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Case Report

Gluten-Related Disorder and Lactose Intolerance Concomitant With Avoidant/Restrictive Food Intake Disorder

Yoshiteru Sato, MD; Masataka Shinozaki, MD; Hazuki Sasaki, MD; Makiko Shiinoki, MD; Taro Shimizu, MD, PhD; Norio Yasui-Furukori, MD, PhD; and Kazutaka Shimoda, MD, PhD

Published: July 2, 2020


Gluten-Related Disorder and Lactose Intolerance Concomitant With Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder (ARFID) is a new diagnosis in the DSM-5. ARFID is characterized by restrictive eating or an avoidance of food in the absence of the cognitive restraint and weight phobia typically associated with anorexia nervosa.1 ARFID cannot be diagnosed in cases in which the presence of a concurrent medical or mental health disorder can explain the behavior observed, but it may be diagnosed if the severity of the eating disturbance exceeds that typically related to the medical condition in question.1

Case Presentation

We present the case of a 21-year-old Japanese woman who suffered from hyperventilation and weight loss. Eight months earlier, she complained of nausea, abdominal pain, and diarrhea. She was diagnosed with infectious gastroenteritis. Although these symptoms improved, her weight decreased 40 kg (88 lb) to 34 kg (75 lb). Her weight loss continued, and 5 months prior to admission, she weighed 31 kg (68 lb). Because respiratory distress, hyperventilation, and palpitations developed, she was referred to a psychiatry clinic in a university hospital Her diagnosis was panic disorder (DSM-5 criteria), but she refused treatment. Although she reported that she ate enough meals, her weight continued to decrease to 29 kg (64 lb) (body mass index: 12.44 kg/m2). The patient was admitted to the hospital’s department of psychiatry for further assessment of her emaciation. She had no desire for weight loss, and she wanted to obtain a weight of approximately 38-40 kg (84-88 lb). There was no history of vomiting or taking purgative medicine. Her laboratory data, including thyroid function, were all within normal limits. She was diagnosed with ARFID according to the DSM-5. In addition, she was diagnosed with lactose intolerance because she had loose stools after drinking dairy products since childhood. Despite eating meals without dairy products, her diarrhea continued. We referred the patient to the Department of Diagnostic and Generalist Medicine. After a wheat flour-free diet was initiated, her diarrhea stopped. She was diagnosed with gluten-related disorder in addition to lactose intolerance. Her weight increased to 30 kg (66 lb), and she was discharged. However, her weight did not exceed 31 kg (68 lb) for 1 1/2 years even though she restricted flour and dairy products. Her mental condition was stable.


Gluten-related disorders include 3 pathologies caused by the ingestion of gluten-containing cereal grains, namely celiac disease, nonceliac gluten sensitivity, and wheat allergy.2 Although all of these disorders are due to the toxicity of gluten proteins in the sensitive subject, their respective pathogenetic mechanisms differ.2,3 Because we did not examine the patient using serology and duodenal biopsy, the diagnosis of a specific gluten-related disorder may not have been established in the patient. However, on the basis of clinical course of the successful treatment with a gluten-free diet, the patient was diagnosed with a gluten-related disorder. While she could consume only a gluten- and dairy-free diet, her weight did not increase over the expected value of 35 kg (77 lb). Therefore, we concluded a diagnosis of gluten-related disorder and lactose intolerance concomitant with ARFID. This phenomenon has not previously been reported. It is also important to differentiate between ARFID and gluten-related disorders and lactose intolerance.

Published online: July 2, 2020.

Potential conflicts of interest: None.

Funding/support: None.

Patient consent: Consent was obtained from the patient to publish the case report, and information has been de-identified to protect anonymity.


1.American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

2.Sapone A, Bai JC, Ciacci C, et al. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Med. 2012;10(1):13. PubMed CrossRef

3.Ludvigsson JF, Bai JC, Biagi F, et al; BSG Coeliac Disease Guidelines Development Group; British Society of Gastroenterology. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut. 2014;63(8):1210-1228. PubMed CrossRef

aDepartment of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi, Japan

bDepartment of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, School of Medicine, Mibu, Shimotsuga, Tochigi, Japan

*Corresponding author: Norio Yasui-Furukori, MD, PhD, Department of Psychiatry, Dokkoyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi 321-0293, Japan (e-mail:

Prim Care Companion CNS Disord 2020;22(4):19l02517

To cite: Sato Y, Shinozaki M, Sasaki H, et al. Gluten-related disorder and lactose intolerance concomitant with avoidant/restrictive food intake disorder. Prim Care Companion CNS Disord. 2020;22(4):19l02517.

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