history of difficulty eating foods inconsistent in color or texture, such as a multicolored food or rough-textured food.

During her assessment, S. denied symptoms of major depression, mania, or psychosis as well as any substance abuse. She had recently changed to a private school setting due to reported social stressors at her prior public school. S. had a history of being an academically high-functioning student, but had asked the school for accommodations for untimed tests and alternative testing locations due to her anxiety.

Her family psychiatric history was significant for multiple first- and second-degree relatives with anxiety, depression, and alcoholism.

Medically, S. was diagnosed with irritable bowel syndrome and possible chronic abdominal pain syndrome by a pediatric gastroenterologist. An upper gastrointestinal (GI) endoscopy done 6 months before her psychiatric assessment had found a grossly normal endoscopy with the exception of possible candida from the distal esophagus, which responded to subsequent antifungal treatment. S. was also recommended to take probiotics, co-Q10 (ubiquinol), for her nausea, and was referred for consultation with a nutritionist. Her abdominal pain was reduced, but she continued to have a fear of vomiting.

S. had been referred for psychotherapy and was started on a course of individual and family therapy. S. was also referred for medication management after her diagnosis of ARFID. However, a previous trial by her primary care provider with the selective serotonin reuptake inhibitor (SSRI), sertraline, at 50 mg daily for about 1 week resulted in agitation, activation, and thoughts of suicide. Sertraline was subsequently discontinued.

After S.'s initial psychiatric office visit, S. was started on buspirone 5 mg twice a day. S.'s dose was increased to 7.5 mg twice daily at 1-month follow-up. At both 1- and 2-month follow-up visits, S. reported reduced anxiety and improved eating with reduced fear of vomiting. Her BMI was 21.7 kg/m² (73rd percentile) at 2-month follow-up and was 21.3 kg/m² (68th percentile) at 4-month follow-up. At 6-month follow-up S. reported some increased anxiety, but S.'s eating habits continued to improve and the weight gain was maintained. The dose of buspirone was increased to 10 mg twice daily. S.'s BMI at 6-month follow-up was 21.4 kg/m² (69th percentile). The anxiety symptoms stabilized again at 8-month follow-up and S. was continued on buspirone at 10 mg twice a day. S.'s BMI at 8-month follow-up was 22.0 kg/m² (73rd percentile). Throughout S.'s treatment with buspirone, S. denied any significant side effects.

Discussion

This adolescent female with ARFID was successfully treated with buspirone. The patient's presentation fulfilled the DSM-5 criteria (American Psychiatric Association 2013): S. had significant weight loss from baseline and marked interference in her psychosocial functioning (Criterion A); her eating disturbance was not better explained by lack of available food or by an associated culturally sanctioned practice (Criterion B); the eating disturbance did not occur during the course of anorexia nervosa or bulimia nervosa, and there was no evidence of distortion of body image (Criterion C); and, although there were associated GI problems, her eating disturbance was not readily attributable to a concurrent medical condition and not better explained by a comorbid anxiety disorder (Criterion D). S. did not meet DSM-5 criteria for generalized anxiety disorder.

In this case, ARFID appears to have developed after an aversive experience associated with eating. This phenomenon was described in an earlier case study of food refusal after an incident of choking (Chatoor et al. 1988). Such food refusal can occur at any age and typically follows a traumatic event or repeated traumatic insults to the oropharynx or GI tract that trigger distress in the child or adolescent, such as severe gagging, choking, vomiting, or force feeding. Reminders of the traumatic event(s) cause distress. The food refusal may pose an acute or long-term threat to the child's health, nutrition, and growth, and threatens the progression of age-appropriate feeding development (Zero to Three 2005). This type of food refusal is associated with anxiety (Lucarelli et al. 2013).

SSRIs are a first-line medication treatment for anxiety, and have been successfully used to treat eating-related problems (Celik et al. 2007). However, SSRIs may lead to activation in child and adolescent patients (Riddle et al. 1991). Patients with ARFID have been described as having hyperarousal (Kerzner et al. 2015), which might increase vulnerability to this effect. Buspirone has successfully treated symptoms of pharyngeal dysphagias and esophageal motility disorders related to GI disorders. For example, buspirone was utilized successfully in the treatment of anxiety associated with pharyngeal dysphagia in a 4-year-old (Hanna et al. 1997), and for the management of patients with ineffective esophageal motility (Scheerens et al. 2015).

There are two significant limitations that must be considered in this report. First, there is the inherent limitation of the case report method; the association noted may be coincidental. Also, the single case involved instead of a case series does not provide for a larger sample size to strengthen the argument that buspirone treatment of anxiety in patients with ARFID is particularly effective as opposed to other medication treatment.

Conclusions

This report describes the development of ARFID in an adolescent female, who benefited from treatment with buspirone. This case suggests further exploration of the potential utility of buspirone in this newly formulated eating disorder.