Written by Joanne Tattersall
Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new eating disorder recognised around the globe, making it a less well-known disorder in the public domain. This does not mean it is any less dangerous or intrusive to the lives of individuals with ARFID and their families than more well-known eating disorders such as Anorexia Nervosa (AN) or Bulimia Nervosa (BN).
What is Avoidant Restrictive Food Intake Disorder (ARFID)?
When the DSM (Diagnostic Statistical Manual) was reviewed and the 5th version released, ARFID was recognised for the first time. The diagnostic criteria as stated in the DSM-5 is [1]:
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
ARFID can be diagnosed in absence of an additional mental health disorder and is not associated with lack of food availability or cultural practice.
Being a relatively new diagnosis, the exact prevalence of ARFID is unknown and understudied. It is, however, estimated to account for approximately 5-13% of patients in specialist psychiatric and medical settings [2].
A key difference between ARFID and some other eating disorders, such as AN, is that abnormal behaviours exist without a preoccupation with weight or body shape, or a disturbance in an individual’s perception of this.
What is the difference between fussy eating and ARFID?
Up to 59% of individuals experience fussy eating at some point during their childhood [3]. This is usually a stage of exploration, perhaps pushing their parents’ boundaries, as they learn more about food variety, and a stage which is outgrown. ARFID, however, is more extreme than a ‘phase’ and often requires specialist intervention to enable broadening of an individual’s diet. You can read more about fussy eating and tips to overcome it.
Can adults have ARFID?
‘Fussy eating’ is something frequently described during childhood however a diagnosis of ARFID can occur at any age. As it is commonly associated with younger people, adults themselves may not recognise their difficulties around food as an eating disorder, especially with stereotyping towards anorexia nervosa and the preoccupation with weight and body shape which is not a defining feature of ARFID. This can delay diagnosis and treatment of ARFID, or make it more complex to manage.
ARFID may be more likely to develop in adults who have a co-morbid physical illness, such as Inflammatory Bowel Disease, IBS or severe food allergies, due to associating foods with symptom onset and a fear accumulating around this. It is worth noting that lack of diagnosis, particularly in the adult population, has likely affected statistics and our understanding of ARFID in adults.
Warning signs for ARFID
Due to the complex nature of eating disorders, signs of ARFID can be both physical and psychological [4]. As both ARFID and AN frequently result in malnutrition through micro and/or macronutrient deficiency, the physical warning signs can be quite similar including:
Weight loss
Gastrointestinal symptoms (e.g. abdominal cramping, bloating, constipation)
Interrupted menstrual cycles
Development of fine hair covering the skin (known as lanugo)
Concentration difficulties
Dizziness and fainting
Electrolyte imbalances (e.g. low potassium)
Anaemia (low iron levels)
Muscle weakness
Brittle hair and nails
Behavioural changes may result from ARFID due to dealing with the anxiety, and potentially embarrassment, that may accompany the eating disorder, as well as to try to accommodate the needs of individuals with ARFID.
Restriction in type or quantity of food eaten
Eating and tolerating only specific textures of food
Lack of interest in food and eating
Disruption of mealtimes to delay eating
Taking longer than expected to eat a meal
Complaining of gastrointestinal symptoms in the lead up to or during mealtimes
Fear of choking or vomiting
Limited range of foods – may be specific to brand or packaging, colour or temperature
It has been identified that ARFID is seen more frequently in individuals with Autism Spectrum Disorder (ASD), learning disabilities and cognitive impairment [5]. If an individual does have a comorbid diagnosis such as this, treatment will be adapted to best suit them and their needs.
What is the treatment for ARFID?
As ARFID covers such a broad spectrum of behaviours and anxieties, treatment is very much tailored to the individual, taking into consideration age and comorbidities such as ASD. With the diagnosis of ARFID being so new, evidence-based treatment suitable for all ARFID presentations is still being researched and continuously evolving [6]. Therapy options may include:
Desensitisation therapy
Particularly helpful in younger children, systematic desensitisation is appropriate for individuals at any body mass index (BMI) [7]. Play can be used as the medium of exposure to new foods, with no pressure or expectation towards consumption of the food.
Cognitive Behavioural Therapy (CBT)
CBT is suitable in patients aged 10 years and older, ARFID-specific CBT (CBT-AR) is designed to take place in both family-supported and 1:1 settings. CBT-AR has 4 key stages that are progressed through, usually over 20-30 sessions, depending upon weight gain is an additional aim of treatment [6].
Eye Movement Desensitisation and Reprocessing Therapy (EMDR)
Frequently recommended for treatment of post-traumatic stress disorder (PTSD), EMDR works to reprocess negative images, bodily sensations, emotions and beliefs connected with traumatic memories [8]. EMDR is likely to be most effective in individuals whose ARFID onset is associated with such memories although it may be used in conjunction with additional talking therapy such as CBT [9].
As with all eating disorders, ARFID is complex and often develops over a relatively long time period; there is no quick fix to resolve the anxieties and behaviours that may have evolved. Due to the high risk of nutritional deficiency that accompanies ARFID, it is important that those affected seek nutrition support from a Registered Dietitian alongside the help of other health professionals such as an Occupational Therapist or Psychologist.
Joanne Tattersall, Registered Dietitian
Paediatric Specialist Dietitian
REFERENCES:
[1] Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Available at: Table 22, DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison - DSM-5 Changes - NCBI Bookshelf (nih.gov) [Accessed 8th July 2021]
[2] Spicer L, Strudwick K and Kelly V. Prevalance rates for avoidant restrictive food intake disorder (ARFID) in tertiary feeding clinic in UK. BMJ: Archives of Disease in Childhood. 2019. Available at: GP82 Prevalance rates for avoidant restrictive food intake disorder (ARFID) in tertitary feeding clinic in UK | Archives of Disease in Childhood (bmj.com) [Accessed 8th July 2021]
[3] Wolstenholme H et al. Childhood fussy/picky eating behaviours: a systematic review and synthesis of qualitative studies. International Journal of Behavioral Nutrition and Physical Activity. 2020; 17(2). Available at: Childhood fussy/picky eating behaviours: a systematic review and synthesis of qualitative studies | International Journal of Behavioral Nutrition and Physical Activity | Full Text (biomedcentral.com) [Accessed 30th April 2021]
[4] National Eating Disorders Association. Avoidant restrictive food intake disorder (ARFID). 2021. Available at: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid [Accessed 28th July 2021]
[5] Nicely TA, Lane-Loney S, Masciulli E, et al. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014;2(1):21. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145233/ [Accessed 28th July 2021]
[6] Thomas JJ, Wons O and Eddy K. Cognitive-Behavioral Treatment of Avoidant/Restrictive Food Intake Disorder. Current Opinion in Psychiatry. 2018; 31(6): 425–430. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235623/ [Accessed 6th September 2021]
[7] Thomas JJ, Lawson EA, Micali N et al. Avoidant/Restrictive Food Intake Disorder: A Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Current Psychiatry Reports. 2017; 19(8): 54. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281436/ [Accessed 6th September 2021]
[8] British Association for Counselling and Psychotherapy (BACP). What is EMDR? 2021. Available at: What is EMDR? | Types of therapy (bacp.co.uk) [Accessed 7th September 2021]
[9] Yasar AB et al., EMDR therapy on trauma-based restrictive eating cases. European Psychiatry. 2017. 1(S1):S560-S561. Available at: (PDF) EMDR therapy on trauma-based restrictive eating cases (researchgate.net) [Accessed 7th September 2021]
Talia Cecchele Nutrition is a team of registered dietitians specialising in eating disorders, disordered eating, gut health and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the UK or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.