Avoidant restrictive food intake disorder (ARFID) is a diagnosis that applies to individuals who restrict their food intake for various reasons. It may be informally known as Selective Eating Disorder (SED), but this disorder is much more serious than “picky- eating.” It causes nutritional and/or energy deficits that are potentially life-threatening. Although it may sound similar to anorexia, the key difference is that restricted food intake is not related to body image. In children the lack of necessary nutritional intake can stall normal developmental growth, while in adults, it may result in a loss of body mass.
Avoidant restrictive food intake disorder is an eating disorder that was renamed and revised officially in 2013 by the Diagnostic and Statistical Manual Version 5 (DSM-V). Previously, it was known as “Feeding Disorder of Infancy or Early Childhood” (according to the DSM-IV). Shortly after the new diagnostic criteria were outlined a multi-site retrospective study found that the average age that this disorder seems to set in is 12.9 years old, reinforcing that it is not limited to infancy or early childhood.
Some Myths and Preconceptions about ARFID:
Research from the US and Canada showed that ARFID could be diagnosed in 13.8% of children and adolescents who have an eating disorder. In individuals between 8 and 18 years old, those with ARFID tended to be younger (13 years old), compared to those with anorexia (16 years old) and bulimia (17 years old). They also tended to have had the illness for much longer, with most individuals suffering for more than 33 months (almost 3 years). Individuals with ARFID were more likely to have lower body mass than those with bulimia.
Participants with ARFID experienced:
- Extremely “picky” or selective eating since childhood (28.7%)
- Generalized anxiety (21.4%)
- Gastrointestinal symptoms (19.4%)
- A history of choking or vomiting (13.2%)
- Food allergies (4.1%)
According to the Diagnostic and Statistical Manual Version 5 (DSM-V), ARFID is diagnosed if:
- A person exhibits an eating or feeding disturbance that results in a continued failure to meet nutritional or energy requirements and manifests as one or more of the following:
- It is important that the eating or feeding disturbance is not better explained by physical/medical reasons or another mental disorder.
- It is also important to consider whether the person had the economic means to meet their nutritional needs or if the feeding disturbance was caused by a culturally sanctioned practice.
- The eating disturbance must not only be present with anorexia nervosa or bulimia and must not be related to disturbances in how the person views their body shape or weight.
There are also 3 unofficial categories or components of ARFID that clinicians can use to help focus treatment and make it as effective as possible for each individual:
- Low interest in eating (person does not feel hungry or finds eating unpleasant)
- Sensory issues (person responds strongly to sensory aspects of food, such as texture, and may gag or vomit, leading to strict rules about food)
- Fear or an extremely traumatic history with food (such as chocking, severe gastrointestinal upset, medical issues that make it harder to eat)
There are many screening tools to help clinicians in making a diagnosis of ARFID. These include:
- Medical tests – such as lab tests for nutrients, minerals and blood count
- The Eating Pathology Symptoms Inventory (EPSI) – a self-report test that investigates 8 features of disordered eating, such as body dissatisfaction, restriction and negative attitudes to obesity
- The Eating Disorders in Youth Questionnaire (EDY-Q) – a tool that can help to distinguish between aspects of disordered eating, such as selective eating and emotional food avoidance.
- The Eating Disorder Assessment for the DSM-5 (EDA-5) – a tool that uses the DSM-5 criteria to determine if the person has anorexia, bulimia, binge-eating disorder or ARFID
- The Pica, ARFID, and Rumination Disorder Interview (PARDI) – the greatest strength of this test is that it can actually tell the severity of ARFID and which of the 3 components of ARFID (mentioned above) affects the person most.
- The Nine-Item ARFID Screen (NIAS) – this test asks the person how much the agree or disagree with statements around selective eating, appetite and fear around eating.
ARFID has been found to occur more frequently in people who:
- Were “picky-eaters” as children
- Are on the autism spectrum
- Have been diagnosed with ADHD
- Have intellectual disabilities
- Have pervasive developmental disorder
- Have an anxiety disorder
- Have a substance use disorder
Patients with ARFID have also been diagnosed with:
- Another medical condition (55%)
- An anxiety disorder (58%)
- A mood disorder (19%)
Dual diagnoses occur when someone has two or more mental health conditions at the same time. It is extremely important to find a treatment center, such as Koru Spring, that has the expertise and training to treat both conditions concurrently. A dual diagnosis helps health professionals to understand and investigate how one mental health condition might exacerbate the other. Treatment of ARFID and other eating disorders requires a holistic approach and this includes treating all mental health conditions that the person is experiencing.
Psychological signs, such as:
- Extreme picky-eating as a child (especially if the types of food eaten narrows over time)
- Dramatic restrictions in the type or amount of food eaten
- Eating very slowly
- Lack of interest in food or appetite
- An extreme aversion to foods with certain sensory associations, such as foods with a certain texture, odor, color, etc.
- Aversion to foods based on a fear of vomiting, gastrointestinal upset or a fear of choking
- The person reports various reasons for not eating at mealtimes (such as feeling full even if they have not eaten recently)
- Inability to focus
- Sleep disturbances
- Being unable to attend social events which involve eating
- Poor school and work performance
Physical signs, such as:
- Drastic loss of body mass or an inability to meet developmental landmarks for weight and height
- Constipation, abdominal pain, stomach cramps and other gastrointestinal symptoms
- Menstrual cycle irregularities
- Lethargy, dizziness or fainting
- Dry skin and nails and the hair on the head thins, becomes brittle and is very dry
- Fine hair grows on the body (lanugo)
- Poor wound healing and impaired immune system
- Nutritional deficits confirmed by laboratory tests (such as anemia or vitamin deficiencies)
- Low blood pressure
- Weak bones
- Muscle weakness and muscle mass loss
ARFID and anorexia share many signs and symptoms, as they both involve a restrictive intake of food. Both will result in nutritional deficits and may involve weight changes. The importance of ensuring that body shape or weight is not related to the restricted nature of eating is crucial in differentiating ARFID from anorexia.
Although research on ARFID and the course of illness is constantly being developed, there are effective treatments and treatment programs for those with the disorder. Although the body is extremely resilient, it can only cope with limited resources by putting itself under a lot of stress. ARFID is more than “picky-eating,” it is a potentially life-threatening eating disorder that requires complex treatment that is tailored to the individual. Treatment centers such as Koru Spring offer holistic treatment plans for eating disorders, such as ARFID.
Treatment programs for ARFID should focus on treating both the psychological and physical aspects of this eating disorder. Individuals with ARFID will need a well-rounded treatment plan including:
- Personalized meal plans by dieticians
- Medical care – potentially including prescription drugs to help with appetite, anxiety and nutrition
- Speech or physiotherapy to help with strong gag reflexes or difficulty chewing or swallowing
- Psychological therapy to help the person understand their anxiety and to help them to overcome psychological obstacles they have surrounding food intake.
- Family therapy to help support the patient’s recovery.
Treatment goals for ARFID often include:
Cognitive behavioral therapies seem to be particularly effective for this eating disorder, as it has many techniques to help reduce anxiety around different food types and aims to reduce the amount or types of foods that the person would usually restrict.
Family-based therapy (FBT) may also be extremely beneficial. As with all eating disorders and other mental illnesses, a good support system is crucial for recovery. Eating disorders affect more than the individual; they affect their loved ones too. FBT works well with other eating disorders, such as anorexia and bulimia and it is being expanded to work with ARFID too.
Family-based therapy focuses on:
- Reminding the family members (especially parents) that the causes of ARFID are unknown. This aims to alleviate guilt and move the family members away from placing blame and towards action.
- Encouraging and emphasizing the parent’s responsibility to take a more active role in encouraging healthy eating behaviors and attitudes (especially if the patient is a child).
- Emphasizing that the eating disorder is something that the person has no control over.
- Dynamics of family meals and the attitudes of family members to eating.
- Restoring the responsibility of eating back to the patient, once they have started to eat without resistance and are gaining weight steadily.
- Addressing personal psychological issues that may be related to the eating disorder or the disruptions that the eating disorder has had on their development.
If you or a loved-one is seeking treatment for avoidant restrictive food intake disorder (ARFID), please do not hesitate to call our team at 844.951.1888
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