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187 Between a Rock and a Hard Place: Challenges in Treating Patient with Phagophobia and Comorbid Panic Disorder and Severe Anorexia
- Po Yu Yen, Faisal Akram, Syed Naqvi
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- Journal:
- CNS Spectrums / Volume 25 / Issue 2 / April 2020
- Published online by Cambridge University Press:
- 24 April 2020, p. 318
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Phagophobia is a rare form of psychogenic dysphagia; it is characterized by an intense fear of swallowing food. It is a disorder which may be potentially life threatening if left untreated. Different effective approaches regarding the management for phagophobia have been documented in the past. However, there have not been sufficient data to support a definitive treatment. We would like to present a case which phagophobia, along with the presence of panic disorder and severe anorexia increase the difficulty in patient management.
Patient is a middle-aged female with history of anorexia nervosa and panic disorder. She presented with an eight-month history of inadequate caloric intake which was related to her fear of gaining weight and being preoccupied with intense fear of intake of food and medications; she stated that her throat was burning in attempt to swallow solids. She also stated that she felt like she had a “lump” in the throat. Her intake of food was limited to only certain types of food. However, after eating, she would engage in purging behaviors. Her hospitalization was complicated by multiple panic attacks in a day.
Patient underwent diagnostic interventions that helped us ruled out the other underlying causes of her symptoms: physical examinations, laboratory findings, bedside swallowing evaluation and esophagogastroduodenoscopy. These evaluations indicated that her symptoms were not caused by a medical condition or physiological effects of a substance. Daily medications aided with Anxiolytics as needed were prescribed for managing her symptoms. Non- pharmacological managements following the recommendations of the expert in positive behavior support were performed aiming to treat her symptoms.
Due to intense fear of swallowing, she was not able to take oral medications for panic disorder, and the effect of psychotherapy for eating disorder was limited due to frequent recurrence of panic attacks. She had not shown improvement of her symptoms: inadequate daily energy intake and medication, non-compliance to oral medications. Her BMI dropped from 14 to 13 over the course of 8 months and the symptoms of panic disorder persisted, and she is at risk of medical emergencies.
In this report, we present the challenges in managing a patient with multiple psychiatric comorbidities, where each illness increased the difficulty of treating another illness. We had reviewed case reports which indicated that cognitive behavioral techniques may be beneficial to patients with phagophobia. However, the effects of non-pharmacological managements were limited as patient’s psychiatric illness prevented her from completing each session. To this date, there has been no report of treatment success in a patient whose situation is similar to hers. Further research, clinical trials, and additional data collected in the future may provide new insights into management of this therapeutic challenge.
Research Domain Criteria as Psychiatric Nosology: Conceptual, Practical and Neuroethical Implications
- FAISAL AKRAM, JAMES GIORDANO
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- Journal:
- Cambridge Quarterly of Healthcare Ethics / Volume 26 / Issue 4 / October 2017
- Published online by Cambridge University Press:
- 22 September 2017, pp. 592-601
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Diagnostic classification systems in psychiatry have continued to rely on clinical phenomenology, despite limitations inherent in that approach. In view of these limitations and recent progress in neuroscience, the National Institute of Mental Health (NIMH) has initiated the Research Domain Criteria (RDoC) project to develop a more neuroscientifically based system of characterizing and classifying psychiatric disorders. The RDoC initiative aims to transform psychiatry into an integrative science of psychopathology in which mental illnesses will be defined as involving putative dysfunctions in neural nodes and networks. However, conceptual, methodological, neuroethical, and social issues inherent in and/or derived from the use of RDoC need to be addressed before any attempt is made to implement their use in clinical psychiatry. This article describes current progress in RDoC; defines key technical, neuroethical, and social issues generated by RDoC adoption and use; and posits key questions that must be addressed and resolved if RDoC are to be employed for psychiatric diagnoses and therapeutics. Specifically, we posit that objectivization of complex mental phenomena may raise ethical questions about autonomy, the value of subjective experience, what constitutes normality, what constitutes a disorder, and what represents a treatment, enablement, and/or enhancement. Ethical issues may also arise from the (mis)use of biomarkers and phenotypes in predicting and treating mental disorders, and what such definitions, predictions, and interventions portend for concepts and views of sickness, criminality, professional competency, and social functioning. Given these issues, we offer that a preparatory neuroethical framework is required to define and guide the ways in which RDoC-oriented research can—and arguably should—be utilized in clinical psychiatry, and perhaps more broadly, in the social sphere.