Understanding ARFID: A Guide about this Newer Eating Disorder

Do you ever wonder if your child’s picky eating habits are more than just intense food likes and dislikes? Are you worried that they could be causing harm to your child’s health? If so, then you may want to familiarize yourself a bit with a relatively new diagnosis. Avoidant restrictive food intake disorder, or ARFID, was introduced in 2013 with the publication of DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition).

What is ARFID?

The diagnosis applies to individuals who experience a disturbance in eating that is restrictive in nature. Restriction might be related to a lack of interest in eating, or involve avoiding certain foods altogether because of texture or color, or due to worry about a consequence of eating. The pattern impacts nutrition and overall physical health. Intake deficits may result in:

• significant weight problems (either losing weight or not being able to gain enough weight for normal development),
• nutritional deficiencies that can lead to dependence on feeding tubes or nutritional supplements,
• or interference with day-to-day functioning, such as the ability to socialize.

Why was this diagnosis added in 2013?

The purpose of the DSM is to provide clinicians with a useful tool to diagnose and treat mental disorders. When additions or changes in the text are made, it is with the intention that the manual becomes more helpful. The addition of ARFID to the Feeding and Eating Disorders section is a perfect example of this. It gives clinicians a framework with which to more accurately capture a cluster of meaningful symptoms.

Using the DSM-IV, if a patient presented with the symptoms described by ARFID, that person may have been diagnosed with “Eating Disorder, Not Otherwise Specified” (EDNOS) or “Feeding Disorder of Infancy or Early Childhood.”

EDNOS did describe a disturbance with eating. But it was a catchall category that could not offer much guidance in terms of treatment or prognosis. One study found that 62.4% of youth with eating disorders were diagnosed with EDNOS using the DSM-IV, despite having very different clinical presentations. Feeding Disorder of Infancy or Early Childhood, on the other hand, was infrequently used. This may have been because the criteria required the onset to be before the age of six. With the most recent DSM updates, this diagnosis was eliminated altogether.

ARFID “in action”

Research is underway to better understand the snapshot of ARFID. For now, the key feature of this disorder involves an eating problem resulting in weight loss (or failure to make expected weight gains) or nutritional issues, and interfering with social-developmental milestones. For a young child, this might mean difficulty eating a snack at a friend’s house on play dates. For an adolescent, it might mean struggling with eating out with friends or when traveling away from the familiar foods at home.

Unlike some other eating disorders, people with ARFID are not particularly “off” in how they perceive their body size. They do not fear their weight or body shape changing. Appearance is basically not a factor motivating the eating behavior. In fact, it may be part of what motivates these individuals to seek treatment (e.g., wanting to gain weight)!

The eating problems seen in ARFID stem from other factors, such as:

• aversions to certain food groups or textures,
• lack of appetite,
• preferences for only specific colors of foods, or
• fears of vomiting or choking.

Overlapping and Distinct Problems

Some factors listed above are associated with other conditions – like autism spectrum disorder, a specific phobia of vomiting, or food allergies. An additional diagnosis of ARFID is given only if the eating behavior leads to significant problems and requires specialized treatment.

There are other problems related to eating that would not qualify as ARFID. A child growing up in poverty who is not eating because he does not have adequate access to food would not be considered to have ARFID, even if his eating pattern has consequences on nutrition or growth. Someone who strictly avoids certain foods or fasts because of religious or cultural beliefs would not be diagnosed with ARFID.

Who is most commonly diagnosed with ARFID?

Since the term was coined in 2013, researchers have been studying who is diagnosed with ARFID. When a multi-site retrospective study considered the profiles of 712 patients previously seen in adolescent-medicine eating disorder programs, 98 patients (13.8%) met DSM-V criteria for ARFID. Comparing these individuals to those who met for anorexia nervosa or bulimia nervosa, patients with ARFID were younger (12.9 years old on average). A greater proportion were male (29%) than in other eating disorder groups (anorexia nervosa – 15%; bulimia nervosa – 6%). People with ARFID had higher incidences of co-occurring anxiety and medical conditions. Yet, they had lower incidences of mood disorders than those with anorexia or bulimia nervosa.

Looking Forward: Diagnosing and Treating ARFID

In a survey of 2,490 Canadian pediatricians, 63% of respondents were unfamiliar with ARFID. Of those who suspected that a prior patient had ARFID, 30% misdiagnosed that patient. These statistics highlight why continuing education is critical. Reports suggest that a diagnosis of ARFID confers a degree of potential medical danger akin to other feeding and eating disorders. For patients requiring hospitalization, one study found that those with ARFID required longer hospital stays and more tube feeding than patients with anorexia nervosa.

Research is underway to explore the course of illness and effective treatments. Some clinicians have wondered if ARFID puts individuals at a greater risk of subsequently developing anorexia or bulimia nervosa, but there is no conclusive data available about this yet.

Psychotherapy treatments emphasize behavioral approaches. This includes interventions exposing patients to specific sensations or foods associated with restrictive eating, to enable nutritional rehabilitation and medical stabilization. To date, no medication trials have been done in this population.

Latest Findings in the First Decade of ARFID

For a research update, check out our summary of what’s been learned since the introduction of this diagnosis into the feeding and eating disorders section of the DSM.

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