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Psychiatric-Mental Health Nursing

20.3 Avoidant/Restrictive Food Intake Disorder

Psychiatric-Mental Health Nursing20.3 Avoidant/Restrictive Food Intake Disorder

Learning Objectives

By the end of this section, you will be able to:

  • Differentiate between anorexia nervosa and avoidant/restrictive food intake disorder
  • Plan nursing care for clients in treatment for avoidant/restrictive food intake disorder

Formery known as feeding disorder of infancy and childhood, avoidant/restrictive food intake disorder (ARFID) is a newer eating disorder characterized as a disturbance with eating or feeding where nutritional or energy needs are continuously not met (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016) and may be present into adulthood. The DSM-5 provides three ways that clients present with ARFID: sensory sensitivity, low appetite/interest in foods, or avoidance due to trauma (Thomas et al., 2017). Clients with sensory sensitivity may avoid certain foods like meats and fruits due to texture while clients with low appetite or interest may restrict food due to not feeling hungry or interested in the foods. Clients who have experienced trauma with eating may avoid specific food(s) that caused the problem.

It is important to note that ARFID is more than being a picky eater. It is characterized by restriction of food that can lead to issues with growth and development along with significant deficiencies that can affect the client’s health (Thomas et al., 2017). ARFID can lead to a complication like a nutritional deficiency where there is a reduction in essential nutrients needed to maintain adequate bodily functions. Common nutrient deficiencies seen in ARFID include zinc, potassium, iron, and vitamins C, K, and multiple B vitamins (Białek-Dratwa et al., 2022). In some cases, clients with ARFID may require artificial nutrition to meet their nutritional needs. Clients with ARFID can present with symptoms that include significant weight loss, abdominal pain, and other gastrointestinal issues (NIMH, 2023).

Comparison with Anorexia Nervosa

ARFID and anorexia are eating disorders that have similarities and differences. They both involve restriction of food that can lead to unmet nutritional or energy needs of the body and are characterized by low body weight. Both ARFID and anorexia can cause vitamin deficiencies that can become severe and require medical intervention. On the other hand, anorexia typically affects adolescents and young adults, and while ARFID can occur during these times, it is also seen in infancy and early childhood. Anorexia also includes issues with body image. ARFID does not involve disturbances with body image and typically involves sensory sensitivity, low appetite/interest in food, and/or avoidance due to food-related experiences. In other words, the psychological drivers of the behaviors differ between the two eating disorders.

Psychological Drivers of Behaviors

Though the etiology of ARFID is unknown, the disrupted eating behaviors seen with ARFID can have psychological influences (Brigham et al., 2018). Mental health disorders such as anxiety, autism spectrum disorder, obsessive-compulsive disorders, and attention-deficit disorder have been found to increase the risk for behaviors associated with ARFID (APA, 2023b). For example, if a client has anxiety and has a bad experience with a food (i.e., a stressful event that took place while eating a certain food), they may worry about and avoid eating that particular food again. Another example is with individuals with autism spectrum disorders. They may have sensory sensitivity issues and strict behaviors related to eating (APA, 2023b). If these behaviors become extreme, they can lead to the disordered eating seen in ARFID.

The avoidance of food seen in ARFID may be due to a history of trauma related to food. Individuals who have had negative experiences with food like vomiting or choking may ultimately avoid or restrict food (APA, 2023b). They may avoid the food or foods that caused the negative experience and even avoid other foods that are similar (Brigham et al., 2018).

Nursing Care

Nurses play an important role in caring for clients with ARFID, including obtaining a thorough history from clients who present with symptoms of ARFID. Questions related to eating habits, food aversions, and history of traumatic experiences related to food should take place along with an assessment of nutritional status. Severe cases of malnutrition may include lanugo, also seen with anorexia nervosa. Other symptoms can include bradycardia, hypothermia, pallor, orthostatic tachycardia, and hypotension, which require prompt medical attention (Brigham et al., 2018). In addition to developing and nurturing the therapeutic relationship, nursing care may include managing severe symptoms along with nutritional replacements to reverse vitamin deficiencies.

Age-Specific Treatment

Treatment for ARFID varies based on the age of the client being treated and should be age appropriate. Young children with nutritional deficiencies are often treated with oral formula supplements, tube feedings, and intensive behavior therapies (Thomas et al., 2017). Though there are no FDA-approved medications for ARFID, off-label use of medications has shown efficacy in infants and young children with ARFID. Studies in children ages seven months to six years old have revealed benefits from medications like cyproheptadine to increase appetite (Brigham et al., 2018). Other medications, such as mirtazapine and olanzapine, have also been used to promote weight gain in children. Children also benefit from cognitive behavioral therapies and behavioral interventions to help stabilize their weight (Thomas et al., 2017).

Collaborative Care and Partnership with Family

A collaborative approach works best for clients with ARFID. Nurses will work with other key members of the health-care team, including dietitians, therapists, clinicians, and behavioral specialists. The collaborative team will work together with the client and/or their family to restore health.

Partnering with families to treat individuals with ARFID is important because ARFID can disrupt family interactions. Partnering with the client’s families in care planning and decision making, called family-based care, is a treatment approach that can be effective. With ARFID, the parents typically take control of their child’s eating and work with a therapist to help decrease disrupted eating behaviors and restore healthy weight. Family-based therapies have been effective with eating disorders, including ARFID (Białek-Dratwa et al., 2022).

Behavioral Therapies

Behavioral therapies can be effective in managing ARFID. Food chaining is a behavioral feeding method that aims to broaden a client’s food selections by introducing safe foods that are similar to avoided foods (Białek-Dratwa et al., 2022). Young children may also benefit from play therapy to help introduce new foods. Play therapy has been found to help reduce anxiety and help prepare the child for the food that will be eaten (Białek-Dratwa et al., 2022). The Feeling and Body Investigators is another behavioral therapy that is used with ARFID. This modality involves exposure therapy that focuses on reframing negative body sensations (Białek-Dratwa et al., 2022).

Cognitive Behavioral Therapy

CBT is an effective modality for treating individuals with ARFID. There are various forms of CBT that are used with ARFID, but most contain elements like consistent eating, exposure to prevent negative responses, relaxation training, and monitoring food intake (Thomas et al., 2018). An example of a CBT for ARFID is the CBT-AR. It has four stages that involve psychoeducation about ARFID and its impact on health: regular eating, which involves creating meal plans with a variety of foods; exposure therapy, which means gradually having individuals try avoided foods and food situations; coping skills training; and relapse prevention (Thomas et al., 2018).

Dialectal Behavior Therapy

DBT can be effective in managing eating disorders like ARFID (Reilly et al., 2020). DBT is a psychotherapy modality that provides skills to help cope with strong emotions and can be modified to focus on disrupted eating behaviors, food intake, and nutritional skills (Pennell et al., 2019).

Goals of Treatment

The goals of treatment for ARFID are to restore nutritional balance, stabilize weight, and modify disrupted eating behaviors and thought processes. Restore nutritional balance by monitoring lab values like electrolytes, blood count, and metabolic function. Abnormalities in essential nutrients values may require nutritional replacement. Weight stabilization may require nutritional supplements to help restore weight. Modifying disrupted eating behaviors and thought processes will involve a collaborative effort of nurses working with members of the health-care team, the client, and their family to establish healthy eating behaviors.


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