1. Overview and definition

Avoidant/restrictive food intake disorder (ARFID) is classified by the American Psychiatric Association as one of the feeding and eating disorders (Figure 1). Although individuals with ARFID may exhibit poor weight gain or loss, unlike those with AN, they do not display a desire for thinness or an intense fear of gaining weight. However, these individuals may exhibit a lack of interest in food, aversion to the sensory characteristics of food, such as its texture or smell, nausea or vomiting after eating, or intense fear of choking, all of which contribute to significant anxiety around eating. Based on the nature of the eating difficulties and limited intake patterns, more detailed classifications have been proposed under the GOS Criteria, including emotional food avoidance disorder, selective eating, restrictive eating, food refusal, functional dysphagia, pervasive refusal syndrome, and appetite loss associated with depressive states. The prevalence of ARFID has increased in recent years, although estimates vary across studies. Compared with AN, ARFID tends to occur more frequently in younger individuals, with male predominance.

2.  Symptoms

The GOS Criteria provide a detailed classification of subtypes within avoidant/restrictive eating behaviors:

① Food avoidant emotional disorder: food avoidance, weight loss, and mood disturbance.

② Selective eating: limited range of foods and unwillingness to try new foods.

③ Restrictive eating: smaller than usual amounts for age.

④ Food refusal: tends to be episodic, intermittent, or situational in nature.

⑤ Functional dysphagia and other phobic conditions: food avoidance, specific fear underlying food avoidance, e.g., fear of swallowing, choking, and vomiting.

⑥ Pervasive refusal syndrome: profound emotional around and withdrawal manifested by avoidance of eating, drinking, walking, talking, or self-care, determined resistance to efforts to help.

⑦ Appetite loss secondary to depression: inability to eat because of a depressive state.

All seven subtypes are distinguished from AN by the absence of distorted body image and lack of obsessive concern with body weight or shape. Physically, individuals may experience a range of complications depending on the severity of malnutrition. Common symptoms include fatigue, irritability, pallor, and cold extremities. Additional manifestations may involve constipation, dry skin, and insomnia. Bradycardia (slow heart rate) and hypotension (low blood pressure) are also often observed. When malnutrition persists over an extended period, concerns arise regarding stunted growth, osteoporosis, and potential effects on fertility.

3.  Diagnosis

Assessment of the circumstances under which the individual began to experience eating difficulty is essential. Potential triggers may include episodes of gastroenteritis, witnessing a peer vomit, bereavement, bullying, changes in the classroom environment or homeroom teachers, school transfers, or experiences of abuse. Growth charts reflecting weight and height changes from early childhood can provide valuable insights. Poor weight gain may have been present even before the onset of overt eating difficulties. In cases of severe weight loss or when other medical conditions that may cause significant weight reduction need to be ruled out, a comprehensive physical examination may be required. These may include blood tests, radiographic imaging, ultrasonography, electrocardiography, magnetic resonance imaging of the brain, and bone density assessments.

4.  Management and treatment

The initial approach is to encourage the child to eat foods they can tolerate, even in small quantities. In some cases, the only acceptable items may be sweet foods such as chocolate or ice cream, or the child may only be able to drink milk. Creating a positive and enjoyable mealtime environment is crucial. Caregivers should avoid expressing anger or giving reprimands and instead trust in the child’s efforts, recognizing that despite the difficulty in eating, the child is trying his/her best. It is important to praise not only the small amounts of food consumed but also the child’s efforts in daily life. When the anxiety level is high, a calm and relaxing environment can support the child’s emotional stability during meals.

5.  Comorbidities

Comorbidities such as autism spectrum disorder (ASD), anxiety disorders, and depressive states have been frequently reported in individuals with ARFID.

6.  Prognosis

Eating difficulties may gradually improve over time; however, even after apparent recovery, symptoms can reemerge in response to some triggers. In cases where neurodevelopmental traits, such as those associated with ASD, are pronounced, or when environmental adjustments are insufficient, persistent challenges with food intake may continue.

DSM-5-TR　Eating and Feeding Disorders
1 Anorexia Nervosa
2 Bulimia Nervosa
3 Binge Eating Disorder
4 Avoidant/Restrictive Food Intake Disorder (ARFID)
5 Pica
6 Rumination Disorder
7 Other Specified Feeding or Eating Disorder (OSFED)
8 Unspecified Feeding or Eating Disorder (UFED)

SUZUKI, Yuki

National Hospital Organization Mie National Hospital