Avoidant/Restrictive Food Intake Disorder (ARFID)

What Is ARFID?

ARFID (Avoidant Restrictive Food Intake Disorder) is an eating disorder that limits the types of food an individual eats. Unlike many other eating disorders, such as anorexia nervosa or bulimia nervosa, ARFID is not motivated by body image issues.

Individuals with ARFID may struggle to eat for one of the following reasons:

• Having a lack of interest in eating
• Avoiding many foods due to their texture, taste, color, or smell
• Anxiety or fear that eating may lead to choking or throwing up

ARFID is also sometimes referred to as “selective eating disorder” because the patient may only have a select amount of foods they feel are “safe.” The restrictive eating habits of ARFID can sometimes lead to weight loss and malnutrition, increasing the risk of other health complications if untreated.

Although ARFID is listed in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), it is a relatively new diagnosis. The first mention of ARFID was in the 2013 release of the DSM-5.

Comparing ARFID and Other Eating Disorders

ARFID may appear similar to other restrictive eating disorders like anorexia, but the reason for restriction is not the same. Many people with eating disorders like bulimia and anorexia are concerned with their weight and body image, causing them to restrict or purge foods they eat.

On the other hand, people with ARFID may restrict their food intake due to a lack of interest in eating, fear of choking or vomiting, or anxiety towards certain foods due to sensory issues.

It’s possible for those with ARFID to also have another eating disorder related to their body image, which would necessitate an additional diagnosis. Body image issues and body dysmorphia are not listed within the diagnostic criteria for ARFID.

How Common Is ARFID?

ARFID was first defined in 2013 with the release of the DSM-5. While the condition obviously existed before 2013, research on its prevalence within the population remains ongoing. That being said, there is some data on the prevalence of the disorder.

• According to research published in the journal Neuropsychiatric Disease and Treatment, an estimated 3.2% of the general population suffers from ARFID. In addition, 14% to 22.5% of children in pediatric treatment programs met the criteria for ARFID.
• A study from Massachusetts General Hospital found that of the 410 participants, ARFID symptoms were present in 23.6% of patients, with 6.3% meeting all DSM-5 criteria for ARFID and 17.3% potentially having ARFID.

Causes and Risk Factors of ARFID

The exact cause of ARFID is not currently known, especially considering it is a relatively newer diagnosis. However, researchers have identified several risk factors associated with its development.

Current research indicates a mixture of genetic factors, mental health conditions, medical conditions, and environmental factors may cause ARFID.

Genetic Factors

Similar to other eating disorders, certain genes passed down by your parents can play a role in the development of ARFID. If an individual has parents, siblings, or other family members with a history of ARFID or other eating disorders, you may be more likely to develop the condition.

Psychological Factors

Certain mental health conditions have been identified as common risk factors or co-occurring conditions, such as autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety disorders, and depression.

Sensory sensitivities can play a large role in the development of ARFID, causing certain foods or entire food groups to be “off limits” for people with ARFID. These sensitivities can make ARFID patients fearful of new foods, sometimes even leading to phobias like food neophobia (fear of new foods).

Traumatic experiences related to choking, vomiting, force-feeding, and food insecurity can also contribute to ARFID.

Environmental Factors

Early childhood trauma and negative family dynamics also contribute to the development of ARFID. As mentioned before, traumatic experiences related to food can increase someone’s risk for ARFID.

Certain traumatic experiences that may contribute to ARFID include:

• Food insecurity due to neglect or poverty
• Force-feeding at the hand of a parent or caretaker
• Trauma from choking or vomiting due to certain foods

Medical Factors

Certain medical conditions can contribute to ARFID for various reasons, from physical changes and discomfort to shifts in metabolism.

Common medical conditions that may lead to the development of ARFID include:

• Gastrointestinal issues, such as irritable bowel syndrome, Crohn’s disease, GERD (gastroesophageal reflux disease)
• Food allergies
• Food intolerances

Symptoms of ARFID

Spotting symptoms of ARFID is important, especially when present in children. If left untreated, ARFID can lead to malnutrition and other health issues as a result.

Common symptoms of ARFID include:

• Food avoidance or aversion towards foods with certain textures, tastes, colors, and smells
• Only eating a very narrow, limited variety of foods
• Increased anxiety and fear around mealtimes
• Fear of choking or vomiting from certain foods
• Significant weight loss
• Food restrictions leading to nutritional deficiency
• Constipation and abdominal cramping
• Dizziness and fainting
• Body hair being very fine
• Low body temperature
• Lethargy and unexplained tiredness
• Irregular menstrual cycles
• Muscle weakness

How Is ARFID Diagnosed?

ARFID is typically diagnosed by a mental healthcare provider or eating disorder specialist.

Diagnosis begins with an interview and may include testing through a number of diagnostic questionnaires, including:

• Eating Pathology Symptoms Inventory (EPSI)
• Eating Disturbances in Youth–Questionnaire (EDY–Q)
• Pica, ARFID, and Rumination Disorder Interview (PARDI)
• Eating Disorder Assessment for DSM-5 (EDA-5)
• Nine-Item ARFID Screen (NIAS)

A medical exam may be required to rule out other medical causes of food avoidance. The most common types of medical examinations are urine tests, blood tests, and physical examinations.

Given no medical causes are found, your healthcare provider will use the DSM-5 to determine if you meet the criteria for ARFID or any other eating disorder. A diagnosis will be made, and the best treatment approach will be recommended.

Is ARFID the Same as Picky Eating?

No. While someone with ARFID may appear to simply be a picky eater, the condition has far more serious implications. Individuals with ARFID have consistently disordered eating patterns and, in severe cases, may struggle to meet their own nutritional needs due to the condition.

Picky eaters may also struggle with certain foods, but they seldom avoid foods that jeopardize their health and well-being. If they start to lose body weight or exhibit the symptoms of ARFID, they should seek help from a health professional.

ARFID and Co-Occurring Conditions

Co-occurring conditions are common with ARFID, especially in individuals who have sensory issues or anxiety about eating. In many cases, addressing these co-occurring conditions is essential to treating ARFID due to the overlap and connection between symptoms.

ARFID and Substance Abuse

Sadly, there is a risk of substance abuse for individuals with ARFID. Individuals with eating disorders already have an increased risk of substance abuse issues. ARFID can be a very isolating disorder and can cause or worsen symptoms of anxiety and depression.

As these symptoms worsen, individuals with ARFID may choose to self-medicate with drugs or alcohol. Compulsive behaviors are also common in those who have ARFID, leading to the compulsive use of substances.

In addition, many ARFID patients also have ADHD, which is typically treated through the use of stimulants. Stimulants are safe and effective when used as prescribed but do come with risks for misuse and abuse.

ARFID and Mental Health Conditions

One of the most common co-morbidities with ARFID is autism spectrum disorder. A study from the University of Iowa found that people struggling with 13% of people with ARFID also had autism. It’s believed that this co-morbidity is related to the sensory issues common in autism.

In addition, anxiety and traumatic experiences are other considerable factors for ARFID. One study from Massachusetts General Hospital discovered that as many as 50% of participating patients with ARFID also had a generalized anxiety disorder.

Other mental health conditions that often co-occur with ARFID include:

• Attention deficit hyperactivity disorder (ADHD)
• Obsessive-compulsive disorder (OCD)
• Anxiety disorders
• Depression

Effects of ARFID

ARFID can have serious effects on your health when untreated, especially those of children and adolescents in puberty. The condition can also have negative effects on adults, as well. For that reason, diagnosis and treatment are essential for avoiding life-threatening issues.

Physical Effects

The most obvious effect of ARFID is weight loss and malnutrition. However, ARFID can also cause other physical effects.

Common physical effects of ARFID include:

• Malnutrition
• Requiring nutritional supplements or tube feeding for adolescents
• Hormone imbalances
• Electrolyte imbalances
• Dehydration
• Delayed puberty
• Stunted growth or changes in growth
• Low blood pressure
• Irregular menstrual cycles
• Osteoporosis
• Cardiac arrest

Psychological Effects

ARFID can also have negative effects on mental health, worsening the fear and anxiety often associated with the disorder.

Common psychological effects of ARFID include:

• Anxiety
• Panic attacks
• Depression
• Social isolation
• Withdrawal from friends and loved ones
• Struggling to keep up with school or work
• Thoughts of self-harm or suicide

ARFID Treatment Options

Several treatments have been proven effective in treating ARFID. The most common and effective form of treatment is cognitive behavioral therapy (CBT) or similar psychotherapies.

CBT can help patients modify thoughts and behaviors that cause food avoidance and build strategies to combat anxiety. For children with ARFID, family therapy can help parents better understand their child’s anxieties and support them at home.

In some cases, exposure therapy to off-limit foods may be helpful. However, exposure therapy should only be done at the direction of a mental healthcare provider in order to avoid traumatizing the patient and worsening their aversion and fear.

Nutritional counseling and meal planning can also help treat and manage ARFID. By working with a nutrition expert, ARFID patients can learn what foods provide the necessary nutrients and modify their safe foods to be more nutritional.

Medications may also help patients with ARFID, especially if co-occurring mental health conditions are present. Antidepressants, anti-anxiety medications, anti-psychotics, and stimulants are common medications that may be used to treat symptoms that worsen ARFID.

Finding Help for ARFID

ARFID is a complex, challenging eating disorder to treat, especially considering how recently it was recognized as a disorder. The symptoms of ARFID can leave children and adults feeling socially isolated and fearful of eating. Thankfully, there are several treatments available.

Start by talking to your doctor, pediatrician, or mental health provider about your or your child’s symptoms. The National Alliance for Eating Disorders hotline at 1-866-662-1235 can help you find treatment options and support groups.

If you’re seeking a treatment center, you can also use SAMHSA’s online treatment locator or 1-800-662-4357 to learn what eating disorder treatment is offered in your area.