Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment
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Purpose of Review
DSM-5 defined avoidant/restrictive food intake disorder (ARFID) as a failure to meet nutritional needs leading to low weight, nutritional deficiency, dependence on supplemental feedings, and/or psychosocial impairment. We summarize what is known about ARFID and introduce a three-dimensional model to inform research.
Because ARFID prevalence, risk factors, and maintaining mechanisms are not known, prevailing treatment approaches are based on clinical experience rather than data. Furthermore, most ARFID research has focused on children, rather than adolescents or adults. We hypothesize a three-dimensional model wherein neurobiological abnormalities in sensory perception, homeostatic appetite, and negative valence systems underlie the three primary ARFID presentations of sensory sensitivity, lack of interest in eating, and fear of aversive consequences, respectively.
Now that ARFID has been defined, studies investigating risk factors, prevalence, and pathophysiology are needed. Our model suggests testable hypotheses about etiology and highlights cognitive-behavioral therapy as one possible treatment.
KeywordsAvoidant/restrictive food intake disorder Eating disorder Feeding disorder
This paper was supported in part by R01MH108595 (mPIs: Thomas, Lawson, Micali).
Compliance with Ethical Standards
Conflict of Interest
Jennifer J. Thomas will receive future royalties from Cambridge University Press for the sale of her forthcoming book Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Dr. Thomas reports grants from National Institute of Mental Health, Hilda and Preston Davis Foundation, and American Psychological Foundation.
Elizabeth A. Lawson is on the Scientific Advisory Board with a financial interest in OXT Therapeutics, Inc. Dr. Lawson reports grants from National Institute of Mental Health and National Institute of Diabetes and Digestive and Kidney Diseases.
Nadia Micali reports grants from National Institute of Mental Health.
Madhusmita Misra reports a grant from Novo-Nordisk and is an advisory board member. Dr. Misra also reports grants from the National Institute of Mental Health.
Thilo Deckersbach reports grants from National Institute of Health.
Kamryn T. Eddy will receive future royalties from Cambridge University Press for the sale of her forthcoming book Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Dr. Eddy reports grants from National Institute of Mental Health, Hilda and Preston Davis Foundation, and American Psychological Foundation.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.American Psychiatric Association. DSM-IV: diagnostic and statistic manual of mental disorders. Washington DC: American Psychiatric Association; 1994.Google Scholar
- 2.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Washington DC: American Psychiatric Association; 2013.Google Scholar
- 3.•• Kurz S, van Dyck Z, Dremmel D, Munsch S, Hilbert A. Early-onset restrictive eating disturbances in primary school boys and girls. Eur Child Adolesc Psychiatry. 2015;24(7):779–85. This questionnaire-based study reported a 3.2% prevalence of ARFID in a primary school setting amongst 8-13 year olds in Switzerland. CrossRefPubMedGoogle Scholar
- 4.• Ornstein RM, Rosen DS, Mammel KA, Callahan ST, Forman S, Jay MS, et al. Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health. 2013;53(2):303–5. This study of patients presenting to adolescent medicine clinics for eating-disorder evaluation found that 14% met criteria for ARFID. Google Scholar
- 6.Fisher MM, Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a "new disorder" in DSM-5. J Adolesc Health. 2014;55(1):49–52.Google Scholar
- 9.• Eddy KT, Thomas JJ, Hastings E, Edkins K, Lamont E, Nevins CM, et al. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Int J Eat Disord. 2015;48(5):464–70. This retrospective charge review reported a 1.5% prevalence of ARFID among boys and girls ages 8-18 years in a pediatric gastroenterology healthcare network. Google Scholar
- 10.Pinhas L, Nicholls D, Crosby RD, Morris A, Lynn RM, Madden S. Classification of childhood onset eating disorders: a latent class analysis. Int J Eat Disord. 2017; 50(6):657–64.Google Scholar
- 11.Dent E. Anorexia of aging and avoidant/restrictive food intake disorder. J Am Med Dir Assoc. 2017;18(5):449–50.Google Scholar
- 12.Forbush KT, Wildes JE, Pollack LO, Dunbar D, Luo J, Patterson K, et al. Development and validation of the eating pathology symptoms inventory (EPSI). Psychol Assess. 2013;25(3):859–78.Google Scholar
- 13.Davis Becker KR, Coniglio KA, Thomas JJ, Eddy KT. Reasons for restriction: Avoidant and restrictive food intake disorder versus anorexia nervosa. Poster presentation at the annual international conference on eating disorders meeting, San Francisco, CA; 2016.Google Scholar
- 15.Sysko R, Glasofer DR, Hildebrandt T, Klimek P, Mitchell JE, Berg KC, et al. The eating disorder assessment for DSM-5 (EDA-5): development and validation of a structured interview for feeding and eating disorders. Int J Eat Disord. 2015;48(5):452–63.Google Scholar
- 16.Bryant-Waugh R, Thomas JJ, Eddy, KT, Micali N, Melhuish L, Cooke L. The development of the Pica, ARFID, and Rumination Disorder Interview (PARDI).Poster presentation at the annual eating disorders research society conference, New York, NY; 2016.Google Scholar
- 17.Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, et al. Psychological and psychosocial impairment in preschoolers with selective eating. Pediatrics. 2015;136(3):e582–90.Google Scholar
- 18.•• Nakai Y, Nin K, Noma SI, Hamagaki S, Takagi R, Teramukai S, et al. Clinical presentation and outcome of avoidant/restrictive food intake disorder in a Japanese sample. Eat Behav. 2017;24:49–53. This retrospective chart review reported on outcomes of adolescents and adults (ages 15-40) with ARFID over an average duration of 85.2 months. Google Scholar
- 22.•• Sharp WG, Volkert VM, Scahill L, McCracken CE, McElhanon B. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care? J Pediatr. 2017;181:116–24. This paper reports a meta-analysis of 11 studies of interventions for children with pediatric feeding disorders. CrossRefPubMedGoogle Scholar
- 24.•• Forman SF, McKenzie N, Hehn R, Monge MC, Kapphahn CJ, Mammel KA, et al. Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative. J Adolesc Health. 2014;55(6):750–6. This paper reports on one-year outcomes of adolescents with ARFID versus AN. Google Scholar
- 27.Fitzpatrick KK, Forsberg SE, Colborn D. Family-based therapy for avoidant restrictive food intake disorder: Families facing food neophobias.Family Therapy for Adolescent Eating and Weight Disorders: New Applications, New York: Routledge; 2015; 256–76. Google Scholar
- 28.Sharp WG, Stubbs KH, Adams H, Wells BM, Lesack RS, Criado KK, et al. Intensive, manual-based intervention for pediatric feeding disorders: results from a randomized pilot trial. J Pediatr Gastroenterol Nutr. 2016;62(4):658–63.Google Scholar
- 35.Silverman AH, Kirby M, Clifford LM, Fischer E, Berlin KS, Rudolph CD, et al. Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program. J Pediatr Gastroenterol Nutr. 2013;57(5):668–72.Google Scholar
- 43.Thomas JJ, Brigham KS, Sally ST, Hazen EP, Eddy KT.Case records of the Massachusetts General Hospital: An 11-year-old girl with difficulty eating after a choking incident. N Engl J Med. 2017;376(24):2377–86.Google Scholar
- 45.Pulumo R, Coniglio K, Lawson EA, Micali N, Asanza E, Eddy KT, et al. DSM-5 Presentations of avoidant/restrictive food intake disorder: Are categories mutually exclusive or overlapping? Poster presentation at the Eating Disorders Research Society meeting, New York, NY; 2016.Google Scholar
- 48.Holsen LM, Lawson EA, Blum J, Ko E, Makris N, Fazeli PK, et al. Food motivation circuitry hypoactivation related to hedonic and nonhedonic aspects of hunger and satiety in women with active anorexia nervosa and weight-restored women with anorexia nervosa. J Psychiatry Neurosci JPN. 2012;37(5):322.Google Scholar
- 50.Thomas JJ, Eddy KT. Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Children, adolescents, and adults. Cambridge: Cambridge University Press; in preparation.Google Scholar