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ARFID vs. Anorexia: Key Differences in Diagnosis and Treatment

Avoidant Restrictive Food Intake Disorder (ARFID) and anorexia nervosa are two very different eating disorders. They can come with similar health effects and medical complications. However, the reason for the behaviors that lead to such nutritional problems and their effects aren’t the same. 

A child, teen, or adult with ARFID might gag at certain textures. Their aversion to food could be attributed to the fear of choking or getting sick. Or, they could lack interest in food. They aren’t trying to prevent weight gain. 

In a person with anorexia, on the other hand, eating disorder behaviors are directly tied to the fear of weight gain. They may count calories or restrict certain foods and food groups to prevent weight gain.

For effective treatment, it’s critical to acknowledge these differences. It’s something healthcare providers need to know. But, it’s also something that loved ones must understand to support someone they care about.

How ARFID Treatment Differs from Anorexia Treatment

While both are eating disorders that involve restriction, treatment approaches are fundamentally different because the “why” behind the restriction is different. In other words, the reason a person with ARFID does not meet their nutritional needs differs from that of a person with anorexia. What clinicians often wish people would realize is that the approach to treatment has to address the underlying causes of the behaviors themselves. 

Let’s compare six ways ARFID treatment differs from anorexia treatment. By the end, you should have a better understanding of what your loved one is going through and what the treatment process should look like.

The Core Focus of Treatment

The first thing to consider is the core focus of treatment. In ARFID, restriction stems from difficulties with texture, fear of choking or vomiting, discomfort with trying new things, or lack of interest in food. This often means that when a person enters treatment, they’re likely eating a very limited variety of foods. Factors like calories do not determine which foods a person eats. ARFID isn’t driven by body image, so treatment doesn’t center on weight-related beliefs. 

ARFID treatment focuses on:

  • Reducing fear or discomfort around food.
  • Expanding food variety and tolerance.
  • Addressing sensory sensitivities or past negative experiences.

Anorexia treatment focuses on:

  • Challenging distorted beliefs about weight and body image.
  • Reducing fear of weight gain.
  • Restoring a healthy relationship with body perception. 

Unlike with ARFID, fear of weight gain is a key symptom of anorexia nervosa. It’s a distinguishing factor professionals look for when they diagnose an eating disorder. The root cause of behaviors is something treatment programs should screen for during the intake process.

Type of Therapy Used for ARFID vs Anorexia

Different types of therapy use distinct strategies. With some types of therapy, like cognitive behavioral therapy (CBT), these strategies can be tailored to help people with specific conditions. For example, in CBT for ARFID, providers first work with patients to determine the reason(s) behind restriction (e.g., fear of allergic reactions or choking, lack of interest in food, texture) and set goals related to these things. CBT for anorexia tends to focus on thought patterns related to body image. 

ARFID:

  • Cognitive Behavioral Therapy for ARFID (CBT-AR). The fear and distress people with ARFID feel about eating often creates a pattern. CBT-AR helps people break thought-related and behavioral patterns that create food avoidance. 
  • Exposure therapy (gradual introduction of feared or avoided foods). Over time–and with the implementation of effective coping strategies and emotional support–professionals work to help people with ARFID feel less anxiety about foods through habituation. 
  • Sensory-based strategies (texture, smell, appearance tolerance). Regulating the nervous system when sensory factors affect eating. 

Anorexia:

  • CBT for eating disorders (CBT-E). Recognizing and modifying thought patterns that lead to restriction; implementing behavioral change; using coping skills. 
  • Family-Based Treatment (FBT). With the help of professionals, parents take the lead in their child’s treatment, enforcing meals and snacks while showing empathy for the child’s emotions. FBT is particularly helpful for adolescents but can be used for adults, too. It can replace or help people transition out of inpatient treatment, depending. 
  • Motivational therapies (e.g., motivational interviewing, which can help people with anorexia identify how their behaviors do not align with their values). 
  • Therapies focused on cognitive distortions and reducing body image distress other than CBT-E. For example, dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT).

Many people with eating disorders benefit from a combination of different therapies. Ideally, care plans should be tailored to fit a person’s individual needs. This could include treatment for co-occurring concerns, like trauma and anxiety, if applicable. Many of these conditions can pair with and feed into eating disorders.

Role of Food Exposure

Food exposure in the treatment of ARFID vs anorexia is another example of how the same approach can be adjusted to help people with completely different diagnoses. In addition to therapy, clients work with dieticians for food exposure. 

In ARFID treatment: 

Food exposure in ARFID treatment is not “just trying new foods.” It’s critical to understand this, whether you have ARFID and are wondering what treatment will look like, or are a loved one who is trying to understand ARFID. Instead, it involves:

  • Structured, gradual integration of new or feared foods.
  • Reducing anxiety around eating experiences. 
  • Building comfort with textures, flavors, and variety.

Dietitians use techniques like food chaining to help people with ARFID integrate new foods. For example, stepping from a familiar brand of chicken nuggets to another breaded chicken product and, eventually, to a chicken breast.  

In anorexia treatment:

Similarly, food exposure in anorexia treatment isn’t the same as telling someone to “just eat.” Medical stability is an initial goal. From there, gradual exposure is used to help a person face their fears while managing distress and getting support from their care team. Important components often include:

  • A focus on consistent nourishment and weight restoration. 
  • Exposure that is less about the fear of food itself and more about eating enough despite the fear of weight gain.

While people with anorexia could still have a lengthy list of fear foods, potential weight gain is the reason for that fear. That’s why anorexia treatment focuses on the fear of weight gain and factors that contribute to the person’s fear. 

Nutritional Goals

Addressing medical problems like nutrient deficiencies can be important for people with both ARFID and anorexia. But, long-term nutritional goals, specifically, tend to have marked differences. 

In treatment for ARFID, we work to:

  • Reduce reliance on a very limited set of “safe” foods
  • Increase the range of accepted foods.
  • Improve nutritional balance. 

Some people with ARFID do lose weight or fail to gain weight. Weight changes in ARFID are an unintended side effect of behaviors. If that is the case, these things tend to repair with treatment. 

Nutritional goals in anorexia treatment often involve: 

  • Weight restoration (when medically necessary).
  • Address restrictive intake driven by weight concerns. 
  • Normalized eating patterns (eating regular, nutritionally sufficient meals and snacks throughout the day, not going too long without eating).
  • When applicable, avoiding refeeding syndrome in those at risk.

Methods like the plate-by-plate approach can be used to promote normal and sustainable eating behaviors in people with anorexia. Though techniques can vary, and this is not the only one professionals might use, eating enough to maintain a healthy weight for the person’s unique body, instead of letting the fear of weight gain win, is key.

Emotional and Psychological Work

The emotional and psychological work required for eating disorder recovery is an area where the distinctions between how to treat ARFID vs anorexia are clear. 

  • ARFID:
    • Anxiety management. For example, reducing sensitivity to fears such as choking, vomiting, or discomfort. Learning coping skills to manage anxiety symptoms without becoming too overwhelmed.  
    • Sensory regulation. Professionals use techniques that help the brain process food textures and smells without a panic response. Creating a comfortable environment during meal time (e.g., not too loud or too bright) can also help manage sensory distress or overload. 
    • Introspective awareness and mechanical eating. For people with ARFID who lack interest in food or do not feel hunger, providers may focus on identifying hunger cues or eating on a schedule to ensure nutritional needs are met and meals aren’t skipped. 

Since ARFID can be driven by different things (e.g., sensory issues, lack of interest), much of the emotional and psychological work people put in during treatment will be tailored toward what drives their condition and behavior.

  • Anorexia:
    • Body image work. Not letting poor body image get in the way of healthy eating patterns and self-care.
    • Identity and control-related patterns. Breaking rituals that present in some people with anorexia, such as excessive exercise, using food scales, counting calories, or measuring food to create a sense of safety. Exploring one’s identity beyond labels like “the athletic one,” “the thin one,” or “the healthy one,” if applicable. When anorexia co-occurs with exercise addiction or orthorexia, this can be particularly critical. 
    • Perfectionism and self-worth. Perfectionism and low self-worth are risk factors for anorexia. They don’t apply to everyone, but when they do, it is vital to address them. Related to identity exploration, this often looks like beginning to view oneself as inherently (rather than conditionally) worthy or breaking perfectionistic patterns that may actually hold them back in life. 

Treating anorexia often involves finding out how the disorder serves the person. Is it something to focus on when the rest of a person’s life feels out of control? Does low self-esteem play a role? Everyone’s different. But, if these things are a part of a person’s experience with anorexia, we will work with them to uncover them so that those needs can be met in a healthier way.

How Progress Is Measured

Part of the eating disorder treatment process is measuring progress regularly. Throughout treatment, professionals will look for signs of improvement. That way, treatment plans can be adjusted as needed, or clients can move on to things like new food exposures. 

ARFID: 

  • Increased food variety. Expanding the overall range of foods and food groups.
  • Reduced fear or avoidance. Less anxiety and discomfort when trying new foods or eating previously avoided foods.
  • Improved flexibility around eating. The ability to eat in more settings (e.g., social settings) and reduction of the need for strict “safe” foods or food-related routines. 

Anorexia:

  • Weight stabilization (when applicable). Restoring a weight appropriate for the person’s body, in the context of medical recovery and genetics.  
  • Reduced eating disorder thoughts. Lessening the severity, frequency of, and distress surrounding calorie or weight-focused thoughts. 
  • Normalized eating behaviors. Eating regular meals and snacks throughout the day; choosing foods based on true personal preference and gentle nutrition rather than always opting for the lowest calorie option. 
  • Improved body image. Decreasing body dissatisfaction, body checking, or distress related to appearance. 

Anorexia treatment can also involve a focus on flexibility, but in the sense that a person may need to break rituals like waiting until a certain time to eat or being able to pick the salad dressing they like instead of the lowest-calorie option (if that is a behavior for them).

Both ARFID and anorexia are serious and treatable. But, they require different clinical approaches. Getting the right diagnosis is a crucial first step. The most effective treatment plans are built around the root cause of the person’s behaviors – not just the symptoms we see from the outside. 

Sanford Behavioral Health provides effective treatment for eating disorders. This includes specialized care for ARFID and anorexia, as well as the underlying causes and co-occurring concerns that might coexist with these conditions. 

Anorexia treatment at Sanford addresses the root causes of the disorder from a trauma-informed, compassionate perspective. Similarly, people in treatment for ARFID at our center get care that addresses their “why.”

We’re here to help you or your loved one find treatment they can trust and make lasting progress. Contact us today to learn more.

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