Most of us have experienced an unpleasant food experience at some point—maybe you choked on something, felt nauseous after eating, or threw up shortly after a meal. It's completely natural to be hesitant about particular foods after an event like that, at least for a while. Similarly, if you have a food allergy, you’ve probably learned to be cautious around certain foods to protect your health, and for good reason.

But for some people, these types of experiences can trigger a persistent fear that leads to food avoidance in general. When this avoidance doesn’t go away, and begins to significantly limit what a person feels safe eating, it can develop into a specific type of avoidant/restrictive food intake disorder (ARFID), known as fear of aversive consequences.

This isn't simply being extra careful or having a few foods you'd rather avoid. People struggling with this ARFID subtype often find their world becoming smaller and smaller, as the fear of choking, getting sick, or having another negative reaction can become so intense that it evolves into severe food restriction. “It generalizes outside of 'I'm not going to eat at that restaurant' to 'I'm not eating any of that food group,' or not eating anything at all,” says Ilana Brodzki Pilato, PhD, a licensed clinical psychologist at Duke Center for Eating Disorders. “This can result in very significant food refusal.” And that, in turn, can lead to serious physical and psychological consequences, such as malnourishment, heart problems, anxiety, social isolation, and more.

If you're concerned that a fear of choking, getting sick, or other food-related anxieties has developed into something more serious for you or a loved one, know that you're not alone—and, more importantly, that there's reason for hope. Skilled therapists and other eating disorder professionals understand this type of ARFID and can guide you or your loved one through evidence-based treatments designed to help patients overcome these fears and develop a positive relationship with food. “You don't have to live with this and suffer in silence,” Pilato says.

Read on to learn more about fear of aversive consequences in ARFID, why it happens, what evidence-based treatment looks like, and how to get help.

The three ARFID presentations

Avoidant/restrictive food intake disorder is an eating disorder where someone significantly limits what they eat, how much they eat, or both—but not because they're trying to lose weight or change how their body looks.

ARFID can present in people in three different ways. People may exhibit symptoms from one or several of the three presentations below, and all presentations are treatable with evidence-based care:

1. Selective eating due to sensory sensitivity

For people with this presentation of ARFID, the texture, smell, color, or tastes of specific foods are repulsive, scary, or otherwise unappealing. They may also have a very strong preference for foods with certain characteristics (i.e., only eating foods with a specific texture). In either case, their sensory sensitivity results in a very small list of "safe" foods that they’re able to tolerate.

2. Lack of interest and low appetite

Some people simply don't experience hunger or pleasure from eating the way most of us do. They might forget to eat for hours or feel full after just a few bites. Food doesn't appeal to them, and eating feels more like a chore than something enjoyable. This lack of interest in food isn't a choice; it's how their body and brain naturally respond to eating.

3. Fear of aversive consequences

Sometimes a single scary experience with food—like choking on something or getting severely sick after eating—can create lasting anxiety that makes eating feel dangerous. People with this presentation of ARFID often develop intense fear around eating the food that previously led to a frightening outcome, as well as a generalized fear of eating. People can also develop fear of aversive consequences ARFID without an identifiable traumatic event.

What is fear of aversive consequences in ARFID?

“People with fear of aversive consequences in ARFID think if they eat certain foods or a certain amount of food, something bad will happen after they eat,” explains Michelle Jones PhD, a licensed psychologist and clinical instructor at Equip. “They restrict the volume and/or variety of their food intake in an effort to prevent or reduce the perceived chance of a specific negative event occurring."

The specific fears in this ARFID presentation vary from person to person, however, the most common ones are:

• Fear of choking
• Fear of vomiting
• Fear of nausea
• Fear of gastrointestinal pain
• Fear of allergic reaction

Often, the fear starts off focused on one specific food (for instance, avoiding steak) and then generalizes to similar foods (like pork chops) and eventually entire food groups (say, all meat). Eventually, it may generalize so broadly that it leads to an avoidance of all solid foods.

Pilato says that in younger children—those who are nine years old or younger—these anxieties may look slightly different. They may fear that food will taste bad or that they'll gag, or they may think the food is disgusting, according to recent research co-authored by Pilato.

Symptoms of fear-of-aversive-consequences ARFID

Symptoms of this ARFID presentation can vary. Some are behavioral symptoms that can occur before, during, or after meals, while others may be physical or mental presentations of malnourishment.

• An immediate avoidance of certain foods, food groups, or all solid foods after a negative food-related event
• Fear of choking, vomiting, nausea, allergic reaction, or pain if a food or volume of food is consumed
• Anxiety, either in general or specifically around food (see below)
• Weight loss
• Fatigue
• Difficulty concentrating
• Constipation
• Electrolyte imbalances
• Irregular menstrual cycles

Anxiety about food is a primary symptom of this ARFID presentation, and it can manifest in many different ways, not all of which are immediately obvious. Some signs of food-related anxiety include:

• Not wanting certain foods in the house
• Avoiding others eating those foods
• Avoiding where the triggering event occurred
• Rapid heart rate, heavy breathing, and muscle tension when thinking about food
• Obsessive thoughts and worries about food and food preparation (before, during, and/or after eating)
• Asking lots of questions about food

Depending on their age, it may be hard to pick up on the signs that your child or loved one has fear of aversive consequences. In Pilato's study of 68 children with ARFID diagnoses or symptoms, 91 percent of kids reported at least one food-related fear, but only 27 percent of parents said fear was causing their child to avoid eating.

That's not to place blame on parents or other caregivers. “In kids, the anxiety often looks like opposition, being defiant, or refusing,” Plato explains. So don't beat yourself up if it takes you some time to realize your child has ARFID—and if you have any suspicion they might, Equip's ARFID screener can help.

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What causes ARFID driven by fear of aversive consequences?

ARFID is a relatively new eating disorder diagnosis (it was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 2013), so we're still learning about the causes. But a few key things seem to be at play for this particular presentation.

A triggering event

“Typically the onset of the symptoms of this presentation of ARFID is precipitated by some type of traumatic event—say, an intense vomiting episode, a choking or near-choking incident or the observation of one, an allergic reaction, or learning they have a food allergy,” Jones explains. “Then the person develops a fear in response to that knowledge or incident. And then there's a belief that the food intake, in terms of volume or variety, could cause that negative event to happen or would cause that negative event to happen.” These fears and beliefs then cause a person to avoid that food, and sometimes the place where the incident occurred, as a way to protect themselves.

Heightened fear system activation

Some researchers theorize that people with the fear of aversive consequences presentation of ARFID may have hyperactive amygdalas and anterior cingulate cortexes. These brain regions play a role in processing fear and activating the fight-or-flight response.

Anxiety and avoidance

Anxiety appears to be a big factor in fear of aversive consequences in ARFID. It can predispose someone to developing this type of ARFID, and it plays a major role in maintaining the ARFID symptoms. When someone experiences fear or anxiety around eating, they naturally develop avoidance behaviors to escape that discomfort. This avoidance provides immediate relief, making it feel “successful” and reinforcing it as a “safe” strategy—but the relief is only short-term, and perpetuates the eating disorder. As Jones explains, over time, this behavior pattern creates a reciprocal, self-reinforcing relationship between avoidance and anxiety: as avoidance increases, so does anxiety about the avoided foods or situations, leading to more avoidance.

The physical effects of restrictive eating can make anxiety worse. Eating too little can lead to constipation, nausea, or early satiety when eating. People with this subtype of ARFID often have heightened awareness of bodily sensations, so they become focused on these physical symptoms, which feeds into their fears and anxieties.

Lastly, avoidance prevents people from facing their challenges. “When you're avoiding things, you're limiting your opportunities to challenge any inaccurate or unhelpful beliefs and thoughts around the likelihood of that traumatic event happening again. And you're underestimating your ability to tolerate any distress or discomfort from that. So you get stuck in a cycle of fear and avoidance that can be really difficult to break,” Jones says.

Food allergies

The relationship between food allergies and ARFID is complex, Jones says, because if someone with a diagnosed allergy comes into contact with that food, they face a real risk to their health. But there's a difference between appropriate safety measures—such as reading ingredient lists or asking once or twice about allergens at a restaurant—and going too far. According to Jones, unnecessary behaviors that might reinforce fears could look like:

• Refusing to eat around others out of fear they might eat something you're allergic to
• Limiting foods that you know don't contain allergens or have a very low risk of cross-contamination
• Asking about allergens excessively at restaurants
• Refusing to eat outside the home
• Refusing to eat foods prepared by trusted people who are aware of your food allergy

How is fear of aversive consequences addressed in ARFID treatment?

Treatment for fear of aversive consequences in ARFID typically involves psychoeducation, weight restoration (if needed), and graded exposure therapy. The goals of treatment are medical stabilization, addressing any malnourishment or nutrient deficiencies, mitigating food-related fears, expanding food variety, and helping the patient enjoy eating again.

Weight restoration

During this first phase of treatment, patients who are underweight receive support and guidance to restore weight. For growing children or adolescents, it may be less about returning to a “normal” weight, and more about catching up to their individual growth curve. In this stage, the focus isn’t yet on food variety, but on volume instead. So the patient may be encouraged to eat large amounts of the “safe” foods they feel comfortable with, as well as drink nutritional supplements, Pilato says. In severe cases, hospitalization and a feeding tube may be necessary for medical stabilization.

Psychoeducation

“We pretty much always start off treatment by making sure the patient understands ARFID and how their experience with ARFID plays out,” Jones says. Patients need to understand their past and current experiences to work on changing them. Education also covers the nutritional consequences of continued restrictive eating and explains how avoidance provides temporary relief while maintaining long-term anxiety. This foundation helps patients develop motivation to change.

Psychoeducation about exposure therapy is equally important. Patients learn how the process works and why it will benefit them, which builds trust in the treatment. "We're asking them to basically face their worst fears on a regular basis," Jones explains. "Sometimes really understanding the rationale can help people shift their perspective."

For younger patients who are doing family-based treatment (FBT), psychoeducation may play a smaller role in treatment. This is because parents (or other caregivers) are generally tasked with helping their child normalize eating habits, and it’s not essential for the child to be motivated or bought into the treatment approach for the process to be successful.

Graded exposure therapy

As treatment progresses, the focus shifts to expanding food variety. This usually starts with creating a hierarchy of fears. To do this, patients work with their therapist to identify foods and situations that they're avoiding (both food-specific and non-food-specific) and rank them from least to most fear-inducing. Graded exposures then begin with the least anxiety-provoking scenario (perhaps look at a picture of a feared food) and progress to more challenging ones (such as eating the food).

“This helps the patient prove to themselves that those fears are unlikely to happen, and if they do, they can tolerate them better than they expect they might be able to,” Jones explains. “This supports new learning that counteracts the unhelpful beliefs that are holding them back from engaging in their lives, and it supports a gradual decrease in fear and anxiety over time.”

Even if two patients both have a fear of choking, their exposures will differ because of their unique experiences. That said, many exposures are interoceptive—meaning they involve experiencing sensations in the body, which may be challenging—and sensory, which can trigger disgust and anxiety responses, Jones says.

Examples of exposures for fear of choking include:

• Having patients press on their throat to create a feeling of tightness
• Wearing a soft scarf around the throat to simulate pressure without actual danger
• Gradually increasing food density, perhaps starting with a piece of soft bread and working up to a piece of steak

Some examples of exposures for fear of vomiting include:

• Spinning in a chair to simulate nausea
• Looking at photos of feared foods
• Watching videos of people eating feared foods
• Watching videos or listening to audio of people vomiting

In young children, rather than using a hierarchy, the therapist may teach the child about their feared body sensations through fun characters and by teaching them to “investigate” and be curious—rather than fearful—about those sensations, Pilato says.

No matter the fear, processing the exposure experience is crucial, Jones says. “We try to identify their expectation, and then violate that expectation in a way that creates cognitive dissonance,” she explains. “It then becomes difficult for them to hold onto that belief because it's not congruent with their real life experiences during exposures.” Throughout the exposure, the therapist monitors the patient's anxiety level and then discusses what actually happened and what the patient learned.

What to do if you, a loved one, or a patient are struggling with fear of aversive consequences

If you or a loved one struggles with fear of aversive consequences, it’s important to seek help from ARFID-informed providers. This eating disorder can lead to serious physical health consequences from malnourishment, including electrolyte imbalances and bradycardia (where the heart beats too slowly).

There can also be significant psychological repercussions. “Avoidance behaviors enforce and maintain the anxiety,” Jones says. “Over time, that anxiety can generalize to more situations.” People may avoid social events, holidays, restaurants, family dinners, or any situation with crowds out of fear of the potential negative consequences. And since food is a frequent part of daily life, “the person is suffering multiple times a day, every day,” Pilato says. “That level of distress and anxiety leads to a life that feels intolerable. Getting support is the only way out.”

It's crucial work with professionals who have specific knowledge, training, and experience treating this presentation of ARFID. This can be a tall order, as not all eating disorder professionals meet these criteria, in part because ARFID is a newer diagnosis and because it requires different treatment approaches than other eating disorders.

Equip is the largest ARFID treatment provider in the U.S., and has specific ARFID programming to support patients of all ages and with all ARFID presentations toward recovery. You can set up a call with our team to learn more about what ARFID treatment looks like at Equip. Alternatively, Pilato suggests looking at larger research facilities and academic research centers with ongoing trials on ARFID, or using ARFID Collaborative to search lists of ARFID-trained therapists and dietitians and see if one is in your area.

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Whatever treatment provider you choose, Jones recommends working with a multidisciplinary team. “Fear of aversive consequences impacts so many areas of a person's life, and each member of the team has their own specialization,” she explains. In addition to a therapist, this typically includes:

• A medical provider to monitor physical health
• A dietitian for nutritional guidance and education about eating a varied diet and addressing nutritional deficiencies
• A psychiatrist, who can prescribe medication when needed
• Specialists like a gastrointestinal (GI) doctor or allergist, if appropriate

All of these team members collaborate to provide comprehensive, coordinated support.

FAQ

What is fear of aversive consequences in ARFID?

Fear of aversive consequences in ARFID is when someone restricts how much they eat or the variety of food they eat because they’re scared that if they eat a certain food, food type, or volume of food, something bad will happen. They may have a fear of choking, vomiting, nausea, gastrointestinal pain, allergic reaction, or some other negative response.

Can fear of choking lead to an eating disorder?

Yes, fear of choking can lead to avoidant/restrictive food intake disorder (ARFID), specifically the subtype of ARFID known as fear of aversive consequences. If someone has choked on food in the past or believes they may choke, it can cause them to restrict the types of food they eat and how much food they eat.

What does it mean if someone is afraid to eat?

From an ARFID perspective, fear of eating centers on anticipated consequences rather than the food itself. “They’re often not scared of the food or what it tastes or looks like,” Jones explains. “They’re scared that if they eat the food, they will vomit, choke, or have an allergic reaction. Or that if they eat more than a small portion, one of these negative outcomes will occur.”

How is fear of choking addressed in ARFID treatment?

In ARFID treatment, all fears are addressed through exposure. With the therapist’s help, the patient creates a hierarchy of fears, ranking them from least- to most-anxiety-provoking. Then they gradually work through these fears by doing exposure exercises that challenge and disprove their beliefs. For fear of choking, exposures often aim to create a sensation similar to choking without any actual risk of choking. This may include the patient pressing on their throat to create a feeling of tightness, wearing a soft scarf to cause a little pressure, and gradually working from eating very soft foods to denser, tougher ones.