Feeding and Eating Disorders (Infancy or Early Childhood): DSM-5 EPPP Lecture Video

The video below is the section for Feeding and Eating Disorders (Infancy or Early Childhood) from Part 5 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 5, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.

Transcript of DSM-5 EPPP Lecture Video: Feeding and Eating Disorders (Infancy or Early Childhood)

The DSM-5 chapter on Feeding and Eating Disorders includes Pica, Rumination Disorder,
Avoidant/Restrictive Food Intake Disorder (formerly known as Feeding Disorder of Infancy or Early Childhood), Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder.

Pica is characterized by the ingestion of non-nutritive substances on a regular basis. Preferred non-nutritive substances tend to vary with age. For example, infants and younger children tend to eat paint, plaster, string, hair, and cloth while older children often consume animal droppings, sand, insects, leaves, and pebbles. Adolescents and adults with the disorder frequently ingest clay or soil. It should be noted that although individuals with Pica persistently eat non-nutritive substances, they do not display an aversion to food. In order to receive a diagnosis of Pica, this behavior must persist for at least a month and not be part of a culturally sanctioned practice. In addition, because chewing on and eating nonfood objects is relatively common before 18-24 months of age, these acts do not necessarily signify the presence of Pica, unless the behaviors are extreme and developmentally inappropriate. Pica generally lasts for several months before remitting, although it may occasionally continue into adolescence and adulthood.

The consumption of nonfood substances in Pica may result in a variety of potentially serious medical complications including exposure to infectious agents; exposure to parasitic infections such as toxoplasmosis, constipation, intestinal ulceration, perforation, obstruction, and lead poisoning; or poisoning due to other toxic substances.

Rumination Disorder is characterized by repeated regurgitation and re-chewing of food without apparent nausea, retching, disgust, or other gastrointestinal distress. In order to qualify for a diagnosis of Rumination Disorder, the behavior must follow a period of normal functioning and must continue for at least a month – and may not appear exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. Although the disorder is most commonly found in infants, it may also occur in older individuals, especially those with mental retardation. According to the DSM-5, infants with Rumination Disorder typically “display a characteristic position of straining and arching the back with the head held back (during regurgitation), make sucking movements with their tongues, and give the impression of gaining satisfaction from the activity”. In most instances, Rumination Disorder remits spontaneously. In more severe cases, however, the course of the disorder may be continuous.

Although infants with Rumination Disorder may consume large quantities of food, they remain hungry and may suffer from malnutrition as food is regurgitated immediately after feeding. Weight loss, failure to make expected weight gains, and lowered resistance to disease are common in infants with Rumination Disorder. As many as 25 percent of infants with the disorder may die, as a result of malnutrition. Rumination Disorder is often associated with psychosocial problems such as high-stress environments, neglect, abuse, lack of stimulation, and impaired parent-child relationships.

Previously called Feeding Disorder of Infancy or Early Childhood, Avoidant/Restrictive Food Intake Disorder (sometimes referred to as “failure to thrive”) is characterized by persistent failure to eat adequately for at least a month in the absence of gastrointestinal or other general medical condition. Onset is prior to age 6 and most often occurs during the first year of life. Inadequate nutrition is evidenced by significant failure to gain weight or significant weight loss, as a child is not consuming enough energy-containing foods, vitamins, and minerals to support normal growth. Infants with this disorder may be irritable, difficult to console, apathetic, and withdrawn. They often display developmental delays.

In general, earlier onset (prior to age 2) of Avoidant/Restrictive Food Intake Disorder is associated with greater degrees of malnutrition and developmental delay. Poverty, stress, separation from family, abuse, neglect, and parental mental illness increase the risk of developing this disorder. Temperamental characteristics, intrauterine growth retardation, and pre-existing developmental impairments that cause the child to be less responsive may also contribute to the development of the disorder. In some cases, Avoidant/Restrictive Food Intake Disorder may be associated with negative parent-child interactions during feeding. For example, this disorder may be more likely to occur if parents force food upon children who are not hungry or who greatly misread children’s hunger cues.

Anorexia Nervosa includes three essential features: 1) persistent energy intake restrictions 2) intense fear of gaining weight of becoming fat 3) a disturbance in self-perceived weight or shape. The DSM-5 no longer requires the criteria of amenorrhea (i.e., the absence of at least three consecutive menstrual cycles) to be present for the diagnosis of Anorexia Nervosa.  Additionally, the new criteria do not adhere to the 85% of normal body weight for age and height.  Instead, the term “significantly low weight” leaves the interpretation open for clinical judgement.  The fear of gaining weight has to be present as well as the presence of poor/inaccurate body image.

Specifiers for Anorexia Nervosa include “Restricting type” and “Binge-eating/purging type.”  The key distinction between a person with Anorexia Nervosa with Binge-eating/purging type and a person with Bulimia is the body weight.  Once a person looses a significant amount of body weight the diagnosis changes from Bulimia to Anorexia even if they use compensatory behaviors like vomiting or laxatives.  If only some of the criteria are met for this diagnosis, then the specifier “In partial remission” must be used.  If none of the criteria are now met, after a full diagnosis, then the specifier “in full remission” is used.  Degree of current severity ranges from Mild to Extreme and is dependent upon the person’s BMI.

The DSM-5 criteria for Bulimia Nervosa remain very similar earlier editions.  Focus is on binge eating, typically within a 2-hour window, large quantities of food that is consumed in secret.  Feelings of loss of control over the eating is also present. These eating behaviors occur at least once a week over a period of 3 months.  Also characteristic of Bulimia Nervosa are the inappropriate compensatory behaviors to offset the impact of consuming a large amount of calories.  Excessive exercise, vomiting, laxative use, diuretics, fasting and other creative methods are used to reduce calories and ameliorate the shame/guilt associated with Bulimia Nervosa.

Binge-Eating Disorder was a diagnosis for further study in DSM-IV-TR, but has graduated to a full-fledged eating disorder diagnosis in DSM-5.  Like Bulimia Nervosa, the person suffering from this diagnosis eats large quantities of food in a rapid and out of control manner.  These behaviors must occur at least once a week for 3 months.  However, unlike Bulimia Nervosa, the individual suffering from this diagnosis does not utilize compensatory behaviors to offset the caloric intake.

Specifiers for both Bulimia Nervosa and Binge-Eating Disorder are identical except that compensatory behaviors are not found in Binge-Eating Disorder.  Both diagnoses should specify, after a full criteria diagnosis has been met, if the frequency of episodes falls below one time per week (In partial remission) or if none of the criteria are now met (in full remission).  Severity of both these diagnoses is specifed by a scale of Mild – Moderate – Severe – Extreme, and these categories are determined by the frequency of episodes each week.

Feeding and Eating Disorders
1. Pica
2. Rumination Disorder
3. Avoidant/Restrictive Food Intake Disorder
4. Anorexia Nervosa
5. Bulimia Nervosa
6. Binge-Eating Disorder

1. Regular ingestion of non-nutritive substances; exact substances vary by age
2. Often linked to mental retardation or Pervasive Developmental Disorders
3. Can lead to serious medical complications (lead poisoning, for example)

Rumination Disorder
1. Repeated regurgitation and (often) re-chewing of food without apparent distress
2. May result in malnutrition and even death, as food not fully digested
3. Linked to stress in parent-child relationships, along with lack of stimulation, child neglect

Feeding Disorder of Infancy or Early Childhood (also termed “failure to thrive”)
1. Avoidant/Restrictive Food Intake Disorder
2. Linked with developmental delays, sometimes with child abuse or neglect, extreme stress in family, clear failures in parental “reading” of infant/child hunger cues
3. Up to 25% of infants may die as a result of malnutrition
4. Onset prior to age 6, most often occurring in first year of life, may display as developmental delays
5. “Significantly low weight:” new criteria to interpret severity

Specifiers of Anorexia Nervosa
1. Restricting Type
2. Distinction between Anorexia Nervosa and Binge-eating/purging type and Bulimia: body weight (with significant weight loss diagnosis changes from Bulimia to Anorexia)
3. Severity ranges from Mild to Extreme, dependent upon BMI

Bulimia Nervosa
1. Binge eating within 2-hour window, consumed in secr
2. Feel loss of control over eating
3. Occurs at least once a week for 3 months
4. Inappropriate compensatory behaviors (extreme exercise, vomiting, laxative use)

Binge-Eating Disorder
1. Eat large quantities of food rapidly and in out of control manner
2. Occur at least once a week for 3 months
3. Don’t use compensatory behaviors to offset caloric intake

Specifiers for Bulimia Nervosa and Binge-Eating Disorders
1. Compensatory behaviors not found in Binge-Eating Disorder
2. Severity: Mild, Moderate, Severe, Extreme (determined by frequency of weekly episodes)

The most likely diagnosis for an infant who makes sucking movements with his tongue, gains satisfaction from the regurgitation of food, and strains and arches his back while holding his head back is:

A. Autism Spectrum Disorder.
B. Rumination Disorder.
C. Pica.
D. Avoidant/Restrictive Food Intake Disorder.

RATIONALE: B is correct, as these are the classic symptoms of Rumination Disorder. A (Autism Spectrum Disorder) involves a constellation of social, language-related, and stereotyped behavior-related symptoms; C (Pica) involves the ingestion of non-nutritive substances; D (Avoidant/Restrictive Food Intake Disorder) is characterized by persistent failure to eat adequately for at least a month in the absence of gastrointestinal or other general medical condition.

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