What is Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)?
Avoidant Restrictive Food Intake Disorder, or ARFID, is a specific type of eating disorder identified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Unlike other eating disorders like anorexia or bulimia, people with ARFID don’t have problems with body image. Instead, they may avoid or limit what they eat due to things like texture, fear of eating, or lack of appetite, which can lead to problems like malnutrition, weight loss, or not getting enough important nutrients. While this disorder can affect people of any age, it usually starts in childhood and can carry on into adulthood. It can also show up alongside other medical or mental health problems, which can make it more difficult to diagnose and treat.
Another challenging aspect of ARFID is that it can look different in different people. For example, one person might have different symptoms than another, based on the main causes of their disorder.
The guidelines for diagnosing ARFID put a lot of emphasis on the fact that people with this disorder don’t have issues with body image, and they don’t have any other eating or medical disorders that could be causing the problem. Diagnosis involves thoroughly checking the person’s physical health, eating behaviors, and mental health.
Treatment for ARFID aims not only to immediately address health concerns but also to help people eat a wider variety of foods and to tackle any fears or discomfort they might have related to eating. Treatment methods can include different types of therapy, sometimes medication, and in severe cases, hospitalization might be required. The best approach to treatment usually involves professionals from various disciplines in healthcare to help ensure the person’s health and quality of life can be improved.
What Causes Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)?
Despite much study, the causes and brain mechanisms of ARFID (Avoidant/Restrictive Food Intake Disorder) are not well-known. ARFID’s origins are complex, involving a mix of genetic factors, environmental effects, brain-related processes, and psychological aspects similar to other eating disorders.
ARFID shares several eating disorder traits with conditions like anorexia nervosa, including limited food intake, low body weight, and nutritional deficiencies. Some studies even suggest that there may be a common cause between anorexia nervosa and ARFID, as people who have ARFID could be diagnosed with anorexia nervosa later in life.
A recent study involving a large group of Swedish twins showed that genetics could seriously impact the likelihood of developing ARFID. The study found that about 79% of the twins’ susceptibility to ARFID could be attributed to inherited genetic factors, while 21% could be traced back to unique environmental factors. This strong genetic influence suggests a need for more research into the genetics of the disorder.
Factors such as early childhood experiences, sensitivity to sensory input, and anxiety disorders might also contribute to ARFID’s development. Theories suggest that irregularities in appetite regulation, sensory perception, and an overly active fear system in the brain could lead to comorbid anxiety disorders and the continuation of restrictive eating behaviors. Importantly, ARFID affects a diverse group of people, with both biological and environmental factors impacting the development and maintenance of their eating habits.
Risk Factors and Frequency for Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
Research has found that ARFID, or Avoidant Restrictive Food Intake Disorder, affects between 0.35% and 3.2% of children, and between 0.3% and 3.1% of adults. It’s interesting to note that, unlike most eating disorders like anorexia or bulimia which primarily affect females, ARFID is quite often found in males, especially in children. Given these findings, it’s important to bear in mind gender when diagnosing and treating the disorder.
- ARFID is found in 0.35% – 3.2% of children and 0.3% to 3.1% of adults.
- ARFID is more common in males than in females.
- This is particularly noteworthy because other eating disorders usually affect more females.
- Because of this, gender should be considered when diagnosing and treating ARFID.
ARFID often co-exists with other conditions, particularly neurodevelopmental disorders like autism and ADHD. Additionally, it’s often associated with learning disabilities, obsessive-compulsive disorders (OCD), and anxiety disorders more frequently than other eating disorders, suggesting that ARFID might be connected to larger issues concerning neurodevelopment and psychological processes. That being said, the exact global prevalence of ARFID remains uncertain due to inconsistencies in diagnostic definitions. However, we know that ARFID is a significant concern due to its diverse and often hidden symptoms.
- ARFID frequently co-occurs with autism, ADHD, learning disabilities, OCD, and anxiety disorders.
- These associations suggest a possible connection with broader neurodevelopmental and psychological processes.
- Global occurrence of ARFID is uncertain due to varied diagnostic approaches.
- Nevertheless, ARFID is seen as a significant concern due to its wide-ranging and often subtle symptoms.
Signs and Symptoms of Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
Avoidant/Restrictive Food Intake Disorder, referred to as ARFID, is diagnosed through detailed patient history and clinical evaluation. It is important to gather in-depth information about the patient’s eating habits, including when they started, how long they’ve been going on, and any events or experiences leading to these eating habits. Recurring stomach related complications, such as abdominal pain or nausea, should also be noted.
ARFID diagnosis is based on the DSM-V criteria:
- Criterion A: The presence of an eating disturbance that leads to significant weight loss, nutritional deficiency, dependence on feeding tubes or dietary supplements, or a substantial reduction in psychosocial functioning.
- Criterion B: The disturbance in eating is not linked to the lack of availability of food, or any religious or cultural factors.
- Criterion C: The disorder is not related to anorexia nervosa or bulimia nervosa, as body image issues are not present.
- Criterion D: Other mental or medical conditions are not the cause of the disturbance.
ARFID manifestation is different for different individuals. People with ARFID may not show interest in food or eating, which can lead to significant weight loss or nutritional deficiencies. The disorder can affect anyone, regardless of their body weight. Patients often show reduced appetite and restrictive eating habits. In women, lack of menstruation due to malnutrition and substantial weight loss may be present. Psychological disorders like anxiety and neurodevelopment disorders like autism spectrum disorder and ADHD are often associated with ARFID.
In-depth assessment of the patient’s eating habits, including the types and quantity of food and drinks consumed, cooking styles, and dietary preferences towards texture, taste, and aroma of food is necessary. Weight loss, growth failure, or dependence on nutritional supplements should be noted. The symptoms typically include abdominal pain, nausea, stomach discomfort while eating and excessive fears of choking, allergies, or illness resulting from eating. Symptoms generally start suddenly, following a traumatic food-related event and are often accompanied by an anxiety disorder.
A comprehensive physical examination is necessary for diagnosis. This involves a review of the patient’s growth charts, including weight, height, and body mass index (BMI). Physical examination may reveal symptoms of malnutrition like muscle wasting, fatigue, lack of concentration, and delayed growth among children and adolescents due to insufficient food intake. Patients might also develop anemia, slow heart rate, and muscle wastage. In pediatric patients, BMI measurements and growth parameters must be carefully reviewed to identify unexpected changes in growth patterns. Signs of delayed gastric emptying or constipation due to low fiber intake might also be present.
Testing for Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
Tests in the laboratory are not able to diagnose ARFID directly, but they are very important for understanding a person’s nutrition levels and spotting any health problems that might be caused by not getting enough to eat. This often includes looking at the levels of different types of cells in your blood, checking your liver and thyroid function, and also checking to see if you might be lacking in any vitamins or minerals. In certain situations, additional tests might be needed to rule out other health conditions. For instance, these tests could look for signs of inflammation, disorders related to hormones, or issues digesting gluten, as in Celiac disease.
Imaging, like an X-ray, is usually not necessary unless you’re experiencing specific symptoms such as stomach pain or difficulty going to the bathroom. Other tests, like those that check your bone density, might be used to see how long-term malnutrition might have impacted your bone health.
Besides physical examination and lab tests, understanding ARFID also involves psychological evaluation. This can come in the form of structured interviews conducted in the office or responses reported by the patient themselves. Different kinds of screens that a clinician might use when talking to you can include the Eating Disorder Assessment for DSM-5 (EDA-5), the Structured Clinical Interview for DSM-5 (SCID-5), the ARFID module of the Eating Disorder Examination (EDE), and others.
On the flip side, self-reported screens might include the Food Phobia Scale (FNS), the Nine-Item ARFID Screen (NIAS), and others. These tools all help the clinician understand different parts of your experience with ARFID. Still, it’s important to remember that these methods, while useful, are not perfect and usually need to be combined with an in-office interview for a thorough evaluation.
In some cases, more evaluations might be needed based on your symptoms and the results of previous tests. It might be recommended that you see a dietitian for a detailed nutritional examination, or a mental health specialist if they suspect you may have other emotional or psychological conditions. If you take longer to eat, you may need to check if there’s an issue with your ability to chew and swallow. If you’re not growing normally, it might be necessary to see a doctor specializing in hormones (endocrinologist), or a stomach specialist (gastroenterologist) if you’re having tummy trouble.
Treatment Options for Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
Due to the relatively recent introduction of Avoidant/Restrictive Food Intake Disorder (ARFID) as a diagnosis, treatment approaches are still being researched and agreed upon. Based on what is currently understood, cognitive behavioral therapy, family-based therapy, and medication are the most frequently suggested treatments.
The main treatment goals for those with ARFID include:
- Addressing immediate health concerns and maintaining overall health.
- Choosing the best treatment setting (outpatient or inpatient) based on the person’s symptoms and needs.
- Regular monitoring of food intake and weight to ensure a healthy weight and growth.
- Increase the variety and amount of food consumed to correct any nutrient deficiencies.
- Address fears or issues related to food, potentially through exposure therapy or other behavioral treatments.
- Encourage an enjoyment of eating by developing a positive relationship with food.
While medication is not the primary treatment method for ARFID, it may be helpful in some cases. For example, mirtazapine can stimulate appetite and reduce anxiety. Cyproheptadine, which boosts appetite, and anti-anxiety drug olanzapine, which can also aid weight gain, have been used as treatments, despite not being officially approved for ARFID treatment. However, use of these drugs should be considered carefully, as research into their effectiveness is limited.
In severe instances of ARFID, hospitalization could be needed to restore healthy eating habits and address malnutrition or dangerously low weight. The American Psychiatric Association recommends considering hospitalization for patients with alarming symptoms such as abnormal body mass index, dehydration, abnormal electrolytes, heart irregularities, and persistent illness or conditions that wouldn’t allow effective outpatient treatment.
Nutritional management is crucial to ARFID treatment. This involves assistance from dietitians who specialize in eating disorders to closely monitor growth and progress, especially in children. The primary focus of such management is to gradually improve the person’s nutritional status, balanced eating habits, and weight. This is achieved by incrementally increasing the food consumed and introduction of new foods into the patient’s diet.
In extreme cases, tube feedings may be necessary . As the patient’s food intake improves, foods and beverages that they previously enjoyed can be reintroduced gradually, with the end goal of returning to their regular diet over time.
Psychological therapy plays a significant role in managing ARFID. Cognitive-behavioral therapy, family-based therapy, and exposure therapies can be particularly effective. These therapies mainly aim to reduce anxiety around meal-time, change disruptive eating patterns, and challenge incorrect beliefs regarding food. Since treatment varies from person to person, collaborative care models that involve a variety of healthcare professionals are considered best practice.
What else can Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder) be?
There are several health conditions that can seem like ARFID (Avoidant/Restrictive Food Intake Disorder) because they have similar symptoms. That’s why, when diagnosing ARFID, doctors need to do a careful assessment to separate ARFID from other medical, mental, or psychiatric conditions. Here is a list of conditions that physicians need to consider when diagnosing ARFID:
- Anorexia and Bulimia (eating disorders affecting food intake)
- Reflux disease (which can cause discomfort when swallowing)
- Eosinophilic esophagitis (allergic inflammation of the esophagus)
- Inflammatory bowel disease (disorders causing inflammation in the gut)
- Food allergies (having adverse reactions to certain foods)
- Celiac disease (an autoimmune disorder triggered by gluten)
- Chronic constipation (having infrequent bowel movements)
- Pica (craving and consuming non-food substances)
- Rumination disorder (regurgitating food)
- Autism (where being picky about foods is common)
- Anxiety and Depression (which both might alter eating habits)
- Social phobia (which might affect eating in public places)
- OCD (Obsessive Compulsive Disorder which might affect eating habits)
- PTSD (Post Traumatic Stress Disorder which might be linked to a traumatic food-related event)
- ADHD (which might lead to impulsive eating behaviors)
- Neurodevelopmental disorders (conditions that might affect the normal development of the nervous system and thus, feeding)
- Structural problems in the throat or gut that can impact food intake
- Endocrine disorders like Addison’s disease or Hypothyroidism (which can affect appetite)
Identifying and ruling out these potential conditions can help ensure a correct diagnosis and guide the most appropriate treatment.
What to expect with Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
There isn’t much information available about the different aspects of ARFID, a type of eating disorder, and the current data are not enough to predict the course or outcome of the disease. Several factors, such as the age when the disease started, how long the patient has been ill, and other health conditions can affect the outcomes for individuals diagnosed with ARFID.
Early detection and treatment are vital for effective management, but the availability of mental health services and treatment options is limited at this time. If left untreated for a prolonged period, ARFID can result in serious nutrition problems and difficulties in social and psychological wellbeing.
To effectively treat ARFID, a detailed approach taking into account biological, psychological, and social factors is necessary. Enhancing public awareness about the disease and providing targeted interventions can lead to better outcomes and ensure more people have access to care. Further research is necessary for more understanding of the long-term outcomes for patients with ARFID.
Possible Complications When Diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
The physical and psychological complications resulting from ARFID (Avoidant Restrictive Food Intake Disorder) can often be similar to those seen in anorexia nervosa due to malnutrition and nutritional deficiencies. The impacts of ARFID can be wide-ranging and long-lasting, affecting many different bodily functions. Various complications can result, causing additional health concerns physically, mentally, and socially.
The primary issues relate to the heart and lung systems. Some of these complications include:
- Slow heartbeat
- Low blood pressure
- Heart rhythm disorders
- Reduced heart muscle mass
- Heart failure
- Difficulties with fluid in the lungs linked to the refeeding process
Kidney complications involve:
- Sudden kidney damage
- Problems with blood mineral levels
- Long-term kidney disease
- Protein in urine
For gastrointestinal complications, expected problems include:
- Constipation
- Slow stomach emptying
- Acid reflux
- Swallowing issues
- Stomach bloating and gas
- Unusual liver function
Hormone and reproductive-related complications include:
- Problems with growth hormone
- Messed-up menstrual cycles
- Adrenal gland issues
- Delayed puberty
- Low blood sugar
- Sexual dysfunctions and pregnancy complications
Muscle and bone-related effects consist of:
- Reduced muscle mass
- Weak and fragile bones
- Slow growth
- Muscle weakness
There can be skin-related complications like:
- Dry, flaky skin
- Bruising
- Hair thinning or loss
- Swelling
Hematological (related to blood) complications include:
- Anemia
- Low white blood cell count
- Low platelet count
Immune system effects can include:
- Increased chances of infections
- Reduced effectiveness of vaccines
Mental health and neurological complications may involve:
- Problems with cognitive function
- Nerve damage
- Developmental delays
- Mood disorders
- Sleep disturbances
Preventing Avoidant Restrictive Food Intake Disorder (ARFID, Selective Eating Disorder)
The approach to dealing with ARFID (Avoidant/Restrictive Food Intake Disorder) involves taking steps to stop the disorder from developing or getting worse. The goal is to teach people about the disorder, what causes it, what its symptoms are, and how to manage it. One of the main things being addressed is trying to build an understanding around the risk factors for ARFID. These can include extremely fussy eating habits or avoiding certain foods altogether, especially in children. It’s important to tackle these issues early to stop the disorder from getting worse.
There are various methods used to educate patients such as information sessions, leaflets, or using online resources. The idea is to provide detailed information about the symptoms of ARFID, the potential outcomes if not treated, and the treatment options available. Also, doctors and other healthcare professionals have a very important role in all of this. They educate both the patient and their families about ARFID, its effects on physical and mental health, and why it’s important to get treatment and support as soon as possible.
