Typically, counseling or school psychology training programs include required courses in psychological theories, research design, statistical methods, therapeutic interventions, developmental issues, assessment procedures, and abnormal psychology. Electives are usually designed to expand on a specific topic related to required courses. What is missing from most of these programs is a course designed to alert future school and counseling psychologists and therapists to medical problems that might cause, or complicate, psychological difficulties. This article demonstrates that a medical disorder, Crohn's disease, might lead to or exacerbate an eating disorder.
In the following case study, the patient was initially evaluated by a pediatrician who noted vague gastrointestinal symptoms with inconclusive test results. Because of the patient's phobic-like behavior toward eating, he was referred to Pediatric Psychology to determine whether some or all of his physical problems were due to emotional sources. After interviews with the patient and his mother, an atypical eating disorder was diagnosed and an intervention implemented that was successful in encouraging him to eat. Yet his rate of weight gain was discouragingly slow. After six months of psychological therapy with nutritional monitoring and an increase in food intake, further medical testing revealed Crohn's disease. A collaborative process was possible because the patient was seen in a teaching hospital where all services were available and members of several disciplines worked as a team. If communication between team members had not been coordinated, the patient's psychological problems might have been further compromised and there might have been a longer delay in the diagnosis of Crohn's disease. The authors believe that counselors or psychologists who do not work in medical settings would benefit from developing a network of resources for consultations.
Physical symptoms of Crohn's disease (a chronic inflammatory bowel disease) in children and adolescents are variable and may include the following: crampy abdominal pain, diarrhea, fever, growth failure, anorexia, chronic malaise, perianal lesions, blood in the stool, arthritis, finger clubbing, iron deficiency anemia, intermittent constipation, poor appetite, delayed puberty, nonspecific fatigue, and a sensation of having a full stomach after ingesting minimal amounts of food (Nelson, Vaughn, & Mccoy, 1969; Lagercrantz, Nelson, Berman, & Vaughn, 1963, 1976). When only a few of the symptoms are displayed, Crohn's disease may be difficult to diagnose in young people.
This disease is more common among some family groups and Jewish persons, and occurs more often in first-born children than their siblings (Nelson, Berman, & Vaughn 1983; Steinhausen & Kies, 1982). Up to 60% of patients may display psychological problems including anxiety, fearfulness, sensitivity, shyness, social withdrawal, relationship problems, and conduct disorders (Steinhausen & Kies, 1982). Children with Crohn's disease may cry more easily than their peers, be emotionally labile, have a negative view of the world, and adapt poorly to new situations (Nelson, Vaughn, & McCoy, 1969). There is no cure for this disease and the "natural history . . . is one of almost inevitable recurrence even when overt lesions are removed" (Brooke, Cave, Gurry, & King, 1977, p. 77). The diagnosis is made by a physician and is managed through psychological support, medication, surgery, and diet (Lagercrantz, 1976).
In diagnosing eating disorders, most practitioners refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III R) (1987). In this case, deliberate purging or bingeing behaviors were not reported, so a diagnosis of bulemia nervosa was not considered. The criteria for a diagnosis of anorexia nervosa were reviewed. They are: Refusal to maintain body weight over minimal normal weight for age and height . …