CHapter 10

PICA (307.52) This involves the persistent and compulsive urge to eat non-nutritive substances that aren’t considered to be food. It is usually diagnosed above the age of five as eating such substances by younger children is considered probably developmentally appropriate. Pica in adults usually happens in those who are intellectually disabled. Pica used to be under the heading of “disorders with onset in childhood and adolescence” but now is under the feeding and eating disorder category. This helps reduce the number of individuals in the eating disorder NOS category, which doesn’t exist in the DSM-V. There is now no upper age limit for pica. Items eaten include dirt, chalk, paper, feces, glass, and other non-food items. Pica may be linked to OCD, because they persistently diet on nonnutritive substances. They are completely conscious of their behavior and know it is both unhealthy and illogical. People who engage in pica may experience some of the same symptoms as a malnourished individual. They may have mineral deficiency, weight loss, and unhealthy hair and nails. They can get intestinal obstruction, abdominal pain, and other serious health problems. It is often 152 coexisting with other mental disorders, such as schizophrenia, autism spectrum disorder, anorexia nervosa, and self-harm. People with factitious disorder can eat non-nutritive substances in order to mimic the symptoms of a more serious medical condition. The DSM-V criteria include persistently eating non-nutritive substances for a minimum of one month, eating these substances beyond what is developmentally appropriate, eating outside of culturally-supported norms, and eating that is severe enough, even in the face of another medical disorder, to warrant its own clinical diagnosis. It isn’t a specifier for OCD in the DSM-V, although this was suggested on the basis of cases that have shown OCD with pica as the sole manifestation. The onset of pica is usually in childhood, although it can be diagnosed at any age. It is seen more commonly in areas with low socioeconomic status and in developing countries. It has been linked to mineral and other nutritional deficiencies. Most of the research has been done in the developmentally disabled population, although neglect and lack of supervision in childhood are also risk factors for the disease. Child abuse in those kids who do not receive adequate nutrition. Some type of brain disorder may be present in some patients with pica. There is a link between iron or zinc deficiency and pica. On the other hand, if pica is a part of a medicinal, spiritual, and social value within the context of a cultural practice, it does not qualify as being pica under the DSM-V criteria. It represents a way to relieve anxiety in some people, making it a feature of anxiety disorders at times. Because it can lead to serious health problems, people can die from having significant pica. The goal of adding this and two other disorders under “feeding and eating disorders” in the DSM-V is to improve the treatment of these disorders. While little research on treatment of pica has been done, cognitive behavioral therapy (CBT) seems to be helpful as well as family therapy. Applied behavior therapy or ABT is one of the most effective therapies as it can be applied to people with comorbidities. It rewards positive behavior and punishes undesired behavior. 153 RUMINATION DISORDER (307.53) This is an uncommon disorder that involves rumination or “regurgitation.” It involves the regurgitation of undigested foods that is not intended as a tool to lose or change weight. It involves people using abdominal contractions, tongue movements, or coughing to bring food back into the mouth. It can affect infants, children, and adults who have mental or intellectual disabilities. The disorder must last at least one month to make the diagnosis under the DSM-V guidelines. The adult with the disorder usually spits out the food but children and infants will chew and reswallow the regurgitated substances. It happens after nearly every meal and about 1-2 hours after the meal. The regurgitation must be unrelated to a GI disorder or to an eating disorder in which weight loss is the goal. In infants, it starts between the ages of 3 and 12 months. A key feature of rumination disorder is that individuals find the behavior pleasant. Still, many people who find it soothing or anxiety-relieving will be embarrassed by the behavior and will not report it. For this reason, the prevalence of the diagnosis is unclear. It appears to be at an increased risk in patients who are institutionalized. In infants with the disorder, it is often due to some type of medical disorder rather than a psychiatric one. There are other psychiatric disorders comorbid with other mental disorders, such as generalized anxiety disorder or intellectual development disorder. It can lead to malnutrition, esophageal damage, dental caries, bad breath, and dehydration. In infants, there can be failure to thrive and malnutrition. In older children, there can be learning and growth delays. It can be fatal in infants. It can affect social functioning in teens and adults, who are embarrassed by the behavior. There are no medical interventions or drugs that have been found to treat rumination disorder. It is a learned behavior, making behavioral therapy a good approach. One behavioral technique is called diaphragmatic breathing training. They learn how to relax and breathe differently during and after breathing, which controls the behavior to some degree because this type of 154 breathing is physically incompatible with regurgitation. Chewing gum after breathing is also effective in stopping regurgitation, particularly in children and the developmentally delayed individual. AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (307.59) This is a new disorder in the DSM-V called ARFID. It can occur at any age but traditionally has been seen mainly as a childhood diagnosis. It is similar to anorexia but the patient restricts food but not because of a distorted body image. The person with ARFID restricts certain kinds of food so they don’t get as many calories as they should. The type of eating done in ARFID is worse than being a picky eater or avoiding foods because of an allergy or intolerance. The patient may have false beliefs about nutrition or may be selfdiagnosing themselves as having an intolerance to gluten, for example. There may be an aversion to the texture, taste, and smell of certain foods, or a problem with dysphagia or choking on certain foods. Common symptoms of ARFID include an indifference to food or eating, refusal to eat certain foods because of the characteristics of the food, rigidity about food, or concern about the effects of eating. The patient may fail to meet normal nutritional or caloric needs, resulting in weight loss or failure to thrive (in children). There can be nutrient deficiencies necessitating nutritional supplementation. These behaviors will cause stress around eating and the patients will avoid social activities involving food. It is not attributable to a lack of food or because of a social or religiouslyaffiliated practice. There is no perception of distorted body image as is seen in anorexia nervosa. There is a specifier for being “in remission.” The disorder will begin by the age of 10 years but will often persist through adulthood. ARFID is not a predictor of anorexia or bulimia; it is slightly different from food neophobia, which is the mistaken perception of food intolerance or allergy. It is seen more often in children than in adults and may persist for some time before it is diagnosed. Triggers for the 155 onset of the disorder include emotional problems, social difficulties, or certain physical illnesses. The prevalence is about 25-35 percent in normal children and higher in children with developmental delays or disturbances. Risk factors that precipitate ARFID include autism spectrum disorder, anxiety disorders, obsessive-compulsive disorder, and ADHD. Environmental risk factors include familial anxiety and having a mother with an eating disorder. Various GI disorders, such as reflux and vomiting, may precipitate ARFID. Choking on food can be a risk factor for ARFID. Comorbidities include anxiety disorders, OCD, autism spectrum disorder, ADHD, and intellectual disabilities. This disorder may be treated with psychoeducation and cognitive behavioral therapy that challenges the patient’s beliefs about fears of choking, food aversions, and other cognitive distortions related to food and eating. There is family tension associated with ARFID and, when it occurs in children, it can affect the parent-child interactions. Certain infants will display fussiness in their temperament that persists through childhood and adulthood. ANOREXIA NERVOSA (307.1) Anorexia nervosa has been included in previous Diagnostic and Statistical manuals. The person has a preoccupation with having a low body weight and who exhibits many behaviors that contribute to having a low body weight. The person will restrict food intake and will even starve themselves of all food in order to avoid gaining weight. They may impulsively exercise on a frequent basis. A simple explanation is that they fear gaining weight but there are complexities to this simple explanation. There can be specific events or social pressures to be thin that predispose the individual to anorexia nervosa. The male to female ratio is 10:1 with an incidence of 0.4 percent per year. Although these patients go to great lengths to hide evidence of their condition, the typical symptoms that can be identified include the following: A. Obsession with the caloric and nutritional content of food B. Using appetite suppressants or laxatives to control weight 156 C. Having a distortion of body image D. Denying being of a low weight E. Being extremely thin or emaciated F. Eating very little or skipping meals G. Weighing oneself obsessively or constantly checking body shape in the mirror H. Vomiting after meals I. Having dizziness, physical problems, and dry skin Symptoms that develop over time include hair loss or brittle hair, growth of lanugo hair over the body, osteoporosis, muscle wasting/weakness, anemia and low blood pressure, constipation, infertility, fatigue, lethargy, brain damage, and organ failure. To meet the disorder, there needs to be three criteria met: 1) having a significantly low body weight as expected by their height; 2) having an intense fear of being fat that doesn’t go away with weight loss; and 3) having a distorted view of their own body size and shape, pointing out areas that they believe are fat. The patient will have OCD tendencies, insomnia, social withdrawal, and depression, and will be obviously underweight. Laboratory and physical findings include serum chemistry abnormalities, decreased WBC count, mild anemia, decreased thyroid hormone levels, osteopenia, and a slowed heart rate. There are two subtypes, depending on how they present themselves. Some are restrictive, others are binge/purging types, and others may be mixed in presentation. Those who fast, diet, and/or exercise are considered “restrictive,” while those who overeat and use vomiting and laxatives are “binge/purge” subtypes. There are many biological, psychological, and environmental causes that contribute to getting anorexia nervosa. These include the following: Psychological factors include excessive fear about the future, anxiety and depression, poor stress management, difficulty expressing emotions, OCD feelings, having perfectionistic tendencies, and being phobic about being fat. Environmental factors include hormonal changes at puberty, pressure or stress to be thin, bullying about body weight, bereavement or other 157 stressor, abusive relationships, and engaging in activities where thinness is idealized. Biological factors include being obsessive in childhood, brain abnormalities, developing an anxiety disorder in childhood, and having a family history of substance abuse, depression, and eating disorders. Anorexia nervosa is a leading cause of mental health-related death and many will not seek help independently. It takes several years of treatment to manage the disorder and there will be many relapses before a final cure is achieved. The disorder affects one in 200 women. Statistics in men are less well-known. Even with treatment, half of all people with the disorder will experience problems with food. Treatment involves several options. The first is psychotherapy, which can be one-on-one or in a group. Cognitive behavioral therapy is often employed as an option to help reorganize distorted thought patterns. Family-based therapy is used with adolescents who have the disorder. Medications include SSRIs, mood stabilizers, and antipsychotic medications. Olanzapine is often used to treat anxiety. SSRIs are the first-line drug of choice for the anxiety and depression associated with eating disorders. BULIMIA NERVOSA (307.51) This is an eating disorder assigned to individuals who overeat on a regular basis and then use measures to prevent weight gain afterward, such as laxative abuse, purging, fasting, or overexercising. They feel out of control with how much food they consume that they will purge at a minimum of once weekly. It affects about 1.5 percent of women as a lifetime prevalence. It is mostly seen in young adults, rarely seen before puberty or after 40 years of age. It can follow a period of dieting or a stressful life event. The major symptoms of bulimia include being of a normal weight but perceiving themselves as being too fat. Other symptoms include overeating or an inability to stop eating, being excessively concerned with weight or body shape, compulsively exercising, vomiting after eating to get rid of eaten food, using diuretics or laxatives inappropriately, and having periods 158 of fasting. They may overeat several times a day over many months and will often eat in secret. They are ashamed and disgusted by their bingeing behaviors and will seek to purge the food from their bodies, bringing a feeling of relief to the patient. Extreme exercising and visiting the bathroom right after eating is a feature of the disorder as they often vomit after eating. There are several things that must be met to make the diagnosis of bulimia nervosa. These include the following: 1) Eating more food in one sitting than most people would with an inability to control eating; 2) Recurrently taking steps to prevent weight gain by fasting, vomiting, and excessively exercising, using laxatives or diuretics; 3) Episodes of binge-eating and purging that occur at least once weekly for a minimum of three months; and 4) preoccupation with body weight and shape. It needs to be identified as separate from the behaviors seen in anorexia. The severity of the disease is specified at the time of diagnosis. Mild bulimia is 1-3 episodes per week; moderate bulimia is 4-7 times per week; severe bulimia is 8-13 times per week; and extreme bulimia is 14 times or more per week. There is no specific test for bulimia except for physical and dental examinations that will show signs of bulimia. There will often be calluses on the finger joints and dental caries from vomiting. There will also be signs of dehydration. Causes of bulimia include familial, psychological, genetic, and societal factors that work together to cause bulimic symptoms. Connections have been made between bulimia and low self-esteem, childhood sexual or physical abuse, dieting, and being involved in activities where weight is a major focus. People who embrace thinness as being the ideal body shape are at a greater risk of developing bulimia. There are usually comorbidities with bulimia, including anxiety and major depressive disorder. Many will have multiple psychiatric conditions that go along with the eating disorder. The onset of the other psychiatric symptoms may predate or postdate the bulimic symptoms. Substance 159 abuse is a common comorbidity with bulimia with a third of all bulimics having alcoholism. PTSD is another common comorbidity. There are physical aspects and side effects to living with bulimia nervosa. These include blood sugar imbalances, nausea, vomiting, bloating, constipation, and abdominal pain. Hormones can be affected and sex hormones can decrease, leading to osteoporosis. There may be a decrease in thyroid hormones, affecting metabolism. There is no particular cure for bulimia but it can be treated. Therapy, medications, nutritional counseling, and medical/psychiatric monitoring need to take place. Treatment includes cognitive-behavioral therapy, acceptance and commitment therapy, dialectical behavioral therapy, psychodynamic psychotherapy, and family-based therapy. SSRIs are commonly used to treat things like depression, anxiety, and social phobia. Tricyclic antidepressants and topiramate can be used to decrease bingeing and purging cycles. About half of patients are symptom-free after five years following initiation of treatment. BINGE-EATING DISORDER (307.51) This is an eating disorder that has compulsive overeating as the main symptom. The patient will eat long after they are full and when they aren’t even hungry. There are no purging behaviors; the patients may be normal weight, slightly overweight, and even obese. This is a new diagnosis under the DSM-V and involves a lack of self-control, usually starting in adolescence or early adulthood. Self-esteem and other psychological factors differentiate it from simple overeating. The episodes can occur several times per day or for several hours in any given day. Patients often have self-hatred over their inability to control their eating habits. The patient will often feel uncomfortably full and will be anxious or depressed, often refusing to eat in front of others. They will often say that they will diet after an episode and return to their destructive patterns of eating shortly after they quit eating. The patient often denies their behavior and lives in secrecy, being ashamed of their behavior. There is no simple diagnosis for the disorder 160 and it is often a diagnosis of exclusion after other things have been ruled out. The exact treatments for binge-eating disorder have not been fully established as this is a new and separate disorder. DBT, behavioral weight loss, interpersonal psychotherapy, and cognitive behavioral therapy have all been tried and are being evaluated for the treatment of this disorder. CBT is the most widely-used therapy for binge-eating, while interpersonal psychotherapy helps the patient uncover the underlying roots of binge-eating. There are many comorbidities, including hypertension, personality disorders, bipolar disorder, and diabetes. A full medical workup is necessary as they have many medical issues as a result of their behaviors. There are many drug therapies that are being looked at, including antidepressants, anticonvulsants, and anti-obesity medications. Anticonvulsants that have been tried include zonisamide, which suppresses the appetite, along with SSRIs, such as fluoxetine and fluvoxamine. The overall prognosis is good if the patient is adequately treated. OTHER SPECIFIED FEEDING OR EATING DISORDER (307.59) This disorder is known as OSFED, which replaces the “eating disorder not otherwise specified” category that existed in the DSM-IV. It involves those feeding and eating disorders that are serious but are not clearly anorexia nervosa or bulimia nervosa. It can involve any of the other feeding and eating disorders as well. There are five examples of OSFED, including atypical anorexia, limited duration bulimia nervosa, purging disorder, low frequency binge-eating disorder, and night eating syndrome. There is an unspecified feeding or eating disorder used to describe those who do not meet the criteria for any of the more obvious OSFED disorders. In atypical anorexia nervosa, there is a normal weight but all of the other criteria for AN are met. In atypical bulimia, the frequency is less than once a week or fewer than three months. Binge-eating disorder does not meet the time criteria for normal BED. In purging, purging is dominant; however, there isn’t binge-eating behavior. Night eating disorder involves eating mainly after awakening from sleep. The prevalence by age twenty years for OSFED was about 11 percent, split between the typical 161 OSFED disorders. The peak age at onset is about 18-20 years. There are still a number of patients that have EDNOS (eating disorder not otherwise specified) but the incidence of this disorder is decreasing with the new diagnosis of OSFED.