Is it picky eating, ARFID, or OCD?

Hate vegetables? Refuse to eat seafood? Need the crust cut off from your sandwich, otherwise the whole meal is ruined? If you have a laundry list of meal-time requirements, you might consider yourself a picky eater. 

Yet picky-eating can be a very subjective term. For instance, some people detest all green produce but still enjoy tasting cuisines from all over the world—is that still being a picky eater, or an adventurous one? “Most people have something picky about how they eat,” says Tracie Zinman-Ibrahim, LMFT, CST, and Chief Compliance Officer at NOCD.

But when eating habits are especially limited, it may be something more than just personal preferences. It might be a sign of an eating disorder like avoidant restrictive food intake disorder (ARFID), or could even be a form of food-related obsessive-compulsive disorder (OCD). 

Picky Eating vs. ARFID: What’s the difference

Picky eating can be characterized as a wide range of habits, from being a bit “fussy” about food to simply having limited food preferences or being averse to trying new things. Picky eating, while not an actual medical diagnosis, is very common in childhood. Some studies show up to fifty percent of preschoolers are finicky about the foods they eat. 

While there’s no one agreed-upon definition of picky eating, one thing that is clear is that it is very different from ARFID, a severe form of food restriction.

What is ARFID?

ARFID is a condition that causes people to limit both the amount and type of food they eat. ARFID was first defined as an eating disorder in 2013, making it a relatively new diagnosis, but one that researchers are learning more and more about.

It’s unlike other eating disorders such as anorexia or bulimia, which are often linked to body image or a desire to control one’s weight. Instead, someone with ARFID might be fearful of things like choking or vomiting, or have a specific aversion to certain textures, colors, smells or tastes in food. 

ARFID is sometimes called “selective eating disorder,” since those with ARFID have a short list of “safe foods”—which are “foods that they feel that they can have versus what they can’t have,” Zinman-Ibrahim explains. “It can be because of how it feels when they swallow it. It can be a flavor thing, it can be a texture thing.” 

Rituals also come into play, as people with ARFID might have to eat the items on their plate in a set order, or maintain other specific meal-time behaviors. ARFID can even cause someone to completely lose interest in eating. “They get very anxious and don’t want to try new things,” says Zinman-Ibrahim.

How is ARFID diagnosed?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the reference manual that clinicians use to diagnose mental health conditions, certain criteria need to be met for an ARFID diagnosis. 

To start, one must have what’s called “an eating or feeding disturbance”—e.g., an apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating—and at least one of the following symptoms:

• Notable weight loss, or growth difficulties in children
• Significant nutritional deficiency
• Dependence on tube-feeding or oral supplements for nutritional value
• Food aversion that interferes with the ability to perform tasks and interact with others

Additionally, the reason someone limits their food intake must not be an issue like food insecurity, religious or cultural practices (like fasting), or another medical condition or treatment. And as mentioned earlier, the restriction is not due to body image issues—like the desire to change one’s shape or weight.

What foods do people with ARFID eat?

There’s no set palette for people with ARFID; their restrictions are individually determined.

Zinman-Ibrahim works with someone with ARFID who only eats four items, which includes french fries from one specific restaurant, one brand of white bread, and one type of salt and vinegar potato chips. “He has only eaten those things for years,” Zinman-Ibrahim says. “He’s been this way since he was young. Back then, others would try to introduce new foods to him. He just wasn’t having any part of it, so he was malnourished and very sick.” 

He was diagnosed with ARFID in adulthood and is finally getting treatment—which includes addressing his malnutrition. Despite having such rigid eating routines, it isn’t a given that someone with ARFID ends up underweight. “This person I work with is actually overweight because he eats fries and white bread and chips,” Zinman-Ibrahim says.

Who’s at risk for developing ARFID?

ARFID can affect anyone, but it usually starts in childhood. That can make it difficult to understand when ARFID is at play versus your typical childhood picky eating, so getting an expert’s assessment is critical.

Experts haven’t pinpointed an exact cause for ARFID, but research suggests anxiety, fear, trauma, and genetics may play a role, as well as sociocultural and environmental factors. You might be more at risk for developing ARFID if you:

• Have a family history of eating disorders
• Fear that food will cause you harm
• Are especially sensitive to specific textures
• Have anxiety, depression or ADHD
• Experienced trauma, especially if it was food-related (choking, growing up without enough to eat, or being force-fed meals)

Can picky eating be a sign of OCD?

At first glance, it can seem that people with ARFID are actually obsessive about limiting their diet. So can ARFID actually be related to obsessive-compulsive disorder (OCD)?

Every case looks different, and for some people, OCD can frequently influence one’s diet. If you’ve never heard of OCD, it’s defined by two symptoms: obsessions and compulsions. Obsessions are recurrent and unwanted thoughts, urges, feelings, sensations or images that cause distress. These obsessions lead to compulsions, a.k.a repetitive behaviors or mental acts done in an attempt to ease discomfort or neutralize distressing thoughts.

Food-related obsessions and compulsions can show up across many different OCD subtypes. Take for instance magical thinking OCD, where people experience intrusive thoughts that if they do not perform specific actions, something bad will happen. Zinman-Ibrahim worked with a therapy member who played a bad hockey game after having eggs for breakfast. They rationalized that whenever they eat oatmeal before games, they play well, so they stopped eating eggs. 

Zinman-Ibrahim has also treated NOCD therapy members who compulsively forced themselves to finish their entire plate, even when they felt stuffed. “Because if they don’t eat everything on their plate, then they’re somehow being wasteful,” Zinman-Ibrahim explains. That’s an example of scrupulosity OCD, a subtype where people frequently worry and experience guilt about violating an ethical or moral code. 

Like with all forms of OCD, the reasoning behind someone’s food-related obsessions and compulsions often doesn’t make sense to others, but that doesn’t mean a person with OCD can just “stop” thinking or acting this way. OCD is a chronic mental health condition that needs specific treatment. 

Common food-related OCD obsessions include:

• Excessive worries that foods may carry diseases or be grown with harmful chemicals (“What if the farmers sprayed their fields with cancer-causing herbicides?”)
• Fear of poisoned food
• Fear of not properly digesting food (“What if I don’t chew my food enough?”)
• Fear that someone bad will happen when someone else is preparing the food
• Fear of having a harmful “reaction” to certain foods (vomiting, choking, unknown allergies, etc.)
• Religious or moral concerns about food (“Will I be punished by God if I accidentally eat non-kosher food?”)
• Hyper-awareness of swallowing
• Needing food proportions to be “just right”

Common food-related OCD compulsions include:

• Hoarding a surplus of groceries, for fear of running out of specific food items
• Avoiding food prepared by anyone else
• Eating a certain number of food items (“I have to eat 8 potato chips instead of 9, because odd numbers just feel wrong.”)
• Engaging in time-consuming rituals as a part of any OCD subtype and “forgetting” to eat
• Practicing repetitive behaviors, like arranging food a certain way or eating in a specific order to prevent something “bad” from happening
• Excessively checking to see if food meets religious/cultural standards (“The grocery store marked this food as Halal, but what if they made a mistake? I need reassurance from an employee.”)
• Checking and rechecking labels

How to tell if it’s OCD or ARFID

If you’re unsure if your eating habits constitute an ARFID or OCD diagnosis, the best way to know for sure is to see a professional for an evaluation. There are some overlapping characteristics—for instance, the fear of choking or vomiting can be present in both ARFID and OCD—so it’s key to consult with someone who is knowledgeable about both conditions. This is also critical for learning if you happen to have both conditions at the same time, as eating disorders and OCD can co-occur.

In the meantime, let’s consider this example that Zinman-Ibrahim gives: “I once worked with somebody who would only eat and drink white foods because they felt it was like purifying their insides, which would make them a good person,” she says. It turned out that scrupulosity OCD was the underlying cause, an OCD subtype in which people may have fears about being a bad person.

If this therapy member avoided white foods simply because the color gave them the ick, it would likely just be general picky eating. If that aversion was part of a larger limitation of foods, perhaps related to sensory sensitivity, it may signal ARFID. 

Another important distinction: If food-related fears appear to spontaneously come out of nowhere, it’s not typically ARFID. “It’s not like you used to eat normally and now you have ARFID. It could happen, but that’s not usually how it shows up,” Zinman-Ibrahim says.

Are OCD and ARFID treated the same way?

While OCD and ARFID have some overlapping qualities, their treatment modalities are quite different. ARFID is best handled by a healthcare team including a therapist and a dietitian. (Some clinicians may recommend medication to help manage ARFID, though it’s not a first-line treatment. The same goes for OCD.)

If ARFID has developed to the point where a person is severely malnourished, hospitalization to get them back to a healthy weight may be necessary. Once they’re physically stable, therapy can be introduced.

While limited research exists on the effectiveness of current therapeutic methods—since the condition is relatively new—many mental health practitioners treat ARFID with cognitive behavioral therapy (CBT). In CBT, a therapist helps their patient identify their thinking patterns, understand how thoughts influence actions, and move away from negative patterns. If the therapy patient is a child, family-based therapy (FBT) is recommended. “It’s basically some CBT that they do with the whole family,” Zinman-Ibrahim says. 

Therapists may also incorporate some exposure and response prevention (ERP) therapy for ARFID patients. ERP is an evidence-based therapy that’s highly effective in treating OCD, and it’s different from general CBT. 

ERP works by gradually exposing you to what triggers your specific fears, and then teaching strategies to cope with any distress. For example, let’s say you are severely worried that if you don’t eat an apple everyday, you’ll get sick. (This may be a manifestation of Health Concern OCD.) Your ERP therapist might have you slice the apple into pieces, and each day you eat one less slice of the apple until eventually you can go a whole day without one.

The more you can allow discomfort to exist, the more you are teaching your brain that you can handle anything without food compulsions.

The bottom line

If you’re living with obsessions or strict rules surrounding food, and your mental and/or physical health is being impacted, it’s important to reach out to a mental health professional. Qualified therapists can help you determine the root cause, and get you on the right treatment plan to give you the food freedom you deserve.