Received: 5 June 2020

DOI: 10.1002/erv.2815

RESEARCH ARTICLE
- -
Revised: 18 November 2020 Accepted: 23 November 2020

Avoidant/restrictive food intake disorder:

Psychopathological similarities and differences in
comparison to anorexia nervosa and the general
population

Laura Cañas1,3 | Carol Palma3 | Ana M. Molano1 | Lola Domene1 |

Marta Carulla‐Roig1 | Raquel Cecilia‐Costa1 | Montserrat Dolz1,2 |
Eduardo Serrano‐Troncoso1,2

1
Child and Adolescent Psychiatry and
Psychology Department, Sant Joan de Déu
Hospital, Esplugues de Llobregat, Spain
2
Children and Adolescent Mental Health
Research Group, Sant Joan de Déu
Research Institute, Esplugues de
Llobregat, Spain
3
Faculty of Psychology, Education and
Sport Sciences Blanquerna, Ramon Llull
University, Barcelona, Spain
Correspondence
Eduardo Serrano‐Troncoso, Paseo de Sant
Joan de Déu, 2, 08950 Esplugues de
Llobregat, Barcelona.
Email: eserrano@sjdhospitalbarcelona.org
Abstract
Introduction: Avoidant/restrictive food intake disorder (ARFID) categorises
patients with selective and/or restrictive eating patterns in the absence of
distorted cognition concerning weight, food, and body image.
Objective: To examine the sociodemographic and clinical profile of patients
with ARFID in comparison to those with anorexia nervosa (AN) and to a non‐
clinical group (NCG).
Method: A descriptive, observational, comparative study made up of three
groups (ARFID, AN and NCG). Ninety‐nine children and adolescents were
analyzed by means of a semi‐structured diagnostic interview and question-
naires on depression, anxiety, clinical fears and general psychopathology.
Results: The ARFID group was significantly younger (10.8 vs. 14.1 years of
age), with a greater proportion of males (60.6% vs. 6.1%), an earlier onset of
illness (6.2 vs. 13.4 years of age), and a longer period of evolution of the illness
(61.2 vs. 8.4 months) compared to the AN group. Clinically, patients with
ARFID showed greater medical (42.4% vs. 12.1%) and psychiatric (81.8% vs.
33.3%) comorbidity—assessed with a semi‐structured diagnostic interview—
greater clinical fear (p < 0.005), more attention problems (p < 0.005) and fewer
symptoms of anxiety and depression (p < 0.005)—measured with self‐report
questionnaires.
Conclusions: ARFID is a serious disorder with a significant impact on the
physical and mental health of the pediatric population. Likewise, some of
these physical and mental conditions may be a risk factor in developing
ARFID. Attention problems and clinical fears in ARFID, and the greater

Abbreviations: ADHD, attention deficit hyperactivity disorder; AN, anorexia nervosa; APA, American Psychiatric Association; ARFID, avoidant/
restrictive food intake disorder; ASD, autism spectrum disorder; CBCL, child behaviour check‐list; CDI, children's depression inventory; DSM,

-
diagnostic and statistical manual of mental disorders; FSSC‐R, fear survey schedule for children‐revised; K‐SADS‐PL, kiddie‐schedule for affective
disorders and schizophrenia‐present and lifetime; NCG, non‐clinical group; OCD, obsessive‐compulsive disorder; SPSS, statistical package for
social science; STAIC, state‐trait anxiety inventory for children's.

Eur Eat Disorders Rev. 2020;1–12. wileyonlinelibrary.com/journal/erv © 2020 Eating Disorders Association and John Wiley & Sons Ltd. 1
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presence of internalised symptoms in AN, were the main differences found in
the psychopathological profiles.
KEYWORDS
ARFID, anorexia nervosa, psychopathology, comorbidity, depression, anxiety
1 | INTRODUCTION
Avoidant/restrictive food intake disorder (ARFID) was
added to the diagnostic and statistical manual of mental
disorders (DSM‐5) (APA, 2013) with the aim of
including those patients presenting food intake avoid-
ance and/or restriction in the absence of distorted
cognition concerning weight and body shape (Kurz
et al., 2015). It may be diagnosed at any age (Eddy
et al., 2015; Nakai et al., 2016); patients are charac-
terised by the presence of restrictive and/or selective
food intake behaviours, significant weight loss or pon-
doestatural delay, relevant nutritional deficiency,
dependence on oral or enteral nutritional supplements
and major psychosocial difficulties (APA, 2013).
Recently, a number of authors have classified patients
with the three main clinical symptoms of ARFID into
three psychopathological dimensions: those with a lack
of interest in food and eating, those with food restriction
deriving from sensorial reaction to foods and those
avoiding specific foods due to fears (Katzman
et al., 2019; Norris et al., 2018; Reilly et al., 2019; Sharp
& Stubbs, 2019; Thomas et al., 2017; Zickgraf &
Ellis, 2018; Zickgraf, Lane‐Loney, et al., 2019).
Regarding prevalence, in the general population it is
estimated at 3.2% (Kurz et al., 2015) and in specific
juvenile eating disorder units are between 13% and 31%
(Cooney et al., 2018; Fisher et al., 2014; Fisher
et al., 2015; Nicely et al., 2014; Norris et al., 2017;
Ornstein et al., 2013).
Upon comparing ARFID and anorexia nervosa (AN),
there are similarities and differences that emerge in the
literature. The underlying reasons for the food restriction
are the principal difference between the two diagnoses,
given that in ARFID the eating behaviour alterations are
not the result of the weight/shape preoccupation and
body dysphoria present in AN (Kurz et al., 2015; Nakai
et al., 2016; Nicely et al., 2014; Ornstein et al., 2013;
Thomas et al., 2017). A number of studies have concluded
that patients with ARFID are younger, more often male,
begin treatment at a younger age and report a longer
evolution time for their disorder than do patients with
ET AL.
Highlights
� The sociodemographic variables and clinical
characteristics had a heterogeneous distribu-
tion between patients with ARFID and those
with AN, making it clear that the two diag-
nostic entities are distinct.
� Patients with ARFID compared to those with
AN form a clinically heterogeneous group
characterised for three patterns of restriction:
lack of interest in eating, avoidance due to the
sensory characteristics of food, and fear of
aversive consequences related to food.
� Patients with ARFID have a significant impact
on the physical and emotional development, in
some instances equal to or greater than those
with AN.
AN (Becker et al., 2019; Bryson et al., 2018; Cooney
et al., 2018; Fisher et al., 2014; Forman et al., 2014;
Katzman et al., 2019; Lieberman et al., 2019; Nakai
et al., 2016; Nicely et al., 2014; Norris et al., 2014; Orn-
stein et al., 2013; Zimmerman & Fisher, 2017). It has also
been found that the medical and psychiatric comorbid-
ities are greater in patients with ARFID than their AN
counterparts (Becker et al., 2019; Bryson et al., 2018;
Fisher et al., 2014; Lieberman et al., 2019; Norris
et al., 2014). In psychiatric terms, higher rates of co-
morbidity in ARFID have been found with anxiety dis-
orders, while in the case of AN, the higher rates are with
mood disorders (Bryson et al., 2018; Cooney et al., 2018;
Fisher et al., 2014; Katzman et al., 2019; Mammel &
Ornstein, 2017; Menzel, Reilly, Luo, & Kaye, 2019; Nicely
et al., 2014; Norris et al., 2014). Autism spectrum disorder
(ASD), attention deficit hyperactivity disorder (ADHD),
obsessive‐compulsive disorder (OCD), and learning dis-
orders are more prevalent in ARFID than in AN
(Beighley et al., 2013; Bryson et al., 2018; Coglan &
Otasowie, 2019; Cooney et al., 2018; Eddy et al., 2015;
Fisher et al., 2014; Katzman et al., 2019; J. Lucarelli
CAÑAS ET AL.
et al., 2017; Nicely et al., 2014; Norris et al., 2014; Orn-
stein et al., 2017; Pennell et al., 2016; Thomas et al., 2017;
Zimmerman & Fisher, 2017). To date, there have been no
studies evaluating the levels of anxiety, depression
symptoms, clinical fears and general psychopathology in
a Spanish sample of children and adolescents diagnosed
with ARFID.
The aim of the present study was to assess the soci-
odemographic and clinical characteristics of a group of
patients diagnosed with ARFID and to compare the re-
sults with those from a group of patients diagnosed with
AN and with a non‐clinical group (NCG). As a hypoth-
esis, we expected that the patients with ARFID would
present significant clinical differences compared to the
AN and NCG groups in terms of sociodemographic var-
iables (younger and a greater proportion of males) and
medical history (longer evolution time of the illness,
earlier age of onset of the eating disorder, and more
complex medical and psychiatric histories). Second, in
the comparison of the groups, our hypothesis was that
the patients with ARFID would show significantly higher
levels of anxiety, clinical fears and psychopathology
compared to the patients with AN and NCG, and that the
patients with AN would present more depressive symp-
toms than the children and adolescents with ARFID and
with NCG.
2 | METHOD
2.1 | Design type, participants, and
inclusion and exclusion criteria
This was a descriptive, observational and comparative
study made up of three groups: a group of patients
diagnosed with ARFID (n ¼ 33), a group of patients
diagnosed with AN (n ¼ 33) and an NCG group (n ¼ 33)
drawn from the general population. A total of 99 children
and adolescents (7–17 years of age) were assessed be-
tween October 2015 and May 2018. The clinical group
sample was drawn from a total of 266 eating disorder
patients seeking treatment, in this period, at the eating
disorders unit of the Hospital Sant Joan de Déu, Barce-
lona, Spain. The patients diagnosed with ARFID and AN,
according to the diagnostic criteria of the DSM‐5
(APA, 2013), were consecutively selected and new cases
drawn with an intentional‐type non‐probabilistic sam-
pling method. Twenty nine (87.9%) patients with ARFID
were outpatients, 4 (12.1%) were in partial hospitalisation
and none were inpatient treatment. Regarding patients
with AN, 3 (9.1%) were outpatients, 28 (84.9%) were in
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partial hospitalisation, and 2 (9.1%) were inpatients. All
the participants were invited to participate in the study
after the first visit in the Eating Disorders Unit. Once
written consent had been obtained, and the assessment
from the children and their families was carried out in
the following 15 days starting from the first visit.
The NCG was made up of members of the general
population also drawn with an intentional‐type non‐
probabilistic sampling method. Drawing on the literature,
we anticipate differences between groups in gender and
age variables, and we considered that it could bias the
study. To control this, a multivariant analysis (MAN-
COVA) was carried out.
The inclusion criteria were being 7 to 17 years old,
fulfilling the diagnostic criteria of the DSM‐5 (APA, 2013)
for ARFID or AN and signing informed consent.
Regarding the status diagnostic (main diagnosis and co-
morbidity), it was assessed with a semi‐structured inter-
view (Kiddie‐Schedule for Affective Disorders and
Schizophrenia‐Present and Lifetime, K‐SADS‐PL) (Kauf-
man et al., 1997) and complemented with a clinical
interview, developed for the authors for the current
study, to evaluate ARFID and the AN criteria in accor-
dance with the DSM‐5 (APA, 2013). This process was
carried out because at the time the exploration was un-
dertaken, and there were no validated instruments
available for the assessment of a new diagnosis of ARFID
nor for the changes in criteria proposed in the latest
version of the DSM‐5 for AN. Izquierdo et al. (2019)
proceeded in the same manner in a recent study with the
same instrument.
The exclusion criteria for the NCG were having an
eating disorder (also determined with semi‐structured
diagnostic interview), and for all the participants, having
a psychiatric disorder or serious medical illness would
preclude participation. Specifically, we excluded patients
with ARFID who were seeking treatment in the eating
disorder unit, but they also had comorbidity with ASD.
All these patients were referred to the ASD unit at the
same hospital for assessment and treatment. All exclu-
sion criteria were related to the difficulty to understand
the questions in the self‐administered questionnaires.
2.2 | Instruments
� K‐SADS‐PL (Kaufman et al., 1997). Semi‐structured
diagnostic interview was validated in Spanish by Ulloa
et al. (2006). It includes Axis I diagnoses in accordance
with the DSM‐IV criteria (APA, 1994). For the present
study, a clinical interview was developed (comple-
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- CAÑAS
mentary to the K‐SADS‐PL) to assess the criteria of the
ARFID and the AN in accordance with the DSM‐5
(APA, 2013); because at the time the exploration was
undertaken, there were no validated instruments
available for the assessment of a new diagnosis of
ARFID nor for the changes in criteria proposed in the
latest version of the DSM‐5 for AN. This process was
carried out in the same manner as a recent study with
the same instrument (Izquierdo et al., 2019).
� An ad hoc questionnaire was designed to elicit socio-
demographic data. It has two parts: one for socio-
demographic data and the other for information
regarding the eating disorder.
� Child Behaviour Check‐List (CBCL) (Achenbach &
Rescorla, 2001; Sardinero et al., 1997). Questionnaire
was completed by the parents concerning the behav-
iour of their children. It is composed of 120 items
organised in eight scales; some are grouped into two
dimensions: internalising behaviour (anxious/
depressed, withdrawn/depressed, somatic complaints)
and externalising behaviour (rule‐breaking behaviour
and aggressive behaviour). The other scales are social
problems, thought problems and, attention problems.
Finally, CBCL has a total problems scale. Depending on
the scale, the reliability indexes (Cronbach's Alpha
scores) range from 0.72 to 0.91.
� Children's Depression Inventory (CDI) (Del Barrio
et al., 1999; Kovacs, 1992). Self‐administered ques-
tionnaire for children and adolescents was given. It
consists of 21 items assessing the presence and seri-
ousness of depressive symptomatology. Cronbach's
Alpha is 0.80 (good internal consistency).
� State‐Trait Anxiety Inventory for Children's (STAIC)
(Spielberger et al., 1973, 1990). Self‐applied inventory
for children and adolescents was made up of 40 items
and was designed to assess two independent concepts
in anxiety: anxiety state (transitory emotional condi-
tion) and anxiety trait (relatively stable anxious pro-
pensity). The reliability index of the scale calculated
with the Kuder‐Richardson KR‐20 formula ranges
from 0.87 to 0.93.
� Fear Survey Schedule for Children‐Revised (FSSC‐R)
(Ollendick et al., 1983). We used the adapted version
validated for the Spanish population (Sandín, 1997). It
is an 80‐item self‐report questionnaire for children that
assess the presence and intensity of fears in the juve-
nile population. The scales have a total fear score and a
five factor‐based subscale scores: fear of failure and
criticism, fear of the unknown, fear of small animals,
fear of danger and death and medical fears. The
Cronbach Alpha reliability index ranges between 0.63
(acceptable internal consistency) and 0.94 (excellent
internal consistency).
ET AL.
2.3 | Procedure
The study was approved by the Clinical Research Ethics
Committee of the Hospital. Once informed signed con-
sent for participation in the study was obtained from the
parents and from children aged 12 and above or verbal
consent from those under 12; the semi‐structured K‐
SADS‐PL interview was administered to the children
and parents. To assure confidentiality and anonymity,
all participants were given an identification code based
on the order in which they were evaluated. Following
this, the battery of questionnaires was administered.
First, we collected the sociodemographic and clinical
data, and then we gave the questionnaires (CDI, STAIC,
and FSSC‐R) to the patients and their parents (CBCL).
All the battery used, both the semi‐structured interview
and the questionnaires, were administered specifically
for this study. All the patients invited to participate in
the study accepted to take part in it. We excluded 6
(9.1%) patients because they were diagnosed with
ARFID, but their main diagnosis was an Autism Spec-
trum Disorder.
2.4 | Statistical analysis
To begin, a descriptive analysis was made. Then, variance
analysis (ANOVA) was used to compare the means ob-
tained for each variable on the scale. Next, multiple
comparisons were made using Bonferroni correction to
assess the significant differences between groups. In
addition, Chi‐squared test (X2) was used to compare the
differences found between the nominal and ordinal var-
iables of the groups. Finally, a multivariant analysis
(MANCOVA) was carried out, including in the model
those variables (gender and age) that could have been
unexpected in the comparison of the groups by diagnosis.
The size of the effect was calculated using Cohen's Eta‐
squared (η2) and including analysis of the observed power
(P). Multivariate contrasts were carried out, as were tests
of the between‐subject effect. For this analysis, the IBM
Statistical Package for the Social Sciences (SPSS) v24.0
was used.
3 | RESULTS
3.1 | Comparative analysis with
sociodemographic, clinical, and
anthropometric variables
Compared to patients with AN, those with ARFID were
significantly younger (10.8 vs. 14.1 years old, p < 0.001),
CAÑAS ET AL.
with a greater proportion of males (60.6% vs. 6.1%,
p < 0.001), an earlier age of illness onset (6.2 vs. 13.7
years of age, p < 0.001) and a longer evolution time for
the illness (61.2 vs. 8.4 months, p < 0.001). Patients with
ARFID also showed greater medical comorbidity (42.4%
vs. 12.1%, p ¼ 0.003) and psychiatric comorbidity (81.8%
vs. 33.3%, p ¼ 0.006) compared to those with AN and the
NCG (p < 0.001). Specifically, patients with ARFID
versus those with AN (assessed with semi‐structured
K‐SADS‐PL interview) had a greater comorbidity with
anxiety disorders, ADHD, OCD, behavioural disorders
and a lower depressive disorder. Finally, patients with
AN were in a significantly lower percentile for body mass
index (BMI) (p < 0.001) than the ARFID and NCG pa-
tients (Table 1).
Regarding the three main clinical symptoms of
ARFID (assessed with the clinical interview comple-
mentary to the K‐SADS‐PL), 26 (78.8%) patients were
classified as having an aversion to the sensory properties
of foods, 29 (87.9%) as having a lack of interest in food
and eating and 13 (39.4%) as having a fear of aversive
consequences from eating.
Taking into account the criteria A symptoms of the
DSM‐5, 20 (60.6%) patients with ARFID had a significant
weight loss or growth failure (A1), 24 (69.7%) had a sig-
nificant nutritional deficiency (A2), 12 (36.4%) had
dependence on oral nutritional supplements (A3) and 16
(48.5%) had marked interference with psychosocial
functioning (A4).
3.2 | Comparative analysis of
depression, anxiety and clinical fear
variables
The differences between groups concerning depression
were significant (p < 0.001); the AN group had an
average score that was significantly higher in the CDI
than the scores for the ARFID group and the NCG.
Regarding anxiety, it was the AN group that had higher
subscale scores for anxiety‐state and anxiety‐trait on the
STAIC; significant differences were found between
groups (p < 0.001).
In the assessment of clinical fears by means of the
FSSC‐R scale, the ARFID group scored significantly
higher than did the AN group and the NCG (p < 0.001) in
the total score. On the FSSC‐R subscales, the ARFID
group scored significantly higher (p < 0.001) on fears of
physical dangers and death, fear of the unknown, and
medical fears than did the patients with AN and the NCG
group (Table 2).
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3.3 | Comparative analysis of the
general psychopathology variable
Patients with ARFID averaged significantly higher than
the AN and NCG patients (p < 0.001) on the attention
problems scale of the CBCL. In contrast, the AN grouped
scored significantly higher (p < 0.001) than the ARFID
and the NCG on anxious‐depressed, withdrawn‐
depressed and internalising behaviour.
On the somatic complaints, social problems, rule‐
breaking behaviour and aggressive behaviour scales, and
on the externalizing behaviour and total problems di-
mensions, there were no significant differences between
the clinical groups, but the average scores were signifi-
cantly higher than those for the NCG (p < 0.05) (Table 3).
3.4 | Multivariant analysis (MANCOVA)
We observed a statistically significant effect of the gender
covariable on the subscale of the FSSC‐R fear of small
animals and minor injuries (p ¼ 0.003; η2 ¼ 0.091;
p ¼ 0.848); the gender covariable, owing to the greater
proportion of males in the ARFID group, serves to
explain the differences observed between the ARFID
group and the AN and NCG groups. The age covariable
had a statistically significant effect on the subscale of the
FSSC‐R fear of the unknown (p ¼ 0.033; η2 ¼ 0.049;
p ¼ 0.573); in this comparison, age explained the differ-
ences on this subscale between the ARFID group on the
one hand and the AN and NCG groups on the other
(Table 4).
4 | DISCUSSION
The aim of this study was to examine the sociodemo-
graphic and clinical characteristics of a sample taken
from Spanish children and adolescents diagnosed with
ARFID and to compare the results of that examination
with those for a group diagnosed with AN and also with a
NCG. The results show a heterogeneous distribution for
the sociodemographic variables and clinical characteris-
tics with significant differences between ARFID and AN
in a number of areas. The first difference we found was
related to sociodemographic results; patients with ARFID
were significantly younger (on average pre‐puberty—10
years old—while those in the AN group were adolescents
—14 years old), with a greater proportion of males (more
than half of the cases compared to less than 10% found in
patients with AN).
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T A B L E 1 Comparative analysis (ANOVA and Chi‐squared) of the sociodemographic variables and clinical characteristics of the three
groups (ARFID, AN and NCG) of children and adolescents

Variables ARFID (n = 33) AN (n = 33) NCG (n = 33) Statistics df p*

2
Gender (n/%) x = 15.94 1 <0.001

Male 20 (60.6%) 2 (6.1%) 18 (54.5%)

Female 13 (39.4%) 31 (93.9%) 15 (45.5%)
Current age, years (mean/SD) 10.85 (2.37) 14.15 (1.82) 11.15 (2.46) F = 21.96 2 <0.001a,c
Age at onset of illness, years (mean/SD) 6.24 (3.53) 13.73 (2.44) ‐ F = 34.35 1 <0.001a
Time of illness onset, months (mean/SD) 61.21 (51.36) 8.45 (5.98) ‐ F = 34.35 1 <0.001a
Medical history (n/%) 14 (42.4%) 4 (12.1%) 4 (12.1%) x2 = 0.00 1 0.003
2
Personal psychiatric/psychological antecedents** (n/%) 16 (48.5%) 8 (24.2%) 2 (6.1%) x = 2.78 1 <0.001
2
Psychiatric comorbidity (n/%) 27 (81.8%) 11 (33.3%) 0 (0%) x = 7.67 1 0.006

Anxiety disorders 16 (59.3%) 5 (45.5%) ‐ ‐ ‐ ‐

Depressive disorders 0 (0%) 6 (54.5%) ‐ ‐ ‐ ‐

ADHD 7 (25.9%) 0 (0%) ‐ ‐ ‐ ‐

OCD 2 (7.4%) 0 (0%) ‐ ‐ ‐ ‐

Behavioural disorders 2 (7.4%) 0 (0%) ‐ ‐ ‐ ‐
Weight, kg 34.30 (12.73) 40.15 (7.10) 42.19 (12.45) F = 4.51 2 0.013b
BMI, kg/m2 16.78 (3.29) 15.75 (1.68) 18.93 (3.03) F = 11.36 2 <0.001b,c
Pc of BMI 36.73 (37.21) 6.24 (7.52) 65.55 (24.14) F = 43.00 2 <0.001a,b,c
a
Differences between ARFID‐AN.
b
Differences between ARFID‐NCG.
c
Differences between AN‐NCG.
*Level of significance set at p < 0.05; **Personal psychiatric/psychological antecedents: Presence of episodes, prior to the current illness that have required
psychiatric or psychological attention/treatment. Differences between groups following Bonferroni correction with p < 0.05.

Clinically, the ARFID group showed an earlier
average age of disorder onset and a longer period of
illness evolution than did the AN group. These results
found in our Spanish sample align with a recent
literature regarding differences (Becker et al., 2019;
Bryson et al., 2018; Cooney et al., 2018; Katzman
et al., 2019; Lieberman et al., 2019; Thomas et al., 2017;
Zickgraf, Murray et al., 2019, Zickgraf, Lane‐Loney
et al., 2019).
Another clinical difference was regarding comorbid-
ity. In our study, patients with ARFID had significantly
more antecedents in their medical and psychiatric his-
tories. It is congruent with literature revised referring to a
greater medical risk found in young people with ARFID
(Becker et al., 2019; Bryson et al., 2018; Coglan & Ota-
sowie, 2019; Fitzgerald & Frankum, 2017; Makhzoumi
et al., 2019; Norris et al., 2016; Zia et al., 2017; Zimmer-
man & Fisher, 2017). Some of these physical and mental
conditions may be in turn a risk factor in developing
ARFID. Gastrointestinal symptoms are the most
commonly reported medical comorbidities (Norris
et al., 2018; Reilly et al., 2019; Zickgraf, Lane‐Loney,
et al., 2019; Zickgraf, Murray, et al., 2019). Regarding
psychiatric comorbidity, our results are also in agreement
with the literature in finding that ARFID shows greater
comorbidity with anxiety disorders, ADHD, OCD and
behavioural disorders, while AN is more strongly asso-
ciated with depressive disorders (Becker et al., 2019;
Bryson et al., 2018; Coglan & Otasowie, 2019; Cooney
et al., 2018; Fisher et al., 2014; Nicely et al., 2014).
In patients with ARFID, significant loss of body mass
is not an exclusion criteria; patients may be underweight,
normal or overweight (Coglan & Otasowie, 2019; Kurz
et al., 2015; Makhzoumi et al., 2019; Nakai et al., 2016;
Norris et al., 2018; Reilly et al., 2019; Zickgraf, Lane‐
Loney, et al., 2019; Zimmerman & Fisher, 2017). In our
study, patients with AN showed a significantly lower BMI
percentile (indicative of significantly low weight) than
ARFID and NCG. However, the nutritional deficiencies
can be observed regardless of low weight, so patients with
ARFID can present the same medical complications that
patients with AN (Coglan & Otasowie, 2019).
CAÑAS ET AL.
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T A B L E 2 Comparative analysis (ANOVA) of the variables depression, anxiety, and clinical fears, assessed in the three groups of
children and adolescents (ARFID, AN, and NCG) with the CDI, STAIC, and FSSC‐R questionnaires

ARFID (n = 33) AN (n = 33) NCG (n = 33)

Variables Mean DS (SD) Mean DS (SD) Mean DS (SD) Statistics df p*
CDI overall 10.55 (8.10) 16.06 (10.59) 4.88 (3.70) F = 16.14 2 <0.001a,b,c

Dysphoria 6.30 (5.44) 10.97 (7.28) 2.82 (2.51) F = 18.58 2 <0.001a,b,c

Negative self‐esteem 4.06 (3.20) 5.42 (4.00) 2.06 (1.73) F = 9.69 2 <0.001b,c

STAIC

Anxiety‐state 30.67 (7.72) 36.64 (10.43) 24.15 (5.00) F = 19.93 2 <0.001a,b,c

Anxiety‐trait 33.82 (8.16) 39.00 (8.30) 29.48 (6.50) F = 12.62 2 <0.001a,c

FSSC‐R overall 131.58 (22.41) 113.24 (20.63) 106.42 (20.15) F = 12.55 2 <0.001a,b

Fear of failure and criticism 27.94 (5.85) 25.42 (7.10) 23.42 (6.05) F = 4.17 2 0.018b

Fear of small animals and minor injuries 20.64 (4.77) 18.15 (3.23) 17.12 (4.11) F = 6.44 2 0.002b

Fear of physical danger and death 32.64 (6.80) 25.67 (8.28) 25.64 (7.73) F = 9.20 2 <0.001a,b

Fear of the unknown 26.30 (5.82) 22.39 (4.40) 20.91 (3.91) F = 11.19 2 <0.001a,b
Medical fears 8.27 (2.91) 6.45 (1.62) 6.27 (1.77) F = 8.47 2 <0.001a,b
Note: Differences between groups following Bonferroni correction with p < 0.05.
Abbreviations: AN, anorexia nervosa; ARFID, avoidant restrictive food intake disorder; CDI, children's depression inventory; df, degrees of freedom; DS,
direct score; FSSC‐R, fear survey schedule for children‐revised; NCG, non‐clinical group; SD, standard deviation; STAIC, state‐trait anxiety inventory for
children.
a
Differences between ARFID‐AN.
b
Differences between ARFID‐NCG.
c
Differences between AN‐NCG.
*Level of significance set at p < 0.05.

Our results support the existing literature in relation
to the presence of three patterns of restriction in patients
with ARFID (lack of interest in food/appetite, avoidance
due to the sensory characteristics of food, and fear of
aversive consequences related to food) (Katzman
et al., 2019; Norris et al., 2018; Reilly et al., 2019; Sharp &
Stubbs, 2019; Thomas et al., 2017; Zickgraf, Lane‐Loney
et al., 2019). These three psychopathological pre-
sentations make patients with ARFID a clinically het-
erogeneous group, especially if we compare it with the
diagnosis of AN, which is more homogeneous because of
the weight requirements and the limited ways to meet
criteria. Zickgraf, Lane‐Loney et al. (2019) reported de-
mographics, comorbidities and illness characteristics
including illness duration, which differ significantly
among the three ARFID presentations.
Regarding the differences in clinical symptomatology
assessed with self‐report questionnaires, the AN group
scored significantly higher on the CDI, clearly demon-
strating a greater presence of depressive symptomatology.
These results match several recent studies (Coglan &
Otasowie, 2019; Cooney et al., 2018; Lieberman
et al., 2019). In measuring anxiety by means of the STAIC
questionnaire and basing ourselves on the studies
published to date, we did not find the results we had
expected; in our sample patients with ARFID, it did not
score significantly higher than those from the AN group.
However, this greater presence of anxiety was reflected in
the results of the K‐SADS‐PL diagnostic interview, in
which 59.3% of patients with ARFID fulfilled the diag-
nostic criteria for anxiety disorders, compared to 45.5% of
those with AN. Other authors (Cooney et al., 2018; Nicely
et al., 2014) found the same discrepancies in measuring
anxiety in a group of patients with ARFID, using a
different measurement instrument. These results suggest
several possible explanations. The differences may be
owing to difficulties on the part of patients with ARFID
in understanding the STAIC questions and responding to
them, given their average age, which is significantly
lower than that of patients with AN. Indeed, it may be the
case that STAIC is not the most appropriate instrument
for discriminating among anxiety disorders in a youthful
ARFID population. On the other hand, underweight/
malnourished found in all patients with AN, versus some
but not all in the ARFID group, could explain the pres-
ence of greater state‐anxiety assessed with the STAIC.
To our knowledge, there have been no studies to date
assessing the presence and intensity of clinical fears in
8
- CAÑAS ET AL.

T A B L E 3 Comparative analysis (ANOVA) of the general psychopathological variable, assessed in the three groups of children and
adolescents (ARFID, AN, and NCG) with the CBCL instrument

ARFID (n = 33) AN (n = 33) NCG (n = 33)

Variables Mean DS (SD) Mean DS (SD) Mean DS (SD) Statistics df p*
CBCL

Anxious/depressed 4.85 (4.01) 8.06 (5.20) 1.52 (2.50) F = 15.50 2 <0.001a,c

Withdrawn/depressed 3.61 (3.97) 5.58 (3.47) 1.33 (1.38) F = 14.97 2 <0.001a,b,c

Somatic complaints 3.03 (2.39) 3.39 (3.20) 1.57 (1.60) F = 6.87 2 0.002b,c

Social problems 3.82 (3.18) 2.79 (2.28) 1.48 (1.95) F = 7.04 2 0.001b

Thought problems 2.67 (2.75) 3.79 (3.31) 1.09 (1.52) F = 8.68 2 <0.001c

Attention problems 6.33 (4.72) 3.79 (3.48) 2.58 (2.37) F = 9.06 2 <0.001a,b

Rule‐breaking behaviour 2.67 (2.11) 2.18 (2.15) 1.09 (1.42) F = 5.78 2 0.004b,c

Aggressive behaviour 7.33 (5.80) 8.39 (4.97) 3.15 (3.31) F = 10.94 2 <0.001b,c

Internalizing behaviour 11.09 (8.69) 18.00 (11.27) 5.24 (4.22) F = 18.30 2 <0.001a,b,c

Externalizing behaviour 10.58 (7.31) 11.21 (7.79) 4.64 (4.18) F = 9.88 2 <0.001b,c
Total problems 39.24 (24.38) 45.09 (29.82) 17.70 (12.44) F = 12.57 2 <0.001b,c
Note: Differences between groups following Bonferroni correction with p < 0.05.
Abbreviations: AN, anorexia nervosa; ARFID, avoidant restrictive food intake disorder; CBCL, child behaviour check‐list; df, degree of freedom; DS, direct
score; NCG, non‐clinical group; SD, standard deviation.
a
Differences between ARFID‐AN.
b
Differences between ARFID‐NCG.
c
Differences between AN‐NCG.
*Level of significance set at p < 0.05.

young people with ARFID. In our study, this variable was
evaluated with the FSSC‐R. The ARFID group scored
significantly higher compared to the other two groups
overall, indicating the presence of clinically significant
fears. Compared to the AN and NCG groups, patients
with ARFID had scores indicative of clinically significant
fears on the total score and the following FSSC‐R sub-
scales: fear of physical danger and death, fear of the
unknown and medical fears. The greater medical co-
morbidity, the earlier average age of disorder onset, the
longer period of illness evolution, along with some
ARFID symptoms related to concerns about aversive
consequences of eating (previous experience of a choking
episode, significant gastroesophageal reflux symptoms or
food allergies) could explain the significant presence of
clinical fears in the ARFID group associated to physical
danger and death and medical fears.
Finally, the findings concerning the psychopatholog-
ical profile as assessed with the CBCL demonstrated a
similar profile for the two clinical groups that was
significantly poorer than that for the NCG. The AN group
showed significantly more interiorizing problems
(anxious/depressive and withdrawn/depressive scales)
than did the ARFID and NCG. In contrast, patients with
ARFID had more attention problems, which might be
explained by the greater proportion of comorbidity with
ADHD in this diagnostic group (Pennell et al., 2016). In
externalising behaviour (rule‐breaking behaviour and
aggressive behaviour), ARFID and AN had analogous
score, indicative of a greater presence of disruptive
behaviour with respect to the NCG, although both ach-
ieved clinical significance only on the aggressive behav-
iour scale. These behavioural problems perceived by
parents of patients with ARFID and AN may be influ-
enced by the burden as caregivers, and recent studies
have found psychological distress in relatives of eating
disorders patients that interferes in the relationship be-
tween parents and children (L. Lucarelli et al., 2018;
Rienecke & Richmond, 2017). In like manner, the parents
reported a similar profile for the groups in social prob-
lems and thought problems, which were significantly
greater than for the NCG. With results similar to ours in
the CBCL, several studies have shown strongly degraded
functioning in subjects with ARFID and AN (Leggero
et al., 2010; L. Lucarelli et al., 2018; Viglione et al., 2006).
In summary, the present study allows us to become
more familiar with the sociodemographic and clinical
characteristics of a group of patients with ARFID and to
highlight those that are similar to and different from the
characteristics of patients with AN. Our findings make it
CAÑAS ET AL.
- 9

TABLE 4 Multivariant analysis (MANCOVA) of the gender and age covariables

Mean DS (SD) Gender and age covariables

F p* η2 p
Variables ARFID AN NCG G A G A G A G A
CDI total 10.55 (8.10) 16.06 (10.59) 4.88 (3.70) 0.247 0.069 0.620 0.794 0.003 0.001 0.078 0.058
CDI dysphoria 6.30 (5.44) 10.97 (7.28) 2.82 (2.51) 0.522 0.000 0.472 0.995 0.006 0.000 0.110 0.050
CDI negative self‐esteem 4.06 (3.20) 5.42 (4.00) 2.06 (1.73) 0.048 0.606 0.827 0.438 0.001 0.007 0.055 0.120
STAIC anxiety‐state 30.67 (7.72) 36.64 (10.43) 24.15 (5.00) 0.362 1.01 0.549 0.317 0.004 0.011 0.092 0.169
STAIC anxiety‐feature 33.82 (8.16) 39.00 (8.30) 29.48 (6.50) 2.12 0.187 0.148 0.666 0.023 0.002 0.303 0.071
FSSC‐R total 131.58 (22.41) 113.24 (20.63) 106.42 (20.15) 0.274 1.62 0.101 0.206 0.029 0.018 0.375 0.243
FSSC‐R fear of failure and 27.94 (5.85) 25.42 (7.10) 23.42 (6.05) 0.436 0.018 0.511 0.893 0.005 0.000 0.100 0.052
criticism
FSSC‐R fear of small animals and 20.64 (4.77) 18.15 (3.23) 17.12 (4.11) 9.12 1.11 0.003a 0.294 0.091 0.012 0.848 0.182
minor injuries
FSSC‐R fear of physical danger 32.64 (6.80) 25.67 (8.28) 25.64 (7.73) 0.469 0.076 0.495 0.783 0.005 0.001 0.104 0.059
and death
FSSC‐R fear of the unknown 26.30 (5.82) 22.39 (4.40) 20.91 (3.91) 2.50 4.69 0.117 0.033b 0.027 0.049 0.347 0.573
FSSC‐R medical fears 8.27 (2.91) 6.45 (1.62) 6.27 (1.77) 3.07 2.86 0.083 0.094 0.033 0.031 0.411 0.388
CBCL anxious/depressed 4.85 (4.01) 8.06 (5.20) 2.52 (2.50) 0.093 0.336 0.762 0.564 0.001 0.004 0.060 0.088
CBCL withdrawn/depressed 3.61 (3.97) 5.58 (3.47) 1.33 (1.38) 1.24 0.300 0.268 0.585 0.013 0.003 0.197 0.084
CBCL somatic complaints 3.03 (2.39) 3.39 (3.20) 1.57 (1.60) 0.559 2.92 0.456 0.091 0.006 0.031 0.115 0.394
CBCL social problems 3.82 (3.18) 2.79 (2.28) 1.48 (1.95) 0.859 2.13 0.356 0.147 0.009 0.023 0.151 0.304
CBCL thought problems 2.67 (2.75) 3.79 (3.31) 1.09 (1.52) 0.041 0.002 0.841 0.968 0.000 0.000 0.055 0.050
CBCL attention problems 6.33 (4.72) 3.79 (3.48) 2.58 (2.37) 0.191 0.330 0.663 0.567 0.002 0.004 0.072 0.088
CBCL rule‐breaking behaviour 2.67 (2.11) 2.18 (2.15) 1.09 (1.42) 0.944 0.320 0.334 0.573 0.010 0.004 0.161 0.087
CBCL aggressive behaviour 7.33 (5.80) 8.39 (4.97) 3.15 (3.31) 0.036 0.157 0.850 0.693 0.000 0.002 0.054 0.068
Abbreviations: A, age; AN, anorexia nervosa; ARFID, avoidant restrictive food intake disorder; CBCL, child behaviour check‐list; CDI, children's depression
inventory; DS, direct score; FSSC‐R, fear survey schedule for children‐revised; G, gender; NCG, non‐clinical group; SD, standard deviation; STAIC, state‐trait
anxiety inventory for children.
a
Corrected for gender.
b
Corrected for age.
*Level of significance set at p < 0.05.

clear that the two diagnostic entities are distinct, and that
ARFID has a significant impact on the physical and
emotional development of patients—in some instances
equal to or greater than that of AN.
The main limitation of the study is the small size of
the sample and the heterogeneity of the groups in terms
of age and gender. At present, the prevalence of ARFID is
inferior to that of AN among patients seeking treatment
for eating disorders. Recent studies estimate that some-
where between 13% and 31% of patients beginning
treatment in childhood units for eating disorders fulfill
the diagnostic criteria for ARFID (Cooney et al., 2018;
Fisher et al., 2015; Nakai et al., 2016; Norris et al., 2016;
Strandjord et al., 2015; Zickgraf, Lane‐Loney, et al., 2019).
Nevertheless, with the aim of controlling for the possible
bias of the effect of the age and gender variables on all the
results, a multivariant analysis (MANCOVA) was carried
out. The analysis indicated that the variables did not
significantly affect the trends noted in the scores that
were obtained. Another limitation of the study is related
to the fact of not having psychopathology measures to
assess the presence of core symptoms of eating disorders
like the drive for thinness or body dissatisfaction, differ-
ential trait in patients with AN versus those with ARFID.
However, these variables were obtained in a categorical
form with a semi‐structured interview and a clinical
interview, the latter designed to adapt the AN and ARFID
diagnostic to the DSM‐5 criteria. Finally, it should be
10
- CAÑAS
noted as another limitation of the study that the three
primary presentations of ARFID were not compared in a
categorical way. Future studies would do well to increase
the sample size so to explore differences among the pri-
mary presentations: those with lack of interest in eating,
restriction as a result of sensory sensitive and those
avoiding specific foods due to fears. This would allow for
greater knowledge of the psychopathological profile of
patients with ARFID. Also, longitudinal studies are
needed to learn more about the results of treatment in the
three primary presentations, thereby allowing for the
development of specific, effective interventions adapted
to the clinical profile of this new diagnostic entity.
A CK NO WL E DG EM EN T S
The authors received no funding for this work.
CON F L I CT OF I N T ER ES T
The authors declare no conflict of interest.
DA TA A VA IL AB I L I T Y S T A T EM E N T
The data that support the findings of this study are
available on request from the corresponding author. The
data are not publicly available due to privacy or ethical
restrictions.
ORCI D
Laura Cañas https://orcid.org/0000-0002-7545-2322
Carol Palma https://orcid.org/0000-0001-5371-7417
Marta Carulla‐Roig https://orcid.org/0000-0002-0611-1145
Montserrat Dolz https://orcid.org/0000-0002-2226-423X
Eduardo Serrano‐Troncoso https://orcid.org/0000-0002-
4935-7348
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How to cite this article: Cañas L, Palma C,
Molano AM, et al. Avoidant/restrictive food intake
disorder: Psychopathological similarities and
differences in comparison to anorexia nervosa and
the general population. Eur Eat Disorders Rev.
2020;1–12. https://doi.org/10.1002/erv.2815