Understanding ARFID: Types, Signs, and Treatment

Imagine a family dinner where someone is sitting at the table with a plate of food untouched. The food looks okay. The smell is okay. In fact, everything seems somewhat normal except to one person at the table. As far as anyone else can tell, the food is exactly as it always is. To this one person, though, a normal dinner can be suddenly unsafe. The smells are too intense. The texture is gag-inducing. Eating the next bite would be a risk that is simply too great. This hesitation would be commonly dismissed as picky eating by many, but for some people, this can be an actual health concern.

This health concern is called avoidant/restrictive food intake disorder, or ARFID. This disorder entails restrictive eating or eating a limited variety of foods that causes compromised nutrition, growth, or functioning (Thomas et al., 2017). It has nothing to do with wanting to be thinner. In this paper, I will discuss what this disorder is and is not, the three common presentations, the warning signs, the diagnostic process, the effects on the mental and physical health of the individuals, and the possible interventions.

What ARFID Is, and What It Is Not

ARFID (Avoidant/Restrictive Eating Disorder) is an eating disorder included, for the first time, in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) by clinicians who diagnose and treat mental disorders (Menzel & Perry, 2024). This definition can be simplified into one sentence: a condition characterised by restricted food intake or nutritionally inadequate diets.

The key difference between ARFID and anorexia nervosa (AN), another eating disorder, is that individuals with AN restrict their food intake “in pursuit of thinness”, whereas individuals with ARFID do not have “weight gain concerns” (Menzel & Perry, 2024). In addition, ARFID differs from picky eating. Many children have food preferences. ARFID is different. It involves a restriction of food intake that goes below what’s needed for proper nutrition. The DSM-5 defines this as nutrient intake that can lead to weight loss, slowed growth, the need for feeding tubes or serious problems in daily life (Thomas et al., 2017).

The last point is often missed: the inability to take part in activities. ARFID can really affect kids and teens. It can cause them to become uninterested in activities they previously enjoyed; for example, a teen who stops going to camps, birthday parties or dining in their favourite restaurants due to worries about food may be diagnosed with Avoidant/Restrictive Food Intake Disorder even if he or she has a normal weight.

Avoidant/Restrictive Food Intake Disorder isn’t a new phenomenon; it is just a newly recognised syndrome. According to Menzel and Perry (2024), the diagnosis of ARFID “encompasses the heterogeneous presentations previously included under the category of feeding disorder of infancy and early childhood, as well as those not easily classified,” and it affects people of all ages.

In fact, the same authors note that ARFID appears to be as prevalent as other eating disorders, including among adults. Furthermore, Fisher et al. (2014) found that children and adolescents with ARFID differ from those with anorexia nervosa in physical and psychological characteristics, supporting the distinction between the two diagnoses.

Three Common Faces of ARFID

1. Sensory Sensitivity

When a person has negative reactions to certain tastes, smells, temperatures, and textures of food, and has trouble eating (Thomas et al., 2021). An example is gagging at the idea of eating something and only allowing yourself to eat crunchies. According to Thomas et al. (2017), this variety of selective eating may be linked to heightened taste sensitivity.

2. Low Interest in Eating

The absence of hunger or feelings of fullness soon after starting to eat. Thomas et al. (2017) note that this pattern may be explained by “altered gastrointestinal hormone function”, meaning that hormones that signal satiety and hunger are out of balance.

3. Fear of Adverse Consequences

Avoidance of certain foods due to the fear of vomiting, choking, or other negative outcomes. For instance, a person who has had an unpleasant experience with choking may start avoiding all solid foods (Menzel & Perry, 2024). This pattern is associated with “central nervous system processing of potentially aversive stimuli” (Thomas et al., 2017).

The causes of these patterns are still unclear; however, the classification proposed by Thomas et al. (2017) is based on a potential biological foundation. Di Cara et al. (2023) note that this model is still a “working hypothesis” since no“biological markers have been identified to date”. The authors also offer a possible explanation of the development of ARFID with a focus on the role of emotions.

They suggest that people affected by this disorder may have a genetic predisposition to “altered taste perception and appetite function,” which can be triggered by “distressing food-related experiences” (Di Cara et al., 2023). As a result, distress, including fear and sadness about eating, may be an element of ARFID.

Signs of ARFID and How It Is Diagnosed

ARFID presents in various ways, but certain symptoms tend to occur together. Common signs include:

• Eating a narrow range of foods and rarely trying new foods, or having no interest in eating (Menzel & Perry, 2024).
• Impaired growth and weight gain in children and adolescents (Thomas et al., 2017).
• Needing enteral nutrition, meaning the introduction of food and fluids directly into the stomach through a tube (Thomas et al., 2017).
• Anxiety-related symptoms around meals and avoiding social events where eating is involved (Di Cara et al., 2023).

ARFID often occurs with other mental and physical health conditions. According to Menzel and Perry (2024), the review article discusses the “high rates of medical and psychiatric comorbidity associated with ARFID,” meaning that the two disorders occur together with considerable frequency. Thomas et al. (2021) found that 40% of the adults in their study had panic disorder. At the time, 40% were diagnosed with generalised anxiety disorder, which is marked by constant and hard-to-control worries.

A diagnosis of ARFID must be made by a medical professional. This includes doctors, psychiatrists or clinical psychologists. During the assessment, the individual will be asked about their eating patterns. Specifically, the interviewer will want to learn about the person’s interest in food, range of foods they are willing to eat, fears, and how their eating affects their daily life.

Additionally, Thomas et al. (2021) note the use of the Pica, ARFID, and Rumination Disorder Interview, which is a standardised tool for both diagnosis and determining the severity of each of the three restricted eating presentations described byBryant-Waugh et al. (2019). There are various screening tools that have been validated in different populations (Menzel & Perry, 2024). The physical examination component of the diagnostician’s assessment will include the individual’s weight and general growth patterns, as well as laboratory tests to identify any nutritional deficiencies (Thomas et al., 2021).

Healthcare professionals must also ensure that another medical condition, cultural practice, or mental health disorder does not better explain the person’s eating difficulties (APA, 2022). This essay is for educational purposes and cannot substitute for a professional assessment.

How ARFID Affects Health and Daily Life

1. Eating and Physical Health

Malnutrition, or the inadequate supply of nutrients, can have a range of effects on physical health in people with ARFID. A systematic review and meta-analysis of studies involving children and young people up to age 25 found that they often involve significant medical issues requiring treatment (James et al., 2024). Malnutrition can manifest in various ways, including being classified as severe or very severe, moderate according to the World Health Organisation classification system, or exhibiting some symptoms but not others. 

Interestingly, the impact of ARFID on a person’s physical health cannot be fully determined by their body mass index (BMI). Out of 15 adults who participated in a study by Thomas et al. (2021), only 4 were underweight, and 7 had a BMI consistent with overweight. At the same time, 14 out of 15 adults reported a significant impact of ARFID on their daily life, and 6 out of 15 relied on enteral nutrition.

2. Social Life and Interpersonal Relationships

As Thomas et al. (2017) note in the DSM-5, interference with social and occupational functioning is one of the symptoms of ARFID. Consequently, ARFID affects people of different ages. Eating is a social activity, and the inability to partake in meals leads to isolation.

3. Emotional Well-Being

Thomas et al. (2017) have emphasised the presence of high levels of anxiety and depression when it comes to meals in individuals with eating disorders. Di Cara et al. (2023) indicate that anxiety and excessive worry around meals or other daily activities are symptoms of ARFID as well.

4. Long-Term Impact

ARFID also appears to be a long-term condition rather than a short-term problem. The participants in the study by Thomas et al. (2021) had symptoms for an average of 17 years, and almost half of them had received treatment previously without positive results. Fortunately, researchers are developing effective interventions and making them available to patients, as discussed in the following section.

How ARFID Is Treated

The intervention for ARFID varies depending on age, general health condition and type of disorder. Thomas et al. (2017) say that early management was based on theories of real studies, but this is starting to change as more people look at ARFID. Di Cara et al. (2023) believe that treating ARFID works best when a team of experts is involved.

This team includes dietitians, physicians and therapists. Menzel and Perry (2024) explain that researchers are developing new treatments for ARFID in children, adolescents, and adults. One such treatment is cognitive-behavioural therapy for avoidant/restrictive food intake disorder (CBT-AR). This is a type of talk therapy where patients learn to spot and change the thoughts and behaviours that are causing trouble. Researchers adapted it for people with ARFID and developed versions for children, adolescents, and adults. The therapy for ARFID has four stages according to Thomas et al. (2021). Understanding these stages can help families support ARFID patients.

• Learning about ARFID, tracking eating and building a regular eating routine.
• Learning about nutrition and choosing foods to practice.
• Exposure practice, which means facing a challenge in small, repeated steps. People with sensory sensitivity taste new foods during sessions. Those with fear build a “fear ladder” from the least scary food to the most scary one. Those with low interest practice monitoring hunger and satiety.
• Creating a relapse prevention plan, which aids in maintaining progress made during therapy after the completion of therapy.

Studies using CBT-AR show promise. In one study, 20 children and adolescents with ARFID who received between 20 and 30 sessions of CBT-AR (each approximately 50 minutes long) had a 70% reduction in ARFID symptoms and incorporated about 17 new foods into their diet on average (Thomas et al., 2020). The treatment was provided in a family-based or individual format.

Thomas et al. (2021) emphasise the need for larger studies using randomised controlled trials, in which researchers randomly assign participants to receive the intervention or a comparison condition. Additionally, healthcare professionals should consider nutritional supplementation, including enteral feeding, as part of medical care for people with ARFID (Strandjord et al., 2015).

Conclusion

ARFID is much more than a finicky eater. It is a recognised eating disorder in which individuals avoid or restrict foods because of low interest in eating, strong sensory reactions, or fear, rather than concerns about body image (Menzel & Perry, 2024). It can affect growth, nutrition, mood and social life, and can affect people of all ages (James et al., 2024; Menzel & Perry, 2024). The good news is there are treatments. Therapies such as CBT-AR have helped many children, adolescents, and adults expand their diets and feel more comfortable with food, although researchers need to conduct more studies to understand their full impact (Thomas et al., 2020; Thomas et al., 2021).

Here is one suggestion. If you feel like you, your child or a loved one has a very limited diet that is in any way detrimental to their health, lifestyle or social life, you should see a doctor about it. Before seeing the doctor, it’s best to write down the list of foods they can eat and can’t eat and when mealtime is the most stressful. Keeping a food diary is also part of CBT-AR (Thomas et al., 2021). Food should nourish us, not make us feel anxious or overwhelmed. Asking for help is always a good idea.

References +

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
• Bryant-Waugh, R., Micali, N., Cooke, L., Lawson, E. A., Eddy, K. T., & Thomas, J. J. (2019). The Pica, ARFID, and Rumination Disorder Interview: Development of a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10–22. International Journal of Eating Disorders, 52(4), 378–387. https://doi.org/10.1002/eat.22958
• Di Cara, M., Rizzo, C., Corallo, F., Cardile, D., Calabrò, R. S., Quartarone, A., Buda, M., & Cucinotta, F. (2023). Avoidant restrictive food intake disorder: A narrative review of types and characteristics of therapeutic interventions. Children, 10(8), Article 1297. https://doi.org/10.3390/children10081297
• Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., Callahan, S. T., Malizio, J., Kearney, S., & Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49–52. https://doi.org/10.1016/j.jadohealth.2013.11.013
• James, R. M., O’Shea, J., Micali, N., Russell, S. J., & Hudson, L. D. (2024). Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): A systematic review and meta-analysis. BMJ Paediatrics Open, 8, Article e002595.
• Menzel, J. E., & Perry, T. R. (2024). Avoidant/restrictive food intake disorder: Review and recent advances. Focus, 22(3), 288–300. https://doi.org/10.1176/appi.focus.20240008
• Strandjord, S. E., Sieke, E. H., Richmond, M., & Rome, E. S. (2015). Avoidant/restrictive food intake disorder: Illness and hospital course in patients hospitalized for nutritional insufficiency. Journal of Adolescent Health, 57(6), 673–678. https://doi.org/10.1016/j.jadohealth.2015.08.003
• Thomas, J. J., Becker, K. R., Breithaupt, L., Burton Murray, H., Jo, J. H., Kuhnle, M. C., Dreier, M. J., Harshman, S., Kahn, D. L., Hauser, K., Slattery, M., Misra, M., Lawson, E. A., & Eddy, K. T. (2021). Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder. Journal of Behavioral and Cognitive Therapy, 31(1), 47–55. https://doi.org/10.1016/j.jbct.2020.10.004
• Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G., Wons, O. B., Keshishian, A. C., Hauser, K., Breithaupt, L., Liebman, R. E., Misra, M., Wilhelm, S., Lawson, E. A., & Eddy, K. T. (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53(10), 1636–1646. https://doi.org/10.1002/eat.23355
• 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), Article 54. https://doi.org/10.1007/s11920-017-0795-5