Received: 8 March 2018 Revised and accepted: 16 August 2018

DOI: 10.1002/eat.22962

REVIEW

A systematic scoping review of diagnostic validity in

avoidant/restrictive food intake disorder
Mattias Strand MD1,2 | Yvonne von Hausswolff-Juhlin MD, PhD1,2 |
Elisabeth Welch PhD1,2,3

1
Stockholm Centre for Eating Disorders,
Stockholm, Sweden Abstract
2
Centre for Psychiatry Research, Department Objective: Avoidant/restrictive food intake disorder (ARFID) was introduced as a new diagnosis
of Clinical Neuroscience, Karolinska in the DSM-5. This systematic scoping review explores how ARFID as a diagnostic entity is con-
Institutet, & Stockholm Health Care Services,
ceptualized in the research literature and evaluates the diagnostic validity according to the
Stockholm County Council, Sweden
3
Feighner criteria.
Department of Medical Epidemiology and
Biostatistics, Karolinska Institutet, Stockholm, Method: A systematic scoping review of papers on ARFID in PubMed/MEDLINE and Web of
Sweden Science was undertaken, following PRISMA and Joanna Briggs Institute guidelines.
Correspondence Results: Fifty-one original research publications, 23 reviews and commentaries, and 20 case
Mattias Strand, Stockholm Centre for Eating reports were identified. The use of ARFID as a conceptual category varies significantly within
Disorders, Wollmar Yxkullsgatan 27B,
this literature. At this time, the ARFID diagnosis does not fulfil the Feighner criteria for evaluat-
118 50 Stockholm, Sweden.
Email: [email protected] ing the validity of diagnostic constructs, the most urgent problem being the demarcation toward
other disorders. A three-dimensional model—lack of interest in food, selectivity based on sen-
sory sensitivity, and fear of aversive consequences—is gaining support in the research literature.
Discussion: The introduction of the ARFID diagnosis has undoubtedly increased the recognition
of a previously largely neglected group of patients. However, this article points to an inability of
the current DSM-5 diagnostic criteria to ensure optimal diagnostic validity, which risks making
them less useful in clinical practice and in epidemiological research. To increase the conceptual
validity of the ARFID construct, several possible alterations to the current diagnostic criteria are
suggested, including a stronger emphasis of the three identified subdomains and further clarify-
ing the boundaries of ARFID.

Resumen
Objetivo: El trastorno evitativo/restrictivo de la ingesta de alimentos (TERIA) (ARFID, en sus
siglas en inglés), fue introducido como una nueva categoría diagnóstica en el DSM-5. Esta revi-
sión sistemática del alcance explora cómo es conceptualizado el ARFID en la literatura científica
y evalúa la validez diagnóstica de acuerdo a los criterios de Feighner.
Método: Se realizó una revisión sistemática del alcance de ARFID en los artículos publicados en
PubMed/MEDLINE y en Web of Science siguiendo los lineamientos PRISMA y del Instituto
Joanna Briggs.
Resultados: se identificaron 51 publicaciones de investigación originales, 23 revisiones y comen-
tarios, y 20 reportes de caso. El uso de ARFID como categoría conceptual varía significativa-
mente dentro de esta literatura. En la actualidad, el diagnóstico de ARFID no reúne los criterios
de Feighner para evaluar la validez del constructo diagnóstico, siendo el problema más urgente
la delimitación con otros trastornos. Un modelo tridimensional –falta de interés en la comida,
selectividad basada en la sensibilidad sensorial y miedo a las consecuencias aversivas – está
ganando apoyo en la literatura científica.
Discusión: La introducción del diagnóstico de ARFID indudablemente ha incrementado el reco-
nocimiento de un grupo grande de pacientes previamente ignorado. Sin embargo, esta revisión
señala la incapacidad de los criterios actuales del DSM-5 para asegurar una validez diagnóstica

Int J Eat Disord. 2018;1–30. wileyonlinelibrary.com/journal/eat © 2018 Wiley Periodicals, Inc. 1

2 STRAND ET AL.

óptima, lo cual pone en riesgo su utilidad tanto en la práctica clínica como en la investigación
epidemiológica. Se sugieren varias modificaciones posibles a los criterios diagnósticos actuales,
con el fin de aumentar la validez conceptual del constructo ARFID, incluyendo un mayor énfasis
en los tres subdominios identificados así como una mayor clarificación de los límites de ARFID.

KEYWORDS

adolescent psychiatry, appetite, child psychiatry, diagnosis, differential, feeding and eating
disorders, feeding and eating disorders of childhood, food preferences

1 | I N T RO D UC T I O N Even though ARFID as a distinct diagnostic category is relatively

new, the existence of a substantial group of patients with restrictive
In the fifth edition of the Diagnostic and Statistical Manual of Mental eating that do not fulfil criteria for any of the “typical” eating disorders
Disorders (DSM-5), published in 2013 (American Psychiatric Associa- has long been recognized. Evidence for optimal diagnostic and treat-
tion, 2013), a new “Feeding and Eating disorders chapter” was intro- ment approaches has, however, been very limited, reflecting a large
duced, integrating the fourth edition (DSM-IV) “Eating Disorders” clinical heterogeneity. Three discrete clinical presentations—a general
chapter and feeding disorders previously found in the chapter “Disor- lack of interest in food and eating, avoidance based on discomfort
ders Usually First Diagnosed in Infancy, Childhood, and Adolescence.” associated with the sensory properties of the food (texture, tempera-
This integration reflects a wish to adopt a life-course approach to psy- ture, color, etc.), and avoidance as a conditioned negative response
chopathology by emphasizing the continuity between child, adoles- due to a previous or anticipated aversive experience (e.g., choking or
cent, and adult manifestations of the same disorders, rather than vomiting)—are touched upon in the DSM-5 description of ARFID
treating psychiatric disorders in the pediatric population as a separate (Eddy et al., 2015; Kurz, van Dyck, Dremmel, Munsch, & Hilbert,
entity (Bravender et al., 2010; Eddy et al., 2010; Nicholls, Chater, & 2015; Thomas et al., 2017b), although they are not explicitly described
Lask, 2000; Uher & Rutter, 2012; Workgroup for Classification of Eat- as subtypes. This triplet is analogous to the alternative syndrome rec-
ing Disorders in Children and Adolescents, 2007). Following this line ognition guidelines for children outlined in the so-called Great
of reasoning, the age-neutral diagnosis “avoidant/restrictive food Ormond Street criteria (Nicholls et al., 2000), reflecting a focus on
intake disorder” (ARFID) was introduced as a replacement and exten- early onset eating disorders.
sion of the DSM-IV diagnosis “feeding disorder of infancy or early However, the DSM-5 also explicitly highlights a substantial num-
childhood.” ber of other clinical scenarios where an ARFID diagnosis can be rele-
According to the DSM-5 criteria (American Psychiatric Associa- vant if the eating disturbance is beyond what can typically be
tion, 2013), ARFID is characterized by a persistent failure to meet expected and becomes a primary focus of intervention—examples
appropriate nutritional and/or energy needs resulting in either a sig- include feeding difficulties in infancy due to inadequate caregiver-
nificant weight loss, significant nutrional deficiencies, nutrional needs child interaction and attachment, rigid eating behaviors and height-
being maintained only with the support of enteral feeding or nutri- ened sensory sensitivity in the context of an autism spectrum disor-
tional supplements, or a marked interference with psychosocial func- der, abnormal eating behaviors due to delusional beliefs as part of a
tioning. An important factor that distinguishes ARFID from other psychotic disorder, oral or esophageal dysfunction caused by congeni-
restrictive eating disorders, such as anorexia nervosa (AN), is that in tal or neurological conditions, appetite loss after surgery or chemo-
ARFID, there is no undue influence of body shape and weight on self- therapy, and appetite loss in old age (American Psychiatric
evaluation, no fear of gaining weight, and no disturbance in the way Association, 2013). It may be argued that these additional examples
one's body weight or shape is experienced. This, however, is further can be seen as extensions of the three clinical presentations described
complicated by the fact that young patients with AN may not always above, so that feeding difficulties in infancy in a context of inadequate
be able to explicitly endorse cognitive restraint, fear of weight gain, attachment is merely one mechanism behind a general lack of interest
etc. despite the presence of overt restrictive behaviors, something in food and that rigid eating behaviors in a person with autism reflect
that by definition “requires abstract reasoning, temporal discounting, a selectivity based on sensory sensitivity, and so forth. Regardless of
and an ability to identify and label emotional experiences, capacities how these clinical examples are interpreted on a constitutive level, it
that continue to develop throughout adolescence” (Workgroup for is evident that the DSM-5 describes a heterogeneous clinical topogra-
Classification of Eating Disorders in Children and Adolescents, 2007, phy where the common denominator is detrimental food restriction
p. S118). Furthermore, according to the DSM-5, an eating disturbance due to other causes than the body image concerns typically
categorized as ARFID should not be attributable to a concurrent medi- seen in AN.
cal condition or better explained by another mental disorder. Even so, This diagnostic heterogeneity must be understood in a historical
if the disturbance does occur in the context of another condition or context. As seen above, the ARFID diagnosis was deliberately con-
disorder, it may be categorized as ARFID if the severity exceeds that structed so as to be able to encompass various clinical presentations
which is commonly seen and warrants additional clinical attention. that had previously been referred to by a number of different
STRAND ET AL. 3

diagnostic terms that were not always used in a consistent and clini- childhood (Shields, Wacogne, & Wright, 2012), nonfat phobic AN
cally coherent way. Against this backdrop, a substantial heterogeneity (Becker, Thomas, & Pike, 2009; Lee, Ho, & Hsu, 1993), food avoidance
that enables ARFID to function as a diagnostic “net” may very well be emotional disorder (FAED) (Bryant-Waugh & Lask, 1995;Nicholls &
a desirable feature, or at the very least better than the state of disar- Bryant-Waugh, 2009 ; Watkins & Lask, 2002), selective or “picky” eat-
ray that preceded it. The DSM-5 field trials found that the test–retest ing (Bryant-Waugh & Lask, 1995; Nicholls & Bryant-Waugh, 2009;
reliability for the proposed ARFID criteria was good (Clarke et al., Watkins & Lask, 2002), functional dysphagia (Nicholls & Bryant-
2013; Regier et al., 2013)—indeed, it was better than for several other Waugh, 2009; Watkins & Lask, 2002), pervasive refusal syndrome
diagnostic categories in the child and adolescent psychiatry field trials, (Bryant-Waugh & Lask, 1995; Lask, Britten, Kroll, Magagna, & Tranter,
such as major depressive disorder and disruptive mood dysregulation 1991; Nicholls & Bryant-Waugh, 2009; Nunn, Lask, & Owen, 2014;
disorder. Even so, excessively heterogeneous criteria may compromise Watkins & Lask, 2002), pediatric autoimmune neuropsychiatric disor-
diagnostic validity. Although all systematic diagnostic categorization is ders associated with streptococcal infections (PANDAS) (Puxley, Mid-
constructivist by definition, a primary aim in establishing diagnostic tsund, Iosif, & Lask, 2008; Toufexis et al., 2015), early symptomatic
criteria must be to delineate and capture an immanent clinical entity; syndromes eliciting neurodevelopmental clinical examinations
that is, even when applied as a “net,” the diagnostic mesh must be (ESSENCE) (Gillberg, 2010), and so forth, within a DSM-5 framework.
wide enough to ensure ecological validity. Naturally, a large heteroge- For the research community to be able to take this next step and
neity within a diagnostic category may simply reflect an inherent move from “expert opinion” to systematic synthesis of robust and spe-
diversity in how an essential underlying disorder is expressed, a life- cific evidence, the conceptual boundaries of ARFID must first be
span approach as emphasized in the DSM-5, or insufficient evidence explored and mapped and its current validity as diagnostic category
to allow robust differentiation. On the other hand, since the DSM-5 evaluated. The purpose of this systematic scoping review is to fill this
explicitly suggests that any food restriction or avoidance that merits research gap.
more clinical attention than usual can give rise to an ARFID diagnosis,
regardless of etiological mechanisms, it is also reasonable to suggest
that the large clinical diversity described in the literature implies that 2 | METHODS
we may not be dealing with a clinical entity in the common sense.
In the early 1970s, a group of psychiatric researchers at the This systematic scoping review was performed in accordance with the
Washington University in St. Louis outlined what has come to be guidelines for scoping reviews developed by the Joanna Briggs Insti-
known as the Feighner criteria (Feighner et al., 1972; Kendler, tute (Peters et al., 2015). As far as possible, we have also adhered to
Muñoz, & Murphy, 2010; Robins & Guze, 1970) to aid in distinguish- the PRISMA statement guidelines for systematic reviews (Liberati
ing clinical entities and evaluating the validity of diagnostic constructs. et al., 2009), although not all checklist items are fully applicable to
According to this framework, diagnostic classification should rest on scoping reviews. Unlike ordinary systematic reviews, the aim of a
at least five pillars, the first of which is the clinical features that the scoping review is not to answer a narrowly specified research ques-
DSM aim to describe. However, in addition to symptomatology, con- tion (such as “what is the prevalence of ARFID in the population?”)
sistent laboratory findings or psychological tests should be estab- but to map and clarify the conceptual boundaries of a heterogeneous
lished. As there are usually no established biological markers for research field that may not yet be ripe for a more precise systematic
psychiatric disorders, this second criterion is often waivered and review. Thus, a systematic scoping review usually engages with a
replaced by recognizable effects of medication or other treatment. broader literature including, for example, letters to the editor, opinion
Third, the diagnostic entity should be clearly delimitated from other pieces, and so forth. The review process may also be of a more itera-
disorders so that an index group with an as large homogeneity as pos- tive nature, due to the focus on conceptual topographies. Notably, a
sible is distinguished. Furthermore, a typical course over time should PRISMA extension for scoping reviews is currently under develop-
be identified and any heritability should be charted. The Feighner cri- ment and an executive summary of the challenges in this work has
teria may seem overly narrow and difficult to apply in practice, but been published (PRISMA Group, 2015).
they undeniably call for critical reflection in the creation of new diag-
nostic categories; for example, the validity of orthorexia nervosa as a
2.1 | Search strategy and selection process
hypothetical diagnostic entity has been rightfully questioned on these
grounds (McInerney-Ernst, 2011). The goal of the literature review was to identify all articles explicitly
The aim of this systematic scoping review is to explore and map discussing eating and feeding problems in terms of ARFID published
how the ARFID diagnosis has been conceptualized and applied in the in scientific journals since the first publication of the proposed DSM-5
research literature since its introduction in the DSM-5. Specifically, ARFID diagnostic criteria in 2010 (these proposed criteria differed
the conceptual validity of the ARFID diagnostic criteria will be from the final version only in that criterion A3 mentioned enteral
reviewed by assessing the available research literature through a feeding but not nutritional supplements). Studies were identified by
Feighner criteria lens. This article is, however, not an attempt to ascer- searching PubMed/MEDLINE and Web of Science for the terms
tain the ontological characteristics of ARFID, such as symptom preva- “ARFID” OR “avoidant/restrictive food intake disorder”; since the aim
lence or treatment effectiveness. A more precise review of the “real” was to identify articles that explicitly employ this terminology, no fur-
characteristics of ARFID would require a meticulous recontextualiza- ther search terms were used. To ensure a full overview of how the
tion of clinical entities such as failure to thrive in infancy and early ARFID category is used, no limits were applied for article type or
4 STRAND ET AL.

FIGURE 1 Literature screening process

language; this, however, is based on the assumption that the abbrevia- conference abstracts), reviews and commentaries (including perspec-
tion ARFID is commonly used in both English and non-English speak- tive and opinion pieces, letters to the editor, etc.), and case reports
ing countries, as all possible translations could not be included in the (including cases reported within reviews as illustrative examples).
literature search. Articles that merely mentioned ARFID (e.g., in simply For original research, data concerning study objective, methodol-
enumerating new DSM-5 diagnoses) but that did not present any fur- ogy and sample, ARFID definition, main findings regarding ARFID, and
ther relevant information on the topic were excluded. The references points made in the discussion section regarding ARFID were
sections of relevant articles were also hand-searched for further cita- extracted. Original research was further grouped into three main cate-
tions of interest. During the literature search, we were made aware of gories according to the primary focus of the research—epidemiological
three relevant conference abstracts that had not been published in studies, treatment studies, and studies on rating instruments—to facili-
journal format. These abstracts were included in the review; however, tate overview. Naturally, many studies report on more than one of
additional searches for abstracts not traceable through PubMed or these main aspects. For reviews and commentaries, data concerning
Web of Science were not performed. The main literature search was objective, ARFID definition, and main findings and suggestions regard-
conducted in October 2017; an additional search update was con- ing ARFID were extracted. For case reports, a brief clinical vignette
ducted in February 2018. and data concerning reported outcome and how the ARFID diagnosis
The systematic literature search yielded a total of 126 records informed treatment were extracted. The review process was highly
after duplicates were removed (93 entries in PubMed, 93 entries in iterative, with an initial assessment of the descriptive data outlined
Web of Science, and four records identified through other sources; above followed by reassessment, critical analysis, and synthesis of the
Figure 1). After screening of abstracts and closer examination of full- data pertaining to diagnostic validity according to the Feighner
text papers, 34 articles were excluded as not relevant. Thus, the criteria.

review included a total of 92 publications. Fifty-one original research Assessment of the quality of evidence or of bias in and across

publications, 23 reviews or commentaries, and 20 case reports studies is not necessarily applicable or relevant within the framework

(18 case report papers and two case reports embedded in narrative of a scoping review. Even so, we chose to perform grading of evi-

review papers) were identified. With the exception of one paper in dence levels and bias assessment to further the understanding of

Dutch, all papers were in English. potential gaps in the available research on ARFID in relation to diag-
nostic validity. For assessment of the quality and evidence levels of
the studies, the methodology developed and described by the Oxford
2.2 | Data extraction and analysis
Centre for Evidence-Based Medicine was adopted (Oxford Centre for
For the purpose of data analysis, the included papers were divided Evidence-Based Medicine, 2009). Evidence levels were assigned
into three groups: original research (including brief reports and based on the characteristics of study methodology in relation to the
STRAND ET AL. 5

TABLE 1 Characteristics of original research literature

Original research publications (n = 51)

Primary focus Epidemiology (n = 38) Treatment (n = 7) Diagnostic instruments (n = 6)
Methodology
Retrospective chart reviews 18 (47%) 3 (43%) 0
Other 20 (53%) 4 (57%) 5 (100%)
Study sample
Clinical population 27 (71%) 6 (86%) 1 (17%)
Nonclinical population 9 (24%) 0 4 (67%)
a b
Other 2 (5%) 1 (14%) 1 (17%)c
Age group (in clinical and nonclinical samples)
Pediatric population 15 (39%) 4 (67%) 2 (40%)
Age-mixed populationd 9 (24%) 2 (33%) 0
Adult population 11 (29%) 0 3 (60%)
Not reported 1 (3%) 0 0
a
Japanese Yogo teachers, a type of school nurse.
b
Physician's treatment choices.
c
Parent population.
d
5–23 years, 8–21 years, 8–25 years, 9–25 years, 15–40 years, >15 years, and so forth.

stated primary outcomes pertaining to ARFID; thus, evidence levels remaining four (17%) are commentaries, letters to the editor, or guide-
cannot readily be compared across studies due to the large variance in lines. Thirteen out of the 19 reviews (68%) are narrative reviews, that
study aims and outcomes. All case reports were by definition assigned is, the methodology employed in reviewing the literature is not
the lowest evidence level, level 5. Likewise, narrative reviews were detailed. The only meta-analysis among the reviewed papers focuses
per default equated with “expert opinion” and assigned the lowest on tube weaning and not on ARFID in a broader perspective. Grading
evidence level. Conference abstract were not assigned evidence levels of evidence levels reveals that the available evidence on ARFID is
due to their very brief descriptions of methodology. mostly within the range of medium to insufficient quality (Table 2).
An attempt to assess risk of publication bias was made by search- The many retrospective cohort studies and narrative reviews and the
ing for studies that have been preregistered but not reported within overall lack of prospective studies, randomized controlled trials, or
reasonable time; notably, however, searching ClinicalTrials.gov, the systematic reviews contribute to this picture. Notably, some of the
WHO International Clinical Trials Registry Platform, the EU Clinical retrospective cohort studies were graded down from level 2b to level
Trials Register, the Open Science Framework, and PROSPERO only 3b, mainly due to the fact that it was not always possible to distin-
yielded one record of a preregistered ongoing clinical trial on the topic guish whether or not patients were included consecutively. Impor-
of ARFID. Likewise, only two of the assessed original research papers tantly, as described in the Methods section, when a scoping approach
referred to a preregistered study protocol. The only explicit sign of is employed to map the boundaries of a heterogeneous research field,
potential publication bias was the mentioning of unpublished survey individual studies with a formally low evidence level (such as case
data on pediatricians' familiarity with the ARFID diagnosis in one of reports) may nonetheless provide valuable information. It should also
the assessed case reports. The conference abstracts included in the be noted that a number of the reviewed studies, primarily those with
review generally described studies undertaken by research groups a focus on selective eating, make use of study samples from Amazon's
that also presented their results on ARFID in the format of original Mechanical Turk web panel. Since the strategies for recruiting the
research papers; thus, the abstracts did not point to the occurrence of worker pool that make up Mechanical Turk are nontransparent, it has
publication bias. Internal assessment of methods and results sections been suggested that the validity of findings from studies utilizing this
did not point to an obvious tendency of selective reporting within database may be compromised (Landers & Behrend, 2015).

studies; however, the overall lack of preregistered study protocols

makes this difficult to evaluate fully. 3.2 | Feighner criterion 1: Clinical description
The first of the five steps in establishing diagnostic validity according
to the Feighner criteria is to describe the clinical picture of the disor-
3 | RESULTS
der. Notably, this does not solely include symptoms but also such dis-
tinguishing features as precipitating factors, age at onset, gender
3.1 | Descriptive data
distribution, and so forth.
The characteristics of the 51 reviewed original research publications In defining ARFID based on symptom criteria, 37 out of 51 (73%)
regarding methodology, composition of study samples, and so forth, original research publications and 20 out of 23 (87%) reviews and
are outlined in Table 1. Among the papers in the category reviews and commentaries use the DSM-5 diagnostic criteria (final or proposed
commentaries, 19 out of 23 publications (83%) are reviews; the versions; Table 2). However, in 14 (27%) of the original research
 6

TABLE 2 Feighner criteria addressed in original research publications, reviews, and commentaries

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
FEIGHNER CRITERION 1: CLINICAL DESCRIPTION
Original research
Eddy et al., 2015 USA Retrospective chart review. 2,231 patients aged Proposed DSM-5 criteria. 1.5% of patients met ARFID criteria and an additional 2.4% 2b
8–18 years, 53.4% female, presenting for initial had “possible ARFID” (one or more symptoms but available
evaluation in a network of pediatric data did not allow a definitive diagnosis). Three subgroups
gastroenterology clinics. identified: little interest in feeding (57.6% of ARFID cases),
sensory sensitivity (21.2%), and aversive/traumatic
experience (9.1%).
Fisher et al., 2013 USA Retrospective case–control study. 98 patients aged Proposed DSM-5 criteria. ARFID cases represented 13.6% of all patients in the n/a
8–18 years that met ARFID criteria presenting programs. The ARFID group was younger and more often
to seven adolescent-medicine ED programs. male compared to non-ARFID group.
Fisher et al., 2014 USA Retrospective chart review. 712 patients aged DSM-5 criteria. 13.8% of patients met ARFID criteria. 28.6% of ARFID 2b
8–18 years, presenting to seven patients were male, compared to 14.3% and 6.0% for AN
adolescent-medicine ED programs. and BN, respectively. Patients with ARFID tended to be
younger. Subgroups identified: Longstanding selective
eating (28.7% of ARFID cases), generalized anxiety (21.4%),
gastrointestinal symptoms (19.4%), fears of choking or
vomiting (13.1%), fear of food allergies (4.1%), and other
reasons (13.2%).
Forman et al., 2014 USA Retrospective chart review at intake and 1-year DSM-5 criteria. 12.4% of participants met ARFID criteria. ARFID patients was 2b
follow-up. 700 outpatients aged 9–21 years with significantly more likely to be male than AN or atypical AN
a restrictive ED. patients (23.0% vs 9.6% vs 16.8%). Female ARFID patients
were significantly more likely to have regular menses than
AN patients (30.4% vs 18.0%). No significant differences
between ARFID and AN in terms of being underweight.
Hay et al., 2017 Australia Two sequential population-based surveys with DSM-5 criteria. 3-month ARFID prevalence was 0.3% in both years. More men 2c
face-to-face interviews of a representative and lower household income in ARFID group year 1 but
sample of the population. 5,737 persons aged even gender distribution and household income in year
>15 years. 2. ARFID group had more nonfunctional days and lower
quality of life than those without an eating disorder.
Inconsistent findings between year 1 and 2 due to low n in
ARFID group. ARFID group was not further assessed for
reasons for food avoidance, which may have resulted in
overestimation of prevalence.
Kurz et al., 2015 Switzerland Screening for ARFID symptoms by using newly DSM-5 criteria combined 3.2% met ARFID criteria. Three subgroups identified 2c
constructed self-report instrument EDY-Q. with Great Ormond (following EDY-Q construct): lack of interest in eating
1,444 schoolchildren aged 8–13 years, 53.9% Street criteria and (39.1% of ARFID cases), sensory sensitivity (60.9%), and
female. related literature. avoidance based on fear of negative consequences such as
choking or vomiting (15.2%). 15.2% of ARFID cases
reported two or more of these disturbances. No significant
group differences in gender or age.
Kurz, van Dyck, Switzerland Factor analysis of newly constructed self-report DSM-5 criteria combined Three different presentations (FAED, selective eating, and 2c
Dremmel, Munsch, instrument EDY-Q. 1,444 schoolchildren aged with Great Ormond functional dysphagia) can coexist, but their uniqueness is
& Hilbert, 2016 8–13 years, 53.9% female. Street criteria and supported factor-analytically.
related literature.
(Continues)
STRAND ET AL.
TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Nakai, Nin, Noma, Japan Retrospective chart review. 1,029 patients aged DSM-5 criteria. 9.2% met ARFID criteria and 24.6% met AN criteria. All ARFID 2b
Teramukai, & 15–40 years, 98.8% female, who sought patients were female.
Wonderlich, 2016 treatment for an ED between 1990 and 2005.
Nakai et al., 2017 Japan Retrospective chart review. Interviews conducted DSM-5 criteria. All ARFID patients were female. None of them reported binge 3b
with participants and/or their parents. eating, purging behaviors, or excessive physical exercise. All
134 female patients aged 15–40 years, who ARFID patients had amenorrhea.
sought treatment for an ED between 1990 and
1997 and who retrospectively met criteria for
ARFID or AN.
Nicely, Lane-Loney, USA Retrospective chart review. 173 patients aged DSM-5 criteria. 22.5% met ARFID criteria, all of whom had a prior DSM-IV 3b
Masciulli, 7–17 years, 92% female, admitted to a day EDNOS diagnosis. ARFID patients were younger (11.1 vs
Hollenbeak, & program for children and adolescents with EDs. 14.2 years) and more often male (20.5% vs 4.5%) compared
Ornstein, 2014 to other patients. No significant differences in BMI.
Norris et al., 2014 Canada Retrospective chart review. 699 patients assessed DSM-5 criteria. ~5% met ARFID criteria. The ARFID group was younger than 2b
through a pediatric tertiary care hospital program the AN group (13.7 vs 14.9 years), more often aged
between 2000 and 2011. <12 years (41.2% vs 2.9%), more often male (20.6% vs
8.3%, not significant), and less often required hospitalization
(24% vs 53%). BMIs did not differ. Most common symptoms
associated with ARFID were abdominal pain (35.3%), fear of
vomiting (26.5%), generalized anxiety (20.6%), feeling full
(20.6%), nausea (17.6%), and unpleasant sensory
experiences (17.6%).
Norris et al., 2018 Canada Retrospective chart review with assignment of DSM-5 criteria. All ARFID patients could be assigned into one of the 2b
three hypothetical subtypes based on clinical hypothesized subtypes. 39% classified as “ARFID-limited
experience. 77 patients with ARFID aged intake,” 18% as “ARFID-limited variety,” and 43% as
8–17 years, 73% female, at a tertiary care “ARFID-aversive.” 22% of cases could be classified as more
pediatric hospital between 2000 and 2017. than one of the subtypes. The “limited variety” group had a
significantly longer illness duration compared to “aversive”
group. The “aversive” group was admitted into tertiary care
more often than other groups. There does not appear to be
a “typical” case of ARFID and this subtyping approach may
better capture the clinical complexities.
Ornstein et al., 2013b USA Retrospective chart review. 215 patients aged Proposed DSM-5 criteria. 14% of participants met ARFID criteria. All ARFID patients had 2b
8–21 years, 88.6% female, with an ED a current DSM-IV EDNOS diagnosis. ARFID patients were
presenting for initial evaluation. underweight but had significantly higher BMI than those
meeting AN criteria.
Ornstein, Nicely, USA Retrospective chart review. 173 patients aged Proposed DSM-5 criteria. 22.5% met ARFID criteria. The ARFID group was younger n/a
Lane-Loney, 7–16, predominantly female, admitted to an ED than the non-ARFID group and had a greater proportion of
Masciulli, & day treatment program. men (20.5% vs 4.5%).
Hollenbeak, 2013a
Pinhas et al., 2017 Canada, Latent class analysis of clinician-recorded data. DSM-5 criteria. Patients in ARFID cluster were significantly younger than 1b
Australia, Secondary analysis of pooled data from three those in AN cluster.
and UK sites. 436 children aged ≤12 years with newly
diagnosed restrictive ED.

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7
 8

TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
Sieke, Strandjord, USA Retrospective chart review. 41 patients with DSM-5 criteria. Groups did not differ in body weight, but weight loss prior to n/a
Richmond, Rome, & ARFID, 145 patients with AN-R, and 58 patients presentation was greater in AN groups compared to ARFID
Khadilkar, 2016 with AN-BP. groups. ARFID patients more often relied on tube feeding.
Strandjord, Sieke, USA Retrospective chart review. 318 patients aged DSM-5 criteria. 13% met ARFID criteria and 64% met AN criteria. ARFID 2b
Richmond, & Rome, 9–25 years hospitalized because of an ED and group presented at younger age, reported lower weight
2015 treated using a refeeding protocol. before illness onset and less weight loss before admission.
38% of ARFID group reported emetophobia, 26%
abdominal pain.
Williams et al., 2015 USA Chart review. 422 children aged 4–219 months, 3 of 4 DSM-5 criteria, 19.7% demonstrated insufficient growth (ARFID criterion 1). 3b
68.0% male, referred to a multidisciplinary explicitly omitting the 17.1% demonstrated nutritional deficiency (defined as
pediatric feeding program. fourth criterion eating 10 or less foods monthly; ARFID criterion 2). 16.8%
“marked interference were dependent on tube feeding and 37.7% received oral
in psychosocial liquid nutritional supplements (ARFID criterion 3). 69% met
functioning” one of these three ARFID criteria, but after exclusion
criteria were applied only 32% met ARFID criteria.
Determining what constitutes a nutritional supplement
(A3 criterion) is not a straightforward task. In contrast to
other studies, here neglect is seen as an exclusion criteria
since food restriction cannot be due to inadequate access.
Zickgraf & Ellis, 2018 USA Exploratory and confirmatory factor analysis of Eating behaviors as A three-factor (“picky” eating, appetite, fear) solution was 2c
NIAS. Three samples: (1) 505 parents of children described in ARFID generated, supporting the addition of three ARFID
aged 5–17 years, 69.5% mothers, recruited case studies and chart subdomains to the DSM: “Picky” eating, poor appetite/
through a nationally representative research reviews. limited interest in eating, and fear of negative
panel service. (2) 455 adults, 48.6% female, consequences.
recruited from Amazon's Mechanical Turk
website. (3) 311 college undergraduates, 68.6%
female.
Reviews and commentaries
Hay et al., 2014 n/a Guidelines for treatment of EDs. DSM-5 criteria. 21.2%-35.2% of children aged <12 years presenting with 3a
weight loss and food avoidance do not report abnormal
body image or fear of weight gain.
Herpertz-Dahlmann, n/a Narrative review. DSM-5 criteria. Clinicians often find it difficult to distinguish ARFID from 5
2017 childhood AN. If ARFID symptoms are associated with
parental neglect, they typically vanish with a change in
caregivers.
Hoek & van Elburg, n/a Narrative review. DSM-5 criteria. In ARFID, unlike other EDs, there is an equal male–female 5
2014 distribution.
Kelly, Shank, Bakalar, & Narrative review. DSM-5 criteria. ARFID prevalence is unknown. There is a significant 5
Tanofsky-Kraff, 2014 heterogeneity in the clinical presentation. Health
consequencs of ARFID may closely mimic AN (including
hypothermia, bradycardia, anemia, halitosis, tooth decay,
and electrolyte imbalances). There is a paucity of research
on psychosocial functioning in ARFID.

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TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Kreipe & Palomaki, n/a Narrative review (including illustrative case reports) Proposed DSM-5 criteria. There have been two approaches in creating alternative 5
2012 systems for the classification of feeding and EDs not
associated with body image or weight concerns: viewing
them as “shared” disorders between caregiver and child or
classifying subgroups. Several such systems are reviewed,
current DSM-IV criteria are critiqued, and the proposed
DSM-5 criteria are introduced.
Mahapatra, Gupta, & n/a Systematic review. DSM-5 criteria. ARFID patients are often younger than in other EDs, and the 3a
Sagar, 2015 female preponderance is less marked.
Mairs & Nicholls, 2016 n/a Narrative review. DSM-5 criteria. ARFID prevalence range from 5% to 23%. ARFID is a broad 5
term that encompasses a variety of clinical presentations,
including a lack of interest in food, heightened sensitivity to
food texture, and fear of choking.
Mammel & Ornstein, n/a Narrative review. DSM-5 criteria. Presentations that would now meet ARFID criteria have long 5
2017 been recognized. Five subtypes suggested by the literature
are outlined: sensory food avoidance, emotional or
anxiety-based food avoidance, fear-based food avoidance,
temperament-based food avoidance, and medical
symptom-related food avoidance.
Norris & Katzman, 2015 n/a Commentary. DSM-5 criteria. The previous DSM-IV category “feeding disorder of infancy 5
and early childhood” was rarely used and available
epidemiological information are thus limited. ARFID
patients are consistently younger and more likely to be male
compared to other EDs.
Norris et al., 2016b n/a Narrative review (including illustrative case report). DSM-5 criteria. ARFID was introduced in an attempt to capture a group of 5
patients with impaired and distressing eating behaviors in
the absence of weight and body image concerns. ARFID
prevalence range from 5% to 14% in pediatric inpatient ED
programs and as high as 22.5% in a pediatric ED day
treatment program.
Thomas et al., 2017b n/a Narrative review. DSM-5 criteria. Little is known about etiology, incidence, prevalence, 5
assessment, longitudinal course, outcome, or treatment
efficacy. A three-dimensional model with biological
abnormalities in sensory perception, homeostatic appetite,
and fear responsiveness underlying three primary ARFID
presentations (sensory sensitivity, lack of interest in eating,
and fear of aversive consequences) is introduced, whereby
it is hypothesized that any individual presentation can be
plotted along such a three-dimensional,
non-mutually-exclusive space.
Zimmerman & Fisher, n/a Narrative review. DSM-5 criteria. ARFID does not have an age restriction but is mostly 5
2017 diagnosed in older children/younger adolescents. Etiology is
heterogeneous. ARFID patients are consistently younger
and more likely to be male.

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9
TABLE 2 (Continued)
10

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
FEIGHNER CRITERION 2: LABORATORY FINDINGS, PSYCHOLOGICAL TESTS, OR TREATMENT EFFECT
Original research
Brewerton & USA Case series with retrospective chart review. DSM-5 criteria. Adjunctive olanzapine in low doses facilitated recovery by 4
D'Agostino, 2017 9 patients aged 9–19 years, 8 females and promoting eating and weight gain and by relieving related
1 male, with ARFID receiving olanzapine as part symptoms of anxiety, depression, and cognitive impairment.
of their treatment.
Dovey, Aldridge, Martin, UK Receiver operating characteristic analysis of the DSM-5 criteria (but A favorable outcome for BPFAS was found, with high scores 2c
Wilken, & Meyer, longer BPFAS and the 6-item CFNS. Two equating ARFID and for sensitivity and specificity. CFNS achieved acceptable
2016 samples: (1) 301 mothers of children from a “feeding disorders” in results. The similarities between the two questionnaires
variety of locations. (2) 28 parents of children parts of the text). allow both to differentiate a clinical sample. BPFAS can
meeting ARFID criteria through dependence of differentiate ARFID cases in extreme CFSN scorers.
oral liquid nutritional supplements.
Ellis, Zickgraf, Whited, & USA Creation of the new instrument APEQ by DSM-5 criteria with Content analysis and factor analysis generated an 18-item 2c
Galloway, 2017b qualitative content analysis of questionnaire specific focus on four-factor (meal presentation, food variety, meal
about eating behaviors and attitudes and selective eating subset. disengagement, and taste aversion) scale. Taste aversion
subsequent factor analysis. Three samples: was the only subscale that did not predict psychosocial
(1) 28 self-identified adult “picky” eaters, 53.6% impairment, possibly because of the clear biological origins
female. (2) 296 self-identified adult “picky” of taste sensitivity.
eaters, 59.1% female. (3) 1339 adults, 60.0%
female. All samples recruited from Amazon's
Mechanical Turk website.
Ellis, Zickgraf, Whited, & USA Receiver operating characteristic analysis of NIAS DSM-5 criteria with 2.5% in general sample and 14.4% in selective sample met n/a
Galloway, 2017c and APEQ. Two samples: (1) 1,219 college specific focus on ARFID criteria. Both NIAS and APEQ demonstrated good
students, and (2) 450 adults recruited specifically selective eating subset. sensitivity and specificity. Higher cutoff values should be
for eating difficulties. used in selective samples.
Kauer, Pelchat, Rozin, & USA Two substudies: (1) Questionnaire about selective Selective eating “Picky” group rated both sweet and bitter flavors are more 2c
Zickgraf, 2015 eating. (2) Ratings of taste stimuli (quinine (described in terms of intense than “nonpicky” group.
sulphate and sucrose) in three concentrations. ARFID in the
(1) 489 adults, 62.5% female, mean age 37 years, discussion section).
solicited at local courthouse or through
advertisements. (2) 34 adults from study 1 (16 in
selective eating group, 18 in nonselective eating
group) who agreed to be recontacted.
Kurz et al., 2016 Switzerland Factor analysis of newly constructed self-report DSM-5 criteria combined Exploratory factor analysis resulted in a four-factor solution 2c
instrument EDY-Q. 1,444 schoolchildren aged with Great Ormond covering FAED, selective eating, functional dysphagia, and
8–13 years, 53.9% female. Street criteria and weight problems.
related literature.
Mancuso et al., 2017 USA Ghrelin blood analysis in fasting and at several DSM-5 criteria. Higher fasting levels of ghrelin were found in AN compared to n/a
time-points following a standardized meal. ARFID and healthy controls. Postmeal decrease in ghrelin
66 adolescent females (34 with typical and was more pronounced in AN than in ARFID.
atypical AN, 6 with ARFID, and 26 healthy
controls), mean age 18.1 years.
Nakai et al., 2017 Japan Retrospective chart review. Interviews conducted DSM-5 criteria. ARFID group scored significantly lower on all subscales of the 3b
with participants and/or their parents. of EAT and EDI.
134 female patients aged 15–40 years, who
sought treatment for an ED between 1990 and
1997 and who retrospectively met criteria for
ARFID or AN.
STRAND ET AL.

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TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Nicely et al., 2014 USA Retrospective chart review. 173 patients aged DSM-5 criteria. ARFID group displayed significantly lower total scores on 3b
7–17 years, 92% female, admitted to a day ChEAT.
program for children and adolescents with EDs.
Norris et al., 2014 Canada Retrospective chart review. 699 patients assessed DSM-5 criteria. ARFID patients displayed lower bone mineral density in the 2b
through a pediatric tertiary care hospital program lumbar spine compared to patients with AN, possibly
between 2000 and 2011. reflecting a longer duration of illness in the ARFID group.
Ornstein, Essayli, Nicely, USA Retrospective chart review. 166 patients (same DSM-5 criteria. In contrast to the AN group, total ChEAT scores were 2b
Masciulli, & population as in Nicely et al. above, but subclinical at intake in the ARFID group.
Lane-Loney, 2017 7 additional patients were excluded for different
reasons).
Schmidt, Hiemisch, Germany Development and validation of the child and parent DSM-5 criteria. 28% of children with ARFID symptoms received ARFID n/a
Wieland, & Hilbert, ARFID module of ChEDE. Nonclinical sample of diagnosis. ARFID module displayed high validity and
2017 25 children with ARFID symptoms compared reliability.
with matched control group of children without
ARFID symptoms. 41% girls and mean age
10.8 years in both groups. Parents completed
parts of the questionnaires.
Sharp et al., 2017b USA Two studies: (1) Double-blind placebo-controlled Dependence on enteral (1) Mealtime behaviors improved significantly in both groups, 1b-
study with randomization to behavioral feeding or oral but D-cycloserine further enhanced intervention response,
intervention + D-cycloserine or behavioral nutritional formula rapidly increasing food acceptance, reducing disruptive
intervention + placebo. 16 children aged supplementation. behaviors, and decreasing the number of meals required to
18 months-6 years, 37.5% female, with ARFID achieve accepted clinical benchmarks. (2) Augmentation of
according to specific criteria. (2) Rodent study avoidance extinction with D-cycloserine was associated with
with postmortem dendritic spine imaging. structural plasticity of dendritic spines in the orbitofrontal
cortex in mice.
Zickgraf & Ellis, 2018 USA Exploratory and confirmatory factor analysis of Eating behaviors as A three-factor (“picky” eating, appetite, fear) solution was 2c
NIAS. Three samples: (1) 505 parents of children described in ARFID generated.
aged 5–17 years, 69.5% mothers, recruited case studies and chart
through a nationally representative research reviews.
panel service. (2) 455 adults, 48.6% female,
recruited from Amazon's Mechanical Turk
website. (3) 311 college undergraduates, 68.6%
female.
Reviews and commentaries
Mairs & Nicholls, 2016 n/a Narrative review. DSM-5 criteria. Appetite stimulant cyproheptadine can be considered when 5
psychological and nutritional interventions have not been
successful.
FEIGHNER CRITERION 3: DELIMITATION FROM OTHER DISORDERS
Original research
Bryson, Scipioni, & USA Retrospective chart review. 20 patients with DSM-5 criteria. 95% of ARFID patients had initially been diagnosed with n/a
Ornstein, 2017 ARFID, mean age 11.4 years, 70% female, psychiatric comorbidity, most commonly GAD (75%).
admitted to an ED day hospital.
Cooney, Lieberman, USA Retrospective chart review. 31 children and DSM-5 criteria. ARFID group represented 8% of all patients. 61.5% had n/a
Guimond, & Katzman, adolescents with ARFID, mean age 13.2 years, psychiatric comorbidity. None of the patients scored within
2017 64.5% female. the clinical range on ED specific rating scales.

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11
TABLE 2 (Continued)
12

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
Eddy et al., 2015 USA Retrospective chart review. 2,231 patients aged Proposed DSM-5 criteria. 1.5% of patients pediatric gastroenterology patients met 2b
8–18 years, 53.4% female, presenting for initial ARFID criteria.
evaluation in a network of pediatric
gastroenterology clinics.
Fisher et al., 2013 USA and Canada Retrospective case–control study. 98 patients aged Proposed DSM-5 criteria. ARFID group more often had a medical condition compared to n/a
8–18 years that met ARFID criteria presenting non-ARFID group.
to seven adolescent-medicine ED programs.
Fitzgerald & Frankum, Australia Modified Munich ED-Quest questionnaire with DSM-5 criteria 79% avoided or restricted certain foods in their diet, most 2c
2017 subjective rating of food avoidance, affect on acknowledged, but commonly due to concerns about aversive consequences
everyday life, weight change, and lifetime need reported food such as allergies (84%), sensory characteristics (30%), or
of nutritional supplements or tube feeding. avoidance per se functional dysphagia (16%). Of those who avoided food due
102 patients aged >18 years, 69% female, at an equated with ARFID in to an allergy, only 73% had a confirmed allergy diagnosis.
immunology clinic and a general practice clinic. interpretation of
findings.
Izquierdo et al., 2017 USA Implicit association tests of thinness and dieting. DSM-5 criteria. Stronger bias towards thinness and dieting was found in AN n/a
74 females (31 with AN, 6 with nonfat phobic and nonfat phobic AN compared to ARFID and healthy
AN, 7 with ARFID, and 30 healthy controls), controls.
mean age 17.9.
Nakai et al., 2016 Japan Retrospective chart review. 1,029 patients aged DSM-5 criteria. Contributing factors in ARFID group were emotional problems 2b
15–40 years, 98.8% female, who sought (83.2%), gastrointestinal symptoms (42.1%), and other
treatment for an ED between 1990 and 2005. reasons such as fear of choking (10.5%).
Nakai et al., 2017 Japan Retrospective chart review. Interviews conducted DSM-5 criteria. Contributing factors in ARFID group were emotional problems 3b
with participants and/or their parents. (55.6%) and gastrointestinal symptoms (70.3%).
134 female patients aged 15–40 years, who
sought treatment for an eating disorder between
1990 and 1997 and who retrospectively met
criteria for ARFID or AN.
Nicely et al., 2014 USA Retrospective chart review. 173 patients aged DSM-5 criteria. ARFID group had a significantly higher comorbidity of anxiety 3b
7–17 years, 92% female, admitted to a day disorders (72% vs 31%), autism spectrum disorder (13% vs
program for children and adolescents with EDs. 0%), learning disorders, cognitive impairment, and attention
problems compared to patients with other EDs. In contrast,
the ARFID group had a lower comorbidity of depression
(23% vs 57%). Although ARFID patients did not have true
body image distortion, 21% exhibited body preoccupation
with somatic concerns.
Norris et al., 2014 Canada Retrospective chart review. 699 patients assessed DSM-5 criteria. Most common symptoms associated with ARFID were 2b
through a pediatric tertiary care hospital program abdominal pain (35.3%), fear of vomiting (26.5%),
between 2000 and 2011. generalized anxiety (20.6%), feeling full (20.6%), nausea
(17.6%), and unpleasant sensory experiences (17.6%). In
both ARFID and AN, high levels of comorbid anxiety
disorders (17.5% vs 21.6%) and depression (25% vs 12%)
were seen. Children often describe anxiety as causing
abdominal symptoms, nausea, or lack of appetite, and some
may restrict food intake as a maladaptive coping strategy.

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STRAND ET AL.
TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Ornstein et al., 2013a USA Retrospective chart review. 173 patients aged Proposed DSM-5 criteria. ARFID group had more often seen other medical specialists n/a
7–16, predominantly female, admitted to an ED before entering the program (46.2% vs 26.1%).
day treatment program.
Pinhas et al., 2017 Canada, Latent class analysis of clinician-recorded data. DSM-5 criteria. Two clusters were found, consistent across three countries: 1b
Australia, Secondary analysis of pooled data from three Cluster 1 characterized by a typical AN presentation (weight
and UK sites. 436 children aged ≤12 years with newly preoccupation, fear of becoming fat, distorted body image,
diagnosed restrictive ED. and excessive physical exercising) and a distinct cluster
2 more consistent with an ARFID presentation (less likely to
be concerned about weight or shape, no perceptual
disturbance in how they experienced their bodies, less
physical exercise, and more somatic complaints). Patients in
ARFID cluster (25%-34% of the sample) were significantly
younger, had more somatic complaints, and a longer
duration of illness prior to initial diagnosis. ARFID cluster
more often had a comorbid psychiatric disorder compared
to the AN cluster (63.0% vs 47.1%); however, whereas an
anxiety disorder was more common in the ARFID cluster
(40.7% vs 27.0%), depression and OCD were less common
(11.1% vs 17.2% and 6.5% vs 12.7%, respectively [not
significant]).
Strandjord et al., 2015 USA Retrospective chart review. 318 patients aged DSM-5 criteria. 38% of ARFID group reported emetophobia, and 26% 2b
9–25 years hospitalized because of an ED and abdominal pain. Psychiatric comorbidity was 3 times more
treated using a refeeding protocol. common in AN group (42% vs 12%).
Toufexis et al., 2015 USA Assessment of patients with PANS/PANDAS and DSM-5 criteria. 66% reported food restriction secondary to contamination 2b
new, abrupt onset of eating restrictions or food fears (involving germs, poison, allergens, bleach, illicit drugs,
avoidance. 29 children aged 5–12 years, 69% or “the essence and personality of other people”). 28%
male. expressed fear of vomiting. 21% expressed fear of choking.
17.2% refused to swallow their own saliva. All children
reported OCD symptoms. These PANS/PANDAS cases
meet ARFID criteria. In contrast to “typical” ARFID cases,
the onset of food restriction was rapid and the patients did
not have a history of selective eating. Management also
differ, as treatment with antibiotics or immunomodulatory
therapies is often curative.
Zia, riddle, DeCou, USA Online survey using measures for both functional DSM-5 criteria. 28% of patients with functional gastrointestinal disorders met n/a
McCann, & gastrointestinal disorders and EDs. 64 patients cutoff scores suggestive of an underlying ED. 21% met
Heitkemper, 2017 with functional gastrointestinal disorders, mean ARFID criteria.
age 43 years, 77% female.
Zickgraf, Ellis, USA Screening for ARFID via self-report measures. Two DSM-5 criteria, with the ARFID group was associated with anxiety and depression. n/a
Franklin, & Whited, samples: (1) 1,219 college students and (2) 450 addition of a
2017 adults recruited specifically for eating difficulties. nonspecified
“subclinical ARFID”
group.
Reviews and commentaries
Cañas, Serrano, Carulla, n/a Systematic review. DSM-5 criteria. ARFID patients differ significantly from AN patients and may n/a
Sanchez, & San, 2015 require a more intensive level of care.

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13
TABLE 2 (Continued)
14

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
Dovey, Wilken, n/a Narrative review. Not detailed. Authors note that the placement of a nasogastric or 5
Martin, & Meyer, gastrostomy tube instantly ascribes the child with a
2017 diagnosable psychiatric disorder.
Kennedy, Wick, & Keel, n/a Narrative review. DSM-5 criteria. ARFID's history in the DSM suggests that it should be viewed 5
2018 as a feeding disorder, although emergent research suggests
that it might be viewed as an ED by the ED community.
ARFID is distinct from EDs in terms of comorbidity, age of
presentation, referral source, gender distribution, and
outcomes. However, ARFID demonstrates key similarities
to AN regarding symptoms of underweight and rigid food
rules, potential transition to cognitive restraint, and
treatment. ARFID may thus be conceptualized both as a
feeding disorder or an ED depending on the clinical
presentation.
Krom, de winter, & n/a Narrative review. DSM-5 criteria. ARFID replaces previous diagnostic category that was not 5
Kindermann, 2017 sufficient for tube-dependent children when weight loss
was prevented by the tube feeding.
Mahapatra et al., 2015 n/a Systematic review. DSM-5 criteria. Rates of co-morbidity are higher in ARFID than in other EDs. 3a
Mairs & Nicholls, 2016 n/a Narrative review. DSM-5 criteria. It can be difficult to distinguish ARFID from AN and careful 5
assessment is needed to ascertain if AN cognitions are
maintaining the eating problem. As ARFID can develop into
AN, reassessment is vital. Neurological, gastroenterological,
or neurodevelopmental disorders underlie some
presentations. A “failure to thrive” ethiology in a context of
abuse or neglect is sometimes seen.
Mammel & Ornstein, n/a Narrative review. DSM-5 criteria. Similarities between ARFID and PANS/PANDAS are noted. 5
2017
Norris & Katzman, 2015 n/a Commentary. DSM-5 criteria. ARFID patients display higher rates of psychiatric and somatic 5
comorbidity compared to other EDs. Patients with a current
DSM-IV ED diagnosis may receive a new diagnosis when
reevaluated, which may be confusing.
Norris et al., 2016b n/a Narrative review (including illustrative case report). DSM-5 criteria. ARFID patients may restrict food intake due to stress or 5
trauma, fear about “dangerous” foods or chemicals, pain,
fear of choking or vomiting, taste or texture sensitivity, or
stressful emotions at mealtime. “Picky eating” is a vague and
heterogeneous term that does not necessarily entail
psychosocial impairment. ARFID is introduced as a more
appropriate diagnostic approach.
Reas, Zipfel, & Rø, 2014 n/a Systematic review of achalasia and its clinical DSM-5 criteria. In patients with achalasia, a concurrent ARFID diagnosis may 3a
presentation in EDs. occasionally be considered.
Sharp, Volkert, Scahill, n/a Systematic review and meta-analysis Dependence of enteral Reports results on tube weaning, etc. All reviewed studies 2a
McCracken, & feeding or oral reported a high frequency of co-occurring medical
McElhanon, 2017a nutritional formula problems, such as gastroesophageal reflux, failure to thrive,
supplements. or unspecified gastrointestinal concerns. ARFID concept
only utilized in methods section.

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STRAND ET AL.
TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Uher & Rutter, 2012 n/a Narrative review. Proposed DSM-5 criteria. ARFID overlaps with AN but differs in psychopathology and 5
motives. Boundaries between ARFID and nonfat phobic AN
presentations need to be explored.
Zimmerman & Fisher, n/a Narrative review. DSM-5 criteria. ARFID patients have higher rates of psychiatric and somatic 5
2017 comorbidity compared to patients with other EDs. ARFID is
classified as a psychiatric disorder and impaired
psychosocial functioning should thus be a required criterion,
not optional. Previously described PANS/PANDAS cases as
well as children with pervasive refusal syndrome meet
ARFID criteria.
FEIGHNER CRITERION 4: COURSE OVER TIME
Original research
Bryson et al., 2017 USA Retrospective chart review. Patients grouped into DSM-5 criteria. At follow-up (31 months on average), 75% described n/a
three hypothetical subtypes: (1) anxiety and/or themselves as mostly or fully recovered. Subtype 3 had the
gastrointestinal symptoms, (2) inadequate/ highest rate of self-reported recovery.
restricted food intake, and (3) fear of choking or
vomiting. 20 patients with ARFID, mean age
11.4 years, 70% female, admitted to an ED day
hospital.
Fisher et al., 2013 USA and Retrospective case–control study. 98 patients aged Proposed DSM-5 criteria. ARFID group had a longer duration of illness compared to n/a
Canada 8–18 years that met ARFID criteria presenting non-ARFID group.
to seven adolescent-medicine ED programs.
Fisher et al., 2014 USA and Retrospective chart review. 712 patients aged DSM-5 criteria. Illness duration at baseline was 33.3 months on average in 2b
Canada 8–18 years, presenting to seven ARFID group compared to 14.5 months in AN group and
adolescent-medicine ED programs. 23.5 months in the BN group.
Forman et al., 2014 USA Retrospective chart review at intake and 1-year DSM-5 criteria. No significant differences between ARFID and AN in terms of 2b
follow-up. 700 outpatients aged 9–21 years with being underweight or in weight recovery. No treatment had
a restrictive ED. a statistically significant effect. ARFID patients were less
likely to be followed for 1-year duration; this was possibly
due to drop-out because they needed other types of
treatment than AN patients, because providers were
uncertain about appropriate follow-up, and because they
were more likely to be male.
Guss, Richmond, & USA Survey study. 83 US-based physician members of DSM-5 criteria. 45% completed survey. 73% of responders admitted ARFID n/a
Forman, 2017 adolescent health and ED interest groups. patients for medical stabilization. Of those who did, 50% did
not use any protocol for nutritional resuscitation. Of those
who used a protocol, 55% used protocols developed for AN
patients and only 23% reported having a non-AN refeeding
protocol for ARFID patients.
Nakai et al., 2017 Japan Retrospective chart review. Interviews conducted DSM-5 criteria. ARFID group displayed a significantly shorter duration of 3b
with participants and/or their parents. illness than AN group (15.5 vs 36.5 months on average) and
134 female patients aged 15–40 years, who showed significantly better outcome than AN group (51.9%
sought treatment for an ED between 1990 and vs 35.5% achieved full recovery over a mean of 7 years).
1997 and who retrospectively met criteria for 15.0% in AN group, but none in ARFID group, died before
ARFID or AN. follow-up.

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15
TABLE 2 (Continued)
16

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
Nicely et al., 2014 UK Retrospective chart review. 173 patients aged DSM-5 criteria. No significant difference in illness duration between patients 3b
7–17 years, 92% female, admitted to a day with ARFID and other EDs.
program for children and adolescents with EDs.
Ornstein et al., 2013a USA Retrospective chart review. 173 patients aged Proposed DSM-5 criteria. ARFID group had more often seen other medical specialists n/a
7–16, predominantly female, admitted to an ED before entering the program than non-ARFID group (46.2%
day treatment program. vs 26.1%).
Ornstein et al., 2017 USA Retrospective chart review. 166 patients (same DSM-5 criteria. 24.6% met ARFID criteria. Patients in ARFID group had a 2b
population as in Nicely et al. above, but significantly shorter length of stay in the program compared
7 additional patients were excluded for different to AN group. ARFID group exhibited weight restoration
reasons). sooner than AN group and similar improvements on
measures of food restriction and anxiety.
Peebles et al., 2017 USA 4-week follow-up study of patients in an inpatient DSM-5 criteria. 4% met ARFID criteria. ARFID patients were more likely to 4
nutritional rehabilitation program after discharge. require nasogastric feeding compared to patients with other
215 patients aged 5–23 years, 88% female. eating disorders (23% vs 8%). Similar levels of weight gain
seen in patients with ARFID, AN, and atypical AN.
Pinhas et al., 2017 Canada, Latent class analysis of clinician-recorded data. DSM-5 criteria. The cluster identified as the ARFID group had been ill for a 1b
Australia, Secondary analysis of pooled data from three duration of 36.0 weeks on average, compared to
and UK sites. 436 children aged ≤12 years with newly 28.6 weeks in the cluster identified as the AN group.
diagnosed restrictive ED.
Sharp et al., 2016 USA Randomized 5-day iEAT intervention (touch screen Dependence on enteral Intervention group showed significantly greater increase in 1b-
collection of mealtime data and manual based feeding or oral bites accepted compared to controls (88.9% vs 5.6%) and a
behavioral treatment) vs waiting list. 20 children nutritional formula significant increase in the volume of food consumed, which
(10 in intervention group, 10 controls) aged supplementation and was even greater at 36-day follow-up than
1–6 years with ARFID according to specific presence of postintervention.
criteria. 9 participants relied on tube feeding, volume-based rather
11 participants on nutritional formula. than variety-based
feeding concerns.
Strandjord et al., 2015 USA Retrospective chart review. 318 patients aged DSM-5 criteria. Similar weight gain was seen during hospitalization but ARFID 2b
9–25 years hospitalized because of an ED and group was nevertheless hospitalized longer (8 vs 5 days).
treated using a refeeding protocol. Similar number of readmissions within 1 year. Higher 1-year
remission rate in ARFID group (62% vs 46%, not significant).
Strandjord et al., 2016 USA Retrospective chart review. 29 patients with DSM-5 criteria. Duration of illness and weight loss were similar at n/a
ARFID and 40 patients with AN aged presentation in both groups. At 6-month follow-up, AN
8–25 years. group was more likely than ARFID group to have received
family-based treatment (80% vs 15%). More ARFID patients
required hospitalization (18% vs 5%). More AN patients
achieved weight restoration (85% vs 54%).
Reviews and commentaries
Dent, 2017 n/a Letter to the editor. DSM-5 criteria. Undernutrition and weight-loss is common in aging persons 5
due to appetite loss, dysphagia, frailty, depression,
dementia, poverty, and so forth. ARFID may be an relevant
diagnosis in such cases and should be further researched in
the geriatric population.
Hay et al., 2014 n/a Guidelines for treatment of EDs. DSM-5 criteria. There is a paucity of data on ARFID in older adolescents and 3a
adults. The most important challenge for future research is
the elucidation of assessment and treatment of ARFID.
STRAND ET AL.

(Continues)
TABLE 2 (Continued)

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
STRAND ET AL.

Hoek & van Elburg, n/a Narrative review. DSM-5 criteria. Duration of illness at clinical presentation is often 5
2014 considerable in ARFID.
Kelly et al., 2014 Narrative review. DSM-5 criteria. Data on treatment consist mainly of case reports. 5
Kennedy et al., 2018 n/a Narrative review. DSM-5 criteria. ARFID patients are are less often self-referred compared to 5
patients with other EDs.
Lock, 2015 n/a Systematic review. DSM-5 criteria. No empirical studies guide treatment for ARFID. ARFID 3a
appears to require individualized behavioral plans to
address specific eating problems. Clinical reports suggest
that behavioral plans, CBT, and family interventions may be
useful.
Mahapatra et al., 2015 n/a Systematic review. DSM-5 criteria. Most studies had been conducted in pediatric populations. 3a
Illness duration in ARFID tends to be longer.
Mammel & Ornstein, n/a Narrative review. DSM-5 criteria. There is no evidence-based treatment for ARFID and it is 5
2017 unlikely that a one-size-fits-most approach will be
identified.
Thomas et al., 2017b n/a Narrative review. DSM-5 criteria. Operationalizing recovery is complex and full-weight 5
restoration may not be realistic.
Zimmerman & Fisher, n/a Narrative review. DSM-5 criteria. It may be clinically helpful to distinguish short-term and 5
2017 long-term ARFID, as treatment and expected outcome may
differ. Short-term ARFID patients generally fare better,
whereas in long-term patients, fully normalized eating
behaviors may not always be a realistic goal.
FEIGHNER CRITERION 5: HERITABILITY
Original research
Norris et al., 2014 Canada Retrospective chart review. 699 patients assessed DSM-5 criteria. AN group were more likely compared to ARFID group to have 2b
through a pediatric tertiary care hospital program immediate family member with a diagnosed psychiatric
between 2000 and 2011. disorder (53% vs 24%).
Strandjord et al., 2015 USA Retrospective chart review. 318 patients aged DSM-5 criteria. A family history of ED and other psychiatric illness was more 2b
9–25 years hospitalized because of an ED and common in AN than in ARFID.
treated using a refeeding protocol.
STUDIES UNRELATED TO ANY OF THE FEIGHNER CRITERIA
Original research
Ellis, Galloway, Webb, USA and Questionnaire study focused on selective eating DSM-5 criteria with Parental pressure to eat in childhood predicted lower adults 3b
Martz, & Farrow, UK among 170 college students, 71.2% female, and specific focus on levels of intuitive eating and higher levels of disordered
2016 one parent self-selected by each participant. selective eating subset. eating behaviors associated with BN, but not drive for
thinness. Childhood selective eating did not predict intuitive
or disordered eating. The new ARFID diagnosis calls for
further study of the stability of selective eating.
Ellis et al., 2017b USA Screening for ARFID with multiple instruments. DSM-5 criteria, with the BMI did not differ across ARFID groups. n/a
1,219 college students. addition of a
nonspecified
“subclinical ARFID”
group.

(Continues)
17
TABLE 2 (Continued)
18

Evidence
Authors Countries Methodology and sample ARFID definition Findings relevant to Feighner criterion level
Ellis et al., 2018 USA Online survey. 1,339 adults, mean age 40.4 years, DSM-5 criteria with Adult selective eating was positively associated with parental 2c
60.0% female, recruited from Amazon's specific focus on pressure to eat in childhood, disgust sensitivity, the
Mechanical Turk website. selective eating subset. presence of a negative experience with food, and BMI.
Authors explicitly state that the study is not about ARFID,
but that the findings may aid in understanding ARFID
etiology and maintenance.
Fisher, Gonzalez, & USA Employing proposed DSM-5 criteria for all new Proposed DSM-5 criteria. 19.4% met ARFID criteria. 2b
Malizio, 2015 outpatients for 16 months. 309 new outpatients
in an adolescent-medicine eating disorders
program.
Maginot, Kumar, Shiels, USA Observational study and retrospective chart DSM-5 criteria. 11.5% were diagnosed with ARFID. A higher initial calorie 3b
Kaye, & Rhee, 2017 review. 87 patients with AN, ARFID or OSFED prescription was not associated with higher risk of
aged 8–20 years treated with a new nutritional electrolyte abnormalities, and so forth.
rehabilitation protocol at an inpatient unit for
patients with malnutrition.
Schreyer et al., 2016 USA Assessment of consecutively admitted underweight DSM-5 criteria. 3.7% of participants had an ARFID diagnosis. Higher levels of 2b
adult inpatients with the perceived coercion perceived coercion were associated with more severe
scale and various illness severity rating scales. eating disorder symptomatology but not with BMI, and
324 adult inpatients, mean age 31.8 years, decreased the likelihood of successful transition to the
94.6% female. partial hospitalization program. No specific data on ARFID
patients are provided.
Seike et al., 2016a Japan Questionnaire study among 655 Yogo teachers in DSM-5 criteria. The encounter rate for ARFID was 10.7%. Highest ARFID 2c
elementary, junior high, senior high, and special encounter rates (14.8%) were found in high schools,
needs schools. followed by junior high schools (11.1%), elementary schools
(10.0%), and special needs schools (6.3%).
Seike et al., 2016b Japan Questionnaire study among 1,886 Yogo teachers in DSM-5 criteria. The encounter rate for ARFID was 13%. 58.8% reported that 2c
elementary, junior high, senior high, and special they lack adequate knowledge about ARFID.
needs schools.
Tanaka et al., 2015 Japan Retrospective chart review. 45 female inpatients DSM-5 criteria. 8.9% met ARFID criteria. 4
aged >17 years.
Zickgraf, Franklin, & USA Two nonclinical samples assessed for selective DSM-5 criteria. 33% in sample 1 self-identified as “picky” eaters. 3.1% in 2c
Rozin, 2016 eating and associated factors: (1) 332 adults, sample 1 and 44.4% in sample 2 met ARFID criteria. Degree
mean age 33.9 years, recruited from Amazon's of self-reported sensory sensitivity did not strongly
Mechanical Turk website. (2) 81 adults, mean differentiate among “picky” eaters with or without ARFID.
age 40.4 years, recruited from online support
group for adult selective eaters.
Zickgraf & Schepps, USA Two nonclinical online samples assessed for DSM-5 criteria. Selective eaters reported eating less varied diets than 2c
2016 selective eating, dietary variety, and associated nonselective eaters, and variety was particularly low for
factors: (1) 139 adults, mean age 35.4 years, vegetables, fruit, and fish. Selective eaters reported fewer
54.7% male, recruited from Amazon's daily servings of vegetables and fruit, findings that were
Mechanical Turk website. (2) 329 adults, mean more pronounced among those who expressed ARFID
age 35.5 years, 50.5% female, recruited symptoms.
Amazon's Mechanical Turk website and from an
online support group for adult selective eaters.

(Continues)
STRAND ET AL.
 STRAND ET AL. 19

publications and three (13%) of the reviews and commentaries, other

Abbreviations: AN = anorexia nervosa; AN-BP = anorexia nervosa, binge-purge subtype; AN-R = anorexia nervosa, restrictive subtype; APEQ = Adult Picky Eating Questionnaire; ARFID = avoidant/restrictictive food
intake disorder; BMI = body mass index; BN = bulimia nervosa; BPFAS=Behavioral Pediatrics Feeding Assessment Scale; CFNS=Child Food Neophobia Scale; ChEAT = Children's Eating Attitudes Test; ChEDE = child
version of the Eating Disorder Examination; EAT = Eating Attitudes Test; ED = eating disorder; EDI = Eating Disorder Inventory; EDNOS = eating disorder not otherwise specified; EDY-Q = Eating Disorders in Youth
Questionnaire; FAED = food avoidance emotional disorder; GAD = generalized anxiety disorder; n/a = not applicable; NIAS=Nine Item Avoidant/Restrictive Food Intake Disorder Screen; OCD = obsessive–compulsive
disorder; OSFED = other specified feeding and eating disorders; PANDAS = pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection; PANS = pediatric acute-onset neuropsychiatric
Evidence definitions are used. In a number of papers, the focus is on specific
level

3a-
3b
subgroups: six original research publications (12%) focus on selective

5
eating, three papers (two original research publications (4%) and one
female and twice as likely to have comorbid depression or review (4%), all by the same research group) explicitly equate ARFID

The dietician role as interdisciplinary team member is vital in

growth and conflicts regarding food. Authors suggest that

who restrict their food intake and do not meet criteria for
Authors suggest that ARFID diagnosis can be used in adults
with dependence on enteral feeding or oral nutritional formula supple-
social anxiety. Selective eating associated with reduced
Children with severe selective eating more likely to be
20.3% of community sample reported selective eating.

the term “picky eating” is obsolete since ARFID was ments, and one original research publication (2%) omits the criterion
about marked interference in psychosocial functioning. In five original
research publications (10%), a combination of criteria from different
sources or looser definitions is applied. Two of the original research
Findings relevant to Feighner criterion

publications (4%) that do use DSM-5 criteria also add the undefined
category of “subclinical ARFID.” Notably, two narrative reviews (11%)
do not define ARFID criteria at all.
the treatment of ARFID.

Authors also differ in their interpretation of the DSM-5 diagnostic

criteria for ARFID. Whereas a few of the reviews discuss caregiver
neglect as one possible etiological factor in the development of ARFID
(Herpertz-Dahlmann, 2017; Kreipe & Palomaki, 2012), in one original
introduced.

other EDs.

research publication, such neglect is explicitly regarded as an exclusion

criterion as according to the DSM-5 B criterion, the food restriction
cannot be due to a lack of food (Williams et al., 2015).
Potential ARFID subdomains are described in seven original
selective eating subset.

research publications (14%) and two reviews (11%). The most com-
mon subgrouping, reported in five original research publications (10%)
DSM-5 criteria with
specific focus on
ARFID definition

(Eddy et al., 2015; Kurz et al., 2015; Kurz et al., 2016; Norris et al.,
DSM-5 criteria.

Not detailed.

2018; Zickgraf & Ellis, 2018) and one review (5%) (Thomas et al.,
2017b), consists of the three presentations that are used as examples
in the DSM-5. One original research publication (Bryson et al., 2017)
also reports the identification of three subdomains, albeit slightly dif-
ferent ones. One original research paper (Fisher et al., 2014) reports
children in phase 1, and (3) laboratory-based case–
3 phases: (1) primary care questionnaire screening of

control phase with 186 of the children in phase 2.

the identification of six subgroups; however, these groups describe

24–71 months recruited in primary care clinics,
(2) in-home parent interview with 917 of the

characteristics of the study population and are not necessarily equiva-

3,433 children with selective eating aged

Systematic review (although described as

lent to subdomains. Finally, one review (Mammel & Ornstein, 2017)

reports the identification of five subgroups as suggested by the litera-
ture. On closer scrutiny, however, several of these alternative sub-
“subjective review” in title).

group suggestions loosely map onto the three-dimensional model

Methodology and sample

touched upon in the DSM-5.

In those original research papers that apply the full DSM-5 cri-
teria, a number of consistent clinical and epidemiological patterns are
Commentary.

found (Table 2). Overall, patients with ARFID tend to be younger than
patients with other eating disorders and the reported gender propor-
tions among them are less skewed towards female gender, although
girls or women still make up a majority of patients. An exception is the
study by Nakai et al. (2016), in which all ARFID patients were female.
Findings on body weight status are not altogether consistent.
USA and UK

Several studies report no significant differences between patients

Countries

with ARFID and AN in terms of underweight, although patients with

n/a

n/a

AN may experience more weight loss before presentation, indicating

that ARFID patients may more often present with longstanding under-
Reviews and commentaries

weight or faltering growth rather than with acute or subacute weight

Jakubczyk, & Wojnar,
(Continued)

loss. In contrast, one study (Ornstein et al., 2013b) found that patients
Zucker et al., 2015

Michalska, Szejko,

with ARFID presented with a higher body weight than AN patients,

although both groups were underweight.
Kohn, 2016

syndrome.

Of the 24 patients described in the case reports (Table 3),

Authors

2016
TABLE 2

16 (67%) were child or adolescent patients and 8 (33%) were adult

patients (18 years of age or older); the youngest described patient
20 STRAND ET AL.

was 4 years old, whereas the oldest was 64 years old. Thirteen (54%) significantly lower on the Children's Eating Attitudes Test (Nicely
of the patients were boys or men and 11 (46%) were girls or women, et al., 2014; Ornstein et al., 2017) and on all subscales of the Eating
mirroring the higher proportion of male patients compared to other Attitudes Test and the Eating Disorder Inventory (Nakai et al., 2017).
eating disorders found in most of the reviewed studies. Twelve Notably, a couple of these studies (Ellis, Galloway, Webb, & Martz,
patients (50%) had a history of selective eating and/or rigid sensory 2017; Zickgraf & Ellis, 2018) utilize the highly opaque convenience
selectivity and 9 (38%) displayed fears of choking, vomiting, or similar samples of Amazon's Mechanical Turk web panel, the validity of which
negative consequences (such as exacerbation of Crohn's disease [King has, as seen above, been questioned (Landers & Behrend, 2015).
et al., 2015]). In two (8%) of the patient cases, food restriction was at In the only published study on pharmacotherapy in ARFID, a small
least in part due to frontotemporal dementia (Sanders et al., 2016) and uncontrolled case series (Brewerton & D'Agostino, 2017), it was
and nausea caused by Addison's disease (Lazare, 2017), respectively. found that adjunctive olanzapine in low doses promoted eating and
Notably, one patient with a typical AN picture was given an ARFID weight gain and relieved related symptoms of anxiety, depression, and
diagnosis solely based on the fact that she cooperated in treatment cognitive impairment; however, similar effects have previously been
(Sanders et al., 2016). shown in other eating disorders (Aigner, Treasure, Kaye, & Kas-
In sum, despite the utilization of various definitions of ARFID per, 2011).
symptom criteria in the reviewed literature, there are consistent find- In sum, similar to most psychiatric disorders, there are currently
ings regarding epidemiological features such as age and gender pat- no established biomarkers or radiological examinations to aid in distin-
terns that distunguish ARFID from other eating disorders. Notably, as guishing ARFID from other eating and feeding disorders. A number of
seen in Table 1, a majority of these studies have been performed uti- diagnostic rating scales have been developed and have shown promis-
lizing pediatric or age-mixed samples of children, adolescents, and ing results in terms of sensitivity and specificity; however, little is
young adults; in contrast, there is a lack of evidence on ARFID fea- known about how ARFID patients differ from patients with other eat-
tures in adults. Although clinical cases are highly heterogeneous, a ing disorders on these instruments. Pharmacological treatment studies
predominant clinical description of longstanding selective eating that are few and generally of limited evidence value. Thus, the second
is further exacerbated by an aversive experience of some kind Feighner criterion is not currently fulfilled.
emerges from the reviewed case reports. It thus appears that the
DSM-5 diagnostic criteria fulfil the first Feighner criteria. 3.4 | Feighner criterion 3: Delimitation from other
disorders
3.3 | Feighner criterion 2: Laboratory findings,
Whereas the creators of the Feighner criteria point to the necessity of
psychological tests, or treatment effect delimitating clinical entities with similar symptomatology from each
In their initial description of what later came to be known as the other (in analogy with somatic medicine, where a combination of
Feighner criteria, Robins and Guze stated that in the second phase in symptoms such as coughing and blood in the sputum can signify a
establishing diagnostic validity, “chemical, physiological, radiological, number of distinguishable clinical conditions), in ARFID as described
and anatomical (biopsy and autopsy) findings” (Robins & Guze, 1970, in the DSM-5, the common denominator of food avoidance in the
p. 107) should be identified. They also noted that reliable and repro- absence of typical AN cognitions is what constitutes the diagnostic
ducible psychological tests may be equated with laboratory studies in kernel. It has already been established that clinical ARFID presenta-
this context. Later, due to the overall lack of established biological tions are heterogeneous. Judging from the substantial variance in the
markers for psychiatric disorders, this second criterion has often been diagnostic criteria that are utilized in studies that claim to discuss
waivered and replaced by recognizable effects of medication or other ARFID, as described above, there also appears to be somewhat of a
treatment. For the purpose of this review, only studies of biomedical meta-heterogeneity in how the current ARFID criteria are understood
treatment that reflect the focus in the criterion on chemical or physio- and applied.
logical properties (such as pharmacological treatment) will be assessed The literature review identified only one study utilizing a latent
here, whereas studies focusing on outpatient treatment or partial hos- class analysis approach in differentiating between clinical entities
pitalization in general are discussed in relation to the fourth Feighner (Pinhas et al., 2017), lending support to a differentiation between
criterion below. ARFID and AN in pediatrics patients. The studies on ARFID and AN
This review did not reveal any published research on radiological epidemiology summarized above also support the distinction between
findings in humans. Only one study on biomarkers, outlining differ- these two diagnostic entities, although they do not apply a latent class
ences in ghrelin levels between AN and ARFID as a potentially impor- analysis approach.
tant neurobiological underpinning of low appetite (Mancuso et al., Whereas the DSM-5 is fairly straightforward about how to differ-
2017), was found. entiate ARFID from AN, the demarcation toward food restriction due
A number of rating instruments for the assessment of ARFID to another psychiatric disorder or medical condition is more problem-
and/or selective eating have shown good or acceptable sensitivity and atic. The DSM-5 emphasizes that to be classified as ARFID, the symp-
specificity (Table 2). These studies have generally not compared tomatology should not be attributable to a concurrent medical
ARFID/selective eating samples with samples representing other eat- condition or another mental disorder. However, it also states that
ing and feeding disorders. However, compared to patients with other when ARFID symptoms do occur in the context of another condition
eating disorders, ARFID patients have been reported to score or disorder, an ARFID diagnosis can still be accurate in cases where
STRAND ET AL. 21

TABLE 3 Case reports of avoidant/restrictive food intake disorder

How did the ARFID diagnosis

Author(s) and year Country Clinical vignette Outcome inform treatment?
Kreipe & USA Two cases: (1) 14-year-old boy with (1) Patient could extend his (1) Nutritional counseling focused
Palomaki, 2012† multimodal food selectivity (temperature, diet after dietician on “sports nutrition” as
smell, color, consistency, separateness on counseling and SSRI motivational factor in increasing
plate, order of ingestion) since infancy, medication. (2) Rapid the variety of acceptable foods.
which had become problematic in social remission after focus on (2) Treatment focused on
situations. Not much weight loss due to biofeedback. self-regulation and traumatic
meticulous parental attention. experience after the initial
(2) 10-year-old girl with restrictive eating choking incident.
after choking incident. No evidence of
body image or weight concerns.
Bryant-Waugh, UK 13-year-old boy with selective eating Patient could extend his Author notes that a focus on
2013 (breakfast cereal, potato chips, biscuits) diet somewhat after minimizing physical and
and general disinterest in food. BMI 16.5, CBT. nutritional risk may be more
that is, on the lower normal limit. Not realistic than achieving fully
bothered by his own eating habits but nonrestrictive eating patterns.
wanted to be taller and bigger.
Katzman, Stevens, & Canada 10-year-old boy with fear of eating after Not described. Not described. Presents
Norris, 2014 choking episode. Decline in weight and unpublished survey data
faltering growth in height. Denied indicating that two-thirds of
intentional weight loss and body image pediatricians are unfamiliar with
concerns, wanted to be taller and less ARFID and that a third
skinny. inappropriately apply exclusion
criteria.
Lopes, Melo, Curral, Portugal 32-year-old man with choking phobia and Remission after treatment Not described.
Coelho, & fear of swallowing after choking incident with SSRI and CBT.
Roma-Torres, during a meal. No prior mental illness.
2014 Weight loss from BMI 22.9 to 19.6.
Difficulty maintaining work because of
fear of eating lunch with colleagues.
Cecilia et al., 2015 Spain 13-year-old boy with disinterest in food and Not reported. Not described.
selective eating since childhood. Delayed
growth, BMI 13.5. No body image
concerns.
Chandran, Anderson, Australia 17-year-old boy with selective eating (rice, Treated with Authors note that while common
Kennedy, Kohn, & French fries, chicken nuggets, chocolate) anticoagulation therapy, practices used to treat other
Clarke, 2015 since childhood. Below-knee amputation bisphosphonate, and eating disorders should be
during infancy after birth deficiency. vitamin supplements. employed, an individual
Restricted fluid intake after fall accident Maintained a varied diet approach is necessary.
because of difficulty mobilizing to the after dietician
bathroom, had to be hospitalized because counselling.
of dehydration. Weight loss from BMI
26.3 to 20.7. Vitamin deficiencies and
osteoporosis. Neurological deficits were
noted and an MRI scan showed spinal
cord atrophy and venous sinus
thrombosis.
King, Urbach, & USA 41-year-old woman with Crohn's disease as Full remission after CBT. Authors note that CBT may be
Stewart, 2015 a child but no recurrences since helpful in targeting eating related
adolescence. Recent gastroenteritis anxiety in a context of broader
triggered previous fears of eating health fears.
stemming from her experiences of
Crohn's disease, resulting in illness
anxiety, restrictive eating, and weight loss
to BMI 15.5. Denied desire to lose
weight and body image concerns.
Maseroli, 2016 Italy 33-year-old man who underwent right Multidisciplinary approach ARFID may have unfavorable
orchiectomy as a child. Low sexual desire. with dietician endocrine consequences,
Obsessive behaviors in pursuit of a counseling, CBT, and requiring endocrinologist
healthy diet, including fasts and excessive SSRI medication led to consultation.
exercise, leading to social isolation. BMI weight gain to BMI 21.5
18.5. Laboratory tests revealed numerous and normalization of
alterations associated with malnutrition, testosterone levels.
including low testosterone levels.
Norris et al., Canada 10-year-old girl with a history of anxiety, Remission after family Treatment included focus on
2016b† frequent stomach pains, and school therapy, individual connection between anxiety and
refusal. Recurrent viral gastroenteritis led therapy targeting gastrointestinal symptoms.
to fear of eating and progressive weight anxiety, and olanzapine
loss. Extensive somatic workup revealed and fluoxetine
no pathology. medication.

(Continues)
22 STRAND ET AL.

TABLE 3 (Continued)

How did the ARFID diagnosis

Author(s) and year Country Clinical vignette Outcome inform treatment?
Pennell, Couturier, Canada Two cases: (1) 10-year-old boy with a Both patients went into Authors note that specific
Grant, & Johnson, history of selective eating who remission after dose approaches should be tailored to
2016 deteriorated with severe weight loss adjustment of the underlying cause of ARFID.
following initiation of medication with lisdexamfetamine and Feared food hierarchy was
lisdexamfetamine for ADHD. additional medication employed. Using nonstimulant
(2) 9-year-old girl with a history of poor with risperidone. medication with less appetite
appetite and selective eating, possibly suppression was considered.
connected to an early allergic reaction to Clinicians may consider
cashew flour. Stunting of height and screening patients for restrictive
weight following initiation of medication eating before using stimulant
with lisdexamfetamine for ADHD. medication.
Sanders, Ewing, & Australia 64-year-old woman with 20 year history Not reported. Not described.
Ahmad, 2016 of anxiety and restrictive eating,
maintaining a BMI between 14 and
18 after an initial wish to lose weight.
Displayed rigid eating behaviors and
delusional beliefs about weight and
appearance but cooperated in treatment,
which led her clinicians to retrospectively
suggest an ARFID diagnosis rather than
AN. Cognitive deficits were noted, the
patient tested positive for the C9orf72
gene mutation and was diagnosed with
familial frontotemporal dementia.
Tsai, Singh, & USA 56-year-old male who 30 years ago Did not adhere to Authors suggest early involvement
Pinkhasov, underwent bilateral testicular mirtazapine medication. of behavioral health expertise for
2017 resection and subsequent removal of Continued to display an patients with distressing
multiple retroperitoneal and pelvic lymph obsessive fixation on his gastrointestinal symptoms.
nodes because of testicular cancer, with constipation, became
severe scarring in the pelvic floor region severely malnourished to
causing pudendal nerve entrapment. the point where he
Severe anorectal pain during defecation needed intensive care,
led to food restriction and enema use. and was subsequently
Weight loss from BMI 23.5 to 12.5. recommended hospice
Denied intentional weight loss and did care.
not express cognitive restriction.
Chiarello, Marini, Italy 18-year-old man with progressive bilateral Treated with vitamin Authors note that treatment varies
Ballerini, & visual loss due to optic neuropathy. supplements. Could across individual presentations.
Ricca, 2017 Common causes ruled out. History of broaden his diet Follow-up is crucial because of
selective eating (chocolate, biscuits, milk, somewhat after dietician possible conversion from ARFID
French fries, apples, ice cream) and counselling. Slight to AN.
mealtime anxiety, but denied body image improvement of right
concerns and attributed his eating eye vision but no
behaviors to nausea. Diagnosed with improvement of left eye
ARFID and optic neuropathy due to vision.
nutritional deficiency.
Lazare, 2017 Canada 30-year-old woman undergoing treatment Clinicians noted bronzed Not described. Authors discuss risk
for cannabis use disorder. Had used skin hue and tests of not adequately contesting an
cannabis for 10 years, initially socially but revealed a diagnosis of eating disorder diagnosis once it
later because of persistent nausea that Addison's disease. has been made.
made her unable to eat. Unintentional Successful treatment
vomiting. Low mood, anxiety, and panic with hydrocortisone,
attacks. On medication with escitalopram which reduced nausea
and bupropion. Denied body image and normalized eating
concerns. Was at this point diagnosed within days.
with ARFID.
Lucarelli, Pappas, USA 4-year-old girl with feeding difficulties since Some progress with Authors highlight the relational
Welchons, & infancy, complicated by gastroesophageal systematic components of feeding
Augustyn, 2017 reflux disease and milk and peanut desensitization disorders, note that effective
allergies. Selective eating (French fries, approach. behavioral interventions may still
crackers, pretzels) and additional rigidity be difficult to maintain in a home
around meals. Diagnosed with ARFID and environment, and emphasize
autism spectrum disorder. shared decision making.

(Continues)
STRAND ET AL. 23

TABLE 3 (Continued)

How did the ARFID diagnosis

Author(s) and year Country Clinical vignette Outcome inform treatment?
Maertens, Couturier, Canada Two cases: (1) 15-year-old girl with severe (1) Started medication with Not described.
Grant, & Johnson, malnutrition and 70% of ideal body escitalopram and
2017 weight due to longstanding fear of olanzapine. Regained
vomiting, intensified by recent some weight but started
gastroenteritis. Excessive handwashing, expressing body image
obsessive rituals, and restrictive eating. concerns, eventually
Concerned about low weight and meeting criteria for
wanting to gain weight. (2) 10-year-old AN. (2) Started
boy with intense fear of vomiting medication with
following recent gastroenteritis. Denied olanzapine, but switched
weight concerns, but was very cautious to clomipramine.
about fat as it made him feel sick. Developed
preoccupation with
eating “healthy,”
eventually meeting
criteria for AN, GAD,
and OCD.
Pitt & Middleman, USA Two cases: (1) 17-year-old girl with brief Both patients were Individualized behavior plans
2017 episode of frequent vomiting, food and admitted to hospital for focusing on reinforcement were
water restriction, and abdominal pain, an extensive period employed, aiding in shifting
related to nervousness about singing solo because of malnutrition. focus from medicalization of
during her high school graduation. Similar Behavior-focused eating behaviors to behavioral
emergency department visits during the interventions eventually contributors.
past years at times of distressing events. led to remission and
Denied body image concerns but had family therapy was
history of selective eating. Context of critical to recovery.
family dysfunction. (2) 13-year-old girl
with persistent constipation and nausea.
History of selective eating but denied
body image concerns. An extensive
somatic workup had not revealed any
pathology. Had received an percutaneous
endoscopic gastrostomy tube, but this
did not lead to weight gain and the tube
was removed due to infection. Marital
discord among parents.
Schermbrucker, Canada 11-year-old boy of Colombian descent with Patient and parents Not described. Authors discuss
Kimber, Johnson, epigastric pain, constipation, dysphagia, declined trial with culturally sensitive diagnostics.
Kearney, & and acute food refusal after visiting a fluoxetine. After
Couturier, 2017 relative in Colombia with terminal throat 6 weeks in hospital, the
cancer. General anxiety. Weight loss, family travelled to
bradycardia, and need of nasogastric tube Colombia where a
feeding. Abdominal X-rays, swallowing physician diagnosed the
studies, laryngoscopy, and boy with “globus”
esophagoscopy revealed no pathology. (i.e., the subjective
feeling of a lump in the
throat), which the family
could more readily
accept. Family relocated
to Colombia.
Thomas, Brigham, USA 11-year-old girl with selective eating since Could extend her diet after Appetite stimulants, such as
Sally, Hazen, & infancy. Accentuated difficulties eating gradual exposure and cyproheptadine, or anxiolytics/
Eddy, 2017a solid food after choking incident. Weight mirtazapine medication. antidepressants with increased
loss. Denied body image concerns, Weight gain and no fear appetite as side effect, such as
wanted to be bigger. Extensive somatic of choking at 1 year mirtazapine, may be considered.
workup did not reveal any pathology. follow-up.
Steen & Wade, Australia 42-year-old man with lack of appetite, Could develop regular Patient found the ARFID diagnosis
2018 depression, and anxiety since childhood. eating patterns, although useful in addressing his drinking
Alcohol use disorder since adolescence. still with preference for problem, at least initially.
BMI 22. Ate one meal at night, followed “plain” food, and reduce
by 10–20 standard drinks of alcohol. alcohol intake to one
Preference for “plain” food (i.e., white night per week after
bread sandwiches) and a strong dislike of CBT. Later relapsed into
the feeling of a full stomach. No body drinking and once again
image concerns. Ascribed his drinking decreased his food
problems to a need for calorie intake. intake.

Abbreviations: ADHD = attention-deficit/hyperactivity disorder; AN = anorexia nervosa; ARFID = avoidant/restrictictive food intake disorder; BMI =
body mass index; CBT = cognitive-behavioral therapy; EDNOS = eating disorder not otherwise specified; GAD = generalized anxiety disorder; OCD =
obsessive–compulsive disorder; SSRI = selective serotonine reuptake inhibitor.
†
Case report(s) embedded in narrative review.
24 STRAND ET AL.

the symptom severity is greater than what is usually seen in that con- ARFID. The case report authored by Bryant-Waugh (2013) may repre-
dition or disorder and warrants additional clinical attention. Whereas sent an archetypal example of how the creators of the ARFID diagno-
the first part of the differentiation criterion—that symptoms are not sis have envisaged the clinical picture, as this author has made major
better explained by another disorder—is shared with most other DSM contributions in introducing the ARFID diagnosis in DSM-5. Still, this
diagnoses, the latter part is a unique feature of the criteria for ARFID, review reveals a large heterogeneity in how clinicians use the ARFID
pica, and rumination disorder (other diagnoses in the feeding and eat- diagnosis in a context of comorbidity. In DSM-5 terms, this heteroge-
ing disorders chapter) that is not found elsewhere in the DSM-5. Of neity is not a formal problem; in applying the Feighner criteria, how-
course, clinical “common sense” must always be an integral part of ever, it is not evident that a 4 year old with selective eating and
psychiatric diagnostics; even so, the fact that the current DSM-5 autism (Lucarelli et al., 2017) and a 64 year old with rigid eating
wording clearly deviates from the common DSM pattern may hypo- behaviors in a context of frontotemporal dementia (Sanders et al.,
thetically confuse even experienced clinicians. It has been suggested 2016) are indeed suffering from the same condition.
(Nicely et al., 2014) that if an eating problem resolves when a concom- Likewise, in the reviewed case reports, it is not always certain
itant disorder is treated, an ARFID diagnosis should not be ascribed. how making the ARFID diagnosis informed further assessment and
This certainly seems reasonable but does not necessarily aid in a con- treatment. For example, a patient that uses cannabis against nausea
text of continuous and sustained comorbidity. caused by Addison's disease (Lazare, 2017) is not necessarily helped
A number of studies point to a higher occurrence of medical by knowing that this could in fact be called ARFID; similarly, an ARFID
comorbidity or somatic complaints in the ARFID group compared to diagnosis does not appear to offer much guidance in the treatment of
patients with other eating disorders (Table 2). Moreover, ARFID a patient with lower abdominal pain after severe pelvic scaring (Tsai
patients had more often seen other medical specialists before entering et al., 2017). In such cases, the ARFID diagnosis could risk becoming a
an eating disorders treatment program, although it is not clear clinical curiosity rather than a helpful tool. Of course, it can be argued
whether this was due to actual medical comorbidity or diagnostic that an accurate application of any diagnostic criteria includes not
uncertainty. Several studies found that gastrointestinal symptoms making clinically irrelevant diagnoses; nonetheless, the available case
were especially common among ARFID patients. Thus, there appears report literature suggests that meaningful delimitation from other dis-
to be ample support for a high prevalence of gastrointestinal symp- orders is not necessarily a straightforward task.
toms and potential comorbidity in patients with ARFID, although this A case in point is PANDAS, a pediatric autoimmune syndrome
does not necessarily imply that it is higher than what is seen in restric- with acute onset of neuropsychiatric symptoms, such as restrictive
tive eating disorders in general (Norris, Spettigue, & Katzman, 2016a) eating, after a streptococcal infection. Toufexis et al. (2015) describe a
or that medical comorbidity is any more difficult to clinically differenti- number of factors that distinguish PANDAS from ARFID: onset and
ate in ARFID than in AN. disease course, medical treatment, and so forth—factors that, if the
The evidence on psychiatric comorbidity in ARFID is not alto- Feighner criteria are applied, clearly help separate these conditions.
gether consistent (Table 2). Importantly, many of these studies have However, in several of the papers reviewed here (Mammel & Orn-
been retrospective chart reviews and it is therefore not certain how stein, 2017; Toufexis et al., 2015; Zimmerman & Fisher, 2017), it is
the criterion on psychiatric comorbidity and boundaries towards other noted that regardless of these distinguishable features, children with
conditions would have been understood at the time, had ARFID been disordered eating due to PANDAS readily fulfill the current DSM-5
available as a diagnostic category. Although patterns of comorbidity ARFID diagnostic criteria.
relative to other eating disorders are not consistent, it is obvious that Similarly, it has been suggested (Dovey et al., 2017) that children
psychiatric comorbidity is common when patients who would have who receive a nasogastric tube are instantly ascribed with a diagnos-
fulfilled the DSM-5 ARFID criteria are assessed in retrospect. able psychiatric disorder according to the DSM-5. This is not neces-
Conceptual issues of demarcation are also found among the sarily the case—again, clinical “common sense” must be applied in all
ARFID case reports (Table 3), which describe a multitude of clinical psychiatric diagnostics and in this specific case it also depends on
conditions that do not necessarily have much in common besides the whether or not the use of a nasogastric tube is seen as an unusually
fact that they are not typical cases of AN. In nearly all the reviewed advanced intervention in relation to an underlying medical condition.
case reports, there is somatic and/or psychiatric comorbidity that Still, it points to the ambiguity and potential overinclusiveness of the
explains or contributes to the restrictive eating, and the ARFID diag- ARFID diagnostic criteria.
noses are thus in many cases based on the second part of the DSM-5 In sum, although there is sound evidence for distinguishing ARFID
differentiation criterion: that the food avoidance warrants more clini- from other eating disorder diagnoses, there is an obvious ambiguity
cal attention than what is usually seen in the comorbid condition. Of surrounding how to understand and maintain conceptual boundaries
course, it should be noted that the case reports reviewed here repre- toward co-occuring medical conditions and psyhciatric disorders. In
sent a highly select material. Usually, case reports are published on light of these problems of delimitation, the third Feighner criterion is
the merit of describing a new and unusual presentation or an unex- not fulfilled.
pected outcome, which may result in a bias toward spectacular cases.
Furthermore, there is no guarantee that the ARFID diagnosis in a
3.5 | Feighner criterion 4: Course over time
reported case is correct, even though it has (hopefully) been subjected
to peer-review; in at least one of the reviewed ARFID case reports According to the fourth Feigner criterion, the course of the disorder
(Sanders et al., 2016), it appears that the patient had AN rather than should be carefully charted to further ensure homogeneity within the
STRAND ET AL. 25

diagnostic category. Robins and Guze note that although the progno- achievement of nonselective eating habits, etc.) may not be realistic
sis of a disorder may certainly vary, marked differences in outcome is (Thomas et al., 2017b; Zimmerman & Fisher, 2017). However, this
indeed a challenge to diagnostic validity. assumption is not uniformly supported by published original research
From the studies that report illness duration at baseline a pattern (Table 2). Reported outcomes in treatment studies also vary. Most of
emerges, although not altogether consistent. The finding that ARFID these studies apply a rather brief follow-up period, which is somewhat
patients have ususally been ill for a longer time at presentation is sup- surprising given that many of them are retrospective chart reviews
ported by several studies (Fisher et al., 2014; Pinhas et al., 2017); where longer duration of “follow-up” should be attainable. Taken
however, the opposite tendency (Nakai et al., 2017) or no differences together, they do not allow for validation of a typical ARFID course of
have also been found (Nicely et al., 2014; Strandjord et al., 2016) illness as demanded by the Feighner criteria.
(Table 2). In contrast, most studies that focus on developing diagnostic
A reported overall longer duration of illness at presentation may instruments for the assessment of ARFID symptoms or selective eat-
reflect the fact that patients with ARFID also tend to be assessed by ing report on adult samples (Table 1). A number of case reports and
physicians in other fields of medicine before they are diagnosed commentaries also raise the importance of recognizing ARFID in adult
(Ornstein et al., 2013a) and that they are less often self-referred or even geriatric populations. Bearing in mind the explicit emphasis of
(Kennedy et al., 2018). Naturally, the fact that a diagnosis is difficult ARFID as an age-neutral disorder in the DSM-5, the lack of research
to make or that it is unknown to large groups of clinicians is not the on adult populations is striking.
type of common characteristic that supports diagnostic validity per In sum, there may be emerging evidence for a typical course of ill-
se. However, combined with the younger age at onset described ness in ARFID whereby longstanding issues of low appetite and selec-
above, a longer duration of illness at presentation suggests that the tive eating are exacerbated by an aversive experience and become
ARFID symptoms may often have been persistent throughout child- unmanagable. Such models warrant further study, but at the present
hood rather than occurring with an acute or subacute onset, as is time, there appears to be no consistent evidence supporting a distinct
often the case in AN. Here, it should be noted that in the three- course of illness in the reviewed literature. Overall, the available
dimensional model presented by Thomas et al. (2017b), it is suggested research indicates that treatment outcomes differ between ARFID
that ARFID patients may commonly present with an acute exacerba- patients and patients with other eating disorders, althought the exact
tion of more or less lifelong food restriction and avoidance. For exam-
patterns (better or worse otucomes in terms of weight normalization,
ple, a typical patient may have a history of longstanding low
etc.) are not consistent.
homeostatic appetite and sensory selectivity that, although trouble-
some, has been managable over the years until an averse experience
(such as choking or an acute gastroenteritis) brings about a sudden
3.6 | Feighner criterion 5: Heritability
intensification of the abnormal eating behaviors and makes the situa- Last, the creators of the Feigner criteria note that regardless of other
tion spiral out of control. This scenario is supported in a number of etiological factors, an explicit heritability of a disorder strongly sup-
case reports (Table 3) and warrants further study. ports the validity of the clinical entity. The available data on heritabil-
In the reviewed literature, there appears to be some confusion ity in ARFID (Table 2) are too scarce to allow for fulfilment of this fifth
regarding whether ARFID should be approached from a life-span per- Feigner criterion.
spective, as suggested by the overall changes in DSM-5, or if it is still
primarily to be seen as a pediatric diagnosis. In part, this mirrors the
uncertainty about whether ARFID should be seen primarily as an eat- 4 | DI SCU SSION
ing disorder or a feeding disorder described in a recent review
(Kennedy et al., 2018). A majority of the reviewed original research The introduction of the ARFID diagnosis in DSM-5 in 2013 was
publications report on a pediatric population (Table 1) and as undoubtedly an important step toward greater diagnostic coherence
described above, in comparisons between diagnostic groups, it is and increased recognition of a group of patients that had until then
often noted that patients with ARFID tend to be younger than those been marginalized to various clinical grey areas. However, this system-
with AN. Thus, despite the fundamental changes in the DSM-5, atic scoping review shows that in the currently available research liter-
ARFID is still conceptualized as a disorder seen in infancy, childhood, ature, the use of ARFID as a conceptual category and the
and adolescence in much of the research literature. interpretation of ARFID diagnostic criteria vary significantly. At the
Likewise, a majority of studies with a primary focus on treatment present time, ARFID does not fulfil the Feigner criteria for distinguish-
outcomes in ARFID have focused on pediatric samples (Table 1). ing clinical entities and evaluating the validity of diagnostic constructs.
Overall, the available evidence suggests that patients with ARFID The first Feighner criterion—the description of a clearly distin-
often benefit from conventional specialist treatment for eating disor- guishable clinical picture—appears to be the least problematic.
ders, although outcome patterns in relation to other eating disorders Although clinical descriptions are highly heterogeneous, a predomi-
vary (Table 2). Whereas this is certainly reassuring, it does not neces- nant clinical picture emerges from the literature and specific epidemi-
sarily help in differentiating ARFID from other eating and feeding dis- ological features can be distinguished. There is also some evidence for
orders. Highly individualized and flexible treatment approaches are a typical course over time—the fourth Feighner criterion—although
usually recommended. In some of the narrative reviews, it is empha- more research is needed. The fact that the second and fifth criteria—
sized that full remission (e.g., full weight restoration/normalization, the identification of biomarkers or comparable psychological tests
26 STRAND ET AL.

(or effective treatments) and the idenfication of patterns of exacerbation of more or less lifelong food restriction and avoidance
heritability—are not fulfilled is an insufficiency that is shared with (Table 3). This exact scenario is given as a typical example by Thomas
many other psychiatric disorders and that does not necessarily pre- et al. (2017b, p. 5) in outlining how the three-dimensional model may
clude the clinical applicability of the diagnosis. be manifested: “a young person with longstanding selective eating
In our view, the most urgent dilemma is the problem of demarca- (i.e., sensory sensitivity) and chronic low appetite (i.e., lack of interest
tion toward other clinical entities—the third Feighner criterion. Distin- in eating) who loses weight precipitously following an acute choking
guishing ARFID from AN does not appear to be the main difficulty; episode (thus developing fear of aversive consequences).” Whether or
the diagnostic criteria are clear about how these diagnoses differ con- not the three presentations should be seen as explicit subtypes or
ceptually and there is evidence to support separate epidemiological merely common variants, a clearer emphasis on these domains would
characteristics. Instead, problems arise in applying the ARFID diagnos- potentially aid in diagnosing ARFID. More research on larger samples
tic criteria in situations when there are comorbid psychiatric or medi- is needed to further understand the full applicability of the model,
cal conditions that may cause restrictive eating and food avoidance or how the three subdomains differ in presentation, course of illness,
selectivity—the examples are manifold, including autism spectrum dis- and so forth, and how treatment can be individualized to address
order, anxiety disorders, obsessive–compulsive disorder, attention- varying degrees of subdomain-specific symptomatology in an
deficit/hyperactivity disorder, affective disorders, gastrointestinal dis- optimal way.
ease, metabolic disorders, etc. Whereas such comorbidity is of course We also suggest that the D criterion for ARFID is harmonized
not always difficult to integrate with an ARFID diagnosis, evidence with the rest of the DSM-5, so that the current ambiguity over delimi-
points to recurrent conceptual bewilderment that makes the ARFID tation from other disorders is resolved. This could be accomplished in
category unnecessarily obscure. several ways. First, the last part of the criterion—describing how an
With this emphasis on conceptual validity, we do not wish to ARFID diagnosis can still be accurate in cases of comorbidity where
imply that the ARFID diagnostic category is redundant. On the con- the symptom severity is greater than what is usually seen in the other
trary, there appears to be an abundance of clinical experience and condition or disorder and warrants additional clinical attention—could
research that points to the necessity of distinguishing a group of simply be removed. This would eliminate the internally incongruous
patients with non-AN food restriction and avoidance. However, this tendency of the criterion, reducing the risk for confusion without nec-
article points to an inability of the current DSM-5 diagnostic criteria essarily making it more difficult to apply in practice. Second, it could
to fully maintain conceptual boundaries, which risks making them less be briefly specified in the criterion what exactly separates ARFID from
useful in clinical practice and in epidemiological research. such comorbid disorders that may cause problems in differential diag-
To increase the conceptual validity of the ARFID construct, we nostics. As an illustration, in the DSM-5 criteria for autism spectrum
suggest several possible alterations to the current diagnostic criteria. disorder it is explicitly stated that although autism and intellectual dis-
One way forward may be to further emphasize the three-dimensional ability frequently co-occur, autism spectrum disorder is distinguished
clinical picture that is currently only hinted at in the DSM-5 diagnostic by specific deficits in social communication. Third, a more detailed
criteria: that is, how an overall lack of interest in food and eating, explanation of how to differentiate between ARFID and food restric-
selectivity based on sensory sensitivity, and fear of negative conse- tion seen as a part of other disorders could be added. For example,
quences of eating related to aversive experiences such as choking or the criteria for disruptive mood dysregulation disorder include a
vomiting may interact in inducing and shaping a clinically relevant section where it is outlined exactly with which other disorders this
ARFID presentation. There is emerging evidence to support such a diagnosis can and cannot formally co-exist and which diagnoses
model. Thomas et al. (2017b, p. 5) introduce a hypothetical three- should be given priority. Similarly, in the criteria for substance/medi-
dimensional model whereby “a given individuals's ARFID presentation cation-induced anxiety or bipolar disorder, it is explicitly stated what
can be plotted as a single point along a three-dimensional space, features that may indicate the presence of an independent anxiety or
meaning that the three prototypic presentations vary in severity and bipolar disorder.
are not mutually exclusive.” The authors propose neurobiological To be able to clarify and extend the ARFID criteria in a meaningful
underpinnings for each of the three presentations: that the ARFID way, more research is needed. For example, to gather further support
subdomain presenting as lack of interest in food might be associated for hypothetical ARFID subdomains and to differentiate between
with differences in activiation of appetite-regulating centers in the ARFID and food avoidance as part of other psychiatric disorders, stud-
brain, that the selective eating subdomain might be associated with ies that employ latent class analyses or similar models are recom-
oversensitivity in taste perception (as seen in Table 2, this has been mended. This review identified only one such study, the latent class
found by Kauer et al., 2015), and that the fear of aversive conse- analysis of childhood-onset eating disorders by Pinhas et al. (2017))
quences subdomain might be associated with hyperactivation of fear that provide support for distinguishing between ARFID and
processing brain circuitry. A recent study by Norris et al. (2018), spe- AN. Furthermore, the life-span approach of DSM-5 is commendable;
cifically exploring whether the three prototypic presentations could however, for it to reach its full potential as a framework of eating dis-
retrospectively be identified as subdomains in a clinical sample of chil- order diagnostics, there is also an urgent need for research on ARFID
dren and adolescents, lends support to the three-dimensional model. in adult populations. Prospective research on how established treat-
Furthermore, as described in the section on the fourth Feighner ment models for eating disorders can be modified to accommodate
criterion above, a number of reviewed case reports support the for the specific features of ARFID is also much needed. Hopefully, this
hypothesis that ARFID patients may commonly present with an acute systematic scoping review can aid in furthering the understanding of
STRAND ET AL. 27

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