Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx

Diagnosis and management of ARFID

1. Avoidant Restrictive food Intake Disorder By Heba Essawy MD.CEDS., International Chapter chair Iaedps USA Prof of Psychiatry , Head of Eating Disorders Clinics Institute Of Psychiatry ,Medical School Ain Shams University

2. Introduction Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5, and was previously referred to as “Selective Eating Disorder.” ARFID is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness. ARFID: Facts and Fictions

3. Roadmap Statistics of ARFID Diagnosis of ARFID *Dimensional on top of Categorical *Categorical Model Of ARFID Risk factors in ARFID WARNING SIGNS & SYMPTOMS OF ARFID Subtypes of ARFID ARFID and it s associations Assessment Of ARFID

4. WHAT IS ARFID ?

5. What is ARFID? ARFID  is a Feeding and  Eating disorder  characterized by : food avoidance or restriction that fails to meet an individual’s nutritional or energy needs Related to sensory concerns Fear of unpleasant experiences such as choking or vomiting Not related to body image concerns.  Other psychiatric disorders including ASD , OCD and ADHD may increase an individual’s risk for ARFID.

6. Statistics In 2013 : Ornstein et .al., study of patients presenting to adolescent medicine clinics for eating-disorder evaluation found that 14% met criteria for ARFID In 2015 :   Kurz S used A questionnaire-based study reported a 3.2% prevalence ARFID in a primary school setting amongst 8–13 year olds in Switzerland In 2015 : Eddy et.al., reported a 1.5% prevalence of ARFID among boys and girls ages 8–18 years in a pediatric gastroenterology healthcare network. ARFID: Facts and Fictions

7. DIAGNOSTIC CRITERIA : DSM-5 An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 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 with psychosocial functioning. The disturbance is not better explained by lack of available food or by an associated culturally allowed practice. ARFID: Facts and Fictions

8. DIAGNOSTIC CRITERIA : DSM-5 The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. ARFID: Facts and Fictions

9. Operationalize  DSM‐5  criterion A Describes four possible sequelae of avoidant (limited variety or avoidance of certain categories of food) and/or restrictive (limited volume or restriction of overall amount) eating. What is  significant weight loss (or failure to achieve expected weight gain or faltering growth in children)  (criterion A1)? Experts defined this variably: BMI < 18.5 kg/m 2  in adults or <5th percentile in youth As in the  DSM‐5  guideline for significantly low weight in anorexia nervosa; weight loss >10 lbs; crossing BMI or weight percentiles; ARFID: Facts and Fictions

10. Operationalize   DSM‐5  criterion A2 What is  significant nutritional deficiency  (criterion A2)? Expert varied on whether blood tests were necessary, or assessment of intake via daily logs may be sufficient to allow clinician estimation of deficiencies as manifestations of avoidant/restrictive eating. Reliance on laboratory data may not be feasible: laboratory data do not necessarily always correlate with either clinical or dietary findings High costs . Individuals may be taking multivitamins and minerals which may be correcting for nutrients low or missing in the diet. ARFID: Facts and Fictions

11. Operationalize   DSM‐5  criterion A2 D ietitians supported the use of -Prospective food records -Dietary recall to identify deficiencies or insufficiencies in nutrient consumption that may increase the risk for deficiency . Operationalization used in research should be clearly specified in any published articles. ARFID: Facts and Fictions

12. Operationalize   DSM‐5  criterion A3 What is  dependence  on enteral feeding or oral nutritional supplements (criterion A3 )? Operationalization of “dependence” varied with using a threshold of ≥2 supplement drinks or any tube feeding. T he majority agreed on a definitional threshold of ≥50% or more of daily caloric intake via oral supplementation or  any  tube feeding that is not required by a concurrent medical condition . ARFID: Facts and Fictions

13. Operationalize   DSM‐5  criterion A4 Is  marked interference with psychosocial functioning  related to avoidant and/or restrictive eating (criterion A4) sufficient to meet criterion A in the absence of criteria A1‐3 clinicians described individuals presenting for treatment with severely restricted diets due to sensory sensitivity are of normal weight with no nutrition deficiencies but unable to attend school, hold jobs, or establish romantic relationships due to inability to manage eating situations. In fact at press‐time the APA was actively considering a proposal to eliminate the above clause to clarify that A4 (in the absence of criteria A1–A3) would satisfy criterion A. ARFID: Facts and Fictions

14. Radcliffe ARFID Workgroup Operational Criteria ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: 1- Weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); 2-Nutritional deficiencies (defined by laboratory assay or dietary recall); 3- Dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition) 4- Psychosocial impairment. ( Radcliffe Institute for Advanced Study, Harvard University,  2018) ARFID: Facts and Fictions

15. Categorical Model Of ARFID Jennifer J. Thomas,2018 ARFID: Facts and Fictions Fear of aversive consequences E.g. : Choking phobia Sensory sensitivity E.g.,:Avoid vegetable and fluids Lack of interest in eating of food e.g., skips meal .eats little Feeding Disorders

16. ARFID: RISK FACTORS ARFID: Facts and Fictions

17. ARFID: RISK FACTORS ARFID involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people. People with autism spectrum conditions are much more likely to develop ARFID, as are those with ADHD and intellectual disabilities. Children who don’t outgrow normal picky eating, or in whom picky eating is severe, appear to be more likely to develop ARFID. Many children with ARFID also have a co-occurring anxiety disorder, and they are also at high risk for other psychiatric disorders. ARFID: Facts and Fictions

18. ARFID: Facts and Fictions What causes ARFID? Genetic factors Eating disorders are  familial illnesses,   and temperamental traits predisposing individuals toward developing an illness are passed from generation to generation. Psychological factors Anxiety and obsessive compulsive disorder symptoms tend to accompany eating disturbances, as do co-occurring mood and anxiety disorders. Sociocultural factors Cultural pressures to eat clean/pure/healthy as well as increased interests in food processing, sourcing, packing and the environmental impact can influence food beliefs and intake

19. WARNING SIGNS & SYMPTOMS OF ARFID Behavioral and psychological  Dramatic weight loss Dresses in layers to hide weight loss or stay warm Reports constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy Reports consistent, vague gastrointestinal issues (“upset stomach”, feels full, etc.) around mealtimes that have no known cause Dramatic restriction in types or amount of food eaten Will only eat certain textures of food Fears of choking or vomiting Lack of appetite or interest in food Limited range of preferred foods that becomes narrower over time (i.e., picky eating that progressively worsens). No body image disturbance or fear of weight gain ARFID: Facts and Fictions

20. WARNING SIGNS & SYMPTOMS OF ARFID Physical  Because both anorexia and ARFID involve an inability to meet nutritional needs, both disorders have similar physical signs and medical consequences. Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.) Menstrual irregularities—missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period) Difficulties concentrating Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts,) Postpuberty Dry skin Dry and brittle nails . Muscle waekness . Poor wound healng . Amenorehea Fine hair on body ( lanugo ) . Dizzness . Fainting . Feeling Cold Thinning of hair on head, Impaired immune functioning . Sleep problems . slow heart rate ARFID: Facts and Fictions

21. HEALTH CONSEQUENCES OF ARFID In ARFID, the body is denied the essential nutrients it needs to function normally.  Body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences. The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body. ARFID: Facts and Fictions

22. Types of ARFID include: ARFID: Facts and Fictions

23. Types of ARFID include: Avoidant:  Patients who only accept a limited diet in relation to sensory features (sensory sensitivity); sensory aversion; sensory over-stimulation Aversive:  Individuals whose food refusal is related to aversive or fear-based experiences (phobic avoidance) including choking, nausea, vomiting, pain and/or swallowing Restrictive:  Individuals who do not eat enough and show little interest in feeding or eating (low appetite); extreme pickiness; distractible and forgetful ARFID “Plus”:  Individuals with avoidant, aversive, or restrictive types of ARFID presentations who begin to develop  features of anorexia nervosa , including concerns about body weight and size, fear of weight gain, negativity about fatness, negative body image without body image distortion and preference for less calorically-dense foods Adult ARFID : Individuals with avoidant, aversive, or restrictive types of ARFID presentations beyond childhood; may have had similar symptoms since childhood including selective or extremely picky eating, food peculiarities, texture, color or taste aversions related to food. ARFID: Facts and Fictions

24. ARFID and SENSORY ISSUES ARFID have sensory issues either hyposensitive (under-sensitive) or hypersensitive (over-sensitive) in terms of: taste, sight, smell. Hyposensitivity can cause sensation seeking, where certain sensations can become addictive and repetitive. Hyposensitive to taste can result in sensory eating non-food items (i.e. pica) such as: soil, dirt, grass, sand, faeces . Sensory differences have an impact on eating, and in some cases can present challenges such as: overeating, under-eating, difficulty progressing through textures when weaning, not recognising signals of hunger or thirst, ARFID , pica, difficulty with the eating environment or meal presentation, ritualistic eating patterns or continuous grazing 7 ARFID: Facts and Fictions

25. ARFID and FEAR OF THROWING UP Some kids have  Emetophobia , the fear of throwing up. This fear directly impacts their eating. Some kids worry if they eat they will throw up. Some kids worry that if they get “too full” they’ll get sick. Other kids just feel nauseous all the time and it directly impacts their appetite. ARFID: Facts and Fictions

26. ARFID and FEAR OF CHOKING Many kids with anxiety have a fear of choking. They get so consumed with this fear that they start to restrict what types of foods they eat. This can start with eliminating chewy meats but the restrictions can start from there. Some kids get so fearful they eventually go on a liquid diet ARFID: Facts and Fictions

27. ARFID and psychiatric disorders FEAR OF GETTING SICK Kids with anxiety and OCD can worry they might get sick from their food. This might be due to germs, expired food or contaminated food that can lead to food poisoning. INTRUSIVE THOUGHTS Kids with OCD will have irrational fears around their food. They might be fixated on what is different about their food (black specks, weird taste, different texture). With OCD an intrusive thought can be just about anything. ARFID: Facts and Fictions

28. ARFID and FEELINGS OF DISGUST Kids with OCD can sometimes have an overwhelming feeling of disgust. Kids with ARFID will randomly be disgusted by their food. This can be due to how the food looks, how the food feels in their mouth or how the food smells. ARFID: Facts and Fictions

29. ARFID and PANDAS/PANS PANDAS stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections PANS is Pediatric Acute-onset Neuropsychiatric Syndrome. This is when an infection caused by Strep or another autoimmune disease cause a series of symptoms that include tics, OCD symptoms, anxiety and commonly, restrictive eating ARFID: Facts and Fictions

30. Assessment and Screening of ARFID

31. Assessment of ARFID Int J Eat Disord .  2019 Apr;52(4):388-397. Interview-based assessment of avoidant/restrictive food intake disorder (ARFID): A pilot study evaluating an ARFID module for the Eating Disorder Examination. Schmidt R ,  Kirsten T ,  Hiemisch A ,  Kiess W ,  Hilbert A .

32. Assessment of ARFID Int J Eat Disord .  2019 Apr;52(4):378-387 Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22. Bryant-Waugh R ,  Micali N ,  Cooke L ,  Lawson EA ,  Eddy KT ,  Thomas JJ

33. Screening for ARFID Self‐report screening tools Eating Disorders in Youth‐Questionnaire (EDY‐Q; Kurz , van Dyck , Dremmel , Munsch , & Hilbert,  2015 ) for children and adolescents . Nine Item ARFID Screen (NIAS; Zickgraf & Ellis,  2018 ) for adults. These both yield dimensional symptom ratings rather than diagnoses. The EDY‐Q in particular has a suggested cut‐off score for possible ARFID.

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