Avoidant-restrictive food intake disorder

Essential (Required) Features:

• Avoidance or restriction of food intake that results in either or both of the following:
• The intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements that has resulted in significant weight loss, clinically significant nutritional deficiencies, dependence on oral nutritional supplements or tube feeding, or has otherwise negatively affected the physical health of the individual.
• Significant impairment in personal, family, social, educational, occupational or other important areas of functioning (e.g., due to avoidance or distress related to participating in social experiences involving eating).
• The pattern of eating behaviour is not motivated by preoccupation with body weight or shape.
• Restricted food intake and consequent weight loss (or failure to gain weight), or other impact on physical health or related functional impairment, are not due to unavailability of food; are not a manifestation of another medical condition (e.g., food allergies, hyperthyroidism) or mental disorder; and are not due to the effects of a substance or medication, including withdrawal effects.

Additional Clinical Features:

• A variety of reasons may be given for restriction of food intake, such as lack of interest in eating, avoidance of foods with certain sensory characteristics (e.g., smell, taste, appearance, texture, colour, temperature) or concern about perceived aversive consequences of eating (e.g., choking, vomiting, health problems), which in some cases is related to a history of aversive food-related experience such as choking or vomiting after eating a particular type of food. In many cases, however, there is no identifiable event that preceded the onset of the disorder.
• Some individuals with Avoidant-Restrictive Food Intake Disorder present with a longstanding lack of interest in food or eating, chronically low appetite, or a poor ability to recognize hunger. In other cases, restriction of food intake may be more variable and significantly affected by emotional or psychological factors. This latter pattern may be associated with high levels of distractibility or with high levels of emotional arousal and extreme resistance in situations in which eating is expected. Individuals with this pattern, especially children, often require significant prompting and encouragement to eat.
• Individuals with Avoidant-Restrictive Food Intake Disorder generally do not experience any difficulties eating foods within their preferred range and may therefore not be underweight.
• Avoidant-Restrictive Food Intake Disorder can negatively impact family functioning, such that mealtimes may be associated with increased distress (e.g., infants may be more irritable during feedings, children may try to negotiate what food is present or how much they need to consume at mealtimes).

Boundary with Normality (Threshold):

• People with unusual patterns of eating behaviour or who are exceptionally ‘picky eaters’ should not be diagnosed with Avoidant-Restrictive Food Intake Disorder in the absence of significant weight loss or other health consequences (e.g., clinically significant nutritional deficiencies, increases in blood lipids due to selective eating of fatty foods) or impairment in psychosocial functioning (e.g., limited participation in social activities where preferred foods are not available). Distress on the part of parents or other caregivers related to selective eating in the absence of identifiable health consequences or impairment in the individual’s functioning is not a basis for assigning the diagnosis.
• Avoidance of specific foods or limitation of food intake due to religious or other culturally sanctioned practices does not meet the diagnostic requirements of Avoidant-Restrictive Food Intake Disorder unless the pattern of restricted food intake has negatively affected the physical health of the individual or resulted in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Course Features:

• Avoidant-Restrictive Food Intake Disorder may be associated with delays in typical development (e.g., growth, learning), particularly if significant malnutrition is present.
• There is limited evidence to support an association between a diagnosis of Avoidant-Restrictive Food Intake Disorder and a later diagnosis of an Eating Disorder.

Developmental Presentations:

• Avoidant eating or feeding often starts in early childhood, but initial presentations in older children, adolescents and adults also occur.

Culture-Related Features:

• Avoidance of specific foods because of widely accepted food choice practices, such as vegetarianism or veganism, or due to religious observances (e.g., fasting, purification, or ritual proscription of foods), should not be diagnosed with the disorder unless the restricted eating behaviour exceeds the usual norms of the individual’s cultural or religious group(s) and is associated with health or functional consequences that warrant clinical attention.

Sex- and/or Gender-Related Features:

• The prevalence of Avoidant-Restrictive Food Intake Disorder is similar among males and females. When Avoidant-Restrictive Food Intake Disorder co-occurs with Autism Spectrum Disorder, there is a higher prevalence in males.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Anorexia Nervosa: Individuals with Anorexia Nervosa, like individuals with Avoidant-Restrictive Food Intake Disorder, present with a pattern of restricted eating and significantly low body weight, with similar health-related consequences. The difference is that in Anorexia Nervosa, behaviours to establish or maintain an abnormally low body weight are usually explicitly motivated by a desire for thinness or an intense fear of gaining weight. However, other rationales for disturbances in eating behaviours or weight loss in Anorexia Nervosa may be given, such as fear of physical discomfort (e.g., stomach bloating), self-punishment, or religious or moral reasons. In cases in which the individual otherwise meets the diagnostic requirements of Anorexia Nervosa but weight or shape-related concerns are not explicitly endorsed, the altered eating behaviours should only be considered as diagnostic of Anorexia Nervosa if clinical observation or collateral history supports the conclusion that they are motivated by an intention to lose weight or to prevent weight gain. Some individuals initially diagnosed with Avoidant-Restrictive Food Intake Disorder may exhibit more explicit weigh or shape-related concerns over the course of treatment as they begin to alter their eating behaviours and to gain weight. In such cases, it may be appropriate to change the diagnosis to Anorexia Nervosa if all diagnostic requirements are met.
• Boundary with Autism Spectrum Disorder: In some individuals with Avoidant-Restrictive Food Intake Disorder, the pattern of food avoidance stems from sensory sensitivities related to the smell, taste, temperature, texture or appearance of foods. For example, an individual may eat only foods of a particular colour or will refuse solids or will accept only a very narrow range of foods based on packaging or a particular brand. Some individuals with Autism Spectrum Disorder may also restrict intake of certain foods because of their sensory characteristics (e.g., hypersensitivity to food texture) or because of inflexible adherence to particular routines (e.g., eating the same foods at the same time in the same order or only eating specific brands of food with specific packaging). However, Autism Spectrum Disorder is also characterized by persistent deficits in initiating and sustaining social communication and reciprocal social interactions and persistent restricted, repetitive, and inflexible patterns of behaviour, interests, or activities that are unrelated to food. If a pattern of restricted eating in an individual with Autism Spectrum Disorder has caused significant weight loss or other health consequences or is specifically associated with significant functional impairment, an additional diagnosis of Avoidant-Restrictive Food Intake Disorder may be assigned.
• Boundary with Specific Phobia and other Anxiety or Fear-Related Disorders: In some individuals with Avoidant-Restrictive Food Intake Disorder, food avoidance may be related to perceived aversive consequences of eating (e.g., fear that swallowing particular foods may cause one to gag, choke or vomit, or concern about the development of health problems such as heart disease or cancer related to food intake). Avoidant-Restrictive Food Intake Disorder is commonly associated with anxiety symptoms in situations related to eating or food, which may become worse over time as the disorder evolves. If the pattern and intensity of anxiety symptoms in an individual with Avoidant-Restrictive Food Intake Disorder meet all diagnostic requirements of Specific Phobia or another Anxiety or Fear-Related Disorder, both diagnoses may be assigned.
• Boundary with other mental disorders: Individuals experiencing a Depressive Episode may present with lack of appetite or reduced interest in eating and weight loss associated with depressed mood and other cognitive-behavioural or neurovegetative symptoms of a Depressive Episode. Similarly, individuals experiencing Manic, Mixed, or Hypomanic Episodes may exhibit reduced interest in eating together with other features of a Bipolar Disorder. Avoidance or restriction of food intake with effects on weight and nutrition can also be present in Schizophrenia or Other Primary Psychotic Disorders due to loss of appetite or due to paranoid ideas (e.g., fear of being poisoned). Motivations for restricted eating should be investigated carefully as a part of a complete mental health assessment in order to distinguish among these conditions. An additional diagnosis of Avoidant-Restrictive Food Intake Disorder is generally not warranted if the restriction of food intake is fully accounted for by another mental disorder.
• Boundary with other medical conditions: Avoidant-Restrictive Food Intake Disorder should not be diagnosed if the eating disturbance is entirely accounted for by a gastrointestinal disorder or another medical condition that leads to reduced hunger, restricted eating, or weight loss (e.g., food allergies, infectious diseases, cancer, hyperthyroidism).