Eating Refusal

We received the following question: 

I have a son with Down syndrome. He had testicular cancer in his late 20s. Since then, he seems to have developed an eating disorder. He always feels he is too heavy (which he is not). I am working with a psychologist and a nutritionist. Do you have any other suggestions? 

We have seen several individuals with Down syndrome who have what we have called for years "eating refusal." We saw it frequently enough that we gave it its own chapter in the first edition of our Mental Wellness book. We have expanded it (chapter 21) for the second edition. 

Since we wrote the first edition of Mental Wellness, the diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID) has been added to the DSM-5 . As described on the website of the National Eating Disorders Association :

"Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5 and was previously referred to as "Selective Eating Disorder." ARFID is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness."

Commonly in our patients, a physical illness triggers the onset of symptoms. This has included peptic ulcers (an ulcer in the stomach or duodenum), a choking episode, conditions causing throat pain, and others. It often seems logical that the physical problem directly serves as a trigger. For example, when a person with an ulcer ate, the person experienced pain and, therefore, stopped eating. Another individual became very concerned about his cholesterol level after being told that it was high. He developed restricted eating in response. He did not have a misperception about his body, but he did have a misperception about his cholesterol value and struggled to eat more normally, even after his cholesterol value returned to normal.

Frequently, the direct cause and effect may be less clear (as perhaps may be the case with someone who developed these symptoms after treatment for testicular cancer). These less direct causes and effects may include the psychological response to being ill, being in the hospital, having anesthesia, or having a change to the body (e.g., removal of the testicle). Hopefully, a psychologist or counselor can assess and help redirect an individual's thinking in these situations. 

In our experience, the individuals have not typically had body image misperceptions as part of their symptoms. Therefore, while not always specifically meeting the criteria for ARFID, their symptoms were closer to meeting the criteria for this diagnosis than for the diagnosis of anorexia nervosa.

While expression of body image concerns is not common in our experience, we have become aware of a few cases more  recently. In these situations, here are some treatment considerations:

• An assessment for contributing physical causes.

• An assessment for other mental health conditions that might be treatable and also benefit the person's symptoms of anorexia nervosa.

• Team approach. The person's team may include a physician to monitor labs, weight, and blood pressure; a dietician to help with a food plan; and a psychiatrist for evaluation and treatment. 

• Treatment modification. Specialized clinics for people with eating disorders may not be beneficial for individuals with Down syndrome; however, it may be possible to modify information from the programs to better support the individual with Down syndrome. For example, perhaps a series of visuals including social stories could be developed. Similarly, counseling may not be possible based on cognitive ability. Other forms of therapy may be considered instead. Additional information on types of therapy is available in Chapter 16 of our Mental Wellness book.

Additionally, obsessive compulsive disorder (OCD) is more frequent in people with Down syndrome and there is often a component of OCD in our patients with eating refusal. As part of the whole treatment plan (including counseling, nutrition, family support, etc.), several individuals have benefited from treatment with medications for OCD.