Transient Eating Problems in an Adolescent without Body Image Disturbances: A Diagnostic Quandary
A 12-year-old young lady belonging to lower socioeconomic rural background was seen by the psychiatry services when referred for problems of eating since past 2 months. The patient had a history of delayed development and achieved milestones slower than other siblings. She would mostly be shy and would interact with children younger than her age. She would answer briefly when spoken to by classmates and teachers. She would eat what was given to her by her mother, and ask for specific food items occasionally. Her school performance remained below average and had difficulties in making small purchases.\nAround 2 years back, the patient developed generalized tonic clonic seizures during sleep which were followed by myoclonic jerks. The electroencephalograpm (EEG) findings were consistent with a diagnosis of juvenile myoclonic epilepsy (JME). Sodium valproate was started, which was gradually increased to 600 mg per day. The episodes of generalized tonic clonic seizures were well controlled with valproate, but myoclonic jerks continued to recur. Due to the occurrence of jerks at school, other children would tease her. Hence she started to refuse going to school. She became irritable with her family members quite often, and would hit the siblings when provoked. She did not have depressive cognitions or change in sleep or appetite then. Due to behavioral problems of refusal to go to school and irritability, she was evaluated in psychiatry outpatient. Intelligence quotient (IQ) assessment was done and reported as 57 with a diagnosis of mild mental retardation.\nSince around 2 months prior, the patient started to refuse specific food stuffs. She would eat rice at the previous amounts, but would refuse to eat rotis, the staple diet of the family. If persuaded, she would get irritable and start crying and go to sleep without eating anything. She would also refuse to eat biscuits and bread at times. She would not give any specific reason for the refusal. At times she said that she was hungry and would ask for food, and would eat rice but refuse rotis. She did not have any associated loose stools, abdominal pain, vomiting, or regurgitation. She would not demand for specific food items like chocolates, etc.; would not appear sad, withdrawn or fearful, or have any disturbances in sleep. Over the period of 1 month, the weight reduced by about 1 kg. On further exploration, no preoccupation with body image, of previously fussiness of eating was reported by the family members. The child had a slow to warm up temperament and there was no history suggestive of eating inedible objects, delusions, hallucinations or repetitive behaviors, significant obstinacy, hyperactivity or inattentiveness. There was no family history of psychiatric illness. The general physical examination was within normal limits, the height and weight was over the 10th percentile and there were no signs of chronic malnutrition. Rapport could be established with difficulty and the child answered briefly only after urging from the mother and therapist. The patient was followed up with the suggestion of keeping a watch on weight. Mother was encouraged to observe the diet and no structured behavioral intervention was done. When patient returned in 2 weeks, there was no further decrement in weight and the patient started to eat all kinds of food stuffs again and to the previous amounts. Even on recovery, she did not elaborate the cause of decreased intake of certain foodstuffs and that of resumption.