CLINICAL CASE REPORT

Avoidant Restrictive Food Intake Disorder:

An Illustrative Case Example
ABSTRACT
Rachel Bryant-Waugh, BSc, MSc, Avoidant/restrictive food intake disorder
DPhil* (ARFID) is a new diagnostic category in
DSM-5. Although replacing Feeding Disor-
der of Infancy or Early Childhood, it is
not restricted to childhood presentations.
In keeping with the broader aim of revi-
sing and updating criteria and text to
pated that the inclusion of specific crite-
ria for ARFID as a category within Feed-
ing and Eating Disorders in DSM-5 will
stimulate research into its typology, prev-
alence, and incidence in different popu-
lations and facilitate the development of
effective, evidence-based interventions
for this patient group. V C 2013 by Wiley

better reflect lifespan issues and clinical Periodicals, Inc.

expression across the age range, ARFID is
a diagnosis relevant to children, adoles- Keywords: ARFID; eating disorder;
cents, and adults. This case example of a feeding disorder; avoidant restrictive
13-year old boy with ARFID illustrates key food intake disorder; diagnosis; case
issues in diagnosis and treatment plan- example; DSM-5
ning. The issues discussed are not ex-
haustive, but serve as a guide for central (Int J Eat Disord 2013; 46:420–423)
diagnostic and treatment issues to be
considered by the clinician. It is antici-

Avoidant/restrictive food intake disorder (ARFID) is
a new diagnostic category in DSM-5,1 also likely to
be included in ICD-11.2 A number of factors form
the impetus behind its inclusion and inform the
development of criteria for diagnosis. An overarch-
ing theme for DSM-5 has been the adoption of a
lifespan approach, the intention being to ensure
that due consideration is given to how symptoms
of mental disorder vary according to age and stage
of development.3 The aim of improving clinical
utility across the lifespan is also a key feature of the
ICD-10 revision process.2 This principle has been
particularly relevant to the revision of criteria for
feeding and eating disorders as it has been recog-
nized that some types of feeding disturbance seen
in young children persist into later childhood, ado-
lescence, and even adulthood, or bear a strong sim-
ilarity to eating disturbances that might have a later
onset.4 It is also well known that the existing DSM-
IV-TR feeding and eating disorder categories do not
adequately capture the full range of eating distur-
Accepted 3 December 2012
*Correspondence to: Rachel Bryant-Waugh, BSc, MSc, DPhil,
Consultant Clinical Psychologist and Honorary Senior Lecturer,
Department of Child and Adolescent Mental Health, Great
Ormond Street Hospital, London, United Kingdom WC1N 3J, UK.
E-mail: rachel.bryant-waugh@gosh.nhs.uk
Published online in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22093
C 2013 Wiley Periodicals, Inc.
V
bances seen in clinical practice in three main
respects. Firstly, the residual category eating disor-
der not otherwise specified (EDNOS) is a place-
holder for a heterogeneous patient population
forming the majority of treatment seeking individu-
als.5 Secondly, Feeding Disorder of Infancy or Early
Childhood has been criticized for being too broad
and non-specific, and therefore of limited clinical
utility.6 Thirdly, a number of presentations which
do not fit any of the existing categories have been
described in middle childhood (e.g., ‘‘food avoid-
ance emotional disorder," ‘‘selective eating").4
Together, these factors have contributed to the
change to a combined section of ‘‘Feeding and Eat-
ing Disorders" in DSM-5, with ARFID as a new cat-
egory within this section. ARFID replaces and
extends Feeding Disorder of Infancy or Early Child-
hood, with the aim of improving clinical utility by
adding more detail about the nature of the eating
disturbance as well as widening the criteria to be
appropriate across the age range. All clinicians will
therefore need to ensure they are fully informed
and up to date with these changes given the life-
span approach adopted in both the DSM and ICD
revision process. This article provides a case
example of ARFID to give a clinical illustration and
preliminary general guidance for assessment and
treatment planning.

420 International Journal of Eating Disorders 46:5 420–423 2013


Case illustration: Presentation
B, aged 13 years 4 months, was brought for assess-
ment by his mother. Ms. T. expressed her concern
that B did not have a healthy diet and did not seem
to have grown much recently. She described him as
a ‘‘lazy eater.’’ B and Ms. T. gave an account of a typ-
ical day’s intake consisting of a limited range of
snack type foods, with little variation from one day
to the next. B had breakfast before school but then
tended to graze rather than sit down for meals. His
staple daily intake included dry breakfast cereal,
breadsticks, a large amount of potato chips, and bis-
cuits. B also had one small raspberry flavored probi-
otic drink each day at his mother’s insistence, and
occasionally soft ice cream from MacDonald’s or
some chocolate. He mostly drank cola, lemonade, or
blackcurrant cordial, refusing sugar free varieties
saying they tasted horrible. He also refused all fruit,
vegetables, meat, and fish. When younger his
mother had been able to get him to take a multi-
vitamin and mineral supplement but he no longer
took this. Ms. T. described B as always having been a
fussy eater and never having been very interested in
food. He had slowly dropped foods from his range.
At assessment, B looked pale and tired but other-
wise well. He had no significant medical history,
other than a proneness to coughs and colds. He
was 35.7 kg and 147 cm, placing him on the 9th
weight centile, 10th height centile, and the 17th
BMI centile (BMI of 16.5; 90% median BMI). Ms. T.
had not kept good records of his weight and growth
but thought that he was average height as a toddler,
but was now one of the smaller boys in his class.
He had always been quite slight. She wondered if
he might be a late developer. Ms. T. reported that
she was 165 cm (50 5@ or 65 inches) and that B’s fa-
ther, Mr. S. was 188 cm (60 2@ or 74 inches).
B’s parents separated when he was 5 years old.
His father moved out of the family home and lived
close by with his own parents. B saw his father fre-
quently but always slept at home. His eating was
no different when with his father or his mother. Ms.
T. reported that she had been the one who had of-
ten tried to encourage B to try different foods but
he almost always refused. She felt that Mr. S. could
do more. This was becoming an increasing source
of friction and Ms. T. described having given up a
bit now that B was a teenager. B agreed his father
did not seem as concerned. B had one older and
one younger sister, neither of whom had any prob-
lems of note, and neither parent had any current
physical problems or current or past history of
diagnosed mental disorder.
When seen individually, B initially stated that he
did not consider his eating to be a problem but said
International Journal of Eating Disorders 46:5 420–423 2013
ARFID CASE EXAMPLE
he would prefer to be taller and to fill out a bit. He
reported sometimes feeling hungry, but equally could
forget about eating when busy, especially when play-
ing on his computer. He described recent dizzy spells
on standing from sitting or lying which had worried
him. B also described some teasing from peers about
his eating which had made him angry as ‘‘it was none
of their business.’’ B described his mood generally as
‘‘OK’’ and said he got on fine at school as long as peo-
ple did not annoy him. He had received some anger
management counseling at school, having been in a
few fights. Academically he was functioning at a low
average level. He reported having a couple of friends
who he saw in school but not outside. B agreed that
his eating was different to his peers and described
something stopping him from trying unfamiliar
foods. He said he did not like the feeling of making
himself try things so generally didn’t.
Discussion of ARFID Presentation and
Guidance for Diagnosis
In order to diagnose ARFID, the clinician needs to
gather specific information. Table 1 includes exam-
ple questions using B’s case as illustration. A num-
ber of additional questions should be asked in rela-
tion to exclusion criteria, to include establishing
whether the avoidance or restriction might be better
accounted for by a lack of available food or by a
socially sanctioned practice, in which case an ARFID
diagnosis is not appropriate. Ms. T. had become
used to B’s restricted eating and as she had limited
income, she had stopped spending money on food
she knew he would not eat. She had also stopped
offering him alternatives. However, there was other
food available in the house, and B had access to a
wider range of food at school. The avoidance or
restriction of food intake in ARFID is not accompa-
nied by a disturbance in the experience of weight or
shape, which can be an important point of distinc-
tion from presentations of anorexia nervosa or buli-
mia nervosa, and should also be checked. B was re-
alistic in his appraisal of his own body size and
shape, and did not like being relatively small and
slight. There was no other medical condition or
mental disorder that could account for B’s presenta-
tion. B therefore meets diagnostic criteria for ARFID;
general requirements for Criterion A are met and
none of the exclusion criteria apply.
At present there is insufficient evidence to sup-
port the identification of discrete subtypes within
ARFID; however, in DSM-5 examples are given of
421
BRYANT-WAUGH

TABLE 1. Diagnostic checklist for Criterion A of ARFID with case example

Question Purpose Case of B

1. What is current food intake (range)?
2. What is current food intake (amount)?
3. How long has the avoidance of certain
foods or the restriction in intake been
occurring?
4. What is current weight and height and has
there been a drop in weight and growth
centiles? (A1)
5. Are there signs and symptoms of
nutritional deficiency or malnutrition? (A2)
6. Is intake supplemented in any way to
ensure adequate intake? (A3)
7. Is there any distress or interference with
day to day functioning related to the
current eating pattern? (A4)
To establish whether intake fails to meet the
individual’s nutritional needs
To establish whether intake fails to meet the
individual’s energy needs
To establish whether there is a persistent
failure to meet the individual’s nutritional/
energy needs
To clarify BMI or BMI centile status and to
establish whether there is weight loss,
failure to gain as expected for age, faltering
growth, etc.
To establish whether there is clinical or lab
evidence of nutritional deficiency
To establish whether there is a dependency on
nutritional supplements or tube feeding
To establish whether there is interference to
the individual’s social and emotional
functioning related to the eating
disturbance.
Met: B’s diet is missing major food groups and is
particularly low in calcium, iron, and vitamins. It is
high in saturated fat, sugar, and salt. His
nutritional needs as an adolescent boy going
through puberty are not being met.
Unsure: B does not eat meals, but grazes
inconsistently and experiences lethargy and
episodes of dizziness. This might in part be due to
insufficient calorie intake at certain times of the
day but high intake of sugary drinks and low iron
intake might also contribute.
Met: B has been a fussy eater since early childhood,
with a worsening picture.
Met: B’s BMI centile is at the lower end of the normal
range, however he has growth faltering with
growth centile having dropped significantly since
early childhood; height not in line with mid-
parental estimation.
Met: Tiredness associated with low iron intake and
resulting anemia; low bone mineral density for
age on DXA (dual-energy X-ray absorptiometry)
scan
Not met: B does not take any nutritional
supplements and is not enterally fed
Met: B is getting teased about his eating at school
which angers him and leads to aggressive outbursts,
also affecting peer relationships. It is possible that
his academic functioning is also being impaired due
to significant nutritional compromise.

different types of avoidance or restriction of eating.
These include restriction related to an apparent
lack of interest in eating or food; sensory based
avoidance of food (e.g., the individual rejects food
on the basis of smell, color, texture, etc.), and
avoidance related to feared consequences of eating,
often based on an aversive experience. Clinical ex-
perience suggests that these features are not neces-
sarily mutually exclusive. B described forgetting to
eat if he was otherwise occupied, and Ms. T.
described him as a ‘‘lazy eater’’ with a longstanding
lack of interest in food. However, he was also highly
selective on the basis of the color and taste of food,
only eating a narrow range of foods all of a cream/
beige/brown color. He refused very similar alterna-
tives of his preferred foods on the basis of appear-
ance or taste if he got as far as trying them. In treat-
ment his anxiety and fear of trying unfamiliar foods
became more apparent; although at assessment he
had indicated that he avoided challenging himself
by saying he did not like the feeling of ‘‘making
myself do something.’’
Case illustration: Management
B demonstrated some motivation to address his eat-
ing. Although he did not have any particular desire
to widen his diet per se, he was able to recognize
that it was causing difficulty for him at school as his
peers noticed and made fun of him. He was keen to
develop physically as he did not like being small and
skinny. He also appeared to be worried about his
spells of light-headedness, and clearly found this an
aversive experience. He was able to engage in think-
ing about his eating and its consequences and will-
ing to see if some sessions might have benefit.
Treatment proceeded with a risk assessment and
joint setting of goals, including information and edu-
cation about a healthy diet, pubertal development,
and consequences of nutritional compromise. A
broad cognitive behavioral therapy (CBT) approach
was used combined with some parental involvement.
Core strategies including self-monitoring, behavioral
experiments, cognitive restructuring, and anxiety
management techniques were employed to address
three overarching goals: to address nutritional risk; to
work on introducing one or two foods useful for
social situations with peers; to increase B’s exercise of
personal responsibility for his own health and well-
being. These broad goals were broken down into
smaller clearly defined targets.
It became clear that anxiety and low self-esteem
were major maintaining factors in B’s presentation.
Family factors also played a role and were
addressed as needed to facilitate progress in rela-

422 International Journal of Eating Disorders 46:5 420–423 2013


tion to treatment goals. By discharge, B’s diet was
far from extensive. Although remaining extremely
cautious around food, he had been able to improve
the nutritional adequacy of his intake by agreeing
to take a multi-vitamin and iron supplement and
adding yoghurt and smoothies. The latter were
selected on the basis of their color, texture, and
similarity in taste to the probiotic drink he was al-
ready having as well as in relation to deficits in his
diet, in particular calcium and vitamins. He was
also able to eat French fries, which he had selected
as useful socially. His growth velocity had improved
with height increasing from the 10th to the 35th
centile, and he had learned to manage his anxiety
better when faced with unfamiliar foods, through
using breathing and progressive muscle relaxation
techniques. B’s motivation and focus fluctuated
during treatment, as did that of his parents.
Discussion of ARFID Treatment and
Intervention
It is impossible to give a ‘‘typical" description of
ARFID as this diagnosis covers a range of different
clinical presentations. Treatment needs are likely to
vary across individuals and, as a rule of thumb, are
generally informed by the main areas of impact of
the avoidance or restriction of food intake. These
include the extent of nutritional compromise, the
impact on weight (and growth in children), and in-
terference with social and emotional development
or function, with associated distress or impairment.
Treatment will commonly include psychological
interventions, nutritional advice or intervention,
and medical monitoring or intervention. Some
individuals with ARFID may present with extreme
low weight, resulting in similar complications to
people with anorexia nervosa. Others, like B, may
present with longstanding serious nutritional com-
promise, impairing physical development and
functioning. In many cases it will be neither realis-
tic nor necessarily desirable to achieve an eating
pattern without any avoidance or restriction. A
more appropriate aim may be to minimize physical
or nutritional risk through behavioral change and/
or to help the individual learn to manage their own
anxiety about trying new foods or extending their
dietary intake.
International Journal of Eating Disorders 46:5 420–423 2013
ARFID CASE EXAMPLE
Conclusion
ARFID is a new diagnosis, envisaged as encompass-
ing a number of commonly described clinically sig-
nificant feeding and eating disturbances across the
age range. As a Feeding and Eating Disorder diagno-
sis in DSM-5, it is reserved for presentations that
fulfill the accompanying definition of ‘‘mental disor-
der,’’ which requires ‘‘significant dysfunction in the
individual’s cognitions, emotions, or behaviors."7 As
a new diagnosis, there is much room for testing
empirically supported treatments specifically with
this population. B’s presentation has been used to
illustrate an example of an ARFID presentation, yet
cannot be regarded as ‘‘typical" in the absence of a
more robust body of evidence about the disorder.
The clinical utility of the criteria, in particular their
ability to inform clinicians about likely prognosis,
appropriate treatment interventions and possible
outcomes now requires comprehensive evaluation.
The author was a member of the DSM-5 Eating Disor-
ders Work Group. No disclosures or conflict of interests
to declare.
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