ARFID Types, Causes, Symptoms and Treatments
Written by ‘Ai Pono Hawaii Staff Writer
Avoidant/Restrictive Food Intake Disorder (usually shortened to ARFID) is an eating disorder that’s characterized by extremely selective eating behaviors, disrupted feeding patterns, or both. As a result, patients with ARFID usually have a chronic failure to obtain their nutritional and/or energy needs, which leads to serious deficiencies. In children, this usually leads to an inability to gain weight.
What is ARFID?
Introduced in the Diagnostic and Statistical Manual of Mental Disorders’ fifth edition (or DSM-5) in 2013, ARFID is a relatively new diagnostic category of eating disorder. It replaced both Selective Eating Disorder (SED) and Feeding Disorder of Infancy or Early Childhood.
It is quite similar to anorexia nervosa (AN) because it also involves severely limiting the types and/or quantity of food that a person eats. However, unlike AN, patients with ARFID are usually not overly concerned with their body size, shape, or weight.
Patients who have ARFID face any of a number of eating or feeding challenges, such as:
overall poor appetite
avoidance of certain kinds of food textures, smells, or colors
unusually slow pace in eating
difficulty in digesting food
This eating disorder is also frequently seen with another disorder (i.e., comorbidity), including:
anxiety disorder
obsessive compulsive disorder
autism spectrum disorder
attention deficit hyperactivity disorder
ARFID can affect both genders, but a 2014 study showed that it may last longer and affect more males compared to AN and BN. While it’s more frequently seen in children and young teenagers, even older adolescents and adults have been diagnosed with this condition.
Causes of ARFID
Just like the rest of the eating disorders, experts propose that ARFID has no singular cause. Rather, clinicians and researchers consider a number of biological or genetic, environmental or sociocultural, and psychological factors as possible contributors to the development of this disorder.
Biological/Genetic Factors
Eating disorders are considered familial conditions. Certain temperamental traits can increase the risk of a person developing this condition, which can be passed on from one generation to the next through the genetic code.
A person who’s predisposed to suffer from ARFID because of his/her genetic or biological makeup can then be triggered to manifest this disorder in certain psychosocial or environmental circumstances (e.g., after a traumatic experience).
Environmental/Sociocultural Factors
The environmental influence of one’s household and other close relationships may also contribute to ARFID. In particular, children tend to imitate adults’ eating behaviors and copy their dieting or restrictive eating patterns.
Sociocultural influences such as the need to eat pure, clean, or healthy food (whatever the criteria for those may be); religious beliefs surrounding dairy and meat; and knowledge of the impact of food-related processes on the environment may also affect one’s views and resulting consumption of certain foods.
Although ARFID shares common symptoms with AN, the former normally doesn’t include issues with body image. However, physical expectations and beauty standards in different cultures can also contribute to the development of ARFID, which can co-occur with AN.
Psychological Factors
These factors explain why comorbid conditions like anxiety disorder, autism, and developmental disabilities are usually comorbid with ARFID. People with those conditions often have extremely heightened senses, which can also lead to heightened selectivity in their food choices.
In particular, people who have anxiety about eating tend to avoid eating in order to prevent facing their fear of choking, vomiting, or even death from eating specific foods.
Types of ARFID
Since this eating disorder is relatively new compared to other eating disorders (like anorexia and bulimia), research on it is still quite limited. Regardless, experts have noted that ARFID can present in a variety of forms.
At present, experts have distinguished three subtypes of ARFID, with each patient possibly having one, two, or all of these subtypes, depending on his/her symptoms:
Sensory Sensitivity (i.e., Avoidant Type)
Patients struggling with ARFID of this subtype demonstrate oversensitivity in terms of how they think certain foods might taste, smell, or feel. As a result, they might avoid fruit and vegetables that have a prickly texture, mushy foods, foods of a certain color, and so on.
Hence, these patients usually don’t expose themselves to different foods. Instead, they prefer to eat only the foods that they consider safe, which they feel comfortable eating on a regular basis. These sensory food aversions typically occur in neurodivergent people, such as those with autism.
Lack of Interest in Eating or Food (i.e., Restrictive Type)
Patients with this ARFID subtype have minimal to no interest in food. They usually say that they don’t feel any hunger during mealtimes. As a result, they often forget to eat on time, and usually have an abnormally low appetite.
When they do eat, they can be extremely picky, get easily distracted while eating, and/or feel full in a much shorter amount of time compared to most people.
Fear of Aversive Consequences (i.e., Aversive Type)
This subtype of patients with ARFID report being afraid that they’ll choke, feel nauseous, vomit, find bugs on their food, feel pain, embarrass themselves, and so on. Fear of getting ill or suffering from an allergic reaction may also make them avoid eating certain foods at all costs.
This is sometimes referred to as post-traumatic feeding disorder, when it refers to a trauma response that happens after a negative feeding experience like vomiting or choking. The patient might then show significant anxiety of another aversive experience happening while he/she is eating.
In addition to those three main subtypes, some experts also refer to two more subtypes: Adult ARFID and ARFID “Plus”.
Adult ARFID
This simply refers to cases of ARFID among adults. The common symptoms of ARFID in adults include extremely selective food choices; aversions to certain food textures, tastes, or colors; and food peculiarities.
ARFID "Plus"
Some people exhibit symptoms of restrictive eating habits, fear-based eating experiences, and avoidant sensory triggers. When they seem to have more than one subtype of ARFID, they may eventually develop classical symptoms of AN, such as fear of weight gain, distress about one’s size and weight, inclination for low calorie foods, and negative view of their body (without body image distortion). These symptoms are characteristic of ARFID “Plus”.
Symptoms of ARFID
Patients who are struggling with ARFID can display a variety of physical and behavioral symptoms.
In general, many children tend to be picky or selective eaters; however, a child with ARFID ends up with inadequate calories for proper growth and development, leading to delays in vertical growth and weight gain.
Meanwhile, in adults, ARFID can hinder the body’s ability to perform basic functions, but weight loss is often observed first. ARFID in adults can also cause school or work issues.
The most common warning signs to look out for, which may lead to a diagnosis of ARFID, are the following:
Physical symptoms
Significant weight loss
Concentration problems
Reduced heart rate
Dizziness and/or fainting
Often feeling cold
Cool and mottled extremities, or swollen feet
Stomach cramps and other non-specific gastrointestinal issues (acid reflux, constipation, etc.)
Irregularities in menstrual cycle, such as missed periods, or absence of period
Abnormal laboratory results (low blood cell counts, anemia, low potassium, low thyroid and hormone levels)
Difficulty sleeping
Dry skin
Growth of fine hair (called lanugo) all over the body
Thinning, dry, and/or brittle hair
Brittle nails
Muscle weakness
Bone density loss or osteoporosis
Slow healing of wounds
Weak immune system (leading to more infections)
Behavioral symptoms
Displaying sudden or extreme limitations in the amount or types of food consumed:
Eating only very small portions of food
Insisting to eat only foods with specific characteristics in terms of texture (e.g., crunchy, soft), color (e.g., colorless), etc.
Avoiding one or more food group (e.g., all grain products)
Eating only foods that were prepared in a certain manner (e.g., steamed)
Showing extremely picky eating that gradually leads to much fewer types of food consume
Displaying extreme emotions or stress in the presence of unfamiliar food items
Gagging, or reporting fear of vomiting, choking, etc. while eating
Reporting abdominal pain, fatigue, lethargy, constipation, cold intolerance, and/or excess energy
Reporting vague, persistent gastrointestinal concerns around mealtimes with no known cause (e.g., feeling full, upset stomach)
Dressing in layers to keep warm and/or conceal drastic weight loss
Lower interest in food and/or appetite
No fear of gaining weight
No anxiety about one’s body image
If you’re the parent or caregiver of a child or teenager who has those signs and symptoms, or you observe those in yourself, it’s important to seek treatment as early as possible to prevent complications.
Risks and Complications of ARFID
Besides the negative effects already mentioned above, ARFID can also lead to dependence on nutritional aids like dietary supplements in order to obtain sufficient calories and nutrients for good health. Social issues like shame when eating with other people and psychological issues like the development of comorbid disorders (e.g., anxiety disorder, depression) are also common complications of ARFID.
As an eating disorder, ARFID can directly affect one’s health. When a patient does not have enough nutrients to support optimal functioning of his/her organs, various body processes may slow down in order to conserve the body’s limited energy.
The human body is amazing and can normally cope with the effects of ARFID in the short term. This is why blood tests of ARFID patients can sometimes show normal results despite them suffering from malnutrition. However, abnormally low levels of electrolytes, including potassium, can lead to sudden death. Liver and kidney failure may also occur. People who have extreme nutritional deficiencies likewise have an increased risk of dying from a heart attack.
While those are all alarming, prompt treatment by experienced professionals can treat or reverse those medical complications and ensure complete recovery. They can also monitor a patient (if needed) for refeeding syndrome. Once health complications (such as severe malnutrition and abnormally low weight) have been addressed and the patient’s health is deemed stable enough, treatment for the eating disorder itself can begin.
It’s important to know that ARFID—like the other eating disorders—can be and is being effectively treated. The earlier you (or your loved one) seek proper treatment, the better the outcomes will be and the faster you can recover from the many detrimental effects and avoid potential complications of this condition.
Treatments for ARFID
The treatment for ARFID usually begins with a comprehensive assessment conducted by a team of specialists (which, at the very least, includes a therapist, medical doctor, and nutritionist/dietitian) in treating eating disorders. Together, they can officially diagnose ARFID and note its severity, determine the subtype of ARFID the patient has, and consider other crucial factors involved in a patient’s case.
Medical stabilization, nutritional rehabilitation and counseling, psychiatric stabilization, and medical care (including weight restoration, if necessary) are all standard elements of treatment plans for ARFID. Feeding therapy may also be included if the patient is afraid of choking, with a speech-language pathologist involved to perform a swallowing and feeding evaluation
Treatment for patients with ARFID is usually focused on helping them achieve the following:
Gain and maintain a healthy weight
Learn and practice healthy eating behaviors
Increase the number and types of food they consume
Discover and practice ways to eat without being afraid of choking, pain, etc.
Boost their appetite or treat their anxiety using prescription medicines (if needed). If the patient suffers from anxiety or trauma, treatment will include teaching the patient and his/her guardians how to manage food-related worries.
Besides the health professionals previously mentioned, a treatment team for patients with ARFID may also include:
psychologists
psychiatrists
occupational therapists
developmental pediatricians
adolescent health physicians
gastroenterologists
and more
As with treating any other eating disorder, a personalized treatment plan is recommended for every patient with ARFID. The treatment plan should address and include these:
The patient's unique developmental background and development stage
The patient's past and current family dynamics
The patient's extrinsic and intrinsic motivators, values, and objectives
The level of involvement of the patient’s family in his/her recovery
Collaboration among members of the patient’s multidisciplinary team (MDT)
Transparent and regular communication between the patient’s treatment providers
Treatment for ARFID may be provided in any of several levels of care, such as outpatient, intensive outpatient, residential, inpatient, and hospitalization. The treatment team will determine and recommend the best treatment program and level of care for each patient’s unique case.
Effective ARFID treatment should be comprehensive and performed by a team of experienced specialists, whose customized treatment plan for each patient usually includes (but is not limited to) the following:
Psychotherapy
A standard element of treatment programs for all eating disorders, psychotherapy addresses issues in a patient’s psychological health.
Cognitive Behavioral Therapy (or CBT)
CBT has been shown effective in treating many eating disorders. Although research on its effectiveness in treating ARFID is still growing, plenty of clinicians have seen the wonderful effects of CBT on patients with ARFID. For patients suffering from post-traumatic feeding disorder, trauma informed therapy can help in managing the trauma that’s triggering their symptoms.
In a nutshell, CBT teaches patients to identify their dysfunctional and/or irrational beliefs and behaviors related to food and change those into more rational and healthier ones. Exposure and response prevention are vital components of CBT. Many patients show improvement in their symptoms after they receive a type of CBT that’s specifically designed for treating ARFID: the Cognitive Behavioral Therapy for ARFID (CBT-AR). It involves a therapist and dietitian who closely collaborate in ensuring that a patient consistently and continuously eats new food items. Afterwards, the therapist guides the patient in processing each emotional experience.
Family therapy
This type of therapy may also be conducted for children suffering from ARFID. Family sessions usually focus on education about the disorder and useful coping strategies for dealing with the child’s symptoms at home or in school. Family Based Therapy for ARFID (FBT-ARFID) has been recently gaining popularity and showing positive results.
Occupational Therapy
Interventions using sensory-based occupational therapy can help patients who have sensory issues associated with ADHD and autism. If a patient’s food avoidance results from sensory issues, occupational therapy can help them cope with such restrictions.
Medications
At present, there is no FDA-approved psychiatric medication for treating ARFID. Nonetheless, studies have shown that lorazepam and mirtazapine can help in lowering anxiety surrounding food. Meanwhile, olanzapine can help lessen patients’ rigid thoughts on food. Medical doctors may also prescribe appetite-stimulating drugs, certain vitamins, and supplements to ensure complete nutrition.
For patients who have comorbid or co-occurring health problems, treatment will also include the necessary medications to address those conditions.
Children and adolescents who are struggling with ARFID seem to benefit the most from child-centered cognitive behavioral therapy, family-based therapy, or parent-based behavioral therapies. A new parent-based approach called SPACE-ARFID—which focuses on replacing parents’ responses and fostering flexibility with regards to food—has also shown promising results.
More treatment options are expected to be developed in the coming years as more light is shed on ARFID.
Begin Your Healing From ARFID
Effectively treating ARFID requires highly specialized guidance from a highly experienced team of specialists in treating eating disorders as well as its comorbid and associated conditions.
‘Ai Pono Hawaii has more than 35 years of success in offering holistic and effective treatment to patients with all kinds of eating disorders, such as ARFID. We provide continuous education to our patients as well as their parents in order to promote long-term healing from their disorder and empower them to prevent and/or manage relapse in case it occurs.