Jennifer J. Thomas and Kamryn T. Eddy joined us for an interview on their book, Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. What follows are our questions in italics, and their thoughtful responses.
Your treatment manual, Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults, has been welcomed with open arms. Who will benefit from CBT-AR?
Thank you for your kind words! We are so glad that the manual has been helpful to our colleagues and their patients. CBT-AR is designed to help children, adolescents, and adults with ARFID ages 10 and up who are medically stable for outpatient treatment and not dependent on tube feeding.
Please tell us about sensory sensitivity and ARFID.
ARFID has three primary presentations described in DSM-5: sensory sensitivity; lack of interest in eating or food; and fear of aversive consequences. Individuals with the sensory sensitivity presentation often avoid specific foods due to their sensory properties (e.g., taste, smell, temperature, appearance). Many rely heavily on processed dairy and grain foods, such as bread, pasta, and ice cream.
There are 4 Stages to CBT-AR. Stage 1 provides for psychoeducation and early change. What is the parents’ role in this stage when their child is the patient?
We always offer a family-supported version of CBT-AR—in which at least one parent attends all sessions—for patients who are under 16 years old and/or have significant weight to gain. Parents play a critical role in preparing food for the patient, encouraging him or her to eat enough, and providing opportunities for at-home exposure to novel foods.
Stage 2/Treatment Planning offers information on nutrition. How does the use of “My Plate” support treatment planning?
In Stage 2, we invite patients to consider the extent to which their current diet maps onto USDA recommendations for healthy eating, which are represented as a plate that comprises fruit, vegetables, dairy, protein, and grains. They draw a picture of their own typical plate and compare it to the MyPlate schematic to determine whether certain food groups (often grains and dairy) are over-represented in their diets, and whether other food groups (often fruits, vegetables, and/or protein) are under-represented and could be added in Stage 3.
Stage 3 focuses on the maintaining mechanisms of ARFID. What are some suggestions for “eating enough”?
In the Stage 3 lack of interest module, we encourage patients to do interoceptive exposure in which they experience and habituate to feelings of fullness, bloating, and nausea. The purpose is to help them realize that they can experience these sensations and cope with them, rather than escaping. We also invite them to bring in highly preferred foods and describe them using all five senses, to re-connect with the pleasantness of eating. Lastly, we ask them to use self-monitoring techniques to increase their awareness of hunger cues. And, of course, we encourage them to continue with Stage 1 strategies such as eating regularly and choosing energy-dense preferred foods, especially if they need to gain weight.
With Relapse Prevention in Stage 4, who creates the relapse prevention plan?
Patients create their own relapse prevention plans using a template that we provide (included in the CBT-AR manual). Of course, the therapist always provides suggestions, as do the parents if the patient is in the family-supported version of the treatment.
About the authors:
Dr. Jennifer Thomas is the Co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, and an Associate Professor of Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Thomas’s research focuses on atypical eating disorders, as described in her books Almost Anorexic: Is My (or My Loved One’s) Relationship with Food a Problem? and Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. She is currently principal investigator on several studies investigating the neurobiology and treatment of avoidant/restrictive food intake disorder, funded by the U.S. National Institute of Mental Health and private foundations. She is the author or co-author of more than 125 scientific publications. She also serves as Secretary for the Academy for Eating Disorders and Associate Editor for the International Journal of Eating Disorders.
Dr. Kamryn Eddy is an Associate Professor of psychology at Harvard Medical School and the co-director of the Massachusetts General Hospital Eating Disorders Clinical and Research Program. She is a clinical psychologist with expertise in the assessment and treatment of eating disorders. She is a Fellow of the Academy for Eating Disorders and President-Elect of the Eating Disorders Research Society and her research is supported through the National Institutes of Health and private foundations. Her program of research focuses on diagnosis, treatment, and neurobiological bases of eating disorders, and longitudinal outcomes. She is the principal investigator of several studies, including two NIMH-funded studies of the neurobiology of low weight eating disorders, and a novel hormonal treatment study of anorexia nervosa and the female athlete triad. The overarching objective of her work is to carefully describe the clinical presentations of individuals with eating disorders in order to address questions about why, and in whom these illnesses are most likely to develop, and to inform the development of novel treatments for these serious conditions. Along with her colleague, Dr. Jennifer Thomas, Dr. Eddy developed a novel cognitive-behavioral therapy for avoidant/restrictive eating disorder (CBT-AR), which was published by Cambridge University Press. She has mentored numerous postdoctoral fellows, medical residents, and psychology graduate students.