Avoidant/Restrictive Food Intake Disorder (ARFID)

overview

ARFID is a relatively new term, which stands for avoidant restrictive food intake disorder, now officially recognised and described in diagnostic criteria.

It involves the avoidance of a large number of foods to the extent that there is nutritional deficiency and health impairment. There is an intense fear of many foods and this usually results in social disturbances, such as being unable to join friends for school dinners or meals out.

The symptoms of avoidant restrictive food intake disorder, can seem very similar to a better-known eating disorder, anorexia; notably low body weight, weight loss and emotional disturbance. However, there is a critical difference: unlike anorexia, the driver of the disorder is not anxiety about body weight, shape and image. The three main causes of ARFID are low interest, sensory difficulties, and fear/trauma.

The positive news is that now avoidant restrictive food intake disorder is firmly established as a diagnosis (included in the 5th edition of the American Psychiatric Association’s classification of disorders, called DSM-5 or DSM-V), it is increasingly better recognised and understood. With this improved awareness and diagnosis, those affected are more likely to benefit from targeted and effective therapy and support.

Causes

The exact cause of ARFID is unknown but, as is the case for all eating disorders, a variety of biological, neurological, genetic, environmental, and sociocultural factors are likely to be involved. The condition is more likely to affect children with a history of extreme picky eating or who don’t grow out of a stage of normal picky eating. Early trauma, including traumatic experiences with food, such as an episode of choking, can play a role. Those with attention-deficit issues, on the autism spectrum or with anxiety disorders or intellectual disabilities are also at higher than normal risk of developing ARFID.

Diagnosis

Doctors use the criteria in the DSM-5 to diagnose ARFID. People with ARFID typically have an eating disturbance, such as:

• lacking interest in eating or food
• avoiding food based on texture
• expressing concern about the unpleasant consequences of eating

In ARFID, the eating disturbance causes a lack of appropriate nutrition, leading to a person not meeting their energy needs. As a result, it can cause:

• significant weight loss
• nutritional deficiencies
• reliance on feeding tubes or supplements
• negative effects on psychosocial functioning

Symptoms

ARFID has several associated warning signs that parents and caregivers may identify. These include:

• dramatic weight loss
• dressing in layers to stay warm or hide weight loss
• digestive issues, such as constipation
• restricting types or amounts of food
• only eating foods with certain textures
• feeling sick or full around mealtimes
• feeling cold
• weakness or excessive energy
• fear of choking or vomiting
• a restricted range of preferred foods that becomes more limited over time

Other symptoms of ARFID include:

• abdominal pain
• a history or fear of vomiting or choking
• gastroesophageal reflux disease(GERD), also known as acid reflux

Types of ARFID

Like other eating disorder conditions, there are several different types of ARFID, depending on the symptoms the individual is experiencing. The types of ARFID include: Avoidant, Aversive, Restrictive, Adult ARFID and ARFID “Plus.”

Avoidant

One common type of ARFID is Avoidant. In this condition, individuals simply avoid certain types of foods in relation to sensory features, causing a sensitivity or over stimulation reaction. These patients may feel sensitive to the smell of foods; textures, including soft foods or fruit and vegetables that have prickly or defined textures; or general appearance, including color.

Aversive

Another type of the ARFID eating disorder is Aversive. Individuals whose food refusal is related to the Aversive type may experience on fear-based reactions. Aversive ARFID evokes a fear of choking, nausea, vomiting, pain and/or swallowing, forcing the individual to avoid the food altogether.

Restrictive

Individuals who experience Restrictive ARFID may show signs of little-to-no interest in food. Restrictive ARFID can make one forget to eat altogether, show signs of a low appetite or get extremely distracted during mealtime. Another symptom of Restrictive includes extreme pickiness of foods, resulting in limited intake.

Adult ARFID

Symptoms of ARFID not only take place in children and adolescents; in fact, many adults can show signs of ARFID. Individuals with ARFID in their adult years may still have symptoms that were experienced in their adolescent years and can be categorized as Avoidant, Aversive or Restrictive types of ARFID. ARFID symptoms in adults can include selective or extremely picky eating, food peculiarities, texture, color or taste aversions related to food.

ARFID “Plus”

Individuals who are experiencing more than one type of ARFID can begin to develop features of anorexia nervosa, including concerns about body weight and size, fear of weight gain, negativity about fatness, negative body image without body image distortion and preference for less calorie-dense foods. This combination of symptoms is categorized as ARFID “Plus,” a co-occurring eating disorder.

Complications

Eating disorders are psychological diseases that cause physical symptoms, which can result in severe illness and death.

People with ARFID, just like those living with anorexia or bulimia, do not meet their daily nutritional needs. Some of the signs and symptoms of these eating disorders are similar, including:

• stomach cramps, constipation,  heartburn
•  missing periods or only having a period when on hormonal birth control
• difficulty concentrating
• low iron
• low thyroid hormone levels
• low potassium
• low blood cell counts
• slow heart rate
• Dizziness
• fainting
• constantly feeling cold
• issues with sleep
• dry skin and nails
• brittle nails
• fine hair on the body, called lanugo
• hair thinning
• dry and brittle hair
• muscle weakness
• poor healing of wounds
• decreased immune function

As the body lacks essential nutrients to keep the organs working properly in people with ARFID, bodily processes slow down to conserve energy.

The body can adapt well to stress resulting from eating disorders, so blood tests can sometimes appear normal even when someone is in danger.

Disturbances in electrolytes, such as potassium, can cause unexpected death, and people with severe nutritional deficiencies can die from a heart attack.

Treatment

ARFID only received a clinical definition in the DSM-5, so doctors have not yet created guidelines for the treatment of the disorder.

However, they do recognize that people living with eating disorders such as ARFID require the care and expertise of a registered dietitian nutritionist.

Other healthcare professionals who may play a role in caring for people with ARFID include:

• occupational therapists
• developmental pediatricians
• gastroenterologists
• psychologists
• psychiatrists
• adolescent health physicians

The involvement of so many professionals can mean that treatment plans become unclear. Some clinicians with experience in treating children with ARFID suggest that the focus of treatment will depend on what factors are causing the eating disorder.

For example, a person with ARFID who has a fear of choking and vomiting may benefit from behavioral strategies to help address those fears.

Children with ARFID need specialized and individualized treatment plans. Further studies are necessary to explore the management and treatment of ARFID.