Skip to main content

Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

Abstract

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.

Recent Findings

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.

Summary

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.

This is a preview of subscription content, access via your institution.

Fig. 1

References

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.

  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.

    Article  PubMed  Google 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.

  5. Norris ML, Robinson A, Obeid N, Harrison M, Spettigue W, Henderson K. Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord. 2014;47(5):495–9.

    Article  PubMed  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.

  7. Nakai Y, Nin K, Noma SI, Teramukai S, Wonderlich SA. Characteristics of avoidant/restrictive food intake disorder in a cohort of adult patients. Eur Eat Disord Rev. 2016;24(6):528–30.

    Article  PubMed  Google Scholar 

  8. Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat disord. 2014;2(1):21.

    Article  PubMed  PubMed Central  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.

  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.

  11. Dent E. Anorexia of aging and avoidant/restrictive food intake disorder. J Am Med Dir Assoc. 2017;18(5):449–50.

  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.

  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.

  14. Kurz S, van Dyck Z, Dremmel D, Munsch S, Hilbert A. Variants of early-onset restrictive eating disturbances in middle childhood. Int J Eat Disord. 2016;49(1):102–6.

    Article  PubMed  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.

  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.

  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.

  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.

  19. Strandjord SE, Sieke EH, Richmond M, Rome ES. Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalized for nutritional insufficiency. J Adolesc Health. 2015;57(6):673–8.

    Article  PubMed  Google Scholar 

  20. Chandran JJ, Anderson G, Kennedy A, Kohn M, Clarke S. Subacute combined degeneration of the spinal cord in an adolescent male with avoidant/restrictive food intake disorder: a clinical case report. Int J Eat Disord. 2015;48(8):1176–9.

    Article  PubMed  Google Scholar 

  21. Tsai K, Singh D, Pinkhasov A. Pudendal nerve entrapment leading to avoidant/restrictive food intake disorder (ARFID): a case report. Int J Eat Disord. 2017;50(1):84–7.

    Article  PubMed  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.

    Article  PubMed  Google Scholar 

  23. Pennell A, Couturier J, Grant C, Johnson N. Severe avoidant/restrictive food intake disorder and coexisting stimulant treated attention deficit hyperactivity disorder. Int J Eat Disord. 2016;49(11):1036–9.

    Article  PubMed  Google 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.

  25. Bryant-Waugh R. Avoidant restrictive food intake disorder: an illustrative case example. Int J Eat Disord. 2013;46(5):420–3.

    Article  PubMed  Google Scholar 

  26. King LA, Urbach JR, Stewart KE. Illness anxiety and avoidant/restrictive food intake disorder: cognitive-behavioral conceptualization and treatment. Eat Behav. 2015;19:106–9.

    Article  PubMed  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.

  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.

  29. Kindermann A, Kneepkens CM, Stok A, van Dijk EM, Engels M, Douwes AC. Discontinuation of tube feeding in young children by hunger provocation. J Pediatr Gastroenterol Nutr. 2008;47(1):87–91.

    Article  PubMed  Google Scholar 

  30. Hartdorff CM, Kneepkens CM, Stok-Akerboom AM, van Dijk-Lokkart EM, Engels MA, Kindermann A. Clinical tube weaning supported by hunger provocation in fully-tube-fed children. J Pediatr Gastroenterol Nutr. 2015;60(4):538–43.

    Article  PubMed  Google Scholar 

  31. Trabi T, Dunitz-Scheer M, Kratky E, Beckenbach H, Scheer PJ. Inpatient tube weaning in children with long-term feeding tube dependency: a retrospective analysis. Infant Mental Health J. 2010;31(6):664–81.

    Article  Google Scholar 

  32. Clawson EP, Kuchinski KS, Bach R. Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy. NeuroRehabilitation. 2007;22(5):397–406.

    PubMed  Google Scholar 

  33. Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008;33(6):612–20.

    Article  PubMed  Google Scholar 

  34. Byars KC, Burklow KA, Ferguson K, O’Flaherty T, Santoro K, Kaul A. A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings. J Pediatr Gastroenterol Nutr. 2003;37(4):473–80.

    Article  PubMed  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.

  36. •• Lukens CT, Silverman AH. Systematic review of psychological interventions for pediatric feeding problems. J Pediatr Psychol. 2014;39(8):903–17. This paper is a qualitative review of 13 studies of treatments of psychological treatments for pediatric feeding disorders.

    Article  PubMed  Google Scholar 

  37. Marshall J, Hill RJ, Ware RS, Ziviani J, Dodrill P. Multidisciplinary intervention for childhood feeding difficulties. J Pediatr Gastroenterol Nutr. 2015;60(5):680–7.

    Article  PubMed  Google Scholar 

  38. Satter E. Feeding dynamics: helping children to eat well. J Pediatr Health Care. 1995;9(4):178–84.

    CAS  Article  PubMed  Google Scholar 

  39. Ellis JM, Galloway AT, Webb RM, Martz DM, Farrow CV. Recollections of pressure to eat during childhood, but not picky eating, predict young adult eating behavior. Appetite. 2016;97:58–63.

    Article  PubMed  Google Scholar 

  40. Berlin KS, Davies WH, Lobato DJ, Silverman AH. A biopsychosocial model of normative and problematic pediatric feeding. Child Health Care. 2009;38(4):263–82.

    Article  Google Scholar 

  41. Lucarelli J, Pappas D, Welchons L, Augustyn M. Autism Spectrum disorder and avoidant/restrictive food intake disorder. J Dev Behav Pediatr. 2017;38(1):79–80.

    Article  PubMed  Google Scholar 

  42. Sant’Anna A, Hammes PS, Porporino M, Martel C, Zygmuntowicz C, Ramsay M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J Pediatr Gastroenterol Nutr. 2014;59:674–8.

    Article  PubMed  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.

  44. Nicholls D, Chater R, Lask B. Children into DSM don’t go: a comparison of classification systems for eating disorders in childhood and early adolescence. Int J Eat Disord. 2000;28(3):317–24.

    CAS  Article  PubMed  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.

  46. Kauer J, Pelchat ML, Rozin P, Zickgraf HF. Adult picky eating. Phenomenology, taste sensitivity, and psychological correlates. Appetite. 2015;90:219–28.

    Article  PubMed  Google Scholar 

  47. Golding J, Steer C, Emmett P, Bartoshuk LM, Horwood J, Smith GD. Associations between the ability to detect a bitter taste, dietary behavior, and growth. Ann N Y Acad Sci. 2009;1170(1):553–7.

    Article  PubMed  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.

  49. Lang PJ, McTeague LM. The anxiety disorder spectrum: fear imagery, physiological reactivity, and differential diagnosis. Anxiety Stress Coping. 2009;22(1):5–25.

    Article  PubMed  PubMed Central  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.

Download references

Acknowledgements

This paper was supported in part by R01MH108595 (mPIs: Thomas, Lawson, Micali).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jennifer J. Thomas.

Ethics declarations

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.

Additional information

This article is part of the Topical Collection on Eating Disorders

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Thomas, J.J., Lawson, E.A., Micali, N. et al. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep 19, 54 (2017). https://doi.org/10.1007/s11920-017-0795-5

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-017-0795-5

Keywords

  • Avoidant/restrictive food intake disorder
  • Eating disorder
  • Feeding disorder