Can You Really Have Both ARFID and Anorexia?
Technically, the diagnostic criteria within the DSM-5 state that a diagnosis of ARFID should not be made if another eating disorder, such as anorexia nervosa, better explains the symptoms. However, this clinical reality is not always straightforward. A person's relationship with food is dynamic, and symptoms can overlap or evolve over time. This makes the co-occurrence, or a sequential history, of both ARFID and anorexia a complex but possible clinical phenomenon.
The Critical Distinction: Motivation
To understand how someone could experience both conditions, it's essential to recognize the fundamental difference in motivation for food restriction. Anorexia is primarily driven by an intense fear of weight gain, body image concerns, and a desire for thinness. In contrast, ARFID is not motivated by concerns about body shape or size. The reasons for food avoidance in ARFID are tied to a lack of interest in eating, sensory sensitivities to food characteristics (e.g., taste, texture), or a fear of negative consequences like choking or vomiting. The overlap occurs when an individual with ARFID develops these weight and shape-related concerns, potentially leading to a crossover diagnosis.
Potential Pathways for Crossover
Research indicates that a person can follow a trajectory from an initial ARFID diagnosis to developing symptoms of another eating disorder, such as anorexia. Here are some pathways this might occur:
- ARFID to Anorexia Crossover: An individual with a history of ARFID might, over time, develop body image issues or a fear of weight gain. The restrictive eating patterns already in place due to their ARFID fears could then become driven by these new shape and weight concerns. A study found that over half of participants with a history of ARFID who crossed over to another eating disorder developed anorexia nervosa.
- Co-occurring Symptoms: In some cases, an individual may present with a complex mix of motivations. They might have long-standing sensory aversions (ARFID-related) but simultaneously struggle with nascent body image fears (AN-related). While a single official diagnosis might be given, effective treatment must address both sets of underlying issues. This is particularly relevant for neurodivergent individuals, for whom sensory disturbances and the need for control can drive both types of eating behaviors.
The Neurodivergent Link
Both ARFID and anorexia are notably prevalent in neurodivergent populations, such as individuals with autism or ADHD. For these individuals, sensory sensitivities are a key feature of ARFID, while the need for routine and control can fuel the restrictive behaviors seen in anorexia. Understanding this neurobiological overlap is crucial for accurate diagnosis and tailored intervention.
A Comparison of ARFID and Anorexia
To illustrate the subtle and significant differences, consider the table below, which compares key features of ARFID and anorexia. It’s important to remember that these are distinct diagnostic categories, but an individual’s experience can present features from both.
| Feature | ARFID | Anorexia Nervosa (AN) |
|---|---|---|
| Driving Motivation | Lack of interest, sensory issues, or fear of aversive consequences (e.g., choking) | Intense fear of gaining weight or becoming fat, distorted body image |
| Body Image Concern | No body image disturbance or fear of weight gain | Significant body image distortion is a core feature |
| Food Variety | Limited range of “safe” foods based on taste, texture, smell, or appearance | Limited range of foods often based on calorie count and strict dietary rules |
| Cognitive Profile | May exhibit steeper delay discounting, favoring immediate relief over long-term dietary expansion | Characterized by a reduced discounting of future outcomes, driving the long-term goal of weight loss |
| Psychosocial Impact | Marked interference with social eating, potentially due to anxiety around food itself | Significant impairment due to social withdrawal and anxiety over being seen eating |
| Comorbidity | Often co-occurs with anxiety, autism, and ADHD | Frequently co-occurs with anxiety, OCD, and depression |
The Path to Diagnosis and Treatment
Given the potential for a complex presentation, a comprehensive diagnostic assessment is vital. Clinicians must go beyond outward symptoms like weight loss and explore the underlying psychological drivers for the restrictive eating behavior. A team of eating disorder specialists, including a therapist, dietitian, and doctor, is often required for an accurate and complete diagnosis, especially in cases where motivations seem mixed. Treatment will then need to address all facets of the individual's condition. For instance, a patient with a history of ARFID that has crossed over to AN will need therapy that tackles both the original sensory or fear-based issues and the later-developed body image concerns.
Conclusion
While a single, formal diagnosis cannot be both ARFID and anorexia simultaneously, it is possible for an individual to have experienced one and then develop the other. The overlap of symptoms, coupled with distinct motivations that can evolve, makes for a complex clinical picture. The key to understanding is to look at the individual's full history and the reasons behind their restrictive behaviors, not just the behaviors themselves. For effective treatment, all underlying psychological factors must be identified and addressed by an experienced, multidisciplinary team of professionals. Understanding that a dual or sequential experience is possible is the first step toward finding appropriate and comprehensive care.
Seeking Help for Eating Disorders
If you or a loved one is struggling with food avoidance or body image issues, seeking professional help is a critical step toward recovery. Early intervention is key, as conditions can become more complex over time. A good place to start is with your primary care provider, who can then offer a referral to an eating disorder specialist or mental health professional.
Visit the National Eating Disorders Association (NEDA) website for resources and support
What is a Comorbid Diagnosis in this Context?
A comorbid condition refers to the presence of two or more medical or psychiatric conditions in an individual. In the case of ARFID and anorexia, a person might have one diagnosis alongside another non-eating disorder condition, such as anxiety or autism. However, according to the DSM-5, a person cannot hold both ARFID and AN diagnoses at the same time because one supersedes the other if weight/shape concerns are present. The nuance is in the potential for sequential diagnoses or overlapping symptoms, rather than a simultaneous formal diagnosis of both eating disorders.
The Importance of a Comprehensive Assessment
As demonstrated, the journey from ARFID symptoms to anorexia can involve subtle shifts in motivations over time. For this reason, a detailed and ongoing clinical assessment is essential. A clinician must look for the emergence of new symptoms, particularly those related to body image and weight concerns. This allows for a more flexible and effective treatment plan that can adapt as the individual's needs change. Without such a comprehensive approach, a person could be misdiagnosed or their evolving condition may go unaddressed, hindering their recovery.
