Avoidant/restrictive food intake disorder

Avoidant/restrictive food intake disorder
Classification and external resources
Specialty	Psychiatry
ICD-10	F50.8
ICD-9-CM	307.59

Avoidant/restrictive food intake disorder (ARFID), also previously known as selective eating disorder (SED), is a type of eating disorder where the consumption of certain foods is limited based on the food's appearance, smell, taste, texture, or a past negative experience with the food.^[1]

Definition

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) renamed "Feeding Disorder of Infancy or Early Childhood" to Avoidant/Restrictive Food Intake Disorder, and broadened the diagnostic criteria. Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.

The DSM-5 defines the following diagnostic criteria:^[2]

• Disturbance in eating or feeding, as evidenced by one or more of:
  • Substantial weight loss (or, in children, absence of expected weight gain)
  • Nutritional deficiency
  • Dependence on a feeding tube or dietary supplements
  • Significant psychosocial interference
• Disturbance not due to unavailability of food, or to observation of cultural norms
• Disturbance not due to anorexia nervosa or bulimia nervosa, and no evidence of disturbance in experience of body shape or weight
• Disturbance not better explained by another medical condition or mental disorder, or when occurring concurrently with another condition, the disturbance exceeds what is normally caused by that condition

Signs and symptoms

Sufferers of ARFID have an inability to eat certain foods. "Safe" foods may be limited to certain food types and even specific brands. In some cases, afflicted individuals will exclude whole food groups, such as fruits or vegetables. Sometimes excluded foods can be refused based on color. Some may only like very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods, or avoid sauces.

Most sufferers of ARFID will still maintain a healthy or normal body weight. There are no specific outward appearances associated with ARFID.^[3] Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting or gagging. Some studies have identified symptoms of social avoidance due to their eating habits. Most, however, would change their eating habits if they could.^[3]

Comorbidity

The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed other mental disorders that are comorbid with ARFID.

ARFID and autism

Symptoms of ARFID are usually found with symptoms of other disorders. Some form of feeding disorder is found in 80% of children that also have a developmental disability.^[4] Children often exhibit symptoms of obsessive-compulsive disorder and autism. Although many people with ARFID have symptoms of these disorders, they usually do not qualify for a full diagnosis. Strict behavior patterns and difficulty adjusting to new things are common symptoms in patients that are on the autistic spectrum.^[3] A study done by Schreck at Pennsylvania State University compared the eating habits of children with ASD and typically developing children. After analyzing their eating patterns, they suggested that the children with some degree of ASD have a higher degree of selective eating. These children were found to have similar patterns of selective eating and favored more energy dense foods such as nuts and whole grains. Eating a diet of energy dense foods could put these children at a greater risk for health problems such as obesity and other chronic diseases due to the high fat and low fiber content of energy dense foods. Due to the tie to ASD, children are less likely to outgrow their selective eating behaviors and most likely should meet with a clinician to address their eating issues.^[5][6]

ARFID as an anxiety disorder

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 suffer from ARFID do not have this fear, but the psychological symptoms and anxiety created is similar.^[3]

Treatment

For adults

With time the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than symptoms may typically disappear without treatment.^[3] Also hypnotherapy may be used. In that it lessens the anxiety associated with food.

There are support groups for adults with ARFID.^[7]

For children

Children can benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment are record, reward, relax and review.^[3]

• In the record stage, children are encouraged to keep a log of their typical eating behaviors without attempting to change their habits as well as their cognitive feelings.
• The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
• The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Often these stories can also include the introduction of new foods with the help of a real person or fantasy person. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.^[3]
• The final stage, review, is important to keep track of the child's progress. It is important to include both one-on-one sessions with the child, as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.

Be aware that this is a disorder that may be very difficult for the child to take over, therefore may take anywhere from months to years to 'cure'.

See also

• Food neophobia
• Orthorexia nervosa

References

1. Fisher, Martin M.; Rosen, David S.; Ornstein, Rollyn M.; Mammel, Kathleen A.; Katzman, Debra K.; Rome, Ellen S.; Callahan, S. Todd; Malizio, Joan; Kearney, Sarah (2014-07-01). "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. doi:10.1016/j.jadohealth.2013.11.013.
2. American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5. Retrieved May 14, 2014, from http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
3. Nicholls, D., Christie, D., Randall, L. and Lask, B.. (2001). "Selective Eating: Symptom, Disorder or Normal Variant." Clinical Child Psychology and Psychiatry. Vol 6(2): 257–270.
4. Chatoor,I., Hamburger, E., Fullard, R., & Fivera, Y. (1994). A survey of picky eating and pica behaviors in toddlers. Scientific Proceedings of the Annual Meeting of American Academy of Child and Adolescent Psychiatry, 10', 50.
5. Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without Autism. Journal of Autism and Developmental Disabilities. 2004; 34: 433-438.
6. Evans, E. (2013). Selective Eating and Autism Spectrum Disorder. In Behavioral Health Nutrition. Retrieved April 2, 2013, from "Archived copy". Archived from the original on 2013-07-19. Retrieved 2013-04-16.
7. Wang, S. (2010, July 5). No Age Limit on Picky Eating. Wall Street Journal. Retrieved April 2, 2013, from http://online.wsj.com/article/SB10001424052748704699604575343130457388718.html

External links

• Avoidant/Restrictive Food Intake Disorder (ARFID), Center for Eating Disorders at Sheppard Pratt
• Overview Of Adolescent Picky Eating and Other Feeding Disorders, by the Association of Pediatric Food Refusal
• Other "Eating Disorders", by Somerset and Wessex Eating Disorders Association
• Welcome to the Eating Disorders Team, UCL Institute of Child Health
• "Cognitive Therapist Daniel Mattila on Picky Eating", radio interview