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Chronic constipation, atypical eating pattern, weight loss, and anxiety in a 19-year old youth.

CASE
A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.