What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder diagnosis that, while lesser known, is commonly experienced by both adults and children. Many misinterpret ARFID behaviors as “picky eating,” which can be a dangerous and harmful mistake.

Having a knowledge of ARFID and how to recognize and address symptoms is key to early intervention and recovery.

Avoidant/Restrictive Food Intake Disorder Definition

Although less well-known than eating disorders such as anorexia nervosa or bulimia nervosa, ARFID is common enough to have its own diagnostic criteria specified in the Diagnostic & Statistical Manual of Mental Illness, Fifth Edition (DSM-5) as well as its own code in the International Classification of Diseases.

 ARFID DSM-5 Criteria

The DSM-5 specifies the following criteria must be met for a diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID):

• An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidant based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
  1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  2. Significant nutritional deficiency.
  3.  Dependence on enteral feeding or oral nutritional supplements.
  4. Marked interference with psychosocial functioning.
• The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
• The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
•  The eating disturbance is not attributable to a concurrent medical condition or not better explained by another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention [1].”

ARFID ICD-10 Code

The ICD-10 code allows professionals around the world to classify mental illnesses and disease. The ICD-10 code that allows professionals to communicate that an individual has met criteria for ARFID is F50.8.

ARFID vs. Anorexia: What are the Differences?

ARFID and Anorexia Nervosa can appear similarly to many and it is true they share some behavioral characteristics such as severe restriction of food intake that leads to significant weight loss, nutritional deficiency, and/or interference in psychosocial functioning.

The biggest difference between the two is the motivation behind the restrictive behaviors. Individuals with ARFID are “not driven by the weight and shape concerns that typify AN [2].” In plain, individuals that struggle with anorexia nervosa experience disturbance in their body weight or shape that motivates their restrictive behaviors. Those with ARFID do not have this same disturbance and are often motivated by other aspects such as sensory characteristics of food.

Individuals with ARFID are also not fearful of weight gain and individuals with anorexia nervosa are.

ARFID Statistics & Facts

There are few studies conducted on ARFID, however, some known facts are that:

• 5% to 14% of those in pediatric inpatient eating disorder programs meet criteria for ARFID [3].
• 22.5% of those in pediatric day eating disorder treatment programs struggle with ARFID [3].
• Patients with ARFID are more likely to be male [3].
• ARFID is most common in younger populations [3].
• Compared with anorexia nervosa and/or bulimia nervosa, those with ARFID are more likely to struggle with comorbid psychiatric diagnoses [3].

Avoidant/Restrictive Food Intake Disorder Signs & Symptoms

Onset of ARFID often occurs in children, making recognition of symptoms key to early intervention and recovery into adolescence and adulthood. Some signs of ARFID might include:

Physical

The physical impact of ARFID can be severe, as the body becomes increasingly malnourished the more limited an individual’s intake is. Some physical red flags of ARFID may be:

• Dry/brittle hair and/or nails.
• Abnormal lab results.
• Difficulty regulating body temperature.
• Stomach cramps.
• Menstrual irregularities.
• Dizziness.
• Fainting.
• Problems falling/staying asleep.
• Muscle weakness.
• Impaired immune system and/or getting sick more frequently.

Behavioral/Emotional

Behaviorally, signs of ARFID are commonly confused as being “simply picky-eating.” ARFID, however, takes “picky eating” to a more clinical level and may present as the following:

• Refusal to eat certain foods which sometimes comes along suddenly.
• Eating slowly.
• Poor school performance.
• Fear of choking or vomiting from eating.
• Reporting no appetite.
• Expressing negative thoughts/beliefs about food related to sensory factors.
• Preference of eating alone.
• Limiting food intake based on food texture.
• Restriction in food amount and types.
• Limited range of preferred or “acceptable” foods.

What are ARFID Health Risks?

As ARFID is characterized by nutritional deficiency, the long-term physical and mental effects can be dire. If left untreated, ARFID can lead to:

• Impaired and/or slowed developmental growth.
• Impaired immune system functioning.
• Damage to the vital organs.
• Cardiovascular complications.
• Increased risk of heart failure.
• Bone and muscle loss.
• Menstrual irregularities.
• Fertility complications.
• Severe impact on daily functioning in career/education.
• Relationship impairment.
• Increased emotional dysregulation such as depression and/or anxiety.
• Increased suicidal ideation.
• Death.

ARFID Causes & Risk Factors

There are many biological, social, and psychological factors that can contribute to development of Avoidant/Restrictive Food Intake Disorder.

Biologically, those whose parents or immediate relatives have struggled with ARFID or a prior eating disorder diagnosis are more likely to experience one themselves. Researchers are continuing to search for the specific neurobiology behind this but have at the very least, consistently united this correlation.

Those that struggle with co-occurring mental health diagnoses are also more likely to struggle with ARFID. This may be the result of using ARFID behaviors to cope with emotional dysregulation, or, depression and anxiety could be a side effect of malnutrition from ARFID behaviors.

Children that experience physical illness may be at increased likelihood to develop ARFID behaviors as they may associate certain foods with pain, nausea, or other symptoms of the illness.

Related Reading

• Eating Disorders in Adolescents
• Fear of Vomiting and Eating Disorders
• Phobia Fear of Food

Those with adverse childhood experiences or experiences of trauma are also more at-risk for ARFID development. These experiences could include food insecurity, a chaotic home environment or family dynamic, and/or verbal, emotional, physical, and/or sexual abuse.

Socially, the messages a child or adolescent is given, both at home and in public, can impact their risk of developing ARFID. If food rules related to certain types of food exist in the individual’s environment, they are likely to internalize these for themselves. They might also create their own interpretations of food rules which could lead to increased rigidity in “acceptable” foods.

Avoidant/Restrictive Food Intake Disorder Treatment Options

Although ARFID is less “in the spotlight” than other eating disorder diagnoses, it is not less treatable. In fact, many of the evidence-based treatments for eating disorders such as anorexia nervosa, bulimia nervosa, and Binge Eating Disorder (BED) are also proven effective in treating ARFID. Some of these treatments include Cognitive Behavioral Therapy and Dialectical Behavior Therapy.

Family-Based Treatment (FBT), also known as “The Maudsley Method,” is also shown to be effective in treating ARFID, as FBT is effective for adolescents and children with eating disorders. FBT acknowledges the importance of the family dynamic in a child or adolescents’ life and uses this dynamic to both educate the individual and family and support behavior change in both parties.

Exposure Therapy can also be helpful for those with ARFID, as they often develop fear-based beliefs around certain foods. Exposure to these foods in the absence of their feared result will help them to rewrite their belief systems based on experience.

ARFID differs in presentation from other eating disorders, however, it is no less serious than these disorders. While curable, early intervention is key to leading struggling individuals to long-term remission and recovery from ARFID.

Resources

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[2] Becker, K. R. et al (2019). Impact of expanded diagnostic criteria for avoidant/restrictive food intake disorder on clinical comparisons with anorexia nervosa. International Journal of Eating Disorders, 52:3.

[3] 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 & Treatment, 12, 213-218.

Author: Margot Rittenhouse, MS, LPC, NCC

Page Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on October 4, 2021
Published on EatingDisorderHope.com