Treatment for Avoidant Restrictive Food Intake Disorder (ARFID)
Are you looking for treatment for ARFID in 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 have an extreme fear of throwing up that has caused you to avoid eating. Or maybe you’ve lost weight but rather than fearing weight gain you fear eating itself. Maybe you fear the pain you get after eating.
If some of the above descriptions fit, you or your loved one may have ARFID.
What is Avoidant Restrictive Food Intake Disorder (ARFID)?
ARFID was first formalized as an eating disorder diagnosis only in 2013. This coincided with the publication of the Diagnostic and Statistical Manual, 5th Edition (DSM-5). 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. As well, 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. These 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. Further, 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 superpowers. Additionally, 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. Unfortunately, ARFID is often missed until it starts to interfere with this process.
What are the Symptoms of ARFID?
Children, teens, and adults with ARFID may exhibit a range of symptoms, which can include:
- Limited food variety compared to peers of the same age
- Weight loss or failure to gain weight in a growing child
- Failure to make expected gains in height
- Nutritional deficiencies
- Dependence on nutritional supplements like shakes to meet daily food requirements
- Difficulty eating in social or school or work settings
- Conflict with others regarding food or meal times
- Strong food aversions
- Avoidance of new foods
- Sensitivity to minor changes in the appearance of food
- Strong negative reactions, such as gagging or disgust, to unfamiliar foods
- Lack of interest in eating
- Absence of enjoyment from eating
- Fear of negative consequences after eating, like choking, pain, or vomiting, which they express verbally
Three Types of Avoidant Restrictive Food Intake Disorder (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. Accordingly, they find that unfamiliar foods have strange or intense smells, textures, or tastes. Consequently, 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 do 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 or witnessed. Consequently, 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 or other eating disorders.
What Causes ARFID?
Like other mental health disorders, ARFID is likely caused by an interplay of genetic and environmental factors. One of the largest factors contributing to the development of ARFID is genetics (Dinkler eat al., 2023). ARFID appears to be one of the most heritable of psychiatric disorders.
Other factors that might contribute to the development of ARFID include:
- other disorders including gastrointestinal, food allergies, autism, and ADHD
- anxious temperament or impulsivity
- traumatic events
- anxiety in the feeding relationship
How Common is ARFID?
Between 1 and 5% of the population might have ARFID. (Dinkler et al., 2021; Dinkler et al., 2023). It affects people of all genders and affects males and females at more similar rates than anorexia and bulimia. ARFID can affect people of any age and any body size. It may have acute onset or be a longstanding difficulty. ARFID is commonly diagnosed in pediatric feeding clinics and pediatric gastroenterology clinics.
What Other Disorders Commonly Occur Alongside ARFID?
Common co-occurring disorders with ARFID include autism, ADHD, intellectual disability, anxiety disorders, OCD, depression, and other developmental disorders. Co-occurring medical disorders can include GERD, food allergies, dysphagia, celiac disease, constipation, IBD, epilepsy, cerebral paresis, heart problems, and asthma.
ARFID in Children
While ARFID can develop in response to an acute incident, it can also be lifelong. People with the lifelong version may show signs as early as age two or three. While children are naturally less adventuresome eaters, those who show severe signs of ARFID may struggle to eat enough in school or social situations or may not gain or grow as expected due to nutritional deficiencies. They may also experience other psychological or medical disorders. We can help you determine whether your child has ARFID that warrants intervention.
ARFID in Adults
While some adults may experience a sudden onset of ARFID in response to a triggering situation (most common in the aversive consequences type), many adults with ARFID have contended with ARFID for much of their lives, often without adequate assessment and treatment. This is at least partially because ARFID was not a recognized diagnosis in those older than age six until 2013. Adults with ARFID seem to struggle in many different domains but many have developed successful strategies for managing it.
How Do We Treat Avoidant Restrictive Food Intake Disorder (ARFID)?
Several of our staff members received advanced training from Dr. Jennifer Thomas and Dr. Kamryn Eddy, the co-authors of CBT-AR, cognitive-behavioral therapy for ARFID as well as from Nancy Zucker, Ph.D., the creator of FBI-ARFID. We first 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 in ARFID Recovery
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. Consequently, we work with you and your family to make sure you are eating regularly throughout the day.
Weight restoration for People with ARFID
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.
Addressing ARFID Maintaining Factors According to CBT-AR
After we first ensure weight is increasing or maintained and eating is more regular, we next turn our focus to addressing the maintaining factors, based on the primary type(s) of ARFID:
ARFID Fear of Aversive Consequences
For ARFID, fear of aversive consequences (including choking and vomiting phobias) type, we follow an exposure-based protocol. 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 often introduce exposure exercises to help you learn to tolerate sensations such as feelings of fullness. We also work to help you develop a schedule of regular eating. Not eating enough sustains ARFID because it causes early fullness and dulled hunger cues due to restricted stomach capacity. Accordingly, we support you to increase the quantities and frequency of food consumed.
ARFID Sensory Sensitivity
For ARFID, sensory sensitivity type, we first help you identify a list of your preferred foods. Next we ask you to incorporate minor variations into the preparation of these foods, such as a different shape of pasta, a different brand of oatmeal, or a different flavor of a preferred brand of yogurt. We also suggest you try to add back any recently dropped foods from your repertoire. We then review an extensive list of potential target foods. The goal is to identify foods about which you are interested in learning.
Next, we ask you to select 5 of these foods each week to bring to the session. In the session, together we will go through the 5 questions. These questions ask you 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.
Fortunately, 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. It is for this reason that you are then encouraged to do the same thing with these 5 foods for a total of 10 to 15 times over the next few weeks as homework. Only after this many trials do we ask you whether you want to incorporate 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 5 major food groups) and reduce any nutritional deficits as well as increase your comfort eating in social situations.
Active Participation for People With All Types of ARFID
Treatment for ARFID requires your active participation and you must be willing to do at-home practices. If your child or teen has ARFID we expect you to be an active participant in their sessions and at-home practices.
Unfortunately, therapy for ARFID 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 in eating in various settings.
Treatment for ARFID is Different than Treatment for Other Eating Disorders
ARFID is a pretty heterogenous diagnostic category. Therefore, 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 eating completion as in the case of anorexia nervosa. Thus, providers and family members working with people with ARFID must 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. Thus, they can benefit from our Health at Every Size(R) approach to care.
Caring for someone with ARFID
Caring for a person with ARFID can be extremely challenging. Learn about how to support a loved one with ARFID.
Feeding a Child with ARFID
Feeding a child with ARFID can be overwhelming. You can learn strategies for feeding your child with ARFID.
Support a Friend With ARFID
Additional ARFID Resources
Begin Counseling for Avoidant Restrictive Food Intake Disorder (ARFID) in Los Angeles and California
Therapy can help you or your loved one recover. Eating Disorder Therapy LA has caring therapists who provide specialized therapy for ARFID. We provide counseling in our office in Los Angeles or virtually to people in California. To begin the counseling process, follow these steps:
- Contact Eating Disorder Therapy LA
- Next speak to our practice manager who will either match you to a therapist or provide referrals
- Start recovering from ARFID and rebuilding your (or your loved one’s) life.
ARFID Groups at EDTLA
Read Our Other Blog Posts on ARFID
- Adults with ARFID
- How Diet Culture Can Harm Your Recovery from ARFID
- Supporting Your Loved One with ARFID
- Supporting a Loved One with Emetophobia
- Helping Others in Your Life Understand ARFID
- ARFID in Children
- Feeding a Child with ARFID and a Narrow Range of Foods
- How to Support a Friend with ARFID
Other Counseling Services at Eating Disorder Therapy LA
At Eating Disorder Therapy LA, we specialize in evidence-based treatments for all eating disorders and related issues. We also provide therapy for Anorexia Nervosa, Bulimia Nervosa, Atypical Anorexia, Binge-Eating Disorder, and Body Image.
Other ARFID Resources
We are also collaborating with other ARFID treatment providers in the ARFID Collaborative. Check it out for more information about training opportunities for professionals, treatment providers, and groups.
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.