(112) Treating an adult patient with Avoidant-Restrictive Food Intake Disorder in the inpatient consultation-liaison setting with exposure and response prevention therapy and medication management: A Case Report

Abstract:

Background: As a new diagnosis in DSM-5, ARFID has been mostly associated with pediatric and adolescent patients. However, recent studies show prevalence in adult patients as well. Patients with ARFID pose unique challenges to inpatient consultation-liaison (C-L) teams due to medical complications that can arise such as malnutrition, electrolyte imbalances, and potential for para-enteral feeding with no clear psychiatric management guidelines. Here, we present a complex case of a patient suffering from ARFID with other psychiatric comorbidities, responding well to short-term exposure and response prevention (ERP) therapy and medication management.

Case: K.O. is a 43-year-old male patient with past medical history of obesity, diabetes, prolonged admission for incarcerated hernia after small bowel obstruction and hernia reduction four months prior to this presentation, past psychiatric history of obsessive compulsive disorder (OCD), possible autism spectrum disorder (ASD), and post traumatic stress disorder (PTSD), presenting with inability to tolerate oral secretions, nausea, and poor intake. Patient reported that the texture of phlegm mixed with food was intolerable, causing him to spit it out. Medical workup revealed hypokalemia, hypophosphatemia and acute kidney injury; CT abdomen pelvis, ENT evaluation, SLP evaluation, and esophagogastroduodenoscopy were unrevealing. C-L recommended initiation of olanzapine to target cognitive rigidity and anxious distress stemming from his underlying OCD. C-L also guided one ERP session, during which the patient held Ensure supplement in his mouth for increasingly long periods of time before swallowing. Brief check-ins by C-L during the following days revealed his progress to a full regular diet. He ultimately met all caloric counts and was discharged to rehab.

Discussion: This is the first known report of a C-L setting combined intervention of ERP therapy and pharmacotherapy in an adult patient with new ARFID. This patient is at high risk for ARFID due to his comorbidities of OCD and ASD¹. Limited research on ARFID includes some evidence for pharmacotherapy and outpatient cognitive-behavioral-therapy, but there are no FDA-approved medications, and no inpatient therapy guidelines¹. This case also highlights the liaison role of C-L in providing psychoeducation for the primary team on diagnosis and treatment options that may otherwise fail to be considered, leading to unnecessary psychiatric admission or invasive medical procedures.

Conclusion: ARFID is a new diagnosis, recognized not only by psychiatry but by other medical fields as well². Unfortunately, there are no specific guidelines for treatment of ARFID in inpatient CL settings. The successful multimodal treatment approach in this case indicates that further thorough research should be considered.

Citations:
Brigham KS, et al. Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Curr Pediatr Rep. 2018;6(2):107-113.
Murray HB et al. Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Adult Neurogastroenterology Patients. Clin Gastroenterol Hepatol. 2020;18(9):1995-2002.