Refuse to eat, resembling eating disorders, may be related to overvalued ideas; beginning during prodrome and transforming into delusions throughout psychosis.(2,3) Clarifying the reason is crucial, as antipsychotics’ side effects can aggravate comorbid eating disorder.(1)

Female, age 16. Referred to our inpatient psychiatry clinic first, by an internist, for her refusal to eat. Height:155cm, Weight:26.3kg, BMI:10.95; was on wheelchair. She had primary amenorrhea. Complained about her fear of eating, excessive need to smoke, insomnia. 3 years ago, she began to refuse eating, reporting foods being fatty. After 6 months, persecutory delusions (being poisoned) and her unique auditory hallucination (“Don't eat, otherwise we'll kill you”) began. She was taken to practitioners and internists repeatedly, was hospitalized but didn't mention her psychotic symptoms. 2 years ago, she noticed that auditory hallucinations reduced when smoking; then became a heavy smoker. Her food intake had reduced in the last year and she had eaten nothing during last 2 months. Alimentation and Risperidone 1.5-3mg/day was administered via nasogastric tube. 3 weeks later; delusions and hallucinations remitted, eating behaviour normalized, smoking reduced explicitly. At 5th and 9th week of medication, weight/BMI were, 34kg/14.15 and 44.5kg/18.52 respectively. Except negative symptoms; she had no positive symptom, no fat phobia and no disturbed body perception. Eating behaviour was normal.

Smoking may be a self-medication in Schizophrenia.(5) Cognitive and emotional component of eating refusal, like fat phobia and disturbed body perception, should be searched carefully after remission of positive symptoms, to exclude comorbid eating disorder.(4)