The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression

Abstract

Objective Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM‐5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self‐reported GI disorder. Method Participants were 2,610 adults ages 18–44 who self‐identified as “picky eaters.” Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L‐ARFID/GI), L‐ARFID‐only, GI‐only, and No‐ARFID/No‐GI. Results Groups with a GI disorder (L‐ARFID/GI, GI‐only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L‐ARFID (L‐ARFID, L‐ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment. Discussion Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.

What do we know about the epidemiology of avoidant/restrictive food intake disorder in children and adolescents? A systematic review of the literature

“…In addition to these results, one study from 2020 reported that over 60% of children with ARFID admitted to a paediatric hospital had some past history of GI problems (Tsang et al., 2020 ). These estimates, although different from each other, suggest that there might be an overlap between ARFID and GI problems, which could be important for understanding the aetiology of some presentations (Nicholas et al., 2021 ). The presence of GI symptoms together with ARFID should inform case formulation with assessment and intervention for GI symptoms being a clinical priority in this patient group (Boerner et al., 2021 ; Nicholas et al., 2021 ).…”

Pediatric Avoidant-Restrictive Food Intake Disorder and gastrointestinal-related Somatic Symptom Disorders: Overlap in clinical presentation

“…Both groups had similar frequencies of physical symptoms, though patients diagnosed with SSRD had more co-occurring medical conditions. The high proportion of patients with ARFID reporting GI symptoms (84%) may be relevant to understanding the underlying etiology of certain presentations of this diagnosis that may overlap with GI disorders, including central sensitization ( Sim et al, 2021 ) and interactions of altered gut physiology with symptom-related distress and fear-learning ( Nicholas et al, 2021 ; Wildes et al, 2021 ). However, it is also possible that some of the reported GI concerns were consequences of malnutrition, such as constipation, rather than an initiating factor for the eating disturbance.…”

The Intersection of Disorders of Gut-Brain Interaction With Avoidant/Restrictive Food Intake Disorder

“…Among those with DGBI, disordered eating patterns (such as food restriction, binge eating, purging) ranges from 5% to 44% 28 . More recently, the phenomenon of ARFID in DGBI has been recognized with cross-sectional and retrospective studies 4,10,11,29–36 …”

“…Differences in self-report frequencies may be due to varying cutoffs applied across studies on one ARFID screening questionnaire [the Nine-Item ARFID Screen (NIAS)], 38,39 as well as characteristics of the clinical populations. Finally, a cross-sectional self-report survey study found that among a community of self-identified “picky eater” adults who self-reported DGBI symptoms, 11% met the diagnostic criteria for ARFID 31 . To our knowledge, no study to date has investigated the frequency of ARFID in DGBI using semistructured or clinician interview (the gold standard for diagnosis of eating disorders), thus current frequency estimates are limited by the use of self-report surveys.…”