Avoidant restrictive food intake disorder (ARFID): Symptoms and treatment

Is your child showing signs of extreme picky eating? Are you worried that they may have an underlying disorder?

In most cases, fussy eating is just a temporary behavior that children outgrow without any serious consequences. However, there is a condition called avoidant/restrictive food intake disorder (ARFID) that’s characterized by extremely picky eating, weight loss, and nutrition deficiencies.

Let’s take a look at the causes, warning signs, and treatment options of this dangerous eating disorder.

If you’d like a full assessment of your cognitive abilities and wellbeing, take our online cognitive test. 

What is avoidant/restrictive food intake disorder (ARFID)?

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves restrictive or avoidant eating behaviors that lead to:

• Significant weight loss
• Failure to gain weight or to grow (in children)
• Nutritional deficiency
• Reliance on nutritional supplements
• Gastrointestinal problems. 

It can also interfere with the patient’s social life and psychological wellbeing. (1)

ARFID is distinct from other eating disorders – such as anorexia nervosa and bulimia nervosa – in that patients don’t have body image distortion: they’re not preoccupied with being thin, they’re not afraid of weight gain and they’re not trying to lose weight. In cases that qualify as ARFID, the disruption in eating patterns cannot be explained by external factors, such as cultural practice or food being in short supply. 

While ARFID most commonly occurs among children and teenagers, it’s not restricted to them – however, we have very limited research on why and how it affects adults.  

How common is avoidant restrictive food intake disorder?

Due to the lack of research focusing on ARFID, we don’t know how common this eating disorder is among the general population. 

Studies that looked at eating disorder patients (children and adolescents) found rates of potential ARFID cases ranging from 5% to 26.7%. (1) The results vary based on the populations studied, the diagnosis methods used, and other factors. 

As for adult patients, a group of researchers who completed a retrospective review of 1029 adult patients with a feeding and eating disorder assessed between 1990 and 2005 found that 9.2% of them met the criteria for ARFID. (2)

There are very few studies that look at broader groups instead of focusing exclusively on eating disorder patients. A non-ED study carried out in a Swiss primary school found that 3.2% of children reported signs of ARFID. (3)

What differentiates ARFID from picky eating?

The difference between ARFID patients and picky or fussy eaters is that the eating problems of those diagnosed with ARFID are so severe that they consistently fall short of their nutritional or energy needs and lose a lot of weight. (1)

Children who are picky eaters may reject some foods or refuse to try new ones, which leads to limited variety in their diet, but they usually have a normal weight. Picky eaters can outgrow their aversion to certain foods, while ARFID patients must be treated to prevent serious health implications.

ARFID vs other eating disorders – more anxiety, less depression

ARFID is a relatively newly identified diagnosis. It was first described as a separate diagnostic group with unique clinical characteristics in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. Before then, patients who showed symptoms of eating disorders but did not meet the criteria for anorexia nervosa or bulimia nervosa were often given the diagnosis of eating disorder not otherwise specified (EDNOS).

It’s essential to recognize ARFID as a unique disorder to be able to treat it in the most effective way and achieve the best outcomes. Research suggests that patients with ARFID have different characteristics than those who suffer from anorexia or bulimia – they are younger, a higher percentage of them are male, and they are likely to have been suffering from the illness for a much longer time. (4)

One study comparing ARFID patients to other eating disorder patients found similar degrees of weight loss and malnutrition in both groups. But they also found that patients with ARFID are more afraid of vomiting and/or choking, have more food texture and sensitivity issues, and are more dependent on nutritional supplements. (5)

It appears that ARFID patients have a greater chance of developing other medical or psychiatric disorders than those who suffer from other eating disorders. Researchers have found a possible link between selective eating and anxiety disorders, obsessive-compulsive disorders, attention deficit disorders, and autism spectrum disorders. (6) On the other hand, ARFID patients seem to be less likely to have mood disorders or depression. (4) (5)

ARFID is now recognized as a unique disorder around the world. Following its initial description in DSM-5, it was also added to the latest edition of the World Health Organization’s International Classification of Diseases, ICD-11, which was released in 2018. 

What is the cause of avoidant restrictive food intake disorder?

Since ARFID was first defined in 2013, there hasn’t been enough research investigating the disorder to reveal what might cause it. The risk factors, prevalence, and pathophysiology of ARFID are still largely unknown.

Symptoms of ARFID

ARFID can present itself in many different ways. In general, signs of avoidant/restrictive food intake disorder can be split into three groups: sensory sensitivity, lack of interest in eating, and fear of aversive consequences. (7) 

1. Sensory sensitivity with regards to food

Patients with ARFID often experience food texture issues or sensitivity to specific colors and smells, which causes them to avoid certain foods and become selective or picky eaters. If picky eating is not resolved by late childhood and/or it gradually worsens over time, it may be a warning sign of ARFID. 

2. Lack of interest in eating or poor appetite

Individuals suffering from ARFID are generally not interested in food or eating. They may refuse to eat in front of others or in public – such as in the school cafeteria or a restaurant. 

3. Fears of negative consequences of eating 

When someone is noticeably afraid of the potential negative consequences of eating – such as choking, vomiting, or developing an allergic reaction – it may be a sign of ARFID. This fear may lead them to eat less or refuse meals altogether. 

Other warning signs that may indicate ARFID include: 

• Frequent stomach aches that have no apparent cause, especially around mealtimes
• Difficulty chewing 
• Vomiting or gagging after exposure to certain foods
• Difficulty digesting certain foods
• Consistently eating very small portions
• Constipation, acid reflux or other gastrointestinal complaints
• Dramatic weight loss
• Social isolation
• Impaired immune function
• Difficulty concentrating
• Sleep problems 
• Dizziness and fainting
• Dry skin, brittle nails, and/or thinning hair
• Menstrual irregularities

How do you treat avoidant restrictive food intake disorder?

There are currently no evidence-based treatment recommendations for ARFID. Rather, treatment approaches are based on clinical experience, which shows that the best treatment option for each patient may depend on what is driving that particular individual’s disordered eating. (1)

ARFID treatment options that have been explored include: 

• Family-based treatment and parent training
• Cognitive-behavioral therapy 
• Hospital-based re-feeding including tube feeding; and 
• Adjunctive pharmacotherapy (8)

Conclusion

Avoidant/restrictive food intake disorder or ARFID is a relatively recently defined diagnosis that is distinct from other eating disorders such as bulimia and anorexia. 

Patients with ARFID have severely restrictive or avoidant eating behaviors which may lead to extreme weight loss, failure to grow at the expected rate for children, nutritional deficiencies, dependence on nutritional supplements, and gastrointestinal complications and psychosocial issues. 

The exact causes of ARFID are currently unknown. Some warning signs to look out for include avoiding foods of a certain color, smell or texture; showing a lack of interest in food or poor appetite; and being afraid of the negative outcomes of eating such as choking or vomiting. 

Treatment for ARFID must be highly specialized and depends on the factors that drive the individual’s eating disorder. 

If you suspect that you or someone you know may be suffering from ARFID, talk to your doctor, and seek specialized treatment immediately.

References

(1) Norris, M. L., Spettigue, W. J., & Katzman, D. K. (2016). Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in children and youth. Neuropsychiatric disease and treatment, 12, 213–218. https://doi.org/10.2147/NDT.S82538

(2) Nakai, Y., Nin, K., Noma, S., Teramukai, S., & Wonderlich, S. A. (2016). Characteristics of Avoidant/Restrictive Food Intake Disorder in a Cohort of Adult Patients. European eating disorders review: the journal of the Eating Disorders Association, 24(6), 528–530. https://doi.org/10.1002/erv.2476

(3) Kurz, S., van Dyck, Z., Dremmel, D., Munsch, S., & Hilbert, A. (2015). Early-onset restrictive eating disturbances in primary school boys and girls. European child & adolescent psychiatry, 24(7), 779–785. https://doi.org/10.1007/s00787-014-0622-z

(4) Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., Callahan, S. T., Malizio, J., Kearney, S., & Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. The Journal of adolescent health: official publication of the Society for Adolescent Medicine, 55(1), 49–52. https://doi.org/10.1016/j.jadohealth.2013.11.013

(5) Nicely, T.A., 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 2, 21 (2014). https://doi.org/10.1186/s40337-014-0021-3

(6) Timimi, S., Douglas, J. and Tsiftsopoulou, K. (1997), Selective eaters: a retrospective case note study. Child: Care, Health and Development, 23: 265-278. doi:10.1111/j.1365-2214.1997.tb00968.x

(7) Thomas, J.J., Lawson, E.A., Micali, N. et al. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep 19, 54 (2017). https://doi.org/10.1007/s11920-017-0795-5

(8) Thomas, J. J., Wons, O. B., & Eddy, K. T. (2018). Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Current opinion in psychiatry, 31(6), 425–430. https://doi.org/10.1097/YCO.0000000000000454