Presentations of ARFID

Combinations of Presentations

• Long-term versus short-term ARFID _{(Zimmerman & Fisher, 2017)}: Individuals with the appetite subtype tend to require long-term treatment and inter- ventions, whereas individuals whose ARFID is triggered by an aversive event, are most likely to have an acute onset with rapid weight loss. The aversive subtype is more likely to require hospital treatment and/or the use of a nasogastric tube than the other subgroups. However, while acute, their condition tends to resolve relatively quickly.

• Norris et al (2018), discovered that 22% of participants had combinations of subtypes in this retrospective study, whereas prospective studies of Duncombe et al (2019), and Richmond et al (2023), found more than 50% of participants had at least one subtype.

• Zickgraf et al (2019) identified a combined 4th subtype in their retrospective study i.e. ARFID - Food Selectivity (sensory) and Limited Interest (low appetite), which affected 20% of patients. This group had a chronic course of poor appetite and was least likely to have an acute trigger. In this study almost half of the participants were of the aversive subtype.

• Richmond et al (2023), reported a prospective study of 239 patients aged 8 -22 years, of which 57% male, where five subtypes emerged from the data. This is the largest study to date, from a multidisciplinary ARFID program developed between the Gastrointestinal Feeding Team and the Adolescent/Young Adult Medicine Eating Disorder Team at Boston Children’s Hospital.

The subtypes were:

1. Sensory Sensitivity (29.3%)

2. Low Appetite (10%)

Another three subtype-combinations described more than 50% of participants:

3. Sensory Sensitivity + Low Appetite (31%)

4. Fear (aversive) + Sensory Sensitivity or Fear (aversive) + Low Appetite (7%)

And lastly a combination of all three subtypes:

5. Fear (aversive) + Low Appetite + Sensory Sensitivity (13%)

• • The subgroup, Low Appetite, had the oldest average age, of 14 years, the highest percentage of males (71%), and the lowest body mass index z score. Whereas the subgroup Fear (aversive) + either Low Appetite or + Sensory Sensitivity had the lowest percentage of males (24%). The lowest mean age of 12 years occurred in the subtype Sensory Sensitivity + Low Appetite _{(Richmond et al., 2023)}.

  • Some findings of Richmond et al (2023) are markedly different to those of Norris et al (2018). Significantly higher rates of Sensory Sensitivity were reported by 75% of participants; in contrast to 18% _{(Norris et al., 2018)}. Richmond et al (2023), reported half their participants presenting with low appetite. Fewer presented with the aversive subtype (25%), compared to 43% of participants in the Norris, et al (2018), study.

In the future, as larger prospective studies are completed, it is hoped that a clearer understanding of the variability in symptoms of ARFID subtypes is developed, enabling individualised interventions to address their needs and level of care. As different mechanisms are maintaining distinctive eating restrictions, these will require specific psychological and psychiatric approaches (Zickgraf et al., 2019).

‘Illness-induced’ ARFID

• Individuals with gastrointestinal disorders can experience uncomfortable and distressing symptoms after eating.

• This repeated cycle can develop a conditioned fear-based food aversion and food avoidance.

• An ARFID diagnosis might be considered when the presentation exceeds what is expected for the illness/medical condition alone.

• Illness may have required invasive or painful procedures such as nasogastric feeding or an investigative scope exacerbating fear of swallowing/choking/eating certain foods.

Duncombe Lowe, K., Barnes, T. L., Martell, C., Keery, H., Eckhardt, S., Peterson, C. B., Lesser, J., & Le Grange, D. (2019). Youth with avoidant/restrictive food intake disorder: examining differences by age, weight status, and symptom duration. Nutrients, 11(8), 1955. doi: 10.3390/nu11081955

Norris, M. L., Spettigue, W., Hammond, N. G., Katzman, D. K., Zucker, N., Yelle, K., Santos, A., Gray, M., & Obeid, N. (2018). Building evidence for the use of de- scriptive subtypes in youth with avoidant restrictive food intake disorder. International Journal of Eating Disorders, 51(2), 170-173. doi: 10.1002/eat.22814 52(4), 402-409. doi: 10.1002/eat.23016

Richmond, T. K., Carmody, J., Freizinger, M., Milliren, C. E., Crowley, P. M., Jhe, G. B., & Bern, E. (2023). Assessment of patients with ARFID presenting to multi-disciplinary tertiary care program. Journal of Pediatric Gastroenterology and Nutrition, 76(6), 743-748. doi: 10.1097/MPG.0000000000003774

Zickgraf, H. F., Lane‐Loney, S., Essayli, J. H., & Ornstein, R. M. (2019). Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program. International Journal of Eating Disorders, 52(4), 402-409. doi: 10.1002/eat.23016

Zimmerman, J., & Fisher, M. (2017). Avoidant/ restrictive food intake disorder (ARFID). Current Problems in Pediatric and Adolescent Health Care, 47(4), 95-103. doi: 10.1016/j.cppeds.2017.02.005