Understanding RISH: A Nutrition and Dietetic Perspective on Restricted Intake as Self-Harm
- sarahelder
- 3 hours ago
- 3 min read
When we talk about restrictive eating, most people immediately think of anorexia nervosa. But there’s a newer, really important concept emerging in clinical practice called Restricted Intake Self-Harm (RISH) — and it’s starting to reshape how clinicians think about certain presentations of food and fluid restriction. For dietitians and nutrition professionals, getting familiar with RISH matters, because management looks very different depending on the function of the restriction and not simply the behaviour itself (Fenton et al, 2024).
What Is RISH?
Restricted Intake Self-Harm (RISH) is a form of self-harm where someone restricts food and/or fluid intake not for weight loss or body-image reasons, but as a way to regulate emotions, communicate distress, or access care that feels otherwise unavailable (CNTW NHS, 2025; Fenton et al., 2024).
Unlike anorexia nervosa — which is driven by weight, shape concerns, and fear of gaining weight — the core driver in RISH is the self-harm function of the restriction, not weight-control intentions (Ellison & Philpot, 2024; CNTW NHS, 2025).
Patients often describe RISH as a way to:
* numb or control overwhelming feelings
* signal distress when verbal communication feels unsafe or ineffective
* access an environment where they get predictable care or containment
This functional difference is huge, because it means a person's medical picture may be similar to someone with AN, but psychologically they’re in a completely different place.
RISH vs. Anorexia Nervosa
AN: restriction is driven by weight/shape concerns and fear of weight gain
RISH: restriction is a method of self-harm, not a weight-focused behaviour
Using anorexia-based treatment pathways for someone with RISH may actually worsen the self-harm cycle or reinforce unhelpful patterns — for example, repeated inpatient admissions may accidentally “reward” the self-harm function of restriction (Fenton et al., 2024).
Why RISH Matters for Dietitians
Dietitians are often the first professionals to spot unusual patterns in intake, hydration, or feeding behaviour. Because RISH carries both physical risks and emotional risk functions, we need a specific approach.
Early recognition
Misdiagnosing RISH as AN can lead to unhelpful or harmful care (Ellison & Philpot, 2024). Dietitians often pick up the subtle clues that something doesn’t quite “fit” the classic ED picture.
Formulation-based care
Treatment plans should be built around why someone restricts intake — not just what they are eating or drinking. This is where dietitians work closely with psychology and psychiatry.
Avoiding iatrogenic harm
Standard AN refeeding protocols or long admissions can worsen RISH presentations by reinforcing the self-harm cycle (Fenton et al., 2024).
MDT collaboration
RISH truly requires a team approach — dietitians, gastroenterologists, psychologists, psychiatrists, and primary care all play a role.
Practical Considerations for Dietitians
Here are some principles that tend to help when supporting someone presenting with RISH:
Assess the function: pair your nutrition assessment with psychological input.
Check fluids carefully: hydration levels may change rapidly. Collaborate on a shared formulation: ensure this is always patient-centred.
Positive risk management: balance safety with avoiding harmful reinforcement.
Avoid automatically using AN pathways.
Plan for purposeful admissions only if essential (Fenton et al, 2024).
Ensure regular MDT review and flexibility in care plans.
So what next?
Restricted Intake Self‑Harm (RISH) represents an important and clinically distinct presentation in the landscape of disordered eating. From a nutrition and dietetic perspective, understanding RISH is more than knowing how to refeed someone: it’s about listening to why they restrict, formulating care around self-harm motivations, collaborating closely with wider mental health services and managing risk in a way that respects both physical and psychological needs.
As awareness of RISH grows, dietitians are uniquely positioned to lead in its recognition, formulation, and management — helping patients get the tailored, compassionate care they deserve.
If you want to learn more about RISH and its management, watch our recorded webinar, where we explore practical strategies, case examples, and multidisciplinary approaches in detail.
References
Ellison, C. & Philpot, U. (2024) ‘Confusion between avoidant restrictive food intake disorder, restricted intake self-harm, and anorexia nervosa: developing a primary care decision tree’, *British Journal of General Practice*, 74(749), p. 559.
Fenton, C., Ellison, C., Philpot, U., Adedeji, A., Cruickshank, K., Goldup, H., Small, I., McMahon, M. & Paine, P. (2024) ‘Restricted intake self-harm (RISH): a composite case example and guidance for management’, *Frontline Gastroenterology*. doi: 10.1136/flgastro-2024-102823.