When you think of an eating disorder, what generally comes to mind? For me, the term eating disorder brings to mind the image of an emaciated young woman, who struggles with her relationship with food. This struggle manifests itself in binging, purging, and/or restricting food intake, due to an unhealthy relationship with one’s weight and body image. In terms of diagnoses, disordered eating is most commonly associated with anorexia nervosa, bulimia nervosa, and binge eating disorder. While these diagnoses are all extremely prevalent in the world of disordered eating, they exclude one particularly important population of individuals who struggle with disordered eating, as well as medical and psychological morbidities. This group of young individuals suffers from Avoidant Restrictive Food Intake Disorder or ARFID.
ARFID is a relatively new eating disorder, only introduced into the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-V. ARFID is characterized by an eating or feeding disturbance, due to a lack of interest in eating or food, avoidance of food based on sensory characteristics, and concern about the aversive consequences of foods. Due to this eating disturbance, individuals with ARFID fail to meet appropriate nutritional and/or energy needs, resulting in significant weight loss or failure to meet growth milestones, significant nutritional deficiencies, dependence on nutritional supplements and/or a feeding tube, and/or interference with psychosocial functioning (American Psychiatric Association, 2013). One key difference between ARFID and other eating disorders, such as anorexia nervosa and bulimia nervosa, is that while anorexia and bulimia are traditionally associated with body image and weight concerns, the diagnosis of ARFID does not include weight or body image concerns.
What, then, causes the development of ARFID? There are various reasons documented for the emergence of ARFID in young individuals. One is selective or picky eating, starting from a young age. This picky eating can include an aversion to familiar foods and/or an aversion to unfamiliar foods, also known as food neophobia (fear of new foods). ARFID also commonly stems from generalized anxiety, fear of vomiting or choking, gastrointestinal symptoms, food allergies, etc. (Fisher et al., 2014).
Because ARFID is a relatively new diagnosis, not much is known about it. What do individuals with ARFID generally look like? Do they have any related symptomology? How do these individuals compare to those with anorexia nervosa (AN) and bulimia nervosa (BN), two more common eating disorders? One study conducted across the United States and Canada aimed to answer these questions.
The purpose of this study was to evaluate the diagnosis of ARFID in the DSM-V, by describing the characteristics of individuals ages 8-18 who met the criteria for ARFID, and comparing them to similar individuals who met criteria for AN and BN (Fisher et al., 2014).
To conduct the study, researchers used a retrospective case-control study, meaning that they reviewed old charts of patients ages 8-18 who came to seven different eating disorder programs in the United States and Canada in 2010. Using these charts, researchers gathered information on individuals who were diagnosed with ARFID, and compared this information to that of an equal number of individuals who were diagnosed with AN and/or BN within the same age range. The information that was gathered included age, gender, ethnicity, weight, height, duration of illness, highest and lowest weights, BMI, intake setting, referral source, and presence of any other medical condition or related symptoms. This information was then statistically analyzed and compared across the different eating disorders (Fisher et al., 2014).
Of 712 individuals who presented to the seven eating disorder centers, 98 (13.8%) individuals met diagnostic criteria for ARFID. The clinical characteristics of these individuals were compared to 98 and 66 patients who suffered from anorexia nervosa and bulimia nervosa, respectively (Fisher et al., 2014).
In terms of age, individuals with ARFID were younger than individuals suffering from AN or BN. The median age of individuals with ARFID was 12.9, while the median ages of individuals with AN and BN were 15.6 and 16.5 respectively (Fisher et al., 2014). This indicates that ARFID generally affects children and adolescents, while AN and BN may be more prevalent in an older age range. Additionally duration of illness, or how long the illness lasts, for those with ARFID was found to be longer, at 33.3 months (almost 3 years), compared to 14.5 months (a little over one year) for AN and 23.5 months (slightly less than 2 years) for BN (Fisher et al., 2014). ARFID, then, may be more enduring than these other two eating disorders, due to the longevity of the illness. Those with ARFID were more likely to be male, with 29% of individuals who presented with ARFID being male, while only 15% of those with AN were male and only 6% of individuals with BN were male (Fisher et al., 2014). This difference can be explained by the fact that there is a tendency to be more issues of body image concern in females vs. males, meaning that those with AN or BN (which are both rooted in body image concern) would be more likely to be female, than those with ARFID (unrelated to body image concerns).
As far as specific symptomology associated with individuals with ARFID, 28.7% of individuals grew up as picky eaters, 21.4% of individuals reported general anxiety issues, 19.4% of individuals had gastrointestinal symptoms, 13.2% of individuals had a history of vomiting or choking, and 4.3% of individuals had food allergies (Fisher et al., 2014). Based on this information, picky or selective eating seems to be most closely associated with ARFID, in comparison to other potential risk factors. Further, patients with ARFID were significantly more likely to have a comorbid medical condition (55%) than those with AN (10%) or BN (11%), and were more likely to have an anxiety disorder as well, with 58% of those with ARFID reporting an anxiety disorder and only 35% and 33% of those with AN and BN, respectively, reporting an anxiety disorder. Interestingly, those with ARFID were less likely to have a mood disorder (58%), such as depression, than those with AN (31%) or BN (58%). This indicates that anxiety may be a precursor for ARFID, while depression or other mood disorders may be a precursor for other eating disorders (Fisher et al., 2014).
The results of this study showed that, while ARFID, AN, and BN are all prevalent eating disorders, those with ARFID are clinically very different from those with AN and/or BN. Though much is not currently known about ARFID, studies like this one are crucial in determining the differences between different eating disorders. This information, then, will inform how these different diagnoses are treated. For example, based on the information in this study, those with ARFID may be treated simultaneously for anxiety or food selectivity, while those with BN may be treated simultaneously for depression or other mood disorders. Further, this study and others like it, aim to increase diagnoses of individuals with ARFID, as they are currently a prevalent, but poorly understood group of individuals. With this early identification, there is a hope of early access to treatment, as well as further research into these individuals. This study, then, serves as a stepping stone towards learning more about ARFID, what risk factors for the disorder are, and how we can work to treat it efficiently.
By Gaurie Mittal
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition (dsm-v). Retrieved from http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm10
Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., …Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. Journal of Adolescent Health, 55, 49-52.