Feeding, Eating, and Elimination Disorders

1
Feeding, Eating, and Elimination Disorders

• Psy 610A
• Gary S. Katz, Ph.D.

2
Feeding, Eating, and Elimination Disorders

• Feeding Disorder of Infancy or Early Childhood
  (307.59)
• Pica (307.52)
• Rumination Disorder (307.53)
• Anorexia Nervosa (307.1)
• Bulimia Nervosa (307.51)
• Eating Disorder NOS (307.50)
• Encopresis (787.6, 307.7)
• Enuresis (307.6)

3
Feeding Disorder of Infancy or Early Childhood
(307.59)

• Essential diagnostic feature persistent failure
  to eat adequately.
• Lack of weight gain
• or
• significant weight loss.
• Onset before age 6.
• Recommend consultation with SP/L to look at
  swallowing and neuromuscular issues with the
  mouth and throat.

4
Feeding Disorder of Infancy or Early Childhood
(307.59)

• A. Feeding disturbance as manifested by
  persistent failure to eat adequately with
  significant failure to gain weight or significant
  loss of weight over at least 1 month.
• B. The disturbance is not due to an associated
  gastrointestinal or other general medical
  condition (e.g., esophageal reflux).
• C. The disturbance is not better accounted for by
  another mental disorder (e.g., Rumination
  Disorder) or by lack of available food.
• D. The onset is before age 6 years.

5
Associated Features

• Infants with feeding disorders may be more
  irritable and difficult to soothe during feeding
  than infants without feeding disorders.
• May appear apathetic and withdrawn may see
  developmental delays.
• Parent-child interactions may contribute to or
  exacerbate feeding disorders.
• Inappropriate food presentation
• Inappropriate reaction to food refusal by parent
  (seeing as act of aggression or rejection)

6
Associated Features

• Inadequate caloric intake may exacerbate other
  features including developmental lags
  irritability, leading to exacerbation of feeding
  problems.
• Infant factors
• Difficult temperament
• Intrautering Grown Retardation (IUGR)
• Preexisting developmental impairments leading to
  diminished responsiveness on the part of the
  infant.
• Parental factors
• Parent psychopathology
• Undereducation or lack of knowledge of parenting
• Dyadic factors
• Abuse, neglect

7
Associated Physical Findings

• Nonspecific findings associated with malnutrition
• Anemia
• Low serum albumin total protein
• Malnutrition may be life threatening.

8
Age Gender Features

• Later onset implies diminished impact of
  developmental delay and malnutrition.
• Growth delay, however, present with later onset
  feeding disorders.
• Equally common in males and females.

9
Prevalence

• 1 to 5 of pediatric hospital admissions are for
  failure to thrive (FTT) up to ½ of these may
  reflect feeding disturbances without predisposing
  general medical conditions.
• Community samples suggest point prevalence for
  FTT to be around 3

10
Failure to Thrive

• Medical diagnosis
• Encompasses Feeding Disorders as well as a range
  of medical and psychological conditions.
• Feeding Disorder of Infancy or Early Childhood is
  a type of FTT, all FTT are NOT Feeding Disorders.
• Organic FTT (not Feeding Disorder)
• Non-organic FTT (may be Feeding Disorder)
• Excessive juice consumption may be part of
  non-organic,
• but
• clearly not a Feeding Disorder.
• Abuse/neglect, poor parenting.

11
Course

• Onset is typically in the first year of life, may
  have an onset in children ages 2-3.
• Majority have improved growth after variable
  lengths of time but typically remain shorter and
  lighter up through adolescence than children who
  did not have feeding disorders.

12
Differential Diagnosis

• Transient minor feeding problems in infancy.
• No significant failure to gain or loss of weight.
• G/I, endocrinological, neurological, cardiac,
  other general medical conditions
• Can diagnose Feeding Disorder only if the feeding
  problems are beyond what would be expected given
  the underlying medical condition.
• Evidence in favor of a Feeding Disorder diagnosis
  would be if there is an improvement in feeding
  and weight gain in response to changing
  caregivers.

13
Pica (307.52)

• Essential feature eating of one or more
  nonnutritive substances on a persistent basis.
• Typical substances vary by age
• Younger children eat paint, plaster, string,
  hair, cloth.
• Older children eat animal droppings, sand,
  insects, leaves, or pebbles.
• Adolescents adults eat clay or soil.
• No food aversions.

14
Pica (307.52)

• A. Persistent eating of nonnutritive substances
  for a period of at least 1 month.
• B. The eating of nonnutritive substances is
  inappropriate to the developmental level.
• C. The eating behavior is not part of a
  culturally sanctioned practice.
• D. If the eating behavior occurs exclusively
  during the course of another mental disorder
  (e.g., Mental Retardation, Pervasive
  Developmental Disorder, Schizophrenia), it is
  sufficiently severe to warrant independent
  clinical attention.

15
Associated Features

• Frequently associated with Mental Retardation and
  PDD.
• Some cases have been reported with nutritional
  deficiencies however, usually no specific
  biological abnormalities.
• Pica may only come to clinical attention as a
  medical consequence of ingesting harmful
  substances
• Lead poisoning from paint, mechanical bowel
  problems or obstructions, intestinal perforation,
  infections from eating fecal matter.
• Poverty, neglect, lack of appropriate parental
  supervision, developmental delay increase risk
  for diagnosis.

16
Culture, Age, Gender Features

• In some cultures, eating of dirt or other
  seemingly nonnutritive substances is culturally
  sanctioned not Pica.
• Odawa soft stones eaten by pregnant Kenyan
  women
• Pica more commonly seen in young children and
  occasionally in pregnant females.

17
Prevalence Course

• Limited epidemiological data.
• Prevalence increases with severity of mental
  retardation (as high as 15 in adults with Severe
  Mental Retardation).
• Onset typically in infancy.
• Typically lasts for several months and then
  remits.
• May continue into adolescence or adulthood
  usually diminishes in the MR population in
  adulthood.

18
Differential Diagnosis

• Normal mouthing / haptic exploration of infancy.
• PDD
• Can occur, but Pica not the focus of the disorder
• Schizophrenia
• Eating is part of a delusional belief
• Other eating disorders
• Rumination Disorder, Feeding Disorder of Infancy
  or Early Childhood, Anorexia Nervosa, Bulimia
  Nervosa.

19
Rumination Disorder (307.53)

• Essential feature repeated regurgitation and
  re-chewing of food occurring after feeding that
  develops in an infant/child after a period of
  normal functioning.
• Partially digested food is brought up into the
  mouth without nausea, retching, disgust, or
  associated G/I disorder.
• Food is either ejected from the mouth or chewed
  and re-swallowed.

20
Rumination Disorder (307.53)

• A. Repeated regurgitation and rechewing of food
  for a period of at least 1 month following a
  period of normal functioning.
• B. The behavior is not due to an associated
  gastrointestinal or other general medical
  condition (e.g., esophageal reflux).
• C. The behavior does not occur exclusively during
  the course of Anorexia Nervosa or Bulimia
  Nervosa. If the symptoms occur exclusively during
  the course of Mental Retardation or a Pervasive
  Developmental Disorders, they are sufficiently
  severe to warrant independent clinical attention.

21
Associated Features

• Infants are generally irritable and hungry
  between episodes of regurgitation.
• Large amounts of food may be taken in, but not
  nutritionally broken down due to regurgitation.
• Leads to malnutrition, weight loss, in infancy
  mortality can be up to 25
• Less common to see malnutrition in older children
  and adults.

22
Associated Features / Prevalence

• Predisposing psychosocial problems
• Lack of stimulation, neglect, stressful life
  situations, problems in parent-child
  relationships
• Disruption in parent-child relationships due to
  perceived failure to feed / noxious odor of the
  regurgitated food.
• Feeding Disorder of Infancy or Early Childhood
  may develop.
• In older children and adults, MR is a
  predisposing factor.
• Appears uncommon. May occur more in males than
  females.

23
Course

• Onset may occur in the context of other
  developmental delays.
• Age of onset between 3 and 12mos, except when MR
  is present.
• With MR present, onset may be somewhat later.
• In infants, often remits spontaneously.
• In some severe cases, course is continuous.

24
Differential Diagnosis

• Congenital abnormalities of the esophagus or
  pylorus (pyloric stenosis)

25
Differential Diagnosis

• Normal vomiting of early infancy
• Cannot diagnose rumination if the symptoms occur
  exclusively during the course of Anorexia Nervosa
  or Bulimia Nervosa.

26
Anorexia Nervosa (307.1)

• Essential features
• individual refuses to maintain a minimally normal
  body weight,
• is intensely afraid of gaining weight,
• and
• exhibits a significant disturbance in the
  perception of the shape or size of his/her body.
• Postmenarcheal females become amenorrheic.

27
Anorexia Nervosa (307.1)

• A. Refusal to maintain body weight at or above a
  minimally normal weight for age and height (e.g.,
  weight loss leading to maintenance of body weight
  less than 85 of that expected or failure to
  make expected weight gain during period of
  growth, leading to body weight less than 85 of
  that expected).
• B. Intense fear of gaining weight or becoming
  fat, even though underweight.
• C. Disturbance in the way in which one's body
  weight or shape is experienced, undue influence
  of body weight or shape on self-evaluation, or
  denial of the seriousness of the current low body
  weight.

28
Anorexia Nervosa (307.1)

• D. In postmenarcheal females, amenorrhea, i.e.,
  the absence of at least three consecutive
  menstrual cycles. (A woman is considered to have
  amenorrhea if her periods occur only following
  hormone, e.g., estrogen, administration.)
• Specify type
• Restricting Type during the current episode of
  Anorexia Nervosa, the person has not regularly
  engaged in binge-eating or purging behavior
  (i.e., self-induced vomiting or the misuse of
  laxatives, diuretics, or enemas)
• Binge-Eating/Purging Type during the current
  episode of Anorexia Nervosa, the person has
  regularly engaged in binge-eating or purging
  behavior (i.e., self-induced vomiting or the
  misuse of laxatives, diuretics, or enemas)

29
Associated Features

• When seriously underweight, may see depressive
  symptoms
• depressed mood, social withdrawal, irritability,
  insomnia, diminished interest in sex
• May meet criteria for Major Depressive Disorder
  however need to re-assess when the individual has
  restored or partially restored weight.
• OCD features, related and unrelated to food may
  occur
• Preoccupied with thoughts of food, collect
  recipes, hoard food
• If obsessions and compulsions unrelated to food
  exist, consider separate DX of OCD

30
Associated Features

• Also see
• Concerns about eating in public
• Feelings of ineffectiveness
• Strong need to control ones environment
• Inflexible thinking
• Limited social spontaneity
• Perfectionism
• Overly-restrained initiative and emotional
  expression

31
Associated Features

• Commonly see Axis II diagnoses as well in adult
  populations with Anorexia Nervosa
• Binge-Eating/Purging subtypes tend to be more
  impulsive, higher risk for substance abuse,
  increased emotional lability, increased sexual
  activity, a greater frequency of suicide in their
  history and more likely to meet criteria for
  Borderline Personality Disorder (adults).

32
Associated Lab Findings

• Starvation causes a range of physical anomalies
• Anemia and other blood chemistry disorders
• Females low serum estrogen
• Males low serum testosterone
• Heart rate changes (bradycardia, arrhythmias)
• EEG changes due to significant fluid and
  electrolyte imbalances
• Resting energy expenditure and metabolic state
  lowered

33
Associated Physical Exam Findings

• Many physical symptoms attributable to starvation
• Ammenorrhea in females
• Constipation, abdominal pain
• Cold intolerance, lethargy, excess energy
• Emaciation most obvious finding
• Low blood pressure, hypothermia, dryness of skin
• Lanugo
• Fine, downy, body hair on trunk
• Edema (swelling) once laxative or diuretic abuse
  is stopped
• Dental enamel erosion (on the back side of the
  teeth)
• Scars/callous on the hand from inducing vomiting.

34
Culture, Age, Gender Features

• Prevalence of AN greatly increased in
  industrialized societies
• Abundance of food
• Attractiveness is linked to being thin
• Rarely begins before puberty
• If AN begins before puberty, severity may be
  greater in other associated mental disorders
• ALSO better prognosis with onset in early
  adolescence (13-18yrs)
• More than 90 of the cases of AN are females.

35
Prevalence

• Among females prevalence rates are about 0.5
• Among males prevalence rates are about 0.05
• Often see individuals with subthreshold eating
  disorders (e.g., Eating Disorder Not Otherwise
  Specified).
• Incidence appears to have increased in recent
  decades.

36
Course

• Typical age of onset 14-18yrs
• Rarely occurs in females older than 40yrs
• Onset may be associated with a stressful life
  event
• Couse and outcome highly variable
• Some recover after a single episode
• Some have a fluctuating pattern of weight
  gain/loss
• Some have a chronic, deteriorating pattern

37
Course

• Hospitalization may be required to restore
  weight, fluid, and electrolyte imbalance.
• Of those admitted to University hospitals,
  mortality is about 10
• Death most commonly results from starvation,
  suicide, or electrolyte imbalance.

38
Familial Pattern

• Increased risk of AN among first-degree
  biological relatives of AN probands.
• Increased risk of Mood Disorders also been noted
  among first-degree biological relatives of AN
  probands.
• Concordance rates for MZ twins higher than DZ
  twins.

39
Differential Diagnosis

• General medical conditions
• Major Depressive Disorder
• Weight loss may occur, but no preoccupation with
  weight loss or fear of gaining weight
• Schizophrenia
• May have odd eating, may have significant weight
  loss
• Will not have fear of gaining weight or body
  image disturbance.
• Social phobia
• fear of eating in public only symptom
• OCD
• Obsessions and compulsions more than just food
  related
• Body Dysmorphic Disorder
• Distortion unrelated to body shape and size
  (e.g., nose too big)
• Bulimia Nervosa
• BN are able to maintain normal body weight

40
Bulimia Nervosa (307.51)

• Essential Features
• Binge eating
• and
• inappropriate compensatory methods to prevent
  weight gain.
• Binge eating in a discrete period of time an
  amount of food that is definitely larger that
  most individuals would eat under similar
  circumstances.
• Inappropriate compensatory methods vomiting
  (80-90 of individuals with BN), misuse of
  laxatives (33 of individuals with BN), misuse
  enemas (rarely used), fast for a day, or
  excessively exercise.

41
Bulimia Nervosa (307.51)

• A. Recurrent episodes of binge eating. An episode
  of binge eating is characterized by both of the
  following
• (1) eating, in a discrete period of time (e.g.,
  within any 2-hour period), an amount of food that
  is definitely larger than most people would eat
  during a similar period of time and under similar
  circumstances
• (2) a sense of lack of control over eating during
  the episode (e.g., a feeling that one cannot stop
  eating or control what or how much one is eating)
  
• B. Recurrent inappropriate compensatory behavior
  in order to prevent weight gain, such as
  self-induced vomiting misuse of laxatives,
  diuretics, enemas, or other medications fasting
  or excessive exercise.
• C. The binge eating and inappropriate
  compensatory behaviors both occur, on average, at
  least twice a week for 3 months.

42
Bulimia Nervosa (307.51)

• D. Self-evaluation is unduly influenced by body
  shape and weight.
• E. The disturbance does not occur exclusively
  during episodes of Anorexia Nervosa.
• Specify type
• Purging Type during the current episode of
  Bulimia Nervosa, the person has regularly engaged
  in self-induced vomiting or the misuse of
  laxatives, diuretics, or enemas
• Nonpurging Type during the current episode of
  Bulimia Nervosa, the person has used other
  inappropriate compensatory behaviors, such as
  fasting or excessive exercise, but has not
  regularly engaged in self-induced vomiting or the
  misuse of laxatives, diuretics, or enemas

43
Associated Features

• Individuals with BN are typically within the
  normal weight range (some may be over or
  underweight).
• Increased frequency of depressive symptoms or
  Mood Disorders
• Increased frequency of anxious symptoms or
  Anxiety Disorders
• Mood and anxiety symptoms generally remit
  following effective treatment for BN
• Lifetime prevalence for Substance
  Abuse/Dependence is at least 30 in individuals
  with BN.
• Often starts with stimulant use to inhibit
  appetite.
• Adults often meet criteria for Personality
  Disorders (most frequently, Borderline
  Personality Disorder)
• Purging subtypes are at greater risk for
  depressive symptoms.

44
Associated Lab/Physical Findings

• Fluid and electrolyte imbalances
• Calcium, Sodium, and Chlorine most common
• Medical findings also seen with frequent vomiting
  (increased alkalosis) and diarrhea (increased
  acidosis).
• Loss of dental enamel on back of teeth
• Teeth can become ragged and moth-eaten from
  stomach acid exposure
• Scars/calluses on hand
• Menstrual irregularities
• Laxative dependence
• Purging subtype more likely to have physical
  problems

45
Culture Gender Features

• BN occurs with similar frequencies in most
  industrialized countries.
• Few studies in other cultures.
• In the US, individuals with BN are primarily
  white, but has been reported in other ethnic
  groups as well.
• 90 of individuals with BN are female in clinic
  and population samples.
• Males with BN have a higher prevalence of
  premorbid obesity than do females with BN.

46
Prevalence / Course

• Lifetime prevalence rates
• Females 1 to 3
• Males .1 to .3
• Usually begins in late adolescence or early
  adulthood.
• Binge eating usually begins after an episode of
  dieting.
• Disturbed eating persists for several years in
  most clinic samples.
• Course can be chronic or intermittent
• Many individuals will remit over time.
• Remission of 1yr or longer is associated with
  better long-term outcome.

47
Familial Pattern

• Increased frequency of BN, Mood Disorders,
  Substance Abuse/Dependence in first-degree
  biological relatives of BN probands.
• Familial tendency toward obesity may exist not
  definitively established.

48
Differential Diagnosis

• Anorexia Nervosa, Binge-Eating/Purging Type
• Binge eating only occurs during Anorexia Nervosa
  episodes.
• Key feature fear of food, gaining weight in AN,
  lack of appropriate body weight in AN
• Difficult to make the distinction between AN,
  Binge-Eating/Purging, in Partial Remission
• and
• Bulimia Nervosa.

49
Differential Diagnosis

• Major Depressive Disorder, with Atypical Features
• Can see disordered eating, but not the
  inappopriate compensatory behavior
• Borderline Personality Disorder (in adults)
• Can see binge eating as part of the impulsive
  symptoms of BPD.
• Can give BPD and BN diagnoses (in adults)

50
Eating Disorder NOS (307.50)

• The Eating Disorder Not Otherwise Specified
  category is for disorders of eating that do not
  meet criteria for any specific Eating Disorder.
  Examples include
• For females, all of the criteria for Anorexia
  Nervosa are met except that the individual has
  regular menses.
• All of the criteria for Anorexia Nervosa are met
  except that, despite significant weight loss, the
  individuals current weight is in the normal
  range.
• All of the criteria for Bulimia Nervosa are met
  except that the binge eating and inappropriate
  compensatory mechanisms occur at a frequency less
  than twice a week or for a duration of less than
  3 months.
• The regular use of inappropriate compensatory
  behavior by an individual of normal body weight
  after eating small amounts of food (e.g.,
  self-induced vomiting after the consumption of
  two cookies).
• Repeatedly chewing and spitting out, but not
  swallowing, large amounts of food.
• Binge-eating disorder recurrent episodes of
  binge eating in the absence of the regular use of
  inappropriate compensatory behaviors
  characteristic of Bulimia Nervosa.

51
Encopresis

• Essential feature passage of feces into
  inappropriate places (e.g., clothing or floor).
• Floor is more atypical than clothing
• May be related to constipation, impaction, and
  retention (787.6) or not (307.7)
• Constipation may be due to psychological reasons
  or physiological predispositions.

52
Encopresis

• A. Repeated passage of feces into inappropriate
  places (e.g., clothing or floor) whether
  involuntary or intentional.
• B. At least one such event a month for at least 3
  months.
• C. Chronological age is at least 4 years (or
  equivalent developmental level).
• D. The behavior is not due exclusively to the
  direct physiological effects of a substance
  (e.g., laxatives) or a general medical condition
  except through a mechanism involving
  constipation.
• Code as follows
• 787.6 With Constipation and Overflow Incontinence
  
• 307.7 Without Constipation and Overflow
  Incontinence

53
Associated Features

• Shame, avoidance of situations (e.g., camp or
  school) that might lead to embarrassment.
• Avoidance linked to impact on self-esteem, social
  ostracism by peers
• and
• anger, punishment, and rejection by caregivers.
• Smearing feces may be deliberate (more ODD) or
  accidental (ineffective attempts to clean or hide
  feces).
• Euresis often co-occurs with encopresis.

54
Prevalence / Course

• Approximately 1 of 5-year-olds have encopresis.
• More common in males than females.
• Not diagnosed under 4yrs of age or for children
  with a developmental delay, a mental age of 4yrs.
• Inadequate, inconsistent toilet training and
  psychosocial stress may be predisposing factors.
• Two types of course
• Primary child never was continent
• Secondary child had a period of continence,
  followed by fecal incontinence.
• Can persist with intermittent exacerbation for
  years.

55
Differential Diagnosis

• General medical conditions
• Can diagnoses Encopresis with another
  co-occurring medical condition if that condition
  involves constipation.
• If the co-occurring medical condition produces
  fecal incontinence (e.g., chronic diarrhea, anal
  stenosis), Encopresis is not diagnosed.

56
Enuresis (307.6)

• Essential feature repeated voiding of urine
  during the day or at night into bed or clothes.
• May be involuntary or intentional.

57
Enuresis (307.6)

• A. Repeated voiding of urine into bed or clothes
  (whether involuntary or intentional).
• B. The behavior is clinically significant as
  manifested by either a frequency of twice a week
  for at least 3 consecutive months or the presence
  of clinically significant distress or impairment
  in social, academic (occupational), or other
  important areas of functioning.
• C. Chronological age is at least 5 years (or
  equivalent developmental level).
• D. The behavior is not due exclusively to the
  direct physiological effect of a substance (e.g.,
  a diuretic) or a general medical condition (e.g.,
  diabetes, spina bifida, a seizure disorder).
• Specify type
• Nocturnal Only
• Diurnal Only
• Nocturnal and Diurnal

58
Associated Features

• Amount of impairment a function of limitations on
  childs social activities (e.g., ineligibility
  for sleep-away camp) or effect on self-esteem,
  social ostracism by peers, and anger, rejection,
  or punishment by caregivers.
• Most children with Enuresis do not have
  co-occurring mental disorders.
• Prevalence of other behavioral disorders is
  higher in children with Enuresis.
• Encopresis, Sleepwalking Disorder, and Sleep
  Terror Disorder may be present.
• Also see urinary tract infections predisposing to
  Enuresis.
• Other predisposing factors
• Delayed or lax toilet training, psychosocial
  stress, delays in the development of normal
  circadian rhythms of urine production, reduced
  functional bladder capacities.

59
Prevalence / Course

• Prevalence
• 5 to 10 among 5-year-olds
• 3 to 5 among 10-year-olds
• 1 among individuals 15yrs or older
• Two types of course
• Primary never been continent
• Secondary incontinent after a period of
  continence
• By definition, primary Enuresis begins at 5yrs of
  age
• Secondary Enuresis begins commonly between 5 and
  8yrs.
• Rates of spontaneous remission between 5 and 10
  after age 5
• Most children with Enuresis are continent by
  adolescence, some continue into adulthood.

60
Familial Pattern

• Approximately 75 of all children with Enuresis
  have a first-degree biological relative who has
  had the disorder.
• Risk of Enuresis is 5x to 7x greater in the
  offspring of a parent with Enuresis.
• Concordance rates higher in MZ twins than DZ
  twins.
• No specific genetic links yet.

61
Differential Diagnosis

• No DX made in the case of a general medical
  condition that causes polyuria or urgency.
• Diagnosis is made when the Enuresis either
  predates the general medical condition or it
  occurs after the general medical condition has
  remitted.