Avoidant/Restrictive Food Intake Disorder (ARFID)

Primer

Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding and eating disorder characterized by avoidance or restriction of food intake, resulting in clinically significant failure to meet requirements for nutrition or insufficient energy intake through oral intake of food.[1]

Epidemiology
  • The prevalence is not well understood, but estimated to be around 1.5%.[2]
  • It is equally common in males and females during infancy and early childhood.
    • ARFID with comorbid autism spectrum disorder has a male predominance however.[3]
Prognosis
  • Food avoidance or restriction associated with insufficient intake or lack of interest in eating commonly develops in infancy or early childhood.
    • Avoidance based on sensory characteristics of food tends to begin in the first decade of life but can continue into adulthood.[4]
  • Malnutrition from ARFID may be associated with growth delay, development delay, and learning difficulties.[5]
  • Regardless of age, family function can be affected, with increased stress at mealtimes and other feeding or eating contexts involving friends and family.[6]
Comorbidity
  • There is currently insufficient evidence directly linking avoid ant/restrictive food intake disorder and subsequent onset of an eating disorder.
Risk Factors
  • Anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder (OCD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD) can increase risk for ARFID, or the characteristics of the disorder.[7]
  • Children of mothers with eating disorders are at increased risk.[8]
  • A history of gastrointestinal issues, gastroesophageal reflux (GERD), and vomiting are associated with ARFID.[9]

DSM-5 Diagnostic Criteria

Criterion 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 at least 1 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
Criterion B

The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

Criterion 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.

Criterion 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.

Specifiers

Remission Specifier

Specify if:

  • In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time.

Signs and Symptoms

  • Infants and young children may not engage with the primary caregiver during feeding or communicate hunger.
  • In older children and adolescents, the avoidance or restriction may be associated with more non-specific emotional difficulties that do not meet the full diagnostic criteria for an anxiety, depressive, or bipolar disorder.
    • This is sometimes referred to as “food avoidance emotional disorder.”[10]
  • In some individuals (in particular in those with autism spectrum disorder), the food avoidance or restriction may be based on the sensory qualities of food (e.g. - the individual has an extreme sensitivity to the appearance, colour, smell, texture, temperature, or taste of the food).
    • This is termed “restrictive eating,” “selective eating,” “perseverant eating,” “chronic food refusal,” “choosy eating,” and “food neophobia” and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others.
  • Food avoidance or restriction can also be a conditioned negative response associated with food intake following (or in anticipation of) an aversive experience such as choking
    • Other aversive experiences may involve medical traumatic investigation (e.g. - esophagoscopy) or repeated vomiting.
    • The terms functional dysphagia and globus hystericus have also been used to describe this presentation.[11]

Screening and Rating Scales

Pathophysiology

Differential Diagnosis

Appetite loss preceding restricted intake is a non-specific symptom that can accompany a number of mental disorder diagnoses. Thus ARFID can be diagnosed concurrently with any of the disorders below if all criteria are met, and if the eating disturbance requires specific clinical attention.

  • Other medical conditions
    • Restriction of food intake can occur in other medical conditions especially those with ongoing symptoms such as vomiting, loss of appetite, nausea, abdominal pain, or diarrhea.
    • This includes congenital abnormalities, gastrointestinal disease, food allergies and intolerances, and occult malignancies.[12]
    • A diagnosis of ARFID requires that the disturbance of intake is beyond that consistent with the physical symptoms of the medical condition. The eating disturbance may also persist after being triggered by a medical condition and after resolution of the medical condition.
    • Since older adults, postsurgical patients, and individuals on chemotherapy can often lose their appetite, an additional diagnosis of ARFID is only given if the disturbance is a primary focus for intervention.[13]
  • Specific neurological/neuromuscular, structural, or congenital disorders and conditions associated with feeding difficulties
    • Feeding difficulties are common in a number of congenital and neurological conditions often related to problems with oral, esophageal, or pharyngeal structure and function. This includes hypotonia of musculature, tongue protrusion, and unsafe swallowing. ARFID can be diagnosed in individuals with such presentations as long as all diagnostic criteria are met.
  • Reactive attachment disorder (RAD)
    • Some withdrawal is characteristic of RAD and can lead to a disturbance in the caregiver-child relationship that can affect feeding and the child's oral intake. Thus, ARFID should be diagnosed only if full criteria are met for both disorders and the feeding disturbance is a primary focus for intervention.
  • Autism spectrum disorder (ASD)
    • Individuals with ASD often have rigid eating behaviours and heightened sensory sensitivities. However, these features do not always result in the level of impairment that would be required for a diagnosis of ARFID. ARFID should be diagnosed additionally only if all criteria are met for both disorders and when the eating disturbance requires specific treatment.
  • Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders.
    • Specific phobia, other type, describes “situations that may lead to choking or vomiting” and can represent the primary trigger for the fear, anxiety, or avoidance required for diagnosis. Distinguishing specific phobia from avoidant/restrictive food intake disorder can be challenging when a fear of choking or vomiting has resulted in food avoidance. Although avoidance/restriction of food intake secondary to a fear of choking or vomiting can be seen as specific phobia, in situations when the eating problem becomes the primary focus of clinical attention, ARFID becomes the most appropriate diagnosis.
    • In social anxiety disorder, the individual may present with a fear of being observed by others while eating, which can also occur in ARFID.
  • Anorexia nervosa
    • Restriction of energy intake relative to requirements leading to significantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also have a fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in ARFID, and the two disorders should not be diagnosed concurrently. The diagnosis between ARFID and anorexia nervosa can be difficult in late childhood and early adolescence since these disorders may share a number of common symptoms (e.g. - food avoidance, low weight). Individuals with anorexia nervosa may also deny any fear of fatness but nonetheless engage in persistent behaviors that prevent weight gain and who do not recognize the medical seriousness of their low weight (sometimes termed “non-fat phobic anorexia nervosa”). Given the complexity of distinguishing between the two, a longitudinal consideration of symptoms, course, psychosocial history, and family history is important. These diagnosis may best made in the context of a clinical relationship over time. In some individuals, ARFID might precede the onset of anorexia nervosa.[14]
  • Obsessive-compulsive disorder (OCD)
    • Individuals with OCD may have avoidance or restriction of intake in relation to preoccupations with food or ritualized eating behavior. ARFID should be diagnosed concurrently only if all criteria are met for both disorders and when aberrant eating is a major aspect of the clinical presentation requiring specific intervention.
  • Major depressive disorder (MDD)
    • In MDD, appetite may be affected to such a degree that individuals present with significantly restricted food intake. Usually the appetite loss and reduction of intake resolve with improvement in mood. Thus, ARFID should only be diagnosed concurrently if full criteria are met for both disorders and when the eating disturbance requires specific treatment.
  • Schizophrenia spectrum disorders
    • Individuals with schizophrenia, delusional disorder, or other psychotic disorders may exhibit unusual or odd eating behaviors. For example, avoidance of specific foods because of delusional beliefs, or other manifestations of avoidant or restrictive intake may occur. ARFID should be diagnosed concurrently only if all criteria are met for both disorders and when the eating disturbance requires specific treatment.
  • Factitious disorder or factitious disorder imposed on another
    • ARFID should be differentiated from factitious disorder or factitious disorder imposed on another. In order to assume the sick role, some individuals with factitious disorder may intentionally describe diets that are much more restrictive than those they are actually able to consume, as well as complications of such behaviour (e.g. - describing enteral feedings or nutritional supplements, inability to tolerate a normal foods, and/or inability to participate in age-appropriate situations involving food). The descriptions and presentation may be impressively dramatic and engaging, and the symptoms reported inconsistently. In factitious disorder imposed on another, the caregiver describes symptoms consistent with ARFID and may induce physical symptoms on another such as failure to gain weight. As with any diagnosis of factitious disorder imposed on another, the caregiver receives the diagnosis rather than the affected individual, and diagnosis should of course be made only on the basis of a careful and comprehensive assessment.[15]

Investigations

  • If there is evidence of malnutrition such low weight or growth delay, then appropriate investigations should be ordered.[16]

Physical Exam

  • As clinically indicated.

Treatment

  • Psychoeducation, family therapy, and cognitive behavioural therapy are indicated.
  • For those with sensory aversions, a food hierarchy can be effective.

Guidelines

Resources

For Patients
For Providers
Articles
Research

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M., ... & Becker, A. E. (2015). Prevalence of DSM‐5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. International Journal of Eating Disorders, 48(5), 464-470.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
14) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
16) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.