ARFID treatment: avoidant restrictive food intake disorder

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Treatment of avoidant restrictive food intake disorder (ARFID) involves working with a multidisciplinary team of healthcare professionals, which includes psychological, nutritional, psychiatric, and physical intervention. This offers a whole-person approach to recovery, as opposed to simply addressing disordered eating behaviors. (1)

The treatment setting for someone with ARFID will depend on the severity of their food restriction, weight loss, and level of malnutrition or other medical comorbidities. (2)

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Levels of care for ARFID

Inpatient

An individual with ARFID may require inpatient hospitalization when their restrictive eating behaviors and thoughts have rendered them medically or psychologically unstable. (3)

Medical instability is defined by:

  • Depressed or unstable vital signs, such as low heart rate
  • Medical complications
  • Abnormal test results that indicate a serious health risk

Psychological instability is defined by:

  • Rapidly worsening ARFID symptoms
  • Suicidal ideation and thoughts of self-harm

Care is provided around the clock in residential treatment, in a hospital setting or specialized unit. Along with individual and group therapy, supervised meals, and nutrition counseling, ARFID patients may require medical management, such as tube feeding, intravenous fluids, supplementation for nutritional deficiencies, and monitoring of vital signs. (4)

Residential

Once a patient with ARFID is medically stable, they may be able to step down to residential care, which provides the supervision and support needed to continue with their treatment plan.

Patients in residential treatment are still psychologically impaired, struggling with disordered thoughts and food restriction.

Partial hospitalization program (PHP)

The next level of care is partial hospitalization, which is appropriate for individuals with ARFID who are medically and psychologically stable, but their disordered eating patterns continue to impair function.

Partial hospitalization programs (PHP) continue to provide support and structure for people with ARFID several days a week for many hours. Most meals will be supervised to monitor for restriction behaviors, and patients will engage in nutritional counseling, as well as individual and group therapy. (5)

In these day treatment programs, a person with AFRID will continue their treatment plan at a hospital during the day but can return home with their family or caregivers at night. (2)

Intensive outpatient (IOP)

Daily medical monitoring is no longer required with patients who are able to maintain their self-control over restriction, even in unstructured settings.

Patients with ARFID attend sessions a few times a week for a few hours for therapy and supported meals. As no lengthy visits or overnight stays are required, individuals can continue working or attend school if they choose.

Outpatient

This is the lowest level of care, which typically involves meetings with a dietician and therapist once or twice a week to monitor progress. (4) 

Individuals who have ARFID in outpatient treatment are self-sufficient in managing food restriction and avoidance, as well as weight gain. Therefore, a person no longer needs to eat meals in treatment but may have a snack.

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Psychotherapy for ARFID

Acceptance and commitment therapy (ACT)

Acceptance and commitment therapy (ACT) typically focuses on what a person can control--feelings, thoughts, and behaviors. During ACT, those with ARFID learn techniques to manage and cope with their disordered food behaviors and fears. (6)

Patients are also asked to identify a set of core values, so goals can be established to help a person uphold these values.

Cognitive behavioral therapy (CBT)

For some individuals with ARFID, unhealthy thoughts and behaviors are at the root of their eating disorder. (7) Cognitive behavior therapy (CBT) is a form of talking therapy that helps individuals identify their self-destructive thoughts and behaviors to help develop strategies to change them.

CBT also helps in the treatment of depression, anxiety, and obsessive-compulsive disorder, which commonly co-occur with ARFID. Components of CBT for ARFID may include:

  • Psychoeducation to understand what maintains a patient’s ARFID
  • Challenging a person’s dietary rules and restricted foods
  • Exposure to fear foods and situations
  • Developing strategies to reduce food restriction
  • Meal planning and food diaries

Cognitive behavioral therapy for ARFID (CBT-AR)

 This new form of cognitive-behavioral therapy is designed specifically for the treatment of ARFID. (2) This modular form of therapy has four stages: (8)

  1. Psychoeducation and Early Change: A therapist provides psychoeducation about ARFID and encourages regular eating and increasing food variety and/or volume.
  2. Treatment Planning: Individuals learn about nutritional deficiencies and are supported in choosing novel foods to learn about.
  3. Addressing Maintaining Mechanisms: Patients are supported in the resolution of nutrition deficiencies and weight gain if necessary. A therapist chooses appropriate modules with common elements, including exposure to fear foods and between-session practice.
  4. Preventing Relapse: Progress is evaluated, and the therapist and patient work together to create a relapse prevention plan.

Dialectical behavior therapy (DBT)

Another form of talking therapy, dialectical behavior therapy (DBT) helps people living with ARFID to accept themselves and work towards changing their disordered eating thoughts and behaviors. During DBT, a therapist uses a variety of acceptance and change techniques:

  • Acceptance techniques focus on understanding why a person engages in food restriction.
  • Change techniques teach a person to replace their disordered behaviors and thoughts with helpful ones.

DBT teaches people to live mindfully within the present moment to help them cope with negative thoughts and emotions. Individuals learn skills for distress tolerance, which enable them to deal with high-anxiety situations and work through negative emotions they experience. (8)

Exposure therapy

Exposure therapy is used to help remove the fear and anxiety attached to certain foods common in people living with ARFID. This is usually done using mental visualization and relaxation techniques, writing and talking about fear foods, and learning positive coping skills.

Individuals with ARFID are also exposed to their fear foods in a safe environment. The intensity of exposure increases over time to improve the level of comfort with anxiety triggers, for example, fear of choking.

For children with ARFID, a ‘tiny tastes’ reward-based program can be used to help overcome the fear of certain foods, away from mealtimes. (7)

Family therapy

Family therapy is designed to empower family members of an individual with ARFID to support their recovery and hope. This type of therapy provides parents and siblings information about ARFID, lifting blame and guilt from the family, as well as encouraging them to implement refeeding strategies and restore healthy eating behaviors. (9)

Group therapy

During group therapy, people with ARFID can form a strong support network and form deep connections with those in a similar situation.

Through these psychologist-led sessions, people with ARFID are encouraged to engage in intimate conversations, which can be incredibly healing for emotional stress and provide the comfort that they’re not alone.

Interpersonal psychotherapy (IPT)

Interpersonal psychotherapy (IPT) works on resolving the anxieties that accompany ARFID, such as fear of choking or trying new food. This form of therapy focuses on where relationships and eating disorders overlap, by exploring how issues within relationships can contribute to eating distress. (10)

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Nutrition counseling and meal support

Nutrition counseling is an important part of ARFID treatment. This type of support helps patients learn about their body’s nutrition needs and what they need to eat to stay healthy. People with ARFID work on repairing their relationship with food and increasing their food intake and variety with a personalized meal plan.

Nutritional counseling may also involve a meeting with a registered dietician to identify any nutritional deficiencies that have arisen due to a restricted diet. This will determine if any additional supplements are needed. (7)

Experimental treatments for ARFID

Speech therapy

A speech therapist can form a key part of the treatment team for ARFID. They can help those who have aversions to food that have led to difficulty swallowing. (2) 

Occupational therapy

Occupational therapists carry out a complete assessment of a person’s sensory, developmental, environmental, behavioral, and cultural factors that could contribute to impaired eating.

This form of therapy can be very useful for children with ARFID and co-occurring autism, ADHD, or sensory processing disorder. Treatment is individualized to each patient but may include sensory diets, stories about self-feeding, and tactile play to promote food acceptance.

Desensitization therapy

Often used with very young children or for those with ARFID who are on the autism spectrum, desensitization therapy involves encouraging play with foods, including fear foods. This helps a child feel more comfortable with the sight, smell, and feel of foods that cause distress. (7)

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Treating ARFID at Within Health

Every patient’s experience with ARFID is unique. So we create individual treatment plans for each of our clients at Within Health. We aim to support our clients with ARFID in helping them learn to embrace flexibility around food and eating, so they can overcome their food phobias and food restriction, and enjoy food and social eating rituals once again.

Our ARFID treatment program consists of three levels of care:

  • Partial hospitalization program
  • Intensive outpatient program
  • Outpatient program

The level of care required for an individual living with ARFID will be determined depending on the severity of the restriction, overall health and wellbeing, and a person’s specific needs. 

Our multidisciplinary team of experienced psychotherapists, dietitians, nurses, and other mental health professionals not only provides cutting-edge treatment, but also unconditional compassion, support, and understanding.

We know how hard it is to seek help for ARFID, so we ensure you will not go through recovery alone. Supported group meals and group psychotherapy are there to make you feel like you’re part of a community, no matter what your gender identity, ethnicity, sexuality, or age, and reassure you that your struggle is not yours alone.

Through the Within Health app, help is available wherever you are, whenever you need it.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Brittany Poulson, M. D. A. (2021, February 9). What is avoidant restrictive food intake disorder? Verywell Health.
  2. Bence, S. (n.d.). How avoidant restrictive food intake disorder (ARFID) is treated. Verywell Health. 
  3. Williams, P. M., Goodie, J., & Motsinger, C. D. Treating eating disorders in primary care. American Family Physician. 2008 Jan 15;77(2):187-195.
  4. Ekern, B., (2020, March 1). Determining the best level of care for eating disorder treatment. Eating Disorder Hope. 
  5. Eating disorder treatment: Know your options. (2017, July 14). Mayo Foundation for Medical Education and Research.
  6. McGuire, J., (2018, April 25). Act & eating disorder treatment: What you need to know. Eating Disorder Hope. 
  7. Treating ARFID. ARFID Awareness UK. (n.d.).
  8. Thomas, J. J., Becker, K. R., Kuhnle, M. C., Jo, J. H., Harshman, S. G., Wons, O. B., Keshishian, A. C., Hauser, K., Breithaupt, L., Liebman, R. E., Misra, M., Wilhelm, S., Lawson, E. A., & Eddy, K. T. (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Feasibility, acceptability, and proof-of-concept for children and adolescents. The International Journal of Eating Disorders, 53(10), 1636–1646. 
  9. Spettigue, W., Norris, M. L., Santos, A., et al. (2018). Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. J Eat Disord. 6, 20 
  10. Solis-Moreira, J. (2021, June 11). What does treatment for ARFID look like?Psych Central.

FAQs

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