Today, Avoidant/Restrictive Food Intake Disorder (ARFID) and its treatment modalities in the world of mental health are explored.

Duration:  17 minutes, 22 seconds

Transcript:

JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. This is another special episode from the Child Psychiatry team. I'm Dr. Josh Feder, the editor-in-chief of the Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice. Second edition, 2023, and prescribing psychotropics.

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice, and an avid reader of The Carlat Psychiatry Report. There is a growing interest in exploring the available treatment options for Avoidant Restrictive Food Intake Disorder, ARFID. Specifically, researchers are examining the efficacy of Selective Serotonin Reuptake Inhibitors, SSRIs, and hydroxazine in treating ARFID. This process involves delving into the complex world of mental health and studying the various medications used to treat this disorder, including olazepine, mirtazapine, and appetite inducing hydroxazine. Today we will delve into the dosages potential side effects, and delicate balance required to effectively treat ARFID that are being examined. This effort provides an opportunity to reflect on past treatment approaches and gain a deeper understanding of how best to approach this condition in the future. So, diving in, let's set the stage for today's talk. Dr. Feder, what can you tell us about ARFID? 

JOSH FEDER: Avoidant Restrictive Food Intake Disorder, ARFID, is an eating disorder characterized by limited food intake. The restriction may arise from sensory sensitivity, fear of adverse consequences from eating, or just a disinterest in eating. Unlike other eating disorders such as anorexia nervosa or bulimia nervosa, preoccupations with body weight or shape are not necessarily involved. Kids or teens struggling with ARFID may intentionally avoid certain foods or food groups, and that makes it difficult to meet their nutritional requirements. People of any age, including children and adults, can be affected by this disorder, and it may persist into adulthood if left untreated. That's something that we've seen in a lot of our patients mirror over the years, right? I mean, a lot of people, particularly because we see a lot of people who are neurodiverse on the autism spectrum and with related challenges. They often have very restricted diets. Like we talk about white, bland food and just really not eating much at all. So diagnosis of ARFID is tricky, right? I mean, partly because it was first described in 2013. So even though that's now 10 years ago, it still hasn't filtered into the clinical community that much. People don't think about it. And then the second piece is sometimes it's hard to it. Figure out, is this ARFID or is it anorexia? And one of the clues is that anorexia is typically hitting kids who are a little bit older, like teens, and ARFID will often come a little bit earlier. You don't necessarily get anorexia that early, but you could get ARFID that sort of grows into something that looks like anorexia. So it gets tricky. There are some screens and scales that you can use to help you, but you really do need to kind of think about that ARFID is in your differential, and then think about the diagnostic criteria and the three different kinds of ARFID that we talked about. The sensory, the worry about bad things happening like choking or whatever, and just the disinterest. So, it's a process of careful exploration to ferret out which is going on. In the careful exploration area, it's really important to unpack with the patient, depending on their age, to discuss mealtimes, foods, preferences, difficulties, and challenges, which we might not think about, which can contribute. To active daily living skills to nutritional health and also give us a clue that there might be some food disorder that's going on, which would require additional investigation. And you got to think about the other co occurring things that might be happening, like other pieces of sensory processing conditions, something we've talked about at The Carlat Child Psychiatry Report before, and also other kinds of phobias. I mean, when you think about it, some forms of ARFID appear almost like a, like a certain kind of food phobia, like a fear of something that's going to happen. But it makes you wonder whether there are other kinds of phobias or other anxiety disorders. that are going on at the same time. And then for people who just aren't interested in eating, was that just food or is there also, for instance, a depressive disorder going on? And could we confuse the two in a way where you might have ARFID without depression or depression with kind of ARFID as a component of it? Can be pretty confusing and as usual when we're talking about kids and teens diagnosis isn't as neat as the DSM would like it to be so don't be surprised if you've got a muddy diagnosis and a number of theories as you move towards treatment.

MARA GOVERMAN:  So how can clinicians help kids and teens with ARFID? 

JOSH FEDER: Well, individuals who you do diagnose with ARFID usually require a comprehensive approach to treatment, and that's no surprise. But think about the different parts of that. It might include dietary guidance. Some kind of feeding therapy, and if necessary, medication. The management of ARFID is kind of crucial because it has the potential to cause significant impairment in social, occupational, or other areas of functioning. Think about a kid who won't eat pizza, for instance, and then they're not part of the pizza party at school. Or if they're at work-we talk about kids and teens here, but you can think about a teen who's on the job and they're not eating during a long day or whatever, they didn't eat after school and they don't have the energy and they're cranky as well as, of course, the nutritional aspects. So it's really essential to recognize ARFID and develop an effective treatment plan to improve the quality of life for the people who are affected by ARFID. When you determine that medication is appropriate, you might try all kinds of off label medications that tend to increase appetite, such as olanzapine or mirtazapine, but it's important to note that there's limited research to support the efficacy of these medications for that purpose.

MARA GOVERMAN: It is interesting to note that a review conducted in 2022 explored the potential use of medication in managing the additional symptoms that are associated with ARFID. Research examined the medical records of 53 children and adolescents who were receiving treatment for ARFID in a partial hospitalization program. To be included in the study, patients had to have received either SSRIs alone or in combination of SSRIs and hydroxyzine as part of their treatment. The majority of patients in the study were pubital females with a BMI in the range of 15 to 16. To monitor progress in terms of weight gain, the study tracked the percent medium body mass index or percent MBMI. This involved dividing the patient's BMI By the medium BMI for their age and multiplying the result by 100, the conventional objective for patients was to attain a percentage MBMI of 90, which was deemed clinically meaningful in the treatment of ARFID. 

JOSH FEDER: Now, I want to make a point about that. We've talked in this podcast before and certainly in The Carlat Psychiatry Report about how we're trying to get away from BMI and our typical clinical use because, well, for one thing, it was invented a long, long time ago. And for another, it doesn't really reflect health. So you've got people who've got BMI. A BMI that's considered in the overweight or obese range who are healthy and having bad body image feelings about themselves. But here, in this very specific kind of situation, we're actually using BMI as a way to guide treatment. And you'll see that's the same when we talk about using antipsychotic medications and deciding which ones to use and whether to use metformin. So just kind of wanted to make that note that here we're using BMI in general in practice for most of our patients, we're avoiding it. And all the patients in this study were dealing with some serious anxiety. The ones who got hydroxyzine along with SSRIs turned out to be a little bit older. H13 compared to 11, and have fewer girls in the mix, 64 percent instead of 92%, and we're showing more signs of feeling down or depressed on the Child Depression Inventory, the CDI. 62 versus 53. So they were slightly different groups, but check this out. Everyone, regardless of the combination they were receiving, saw positive changes with SSRIs. Anxiety, depression, and even the fear of eating got dialed down. And when it came to gaining weight, both groups saw improvements. Those taking SSRIs alone went from a percent MBMI of 88 to 96 over the course of a year, and the people on SSRIs with hydroxyzine went from 89 to 98 in the same time frame. So pretty similar kinds of responses. Here's an interesting tidbit. Hydroxyzine not only helped with the fear of eating, but also helped with nausea, especially. And the more severe cases were both medications were being used together. And there were some side effects, a little bit of drowsiness and fatigue for the people on hydroxyzine. That's not a surprise for those who know that medication. And some headaches for the SSRIs, which again, not necessarily a surprise.

MARA GOVERMAN: Yes, side effects can be a concern, although the conclusions of the review were really interesting. According to researchers, if you are starting with SSRIs, it is recommended to begin with a gentle 5mg dose of fluoxetine or a similar medication and gradually increase the dosage to avoid unexpected anxiety. Hydroxazine's efficacy is dependent on time. It takes around 15 to 30 minutes to take effect and peaks at around two hours. The suggested dosage is 0.5 mg per kg every 4 to 6 hours, as needed to manage anxiety. For those who struggle with taking pills, the liquid version of hydroxazine is a good alternative, so it may be smart to move to opt for it. Some people might have some concerns about using hydroxazine for ARFID several times a day for a long period of time. I think that as long as you're monitoring its use, you're probably okay. There are occasional instances where people become, addiction's probably a strong word for it, but stuck on hydroxyzine, on diphenhydramine, and similar medications. There have also been some concerns about The lifetime load of anti cholinergic or even anti histaminic medications, whether they might impact the propensity for dementia much later in life. So is that something we're thinking about with kids and teens? Probably not in the moment when we're trying to specifically treat ARFID, but it kind of goes with our general ethos that whenever we're on a medication, we're trying to treat a condition and then be able to move away from the medication once treatment is, Completed. And what does that mean? It means that we don't just use medications. We try to use medications alongside therapies so that we can more likely move away from those medications. Can you be a little more specific in your timeline for check ins and then also time frame for medication usage? If you've got somebody who's got a fairly serious eating disorder where their nutrition isn't very good, I want to know what's going on.You know, maybe a couple times a week, and then if they're doing a little bit better every week, this is not the kind of thing where you're saying, oh, go do this and come back in a month. This is a more acute kind of situation when there's, nutrition, significant nutritional risk. Now, there are other people who kind of meander along.

JOSH FEDER: They've got ARFID. We've got patients together with this. We've got ARFID, and yet they're Consequences don't seem to be a big deal. They're not losing weight, they're continuing to grow, but boy, they have a restricted range of what they'll eat, and we're worried about these growth parameters, so it's going to depend on the clinical case.

MARA GOVERMAN: Dr. Feder what are your overall thoughts on the research?

JOSH FEDER: Well, it's certainly compelling. While this study was not extensive and didn't have strict controls, it does provide some valuable insights. It highlights the importance of closely monitoring anxiety levels in individuals with ARFID. It highlights the importance of closely monitoring anxiety levels in individuals with ARFID. The study suggests that SSRIs may be effective in reducing ARFID in patients. We want you to keep in mind that we really need more research to better understand the effects of SSRIs on ARFID, and again, ARFID is a young condition in terms of the DSM, and we don't have a lot of research yet. And when ARFID is more severe, Think about combining hydroxyzine with the SSRI. That might be a game changer. Hydroxyzine, as we said, is an antihistamine that can help reduce anxiety, and while SSRIs increase levels of serotonin in the brain. Do we know exactly how these medicines work? No, we just know what they do to various receptors, so we can't tell you how they work, we just tell you what they do, and we can see by research that they work. It's confusing, but that's the story in most of medicine. Together, they can provide relief from anxiety in ARFID patients, and of course, you need to discuss the risks and benefits of the medications with patients and families. So, my conclusion that as we're navigating the evolving landscape of ARFID treatment, this study serves as a valuable checkpoint, prompting consideration of medication choices and the need for comprehensive research in this domain. So the journey towards understanding and effectively managing ARFID continues with a focus on therapy, but when they need us to be prescribing, these are the insights that contribute to the ongoing conversation within the medical community. It might be very helpful to collaborate with other professionals to be able to reflect on a solid treatment plan.

JOSH FEDER: For more information on the article, we discussed today, check out our October/November/December 2022 Newsletter.

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