Monday, September 26, 2016
The most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) contains eight distinct feeding and eating disorder diagnoses; however, most people are familiar with only a few - typically anorexia and bulimia. My goal today is to introduce you to a lesser known but equally as important disorder – Avoidant/Restrictive Food Intake Disorder (ARFID). Previously known as Feeding Disorder of Infancy and Childhood, ARFID is a new diagnosis in DSM-5 expanded to include adults as well as children and adolescents. The criteria for ARFID has been revised to capture a variety of issues that might lead a child or adult to become malnourished as the result of inadequate food intake.
The main feature of ARFID is avoidance or restriction of food to the point where one becomes underweight, malnourished, dependent upon alternative methods of feeding (i.e. tube feeding or nutritional supplements), and/or unable to function in his or her day-to-day life. While in adults we may see weight loss, in children ARFID can manifest through failure to meet or maintain developmental weight and height benchmarks. There are numerous reasons why someone might avoid or restrict food. Three of the most common types of eating disturbances associated with ARFID are listed below:
- Selective eating: this category goes beyond not liking lima beans or crusts on sandwiches. It includes children and adults who have severely restricted the range of foods they eat based on sensory qualities such as texture, taste, color, or temperature. Individuals with neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, and intellectual disorders are at an increased risk for developing selective eating. This category also includes individuals with difficulty digesting and lack of appetite or interest in food.
- Adverse eating-related event: when an individual experiences a frightening or traumatic episode such as choking, vomiting, or gagging they may significantly restrict their food intake in an attempt to avoid re-experiencing the unpleasant event. This can also apply to individuals who have experienced some type of critical medical issue such as a bowel obstruction or severe abdominal pain. These individuals may restrict their intake or avoid food altogether in an attempt to manage their fear about having another medical episode. In particular, those with a history of gastrointestinal conditions, reflux disease, and/or vomiting are at increased risk for developing ARFID.
- Emotional disturbance: depression, anxiety, and schizophrenia spectrum disorders may result in a change in eating habits. In all but extreme cases, any disruption is minimal and lessens once the emotional disturbance resolves. However, in severe depression appetite can be impacted and significant weight loss may require treatment. Anxiety disorders, particularly specific phobias and obsessive compulsive disorder, have a high occurrence rate with ARFID and may affect eating behaviors. Additionally, individuals with psychotic disorders may exhibit odd eating behaviors and/or delusional beliefs about food. In extreme cases, this may lead to avoidance of nearly all foods and fluids.
You may have noticed that none of the above rationales involve weight or shape issues. This is important – with ARFID there is not significant body image distortion or drive for thinness. Why is this a crucial distinction? Well, on the surface ARFID and anorexia can present similarly given they both involve restrictive eating and low body weight. However, in order to meet criteria for ARFID an individual cannot have a disturbance in the way they perceive their body, a fear of becoming fat, or behaviors that interfere with weight gain.
Like eating disorders such as anorexia and bulimia, ARFID can significantly interrupt one’s life. Restrictive eating tends to lead to a restricted life, threatening one’s professional, interpersonal, and overall wellbeing. In children, ARFID can negatively impact social development, disrupt family life, and interfere with academic performance. For adults, ARFID can make it difficult to hold down a job, attend college, establish or maintain relationships with others, and may lead to depression or isolation.
Fortunately, with treatment – including medical, psychological, and nutritional care – ARFID can be resolved and normal functioning resumed. Treatment for ARFID typically includes developing a weight restoration meal plan and engaging in psychotherapy to address any fears, compulsions, mood disturbances, sensory sensitivities, etc. that may interfere with eating. Expert medical care is also a critical component of treating ARFID because significant weight loss and malnutrition can lead to anemia and iron deficiency, fatigue, weakness, slow heart rate, low blood pressure, and reduction in bone density.
Often individuals with ARFID are uncertain as to where to seek treatment and can shy away from what is perceived as traditional eating disorder treatment fearing they’ll be out of place. ACUTE Center for Eating Disorders provides specialized medical and psychiatric care for adults with severe feeding disorders such as ARFID. ACUTE’s intimate, one-on-one environment allows for patients to receive care that is relevant to them. For our ARFID patients, this means psychotherapy is typically geared towards resolution of whatever barriers to eating are present, rather than body image issues. ACUTE providers are familiar and comfortable with the treatment of ARFID, having served the needs of many patients with feeding disorders and published literature specific to ARFID. If you or someone you know is suffering from ARFID, contact ACUTE to learn more about our program.
Gillian Taylor Lashen, PsyD