What Eating Disorder is This?! Avoidant Restrictive Food Intake Disorder (ARFID)
Blog Post By Gabrielle Katz, LCSW, CEDS-S
“I can’t eat that. It doesn’t have to do with my weight. It doesn’t have to do with my body image! It doesn’t have to do with the calories. I just can’t eat that.”
What Is ARFID?
Typically, when people think about eating disorders, they associate them with body image distress and/or body image dissatisfaction. Well, not with this one. The eating disorder Avoidant Restrictive Food Intake Disorder (ARFID) has nothing to do with any of those symptoms. The way most eating disorder specialized clinicians explain this disorder is by describing it as “extreme picky eating.”
This is when a client has fear foods and safe foods, but for reasons unrelated to weight, shape, or body image concerns. Fear foods could exist due to texture, fear of vomiting or another physical reaction/sensation, or aversion to eating.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication that classifies different mental health diagnoses written by the American Psychiatric Association. When you look at the diagnostic criteria for ARFID you will see:
An eating or feeding disturbance 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 nutrition 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 disorder does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of disturbance in the way in which one’s body weight or shape is experienced
The eating disturbance is not attributed to a concurrent medical condition or not better explained by another mental disorder
Are There Different Types of ARFID?
There are different types of ARFID. Avoidant type has to do with sensory avoidance (Ex: trying to stay away from certain smells or textures). Aversive type is a fear-based reaction (Ex: fear of throwing up or choking). Restrictive/Lack of interest type is when a client has low appetite and/or disinterest in food or the act of eating. There is also a mixed type which is a combo/dual presentation.
Just like any other eating disorder, ARFID does not discriminate. While research shows that ARFID is more common in children and young adolescents, it can affect children, adolescents, and adults. Studies have also found that ARFID affects more males than females, but all genders may have this diagnosis. Although an official diagnosis and access to care is harder to receive in marginalized communities, anyone from any culture and any race may have ARFID. Just like any eating disorder, research shows there are genetic and environmental (psychosocial) components to what causes ARFID.
How Do I Know If Someone Has ARFID?
Now that we have just discussed the clinical criteria of this diagnosis, let’s dive into this more colloquially.
Here is what you may see if someone has ARFID:
Fearful of new foods
Denies feeling hungry
Gagging on food
Spitting out food
Taking a long time to eat
Seeing eating as a chore
Appearing to be a picky eater
Always eating the same foods (safe foods)
Only eating foods of similar color or texture
Anxious during meal times
Anxious during, or avoiding, social events with food
Only eating certain brands of foods
Only eating foods prepared in a specific way
Scared to eat
Loss of weight
Did not gain weight when expected to
Medical complications of malnutrition including but not limited to constipation, fatigue, abnormal labs, cold intolerance, stomach pain, impaired immune functioning, and muscle weakness
There are still many unknowns when it comes to ARFID. That being said, research has uncovered a few risk factors that may increase the likelihood of this diagnosis. Risk factors include:
Individuals who are neurodivergent, including those who are diagnosed on the autism spectrum, have attention deficit disorder, or have other intellectual disabilities
Individuals who have not grown out of expected picky eating from childhood
Individuals who have anxiety disorders
As we discuss risk factors for ARFID, we must also acknowledge and recognize that ARFID itself is a risk factor to something too: ARFID is a risk factor in the development of Anorexia Nervosa. There is a type of ARFID called ARFID Plus. This is a type of ARFID for those who begin to develop features of anorexia.
Is ARFID Treatable?
Just like all other eating disorder diagnoses, ARFID is treatable!
Two evidence-based treatments for ARFID are cognitive behavioral therapy (CBT) and exposure response prevention therapy (ERP). Psychotropic medication may be recommended as a part of the treatment as well.
Best practices dictate that a client being treated for ARFID should have a full treatment team. This would include an eating disorder specialized therapist, eating disorder specialized registered dietitian, primary care physician, and if needed or recommended, a psychiatrist. Ideally all treatment providers would be eating disorder specialized, or at least eating disorder informed. However, depending on location and resources, it is understandable that it may be difficult to assemble a full eating disorder informed team. It may be especially hard to find a primary care physician or psychiatrist that specializes in eating disorders. At the very least, if you can get a therapist and registered dietitian who specialize in eating disorders, that is good enough. Those providers can collaborate with the medical providers on the team to ensure that an eating disorder lens of care is being used.
I don’t want to end this by just labeling CBT and ERP therapy as evidence-based treatments and leave it at that. So, I will provide a little explanation of each.
Cognitive Behavioral Therapy (CBT) is a type of therapy that teaches clients how to recognize, challenge, and cope with distressing thoughts. In CBT we call those distressing thoughts either thought distortions or negative automatic thoughts. We use CBT to help us with the distress tolerance that often comes with the implementation of ERP.
Exposure and Response Prevention (ERP) is a therapeutic approach that helps clients move toward the situation, item, food, etc. that they fear. Evolutionarily we have learned to stay away from the things we fear. Our internal system doesn’t understand that we can be scared of something that isn’t actually life threatening. Our anxiety gets worse the longer we stay away from something, it doesn’t get better.
So, with a trained therapist or dietitian we want to move toward the food items we fear. ERP involves exposing yourself to fear foods, or new foods you have never tried before. ERP helps to decrease the fear through repetitive attempts (and successes) of eating fear foods to learn how to disconnect/remove the fear you once had to them.
Well, that’s a wrap - I hope you all found this information helpful! As the research on ARFID continues to expand and evolve, we can all look forward to learning more about this diagnosis and its treatment.
References
Eddy, Kamryn T et al. “Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network.” The International journal of eating disorders vol. 48,5 (2015): 464-70. doi:10.1002/eat.22350
Norris, Mark L et al. “Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in children and youth.” Neuropsychiatric disease and treatment vol. 12 213-8. 19 Jan. 2016, doi:10.2147/NDT.S82538
About Gabrielle Katz, LCSW, CEDS-S: Gabrielle, who goes by Gabby, is the practice owner of Coastal Collaborative Care.
She is a Licensed Clinical Social Worker (LCSW), Licensed Clinical Social Worker Supervisor, and a Certified Eating Disorders Specialist and approved Supervisor (CEDS-S) through the International Association of Eating Disorder Professionals (iaedp).
Since 2014 Gabby has worked with clients in eating disorder higher level of care treatment settings including inpatient, partial hospitalization programs, and intensive outpatient programs. Gabby started off as a Clinical Therapist, moved to a Program Manager, and concluded her time in higher level of care settings as a Program Director.
On top of her extensive eating disorder treatment experience, Gabby has worked in inpatient settings for general mental health, has been a hotline counselor for a sexual assault hotline, and was the Board President of the American Foundation for Suicide Prevention (AFSP). Gabby started providing trainings on suicide education and first aid while at AFSP and continues to provide trainings to the public today.
Gabby opened her outpatient practice in 2020. The Coastal Collaborative Care team is an in-person and telehealth therapy practice where everyone specializes in the treatment of eating disorders, trauma, anxiety disorders, and depressive disorders.