Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx

Click to edit Master title style
• Edit Master text styles
• Second level
• Third level
• Fourth level
• Fifth level
Avoidant Restrictive food Intake Disorder
By Heba Essawy MD.CEDS.,
International Chapter chair Iaedps USA
Prof of Psychiatry , Head of Eating Disorders Clinics
Institute Of Psychiatry ,Medical School
Ain Shams University

• Second level
• Third level
• Fourth level
• Fifth level
Introduction
• Avoidant Restrictive Food Intake Disorder (ARFID) is a new
diagnosis in the DSM-5, and was previously referred to as
“Selective Eating Disorder.”
• ARFID is similar to anorexia in that both disorders involve
limitations in the amount and/or types of food consumed, but
unlike anorexia, ARFID does not involve any distress about
body shape or size, or fears of fatness.
ARFID: Facts and Fictions

• Second level
• Third level
• Fourth level
• Fifth level
Roadmap
• Statistics of ARFID
• Diagnosis of ARFID
*Dimensional on top of Categorical
*Categorical Model Of ARFID
• Risk factors in ARFID
• WARNING SIGNS & SYMPTOMS OF ARFID
• Subtypes of ARFID
• ARFID and it s associations
• Assessment Of ARFID

• Second level
• Third level
• Fourth level
• Fifth level
WHAT IS ARFID ?

What is ARFID?
ARFID is a Feeding and Eating disorder characterized by :
 food avoidance or restriction that fails to meet an individual’s
nutritional or energy needs
 Related to sensory concerns
 Fear of unpleasant experiences such as choking or vomiting
 Not related to body image concerns.
 Other psychiatric disorders including ASD , OCD and ADHD may
increase an individual’s risk for ARFID.

Statistics
• In 2013 : Ornstein et .al., study of patients presenting to
adolescent medicine clinics for eating-disorder evaluation
found that 14% met criteria for ARFID
• In 2015 : Kurz S used A questionnaire-based study reported
a 3.2% prevalence ARFID in a primary school setting amongst
8–13 year olds in Switzerland
• In 2015 : Eddy et.al., reported a 1.5% prevalence of ARFID
among boys and girls ages 8–18 years in a pediatric
gastroenterology healthcare network.

• Second level
• Third level
• Fourth level
• Fifth level
DIAGNOSTIC CRITERIA : DSM-5
• An eating or feeding disturbance (e.g., apparent lack of interest in
eating or food; avoidance based on the sensory characteristics of
food; concern about aversive consequences of eating) as
manifested by persistent failure to meet appropriate nutritional
and/or energy needs associated with one (or more) of the
following:
• Significant weight loss (or failure to achieve expected weight gain or
faltering growth in children).
• Significant nutritional deficiency.
• Dependence on enteral feeding or oral nutritional supplements.
• Marked interference with psychosocial functioning.
• The disturbance is not better explained by lack of available food or
by an associated culturally allowed practice.

• Second level
• Third level
• Fourth level
• Fifth level
DIAGNOSTIC CRITERIA : DSM-5
• The eating disturbance does not occur exclusively during the
course of anorexia nervosa or bulimia nervosa, and there is no
evidence of a disturbance in the way in which one’s body
weight or shape is experienced.
• The eating disturbance is not attributable to a concurrent
medical condition or not better explained by another mental
disorder. When the eating disturbance occurs in the context of
another condition or disorder, the severity of the eating
disturbance exceeds that routinely associated with the
condition or disorder and warrants additional clinical
attention.

• Second level
• Third level
• Fourth level
• Fifth level
Operationalize DSM‐5 criterion A
• Describes four possible sequelae of avoidant (limited variety
or avoidance of certain categories of food) and/or restrictive
(limited volume or restriction of overall amount) eating.
• What is significant weight loss (or failure to achieve expected
weight gain or faltering growth in children) (criterion A1)?
 Experts defined this variably: BMI < 18.5 kg/m2 in adults or
<5th percentile in youth
 As in the DSM‐5 guideline for significantly low weight in
anorexia nervosa; weight loss >10 lbs; crossing BMI or weight
percentiles;

• Second level
• Third level
• Fourth level
• Fifth level
Operationalize DSM‐5 criterion A2
What is significant nutritional deficiency (criterion A2)?
Expert varied on whether blood tests were necessary, or
assessment of intake via daily logs may be sufficient to
allow clinician estimation of deficiencies as manifestations
of avoidant/restrictive eating.
Reliance on laboratory data may not be feasible:
 laboratory data do not necessarily always correlate with
either clinical or dietary findings
 High costs .
 Individuals may be taking multivitamins and minerals which
may be correcting for nutrients low or missing in the diet.

• Second level
• Third level
• Fourth level
• Fifth level
• Dietitians supported the use of
-Prospective food records
-Dietary recall to identify deficiencies or insufficiencies in
nutrient consumption that may increase the risk for
deficiency.
• Operationalization used in research should be clearly
specified in any published articles.

• Second level
• Third level
• Fourth level
• Fifth level
What is dependence on enteral feeding or oral nutritional
supplements (criterion A3)?
• Operationalization of “dependence” varied with using a
threshold of ≥2 supplement drinks or any tube feeding.
• The majority agreed on a definitional threshold of ≥50% or
more of daily caloric intake via oral supplementation
or any tube feeding that is not required by a concurrent
medical condition .

• Second level
• Third level
• Fourth level
• Fifth level
• Is marked interference with psychosocial functioning related to
avoidant and/or restrictive eating (criterion A4) sufficient to
meet criterion A in the absence of criteria A1‐3
• clinicians described individuals presenting for treatment with
severely restricted diets due to sensory sensitivity are of
normal weight with no nutrition deficiencies but unable to
attend school, hold jobs, or establish romantic relationships
due to inability to manage eating situations.
• In fact at press‐time the APA was actively considering a
proposal to eliminate the above clause to clarify that A4 (in
the absence of criteria A1–A3) would satisfy criterion A.

• Second level
• Third level
• Fourth level
• Fifth level
Radcliffe ARFID Workgroup Operational
Criteria
• ARFID eating is characterized by
food avoidance and/or restriction, involving limited volume
and/or variety associated with one or more of the following:
1- Weight loss or faltering growth (e.g., defined as in anorexia
nervosa, or by crossing weight/growth percentiles);
2-Nutritional deficiencies (defined by laboratory assay or dietary
recall);
3- Dependence on tube feeding or nutritional supplements (≥50%
of daily caloric intake or any tube feeding not required by a
concurrent medical condition)
4- Psychosocial impairment.
( Radcliffe Institute for Advanced Study, Harvard University, 2018)

• Second level
• Third level
• Fourth level
• Fifth level
Categorical Model Of ARFID
• Jennifer J. Thomas,2018

• Second level
• Third level
• Fourth level
• Fifth level
ARFID: RISK FACTORS

• Second level
• Third level
• Fourth level
• Fifth level
ARFID: RISK FACTORS
• ARFID involve a range of biological, psychological, and
sociocultural issues. These factors may interact differently in
different people.
• People with autism spectrum conditions are much more likely
to develop ARFID, as are those with ADHD and intellectual
disabilities.
• Children who don’t outgrow normal picky eating, or in
whom picky eating is severe, appear to be more likely to
develop ARFID.
• Many children with ARFID also have a co-occurring anxiety
disorder, and they are also at high risk for other psychiatric
disorders.

• Second level
• Third level
• Fourth level
• Fifth level
What causes ARFID?
Genetic factors
• Eating disorders are familial illnesses, and temperamental traits
predisposing individuals toward developing an illness are passed from
generation to generation.
Psychological factors
• Anxiety and obsessive compulsive disorder symptoms tend to
accompany eating disturbances, as do co-occurring mood and anxiety
disorders.
Sociocultural factors
• Cultural pressures to eat clean/pure/healthy as well as increased
interests in food processing, sourcing, packing and the environmental
impact can influence food beliefs and intake

• Second level
• Third level
• Fourth level
• Fifth level
WARNING SIGNS & SYMPTOMS OF ARFID
Behavioral and psychological
• Dramatic weight loss
• Dresses in layers to hide weight loss or stay warm
• Reports constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
• Reports consistent, vague gastrointestinal issues (“upset stomach”, feels full, etc.)
around mealtimes that have no known cause
• Dramatic restriction in types or amount of food eaten
• Will only eat certain textures of food
• Fears of choking or vomiting
• Lack of appetite or interest in food
• Limited range of preferred foods that becomes narrower over time (i.e., picky eating
that progressively worsens).
• No body image disturbance or fear of weight gain

• Second level
• Third level
• Fourth level
• Fifth level
WARNING SIGNS & SYMPTOMS OF ARFID
Physical
• Because both anorexia and ARFID involve an inability to meet nutritional needs, both disorders
have similar physical signs and medical consequences.
• Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
• Menstrual irregularities—missing periods or only having a period while on hormonal
contraceptives (this is not considered a “true” period)
• Difficulties concentrating
• Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low
blood cell counts,)
• Postpuberty Dry skin
• Dry and brittle nails . Muscle waekness . Poor wound healng . Amenorehea
• Fine hair on body (lanugo) . Dizzness . Fainting . Feeling Cold
• Thinning of hair on head,
• Impaired immune functioning . Sleep problems . slow heart rate

• Second level
• Third level
• Fourth level
• Fifth level
HEALTH CONSEQUENCES OF ARFID
• In ARFID, the body is denied the essential nutrients it needs
to function normally.
• Body is forced to slow down all of its processes to conserve
energy, resulting in serious medical consequences.
• The body is generally resilient at coping with the stress of
eating disordered behaviors, and laboratory tests can
generally appear perfect even as someone is at high risk of
death.
• Electrolyte imbalances can kill without warning; so can
cardiac arrest. Therefore, it’s incredibly important to
understand the many ways that eating disorders affect the
body.

• Second level
• Third level
• Fourth level
• Fifth level
Types of ARFID include:

• Second level
• Third level
• Fourth level
• Fifth level
Types of ARFID include:
• Avoidant: Patients who only accept a limited diet in relation to sensory
features (sensory sensitivity); sensory aversion; sensory over-stimulation
• Aversive: Individuals whose food refusal is related to aversive or fear-based
experiences (phobic avoidance) including choking, nausea, vomiting, pain
and/or swallowing
• Restrictive: Individuals who do not eat enough and show little interest in
feeding or eating (low appetite); extreme pickiness; distractible and forgetful
• ARFID “Plus”: Individuals with avoidant, aversive, or restrictive types of
ARFID presentations who begin to develop features of anorexia nervosa,
including concerns about body weight and size, fear of weight gain, negativity
about fatness, negative body image without body image distortion and
preference for less calorically-dense foods
• Adult ARFID: Individuals with avoidant, aversive, or restrictive types of
ARFID presentations beyond childhood; may have had similar symptoms
since childhood including selective or extremely picky eating, food
peculiarities, texture, color or taste aversions related to food.

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and SENSORY ISSUES
•
ARFID have sensory issues either hyposensitive (under-sensitive)
or hypersensitive (over-sensitive) in terms of: taste, sight, smell.
Hyposensitivity can cause sensation seeking, where certain
sensations can become addictive and repetitive.
Hyposensitive to taste can result in sensory eating non-food
items (i.e. pica) such as: soil, dirt, grass, sand, faeces .
• Sensory differences have an impact on eating, and in some cases
can present challenges such as: overeating, under-eating, difficulty
progressing through textures when weaning, not recognising
signals of hunger or thirst, ARFID , pica, difficulty with the eating
environment or meal presentation, ritualistic eating patterns or
continuous grazing7

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and FEAR OF THROWING UP
Some kids have Emetophobia, the fear of throwing up.
 This fear directly impacts their eating. Some kids worry if
they eat they will throw up.
 Some kids worry that if they get “too full” they’ll get sick.
 Other kids just feel nauseous all the time and it directly
impacts their appetite.

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and FEAR OF CHOKING
• Many kids with anxiety have a fear of choking.
 They get so consumed with this fear that they start to
restrict what types of foods they eat.
 This can start with eliminating chewy meats but the
restrictions can start from there.
 Some kids get so fearful they eventually go on a liquid diet

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and psychiatric disorders
• FEAR OF GETTING SICK
Kids with anxiety and OCD can worry they might get sick from their
food. This might be due to germs, expired food or contaminated food
that can lead to food poisoning.
• INTRUSIVE THOUGHTS
Kids with OCD will have irrational fears around their food. They might
be fixated on what is different about their food (black specks, weird
taste, different texture). With OCD an intrusive thought can be just
about anything.

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and FEELINGS OF DISGUST
 Kids with OCD can sometimes have an overwhelming
feeling of disgust.
 Kids with ARFID will randomly be disgusted by their food.
 This can be due to how the food looks, how the food feels in
their mouth or how the food smells.

• Second level
• Third level
• Fourth level
• Fifth level
ARFID and PANDAS/PANS
 PANDAS stands for Pediatric Autoimmune
Neuropsychiatric Disorders Associated with Streptococcal
Infections
 PANS is Pediatric Acute-onset Neuropsychiatric
Syndrome.
 This is when an infection caused by Strep or another
autoimmune disease cause a series of symptoms that include
tics, OCD symptoms, anxiety and commonly, restrictive
eating

• Second level
• Third level
• Fourth level
• Fifth level
Assessment and Screening of ARFID

• Second level
• Third level
• Fourth level
• Fifth level
Assessment of ARFID
• Int J Eat Disord. 2019 Apr;52(4):388-397.
Interview-based assessment of avoidant/restrictive food
intake disorder (ARFID): A pilot study evaluating an
ARFID module for the Eating Disorder Examination.
Schmidt R, Kirsten T, Hiemisch A, Kiess W, Hilbert A.

• Second level
• Third level
• Fourth level
• Fifth level
Assessment of ARFID
• Int J Eat Disord. 2019 Apr;52(4):378-387
• Development of the Pica, ARFID, and Rumination Disorder
Interview, a multi-informant, semi-structured interview of
feeding disorders across the lifespan: A pilot study for ages
10-22.
• Bryant-Waugh R, Micali N, Cooke L, Lawson EA, Eddy
KT, Thomas JJ

• Second level
• Third level
• Fourth level
• Fifth level
Screening for ARFID
Self‐report screening tools
 Eating Disorders in Youth‐Questionnaire (EDY‐Q; Kurz, van
Dyck, Dremmel, Munsch, & Hilbert, 2015) for children and
adolescents .
 Nine Item ARFID Screen (NIAS; Zickgraf & Ellis, 2018) for
adults.
These both yield dimensional symptom ratings rather than
diagnoses. The EDY‐Q in particular has a suggested cut‐off
score for possible ARFID.

• Second level
• Third level
• Fourth level
• Fifth level

Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx

Similar to Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx (20)

More from Heba Essawy, MD

More from Heba Essawy, MD (20)

Recently uploaded

Recently uploaded (20)

Recent updates of Avoidant Restrictive food intake disorder ARFID .pptx