How to Treat Patients with ARFID via Telehealth

Stage 3: Example in-session exposure for ARFID fear of aversive consequences

And then at the end of that exposure, I'll ask like, "So what actually happened?" And they might say, "Well, I felt nauseous but I didn't actually end up vomiting." I might say, "How certain are you that you'll vomit next time you eat pizza?" And maybe that certainty will go down. Maybe it's only 50% because they've actually now had an actual experience of not vomiting while eating pizza. And then I'll take a look at what their SUDS rating might be at the end. So maybe it has gone down to say a 30 on a 0 to 100 scale because they had the experience of not vomiting, they're feeling a little bit better. And we'll just continue to do that for many of the things on their hierarchy.

Another telehealth tip is that at-home therapies are great opportunities to generalize exposures to the home setting. A lot of times when folks are coming into the clinic for therapy, they'll start to see the clinic itself as like a safety cue or they'll think, well, I can do this pizza exposure when I'm sitting next to you as the therapist or when I'm in your clinic conference room, but it might be really difficult for them to actually do it at home. So a nice thing about telehealth is that patients might already be at home and they're already then generalizing these new learning opportunities to their natural environment.

CBT-AR: Stage 3 - Lack of interest in food or Eating Module

Then the last thing I'll say about stage three is that for folks who have the lack of interest in eating or food, we're using a similar strategy in terms of exposures and self-monitoring, and then having them learn about foods through the five senses, but the target is a little bit different. So with the framework I've already introduced, and then the content will be different. So we actually do intraceptive exposures with these guys. We want to help them to increase their tolerance of physical sensations that may be associated with fullness or bloating or nausea.

So we'll say, why don't you rapidly drink several classes of water so that you can feel what it feels like to feel full. And as you push your belly out really far and really hard to mimic what it's like to feel bloated. And for nausea, why don't you spin around in a chair, though nausea is a little trickier with telehealth because people may not have a spinning chair at home, but we could have them stand up and spin around, for example. What we're trying to do there is to help them to see that maybe they can actually tolerate some of these physical sensations that go along with eating and that it can actually be okay.

We also will have them try to increase their awareness of how hungry and full they are throughout the day by using self-monitoring records. And then we'll use that same five step framework to help them kind of learn about foods, but we'll do that with foods that they already prefer. So we'll say, what are your most favorite foods that you really like that kind of remind you of happy times, like maybe birthday cake or your mom's special lemon bread, and then why don't you bring those to the session in telehealth and have them at your kitchen table, and then we'll explore what those are like through the five senses.

CBT-AR Stage 4

And then lastly, to wrap up the treatment in stage four, we have patients kind of evaluate their treatment progress. I'd say patients are unlikely to become foodies and be liking to eat as per go, for example, even if the treatment is successful, but the treatment is really meant to expand patient's diets, help them to restore their weight, correct nutritional deficiencies, and then really reduce that impairment that is related to ARFID. We've had patients that started out eating two food groups and then by the end they were eating all five.

Many patients have been able to restore their weight to a healthy level, maybe get their period back in females. We've had patients who've been able to... They started with deficiency in vitamin C, but then they added items like oranges and clementines and grapefruit and then they were not deficient by the end. And then patients who maybe started out not being able to socialize around food and now they can. Sometimes that socializing has to take place on a Zoom party, but that might be another good practice for them. And then lastly, we'll help them to co-create a relapse prevention plan to identify strategies to continue and set goals for continued progress.