Avoidant or restrictive food intake disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2] Joseph Nasr, M.D.[3]

Synonyms and keywords: Avoidant food intake disorder; restrictive food intake disorder; ARFID

Overview

This disorder is characterized by the abnormal feeding habits. This may lead to critical weight loss, nutritional deficiency and decrease in psychosocial functioning. In this instance, the causes are not attributed to a physical condition.

Differential Diagnosis

• Gastrointestinal disease
• Food allergies and intolerances
• Occult malignancies
• Specific neurological/neuromuscular
• Structural, or congenital disorders
• Conditions associated with feeding difficulties
• Reactive attachment disorder
• Autism spectrum disorder
• Specific phobia
• Social anxiety disorder (social phobia)
• Anorexia nervosa
• Obsessive-compulsive disorder
• Major depressive disorder
• Schizophrenia spectrum disorders
• Factitious disorder

Risk Factors

• Anxiety disorders
• Autism spectrum disorder
• Attention-deficit/hyperactivity disorder
• Obsessive-compulsive disorder
• Family history of familial anxiety
• Gastroesophageal reflux disease
• History of gastrointestinal conditions
• Vomiting

Diagnostic Criteria

DSM-V Diagnostic Criteria for Avoidant or Restrictive Food Intake Disorder

“

A. An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). Significant nutritional deficiency. Dependence on enteral feeding or oral nutritional supplements Marked interference with psychosocial functioning. B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Specify if: In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time.

”

AVOIDANT / RESTRICTIVE FOOD INTAKE DISORDER (ARFID)

Step 1. Identify the eating disturbance Ask for the mechanism of restriction: 1.Are you avoiding foods due to texture, smell, or appearance? 2.Are you afraid of choking, vomiting, pain, or other aversive consequences? 3.Do you have a low interest in eating or low appetite? 4.Is the restriction driven by fear of weight gain or body image concerns?

Step 2. Confirm required consequences At least one must be present: 1.Significant weight loss or failure to achieve expected weight gain in children 2.Nutritional deficiency 3.Dependence on supplements or enteral feeding 4.Marked interference with psychosocial functioning

Step 3. Exclusions that change diagnosis 1.Not due to food scarcity or culturally sanctioned practice 2.Not better explained by anorexia nervosa or bulimia nervosa 3.Restriction is not driven by body image disturbance or fear of weight gain

Step 4. Safety screen 1.Syncope, severe weakness, dehydration 2.Rapid weight loss or failure to thrive in children 3.Suicidality or severe psychiatric crisis Escalate level of care if present

Step 5. Physical examination 1.Vitals including orthostatic measurements if symptomatic 2.Signs of malnutrition and dehydration 3.Growth parameters and pubertal development in children and adolescents

Step 6. Investigations to define deficiency and exclude medical disease 1.Complete blood count 2.Electrolytes and renal function 3.Nutrition related labs as clinically indicated 4.Additional workup guided by symptoms to exclude GI or endocrine causes of restriction