Avoidant/Restrictive Food Intake Disorder: Review and Recent Advances.

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder recently codified in DSM-5 that affects individuals of all ages. A proliferation of ARFID research has emerged over the years, and this review provides a brief overview of the current understanding of ARFID epidemiology, symptoms, comorbid conditions, assessment, and treatment. The review highlights recent research updates regarding ARFID among adults, putative neurobiological mechanisms underlying ARFID, and new treatment trials. Findings from this review demonstrate that ARFID is as prevalent as other eating disorders, even among adults, and is associated with significant medical and psychiatric comorbid conditions. New, promising treatments for children, adolescents, and adults are in the early stages of development. Several assessments are now available to aid in the screening and diagnosis of ARFID and have demonstrated cross-cultural validity. Areas for future research and clinical guidance, including unresolved questions regarding ARFID categorization and differential diagnosis, are discussed.

Development of a gender-affirming care protocol in eating disorder treatment settings.

Transgender and gender-expansive (TGE) individuals suffer from eating disorders (EDs) at disproportionate rates relative to their gender-conforming counterparts. While literature on EDs in TGE populations is growing and evolving, best practice guidelines are scant. A framework for providing gender-affirming care (GAC) in an ED treatment setting was developed by integrating findings from a focused literature review and insights from leading experts. Following synchronous and asynchronous training, the protocol was implemented in a virtual ED treatment setting with a national reach serving patients ages 6-24 years. This paper offers a summary of best practices and approaches for providing GAC in ED treatment settings. The use of GAC practices has the potential to address underlying issues and inequities in treatment delivery and outcomes. We encourage ED treatment providers to consider the adoption/adaptation of GAC best practices to more effectively meet the needs of TGE patients. More research is needed to better understand the influence of individual and collective GAC practices on specific ED treatment outcomes.

Early weight gain as a predictor of weight restoration in avoidant/restrictive food intake disorder.

BACKGROUND: Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. METHODS: Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients' %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. CONCLUSION: Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

Results from this study indicate that when patients with avoidant/restrictive food intake disorder (ARFID) gain weight steadily at the beginning of treatment, it helps them reach 95% expected body weight (EBW) by week 20 of treatment. The more weight the patients gain each week early on, the better their chances of getting to 95% EBW by week 20. However, there are two important things to consider: how much the patients weigh when they start treatment (starting %EBW) and how much weight they gain each week. Both of these factors affect the chances of reaching 95% EBW by week 20. Thus, this study highlights the goals for gaining weight at the start of treatment need to be different for each person, depending on how much they weigh when they begin. This may help patients with ARFID reach the goal of being at 95% EBW within 20 weeks.

Pharmacotherapy for attention deficit/hyperactivity disorder in youth with avoidant restrictive food intake disorder: a case series of patients prescribed stimulant medication in a partial hospitalization program for eating disorders.

BACKGROUND: Appetite suppression and weight loss are established potential side effects of most medications for attention deficit/hyperactivity disorder (ADHD). These side effects may be especially problematic when using stimulants to treat ADHD in the context of a restrictive eating disorder, such as avoidant restrictive food intake disorder (ARFID), although these diagnoses are often comorbid in children. This paper presents a combined approach to treating ADHD comorbid with ARFID using stimulant medication and behavior management within a partial hospitalization program (PHP) and intensive outpatient program (IOP)for eating disorders. The aim of this paper is to determine if the continued or new use of stimulant medication allows for adequate weight restoration by reviewing a series of cases receiving the combined treatment. CASE PRESENTATIONS: Consecutive patients with a historical or new diagnosis of ADHD when presenting for treatment for ARFID were included in this case series. This series included 10 patients (8 male, 2 female) who received pharmacotherapy using stimulants and behavior management interventions involving structured mealtimes and contingency management. All treatment occurred within the context of a PHP/IOP for childhood eating disorders. All youth were able to effectively continue on stimulant medication, show clinical benefit in core ADHD symptoms, and able to gradually restore weight. In all cases, stimulant medications were not discontinued, but in some cases, doses were optimized (increased or decreased), switched to a different stimulant, or augmented with non-ADHD medication, such as mirtazapine, to support the management of ADHD while concurrently assisting in weight gain as necessary for the treatment of ARFID. Only one patient was newly started on a stimulant medication; as this was near the end of her treatment stay, limited conclusions can be drawn from this case. CONCLUSIONS: These findings support the use of pharmacotherapy, including continuing stimulant medication, when combined with behavior management strategies as a potentially effective treatment approach for ADHD in youth with ARFID in the PHP/IOP setting. Future studies using more rigorous methodology, longer follow-up times, and within other treatment settings are needed.

Exploring the role of disgust sensitivity and propensity in selective eating.

While disgust is a clinically and theoretically relevant construct for selective eating, limited research has examined how different aspects of disgust relate to selective eating severity in adults. Thus, the present study sought to 1) compare disgust propensity (how easily people are disgusted) and disgust sensitivity (how unpleasant disgust is) across a spectrum of selective eaters, 2) explore the specificity of the associations between disgust sensitivity/propensity and selective eating across selective eating and related phenotypes, and 3) explore whether the relationship between selective eating and disgust is food-specific. Participants were 554 adults recruited on Amazon's Mechanical Turk who completed cross-sectional surveys on study constructs. The sample was recruited to over-represent individuals with high levels of selective eating. Results support that disgust propensity, but not sensitivity, was elevated in the impaired selective eating group compared to non-impaired selective eaters and non-selective eaters. Only the selective eating phenotype was independently associated with both disgust sensitivity and propensity. Correlation results supported that the associations between selective eating and disgust were specific to the disgust elicited by food (i.e., animal protein, fruits, vegetables). Overall, results support that disgust propensity and disgust sensitivity play a role in selective eating. Results imply that disgust sensitivity associated with selective eating appears limited to the food domain and may be more specific to disgust eliciting food itself, rather than signs of food contamination or spoilage.

The Role of Disgust in Eating Disorders.

PURPOSE OF REVIEW: In current review, we evaluate the current literature examining the role of disgust in eating disorders (EDs), and provide a theoretical model designed to inform the study and treatment of disgust-based symptoms in EDs. RECENT FINDINGS: Findings from this review suggest that aberrant disgust-conditioning processes represent promising but understudied mechanisms that may contribute to the risk and maintenance of core eating disorder (ED) psychopathology. In addition, preliminary evidence supports the use of interventions designed to target aversive disgust cues and disrupt maladaptive disgust-based conditioning that may maintain eating pathology. However, experimental studies designed to elucidate the role of disgust and aversive learning processes remain limited. Disgust is a promising risk and maintenance factor in EDs. Future systematic investigation is needed to examine disgust-based processes at a mechanistic level in order to better understand the links between disgust, avoidance behaviors, and EDs. Further investigation of the mechanistic role of disgust in EDs is warranted.

Exploring the cooccurrence of behavioural phenotypes for avoidant/restrictive food intake disorder in a partial hospitalization sample.

OBJECTIVE: Literature providing clinical characterizations of avoidant/restrictive food intake disorder (ARFID) has proposed the occurrence of three functions for food refusal: fear of negative consequences, lack of hunger, or sensory sensitivity. Recent studies have suggested that these functions may be used to subtype patients presenting with ARFID; however, other work suggests that these categories are not mutually exclusive and instead represent neurobiological dimensions that can cooccur. The current study explored the potential cooccurrence of behavioural phenotypes in patients with ARFID presenting to a partial hospitalization program. METHOD: Two raters conducted a retrospective chart review of patients with ARFID presenting to treatment from June 2014 to May 2018 (N = 59). RESULTS: Regarding cooccurrence of symptoms consistent with behavioural phenotypes, raters showed excellent agreement, and over 50% of the sample endorsed symptoms consistent with more than one phenotype. The sensory sensitivity phenotype was most common in the sample and frequently cooccurred with both other phenotypes. DISCUSSION: Results suggest that multiple functions for food avoidance may be present within one individual. Future work should aim to further characterize individuals presenting with singular versus multiple phenotype characteristics.

Development and validation of the Physical Activity Body Experiences Questionnaire.

Embodiment is defined as a state in which one experiences one's physical body as an essential aspect of one's lived experiences, a potential protective factor against body image and eating disturbance. The Physical Activity Body Experiences Questionnaire (PABEQ) was rationally derived as a measure of embodiment based on focus groups, literature reviews, and expert review. The PABEQ and measures of body image, self-objectification, and disordered eating were administered to two samples randomly selected from a pool of 606 female undergraduate students at least 18 years of age and a third test-retest sample of 58 female undergraduates. Exploratory factor analyses and reliability estimates supported a two-factor scale: Mind-Body Connection and Body Acceptance. Results indicated the utility of the subscales in predicting body awareness, body responsiveness, positive body image, body satisfaction, self-objectification, disordered eating, and positive body image.

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field.

OBJECTIVE: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. METHOD: In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder. RESULTS: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. CONCLUSIONS: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

Conceptualizing the role of disgust in avoidant/restrictive food intake disorder: Implications for the etiology and treatment of selective eating.

Selective eating is a common presenting problem in Avoidant/Restrictive Food Intake Disorder (ARFID). Understanding the etiology of selective eating will lead to the creation of more effective treatments for this problem. Recent reports have linked disgust sensitivity to picky eating, and the field has yet to conceptualize the role that disgust might play in ARFID. Disgust has long been tied to formation of taste aversions and is considered at its core to be a food-related emotion. A brief review of the literature on disgust reveals that disgust has a unique psychophysiological profile compared to other emotions, like anxiety, and that disgust is resistant to extinction procedures. If disgust is implicated in the etiology of selective eating, its presence would have a significant impact on treatment approaches. This article provides an overview of the research on disgust and eating, a clinical example of the treatment challenges that disgust may pose, and an overview of the unique clinical features of disgust as they apply to psychopathology. We pose several research questions related to disgust and selective eating and discuss initial hypotheses for pursing this line of inquiry. Finally, we discuss the possible implications of this line of research for treatment.

Mirtazapine and Weight Gain in Avoidant and Restrictive Food Intake Disorder.

Avoidant and restrictive food intake disorder (ARFID) is a newly classified disorder in the DSM-5 that describes a pattern of restrictive eating across the lifespan that results in significant weight loss, nutritional deficiency, dependence on enteral feeding or nutritional supplements, or marked interference in psychosocial functioning.1 Currently, there are no evidence-based treatment approaches or medications for this disorder.2 We have administered a range of psychoactive medications to those with ARFID in our treatment program in an attempt to find an effective medication. One medication of interest has been mirtazapine because it promotes appetite and weight gain, decreases nausea and vomiting, and improves gastric emptying. Although mirtazapine is an off-label approach in a pediatric population and carries a black box warning for an increased risk of suicide, it is an effective treatment for depression and anxiety symptoms in adults and is generally well tolerated.3,4 There are no studies to date reporting on the use of mirtazapine in patients with ARFID.

Self-objectification, body shame, and disordered eating: Testing a core mediational model of objectification theory among White, Black, and Hispanic women.

Objectification theory asserts that self-objectification, which manifests as self-surveillance, leads to increased body shame and subsequent eating pathology. Although evidence supports the core mediational model, the majority of this work utilizes primarily White samples, limiting generalizability to other ethnic groups. The current study examined whether the core tenets of objectification theory generalize to Black and Hispanic women. Participants were 880 college women from the United States (71.7% White, 15.1% Hispanic, 13.2% Black) who completed self-report measures of self-surveillance, body shame, and disordered eating. Multivariate analysis of variance tests indicated lower levels of self-surveillance and disordered eating among Black women. Moreover, body shame mediated the relationship between self-surveillance and disordered eating for White and Hispanic women, but not for Black women. These analyses support growing evidence for the role of body shame as a mediator between body surveillance and eating pathology, but only for women in certain ethnic groups.

Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial.

AIMS: To examine the feasibility, acceptability and preliminary efficacy of family-based exposure/response prevention therapy (E/RP) versus treatment as usual (TAU) in a cohort of very young children with early onset obsessive-compulsive disorder (OCD). METHODS: Thirty-one children ages 3-8 years (M = 5.8 years) with a primary diagnosis of OCD were randomized to E/RP or TAU. The E/RP condition received 12 sessions of family-based E/RP twice weekly over 6 weeks. Families were assessed at baseline, post-treatment, 1-month and 3-month follow up. The Children's Yale Brown Obsessive Compulsive Scale and Clinical Global Impression served as primary outcome measures. RESULTS: A large group effect emerged in favor of the E/RP group (d = 1.69). Sixty-five percent of the E/RP group was considered treatment responders as compared to 7% in the TAU group. Symptom remission was achieved in 35.2% of the E/RP group and 0% of the TAU group. There was no attrition and satisfaction was high; gains were maintained at 3 months. CONCLUSIONS: Even amongst children as young as 3 years, developmentally tailored E/RP is efficacious and well-tolerated in reducing OCD symptoms. Key adaptations for younger children include extensive parent involvement, targeting family accommodation, and frequent meetings while delivering a full course of E/RP. CLINICALTRIALSGOV IDENTIFIER: NCT01447966 http://clinicaltrials.gov/ct2/show/NCT01447966?term=ocd+and+st+petersburg&rank=1.

Differences in appearance-related commentary, body dissatisfaction, and eating disturbance among college women of varying weight groups.

This study examined appearance-related commentary, body dissatisfaction, and eating disturbance in 924 undergraduate females. Significant group differences were found in type of appearance-related commentary received across weight groups. Overweight and obese women experienced negative weight and shape-related comments at greater frequencies and positive weight and shape-related comments at lower frequencies compared to underweight and normal weight women. A higher frequency of positive weight and shape-related commentary was associated with less body dissatisfaction for all women and less shape and weight concerns for obese women. These findings suggest that the weight status of young women likely influences the appearance-related commentary that they receive and the manner in which such commentary affects their body image and eating behaviors.

Media effects of experimental presentation of the ideal physique on eating disorder symptoms: a meta-analysis of laboratory studies.

BACKGROUND: Older meta-analyses of the effects of the media's portrayal of the ideal physique have found small effects revealing that exposure to the ideal physique increases body image concerns. These meta-analyses also included correlational, quasi-experimental, and experimental studies, with limited examination of moderators and other relevant outcomes besides body image. METHODS: We conducted a systematic literature search and identified 33 experimental (i.e., pre and post data for both experimental and control groups) laboratory studies examining the effects of acute exposure to the media's portrayal of the ideal physique on eating disorder symptoms (i.e., body image, positive affect, negative affect, self-esteem, anger, anxiety and depression) and the mechanisms that moderate this effect. RESULTS: Fourteen separate meta-analyses revealed a range of small to moderate effect sizes for change in outcomes from pre to post for both experimental and control groups. Exposure to images of the ideal physique resulted in small effect sizes for increased depression and anger and decreased self-esteem and positive affect. Moderator analyses revealed moderate effect sizes for increased depression and body dissatisfaction among high-risk participants. CONCLUSIONS: This meta-analysis makes it clear that media exposure of the ideal physique results in small changes in eating disorder symptoms, particularly with participants at high risk for developing an eating disorder. Further research is needed to examine the longitudinal effects of media exposure of eating disorder symptoms.

Development and validation of the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS).

The goal of the current investigation was to develop and validate a measure to assess an individual's eating-related behaviors related to alcohol consumption, specifically behaviors intended to compensate for calories so that more alcohol could be consumed or restrict calories to enhance the psychoactive effects of alcohol consumption. Two hundred and seventy four undergraduate students (n=51 males; 75.2% Caucasian) completed a newly developed scale, the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS), along with measures of eating restriction, bulimia, and body dissatisfaction. An exploratory factor analysis on the CEBRACS revealed the existence of 4 clear-cut factors: alcohol effects, bulimia, dieting and exercise, and restriction. Internal consistency statistics for all subscales ranged from .79 to .95. Pearson product-moment correlations between the CEBRACS and measures of bulimia, restriction, and body dissatisfaction ranged from .04 to .44. T-tests revealed no gender differences in compensatory eating behaviors. Future research directions and limitations of the current study are discussed.

Appearance-related teasing, body dissatisfaction, and disordered eating: A meta-analysis.

A meta-analysis was conducted to determine the relationship between appearance and weight-based teasing and three outcome measures: body dissatisfaction, restrictive eating, and bulimic behaviors. Four meta-analyses were conducted. Fifty effect sizes (N=10,618) resulted in a moderate effect size of .39 for the relationship between weight teasing and body dissatisfaction; 24 effect sizes (N=7190) resulted in an effect size of .32 for the relationship between appearance teasing and body dissatisfaction; 20 effect sizes (N=4792) resulted in an effect size of .35 for the relationship between weight teasing and dietary restraint; and 22 effect sizes (N=5091) resulted in an effect size of .36 for the relationship between weight teasing and bulimic behaviors. Significant moderators that emerged were teasing measure type, publication type, study type, age group, and gender. The findings offer further support for the inclusion of strategies in body image and eating disorders' prevention and intervention programs that focus on handling negative, appearance-related commentary.