(115) Failure to Thrive and Malnutrition in an Adult with OCD: An Inpatient Multidisciplinary Approach to Management of Co-morbid ARFID in the General Hospital

Background/Significance:
Avoidant-restrictive food-intake disorder (ARFID) is a diagnosis introduced in the fifth edition of the Diagnostic and Statistical manual (DSM-5) that extended the DSM-IV diagnosis of feeding disorder in infancy or early childhood through adulthood. ARFID patients have higher psychiatric and medical illness co-morbidity compared to anorexia nervosa (Norris, 2014), resulting in diagnostic and management challenges for the consultation-liaison psychiatrist (CLP). We present a case of ARFID with multiple co-morbidities and suggestions for diagnosis and management.

Case:
A 52-year-old woman was admitted after a fall at home and was found to have severe malnutrition and deconditioning. She was couch-bound for years and dependent on her elderly mother. Admission BMI was 9.55, and labs revealed vitamin D and C deficiencies, hypoalbuminemia, and anemia. Psychiatry was consulted for diagnosis, decision-making capacity, and discharge planning. She endorsed childhood-onset OCD, expressed desire for healthy weight, and denied concerns for body image, depressive or psychotic symptoms. SLUMS neurocognitive screen was negative. She endorsed limited nutrition intake attributed to OCD. She repeatedly declined a feeding tube but eventually consented. She agreed to fluoxetine titration to 80mg daily. Despite this plan, hospitalization was markedly prolonged with weight fluctuations and impaired engagement in therapies. Persistence of rituals and somatic complaints inhibited eating. Her diagnosis was challenging due to disordered eating in the context of OCD and obsessive-compulsive personality disorder (OCPD) traits, with further discovery highlighting eating rituals, yet she was also found to meet criteria for ARFID. This led to a multidisciplinary restructuring of the eating disorder protocol and a patient-centered psychotherapeutic approach with psychology, physical, and occupational therapy support to target compulsions exacerbated by strict adherence to the standard protocol. This approach resulted in reaching nearly 75% of ideal body weight and discharge home after 100 days to follow up with outpatient behavioral health.

Discussion:
This case illustrates the diagnostic and treatment planning challenges the CLP faces in the hospital for patients with severe malnutrition and disordered eating. There were multiple diagnostic considerations of OCD, OCPD, neuropsychiatric effects of malnutrition and vitamin C deficiency, anorexia, and bulimia. The patient met criteria for adult ARFID (Nakai 2016). Patient age and focus on OCD presentation deterred identification of ARFID. Clarification of ARFID separate from OCD enabled a more effective approach to care and weight restoration, which included cognitive-behavioral therapy (CBT) interventions.

Conclusion:
Food avoidance and medical complications of malnutrition can be secondary to both the compulsive rituals of OCD and the eating-related somatic fears associated with ARFID. Hospital management of ARFID with OCD may benefit from a combination of a targeted eating disorder protocol and a multidisciplinary CBT approach.

References:
Nakai, Y. et al.: Characteristics of Avoidant/Restrictive Food Intake Disorder in a Cohort of Adult Patients. Eur Eat. Disorders Rev. 2016; 24: 528-530

Norris ML et al.: Exploring Avoidant/Restrictive Food Intake Disorder in Eating Disordered Patients: A Descriptive Study. Int J Eat Disord 2014; 47: 495-499