PHOTO: Katarina Wolnik Vera
Text: Nicoleta Casangiu and Alejandra Misiolek
In this post we will define what avoidant/restrictive food intake disorder (ARFID) is and the differences and similarities between ARFID, anorexia nervosa and the general population.
A significant number of children and adolescents with eating difficulties have previously failed to be correctly diagnosed using the Diagnostic and Statistical Manual of Mental Disorders DSM- IV classification system (previous to the current version). As they did not match the criteria of an eating disorder such as anorexia nervosa (AN) or bulimia nervosa (BN), they were often diagnosed as having an not otherwise specified eating disorder.
Although these patients did not meet the criteria for a specific eating disorder in the DSM-IV manual of mental disorders, they experienced high impairment and were at risk for serious medical complications.
This heterogeneous category included a subgroup of patients who were generally younger than those with AN or BN and did not manifest significant body image distortion or fear of weight gain. Clinicians reported that many of the patients in this subgroup had experienced episodes of choking or vomiting followed by the development of fear of eating solid food, had restricted diets since early childhood, or had reported abdominal pain that had prevented them from eating enough.
In order to better identify these patients and because of the need for a more precise diagnosis, Avoidant/restrictive Food Intake Disorder (ARFID) was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
It refers to those patients who have an avoidance and/or restriction of food intake in the absence of distorted cognition regarding body weight and body shape.
ARFID is considered a serious disorder with significant physical and psychosocial consequences. In addition, in recent years there has been an increase in demand in juvenile eating disorder units.
The prevalence in the general population is 3.2% and in specific youth eating disorder units it is between 13% and 31%.
According to APA, the American Psychological Association, the diagnostic criteria for ARFID food avoidance/restriction disorder in the DSM-5 Diagnostic Manual are:
-failure to meet nutritional and/or energy needs associated with 1 or more of the following criteria:
- significant weight loss,
- significant nutritional deficiency,
- dependence on enteral feeding or nutritional supplementation (oral).
-There is significant interference with psychosocial functioning and the impairment is not explained by lack of available food/culture.
-No preoccupation with weight or body shape.
-May occur in the context of another medical illness.
Three subtypes of ARFID have been identified:
- Lack of interest in eating or food, related to low appetite, underweight, stunting and medical problems.
- Restriction/selection of sensory properties of food, such as color, texture, taste, brands.
- Food avoidance due to specific fears, related to anxiety: choking, vomiting, pain.
What are the differences and similarities between ARFID, anorexia nervosa and the general population?
The underlying reasons for food restriction are the main difference between the diagnosis of AN and ARFID, since in ARFID the eating behavioral disturbances are not the result of weight/shape preoccupation and body dysphoria that are present in AN.
A study on the differences and similarities between ARFID, anorexia nervosa and the general population has revealed significant results. On the one hand, patients with ARFID show significant clinical differences compared to the AN (anorexia nervosa) and NCG (general population without any diagnosis) groups: younger and a higher proportion of males, longer disease course, earlier age of onset of the eating disorder, and more complex medical and psychiatric histories. Secondly, patients with ARFID would show significantly higher levels of anxiety, clinical fears and psychopathology compared to patients with AN and NCG, and that patients with AN have more depressive symptoms than children and adolescents with ARFID and no diagnosis.
Because ARFID is a relatively new diagnosis, researchers are still exploring the best ways to treat it, and there is not yet a clear treatment model. It is important to note that ARFID is an ED that has significant clinical severity and has a strong impact on the overall development (physical, emotional, social, school and family) of those who suffer from it.
As we can see, eating disorders are a heterogeneous and complex group of disorders whose severity cannot be underestimated. Anorexia or bulimia are disorders that, although not free of stigma, are better known and have received more attention and recognition. Disorders such as ARFID, being new and very little known, are not understood by society or by the families of the children or adolescents who suffer from them. Often even health professionals, such as general practitioners, do not understand this pathology. These children are often labeled as stubborn, whimsical, or picky eaters and do not receive adequate treatment and care. It is important to raise awareness and to react more with concern for the symptoms than with criticism. However, when eating behavior affects emotional and medical health, the recommendation is always to see a specialist for a professional and specialized assessment of the situation.
- Cañas L, Palma C, Molano AM, et al. Trastorno evitativo/restrictivo de la ingesta de alimentos: Semejanzas y diferencias psicopatológicas en comparación con la anorexia nerviosa y la población general, Eur Eat Disorders Rev. 2021;29:245–256.
- Martin M. Fisher et al, Características del Trastorno por Evitación/Restricción de la Ingesta de Alimentos en niños y adolescentes: Un “nuevo trastorno” en el DSM-5, Journal of Adolescent Health 55 (2014).