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Avoidance/restrictive food intake disorder (ARFID) is an eating disorder characterized by highly selected eating habits, typically driven by negative psychological associations with certain foods and eating.
ARFID is not as clearly understood as some other eating disorders. However, the recent reclassification of ARFID in the DSM-V as an eating disorder as opposed to a feeding disorder opens up more treatment options.
The term ARFID was introduced to account for patients who struggle with impaired and distressing eating symptoms and behaviors but who lack body image-related concerns associated with anorexia nervosa (AN) and bulimia nervosa (BN).
The previous diagnosis of ARFID relied on the presence of weight loss or failure to gain weight, failing to account for clients that may stay adequately nourished thanks to enteral feeding or oral nutritional supplementation. Plus, the diagnostic category was restricted to children aged 6 and under and emphasized the negative interactions between child and caregiver.1
However, these criteria did not account for the subset of adolescents and adults who displayed feeding issues but didn’t meet the diagnostic criteria for AN or BN, which were often categorized as having an eating disorder not otherwise specified. The addition of ARFID to the DSM-5 cleared up much of the murkiness surrounding the diagnosis in this subset, as well as accounted for their need for multidisciplinary treatment.
According to the DSM-5, ARFID is an eating or feeding disturbance with:2
Plus, clients with ARFID have one of the following:
While more studies are needed to determine the prevalence of ARFID, results from early population studies that:1
Studies have also shown that those with ARFID are also commonly diagnosed with comorbid psychiatric and/or medical symptoms.1 Most common co-occurring psychiatric comorbidities include anxiety disorders (including obsessive-compulsive and trauma-related disorders) and neurodevelopmental disorders (including ADHD and conduct disorders).3
Those with ARFID are more likely to have a history of:
Somatic maintenance mechanisms of ARFID include avoiding adverse tastes or textures, pain, nausea, or risk of choking or vomiting.1
Living with ARFID can have wide-ranging psychological impacts, including:
A multidisciplinary assessment of ARFID is required to determine the right treatment plan for a client, which can include:
The psychological assessment of ARFID involves both structured interviews and self-report measures:
There are three primary subtypes of maintaining factors that drive ARFID behaviors, and a client can have more than one maintenance factor at any one time:4
Assessing a client’s maintenance factors and any overlap between them is important as it allows treatment to be personalized to the driving factors behind their avoidance and restriction.
A nutrition assessment provides an opportunity to get more information on the ARFID presentation and how it has physically affected the client. A nutrition assessment typically involves:
A limited intake of food/limited food variety can result in nutrient deficiencies, including but not limited to:5
It’s important to note that a client can be nutrient deficient without the common signs of malnutrition, such as weight loss, low weight, or low fat stores. Furthermore, while a classic lab panel screens for common nutrient deficiency, such as folate, iron, and calcium, other key nutrients like zinc and vitamin K. This is where a nutrition-focused physical exam comes in, which checks for physical signs of deficiency, such as inflamed gums for vitamin C deficiency.
Assessing a client’s current intake is a useful tool to identify opportunities for exposure. It provides information about when and why certain foods become “unsafe.” Many hierarchies of food tools are available, including a free one in the CBT-AR workbook.
At Within Health, we use a “Food Preference List,” which includes an extensive, descriptive list of foods to assess current intake and interest in food to include in exposure therapy. This is done in registered dietitian sessions, care partner sessions, or independently.
The goals of treatment of ARFID are as follows:
There are a wide variety of therapeutic interventions that can be used in the multidisciplinary treatment of ARFID, including:
While the ultimate nutrition goal for ARFID treatment is for a client to eat food from all food groups and expand on the foods they consume, the initial goal for meal planning is getting enough energy:
This evidence-based treatment modality is designed to treat phobias, fears, and anxieties, which breaks the cycle of fear and gradually exposes the client to fear in a controlled, monitored manner. This can start by simply sitting with the food, building up to eating the food.
The Subjective Units of Distress Scale (SUDS) is used throughout exposure therapy to rate the amount of anxiety a client is feeling. It’s like a thermometer that measures how “hot” anxiety gets and helps determine what helps “cool” it.
One method of exposure therapy is incorporating new foods, which can involve:
A specialized form of cognitive behavior therapy for ARFID, CBT-AR is typically delivered on an outpatient basis over 20-30 sessions. It consists of 4 modules:7
While more research is needed, early studies indicate that CBT-AR is a feasible treatment for ARFID. A 2020 study by Thomas et al. found that following CBT-AR, the underweight subgroup showed a significant weight gain, and 70% of patients no longer met the criteria for ARFID.7
Family and loved ones form an important part of ARFID treatment. The goals of supporter involvement in treatment are to:
Intensive treatment is effective in reducing ARFID symptoms in clients, and it allows access to a multidisciplinary team.
It’s estimated that only 20% of those living with eating disorders can access traditional treatment.8 There are many barriers affecting access to treatment, which include geographic and financial barriers, lack of inclusions, long waiting lists, and more. Virtual treatment can help overcome many of these barriers, as well as offering many other benefits, including:
There are some setbacks to virtual treatment, which may include:
Within Health offers multidisciplinary treatment for ARFID in a virtual setting, which includes:
Nutrition support can help clients repair their relationship with food and gradually increase the quantity and variety of food. Elements of individualized nutrition support include:
All ARFID clients at Within Health have a one-to-one assessment with a movement specialist, which includes evaluating current levels of physical activity and developing movement goals. The Within Health movement protocol has four phases:
Creating the ideal sensory environment is always individualized to the client’s needs and preferences, but can include:
The Within Health ARFID protocol has been put together using both what has been found in the literature and their client’s loved experiences, including their ongoing feedback.