Day # 149: Other Eating Disorders (Avoidant/Restrictive, Rumination, & Pica)

Today we will continue our current theme of eating disorders as we discuss three less well known eating disorders: Avoidant/Restrictive Food Intake Disorder, Rumination Disorder, and Pica.

Today's Content Level: Beginner and Intermediate

Introduction 1

• Avoidant/Restrictive Food Intake Disorder (ARFID): Eating disturbance characterized by a persistent failure to meet appropriate nutritional and energy needs. The reason for the eating disturbance does not include distorted body image and is often based on a lack of interest in food or avoidance based on food characteristics. Usually a disorder of infants or children.

• Rumination Disorder: Characterized by the repeated regurgitation of food that occurs for at least 1 month. It is often comorbid with intellectual disability.

• Pica: Persistent eating of non-nutritive non-food substances for at least 1 month that is inappropriate for their developmental level. It is also often comorbid with intellectual disability.

Diagnostic Criteria 2

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Eating or feeding disturbance leading to persistent failure to meet appropriate nutritional and/or energy needs.

• The eating disturbance may be related to a lack of interest in eating or food, avoidance based on the sensory characteristics of food, or concerns about aversive consequences of eating.

• Must be associated with ≥1 of the following:

• Significant weight loss (or failure to achieve expected weight gain in children).

• Significant nutritional deficiency.

• Dependence on enteral feeding or oral nutritional supplements.

• Marked interference with psychosocial functioning.

• Not better explained by lack of available food.

• Not better explained by an associated culturally sanctioned practice.

• Does not occur exclusively during the course of anorexia or bulimia nervosa.

• No evidence of a disturbance in body image.

• Not attributable to a concurrent medical/mental condition.

Rumination Disorder

• Repeated regurgitation of food for ≥ 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

• Not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).

• Does not occur exclusively during the course of other eating disorders.

Pica

• Persistent eating of non-nutritive non-food substances for ≥ 1 month.

• Inappropriate to the developmental level of the individual.

• The eating behavior is not part of a culturally supported or socially normative practice.

Epidemiology/Pathogenesis 3, 4, 5

• Avoidant/Restrictive Food Intake Disorder (ARFID): Since ARFID is a relatively new diagnosis, population-based prevalence studies are limited. Proposed risk factors include anxiety disorders, autism spectrum disorder, OCD, ADHD, developmental delays, children of parents with eating disorders, and a personal history of gastrointestinal conditions.

• Rumination Disorder: No systematic studies have reported the prevalence of rumination disorder; most of the information about this disorder is derived from small case series or single case reports. It is more common in individuals with intellectual disability and other neurodevelopmental disorders. Risk factors may include problems in the parent-child relationship, neglect, lack of stimulation, and stress.

• Pica: Prevalence is unclear. Pica can occur at any age, although it is most common in children and individuals with intellectual disabilities. Interestingly, it may also present in pregnancy, when specific cravings of non-nutritive non-food substances can occur. Some studies have also linked pica with OCD, schizophrenia, child neglect, nutritional deficiency, stress, and low socioeconomic status.

Clinical Pearls 6, 7, 8

• Avoidant/Restrictive Food Intake Disorder (ARFID): Examples of sensory properties of food include texture, taste, smell, and appearance. Examples of fear of potential adverse consequences including choking, vomiting, or gastrointensinal pain. For individuals with sensory sensitivity, food avoidance is often longstanding, having developed in early childhood. Due to a fear of trying novel foods, individuals frequently rely on highly processed energy-dense foods and may have significant deficiencies in vitamins and minerals. Other individuals describe a lack of interest and describe eating as a chore which leads to low-volume intake. Medical workup is important in patients with AFRID which should be tailored based on the deficiencies in their diet and their clinical status. Examples of deficiencies include meat/animal products (vitamin B12, B2, zinc, iron), dairy (calcium, vitmain D), fruits and vegetables (folate, vitamin C), very low protein or fat (vitamin A, vitamin K, protein, fat). Most patients should have screening blood work including CMP, magnesium, phosphorus, CBC with differential, TSH, ESR, and CRP, as well as a urinalysis. It is worth considering screening for celiac disease with a total immunoglobulin A (IgA) and tissue transglutaminase IgA, as there is a high rate of co-occurrence of celiac disease. Patients with bradycardia or hemodynamic instability should have an EKG.

• Rumination Disorder: Previously swallowed food may be partially digested and brought into the mouth without apparent nausea, involuntary retching, or disgust. Regurgitation in rumination disorder should be fre­quent, occurring at least several times per week, typically daily. Medical workup should rule out other potential gastrointestinal causes such as pyloric stenosis, gastroparesis, hiatal hernia, and gastroesophageal refulux.

• Pica: Typical substances ingested tend to vary with age and availability and might include paper, soap, cloth, hair, string, wool, soil, chalk, paint, gum, metal, pebbles, charcoal or coal, ash, clay, starch, or ice. A minimum age of 2 years is suggested for a pica diagnosis to exclude developmentally normal mouthing of objects by infants that re­sults in ingestion. There is typically no aversion to food in general. Deficiencies in vitamins or minerals such as zinc or iron have been reported, however often no specific nutritional abnormalities are found. In some cases, pica may lead to significant intestinal complications (e.g. intestinal obstruction from a bezoar, perforations, poisoning, or infections such as toxoplasmosis and toxocariasis as a result of ingesting feces or dirt. Screening for lead levels is recommended.

Treatment 9, 10, 11

• Applies to all: Initial management prioritizes correction of any nutritional deficiencies, weight restoration, and treating any additional medical consequences of their behaviors. Treatment can range from an outpatient multidisciplinary team treatment to inpatient medical hospitalization depending on severity. After medical stabilization, treatment is focused on education regarding the disease process, reassurance, and behavioral modifications to reduce the eating disturbances. There are no FDA approved medications and no pharmacological randomized placebo-controlled trials (RCTs) in these conditions. Overall, there is little evidence supporting treatment strategies and consensus guidelines have not yet been developed.

• Avoidant/Restrictive Food Intake Disorder (ARFID): Weight restoration based on BMI growth charts. Psychological treatments are emerging for this disorder to include CBT for ARFID (CBT-AR) and Family-Based Therapy (FBT). Treatment focuses on nutritional rehabilitation in stages ("volume before variety"). Patients who are underweight are encouraged to eat larger volumes of preferred food in the early stages of treatment, before increasing dietary variety in later stages. The key intervention is structured and systematic exposure to the patient's most relevant concerns such as sensory sensitivity, fear of aversive consequences, or lack of interest in food and eating. Case reports and small case series have described the use of mirtazapine or lorazepam to decrease anxiety related to eating; and olanzapine to reduce cognitive rigidity in beliefs about food and to promote weight gain. Future RCTs are needed to evaluate the efficacy of these medications for the resolution of ARFID symptoms.

• Rumination Disorder: Diaphragmatic breathing is the first-line treatment for rumination syndrome. It works by initiating a competing mechanism to the acquired, unperceived contractions of the abdominothoracic muscles. Diaphragmatic breathing should be initiated after completion of a meal or with signs of incoming regurgitations. Referral to a behavioral therapist for additional behavioral strategies and CBT for rumination disorder (CBT-RD) can be used as adjuncts. Generally, pharmacotherapy for rumination syndrome should be reserved for patients who fail initial management with behavioral therapy. A small crossover study demonstrated improved outcomes with baclofen (counteracts transient lower esophageal sphincter (LES) relaxations by increasing the basal LES pressure, thereby limiting regurgitation episodes). Buspirone may play a role due to its positive gastric fundus relaxation properties, however there are no specific studies in this population. Expert review considered a trial of buspirone for rumination syndrome in refractory cases as reasonable.

• Pica: First, address any underlying nutritional deficienies (e.g. iron, zinc), which may ease pica urges/symptoms. In children and pregnant women, pica often goes away in a few months without treatment. If pica is severe or persistent, treatment may involve behavioral therapy, such as CBT or habit reversal training (HRT). If present, medication may be prescribed to treat related underlying mental health conditions, such as OCD or schizophrenia.

Conclusion

• Congratulations. We have finished the eating disorders theme. Next lesson will be a review quiz before we move on to our next theme: sleep disorders. If you want more learning resources then check out our recommended resources page.

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• Resources for today's post include: Kaplan and Sadock’s Synopsis of Psychiatry, DSM-5-TR, Maudsley Prescribers Guide, and the articles referenced above.