What are the diagnostic criteria for Avoidant/Restrictive Food Intake Disorder (ARFID)?

From the Guidelines

Avoidant/Restrictive Food Intake Disorder (ARFID) is diagnosed when a person has significant eating or feeding disturbances that result in persistent failure to meet nutritional needs, as outlined in the most recent guidelines 1. The diagnostic criteria for ARFID include an eating disturbance manifested by one or more of the following:

• significant weight loss or failure to achieve expected weight gain in children
• significant nutritional deficiency
• dependence on enteral feeding or oral nutritional supplements
• marked interference with psychosocial functioning. Importantly, these disturbances cannot be better explained by lack of available food, cultural practices, or another medical condition. Unlike anorexia nervosa, ARFID does not involve disturbances in body weight or shape perception. The disorder also cannot be attributed to another mental disorder or medical condition, and when it occurs alongside another condition, the severity exceeds what would typically be associated with that condition. ARFID often presents in three main ways:
• sensory sensitivity to food characteristics
• lack of interest in eating
• fear of aversive consequences from eating such as choking or vomiting. Diagnosis requires a comprehensive assessment by healthcare professionals with expertise in eating disorders, typically including medical evaluation, nutritional assessment, and psychological evaluation to rule out other potential causes of restricted eating, as recommended by recent guidelines 1. It is essential to screen patients with non-CIPO GINMD or DGBI for ARFID, as well as Shape and Weight-motivated eating disorders (SWED) such as anorexia nervosa and bulimia, and to avoid parenteral nutrition in both ARFID and SWED, other than in life-threatening malnutrition extremis as a temporary bridge to optimal eating disorder MDT management 1. Additionally, patients with severe or refractory functional dyspepsia presenting with weight loss and food restriction should be assessed for eating disorders and disordered eating, including ARFID 1. Early dietitian involvement in patients with severe or refractory functional dyspepsia can help avoid an overly restrictive diet and potential development of ARFID 1. The optimal psychological and nutritional rehabilitation approach in ARFID is graded exposure in a cognitive behavioral therapy (CBT) setting rather than further reinforcing restriction 1.

From the Research

Diagnostic Criteria for Avoidant/Restrictive Food Intake Disorder (ARFID)

The diagnostic criteria for ARFID have been a subject of discussion since its introduction to the DSM in 2013 2. The current diagnostic criteria for ARFID are based on impairment, with no requirement for a specific pattern of behavioral or cognitive/affective symptoms to be present.

• The proposed framework for DSM criteria involves food avoidance maintained by beliefs/hedonic reactions that are temporally close to and realistically/functionally associated with a specific food or eating occasion, characterized by one or more of the following expected aversive responses:
  • Disgust/distaste
  • Anhedonia/uncomfortable fullness
  • Acute fear/panic 2
• The current definition of ARFID requires dietary intake that is inadequate to support energy or nutritional needs, but there is a proposal to broaden the criteria to include psychosocial impairment as sufficient for an ARFID diagnosis 3
• The diagnostic criteria for ARFID should include four manifestations of impairment, which are necessary but not sufficient for the ARFID diagnosis, and should be diagnosed regardless of co-occurring/comorbid conditions 2

Comparison with Other Eating Disorders

ARFID is distinct from other eating disorders, such as anorexia nervosa (AN), in terms of clinical presentation and characteristics.

• Individuals with ARFID are younger, report earlier age of onset, and have higher percent median BMI (%mBMI) than those with AN 3
• ARFID can be distinguished from AN by relatively higher levels of food neophobia, and individuals with ARFID score lower on measures of eating pathology, depression, anxiety, and clinical impairment 3

Treatment Approaches

There is limited research on the treatment of ARFID, but the extant research supports hospital-based behavioral therapy and a multidisciplinary treatment approach 4.

• Cognitive-behavioral treatment (CBT) is a novel approach currently under study, which is appropriate for children, adolescents, and adults ages 10 years and more 5
• A medical and behavioral treatment model has been shown to be effective in targeting oral consumption in individuals with ARFID, with 92% of participants consuming 100% of their nutritional needs orally 4