Recognizing When Food Restriction Has Little to Do With Weight

An 11-year-old girl came to our clinic, accompanied by her mother, after being referred by her pediatrician. The mother explained that the girl had always been a picky eater and avoided foods with thick textures, such as mashed potatoes, and foods that had strong smells, such as chicken soup. The girl’s restrictive eating and general food avoidance had worsened during the current school year, as she began middle school and needed to eat more of her meals independently.

The girl denied any concerns about her body shape or weight and insisted that her only motivation for limiting her intake related to “how the food feels.” The pediatrician became worried about the girl’s growth as her Body Mass Index (BMI) fell from the 10th percentile at age 9 to the 5th percentile for her age.

Upon physical exam, the girl was found to have sinus bradycardia, with a heart rate of 52 beats per minute, and was hypotensive, with blood pressure of 92/60 mm Hg.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced avoidant/restrictive food intake disorder (ARFID) into the category of feeding and eating disorders. ARFID is a diagnosis that aims to clarify and expand a little used pediatric diagnosis listed in DSM-IV called feeding disorder of infancy or early childhood. ARFID describes individuals whose significant food avoidance or restriction does not result from excessive concerns about body shape or weight. Rather, it is characterized by avoidant or restrictive eating behavior due to decreased interest toward food or eating, the sensory characteristics of food, and/or concern about aversive consequences of eating, such as vomiting.

ARFID’s eating behavioral disturbances are associated with persistent failure to meet appropriate nutritional and/or energy needs, including significant weight loss or failure to achieve expected growth in children, significant nutritional deficiency, dependence on nutritional supplements, and/or marked interference with psychosocial functioning. The disturbance is not better explained by lack of available food or by a culturally sanctioned practice and may not be present during the course of anorexia nervosa or bulimia nervosa. If ARFID occurs in the context of another condition or disorder, the severity of the eating disorder exceeds that routinely associated with the condition and warrants additional clinical attention.

Since the publication of DSM-5, ARFID has begun to receive research attention from pediatricians, adolescent medicine specialists, and mental health clinicians. ARFID affects children and adolescents most commonly but may affect individuals across the lifespan. Children who present with ARFID tend to be younger than those with anorexia nervosa or bulimia nervosa. Individuals with ARFID are low weight, on average, but less so than those with anorexia nervosa. While clinical samples include more females than males, the gender imbalance is less extreme than that seen in anorexia nervosa.

Due to its recent introduction into DSM-5, less is known about treatment for ARFID than for the other eating disorders. However, commonly, weight restoration and nutritional rehabilitation are emphasized, with behaviorally focused treatments recommended. Individuals who have fear of choking or vomiting that contributes to restrictive eating might benefit from anxiety-based treatments, such as exposure therapy and response prevention. Individuals who have difficulty tolerating sensory aspects of food may also benefit from exposure and other behavioral strategies.

The Eating Disorders Assessment for DSM-5 (EDA-5) is a new tool to guide the assessment of feeding and eating disorders according to the DSM-5 criteria. This semi-structured interview is available at no cost at www.eda5.org. The use of this tool combined with a clinically useful discussion about evaluating and treating individuals with eating problems and formal eating disorders is thoroughly presented in Handbook of Assessment and Treatment of Eating Disorders, scheduled for publication by American Psychiatric Association Press in the fall. ■

The Eating Disorder Assessment for DSM-5 is posted at www.eda5.org.