(027) A Case of ARFID Presenting With Catatonia, Responsive to ECT

‎Background/significance: Consultation-liaison psychiatrists are frequently asked to evaluate the patient with ‎decreased oral intake, and careful discernment for conditions with life threatening sequelae such as catatonia and ‎disordered eating is required. Rarely, the two have been described to co-exist in the same patient. Here we present a ‎case of severe ARFID, avoidant restrictive food intake disorder, which was complicated by catatonia and was ‎eventually responsive to ECT with full remission of both catatonic and disordered eating symptoms.‎

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Case: HD is a 24-year-old female who presented with generalized weakness in the setting of decreased ‎appetite, weight loss, and difficulty swallowing. The patient reported subjective dysphagia for a few weeks and voiced ‎overvalued ideas of a variety of food intolerances reported as "allergies." Patient and family denied psychiatrist ‎history, history of intentional food restriction, or fat phobia. Presenting BMI was 11.2. Medical work-up, including ‎extensive gastroenterological, neurological and autoimmune testing, was unrevealing. She developed symptoms of ‎catatonia, including stupor, mutism, staring, catalepsy, echopraxia/echolalia, negativism, waxy flexibility and ‎withdrawal. Lorazepam was initiated with only moderate response in catatonic symptoms. She continued to have poor ‎weight gain and failure to thrive over the next three months. She was eventually transferred to an academic center ‎where she underwent 16 rounds of ECT with full resolution of her catatonic syndrome and ARFID symptoms. She was ‎increasingly able to tolerate oral intake with BMI of 16.1 at time of discharge.‎

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Discussion: Catatonia, an etiologically diverse neuropsychiatric syndrome, warrants urgent psychiatric ‎evaluation and treatment due to its potential life-threatening sequelae. [Densynko, 2015; Fricchione 1997] ‎Withdrawal, or the avoidance of oral intake, is a nonspecific finding in catatonia that also occurs in a number of other ‎psychiatric conditions. Patients with catatonia and eating disorders have a high burden of disease morbidity and ‎mortality and require careful attention from the consultant in making the diagnosis and intervening swiftly. In our case, ‎while disordered eating and malnutrition was readily apparent, recognition of the catatonic syndrome was delayed. ‎Her stupor, mutism, and withdrawal were initially interpreted as hypoactive delirium secondary to profound ‎malnourishment/refeeding syndrome. ECT was considered earlier in her treatment course but was not available at our ‎facility.‎

Our case contributes to the limited body of literature supporting co-existing eating disorders and catatonia. It is further ‎unique in that the ECT not only lysed the catatonic syndrome, but apparently cured her ARFID. She demonstrated no ‎further food avoidance, dysphagia or food intolerance following treatment.‎

‎Conclusion/Implications: On a busy consultation-liaison psychiatry service, both catatonia and eating disorders ‎are seen relatively frequently, though not often in the same patient. CL psychiatrists should maintain a high index of ‎suspicion of catatonia in any patient with prominent withdrawal, and initiate potential life-saving treatment rapidly.‎

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References: ‎
‎[1] Densynko L, Freudenrich O, et al. Catatonia in Medically Ill Patients. An Evidence-Based Medicine (EMB) ‎Monograph for a Psychosomatic Medicine Practice. 2015. ‎
‎[2] Fricchione G, Bush G, Fozdar M, Francis A, Fink M. Recognition and treatment of the Catatonic Syndrome. J ‎Intensive Care Med 1997:12:135-147.‎