Strategies available to help patients, families manage food allergy anxiety
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Key takeaways:
- Anxiety is normal but becomes problematic when it interferes with daily activities.
- Cognitive behavioral therapy helps identify and change patterns.
- Referrals to mental health providers may be necessary.
BOSTON — Cognitive behavioral therapy can help patients and their families manage anxiety related to their food allergies, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“Anxiety is a feeling of worry, nervousness or unease, typically about an imminent event or something with an uncertain outcome,” Jennifer LeBovidge, PhD, attending psychologist, allergy program, Boston Children’s Hospital, said during her presentation.
As a common, normal and often adaptive response to stress, LeBovidge continued, anxiety and its behavioral and physical responses can help people focus, remain vigilant, plan and prepare for new situations while providing a burst of energy to cope with the problem.
“Anxiety can become problematic, however, when it’s persistent, difficult to control, interferes with daily activities and is out of proportion to the actual risk,” she said.
Cognitive behavioral therapy
LeBovidge defined cognitive behavioral therapy (CBT) as “evidence-based treatment for management of anxiety in which patients learn to identify patterns of thinking and behavior that contribute to distress and impairment and ways to change these patterns.”
Common elements of treatment include psychoeducation about anxiety, identifying and challenging anxious thinking patterns, and skill building via problem solving, role playing or relaxation. It also may include graded, systematic exposures to safe situations that patients otherwise avoid.
“Many mental health practitioners in the community, at medical institutions, are using CBT to help support patients and caregivers with food allergy anxiety,” LeBovidge said.
LeBovidge noted four studies indicating that CBT can be effective in improving food allergy anxiety and quality of life. The CBT approaches in these studies included education to help patients and families accurately assess risks, shifting anxious thoughts, graded exposures and problem solving.
“Can we use CBT strategies and tools to help manage food allergy anxiety during clinic visits?” LeBovidge asked. “Yes, we can.”
The first step is validating patient and caregiver anxiety, she said.
“This really requires asking questions,” LeBovidge said. “Patients and parents may not open up about this if we don’t ask.”
LeBovidge encouraged clinicians to ask patients and families if they or their child ever feel anxious about food allergies, if they ever skip social events, if they refuse to eat safe foods and if they worry about the child being left with other caregivers.
“Then it’s really important, I think, to normalize anxiety as a common experience,” she said. “How can they keep this adaptive caution and distinguish this from the unhelpful anxiety?”
When LeBovidge meets with families, she said, she listens to them as they describe the things they do to be safe, such as reading labels and carrying their autoinjector.
“I will ask them to thank their brain for all the work that they are doing to try to stay safe,” she said.
But then she will ask them about the times when their worry creates false alarms.
“Our goal is to really separate those smart things from the small false alarms so that they can safely participate in the things that are important to them,” she said.
Also, LeBovidge said that support for families equals empathy with or validation of their experience of anxiety, plus confidence that you can work together to help them develop a plan.
“When you’re thinking about supporting patients and families experiencing anxiety, this recipe for support is really important,” she said.
Patient education
CBT often begins with education about misconceptions pertaining to airborne allergens, casual contact, epinephrine, and test results. It should then address safety routines that help patients and families build confidence.
LeBovidge also advised clinicians to provide ongoing and developmentally tailored information.
“Precautions for toddlers are going to look very different than precautions for a second grader or teenager,” she said.
Physicians should address children as well as their caregivers during these visits, she continued.
“Kids are often diagnosed with food allergies when they’re young, and a lot of that education is directed to the caregiver, to the parents,” she said. “Think about really engaging with the child and reminding parents too that the kids pick up on their cues. So, when they can show a confident approach to food allergy management, that helps.”
Physicians can help families shift their anxious thinking as well, LeBovidge continued, noting that worried thoughts may feel like definitive facts when they really are not.
“The job of anxiety is to help us focus, avoid a threat or solve a problem,” she said. “We want families to shift that thinking a lot and help families really focus on their plan. What are the likely risks in the situation, and how can I manage them?”
Specifically, physicians can help children translate facts about food allergy into coping thoughts. For example, children in a school cafeteria can remind themselves that they will not be eating their friends’ food.
Children also can remind themselves that smells cannot induce allergic reactions and that there is no danger in being near an allergen. If any food gets on their skin, they can just tell someone and wash it off. Also, they can remind themselves that their autoinjector is their friend.
LeBovidge also encouraged physicians to discuss common food allergy myths with their patients and families and debunk them, which also improves anxiety and quality of life related to food allergy. The food allergy stages handouts provide information and tools for managing food allergy and coping with anxiety at different developmental stages as well.
Coping plans for self-efficacy
“Then we want to think about creating coping plans with our families,” LeBovidge said.
Reassurance and statistics alone probably will not be enough, she said, adding that patients and families need to build confidence in their abilities to manage risks, turning “what if,” which suggests avoidance, into “OK, what if,” indicating confidence.
“We can think about routines and practices that reduce risk,” LeBovidge said. “Practice with an autoinjector trainer. Engage in some role-plays of the language they would use in a restaurant if they were asking about ingredients.”
Physicians can help families develop action plans for dining out, leaving children with a babysitter, participating in an oral food challenge, introducing a new high-risk food and other situations that provoke anxiety. LeBovidge remembered one of her pediatric patients who really wanted to visit a friend’s house.
“The patient and the caregiver were a little nervous about it,” she said. “However, we really thought through what this plan would look like.”
When anxiety persists despite these plans, LeBovidge recommended breaking goals down into smaller, manageable steps with graded exposures that violate threat expectations and safely give patients and families confidence.
With a good management plan in place, LeBovidge said, physicians can target medically unnecessary avoidance while aligning exposures with patient and family values during these smaller steps.
Specifically, proximity challenges show patients and families that they can be safe near an allergen and even smell and touch it.
“In your office, this might work really well for patients who might have lower levels of anxiety,” LeBovidge said. “But for those who have more extreme levels, it might be helpful to coordinate with a mental health provider with experience in this field.”
LeBovidge said she often coordinates these challenges with allergists on her team.
The need for referrals
When anxiety interferes with important school or social activities, leads to avoidance of safe foods or inhibits or prevents allergy care despite the education and coping skills provided in the allergy clinic, LeBovidge said, it is time to refer the patient to a mental health professional, LeBovidge said.
Validated food allergy-specific anxiety questionnaires can help allergists assess these patients, LeBovidge said, adding that she often uses the Scale of Food Allergy Anxiety from Children’s Hospital of Philadelphia.
“This is really nice. You could use it to track changes in anxiety,” she said.
The Food Allergy Anxiety Scale from Ireland, Worry About Food Allergy Questionnaire from Eastern Michigan University, and Impairment Measure for Parental Food-Allergy Associated Anxiety and Coping Tool from BC Children’s Hospital also are options.
LeBovidge encouraged physicians to look for providers who are experienced with evidence-based treatments for anxiety in the patient’s age group. Additional experience with food allergy would be a plus.
Experience with other chronic medical conditions often indicates a good fit as well, LeBovidge continued, adding that mental health providers should be willing to learn more about food allergy.
Mental health providers can be found via insurance companies, primary care providers, Psychology Today, state psychological associations and the Association for Behavioral and Cognitive Therapies. Also, The Food Allergy Counselor website highlights mental health professionals with expertise in food allergy.
Your turn
LeBovidge was optimistic about treating patients and families with food allergy anxiety.
“Some anxiety is expected and can be adaptive for individuals with food allergies and their parents and caregivers,” she said. “Allergy specialists can help families achieve balanced coping with food allergy.”