Mirtazapine for Choking Phobia: Report of a Pediatric Case.

Abstract

[Author Affiliation]Canan Tanidir. 1 Child and Adolescent Psychiatry Clinic, Bakirkoy State Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey.Sabri Herguner. 2 Department of Child and Adolescent Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey.Address correspondence to: Sabri Herguner, Meram Tip Fakultesi, Cocuk ve Ergen Psikiyatrisi AD, 42090, Konya, Turkey, E-mail: herguners@yahoo.comTo The Editor:Choking phobia, also known as posttraumatic eating or phagophobia, is characterized by the excessive fear and avoidance of eating, chewing, or swallowing solids and/or liquids without an underlying physiological cause (Lopes et al. 2014). Although it was defined as a specific in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), DSM-5 included chocking phobia in the diagnostic category of avoidant/restrictive food intake disorder (ARFID) (American Psychiatric Association 1994, 2013).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 and obsessive-compulsive (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 ReportA 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 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. …