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. 2021 Sep 7;82(5):20m13831.
doi: 10.4088/JCP.20m13831.

A Moving Target: How We Define Avoidant/Restrictive Food Intake Disorder Can Double Its Prevalence

Stephanie G Harshman  1   2   3   4 , Jenny Jo  1   2 , Megan Kuhnle  1   2 , Kristine Hauser  1   2 , Helen Burton Murray  2   3 , Kendra R Becker  2   5 , Madhusmita Misra  1   3   6 , Kamryn T Eddy  2   5 , Nadia Micali  7   8   9 , Elizabeth A Lawson  1   3   10 , Jennifer J Thomas  2   5   10
Affiliations

A Moving Target: How We Define Avoidant/Restrictive Food Intake Disorder Can Double Its Prevalence

Stephanie G Harshman et al. J Clin Psychiatry. .

Abstract

Objective: The DSM-5 criteria for avoidant/restrictive food intake disorder (ARFID) include ambiguities. Diagnostic criteria that allow for clinical judgment are essential for clinical practice. However, ambiguities can have major implications for treatment access and comparability and generalizability of research studies. The purpose of this study was to determine the degree to which distinct operationalizations of the diagnostic criteria for ARFID contribute to differences in the frequency of individuals who are eligible for the ARFID diagnosis.

Methods: Because criteria B, C, and D are rule-outs, we focused on criterion A, identified 19 potential operational definitions, and determined the extent to which these different methods impacted the proportion of individuals who met criteria for ARFID in a sample of children, adolescents, and young adults (n = 80; September 2016-February 2020) enrolled in an avoidant/restrictive eating study.

Results: Within each criterion, the proportion of individuals meeting diagnostic criteria differed significantly across the methodologies (all P values < .008). Using the strictest definition of each criterion, 50.0% (n = 40) of participants met criteria for ARFID. In contrast, under the most lenient definition of each criterion, the number nearly doubled, resulting in 97.5% (n = 78) meeting ARFID criteria.

Conclusions: Comparison of diagnostic definitions for ARFID among children, adolescents, and young adults confirmed a broad range of statistically distinct proportions within a single sample. Our findings support the need for additional contextual support and consensus among disciplines on operationalization in both research and clinical settings.

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Conflict of interest statement

Conflict of Interest Disclosures (includes financial disclosures): Drs. Thomas and Eddy receive royalties from Cambridge University Press for the sale of their book Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Drs. Thomas, Becker, and Eddy will receive royalties for their forthcoming self-help book for adults with ARFID. Dr. Lawson is on the scientific advisory board and has a financial interest in OXT Therapeutics, a company developing an intranasal oxytocin and long-acting analogs of oxytocin to treat obesity and metabolic disease. Dr. Lawson’s interests were reviewed and are managed by Massachusetts General Hospital and Partners HealthCare in accordance with their conflict of interest policies. All other co-authors have no conflicts of interest.

Figures

Figure 1.
Figure 1.
Comparison of diagnosis proportions in an observational study of individuals with full or subthreshold avoidant/restrictive food intake disorder based on different definitions for the diagnostic criteria. A) criterion A1: significant change in weight; failure to maintain adequate growth; B) criterion A2: nutritional deficiency; C) criterion A3: dependence on enteral feeding or nutrition supplements; and D) criterion A4: psychosocial impairment. Data are presented as percentage of individuals meeting applied diagnostic method. An asterisk (*) designates items from the Pica, ARFID, and Rumination Disorder Interview.
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