Rural, Regional, Remote Residence, Anxiolytic Use, Multiple Site Surgery, Smoking Status Associated With Patient-Initiated Communication After Mohs Micrographic Surgery.

Restrictive eating is a defining symptom of both anorexia nervosa (AN) and avoidant/restrictive food intake disorder (ARFID) (). Although lesser known, restrictive eating is also a core symptom of pediatric acute-onset neuropsychiatric syndrome (PANS), a post-infectious autoimmune neuropsychiatric disease characterized by the sudden onset or relapse of obsessive-compulsive disorder (OCD) and/or restrictive eating (). Youth with PANS present with a range of neuropsychiatric syndromes, including anxiety, emotional lability or depression, irritability/oppositional behavior, behavioral/developmental regression, deterioration of school or cognitive skills, sensory or motor abnormalities (e.g., tics), and somatic symptoms (e.g., sleep disruption, urinary symptoms; ; ; ; ; ). While the restrictive eating behavior may present similarly in PANS and eating disorders, PANS is often linked to immunological or inflammatory conditions, such as H1N1 influenza, Epstein Barr virus, and Borrelia burgdorferi (Lyme) disease. However, the PANS diagnosis is agnostic to infections due to the challenge of identifying a causal relationship between symptoms and specific infections (; ; ; ). To date, only three studies have reported the prevalence of PANS within an eating disorders sample (; ; ) and only one study has specifically reported on ARFID (). PANS represents a clinical syndrome that is an expansion of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Both PANS/PANDAS symptoms may follow a relapsing and remitting course, marked by “flare” periods where symptoms dramatically worsen for approximately 3–4 months (). While PANDAS initially focused only on the abrupt onset of OCD and/or tics, clinical observations of the acute onset of restrictive eating behaviors promoted the inclusion of restrictive eating in PANS (). For example, several cases of children with PANS/PANDAS have described restrictive eating motivated by concerns of being overweight (), sensory sensitivity (), and fear of aversive consequences — such as fears of choking (; ; ), contamination (; ), vomiting (), or allergic reaction (). Although some cases involved co-occurring or subsequent body image concerns aligning more closely with AN, many have primarily described avoidant/restrictive eating behaviors (), highlighting the potential overlap between PANS/PANDAS and ARFID (). Notably, in the study examining PANS/PANDAS diagnoses among youth with eating disorders, only 23% ( = 23) were diagnosed with ARFID, with no detailed information on ARFID presentations available. Among the individuals with ARFID, 43% ( = 10) received a PANS diagnosis, with no PANDAS cases reported (). ARFID is an eating disorder characterized by extreme food avoidance due to sensory sensitivity, a lack of interest in food, and/or fear of aversive consequences that may occur with eating (). The presentation of ARFID is heterogeneous, fitting a dimensional model, whereas individuals show heterogeneity in both symptom severity and profiles (). OCD, encompassing the core symptoms of PANS/PANDAS, is often comorbid with ARFID, with suggested rates of comorbidity from 3% to 20% (; ; ; ; ). Specifically, greater severity in the sensory sensitivity or the fear of aversive consequences profiles of ARFID is uniquely associated with up to triple the odds of OCD and related disorders (). Although studies supported the association between ARFID and OCD (; ; ; ;), no study has investigated the associations between ARFID profiles and OC severity, which may highlight important insights into the nuances of ARFID presentations and inform more targeted interventions.