Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder (CBT-AR) Jennifer J. Thomas, Ph.D. Kamryn T. Eddy, Ph.D. Kendra R. Becker, Ph.D. Eating Disorders Clinical & Research Program, Massachusetts General Hospital Department of Psychiatry, Harvard Medical School Massgeneral.org/eatingdisorders
Disclosures (Thomas) • I receive royalties for the sale of my book, Almost Anorexic: Is My (Or My Loved One’s) Relationship with Food a Problem? from Harvard Health Publications/Hazelden. • I receive royalties for the sale of my book Cognitive- Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults from Cambridge University Press. • I receive an honorarium for serving as Associate Editor of the International Journal of Eating Disorders. • I receive a travel stipend for my role on the Board of Directors of the Academy for Eating Disorders. Massgeneral.org/eatingdisorders
Disclosures (Eddy) • I receive royalties for the sale of my book Cognitive- Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults from Cambridge University Press. Massgeneral.org/eatingdisorders
Disclosures (Becker) • None Massgeneral.org/eatingdisorders
Agenda 9:00-10:30am Introduction to ARFID: Neurobiology, assessment, and treatment 10:30-10:50am Break 10:50-12:30pm CBT-AR Stages 1-2 12:30-1:30pm Lunch 1:30-3:00pm CBT-AR Stage 3 3:00-3:20pm Break 3:20-4:00pm CBT-AR Stage 4 Massgeneral.org/eatingdisorders
Agenda 9:00-10:30am Introduction to ARFID: Neurobiology, assessment, and treatment 10:30-10:50am Break 10:50-12:30pm CBT-AR Stages 1-2 12:30-1:30pm Lunch 1:30-3:00pm CBT-AR Stage 3 3:00-3:20pm Break 3:20-4:00pm CBT-AR Stage 4 Massgeneral.org/eatingdisorders
DSM-5 Criteria for ARFID • Food avoidance or restriction leading to persistent failure to meet nutritional needs, causing > 1 of the following: • Significant weight loss • Significant nutritional deficiency • Dependence on tube feeding or oral supplements • Psychosocial impairment • Not due to lack of available food or cultural practice • No fear of weight gain or body image disturbance • Not accounted for by another medical or psychiatric condition DSM-5 , 2013, APA Massgeneral.org/eatingdisorders
ARFID Prevalence Retrospective chart review of 2,231 consecutive new referrals (ages 8 – 18 years) to 19 Boston area pediatric gastroenterology clinics for evidence of DSM-5 ARFID. Eddy et. al., 2015 IJED Massgeneral.org/eatingdisorders
Although both involve restrictive eating, ARFID differs from AN N = 129 male and p = ns female patients (ages 10-78yo) with restrictive eating p < .05 disorders at the MGH EDCRP Becker et al., 2019, IJED Massgeneral.org/eatingdisorders
Although both involve restrictive eating, ARFID differs from AN N = 59 male and female patients p < .05 (ages 10-78yo) with restrictive eating disorders at the MGH EDCRP Becker et al., 2019, IJED Massgeneral.org/eatingdisorders
3 Prototypical ARFID Presentations Food selectivity due to sensory sensitivity Fear of Aversive Consequences Lack of interest in food or eating Massgeneral.org/eatingdisorders
Are prototypical presentations categorical or dimensional? Thomas et al., 2017, Curr Psychiatry Rep Massgeneral.org/eatingdisorders
New Structured Interview: PARDI • Pica, ARFID, and Rumination Disorder Interview (PARDI) – 45-minute investigator-based interview – Confer diagnoses and determine severity of ARFID presentation(s) – Severity items scored 0-6 • Evidence of reliability (N = 57) – Cronbach’s alphas for subscales • Sensory sensitivity (.74) • Lack of interest (.89) • Fear of aversive consequences (.70) • Severity (.87) – Cohen’s kappa for ARFID diagnosis (k = .75) • Evidence of convergent & divergent validity Bryant-Waugh, Micali, Cooke, Lawson, Eddy, & Thomas, 2019, IJED Massgeneral.org/eatingdisorders
PARDI scores suggest ARFID presentations are dimensional & overlapping Massgeneral.org/eatingdisorders
Our new R01 is investigating why some children may be vulnerable • Neurobiological and Behavioral Risk Mechanisms of Youth Avoidant/Restrictive Eating Trajectories – Recruiting males and females ages 10-22yo • Aiming to clarify: – Neurobiology of ARFID (brain imaging, hormones) – 2-year outcomes • We hypothesize that neurobiology underlies the presence and severity of each of the 3 ARFID presentations and will predict longitudinal trajectory 1R01MH108595, PIs: Thomas, Lawson, Micali Massgeneral.org/eatingdisorders
Food preferences are normal: Even infants prefer sweet foods v. bitter First exposure to bananas First exposure to peas (5 months old) (6 months old) Massgeneral.org/eatingdisorders
Audience Participation Activity: Are You a Supertaster? Supertaster Medium taster Non-taster Massgeneral.org/eatingdisorders
Do abnormalities in taste perception underlie ARFID sensory sensitivity? Prior studies have found that children identified by parents as selective eaters are more likely to be supertasters than healthy controls. Super-tasters have a greater density of taste buds on their tongues, and typically report greater dislike for bitter foods (e.g., vegetables), compared to non-tasters. We hypothesize among youth with ARFID, those with sensory sensitivity will be more likely to be supertasters, compared to healthy controls. 1R01MH108595, PIs: Thomas, Lawson, Micali Massgeneral.org/eatingdisorders
Sensory A/R group exhibited weaker olfactory performance than non- sensory A/R and healthy controls * • 54 individuals (sensory A/R, n=24; * non-sensory A/R, n=20; (HC), n=10) volunteered for a research study at MGH investigating the neurobiology of ARFID. • Age:10-22 years; 50% male “Please point to the word on the card that best describes the particular smell.” Ham Bread Fish Cheese Wons et al., ABCT, 2018 Massgeneral.org/eatingdisorders
Do abnormalities in fear processing underlie ARFID fear of aversive consequences? We hypothesize that, among youth with ARFID, phobic features will be positively correlated with trait fearfulness, as well as amygdala hyperactivation, arousal (skin conductance, heart rate), and cortisol and oxytocin secretion, in response to aversive food and eating images (i.e., choking, vomiting). 1R01MH108595, PIs: Thomas, Lawson, Micali Massgeneral.org/eatingdisorders
Do abnormalities in appetite regulation underlie ARFID lack of interest? We hypothesize that, among youth with ARFID, lack of interest in eating will be positively correlated with hypothalamus and insula hypoactivation when viewing food images. With also expect lower preprandial levels of orexigenic hormones (e.g., ghrelin) in ARFID v. healthy controls prior to a laboratory test meal. Massgeneral.org/eatingdisorders
ARFID lack of interest presentation associated with insula hypoactivation Our preliminary findings suggest hypoactivation in appetite neural circuitry (e.g., insula) in ARFID vs. controls, similar to adolescents with AN. R01MH103402, PIs: Misra, Lawson, Eddy; Thomas et al., NEJM, 2017 Massgeneral.org/eatingdisorders
For Whom is CBT-AR Appropriate? Children, adolescents, or adults ages who: • Have a diagnosis of ARFID • Are able to cognitively engage in treatment – Are ages 10 and up – If a developmental disorder is present, it is of mild severity • Are eating by mouth – Are at least able to orally consume liquids or soft foods – Do not require tube feeding • Monitored by a physician – ARFID can have serious medical consequences – Patients who are underweight are at risk for re-feeding syndrome Massgeneral.org/eatingdisorders
ARFID cognitive-behavioral model Biological Predisposition Food-Related Trauma Negative Feelings and Predictions about Consequences of Eating Food Restriction (Volume and/or Variety) Limited Opportunities for Nutritional Compromise Exposure Thomas & Eddy, 2019, Cambridge University Press Massgeneral.org/eatingdisorders
4 Stages of CBT-AR 1. Psychoeducation and early change (2-4 sessions) 1. Treatment planning (2 sessions) 1. Address maintaining mechanisms in each ARFID domain (14-22 sessions) a. Sensory sensitivity b. Fear of aversive consequences c. Lack of interest in food or eating 2. Relapse prevention (2 sessions) Massgeneral.org/eatingdisorders
Tailoring CBT-AR to the patient Massgeneral.org/eatingdisorders
Two formats • Family-supported CBT-AR – Child and early adolescent patients (10-15yo) – Young adult patients (16yo+) who live at home and have significant weight to gain • Individual CBT-AR – Late adolescent and adult patients without significant weight to gain (16yo+) • Though session attendees differ, interventions are similar across the age span Massgeneral.org/eatingdisorders
CBT-AR: Stage 1 • Psychoeducation on ARFID • Self- or parent-monitoring • Regular eating (eating preferred foods at each meal/snack) • Personalized formulation • If underweight: – Begin to restore weight by increasing volume of preferred foods – Conduct in-session therapeutic meal to provide coaching • If not underweight: – Make small changes in presentation of preferred foods and/or reintroduce recently dropped foods Massgeneral.org/eatingdisorders
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