AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (ARFID)
*** Disclaimer: The following article includes information derived from our clinical team’s impressions as specialized professionals working directly with Eating Disorders in Windsor/Essex County.
Avoidant/Restrictive Food Intake Disorder, commonly referred to by its acronym “ARFID”, is an eating disorder that few know to exist. ARFID appeared in previous editions of the diagnostic manual as “Selective Eating Disorder”, “Feeding Disorder”, “Failure to Thrive”, or “feeding/eating disturbances”, and was typically directed towards children. Now, ARFID is more clearly outlined as its own diagnosis, and is being recognized in adolescents and adulthood; the diagnostic criteria is no longer age-specific. However, it cannot be denied that ARFID does occur more frequently within child populations.
In the 2018-2019 year, we collected data on our active clients to determine how frequent each eating disorder diagnosis is at BANA. During this year, along with many others, there have been no diagnoses of ARFID within our client population. However, this does not necessarily mean that BANA’s intake department has not seen client’s with ARFID. Nor does this suggest that BANA does not work with this diagnostic population. Rather, because ARFID tends to be very unique from other eating disorders and has a very diverse range of presentations, it is likely that these clients are not referred to BANA as often, or the symptoms may be missed/overlooked. Furthermore, BANA works exclusively with the adult population; as noted above, ARFID tends to be more common with children. Therefore, it is likely these individuals received treatment before they reached adulthood and could access BANA programming.
The 5th rendition of the Diagnostic Statistical Manual (DSM-5) is the current guideline used in North America to diagnose all mental health disorders. It outlines the requirements that must be met in order to receive any diagnosis within its pages. It is important to note that because there is such a vast array of presentations in ARFID, many do not fit the criteria exactly but still may require support. It has been speculated that future DSM’s may include subtypes to assist in the identification of this disorder.
DSM-5 CRITERIA FOR AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER:
A) An eating or feeding disturbance (ex: Apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) – manifested by persistent failure to meet appropriate nutritional/energy needs, associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain/faltering growth in children)
- Significant nutritional deficiency
- Dependence on enteral feeding (intake via the G.I. tract, typically seen as a feeding tube) or oral nutritional supplements
- 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 during the course of Anorexia or Bulimia Nervosa, and there is no evidence of a disturbance in the way in which one’s body weight/shape is experienced
D) The eating disturbance is not attributable to a medical condition, or better explained by another mental disorder
PICKINESS VS. ARFID
ARFID is often seen by parents and professionals as “picky eating”, which can cause the disorder to be overlooked and left untreated. It is important to distinguish ARFID from picky eating so that these individuals can be connected with appropriate supports.
One key marker that helps to differentiate picky eating from ARFID is persistence; a “picky eater” may have food-preferences that change from time-to-time, and their nutrition and growth will likely remain unaffected. When eating disturbances are persistent and prolonged, and impact the individual’s nutritional needs and growth, this speaks more to ARFID. Finally, picky eaters still tend to be interested in food and report an appetite, whereas individuals with ARFID may have no interest in food and often do not report feeling hungry.
When differentiating ARFID from more normative disturbances in feeding/eating, eating disorder professionals recommend taking the following into account:
- Nutrition and growth (energy/nutrient intake, food variety, developmental growth, weight loss)
- Feeding/eating factors (feeding skills, appropriate age/developmental stage, ability to self-feed, ability to meet one’s own nourishment needs, the “feeding relationship”)
- Psycho-social functioning (feeding dynamics within family relationships, stress of the individual and family members, level of social eating, impact on quality of life)
The nature of restriction behind ARFID is quite different than that of other eating disorders. Unlike restriction seen in Anorexia and Bulimia Nervosa, restriction in ARFID is not driven by preoccupations surrounding weight/shape (see discussion of “Body Image & ARFID” below). If restriction is occurring in the individual, it is likely attributable to what can be referred to as “the 3 main influences”; these factors tend to be the driving forces behind feeding/eating disturbances:
- Low appetite à disinterest in food, low desire to eat, often report not being hungry
- Aversive eating experiences à historical events that may have included food in a negative way, or posed with unpleasant consequences (ex: fear of vomiting or choking)
- Sensory avoidance and/or sensitivity à aversion to certain characteristics of the food (ex: texture, smell, colour)
BODY IMAGE, ANOREXIA NERVOSA & ARFID
ARFID is a unique eating disorder, particularly because it excludes distortions in the way one’s weight/shape is experienced. Although individual’s with ARFID may have some body image concerns (which is typically normative across the general population), body image is not a driving factor for distress, disruption of functioning, or influenced intake as it would be for other eating disorder diagnoses.
For example: in Anorexia Nervosa, diagnostic criteria requires that the individual not only has fears about weight gain/”fatness”, but that the individual also has a distorted view of these concepts. As you can see above, ARFID does not necessitate either of these criteria for a diagnosis.
It is common that ARFID is mistaken for Anorexia Nervosa due to what seems like shared symptoms (weight loss, restriction). However, these are important diagnoses to differentiate because challenging the fear of “fatness” is pertinent to the treatment of Anorexia, but would not typically be addressed in ARFID treatment regimens.
ARFID is very often misunderstood, can be excused as “picky eating”, or may be incorrectly diagnosed as Anorexia Nervosa. These factors could account for why ARFID appears to be somewhat rare, as professionals or the individual’s themselves may struggle to identify and/or correctly classify symptoms. If any of the criteria outlined in this article hit-home, but you’re not sure if they meet all the requirements for a diagnosis, do not hesitate to contact us through general intake. We can meet with you to discuss potential symptoms, and can support you through some of your concerns.
Our general intake number is: 1-855-969-5530
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and treatment of avoidant/restrictive food intake disorder (ARFID) in adolescents. Current pediatrics reports, 6(2), 107-113.
National Eating Disorders Association. (2018). Anorexia nervosa. Retrieved from https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
Porter, D. (2020). Avoidant restrictive food intake disorder DSM-5 307.59. Retrieved from https://www.theravive.com/therapedia/avoidant-restrictive-food-intake-disorder-dsm–5-307.59
The NEDIC, & Wong, G. (2019). Webinar: Understanding ARFID. Retrieved from https://www.youtube.com/watch?v=ckPY468z-_w
Zickgraf, H. F., Lane‐Loney, S., Essayli, J. H., & Ornstein, R. M. (2019). Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program. International Journal of Eating Disorders, 52(4), 402-409.