Because avoidant restrictive food intake disorder (ARFID) dramatically limits the food and drink a person is willing to consume, people with the condition are at increased risk for many mental and physical health complications. To avoid the pitfalls linked to the condition, a person with ARFID should access and commit to effective treatment options.
One possible barrier to care is the notion that ARFID is a newer mental health diagnosis that lacks the decades of research other conditions boast. Fortunately, a number of evidence-based treatments exist that incorporate therapy, physical health stabilization and nutrition counseling.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) carries a favorable reputation in mental health care for its efficacy in many situations. Originally, the treatment was designed to treat depression, but over the years, it has become an often-utilized treatment for many mental health conditions. Clinicians have even been able to use CBT in finding helpful treatments for physical health conditions like type 2 diabetes.
CBT is centered on the principle that a person’s thoughts, feelings and behaviors are all interconnected. If someone has unwanted emotions, they can achieve relief by addressing the thoughts and behaviors that accompany the feelings. If the behaviors are problematic, the person can target the thoughts and feelings.
CBT emphasizes the impact of negative thinking patterns and works to change them. In the case of CBT for ARFID, a person may have distorted views of food and eating, so a CBT therapist will work with the person to:
- Notice distorted thoughts
- Judge if these thoughts are accurate
- Challenge inaccurate ideas
- Shift behaviors based on new judgments
By detecting and debating the irrational thoughts, the person is left to decide if the avoidance and restriction of food is the path they want to pursue. Once the decision is made, the therapist can present the client with various options to adjust their behaviors.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a psychological approach that was devised to treat the intense emotions and chronic suicidality linked to conditions like borderline personality disorder. Just as CBT expanded from its original purpose, mental health practitioners have used DBT to treat a variety of mental health conditions, including substance use disorders.
DBT works by enhancing basic life skills that may be limited in the individual. DBT aims to boost:
- Distress tolerance: the person’s ability to feel and experience intense emotions without reacting in dangerous ways
- Emotional regulation: being able to identify and track feelings and work to change them toward more desired outcomes
- Mindfulness: using their senses to focus on the here and now of the present rather than negative issues and situations from the past
- Interpersonal effectiveness: learning to interact in healthier, more effective ways through assertive communication and increased listening skills
DBT for ARFID uses mindfulness and distress tolerance skills to reduce anxiety while emotional regulation works to identify the source of the food avoidance and restriction. From there, the person can take steps to change the connections to the food trigger to feel more comfortable consuming foods in a typical way.
Exposure therapy is an effective tool for many mental health conditions associated with high levels of anxiety, like ARFID. With an experienced therapist guiding exposure therapy, a person with ARFID could resume a desirable eating pattern quickly.
Exposure therapy for ARFID often starts by understanding the interaction of food and discomfort in the client to accurately assess the impact of ARFID. Therapists then work with the client to create a list, called a fear hierarchy, of stressful situations involving eating. The most stressful experiences will go at the top of the list with the least stressful at the bottom.
With this in place, the therapist works to expose the client to anxiety-provoking situations in a systematic way. When exposed, the client’s anxiety will increase at first and then slowly fade, which allows treatment to move to the next item on the list. Since people with ARFID feel anxiety about eating, the therapist may ask the client to eat during sessions to practice managing the tension.
Some therapists may employ a specialized type of exposure therapy called exposure with response prevention (ERP). ERP uses many exposure therapy principles while observing the client’s current coping skills and teaching them new ones. ERP may view the current coping techniques as problems that actually maintain the unhealthy eating patterns.
A person with ARFID may attend individual sessions to address their condition. During these sessions, they meet one-on-one with a therapist to discuss the situation and learn methods to shift their behaviors.
Group therapy involves one or more therapists meeting with two or more clients who did not know each other prior to the beginning of treatment. Group therapy is helpful because the other clients, as well as the therapists, become useful tools to accomplish treatment goals.
CBT, DBT and exposure therapy are theoretical orientations a therapist uses to access and address symptoms of a mental health condition. Fortunately, these same therapies are used in group therapy settings also.
Group therapy sessions may employ positive peer pressure to encourage group members to engage in desired eating habits. Some group therapies may focus on group meals where members challenge themselves and others to eat in uncomfortable settings.
Support group meetings lack the professional interventions from a therapist but can be helpful to people with ARFID by creating a network of similar people. An ARFID support group could involve people with the condition of discussing their situation and searching for useful treatments.
Online or in-person support groups are great ways to complement professional treatment options.
Like group therapy, family therapy works to offer the same therapeutic tools as individual and group therapies in a slightly different setting. Family therapy involves one or more therapists meeting with a person identified as the client and one or more people from their life.
People who can attend family sessions may include:
- Parents and grandparents
- Romantic partners
Just because someone is not technically a family member does not necessarily mean they are excluded from family therapy. The only people who should not attend family therapy are those who consistently trigger or upset the client while showing no interest in changing their communication or behavior. These people could hinder any progress made in therapy.
Family therapy is especially important for young people with ARFID as their parents and other family members may accidentally worsen symptoms. In family sessions, a therapist can inspect the communication and interactions between family members to look for any troubling dynamics.
For example, a parent may put too much pressure on eating, which only makes the client resist and avoid food even more. A family therapist will point out this issue and offer alternative approaches to end the power struggle involving food and eating.
Medical Stabilization and Nutrition Counseling
People with ARFID face a range of medical challenges caused by the condition and its impact on diet, appetite and nutrition. Having ARFID can lead to:
- Low weight
- Growth delays
Some people with ARFID will require artificial nutrition in the form of a feeding tube placed in the abdomen or down the esophagus via the nose. Even with a feeding tube, getting the required nutrition may prove difficult.
Due to the lack of food intake, medical issues linked to ARFID can match the complications from anorexia including:
- Stomach cramps
- Acid reflux
- Menstrual irregularities
- Low immune system
- Poor thyroid functioning
- Low blood cell counts
All of these issues will require eating disorder medical stabilization with observation and intervention as needed. Physicians can monitor people with ARFID to ensure their levels are safe and offer methods to improve health and well-being when problems emerge. If needed, they can recommend hospitalization and other intensive treatments to ensure stability.
Doctors may also recommend psychiatric medications like Zyprexa or Prozac to lower levels of anxiety and depression linked to the ARFID.
Once the person with ARFID is medically stable, the treatment team can initiate nutritional counseling. ARFID nutritional counseling involves the client meeting with a dietitian or other nutrition expert to learn about food, the impact of food in the body and the risks of not eating well.
The nutritional counselor may implement a plan aimed at increasing the food intake gradually over time with specific meals to ease the process. Ideally, therapists, doctors and nutritional counselors will collaborate to create the most successful outcomes.
Treating ARFID and Co-Occurring Disorders
Treatment for ARFID and other eating disorders is often an involved process. The situation becomes even more complicated with the presence of other mental health conditions or addictions.
Called co-occurring disorders, many people with ARFID have other psychological and substance use disorders. According to the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, the most common disorders to co-occur with ARFID are:
- Anxiety disorders like generalized anxiety, panic disorder and phobias
- Obsessive-compulsive disorder
- Autism spectrum disorder
- Attention-deficit hyperactivity disorder
- Intellectual disabilities
The most appropriate treatments address the entire person and all of their disorders in a comprehensive way. Rather than treating one condition at a time, they will target all symptoms simultaneously.
The most effective treatments for someone with ARFID and co-occurring conditions include a variety of individual, group and family sessions. ARFID treatment providers may use helpful therapeutic approaches like:
- Cognitive behavioral therapy
- Dialectical behavioral therapy
- Exposure therapy, especially exposure with response prevention
People with ARFID and co-occurring substance use disorders should receive specialized care. If you know someone in this situation or find yourself living with ARFID and an addiction, call The Recovery Village. Getting in touch with The Recovery Village can help you start the process of recovery today.
American Psychiatric Association. “Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition.” 2013.
National Eating Disorder Association. “Avoidant Restrictive Food Intake Disorder (ARFID).” Accessed May 28, 2019.
Rogers Behavioral Health. “More Than Picky Eating – 7 Things to Know About ARFID.” October 4, 2018. Accessed May 28, 2019.
Spettigue, Wendy; Norris, Mark L.; Santos, Alexandre; Obeid, Nicole. “Treatment of Children and Adolescents with Avoidant/ Restrictive Food Intake Disorder: A Case Series Examining the Feasibility of Family Therapy and Adjunctive Treatments.” Journal of Eating Disorders, August 3, 2018. Accessed May 28, 2019.