PACED: a framework for working with fear-based ARFID

It's the predicted outcome, not the food - a framework for fear-based ARFID.

Fear-based ARFID (Avoidant/Restrictive Food Intake Disorder) is the presentation where restriction is driven by anticipatory anxiety about a physical outcome rather than by sensory aversion or low appetite. The person isn't avoiding food because of how it tastes or feels, and they're not simply under-eating. They're avoiding it because of what they're afraid will happen if they eat - choking, vomiting, an allergic reaction, gastrointestinal distress, or getting sick. The food isn't the problem. The predicted outcome is.

One thing that comes up often is how much this overlaps with anorexia nervosa. The two can look very similar from the outside - narrowed intake, weight loss, avoidance that has organised itself around eating - and they frequently co-occur. But the driver isn't always the same. In anorexia, restriction tends to be organised around weight, shape, and body image. In fear-based ARFID, it's organised around a feared physical consequence. Sometimes both are present at once, sometimes only one is, and the mix matters for how you work. It's something to assess for rather than assume, in either direction.

PACED is a sequenced, consent-based way of thinking about these presentations. It stands for Person-Directed, Anticipatory Anxiety, Consent and Readiness, Exposure through inhibitory learning, and De-escalate the Environment. The thread running through all of it is that exposure is one option, not the assumed next step. The person sets the goals. Dietary expansion isn't taken for granted. Anticipatory anxiety is treated as the primary target, not the eating behaviour itself. And when exposure is indicated, how it's done - whether the person is present enough to actually register that the feared outcome didn't occur - matters as much as whether it's done at all.

The resource comes as a one-page framework plus a set of clinical companion notes with the questions to ask, the fear profiles to look for, and how to think about consent, exposure, and working with families and schools.

Download the tool now:

PACED
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PACED Companion Notes