Avoidant Restrictive Food Intake Disorder (ARFID)

Reviewed by Kamryn Eddy, PhD

Avoidant/Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5, and represents a reformulation of what used to be called “Feeding Disorder of Infancy or Early Childhood.”1 Individuals with ARFID limit the volume and/or variety of foods they consume, but unlike the other eating disorders, food avoidance or restriction is not related to fears of fatness or distress about body shape, size or weight. Instead, in ARFID, selective eating is motivated by a lack of interest in eating or food, sensory sensitivity (e.g., strong reactions to taste, texture, smell of foods), and/or a fear of aversive consequences (e.g., of choking or vomiting).2

While there is limited research on the prevalence of ARFID, studies have found that between 0.5%-5% of children and adults in the general population have the disorder.3 Though ARFID most commonly develops during infancy or early childhood, it can persist into adulthood or develop at any age.3,4

Although many children go through phases of picky or selective eating, a person with ARFID has a diet that is so limited it leads to medical, nutritional, and/or psychosocial problems.5 This may mean weight loss, or stalled growth; significant nutritional deficiencies that will vary based on diet; and interference in relationships or engagement in school or work due to difficulties eating.5  

Diagnostic Criteria


According to the DSM-5 TR, ARFID is diagnosed when:4

  • 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:
    • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
    • Significant nutritional deficiency.
    • Dependence on enteral feeding or oral nutritional supplements.
    • 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 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.

Risk Factors


As with all eating disorders, the risk factors for ARFID are suspected to involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people, which means two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Emerging longitudinal research is examining factors that may increase vulnerability to the development of ARFID. Most of what is known currently is based on cross-sectional data, that is, from studies of individuals who have already been diagnosed with ARFID. Here’s what we know:

  • Children who don’t outgrow normal picky eating, or in whom picky eating is severe, appear to be more likely to develop ARFID.6
  • People with certain medical conditions that make eating uncomfortable, or developmental disorders such as autism may be more likely to develop ARFID.4,5
  • Comorbid conditions, such as autism spectrum disorder, ADHD, anxiety disorders, and depression, are common amongst those with ARFID.4
  • While ARFID cannot be diagnosed if another eating disorder such as anorexia nervosa or bulimia nervosa, for example, is present, some people with ARFID can develop weight and shape concerns, and a small portion of these will transition from ARFID to another eating disorder over time.4,7

Warning Signs and Symptoms of ARFID


Behavioral and psychological signs:4

  • Although weight loss is not always present in ARFID, dramatic weight loss or faltering growth can signal restrictive eating
  • Dresses in layers to hide weight loss or stay warm
  • Reports constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
  • Reports consistent, vague gastrointestinal issues (“upset stomach”, feels full, etc.) around mealtimes that have no known cause
  • Dramatic restriction in types or amount of food eaten
  • Will only eat certain textures of food
  • Fears of choking or vomiting
  • Lack of appetite or interest in food
  • Limited range of preferred foods that becomes narrower over time (i.e., picky eating that progressively worsens).
  • Body image disturbance or fear of weight gain do not drive restrictive eating patterns

Physical signs:4,8,9,10

Physical effects of ARFID are highly variable based on the individual’s pattern of eating. Some—but certainly not all—will experience physical signs and medical consequences of starvation, akin to anorexia nervosa:

  • Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
  • Menstrual irregularities—missing periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
  • Difficulties concentrating
  • Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
  • Postpuberty female loses menstrual period
  • Dizziness
  • Fainting/syncope
  • Feeling cold all the time
  • Sleep problems
  • Dry skin
  • Dry and brittle nails
  • Fine hair on body (lanugo)
  • Thinning of hair on head, dry and brittle hair
  • Muscle weakness
  • Cold, mottled hands and feet or swelling of feet
  • Poor wound healing
  • Impaired immune functioning

Health Consequences of ARFID


Health consequences of ARFID will be highly variable depending on the individual’s diet composition and eating pattern. For some individuals who limit the overall volume of food, they may lose weight and experience consequences of starvation similar to those for individuals with anorexia nervosa. Others may keep their weight at or above a normal weight and experience minimal health consequences. Those with a highly selective diet in which they are avoiding multiple foods or categories of foods (e.g., fruits, vegetables, proteins) may experience significant deficiencies of key nutrients that can have a range of subsequent effects.5

Treatment Considerations


Treating ARFID requires working with a multidisciplinary team of health and mental health professionals who ideally have expertise in treating this specific type of eating disorder. This treatment team may include a physician, psychiatrist, psychotherapist, and dietician to address the mental, physical and nutritional impact of the disorder. Since ARFID is a relatively newer diagnosis there is limited research on the effectiveness of different treatment modalities, however most outpatient treatment for ARFID includes some form of family-based therapy, cognitive behavioral therapy, or parent-based behavioral approaches.11 More recent studies have found some evidence to support the effectiveness of several treatment approaches including but not limited to:

  • Cognitive Behavioral Therapy for ARFID (CBT-AR) – involves short-term, symptom-oriented therapy focusing on the beliefs, values, and cognitive processes that maintain the eating disorder. For example, one type of CBT-AR consists of 20–30 sessions which include psycho-education, treatment planning, addressing the mechanisms maintaining ARFID symptoms, and strategies for prevention of relapse. Case studies have found CBT-AR to be effective in reducing the severity of ARFID symptoms in adolescent patients.12
  • Family Based Therapy for ARFID (FBT-ARFID) – includes participation from family members, including chosen family and seeks to empower them to help their loved ones re-establish healthy eating and reduce the symptoms of the disorder (i.e. lack of interest, sensory sensitivities, fear of aversive consequences). Several studies have found this approach helpful in reducing symptom severity, restoring weight, and increasing parental self-efficacy in re-feeding their child.13
  • Supportive Parenting for Anxious Childhood Emotions for ARFID (SPACE-ARFID)– seeks to help parents respond to their child’s problematic eating habits and encourage greater food flexibility. Studies have found this approach helpful in reducing the severity and level of impairment of ARFID symptoms.14

No matter what treatment modality one chooses, it is essential to seek professional help as soon as possible given the serious physical and psychological consequences that can result from ARFID. Early intervention has also been shown to be an important factor in improving treatment outcomes.

Learn more about treatment here.
Learn more about finding treatment providers in your area here.

Sources


[1] Harshman, S. G., Wons, O., Rogers, M. S., Izquierdo, A. M., Holmes, T. M., Pulumo, R. L., Asanza, E., Eddy, K. T., Misra, M., Micali, N., Lawson, E. A., & Thomas, J. J. (2019). A Diet High in Processed Foods, Total Carbohydrates and Added Sugars, and Low in Vegetables and Protein Is Characteristic of Youth with Avoidant/Restrictive Food Intake Disorder. Nutrients, 11(9), 2013. https://doi.org/10.3390/nu11092013

[2] Kambanis, P. E., Kuhnle, M. C., Wons, O. B., Jo, J. H., Keshishian, A. C., Hauser, K., Becker, K. R., Franko, D. L., Misra, M., Micali, N., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2020). Prevalence and correlates of psychiatric comorbidities in children and adolescents with full and subthreshold avoidant/restrictive food intake disorder. The International journal of eating disorders, 53(2), 256–265. https://doi.org/10.1002/eat.23191

[3] Kennedy, H. L., Dinkler, L., Kennedy, M. A., Bulik, C. M., & Jordan, J. (2022). How genetic analysis may contribute to the understanding of avoidant/restrictive food intake disorder (ARFID). Journal of eating disorders, 10(1), 53. https://doi.org/10.1186/s40337-022-00578-x

[4] American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787 

[5] Thomas, J. J., Lawson, E. A., Micali, N., Misra, M., Deckersbach, T., & Eddy, K. T. (2017). Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Current psychiatry reports, 19(8), 54. https://doi.org/10.1007/s11920-017-0795-5

[6] Diamantis, D. V., Emmett, P. M., & Taylor, C. M. (2023). Effect of being a persistent picky eater on feeding difficulties in school-aged children. Appetite, 183, 106483. https://doi.org/10.1016/j.appet.2023.106483

[7] Becker, K. R., Breithaupt, L., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2020). Co-occurrence of Avoidant/Restrictive Food Intake Disorder and Traditional Eating Psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry, 59(2), 209–212. https://doi.org/10.1016/j.jaac.2019.09.037

[8] Kambanis, P. E., Harshman, S. G., Kuhnle, M. C., Kahn, D. L., Dreier, M. J., Hauser, K., Slattery, M., Becker, K. R., Breithaupt, L., Misra, M., Micali, N., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2022). Differential comorbidity profiles in avoidant/restrictive food intake disorder and anorexia nervosa: Does age play a role?. The International journal of eating disorders, 55(10), 1397–1403. https://doi.org/10.1002/eat.23777

[9] Aulinas, A., Marengi, D. A., Galbiati, F., Asanza, E., Slattery, M., Mancuso, C. J., Wons, O., Micali, N., Bern, E., Eddy, K. T., Thomas, J. J., Misra, M., & Lawson, E. A. (2020). Medical comorbidities and endocrine dysfunction in low-weight females with avoidant/restrictive food intake disorder compared to anorexia nervosa and healthy controls. The International journal of eating disorders, 53(4), 631–636. https://doi.org/10.1002/eat.23261

[10] Murray, H. B., Kuo, B., Eddy, K. T., Breithaupt, L., Becker, K. R., Dreier, M. J., Thomas, J. J., & Staller, K. (2021). Disorders of gut-brain interaction common among outpatients with eating disorders including avoidant/restrictive food intake disorder. The International journal of eating disorders, 54(6), 952–958. https://doi.org/10.1002/eat.23414

[11] Shimshoni, Y., & Lebowitz, E. R. (2020). Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach. Journal of cognitive psychotherapy, 34(3), 200–224. https://doi.org/10.1891/JCPSY-D-20-00009

[12] Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G., Wons, O. B., Keshishian, A. C., Hauser, K., Breithaupt, L., Liebman, R. E., Misra, M., Wilhelm, S., Lawson, E. A., & Eddy, K. T. (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents. The International journal of eating disorders, 53(10), 1636–1646. https://doi.org/10.1002/eat.23355

[13] Van Wye, E., Matheson, B., Citron, K., Yang, H. J., Datta, N., Bohon, C., & Lock, J. D. (2023). Protocol for a randomized clinical trial for Avoidant Restrictive Food Intake Disorder (ARFID) in low-weight youth. Contemporary clinical trials, 124, 107036. https://doi.org/10.1016/j.cct.2022.107036

[14] Shimshoni, Y., Silverman, W. K., & Lebowitz, E. R. (2020). SPACE-ARFID: A pilot trial of a novel parent-based treatment for avoidant/restrictive food intake disorder. The International journal of eating disorders, 53(10), 1623–1635. https://doi.org/10.1002/eat.23341