TABLE 1 : Diagnostic Criteria for ARFID 307.59 ( F50.8 )
A . Eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional / energy needs associated with one or more :
1 . Significant weight loss 2 . Significant nutritional deficiency 3 . Dependence on enteral feeding / oral nutrition supplements 4 . Marked interference with psychosocial functioning B . Disturbance is not better explained by lack of available food or any culturally sanctioned practice
C . Eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa ; no evidence of a disturbance in the way in which body weight or shape is experienced
D . Eating disturbance not attributable to a concurrent medical condition or another mental disorder . When other conditions co-occur , the severity of the eating disturbance exceeds that routinely associated with the condition and warrants additional clinical attention
ARFID : avoidant-restrictive food intake disorder ; Reference : DSM-5 Feeding and Eating Disorders . 3
A detailed review of the patient ’ s medical history was conducted for the 3.5-year span between the patient initiating care in the FM clinic and her presentation to the FED treatment team . During the study time frame , the patient made 33 FM and 6 emergency room ( ER ) visits , primarily for GI complaints ( nausea , abdominal pain ), syncopal episodes , and weight loss , especially in the latter 2.5 years ( Figure 1 ). Extensive evaluations focusing on her gastrointestinal tract over the 3.5 years , including colonoscopy , esophagogastroduodenoscopy , and gastric emptying studies , were all within normal limits and did not establish a GI cause for her symptoms . At intake , the patient ’ s BMI was 12.74 , heart rate was 83 , blood pressure was 90 / 58 , and oxygen saturation was 97 %. She appeared severely malnourished but in no acute distress . Her liver enzymes and alkaline phosphatase were elevated , which is a common finding in severe restrictive eating disorders , 1 as well as creatinine , which was attributed to her stage III chronic kidney disease .
Upon admission to the FED clinic , the patient met full criteria for avoidantrestrictive food intake disorder ( ARFID ). Her pattern of food avoidance , obsessions , and rigidity were due to concerns about the aversive consequences of eating . Specifically , she developed an aversion to and hypervigilance of the sensation of food , the digestive process , stool in her GI tract , and extreme fears of bowel obstruction . In hindsight , it is likely that the extreme food fears , and resultant restrictive eating behaviors contributed to many years of nausea and GI discomfort , which further perpetuated this dangerous behavioral cycle . Anorexia nervosa was not diagnosed , as her marked weight loss occurred in the context of her pervasive food / GI fears . The patient expressed acknowledgement of and concern for her low weight , and she did not fear weight gain ; instead , she sought it actively in the treatment that followed .
Interprofessional treatment was undertaken to increase the patient ’ s quantity and variety of food intake and improve her tolerance of fear / unpleasant emotions and body sensations when eating . Interventions also consisted of monitoring for complications such as refeeding syndrome due to very low BMI 2 and psychiatric assessment for comorbidities . A registered dietician provided medical nutritional therapy to structure and plan meals to increase food intake gradually over time . The clinical psychologist on the team provided behavioral treatment to teach coping techniques to better tolerate the distress experienced during and after eating , including exposure therapy interventions , and commitment strategies to maintain motivation to make these difficult changes . Although the patient was receptive and engaged with treatment , behavior change was slow . During three months of weekly treatment sessions , she gained eight pounds and increased her daily intake to three full meals and two snacks . Although the patient chose to discontinue treatment earlier than recommended , she made significant gains in her quality of life and medical markers of malnourishment .
DISCUSSION
ARFID feeding disturbances may present in a variety of ways , including desire to avoid foods because of sensory characteristics ( e . g ., texture , color , smell , temperature , taste ), lack of interest in eating , or worries about aversive consequences after eating ( e . g ., fears of vomiting , choking , GI upset ). 3 DSM-5 diagnostic criteria for ARFID are listed in Table 1 . Individuals with anxiety disorders , neurodevelopmental disorders ( e . g ., ADHD , autism spectrum disorder ), obsessive-compulsive disorder , and / or a family history of anxiety or FEDs may be at higher risk for restrictive eating behaviors . Furthermore , GI conditions , gastroesophageal reflux disease , and other medical problems increase vulnerability to the development of ARFID . 3
Though most often diagnosed in children , ARFID also affects adults across the life span . 3 FEDs are increasing in prevalence in older adults but are often under-recognized by providers , which can delay appropriate treatment . 4 , 5 Data on ARFID prevalence and characteristics in adult
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