Avoidant Restrictive Food Intake Disorder (ARFID)

 

Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnostic category in the DSM-5.  It is defined as a persistent feeding or eating disturbance leading to avoidance of food, which results in significant weight loss or nutritional deficiency and/or impairment in psychosocial functioning.  Unlike anorexia nervosa and bulimia nervosa, ARFID is not characterised by preoccupation with body shape and weight or by intentional weight loss behaviours.  Instead, patients suffering from ARFID may be disinterested in food and eating with lack of appetite leading to slower rate of eating, eating smaller portions, and greater struggles around food.  There appears to be a genetic predisposition towards picky eating or heightened sensitivity toward internal and external stimuli and patients may avoid foods because of dislike of colour, texture, smell or taste. Picky eating habits tend to appear in early childhood and tend to be relatively stable and persist long term. Some individuals might also develop a fear of choking, gagging or vomiting.

It is quite important to distinguish AlRFID from picky eating, which is relatively common among children (20-30%) but only for a small subgroup of picky eaters their behaviour becomes more persistent, leading to either malnutrition and weight loss with medical complications similar to anorexia nervosa and/or impairment of psychosocial functioning.

The avoidance of eating may also be caused by traumatic experiences related to consuming food, such as a personal or witnessed episode of choking, gagging or vomiting.  

Some studies have identified incidences of ARFID between 5% and 10%.  In comparison with anorexia, patients with ARFID tend to have a longer duration of illness and a higher proportion of males.  There are also higher rates of co-morbid anxiety disorders (up to 75%) as well as higher rates (up to 55%) of co-morbid, often functional gastrointestinal conditions like bloating, nausea, heartburn, irritable bowel syndrome etc.

Common Signs of ARFID

  • Long history of ‘picky eating’ since childhood
  • Lack of interest in food and eating
  • Lack of appetite 
  • Slow rate of eating
  • Eating smaller portions
  • Greater struggles around food
  • Avoidance of foods because of dislike of colour, texture, smell or taste
  • Fear of choking, gagging or vomiting
  • Gastrointestinal complaints like bloating, heartburn, nausea, constipation
  • Weight loss and signs of malnutrition
  • Avoidance of situations of social eating

Treatment of ARFID

Given that the diagnosis is relatively new there is no scientific evidence yet to inform best treatment recommendations. Treatment goals have to be weight restoration and correction of nutritional deficiencies as well as adding new foods to increase variety and at the same time address the anxiety and other relevant co-morbidity.   A modified form of FBT for anorexia should be considered as first line treatment for young people presenting with low weight.  Treatment includes coaching around behaviour strategies to manage mealtimes which include exposure to new foods.  Often also anxiety symptoms need management and treatment.  Patients with co-morbid functional GI disorders might also benefit from biofeedback as well as anxiety management strategies.  In essence, treatment will be reasonably individualised but will also include behavioural strategies.  Given that there is a strong habit formation involved with ARFID behaviour, which might even have affected the whole family, treatment will also emphasise the importance of developing and maintaining new eating behaviours and habits.