Written by Kate Fisch, LCSW – AVP of Clinical Partnerships, Eating Disorder Network
Avoidant/restrictive food intake disorder (ARFID) is a relatively new addition to the family of eating disorder diagnoses, which may explain why it continues to be misdiagnosed or go undetected by medical and behavioral health providers. According to a 2021 study, 63% of pediatricians were unfamiliar with ARFID, which is concerning since preliminary estimates suggest that ARFID may affect up to 5% of children and over 6% of adults.Before ARFID was officially added to the diagnostic manual, its symptoms were listed under the label selective eating disorder. More commonly though, it was known just as “extreme picky eating”. But there’s a significant difference between a picky eater and ARFID in that the disorder markedly interferes with someone’s quality of life, physical health, and development.
Provided below is the full list of criteria professionals use to diagnosis ARFID:
- An eating or feeding disturbance such as a lack of interest in eating, avoidance based on sensory characteristics of food, and/or concern about aversive consequences of eating like choking or vomiting. This disturbance is demonstrated by a persistent failure to meet appropriate nutritional needs, causing:
- Significant weight loss (or failure to achieve expected weight gain/faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements
- Marked interference with psychosocial functioning
- This disturbance isn’t better explained by lack of available food
- This disturbance doesn’t occur during anorexia or bulimia and there’s no evidence of negative self-evaluation based on body shape/size
ARFID is currently categorized into three subtypes:
- Avoidant: As its name implies, this is a common type of ARFID. An individual struggling with this type of ARFID avoids certain types of food based on a negative or heightened sensory experience of the food. This might be based on texture of the food, the way the food smells, or even the color of the food.
- Aversive: Individuals in the aversive ARFID subtype have a fear of a negative consequence of ingesting food. This can include the fear of vomiting, choking, or abdominal pain, or having an allergic reaction to a food and might be based on traumatic experience related to the feared consequence.
- Restrictive: This type of ARFID is used to describe individuals who show little or no interest in food in general. These individuals may not experience hunger cues or lack an appetite leading to below normal food intake. They might also have extreme pickiness about what foods they are willing to eat which also results in limited caloric intake.
ARFID vs Other Eating Disorders
As mentioned above, an individual struggling with ARFID doesn’t typically express a negative self-evaluation of their body shape and size. This negative self-evaluation of body shape and size, along with a debilitating fear of weight gain is a fundamental criterion for a diagnosis of anorexia and other eating disorder types. Other differences between ARFID and other eating disorder diagnoses include:
- Those diagnosed with ARFID are typically younger than those with anorexia or bulimia
- Those diagnosed with ARFID have longer durations of illness than those with other types of eating disorders
- Children diagnosed with ARFID are more likely to be male
- Those diagnosed with ARFID are more likely to have a comorbid medical condition or anxiety disorder
- Those diagnosed with ARFID are more likely to have autism spectrum disorder (ASD)
These differences from other types of eating disorders are important to recognize because they make treatment for ARFID unique. Evidence-based therapies used to treat anorexia, bulimia, and associated disorders, including cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) are also used to treat ARFID. However, other types of interventions are needed as well.
For example, exposure and response prevention (ERP) therapy is an intervention designed to gradually expose a person to the specific stimuli that triggers the distressing behavior or thoughts around food. Someone diagnosed with avoidant type ARFID might avoid foods that have a soft or smooth texture, like pasta. Working with a licensed professional, this individual would very slowly make progress towards consuming the pasta without experiencing unwanted distress – a goal called habituation.
Ideally, treatment for ARFID begins with a visit to a gastroenterologist, to rule out any medical issues contributing to the individual’s avoidance, aversion, or restriction of food. And like treatment for anorexia and bulimia, a “team” approach is considered best practice. The team is typically made up of:
- A dietician who can properly assist in weight restoration
- A therapist to address emotional and psychological concerns
- A medical provider who oversees the individual’s health and safety during the treatment
- An occupational therapist to ensure that the individual’s muscle development in the mouth and throat are normal and not interfering with the ability to chew or swallow
Finally, family is an integral part of the treatment process, especially for children. Living and caring for someone with ARFID can be difficult, especially if the disorder has gone undiagnosed. It’s important for the family to receive education about the disorder, its treatment, and how to avoid relapse once treatment is complete.
Professionals are still getting to know ARFID, and it continues to be studied to better understand the most effective treatment. As with all eating disorders, ARFID is a complex diagnosis that needs to be treated by professionals with clinical training specific to the disorder. Without proper treatment, the limitation of adequate nutrition could result in the disruption of healthy development in children and the impairment of bodily functioning in adults.
Although ARFID is a complex disorder, recovery is possible. Contact Toledo Center today to learn more about how our highly trained eating disorder professionals can help.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA.
- Katzman DK, Spettigue W, Agostino H, et al. Incidence and Age- and Sex-Specific Differences in the Clinical Presentation of Children and Adolescents with Avoidant Restrictive Food Intake Disorder. JAMA Pediatr. 2021;175(12):e213861. doi:10.1001/jamapediatrics.2021.3861
- Murray HB, Bailey AP, Keshishian AC, Silvernale CJ, Staller K, Eddy KT, Thomas JJ, Kuo B. Prevalence and Characteristics of Avoidant/Restrictive Food Intake Disorder in Adult Neurogastroenterology Patients. Clin Gastroenterol Hepatol. 2020 Aug;18(9):1995-2002.e1. doi: 10.1016/j.cgh.2019.10.030. Epub 2019 Oct 24. PMID: 31669056.
- Norris ML, Spettigue W, Hammond NG, Katzman DK, Zucker N, Yelle K, Santos A, Gray M, Obeid N. Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder. Int J Eat Disord. 2018 Feb;51(2):170-173. doi: 10.1002/eat.22814. Epub 2017 Dec 7. PMID: 29215749.