2026 ECNP Congress

EP01-1039

Avoidant/restrictive food intake disorder after single anastomosis sleeve ileal bypass: a case report

Candost Demiröz — N. Zengin, E. Tatlıdil · Kocaeli University Faculty of Medicine, Psychiatry Department, Kocaeli, Türkiye

2026 ECNP Congress

Background

Avoidant/restrictive food intake disorder (ARFID) was introduced in DSM-5 and is occasionally reported in adults, but the post-bariatric phenotype is poorly described. Cass et al. described an adult case after Roux-en-Y gastric bypass [1]. Rigby reported a similar presentation in a bariatric patient who did not meet ARFID criteria because of self-induced vomiting [2]. A separate case after single anastomosis sleeve jejunal bypass was managed as post-operative food refusal without a formal eating disorder diagnosis [3]. The single anastomosis sleeve ileal bypass (SASI) is a different metabolic procedure that combines restrictive and malabsorptive components, but its psychiatric sequelae have attracted little attention.

Aims

We describe the clinical course, diagnostic process and treatment response in an adult male who developed ARFID, fear of aversive consequences subtype, after SASI.

Methods

The patient was assessed across three psychiatric consultations during recurrent admissions for malnutrition and outpatient follow-up. Assessment followed DSM-5-TR criteria and used the Nine Item ARFID Screen (NIAS) and the Generalised Anxiety Disorder 7-item scale (GAD-7). Albumin, electrolytes and weight were monitored. NIAS and GAD-7 were repeated at three-month follow-up to assess symptom change. Written informed consent for publication was obtained. No statistical analysis was performed.

Results

A 55-year-old male underwent laparoscopic SASI for morbid obesity in December 2024. Recovery was uneventful and he ate normally for nine months. Symptoms began during a period of acute psychosocial stress, while he was the primary caregiver for his father, who was undergoing cardiac procedures. Appetite loss came first, then intermittent vomiting after small meals. He lost 20 to 25 kg over three months. Albumin fell from 30.9 to 19.4 g/L, with peripheral oedema, hyponatraemia and prerenal acute kidney injury. Three admissions followed.

Upper endoscopy showed a patent anastomosis without stricture; abdominal imaging and biopsy were unremarkable. At the third structured psychiatric assessment the patient described anticipatory thoughts that even small intake, or eating quickly, would make him vomit. He denied weight or shape concerns, self-induced vomiting, calorie counting or other compensatory behaviours. NIAS was 23 and GAD-7 was 15. DSM-5-TR criteria for ARFID, fear of aversive consequences subtype, were met[4].

Mirtazapine was started at 7.5 mg/day and titrated to 15 mg/day. Brief cognitive–behavioural psychoeducation addressed catastrophic post-prandial cognitions, and a time-anchored small-portion feeding schedule was introduced. Nutritional support continued in parallel. At three-month follow-up he was euthymic, sleeping normally, eating without anticipatory anxiety and functionally restored. NIAS had decreased from 23 to 10, with the fear subscale falling below the validated cut-off, and GAD-7 had decreased from 15 to 5.

Conclusions

The nine-month asymptomatic interval suggests gradual conditioning between eating and aversive somatic signals, with the acute stress period acting as a final precipitant via heightened negative valence processing [5]. The absence of weight and shape overvaluation distinguishes this presentation from atypical anorexia nervosa, which can also occur after rapid post-bariatric weight loss. Mirtazapine, a serotonin and norepinephrine receptor antagonist with orexigenic, anxiolytic and antiemetic effects, combined with brief cognitive–behavioural work, was followed by sustained recovery. NIAS may help identify ARFID in post-bariatric follow-up, where weight and shape concerns are absent.

References

  1. Cass, K., Leggett, A., Gibson, D.G., 2025. Diagnostic dilemma of avoidant/restrictive food intake disorder after bariatric surgery: a case report and review of literature. World J. Clin. Cases 13 (24), 106941.
  2. Rigby, A., 2018. Transdiagnostic approach to food avoidance after bariatric surgery: a case study. Clin. Case Stud. 17 (5), 280–295.
  3. Mirhashemi, S.H., Jam, S., Omidvari, S., Samadi, Y., Shishvan, S., Hakakzadeh, A., 2022. Case report of multidisciplinary approach to post single anastomosis sleeve jejunal bypass (SASJ) surgery refusal to eat. Int. J. Surg. Case Rep. 99, 107702.
  4. American Psychiatric Association, 2022. Diagnostic and Statistical Manual of Mental Disorders, fifth ed., text revision. American Psychiatric Association Publishing, Washington.
  5. Thomas, J.J., Lawson, E.A., Micali, N., Misra, M., Deckersbach, T., Eddy, K.T., 2017. Avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. Curr. Psychiatry Rep. 19 (8), 54.