Kaplan + Sadock's Synopsis of Psychiatry, 11e

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31.9c Avoidant/Restrictive Food Intake Disorder

of the mother–child relationship reveals deficits that can be influenced by offering guidance to the mother. Behavioral inter- ventions, such as habit-reversal are aimed at reinforcing an alter- nate behavior that becomes more compelling than the behaviors leading to regurgitation. Aversive behavioral interventions, such as squirting lemon juice into the infant’s mouth whenever rumi- nation occurs, have been used in the past to diminish rumina- tion behavior. Although aversive behavioral interventions have been reported anecdotally to be effective in some cases, current recommendations support the use of habit-reversal techniques. When features of child maltreatment of neglect may have contributed to rumination behaviors in an infant, treatments include improvement of the child’s psychosocial environment, increased tender loving care from the mother or caretakers, and psychotherapy for the mother or both parents. Anatomi- cal abnormalities, such as hiatal hernia, are not uncommon, and must be evaluated, in some cases leading to surgical repair. In severe cases in which malnutrition and weight loss have occurred, placement of a jejunal tube may need to be inserted before other treatments can be utilized. Medication is not a standard part of the treatment of rumina- tion. Case reports, however, cite a variety of medications that have been tried, including metoclopramide (Reglan), cimeti- dine (Tagamet), and even antipsychotics such as haloperidol (Haldol) have been cited to be helpful according to anecdotal reports. The treatment of adolescents with rumination disorder is often complex and includes a multidisciplinary approach consisting of individual psychotherapy, nutritional intervention, and pharmacologic treatment for the frequent comorbid anxiety and depressive symptoms. Avoidant/restrictive food intake disorder, formerly known as feeding disorder of infancy or early childhood, is characterized by a lack of interest in food, or its avoidance based on the sen- sory features of the food or the perceived consequences of eat- ing. This newly included DSM-5 disorder adds more detail about the nature of the eating problems, and has also been expanded to include adolescents and adults. The disorder is manifested by a persistent failure to meet nutritional or energy needs as evi- denced by one or more of the following: significant weight loss or failure to achieve expected weight, nutritional deficiency, dependence on enteral feedings or nutritional supplements, or marked interference with psychosocial functioning. It may take the form of outright food refusal, food selectivity, eating too little, food avoidance, and delayed self-feeding. The diagnosis should not be made in the context of anorexia nervosa or bulimia nervosa, or if caused by a medical condition, by another mental disorder, or by a true lack of available food. Infants and children with the disorder may be withdrawn, irri- table, apathetic, or anxious. Because of the avoidant behavior dur- ing feeding, touching and holding between mothers and infants are diminished during the entire feeding process compared with other children. Some reports suggest that food avoidance or 31.9c Avoidant/Restrictive Food Intake Disorder

and his ruminatory activity decreased accordingly. After 1 week in the hospital, small feedings were started; however, Luca again suc- cessfully was able to bring up his food by his rumination activity, and the oral feedings had to be temporarily stopped. At this point, Luca’s mother decided to stop working and take Luca home to con- tinue an intensive behavioral “distracting” intervention in order to interrupt his rumination during meals. Luca’s mother started small feedings while playing with him during and after feedings, and was able to interest him in other activities, so that he would not rumi- nate. After 4 weeks of slow increments in his feedings, Luca was able to take all his feedings by mouth without ruminating, and the nasojejunal tube could be removed. Luca and his mother contin- ued to use simulating and distracting activities during and just after meals, which over time became more interesting to Luca than his previous ruminating behavior.

Pathology and Laboratory Examination

No specific laboratory examination is pathognomonic of rumi- nation disorder; however, rumination disorder is not uncom- monly associated with gastrointestinal abnormalities. Clinicians are recommended to evaluate other physical causes of vomiting, such as pyloric stenosis and hiatal hernia, before making the diagnosis of rumination disorder. Rumination disorder can lead to states of malnutrition and dehydration. In very severe cases, laboratory measures of endocrinological function, serum elec- trolytes, and a hematological workup may determine the need for medical intervention. Differential Diagnosis To make the diagnosis of rumination disorder, clinicians must rule out primary gastrointestinal congenital anomalies, infec- tions, and other medical illnesses that could account for fre- quent regurgitation. Pyloric stenosis is usually associated with projectile vomiting and is generally evident before 3 months of age, when rumination has its onset. Rumination has been asso- ciated with both autism spectrum disorder and intellectual dis- ability in which stereotypic behaviors and eating disturbances are not uncommon. Rumination behavior may occur comorbidly in youth with severe anxiety disorders as well. Rumination dis- order may also occur in patients with other eating disorders, such as anorexia nervosa and bulimia nervosa. Course and Prognosis Rumination disorder is believed to have a high rate of spontane- ous remission. Indeed, many cases of rumination disorder may develop and remit without ever being diagnosed. Limited data are available about the prognosis of rumination disorder in ado- lescents and adults. Behavioral interventions using habit-reversal techniques may significantly lead to improved prognosis. Treatment The treatment of rumination disorder is often a combination of education and behavioral techniques. Sometimes, an evaluation