What is ARFID? Cognitive-Behavioral Therapy for Avoidant / Restrictive Food Intake Disorder
In both my personal and professional life, I have noticed that when the term “ARFID” comes up, it is still met with furrowed brows or blank stares. Because it was introduced in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013, ARFID is a relatively new diagnosis. It can often be mislabeled, misdiagnosed, or diagnosed later than is ideal, due to the nature of the disorder and getting confused with picky eating or mistaken as anorexia nervosa due to shared symptoms of low weight and malnutrition. So, let’s break it down and also talk about what treatment can look like.
ARFID Subtypes
ARFID is different from other eating disorders, like anorexia nervosa, because food avoidance or restriction is not related to fears of fatness or distress with body shape or weight. There are three core drivers of avoidant and restricted eating behavior that make up the subtypes of this diagnosis:
Avoidance based on sensory characteristics of food. (Avoidant type) Some individuals with ARFID find that certain foods have strange or intense tastes, textures, or smells, and they feel safer eating foods that they know well and are familiar with. Because of the heightened sensitivity to taste and texture of foods, you may hear the term ‘super taster’ being used here.
Concerns about aversive consequences related to eating. (Aversive type) Others have had scary experiences with food, like throwing up, choking, or an allergic reaction, so they may avoid the foods that made them sick, or stop eating altogether.
An apparent lack of interest in eating or food. (Restrictive type) These folks may forget to eat, have a low appetite or get full very quickly, find eating to be a chore, or regularly get distracted during mealtime.
It is important to note that these three presentation types are not mutually exclusive and can co-occur within the same individual. For those who experience more than one type of ARFID, they may develop features of anorexia nervosa. This co-occurring eating disorder is referred to as ARFID Plus.
Signs & Symptoms of ARFID
Sudden refusal to eat foods previously eaten
Eating only foods prepared in a certain manner
Social avoidance stemming from anxiety around eating and food
Fear of choking, vomiting, pain or nausea due to certain foods or the act of eating
Lack of appetite or low appetite without medical cause
Very slow eating, easily distracted during eating, or forgetting to eat
Significant weight loss or inability to maintain a healthy weight
Other physical symptoms such as: weakened bones, low blood sugar, GI issues (acid reflux, constipation), loss of menstrual period, etc.
Treatment for ARFID (CBT-AR)
Research on ARFID treatment is still growing. So far, cognitive behavioral therapy for ARFID (CBT-AR) is showing promising outcomes and is considered a first line intervention for ARFID. Check out this 2020 study.
CBT-AR is appropriate for children, adolescents, and adults ages 10 and up and is available in both individual and family-supported versions. It consists of four treatment stages across 20-30 sessions. Sessions are highly structured and practice between sessions is essential to treatment success.
The stages of treatment in CBT-AR involve:
Stage One: Psychoeducation and understanding the drivers of the restrictive/avoidant eating, clarifying treatment goals, and establishing a regular pattern of eating if not already present. Treatment goals could include correcting any nutritional deficiencies, eating foods from each of the five basic food groups, or working to feel more comfortable eating in social situations.
Stage Two: Treatment planning and collaboratively identifying targets for the remainder of treatment, as well as possible barriers to treatment progress.
Stage Three: Through exposure, systematically working through food fears and aversions. Individuals gradually acclimate to new food experiences. It depends on the treatment goals, but this could look like tolerating increases in food volume to support healthy weight or practicing tasting foods that have been avoided. Avoidance breeds further fear/anxiety and therefore this stage is a critical step towards breaking that cycle.
Stage Four: Focuses on setting up the individual for long-term success by developing a relapse prevention plan.
In addition to CBT-AR, family based therapy for ARFID (FBT-ARFID) and supportive parenting for anxious childhood emotions for ARFID (SPACE-ARFID) have demonstrated effectiveness in recent studies. Choice of treatment is based on the specific needs of the client.
Additional ARFID Resources
Off the C.U.F.F.: A Parent Skills Book for the Management of Disordered Eating, By Dr. Nancy Zucker
The Picky Eater's Recovery Book: Overcoming Avoidant/Restrictive Food Intake Disorder, by Dr. Jennifer Thomas
ARFID Avoidant Restrictive Food Intake Disorders: A Guide for Parents and Carers – by Rachel Bryant-Waugh
If you are a provider, consider use of validated ARFID screening (PARDI-AR-Q, NIAS) or diagnostic (EDY-Q) tools
Dr. Nadia Micali and Dr. Lisa Dinkler present a webinar on ARFID and understanding its genetic and environmental causes
Support groups offered through the ARFID Collaborative
Find an ARFID-specific provider (dietician, therapist, doctor, or feeding specialist) also through the ARFID Collaborative
References
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Fifth ed. 2013, Arlington, VA: American Psychiatric Publishing.
Fisher, M. M. et al (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49-52.
Thomas, J.J., et al (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.
Thomas, J.J. & Eddy, K.T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, & Adults. Cambridge: Cambridge University Press.
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