Avoidant/Restrictive Food Intake Disorder

Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by a “persistent failure to meet appropriate nutritional and/or energy needs” (DSM-5, p. 334) associated with a lack of interest in eating or food, food avoidance based on extreme sensitivity to the sensory (e.g., color, smell, texture, temperature, taste) characteristics of food, or concern about negative consequences of eating, such as choking or vomiting.

The eating disturbance results in weight loss or failure to gain weight (in children), nutritional deficiency, the need for food supplements, or impairment in psychosocial (school, work, and social) functioning.

Although ARFID occurs most frequently in infancy and early childhood (when it is commonly known as “failure to thrive”), in DSM-5, the diagnostic concept has been expanded to include food avoidance or restriction that may occur in individuals of any age.

ARFID thus subsumes “choosy eating” or “chronic food refusal” that is not related to Anorexia NervosaOpens in new window or Bulimia NervosaOpens in new window, is not attributable to a concurrent medical condition, and is not better explained by another mental disorder.

It may occur in association with other mental disorders, such as Anxiety DisordersOpens in new window, Autism Spectrum DisorderOpens in new window, Obsessive-Compulsive DisorderOpens in new window, or Attention-Deficit/Hyperactivity DisorderOpens in new window. In such cases, ARFID is diagnosed in addition to the other disorder if food avoidance is particularly severe or requires special clinical attention. If gastrointestinal problems, such as gastroesophageal reflux, cause food avoidance, a diagnosis of ARFID is not warranted.

Case study 1 \| Bottle Baby
Six-month-old Roberto was admitted to a hospital for evaluation of his failure to gain weight when, at 15 pounds, he fell below the 15th percentile for weight for his age. He was the second of two children born to working-class parents following an unplanned but normal pregnancy. He weighed almost 9 pounds at birth. Although Roberto, as the only son, was the apple of his father’s eye, Roberto’s mother has had continual difficulties with the infant. He was bottle fed, and his mother reported that he had severe colic (i.e., recurrent episodes of prolonged crying and irritability). His pediatrician made several formula changes and suggested other treatments for colic, but Roberto continued to fail to gain weight. In the hospital, nurses watched his mother attempt to feed him. There was poor synchrony between the mother and baby around feeding, in that his mother often did not seem to know when Roberto was hungry, when he needed to be burped, and when he was finished eating. Consequently, Roberto seemed often disinterested in feeding, which became a distressing experience for both mother and child. However, the nurses and aides were able to feed Roberto without any difficulty. Various medical investigations failed to disclose any specific medical condition that might account for the baby’s difficulties. Discussion with the mother gradually revealed that she had been depressed throughout the pregnancy and resented the baby’s demands. Treatment of her depression and the underlying marital problems, as well as focused instruction on feeding, facilitated the mother’s adjustment. Roberto’s feeding difficulties gradually diminished, and within a few weeks he gained several pounds.

Case study 1 | Bottle Baby

Six-month-old Roberto was admitted to a hospital for evaluation of his failure to gain weight when, at 15 pounds, he fell below the 15th percentile for weight for his age. He was the second of two children born to working-class parents following an unplanned but normal pregnancy. He weighed almost 9 pounds at birth.

Although Roberto, as the only son, was the apple of his father’s eye, Roberto’s mother has had continual difficulties with the infant. He was bottle fed, and his mother reported that he had severe colic (i.e., recurrent episodes of prolonged crying and irritability). His pediatrician made several formula changes and suggested other treatments for colic, but Roberto continued to fail to gain weight.

In the hospital, nurses watched his mother attempt to feed him. There was poor synchrony between the mother and baby around feeding, in that his mother often did not seem to know when Roberto was hungry, when he needed to be burped, and when he was finished eating. Consequently, Roberto seemed often disinterested in feeding, which became a distressing experience for both mother and child. However, the nurses and aides were able to feed Roberto without any difficulty. Various medical investigations failed to disclose any specific medical condition that might account for the baby’s difficulties. Discussion with the mother gradually revealed that she had been depressed throughout the pregnancy and resented the baby’s demands. Treatment of her depression and the underlying marital problems, as well as focused instruction on feeding, facilitated the mother’s adjustment. Roberto’s feeding difficulties gradually diminished, and within a few weeks he gained several pounds.

Discussion of “Bottle Baby”

ARFID (DSM-5, p.334) is diagnosed when a child fails to eat adequately, which results in a significant failure to gain weight or a significant weight loss, and when the condition, as in this case, cannot be better accounted for by a medical condition (e.g., gastroesophageal reflux), by simple absence of available food, or by Rumination Disorder.

In Rumination DisorderOpens in new window, weight loss is sometimes observed, but it is accompanied by characteristic regurgitation and re-chewing or spitting out of food.

In this case, marital problems and maternal depression probably contributed to the mother’s difficulties in feeding Roberto. Problems in parent-child interactions are known to contribute to the infant’s feeding problems in some instances.

Case study II \| Picky Eater
Nicole is a 14-year-old ninth grader whose mother brought her to treatment because of concerns about Nicole’s ability to socialize with peers outside of school and her timidity in approaching new situations. Nicole states that she prefers to be alone and finds going to parties or any new places difficult. She avoids eating in public when possible, but she will eat a limited amount at school lunch because she is unable to go the whole school day without eating. She takes a grilled cheese sandwich to school daily for lunch and is embarrassed that her friends notice that she eats the same thing every day and does not eat very much. She refuses to go to restaurants or to any parties where food is served Nicole has limited preferred foods: white bread and butter, crepes, grilled cheese, pizza, yogurt drinks, milk, and one brand of juice. She does not eat fruits, vegetables, meat, or chicken. She avoids trying new foods because she does not like new textures and worries about experiencing abdominal pain after trying new foods. Although Nicole does not focus on any particular experience when abdominal pain has caused her problems, she limits both the quantity and the type of food to minimize the risk of stomach upset. It is notable that Nicole’s preferred foods are all soft, bland and generally colorless with the exception of pizza. Nicole worries about evaluation by others in situations beyond eating or meals, including giving presentations in class, speaking when the teacher calls on her, or introducing herself to a new person. She reports having many friends but not a best friend. Nicole has always been below the normal curve for weight on a growth chart. She recently has grown significantly in height so that she is now below the 1st percentile for weight (73 pounds) but is in the 12th percentile for height (5’); therefore, she has become even more significantly underweight. Nicole has not started menstruating, which may be attributable to low weight/body fat; in contrast, her mother’s menarche was at age 11. Nicole acknowledges that she is tall and lanky. She denies any concerns about her appearance. She understands that she may be too thin to begin menstruating and she wants to avoid having any medical problems. She denies any concern about how she would look if she gained weight (to a medically healthy weight that allows menarche), but she is overwhelmed about the prospect of needing to eat more food or different foods that may provide more nutritional value. Nicole’s development history is remarkable for early feeding concerns. She was started on formula because of a suspected milk allergy, but she refused to drink soy-based formula and ultimately had to be switched to a milk-based formula, which she tolerated. Her mother recalls that when introduced to solid foods, Nicole often threw new foods on the floor and refused to try them even after they were offered on multiple occasions (as recommended by the pediatrician). Her mother states that Nicole ate a slightly larger variety of foods at a young age but never ate fruits, vegetables, or proteins beyond dairy. Otherwise, she met developmental milestones within normal time frames and has done well in school academically. Because of Nicole’s feeding difficulties, her mother once requested a medical assessment and a barium swallow study of Nicole’s gastrointestinal tract, which showed no abnormalities. Nicole’s treatment was informed by the evidence-based treatments used in Eating and Anxiety Disorders. Her comorbid social anxiety symptoms caused significant impairment; therefore, the severity of her anxiety was considered to be in the moderate to severe range, for which the recommended treatment is a combination of medication (a selective serotonin reuptake inhibitor, SSRI) and cognitive-behavioral therapy (CBT). Fluoxetine was initiated, as well as weekly CBT. The reasoning underlying these treatments is that a lowered anxiety level allows for less rigidity overall, which extends into the realm of feeding and eating behavior, and/or that anxiety underlies avoidant and restrictive eating, in which case the SSRI is more directly therapeutic. Treatment goals to increase Nicole’s ability to eat in different settings were incorporated into her social anxiety hierarchy. A separate hierarchy was established with feared foods to expand her food variety, and parent management strategies informed by family-based treatment used for Anorexia Nervosa were implemented to increase Nicole’s food intake. Additionally, phobia exposure work was used to target Nicole’s concerns about abdominal pain.

Case study II | Picky Eater

Nicole is a 14-year-old ninth grader whose mother brought her to treatment because of concerns about Nicole’s ability to socialize with peers outside of school and her timidity in approaching new situations.

Nicole states that she prefers to be alone and finds going to parties or any new places difficult. She avoids eating in public when possible, but she will eat a limited amount at school lunch because she is unable to go the whole school day without eating. She takes a grilled cheese sandwich to school daily for lunch and is embarrassed that her friends notice that she eats the same thing every day and does not eat very much. She refuses to go to restaurants or to any parties where food is served

Nicole has limited preferred foods: white bread and butter, crepes, grilled cheese, pizza, yogurt drinks, milk, and one brand of juice. She does not eat fruits, vegetables, meat, or chicken. She avoids trying new foods because she does not like new textures and worries about experiencing abdominal pain after trying new foods. Although Nicole does not focus on any particular experience when abdominal pain has caused her problems, she limits both the quantity and the type of food to minimize the risk of stomach upset. It is notable that Nicole’s preferred foods are all soft, bland and generally colorless with the exception of pizza.

Nicole worries about evaluation by others in situations beyond eating or meals, including giving presentations in class, speaking when the teacher calls on her, or introducing herself to a new person. She reports having many friends but not a best friend.

Nicole has always been below the normal curve for weight on a growth chart. She recently has grown significantly in height so that she is now below the 1st percentile for weight (73 pounds) but is in the 12th percentile for height (5’); therefore, she has become even more significantly underweight. Nicole has not started menstruating, which may be attributable to low weight/body fat; in contrast, her mother’s menarche was at age 11. Nicole acknowledges that she is tall and lanky. She denies any concerns about her appearance. She understands that she may be too thin to begin menstruating and she wants to avoid having any medical problems. She denies any concern about how she would look if she gained weight (to a medically healthy weight that allows menarche), but she is overwhelmed about the prospect of needing to eat more food or different foods that may provide more nutritional value.

Nicole’s development history is remarkable for early feeding concerns. She was started on formula because of a suspected milk allergy, but she refused to drink soy-based formula and ultimately had to be switched to a milk-based formula, which she tolerated. Her mother recalls that when introduced to solid foods, Nicole often threw new foods on the floor and refused to try them even after they were offered on multiple occasions (as recommended by the pediatrician). Her mother states that Nicole ate a slightly larger variety of foods at a young age but never ate fruits, vegetables, or proteins beyond dairy. Otherwise, she met developmental milestones within normal time frames and has done well in school academically. Because of Nicole’s feeding difficulties, her mother once requested a medical assessment and a barium swallow study of Nicole’s gastrointestinal tract, which showed no abnormalities.

Nicole’s treatment was informed by the evidence-based treatments used in Eating and Anxiety Disorders. Her comorbid social anxiety symptoms caused significant impairment; therefore, the severity of her anxiety was considered to be in the moderate to severe range, for which the recommended treatment is a combination of medication (a selective serotonin reuptake inhibitor, SSRI) and cognitive-behavioral therapy (CBT). Fluoxetine was initiated, as well as weekly CBT. The reasoning underlying these treatments is that a lowered anxiety level allows for less rigidity overall, which extends into the realm of feeding and eating behavior, and/or that anxiety underlies avoidant and restrictive eating, in which case the SSRI is more directly therapeutic. Treatment goals to increase Nicole’s ability to eat in different settings were incorporated into her social anxiety hierarchy. A separate hierarchy was established with feared foods to expand her food variety, and parent management strategies informed by family-based treatment used for Anorexia Nervosa were implemented to increase Nicole’s food intake. Additionally, phobia exposure work was used to target Nicole’s concerns about abdominal pain.

Discussion of “Picky Eater”

Several disorders need to be considered as possible explanations for Nicole’s restricted repertoire of eating. If she had a disturbance in the way she experienced her body weight and shape and an intense fear of gaining weight or becoming fat, she might be diagnosed as having Anorexia NervosaOpens in new window. However, she acknowledges that she is tall and lanky and she denies any concerns about her appearance or how she would look if she gained weight, so the diagnosis of Anorexia Nervosa does not apply.

Nicole also reports embarrassment in situations in which she is eating the same thing every day at school and has some social anxiety that extends beyond her eating behavior to making presentations in class, answering teacher questions, meeting new people, and trying new activities.

These concerns may warrant a diagnosis of Social Anxiety DisorderOpens in new window, but embarrassmentOpens in new window over eating in public does not appear to capture the essence of her eating problems.

When a person has significant weight loss or failure to gain expected weight for his or her age due to food restriction that is due to the sensory characteristics of food (she eats only soft, bland, and colorless food) and/or potentially aversive consequences of eating (she worries about developing abdominal pain), the diagnosis is ARFID (DSM-5, p. 334).

This case illustrates that ARFID usually us manifest in childhood, but it can persist into adolescence (and beyond). Also, even though Nicole does not have Anorexia Nervosa, some of the same treatment techniques that are used with such patients to encourage healthy eating and healthy portions can also be useful in ARFID. Treatment for mental disorders are often symptom or problem focused rather than diagnosis specific.

Continue studying Eating Disorders:

Citation

Akkerman, K., Kaasik, K., Kiive, F., Nordquist, N., Oreland, L., & Harro, J. (2012, January). The impact of adverse life events and the serotonin transporter gene promoter polymorphism on the development of eating disorder symptoms. Journal of Psychiatric Research, 46(1), 38 – 43.
Alonso, D.R., Cortazar, A. E., Guillen, R.H., Fuentes, M.S., & Remesal, C. R. (2016, March). Food, body image, perfectionism. European Psychiatry, 33, S425.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Arlington, VA: The American Psychiatric Association.

Specialties

Avoidant/Restrictive Food Intake Disorder

Discussion of “Bottle Baby”

Discussion of “Picky Eater”

Continue studying Eating Disorders: