Previously known as “Selective Eating Disorder.” Avoidant Restrictive Food Intake Disorder (ARFID) is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not necessarily involve distress about body shape or size, or fears of fatness. The fear is focused on the food itself.
Many people, mostly children, go through phases of selective and picky eating. Anywhere between 13 to 22 percent of children will exhibit picky eating behavior between three and eleven years of age, at any given time. While most young children will outgrow their pickiness, between 18 to 40 percent will persist in their pickiness, into adolescence. However, a child with ARFID fails to consume enough calories for normal physical development. In adults, this presents as being unable to maintain basic body function. In children and adults, the disorder may also result in social problems, especially when it comes to eating with others or finishing a meal in the time allowed.
It is important to note that ARFID goes beyond the scope of a person’s food preferences by severely restricting “allowed” foods to as few as 3 or 4, which may actually threaten the individuals ability to survive.
ARFID is a relatively new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It stands for Avoidant Restrictive Food Intake Disorder but is sometimes referred to as “picky eaters” disorder. According to the DSM-5, ARFID is diagnosed when:
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food or concern about aversive consequences of eating such as vomiting or nausea) 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 nutritional 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 disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
- The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
- When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
Is ARFID An Eating Disorder?
This diagnosis is often given to individuals who experience difficulty with both eating and with food. However, generally, they don’t exhibit the classic symptoms of an eating disorder. (Link to EDs) (i.e. anorexia nervosa, bulimia, etc.).
In my experience ARFID looks different in every individual. Often the ARFID victim has been mis-diagnosed as Anorexic. Unlike the anorexic, however, who refuses to eat enough food to maintain weight, the individual suffering from ARFID deselect‘s foods on the basis of some characteristic such as color or texture. In other cases, it could be avoidance of a particular food out of a fear of nausea, vomiting or GI pain and bloating.
In most cases ARFID sufferers eliminate whole classes of foods such as vegetables or meat until they are down to only a few choices. The biggest distinction between the two conditions, however, is that in those suffering from ARFID the fear is about the food, whereas in those suffering from anorexia the fear is about gaining weight from eating the food.
Many people with ARFID develop this condition due to a fear of choking or vomiting. When this is the case, I recommend that the individual be evaluated by a speech therapist who specializes in swallowing disorders to make sure there is not an actual medical issue related to swallowing.
Despite the fact that the individual suffering from AFRID starts out focused on the food and not the weight, when severe weight loss occurs, the disorder can begin to take on the symptoms of Anorexia as the individual gets hooked on the number of pounds weighed going down. That said, I have also seen individuals who are only eating 4 or 5 foods but have gained considerable weight as a result of the more or less continuous eating of those 4 foods. This is especially likely to happen when the foods that they are eating are highly processed, not organic and loaded with sugar, fat and starch.
How Serious is ARFID?
Individuals suffering from ARFID may have problems in social situations, family relationships and work or school that can become extreme. In addition, I have treated patients that weighed less than 80 pounds as well as patients that weighed over 250 pounds, although the latter is much less common. The point is that low weight is not always a determining factor. It is important to understand that even if the individual with ARFID is overweight, they are still likely to be malnourished.
Parents of children with ARFID experience a great deal of stress and anxiety because it is so difficult to find the foods that their child is willing to eat. Meals become tense battlegrounds disrupting the entire meal for everyone. This is especially difficult during holidays, when traveling or going to restaurants. Parents with a child suffering from ARFID are often so desperate to find a food that their child will eat that they inadvertently reinforce the disorder by going to great lengths to provide the one thing the child will eat.
For adults with ARFID, it can also interfere in marital relationships, as the spouse often resents the anxiety attendant to the disorder. In general, most loved ones feel as if their lives revolve around getting their loved one to eat.
ARFID is also associated with other mental health conditions, such as anorexia nervosa, Autism Spectrum Disorder, Obsessive Compulsive Disorder, and Depression.
Signs and Symptoms of ARFID
ARFID isn’t always easy to identify as everyone presents differently. Here is what to look for:
- Selective eating such as sensory food aversions (not liking the texture, smell, or taste of a certain food), very restricted range of foods, or fear of new foods
- Physical problems such gastrointestinal symptoms, abdominal pain, or physical symptoms beyond what would normally be expected if a medical diagnosis is present
- Phobia of severe allergic reaction
- Vomiting phobia (known as Emetophobia)
- Choking phobia
- Food avoidant emotional disorder which is a lack of interest in food, emotional problems that interfere with appetite and eating like anxiety, depression, trauma; with NO medical explanation or origin
These symptoms can be seen in any combination, while others may only have one of these symptoms.
What Causes ARFID?
it is not clear exactly what causes ARFID. It is often connected to an experience with food that was frightening, but not always. My theory is that conventional foods, which can cause a great deal of gastrointestinal distress for anyone eating them, could be part of the issue. In other words, if it makes your stomach hurt when you eat polluted foods, it’s not unreasonable to assume that you will not want to continue to eat those foods…
Another condition which seems connected among individuals suffering from ARFID is acid reflux, which is broadly defined as the result of acidic stomach contents regurgitating back into the esophagus. Patients suffering from gastroesophageal reflux disease (GERD) have a weak or relaxed lower esophageal sphincter. Factors that contribute include hiatal hernias, obesity, pregnancy, certain medications, or smoking.
GERD has been reported to impact roughly 18-27% of the general North American populations with 20% of adults stating they have weekly heartburn.
The saddest thing about Gerd is that the treatment makes the condition worse. In other words, antacids do not help but actually make the condition worse as it is not too much acid causing the problem but a relaxed sphincter. The source of the relaxed sphincter can be purging brought on by bulimia in some cases. But I believe that in most cases the cause is fats or other non-organic foods, especially those containing glyphosate, GMOs and other nasties, regularly found in conventional US foods. We are the most obese nation in the world, along with being the wealthiest/unhealthiest country in the world with the lowest rate of infant survival. Out food is the issue. It sucks. It also causes acid reflux.
What I have noticed in my practice is that many people suffering from ARFID also suffer from acid reflux. There needs to be more research on whether there actually is a connection and if so what it is.
Types of ARFID Treatment:
There are several types of treatment that have been shown to be effective with those suffering from ARFID. It is important to know that there is no one size fits all approach. Treatment must be tailored to the individual. The research shows the following to have efficacy:
1. Family Based Treatment
If I have a child suffering from ARFID, the family is key in terms of recovery. Sometimes, more of the therapy is done with parents than with the child. There is increasing evidence that Family Based Treatment (FBT) may be the most effective form of treatment for ARFID. In this type of treatment, the family is intimately involved in helping the child reach his or her goals related to increasing their food intake. FBT was initially developed for the treatment of Anorexia Nervosa but for ARFID is tailored to meet the needs of this specific population. In some cases, the FBT may be combined with other treatment protocols that help the person develop more coping skills.
2. Exposure Therapy
In this type of therapy, a therapist will gradually expose a patient to fear-inducing foods through mental visualization, writing, and verbally talking about them. Working from the least to the most anxiety-causing, the patient can gradually become more comfortable with the foods they fear.
3. Dialectical Behavioral Therapy
This is my favorite form of intervention. Originally developed by Marsha Lenihan to treat borderline personality disorder, dialectical behavior therapy (DBT) teaches patients how to manage their own distress so that they stop using self-destructive coping mechanisms. This can be very helpful to those with ARFID because re-introducing the foods they have not been eating can be quite overwhelming and distressing. In some cases, they will even gag or vomit when trying a new food, so it is important to develop strong, healthy coping skills as one tries to change the relationship with food.
4. Group Therapy
I particularly like group therapy for adults suffering from ARFID. It offers a unique opportunity to both support another and receive support from those who truly relate to and understand you and your struggles. As treatment progresses, this might mean eating in a public place or visiting the grocery store as a group. Given the power of empathy in healing, being among those who struggle with similar issues is invaluable.
Supplements That Help:
- Melatonin (6mg) not only balances circadian rhythms but also suppresses stomach acid production.
- Marshmallow Root – is known to reduce stomach acidity and acts as a barrier to stop irritation of the esophagus and GI tract.
- Folate – clinical studies have shown Folate can improve acid reflux symptoms by up to 40%.
- Key vitamins, minerals, and amino acids can also help balance pH levels and suppress the production of acid while soothing inflammation of the intestines. These include 5-HTP, Calcium, Vitamin D3 (best way to get it is to sit in the sun long enough to get a tan line or in raw, 100% grass-fed milk,) L-methionine, L-Taurine, Betaine, and Riboflavin.
- Vitamin B6 – or pyridoxine, plays a role in breaking down carbohydrates and fats in the stomach and supporting immune function and has also been shown to reduce symptoms of acid reflux.
Does someone you love suffer from an eating disorder?
Dr. Renae Norton specializes in the treatment of eating disorders. Located in Cincinnati, Ohio. Call 513-205-6543 to schedule an appointment or fill out our online contact form for someone to call you to discuss your concerns. Tele-therapy sessions available. Individual and family sessions also available.