The New Diagnosis: Avoidant or Restrictive Food Intake Disorder (ARFID) and Management
Avoidant or Restrictive Food Intake Disorder (ARFID) (also known as Selective Eating Disorder (SED)) is an eating disorder that prevents the consumption of certain foods. It is often viewed as a phase of childhood that is generally overcome with age. Some people may not grow out of the disorder, however, and may continue to be afflicted with ARFID throughout their adult lives.
ARFID was introduced as a new diagnostic category in the recently published DSM-V. The ARFID diagnosis describes individuals whose symptoms do not match the criteria for traditional eating disorder diagnoses, but who, nonetheless, experience clinically significant struggles with eating and food. Symptoms of ARFID typically show up in infancy or childhood, but they may also present or persist into adulthood.
Individuals who meet the criteria for ARFID have developed some type of problem with eating (or for very young children, a problem with feeding). As a result of the eating problem, the person isn’t able to take in adequate calories or nutrition through their diet. There are many types of eating problems that might warrant an ARFID diagnosis – difficulty digesting certain foods, avoiding certain colors or textures of food, eating only very small portions, having no appetite, or being afraid to eat after a frightening episode of choking or vomiting.
Because the person with ARFID isn’t able to get enough nutrition through their diet, they may end up losing weight. Or, younger kids with ARFID might not lose weight, but rather may not gain weight or grow as expected. Other people might need supplements to get adequate nutrition and calories. And most of all, individuals with ARFID may have problems at school or work because of their eating problems – such as avoiding work lunches, not getting schoolwork done because of the time it takes to eat, or even avoiding seeing friends or family at social events where food is present. It is possible that some individuals with ARFID may go on to develop another eating disorder such as anorexia or bulimia.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) renamed “Feeding Disorder of Infancy or Early Childhood” to Avoidant/Restrictive Food Intake Disorder, and broadened the diagnostic criteria. Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.
The DSM-5 defines the following diagnostic criteria:
- An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
- Significant nutritional deficiency.
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced [body image].
4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
- Disturbance in eating or feeding, as evidenced by one or more of:
- Substantial weight loss (or, in children, absence of expected weight gain)
- Nutritional deficiency
- Dependence on a feeding tube or dietary supplements
- Significant psychosocial interference
- Disturbance not due to unavailability of food, or to observation of cultural norms
- Disturbance not due to anorexia nervosa or bulimia nervosa, and no evidence of disturbance in experience of body shape or weight
- Disturbance not better explained by another medical condition or mental disorder, or when occurring concurrently with another condition, the disturbance exceeds what is normally caused by that condition
- Sufferers of ARFID have an inability to eat certain foods based on texture or aroma. “Safe” foods may be limited to certain food types and even specific brands. In some cases, afflicted individuals will exclude whole food groups, such as fruits or vegetables. Sometimes excluded foods can be refused based on color. Some may only like very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods, or avoid sauces.
- Most sufferers of ARFID will still maintain a healthy or normal body weight. There are no specific outward appearances associated with ARFID. Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting or gagging. Some studies have identified symptoms of social avoidance due to their eating habits. However, most do not desire to change their eating behaviors.
Comorbidity The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed other mental disorders that are comorbid with ARFID.
- ARFID and Autism Symptoms of ARFID are usually found with symptoms of other disorders. Some form of feeding disorder is found in 80% of children that also have a developmental handicap. Children often exhibit symptoms of obsessive-compulsive disorder and autism. Although many suffers of ARFID have symptoms of these disorders, they usually do not qualify for a full diagnosis. Strict behavior patterns and difficulty adjusting to new things are common symptoms in patients that suffer from some degree of autism spectrum disorder. A study done by Schreck at Pennsylvania State University compared the eating habits of children with ASD and typically developing children. After analyzing their eating patterns they suggested that the children with some degree of ASD have a higher degree of selective eating. These children were found to have similar patterns of selective eating and favored more energy dense foods such as nuts and whole grains. Eating a diet of energy dense foods could put these children at a greater risk for health problems such as obesity and other chronic diseases due to the high fat and low fiber content of energy dense foods. Due to the tie to ASD, children are less likely to outgrow their selective eating behaviors and most likely should meet with a clinician to address their eating issues.
- ARFID as an anxiety disorder Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who suffer from ARFID do not have this fear, but the psychological symptoms and anxiety created is similar.
Although ARFID is being presented as a new diagnosis, it might be more useful to simply consider it as a way of describing symptoms more specifically. A lot of patients with eating disorders don’t “fit” perfectly into a diagnosis of anorexia nervosa or bulimia nervosa – and so, prior to the release of the DSM-V, clinicians would often give those folks the diagnosis of Eating Disorder, Not Otherwise Specified (EDNOS). Unfortunately, if you say that someone has EDNOS, it doesn’t really give us much information about the person’s symptoms, other than that they have some kind of eating disorder.
In the past, before the DSM-V, kids with ARFID might have been diagnosed with EDNOS. They also could have been given another diagnosis called “Feeding Disorder of Infancy or Early Childhood” (although most clinicians didn’t use that diagnosis especially since one of its requirements was that the age of onset has to be before age six). But what about those kids or adults who have restrictive eating not related to fear of weight gain, who may or may not be a normal weight, and whose lives are severely impacted by their symptoms? This is where ARFID can fill in the gaps and help us to better understand those individuals.
As ARFID is officially still a new diagnostic category, there is little data available on its development, disease course, or prognosis. We do know that symptoms typically present in infancy or childhood, but they may also present or persist into adulthood. It is possible that some individuals with ARFID may go on to develop another eating disorder, such as anorexia nervosa or bulimia nervosa, but again, no research is available yet to give a clear picture of what happens down the road for these individuals. We also are still learning about effective treatments for individuals with ARFID. Although research is just beginning, we believe that behavioral interventions, such as forms of exposure therapy, may be useful. And of course, as in other eating disorders like anorexia or bulimia, treatment of underlying conditions such as anxiety or depression is crucial.
Many kids develop different or strange patterns of eating at some point in their life – refusing to eat vegetables for a few months, or wanting to eat only chicken nuggets for dinner – but for most individuals, those patterns eventually resolve on their own without intervention. For the small subset of individuals who have persistent or worsening problems with food intake, however, the introduction of ARFID means we are now able to better diagnose and describe their symptoms, which should ultimately result in better clinical outcomes.
- With time the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than symptoms may typically disappear without treatment.
- Children can benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment are record, reward, relax and review.
- In the record stage, children are encouraged to keep a log of their typical eating behaviors without attempting to change their habits as well as their cognitive feelings.
The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Often these stories can also include the introduction of new foods with the help of a real person or fantasy person. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.
The final stage, review, is important to keep track of the child’s progress. It is important to include both one-on-one sessions with the child, as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.
- There are picky eating support groups for adults with ARFID
- Wang, S. (2010, July 5). No Age Limit on Picky Eating. Wall Street Journal. Retrieved April 2, 2013, from http://online.wsj.com/article/SB10001424052748704699604575343130457388718.html
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.
- Kenney L, Walsh B. Avoidant/Restrictive Food Intake Disorder (ARFID) – Defining ARFID. Eating Disorders Review, Gurze Books, 2013; Vol 24, Issue 3.
- American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5. Retrieved May 14, 2014, from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
- Nicholls, D., Christie, D., Randall, L. and Lask, B.. (2001). “Selective Eating: Symptom, Disorder or Normal Variant.” Clinical Child Psychology and Psychiatry. Vol 6(2): 257-270.
- Chatoor,I., Hamburger, E., Fullard, R., & Fivera, Y. (1994). A survey of picky eating and pica behaviors in toddlers. Scientific Proceedings of the Annual Meeting of American Academy of Child and Adolescent Psychiatry, 10′, 50.
- Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without Autism. Journal of Autism and Developmental Disabilities. 2004; 34: 433-438.
- Evans, E. (2013). Selective Eating and Autism Spectrum Disorder. In Behavioral Health Nutrition. Retrieved April 2, 2013, from http://www.bhndpg.org/students/selective.asp
- The Center for Eating Disorders. What is ARFID? http://eatingdisorder.org/blog/2013/08/what-is-arfid/
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