Avoidant/Restrictive Food Intake Disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is an eating or feeding disturbance associated with an apparent lack of interest in eating or food. 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.

Figure 1. Someone with ARFID may avoid eggplant altogether because of its color.

People with avoidant/restrictive food intake disorder (ARFID) have an inability to eat certain foods. “Safe” foods may be limited to certain food types and even specific brands. In some cases, individuals with the condition 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 people with avoidant/restrictive food intake disorder (ARFID) will still maintain a healthy or typical 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. Most, however, would change their eating habits if they could.

In a research study of children and adolescents who were receiving treatments for an eating disorder at a clinic, 14% of the patients met the criteria for AFRID and were more likely to be younger and male.^[1]

Diagnosis

The DSM-5 defines the following diagnostic criteria for avoidant/restrictive food intake disorder (ARFID):

• disturbance in eating or feeding, as evidenced by one or more of the following:
  • 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 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

Associated Conditions

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 conditions that co-occur with ARFID.

There are different kinds of sub-categories identified for ARFID:

• sensory-based avoidance, where the individual refuses food intake based on smell, texture, color, brand, presentation
• a lack of interest in consuming the food, or tolerating it nearby
• food associated with fear-evoking stimuli that have developed through a learned history
• anorexia and bulimia co-occurring in individuals suffering from ARFID

Autism

Symptoms of ARFID are usually found with symptoms of other disorders or with neurodivergence. Some form of feeding disorder is found in 80% of children that also have a developmental disability. Children often exhibit symptoms of obsessive-compulsive disorder and autism. Although many people with 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 are on the autistic spectrum.

A study done by Schreck at Pennsylvania State University compared the eating habits of children with autism spectrum disorder (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.

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 have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar. Nearly half of the children with an AFRID diagnosis report emetophobia (i.e., fear of vomiting),^[2] and others may report a fear of choking.

Treating ARFID

Figure 2. ARFID often involves certain foods due to sensory concerns, and a common treatment method includes systematic desensitization and gradual exposure to the types of foods that have been avoided. It is also helpful to identify concerns and review the progress.

For Adults

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 CBT. Working with a clinician can help to change behaviors more quickly than symptoms may typically disappear without treatment.

For Children

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.^[3]

• 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 someday. 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 storyline 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.