# **CASE REPORT Open Access** # Integrating cognitive-behavioral and medical interventions for ARFID in an adolescent: a case report from Turkiye Hakan Öğütlü1,2\* [,](http://orcid.org/0000-0002-1325-446X) İbrahim Tiryaki3 , Meryem Kaşak4 , Hakan Türkçapar5 , Kamyrn T. Eddy6† and Jennifer J. Thomas6† # **Abstract** This case report presents the comprehensive, multidisciplinary treatment of a 17-year-old male adolescent diagnosed with avoidant/restrictive food intake disorder (ARFID) in Turkiye. The patient developed severe food avoidance, vomiting, and significant weight loss after experiencing traumatic medical interventions, including nasogastric tube placement. His clinical course was further complicated by medical comorbidities such as achalasia, superior mesenteric artery syndrome, and gallstones, which contributed to persistent gastrointestinal discomfort and reinforced his restrictive eating behaviors. Treatment combined with outpatient Cognitive Behavioral Therapy for ARFID (CBT-AR), psychopharmacological support, family-based interventions, and ongoing medical management. CBT-AR was flexibly adapted to address the patient's fear of negative eating consequences, sensory sensitivities, and low appetite, while considering family dynamics and culturally relevant eating practices. Over a 12-month period, the patient's weight increased from 42.6 kg to 55 kg, his dietary variety expanded with the addition of 38 new foods, and his ARFID symptoms showed significant clinical improvement. This is the first documented case of CBT-AR applied in Turkiye, highlighting the feasibility and effectiveness of a combined medical-psychological approach for complex ARFID presentations. The case underscores the necessity of individualized, culturally sensitive treatment strategies and multidisciplinary collaboration in addressing ARFID, particularly in medically compromised patients. **Keywords** ARFID, Avoidant/restrictive food intake disorder, CBT-AR, Adolescent, Case report, Turkey, Medical complications Kamyrn T. Eddy and Jennifer J. Thomas are share senior authorship. \*Correspondence: Hakan Öğütlü hogutlu@gmail.com Department of Child and Adolescent Psychiatry, Cognitive Behavioral Psychotherapies Association, Karum Is Merkezi Iran Caddesi No: 21 06680 Gaziosmanpasa Mah. 06680 Cankaya Ankara, Ankara, Turkey Department of Child and Adolescent Psychiatry, University College Dublin, Dublin, Ireland Department of Child and Adolescent Psychiatry, Sultan 1. Murat State Hospital, Edirne, Turkey 4 Department of Child and Adolescent Psychiatry, University of Health Sciences, Ankara Etlik City Hospital, Ankara, Turkey Department of Psychology, Social Sciences University of Ankara, Ankara, Turkey Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds40337-025-01463-z/_page_0_Picture_19.jpeg) © The Author(s) 2025. **Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://creativecommons.org/licenses/by-nc-nd/4.0/) [vecommons.org/licenses/by-nc-nd/4.0/.](http://creativecommons.org/licenses/by-nc-nd/4.0/) # **Introduction** Avoidant/restrictive food intake disorder (ARFID) was added to the *Diagnostic and Statistical Manual of Mental Disorders*, fifth edition (*DSM-5*), as a reformulation of the *DSM-IV* diagnosis of feeding disorder in infancy and early childhood [[1\]](#page-9-0). According to the *DSM-5*, diagnostic criteria for ARFID include eating difficulties that may result from an individual's inability to tolerate certain sensory characteristics of food (e.g., texture, taste, appearance); fear of possible negative consequences of eating (e.g., choking, vomiting); and/or a general lack of interest in food or eating. To meet the criteria for ARFID, food restriction or avoidance must lead to one or more consequences, such as weight loss or slowed growth, nutritional deficiency, dependence on oral nutritional supplements or tube feeding, or psychosocial impairment. ARFID is a relatively new diagnosis, with prevalence estimates varying widely depending on the population studied, ranging from 0.3% to 15.5% in non-clinical populations and 1.5% to 32% in clinical settings [\[2](#page-9-1)[–5\]](#page-9-2). ARFID typically onsets earlier than other eating disorders and is equally or more common in males than females [\[6](#page-9-3)–[8\]](#page-9-4). It is often associated with co-occurring challenges, including gastrointestinal issues, nutritional deficiencies, neurodevelopmental disorders, and anxiety [\[9](#page-9-5)[–12](#page-9-6)]. Unlike anorexia nervosa (AN), restrictive intake in ARFID is not driven by a fear of weight gain or a desire to control weight or shape. It also differs from developmentally normative selective eating in its persistence and severity, often resulting in significant medical and psychosocial complications [[13](#page-9-7)[–15](#page-9-8)]. Emerging research suggests neurobiological and psychological factors interact to drive ARFID's behavioral presentations [\[16](#page-9-9), [17\]](#page-9-10). The current evidence base for the treatment of ARFID comprises case reports [\[18\]](#page-9-11), case series [\[10](#page-9-12), [19](#page-9-13)], retrospective chart reviews [[20](#page-9-14), [21\]](#page-9-15), and a small number of randomized controlled trials [\[22](#page-9-16), [23\]](#page-9-17) in very young children. Recently described treatments for ARFID in the literature include cognitive-behavioral approaches, family-based treatment and parent education, hospital refeeding including tube feeding, and adjunctive pharmacotherapy [[24](#page-9-18)[–27](#page-9-19)]. Cognitive-behavioral therapy for ARFID (CBT-AR) is one such new approach for the treatment of ARFID. CBT-AR is suitable for children, adolescents, and adults aged ten years and older, progresses through four phases delivered in 20–30 sessions, and is available in both individual and family-supported versions [[24](#page-9-18)]. The aim of CBT-AR is to help patients achieve adequate growth (e.g., reaching a healthy weight)address nutritional deficiencies, increase dietary diversity, eliminate dependence on nutritional supplements, and reduce psychosocial impairment. The current body of research on ARFID treatment predominantly originates from high-income countries such as the United States, the United Kingdom, and Australia, with limited data available from low- and middle-income countries, including Turkiye. This geographic bias raises concerns about the generalizability and cultural applicability of existing findings to diverse populations. For instance, the unique sociocultural, dietary, and healthcare system contexts in Turkiye may influence the presentation, diagnosis, and treatment outcomes of ARFID. Addressing this gap is critical to ensure the development of effective and culturally sensitive interventions. Moreover, the underrepresentation of low- and middle-income countries in psychiatric research, as highlighted in Patel and Sumathipala's research, underscores the importance of expanding the evidence base to include these regions [[28\]](#page-9-20). This case study contributes to the literature by establishing the occurrence of ARFID within the Turkish population and exploring the suitability of current treatment approaches in this context. In this case report, we present a male adolescent patient who experienced significant weight loss due to avoidant and restrictive feeding behaviors, which were reinforced by a traumatic experience with eating. This case is particularly significant for two reasons. First, it demonstrates how CBT-AR can be adapted for a medically complex presentation of ARFID, where gastrointestinal complications intersect with severe eating-related anxiety. Second, as the first published example of CBT-AR applied in Turkiye, this case illustrates how the intervention can be flexibly and effectively adapted within a different cultural and healthcare system context. Given that most ARFID research originates from high-income, Western countries, this case contributes to addressing geographic and cultural gaps in the evidence base. # **Case** The case involves a 17-year-old male adolescent who was admitted to our pediatric psychiatry department with complaints of eating restriction and weight loss. Before the onset of symptoms, his premorbid weight was 73 kg, height was 178 cm (BMI: 23.0 kg/m²; between the 50th and 75th percentiles), with no previous history of eating or gastrointestinal problems. We learned that five months earlier, the patient had undergone an appendectomy at a private hospital due to suspected acute appendicitis following nausea and vomiting after a trip out of the city. When his symptoms persisted, he underwent a second laparoscopic operation due to suspicions of Crohn's disease or ileus. During this period, he was fed through total parenteral nutrition (TPN) and a nasogastric catheter (NGC). However, he lost approximately 10 kg because he could not consume sufficient calories despite these interventions, due to limited tolerance to enteral feeding and difficulties in increasing TPN infusion rates secondary to gastrointestinal discomfort and metabolic complications. One month later, he was admitted to the gastroenterology department of a university hospital. The medical team reported that NGC feeding could not be continued because the patient developed a sudden and intense fear of suffocation after experiencing nosebleeds caused by the NGC rubbing against the posterior wall of his nasopharynx during insertion. After discharge, he began vomiting after eating, continued to avoid food, and reported jaw pain when attempting to eat, abdominal distension after meals, and severe abdominal pain that was only relieved by vomiting. His weight decreased from 73 kg to 57 kg over a period of approximately three months. His premorbid health status was reportedly normal, with no previous eating or gastrointestinal problems. One month later, the patient was admitted to another university hospital, weighing only 51 kg. TPN and corticosteroids were initiated, and several psychiatric medications, including escitalopram, olanzapine, vortioxetine, and mirtazapine, were prescribed during psychiatric consultations. We learned that despite receiving TPN providing approximately 2000 calories daily, the patient continued to vomit, avoid foods he previously consumed, and experience increased difficulty eating those foods. He developed the cognition, "I will be relieved if I vomit." Five months after these initial treatments, the patient was admitted to our clinic with ongoing complaints of food restriction, weight loss, and vomiting. The patient reported a history of methylphenidate use approximately seven years earlier for attentional difficulties; however, he did not carry a current diagnosis of ADHD, and this was not considered to have contributed to the present ARFID presentation. This past history was not judged to be directly related to the current ARFID presentation. His mother, who has generalized anxiety disorder (GAD), shared that her own anxiety had worsened due to her son's difficulties, but she had not sought treatment for herself. Her generalized anxiety disorder may also have heightened the patient's vulnerability to the fear-based ARFID subtype. At presentation, the patient weighed 46 kg with a height of 178 cm (BMI for sex and age: 0.02 percentile). He scored above clinical cut-offs (and near the maximum of 15), on each subscale of the nine-item ARFID Screen (NIAS) as follows: picky eating, 12; low appetite, 14; and fear, 14 [\[29](#page-10-0)]. Regarding the Eating Disorder Examination-Questionnaire (EDE-Q), his total score was 1.1, which is considered low and not indicative of non-ARFID eating disorders. The patient fulfilled the DSM-5 diagnostic criteria for ARFID. The patient's presentation was most consistent with the fear and low appetite ARFID subtypes, with less evidence for the picky-eating profile. This pattern resulted in significant weight loss and psychosocial impairment, reflected in withdrawal from social life. The diagnosis of ARFID was established by a child and adolescent psychiatrist following a comprehensive clinical evaluation. We ordered necessary investigations and conducted an emergency evaluation, concluding that hospitalization was not required. Outpatient follow-up was deemed appropriate as the patient's vital signs, including blood pressure, heart rate, and temperature, were within normal limits, and no acute medical instability was observed. In the first stage, we set the goal of reaching a body mass index in the 5th percentile (59 kg). Given the potential benefit of family-supported CBT-AR treatment, we initiated weekly psychotherapy, noting that the patient had no prior history of structured mental health treatment. Figure [1](#page-3-0) summarizes key clinical events with corresponding BMI changes. # **Cognitive behavioral therapy and pharmacotherapy applications** # **Phase 1: psychoeducation and initial changes** The CBT-AR implemented in this case consists of four broad stages, along with case-specific adaptations, which are shown in Table [1.](#page-3-1) In the first session, the patient received psychoeducation about nutrition, eating, and ARFID. The therapist introduced the CBT model for ARFID, and the patient was instructed to keep self-monitoring records to track his eating habits and behaviors. Fluoxetine (20–40 mg/day) and Olanzapine (2.5 mg/day) were prescribed by the therapist as part of the treatment plan to address ARFID. The choice of psychopharmacology aimed specifically to target mood symptoms, anxiety related to eating, and distorted cognitions around food, while also supporting appetite regulation. In the following session, the therapist identified and recorded the patient's negative cognitions about eating. The patient was encouraged to organize his diet into three main meals and three snacks per day and to record his food intake with the support of his family. The therapist emphasized the importance of increasing the amount of food eaten to ensure adequate nutrition. Using gastrointestinal system illustrations, the therapist explained that the patient's hunger and satiety signals were distorted, causing him to constantly feel full and uncomfortable due to changes in the capacity of his stomach. These illustrations helped the patient understand the physiological changes and how they affected his perception of fullness and discomfort. Additionally, the therapist stressed the importance of regular nutrition, particularly for regulating blood sugar. The therapist highlighted the risks associated with irregular eating patterns, including blood sugar fluctuations, electrolyte imbalances caused by vomiting, and the potential for cardiac arrhythmias, underscoring the need for a consistent and balanced diet. ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds40337-025-01463-z/_page_3_Figure_3.jpeg) **Fig. 1** Timeline of clinical events, weight, and BMI \*BMI: Body Mass Index; CBT-AR: Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder **Table 1** Four broad phases of CBT-AR | Phase | Interventions described in CBT-AR | Interventions applied to the patient | |------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Phase 1: psycho | Psychoeducation about ARFID: introduced CBT-AR principles | - Psychoeducation on ARFID, hunger, and satiety | | education and initial
changes | Preferred food log: encouraged eating preferred foods regularly
and keeping eating diaries | - Self-monitoring records of eating habits | | | Family-based caloric support: increased caloric intake by 500
calories/day with family support | - Started preferred foods like soup and bread | | | | - Family-supported caloric increase | | | | - Conducted therapeutic family meals, teaching supportive
behaviors | | Phase 2: address
ing nutritional
deficiencies | Nutritional psychoeducation: highlighted negative conse
quences of deficiencies | - Psychoeducation on risks of nutritional deficiencies (e.g.,
electrolyte imbalances, cardiac risks) | | | Introducing nutrient-dense foods: added foods to promote
weight gain and eliminate deficiencies | - Introduced snacks like yogurt, fruit, milk, ayran, and kefir
- Added new foods to diet | | Phase 3: core
interventions | Fear of negative consequences: used fear hierarchies for feared
foods and situations. Applied interoceptive exposures to toler
ate internal sensations like fullness and nausea | Fear of negative consequences:
- Exposure hierarchies for choking and fullness fears
- Behavioral experiments (e.g., eating with family) challenged
negative cognitions like "gagging relaxes me."
- Jelly bean experiment addressed choking fears
- Gradual exposure to challenging foods | | | Sensory sensitivity: applied structured sensory exposure (e.g.,
"Five-Step Model") to help patients tolerate new food textures
Disinterest in food:
- Encouraged consistent mealtimes to rebuild appetite regu
lation-Introduced interoceptive exposures to address satiety
tolerance-Satiety Ratings-Focused on hedonic food exposure
to rekindle enjoyment in eating | Sensory sensitivity:
- Gradual exposure to foods
Disinterest in food:
- Encouraged three meals and snacks daily-Used positive
reinforcement to maintain engagement-Interoceptive
exposures-Satiety Thermometer helped monitor fullnessRe
introduced enjoyable foods through structured café outings | | Phase 4: progress as
sessment and relapse
prevention | - Monitoring progress: assessed patient's achievements using
tools like NIAS
- Relapse prevention plan: developed strategies to sustain
progress, including family support
- Goal setting: focused on long-term social eating and nutri
tional goals | - NIAS scores showed improvement
- Relapse prevention plan included social eating goals
- Family supported ongoing independence (e.g., no
spoon-feeding)
- Added 38 foods to diet
- Final weight: 55 kg | One week later, the patient reported that he had started drinking soup and eating bread—foods he had not consumed recently. Although he no longer vomited, he described frequent retching throughout the day and reported that he often attempted to induce vomiting to relieve abdominal discomfort, though these attempts were mostly unsuccessful. The therapist also noted that the patient's water consumption was limited. The therapist emphasized the importance of adequate hydration for his health and encouraged him to increase his water intake. To support his nutritional needs and promote recovery, the therapist suggested healthy snacks, such as cookies, yogurt, milk, ayran, kefir, and fruit. These items were introduced to provide a balanced diet and address potential nutritional deficiencies. CBT-AR strategies were applied throughout the sessions to enhance the patient's engagement in his recovery process. These strategies included setting achievable dietary goals, providing positive reinforcement, and offering consistent encouragement to help the patient stay committed to his treatment plan. # **Phase 2: addressing nutritional deficiencies** A therapeutic family dinner was organized to reintroduce a previously avoided food in a supportive setting. The family brought a burger that the patient had enjoyed in the past, and the therapist coached the parents to provide encouragement without criticism or pressure. Although initially hesitant, the patient gradually resumed eating and was ultimately able to finish the entire burger. This small but meaningful achievement illustrated the effectiveness of graded exposure in a familiar context and highlighted the crucial role of consistent family support in helping the patient overcome eating-related anxiety. # **Phase 3: core interventions** # *a. Fear of negative consequences* The patient persistently feared that eating solid foods would lead to severe abdominal pain, gagging, or vomiting. He closely monitored bodily sensations during meals and interpreted normal post-prandial fullness as evidence that "something is wrong." Central safety behaviors included delaying or skipping meals, restricting to liquids or very soft textures, eating in very small amounts, and attempting to gag or retch to "feel relief." Two core assumptions organized his avoidance: - 1. *Catastrophic prediction:* "If I eat too much and feel bloated, I won't be able to cope; I'll feel extremely bad." - 2. *Safety/relief belief:* "Gagging relaxes me; it's necessary to reduce abdominal discomfort." A cognitive-behavioral formulation targeted these drivers. After medical clearance that there was no mechanical obstruction or acute aspiration risk (with later esophageal motility findings treated in parallel), we proceeded with graded, meal-based exposure and response prevention consistent with CBT-AR. Psychoeducation covered how gastrointestinal sensations fluctuate naturally and how attention, anxiety, and protective behaviors (e.g., gagging) can maintain distress. Using an anxiety-over-time curve, the therapist illustrated that anticipatory anxiety peaks and then declines if avoidance is prevented. Cognitive restructuring focused on probability and cost–coping appraisals ("How likely is the feared outcome?", "If discomfort occurs, how tolerable and timelimited might it be?"). The patient generated balanced alternatives (e.g., "Discomfort can subside on its own; gagging is not required for relief."). To strengthen these new appraisals, we implemented behavioral experiments across progressively harder foods (liquid → purée/soft solids → denser textures). He practiced eating without gagging, rating discomfort and anxiety before, during, and after meals. In response-prevention trials, he postponed gagging, observing that discomfort decreased spontaneously. A structured Theory A/Theory B exercise directly tested the belief "gagging relaxes me": on "Theory A" days he followed the belief; on "Theory B" days he inhibited gagging and monitored outcomes. His self-monitoring showed that only a very small fraction of gagging episodes were followed by transient relief—comparable to ordinary fluctuations—providing corrective evidence that gagging was neither necessary nor reliably helpful. Belief ratings in the statement "If I don't gag, my abdominal pain will continue" decreased from nearly complete conviction at baseline to moderate levels, and later to around one-third with repeated practice. Anticipatory anxiety before meals diminished, meal completion increased, and he began tolerating a broader range of textures and portions with less distress. At the outset of this phase, a very low dose of lorazepam (0.5 mg, half a milligram, taken shortly before meals) was prescribed to reduce acute anticipatory anxiety and to facilitate participation in exposure tasks. As behavioral progress consolidated, lorazepam was gradually tapered and then discontinued, and the patient was able to maintain improvements without pharmacological support. Exposure practice was extended into social eating contexts (e.g., cafés), consolidating skills in real-world settings and countering isolation. Overall, this package directly addressed the fear-based ARFID driver, reduced reliance on safety behaviors (especially gagging), and enabled sustained increases in oral intake and dietary variety. # *b. Disinterest in food and sensory sensitivity* The patient had increased his daily caloric intake to 1700 calories and had also begun consuming solid foods again. His engagement in activities was very positive, and it was noted that his appetite had increased. A plan was made for him to meet his friends at a cafe and enjoy eating cheesecake, reflecting his progress in social eating situations. His weight had increased to 47 kg, and he was also planning to visit his relatives in Istanbul. The importance of eating in social settings was emphasized. During outpatient CBT-AR, the patient continued to receive supplemental tube feeding to support his caloric intake and weight gain. His weight further increased to 48.7 kg and eventually 51 kg with the help of catheter support. During this period, his appetite increased further, and he began to enjoy eating more. This progress highlighted the combined benefits of CBT-AR strategies and nutritional supplementation in facilitating recovery. #### **Pandemic-related challenges and adaptations** The coronavirus disease 2019 (COVID-19) pandemic interrupted in-person therapy for three months, leading to weight loss and reduced motivation. Sessions were continued online, and several adaptations were made to sustain progress. Cognitive-behavioral strategies were emphasized, including a behavioral experiment with a jelly bean to address the patient's fear of food sticking in his throat. Under therapist guidance, he chewed and swallowed a small piece of candy while monitoring throat sensations, which provided corrective evidence that swallowing could be completed safely. This simple but powerful exercise reduced anticipatory anxiety and increased his confidence in oral intake. A 'satiety thermometer' was also introduced to help him better gauge fullness and prevent premature meal termination, while short walks after meals were encouraged to reduce expulsion behaviors. Depressive symptoms had not been reported previously but became apparent during this phase, further influencing his motivation and engagement with eating. Mindfulness and breathing techniques were added to manage anxiety and mood symptoms. In addition, separate family sessions addressed inconsistent feeding practices, such as spoon-feeding and parental disagreements, and emphasized the importance of unified, supportive responses. Despite the limitations of remote therapy, these combined strategies stabilized the patient and prevented further deterioration until face-to-face sessions could resume. # **Medical complications and continued recovery** During this period, the patient's weight fell to 45 kg, accompanied by fever. He was treated with antibiotics and intravenous dextrose to stabilize his acute condition. Following this episode, therapeutic focus shifted to reinforcing family mealtimes as a way to promote normalcy and support. It was discovered that the family had been spoon-feeding him during his illness, a practice the therapist strongly discouraged in order to promote independence. This shift toward self-feeding was intended to strengthen autonomy and resilience, key elements for long-term recovery. During the summer holiday, the patient experienced feelings of weakness and inadequacy while staying at a hotel. A motivational interview was conducted to encourage him to increase nutritional intake and to gradually engage in sports to build strength before future vacations. To further support his recovery, the patient began consultations with a dietitian and a physiotherapist. The dietitian provided tailored nutritional guidance to correct deficiencies and encourage weight gain, while the physiotherapist targeted muscle weakness related to prolonged malnutrition. These interventions complemented psychotherapy by addressing the physical consequences of ARFID. In therapy, attentional practices, mindfulness techniques, and behavioral activation strategies were introduced both in sessions and as homework assignments. These tools were designed to help the patient manage crises, reduce anxiety, and improve daily functioning. Despite these efforts, his weight at one point dropped further to 44.5 kg. Nevertheless, he was able to participate in a family holiday and, notably, managed to ride a water slide—an event he described as a turning point. Feeling physically stronger and more hopeful, he declared, "I'm healed, I'm back to my normal life, but I'm just a little weak. We'll get that sorted out." He estimated being "80% convinced" of his recovery, and his spontaneous reports of hunger suggested improving appetite. As part of his ongoing recovery, a structured plan was set for him to consume a complete breakfast daily, followed by full lunches. He successfully implemented these routines, which coincided with improved academic performance and classroom engagement. Despite this progress, his eating habits deteriorated again, and weight rapidly declined to 42.6 kg (BMI 13.3 kg/m²). Due to the severity of weight loss, a nasogastric (NG) tube was placed with difficulty, and daytime NG feeding was initiated. This intervention helped restore weight to 43.5 kg, but complications soon followed. On a day of intensive NG feeding, he developed severe abdominal pain, bilious vomiting, and high fever, requiring hospitalization and a pause in psychotherapy. During his hospital stay, five major diagnoses were made. He was diagnosed with achalasia, for which balloon dilatation was performed, significantly improving swallowing capacity. Superior mesenteric artery (SMA) syndrome was also identified, secondary to severe weight loss, causing postprandial discomfort. He developed acute pancreatitis, attributed to vascular compression, which was managed conservatively. In addition, he experienced pneumonia due to food regurgitation, treated with antibiotics. Finally, cholelithiasis and choledocholithiasis were diagnosed, managed with ursodeoxycholic acid and reserved for surgical intervention if symptoms persisted. This cluster of medical diagnoses was striking, as previous investigations had not revealed any somatic disorder. With balloon dilatation, oral intake improved substantially. Although occasional pain related to SMA syndrome persisted, food diversity and tolerance gradually increased. Psychotherapy was resumed alongside medical care, and weight improved first to 45 kg, then to 47 kg. To enhance motivation, the family introduced a financial reward for reaching 50 kg, which he eventually achieved, further reinforcing his commitment to recovery. # **Phase 4: progress assessment and relapse prevention** In the final phase of his treatment, a relapse prevention plan was developed with the patient, and future goals were set to ensure continued progress and stability. After one year of CBT, the patient's weight increased from 42.5 kg to 55 kg. His BMI improved from less than the 0.02 percentile to the 1st percentile. His NIAS scores showed significant improvement across all subscales: picky eating decreased from 12 to 4, low appetite from 14 to 6, and fear from 14 to 5. These changes indicate a substantial reduction in negative cognitions and eatingrelated anxiety. He was able to finish most of his meals and consume a variety of foods, which marked a substantial improvement in his eating habits. In the grains category, he began eating bread, toast, rice, pasta, crackers, cereal, granola bars, oats, and noodles. His fruit intake increased to include apples, bananas, grapes, strawberries, and oranges. Among vegetables, he incorporated carrots, tomatoes, potatoes (e.g., mashed or baked), and spinach (often cooked in soup). In the protein category, he added eggs (boiled or scrambled), chicken (shredded in soup), fish (e.g., salmon), meatballs, lentils (in soup), chickpeas, turkey slices, and tofu. His dairy consumption expanded to include milk, yogurt, cheese (e.g., feta, cheddar), butter, ayran, kefir, ice cream, and pudding. Additionally, he introduced other items like soup, honey, jam, and peanut butter. Altogether, the patient successfully added 38 new foods to his diet, reflecting a substantial improvement in variety and nutritional balance. The positive changes in the patient's behavior also greatly improved the mood of both the patient and his family, who expressed happiness and optimism. His medications were gradually reduced and eventually discontinued, further underscoring his remarkable progress. # **Discussion** This case describes the successful treatment of an adolescent male with ARFID and represents the first documented application of CBT-AR in Turkiye.While the patient already exhibited symptoms of ARFID when he was admitted to the hospital and required an NG tube, his condition significantly worsened following the traumatic medical procedures. The painful NG tube insertion likely exacerbated his existing fear of choking and further reinforced his avoidant and restrictive eating behaviors. This aligns with documented cases where eating behaviors deteriorated following trauma [\[30](#page-10-1), [31](#page-10-2)]. The family history of anxiety, as seen in our patient, may have increased the risk for developing ARFID-fear, given their common co-occurrence in clinical samples. Kambanis et al. suggest that shared genetic and environmental factors could contribute to the overlap between anxiety disorders and ARFID subtypes involving fear of eating consequences [\[32\]](#page-10-3). Beyond anxiety, psychiatric and neurodevelopmental comorbidities also played a role. The patient's remote history of stimulant-treated ADHD was not linked to his current ARFID presentation but underscores the need to monitor appetite in such contexts, particularly given the inflated rates of ARFID reported in neurodivergent cohorts, including ADHD and autism spectrum disorder [[33](#page-10-4), [34\]](#page-10-5). Depressive symptoms, which emerged later in treatment, further complicated engagement with food and likely amplified avoidance. Together, these observations highlight the importance of screening for ADHD, anxiety, and depression in ARFID, as comorbidities can significantly influence treatment needs and recovery trajectories. Although medical complications dominated this case, psychiatric and neurodevelopmental comorbidities also played a role. The patient's remote history of stimulanttreated ADHD was not linked to his current ARFID presentation, yet highlights the need to monitor appetite in such contexts Depressive symptoms, emerging later in treatment, further complicated engagement with food and likely amplified avoidance. These observations underline the importance of screening for ADHD, anxiety, and depression in ARFID, as comorbidities can shape treatment needs and recovery. #### **Medical interventions** Pharmacological interventions for ARFID included fluoxetine, olanzapine, and lorazepam. Despite the lack of FDA-approved medications specifically for ARFID, SSRIs like fluoxetine are frequently used off-label to treat anxiety disorders in children and adolescents [[35](#page-10-6)]. However, SSRIs may be less effective in underweight individuals due to the time required to reach therapeutic levels and potential malnutrition interference [\[36\]](#page-10-7). Olanzapine, a D2-5HT2 antagonist, was used instead to improve eating behaviors and facilitate weight gain [[31,](#page-10-2) [37\]](#page-10-8). Olanzapine has been effective in reducing cognitive rigidity and anxiety, thus facilitating weight gain in ARFID patients [[38\]](#page-10-9). Lorazepam was used early in treatment to help the patient transition from tube-feeding to oral intake, particularly to manage acute anxiety symptoms related to eating, which is supported by literature indicating its short-term effectiveness in reducing trauma-related eating anxiety [\[39](#page-10-10)]. While not typically recommended as a long-term strategy before exposure-based interventions, its use in this case was aimed at facilitating the initial steps toward oral intake. The patient's report of benefiting from lorazepam before meals highlights its potential utility as a temporary measure during the early phases of treatment to reduce severe anxiety interfering with eating. During the treatment, the patient experienced several significant medical conditions. The patient was diagnosed with achalasia, a rare disorder making it difficult for food and liquid to pass into the stomach, which was treated with balloon dilatation [\[40\]](#page-10-11). Additionally, he developed SMA syndrome, which occurs when the duodenum is compressed, often due to significant weight loss. This syndrome contributed to the patient's eating difficulties and abdominal pain, but the condition was expected to improve with weight gain [[41\]](#page-10-12). Complications also included acute pancreatitis, pneumonia due to food regurgitation, and cholelithiasis and choledocholithiasis, which involve gallstones. These diagnoses underscore the complex interplay of medical and psychological factors in ARFID and the necessity for comprehensive treatment plans. Acute pancreatitis and pneumonia were managed with supportive treatments and antibiotics, while gallstones were treated with ursodeoxycholic acid, with surgery as a potential future intervention if necessary [\[42–](#page-10-13)[44\]](#page-10-14). Identifying and treating these medical conditions were crucial for stabilizing the patient and enabling him to participate more fully in therapeutic interventions. ### **Cognitive behavioral therapy for ARFID (CBT-AR)** The case highlights the application of CBT-AR alongside pharmacological treatment. The therapy aimed to reduce restrictive and selective eating symptoms, improve weight, address nutritional deficiencies, and enhance daily living functions. Significant improvements were observed in the patient's eating habits and overall health, aligning with previous research on CBT-AR [[45](#page-10-15)]. This case included specific enhancements to the standard CBT-AR protocol, demonstrating flexibility and responsiveness to individual patient needs. For instance, positive reinforcement and family involvement were critical in sustaining the patient's engagement and progress. Additionally, integrating medical treatments like balloon dilatation and the temporary continuation of tube feeding facilitated weight gain and allowed the patient to engage more fully in outpatient CBT-AR. The collaborative approach, which involved regular consultations with a dietician and a physical therapist to support posture and gastrointestinal comfort, ensured a well-rounded treatment plan that addressed ARFID's psychological and physical aspects. The comprehensive treatment approach, combining medical interventions and CBT, successfully addressed both his physical and psychological needs, leading to a remarkable improvement in his overall health and well-being. The patient did not regain his premorbid weight; however, CBT-AR was concluded after he achieved functional recovery — including independent eating, reduced eating-related anxiety, psychosocial improvement, and medical stabilization. Given his complex medical comorbidities, we prioritized sustained behavioral change and quality of life over complete weight restoration. Ongoing follow-up was arranged to monitor his long-term progress. Although CBT-AR was developed in Western contexts, this case involved culturally sensitive adaptations to suit the Turkish setting. For instance, the therapist used familiar Turkish comfort foods (such as soup, ayran, and yogurt) during early refeeding efforts, involved extended family members in therapy, and addressed common beliefs around food, satiety, and family caregiving (e.g., spoon-feeding by parents during illness). These modifications helped ensure the intervention was accessible, feasible, and aligned with familial norms, thus enhancing engagement and compliance. At the same time, certain cultural factors also posed challenges, such as parental insistence on the child eating more than recommended, heightened anxiety about weight loss within the family, and occasional resistance to shifting away from traditional caregiving roles. Addressing these tensions required careful negotiation to balance therapeutic goals with cultural expectations. These findings from CBT-AR, together with the patient's medical stabilization, provided the basis for the final conclusions outlined below. In this case, the onset and persistence of ARFID symptoms appeared to be strongly shaped by traumatic medical experiences, particularly the painful NG tube insertion and repeated hospitalizations. These events likely reinforced the patient's avoidance of eating by associating food intake with distress and fear. This clinical course aligns with emerging evidence suggesting elevated rates of trauma-related disorders in ARFID, comparable to those seen in other eating disorders [[38](#page-10-9), [46\]](#page-10-16). Trauma exposure may heighten sensitivity to bodily sensations, exacerbate anxiety around swallowing or choking, and, in some cases, amplify family anxiety that is transmitted to the child. From a therapeutic perspective, incorporating trauma-informed approaches—such as paced exposure techniques, psychoeducation for families, and enhanced attention to safety and trust in clinical settings—may help mitigate the reinforcing cycle of fear and avoidance. Recognizing the role of trauma in ARFID presentations is therefore crucial for tailoring interventions and supporting long-term recovery. #### **Challenges during treatment** Although the overall outcome of this case was positive, certain phases of the treatment did not progress smoothly and warrant further discussion. The transition to online therapy during the COVID-19 pandemic coincided with decreased patient motivation and a temporary resurgence of avoidant eating behaviors, highlighting the difficulties of sustaining engagement in remote treatment settings. Medical complications, including infections and the repeated insertion of an NG tube, also led to setbacks, with renewed avoidance and weight loss. Additionally, inconsistent family dynamics at mealtimes—such as parental disagreements and spoon-feeding—at times complicated the patient's autonomy and therapeutic gains. Addressing these obstacles may require the use of more interactive telehealth tools to maintain motivation, proactive relapse prevention strategies to prepare for medical setbacks, and greater emphasis on familybased interventions to promote consistency and support at mealtimes. Incorporating these strategies into future cases may enhance resilience against setbacks and support more stable treatment trajectories. # *The relationship of trauma with ARFID and other health outcomes* The traumatic medical experiences observed in this case are consistent with broader evidence highlighting the role of trauma in ARFID. Emerging evidence suggests that psychological trauma plays a significant role in both the onset and maintenance of ARFID. Trauma exposure has been particularly associated with specific ARFID profiles, such as sensory sensitivity and fear of adverse consequences, which show higher rates of trauma-related, anxiety, and obsessive-compulsive disorders [[47](#page-10-17)[–49](#page-10-18)]. Notably, individuals with a "picky eating" profile have been shown to have elevated rates of trauma history, and these experiences may negatively affect treatment outcomes [[49\]](#page-10-18). Furthermore, adverse childhood experiences (ACEs) have been linked not only to ARFID but also to broader physical and psychological consequences including depression, chronic pain, and multimorbidity, suggesting shared neurobiological pathways related to stress responsivity and inflammation [\[47,](#page-10-17) [50\]](#page-10-19). Taken together, psychological trauma and psychiatric comorbidities are highly prevalent among individuals with ARFID. Specific ARFID profiles appear more closely linked to traumarelated disorders, supporting the need for a holistic assessment and trauma-informed treatment approach to optimize outcomes. # **Limitations** This case report has several limitations. First, no structured diagnostic interview, such as the Eating Disorder Assessment for DSM-5 (EDA-5), Structured Clinical Interview for DSM-5 (SCID-5), or Pica, ARFID, and Rumination Disorder Interview (PARDI), was administered to confirm the diagnosis, and no parentreport interviews were used to complement patient selfreports. Second, this is a single-case report, which limits the generalizability of the findings, and the available follow-up period was relatively short. Third, the CBT-AR protocol was adapted to the cultural context, which may have influenced outcomes, and the concurrent medical interventions (e.g., balloon dilatation, pharmacological treatments) could not be fully disentangled from the psychological treatment effects. Finally, additional standardized measures for anxiety, sensory sensitivity, and parental mental health (e.g., SCARED, Sensory Profile, Beck Depression Inventory) were not administered, limiting the comprehensiveness of the clinical assessment. # **Conclusion** This case underscores the effectiveness of a comprehensive treatment strategy for ARFID, integrating medical interventions and CBT-AR. The significant improvements in the patient's weight, eating habits, and mental health illustrate the potential for recovery with appropriate, individualized care. This multidisciplinary approach, which includes family involvement, pharmacological support, and tailored CBT, provides a robust model for treating ARFID. The diagnoses of achalasia, SMA syndrome, acute pancreatitis, pneumonia due to regurgitation, and gallstones highlight the complexity of ARFID cases and the necessity for thorough medical evaluations and interventions. Understanding the interplay between these medical conditions and psychological factors is crucial for effective treatment. These medical conditions often interconnected with ARFID, necessitated a detailed and integrated treatment approach to ensure the patient's recovery and prevent relapse. This case also emphasizes the need for more treatment outcome studies in Turkiye, as such data are currently lacking. Addressing this gap in research is essential to better understand the applicability of existing treatment models within different cultural and healthcare contexts. Future research should continue to refine these approaches, exploring the integration of new therapeutic techniques and the role of family dynamics in treatment. Understanding the complex interplay between physical and psychological factors in ARFID will help optimize outcomes and support long-term recovery for affected individuals. The development of standardized protocols incorporating medical and psychological treatment modalities will be vital in managing ARFID effectively, particularly in underrepresented regions such as Turkiye. #### **Acknowledgements** The authors would like to express their sincere gratitude to the patient and his family for their collaboration and consent to share their experiences for the benefit of clinical learning and scientific advancement. #### **Author contributions** HÖ: Patient assessment and follow-up, case conceptualization, supervision of clinical management, and manuscript drafting. İT: Contribution to manuscript writing and literature review. MK: Contribution to manuscript writing and literature review. HT: Supervision of clinical and therapeutic process, and manuscript revision. KTE: Supervision of clinical management and manuscript development, critical revisions and final approval of the manuscript. JJT: Supervision of clinical management and manuscript development, critical revisions and final approval of the manuscript.\*Drs. Thomas and Eddy share senior authorship. #### **Funding** This research received no specific grant from any funding agency, commercial or not-for-profit sectors. #### **Data availability** Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. # **Declarations** # **Ethics approval and consent to participate** As this is a single case report, formal ethical approval was not required. Written informed consent for participation and publication of identifying clinical details was obtained from the patient and his legal guardians. #### **Consent for publication** Written informed consent for publication of this case was obtained from the patient and his legal guardians. #### **Competing interests** The authors declare no competing interests. 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