Brief CBT Eases Food Allergy Anxiety, With Marcus Shaker, MD

Many patients with food allergies live in fear when it comes to meals—not just their own, but the meals of others at the table.

Earlier this year, HCPLive spoke with Katherine K. Dahlsgaard, PhD, ABPP, from Brave is Better LLC - Therapy and Consulting in Philadelphia, and Megan O. Lewis, MSN, RN, CPNP-PC, from Children’s Hospital of Philadelphia, on their review addressing when allergists should consider conducting in-office proximity challenges for patients with food allergy anxiety.

In a similar vein, Marcus Shaker, MD, professor of pediatrics at Dartmouth Geisel School of Medicine, and colleagues, published a review on the link between food allergy and significant psychosocial impairment. The team provided numerous ways to address the psychosocial impairment: Allergist-immunologists dispelling misconceptions by providing evidence-based information, motivational interviewing, and cognitive behavioral therapy (CBT).

In this Q&A, Shaker addressed food allergy misconceptions, the role of brief CBT and motivational interviewing in food allergy anxiety, and the scalability and future integration of these treatments.

HCPLive: Can you describe the scope of psychosocial impairment associated with allergic diseases, particularly food allergies, and how it presents in the allergy clinic?

Shaker: Patients with food allergy can have generalized anxiety, food-specific anxiety, or both, and each form of anxiety can influence the other. In a recent study of young adolescents and their parents, Ho and colleagues reported 37% of patients with food allergy scored above clinical cut-offs for overall anxiety.

HCPLive: What are some of the most common misconceptions you've observed among patients with food allergy that contribute to anxiety or maladaptive behaviors?

Shaker: The key is to keep risk in perspective. Food allergies can be life-threatening, so it is understandable that children and families might focus on the risk of dying from food allergy and become really scared. When I am counseling families who worry about food allergy fatality, I often ask my patient, “What do you think is more dangerous: having a bicycle or having a food allergy?” It turns out the risk of bicycle fatality and food allergy fatality are about the same.

While nobody chooses to have a food allergy, many kids (and parents) choose to have a bicycle. For many of my patients, realizing that everyday risks of life are greater than everyday risks of food allergy has been very empowering.

HCPLive: What led you and your colleagues to explore the use of motivational interviewing and brief cognitive behavioral therapy in the allergy-immunology setting?

Shaker: The observation that talking about risk in perspective could correct false perceptions and beliefs sparked our interest in how brief moments of cognitive behavioral therapy could help patients and their families reset health beliefs. Appreciating that situations do not cause our emotions and behaviors, but that our thoughts do, and [understanding] that thoughts are always open to questioning and change, can help families [see] where risk is significant and where it is probably not high enough to worry about.

HCPLive: What unique benefits does this integrated approach offer in terms of patient outcomes?

Shaker: It can be difficult and expensive to get in with a clinical psychologist, although this can be a really valuable step for many patients. The idea of brief CBT is not to replace CBT with a clinical psychologist, but instead to highlight the touchpoints where allergist-immunologists can make a meaningful difference by a slight shift in perspective.

Take the bicycle example—by helping kids appreciate that they are not their food allergy, but instead they are a unique and talented individual who happens to also have a food allergy, can help reset the focus from risk-aversion to risk-mitigation. Just like we don’t ride bicycles in the middle of an interstate highway or without a bicycle helmet, we make sure to have epinephrine available when eating out, and we check [the] labels of foods we eat if we have a food allergy.

HCPLive: How can allergist-immunologists incorporate curious questions and brief CBT strategies into routine clinical encounters without significantly extending visit times?

Shaker: The time investment for brief CBT may vary. In Pennsylvania, the “Food Allergy Bravery” program has been successful [in] helping kids and families appreciate what is risky and what is not. Using proximity challenges, allergists-immunologists can help empower children that they don’t need to be afraid of airborne reactions when a classmate is eating a peanut butter sandwich, provided they don’t eat the peanut butter themselves. Similar approaches have been used to help empower children with needle phobia, although now a needle-free epinephrine option can also be prescribed for those who worry about injections.

HCPLive: What are some practical examples of motivational interviewing or CBT-style interventions used during a typical allergy consultation?

Shaker: Risk framing, proximity challenges, and threshold food challenges can all be used to help patients who worry about trace exposures causing severe reactions.

HCPLive: What evidence supports the use of motivational interviewing and brief cognitive behavioral therapy in allergy clinics?

Shaker: Many allergists are already using some of these methods, but placing them in a bCBT context can make them more powerful. The cBT context involves exploring where patients and families are at in their relationship with allergy risk, and whether or not they are comfortable there or feel a change would be helpful. This is where the ‘curious questions’ can be helpful – questions that explore how they feel about risk for themselves and for others, and how their health beliefs align with the science of food allergy risk.

HCPLive: Are there specific patient populations within allergy-immunology that seem to benefit most from this approach?

Shaker: Across allergy-immunology, there are patients who struggle with psychosocial impacts of their diseases. This applies to asthma, allergic rhinitis, atopic dermatitis, and others. Approach patients with compassion to partner with them, and acknowledge that these can be difficult problems, with [a] commitment to work to make things better, can make a difference.

HCPLive: How scalable is this model across various clinical settings, from large academic centers to smaller community practices?

Shaker: I think a large part of this relates to treatment philosophy—meeting individuals where they are, and then using simple steps to address issues which we may otherwise not identify. It is important to keep risk in perspective. So often, we focus heavily on disease during a medical visit but fail to acknowledge that every patient has more health than disease Of course, there are many situations that are beyond the scope of what can be accomplished in a short visit, but by taking a holistic view, we can often stand by the good and make it better.

HCPLive: How do you envision the future of integrated behavioral support in allergy and immunology care evolving? Are there plans for further research, trials, or implementation studies?

Shaker: Yes, we are currently working on this. By leveraging teamwork and partnerships, offerings for bCBT can expand and become more fruitful. Examples include building teams to include clinical psychologists, dual-certified nurse practitioners, and others.

References

Ho S, Cooke F, Ramos A, McQuaid EL, Sharma H, Herbert LJ. Anxiety among youth with food allergy. J Pediatr Psychol. 2024;49(7):473-481. doi:10.1093/jpepsy/jsae026