Sometimes known as selective eating disorder, ARFID (Avoidant/Restrictive Food Intake Disorder) is a psychiatric disorder that can result in nutritional imbalance or even malnutrition in extreme cases. It’s characterized by the refusal to eat any but a few types of food. These “fear foods” cause a person great distress, and can be impactful on their psychosocial functions as well as negatively affecting their health. It often starts in childhood, but unlike picky eating, so common in children, ARFID continues well past adolescence and into adulthood.
ARFID is much more than simple “picky eating,” however. Many small children are picky eaters – who hasn’t tried to explain to a small child that, say, broccoli is delicious and has been met with a blanket refusal to even try it? Even past a young age, most people have foods they don’t like. However, adults who compulsively avoid eating all but a very few types of food may need ARFID treatment to overcome the disorder and restore a proper nutritional balance. Treatment can also aid in the psychosocial difficulties ARFID brings about.
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Diagnosing ARFID
In the past, ARFID (selective eating disorder) was not as recognized as bulimia nervosa or anorexia nervosa, but it was finally listed in the Diagnostic and Statistical Manual of Mental Disorder V, the most recent version of the official guidelines for mental health professionals in the United States. This means that the mental health community has identified several unique criteria that indicate a diagnosis can be made:
- Failure to meet nutritional requirements and appropriate weight maintenance. This failure may require people with ARFID to undergo a weight management regimen and receive supplemental nutrition.
- A diagnosis of ARFID must not be related to cultural values or lack of access to different kinds of food – for example, if a Jewish person will not eat pork or a person is in a food desert and can’t get a certain kind of vegetable, they do not necessarily have ARFID.
- A diagnosis of selective eating disorder cannot be explainable by another medical condition or mental illness.
Unlike other prominent eating disorders like bulimia nervosa, anorexia nervosa, and binge eating disorder, ARFID does not contain negative body image, distorted self-perception, or pathological desire to lose weight as an essential part of its diagnosis. These qualities may exist (just as another eating disorder may coexist with ARFID), but some people with ARFID are not driven to avoid foods because of their effects on their weight.
Instead, ARFID is often triggered by a negative experience with the “fear food”. As a child, they may have choked, gotten sick, or simply eaten a bad example of the food that turned them away from eating it again in the future. Of course, this sounds reasonable, but when it becomes a compulsion to avoid that food, and similar ones, it can become problematic. Therefore, parents should keep an eye out if their young child is especially picky or becomes agitated by the mere presence of a kind of food.
How to Tell ARFID Apart from Picky Eating
Amateur diagnoses of any kind of mental health disorder are always a bad idea. It’s just too easy to lean too far in one direction or another – thinking that the picky eating is proof that there is a serious eating disorder, or conversely imagining that ARFID can be dismissed as a simple “normal” part of childhood. However, certain behavioral signs can help loved ones decide whether to seek out professional help.
Here are some of the things to look out for:
1. Sudden or significant weight loss
An individual with ARFID may demonstrate sudden or significant weight loss. This could be a result of sensory sensitivities, aversions to food, and/or lack of interest in food that cause restrictive eating. Aversions or sensory sensitivities are most often caused by an adverse event or effect of eating that could include vomiting, choking or a real or feared allergic reaction. Developmentally appropriate picky eaters are generally able to maintain weight despite limited food selection and do not typically experience weight loss due to a fear of vomiting or choking.
2. Failure to gain or maintain weight
Another characteristic of ARFID, specifically children diagnosed with this condition, can be a failure to achieve expected weight gains. This means that a child has fallen off their expected growth trajectory or might experience a failure to thrive or grow from an early age. Adults with ARFID may fail to maintain a weight that is appropriate for their unique nutritional needs. Picky eaters are generally still able to get enough nutrition and calories to maintain growth within their expected ranges on growth charts, or maintain a healthy weight.
Someone with ARFID may be reliant on feeding tubes or nutritional supplements such as Ensure in order to obtain appropriate nutrition. Picky eaters are generally able to eat enough foods and enough variety that they do not require supplementation to meet caloric needs.
3. Interference with psychosocial functioning
Those who struggle with ARFID may find it difficult to eat in a variety of settings such as at a friend’s house, in cafeterias, or at events. They may also find it challenging to be around certain types of foods. The intense anxiety experienced can significantly limit their ability to engage in age-appropriate social settings and cause an increase in isolation. Generally, a picky eater is able to attend social activities with little to no distress regarding foods that will be present or the environment itself.
4. Sensory Sensitivities
Although a picky eater may not eat a food due to the smell or look of a food, they often can tolerate a variety of textures, smells, and visual presentations of food with some distress. However, someone struggling with ARFID will have increased anxiety and reported inability to consume foods due to texture, taste, smell, visual presentation, etc. without high distress or other symptoms such as gagging or spitting out food.
5. Adverse Consequences
While a picky eater may also avoid a food due to a negative experience, those struggling with ARFID have an intense aversion to foods either due to the fear of choking or vomiting, witnessing someone choking or vomiting, or a real or perceived allergic reaction. The avoidance of these foods can often be extreme in response to an aversive situation, for example, consuming an all liquid diet after choking. A picky eater does not often express fear as the drive to limited eating or food choices.
6. Lack of Interest in Food or Eating
Lastly, a lack of interest in food or eating can be a sign of ARFID. Often, people with ARFID will say they are not hungry, do not think about food, and can even forget to eat because food is not a priority. In contrast, picky eaters do often feel hungry, are interested in eating the foods they enjoy, and do not have the same lack of interest in food and eating.
While there are many differences between an actual diagnosis of ARFID and picky eating, the line can often be blurred. If you have concerns that you or your child’s picky eating may have become a problem, further assessment may be helpful.
Types of Treatment
Eating disorder treatment centers provide treatment for selective eating disorders using cognitive behavioral therapy, dialectical behavioral therapy, nutritional counseling, and other talk therapy and cognitive retraining methods. ARFID treatment, like any psychiatric treatment, is not a simple process. ARFID requires several in-depth sessions to identify initially, even before treatment starts. Some symptoms may be similar to other types of eating disorders as well as sharing characteristics of autism and other well known mental health diseases.
Below are some of the commonly applied treatment techniques used for ARFID. They are also used for other kinds of eating disorder treatment, including treatment for bulimia nervosa, binge eating disorder, orthorexia nervosa, and anorexia nervosa. This is certainly not an exhaustive list, and you can learn more about treatment methodologies here.
Cognitive Behavioral Therapy
CBT is a subtype of psychotherapy that teaches people with distorted behaviors how to recognize negative thought patterns so they can be replaced with more healthful ones. Cognitive Behavioral Therapy shows the client that these disordered thoughts are flawed and helps them understand how that has been affecting their behavior. It reveals the irrationality of these disordered thoughts through a series of logical discourses between the client and therapist.
Cognitive Rehearsal
Often an eating disorder treatment professional will ask their client to think about how they’ve dealt with stressful or difficult situations in the past. If that centers around disordered eating patterns, they work together to accept that these behaviors are harmful and work to replace them with more positive coping mechanisms. By regularly “rehearsing” positive thoughts regarding stress and other triggers for disordered eating, cognitive rehearsal helps ARFID patients learn to use positive thoughts to deal with current issues related to their eating disorder.
Exposure Therapy and ARFID Treatment
There are more possibilities than only CBT for treating ARFID, although many are similar cognitive retraining methods such as DBT (Dialectical Behavioral Therapy) or CPT (Cognitive Processing Therapy, a form of CBT designed to treat PTSD). There are more direct activities that can be implemented as well, like exposure therapy.
Originally designed to help people with extreme phobias, exposure therapy involves exposing people with ARFID to the foods they avoid, if only for a short period. For example, if they refuse to eat dairy products, the therapist may have them take a sip of milk or eat a tiny piece of cheese, even if it causes some distress. Or, a small piece of cheese could be melted on a hamburger instead of eaten alone. The goal is to eventually get them accustomed to including this type of food in their regular eating pattern.
Treatment for Eating Disorders Is Available
Eating disorder treatment centers offer professional in-patient or outpatient help for teens and adults with ARFID, anorexia nervosa, bulimia nervosa, or other lesser-known eating disorders. There is more than one way to approach recovery. If you’re struggling with ARFID, do your research and reach out to a treatment center today.
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