Avoidant/Restrictive Food Intake Disorder (ARFID): What is ARFID and what are the available treatments?

By: Megan C. Kuhnle, B.A., and Jennifer J. Thomas, Ph.D.
Eating Disorders Clinical and Research Program, Massachusetts General Hospital
Department of Psychiatry, Harvard Medical School

Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding and eating disorder characterized by limiting the amount or type of food consumed. ARFID often starts early in childhood but can also affect older children, adolescents, and adults. In contrast to the better-known eating disorders—like anorexia nervosa, bulimia nervosa, and binge eating disorder—people with ARFID are not usually greatly concerned with their shape and weight. Instead, they may limit their intake due to sensory sensitivity, lack of interest in eating or food, and/or fear of aversive consequences of eating such as choking, vomiting, or gastrointestinal pain. Sensory sensitivity can manifest in issues with texture, taste, or smell, leading to avoidance of entire food groups. Some people with ARFID eat food from just one or two food groups (e.g., grains, dairy) or even just one or two foods (e.g., ice cream, pasta).  People who have lack of interest often report not feeling hungry at mealtimes, not enjoying food, and feeling full before they finish meals. People who have a fear of aversive consequences may have had a prior traumatic experience choking or vomiting and may engage in safety behaviors like eating very slowly and taking sips of water between each bite. Someone with ARFID may present with one, two, or all three profiles.

The ARFID diagnosis was added to the DSM-5 in 2013 as a reformulation of the DSM-IV diagnosis Feeding Disorder of Infancy and Early Childhood. It goes beyond picky eating and can cause significant health and social consequences if not addressed. To be diagnosed with ARFID, a person’s food restriction and avoidance must lead to one of the following problems, including:

• Significant weight loss, or failure to gain weight/grow taller
• Significant nutritional deficiency (e.g., iron-deficiency anemia, low vitamin B12)
• Dependence on nutritional supplements (e.g., Vitamin C, Boost, Ensure) or tube feeding
• Marked interference with psychosocial functioning (e.g., cannot eat at or even attend social events due to food being served, has difficulties at school or work due to eating habits)

ARFID can be challenging for patients and their families, but help is available. As we like to say at Mass General, never worry alone! Potential treatments for ARFID include cognitive-behavioral therapy, family-based treatment, medication management, speech-language therapy, occupational therapy, inpatient/partial hospital care, and more. A new treatment that our team has developed and is currently studying is called Cognitive Behavioral Therapy for ARFID (CBT-AR). CBT-AR is highly structured and begins with helping the person with ARFID to start eating at regular intervals (3 meals + 2-3 snacks) throughout the day, focusing on preferred foods at first. In line with the CBT-AR principle of volume before variety, the patient first works on restoring weight, if necessary, before introducing novel foods. CBT-AR then moves onto different modules based on the specific presentation(s) of ARFID that the patient may be experiencing.

For example, patients with sensory sensitivity identify a list of new foods to learn about and practice describing foods in a neutral way, trying small tastes of the foods during therapy sessions, and later incorporating full portion sizes of the new foods into their diet outside of sessions. Patients who have lack of interest will work on exposures to bodily sensations that prevent them from eating enough, including feeling overly full, nauseous, or bloated. Lastly, patients who have a fear of aversive consequences will work on a fear hierarchy to become more comfortable with the foods and eating-related experiences that they fear. Young patients as well as older patients who are underweight will typically work with their families as well as a therapist to bring about these important changes. We view families as our best partners in helping patients change!

A recent uncontrolled study of youth and adolescents ages 10-17 found that after 20-30 sessions of CBT-AR, 70% of participants no longer met criteria for ARFID (Thomas et al., under review). On average, they added 16 new foods to their diet during the course of treatment. The graphical abstract below summarizes the study findings. Although CBT-AR requires further research—including comparing it to other treatments—it is at least one promising potential therapy for ARFID.

To learn more about the specifics of CBT-AR, the clinician manual is available here and the free workbook is available here. CBT-AR may not be appropriate for everybody; for example, some patients may need a higher level of care, and there are both inpatient and intensive outpatient treatment options available throughout the United States and around the world.

While ARFID is still a relatively new diagnosis, our team is excited to be running a National Institute of Mental Health-funded research study taking place at Massachusetts General Hospital in Boston investigating brain, hormone, and behavioral differences in children and adolescents with ARFID compared to healthy controls who do not have any eating difficulties. This study aims to create a knowledge base about ARFID and launch future studies based on its findings. With preliminary data from the study, we have already published papers on the typical diet of people with ARFID, showing that those with ARFID eat more grains and less protein compared to healthy controls, and psychiatric problems that co-occur with ARFID, finding that over half of the sample met criteria for another lifetime psychiatric diagnosis, most typically an anxiety disorder.

The study is currently recruiting males and females ages 14-23 with ARFID and healthy controls ages 10-17. If your child is interested in participating in the study, you can fill out this pre-screen survey and someone from the study team will be in touch should it seem that they qualify: https://redcap.partners.org/redcap/surveys/?s=CEEHL9D3MD. Although most of our participants have come from the New England area, we do have some funding to support travel in case you are located in another part of the United States. We especially welcome participants from diverse backgrounds, including those who identify as black, indigenous, or people of color.

In summary, ARFID can be an incredibly challenging issue for families to navigate, but, through research, we are learning more every day. There is help available, and—as with all feeding and eating disorders—parents are crucial partners in the recovery process.

Editor’s Note: More information on ARFID can be found here .