Avoidant Restrictive Food Intake Disorder (ARFID): Signs, Symptoms & Treatment

What is ARFID?

Avoidant Restrictive Food Intake Disorder (ARFID) is a feeding disturbance characterized by a persistent failure to meet appropriate nutritional or energy needs. ARFID shares many of the symptoms of anorexia nervosa but lacks body image disturbance.  However, ARFID can still lead to serious health consequences and medical complications.

ARFID was introduced in the DSM-5 and replaced both Selective Eating Disorder (SED) and Feeding Disorder of Infancy or Early Childhood. While ARFID has historically been seen in pediatric and adolescent patients, it is emerging as a common adult eating disorder diagnosis and it can affect those of any age.

Three subtypes of ARFID have been suggested and validated in the scientific literature: sensory, lack of interest, and fear of adverse consequences.

• Sensory: Individuals avoid certain types of food due to sensory features that cause a sensitivity or over-stimulation. Patients may be sensitive to smells, textures or appearance and color.
• Lack of interest: Individuals show little-to-no interest in food. Patients may forget to eat, have a low appetite, exhibit extreme pickiness, or regularly get distracted during mealtime.
• Fear of adverse consequences: Individuals who experience fear-based reactions to food. Patients may be afraid of choking, nausea, vomiting or pain.

It’s important to remember that the different types of ARFID are not exclusive, and patients can exhibit behaviors of multiple types at the same time.

Signs & Symptoms of ARFID

ARFID symptoms tend to self-perpetuate without intervention and do not resolve with time. Unlike eating disorders, like anorexia nervosa or bulimia, ARFID is not associated with distorted body image or a drive for thinness. Signs and symptoms of ARFID include:

• Sudden refusal to eat foods previously eaten
• Fear of choking, vomiting, pain or nausea due to certain foods or the act of eating
• Lack of appetite or low appetite without medical cause
• Very slow eating, easily distracted during eating or forgetting to eat

Medical Complications of ARFID

Few studies have evaluated medical complications of ARFID. The limited literature available suggests complications associated with ARFID may most closely mirror the medical complications of anorexia nervosa. Some of the more common complications associated with ARFID include:

• Loss of bone mineral density
• Bradycardia
• Amenorrhea
• Anemia
• Low blood sugar
•  Elevated liver function tests
• Bloating and gastrointestinal issues

With prompt treatment from experienced professionals, many of these complications can resolve and a full recovery is possible.

ARFID and Autism or Other Developmental Disabilities

Pediatric feeding disorders are common, with about 25% of children exhibiting symptoms, but are over three times as common in children with developmental disabilities. 80% of children with developmental disabilities experience feeding disorders.

Eating a limited diet is also commonly reported in individuals with autism, with ARFID patterns of feeding behavior considerably overlapping with autism symptoms and sensory experiences. Individuals on the autism spectrum may experience sensitivities to smells, tastes, textures and noises or may find situations or bodily sensations associated with eating uncomfortable or perceive them as harmful, causing distress during meals or digestion. Consistently aversive sensory experiences reinforce avoidance of certain foods or eating restriction.

Diagnosing ARFID

Avoidant/restrictive food intake disorder (ARFID) is categorized under feeding and eating disorders in the DSM-V. Providers should pay attention when a patient:

• Experiences significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
• Experiences significant nutritional deficiency
• Depends on enteral feeding or oral nutritional supplements

ARFID may be misdiagnosed as anorexia nervosa due to shared symptoms of low weight and malnutrition, as well as a lack of quality eating disorder treatment education. It’s important to determine whether body image distortion could be present, as the major difference between ARFID and anorexia nervosa is that patients with ARFID do not have a preoccupation with weight or shape.

Providers should consider one or more of the following tests or questions:

• Obtain and review history of patient’s eating habits
• Ask about patient’s views on body weight and shape to rule out anorexia nervosa, bulimia or any other related eating disorder
• Consider use of validated ARFID screening (NAIS, PARDI-AR-Q) or diagnostic (EDY-Q) tools
• Refer to a psychologist or psychiatrist with experience in treating eating disorders; look for the Certified Eating Disorder Specialist (CEDS) designation

Treatment of ARFID

Treatment can range from an outpatient multidisciplinary team treatment to inpatient medical hospitalization and encompasses every level of eating disorder care in between. Because ARFID is such a new diagnosis, there is little evidence supporting treatment strategies, however treatment goals for ARFID are similar to other eating disorders, including nutrition and weight restoration, which are most efficiently achieved through a multidisciplinary approach. Emerging modalities of treatment for ARFID include Cognitive Behavioral Therapy for ARFID (CBT-AR) and Family Based Therapy for ARFID (FBT-ARFID).

Severe complications as a result of ARFID can be deadly. Patients who have become medically compromised due to ARFID may require medical stabilization at a specialized unit for severe malnutrition to safely restore weight and nutrition as well as monitor for refeeding syndrome.

References

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Fifth ed. 2013, Arlington, VA: American Psychiatric Publishing.

• Zickgraf, H.F., et al., Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program. Int J Eat Disord, 2019. 52(4): p. 402-409.
• Schorr, M., et al., Bone mineral density and estimated hip strength in men with anorexia nervosa, atypical anorexia nervosa and avoidant/restrictive food intake disorder. Clin Endocrinol (Oxf), 2019. 90(6): p. 789-797.
• Makhzoumi, S.H., et al., Hospital course of underweight youth with ARFID treated with a meal-based behavioral protocol in an inpatient-partial hospitalization program for eating disorders. Int J Eat Disord, 2019. 52(4): p. 428-434.
• Middleman, A.B., B. Griffin, and L. DeShea, Menstrual Patterns Among Patients With Anorexia Nervosa and Avoidant/Restrictive Food Intake Disorder: Does "Junk Food" Play a Role? J Pediatr Adolesc Gynecol, 2021. 34(6): p. 811-814.
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