ARFID — diagnosis, medical risk, and specialised treatment (MEQ)

(i) Diagnosis and differentials. Preferred diagnosis: avoidant/restrictive food intake disorder (ARFID) with mixed sensory sensitivity and fear-of-aversive-consequences presentations (longstanding extreme selectivity plus post-choking solid refusal), causing significant weight loss and psychosocial impairment (family meal collapse). There is no fear of fatness or body-image overvaluation; he wants to gain weight — this discriminates from anorexia nervosa.[1][5] Differentials: AN (excluded if body-image/fear-of-fatness truly absent — re-check carefully), medical dysphagia/ENT pathology, coeliac/IBD/EoE, depression with appetite loss, OCD contamination, autism-related selectivity without full ARFID threshold (can co-occur). Organic exclusion as indicated by history/exam.[5][6]

(ii) Immediate medical assessment. Features of medical instability: underweight, bradycardia, low BP, substantial recent loss. Same-day senior medical review; likely admission under joint medical–psychiatric/ED pathway. Stop exercise. Vitals including orthostatics; ECG; growth chart; full physical for malnutrition. Investigations: FBC, U&E, phosphate, Mg, Ca, LFT, glucose, iron studies and other micronutrients as indicated; consider coeliac serology and ENT/GI review if red flags. Suicide/self-harm screen; family accommodation history.[4][6]

(iii) Refeeding. High refeeding risk because of malnutrition and low weight. Plan protocolised nutrition (oral if safe; NG if inadequate/unsafe) with thiamine/multivitamins per protocol; frequent phosphate/K/Mg monitoring and proactive replacement; fluid balance; dietetic leadership. Do not use unsupervised high-carbohydrate boluses. Higher-calorie protocols only within monitored inpatient systems following local restrictive-ED medical guidance (SAHM/MEED-type principles).[4]

(iv) Psychological/family treatment. After medical stabilisation pathway begins: multidisciplinary team. Adapted FBT — empower parents to lead renourishment and gradual variety expansion rather than colluding with the three-food list.[3] CBT-AR components for youth: psychoeducation, formulation by sensory + fear pathways, regular eating, graded exposure hierarchy (textures/solids after medical clearance of choking risk), reduce avoidance and family accommodation.[1][2] Not unmodified body-image CBT-E as sole model.

(v) Autism and medication. Screen for autism and anxiety — sensory ARFID commonly interfaces with ASD; dual formulation if both present; adaptations enable treatment rather than replace it.[1][5] No licensed ARFID-specific first-line drug; do not offer olanzapine as a cure. Treat comorbid anxiety/depression with standard agents only when indicated, always with behavioural and nutritional care.[6]