Avoidant Restrictive Food Intake Disorder (ARFID)

Now Providing Treatment for ARFID in Los Angeles (and throughout California)

Are you or is someone you love a picky eater? Maybe you have been a picky eater since early childhood and have a very narrow list of foods you are comfortable eating. Are you very sensitive to different textures in food? Do the thoughts of eating your non-preferred foods scare you? Maybe you find it embarrassing when you go out with friends because you won’t eat what everyone else is eating. Maybe you or your child has recently become afraid of choking and now refuses to eat anything solid. Maybe you have an extreme fear of throwing up that has caused you to avoid eating. Maybe you’ve lost weight but rather than fearing weight gain you fear eating itself. Maybe you fear the pain you get after eating. Maybe your child is very particular about the particular brands of the few foods they consume. You or your loved one may have ARFID.

We provide treatment for children, teens, and adults with ARFID ages 10 and up.

What is ARFID?

ARFID is an eating disorder that was formalized as a diagnosis only in 2013 with the publication of the Diagnostic and Statistical Manual, 5^th Edition (DSM-5) in 2013. In the previous edition, the condition was only recognized in children six and younger. Thus, there are not many established treatment protocols for people with ARFID over six and there are limited providers who are trained in treating this disorder.

Individuals with ARFID eat a limited variety or amount of food which causes problems in their lives. The problems can be health-related—such as losing too much weight or having nutritional deficits—or social — for example, being unable to eat with others. However, people with ARFID, unlike individuals with anorexia nervosa, do not worry about their weight or shape or becoming fat. People with ARFID experience anxiety and disgust around eating. They may gag and experience physical symptoms such as nausea and stomach pain. People with ARFID are often highly anxious and seem to have sensory super powers. Tastes and textures as well as regular internal body sensations may be more intense for people with ARFID.

We are seeing increased cases of ARFID in preteens and teens. This should be a time when appetite and dietary intake increase to propel puberty and a growth spurt. ARFID often gets noticed when it interferes with this process.

Three Types of ARFID

There are three primary types of ARFID:

Sensory sensitivity: people with this type usually have sensory issues from early childhood that make them sensitive to certain textures or strong tastes. They find that unfamiliar foods have strange or intense smells, textures, or tastes, and they feel safer eating familiar food and cling to a narrow range of food.
Low interest: people with this presentation tend to have lower levels of hunger and not find food as rewarding. This usually begins at a young age as well. They may find that they don’t get hungry often, get full quickly, or find eating to be a chore.
Fear of aversive consequences: people with this variation develop a fear of choking, swallowing, or vomiting or a fear of pain after eating often in response to a traumatic situation they experienced themselves or witnessed. They may stop eating foods that they believe will cause these outcomes. This type usually has a more sudden onset and can develop at any age.

People can have one or more types of ARFID. Sometimes ARFID can co-occur with Anorexia Nervosa.

How is ARFID treated?

Several of our staff members have received advanced training from Dr. Jennifer Thomas and Dr. Kamryn Eddy, the co-authors of CBT-AR, cognitive-behavioral therapy for ARFID. In this approach, first, we conduct a detailed assessment to clarify the diagnosis. Next, we provide psychoeducation regarding factors that maintain the disorder and develop a treatment plan. We provide education and teach you all about ARFID.

Establishing regular eating

A key component of early treatment is the establishment of a schedule of regular eating—usually three meals and two to three snacks daily. People with ARFID often have missed meals and or patterns of grazing or snacking which can further dull hunger cues and make it hard to get enough food or enough nutritious food. We work with you and your family to make sure you are eating regularly throughout the day.

Weight restoration

If a person needs weight restoration, we work to help them gain weight first by gradually increasing their intake through regular meals and snacks consisting of preferred foods. This may feel counterintuitive to some people. But, yes, if your preferred foods are donuts and fried chicken we will work with you on increasing the volume of these foods. In CBT-AR we say “volume over variety,” meaning it’s important to focus on increasing volume (and weight gain) before focusing on increasing variety.

Then we focus on addressing the maintaining factors, based on the primary type(s) of ARFID:

For ARFID, fear of aversive consequences (including choking and vomiting phobias) type, we follow an exposure-based protocol as described in greater detail. We teach you to be curious, rather than fearful, of normal body sensations and to approach, rather than avoid, eating.

For ARFID, low-interest type, we introduce exposure exercises to help you learn to tolerate sensations such as feelings of fullness. We work to put you on a schedule of regular eating and help you to increase the quantities and frequency of food consumed. Not eating enough sustains ARFID because it causes early fullness and dulled hunger cues due to restricted stomach capacity.

For ARFID, sensory sensitivity type, we work with you to develop a list of your preferred foods. We ask you to incorporate minor variations into the preparation of these foods and to try to add back any recently dropped foods from your repertoire. We then review an extensive list of target foods, with the goal of identifying foods about which you are interested in learning. You are then asked to select 5 of these foods each week to bring to session. In session, together we will go through the 5 questions where you are asked to describe what the food looks like, what it feels like in your fingers, what it smells like, what it tastes like, and what it feels like in your mouth as you taste and swallow a teeny bit.

There is no pressure to enjoy the food. In fact, we assume that because this food is so unfamiliar, it is not possible for you to like it upon the first taste. This is why you are then encouraged to do the same thing with these 5 foods for a total of 15 times over the next few weeks as homework. Only after 15 trials are you asked whether you want to add any of the foods you have learned about into your regular meals. The goal is to add foods to diversify your diet (eating from all the 5 major food groups) and reduce any nutritional deficits as well as increasing your comfort eating in social situations.

Treatment for ARFID requires your active participation and you must be willing to do at-home practices. If your child or teen has ARFID you will be expected to be an active participant in their sessions and at-home practices.

This can be a slow and sometimes tedious process, but the good news is that with time and effort you can expand your repertoire of accepted foods, improve your diet, increase your food flexibility, and increase your comfort eating in various settings.

Treatment for ARFID is different than treatment for other eating disorders. Treatment for people with ARFID needs to be individualized. People with ARFID struggle with strong aversions and disgust which cannot as easily be overcome with strict exposure and required completion of eating as in the case of anorexia nervosa. Providers and family members working with people with ARFID need to be patient and creative.

Although ARFID is not usually motivated by concerns about shape and weight, people with ARFID are not immune to the impact of diet culture and can benefit from our Health at Every Size(R) approach to care.

Learn about how to support a loved one with ARFID.

Eating Disorder Therapy LA staff therapists can provide in-person therapy for ARFID in our office in Los Angeles or virtually to people in California.

We offer a free virtual support group for adults in California with ARFID. We also offer a monthly support group for parent of youth (10 to 20) with ARFID.

Blog posts on ARFID

Sources

Thomas J. J., Wons B. W., & Eddy K. T. (2018). Cognitive‐behavioral treatment of avoidant/ restrictive food intake disorder. Current Opinion in Psychiatry, 31, 425–430.

Thomas J. J., & Eddy K. T. (2019). Cognitive‐behavioral therapy for avoidant/restrictive food intake disorder: Children, adolescents, and adults. Cambridge, UK: Cambridge University Press.