Avoidant/Restrictive Food Intake Disorder (ARFID) is about more than "picky eating”. It stems from chronic food avoidance or restriction that leads to severe weight loss and nutritional deficiency. Unlike other eating disorders, ARFID is not related to body image.

ARFID was first introduced in 2013 in the American Psychiatric Association’s (APA) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2022, the DSM-5 text revision (DSM-5-TR) further refined its diagnostic criteria for ARFID. The diagnosis is characterized by substantial weight loss and nutritional deficiency due to the persistent avoidance or restriction of food or eating. In children, underweight may manifest as limited growth or an inability to gain the expected weight for age. The avoidant/restrictive behaviors are not related to cultural practices or food scarcity, and the disorder interferes with psychosocial functioning. Importantly, ARFID is not related to body image or fear of weight gain.

ARFID is most often diagnosed during childhood or adolescence but can occur at any age. Compared to anorexia nervosa or bulimia nervosa, ARFID is more prevalent in younger persons, male adolescents, those with comorbid psychiatric conditions such as anxiety or autism spectrum disorders (ASD), and in people with medical conditions, including food allergies and gastrointestinal disorders that cause eating-related distress (gagging, choking, nausea, or pain).

Over the long-term, ARFID may contribute to underdevelopment in children, impaired psychosocial functioning, depression, anxiety, and an overall reduction in quality of life. In patients with severe malnutrition who require in-patient nasogastric or enteral nutrition to reach homeostasis and tolerance for oral nutrition, refeeding syndrome is an uncommon though potentially serious or even fatal complication.

How is ARFID Diagnosed?

Consider six-year-old Lauren, described in a case report. She had a prior diagnosis of ASD and separation anxiety. Other than refusing rice or pasta, her mother reported that her diet was relatively varied and balanced. When Lauren entered primary school, she developed a reluctance to eat in front of her classmates. Her weight remained stable until the end of the school year but then she acquired a throat infection that left her afraid of choking and getting food stuck in her throat.

Lauren became increasingly sensitive to the sight and smell of food, displayed irritability, and started to restrict her intake. Her pediatrician prescribed risperidone for aggressive behavior. Within a three-week period, Lauren lost three kg (6.6 lbs.) and became medically unstable and was hospitalized. She received artificial nutrition via nasogastric tube (NGT) and continued with the NGT upon discharge. She was prescribed fluoxetine for generalized anxiety and referred to psychology services for family-based treatment of an eating disorder.

The physical signs and symptoms of inadequate energy intake in cases like Lauren’s are important to note. They can range from weakness, dizziness or syncope, abdominal pain or constipation, low body temperature, dry or pale skin, hair loss, and/or amenorrhea in menstruating persons to other sequelae from malnutrition. In children, developmental abnormalities and psychological disturbances may also result from malnutrition and inhibited growth. For an ARFID diagnosis, however, these factors must occur alongside key eating-related behavior changes.

Look for changes or patterns in food repertoire, including the range of “accepted” and “avoided” foods or the narrowing or elimination of foods or entire food groups, sometimes based on smell or texture. Determine whether food avoidance is related to fear of discomfort (nausea, pain, gagging, choking), and consider the possibility of other eating-related behaviors (binge eating, rumination, regurgitation, chewing and spitting).

Try to establish the onset and duration and the extent of food-related impairment. Lauren was never a fan of rice or pasta, but her eating behaviors began to shift when she changed schools and was uneasy about eating in front of her peers. The dramatic shift toward food restriction occurred after the infection that made swallowing a source of anxiety. This was the catalyst for her shift into ARFID.

Prior to making an ARFID diagnosis, exclude conditions that may present with weight loss or decreased interest in food or eating. Rule out other eating disorders, such as anorexia nervosa which involves distorted body image and fear of weight gain that is not a feature of ARFID. Consider food allergies or gastrointestinal disorders, including gastroesophageal reflux disease (GERD) and celiac disease, that explain the presence of nutritional deficiencies and/or changes in weight or development. Bear in mind that psychiatric and neurodevelopmental disorders may also contribute to changes in eating habits or lack of interest in food that, in some cases, can result in comorbid ARFID. Lauren’s history of ASD, for example, reflects a common ARFID comorbidity.

Structured clinical interviews such the ARFID module of the Eating Disorder Examination (EDE) and PARDI (Pica, ARFID, and Rumination Disorder Interview) may aid in the diagnosis of ARFID but should not be the sole method for determination. Self-report questionnaires such as NIAS (Nine-Item ARFID Screen) and EDY-Q (Eating Disorder Examination - Questionnaire) may also be helpful.

Tune in next week to read about management approaches for this complex eating disorder.

For handouts and information to share with your patients, see DynaMedex Patient Information on ARFID.