Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Noah," 9-year-old boy, referred by his pediatrician for failure to gain weight due to severely limited diet consisting of only 5 foods.

Chief Concern: Mother: "Noah will only eat white bread, plain pasta, chicken nuggets, apple juice, and french fries. He has refused every other food since age 3. He gags if any other food touches his plate. He's underweight and his pediatrician says he's nutritionally deficient."

History of Present Illness: Noah has been an extremely selective eater since age 3. His diet consists exclusively of 5 foods: white bread, plain pasta (no sauce), a specific brand of chicken nuggets, apple juice, and french fries. He refuses all fruits, vegetables, meats (other than nuggets), dairy products, and any food with visible color, texture variation, or strong smell. When presented with novel foods, he gags, cries, and leaves the table. He has no interest in expanding his diet and reports no desire to eat other foods. His restriction is driven by sensory aversion: 'It looks wrong,' 'the texture is slimy,' 'it smells weird.' He has NO fear of gaining weight, NO body image disturbance, and NO desire to be thinner. He has never commented on his body shape or weight. His growth has been affected: weight at 10th percentile (previously 50th at age 2), height at 25th percentile. Lab work: iron deficiency anemia, low vitamin D, low zinc. He eats his 5 accepted foods in appropriate quantities and does not restrict portion sizes.

Medical History: Iron deficiency anemia. Low vitamin D. Low zinc. Weight at 10th percentile (failure to thrive trajectory).

Mental Status Exam: Age-appropriate appearance. Underweight. Cooperative but anxious about food discussion. Articulate for age. Describes food aversions in sensory terms (texture, smell, appearance). No weight or shape concerns. No depressive symptoms. No anxiety beyond food-related situations. Eye contact normal. Reciprocal social engagement normal. No restricted interests or repetitive behaviors.

Step 1: ARFID DSM-5-TR Criteria

Criterion A: An eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with ≥1 of: (1) significant weight loss/failure to gain weight, (2) significant nutritional deficiency, (3) dependence on enteral feeding or oral supplements, (4) marked interference with psychosocial functioning.

(1) Weight dropped from 50th to 10th percentile (failure to gain). (2) Iron deficiency anemia, low vitamin D, low zinc (nutritional deficiency). (4) Cannot eat at restaurants, friends' homes, or school cafeteria without his 5 foods. MET — 3 of 4 subcriteria present.

Criterion B: Not better explained by lack of available food or culturally sanctioned practice.

Food is abundantly available. Family offers varied diet. Restriction is about sensory aversion, not access. MET.

Criterion C: Not better explained by anorexia nervosa or bulimia nervosa; no evidence of disturbance in body weight or shape perception.

No weight or shape concerns. No desire to be thinner. No body image disturbance. No caloric restriction for weight loss. He eats adequate portions of his accepted foods. MET — explicitly NO body image pathology.

Criterion D: Not attributable to a concurrent medical condition or other mental disorder, or when occurring with another condition, the severity exceeds expectations.

No medical condition causing food restriction. No ASD (normal social reciprocity, no restricted interests, no repetitive behaviors). Sensory sensitivity is limited to food domain. MET.

Step 2: ARFID vs. Picky Eating vs. Anorexia

Feature ARFID Picky Eating (Normal) Anorexia Nervosa This Patient
Motivation for restriction Sensory aversion, fear of aversive consequences, lack of interest in food Preference without rigidity Fear of weight gain, body image distortion ARFID: sensory aversion
Body image concern ABSENT Absent PRESENT (core feature) ABSENT
Nutritional impact Significant deficiency or growth failure Minimal Weight loss from restriction Iron, vitamin D, zinc deficient; growth faltering
Flexibility Rigid — cannot be coaxed or persuaded Moderate — can be encouraged Calculated — restricts specific macronutrients Completely rigid — 5 foods only for 6 years
Treatment Graduated exposure, sensory desensitization Parental strategies, patience FBT/CBT-E, nutritional rehabilitation Graduated food exposure therapy

Diagnostic Distinction

The ABSENCE of body image disturbance is the critical differentiator between ARFID and AN. Noah restricts because foods look, feel, or smell aversive to him — not because he fears weight gain. This determines the entire treatment approach: sensory desensitization rather than body image work.

Diagnostic Formulation

Diagnostic Conclusion

Avoidant/Restrictive Food Intake Disorder (F50.89): All 4 DSM-5-TR criteria met. Sensory-based food restriction to 5 foods for 6 years. Nutritional deficiencies (iron, vitamin D, zinc). Growth faltering (50th to 10th percentile). No body image disturbance. Treatment: graduated food exposure therapy (systematic desensitization to novel foods using sensory hierarchy), nutritional supplementation for deficiencies, family-based mealtime restructuring, occupational therapy for sensory processing.

Teaching Points

  • ARFID was introduced in DSM-5 to capture clinically significant food restriction that is NOT driven by body image or weight concerns. It replaced DSM-IV's 'Feeding Disorder of Infancy or Early Childhood,' which was limited to children under 6.
  • Three presentations of ARFID are recognized: (1) sensory sensitivity (aversion to texture, taste, smell, appearance — Noah's presentation), (2) lack of interest in eating or food, and (3) concern about aversive consequences of eating (choking, vomiting). Different presentations require different treatment approaches.
  • The absence of body image disturbance is the pathognomonic distinction between ARFID and AN. Both can produce significant weight loss and nutritional deficiency. The treatment differs fundamentally: ARFID requires food exposure and sensory work; AN requires body image and weight restoration work.
  • ARFID can co-occur with ASD, ADHD, and anxiety disorders. When food selectivity occurs in the context of ASD, ARFID should be diagnosed as a comorbid condition only if the severity exceeds what is typically associated with ASD alone.
  • Graduated food exposure for ARFID follows a sensory hierarchy: starting with tolerated sensory properties (e.g., if white foods are accepted, introducing white foods with slightly different textures) and gradually expanding toward more varied foods. Forced feeding and coercive approaches are contraindicated and worsen food avoidance.