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Avoidant/restrictive food intake disorder

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Avoidant/restrictive food intake disorder
SpecialtyPsychiatry, clinical psychology

Avoidant Restrictive Food Intake Disorder (ARFID) is a feeding or eating disorder in which individuals significantly limit the volume or variety of foods they consume, causing malnutrition, weight loss, and/or psychosocial problems.[1] Unlke eating disorders such anorexia nervosa and bulimia, body image disturbance is not a root cause.[2][3] Individuals with ARFID under-eat due to the sensory characteristics of food (appearance, smell, texture, or taste); fears of choking or vomiting; low appetite, or a combination of these factors.[3]

ARFID was first included as a diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013, extending and replacing the diagnosis of feeding disorder of infancy or early childhood included in prior editions.[3][4] It was subsequently also included in the eleventh revision of the International Classification of Diseases (ICD-11) published in 2022.[5]

Signs and symptoms

ARFID comprises a range of selective and restrictive eating behaviors. In some cases, ARFID presents as extreme "picky eating," often due to sensory sensitivities or a fear of aversive consequences.[6] In other cases, ARFID subjects may eat a variety of foods but --due to lack of interest or low appetite -- not eat enough to meet growth and/or nutritional needs.[7] People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.[8] For some people with ARFID, multiple reasons for undereating apply.[3][9]

Sensory issues with food are among the most common reasons. For example, people who experience the taste of fruits or vegetables as intensely bitter might avoid eating them. For others, the smell, texture, appearance, color, or temperature of certain foods is unbearable. Some might find it impossible to tolerate the smell of food eaten by others. Sensory sensitivities can also lead people to refuse eating foods of specific brands. A diet limited to certain foods can lead to nutritional deficiencies, such as a lack of vitamins and minerals if only highly processed foods are consumed. Food avoidance due to sensory issues often develops in early childhood and is long-lasting.[3][9]

People might also avoid certain foods or restrict the amount of food they eat out of fear of negative consequences such as choking, vomiting, or stomach aches. In many cases, this behavior is motivated by a traumatic experience related to food that people wish to prevent from re-occurring. While avoiding the associated foods can provide relief in the short term, over time it can lead to growing anxiety as there is no opportunity to make corrective, positive experiences. Further, the range of avoided foods can grow over time, up to encompassing all solid foods in extreme cases. Food avoidance due to fear of aversive consequences often develops acutely.[3][9]

A general lack of interest in food or eating is a third common reason to avoid or restrict food intake. Often, these people perceive eating as a chore. Within this group, a low body weight or failure to thrive are common and the experienced lack of interest is long-lasting.[3][9]

Restriction of food intake due to unavailability, such as in situations of food insecurity, or dietary restrictions due to cultural practices such as religious fasting or dieting are not included in ARFID. Likewise, restricted eating and avoiding food out of concern for body weight or shape, as is typical for anorexia nervosa and bulimia nervosa, do not fall under ARFID.[3]

Diagnosis

Diagnosis is often based on a diagnostic checklist to test whether an individual is exhibiting certain behaviors and characteristics. Clinicians will look at the variety of foods an individual consumes, as well as the portion size of accepted foods. They will also question how long the avoidance or refusal of particular foods has lasted, and if there are any associated medical concerns, such as malnutrition.[10]

Criteria

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013 was the first to include ARFID as a diagnosis.[4]

The criteria were changed in the text revision published in 2022 (DSM-5-TR). The change eliminated an inconsistency in the phrasing of criterion A, clarifying that a failure to meet nutritional requirements is not required to meet the diagnostic criteria for ARFID.[11]

A diagnosis of ARFID can also be given if the full criteria are no longer met for a sustained period of time. In this case, it is specified that the person is in remission.

Assessment

The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS)[12] has been developed to assess the presence of ARFID. Across nine items that are scored on a 6-point Likert scale, the NIAS assesses picky eating, appetite, and fear scale.[13][14]

Associated conditions

According to a 2023 review of ARFID studies, "More than half of individuals with ARFID also have other neurodevelopmental, psychiatric, or somatic diagnoses. Anxiety, depression, sleep disorders, and learning difficulties are particularly common co-occurring issues."[15]

Autism

A 2023 review concluded that "there is considerable overlap between ARFID and autism," finding that 8% to 55% of children diagnosed with ARFID were autistic.[16]

Autisim has been shown to have a significant impact on dietary variety, with many subjects exhibiting atypical eating behaviors.[17][18] Autistic children are less likely to outgrow selective eating behaviors.[19][20] Autistic children are more likely than other children to have atypical eating behaviors.[18] The most common symptom seen in patients with both autism and avoidant-restrictive food intake disorder is sensory-based avoidance, however fear-based restriction and lack of interest in food are prevalent in this population as well.[21] If eating behaviors are clinically significant and severely impacting consumption, a person will be diagnosed with avoidant-restrictive food intake disorder in addition to autism spectrum disorder.[21]

Anxiety disorder

Anxiety disorders are the most common comorbidity with ARFID. 36-72% of people struggling with ARFID also have a diagnosed anxiety disorder.[22] Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar.[23] Some people with ARFID have fears such as emetophobia (fear of vomiting) or a fear of choking.

Anorexia nervosa

Though the physical symptoms may be identical, anorexia nervosa differs from ARFID because the lack of food intake in ARFID is not related to body image or weight concerns.[3][24]

Additionally, in a study analyzing the similarities between patients with AN and patients with ARFID, those with ARFID were significantly younger (10.8 vs 14.1 yrs old) with an earlier onset of illness (6.2 vs 13.7 yrs old) and a longer evolution time (61.2 vs 8.4 months). Also, a greater proportion of the ARFID patients were male rather than female (60.6% vs 6.1%).[25] Additionally, when compared to patients diagnosed with anorexia nervosa or bulimia nervosa, patients with ARFID are more likely to be diagnosed with a co-occurring medical condition.[9] Lastly, ARFID patients are more likely to have an anxiety disorder, but less likely to present with a mood disorder (e.g., bipolar, depression).[4]

Attention deficit hyperactivity disorder (ADHD)

Those with ADHD often struggle with inattentiveness or distraction, which may lead to missing meals or forgetting to eat for long periods of time.[26] Additionally, people with ADHD are more likely than the general population to struggle with mood disorders, such as anxiety and depression, which have a strong link with ARFID.[26] Medication used to treat ADHD, such as stimulants, often suppress appetite, which can make eating disorder treatment more difficult.[26]

Pediatric acute-onset neuropsychiatric syndrome

An assessment of symptoms and onset of these symptoms must be completed in order to determine if someone has obsessive-compulsive and related disorder. This can be caused by pediatric acute-onset neuropsychiatric syndrome (PANS) that is characterized by a sudden onset of obsessive-compulsive symptoms or severely restricted food intake. These conditions together can lead to additional neuropsychiatric symptoms.[3]

Obsessive compulsive disorder

Those with obsessive-compulsive disorder may exhibit symptoms of avoidant-restrictive food intake disorder, however these behaviors may or not be clinically significant and require an ARFID diagnosis along with a diagnosis of obsessive compulsive disorder.[3] Common overlap in symptoms include obsessions related to food and food intake or rituals related to eating.[3]

Major depressive disorder

Major depressive disorder often makes it difficult for patients to be interested in food, which is a common sign of avoidant-restrictive food intake disorder. Often, food intake is resolved with improvement of mood problems. A diagnosis of avoidant-restrictive food intake disorder should be given in addition to major depressive disorder if full criteria for both diagnoses are met and specifically if food interest or intake does not improve with improvements in mood. Also, if it seems as though the lack of interest in food needs to be specifically focused on in treatment, the ARFID diagnosis should be given.[3]

Developmentally normal behavior

Avoidant-restrictive food intake disorder may look similar to "picky eating" that is commonly seen in toddlers and young children, however the key difference between a normal narrow range of acceptable foods versus ARFID is that "picky eating" tends to resolve on its own without intervention whereas ARFID will not resolve unless the person struggling has access to support and treatment.[3] In ARFID, the behaviors are so severe that they lead to nutritional deficiencies, poor weight gain or significant weight loss, a reliance on enteral feeding or nutritional supplements, and/or significant interference with "psychosocial functioning."[3]

Treatment

Types of ARFID patients

There are two types of ARFID patients identified:[27] short-term and long-term patients. These are based on the amount of time an individual has had ARFID symptoms. Short-term patients have been recently diagnosed with ARFID. More recent onset can be associated with fear of choking or vomiting after experiencing or witnessing an event, fear of gastrointestinal problems, or both. Long-term patients are those who report with a long history of ARFID symptoms. Long-term ARFID patients include a history of selective or poor eating habits, a history of gastrointestinal problems, or generalized anxiety that affected eating behaviors throughout childhood or for the past number of years.

For adults

With time the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for ARFID is some form of cognitive-behavioral therapy.[23] Another common treatment is responsive feeding treatment (RFT) that is often used in children, however the same principles can be applied to treatment for adolescents and adults.[28] Responsive feeding treatment often involves a support person establishing mealtime routines with pleasant interactions and modeling to encourage the person struggling with ARFID to respond to hunger cues.[28]

There are support groups for adults with ARFID.[29]

For children

Children can benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment are record, reward, relax and review.[23]

  1. In the 'record stage', children are encouraged to keep a log of their typical eating behaviors without attempting to change their habits as well as their cognitive feelings.
  2. The 'reward stage' involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
  3. The 'relaxation stage' is most important for those children with severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Often these stories can also include the introduction of new foods with the help of a real person or fantasy person. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.[23]
  4. The final stage, 'review', is important to keep track of the child's progress, both in one-on-one sessions with the child, as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.

For both adults and children

A suitable treatment for older children and adults alike is CBT-AR (Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder), in which around 90% of participants have found high levels of satisfaction with the program.[30] While the rate of remission to this type of programme is said to be around 40%,[30] it has seen higher efficacy among children and young adults compared to adults, and greater family involvement has also been seen to help.[30] The main goals of treatment for CBT-AR are to achieve or to maintain a health weight, treat nutritional deficits, consume items from all five of the basic dietary groups, and to be more comfortable in social settings and circumstances. CBT-AR workbook can be used as a resource for professionals.[31] This workbooks includes psychoeducation about ARFID, self-monitoring records for food logs, and the different stages in treatment.

The treatment is broken up into four stages and aimed to help "reduce nutritional compromise and increase opportunities for exposure to novel foods to reduce negative feelings and predictions about eating".[32] In a simplified format, the stages of this treatment are:[32]

  1. Psychoeducation regarding ARFID and CBT-AR, setting up a regular pattern of eating and self-monitoring.
  2. Psychoeducation about nutrition deficiencies, selecting new foods to help aid the loss of those deficiencies.
  3. Figuring out the root cause(s) of the patient's ARFID, bringing in 5 new foods to examine, describe their features and try tasting them throughout the week, lastly exposure to the foods in the sessions.
  4. Evaluating progress and compiling a relapse prevention plan.

This is set to take place over 20–30 sessions ranging from six months to a year.

Medical treatment

Individuals with ARFID might need additional help outside of psychotherapy to increase their caloric intake and get to receive nutritional needs.[13] Individuals with ARFID might take nutritional supplements. Patients may require nasogastric or gastrostomy tube feeding.[33] Patients with ARFID are more likely than those diagnosed with another eating disorder to be initially evaluated in an outpatient setting while relying on long-term nasogastric or gastrostomy feedings.[9]

Prevention

While there is no way to predict who will develop ARFID, there might be ways to help diminish the probability of developing the disorder. Pediatricians should take special care in recognizing a child's eating patterns and intake,[27] specifically parental concerns. Particularly, many parents worry that their child is not consuming enough food daily. As a result, they frequently coerce or bribe the child into eating even though the child is of normal development. This could negatively impact the child's view on different foods and create backlash from the child to the parent. Also, it is important for the parent and child to establish appropriate feeding practices.[27] The child's doctor can assist to establish the proper feeding tool to allow the child to develop normally and create a positive relationship towards food and eating. The parent is responsible for when, where, and what the food is, and the child is responsible for how much they eat.

Epidemiology

Unlike most eating disorders, there may be a higher rate of ARFID in young boys than there is in young girls.[34] Presentations are often heterogenous.[9] Additionally, literature suggests that parental pressure for a child to eat could potentially have a negative impact on the child's food intake. This is associated with picky eating and a decrease in weight during childhood.[35][36] This can be contributing to the child's hunger cues, as well as, the child eating for reasons other than their hunger (e.g., emotions).[37][38]

In a study conducted between 2008 and 2012, 22.5% of children aged 7–17 in day programs for eating disorder treatment were diagnosed with ARFID.[34] In a 2021 study ARFID also has a high comorbidity with autism spectrum disorder (ASD), with up to 17% of adults with ASD at risk of developing disordered eating, with modest evidence for heritability. Among children, one study revealed a 12.5% prevalence of ASD among those diagnosed with ARFID.[39] Other risk factors include sensory processing sensitivity, gastrointestinal disease and anxiety associated with eating.[40] Prevalence among children aged 4–7 is estimated to be 1.3%,[41] and 3.7% in females aged 8–18.[41] The female cohort study also had a BMI of 7 points lower than the non-ARFID population.[42]

Prevalence of ARFID compared to picky eating

Children are often picky eaters, but this does not necessarily mean they meet the criteria for an ARFID diagnosis. ARFID is a rare condition, and though it shares many symptoms with regular picky eating, it is not diagnosed nearly as much. Picky eating, which can exhibit symptoms similar to those of ARFID, can be observed in 13–22% of children from ages 3–11,[43] whereas the prevalence of ARFID has "ranged from 5% to 14% among pediatric inpatient ED [eating disorder] programs and as high as 22.5% in a pediatric ED day treatment program".[44]

History

Prior to the DSM-5, the DSM was not inclusive in recognizing all of the challenges associated with feeding and eating disorders in 3 main domains:[10]

  • Eating Disorders Not Otherwise Specified (EDNOS) was an all-inclusive, placeholder group for all individuals that presented challenges with feeding
  • The category of Feeding Disorder of Infancy/ Early Childhood was noted to be too broad, limiting specification when treating these behaviors
  • There are children and youth who present feeding challenges but do not fit within any existing categories to date

The definition introduced in the DSM-5 is broad, which can be both a detriment and an advantage: Stephanie G. Harshman of the neuroendocrine unit at Massachusetts General Hospital has been quoted saying: "The broad definitions used among DSM-5 criteria for [ARFID] provide substantial flexibility in a clinical setting".[45][46] It can be detrimental, as a broad scope can lead to false positive diagnoses of ARFID, though as an advantage it is better than the DSM-IV description which landed people with ARFID in the "EDNOS" (eating disorder not otherwise specified) category and made it more difficult for people with the condition to reach potential treatment.[4]

References

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Further reading

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