Clearer guidelines needed for avoidant/restrictive food intake disorder diagnosis

The prevalence of avoidant/restrictive food intake disorder varied significantly based on how the disorder was defined, according to study results published in Journal of Clinical Psychiatry.

“The broad definitions used among DSM-5 criteria for [avoidant/restrictive food intake disorder (ARFID)] provide substantial flexibility in a clinical setting,” Stephanie G. Harshman, PhD, of the neuroendocrine unit at Massachusetts General Hospital, and colleagues wrote. “However, the open-ended nature of the definitions and operationalization in research can result in challenges associated with access to mental health treatment and comparability and generalizability of research studies. Various diagnostic tools for ARFID are currently under development, which is a significant advance for the field; however, they are subject to the same challenges resulting from the broad definitions of DSM-5 criteria.”

Because DSM-5 ARFID criteria B, C and D are exclusionary, meaning they rule out other eating disorders or factors that could otherwise account for avoidant/restrictive eating, ARFID diagnosis depends almost wholly on criterion A.

This criterion outlines four possible sequelae of avoidant and/or restrictive eating behaviors, any of which qualify an individual for AFRID diagnosis. The sequelae are A1, which includes significant weight loss and failure to maintain adequate growth; A2, which includes nutritional deficiency; A3, which includes dependence on enteral feeding or nutrition supplements; and/or AD, which includes psychosocial impairment.

Harshman and colleagues aimed to determine the extent to which certain operationalizations of the diagnostic criteria for ARFID affect differences in the frequency of individuals who qualify for the diagnosis. They focused on criterion A, as it is not exclusionary, and identified 19 possible operational definitions.

Further, they determined the extent to which these various methods affected the proportion of individuals who met ARFID criteria among a sample of 80 children, adolescents and young adults who enrolled in an avoidant/restrictive eating study between September 2016 and February 2020.

Results showed the proportion of individuals who met diagnostic criteria varied significantly across the methodologies within each criterion (all P values < .008). A total of 50% of participants met ARFID criteria when the researchers used the strictest definition of each criterion, whereas 97.5% met ARFID criteria when they used the most lenient definition of each criterion.

“Our findings support the need for clearer guidelines in operationalizing the DSM-5 diagnostic criteria for ARFID in both research and clinical settings,” Harshman and colleagues wrote. “The current diagnostic criteria would benefit from additional contextual support to guide providers/researchers within multiple disciplines on the most effective operationalization of DSM-5 diagnostic criteria for ARFID and by more frequent revisions and continual development of DSM-5 intermediate to whole manual revisions. Gaining consensus among different fields about operationalization of DSM-5 diagnostic criteria for ARFID is critical as our understanding of ARFID continues to evolve for both research and clinical work.”