Avoidant/restrictive food intake disorder | |
---|---|
Specialty | Psychiatry |
Symptoms | Aversion towards eating, over-sensitivity to food taste or texture, fear of trying new food, poor weight gain |
Complications | Malnutrition, food neophobia |
Duration | Chronic |
Risk factors | Autism, obsessive–compulsive disorder, negative experiences from eating (e.g., choking, nausea from eating) |
Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which individuals significantly limit the volume or variety of foods they consume, causing malnutrition, weight loss, or psychosocial problems. [1] Unlike eating disorders such as anorexia nervosa and bulimia, body image disturbance is not a root cause. [1] [2] Individuals with ARFID may have trouble eating due to the sensory characteristics of food (e.g., appearance, smell, texture, or taste), executive dysfunction, fears of choking or vomiting, low appetite, or a combination of these factors. [2] While ARFID is most often associated with low weight, ARFID occurs across the whole weight spectrum. [3]
ARFID was first included as a diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013, extending and replacing the diagnosis of feeding disorder of infancy or early childhood included in prior editions. [2] [4] It was subsequently also included in the eleventh revision of the International Classification of Diseases (ICD-11) published in 2022. [5]
Avoidant/restrictive food intake disorder is not simple "picky eating" commonly seen in toddlers and young children, which usually resolves on its own. [2] In ARFID, the behaviors are so severe that they lead to nutritional deficiencies, poor weight gain (or significant weight loss), and/or significant interference with "psychosocial functioning." [2]
ARFID comprises a range of selective and restrictive eating behaviors. In some cases, ARFID presents as extreme "picky eating," often due to sensory sensitivities or a fear of aversive consequences. [6] In other cases, ARFID subjects may eat a variety of foods but -- due to lack of interest or low appetite -- not eat enough to meet growth and/or nutritional needs. [7] People with ARFID may also be afraid of trying new foods, a fear known as food neophobia. [8] For some people with ARFID, multiple reasons for undereating apply. [2] [9]
Sensory issues with food are among the most common reasons. For example, people who experience the taste of fruits or vegetables as intensely bitter might avoid eating them. For others, the smell, texture, appearance, color, or temperature of certain foods is unbearable. Sensory sensitivities can also lead people to refuse eating foods of specific brands. A diet limited to certain foods, particularly highly processed foods, can lead to nutritional deficiencies. Food avoidance due to sensory issues often develops in early childhood and is long-lasting. [2] [9]
People might also avoid certain foods or restrict the amount of food they eat out of fear of negative consequences such as choking, vomiting, or stomach aches. In many cases, this behavior is motivated by a previous traumatic experience related to food. While avoiding the associated foods can provide relief in the short term, over time avoidance can excerbate anxiety, depriving someone of the opportunity to make corrective, positive experiences. Further, the range of avoided foods can grow over time, expanding to encompassing all solid foods in extreme cases. [2] [9]
A lack of appetite or interest in food is a third common reason to avoid or restrict food intake. ARFID patients may perceive eating as a chore. Within this group, a low body weight or failure to thrive are common and the experienced lack of interest is long-lasting. [2] [9]
Restriction of food intake due to unavailability, such as in situations of food insecurity, or dietary restrictions due to cultural practices such as religious fasting or dieting are not included in ARFID. Likewise, restricted eating and avoiding food out of concern for body weight or shape, as is typical for anorexia nervosa and bulimia nervosa, do not fall under ARFID. [2]
According to a 2022 Harvard study of ARFID, "More than half of individuals with ARFID also have other neurodevelopmental, psychiatric, or somatic diagnoses. Anxiety, depression, sleep disorders, and learning difficulties are particularly common co-occurring issues." [10]
A 2023 review concluded that "there is considerable overlap between ARFID and autism," finding that 8% to 55% of children diagnosed with ARFID were autistic. [11]
Autistic children are more likely than other children to have atypical eating behaviors and eating disorders. [12] [13] The most common symptom seen in patients with both autism and ARFID is sensory-based avoidance, however fear-based restriction and lack of interest in food are prevalent in this population as well. [14]
Anxiety disorders are the most common comorbidity with ARFID. 36–72% of people struggling with ARFID also have a diagnosed anxiety disorder. [15] Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar. [16] Some people with ARFID have fears such as emetophobia (fear of vomiting) or a fear of choking.[ citation needed ]
Anorexia nervosa is distinguished from ARFID by the fact that body image or weight concerns motivate food restriction. [2] [17] However, the distinction between the two disorders is not always clear and there can be overlap. [18] A person with anorexia nervosa, for example, may initially restrict food intake due to body concerns, but, over time, get over those concerns yet still undereat due to nausea and anxiety around food, fitting ARFID's low-appetite presentation. Alternately, an adolescent may at first restrict intake due to severe sensory processing issues, often seen in ARFID, and later develop body image concerns. [18] In the 1940s, the seminal Minnesota Starvation Experiment demonstrated that the effects of starvation – whatever the cause – can result in a variety of eating disorder behaviors, further suggesting overlap between different eating disorders. [19]
Family-based therapy (FBT), initially developed to treat anorexia nervosa, is also used to treat children and teens with ARFID. [20]
Those with attention deficit hyperactivity disorder (ADHD) often struggle with inattentiveness or distraction, which may lead to missing meals or forgetting to eat for long periods of time. [21] Additionally, people with ADHD are more likely than the general population to struggle with mood disorders, such as anxiety and depression, which have a strong link with ARFID. [21] Medication used to treat ADHD, such as stimulants, often suppress appetite, which can make eating disorder treatment more difficult. [21]
Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by a sudden onset of obsessive-compulsive symptoms or severely restricted food intake. [2] According to the PANS/PANDAS Physicians Network, PANS may also be a subset of ARFID. [22]
ARFID is known to co-occur with obsessive–compulsive disorder (OCD). [2] [23] Common overlap in symptoms include obsessions related to food and food intake or rituals related to eating. [2]
People with ARFID are more likely to have major depressive disorder than the general population. [2] [23] However, more clinical research is needed to better understand the relations between ARFID and major depressive disorder — and other mood disorders. [23]
Diagnosis is often based on a diagnostic checklist to test whether an individual is exhibiting certain behaviors and characteristics. Clinicians will look at the variety of foods an individual consumes, as well as the portion size of accepted foods. They will also question how long the avoidance or refusal of particular foods has lasted, and if there are any associated medical concerns, such as malnutrition. [24]
The DSM-5 published in 2013 was the first to include ARFID as a diagnosis. [4]
The criteria were changed in the text revision (DSM-5-TR) published in 2022. The change eliminated an inconsistency in the phrasing of criterion A, clarifying that a failure to meet nutritional requirements is not required to meet the diagnostic criteria for ARFID. [25]
A diagnosis of ARFID can also be given if the full criteria are no longer met for a sustained period of time. In this case, it is specified that the person is in remission.[ citation needed ]
The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS) [26] has been developed to assess the presence of ARFID. Across nine items that are scored on a 6-point Likert scale, the NIAS assesses picky eating, appetite, and fear scale. [27] [28]
As of June 2024, diagnostic tools and treatment protocols for ARFID are still in the process of development. [29] According to a review from the Journal of Eating Disorders, the limited understanding of avoidant and restrictive eating and its neurobiology poses challenges to effective treatment and management. [29] The authors argue that it is important to avoid segmenting ARFID patients into separate sub profiles — such as "sensory" patients — and personalize treatment for each individual. [29]
Current treatments commonly involve a multidimensional approach, drawing on these three areas:
Nutritional interventions: Working with clinicians — including a dietitian — to come up with a plan to address immediate needs in regard to weight restoration and/or nutritional deficits. Individuals with ARFID may be treated with nutritional supplements. In severe cases, patients may require nasogastric or gastrostomy tube feeding. [30]
Pharmacological interventions: The U.S. Food and Drug Administration has not approved any psychotropic medication for treatment of ARFID, and empirical evidence on this front is currently extremely limited. However, small case studies have pointed to a few possible pharmacological interventions: olanzapine, a second-generation atypical antipsychotic; mirtazapine, an antidepressant known for its safety and efficacy in treating depressive and anxious symptoms in adults; and buspirone, typically used to treat generalized anxiety disorder. [29]
Behavioral interventions: Again, solid evidence on effective treatment is limited, but U.S. case studies and non-randomized clinical trials have shown promising results from cognitive behavioral therapy (CBT) adapted for ARFID, as well as family-based therapy (FBT). [16] [29] In Australia, a common treatment is responsive feeding therapy (RFT) [31] Responsive feeding treatment involves a support person establishing mealtime routines with pleasant interactions and modeling to encourage the person struggling with ARFID to respond to hunger cues. [31]
There are support groups for adults with ARFID. [32]
A suitable treatment for older children and adults alike is CBT-AR (Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder), in which one study found 90% of participants had high levels of satisfaction with the program. [33] While the rate of remission to this type of programme is said to be around 40%, [33] it has seen higher efficacy among children and young adults compared to adults, and greater family involvement has also been seen to help. [33] The main goals of treatment for CBT-AR are to achieve or to maintain a health weight, treat nutritional deficits, consume items from all five of the basic dietary groups, and to be more comfortable in social settings and circumstances. CBT-AR workbook can be used as a resource for professionals. [34] This workbook includes psychoeducation about ARFID, self-monitoring records for food logs, and the different stages in treatment.
The treatment is broken up into four stages and aimed to help "reduce nutritional compromise and increase opportunities for exposure to novel foods to reduce negative feelings and predictions about eating". [35] In a simplified format, the stages of this treatment are: [35]
This is set to take place over 20–30 sessions ranging from six months to a year.
While there is currently no way to predict who will develop ARFID, there may be ways to help reduce the probability of developing a disorder or reducing its severity. [36] Many parents worry that their child is not consuming enough food daily. A key tool in spotting whether a child's intake is actual cause for concern is the growth chart maintained by their pediatrician. [36] (Families can also maintain growth charts at home by plugging height and weight data from their doctors into an app.) A child over age 3 or 4 who falls downward across 2 percentile curves on the weight chart is a cause for concern. [37]
Families can help mitigate future eating problems by establishing appropriate feeding practices at home. [36] [38] [39] This includes avoiding bribing or coercing children into eating different foods, which may cause backlash and heighten anxiety around eating. The parent is responsible for when, where, and what the food is, and the child is responsible for how much they eat. [36] [38] [39]
Unlike most eating disorders, there may be a higher rate of ARFID in young boys than there is in young girls. [40] Presentations are often heterogenous. [9] Additionally, literature suggests that parental pressure for a child to eat could potentially have a negative impact on the child's food intake. This is associated with picky eating and a decrease in weight during childhood. [41] [42] This can be contributing to the child's hunger cues, as well as, the child eating for reasons other than their hunger (e.g., emotions). [43] [44]
In a study conducted between 2008 and 2012, 22.5% of children aged 7–17 in day programs for eating disorder treatment were diagnosed with ARFID. [40] In a 2021 study ARFID also has a high comorbidity with autism spectrum disorder (ASD), with up to 17% of adults with ASD at risk of developing disordered eating, with modest evidence for heritability. Among children, one study revealed a 12.5% prevalence of ASD among those diagnosed with ARFID. [45] Other risk factors include sensory processing sensitivity, gastrointestinal disease and anxiety associated with eating. [46] Prevalence among children aged 4–7 is estimated to be 1.3%, [47] and 3.7% in females aged 8–18. [47] The female cohort study also had a BMI of 7 points lower than the non-ARFID population. [48]
Children are often picky eaters, but this does not necessarily mean they meet the criteria for an ARFID diagnosis. ARFID is a rare condition, and though it shares many symptoms with regular picky eating, it is not diagnosed nearly as much. Selective eating, or picky eating, which can exhibit symptoms similar to those of ARFID, can be observed in 13–22% of children from ages 3–11, [49] whereas the prevalence of ARFID has "ranged from 5% to 14% among pediatric inpatient ED [eating disorder] programs and as high as 22.5% in a pediatric ED day treatment program." [50]
Prior to the DSM-5, the DSM was not inclusive in recognizing all of the challenges associated with feeding and eating disorders in 3 main domains: [24]
The definition introduced in the DSM-5 is broad, which can be both a detriment and an advantage: Stephanie G. Harshman of the neuroendocrine unit at Massachusetts General Hospital has been quoted saying: "The broad definitions used among DSM-5 criteria for [ARFID] provide substantial flexibility in a clinical setting". [51] [52] It can be detrimental, as a broad scope can lead to false positive diagnoses of ARFID, though as an advantage it is better than the DSM-IV description which landed people with ARFID in the "EDNOS" (eating disorder not otherwise specified) category and made it more difficult for people with the condition to reach potential treatment. [4]
An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health. These behaviors may include eating either too much or too little. Types of eating disorders include binge eating disorder, where the patient keeps eating large amounts in a short period of time typically while not being hungry; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity. People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.
Bulimia nervosa, also known simply as bulimia, is an eating disorder characterized by binge eating followed by compensatory behaviors, such as vomiting, excessive exercise, or fasting to prevent weight gain.
Pica is the craving or consumption of objects that are not normally intended to be consumed. It is classified as an eating disorder but can also be the result of an existing mental disorder. The ingested or craved substance may be biological, natural or manmade. The term was drawn directly from the medieval Latin word for magpie, a bird subject to much folklore regarding its opportunistic feeding behaviors.
Orthorexia nervosa is a proposed eating disorder characterized by an excessive preoccupation with eating healthy food. The term was introduced in 1997 by American physician Steven Bratman, who suggested that some people's dietary restrictions intended to promote health may paradoxically lead to unhealthy consequences, such as social isolation, anxiety, loss of ability to eat in a natural, intuitive manner, reduced interest in the full range of other healthy human activities, and, in rare cases, severe malnutrition or even death.
Appetite is the desire to eat food items, usually due to hunger. Appealing foods can stimulate appetite even when hunger is absent, although appetite can be greatly reduced by satiety. Appetite exists in all higher life-forms, and serves to regulate adequate energy intake to maintain metabolic needs. It is regulated by a close interplay between the digestive tract, adipose tissue and the brain. Appetite has a relationship with every individual's behavior. Appetitive behaviour also known as approach behaviour, and consummatory behaviour, are the only processes that involve energy intake, whereas all other behaviours affect the release of energy. When stressed, appetite levels may increase and result in an increase of food intake. Decreased desire to eat is termed anorexia, while polyphagia is increased eating. Dysregulation of appetite contributes to ARFID, anorexia nervosa, bulimia nervosa, cachexia, overeating, and binge eating disorder.
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.
Neophobia is the fear of anything new, especially a persistent and abnormal fear. In its milder form, it can manifest as the unwillingness to try new things or break from routine. In the context of children the term is generally used to indicate a tendency to reject unknown or novel foods. Food neophobia, as it may be referred to, is an important concern in pediatric psychology.
Autism spectrum disorder (ASD) or simply autism is a neurodevelopmental disorder that begins in early childhood, persists throughout adulthood, and is characterized by difficulties in social communication and restricted, repetitive patterns of behavior. There are many conditions comorbid to autism, such as attention deficit hyperactivity disorder, anxiety disorders, and epilepsy.
An underweight person is a person whose body weight is considered too low to be healthy. A person who is underweight is malnourished.
Relative energy deficiency in sport (RED-S) is a syndrome in which disordered eating, amenorrhoea/oligomenorrhoea, and decreased bone mineral density are present. It is caused by eating too little food to support the amount of energy being expended by an athlete, often at the urging of a coach or other authority figure who believes that athletes are more likely to win competitions when they have an extremely lean body type. RED-S is a serious illness with lifelong health consequences and can potentially be fatal.
Night eating syndrome (NES) is classified as an Other Specified Feeding or Eating Disorder (OSFED) under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). It involves recurrent episodes of night eating after awakening from sleep or after the evening meal. Awareness and recall of the eating is present, which is a key characteristic that differentiates the disorder from Sleep-Related Eating Disorder (SRED). Although there is some degree of comorbidity with binge eating disorder (BED), it differs from binge eating in that the amount of food consumed in the night is not necessarily objectively large nor is a loss of control over food intake required. The syndrome causes significant distress or functional impairment and cannot be better explained by external influences such as changes in the sleep-wake cycle, social norms, substance use, medication, or another mental or medical disorder.
Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.
Purging disorder is an eating disorder characterized by the DSM-5 as self-induced vomiting, or misuse of laxatives, diuretics, or enemas to forcefully evacuate matter from the body. Purging disorder differs from bulimia nervosa (BN) because individuals do not consume a large amount of food before they purge. In current diagnostic systems, purging disorder is a form of other specified feeding or eating disorder. Research indicates that purging disorder, while not rare, is not as commonly found as anorexia nervosa or bulimia nervosa. This syndrome is associated with clinically significant levels of distress, and that it appears to be distinct from bulimia nervosa on measures of hunger and ability to control food intake. Some of the signs of purging disorder are frequent trips to the bathroom directly after a meal, frequent use of laxatives, and obsession over one's appearance and weight. Other signs include swollen cheeks, popped blood vessels in the eyes, and clear teeth which are all signs of excessive vomiting.
Anorexia nervosa (AN), often referred to simply as anorexia, is an eating disorder characterized by food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin.
The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.
A feeding disorder, in infancy or early childhood, is a child's refusal to eat certain food groups, textures, solids or liquids for a period of at least one month, which causes the child to not gain enough weight, grow naturally or cause any developmental delays. Feeding disorders resemble failure to thrive, except that at times in feeding disorder there is no medical or physiological condition that can explain the very small amount of food the children consume or their lack of growth. Some of the times, a previous medical condition that has been resolved is causing the issue.
Other specified feeding or eating disorder (OSFED) is a subclinical DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR. It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder. OSFED includes five examples:
Emotional eating, also known as stress eating and emotional overeating, is defined as the "propensity to eat in response to positive and negative emotions". While the term commonly refers to eating as a means of coping with negative emotions, it sometimes includes eating for positive emotions, such as overeating when celebrating an event or to enhance an already good mood.
Atypical anorexia nervosa is an eating disorder in which individuals meet all the qualifications for anorexia nervosa, including a body image disturbance and a history of restrictive eating and weight loss, except that they are not currently underweight. Atypical anorexia qualifies as a mental health disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), under the category Other Specified Feeding and Eating Disorders (OSFED). The characteristics of people with atypical anorexia generally do not differ significantly from anorexia nervosa patients except for their current weight.
Selective eating, also known as picky eating, is a variety of behaviors whereby people are highly selective in what they eat and do not eat. Selective eating is common in younger children and can also sometimes be seen in adults.
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