International Conference on Treatment Modalities for Eating Disorders: Consensus and Controversy Jerusalem - February 2013

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Marjory Maxwell
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FOOD AVOIDANT EMOTIONAL DISORDERS (FAED) Rose Geist, MD Chief of

1 International Conference on Treatment Modalities for Eating Disorders: Consensus and Controversy Jerusalem - February 2013 FOOD AVOIDANT EMOTIONAL DISORDERS (FAED) Rose Geist, MD Chief of Mental Health Programs - Trillium Health Partners University of Toronto Canada 1

2 Work Shop FOOD AVOIDANT EMOTIONAL DISORDER

3 FAED History Higgs, Goodyear Birch 1989 ( AN and FAED Archives of Diseases in Childhood ) To identify the nature course and outcome of cases meeting criteria of AN

4 Classification of Youth Eating Related Disturbances ED-NOS SELECTIVE EATING FAED FUNCTIONAL DYSPHAGIA PERVASIVE REFUSAL SYNDROME 4

5 Table 1. Great Ormond Street criteria Anorexia Nervosa Determined weight loss (e.g., food avoidance, self-induced vomiting, excessive exercising, abuse of laxatives) Abnormal cognitions regarding weight and/or shape Morbid preoccupation with weight and/or shape Food avoidance emotional disorder Selective eating Functional dysphagia Food avoidance not accounted for by primary affective disorder Weight loss Mood disturbance not meeting criteria for primary affective disorder Narrow range of foods for at least 2 years Food avoidance Unwillingness to try new foods No abnormal cognitions regarding weight or shape Fear of swallowing, choking or vomiting No abnormal cognitions regarding weight or shape No abnormal cognitions regarding weight or shape No morbid preoccupation regarding weight or shape No organic brain disease or psychosis No fear of choking or vomiting Weight may be low, normal, or high No morbid preoccupation regarding weight or shape No organic brain disease or psychosis Bulimia nervosa Recurrent binges and purges Sense of lack of control Pervasive refusal syndrome Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help Morbid preoccupation with weight and shape Children into DSM don't go: a comparison of classification systems for eating disorders in childhood and early adolescence. D D Nicholls, R R Chater, and B B Lask Int J Eat Disord 28(3): (2000) 5

6 FAED Fear and Avoidance of Food and Eating Determined refusal behaviour Weight loss 6

7 FAED Anticipatory Fears A) FOOD 1. Contamination 2. Feeling of fullness B) PROCESS OF EATING 1. Pain 2. Choking 3. Vomiting 4. Nausea 7

8 Refusal Behaviours I WON T ANGER DEVELOPMENT OF AUTONOMY AND IDENTITY EXPECTATIONS RELATIONSHIPS- POWER AND CONTROL STRUGGLE I CAN T ANXIETY EXPECTATIONS SCHOOL REFUSAL TOILETING REFUSAL REFUSAL TO GO TO BED AT NIGHT PERVASIVE REFUSAL FOOD REFUSAL 8

9 FAED 1. No eating disorder psychopathology 2. Significant weight loss 3. Comorbid anxiety and depressive disorder 9

10 Initial Family meeting ( Individual in the Family meeting) Individual Assessment FAED ASSESSMENT PRINCIPLES Medical and nutritional status Psychiatric evaluation Family psychiatric history of eating and affective disorders, stress Family communication/ relationship patterns re autonomy power control 10

11 FAED MANAGEMENT PRINCIPLES (1)Parents as therapeutic allies (2)Medical/nutritional rehab (3)Co-morbid psychiatric disorder (4)Family Support 11

12 Case summaries 10 yr old girl Admitted to inpatient pediatric department with 5 months of dramatic weight loss secondary to nutritional restriction and excessive exercise 70% ABW bradycardia and slight ventricular conduction delay Denied pursuit of thinness fears of fate body shape and weight concerns B?P or use of diet pills or laxatives. Main fear- related to maturity

13 Case summaries 14 yr old girl Referred by pediatrician for poor growth since age 6 BMI 12.7, 67 % ABW Since age 6 restricted intake because of fear of vomiting associated with eating Poor school attendance for 3 years Chronic epigastric pain primary amenhorrea Denied fears of fat, body weight or shape preoccupations B/P excessive exercise or use of medications Sad because of fears of pain and vomiting Parents worried about food allergies

14 Case summaries 16 yr old girl Nausea and abdominal pain for 6 months Weight loss 20 lb stomach feels full gagging in my throat

15 Case Summary 11 yr old girl 4 month history of dysphagia for solids and 6 lb weight loss, fear that food would get stuck Multiple visits to the ER ENT bedside larygoscope, CXR Nasophargeal xray CRP ESR CBV

16 Case summary: Management In ER- healthy girl- affect flat stress related to bullying at school- school avoidance for 1 month Admitted to pediatrics accompanied by mom, Frequent spitting No ED psychopathology, wants to gain weight but scaird Liquid boost Individual assessment in family meeting ( both parents)

17 Summary FAED Management Principles Comprise a significant proportion of youth ( usually prepubertal) who present with determined food avoidance and weight loss Males are not uncommon Nutritional rehabilitation and mental health treatment and support Family based therapy Individual: high achievers comorbid anxiety depression and perfectionism Many become eating disorders More research important

18 Thank you. 18

Early-onset eating disorders

Early-onset eating disorders Principal investigators Debra K. Katzman, MD, FRCPC, Division of Adolescent Medicine, Department of Paediatrics* Anne Morris, MB, BS, MPH, FRACP, Division of Adolescent Medicine,