The introduction of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)1 has markedly increased the relevance of eating disorders outside the realm of the familiar diagnoses of anorexia nervosa (AN) and bulimia nervosa (BN). Prior to the publishing of the new manual, disorders outside of AN and BN were specified as eating disorder not otherwise specified (EDNOS). EDNOS was a complex categorization of symptoms that did not fit directly with AN or BN but still caused “clinical impairment in development and function and were at risk for severe medical complications.”2 Some of these patients did not endorse body image or weight-gain fears, such as those congruent with AN and BN diagnoses. Before the DSM-5,1 EDNOS acted as a catch-all diagnosis for those with symptoms that did not meet criteria for an established disorder.
The DSM-51 revised criteria for eating disorders, with the goal of reducing the number of EDNOS diagnoses, as they accounted for almost 50% of total eating disorder diagnoses.3 Within this objective, criteria for AN were adapted, removing the amenorrhea and weight criteria while increasing focus on behavioral symptomology. BN criteria changed as well, reducing the frequency of binge eating and compensatory behaviors to 1 time per week, as opposed to the original 3 times. Binge-eating disorder was also recognized as a disorder in and of itself. Most notably, avoidant/restrictive food intake disorder (ARFID) was added to describe the disordered patient demonstrating restrictive eating and malnutrition but without the fear of weight gain or body image disturbance that is evident in AN and BN.3 The development of the AFRID diagnosis was manifested as an update of the feeding and eating disorders of infancy and early childhood (FEDIEC), which had an age limit of 6 years or younger.4 In early research by Watkins and Lask,5 atypical childhood-onset eating disorders with similar etiologies as ARFID were classified as several different disorders: food avoidance emotional disorder, selective eating, and functional dysphagia.5 Food avoidance emotional disorder is detailed as a mood disturbance (depression, anxiety) causing food avoidance or weight loss. Selective eating is a disorder that describes the patient as having very little variety in food intake, with efforts to change met with high resistance and anxiety. Functional dysphagia causes a large avoidance of food, particularly from the intense fear of choking or vomiting. Preoccupations with weight concerns are not evident in these diagnoses.5 FEDIEC, misdiagnosed AN, and EDNOS, including atypical childhood-onset eating disorders, all have symptoms that could be used to diagnose patients with ARFID.4
Diagnosis and Diagnostic Criteria
The DSM-51 has four distinct criteria to meet for an ARFID diagnosis. Criteria A demonstrates an eating or feeding disturbance associated with at least one the following: significant weight loss or failure to grow, significant nutritional deficiency, dependence on enteral feeding or oral supplements such as a nutritional formula, and a marked change in functioning due to the inability to eat sufficiently. In this case, a feeding disturbance could be caused by the sensory characteristics of the food as well as a fear of consequences from eating. Criteria B demonstrates that the interference with eating is not due a cultural or religious practice or due to availability of food. Criteria C, perhaps one that requires more discussion, demonstrates that the feeding disturbance is not due to another eating disorder such as AN or BN. This would be evident in the lack of preoccupation with body weight or appearance. Similar to criteria B and C, criteria D demonstrates that the feeding disturbance is not due to another medical or psychiatric condition that may better explain the symptoms.1,4
Although there are clearly outlined criteria, there are a lack of tools used to measure these behaviors. Currently there are validated self-report tools used to measure fear of choking, phobia of vomiting, food motivation, and appetite, all of which are symptoms of ARFID but are not used explicitly for the diagnosis itself. However, within these measurement tools, there is some evidence to suggest that these symptoms may lead to weight loss or nutritional insufficiency. A 2018 study, 5 years after the implementation of the DSM-5, attempted to validate a multidimensional measure of three AFRID eating behaviors: picky eating, fear of negative consequences related to eating, and poor appetite/interest in eating.6 The study provides preliminary support for the use of the nine-item ARFID screen (NIAS) that was developed to evaluate eating restrictions in children and adults and cross reference them with depressive and anxiety traits. This study stresses that research in the adult population is very limited, as ARFID-related diagnoses were previously only in children. The NIAS, if implemented, would provide a multidimensional diagnostic tool for patients of all ages afflicted with ARFID. However, there is still a need for further research as the etiology of ARFID is varied and complex.6
A diagnosis of ARFID has been correlated with higher prevalence of neurocognitive disorders, specifically attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder.7 Due to the complexity of these disorders in and of themselves, complications with feeding abnormalities have been studied in certain cases. Standard pharmacotherapy for the treatment of ADHD includes stimulants, which are typically prescribed at diagnosis in childhood. A common side effect of stimulants is suppressed appetite, sometimes leading to significant weight loss. In a recent case study, two children with ADHD on stimulant medication were observed, both presenting with eating distress, even before administration of stimulant medication.8 The children presented with the common theme of oppositional behavior and generalized anxiety disorder. In both cases, food avoidance and distress were exacerbated by stimulant medication. Through the course of treatment, the medication was reduced to stimulate appetite and psychotherapy was directed at family frustration, oppositional behavior, and anxiety, which all catalyzed food avoidance in the patients. There are currently no guidelines that describe the best approaches in the treatment of comorbid ARFID and ADHD. There is clear a need for continued research on comorbidities that occur with ARFID.8
Retrospective Comparisons with Patients with Anorexia Nervosa
There have been several retrospective studies that examined the differences in outcomes between patients meeting the DSM-5 criteria for AN and for ARFID. A 2015 retrospective chart review at Cleveland Clinic assessed patients with eating disorders (age 9 to 25 years) in an inpatient setting.9 Thirteen of the patients met diagnostic criteria for ARFID whereas 64% met criteria for AN, both of which were included in the study.9 Several differences were found between the two populations including presentation age, weight at entrance, psychiatric history, and hospitalization time.9 Patients meeting criteria for ARFID presented at a younger age, had less weight loss before admission, and did not engage as often in excessive exercise and purging to control their weight. In fact, patients with AFRID presented more often with a fear of vomiting or abdominal pain. Patients with AN, on the other hand, presented with greater rates of bradycardia, greater weight loss, and higher rates of compensatory behaviors. Patients with AN had a higher rate of family history of mental illness and eating disorders, although this was not as common in those with ARFID. Patients with ARFID showed more electrolyte abnormalities and had longer courses of hospitalization, mostly due to the use of enteral nutrition during the refeeding process, as this results in a longer nutritional rehabilitation process. Overall, a higher percentage of patients with ARFID achieved remission than patients with AN; however, this was not statistically significant.9 Over the course of many retrospective case studies, the results have been inconclusive regarding the treatment outcomes in comparison to patients with AN. A recent Japanese study that examined outcomes over the course of 7 years found that ARFID patients had better outcomes than patients with AN as they showed better improvement in eating behaviors and psychological states.10 Results of similarly published studies were inconclusive.9,11 In the 2015 study described previously, patients with ARFID and AN achieved recovery similarly, although patients with ARFID had longer hospital stays due to reliance on enteral nutrition.9 Another study revealed that patients with AN patients had higher rates of recovery after 1 year.11
There are no definitive studies that establish proven first-line treatments for ARFID. Several case studies have examined effective management of the disorder through weight and nutritional management, psychological intervention, and pharmacological intervention—all of which need to address the extent to which the patient has suffered both medically and psychologically.12 Due to the heterogeneity of an ARFID presentation, treatment may vary greatly due to symptom etiology. In addition, patients are likely to present with a complex medical and psychological history, which makes a generalized treatment approach difficult to define.4
In the current literature, AFRID case studies have presented treatments using cognitive-behavioral therapy (CBT), family-based treatment for children and adolescents, pharmacotherapy, and nutrition therapy, all addressing reducing anxiety, restoring nutritional heath and incorporating problem foods back into the diet using exposure therapy.4,13 A 2015 case study also described success with hospital-based refeeding, as it reported positive outcomes for those with low-weight ARFID. This study also examines the use of tube feeding as patients with ARFID are “significantly more likely than those with other eating disorders to require tube feeding during inpatient hospitalization.”9 Although tube feeding does provide nutritional rehabilitation for patients who are low weight, tube feeding has potentially iatrogenic effects, causing potential feeding-tube dependence and decreased oral intake.14
One treatment method developed by Massachusetts General Hospital has been studied using a CBT approach with the goals of the treatment including being able to resolve nutritional deficiencies, increasing food variety, reducing dependence on nutritional supplements, improving psychosocial well-being, and attaining a healthy weight.13 The treatment method revolved around the concept that certain people have a predisposition to sensory sensitivity, low interest in eating, and fear of consequences of eating, all of which can cause negative feelings toward food. Over three stages, the practitioner administered up to 30 sessions over 6 to 12 months, focused on nutrition restoration, psychoeducation, and gradual reintroduction of certain foods. Exposure therapy was the common theme throughout the sessions as patients learned to understand and accept characteristics about food nonjudgmentally. This method is described as a “novel” form of treatment as it can be used for children, adolescents, and adults and can be catered to the heterogeneity of the disorder itself.13
Research on pharmacological management of ARFID is sorely lacking, although one case series was published this year that described clinical course, treatment, and outcomes among six patients with ARFID (5 of 6 patients were girls and average age was 12.9 years).15 All six patients presented with severe anxiety. Patients were treated using medication, CBT, family therapy, and medical monitoring. Medications that were used (in an off-label fashion) included olanzapine, fluoxetine, and cyproheptadine. All six patients achieved their goal weights at the end of treatment.15
Conclusions and Future Directions
Retrospective case examination indicated that 13% to 22% of patients with eating disorder met the DSM-5 diagnostic criteria for ARFID.16 The ARFID diagnosis encompasses a more heterogeneous population that includes a greater proportion of male patients and a larger potential age range compared to other eating disorders. Patients may also present with varied symptoms and behaviors, creating a need for more validation measures and customized screening tools that can be used to diagnose and treat ARFID successfully.
As research to date has been mostly in case series or reports, as well as restrospective comparisons with AN patients, there is a clear need for further research (including controlled trials) that examines the most effective treatments for ARFID, including psychotherapeutic/behavioral treatments, pharmacological treatments, and nutritional treatments. Future studies may also follow the longer-term outcomes of patients with ARFID. In addition, studies that examine the best ways to combine treatment methods are needed for this complex disorder that has varying presentations, and studies that examine pharmacological treatments are sorely lacking.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Peebles R, Hardy KK, Wilson JL, Lock JD. Are diagnostic criteria for eating disorders markers of medical severity?Pediatrics. 2010;125:e1193–e1201. doi:. doi:10.1542/peds.2008-1777 [CrossRef]
- Ornstein RM, Rosen DS, Mammel KA, et al. Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health. 2013;53:303–305. doi:. doi:10.1016/j.jadohealth.2013.03.025 [CrossRef]
- Zimmerman J, Fisher M. Avoidant/restrictive food intake disorder (ARFID). Curr Probl Pediatr Adolesc Health Care. 2017;47:95–103. doi:. doi:10.1016/j.cppeds.2017.02.005 [CrossRef]
- Watkins B, Lask B. Eating disorders in school-aged children. Child Adolesc Psychiatr Clin N Am. 2002;11(2):185–199. doi:10.1016/S1056-4993(01)00003-7 [CrossRef]
- Zickgraf HF, Ellis JM. Initial validation of the nine item avoidant/restrictive food intake disorder screen (NIAS): a measure of three restrictive eating patterns. Appetite. 2018;123:32–42. doi:. doi:10.1016/j.appet.2017.11.111 [CrossRef]
- Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy ET. Avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. Curr Psychiatry Rep. 2017:19(54):1–9. doi:. doi:10.1007/s11920-017-0795-5 [CrossRef]
- Pennell A, Couturier J, Grant C, Johnson N. Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorder. Int J Eat Disord. 2016;49:1036–1039. doi:. doi:10.1002/eat.22602 [CrossRef]
- Strandjord SE, Seike EH, Richmond M, Rome ES. Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalized for nutritional insufficiency. J Adolesc Health. 2015;57:673–678. doi:. doi:10.1016/j.jadohealth.2015.08.003 [CrossRef]
- Nakai Y, Nin K, Noma S, et al. Clinical presentation and outcome of avoidant/restrictive food intake disorder in a Japanese sample. Eat Behav. 2017;24:49–53. doi:. doi:10.1016/j.eatbeh.2016.12.004 [CrossRef]
- Forman SF, McKenzie N, Henh R, et al. Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative. J Adolesc Health. 2014;55(6):750–756. doi:. doi:10.1016/j.jadohealth.2014.06.014 [CrossRef]
- Bryant-Waugh R. Avoidant/restrictive food intake disorder: an illustrative case example. Int J Eat Disord. 2013;46(5):420–423. doi:. doi:10.1002/eat.22093 [CrossRef]
- Thomas JJ, Wons OB, Eddy KT. Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Curr Opin Psychiatry. 2018;32:1–6. doi:. doi:10.1097/YCO.0000000000000454 [CrossRef]
- Dovey TM, Wilken M, Martin CI, Meyer C. Definitions and clinical guidance on the enteral dependence component of the avoidant/restrictive food intake disorder diagnostic criteria in children. JPEN J Parenter Enteral Nutr. 2018;42:499–507. doi:10.1177/0148607117718479 [CrossRef].
- Spettigue W, Norris ML, Santos A, et al. Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. J Eat Disord. 2018;6:20. doi:. doi:10.1186/s40337-018-0205-3 [CrossRef]
- Fisher MM, Rosen DS, Ornstein RM, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. J Adolesc Health. 2014;55:49–52. doi:. doi:10.1016/j.jadohealth.2013.11.013 [CrossRef]