The Complex Intersection of ARFID and Anorexia

We need a more nuanced understanding of body image in ARFID as it is just not true that all individuals with ARFID don't have body image difficulties.

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According to the DSM;

Anorexia Nervosa is characterised by restrictive oral intake in the content of body image disturbance, 

Whereas ARFID (Avoidant Restrictive Feeding Intake Disorder) is characterised by selective eating in the context of sensory aversions or difficulties with food based on non-weight fears, such as emetophobia (fear of vomiting) or fear of food induced illness.

ARFID and Anorexia can overlap in the following ways:
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• Distress of being in an adult body - can include gender distress
• Phobia of specific foods
• Specific food rules
• Difficulty coping with change (especially relating to food) or food being unexpected in some way
• Ritualised eating
• Gastrointestinal difficulties
• Interoceptive differences
• Themes of overexercising or movement based stimming (especially pacing)

But, they have the following areas of difference:
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• Primary motivation - ARFID is typically driven by sensory aversions, fear of adverse consequences, or apparent lack of interest in eating, while Anorexia is primarily motivated by fear of weight gain
• Recognition of undernourishment - many with ARFID express desire to gain weight but find it difficult, while those with Anorexia often resist weight restoration
• Food selection patterns - ARFID often involves consistent "safe foods" based on sensory properties rather than caloric or macro content
• Onset age - ARFID frequently emerges in early childhood, while Anorexia typically develops in adolescence

The Neurodivergent Experience

For many individuals, particularly those who identify as neurodivergent, body image concerns exist alongside ARFID features in ways the DSM fails to capture. The sensory and interoceptive differences common in autism, ADHD, and complex trauma can create complex relationships with one's body that don't fit neatly into diagnostic categories.

Many clinicians still use outdated either/or frameworks that force patients into ill-fitting diagnoses rather than recognising the spectrum of experiences that exist. This approach particularly fails neurodivergent individuals whose body image concerns may manifest differently but are no less valid.

Individuals with Anorexia Nervosa who have intense body weight and shape concern can also present with sensory preferences and aversions or have difficulties with food due to negative experiences of eating from food intolerances, vomiting or fear of vomiting, PTSD relating to the body, and even trauma from intensive eating disorder treatment.

Moving Beyond Binary Thinking

Our understanding of eating disorders requires evolution beyond rigid categorisation. By recognising that body image concerns can coexist with ARFID features, we can develop more effective, personalised treatment approaches that honour each individual's unique experience.

Individuals with Anorexia Nervosa who have intense body weight and shape concern can also present with sensory preferences and aversions or have difficulties with food due to negative experiences around eating from food intolerances, vomiting or fear of vomiting, PTSD from early childhood or sexual abuse, or even trauma from intensive eating disorder treatment.

Likewise, individuals with ARFID can be concerned about body image and have a desire to be smaller or thinner. 

Which Framework To Go With?

When considering which diagnosis or framework to go with, consider the following:

- Which is the primary driver for the eating differences? Sensory differences or non weight food based distress vs. body image distress?
- Which framework is most affirming to the individual? Do they have a preference?
- Which funding body best supports the individual? If the individual is autistic and under the NDIS they are best served by a diagnosis of ARFID with features of Anorexia Nervosa, if they are under Medicare, they are likely to be better served by a diagnosis of Anorexia Nervosa with ARFID features (Australia’s Medicare Eating Disorder Plan does not cover ARFID)

A Note on Lived Experience

As professionals, we must listen to patients' lived experiences rather than forcing them to conform to diagnostic checkboxes. Only by embracing this complexity can we provide truly inclusive and effective care for all individuals struggling with disordered eating.

To learn more, check out our FREE resource Is It Neurotype or Eating Disordered?

Are you are clinician and want to know more about untangling neurodivergence and disordered eating? Check out our online training A Neurodiversity Affirming Approach to Working With Eating Disorders in Adolescents and Adults

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