Proximity challenges help patients overcome food allergy anxieties
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Key takeaways:
- Challenges increase patient exposures to their allergen while incorporating coping strategies for anxiety.
- Collaboration between the allergist and the mental health professional is essential to the protocol.
Allergists can work with mental health providers to incorporate proximity challenges into food allergy treatment to help patients overcome clinical anxiety, according to an article published in Annals of Allergy, Asthma & Immunology.
These interventions may improve quality of life for patients with food allergy anxieties, Ashley M. Ramos, PhD, pediatric psychologist at University Hospital’s Rainbow Babies and Children’s Hospital in Cleveland, and colleagues wrote.
The need for interventions
Most patients with food allergy can safely tolerate physical proximity to their allergens, but misinformation about how reactions are triggered may cause some patients to feel anxiety, avoid safe situations and experience social isolation, the authors said.
“We do not have exact prevalence rates for anxiety in patients with food allergy, mainly due to variations in the way anxiety is measured in research studies,” Ramos told Healio.
“Current research suggests that although children with food allergy are not at an increased risk for generalized anxiety disorder, many experience food allergy-specific anxiety that can significantly impact their lives,” she said.
But the limited number of mental health professionals trained in food allergy is one of the biggest challenges in providing specialized care, which patients have indicated is important as most of them look to their allergy providers for support, Ramos said.
“Unfortunately, providers have not had many evidence-based tools other than education to increase food allergy knowledge and problem-solving specific to this stressful situation,” she said.
Mental health providers trained in food allergy have used evidence-based cognitive behavioral therapy, as well as exposure and response prevention adapted for fears specific to food allergy, to decrease those worries among children and caregivers.
“However, this is one of the first times these interventions have been used to directly address the fear of touching an allergen,” Ramos said.
The protocol
Mental health providers who work in or with allergy clinics can lead these patients through proximity challenge interventions, which involve a progression through a predictable and controlled stepwise hierarchy of increasing environmental contact with their allergens.
Patients do not consume the allergen. Providers recreate distress at a tolerable level without giving the patient any opportunity to escape the situation via behavioral avoidance, creating opportunities for behavioral mastery and cognitive appraisals.
By working through the emotional distress of being near their allergen, the authors said, patients develop confidence and break the cycle of avoidance in a structured, supportive, therapeutic environment.
Interventions begin based on the level of anxiety that each individual patient feels. Some patients begin with cartoon images or photographs of the allergen, while others may be able to begin with the allergen in the same room.
The authors outlined four steps in the protocol, noting that patients will proceed through these steps at their own individual paces.
First, the mental health provider should establish a list of the patient’s food allergens and confirm the allergist’s management recommendations. Next, the provider should engage in food allergy education and anxiety management psychoeducation.
This comprises information about food allergies, allergen avoidance and treatment for allergic reactions, as well as information about anxiety. Relaxation strategies, thought challenges and positive self-statements should be introduced and practiced as well.
Providers also should help patients understand the differences between sensations due to anxiety and those due to allergic reactions. Further, the provider and patient should establish a “thermometer” based on subjective units of distress as well as a fear hierarchy and appropriate counter-thoughts for self-assessing and combatting anxiety.
Third, the patient compiles a list of situations that cause anxiety, such as being in the same room as their allergen, touching or holding a sealed container of their allergen, or sniffing and touching their allergen. Using the subjective units of distress, patients rate the distress they would feel in each of these situations.
Finally, the provider would conduct exposures, beginning with moderately feared situations and then proceeding gradually and systemically through increasing exposures. These exposures should be long enough for anxiety levels to fall while patients use strategies such as thought challenges and positive self-statements.
Before and after each exposure, the authors said, the provider should assess the patient’s fear according to the subjective units of distress. Once the patient has demonstrated less fear of the exposure, the intervention should proceed to a more highly feared situation.
For example, patients with a peanut allergy may begin by looking at a picture of a peanut. Then, they may be in a room with a closed jar of peanut butter. After the patient gets closer to the jar, it may be opened, and the patient may smell it.
The patient eventually may touch the open jar and then the peanut butter itself, washing their hands immediately, before touching the peanut butter again but waiting 30 seconds before washing their hands.
Early results
The authors do not have data on the protocol’s effectiveness in large samples yet, but they do say that clinically, they have found it to be very effective for treating food allergy anxiety among their patients across a range of ages, allergens and experiences.
“After completing the protocol, patients report improvements in their food allergy-related anxiety and in their quality of life, such as feeling more comfortable at mealtimes, being less hypervigilant of allergens in the environment and having a decreased fear of allergic reactions due to allergen contact,” Ramos said.
The authors advised close collaboration between allergists and mental health professionals in crafting these individual exposures in the hierarchy, with the mental health providers well versed in the patient’s emergency management plan.
“If the patient has low anxiety and is comfortable with a one-step process, a provider can easily conduct touch exposure in office,” Ramos said.
“If the patient has significant anxiety, they would benefit from engaging in this protocol with a mental health provider who can lead them through gradual exposure steps while using coping strategies to manage distress,” she continued.
Next, Ramos said it will be important to collect comprehensive pre-intervention and post-intervention data among a sample of pediatric patients on how standardized implementation of the protocol affects their food allergy anxiety and quality of life.
“More broadly, we continue to prioritize development of evidence-based interventions to support the psychosocial well-being of patients managing food allergy,” Ramos said.
Perspective
Back to Top
In recent years, there has been increased focus on anxiety among youth with food allergy, with calls for intervention efforts. This article answers those calls by describing an innovative approach of applying exposure and response prevention, an evidence-based psychological treatment for anxiety disorders, in the context of pediatric food allergy.
Ramos and colleagues target a very specific type of anxiety – fear of being near their allergen – through proximity challenges with graded exposures. They vividly illustrate how proximity challenges can be effectively conducted in a personalized and flexible approach while adhering to both physical safety and evidence-based principles.
It is important to address food allergy anxiety because it can significantly impair quality of life for patients and families. High levels of anxiety may lead to avoidance of relatively benign situations. For instance, children who fear being in the same room as their allergen may avoid attending birthday parties or eating lunch in the school cafeteria. However, psychoeducation and exposure therapy may teach them that they can safely participate in these activities with reasonable precautions, such as bringing their own safe food. It is important to address this anxiety early on, given that untreated child anxiety predicts adverse mental health outcomes across development.
In my work with pre-adolescents, adolescents and young adults with food allergy, I see high levels of anxiety, which often impairs social functioning. For example, I have worked with college students who believe they cannot be in a lecture hall if someone is eating one of their allergens, which leads to great distress and impairment. While the authors illustrate this process with an 11-year-old girl, it is likely that this intervention could be effective and impactful across the developmental spectrum.
Early intervention and prevention efforts are critical to reducing fears related to allergen proximity. From an intervention standpoint, it would be worthwhile for allergy treatment teams to assess both fears and daily life behaviors related to allergen proximity. Patients with high levels of avoidance should then be provided with treatment as outlined by Proctor and colleagues.
Unfortunately, exposure therapies are rarely used in medical centers, and, as the authors discuss, there is a dearth of providers with expertise in allergy. It is important that the long-lasting efficacy of this intervention be empirically examined and then disseminated both in allergy clinics and within the community. Exposure interventions in a group format may be a promising avenue to increase the availability of treatment.
From a prevention standpoint, increased psychoeducational efforts for families of children with food allergy are greatly needed. Messaging related to food allergy management is often rooted with fear, perhaps contributing to over-avoidance. It would be worthwhile to develop and disseminate psychoeducational materials related to food allergy, anxiety, avoidance, and more adaptive behaviors.
References:
Bittner A, et al. J Chihld Psychol Psychiatry. 2007;doi:10.1111/j.1469-7610.2007.01812.x.
Polloni L, et al. Clin Exp Allergy. 2019;doi:10.1111/cea.13548.
Whiteside SPH, et al. J Anxiety Disord. 2016;doi:10.1016/j.janxdis.2016.04.001.
Whiteside SPH, et al. Behav Modif. 2017;doi:10.1177/0145445517730831.
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