Therapy available when food allergy anxiety impacts daily activities

Key takeaways:

• Fear over rare but possible life-threatening reactions drives food allergy anxiety.
• Patient education may mitigate or prevent anxiety.
• Cognitive behavioral therapy and proximity challenges may help.

ANAHEIM, Calif. — Therapies can help patients with food allergies manage anxiety, with referrals for mental health as needed, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“Anxiety, it’s really important to state, is a normal response to stressful or scary situations,” Jennifer S. LeBovidge, PhD, attending psychologist in the division of immunology at Boston Children’s Hospital, said during her presentation.

Healthy levels of anxiety can lead to caution, vigilance or arousal to keep people safe or in tune with their surroundings, face challenges and achieve goals, she continued.

“Anxiety disorders are conditions that cause intense, persistent worry and fear that’s difficult to control, interfere with daily activities, and are out of proportion to the actual danger,” LeBovidge said.

Sources of anxiety

Food allergy anxiety is common because life-threatening reactions, although rare, are possible, LeBovidge said.

Jennifer S. LeBovidge

“That often drives the anxiety for patients and families,” she said.

Food is part of everyday life, so these patients and families live with risk, but levels of knowledge about food allergies between families varies. And because management of food allergy largely is preventive, LeBovidge continued, there is anxiety about what “could happen.”

“What if I don’t manage things perfectly?” she said.

Anxiety increases as children reach developmental transitions as well. For example, anxiety may grow as young children begin daycare or school and families must trust others with allergy management. The children themselves may develop anxiety as they grow old enough to understand the risks as well.

“Around the 8- to 10-, 12-year range, we can see kids who may have been pretty matter of fact in their food allergy management start to develop anxiety about the what-ifs,” LeBovidge said. “They start to have a different understanding of the risk.”

Misinformation about what triggers anaphylaxis, anxieties about how to treat reactions, and fears relating to using autoinjectors also drive anxiety, in addition to potential for casual contact with allergens.

“A lot of worry about just being near the foods they’re allergic to or smelling them,” LeBovidge said. “Or what if they accidentally touch something in their environments?”

Adaptive food allergy is helpful, LeBovidge said, because some anxiety is expected and appropriate. It drives adherence to self-management behaviors and helps patients safely participate in daily activities. Balanced coping, then, is the goal.

“We want people to have food allergy management skills that they can then integrate into daily life so that patients are able to participate in developmentally typical activities,” LeBovidge said.

However, anxiety is excessive when it is persistent and extreme and when it results in medically unnecessary restrictions on daily activities. Cognitive, behavioral and physiological impacts may follow.

Patients may overestimate their risk for severe reactions, be preoccupied with potential exposure or underestimate their ability to cope with or treat reactions.

Using avoidance as a primary coping strategy, patients may limit how much they eat outside the home or participate in social activities, engage in excessive checking or other safety behaviors, or follow overly restrictive diets.

“It’s good to read a label,” LeBovidge said. “We might see patients who are reading that label 10 times.”

Patients additionally may interpret physical sensations or anxiety as impending allergic reactions.

“Some of the somatic symptoms of anxiety — things like shortness of breath, dizziness, GI distress or chest tightness — these are things that might look fairly similar to symptoms of an allergic reaction,” LeBovidge said.

These behaviors may be self-reinforcing and lead to a cycle of increasing anxiety too, she continued, citing a 2020 study by Katherine K. Dahlsgaard PhD, ABPP, et al.

“The child is in a situation where they could potentially eat but they get anxious. They avoid that safe situation, and the parent rescues or facilitates the avoidance,” LeBovidge said, adding that parents are well-meaning and want to reduce anxiety in the moment.

“The next time they’re in that situation, they’re just as anxious or even more so because the cognition is now, ‘I was safe because I did all of these things,’” she explained.

Patient education

All patients with food allergy can benefit from education about food allergy management and from resources for navigating social situations, in addition to screenings for excessive anxiety, LeBovidge said, adding that allergists can employ these universal strategies to promote balanced coping and prevent excessive anxiety.

“We can certainly acknowledge, ask about and validate anxiety related to food allergy,” LeBovidge said. “Families are more likely to bring these things up if they feel that providers understand.”

The goal is self-efficacy and self-confidence in food allergy management, LeBovidge said, with age-appropriate education in evidence-based routines and reminders that families already have these tools and skills. LeBovidge compared it with teaching children to cross the street by themselves.

“If kids develop routines, they feel confident. They follow them,” she said.

Similarly, caregivers with lots of worry limit their activities, LeBovidge said, whereas those with high self-efficacy or confidence in managing food allergies do not experience as many limitations.

“We can normalize some anxiety and help families direct their efforts toward adaptive vigilance that helps children safely participate in activities,” she said.

Allergists also can take advantage of the Food Allergy Stages Handouts from the American Academy of Allergy, Asthma & Immunology, LeBovidge said, which provide support and information for patients based on age, from infants through early and late childhood, early and late adolescence, and early adulthood.

“You can’t cover everything in every visit, so they can be great resources for families looking at food allergy management at different stages,” she said.

Clinical treatment

Patients who are experiencing anxiety about an upcoming food challenge or who have just had an allergic reaction might need additional monitoring or guidance or even consultation with a mental health professional, LeBovidge said.

However, patients with symptoms that impair function or interfere with medical care would require referral to a mental health professional for clinical treatment, LeBovidge said.

LeBovidge described a patient named Katie, aged 12 years, with allergies to peanuts, tree nuts and sesame who developed hives after getting a drink at a coffee shop that she had enjoyed on previous visits. The hives resolved without further symptoms or treatment.

Katie had always been careful but not worried about her allergies, LeBovidge said, but after this incident, Katie’s mother described her as the most anxious she had ever been.

Although family history of anxiety and prior history of anaphylaxis may predict greater risk for anxiety, LeBovidge said, the most important factor in determining whether patients like Katie should be referred would be the impact on daily functioning.

“Is the anxiety helping the patient to safely participate in daily activities and things they want to do, or is it instead pulling them out and causing them to avoid activities?” LeBovidge said.

Other indicators include refusal of new or safe foods due to fears of an allergic reaction, activities that go beyond the patient’s management plan such as repetitive hand washing, interference with allergy care such as oral food challenges, duration and frequency of these disruptions, and whether reassurance or education has any helpful effect.

Although Katie sat at a nut-free table during lunch at school, she did not want to touch equipment that other children had used during gym class. She also did not attend a cast party for the school play and stopped going to friends’ houses. She repeatedly read ingredient food labels and texted her mother for reassurance as well.

LeBovidge assessed Katie and diagnosed her with an anxiety disorder, noting that the anxiety was out of proportion to the actual danger posed and that it led to the avoidance of normative social and school activities.

LeBovidge used the 21-item Scale of Food Allergy Anxiety, which is designed for patients aged 8 to 17 years or their caregivers, in her diagnosis.

“I really like it because the questions are food allergy specific and they focus on observable food avoidance behaviors,” LeBovidge said. “Families might not always think that these things are excessive. But we can still look at them and look and see if this may be impacting the child’s functioning.”

Other validated questionnaires specific to food allergy anxiety include the Food Allergy Anxiety Scale, the Worry About Food Allergy questionnaire and the Impairment Measure for Parental Food Allergy-Associated Anxiety and Coping Tool.

Katie’s treatment included education about food allergy and anxiety as well as identification of her goals.

“She wanted to be with her friends,” LeBovidge said.

LeBovidge employed cognitive behavioral therapy (CBT), which identifies patterns of thinking and behavior that contribute to distress and impairment as the patient learns ways to change these patterns.

“It’s typically time limited, often six to 12 sessions,” LeBovidge said. “It’s not so much positive thinking. It’s more realistic thinking.”

People with anxiety may have thinking errors where they engage in what-ifs and worst-case scenarios, LeBovidge said. CBT helps patients identify more realistic and helpful thinking patterns via skill building, relaxation, role playing and problem solving.

The therapy also used in-office proximity challenges where Katie smelled and touched her allergens, conducted in collaboration with the allergist, in addition to real-world exposures at school and with her family.

“The family really felt that those proximity challenges were powerful,” LeBovidge said.

Additionally, LeBovidge helped Katie’s parents reduce their accommodation practices, as they learned how to be supportive while promoting brave practices.

“Finally, after seven sessions, she was eating at the lunch table. Her family was able to eat nut products at home. She actually was able to eat during a big theater competition with lots of other students,” LeBovidge said.

Next steps

When allergists need to make a referral, they should look for providers who have experience in evidence-based treatments for anxiety with the patient’s specific age group, LeBovidge said, with experience with food allergy itself a plus.

Providers who have experience with other chronic medical conditions may be a good fit, LeBovidge continued, although they also should be willing to learn more about food allergy if they lack this experience.

Candidates for referrals also may come from the patient’s insurance company, the primary care provider, the school, Psychology Today, the state psychological association, local health departments and the Association for Behavioral and Cognitive Therapies.

“There’s also the great Food Allergy Counselor website, with mental health professionals with this experience,” LeBovidge said.

Noting that some anxiety is expected and can be adaptive for patients and families with food allergies, LeBovidge emphasized that allergists should address anxiety that is persistent, causes distress or results in unnecessary restrictions or impacts on daily activities, potentially via referrals to mental health professionals for CBT or other treatment.

Reference:

Dahlsgaard KK, et al. J Allergy Clin Immunol. 2020;doi:10.1016/j.jaci.2020.07.010.