Avoidant Restrictive Food Intake Disorder DSM-5 307.59
DSM-5 Category: Feeding and Eating Disorders
ARFID ( Avoidant/Restrictive Food Intake Disorder) is a newly recognized eating disorder described in the DSM-5, which can occur throughout the lifespan, in infants, children, teens and adults (American Psychiatric Association, 2013). This disorder was formerly diagnosed in infants in children as a feeding disorder, but in the DSM 5, it has been recognized beyond early childhood. (Kenny, and Walsh, 2013) This disorder is differentiated from anorexia, in that although it involves food restriction, the underlying motives are very different than the distorted body image at the core of anorexia nervosa. (About Eating Disorders, 2014). ARFID involves rigidity around eating, by avoiding certain types of food resulting in insufficient caloric intake. This is beyond being a finicky eater,or avoiding foods for adaptive and prudent reasons- e.g.- a nut allergy, or lactose intolerance. There are multiple motivating factors for ARFID. Food avoidance may be based on inaccurate information and incorrect beliefs about food intolerance and nutrition. There are rigidly held beliefs which conflict with empirical evidence, e.g.- the prevalence of individuals self diagnosing with gluten intolerance, (Di Sabatino and Corazza , 2012) which will cause people to avoid certain foods. There may be an aversion to the smell, taste, temperature or texture of certain foods, or ARFID can result from traumatic avoidance related to food- e.g., choking, or painful esophageal spasms due to dyspaghia (American Psychiatric Association, 2013).
Symptoms of Avoidant/Restrictive Food Intake Disorder
According to According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) the diagnostic criteria for ARFID is:
1. In the absence of another discrete mental disorder or medical condition, An eating or feeding disturbance which can include indifference to eating or food; rigidity and refusal to eat foods based on smell, taste, texture, or appearance, or concern about aversive consequences of eating. This will be expressed by persistent failure to meet nutritional or caloric needs, and result in significant weight loss /inability to gain weight, or in children, not meeting growth milestones. Micro-nutrient deficiencies can occur, and there may be a need for compensatory feeding such as enteral feeding or use of oral nutritional supplements. There will be marked interference with psychosocial functioning- e.g.- stress around the family dinner table, or avoidance of social activities involving food. ARFID is not attributable to lack of food or a culturally sanctioned practice. ( e.g., religious fasting, or prohibitions against eating certain foods). ARFID is also exclusive from anorexia nervosa or bulimia nervosa, in that there is no perception of distorted body image (American Psychiatric Association, 2013).
The clinician can include this specifier:In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been apparent for a prolonged period. (American Psychiatric Association, 2013).
Onset of Avoidant/Restrictive Food Intake Disorder
The DSM -5 indicates ARFID symptoms based on food taste, smell, texture, or appearance tend to appear by age 10, but may persist into adulthood One's taste perception changes with age, and food that were once objectionable will become enjoyable- and previously enjoyed food swill no longer be a source of interest, Avoidance related to aversive consequences - e.g. choking, or the mistaken perception of a food intolerance or allergy which is more accurately attributed to another cause. can arise at any age. This has been referred to as food neophobia (Lock, 2009). ARFID is not a predictor of anorexia or bulimia, as there is insufficient evidence correlating avoidant/restrictive food intake disorder with the subsequent onset of an another eating disorder. Avoidant/restrictive food intake disorder manifests more commonly in children than in adults, and there may be a long delay between onset and clinical presentation. Triggers for presentation vary considerably and include physical, social, and emotional difficulties.(American Psychiatric Association, 2013).
Prevalence of Avoidant/Restrictive Food Intake Disorder
The prevalence rate of feeding disorders ranges from 25% to 35% in children with normal intellectual and adaptive development, and 40% to 60% in children with developmental disabilities ( McCormick & Markowitz, 2013 ;American Psychiatric Association, 2013).
Risk Factors for Avoidant/Restrictive Food Intake Disorder
The DSM -5 notes a number of disorders which may precipitate ARFID, including: Anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder may increase risk for avoidant/ eating behavior. Environmental risk factors for avoidant/restrictive food intake disorder include familial anxiety. Higher rates of feeding disturbances may occur in children of mothers with eating disorders. A history of gastrointestinal conditions, GERD ( Gastroesophageal Reflux Disease), vomiting, and a range of other medical problems has been associated with feeding and eating behaviors characteristic of avoidant/restrictive food intake disorder. An incident of choking on food can precipitate ARFID (American Psychiatric Association, 2013).
Comorbidity with Avoidant/Restrictive Food Intake Disorder
The DSM -5 notes comorbidity with Anxiety disorders, obsessive-compulsive disorder, and neurodevelopmental disorders including autism spectrum disorder, attention-deficit/hyperactivity disorder, and intellectual disability.(American Psychiatric Association, 2013).
Treatment for Avoidant/Restrictive Food Intake Disorder
CBT (Cognitive Behavioral Therapy) is described as an ideal treatment for anorexia and bulimia, due to cognitive distortion around body image. (Murphy, Straebler, Cooper, & Fairburn, 2010) However, ARFID does not present with distorted body image. CBT could be useful however to challenge rigid beliefs about food, and fear of choking. Psychoeducational information from the scientific literature on nutrition could be beneficial if food avoidance is based on inaccurate information. (American Psychiatric Association, 2013).
Impact on Functioning
The DSM-5 indicates that weight loss, and nutritional deficiencies can occur with ARFID. Family and friends may become frustrated with the person displaying selective eating, as in social situations, in can be offensive to refuse food which has been offered to you. This is especially true in cultures where food is scarce, or has has been so historically, and sharing food is a honorable and almost sacred act. This disorder could create family tension. Infants with avoidant/restrictive food intake disorder may be fussy and difficult to comfort during feeding. Parent-child interaction may be a contributing factor, such as presenting food to abruptly or forcefully. Associated factors could include infant temperament, such as avoidance of novel experiences, which could be expressed as reluctance to try newly introduced foods. In older children, adolescents, and adults, social functioning can also be impacted at meal time (American Psychiatric Association, 2013).
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McCormick, V. and Markowitz, G. (2013). Picky Eater or Feeding Disorder? Strategies for determining the difference. Advance health care network for NP's and PA's. Retrieved February 20, 2014, from: http://speech- language-pathology-audiology.advanceweb.com/Features/Articles/Picky- Eater-or-Feeding- Disorder.aspx
Murphy, R., Straebler, S., Cooper, Z., and Fairburn, C. G. (2010). Cognitive Behavioral Therapy for Eating Disorders. Psychiatry Clinics of North America. 33(3): 611–627. doi: 10.1016/j.psc.2010.04.004
Gavura, S. (2012). Is gluten the new Candida? Science based Medicine. Retrieved Retrieved February 20, 2014 from: http://www.sciencebasedmedicine.org/is-gluten-the-new-candida/
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