Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new diagnosis, introduced in the latest edition of the Diagnostic and Statistical Manual (DSM-V). As a result, it has not been studied as extensively as other eating disorders. Let’s explore what ARFID looks like, how it may be diagnosed, and what treatments are best suited to help reduce its occurrence.

What is ARFID?

ARFID is an eating disturbance marked by a failure to meet nutritional and/or energy needs. It is usually associated with unhealthy weight loss, nutritional deficiency, and interruption in everyday functioning. It can occur across the lifespan but it is more often associated with childhood-onset, especially with the autistic population. Unlike other eating disorders, it is not associated with a distorted body image or a desire to lose weight.

Is ARFID Just Picky Eating?

Although it can look similar to picky eating, people suffering from ARFID exhibit some significant differences: people with ARFID do not consume enough calories to maintain regular weight and/or bodily functions. Additionally, eating restriction interferes with their social functioning. For example, they may be unwilling to go out with friends because they are worried there will be nothing for them to eat. Further, even picky eaters are usually willing to try new foods as they develop; people with ARFID tend to become more restrictive as they grow older. In general, the consequences of ARFID are much more severe than picky eating.

The Three Presentations of ARFID

It is believed that ARFID presents in three distinct variations:

Sensory Sensitivity

Those that exhibit sensory sensitivity may avoid eating certain foods due to aversions to specific tastes, textures, or smells. This is especially common among individuals on the autistic spectrum. It is speculated that sensory sensitivity is due to an oversensitivity in taste perception rather than any cognitive or affective process. 

Fear of Aversive Consequences

Individuals with this presentation usually have had some traumatic experience with food that causes them to avoid specific foods or stop eating entirely (e.g., a choking incident or a chronic feeding issue). It can be so severe that some believe that they may die if they eat a certain food. Individuals are likely to have accompanying physical symptoms, such as mouth and throat tissue that contracts as a result of a perceived food threat.

Lack of Interest

Some people with ARFID possess a genuine lack of interest in eating or have a low appetite. It is hypothesized that a lack of interest in food may be spurred by irregularities in the brain’s appetite centers.

Assessment

Because of its recent designation as a psychiatric diagnosis, the assessment of ARFID is in its infancy, with few validated tools. The following are assessments used to diagnose ARFID with varying levels of success:

Eating Disturbances in Youth-Questionnaire (EDY-Q)

A self-report questionnaire for school-aged children, the (EDY-Q), has been used as a measure to identify ARFID, with 12 questions specifically related to emotional food avoidance, selective eating, food restriction due to fear of aversive consequences, and weight problems. The EDY-Q has shown preliminary evidence of validity as a screening measure of ARFID.

Eating Pathology Symptoms Inventory (EPSI)

Another self-report measure, the EPSI found some discriminant validity between Anorexia Nervosa and ARFID on a factor measuring restraint (a self-report measure of purposeful dieting), but no significant difference on a measure of restriction (a self-report measure of  deficits in calorie intake), thus exhibiting mixed results as to its effectiveness as an assessment tool for ARFID.

Pica, ARFID, and Rumination Disorder Interview (PARDI)

A structured interview, the PARDI is used to assess Pica, ARFID, and Rumination disorder for use in treatment planning in clinical and research settings. People with ARFID scored significantly higher on the PARDI profiles than a non-ARFID control sample, pointing to its accuracy in diagnosing ARFID.

Eating Disorder Examination (EDE)

The EDE is a structured interview that has both a parent and a child component. A small pilot study for an ARFID module of the EDE found evidence of reliability and validity on a non-clinical sample.

The Eating Disorder Assessment for DSM-5 (EDA-5)

The EDA-5 is a structured interview developed specifically for the assessment of eating disorders found in the DSM-V. However, Its validity in relation to ARFID has yet to be verified.

Treatment

As with assessment, research on treatments for ARFID is in its early stages. There has not been enough research to verify definitive treatment methods for ARFID. However, there are a few modes of treatment that have been developed for use with ARFID.

Cognitive Behavioral Therapy for ARFID (CBT-AR)

CBT-AR has been conceptualized for use by people ages 10 and older. It uses different techniques to address the three presentations of ARFID. First, for people with sensory sensitivity, it teaches skills for gradually approaching new foods. Second, for those with a lack of interest in food, it utilizes parent support to increase dietary volume for youth who are underweight. Third, for those who have experienced trauma, it uses exposure to manage avoidant responses to traumatic stimuli. This intervention is similar to exposure and response prevention. Trials of CBT-AR are currently ongoing.

Family-Based Treatment (FBT)

Maudsley family-based treatment has been effective in the treatment of other eating disorders, most notably anorexia nervosa. Using a similar rationale for ARFID, families are educated and taught to support their children in increasing dietary volume and dietary variety through repetitive exposure to new foods.

Somatic Experiencing Therapy

This therapy, developed by Dr. Peter Levine, works under the presumption that mouth and throat tissue needs to be retrained to be tolerant of new foods. Due to past trauma, it is believed that tissues constrict when they encounter novel foods, causing the individual to restrain their intake. The therapy focuses on easing anxiety and tension, which in turn loosens tissues, so new foods can be experienced.

Medication

Although there is no medication yet approved for ARFID treatment by the US Food and Drug Administration, there are a few medications that have led to some optimism. Olanzapine, mirtazapine, and D-cycloserine (DCS) have all found success in increasing food intake and weight gain in children with ARFID.

ARFID is a relatively new diagnostic category of eating disorder which causes individuals to engage in extreme food avoidance and restriction. Unlike picky eating, the social, emotional, and health consequences are quite severe. Luckily, there are promising efforts underway aimed at effective assessment and treatment. If you or a loved one appears to suffer from ARFID, it is important to seek professional help.