ARFID: When Remission Is Not Silence

TALES FROM THE CLINIC

-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry, we explore the complicated issue of remission. Remission in psychiatric disorders is often defined by the absence of behaviors or symptoms. Yet patients may continue to experience the residual impact of their illness, expressed through bodily sensations, anxiety, or maladaptive patterns that persist despite measurable recovery. This case describes a young woman with a history of avoidant/restrictive food intake disorder (ARFID) behaviorally remitted for several years, who presented to the emergency department (ED) with panic attacks. Despite behavioral recovery and insight into her condition, she continued to experience somatic fear responses, illustrating that recovery encompasses more than the absence of symptoms. This case highlights the importance of attending to the patient's lived experience, recognizing ongoing vulnerability, and supporting agency and coping beyond symptom remission.

Case Vignette

“Lily,” a 23-year-old woman, presented to the ED with increased anxiety and panic attacks following a motor vehicle accident that occurred 1 month prior. She reported palpitations, dizziness, and a familiar, distressing constriction in her throat. While she experienced fleeting thoughts that it might be easier not to be alive, she denied suicidal intent or plan, describing it as a reaction to overwhelming physiological fear. Her medical evaluation offered no acute explanation for her symptoms.

To understand her presentation at 23, it is necessary to revisit her history at 14. By her mother's account, Lily had been an easygoing, food curious child with no prior history of restrictive eating. That changed the autumn when a hurricane struck her town. Her family evacuated with what they could carry and returned to a flooded first floor and a neighborhood that took months to recover. Lily was not physically injured, but the weeks of displacement, sirens, and visible fear in the adults around her appeared to mark her in ways that became clear only later. A few weeks after the family returned home, she choked on a piece of chicken at dinner, a brief and relatively ordinary incident that most children forget within days. Lily did not forget it. Within a week she was cutting food into increasingly small pieces. Within a month, solid food of almost any kind triggered intense panic and she would leave the table. By winter, she was subsisting on smoothies and crackers, reporting a persistent fear that anything more substantial would cause her to choke.

Her pediatrician initially treated this as a phobia expected to resolve on its own. It did not. Over the next 2 years, Lily was hospitalized twice for dehydration and malnutrition and was ultimately enrolled in 3 separate residential eating disorder programs between the ages of 15 and 17. She received occupational therapy for oral motor and sensory difficulties, was diagnosed with mild dysphagia and reduced esophageal motility on swallow study, and completed early rounds of exposure based feeding therapy. Relapses tended to cluster around the anniversary of the storm, a seasonal pattern her treatment team came to anticipate. Her academic and social development during this period was significantly disrupted. She missed nearly 2 years of consistent schooling and lost contact with most of her middle school peers.

By age 18, with sustained cognitive behavioral therapy, family support, and gradual reintroduction of a wide range of foods, Lily reached what her treatment team characterized as full behavioral remission. She ate 3 meals daily across a variety of textures, maintained a stable, healthy weight, and was able to eat in restaurants and social settings without distress. She enrolled in community college shortly after.

The car accident occurred 5 years later. It was minor, a low speed collision with no serious injuries. Within a month, panic attacks began, accompanied by the same throat sensation she had experienced at 14. Notably, this was not a return to restrictive eating. She was not avoiding food, was not losing weight, and reported no renewed fear of eating itself. Rather, her body appeared to be producing a familiar physiological response, the throat constriction, in reaction to a stressor entirely unrelated to food or choking.

In the ED and in subsequent follow up, Lily demonstrated notable insight into this distinction. She did not believe she was experiencing an ARFID relapse, and her clinical presentation supported this view. She used grounding techniques learned years earlier, including naming objects in her environment and focused breathing, which were eventually effective. She was not seeking nutritional counseling, having maintained a stable relationship with food for several years. What she needed instead was help understanding why a body in recovery could still generate the somatic language of an illness she believed she had left behind.

What Is ARFID?

ARFID is a diagnostic category introduced in the DSM-5 to describe individuals whose restrictive eating is not driven by body image distortion or a desire for weight loss.¹ Unlike anorexia nervosa or bulimia nervosa, ARFID is characterized by an intake of insufficient quantity or variety that results in significant nutritional deficiency, dependence on enteral feeding, or marked interference with psychosocial functioning.¹

ARFID is prevalent across the lifespan and is frequently comorbid with anxiety disorders, autism spectrum disorder, and ADHD.² Population based estimates vary considerably by age and methodology. A 2023 systematic review of pediatric and adolescent samples found ARFID prevalence ranging from 0.3% to 15.5% in nonclinical, general population samples, with considerably higher rates in clinical settings: 5% to 22.5% in specialized eating disorder services and up to 64% in specialist feeding clinics.³ Within pediatric eating disorder treatment programs specifically, ARFID has been found in 5% to 14% of inpatients and up to 22.5% of outpatients.⁴ Psychiatric comorbidity is common rather than exceptional. Across studies reviewed in that same systematic review, anxiety disorders are diagnosed in 9.1% to 72% of individuals with ARFID and autism spectrum disorder in 8.2% to 54.75%.³ ADHD comorbidity has been reported across a similarly wide range, from 4% to 26% depending on the study and population.⁵ The condition is generally categorized into 3 primary drivers: (1) sensory sensitivity to food characteristics (eg, texture, smell), (2) a perceived lack of interest in eating or low appetite, and (3) a fear of aversive consequences, such as the fear of choking, vomiting, or abdominal pain (Figures 1 and 2).²

Diagnosis

Diagnosing ARFID requires a clinical assessment that rules out the body image driven psychopathology characteristic of anorexia nervosa or bulimia nervosa, and confirmation that the disturbance results in significant medical, nutritional, or psychosocial impairment, as detailed in Figure 3.¹

Clinicians must also rule out other medical conditions that cause dysphagia or gastrointestinal distress, since these can present with overlapping symptoms of food avoidance.⁶ In the fear of aversive consequences subtype, which describes Lily's presentation, the diagnostic process often reveals a clear inciting event, such as a choking episode or medical trauma, that leads to a conditioned response of avoidance.⁷

What makes Lily's case diagnostically instructive is not her original ARFID presentation, which was relatively typical for the fear based subtype, but the reemergence of ARFID adjacent somatic symptoms years into established remission. A clinician meeting her for the first time in the ED, without access to her longitudinal history, might reasonably suspect relapse. Distinguishing a true behavioral relapse from a conditioned somatic response carries direct treatment implications. One scenario calls for renewed nutritional rehabilitation. The other calls for trauma informed anxiety treatment.

Treatment Options

Treating ARFID requires a multidisciplinary approach including medical, nutritional, and psychological care tailored to the individual's clinical presentation.⁸ A leading evidence based framework for behavioral intervention is cognitive behavioral therapy for ARFID (CBT-AR). This protocol involves 4 stages: (1) reaching nutritional requirements and normalizing eating patterns, (2) identifying and exposing the patient to feared or avoided foods, (3) addressing specific sensory sensitivities, and (4) relapse prevention (Figure 4).⁹ For individuals presenting with lack of interest or low appetite, stage 3 incorporates interoceptive exposure exercises aimed at increasing tolerance of internal sensations related to eating, such as fullness. This treatment approach has demonstrated feasibility and preliminary efficacy across age groups.⁹

While no medications are currently FDA approved specifically for ARFID, pharmacotherapy such as selective serotonin reuptake inhibitors and hydroxyzine is often used as an adjunct to therapy to manage comorbid symptoms.¹⁰ Low dose mirtazapine is frequently used in clinical practice for appetite stimulation, nausea reduction, and facilitating weight gain.¹¹ For pediatric and adolescent patients, family based treatment adapted for ARFID has shown case level success in helping young patients improve eating behaviors with caregiver support.¹² Notably, outcome data suggest that Lily's clinical profile, the fear of aversive consequences subtype, carries a comparatively favorable prognosis. One predictor study found that presence of this fear based presentation was associated with an almost 3-fold increased likelihood of remission with CBT-AR relative to the sensory sensitivity or low interest presentations.¹³ For patients like Lily, now years removed from active treatment, the more relevant clinical work concerns distress tolerance rather than nutrition: psychoeducation on the autonomic nervous system, grounding and interoceptive awareness skills, and a clear framework for understanding that physiological arousal does not necessarily indicate relapse.

Discussion

The emergence of acute panic in a patient with a history of ARFID creates significant diagnostic challenges. When somatic symptoms such as throat tightness are present in a patient who previously struggled with restrictive eating, the clinician must determine if the presentation signifies a behavioral relapse or an independent panic event.

This case highlights the persistence of physiological patterning, where the autonomic nervous system retains a conditioned response to distress. In psychiatry, remission is often documented as the absence of observable behaviors such as the cessation of food restriction. However, behavioral recovery does not always correlate with the extinction of underlying neural pathways. Even when weight is restored and dietary variety is achieved, the circuits associated with the initial trauma can remain primed. In this context, the body may utilize established autonomic scripts to express new, unrelated stressors, such as the trauma of a motor vehicle accident in this patient.

Consequently, the goal of long term recovery in ARFID should be expanded beyond nutritional metrics. Clinical stability is best characterized by psychological flexibility, the ability to experience these conditioned physiological sensations without reverting to restrictive behaviors. When a patient can recognize and tolerate these internal alarms without resorting to avoidance, they demonstrate a robust form of remission. Success is found in the space between the physical sensation and the behavioral response, where the patient maintains agency rather than reacting to a conditioned autonomic signal.

Dr Desai is PGY-3 psychiatry resident at Baptist Hospitals of Southeast Texas in Beaumont, TX.

Dr Memon is a child, adolescent, and adult psychiatrist; the program director of the Child & Adolescent Psychiatry Fellowship Program; and is the associate program director of the Psychiatry Residency Program at Baptist Hospitals of Southeast Texas in Beaumont, TX

References

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