Clinicians' Corner / Research Updates

ARFID: What have we learned?

Avoidant/Restrictive Food Intake Disorder, more commonly referred to as ARFID, was added to the Feeding and Eating Disorders section of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013.  As the name suggests, the hallmark feature of this disorder is highly restrictive eating, with associated medical problems or social difficulties. ARFID is a reformulation of a disorder that in previous editions of the DSM was called feeding disorder of infancy and early childhood. In DSM-5, the age-of-onset feature was removed as a diagnostic criterion, in acknowledgment that people of all ages can have significant avoidant or restrictive eating and that this does not always start in childhood. To learn more about the basics of ARFID, click here.

The addition of a diagnosis, or diagnostic formulation, into DSM heralds a new phase in the research agenda of the disorder. Seven years after its introduction into the category of eating disorders, here’s where the field is at:

Who gets ARFID?

ARFID is not the same as picky eating (Give a listen to this podcast for a better understanding of what this problem looks like in action.). Although about 25% of children and adolescents experience feeding or eating problems, ARFID is different from picky eating because of its severity and persistence. While the group of those affected appears to be rather heterogeneous, early reports suggest that these patients are more likely to be younger, male, and have other psychiatric or medical conditions compared to individuals with other kinds of eating disorders.  Many individuals diagnosed with ARFID have also been diagnosed with autism spectrum disorder, oppositional defiant disorder, or attention deficit/hyperactivity disorder.  Unfortunately, we don’t yet have much data on prevalence.  A study in a gastroenterology clinic with children between the ages of 8 and 18 years old estimated the prevalence to be 1.5%.  In North American pediatric tertiary care eating disorder programs the prevalence of ARFID is estimated to be between 5 and 14%, and in day treatment programs for eating disorders, the prevalence is estimated to be 23%.  This question becomes even more complicated when you add adults to the mix since most studies on ARFID have only included youth samples.

Is the restrictive eating behavior of ARFID comparable to anorexia nervosa?

Individuals with ARFID do not by diagnostic definition experience a fear of fat or weight gain, or body image distress. Yet, they are eating restrictively. The field has wondered if and how eating behavior differs between these diagnostic groups. It is now clear that the foods preferred by individuals with ARFID tend to be processed, energy-dense, high-fat, and high-carbohydrate. Food restriction or avoidance is often guided by principles related to color or texture, or due to lack of interest in food and eating, rather than macronutrient content. Compared to people with anorexia nervosa, those with ARFID consume a daily diet with a significantly lower ratio of protein (Presentation by Izquierdo, Thomas, Mancuso, et al. at the 2017 conference of the Eating Disorders Research Society).

What kind of treatment is recommended based on available data?

Because ARFID is broad in its scope, there are various manifestations of this disorder that might warrant diverse treatment approaches.  Outpatient treatments include cognitive-behavioral therapy (CBT) and family-based treatment (FBT).

  • CBT for ARFID focuses on providing education on the diagnosis, normalizing eating by increasing intake and variety, identifying the thoughts that maintain the patient’s avoidant/restrictive eating behavior and addressing the thoughts and behaviors through food exposures and behavioral experiments. This model assumes some individuals are predisposed to sensory sensitivity and/or fear aversive consequences such as choking or vomiting. CBT for ARFID is a 20-30 session intervention currently being studied in individuals ages 10 and older and a clinician treatment manual is available.
  • FBT for ARFID is similar to FBT for anorexia nervosa (read more about FBT here). The difference is that parents are asked to increase diet variety with repeated exposure to feared food and avoid making accommodations related to eating behavior they’ve likely been making for years.  Currently, clinical trials to study the effectiveness of FBT for ARFID are underway. Case studies suggest that the main principles of FBT are applicable for a range of clinical presentations of ARFID.

For low-weight children and adolescents with medical instability, hospital-based refeeding programs may be helpful.  There are no medications currently indicated for the treatment of ARFID.

What additional research questions are people asking?

The Eating Disorders Clinical and Research Program at Mass General Hospital is working to understand the hormones and areas of the brain involved in emotion, fear and sensory processing for individuals with ARFID.  The Eating Disorder Research Laboratory at Duke Psychiatry and Behavioral Sciences is conducting an online survey for children and adults to better understand the range of eating problems and behaviors.

Where to seek help:

If you are looking for help for yourself or someone else, consider the following referral resources:

As always, you can contact us with referral questions at 646-774-8066 or email us at edru@nyspi.columbia.edu.

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