Defining the familiar: the birth of Avoidant or Restrictive Food Intake Disorder

Dr Rachel Bryant-Waugh has seen many changes in the 30 years she has spent helping children and adolescents overcome their eating disorders. Among these changes was the 2013 inclusion of a new disorder in the psychiatrists’ bible – the DSM.

The arrival of Avoidant or Restrictive Food Intake Disorder (ARFID) can be used to illustrate the tentative journey – from case study and anecdote, to definition and formal diagnosis – which new disorders take.

ARFID “isn’t a new kid in town”

Speaking at the 2017 Emanuel Miller Lecture and Conference, Rachel introduced the nuances of this familiar but poorly understood disorder.

ARFID “isn’t a new kid in town”; Rachel told a packed room at the Royal College of Physicians in London.

The clinical presentations ARFID captures are associated with an eating pattern that those working in the field will be well-acquainted with – a diet that cannot support a patient’s energy or nutritional needs.

“It is not simply picky eating,”

But absolutely central to a diagnosis of ARFID is that the food restriction or avoidance behaviours are not related to body image concerns – this separates it from bulimia or anorexia nervosa.

“It is not simply picky eating,” she said, going on to outline some common causes of these constrained diets. They include a lack of interest in food, an aversion to the texture or appearance of it, or some form of phobia based on the consequences of eating.

Rachel described how a lack of interest can arise, such as being unaware of having an appetite, or being easily distracted from eating. She paints a picture of sensory aversion, of a young person who might only tolerate food that is crunchy or a recognisable brand, or less commonly, puréed.

Phobic presentations of ARFID make clear just how disruptive it can be to a child’s development and family life. Debilitating fears of choking or vomiting, whether as a result of an illness or a previous medical procedure, can significantly interfere with the child’s psychological development – another DSM diagnostic criterion.

“We’ve recently seen a boy who choked on a boiled sweet in the cinema when he was watching a scary film,” Rachel said, noting the patient was already an anxious child.

The mortal fear he developed could be separated from a conventional phobia by its profound impact on his eating habits – he required feeding by nasogastric tube.

A potentially counterintuitive aspect of ARFID is that patients may present as being normal or overweight – or as being as severely underweight as those with anorexia nervosa. Another feature that stymied earlier categorisations, Rachel said, was that ARFID can present across a range of ages, and is not limited to children and adolescents. As you can imagine – weight is no indication of health for those with ARFID.

“If you exist on a diet that consists solely of biscuits, chips, crisps, whatever it is, you’re going to be lacking in essential nutrients” said Rachel “it can be very dangerous, particularly in children.”

As a member of the eating disorders workgroup for the fifth edition of the DSM, Rachel had a privileged insight into the development of the classification. As a consultant clinical psychologist with 20 years’ of practical experience at Great Ormond Street Hospital, she also knows how treatment can be hindered by a lack of agreed terminology.

Rachel points out that ARFID isn’t actually a new term, but a renaming of the less-specific ‘feeding disorder’ category in the fourth edition of the DSM. “It’s really problematic in terms of trying to develop effective treatments” she said, referring to the familiarity of ARFID-type presentations, but the previously frustrating lack of name to build a treatment pathway around.

She goes on to quote a parent of an ARFID patient at length, who is overjoyed that their toddler’s behaviour will no longer simply be dismissed as a ‘picky eating’. Despite a lack of epidemiological data on the prevalence of such a recently defined disorder, Rachel said her experiences have suggested a higher incidence in males and a longer duration compared to other eating disorders, and that the condition tends to appear at a relatively younger age.

Looking to the future, Rachel explains the need for comprehensive assessments and standardised treatments for the disorder, neither of which exist at the present.

By way of practical advice, she tells delegates who find themselves treating ARFID to “be clear what you are trying to change” whether it is avoidance or restriction, and whether therapist and patient are working on improving the range or amount of food consumed. She also advises practitioners to “select sparingly from existing evidence-based approaches” and use an impact grid and plan steps carefully.

Rachel closed her talk by rallying her audience on the importance of addressing ARFID. “It’s really important to continue to raise awareness” she said “of what remains a very under-recognised and marginalised problem.”

Hopefully some in that audience will carry her words and work forward, helping young people affected by ARFID through their research and clinical practice.

An excerpt of Dr Bryant-Waugh’s talk is available on ACAMH’s SoundCloud.

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