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ARFID vs Picky Eating: What are the Differences?

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.

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:

  • Sensitivity to Sensory Input – For ARFID sufferers, the smell, taste, texture, or appearance of the food does more than make them dislike it. These sensory aspects will make them distressed or unable to tolerate their presence. This makes eating anything in the same vicinity as the “fear food” feel close to impossible.
  • Sudden Weight Loss or Significant Weight Loss Over Time – Especially for children and adolescents, this is a telling sign that something is wrong – after all, children grow and increase weight naturally. But in adults as well as children, a sudden drop in body weight or a significant long-term reduction in weight can be a sign of illness. If they are refusing to eat certain foods, the weight loss may correspond.
  • Showing No Interest in Food or Eating – This may be tied to the sensitivity mentioned above – if the mere presence of a “fear food” can turn a person away from a meal, they may simply lose interest in eating at all. As children, they may not have any favorite foods or treats they enjoy. For adults, they might not want to talk about food or show any interest in planning meals or going to restaurants.
  • Psychosocial Disturbances – Sounds complicated, yes? This is just another way of saying that a person’s mental health condition is interfering with their life. ARFID can cause so much anxiety and distress that the person cannot cope with everyday social situations like sharing a meal or being around people eating their fear food. It can greatly impact their ability to function in school or at work and damage relationships and self esteem.
  • Extreme changes in diet – Unlike someone who undergoes a weight-loss program that changes the amounts and types of food they eat, ARFID sufferers might suddenly and drastically change their eating patterns. One example is a person who is afraid of choking due to ARFID and suddenly deciding to go on an all-liquid diet. Another example would be a person deciding to cut out all meat after having a piece of undercooked chicken. These changes can become more drastic and pronounced as ARFID progresses.

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.

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.