Feeding and Eating Disorders

Feeding Disorders

Feeding disorders are a type of eating disorder that prevents the consumption of certain foods, often based on color, texture, or other factors.

Learning Objectives

Summarize the diagnostic criteria, etiology, and treatment of avoidant/restrictive food intake disorder

Key Takeaways

Key Points

  • A feeding disorder involves a child’s or an adult’s refusal to eat certain food groups, textures, solids, or liquids for a period of at least one month, which causes them to not gain or maintain enough weight or grow naturally.
  • In the 5th edition of the DSM (DSM-5), the diagnosis of feeding disorder of infancy or early childhood was renamed to avoidant/restrictive food intake disorder (ARFID), and the criteria were expanded.
  • Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.
  • Children with feeding disorders often exhibit symptoms of obsessive-compulsive disorder (OCD) and/or autism spectrum disorder (ASD), and feeding disorders are found in 80% of children with developmental disability.
  • The most common type of treatment for adults with ARFID is some form of cognitive -behavioral therapy; hypnotherapy and support groups can also be helpful. Some children with ARFID benefit from a four stage in-home treatment program based on the principles of systematic desensitization.

Key Terms

  • systematic desensitization: A type of behavior therapy used in the field of psychology to help effectively overcome phobias and other anxiety disorders.
  • comorbid: Occurring at the same time as another disease or symptom.
  • failure to thrive: A term used in pediatric and adult medicine to indicate insufficient weight gain or inappropriate weight loss.

Defining Feeding Disorders

A feeding disorder involves a child’s or an adult’s refusal to eat certain food groups, textures, solids, or liquids for a period of at least one month, which causes them to not gain enough weight or grow naturally. Most often seen in children, feeding disorders resemble failure to thrive, except there is no medical or physiological condition that can explain the very small amount of food the children consume or their lack of growth.

In the 5th edition of the DSM (DSM-5), the diagnosis of feeding disorder of infancy or early childhood was renamed to avoidant/restrictive food intake disorder (ARFID), and the criteria were expanded. ARFID is an eating disorder that prevents the consumption of certain foods, and it is often viewed as a phase of childhood that is generally overcome with age. Some people may not grow out of the disorder, however, and may continue to be afflicted with ARFID throughout their adult lives. Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.

Foods that are considered “safe” for people with ARFID may be limited to certain food types and even specific brands. In some cases, afflicted individuals will exclude whole food groups, such as fruits or vegetables; others may avoid specific types of foods, such as sauces. Some may only like foods of a certain color, very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods. Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting, or gagging. Some studies have identified symptoms of social avoidance due to the person’s eating habits.

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Feeding Disorders in Childhood: Children with feeding disorders may refuse to eat certain foods based on color, texture, temperature, or other factors.

DSM-5 Diagnostic Criteria

According to the DSM-5, a diagnosis of ARFID requires a disturbance in eating or feeding as evidenced by substantial weight loss (or, in children, absence of expected weight gain), nutritional deficiency, dependence on a feeding tube or dietary supplements, and/or significant psychosocial interference. This disturbance must not be due to unavailability of food; to observation of cultural norms; to anorexia nervosa, bulimia nervosa, or another eating disorder; to perceived flaws in one’s body shape or weight; or to another medical condition or mental disorder. When the disorder occurs concurrently with another medical or mental condition, the disturbance must exceed what is normally caused by that condition.

Etiology

The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed other mental disorders that are comorbid with ARFID—indeed, symptoms of ARFID are usually found with symptoms of other disorders. For example, some form of feeding disorder is found in 80% of children that also have a developmental disability. Children with feeding disorders often exhibit symptoms of obsessive-compulsive disorder (OCD) and/or autism spectrum disorder (ASD). Although many people with ARFID have symptoms of these disorders, they often do not qualify for a full diagnosis. Specific food avoidances could also be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Other forms of eating disorders, such as anorexia nervosa or bulimia nervosa, involve a fear of gaining weight; while those who suffer from ARFID do not have this specific fear, the psychological symptoms and resulting anxiety are similar.

Treatment

With time, the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for adults with ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than allowing the symptoms to disappear without treatment. Hypnotherapy can also be used to lessen the anxiety associated with food; in addition, there are support groups for adults with ARFID.

Some children with ARFID benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment include record, reward, relax, and review:

  • In the record stage, children are encouraged to keep a log of their typical eating behaviors as well as their cognitive feelings, without attempting to change their habits.
  • The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
  • The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.
  • The final stage, review, is important to keep track of the child’s progress. It is important to include both one-on-one sessions with the child as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.

Eating Disorders

Eating disorders are mental disorders defined by abnormal eating habits, such as bingeing, purging, and/or fasting.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among various eating disorders

Key Takeaways

Key Points

  • There are four types of eating disorders that are recognized in the DSM-5: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified (NOS).
  • Anorexia nervosa is characterized by extreme food restriction and excessive weight loss, accompanied by the fear of being fat. Bulimia nervosa is characterized by recurrent binge eating followed by compensatory behaviors such as purging.
  • Binge eating disorder is characterized by excessively uncontrolled, impulsive eating with no compensatory behavior afterward. Eating disorder not otherwise specified (EDNOS) is any combination of disordered eating behaviors that may not fit into a diagnostic category.
  • The cause of eating disorders may include genetic predispositions, psychological factors (such as depression or obsessive-compulsive disorder), history of trauma, and environmental influences (such as social isolation, parental influence, peer pressure, and cultural pressure).
  • Cultural idealizations of thinness and youthfulness have contributed to eating disorders affecting diverse populations, but especially young Caucasian women. Peer pressure and idealized body types seen in the media may be significant factors.
  • While more research is needed, treatment for eating disorders often involves psychotherapeutic interventions (such as cognitive behavior therapy, dialectical behavior therapy, or family therapy) in a variety of inpatient or outpatient settings.

Key Terms

  • amenorrhea: Absence of menstrual discharge in biological females.
  • purge: An evacuation of the bowels or a vomiting.
  • fast: The act or practice of abstaining from food or of eating very little food
  • binge: A rapid and excessive consumption of food.

Defining Eating Disorders

Eating disorders are mental disorders defined by abnormal eating habits. These abnormal habits may involve either insufficient or excessive food intake to the detriment of an individual’s physical and mental health. People with eating disorders can appear underweight, of healthy weight, or overweight. Symptoms of these disorders are culturally influenced, being found primarily in young Caucasian women; however, eating disorders occur across populations of all genders, races, ages, and socioeconomic status. Furthermore, one person can have multiple types of disorder.

There are four types of eating disorders that are recognized in the DSM-5: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified (NOS). Some people with eating disorders suffer also from body dysmorphic disorder, a disorder which alters the way a person sees themselves.

Anorexia Nervosa

Anorexia nervosa is characterized by extreme food restriction and excessive weight loss, accompanied by the fear of being fat. An anorexic person often perceives himself or herself as fat even if they are severely underweight. Anorexia is further characterized by refusal to maintain a healthy body weight, an obsessive fear of gaining weight, and an unrealistic perception of current body weight.

Anorexia can cause menstruation to stop in females, and often leads to bone loss and loss of skin integrity. It greatly stresses the heart, increasing the risk of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this disease. Complications consistent with this malnourished physical state include bradycardia, hypotension, hypothermia, and leuhopenia. Physical symptoms include hair loss; development of downy hair growth on the face, neck, and extremities; salivary gland enlargement; indigestion; and constipation, among others.

DSM-5 Diagnostic Criteria

To be diagnosed with anorexia nervosa, a person must engage in a restriction of food to the point of a significantly low body mass index; must experience an intense fear of gaining weight, even though they are underweight; and must experience a disturbance in their self-image or self-experience (for example, perceiving themselves as overweight even if they are significantly underweight). Relative to the previous version of the DSM (DSM-IV-TR) the 2013 revision (DSM-5) reflects changes in the criteria for anorexia nervosa, most notably that of the amenorrhea criterion being removed. Amenorrhea was removed for several reasons: it doesn’t apply to males, it isn’t applicable for females before or after the age of menstruation or taking birth control pills, and some women who meet the other criteria for AN still report some menstrual activity.

Bulimia Nervosa

Bulimia nervosa is characterized by recurrent binge eating followed by compensatory behaviors for the intake of food, such as purging. Bingeing is characterized by eating a large amount of food in a short period of time (relative to a person’s normal eating habits). A purge can include self-induced vomiting, excessive use of laxatives/diuretics, fasting, or excessive exercise.

BN affects predominantly adolescents and young adults in industrialized societies, but has also been described in a variety of non-Western cultures as well. The frequency and intensity of binge-purge episodes tends to escalate over time, enough so that many patients develop the ability to induce vomiting without mechanically triggering the gag reflex.

DSM-5 Diagnostic Criteria

Bulimia nervosa can be difficult to detect compared to anorexia nervosa, because people with bulimia tend to be of average or slightly above or below average weight. Many people with bulimia may also engage in significantly disordered eating and exercising patterns without meeting the full diagnostic criteria for bulimia nervosa. The diagnostic criteria utilized by the DSM-5 includes repetitive episodes of binge eating compensated for by excessive or inappropriate measures taken to avoid gaining weight. The diagnosis requires the episodes of compensatory behaviors and binge eating to happen a minimum of once a week for a consistent time period of 3 months. The diagnosis is made only when the behavior is not a part of the symptom complex of anorexia nervosa and when the behavior reflects an overemphasis on physical mass or appearance.

Binge Eating Disorder

Binge eating disorder, also referred to as “compulsive overeating,” is characterized by uncontrollably eating a large amount of food in a short period of time; after a bingeing episode a person will not purge and will feel an extreme sense of guilt. Episodes of bingeing may be a method of self-soothing in the face of emotional stressors; social isolation and loneliness, in particular, have been implicated as triggering factors in binge eating. BED is seen most commonly in middle-aged individuals, and is evenly distributed across gender and racial demographics, though there is some evidence to suggest that women may be more likely to seek treatment.

DSM-5 Diagnostic Criteria

Previously considered a topic for further research exploration, binge eating disorder was included in the eating disorders section of the DSM-5 in 2013. In order to be diagnosed, a person must experience recurrent episodes of binge eating together with distress about the binges, on a frequency of at least once a week over a time period of 3 months. The binges must not be accompanied by compensatory purging behavior seen in bulimia nervosa.

Eating Disorder Not Otherwise Specified

Eating disorders not otherwise specified (EDNOS) is an eating disorder that does not meet the DSM criteria for anorexia, bulimia, or binge eating disorder. Examples include someone who may be at a “healthy weight” but who has anorexic thought patterns and behaviors. Individuals with EDNOS usually fall into one of three groups: sub-threshold symptoms of another eating disorder, mixed features of different eating disorders, or extremely atypical eating behaviors that are not characterized by any of the other established disorders.

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Poor Self-Image: Sufferers of eating disorders may also suffer from body dysmorphic disorder (BDD), a mental illness characterized by obsession with perceived body defects that are unnoticeable to the public or do not exist at all, such as being overweight.

Etiology

The precise causes of eating disorders are not entirely understood, but there is evidence that they may be linked to other medical conditions and are often a combination of circumstances. These circumstances may include biological contexts, genetic predispositions, psychological factors (such as depression or obsessive-compulsive disorder), and environmental influences (such as social isolation, parental influence, peer pressure, and cultural pressure).

There is evidence that genetics may predispose certain individuals, as well as neuro-chemical abnormalities. Depression, anxiety disorders, and low self-esteem have been described as possible predisposing factors. There are also many other possibilities such as environmental, social, and interpersonal issues that could promote and sustain these illnesses. Cultural idealizations of thinness and youthfulness in the United States have contributed to eating disorders affecting diverse populations. Peer pressure and idealized body types seen in the media may be significant factors. The media is often blamed for the rise in the incidences of eating disorders due to the fact that media images of idealized slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. Cultural influences are accused of distorting reality, in the sense that people portrayed in the media are unnaturally thin by putting excessive pressure on themselves (often through eating disorders), or thin by means of editing and airbrushing photos to make them look thinner and blemish-free.

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Cultural Ideal of Perfection: The common practice of editing photos before publishing leads many women of all ages to strive towards an unrealistic ideal.

Child abuse (such as neglect or physical, psychological, or sexual abuse) has been shown by many studies to be a precipitating factor in a wide variety of psychiatric disorders, including eating disorders. Children who are subjected to abuse may develop eating disorders in an effort to gain some sense of control or for a sense of comfort, or they may be in an environment where the diet is unhealthy or insufficient.

Treatment

Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized. However, there is lack of good evidence about treatment and management, which means that current views about treatment are based mainly on clinical experience. Treatment can take place in a variety of different settings such as community programs, hospitals, day programs, and groups. Some of the treatment methods include cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), family therapy, nutritional counseling, and medication to treat comorbid (co-occurring) disorders (such as anxiety, depression, obsessive-compulsive disorder, bipolar disorder, etc.).