ARFID: Understanding the Signs and Treatments

Jennie Lannette, Author
June 9, 2021

Do you feel like you’re a particularly picky eater, or are you close to someone who is? While picky eating alone doesn’t suggest a disorder, some people struggle with this problem to the extreme. Such symptoms are sometimes diagnosed as avoidant/restrictive food intake disorder, or ARFID.

picky eater

ARFID is an eating disorder that is generally characterized by a lack of interest in eating, avoiding certain textures of food, eating less calories than are needed, a lack of proper nutrition, and experiencing anxiety related to eating. It is a formal diagnosis that is among the more recent additions to the Diagnostic and Statistical Manual of Mental Disorders (DSM). It’s commonly thought of as affecting children and teens, but can impact adults as well.[1]

Health consequences of ARFID include weight loss, nutritional deficiency, and for children, an interference in normal growth and development. Children and adults can also suffer from cognitive damage due to the lack of nutrition.[2]

ARFID can be confused with anorexia or bulimia, or with simply not liking or eating a variety of foods. It’s sometimes referred to as “extreme picky eating.” However, here are some key differences between ARFID and other eating issues:

  • With anorexia and bulimia, there are fears and misperceptions about self and body image, which are not present with ARFID.
  • With picky eating, people can still get enough calories from the foods they do like. People suffering with ARFID don’t get enough calories in general and suffer weight loss.
  • Generally picky eaters don’t have high anxiety related to foods. With ARFID, such fears can interfere with socializing and daily functioning.

Signs of ARFID

When specialists assess for ARFID, they will first rule out other eating disorders (such as anorexia), along with physical issues that may affect appetite. If these are not present, then they will consider the remaining symptoms. Signs of ARFID may include the following:[1]

  • Lack of appetite overall, with little interest in eating
  • Major weight loss or not gaining weight appropriately
  • Restrictions in types of food eaten (such as certain textures), which worsen over time
  • Fears of vomiting or choking, or other negative outcomes from eating
  • Suffering from an “upset stomach” or other digestion issues
  • No expressed concerns about body image or being “thin” or “overweight”
  • Nutritional problems affecting skin, hair, menstruation, and other health issues relating to vitamin deficiency
  • Weakness and decreased muscle mass
  • Poor immune system
  • Social isolation or avoidance (which can relate to anxiety about food)

Causes of ARFID

Researchers aren’t sure yet what causes ARFID. It seems that people may develop this disorder for different reasons. For example, some people who have a disturbing experience of choking or vomiting develop phobias around eating. Others are particularly sensitive to certain textures and tastes, which leads to the restrictive diet. Or, someone may simply have a naturally low appetite to begin with.

Over time, limited eating and avoiding types of foods makes the problem worse. The individual may become more disgusted or fearful of foods that are typically avoided. This leads to such severe symptoms that it interferes with the life and health of the person suffering from it.

Scientists are still trying to understand the connection between ARFID and other psychological disorders. Those with autism may struggle with this and related food issues. This could be due to underlying stomach problems, sensory differences, or perception differences, but research on this is limited so far.[3]

Some have noted a co-occurrence of ARFID and attention-deficit/hyperactivity disorder (ADHD). However, in some cases studied, the individuals in question were on stimulant medications, which can decrease appetite.[4] Researchers need to study this further to understand the connections between the disorders.

ARFID Treatment

The first step in treatment for ARFID is to ensure basic calorie needs are being met. If the case is severe and life-threatening at the time, hospitalization might be required. In other cases, doctors may begin with nutritional treatment that compensates for the lack of vitamins and calories.

In the long term, a combination of medical treatment, dietary guidance, and psychotherapy is recommended, along with psychiatric medication if needed. Just as researchers are still trying to understand the causes of ARFID, therapists are learning about the best treatments. Here’s a look at types of therapies that are promising.

Cognitive Restructuring Through CBT

In cognitive behavioral therapy (CBT), therapists work with clients to change their perception and thoughts relating to certain issues. Someone with ARFID may have unrealistic thoughts relating to the risk of choking, or fear of the discomfort they will feel when eating certain foods. Therapists experienced in CBT can help people identify such thoughts, and challenge their accuracy. This can help individuals begin to understand and see things differently. So far, there have been a few cases published that involved use of CBT for ARFID. All of those cases also included a type of exposure, or desensitization to avoided foods.[5]

Exposure Therapy

Many types of phobias and anxieties are treated with exposure therapy. For example, someone who has a fear of spiders may begin by looking at pictures of spiders and work up to getting up-close and personal with an eight-legged friend. This type of exposure can also help with food aversion. A therapist can help someone slowly become exposed to foods or situations they are avoiding. Over time, they can overcome their fears and avoidance.

CBT-AR

Specialists in Massachusetts have developed a structured type of cognitive behavioral therapy that specifically treats ARFID, called CBT-AR. In this treatment, patients are encouraged to start by eating more of the foods they like. This allows them to get at least the minimum amount of calories needed. As treatment progresses, the therapists help individuals through exposure to the foods or textures they try to avoid. The therapy also includes traditional CBT thought restructuring, focused on topics related to ARFID. So far, trials have shown benefits including healthy weight gain.[6]

Family-Involved Therapy

Some therapists have found that using an approach similar to those used for other eating disorders can be helpful. Parents or other family members are involved to help reinforce the new behaviors, and to learn healthy behaviors for themselves.[7]

Dialectical Behavioral Therapy

Other therapies, such as dialectical behavioral therapy (DBT), may also be offered for those dealing with ARFID. DBT and related models include mindfulness, development of coping skills, and help for socializing and dealing with relationships. While these don’t specifically treat the symptoms of ARFID, they may be helpful as a supplemental treatment. Learning overall coping and self-care strategies can add to the effectiveness of other treatments. And they can help increase the quality of life for the person suffering.

Finding Help for ARFID

While we still have much to learn about ARFID, one thing is clear; over time, it can cause the body serious and potentially life-threatening harm. And as the condition worsens, people can suffer from long-term physical and cognitive damage.

If you believe you may suffer from ARFID, or know someone who does, it’s important to get an assessment. You can begin with a doctor or therapist experienced with ARFID or other restrictive eating conditions. They can help you assess the situation, and come up with a medical and psychiatric plan to increase calories and begin to treat this disabling condition.


References

  1. Seetharaman S, Fields EL. Avoidant/Restrictive Food Intake Disorder. Pediatr Rev. 2020 Dec;41(12):613-622. doi: 10.1542/pir.2019-0133. PMID: 33262151.
  2. Feillet, F., Bocquet, A., Briend, A., Chouraqui, J. P., Darmaun, D., Frelut, M. L., Girardet, J. P., Guimber, D., Hankard, R., Lapillonne, A., Peretti, N., Rozé, J. C., Simeoni, U., Turck, D., Dupont, C., & Comité de nutrition de la Société française de pédiatrie (CNSFP) (2019). Nutritional risks of ARFID (avoidant restrictive food intake disorders) and related behaviorArchives de pediatrie : organe officiel de la Societe francaise de pediatrie26(7), 437–441. https://doi.org/10.1016/j.arcped.2019.08.005
  3. 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 TreatmentCurrent psychiatry reports19(8), 54. https://doi.org/10.1007/s11920-017-0795-5
  4. Pennell, A., Couturier, J., Grant, C., & Johnson, N. (2016). Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorderThe International journal of eating disorders49(11), 1036–1039. https://doi.org/10.1002/eat.22602
  5. Görmez, A., Kılıç, A., & Kırpınar, İ. (2018). Avoidant/Restrictive Food Intake Disorder: An Adult Case Responding to Cognitive Behavioral Therapy. Clinical Case Studies, 17(6), 443–452. https://doi.org/10.1177/1534650118795286
  6. Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in AdolescentsCurrent pediatrics reports6(2), 107–113. https://doi.org/10.1007/s40124-018-0162-y
  7. Eckhardt, S., Martell, C., Duncombe Lowe, K. et al. An ARFID case report combining family-based treatment with the unified protocol for Transdiagnostic treatment of emotional disorders in childrenJ Eat Disord 7, 34 (2019). https://doi.org/10.1186/s40337-019-0267-x
Jennie Lannette, Author

Jennie Lannette is a licensed therapist who specializes in trauma, PTSD, and related issues. She has trained extensively in multiple evidence-based treatments. She has a decade of experience in inpatient, community, and private practice settings.