(155) Psychosocial Considerations for the Acute Management of Adults with ARFID and Gastrointestinal Symptoms: A Case Report

Background/Significance: Avoidant/Restrictive Food Intake Disorder (ARFID) is increasingly diagnosed in adults, characterized by three subtypes of motivation for food avoidance. The subtype related to aversive consequences of eating, often gastrointestinal sensations or symptoms, is frequently encountered in adults (Nakai et al., 2017). A significant overlap exists between functional gastrointestinal complaints and ARFID in adults (Murray et al., 2021). Distinct characteristics differentiate ARFID from other eating disorders like anorexia nervosa. However, current treatments for DGBI (e.g., exclusion diets) and certain treatments for other eating disorders (e.g., enteral or parenteral nutrition) might inadvertently perpetuate ARFID symptoms. Notably, there are no established guidelines for the acute inpatient nutritional management of patients with ARFID (Guss et al., 2018). Despite this, patients admitted to medio-surgical units are sometimes offered tube feeding or parenteral nutrition.

Case: The patient is a 19-year-old female who sought outpatient gastroenterology care for gastrointestinal symptoms, leading to a 17-pound weight loss over three months (epigastric pain, nausea with occasional vomiting, early satiety, and bloating, constipation). Despite a diagnosis of delayed gastric emptying and pelvic floor dysfunction, outpatient gastrointestinal management proved ineffective, with continued weight loss, prompting inpatient admission for nutritional management and initiation of enteral feeding via tube feeds. On admission day 1, the patient's BMI was 17, and a tube feed was placed. Over the first six days of admission, the patient refused feeding initiation and had minimal oral intake. The team then recommended total parenteral nutrition (TPN), and the consult-psychiatry team was consulted on day 7. On the initial encounter with psychiatry, the patient was hyper-focused on the initiation of TPN and met criteria for ARFID, obsessional personality traits, and emetophobia. It was noted that the mother was often composed at the bedside but crying in the hallway. With daily integrated psychiatric interventions, the patient started eating again, progressively meeting her nutritional goals via oral nutrition, and could be discharged home safely on day 14.

Discussion: This case highlights how a comprehensive understanding of psychosocial factors can guide appropriate interventions for patients with ARFID and gastrointestinal complaints. In this case, mirtazapine 15 mg was initiated for the symptomatic treatment of sleep and nausea, alongside as-needed low-dose lorazepam. Psychosocial intervention focused on 1) psychoeducation on the gut-brain axis, 2) a confrontation with the potential impact of denutrition and 3) a family-based intervention focused on emotional expression for the mother, enabling a reversal of emotional avoidance in the patient and the creation of an alliance between the mother and the patient. Finally, it highlights how multidisciplinary interventions must be guided by psychosocial factors, and how providers must be cognizant of these in assessing the expected benefits and risks of an intervention.

Conclusion/Implications: In conclusion, this case underscores the need for comprehensive psychosocial considerations in the management of patients with ARFID and gastrointestinal symptoms, emphasizing the importance of tailored interventions and the necessity for further research and clinical guidelines in this specific domain.

References:

1. Guss, C. (2018). https://doi.org/10.1186/s40337-018-0212-4

2. Murray, H. B. (2021). https://doi.org/10.1002/eat.23414

3. Nakai, Y. (2017). https://doi.org/10.1016/j.eatbeh.2016.12.004

 

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This poster reflects the work of an early career faculty member who identifies as a member of a sexual orientation minority group