Adult avoidant/restrictive food intake disorder: a case report / Transtorno alimentar evitativo/restritivo em uma adulta: um relato de caso

ABSTRACT The aim this report is to present an adult case of avoidant/restrictive food intake disorder (ARFID) in a patient with atypical development. To emphasize the diagnostic and behavioral characteristics of this new nosological category included in the Feeding and Eating Disorders (FED) section of DSM-5. A woman with Down Syndrome in early adulthood who developed restriction and avoidance symptoms of food until the total eating refusal with weight loss, malnutrition and dependence exclusively on enteral feeding by gastrostomy tube. This case exemplified how ARFID may remain a hidden diagnosis and even be misdiagnosed as other eating disorders, such as anorexia nervosa. The increase in diagnostic suspicion for this nosological entity with neurobiological/behavioral mechanisms involved in its clinical presentations in mind, might increase knowledge about this serious eating disorder, aiming the development of evidence-based interventions.

RESUMO O objetivo deste relato é apresentar um caso de transtorno alimentar evitativo/restritivo (TARE) em uma paciente adulta com desenvolvimento atípico e salientar as características diagnósticas e comportamentais dessa nova categoria nosológica incluída na seção de Transtornos Alimentares da DSM-5. Mulher com síndrome de Down que, no início da vida adulta, evoluiu com sintomas de restrição e evitação alimentar até a recusa total da alimentação, com perda de peso, desnutrição e dependência total de alimentação enteral por gastrostomia. Este caso elucida como o diagnóstico de TARE pode permanecer oculto e ser confundindo com outras condições patológicas alimentares, como a anorexia nervosa. O aumento da suspeição diagnóstica para essa entidade nosológica, tendo em mente os mecanismos neurobiológicos/comportamentais envolvidos em suas apresentações clínicas, possibilitará o aumento do conhecimento sobre esse grave transtorno alimentar, visando ao desenvolvimento de intervenções eficazes baseadas em evidências.

Eating Disorders Impact on Vigilance and Decision Making of a Community Sample of Treatment Naive Attention-Deficit/Hyperactivity Disorder Young Adults.

Although impulsivity is suggested as a possible link to explain the association of Attention-Deficit/Hyperactivity Disorder (ADHD) with an Eating Disorder (ED), there is little research on how clinical and cognitive/neuropsychological functioning might change when this comorbidity occurs. ADHD individuals are at a higher of developing ED and also obesity. Some research has described the impact of ADHD in clinical treatment-seeking samples of ED patients. Consequently, we investigated how ED impacted on clinical and cognitive variables of a community sample of treatment-naive ADHD individuals. Ninety college students arranged in three groups (ADHD+ED, ADHD only and Controls) were analyzed using semi-structured interviews for ADHD (K-SADS), the Iowa Gambling Task, the Conner's Continuous Performance Test, Digit and Visual span, as well as rating scales for anxiety (STAI), depression (BDI) and impulsivity (BIS-11), and binge eating (BES). We found that ADHD+ED individuals significantly differed from both groups, presenting with a higher body mass index; more hyperactivity-impulsivity symptoms; higher binge eating scores; more omission errors on the Continuous Performance Test; disadvantageous choices on the Iowa Gambling Task. Also, we demonstrated through a moderation/mediation analysis that a greater level of binge eating mediated the increases in body mass index on our sample. There were no significant paths to explain binge-eating severity through changes on any of the neuropsychological tests used. The presence of an ED in normal weight in a community sample of ADHD individuals is associated with higher body mass index and a worse cognitive functioning.

An examination of the clinical outcomes of adolescents and young adults with broad autism spectrum traits and autism spectrum disorder and anorexia nervosa: A multi centre study.

OBJECTIVES: To compare the clinical outcomes of adolescents and young adults with anorexia nervosa (AN) comorbid with broad autism spectrum disorder (ASD) or ASD traits. METHOD: The developmental and well-being assessment and social aptitude scale were used to categorize adolescents and young adults with AN (N = 149) into those with ASD traits (N = 23), and those who also fulfilled diagnostic criteria for a possible/probable ASD (N = 6). We compared both eating disorders specific measures and broader outcome measures at intake and 12 months follow-up. RESULTS: Those with ASD traits had significantly more inpatient/day-patient service use (p = .015), as well as medication use (p < .001) at baseline. Both groups had high social difficulties and poorer global functioning (strengths and difficulties questionnaire) at baseline, which improved over time but remained higher at 12 months in the ASD traits group (p = .002). However, the improvement in eating disorder symptoms at 12 months was similar between groups with or without ASD traits. Treatment completion rates between AN only and ASD traits were similar (80.1 vs. 86.5%). DISCUSSION: Adolescents with AN and ASD traits show similar reductions in their eating disorder symptoms. Nevertheless, their social difficulties remain high suggesting that these are life-long difficulties rather than starvation effects.

The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis.

OBJECTIVE: There has been interest in whether people with Attention-Deficit/Hyperactivity Disorder (ADHD) are at higher risk of developing an Eating Disorder (ED). The aim of this study was estimate the size of this association with a meta-analysis of studies. METHODS: We retrieved studies following PRISMA guidelines from a broad range of databases. RESULTS: Twelve studies fitted our primary aim in investigating ED in ADHD populations (ADHD = 4,013/Controls = 29,404), and five exploring ADHD in ED populations (ED = 1,044/Controls = 11,292). The pooled odds ratio of diagnosing any ED in ADHD was increased significantly, 3.82 (95% CI:2.34-6.24). A similar level of risk was found across all ED syndromes [Anorexia Nervosa = 4.28 (95% CI:2.24-8.16); Bulimia Nervosa = 5.71 (95% CI: 3.56-9.16) and Binge Eating Disorder = 4.13 (95% CI:3-5.67)]. The risk was significantly higher if ADHD was diagnosed using a clinical interview [5.89 (95% CI:4.32-8.04)] rather than a self-report instrument [2.23 (95% CI:1.23-4.03)]. The pooled odds ratio of diagnosing ADHD in participants with ED was significantly increased, 2.57 (95% CI:1.30-5.11). Subgroup analysis of cohorts with binge eating only yielded a risk of 5.77 (95% CI:2.35-14.18). None of the variables examined in meta-regression procedures explained the variance in effect size between studies. DISCUSSION: People with ADHD have a higher risk of comorbidity with an ED and people with an ED also have higher levels of comorbidity with ADHD. Future studies should address if patients with this comorbidity have a different prognosis, course and treatment response when compared to patients with either disorder alone. RESUMEN OBJETIVO: Ha habido interés en saber si la gente con Trastorno por Déficit de Atención e Hiperactividad (TDAH) están en mayor riesgo de desarrollar un Trastorno de la Conducta Alimentaria (TCA). El objetivo de este estudio fue estimar el tamaño de esta asociación con un meta-análisis de los estudios. Métodos: Recuperamos estudios de una amplia gama base de datos,  que siguen los lineamientos PRISMA. Resultados: Doce estudios encajaron con nuestro objetivo primario de investigar los TCA en poblaciones con TDAH (TDAH = 4,013/Controles = 29,404), y 5 exploraron TDAH en poblaciones con TCA (TCA = 1,044/Controles = 11,292). El odds ratio (OR) agrupado de diagnosticar cualquier TCA en el TDAH se incrementó significativamente, 3.82 (95% CI:2.34-6.24). Un nivel de riesgo similar fue encontrado en todos los síndromes de TCA [Anorexia Nervosa = 4.28 (95% CI:2.24-8.16); Bulimia Nervosa = 5.71 (95% CI:3.56-9.16) y Trastorno por Atracón = 4.13 (95% CI: 3-5.67)]. El riesgo fue significativamente mayor si el TDAH fue diagnosticado utilizando una entrevista clínica [5.89 (95% CI:4.32-8.04)] en lugar de un instrumento de auto-reporte [2.23 (95% CI:1.23-4.03)]. El odds ratio (OR) agrupado de diagnosticar TDAH en participantes con TCA fue significativamente incrementado, 2.57 (95% CI:1.30-5.11). El análisis de los subgrupos de cohort con atracones solamente produjo un riesgo de 5.77 (95% CI:2.35-14.18). Ninguna de las variables examinadas en los procedimientos de meta-regresión explicaron la varianza en el tamaño del efecto entre los estudios. Discusión: La gente con TDAH tiene un mayor riesgo de comorbilidad con un TCA y la gente con un TCA también tiene niveles altos de comorbilidad con TDAH. Los estudios futuros deberán abordar si los pacientes con esta comorbilidad tienen diferente pronóstico, curso y respuesta a tratamiento cuando son comparados con pacientes que solamente tienen uno de los trastornos.  © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016) © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1045-1057).

Right hemisphere dominance for language in a woman with schizophrenia and a porencephalic cyst of the left hemisphere.

A large left hemisphere porencephalic cyst was incidentally found in a 48-year-old woman (MS) with a Diagnostic and Statistical Manual (DSM)-5 diagnosis of schizophrenia. The encephaloclastic characteristics of the cyst indicated that it was acquired between the 22nd and 24th gestational weeks, after the major waves of neuronal migration had tapered off. The cyst destroyed the left temporal and occipital lobes, and the inferior parietal lobule. Surprisingly, MS had no evidence of aphasia, alexia, agraphia, or ideational apraxia; in contrast, cognitive functions dependent on the integrity of the right hemisphere were severely impaired. To test the hypothesis that the development of language in MS took place at the expense of functions that are normally carried out by the right hemisphere, we investigated MS's correlates of oral comprehension with fMRI as a proxy for auditory comprehension and other cognitive functions strongly lateralized to the posterior left hemisphere, such as ideational praxis and reading. Comprehension of spoken language engaged the homologous of Wernicke's area in the right planum temporale. Porencephaly may represent a natural model of neuroplasticity supervening at predictable epochs of prenatal development.

ADHD Rate in Obese Women With Binge Eating and Bulimic Behaviors From a Weight-Loss Clinic.

OBJECTIVE: Few studies have demonstrated a possible association between ADHD and obesity in adults. The aim of this study was to investigate the prevalence of ADHD in a sample of obese women seeking treatment, and its relations with binge eating and bulimic behaviors. METHOD: We performed a cross-sectional study in a clinical sample of one hundred fifty-five women, with a mean age of 38.9 (+10.7) years and a mean body mass index (BMI) of 39.2 (+5.29). Participants were evaluated with semistructured interviews and completed self-report psychiatric rating scales. RESULTS: The rate of ADHD in the sample was of 28.3%. The presence of ADHD was significantly correlated with more severe binge eating, bulimic behaviors, and depressive symptomatology. CONCLUSION: Similar to previous studies, a higher than expected rate of ADHD was observed among obese women. ADHD in obese individuals may be a risk factor for greater severity of disordered eating patterns.

Antidepressant induced excessive yawning and indifference / Bocejos excessivos e indiferença induzidos por antidepressivos

Introduction Antidepressant induced excessive yawning has been described as a possible side effect of pharmacotherapy. A syndrome of indifference has also been described as another possible side effect. The frequency of those phenomena and their physiopathology are unknown. They are both considered benign and reversible after antidepressant discontinuation but severe cases with complications as temporomandibular lesions, have been described. Methods We report two unprecedented cases in which excessive yawning and indifference occurred simultaneously as side effects of antidepressant therapy, discussing possible physiopathological mechanisms for this co-occurrence. Case 1: A male patient presented excessive yawning (approximately 80/day) and apathy after venlafaxine XR treatment. Symptoms reduced after a switch to escitalopram, with a reduction to 50 yawns/day. Case 2: A female patient presented excessive yawning (approximately 25/day) and inability to react to environmental stressors with desvenlafaxine. Conclusion Induction of indifference and excessive yawning may be modulated by serotonergic and noradrenergic mechanisms. One proposal to unify these side effects would be enhancement of serotonin in midbrain, especially paraventricular and raphe nucleus. .

Introdução Alguns relatos de caso descrevem pacientes com bocejos excessivos induzidos por antidepressivos. Também é relatada a capacidade dos antidepressivos induzirem uma síndrome de indiferença. A frequência desses efeitos colaterais é desconhecida, assim como seus mecanismos fisiopatológicos. Ambos os efeitos são considerados benignos e costumam ser reversíveis após a suspensão dos antidepressivos, porém há relatos de casos graves com a ocorrência de luxação temporomandibular devida aos bocejos excessivos induzidos por antidepressivos. Métodos Relatamos dois casos inéditos de pacientes, apresentando esses efeitos colaterais de forma concomitante, discutindo os possíveis mecanismos fisiopatológicos e explicando essa coocorrência. Caso 1: O paciente apresentou bocejos excessivos e apatia com o uso de venlafaxina XR (cerca de 80 bocejos por dia) e, após a troca para escitalopram por conta desse efeito, teve redução para cerca de 50 bocejos por dia. Também relatava sentimento de lentidão e apatia com ambas as medicações. Caso 2: A paciente apresentou bocejos excessivos (cerca de 25 por dia) e declínio na responsividade emocional a estímulos ambientais, associado à incapacidade de chorar com o uso de desvenlafaxina. Conclusão A indução de indiferença e de bocejos excessivos parece ser modulada por mecanismos serotonérgicos e noradrenérgicos. Uma proposta que poderia unificar esses efeitos é pelo aumento serotoninérgico no mesencéfalo, especialmente nos núcleos paraventriculares hipotalâmicos e da rafe. .

Review of literature of attention-deficit/hyperactivity disorder with comorbid eating disorders: [review] / Revisão da literatura sobre a comorbidade do transtorno do déficit de atenção e hiperatividade com transtornos alimentares: [revisão]

OBJECTIVE: According to studies of prevalence, up to 70 percent of adults with attention deficit/hyperactivity disorder have at least one psychiatric comorbidity, which leads to diagnostic and therapeutic difficulties as well as more severe functional impairment. There is a paucity of data on the comorbidity of attention deficit/hyperactivity disorder and eating disorders. The objective of this study was to review the literature regarding the attention deficit/hyperactivity disorder/eating disorders comorbidity, performing a critical analysis of relevant data. METHOD: Articles in Medline, Lilacs, SciELO, ISI and PsycINFO databases from 1980 up to 2008, were searched. The references from the articles were used as additional sources of data. RESULTS: Fourteen articles were found: five prevalence studies, four case reports, three case-control studies, one symptom-assessment study of attention deficit/hyperactivity disorder and eating disorders, and one article regarding possible causes of the association between attention deficit/hyperactivity disorder and eating disorders. These articles suggested that adult women with attention deficit/hyperactivity disorder are at higher risk of developing eating disorders, especially bulimia nervosa. Bulimia Nervosa rates found in attention deficit/hyperactivity disorder groups ranged from 1 percent to 12 percent, versus 0 percent to 2 percent in control groups. CONCLUSIONS: Although there seems to be a relationship between attention deficit/hyperactivity disorder and eating disorders, the reduced number of studies available, with various methodologies, and small sample sizes limit the generalization of the findings.

OBJETIVO: De acordo com os estudos de prevalência de comorbidades, até 70 por cento dos adultos com transtorno do déficit de atenção e hiperatividade apresentam pelo menos uma comorbidade psiquiátrica, ocasionando dificuldades diagnósticas e terapêuticas, bem como um maior prejuízo funcional. Existem poucos estudos sobre a comorbidade entre transtorno do déficit de atenção e hiperatividade e transtornos alimentares. O objetivo deste estudo foi realizar uma revisão da literatura sobre a comorbidade transtorno do déficit de atenção e hiperatividade/transtornos alimentares, realizando uma análise crítica dos dados encontrados. MÉTODO: Procedeu-se a uma revisão sistemática da literatura por meio de pesquisa bibliográfica de artigos publicados no período de 1980 a 2008, utilizando as bases de dados Medline, Lilacs, SciELO, ISI e PsycINFO. RESULTADOS: Foram identificados 14 artigos, sendo cinco estudos de prevalência de comorbidades, quatro relatos de casos, três estudos caso-controle, um estudo de avaliação de sintomas de transtorno do déficit de atenção e hiperatividade e de transtornos alimentares e um sobre as possíveis causas da associação entre transtorno do déficit de atenção e hiperatividade e transtornos alimentares. Os artigos identificados evidenciaram maior risco de desenvolvimento de transtornos alimentares, especialmente bulimia nervosa, em mulheres portadoras de transtorno do déficit de atenção e hiperatividade. As taxas de bulimia nervosa encontradas nos grupos com transtorno do déficit de atenção e hiperatividade variaram de 1 por cento a 12 por cento, enquanto que nos grupos controle foram de 0 por cento a 2 por cento. CONCLUSÕES: Embora pareça existir uma relação entre transtorno do déficit de atenção e hiperatividade e transtornos alimentares, a escassez de trabalhos existentes, com metodologias variadas e pequenas amostras avaliadas não permitem a generalização dos resultados.

Review of literature of attention-deficit/hyperactivity disorder with comorbid eating disorders.

OBJECTIVE: According to studies of prevalence, up to 70% of adults with attention deficit/hyperactivity disorder have at least one psychiatric comorbidity, which leads to diagnostic and therapeutic difficulties as well as more severe functional impairment. There is a paucity of data on the comorbidity of attention deficit/hyperactivity disorder and eating disorders. The objective of this study was to review the literature regarding the attention deficit/hyperactivity disorder/eating disorders comorbidity, performing a critical analysis of relevant data. METHOD: Articles in Medline, Lilacs, SciELO, ISI and PsycINFO databases from 1980 up to 2008, were searched. The references from the articles were used as additional sources of data. RESULTS: Fourteen articles were found: five prevalence studies, four case reports, three case-control studies, one symptom-assessment study of attention deficit/hyperactivity disorder and eating disorders, and one article regarding possible causes of the association between attention deficit/hyperactivity disorder and eating disorders. These articles suggested that adult women with attention deficit/hyperactivity disorder are at higher risk of developing eating disorders, especially bulimia nervosa. Bulimia Nervosa rates found in attention deficit/hyperactivity disorder groups ranged from 1% to 12%, versus 0% to 2% in control groups. CONCLUSIONS: Although there seems to be a relationship between attention deficit/hyperactivity disorder and eating disorders, the reduced number of studies available, with various methodologies, and small sample sizes limit the generalization of the findings.