A Study of Psycho-Pathology and Treatment of
A Study of Psycho-Pathology and Treatment of
A Study of Psycho-Pathology and Treatment of
Okayama, 2007
Vol. 61, No. 5 pp. 261269
Copyright 2007 by Okayama University Medical School.
http ://www.lib.okayama-u.ac.jp/www/acta/
262
Okada et al.
Post-traumatic
type
Results
The characteristics of 6 subjects,
classied
We had 6 patients with phagophobia of 314 outpatients. Forty-six patients (14.6) complained of eating behavior problems, including food refusal (dysphagia, appetite loss,
), and weight loss or poor
weight gain. Of these, 22 patients (47.8) were
diagnosed with AN, 6 (13.0) were with phagophobia, 3 (6.5) with psychogenic vomiting, 2 (4.3)
with functional dysphagia, and 13 (28.3) with other
disorders. Although bias was introduced by the fact
that the Department of Psychiatry in our hospital
predominantly treats AN of adolescence, 13.0 of
patients who presented with maladaptive eating problems were diagnosed with phagophobia.
October 2007
Phagophobia
263
Family character
Type of
Forcing
phagopobia
the patient
to eat
Age
(years)
Sex
(MMale,
FFemale)
Premorbid
eating
habits
Premorbid
character
Trigger
event
Chief
complaint
Single
Parent
Family
problems
none
easygoing
vomiting from
eating too
much
fear of vomiting
diculty of
swallowing
none
Posttraumatic
none
vomiting from
fear of vomiting
easygoing
acute
nausea after eating
gastroenteritis
father died
sister with
mental
retardation
Posttraumatic
fear of vomiting
diculty of
swallowing
nausea after eating
none
Posttraumatic
15
small
neurosis
appetite
obsessive
picky eating
fearful
small appetite
neurosis vomiting from
diet therapy
obsessive
acute
due to atopic
fearful gastroenteritis
dermatitis
fear of vomiting
diculty of
swallowing
appetite loss
lack of
friendship
in school
Posttraumatic
impulsive
vomiting from
immature
chemotherapy
hyperkinetic
fear of vomiting
appetite loss
mother s
new
boyfriend
Gain-fromillness
vomiting from
acute
gastroenteritis
fear of vomiting
nausea and
heartburn after
eating
lack of
friendship
in school
Gain-fromillness
10
11
Symptoms
10
none
none
impulsive
immature
looking her
mother
vomiting
nal symptoms such as nausea, heartburn, and abdominal bloating. We describe below case reports of 3
typical patients. To protect patient s privacy, details
of the cases have been altered to an extent that does
not detract from the substance of the article.
1. No deviation of premorbid personality,
post-traumatic type.
Case 1: 5-year-old girl, kindergarten.
Premorbid personality: No marked deviation.
History of present illness: After vomiting due to
overeating, the patient became fearful of vomiting and
her appetite decreased. Over a period of 4 months,
her weight decreased by 2.0 kg. At the rst visit, she
was 111.4 cm tall, weighed 18.9 kg, and displayed an
obesity index of 4.1.
Measures taken by the family: Her father was
inconsistent, and he tried to prompt her to eat
through admonishments and scolding. The patient
264
Okada et al.
Psychotherapy
environmental
manipulation
Duration of
treatment
(Y Year,
M Month)
Prognosis
(walking,
taking bath)
6M
Cure
4M
Cure
(self relaxation,
dancing)
4Y
Improve
(self relaxation,
drawing)
1Y 6 M
Cure
(self relaxation,
chewing some sweets)
5M
Cure
3M
Cure
Inpatient
Tube
feeding
IVH
Solution
focused
approach
peripheral
transfusion
Outcome
Practice stress
management
October 2007
Phagophobia
265
History of present illness: When he was 10-yearsold, the patient underwent surgery for resection of a
brain tumor, followed by radio- and chemotherapy.
During therapy, he began to vomit frequently, despite
receiving anti-emetic medication. Vomiting persisted
after treatment was completed. The patient refused
food for fear of vomiting. Over a 6-month period, his
weight decreased by 5.0 kg. He was 131.2 cm tall,
weighed 21.2 kg, and displayed an obesity index of
18.5.
Measures taken by family: His mother saw the
patient on an irregular basis, due to taking care of his
sister and meeting her boyfriend. When he was vomiting, his mother stayed longer by his bedside.
Treatment course (5 months): Cranial MRI and an
upper gastrointestinal endoscope excluded organic
disease. The aection of radio- and chemotherapy was
also excluded because of an atypical onset period. The
mother was concerned about a recurrence of the brain
tumor, although she was relieved at the examination
results. We explained her son s condition as phagophobia and asked the mother about circumstances in
which he was prone to vomiting. She recalled that he
often vomited in her absence, and suggested that he
may be lonely. We suggested that she spend time with
her son on a regular basis.
The mother and nursing sta decided that the
patient would be given attention not when symptoms
occurred, but instead when he was able to suppress
symptoms. The patient decided to try measures such
as chewing gum or putting something sweet in his
mouth. The fact that his weight increased as a result
of his method gave him condence. His mother praised
him for his eorts, creating a virtuous circle. His
weight increased to 25.0 kg, with an obesity index of
10.0, and he was discharged. After resuming
school attendance, he exhibited favorable group
adjustment and no problematic behaviors. No recurrence of phagophobia occurred, but the patient died 2
years later due to a recurrence of the primary disease
(brain tumor).
Discussion
Disorders associated with eating represent some of the most common problem behaviors in
children, although there have been few reports of
266
Okada et al.
Disorder of Eating
Food Avoidance
Food avoidance
emotional disorder
(FAED)
food avoidance
weight loss
mood disturbance
(mild depression/anxiety/
obsessionality/phobia)
no organic brain disease, psychosis,
illicit drug use or prescribed drug
related side-effects
Anorexia Nervosa
determined weight loss
morbid preoccupation with weight
and/or shape, food and/or eating
fear of the act of eating
amenorrhea
Phagophobia
food avoidance
liquids may not be able to swallow
fear of swallowing/choking/vomiting
fear of the act of eating
no organic medical problem
Abnormal Cognition
regarding weight and/or shape
Functional Dysphagia
food avoidance
liquids may be able to swallow
fear of swallowing/choking
fear of the act of swallowing
no organic medical problem
Swallowing disorder
None
Fig. 1Diagnostic map for patients with food avoidance and disorder of swallowing
October 2007
During
childhood, vomiting often occurs as a result of infection or overeating, and painful experiences cause
transient fear. Although the conditions of the patients
were physically serious, all cases that we encountered
except cases 3 and 4 were cured within 6 months.
Premorbid personalities in cases 3 and 4 were obsessive. Kim [9] has reported that FD and organic dysphagia display no dierence with respect to frequency
of complicating psychological problems in adults.
However, children with complicating psychological
problems are reportedly prone to the formation of
inappropriate eating behaviors [10]. Okuma [11] has
described that obsessive children are unable to eat or
relax while eating unless the food is in a specic
shape. Based on these ndings, we concluded that
patients with obsessive premorbid personalities tend
Phagophobia
267
to be refractory to treatment.
The role of family is also important. Lynn [12]
has reported 3 cases with food phobia and signicant
psychological stressors were also noted in each family.
As indicated in Table 2, domestic discord was present
in cases 36. Inadequate communication in the family
directly aects mealtime circumstances and increases
family tension. It was setting the stage for the disorder. In addition, all of the families that had forced
their child to eat had made the symptoms more severe.
The children engaged in avoidance behaviors in
response to fear, and refused to eat in an eort to
maintain psychological stability. The family urged
them to eat increased patient anxiety, resulting in the
emergence of gastrointestinal tract symptoms. These
symptoms further increased the patient s anxiety about
their bodies, in turn exacerbating their fear and creating a vicious circle. The severity of the preexisting
family discords and the subsequent reaction of the
family were the factors that inuenced the severity of
the disorder.
To understand the psycho-pathology of phagophobia, it is also important that it be classied into 2
types. The post-traumatic type is acute onset and the
core of symptoms is phobia. The gain-illness type also
has some trigger, but the core of symptoms is conversion, so improvement of symptoms requires circumstance manipulation.
The authors views regarding appropriate treatment plans are indicated below (numbers of corresponding gures are indicated in brackets). We have
described the approach for the patients and their family because the family plays a crucial role and cooperation of family members is essential.
When little deviation is observed in the premorbid
personality and domestic discord is absent, as in
cases 1 and 2, patients fall into the group described
by Okuma [11]. They have normal childhood fears and
require no psychiatric intervention. In such cases, the
initial stage of treatment is eective and pediatric
care can be adopted. However, in cases of strong
obsession (deviated premorbid personality), as in
cases 3 and 4, or cases of gain-from-illness type, as in
cases 5 and 6, improvement is dicult and psychotherapy becomes necessary.
In the initial stage of treatment, we need to assess
the patient s nutritional condition (1). In children, the
268
Okada et al.
Therapist
Initial stage
Second Stage
Specic psychotherapy
(1)
()
Patient
Malnutrition
()
Improvement malnutrition
(2)
Improvement physical
condition
Make condence
(3)
Not Cure
Improvement
maladaptive eating
Posttraumatic
type
(4)
Gainfrom-illness
type
identify way to
relaxation
behavioral therapy resolve problem
without illness
(desensitization
therapy)
Cure
Family
Support their
child
Identify conicts
Environment
manipulation
Fig. 2Treatment Course Therapeutic strategies for the patient and family with phagophobia
October 2007
Phagophobia
269
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