What are the diagnostic changes for Avoidant/Restrictive Food Intake Disorder across the Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III‑TR, IV, V, V‑TR and the International Classification of Diseases (ICD) versions X and XI?

Evolution of Avoidant/Restrictive Food Intake Disorder Diagnosis Across DSM and ICD Versions

Avoidant/Restrictive Food Intake Disorder (ARFID) is a new diagnostic entity that first appeared in DSM-5 (2013) and ICD-11 (2022), replacing the much narrower DSM-IV diagnosis of "Feeding Disorder of Infancy or Early Childhood" and having no equivalent in DSM-III, DSM-III-TR, or ICD-10. 1, 2, 3

DSM-III and DSM-III-TR (Text Revision)

• ARFID did not exist as a diagnostic category in these versions 2, 3
• No comparable diagnosis captured the clinical presentation of restrictive eating without body image concerns across the lifespan 4

DSM-IV

• The predecessor diagnosis was "Feeding Disorder of Infancy or Early Childhood", which was severely limited in scope 2, 4, 3
• This diagnosis was restricted to children 6 years of age or younger 4, 3
• It required weight loss as a diagnostic criterion 4
• The narrow age restriction and weight loss requirement left many patients with clinically significant restrictive eating "diagnostically orphaned" 4

DSM-5 (2013)

DSM-5 introduced ARFID as an entirely new diagnosis that dramatically expanded the diagnostic umbrella beyond its DSM-IV predecessor 1, 2, 3:

Key Diagnostic Criteria in DSM-5:

• Abnormal eating or feeding behaviors resulting in insufficient quantity or variety of food to meet adequate energy or nutritional requirements 5, 6
• Must result in at least one of the following:
  • Significant weight loss or failure to meet expected weight/height gain in children 5, 6
  • Significant nutritional deficiency 5, 6
  • Dependence on enteral feeding or oral nutritional supplements 5, 6
  • Marked interference with psychosocial functioning 5, 6

Critical Distinctions from Other Eating Disorders:

• No body image distortion or fear of weight gain (distinguishing it from anorexia nervosa) 5, 6, 3
• Not attributable to food availability or cultural practices 5
• No age restriction—applicable to children, adolescents, and adults 1, 2, 3
• No weight loss requirement 4

Clinical Significance of DSM-5 Changes:

• The removal of age restrictions captured an older cohort accessing eating disorder clinics 4
• The broader criteria provided a diagnostic home for previously unclassified pediatric feeding disorder subgroups 4
• ARFID is recognized as highly heterogeneous, encompassing patients who avoid food based on sensory characteristics, fear of adverse consequences, or apparent lack of interest in eating 7

DSM-5-TR (Text Revision)

• The evidence provided does not indicate substantive changes to ARFID diagnostic criteria between DSM-5 and DSM-5-TR 1, 2
• The core diagnostic framework established in DSM-5 appears to have been maintained 2

ICD-10

• ARFID did not exist as a distinct diagnostic category in ICD-10 5
• Patients with restrictive eating without body image concerns lacked appropriate classification 4

ICD-11 (2022)

ICD-11 introduced ARFID as a new diagnostic category, defined as "characterized by abnormal eating or feeding behaviors resulting in the intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements" 5:

• This represents one of multiple new diagnostic categories added to the Mental, Behavioural or Neurodevelopmental Disorders chapter 5
• The ICD-11 definition aligns conceptually with DSM-5 criteria, emphasizing insufficient intake without body image disturbance 5
• ICD-11 maintained a largely categorical approach while adding dimensional expansions for some diagnoses, though specific dimensional qualifiers for ARFID are not detailed in the provided evidence 5

Clinical Implications of Diagnostic Evolution

Recognition Across the Lifespan:

• The expansion from a pediatric-only diagnosis to one applicable across all ages fundamentally changed clinical practice 1, 2, 3
• Adolescents and adults with restrictive eating patterns can now receive appropriate diagnosis and treatment 1, 2

Heterogeneity Challenges:

• ARFID is widely recognized as lacking specificity, encompassing diverse presentations that may benefit from subtype differentiation 4, 7
• The broad diagnostic umbrella, while capturing previously undiagnosed patients, creates challenges for targeted treatment development 4, 7

Common Diagnostic Pitfalls:

• Do not overlook ARFID in older adolescents and adults—the diagnosis is not limited to young children 1, 2, 3
• Carefully distinguish from anorexia nervosa—the absence of body image distortion and fear of weight gain is essential 5, 6, 3
• Recognize that weight loss is not required—patients may present with nutritional deficiency, growth failure, or psychosocial impairment without significant weight loss 4
• Consider the three main avoidance patterns: sensory-based avoidance, fear of aversive consequences (choking, vomiting), and lack of interest in eating 7