Hema Mekala, M.D., Sayeda Basith, M.D., Lalasa Doppalapudi, M.D., Kaushal Shah, M.D.

Food refusal is commonly seen in hospitalized patients with mental illness resulting in cachexia and death if left untreated. In acute conditions, it may lead to a medical emergency. If it is a chronic issue, it can become an ingrained behavior that is difficult to change. In a study involving 206 schizophrenic patients, 56.5% of patients refused food. Of them, 54.6% reported having decreased appetite, while 32.5% described paranoia (1). Patients suffering from schizophrenia having paranoid delusions involving food or persecutory delusions, that food is contaminated or poisoned, can be common reasons for food refusal. Lack of contact with reality or ego identification may also be contributing. Auditory hallucinations and negative symptoms of schizophrenia are associated with a reduced impulse to restrict eating or binging (2).

Depression in schizoaffective patients might also result in reduced appetite and food refusal. Along with refusal to eat or drink, pica, phobia, and carbohydrate preference might also be seen in patients suffering from schizophrenia. Avolition, mannerisms, and posturing, as in catatonic schizophrenia, were found to be positively associated with food refusal (3). Eating problems might also result from social reinforcement such as coaxing, spoon-feeding, or persuading the patient, wherein the patient seeks attention by refusing to eat.

On the other hand, psychotic symptoms can occur in severe eating disorders. Schizophrenia might present initially with anorexia, and vice versa, as many cases of anorexia nervosa were reported to show psychotic symptoms following starvation. Dopamine receptor polymorphisms and Catechol O-Methyltransferase (COMT) Val158Met gene polymorphisms are seen in anorexia and schizophrenia, showing that dopaminergic dysfunction is an underlying cause for both the conditions (4). Refusal of food can result in electrolyte imbalance and nutritional deficiencies and worsen psychotic symptoms. When patients refuse to eat, they are at risk of having a seizure due to poor nutrition. A subsequent complication of this could be that new psychotic symptoms could emerge in the interictal and postictal phase of the seizure. Overall, the mortality rate is higher for a patient refusing to eat and has psychiatric comorbidity (5).

Treatment of the primary psychosis should be the first step. Antipsychotic medications not only treat the psychosis but also induce changes in leptin, endocannabinoid, opioid, and melatonin signaling, thereby improving food intake. Capacity assessment should be done before adopting force-feeding measures. Spoon feeding, tube feeding, and intravenous feeding may have to be used to prevent starvation. However, these are only short-term interventions and should be discontinued when the patient re-starts oral intake. Ethical considerations, legal issues, and social support also come into play in the treatment of psychiatric patients who refuse food. It was found that patients who perceived adequate social support were four times less likely to report food refusal (1). Hence, a multifaceted approach to the treatment of physical and mental health is required.

References:

1. Osuji PN, Onu JU: Feeding behaviors among incident cases of schizophrenia in a psychiatric hospital: association with dimensions of psychopathology and social support. Clin Nutr ESPEN 2019; 34:125-129

2. Deckelman MC, Dixon LB, Conley RR: Comorbid bulimia nervosa and schizophrenia. Int J Eat Disord 1997; 22:101-105

3. Seeman MV: Eating disorders and psychosis: seven hypotheses. World J Psychiatry 2014; 4:112

4. Gratacòs M, González JR, Mercader JM, de Cid R, Urretavizcaya M, Estivill X: Brain derived neurotrophic factor val66met and psychiatric disorders: meta-analysis of case control studies confirm association to substance-related disorders, eating disorders, and schizophrenia. Biol Psychiatry 2007 61:911-922

5. Kask J, Ekselius L, Brandt L, Kollia N, Ekbom A, Papadopoulos FC: Mortality in women with anorexia nervosa: the role of comorbid psychiatric disorders. Psychosom Med 2016; 78(8):910-919