ARFID: Avoidant Restrictive Food Intake Disorder

Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood.
The DSM-Vis the manual used for diagnosing psychiatric problems. It stands for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  The Fifth edition has been out since May 2013 and includes changes to how eating disorders are categorized and diagnosed.

This post will address one of those changes, which the new diagnosis is called Avoidant / Restrictive Food Intake Disorder (also known as ARFID).

When people are diagnosed with any type of mental health disorder by a psychologist, it essentially means they meet diagnostic criteria set forth by the DSM-V, just as someone would meet criteria and be diagnosed with a medical problem like high blood pressure. An important goal of diagnosing specific disorders is to develop the best possible treatment plan and apply evidence-based interventions.

According to The DSM-V, ARFID includes:
A.An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance 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.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. 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.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

 Can you say that in English please? 
Basically, what the DSMV says is that individuals who meet the criteria for ARFID have developed some type of problem with eating. As a result of the eating problem, the person isn’t getting adequate nutrition. There are many forms the eating problem could take – trouble digesting certain foods, avoiding certain colors or textures of food, eating only very small portions, having no appetite, or being afraid to eat after an episode of choking or vomiting.

In my private practice, the most common form of ARFID I diagnose and treat is when a child is afraid to eat due to fear of vomiting. This usually develops after an episode of vomiting at a time or location that was embarrassing or frightening to the child.

Sophie (not her real name) felt sick at school a few months prior to her meeting with me for the first time. She had tried to ignore the nausea, and went to lunch in the cafeteria with her friends. When at the lunch table with her peers, she vomited. Everyone saw. She felt humiliated. As a result of the scene in the cafeteria, Sophie was afraid to eat because she worried she would throw up. Her friends and parents were worried because Sophie was losing weight and eating very little.

Because kids with ARFID don’t derive enough nutrition through their diet, they may end up losing weight. Or, younger kids with ARFID might not lose weight, but rather may not grow as expected. Other individuals with ARFID might need supplements (like Ensure or Pediasure) to get enough nutrition.

Kids with ARFID may have problems at school or work because of their eating issues. They may avoid lunch with peers, not get schoolwork done because of the time it takes to eat, or even avoid seeing friends or family at social events where food is present.

A good example is of a ten year old boy, “Luke”, who almost choked on chicken nuggets one time, and now refuses to eat any type of solid food. He can’t eat school lunches or even enjoy a taste of his favorite snack.

How is ARFID different from anorexia or other eating disorders?

People with anorexia or bulimia struggle with distortions in how they see their body. Kids with ARFID typically don’t FEAR weight gain and don’t have a distorted body image

Filling in the gaps

Although ARFID is considered a new diagnosis, it is just a way of describing symptoms more specifically. A lot of people with eating disorders don’t “fit” perfectly into a diagnosis of anorexia nervosa or bulimia nervosa. Before the release of the DSM-V, clinicians would often give the diagnosis of Eating Disorder, Not Otherwise Specified (EDNOS). Unfortunately, if you say that someone has EDNOS, it doesn’t really give us much information about the person’s symptoms, other than that they have some kind of eating disorder.

In the past, before the DSM-V, kids with ARFID might have been diagnosed with EDNOS. They also could have been given another diagnosis called “Feeding Disorder of Infancy or Early Childhood” (although most clinicians didn’t use that diagnosis especially since one of its requirements was that the age of onset has to be before age six).
But what about children or adults with restrictive eating NOT related to fear of weight gain, who may or may not be a normal weight, and whose lives are impacted by their symptoms? This is where ARFID fills in the gaps and helps us to better understand those individuals.

As ARFID is officially a new diagnostic category, there is not much data available on its development, course, or prognosis. We do know that symptoms typically present in infancy or childhood, but they may also present or last into adulthood (especially if untreated).

It is possible that some individuals with ARFID may go on to develop another eating disorder, such as anorexia nervosa or bulimia nervosa, but again, no research is available yet to give a clear picture of what happens down the road for these individuals. We also are still learning about treatments for individuals with ARFID. Although research is just beginning, it is likely that behavioral interventions, such as forms of exposure therapy, may be useful. And of course, as in other eating disorders like anorexia or bulimia, treatment of underlying conditions such as anxiety or depression is crucial.

Many kids develop different or strange patterns of eating at some point in their life – refusing to eat vegetables for a few months, or wanting to eat only chicken nuggets for dinner – but for most individuals, the patterns eventually resolve on their own without intervention. For the small subset of individuals who have persistent or worsening problems with food ingestion, however, the introduction of ARFID means we are now able to better diagnose and describe their symptoms. This should result in better clinical outcomes.

Dr. Elayne Daniels

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