Feeding Disorders (16:57 minutes)

Feeding Disorders Transcript

Feeding Disorders Transcript

This is Professor Monique to discuss feeding disorders on again, an overview of other eating disorders not otherwise specified. This is going to be located on page 164 of Synopsis of Psychiatry. I just want to make an awareness that these are differential diagnoses that you may see in your clinical setting or future practice.

So we’re going to talk about pica today, rumination disorder, avoidant, restrictive food intake disorder known as ARFID, and other eating disorders. We’re going to give— I want to give some examples of common eating disorders that you can see in your clinical practice as well as possibly future in practice. So if you’re at the pediatric population, you’ll see this more often.

The negative consequences of eating disorders on otherwise specified. And then how do we evaluate and develop differentials for this type of presentation. So let’s start with pica to the diagnostic features. Remember that it’s going to be unique to the pediatric population.

You can see a pica onset in the elderly population. It’s very uncommon, and you rarely see it as an adult onset. But for pica, there’s specific criteria in a timeline. Review that in the DSM-5 as well in synopsis, that should be there.

So this is a nonnutritive, nonfood substances. Think about laundry soap, bricks stones, clay pottery. But it’s persistent over a period of at least one month, that’s criteria A. And it’s severe enough to warrant clinical attention. So parents are aware of it. It’s also eating nonnutritive nonfood substances, that’s developmentally inappropriate.

So look at the milestones of that pediatric patient that presents to you, or an adult. Would that behavior be considered a milestone? Pica would not be culturally supportive, it would be of a soci— it would be abnormal for their culture to socially accept pica. Some cultures are going to be different, so we take that into account.

But remember the diagnostic pica is two years old. That’s when you’re going to start looking at it or and parents will report it— because remember, children explore the world through their mouth. Well, what’s a little trivia about pica, it’s a Latin word for magpie. Magpie is a bird that’s thought to have odd eating habits. So you can always connect your thought process of magpie to pica.

Then you want to compare the developmental age of a child to the expected milestones. And look at some other causes, such as low iron, and zinc or calcium deficiency. Patients will consume laundry starch, ice, soil clay, pottery. But remember, and be mindful that, laundry and clay, starch— or clay and laundry starch combined, can bind in the GI system, and that exasperates the deficiency.

Lead exposure is also another cause. You’ll see that more the older homes, that have lead-based painting. And then also some potters have lead paint based. Some dangers of pica it’s going to be obviously our liver and kidney function, that can result if it’s low or damaged but you’re looking at electrolyte disturbances as well. In the cardiac, arrhythmia has a possibly seizures. We know that seizures can result in coma or death, so those are very important to take in the objective.

Toxic poisoning, such as mercury poisoning or lead paint based. There’s a call a danger, causing that poisoning level. Internal damage or sharp items, can cause intestinal obstructions as well as internal blockages or constipation.

Parasites or intestinal infections from the soil, can result in damage to the teeth. And it’s not just like a— it will be very pronounced— if they’re eating bricks, or stone, or rock. And they may not have any teeth, they will be worn down.

Final then a result of nutrition deprivation, that can lead to malnutrition and anemia we know that will also affect the brain, if the patient is malnourished. How you treat pica? So we will start with a physical screen mostly by medical providers. So you would want to get those results to you, so you could do overview.

And you want to screen for missing nutrients. And you do that by looking at medical issues such as anemia. Also anemia caused by lead poisoning, so you look at the environment as well. What are they— where do they live? What are they exposed to?

And then you can have the parents control some of the behavior by limiting the environment to where they’re exposed. So if there are young children and your parents are taking them to a park to play, just make sure that it’s not a park that uses park as the base or the playground to avoid children getting hurt. I don’t know if that’s even done anymore.

Include CBT and daily logs, if the patients are old enough and cognitively intact to do that. About the association of eating nonfood items with the trigger. Reduce the impulse by abnormal eating with pharmacological interventions, which we’ll get to in a few more slides.

Rumination disorder diagnostic features. You’re looking that this has to be regurgitation of food over a one month period. But it has to happen six months prior to your diagnosis. And that’s going to be food that is either re-swallowed or spit out. It’s not associated with the GI or medical condition. So GERD or pyloric stenosis would not be a cause of this disorder.

And it doesn’t— it doesn’t occur exclusively during the course of anorexia, bulimia, BED or ARFID. So rumination could be a differential, if you have any of those as your primary diagnosis. You’re also going to consider a mental disorder. So intellectual developmental causes are diagnosis neurodevelopmental disorders as well.

You can also have maybe some autism with this, I’m not sure how often I’ve seen together. But you want to specify if rumination is in remission or if it was previously met, but not for a sustained period. You want to document that.

And it has to have at least several times a week, typically daily after feeding or eating. So that means that it’s not going to happen during the patient’s sleep. There’s no involuntary retching. No nausea. No disgust and afterward— no disgust and afterward it’s that habit of re-chewing, re-swallowing or spitting out.

Functional consequences result in restrictive eating and avoidance of social setting, and medical consequences or malnutrition, and weight loss. Some causes are viral illnesses, emotional stress or physical injury. Those are the common three of this disorder.

The piece below is just some pathophysiology that I come across. Often in this type of patient will do this behavior as a way to relieve the abdominal muscles. And the problem with, is it comes back. So just before I— how do you treat?

Some strategies include diaphragmatic breathing, relaxation. I guess you could rese— need also refer to the massage therapist, the biofeedback. You want to include other professionals to screen for mood disorders and psychopathology. But not so much a psychiatrist, because we can do that as nurse practitioners, but psychologists bring them in especially when they’re very young.

You have nutritionists and occupational therapists to aid in those muscles shrinks for the throat and swallowing. Look at the co-occurring mood disorders. You’ll find anxiety— a common one. Nausea and stomach discomfort is also common.

May have to refer back to medical for that treatment. We can use SSRI’s to help with major depressive disorder or generalized anxiety disorder. Baclofen has had some behavioral interventions. But baclofen has may have to be dosed high— we know that we can’t just disrupt and stop that baclofen. It has to be tapered or psychosis can result.

And then neuromodular agents such as tricyclic antidepressants. Those are good in the aspect of the gut-brain interaction. You can use tricyclic for generalized anxiety disorder. But you’d have to use really low doses, because they affect the adrenal receptors, which will result in hypertension, especially in the elderly population.

Avoidant restrictive food intake overview. This is a very large discussion. I just compressed it. I just want to talk about the difference between ARFID and bulimia, or even anorexia. This ARFID patient, will not have a problem with their body image, and they’re not trying to lose weight— they’re not fear of gaining weight.

They are often diagnosed younger than patients with anorexia. So but that again, there is no age limitation. A higher percentage of ARFID patients are male, but you can have females as well. So don’t exclude it to gender.

And they often persist much longer than other eating disorders. This is a lifetime type of disorder. It’s very hard to treat and takes a long time with patients. So people with ARFID— they have it eating dis— eating disturbance.

They lack interest in eating of food, but they don’t have a fear of weight gain. And they will avoid food based on texture. So they may be able to eat pizza, but not a cheese stick. It’s what’s up to, it’s individualized.

And they have the expressing concern about unpleasant consequences of eating. So if they do eat a pizza or if they do eat cheese sticks, they’re very consumed by the consequence of eating a new food or trialing a new food. They have a lack of appropriate nutrition. They often may not have their energy needs met, and it can result in weight loss, nutritional deficiencies.

The extreme would be reliance on feeding tubes or supplements. And then they have the negative effects on psychosocial functioning. So this is not the type of patient that’s going to meet friends out for dinner. And if they are going to be that courageous to go out to dinner, they’re going to look at that menu for four or five days prior to eating out.

They’re going to have a restaurant pick that will have the foods they will eat, and it will be a very limited eating plate. They won’t eat a lot. The symptoms are— they have digestive issues such as constipation. And when these symptoms develop, this is where you talk to the parents, caregivers, that could help identify the symptoms.

Restricting not so much the amount of foods, but also the types and/or amounts. So it’s a type of food as well. They’re only interested in eating certain textures. And that’s individualized, it’s not going to be a bland per se. It might be something more richer than that.

So they could have maybe pretzels and a soda, but they can’t have a solid. They often will feel sick or fool around mealtime, so they may not even participate in eating— they feel weakness, but they can also have some energy at times. So you look at also bipolar that could come in as well. So you have to really expand beyond morphine. It takes a long time to diagnose.

They have a fear of choking or vomiting, and this irrational. And they restrict again, the range of preferred foods. And as they get older, the foods become more limited. So it’s again, a newer diagnosis that’s— the guidelines aren’t created yet.

And so they require the expertise of a dietician that’s registered. Probably some CBT. The need a specialized and individualized treatment plans. So you want to think about that fear of choking or vomiting. And how will they benefit from behavioral strategies, to address those fears.

Diaphragmatic breathing, mindfulness and CBT, family-based therapy. Exposure therapy be very careful to make sure that you have that patient safe, before you do exposure therapy. And you have the license and skill and certification.

The last thing I want to talk about is other eating disorders. And this is probably back in the eating disorder chapter. But I want to make you just aware that, there is a purging disorder, there’s a night eating syndrome, and then other specified feeding or eating disorder OSFED.

So how a purging disorder is going to be different from bulimia. And the aspect that it’s going to be about small amounts of foods and normal people— persons of normal weight. But they do have a distorted image.

But again, purging disorder won’t be associated with anorexia purging type. So differentiate those and know that there’s a spectrum of eating disorders, with purging disorder occurs a once a week for a three-month period for diagnosis. Night eating syndrome— that one is consumption of large amounts of food after an evening meal. So it’s going to be different from BED.

There’s little appetite during the day, and they’re often having a reporting insomnia. You would treat night eating syndrome with SSRI’s. Probably weight loss you could use topiramate or Topamax.

But just remember that, when you’re dosing that it takes a slow go to get it to the right dose. And if it’s a dose at a very high, well, milligrams, over 100 and 200, you have to think about their cognitive functioning. And when you’re ready to discontinue it, it’s going to take a taper. If their depression is present with night eating syndrome, think about CBT or bright light therapy.

And then other specified feeding or eating disorders that’s not found in the DSM-5, but it includes other conditions that have symptoms similar to those of an eating disorder. But they do not fit nicely into a category or diagnosis of the DSM-5 I know that’s a lot of information. I just wanted to give an overview that there’s more than anorexia, bulimia, and binge eating disorder. We actually have a spectrum of feeding disorders and eating disorders.

So keep those in mind as you are practicing in the clinical setting diagnosing, as well as your future practice to use these differentials to make sure you have a strong diagnosis, because that’s what will serve your patient well is safe practice. Well, this is Monique, I’ve enjoyed overview of these eating disorders, and let me know if you have questions, signing off.