Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake - - PowerPoint PPT Presentation

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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

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• 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
• f 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.

Disclosures (Thomas)

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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.

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• None

Disclosures (Becker)

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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

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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

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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

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Eddy et. al., 2015 IJED

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.

ARFID Prevalence

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Although both involve restrictive eating, ARFID differs from AN

Becker et al., 2019, IJED p < .05 p = ns N = 129 male and female patients (ages 10-78yo) with restrictive eating disorders at the MGH EDCRP

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Although both involve restrictive eating, ARFID differs from AN

p < .05 N = 59 male and female patients (ages 10-78yo) with restrictive eating disorders at the MGH EDCRP Becker et al., 2019, IJED

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3 Prototypical ARFID Presentations

Lack of interest in food or eating Food selectivity due to sensory sensitivity Fear of Aversive Consequences

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Are prototypical presentations categorical or dimensional?

Thomas et al., 2017, Curr Psychiatry Rep

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• 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

New Structured Interview: PARDI

Bryant-Waugh, Micali, Cooke, Lawson, Eddy, & Thomas, 2019, IJED

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PARDI scores suggest ARFID presentations are dimensional & overlapping

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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

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First exposure to bananas (5 months old) First exposure to peas (6 months old)

Food preferences are normal: Even infants prefer sweet foods v. bitter

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Audience Participation Activity: Are You a Supertaster?

Non-taster Supertaster Medium taster

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Do abnormalities in taste perception underlie ARFID sensory sensitivity?

1R01MH108595, PIs: Thomas, Lawson, Micali

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.

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Sensory A/R group exhibited weaker

• lfactory 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

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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).

Do abnormalities in fear processing underlie ARFID fear of aversive consequences?

1R01MH108595, PIs: Thomas, Lawson, Micali

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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.

Do abnormalities in appetite regulation underlie ARFID lack of interest?

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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

ARFID lack of interest presentation associated with insula hypoactivation

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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

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ARFID cognitive-behavioral model

Thomas & Eddy, 2019, Cambridge University Press Negative Feelings and Predictions about Consequences of Eating Food Restriction (Volume and/or Variety) Nutritional Compromise Biological Predisposition Food-Related Trauma Limited Opportunities for Exposure

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• 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)

4 Stages of CBT-AR

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Tailoring CBT-AR to the patient

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• 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

Two formats

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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

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CBT-AR Stage 2

• Psychoeducation about 5

basic food groups and nutrition deficiencies

• Select new foods to learn

about in Stage 3

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CBT-AR: Stage 3 Sensory Sensitivity Module

Food selectivity due to sensory sensitivity

• Select foods to learn about that

– Increase representation from 5 food groups – Correct nutritional deficiencies – Reduce psychosocial impairment

• Early sessions: Repeated

exposure to very small portions

• Later sessions: Incorporate larger

portions into meals and snacks to meet calorie needs

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CBT-AR: Stage 3 Fear of Aversive Consequences Module

• Provide psychoeducation on how

avoidance increases anxiety

• Create exposure hierarchy to

include small steps leading up to food or eating-related situation that led to initial avoidance

• Continue exposures until patient

has completed the most distressing task on the hierarchy

Fear of Aversive Consequences

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CBT-AR: Stage 3 Lack of Interest in Food or Eating Module

Lack of interest in food or eating

• Interoceptive exposures to increase

tolerance of physical sensations:

– Fullness: Rapidly drink several glasses

• f water

– Bloating: Push belly out – Nausea: Spin in chair

• Self-monitoring to increase

awareness of hunger and fullness

• In-session practice with highly

preferred foods

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CBT-AR: Stage 4

• Evaluate treatment progress

– Patients unlikely to become “foodies,” even if treatment is successful – CBT-AR is designed to expand diet, restore weight, correct nutritional deficiencies, and reduce psychosocial impairment related to ARFID

• Co-create relapse prevention plan

– Identify CBT-AR strategies to continue – Set goals for continued progress

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Feasibility: Most patients completed CBT-AR and few dropped out

Of 20 patients:

• 18 completers
• 2 dropouts

Offered 30 sessions Offered 20 sessions

The remaining analyses will be intent-to-treat, assuming no change among dropouts Recruited 20 participants from neurobiology study to receive CBT-AR

22.2±9.1 19.0±1.8

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Acceptability: Patients & families rated CBT-AR as credible and satisfactory

7.9±1.8 7.8±1.7 30.2±2.2 30.0±2.4

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Efficacy: PARDI ARFID severity decreased

t(19) = 5.34, p < .001 d = 1.19

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Efficacy: Patients who were underweight gained significant weight

Pounds gained in underweight individuals during treatment: M = 10.2, SD = 7.2

t(13) = -5.315, p < .001 d = 1.42

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Efficacy: Food Neophobia & Food Fussiness decreased; New foods incorporated

Number of New Foods Incorporated: M = 18.5, SD = 10.5

t(19) = 3.723, p < .01 d = 0.83 t(19) = 4.121, p < .001 d = 0.92

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Efficacy: Most patients did not meet criteria for ARFID post-tx (via PARDI)

100.0% 65.0% 35.0%

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• Combine neurobiology and treatment using

experimental therapeutics approach

• Mediators: Can CBT-AR change underlying

neurobiology?

– Evaluating change in fMRI and appetite-regulating hormones from pre- to post-treatment

• Moderators: For whom is CBT-AR most

appropriate?

– Can baseline fMRI and hormones predict treatment response?

Future directions

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Fudo app to support CBT-AR

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Acknowledgements

Collaborators:

• R01MH108595: Liz Lawson, MD; Nadia Micali, MD, PhD
• R01MH103402: Madhu Misra, MD
• R01 key staff: Elisa Asanza NP; Tumi Pulumo; Olivia Wons;

Ani Keshishian

• BCH Adolescent Medicine: Melissa Freizinger PhD; Elana

Bern, MD Funding from:

• National Institute of Mental Health
• Hilda & Preston Davis Foundation
• American Psychological Foundation
• Global Foundation for Eating Disorders

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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

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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

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Stage 1 in Action:

Psychoeducation and Early Change

2 sessions (not underweight)

• r

4 sessions (if underweight)

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• Early change in volume or variety

– For underweight patients: increase in volume (about 500 calories/day) to promote weight gain – For non-underweight patients: small increase in variety to jumpstart change

Objectives for Stage 1

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• 1. Verbally set the session agenda
• 2. Weigh the patient
• 3. Review homework from last session
• 4. Implement intervention related to current

treatment stage

• 5. Review any agenda items brought in by patient

and/or significant other(s)

• 6. Plan at-home practice task(s) to be completed

before next session

Outline of a Typical Session

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Stage 1: Psychoeducation on ARFID

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Stage 1: Psychoeducation on CBT-AR

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Stage 1: Self- or Parent-Monitoring

Time Food/drink consumed Thoughts, feelings Physical sensations

7:30am 12:00pm 4:15pm 8:20pm 2 pieces of toast with butter, 2 cups of tea Skipped lunch 1 order of chicken nuggets (one with breading peeled off) and 1 order of French fries from McDonalds, 1 glass

• f water

1 order of Chicken nuggets, 1 glass of water Trying to eat at least something small

• Ugh. I couldn’t bring myself to eat

lunch at work today. Finally after work I got some McDonalds nuggets. I don’t feel comfortable eating other nuggets except the ones from McDonalds. The

• ther ones have a weird texture. I tried

peeling the breading off one nugget like we talked about, and it was OK but not great. My roommate was cooking pasta with garlic in our apartment tonight. It made my stomach turn because it was so strong. I went to my room so I could eat my leftover McDonalds nuggets in my room in peace. Not hungry Tired Hungry, but stomach upset from garlic smell

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Stage 1: First Change

• Rapid change is the expectation from day 1!
• For underweight patients:
• Start adding 500 calories/day this week
• For non-underweight patients:
• Small change in presentation of preferred food
• Re-introduce previously dropped food
• Rotate preferred meals
• Eliminate minor safety behavior

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Stage 1: Example Formulation

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Stage 1: Regular Eating

Time Food/drink consumed 7:00 am 10:00 am 1:00 pm 4:00 pm 6:30 pm 9:00 pm Breakfast Snack Lunch Snack Dinner Snack

• 3 meals + 2-3 snacks
• Eating every 3-4 hours
• For underweight patients:

3 snacks are nearly always necessary

• Programming reminders

can help

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Stage 1: Supporting Weight Gain

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• Meal comprises energy-dense preferred foods plus
• ne novel presentation item
• Therapist coaches parents to give specific instructions

(or coaches patient) to increase volume

– Increase eating speed (“Don’t put down your fork”) – Specific requests (“Take another bite of pizza”) – Persistence with reasonable demand (“I know you can do it. Take another bite.”) – Specific praise (“Great work finishing your pasta!”)

• After patient has eaten adequate volume, parents (or

therapist) encourage one bite of novel item

Stage 1: Therapeutic Meal (underweight patients only)

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• In both, the challenge is in volume and variety
• In FBT-AN, volume and variety are singular

challenge (eat more of avoided foods)

• But, in CBT-AR, the principle is volume before

variety

– Volume: Consume larger amount of preferred foods (even if preferred foods are “unhealthy”) – Variety: Have one bite of a novel presentation of food (e.g., preferred or recently dropped food)

Stage 1: How do meals differ in CBT-AR vs. FBT for Anorexia Nervosa?

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• 14yo female with ARFID (lack of interest in eating or food,

sensory sensitivity)

– Low weight (5‘2”, 89.4 lbs; BMI = 16.3, underweight range) – Premenarchal – Grazing pattern w/ few regular meals – Consumes primarily branded/packaged foods (e.g., candy, chips)

• Family supported CBT-AR (28 sessions)

– Stage 1 and 2 focused on weight gain – Stage 3 focused on lack of interest and sensory sensitivity – Now weight restored (104 lbs, BMI = 19.0) & menstruating – Now eating 3 meals + 3 snacks per day – Incorporated 9 foods (e.g., cheese, almonds, orange juice, lettuce)

Shirley: 14yo female

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• What if the patient isn’t eating/drinking at all?
• Since CBT-AR is focused on eating, can the patient

see another therapist concurrently?

• What if patient doesn’t do the self-monitoring?
• What if the patient isn’t gaining weight?

Troubleshooting Stage 1

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✓The patient understands ARFID and what will happen in CBT-AR ✓The patient understands his or her specific ARFID presentation ✓The patient has established self-monitoring (or parent-monitoring) of daily food intake ✓The patient is eating at regular intervals ✓The patient has begun increasing volume (by 500 calories/day, if underweight) or variety

Checklist for Moving to Stage 2

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Stage 2 in Action:

Treatment Planning

2 sessions

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• Continue focus on increasing volume and

variety

• Learn about nutritional deficiencies and how

food from all 5 food groups can address these

• Identifying maintaining mechanisms and

treatment targets for Stage 3

Objectives for Stage 2

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Stage 2: Nutrition Deficiencies

Deficiency Signs and symptoms Foods rich in this nutrient (in order of nutrient density) Vitamin B12 Fatigue, weakness, constipation, loss of appetite, weight loss, numbness, tingling, depression, confusion, poor memory, soreness of mouth/tongue Liver (all types), fish, meat, poultry, eggs, milk, yogurt, cheese, nutritional yeast Tip: Vitamin B12 is found in animal products and not plant based foods Vitamin C Severe deficiency (scurvy) can cause tiredness and weakness with severe medical complications Bell peppers, orange juice, oranges, grapefruit juice, kiwi, broccoli, strawberries, Brussels sprouts, grapefruit Zinc Poor growth, loss of appetite, low immune function, taste changes, depression, hair loss, diarrhea, eye and skin lesions Oysters, crab, beef, lobster, pork, baked beans, chicken, yogurt, cashews, chickpeas, cheese,

• atmeal, milk, fortified cereals

Tip: Zinc is easier to absorb in animal sources

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Stage 2: MyPlate

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Stage 2: Building Blocks

Consistently eating? Willing to learn about? Number of tastes since starting CBT-AR? FRUITS 100% Fruit juice

• Apple juice
• Cranberry juice
• Grape juice
• Grapefruit juice
• Mango juice
• Orange juice
• Papaya juice
• Pineapple juice
• Pomegranate juice
• Prune juice

Berries

• Acai berries
• Blackberries
• Blueberries
• Cranberries
• Currants

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• What if the patient does not select any foods that he
• r she is interested in “learning about”?
• What if the patient is not continuing to gain weight?

Troubleshooting Stage 2

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✓ The patient is steadily gaining weight (if underweight) ✓ The patient has identified foods that could be added to correct any nutritional deficiencies ✓ If applicable, the patient has continued to increase eating flexibility by consuming slight variations on preferred foods or eliminating minor safety behaviors ✓ Patient has identified several foods from the Primary Food Group Building Blocks to learn about in Stage 3

Checklist for Moving to Stage 3

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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

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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

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Stage 3 in Action:

Maintaining Mechanisms

14-22 sessions (depending on number and severity of maintaining mechanisms)

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• Begin with mechanism causing most

impairment

• Consistent with volume before variety, begin

with Lack of Interest in Eating or Food or Fear

• f Aversive Consequences
• Sensory Sensitivity is typically last
• Continue to support weight gain (if necessary)

Stage 3: How to Prioritize Maintaining Mechanisms

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• Set agenda
• Weigh patient
• Review at-home practice tasks

– Did patient bring 5 novel foods to learn about? – Did patient taste and/or incorporate a novel food every day in the past week?

• Psychoeducation about necessity of repeated exposure to enhance

liking for novel foods (first session of module only)

• Therapist helps patient explore these foods using the 5 steps

– Look, feel, smell, taste, touch – Is the patient willing to continue learning about this food?

• Assign HW

– Taste novel foods daily and log all tastes on Building Blocks worksheet – Consider when tasted foods are ready to be incorporated

Stage 3: Sensory Sensitivity Session Template

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Stage 3: Sensory Sensitivity

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• The patient decides which of the five foods tasted in

session they are willing to continue learning about

• The therapist assists the patient in planning practice

tastings of the foods from the session

– The patient should be practicing with at least one the novel foods (tasted in session) every day

• Its GREAT if the patient spontaneously tries other

foods but they are still expected to practice with the foods from session

Tasting Practice at Home

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Stage 3: Sensory Sensitivity

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Stage 3: Fear of Aversive Consequences Session Template

• Set agenda
• Weigh patient
• Review at-home practice tasks

– Did the patient complete assigned exposures from last session?

• Psychoeducation about avoidance (first session of module only)
• Co-create exposure hierarchy (first session of module only)

– Explain Subjective Units of Distress

• Conduct in-session exposure (later sessions of module only)

– Before and after exposure, ask about SUDS and probability of feared outcome – Identify and reduce safety behaviors

• Assign at-home practice tasks

– Practice exposures at home – Identify new items to add to hierarchy

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Stage 3: Fear of Aversive Consequences

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Stage 3: Fear of Aversive Consequences

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• 21yo male with ARFID (fear of aversive consequences, lack
• f interest in eating or food)

– Allergic to Brazil nuts – Following an episode of anaphylaxis, began cutting out foods until he was left with a limited range of safe foods – Low weight (5’5”, 106 lbs; BMI = 17.6)

• Individual CBT-AR (14 sessions)

– Stage 1 and 2 focused on increasing volume of preferred foods – Stage 3 focusing on fear of aversive consequences, in collaboration with his allergist – Gained 7 lbs – Requested to end treatment early once he had incorporated many new foods including multiple kinds of nuts

Chad: 21yo male

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Stage 3: Lack of Interest Session Template

• Set agenda
• Weigh patient
• Review at-home practice tasks

– Review progress with increasing calories – Review hunger/fullness ratings

• Review strategies for eating enough (first session of module only)
• Conduct interoceptive exposures
• Assign or review extended self-monitoring
• Five steps for highly preferred foods
• Assign at-home practice tasks

– Practice interoceptive exposures and preferred foods at home – Identify more preferred foods to bring to next session

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Stage 3: Lack of Interest in Eating or Food

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Stage 3: Lack of Interest in Eating or Food

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Stage 3: Lack of Interest in Eating or Food

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• 14yo male with ARFID (lack of interest in eating or food,

sensory sensitivity)

– Few foods in each food group – Skipped most meals and never reported being hungry – Underweight (5’5.75”, 90.9 lbs; BMI < 1st percentile) – Deficient in vitamin D – Parent worried about feeding him dairy due to GI distress – Comorbid ADHD, learning disability, and ODD

• Family-based CBT-AR (18 sessions) with single parent

– Stage 3 focused on lack of interest, than sensory sensitivity – EOT BMI in 21st percentile (healthy range) – Grew 2 inches in height, gained 25 lbs – Eating more than 10 foods in each category

Rob: 14yo male

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• What if a patient with sensory sensitivity does not

bring 5 foods to session?

• What if a patient with fear of aversive consequences

actually experiences the aversive consequence (e.g., chokes, vomits, has allergic reaction) during an exposure?

• What if the patient with fear of aversive

consequences denies or minimizes anxiety?

• What if a patient with apparent lack of interest in

eating or food vomits after eating a larger volume of food?

Troubleshooting Stage 3

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✓ Patient is no longer underweight ✓ Patient is eating at regular intervals, and has increased volume or variety within meals and snacks ✓ Patient is regularly incorporating foods that will help resolve nutrition deficiencies ✓ Patient’s primary ARFID maintaining mechanism(s) has been at least partially resolved

Checklist for Moving on to Stage 4

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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

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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

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Stage 4 in Action:

Relapse Prevention

2 sessions

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• Assess progress to determine if termination is

appropriate

• Create relapse prevention plan
• End treatment

Objectives for Stage 4

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• Revisit personalized formulation
• Revisit Primary Food Building Blocks

Stage 4: Evaluating Progress

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• Patient no longer meets criteria for ARFID or symptom

severity has decreased

– Patient eats and incorporates several foods in 5 food groups – Patient’s growth (height and weight) has increased to that expected – Nutritional deficiencies are resolved or the patient is eating foods to resolve them – Patient no longer experiences clinically impairing psychosocial consequences

Stage 4: Is the Patient Ready to Complete CBT-AR?

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Stage 4: Relapse Prevention

Ways that my eating has improved since the start of treatment:

• I can eat all the foods I used to eat before I choked, but without a fear of choking
• Have added 25 new foods to my diet!
• I feel braver about trying new foods in social situations

Possible future triggers for relapse:

• Choking on my food again
• Going to college and having to choose food from the dining hall

Red flags that I might be starting to relapse:

• Going on a food jag where I eat the same food multiple times per day or week (e.g., brownies)

CBT-AR techniques to continue or try on my own after treatment is completed:

• Taking in new foods slowly and using the the 5 steps
• I can stop at any point along the 5 steps; I can look/smell without eating, and I need to remind myself

that that’s still progress

• I only need to try a little bit of the new food
• Self-monitoring

Ways I’d like to continue to change my eating post-treatment:

• Continue to try foods on my “Primary Food Groups Building Blocks” list
• Go on more food-related dates (e.g., out to dinner)
• Try to cook new recipes

Massgeneral.org/eatingdisorders

• 11yo male with ARFID (sensory sensitivity, lack of interest)

– Two fruits; no vegetables at all – Weight was at lower end of normal range – Deficient in vitamin A and K – Additionally, phobic of yogurt

• Family-based CBT-AR (22 sessions)

– Stage 1-2 focused on regular eating, gaining slight amount of weight – Stage 3 focused on sensory sensitivity – At the EOT, Steve no longer met criteria for ARFID – Eating 5-10 fruits and vegetables, and eating foods from all categories daily – Able to sit at the table with his family for meals (including yogurt!)

Steve: 11yo male

Massgeneral.org/eatingdisorders

• What if the patient is reluctant to end CBT-

AR?

Troubleshooting Stage 4

Massgeneral.org/eatingdisorders

Questions?

jjthomas@mgh.harvard.edu keddy@mgh.harvard.edu krbecker@mgh.harvard.edu