"I'm the skinny one"

ARFID and the 'thin identity'

Children with ARFID can come in all shapes and sizes but many find themselves chronically underweight. In school and at home this can become something that attracts comments, both good and bad. Most people are aware of the negative impact that bullying comments about appearance can have on children, but there is less awareness of how positive comments about weight and shape can impact. Amongst friends a child with ARFID may be given nicknames that reflect their weight, "Twiggy", Elfin","Shrimp" which are affectionate and not intended to harm. As that child starts to form their identity, particularly in their teenage years they can start to incorporate their weight and shape as a core part of their identity, "I'm the skinny one". They become proud of their nickname and may start to feel their popularity is somewhat based around their thinness.

During life there are always ups and downs, however, in the teen years these are more dramatic and come thick and fast. Often this results in a few self-esteem challenges and for young people with ARFID, their self-esteem is already likely to be a bit more vulnerable due to their atypical diet. When self-esteem drops young people seek a way to increase it rapidly. Unfortunately, we live in a society that repeatedly drums into everyone that thin = happy. It is this combination that can then make affectionate comments about weight and shape become problematic. "I'm the skinny one, that's who I am", therefore to feel happy when self-esteem dips it could feel like it makes sense to lose a bit of weight. When someone with ARFID develops an identity around being thin they can become more vulnerable to other eating disorders, particularly anorexia nervosa.

Some of the symptoms of ARFID can also increase the vulnerability to Anorexia. In ARFID there is often a poor appetite drive, this means if someone with ARFID decides to try to deliberately lose weight they often find they are able to easily and rapidly. The diet in ARFID is already very restricted (though in a different way from anorexia) but this means that when any deliberate weight loss is attempted the restriction can become very extreme. Anorexia with ARFID can result in significant and rapid health problems as those with ARFID do not have much in the way of nutritional reserves and the rapidity of weight loss when they lose weight deliberately puts their body under enormous strain.

It is almost inevitable that those underweight with ARFID will invite some affectionate weight or shape comments from loved ones, however, it may not be helpful for those with ARFID to be encouraged to think of themselves in this way. No one should define their identity by their skin cells, muscle cells or fat cells. If they do, the changes that come with age, illness or accidents will have a significant impact on their sense of self. Identity should be shaped around passions and personality. Instead of being "I'm the skinny one" be "I'm the one who loves ice skating, pets and all things family... and I happen to be skinny, but that's not who I am"

Dr Clare Fenton

MBChB BSc MSc MRCPsych

Consultant Child and Adolescent Psychiatrist