Avoidant and Restrictive Food Intake Disorder
Elizabeth Mariutto, PsyD, CEDS
When the average person is asked to describe eating disorders, body image concerns are one of the most identified symptoms. However, not everyone with an eating disorder struggles with body image. Those with Avoidant and Restrictive Food Intake Disorder (ARFID) avoid or restrict certain foods, but do not do so out of fear of weight gain, desire to lose weight, or body dissatisfaction. Instead, those with ARFID limit their eating based on sensory features of the food, fear of something bad happening when one eats, or a lack of interest in eating (Thomas & Eddy, 2019).
However, ARFID is more than picky eating. Those with ARFID are highly selective in what they eat, and this selectivity leads to some type of impairment in their lives (American Psychiatric Association, 2013). Children or teenagers may not grow as expected, leading to pediatricians being concerned that they have not followed the typical growth curve that had been evidenced earlier in their lives. Those with ARFID may lose a significant amount of weight unintentionally. Others end up needing to rely on oral supplements or nasogastric tube feedings to get in sufficient energy, and those with ARFID may display nutritional deficiencies. Additionally, many with ARFID struggle socially (American Psychiatric Association, 2013). Many get-togethers, holidays, and celebrations with family and friends revolve around food, which can be anxiety and shame-inducing for those that eat more selectively, often leading to avoidance of such social gatherings and consequently, problems in relationships.
The same factors that lead to the onset of ARFID are worsened by its symptoms, which creates a cyclical pattern. Those who develop ARFID may experience more intense sensory experiences (Thomas & Eddy, 2019). They may be more sensitive to textures and/or may be a “supertaster” and pick up on more subtle variations of flavor than others. However, eating the same few foods repeatedly can lead to sensory-specific satiety, leading to those few foods becoming more aversive with time. Furthermore, if nutritional deficiencies develop, the taste of new foods can be altered, thus leaving someone to feel they have very few tolerable options. Others with ARFID may start out simply not having much interest in eating. When they eat less as a natural result, their fullness cues start kicking in prematurely and hunger cues dissipate, leading to eating even less. Lastly, those who develop ARFID after having some type of aversive experience around food (i.e., choking) start to avoid the food that led to the negative experience hoping to avoid the same event. This expands into avoidance of similar foods as well. The avoidance of these foods reinforces the fear, as these individuals do not have recent fear-countering experiences to teach them that they can safely consume these foods. Avoidance leads to increased anxiety, making the fear more entrenched.
ARFID treatment approaches resemble those for other forms of eating disorders but may include some modifications that more closely resemble the exposure treatment that is often used for obsessive compulsive disorder and anxiety disorders. A treatment provider will likely do a thorough evaluation and case formulation of what factors need addressed in treatment. First and foremost, patients may require medical stabilization to manage any of the acute health concerns that have risen with malnutrition. Second, to prevent further medical problems from occurring and to begin the process of nutritional stabilization, clients often need to increase the overall volume of food.
There has not been much research on treatment for ARFID, although a modified version of cognitive behavioral therapy, CBT-AR, is being researched for ARFID and is showing promise (Thomas et al., 2020; Thomas et al., 2021). CBT-AR pulls from existing eating disorder, obsessive compulsive disorder, and anxiety disorder treatments and extensively educates the patient on how the disorder develops and is maintained, nutritional deficiencies and the importance of volume and variety, then gradually helps patients expose themselves to the foods that they have been avoiding (Thomas & Eddy, 2019). Furthermore, Family-Based Treatment, which is a front-line treatment for adolescents with eating disorders, has been recently modified to address ARFID more specifically, also showing promising results (Lock, Sadeh-Sharvit, & L’Insalata, 2019). This treatment, which addresses the eating behaviors directly and conveys the seriousness of the eating disorder, empowers parents to refeed their child, takes a non-blaming approach to the illness, and helps parents and patients separate the illness from their identity (Lock et al., 2018).
Getting professional support can help patients with ARFID improve medically, nutritionally, psychologically, and socially. While therapists can provide support and teach specific techniques, the patient ultimately has a significant say into what foods to incorporate, when, and how. With persistence, those with ARFID can eat with much greater variety and flexibility.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.
Lock. J., Robinson, A., Sadeh-Sharvit, S., Rosania, K., Osipov, L et al. (2018). Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa. International Journal of Eating Disorders, 52, 439-446. doi: 10.1002/eat.22994
Lock, J., Sadeh-Sharvit, S., L’Insalata, A. (2019). Feasibility of conducting a randomized clinical trial using family-based treatment for avoidant/restrictive food intake disorder. International Journal of Eating Disorders, 52, 6, 746-751. doi: 10.1002/eat.23077
Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G. et al (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (CBT-AR): Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53, 10, 1636-1646. doi: 10.1002/eat.23355
Thomas, J. J., Becker, K. R., Breithaupt, L., Burton Murray, H., Jo, J. H., et al. (2021). Cognitive-behavioral therapy for adults with avoidant/restrictive food intake disorder. Journal of Behavioral and Cognitive Therapy, 31, 1, 47-55. doi: 10.1016/j.jbct.2020.10.004
Thomas, J. J., & Eddy, K. T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Cambridge: University Printing House.