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What is ARFID? A Comprehensive Guide to ARFID Symptoms and Treatment

Avoidant Restrictive Food Intake Disorder, otherwise known as ARFID, is an Eating Disorder that is characterized by difficulty eating enough or enough variety of food to grow or maintain appropriate weight and nutrition. Some people with ARFID may rely on nutritional support such as supplements to help receive enough calories, vitamins and nutrients to maintain their health. This can lead to social issues or psychological issues such as extreme picky eating, difficulty eating in public or with other people which can impact mental health resulting in increased anxiety or depression. 

DSM-V Diagnostic Criteria for ARFID

  1. 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.
  2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
  3. 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.
  4. 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.

Subtypes of ARFID

Research on ARFID tends to be limited as it is a relatively new diagnosis. It previously replaced “Feeding disorder of infancy or early childhood”, which could only be diagnosed under the age of 6. At Integrated Care Clinic, we see children, teens, and adults with ARFID with a variety of presentations. There are hypothesized to be three subtypes of ARFID, and clients may have 1, 2 or all 3 subtypes. [1]

  1. Sensory Sensitivity: Clients who have this subtype are characterized by possible over sensitivity in what they perceive food may taste like as well as a lack of exposure or experience with variety of foods, as a result they stick to only the safe, comfortable foods they are able to eat and rarely venture beyond that 
  2. Lack of Interest in Food or Eating: Clients who have this subtype often report that they do not feel hungry at mealtimes, forget to eat, and feel full more quickly than others
  3. Fear of Aversive Consequences: Clients who experience this subtype sometimes report they have a fear of choking, or a specific fear associated with eating such as embarrassing themselves, fear of bugs in their food, trauma associated with food, or fear of vomiting if they eat a new or unfamiliar food. 

How is ARFID different from Anorexia Nervosa?

The main difference between ARFID and Anorexia Nervosa is the component of body image, specifically the presence or lack of an ‘intense fear of weight gain’. Clients with ARFID who struggle with low weight or underweight bodies tend to WANT to gain weight. They tend to see their low weight as a sign that something is wrong and that they appear ‘sick’, ‘too skinny’, or ‘ill’. Clients with ARFID are usually motivated to gain weight, so when providers set forth a treatment plan that involves weight gain, clients with ARFID are often relieved and occasionally excited to have help gaining weight. 

Clients with Anorexia Nervosa experience high levels of distress when tasked with gaining weight. There can be denial of the seriousness of the low weight or unaware of the seriousness of the disease, which is called anosognosia. As a result, when physicians, therapists, and dietitians set forth a treatment plan that involves weight gain or weight restoration, clients with Anorexia Nervosa become anxious, overwhelmed, or resistant. 

Medical Complications Associated with ARFID

Health and medical risks can range from mild to severe with ARFID. Complications associated with low weight and nutritional deficiencies can include the following. If you or your loved one is struggling with symptoms consistent with ARFID please seek out medical care to ensure long term damage isn’t being done. Some individuals have had such extreme complications as blindness from nutritional deficiencies and limited diet. 

  • Heart problems (low heart rate, arrhythmias, fainting, blood pressure issues)
  • Kidney or liver failure
  • Potassium or electrolyte imbalances
  • Gastrointestinal issues such as gastroparesis, constipation, bloating, GERD
  • Low bone density, osteoporosis or osteopenia
  • Vision problems
  • Hair loss or thinning hair

How do you treat ARFID?

ARFID can be treated in a variety of ways. It is important to understand what subtype of ARFID someone has prior to treating them. Those who struggle with Sensory Sensitivity may do well with Systematic Desensitization, Exposure Response Prevention, or sensory play. Those who have an overall Lack of Interest in Food or Eating may do well with regular eating schedules to stimulate appetite, appetite-enhancing medications, and hunger-fullness training. And those with a Fear of Aversive Consequences may do well with Cognitive Behavioral Therapy, Systematic Desensitization, and Exposure Response Prevention. 

The goal in the treatment of ARFID would be individualized based on the client’s needs and goals. If a client is of low weight, weight restoration will be part of treatment as being low weight can have a negative impact on cognitive development (e.g. processing speed, mood, irritability, anxiety) as well as physical development (e.g. bone health, digestion). If a client is struggling with inflexible eating patterns then treatment would be positioned around breaking food rules, expanding food choices, and decreasing sensory sensitivities. It is important to treat ARFID early as this level of inflexibility can also lead to other eating disorders such as Anorexia Nervosa or Bulimia Nervosa. 

It is important to select healthcare providers that are knowledgeable and skilled in treating ARFID, as eating disorders are a specialty field that requires additional training to become competent. 

Exploring the differences between ‘disgust’ and ‘fear’ when treating ARFID

Another important distinguishing factor in treating ARFID is to determine if the core emotion related to food is fear or disgust. With clients who experience high levels of fear, for example a fear of choking or a fear of not liking the texture of food, a therapist or dietitian might focus more on exposing the client to a variety of foods and developing food hierarchies to gradually reduce fears. Exposure Response Prevention is a type of systematic desensitization therapy that gradually has clients face their fears to experience the discomfort of novel stimuli (e.g. new food). 

If a client has more of a disgust feeling or reaction to food, then along with therapeutic interventions covered earlier, clients would develop a solid understanding of their own goals and their “personal why” to treating their ARFID. To be able to eat with others, to be able to go on that trip to Europe, to be able to sleep at a friend’s house, to go on a date. All relevant goals for individuals struggling with ARFID. 

Do I Have ARFID? An ARFID Screening Tool

The following is the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS) [2]. This screening tool is rated from Strongly Disagree to Strongly Agree, along a 6-point likert scale. Scores of 24 or above are considered to be a positive ARFID screening.  Here are the following questions: 

Strongly Disagree

0

Disagree

1

Slightly Disagree

2

Slightly Agree

3

Agree

4

Strongly Agree

5

 

  1. I am a picky eater
  2. I dislike most of the foods that other people eat
  3. The list of foods that I like and will eat is shorter than the list of foods I won’t eat
  4. I am not very interested in eating; I seem to have a smaller appetite than other people
  5. I have to push myself to eat regular meals throughout the day, or to eat a large enough amount of food at meals
  6. Even when I am eating a food I really like, it is hard for me to eat a large enough volume at meals
  7. I avoid or put off eating because I am afraid of GI discomfort, choking, or vomiting
  8. I restrict myself to certain foods because I am afraid that other foods will cause GI discomfort, choking, or vomiting
  9. I eat small portions because I am afraid of GI discomfort, choking, or vomiting

Does my child have ARFID?

ARFID can be diagnosed by a pediatrician, psychiatrist, a licensed therapist or psychologist, or a physician. Remember that ARFID is a relatively new diagnosis (within the past 10 years), so finding an eating disorder specialist will be crucial to determining if there are any other factors affecting your child’s eating. Furthermore, 63 percent of pediatricians and pediatric subspecialists were unfamiliar with the diagnosis of ARFID. So if you feel like you or your child have been seeking answers for these behaviors, consider seeking out a provider that has extensive experience in diagnosing and treating eating disorders.  You can look for the credentials of CEDS (Certified Eating Disorder Specialist) to ensure your provider is trained and specializes in eating disorders.

With regard to statistics on ARFID, it seems that boys are slightly more likely to develop ARFID compared to girls and as many as 5% of children could have ARFID [3]. ARFID tends to be more common in children and teens compared to the adult population, however adults can have ARFID. ARFID can also go hand-in-hand with other types of mental health conditions such as anxiety or obsessive-compulsive behaviors [4].

Adults with ARFID

ARFID is not a diagnosis specific to children and teens, adults can also have ARFID. Adults with ARFID may begin to feel more of the effects of their inflexible or avoidant eating patterns. Socially it may begin to affect their ability to socialize at work, feel relaxed around meals with others, or participate in typical activities that involve food such as birthdays, Thanksgiving, or 4th of July BBQs. Adults with ARFID may also report difficulty with dating, as dating also involves eating with others. Fears of gagging, choking, or other gastrointestinal issues may prevent adults with ARFID from enjoying life to the fullest. These behaviors may have been more socially overlooked when younger teens with ARFID can typically eat meals like chicken nuggets and french fries and not appear socially outcast. However as adults with ARFID, it may be more difficult to participate in social events if your pallet is limited. Additionally, ARFID can lead to the development of other eating disorders such as Anorexia Nervosa or Bulimia Nervosa, so it is important to seek help as soon as possible. 

ARFID Treatment at Integrated Care Clinic

At Integrated Care Clinic we can assess, diagnose, and develop a treatment plan that suits the needs of you or your loved one. Our team of Licensed Psychologists and Registered Dietitians will help you treat your ARFID using evidence based treatment and best practices. We will work closely with your physician or pediatrician for an integrated approach to treatment. 

Treatment for ARFID can last between 6 months to 2 years depending on a number of factors including length of illness, severity, level of flexibility, willingness or motivation for recovery, and personal goals they would like to achieve. The psychologists at Integrated Care Clinic are able to effectively help you or your loved one achieve more flexible eating at home and in public, help eliminate adverse consequences such as gagging while eating or fears of choking, as well as help clients diversify the foods they currently eat to better equip them for social and cultural connections. 

If you or your loved one may be struggling with an Eating Disorder or ARFID please give us a call at 727-490-8811 or book an appointment with one of our providers. https://integratedcareclinic.com/our-team/

References

[1] 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

[2] Zickgraf, Hana F., and Jordan M. Ellis. “Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns.” Appetite 123 (2018): 32-42.

[3] Norris, M. L., Spettigue, W., & Katzman, D. K. (2016). Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in children and youth. Neuropsychiatric Disease and Treatment, 12, 213-218.[4]

ARFID: Some new twists and some old themes. Ovidio Bermudez, MD, FAAP, FSAHM, FAED, F.iaedp, CEDS. (2016)

Dr. Winton is the owner and clinical director at Integrated Care Clinic. She is a licensed psychologist that specializes in eating disorders, body dysmorphia, food anxiety, body image, intuitive eating, and perfectionism.

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