Avoidant/Restrictive Food Intake Disorder Flashcards
how many criteria are there for ARFID
4
criterion A for ARFID
an eating or feeding disturbance as manifested by PERSISTENT FAILURE to meet appropriate nutritional and/or energy needs associated with one or more of the following (at least one of these must be present):
- -significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- –significant nutritional deficiency
- -dependence on enteral feeding or oral nutritional supplements
- -marked interference in psychosocial functioning
what are the feeding or eating disturbances that may be seen in ARFID (listed/included in criterion A)
–apparent LACK OF INTEREST in eating or food
–avoidance based on SENSORY characteristics of food
–concern about AVERSIVE CONSEQUENCES of eating
criterion B of ARFID
disturbance not better explained by lack of available food or by an associated culturally sanctioned practice
criterion C of ARFID
eating disturbance does not exclusively occur during the course of AN or BN, and there is NO EVIDENCE of disturbance in the way in which one’s body weight or shape is experienced
what distinguishes ARFID from AN, BN
in ARFID, there is no disturbance in the way ones weight or shape is experienced
criterion D for ARFID
the eating disturbance is not attributable to a concurrent medical disorder or not better explained by another mental disorder
when ARFID occurs int he context of another condition or disorder, severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention
what does ARFID replace from the DSM-IV
replaces and extends the previous dx of “feeding disorder of infancy or early childhood”
what is the main diagnostic feature of ARFID
AVOIDANCE or RESTRICTION of food intake manifested by clinically significant failure to meet requirements for nutrition or energy requirements through oral intake of food
how do you determine if weight loss is significant (i.e as in criterion A)
it is a CLINICAL judgment (as is determination of significant nutritional deficiency)
can ARFID have a significant impact on physical health?
yes–> related impact on physical health can be of similar severity to that seen in AN (i.e hypothermia, bradycardia, anemia)
what does “dependence” on enteral feeding/supplements mean?
means that supplementary feeding is required to sustain adequate intake
i.e NG tube, nutritionally complete supplements, GJ tubes
what are terms used to describe those that engage in food avoidance or restriction due to severe sensory sensitivity to characteristics of the food?
(i.e may be sensitive to the food colour, smell, texture, temperature or taste)
"restrictive eating" "selective eating" "choosy eating" "perseverant eating" "chronic food refusal" "food neophobia"
what is functional dysphagia/globus hystericus?
describes a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience
i.e choking, traumatic investigation of the GI tract (i,e EGD), or repeated vomiting
can be a cause of ARFID (see criterion A)
how might infants or young children with ARFID present
may not engage with the primary caregiver during feeding
may not communicate hunger in favor of other activities
how might very young infants with ARFID present
as being too sleepy, distressed, agitated to feed
how might older children and teens with ARFID present
food avoidance or restriction may be associated with more generalized emotional difficulties that do not meet diagnostic criteria for an anxiety, depressive or bipolar disorder (may be called “food avoidance emotional disorder”)
when does ARFID usually present
if related to lack of interest or sensory sensitivities–> in infancy or early childhood, and can persist in adulthood
(sensory sensitivities usually present in first decade of life)
if related to fear of aversive consequences–> can present at any age
what is the natural course of ARFID related to sensory sensitivities
little data–> course appears to be relatively stable and long standing
*when persisting into adulthood, such avoidance/restriction can be associated with relatively normal functioning
is there evidence directly linking ARFID and subsequent onset of an eating disorder?
no
when should you consider coexisting parentel psychopathology or child abuse/neglect in the setting of suspected ARFID
if feeding and weight improve with change in caregivers
temperamental risk factors for ARFID
anxiety disorders
ASD
OCD
ADHD
environmental risks for ARFID
familial anxiety
how does the presence of maternal eating disorder affect presence of ARFID
higher rates of feeding disturbances may occur in children of mothers with eating disorders
genetic and physiological risk factors for ARFID
hx Gi conditions
GERD
vomiting
how does gender affect dx ARFID
equally common in males and females in infancy
ARFID comorbid with ASD affects more males than females
can ARFID be diagnosed with other medical conditions
yes, if all criteria are met and the eating disturbance requires specific clinical attention
ddx ARFID
- other medical conditions
- -GI diseases
- -food allergies/intolerances
- -occult malignancies - specific neurological/neuromuscular, structural, congenital disorders
- -those related to oral/esophageal/pharyngeal sturucture and function i.e hypotonia of musculature, tongue protrusion, unsafe swallowing - reactive attachment disorder
- ASD
- specific phobia, social anxiety disorder, other anxiety disorders
- Anorexia nervosa
- OCD
- MDD
- Schizophrenia specturm d/os
- factitious disorder
what is a specific phobia that may result in/be diagnosed instead as ARFID
specific phobia, other type, specified as “situations that may lead to choking or vomiting”
can represent the primary fear, anxiety or avoidance required for diagnosis
in situations when the eating problem becomes the primary focus of clinical attention (rather than the anxiety/fear/phobia itself), ARFID becomes the appropriate diagnosis
can you diagnose ARFID and AN concurrently?
no–> ARFID has no distortion of body image/fear of gaining weight
*dx can be complicated in those with suspected AN that deny fear of gaining weight
how do you distinguish between factitious disorder and ARFID
“the presentation may be impressively dramatic and engaging, and the symptoms reported inconsistently”
what are the most commonly comorbid disorders with ARFID
anxiety disorders
OCD
neurodevelopmental disorders
- -ASD
- -ADHD
- -intellectual disability
are there any consensus guidelines for ARFID treatment
no not yet because dx is so new
what should be the goals of treatment in ARFID
until more evidence available, likely focus should be similar to other restrictive disorders which is weight restoration and resumption of menses in amenorrheic females
do people with ARFID typically present with the same level of bradycardia and hypotension as those with AN?
no–> have often achieved a level of homeostasis as often have been underweight for long time
at what point might medical admission be considered for ARFID
if BMI less than 75% of the median BMI for sex and age
how to manage ARFID in patients who are not medically compromised
consider whether outpatient psychotherapy is sufficient
may need referral to a day treatment or intensive outpatient treatment ED program
consider nutrient replenishment ie with supplements
what medications might be used in treatment of ARFID
tldr; cyproheptadine, mirtazapine, lorazepam, olanzapine
- -
1. cyproheptadine - -> antihistaminergic and antiserotonergic
- -> can have weight gain and positive changes in meal times and feeding behaviours compared to those who dont take it
- -> seems to promote increased appetite and gastric accomodation
- there is no psychotropic medication treatment for ARFID approved by US FDA
- -> case reports decribes use of mirtazapine, lorazepam and olanzapine
list psychological treatments for ARFID
CBT-AR
–> ages 10 and older
what is the role of mirtazapine and lorazepam in treatment of ARFID
to decrease anxiety related to eating
what is the role of olanzapine in treatment of ARFID
decrease cognitive rigidity in beliefs about food and promote weight gain
what is cyproheptadine
OFF LABEL for ARFID
- -> antihistaminergic and antiserotonergic
- -> can have weight gain and positive changes in meal times and feeding behaviours compared to those who dont take it
- -> seems to promote increased appetite and gastric accomodation
- -> there is a study that showed benefit in kids ages 6-7 with variety of feed/eat disorder
