Avoidant/Restrictive Food Intake Disorder

What is Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder (ARFID) is characterised by persistent food avoidance and a diet so restrictive and nutritionally inadequate that it causes clinically significant medical and/or psychosocial decline. The diagnosis was introduced to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (1) in 2013, as a reformulation of a previous disorder called ‘feeding disorder of infancy and early childhood’, which was diagnosed in children of 6 years of age and under who exhibited extreme feeding and eating difficulties (2). 

 

While a harmless and developmentally appropriate kind of ‘picky eating’ is common in young children, the restrictive eating behaviours seen in ARFID are more persistent, severe, and lead to medical and psychosocial disturbances. Childhood picky eating tends to naturally subside with age, while ARFID worsens and becomes more ingrained throughout childhood and adolescence when left untreated (3). A 2015 study reported that 46% of the population of young children struggle with 

typical picky eating (5), while only 14-15% struggle with extreme picky eating (6). 

Does it only affect children? 

No. Research has found ARFID to be most common amongst younger age-groups and males (3), however it is not limited to these populations, and it does occur across all age groups and genders. Many cases have their roots in childhood, while other cases emerge for the first time in late adolescence or adulthood. These cases tend to be ignited by unexpected, negative experiences with food. 

It is not Anorexia. 

ARFID has a lot in common with anorexia nervosa; it involves food avoidance, restrictive eating behaviours, nutritional and medical instability, starvation syndrome, unhealthy weight loss and low body weight. However, the two conditions are not the same. The restrictive eating that happens in ARFID does not happen because of appearance or body image concerns. Instead, people with ARFID avoid food for the following reasons: 

  1.  Avoidance based on the sensory characteristics of food (sensory sensitivity),
    People who have sensory sensitivity are likely to experience non-preferred foods as intensely negative. Sensory research has found that children and adults who are described as ‘fussy eaters’ consistently rate bitter and sweet solutions as significantly more intense than others do and are more likely to be classified as ‘supertasters’ (9, 10). 
     

  2. Apparent lack of interest in eating or food (lack of appetite),​Research is continuing in this area. So far, links have been found between brain reactions to under-nourishment and subsequent appetite decreases (11).  
     

  3. Concern about aversive consequences of eating (fear of choking or vomiting).​People struggling with this barrier to eating have typically experienced a traumatic experience involving choking, vomiting, or abdominal pain after eating, and have developed an intense fear of certain foods as a reaction to this. While most people experience adverse consequences after eating at some point in their lives, not everyone will go on to develop ARFID. Ongoing research is looking further into the relationship between ARFID and individual differences in neurobiological threat responses (12). 

Current research suggests that the above presentations of ARFID are not mutually exclusive, and that nearly half of all individuals with the disorder experience difficulties in eating across multiple domains (7, 8). 

Diagnosis: 

A diagnosis of ARFID is given when a person has an eating or feeding disturbance due to sensory sensitivity, low appetite and/or intense anxiety. They will also show persistent failure to adequately meet their nutritional and/or energy needs, which will be made evident by one or more of the following:

 

1.Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 

2.Significant nutritional deficiency. 

3.Dependence on enteral feeding or oral nutritional supplements. 

4.Marked interference with psychosocial functioning. 
 

A diagnosis of ARFID can only be given when the eating disturbance: 

  • Is not better explained by a lack of access to food or culturally sanctioned practices, 

  • Does not occur exclusively in the context of another eating disorder, such as anorexia nervosa or bulimia nervosa, 

  • Does not involve any disturbance in the way the individual’s body weight or shape are experienced, and 

  • Is not attributable to a concurrent medical condition or better explained by another mental disorder – unless the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention (1).​

To be diagnosed with ARFID, an individual will need to be assessed by a trained mental health professional and a medical professional who can confirm that the diagnostic criteria laid out in the DSM-5 have been met. 

 

Symptoms and Causes

As with most eating disorders, the symptoms of ARFID can manifest behaviourally, psychologically and/or physically. They might not always be noticeable, and some may overlap with the symptoms of other conditions. Here are some warning signs to look out for (13): 
 

Behavioural:

  • Lack of interest in food and/or eating 

  • Refusal to eat or a reduction in foods previously eaten 

  • Slow eating 

  • Stating a fear of choking or eating certain foods 

  • Fear of vomiting certain foods 

  • Difficulty eating meals with others 

  • Only eating a small number of foods. These foods may be similar in taste, texture, smell or sight. 
     

Psychological:

  • Anxiety and/or distress around food and mealtimes 

  • Difficulty concentrating or learning 

Physical:

  • Delayed growth 

  • Weight loss 

  • In children, a failure to gain weight 

  • Reduced appetite 

  • Brittle nails, dry hair, hair loss 

  • Tiredness or lack of energy 

  • Other symptoms of micronutrient deficiencies

There is no single known cause for ARFID, however research has linked the condition with autism, anxiety disorders and ADHD (7). Ongoing research is looking more closely at these links. 

 

Risks and complications (3, 13):

  • Dangerous weight loss 

  • Heart problems 

  • Osteoporosis 

  • Nutritional deficiencies including anaemia or iron deficiency, low vitamin A, low vitamin C 

  • Malnutrition characterised by fatigue, weakness, brittle nails, dry hair, hair loss, and difficulty concentrating, low energy 

  • Growth failure, failure to thrive, or stunted growth in children and adolescents 

  • Kidney and liver failure 

  • Electrolyte disturbances 

  • Low blood sugar 

  • Gastrointestinal problems 

  • Anaemia 

  • Low energy 

  • Weakness, Numbness and tingling of extremities 

  • Unsteadiness and trouble walking 

  • Constipation 

  • Anxiety 

  • Depression 

  • Social anxiety or social withdrawal 

  • Low self-esteem 

  • Poor memory 

  • Poor concentration 

  • Learning and cognitive difficulties 

  • Irritability 

  • Mood changes 

  • Psychosis 

  • Mouth/tongue discomfort 

  • Poor growth and development 

  • Weakened immune system 

  • Impaired night vision 

  • Taste and smell problems 

  • Hair loss 

  • Diarrhea 

  • Poor wound healing 

  • Fatigue/sleepiness 

  • Headaches 

  • Temperature intolerance 

  • Decreased exercise endurance 

  • Skin problems 

  • Cataracts 

  • Petechiae and easy bruising 

  • Bleeding and swollen gums 

  • Muscle and joint pain 

  • Corkscrew hair 

  • Perifollicular haemorrhage 

  • Hyperkeratosis 

  • Heart palpitations 

  • Shortness of breath 

  • Oral ulcerations 

  • Increased risk of birth defects 

  • Amenorrhea 

  • In extreme cases: death. 

Treatment 

Research into effective treatment options for ARFID are ongoing. As with all eating disorders, early recognition and treatment is crucial and gives the best chance at achieving full recovery. If you are concerned that you or someone you love may have ARFID, it is paramount that you seek professional support right away. 

Current evidence supports Cognitive Behaviour Therapy (CBT) and Responsive Feeding Therapy (RFT) - typically used with children - as effective treatments for ARFID, and there are no medicinal treatment recommendations so far. Most people can recover from an eating disorder with community-based treatment, and where the restriction causes severe medical complications, treatment in hospital is recommended. 
 

What to expect when you begin treatment with us: 

At Treat Yourself Well Sydney, we tailor our evidence-based treatment plans to the unique needs of each individual client, and we involve our clients in all decision-making related to  their treatment. We work within a wider treatment team, which typically includes a GP, dietitian, and a psychiatrist, which means that our clients are supported in every way 

possible. While we don’t offer family-based therapy, we do encourage family involvement where appropriate and particularly for our younger clients.  Our goal is to walk alongside you, supporting you on your pathway to recovery

References: 

1.American Psychiatric Association, American Psychiatric Association DSM-5 Task Force. Diagnostic and statistical manual of mental disorders : DSM-5. 5th ed. ed. Arlington, VA; 2013. 

2.American Psychiatric Association, American Psychiatric Association Task Force on DSM. Diagnostic and statistical manual of mental disorders : DSM-IV. 4th ed. ed. Washington, DC; 1994. 

3.Brigham KS, Manzo LD, Eddy KT, Thomas JJ. Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Curr Pediatr Rep. 2018 Jun;6(2):107-113. doi: 10.1007/s40124-018-0162-y. Epub 2018 Apr 16. PMID: 31134139; PMCID: PMC6534269. 

4.Fisher MM, Rosen DS, Ornstein RM, et al. Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5. J Adolesc Health.  2014;55(1):49-52. doi:10.1016/j.jadohealth.2013.11.013 

5.Cardona Cano S, Tiemeier H, Van Hoeken D, Tharner A, Jaddoe VW, Hofman A, Verhulst FC,  Hoek HW Int J Eat Disord. 2015 Sep; 48(6):570-9. 

6.Koomar, T., Thomas, T. R., Pottschmidt, N. R., Lutter, M., & Michaelson, J. J. (2021). Estimating the Prevalence and Genetic Risk Mechanisms of ARFID in a Large Autism Cohort. Frontiers in psychiatry, 12, 668297. https://doi.org/10.3389/fpsyt.2021.668297 

7.Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT. Avoidant/Restrictive Food Intake Disorder: a Three Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep 2017. August;19(8):54–017–0795–5. [PMC free article]  [PubMed] [Google Scholar] 

8.Pulumo R, Coniglio K, Lawson EA, Micali N, Asanza E, Eddy KT, Thomas JJ. DSM-5  Presentations of avoidant/restrictive food intake disorder: Are categories mutually exclusive or overlapping? Poster presentation at the Eating Disorders Research Society meeting, New York, NY; 2016. 

9.Kauer J, Pelchat ML, Rozin P, Zickgraf HF. Adult picky eating. Phenomenology, taste sensitivity, and psychological correlates. Appetite 2015. July 1;90:219–28. 

10.Golding J, Steer C, Emmett P, Bartoshuk LM, Horwood J, Smith GD. Associations between the ability to detect a bitter taste, dietary behavior, and growth. Annals of the New York Academy of Sciences 2009. July 1;1170(1):553–7. 

11.Holsen LM, Lawson EA, Blum J, Ko E, Makris N, Fazeli PK, Klibanski A, Goldstein JM. Food motivation circuitry hypoactivation related to hedonic and nonhedonic aspects of hunger and satiety in women with active anorexia nervosa and weight-restored women with  anorexia nervosa. Journal of psychiatry & neuroscience: JPN 2012. September 1;37(5):322. 

 12.Lang PJ, McTeague LM. The anxiety disorder spectrum: Fear imagery, physiological reactivity, and differential diagnosis. Anxiety, Stress, & Coping 2009. Jan 1;22(1):5–25. 

13.The National Eating Disorders Collaboration. Avoidant/restrictive food intake disorder (ARFID). https://nedc.com.au/eating-disorders/eating-disorders-explained/types/arfid/