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

Stephanie G. Harshman, PhD^a,b,d ; Jenny Jo, MS^a,b ; Megan Kuhnle, BS^a,b ; Kristine Hauser, MSN^a,b ; Helen Burton Murray, PhD^b,d ; Kendra R. Becker, PhD^b,c ; Madhusmita Misra, MD^a,d,e ; Kamryn T. Eddy, PhD^b,c ; Nadia Micali, MD, PhD^f,g,h ; Elizabeth A. Lawson, MD^a,d,‡ ; Jennifer J. Thomas, PhD^b,c,‡

J Clin Psychiatry 2021;82(5):20m13831

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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