Eating disorders and other childhood feeding disorder

important psychiatric disorders- need specialized attention

1. Seminar Eating Disorders Presenter: Dr Diptadhi Mukherjee Moderator: Dr D.J. Chetia Dr Hemanta Dutta LGBRIMH, Tezpur 23/09/15

2. Outline Introduction History Cross-cultural influence Epidemiology Etiology Nosology Differential diagnosis Comorbidity Complication Indian scenario Management Feeding and eating disorders of childhood Conclusion

3. Introduction Eating disorders are disorders of eating behaviors, associated thoughts, attitudes and emotions, and their resulting physiological impairments. Anorexia nervosa & Bulimia nervosa based on 2 factors: (1) Overvaluation of the presumed benefits of weight loss or shape change (2) Fear of fat or somato -visceral discomforts associated with ingesting food that result in functional medical, psychological, and social impairment. Binge eating disorder- impulsive or compulsive rapid consumption of large quantities of food and attendant psychological and weight-related consequences They rarely present as sole diagnostic entities- almost always accompanied by significant comorbid

4. History cont… First cases reported in 1689 by Richard Morton – “ wasting ” disease of nervous etiology in one male and one female (Gordon, 2000). The first formal description of AN, however, is credited to Sir William Gull , physician to Queen Victoria, who in 1868 named the disorder “anorexia hysterica ”- emphasizing its psychogenic origins.

5. History: Bulimia Nervosa The word bulimia is derived from Greek and means “ ravenous hunger, ” quite the opposite of anorexia. Bulimia Nervosa (BN), by contrast, was first clinically described in 1979 by Russel Some authors have hypothesized that bulimia nervosa was nonexistent before recent times Historical accounts date to 1398, when “ true boulimus ” was described in an individual having an intense preoccupation with food and over eating at very short intervals, terminated by vomiting (Stein & Laakso , 1988).

6. Eating Disorders and Cross-Cultural Influences Eating disorders more prevalent in industrialized societies which emphasize thinness. US, Canada, Japan, Europe When women from countries with low prevalence rates move to countries with higher prevalence rates, prevalence increases. Variations in assessment methods and diagnostic criteria make it difficult to be certain about differences in prevalence rates from country to country.

7. Epidemiology Prevalence : Anorexia nervosa, approximately 0.4% of young women; Bulimia nervosa, 1 to 1.5% of young women Gender : Women > men (2:1 to 3:1 in community; 10:1 to 20:1 in clinical series) Age : Peaks occur at early and late teen years, but onset can be pre-pubertal through 8 th decade. Rural vs. urban : Higher with move from rural to urban setting Socioeconomic class : Anorexia nervosa- higher with social class; bulimia nervosa- independent of social class Premature mortality : 0 to 19% on 10- to 20-year follow-up after hospitalization (medical causes, closely followed by suicide); >50 times increased suicide rate when an eating disorder co-occurs with alcohol dependence ; anorexia nervosa plus insulin-dependent diabetes mellitus have 10 times higher mortality than either anorexia or diabetes alone Vocational, avocational risks : Ballet, modeling, amateur wrestling, visual media roles, appearance sports (female gymnastics, figure skating)

8. Etiology of Eating disorders A “hijacking” of normal neurobiologically regulated eating behaviors- abnormal eating pattern becomes autonomous Similarities between eating disorders and drug abuse- a vicious circle Multifactorial etiological approach may better account for current data

9. “The most compelling perspective is a recognition that eating disorders probably derive from a cluster of predisposing vulnerability factors reacting to precipitating events , especially those occurring during vulnerable “windows” in development, and are maintained by sustaining social, psychological, and biomedical reinforcements.” - CTP

10. Biological Factors Genetic vulnerability- Twin studies three times higher concordance in monozygotic twins than in dizygotic twins Monozygotic twins have a 50 to 80 percent concordance rate for eating disorders. Personality, a highly heritable variable, plays a major role Restricting-type anorexia nervosa specific genetic endowment of perseverance, sensitivity, perfectionism, and low impulsivity Binge eating–purging type-Impulsive and extroverted personality styles

11. Biological factors cont…. Molecular genetic research- loci and polymorphisms associated with genes for the 5-hydroxytryptamine types 1B (5-HT1B), 1D (5-HT1D), 2A (5-HT2A), and 2C (5-HT2C) receptors, norepinephrine transporter, dopamine receptor, monoamine oxidase A, delta opioid receptor, cannabinoid receptor (CNR1), brain derived neurotropic factor (BDNF), preproghrelin , CLOCK (endogenous oscillator) system, uncoupling proteins 2 (UCP2) and 3 (UCP3), beta-type estrogen receptor, hSKCa3 potassium channel, and human agouti protein ( AgRP ) functional magnetic resonance imaging ( fMRI ) study of body image distortion in patients with anorexia nervosa- amygdala activation, confirming that the amygdala , a major center for the “fear network,” is involved in distorted and distressed body image

12. Etiology: Biological Theory cont.. Biological theories focus on the role of the hypothalamus; The ventromedial hypothalamus has been called the satiety center. When this part of the brain is stimulated eating behavior stops, correlating to a feeling of being satiated. Conversely the lateral hypothalamus, when stimulated, correlates to eating behavior. When operating properly these two areas operate to keep the body at a specific body weight, termed the set point. Damage to either of these regions causes the set point to be altered. Eating will then reflect the new set point , thus, if it is lower then normal the animal can literally starve themselves to death. Support for this theory comes from neurotransmitter studies showing an increase in Corticotropin Releasing Factor (CRF) in the CSF of anorexic patients When administered to rats, CRF leads to a reduction in food intake, feeding time, & feeding episodes; it also leads to an increase in grooming time & grooming episodes The occurrence of amenorrhea before weight loss also suggests a hypothalamic disturbance (occurs in 20% of patients)

13. Biological Theory: Biochemical Factors Chemical imbalances in the neuroendocrine system These imbalances control hunger, appetite, digestion, sexual function, sleep, heart and kidney function, memory, emotions, and thinking Serotonin and norepinephrine are decreased in acutely ill anorexia and bulimia patients Representing a link between depression and eating disorders Excessive levels of cortisol in both anorexia and depression Caused by a problem that occurs in or near the hypothalamus Vomiting leads to an increase in DA levels which reinforces/rewards the vomiting behavior

14. Biochemical Factors cont… Theories of serotonergic hyperfunctioning in anorexia and serotonergic hypofunctioning in bulimia are attractive This indicates that Anorexic patients, may have overactive serotonerigic response centers , leading to a need to reduce the levels of serotonin in their brains by restricting their food intake. Excessive levels of serotonin are correlated with a nervous, jittery feeling. Self-starvation may be an attempt to rid the body of this uncomfortable feeling. On the other hand, Bulimics may have a faulty satiation response center . A desire to feel satiated may cause the bulimic to try to flood their brain with tryptophan , by overeating on sugars which will lead to this precursor. The theories don ’ t explain why SSRIs are sometimes helpful for both The successful treatment of bulimia with SSRIs suggests the importance of serotonin in eating disorders.

15. Biochemical Factors cont… A few sources suggested that anorexics are addicted to fasting, apparently because of the chemical changes brought on by starvation. The opioids, enkephalins and endorphins are found to be at elevated levels in the spinal fluid of patients with anorexia. It is unclear however, whether or not the starving was caused by, or was the cause of, these elevated opioid levels. Some studies have found that drugs which inhibit the functioning of these opioids cause anorexic patients to gain weight .

16. Social Factors Practices in society's emphasis on thinness and exercise Close yet troubled relationships with their parents. Low levels of nurturance and empathy, strained marital relationships in parents Mothers who are overly concerned about their daughter’s weight and physical attractiveness H/O being teased or ridiculed based on size or weight H/O trauma, sexual, physical and/or mental abuse - 60-75% of all bulimia nervosa patients have a history of physical and/or sexual abuse Vocational and avocational interests - participation in strict ballet schools increases the probability of developing anorexia nervosa at least 7-fold In high school boys, wrestling is associated with a prevalence of full or partial eating disordered syndromes during wrestling season of approximately 17 % Gay orientation in men- norms for slimness, albeit muscular slimness, are very strong in the gay community

17. Psychological factors Low self-esteem Feelings of inadequacy or lack of control in life Fear of becoming fat Depressed, anxious, angry, and lonely feelings Keep feelings to themselves Perfectionists Achievement oriented Good students Excellent athletes Competitive careers

18. Psychological factors Food and the control of food is used as an attempt to cope with feelings and emotions that seem overwhelming Having followed the wishes of others... Not learned how to cope with problems typical of adolescence, growing up, and becoming independent People binge and purge to reduce stress and relieve anxiety Anorexic people thrive on taking control of their bodies and gaining approval from others Highly value external reinforcement and acceptance

19. Nosology ICD-10 F50 Eating disorders F50.0 Anorexia nervosa F50.1 Atypical anorexia nervosa F50.2 Bulimia nervosa F5O.3 Atypical bulimia nervosa F50.4 Overeating associated with other psychological disturbances F5O.5 Vomiting associated with other psychological disturbances F50.8 Other eating disorders F50.9 Eating disorder, unspecified

20. Anorexia nervosa

21. Anorexia Nervosa- DSM-5 Diagnostic Criteria Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.  Intense fear of gaining weight or becoming fat, even though underweight. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. Subtypes: Restricting type Binge-eating/purging type

22. Period criteria- 3 months Severity- Mild: BMI ≥ 17 kg/m 2 Moderate: BMI 16-16.99 kg/m 2 Severe: BMI 15-15.99 kg/m 2 Extreme: BMI< 15 kg/m 2

23. Bulimia nervosa

24. Bulimia Nervosa- DSM-5 Diagnostic Criteria Recurrent episodes of binge eating characterized by BOTH of the following: Eating in a discrete amount of time (within a 2 hour period)large amounts of food. Sense of lack of control over eating during an episode. Recurrent inappropriate compensatory behavior in order to prevent weight gain (purging). The binge eating and compensatory behaviors both occur, on average, at least once a week for three months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

25. Period criteria- 3 months Current severity- Mild: 1-3 episodes Moderate: 4-7 episodes Severe: 8-13 episodes Extreme: more that 14 episodes

26. Anorexia vs. Bulimia Denies abnormal eating behavior Introverted Turns away food in order to cope Preoccupation with losing more and more weight Recognizes abnormal eating behavior Extroverted Turns to food in order to cope Preoccupation with attaining an “ ideal ” but often unrealistic weight

27. Differential Diagnosis of Anorexia nervosa Medical illness- Malignancy/ Brain tumor Other Severe Mental Illness- Depressive disorders- Differentiating points- Anorexia nervosa- normal appetite, planned and ritualistic aggression, preoccupation with recipes, the caloric content, intense fear of obesity or disturbance of body image Somatization disorder- severity of weight loss, morbid fear of weight loss. Schizophrenia- concerned with caloric content vs food to be poisoned, fear of weight loss, Hyperactivity. Bulimia nervosa

28. Differential Diagnosis of Bulimia nervosa Anorexia nervosa, binge eating-purging type Neurological disease- epileptic-equivalent seizures, central nervous system tumors, Kluver - Bucy syndrome Kleine -Levin syndrome Seasonal affective disorder and atypical depression

29. Comorbidity

30. Comorbodity

31. Medical Complications of Eating Disorders Related to weight loss Cachexia : Loss of fat, muscle mass, reduced thyroid metabolism (low T3 syndrome), cold intolerance, and difficulty in maintaining core body temperature Cardiac : Loss of cardiac muscle; small heart; cardiac arrhythmias, including atrial and ventricular premature contractions, prolonged His bundle transmission (prolonged QT interval), bradycardia , ventricular tachycardia; sudden death Digestive-gastrointestinal : Delayed gastric emptying, bloating, Constipation, abdominal pain Reproductive : Amenorrhea, low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) Dermatological : Lanugo (fine baby-like hair over body), edema Hematological : Leukopenia Neuropsychiatric : Abnormal taste sensation (?zinc deficiency), apathetic depression, mild cognitive disorder Skeletal : Osteoporosis

32. Medical Complications cont.. Related to purging (vomiting and laxative abuse) Metabolic : Electrolyte abnormalities, particularly hypokalemic , hypochloremic alkalosis; hypomagnesemia Digestive-gastrointestinal : Salivary gland and pancreatic inflammation and enlargement with increase in serum amylase, esophageal and gastric erosion, dysfunctional bowel with haustral dilation Dental : Erosion of dental enamel, particularly of front teeth, with corresponding decay Neuropsychiatric : Seizures (related to large fluid shifts and electrolyte disturbances), mild neuropathies, fatigue and weakness, mild cognitive disorder

33. Scenario in India Jha and Awadhia were probably the first to report a case of eating disorder in India in 1967. 6 published case report/case series With rapid cultural transformation, the classical forms of these conditions are being described

34. 2 patients scored above the cutoff for bulimia nervosa, giving a prevalence of around 0.4%

35. General principles in the management of eating disorders Multidisciplinary approach involving psychiatrists, psychologists, endocrinologists, dentists, gastroenterologists Establish and maintain a therapeutic alliance- addressing patient’s resistance to treatment and enhancing their motivation for change Assessment of eating disorder symptoms- Identifying target symptoms and behaviors Detailed report of food intake during a single day in the patient’s life may be quite informative. Family history regarding eating disorders and other psychiatric disorders, alcohol and other substance use disorders, obesity KAP of family members in relation to the patient’s disorder, and toward eating, exercise, and appearance

36. General principles in the management of eating disorders Assessment of eating disorder symptoms cont… Instruments to interview patients in a structured format - “gold standards” to determine clinical diagnoses Clinician administered measures like Eating Disorder Examination (EDE) and Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS)- can be completed within 10-40 minutes. Self reported instruments e.g. Diagnostic Survey for Eating Disorders (DSED), Bulimia Test-Revised (BULIT-R), Eating Attitudes Test (EAT), Eating Disorder Examination-Questionnaire (EDE-Q), Eating Disorders Inventory-2 (EDI-2), Eating Disorders Questionnaire (EDQ)

37. General principles in the management of eating disorders Assessment of patient’s physical status- Detailed physical examination- particular attention to - Vital signs; physical status (including height and weight); heart rate and rhythm; jugular venous pressure; heart sounds (especially midsystolic clicks or murmurs from mitral valve prolapse ); Acrocyanosis; delayed capillary refill; lanugo ; Salivary gland enlargement; scarring on the dorsum of the hands (Russell’s sign); Evidence of self-injurious behavior such as ecchymoses , linear scars, and cigarette burns; Muscular weakness; indications of muscular irritability due to hypocalcaemia, such as in Chvostek’s and Trousseau’s signs; Gait and eye abnormalities Regular monitoring of BMI

38. Laboratory and other investigation For all patients : Complete blood count (anemia is frequent) Electrolytes- Na/K/Ca/Mg Blood urea nitrogen, creatinine Thyroid-stimulating hormone, free thyroxine Electrocardiogram- Look for Arrhythmia, prolonged QT interval, T wave changes Total protein and prealbumin Fasting glucose Amylase if purging occurs Serum phosphate Bulimic syndromes In addition to above, amylase (fractionated if abnormal to determine parotid/salivary gland origin vs. pancreatic origin) If amenorrhea >3 months Bone mineral density (dual energy X-ray absorptiometry ) In men with weight loss - Testosterone

39. General principles in the management of eating disorders Choice of treatment setting- Intensive inpatient settings (in which subspecialty general medical consultation is readily available) Residential and partial hospitalization programs Outpatient care Factors determine hospitalization- Considerable difficulty gaining healthy weight Rapid or persistent decline in oral intake Decline in weight despite maximally intensive outpatient care Presence of additional stressors, such as dental procedures- may interfere the patient’s ability to eat Weight at which the patient was medically unstable in the past; Co-occurring psychiatric problems that merit hospitalization Patient’s denial and resistance to participate in his or her own care in less supervised settings

40. Treatment of Anorexia Nervosa Nutritional rehabilitation- Goals- Restore weight Normalize eating patterns Achieve normal perceptions of hunger and satiety Correct biological and psychological sequelae of malnutrition A healthy goal weight for female patients is the weight at which normal menstruation and ovulation are restored and, for male patients, the weight at which normal testicular function is resumed (APA, 2006).

41. Refeeding programs - Nursing supervised oral refeeding of normal food in appropriate amounts and composition Realistic targets- 1-1.5 Kg/week for hospitalized patients and 0.25-0.75 Kg/ week for individuals in outpatient programs Intake levels start at 30-40 kcal/kg per day (approximately 1,000-1,600 kcal/day) During the weight gain phase, intake advances progressively to as high as 70-100 kcal/kg per day In case of gain > 2-3 Kg/week- carefully monitored for refeeding syndrome and fluid retention 10-15 % require hospital based involuntary treatment Forced nasogastric or parenteral feeding- used with caution Patients physically resist and constantly remove their nasogastric tubes- surgically inserted gastrostomy or jejunostomy tubes

42. Pharmacotherapy- Antidepressants- SSRI- Fluoxetine- 2 RCTs- No significant differences between fluoxetine and placebo on weight gain, psychological features of eating disorders, or depression or anxiety measures Citalopram- 1 trial- no differences in weight gain after three months of treatment but modest advantages regarding symptoms of depression, obsessive-compulsive symptoms, impulsiveness, and trait anger. TCA- Amitriptyline and Cyproheptadine- Daily caloric intake significantly higher for cyproheptadine than for placebo; significantly fewer days were needed to achieve target weight (in those who did) with both amitriptyline and cyproheptadine groups than with placebo

43. Antipsychotics Small open-label studies- olanzapine , quetiapine may improve weight gain and psychological indicators- One RCT showed that 87.5% of patients given olanzapine achieved weight restoration (55.6% placebo). low-dose (1-2 mg) haloperidol in addition to standard treatment and were reported to benefit Hormones Transdermal testosterone (150 mg or 330 mg) for 3 weeks- greater decreases in depression in patients who were depressed at baseline, but no differences in weight gain Growth hormone (15 mg/kg/day)- rapid improvement in normal orthostatic heart rate response to standing challenge Estrogen/progesterone versus non-medication control- no differences between groups on bone density at six months

44. Antiepileptic drugs- Carbamazepine and Valproate may be effective in treating patients of Anorexia nervosa when they are used to treat an associated psychiatric (e.g. mood) or neurological (e.g. seizure) disorder; otherwise, both agents, particularly valproate , are associated with weight gain (McElroy et al.) Nutritional supplement- Zinc (14 mg per day)- associated with accelerated increase of BMI compared to placebo ( Birmingham et al.)

45. Psychosocial interventions- Considered to be the mainstay of effective treatment for anorexia nervosa Cognitive behavioral therapy (CBT)- Monitoring - monitor their food intake, their feelings and emotions, their binging and purging behaviors, and their problems in interpersonal relationships Cognitive restructuring to identify automatic thoughts, to challenge their core beliefs Problem solving to think through and devise strategies to cope with their food-related and interpersonal problems. Significantly reduced relapse risk- increased the likelihood of good outcome compared to nutritional counseling based on nutritional education and food exchanges after inpatient weight restoration Nonspecific supportive clinical management (NSCM)> CBT> IPT> Medication Family therapy- patients under the age of 18 benefited from family therapy, whereas patients over the age of 18 did worse in family therapy than with the control therapy

46. Treatment of Bulimia Nervosa Pharmacotherapy- Antidepressants- SSRI- Fluoxetine (60 mg/day) - Six trials- Fluoxetine was associated with significant improvements in measures of restraint, weight concern, and food preoccupation Fluvoxamine (150-200 mg /day)/ Sertaline (100 mg/day)- statistically significant reduction in the number of binge eating crises and purging compared with the group who received placebo Trazodone (400 mg/day)- also may be helpful TCA- dropped out more frequently Desipramine (200-300 mg/day)- decreasing binge eating, vomiting, and scores on EAT

47. 5-HT3 antagonist Ondansetron Other medications- Topiramate - efficacious in treating Bulimia nervosa symptoms in 2 randomized trials Fenfluramine - banned Lithium carbonate Opiate antagonist- naltrexone (50-120 mg/day)- not superior to placebo

48. Psychosocial interventions- Cognitive behavioral therapy (CBT) Considered the benchmark, first-line treatment Strict adherence to rigorously implemented, highly detailed, manual-guided treatments 18 to 20 sessions over 5 to 6 months Both cognitive and behavioral procedures to- (1) interrupt the self-maintaining behavioral cycle of bingeing and dieting (2) alter the individual's dysfunctional cognitions; beliefs about food, weight, body image; and overall self-concept. CBT superior to nutritional counseling alone as well as to supportive-expressive therapy (a nondirective psycho dynamically oriented treatment) & Interpersonal therapy

49. Dynamic Psychotherapy Concretize introjective and projective defense mechanisms. In a manner analogous to splitting Patients divide food into two categories: Nutritious items and those that are unhealthy Food that is designated nutritious may be ingested and retained because it unconsciously symbolizes good introjects . Junk food is unconsciously associated with bad introjects and, therefore, is expelled by vomiting, with the unconscious fantasy that all destructiveness, hate, and badness are being evacuated. Patients can temporarily feel good after vomiting because of the fantasized evacuation, but the associated feeling of “being all good” is short-lived because it is based on an unstable combination of splitting and projection .

50. Self help groups Manual including visits with non-specialists in eating disorders to check on progress Self help versus CBT group Support groups/12-step programs ‘Overeaters Anonymous’ ‘Weight Watchers’

51. Binge Eating Disorder- DSM-5 Diagnostic Criteria Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances a sense of lack of control over eating during the episode The binge-eating episodes are associated with three (or more) of the following: eating much more rapidly than normal eating until feeling uncomfortably full   eating large amounts of food when not feeling physically hungry   eating alone because of feeling embarrassed by how much one is eating feeling disgusted with oneself, depressed , or very guilty afterwards Marked distress regarding binge eating is present. The binge eating occurs, on average, at least once a week for three months . The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (for example, purging) and does not occur exclusively during the course Anorexia Nervosa, Bulimia Nervosa, or Avoidant/Restrictive Food Intake Disorder.

52. Binge Eating Disorder Most common eating disorder 25 % of patients with obesity who seek medical care 50-75% of those with severe obesity (BMI>40) Twice common in females (4% Vs 2%) Impulsive and extroverted personality style are predisposed Period of stress- binge may reduce anxiety/ depressive symptoms Obesity- 3% in long term follow up 5-years follow up- < 20% had clinically significant symptoms

53. Treatment- Psychotherapy Self-help group Medication- SSRI/ TCA CBT + Medication > CBT > Medication > Placebo

54. Other Specified Feeding or Eating Disorder (OSFED) According to the DSM-5 criteria, to be diagnosed as having OSFED a person must present with a feeding or eating behaviours that cause clinically significant distress and impairment in areas of functioning , but do not meet the full criteria for any of the other feeding and eating disorders . Atypical Anorexia Nervosa Atypical Binge Eating Disorder Atypical Bulimia Nervosa Purging Disorder Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. Binge eating disorder).

55. Feeding and Eating Disorders of Infancy or Early Childhood Pica Rumination disorder Avoidant/Restrictive Food Intake Disorder

56. Pica According to the DSM-5 criteria, to be diagnosed with Pica a child/person must display: Persistent eating of non-nutritive substances for a period of at least one month. The eating of non-nutritive substances is inappropriate to the developmental level of the individual. The eating behaviour is not part of a culturally supported or socially normative practice. If occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention. Note: Pica often occurs with other mental health disorders associated with impaired functioning. Change: Criteria has been revised to allow diagnosis for individuals of all ages.

57. Retrograde diagnosis common- after intestinal obstruction/ infections, lead poisoning. 75 percent of 12-month-old infants and 15 percent of 2- to 3-year-old toddlers placed nonnutritive substances in their mouth but seldom results in ingestion. Commonly comorbid with other developmental disorders (>15% of IDD) Affect both sexes.

58. Etiology Several theories- Hereditary - higher than expected incidence in the relatives of persons with the symptoms. Nutritional deficiencies - cravings for dirt and ice sometimes associated with iron and zinc deficiencies- corrected by their administration. Children's psychological deprivation - high incidence of parental neglect and deprivation associated- suggested that pica is a compensatory mechanism to satisfy oral needs. Most often a transient disorder Comorbid depressive symptoms and use of substances common

59. Laboratory test No single test confirms or rules out Serum levels of iron and zinc Hemoglobin level Lead level Course and Prognosis Usually good- children of normal intelligence remits spontaneously within several months In pregnant women- usually limited to the term of the pregnancy In some adults- mentally retarded- can continue for years .

60. Treatment No definitive treatment The first step- determining the cause Neglect or maltreatment- need to be altered immediately. Exposure to toxic substances, such as lead, must be eliminated/ rendered inaccessible Emphasize psychosocial, environmental, behavioral, and family guidance approaches- Ameliorate any significant psychosocial stressors. Several behavioral techniques - Positive reinforcement, modeling, behavioral shaping, and overcorrection treatment Increasing parental attention, stimulation, and emotional nurturance In some patients, correcting an iron or zinc deficiency has eliminated pica. Medical complications (e.g., lead poisoning)- must also be treated.

61. Rumination disorder According to the DSM-5 criteria, to be diagnosed as having Rumination Disorder a person must display: Repeated regurgitation of food for a period of at least one month Regurgitated food may be re-chewed, re-swallowed, or spit out. The repeated regurgitation is not due to a medical condition (e.g. gastrointestinal condition). The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder. If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention. Change: Criteria has been revised to allow diagnosis for individuals of all ages

62. Epidemiology Rumination is a rare disorder. more common among male infants- between 3 months and 1 year of age. Persists more frequently among children and adults who are mentally retarded. Adults with rumination usually maintain a normal weight. Etiology Rumination and gastroesophageal reflux often coexist- high intra-gastric pressure Self-soothing or produces a sense of relief, leading to a continuation of behaviors. In mentally retarded, the disorder may be to self-stimulatory behavior. Psychodynamic theories hypothesize various disturbances in the mother-child relationship as a contributing factor in the development - increased levels of marital conflict, leading to understimulation and inadequate emotional attention to the baby- result in insufficient emotional gratification and stimulation for the infant who seeks to self-stimulate. Overstimulation and tension have also been suggested as causes A dysfunctional autonomic nervous system may be implicated.

63. Pathology and Laboratory Examination No specific laboratory examination Must rule out physical causes of vomiting, such as pyloric stenosis and hiatal hernia, before making the diagnosis of rumination disorder. Can be associated with failure to thrive and varying degrees of starvation- endocrinological function (thyroid function tests, dexamethasone suppression test), serum electrolytes, and a hematological workup help determine the severity of the effects of rumination disorder. Differential Diagnosis Gastrointestinal congenital anomalies/infections/other medical illnesses. Pyloric stenosis is usually associated with projectile vomiting and is generally evident before 3 months of age, when rumination has its onset. Associated with various mental retardation syndromes in which other stereotypic behaviors and eating disturbances, such as pica, are present. Can co-occur with other eating disorders, such as bulimia nervosa. Course and Prognosis High rate of spontaneous remission- may develop and remit without ever being diagnosed.

64. Treatment Combination of education and behavioral techniques Evaluation of the mother-child relationship-offering guidance to the mother Behavioral technique- Habit-reversal technique - reinforcing an alternate behavior that becomes more compelling than behaviors leading to regurgitation Aversive behavior intervention- squirting lemon juice into the infant's mouth whenever rumination occurs Anatomical abnormalities (e.g. hiatal hernia)- surgical repair may be necessary. If an infant is malnourished and continues to lose most nutrition through rumination, a jejunal tube may need to be inserted before other treatments can be utilized. Medications are not a standard part of the treatment- metoclopramide , cimetidine , haloperidol

65. Avoidant/Restrictive Food Intake Disorder (ARFID)  According to the DSM-5 criteria, to be diagnosed as having ARFID a person must display: 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: Significant loss of weight (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 with psychosocial functioning The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice. The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced. The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. When is does occur in the presence of another condition/disorder, the behavior exceeds what is usually associated, and warrants additional clinical attention.

66. Changes: Previously feeding disorders of infancy or early childhood. Criteria is significantly expanded making it a broader category to capture a wider range of clinical presentations.

67. ICD-10

68. Epidemiology Between 15 and 35 % of infants and young children have transient feeding difficulties Prevalence of 4.8 % with equal gender distribution Differential Diagnosis Structural problems with the infants' gastrointestinal tract- feeding disorders and organic causes of swallowing difficulties often coexist Video-fluoroscopic evaluation - 92% sensitive to exclude organic disorders Course and Prognosis Most infants present within the first year of life- appropriate recognition and intervention- no sign of develop failure to thrive. In children 2 to 3 years of age- growth and development can be affected 70 % of infants who persistently refuse food in the first year of life continue to have some feeding problems during childhood.

69. Treatment- Individualized and targeting the interactions between the infant and mother Identifying factors that can be changed to promote greater ingestion Transactional model of intervention- training process for parents- done in an intense manner within a short period of time. Education for the parents Feed on a regular basis at 3- to 4-hour intervals- offer only water between meals Praise for any self-feeding efforts Limit any distracting stimulation during meals In severe cases hospitalization and nutritional supplementation Treatment of comorbid for anxiety and mood symptoms Risperidone observed to be associated with an increase in oral intake and accelerated weight gain

70. Conclusion Eating disorders- culture bound syndromes-restricted to countries with Western culture- formative as well as the pathoplastic effect on eating disorders. The study of eating disorders in developing countries like India could be illuminating- unique opportunity for testing the role of culture in the etiology of eating disorders. The studies conducted in the management have a limitation of small sample size and short follow up period- failed to address the optimal approach to re-nutrition Newer medications affecting hunger, satiety, and energy expenditure as well as novel approach in behavior intervention need to be developed and tested.

71. References Sadock , Benjamin J.; Sadock , Virginia A.; Ruiz, Pedro. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition.2009 Lippincott Williams & Wilkins Sadock , Benjamin James; Sadock , Virginia Alcott. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th Edition. 2014 Lippincott Williams & Wilkins The Maudsley prescribing guidelines in psychiatry / David Taylor, Carol Paton, Shitij Kapur . – 12th edition. The ICD-10 classification of mental and behavioural disorders : clinical descriptions and diagnostic guidelines. DSM-5. APA Chakraborty and Basu : Management of eating disorders. Indian J Psychiatry 52(2), Apr-Jun 2010 Sharan and Sundar : Eating disorders in women. Indian J Psychiatry 57 (Supplement 2), July 2015

72. Thank you