Table Of ContentCognitive-Behavioral Therapy
for Avoidant/Restrictive Food
Intake Disorder
Thispractical,accessiblemanual,writtenbytwooftheleadingexpertsinthe
emergingARFIDfield,willbeaverywelcomeadditiontotheclinician’slibrary.I
anticipatethatitwillquicklybecomeamuchusedvolumebyanyoneofferingcare
andtreatmenttopatientswiththisdisorder.Untilnowtherehasbeenverylittleby
wayofguidanceintermsofevidence-basedtreatmentsspecificallyforARFID.This
clearlywrittenbook,basedonsoundtheoreticalprinciples,enablestheoutstanding
skills,expertise,andinsightsofitsauthorstobesharedbyamuchwideraudience,
whichcanonlybenefitpatientcare.
Dr.RachelBryant-Waugh
Itisrarethatanewlyconceptualizedmentaldisorderisintroducedintosystemsof
nosologywithoutanexistingtreatmentapproachwithsomeevidenceforefficacy;but,
thiswasthecasewithARFID.Now,fromoneoftheleadingeatingdisorderscenters
intheworldcomesaverywell-conceivedstagemodelofinterventionthatcanbe
personalizedfortheindividualpatient,aswellasthepatient’sfamily.Anyonetreating
eatingdisordersshouldfindthisnewclinicalmanualinvaluable.
Dr.DavidH.Barlow
ARFIDsoundsalittlelessunfamiliartodaythanwhenitwasintroducedbyDSM-5
onlyfiveyearsago.Sincethen,asmallcadreofclinicalresearchershasdevoted
considerableenergytoexploretreatmentsforthispatientpopulation.Thomasand
Eddyhavebeenleadersinthisdomain.Throughtheirfocusedefforts,theauthors
haveputtogetheranextraordinarilyhelpfultreatmentmanualthateveryonewho
wantstolearnmoreaboutARFID,whetheratreatingclinician,curioustrainee,or
worriedparent,wouldbewelladvisedtoconsult.Thisclinicianmanualfirstprovides
thereaderwithanexcellentpsycho-educationaloverviewofARFID,before
delineatingthefourstagesofCBT-AR.Theauthorsroundoutthismanualby
demonstratingtheirtreatmentapproachbywayoffiveelucidatingclinicalcase
examples.Thisbookisamostwelcomeadditiontothesmallfamilyofclinical
treatmentmanualsforeatingdisorders.
Dr.DanielLeGrange
AsanARFIDadvocate,authoronthetopic,andmothertoarecoveredchildwith
ARFID,Icouldn’tbemorethrilledwiththisbook.Cognitive-BehavioralTherapyfor
Avoidant/RestrictiveFoodIntakeDisorderisvitaltowardtheeducationand
treatmentofARFID.Withcomprehensiveanddetailedinformation,workablesteps
fortreatment,andactualcasestudies,thisbookisdesperatelyneededintheeating
disordercommunity,andonethatIwishhadbeenavailablewhenourfamilywas
strugglingtofindanswers.
Forsomanyyears,ourdaughterwasmisdiagnosed,misunderstood,andmisheard
untilshereceivedthepropertreatment–andthattreatmentverymuchmirrorswhat
authors/doctorsJenniferThomasandKamrynEddyoutlineintheirbook.Itwas
extremelyencouragingtoreadaboutCBT-ARandtohavesomanyofthetechniques
andstagesfeelfamiliartowhatweexperiencedwithourdaughter’streatment.
ThereismuchtolearnaboutARFID,butthismanualisaterrificstartingpointin
helpingclinicians,physicians,therapists,andevenparentslearnmoreaboutthisvery
prevalentandverymysteriouseatingdisorderthataffectschildrenandadultsof
allages.
Ican’twaitforthisbooktobepublishedbecauseIamgoingtosingle-handedly
contacteveryoneIknowwhohasstruggledwithARFIDandtellthemtheyabsolutely
needthismanual!
StephanieElliot,authoroftheyoungadultnovel,SadPerfect,ARFIDadvocate,and
mothertoadaughterrecoveredfromARFID
Cognitive-Behavioral Therapy
for Avoidant/Restrictive
Food Intake Disorder
Children, Adolescents, and Adults
Jennifer J. Thomas
HarvardMedicalSchool
Kamryn T. Eddy
HarvardMedicalSchool
UniversityPrintingHouse,CambridgeCB28BS,UnitedKingdom
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www.cambridge.org
Informationonthistitle:www.cambridge.org/9781108401159
DOI:10.1017/9781108233170
©JenniferJ.ThomasandKamrynT.Eddy2019
Thispublicationisincopyright.Subjecttostatutoryexception
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noreproductionofanypartmaytakeplacewithoutthewritten
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Firstpublished2019
PrintedandboundinGreatBritainbyClays,StIvesplc,ElcografS.p.A.
AcataloguerecordforthispublicationisavailablefromtheBritishLibrary.
LibraryofCongressCataloging-in-PublicationData
Names:Thomas,JenniferJ.,author.|Eddy,KamrynT.,1977–author.
Title:Cognitive-behavioraltherapyforavoidant/restrictivefoodintake
disorder:children,adolescents,andadults/JenniferJ.Thomas,
KamrynT.Eddy.
Description:Cambridge,UnitedKingdom;NewYork,NY:
CambridgeUniversityPress,2019.|Includesbibliographical
referencesandindex.
Identifiers:LCCN2018023258|ISBN9781108401159(pbk.:alk.paper)
Subjects:|MESH:FeedingandEatingDisorders–therapy|Cognitive
Therapy–methods
Classification:LCCRC552.E18|NLMWM175|DDC616.85/26–dc23
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..................................................................
Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateand
up-to-dateinformationthatisinaccordwithacceptedstandardsandpractice
atthetimeofpublication.Althoughcasehistoriesaredrawnfromactual
cases,everyefforthasbeenmadetodisguisetheidentitiesoftheindividuals
involved.Nevertheless,theauthors,editors,andpublisherscanmakeno
warrantiesthattheinformationcontainedhereinistotallyfreefromerror,
notleastbecauseclinicalstandardsareconstantlychangingthroughresearch
andregulation.Theauthors,editors,andpublishersthereforedisclaimall
liabilityfordirectorconsequentialdamagesresultingfromtheuseof
materialcontainedinthisbook.Readersarestronglyadvisedtopaycareful
attentiontoinformationprovidedbythemanufacturerofanydrugsor
equipmentthattheyplantouse.
For Asher and Colby
Contents
Foreword ix
Preface xi
Acknowledgments xii
1 What IsARFID? 1 6 Stage 1:Psychoeducation and Early
Definition 1 Change 33
Prevalence 2 Stage 1, Session 1 33
DistinctionfromClassicalEatingDisorders 3 Stage 1, Session 2 46
Etiology 5 Stage 1, Session 3(underweight
patients only) 51
2 Overview of Existing Treatments for Feeding,
Stage 1, Session 4(underweight
Eating, andAnxietyDisorders 7
patients only) 53
Pediatric Feeding Disorders 7
Troubleshooting Stage 1 53
Eating Disorders 9
Checklistfor Moving on to
Anxiety Disorders 11 Stage 2 54
The Need for aNovel Approach 13
7 Stage 2:Treatment Planning 55
3 Assessment of ARFID 14 Stage 2, Session 1 55
Assessing the Specific Psychopathology Stage 2, Session 2 58
ofARFID 14
Troubleshooting Stage 2 68
Assessing the MedicalSequelae
Checklistfor Moving on to Stage 3 69
ofARFID 16
UsingtheAssessmenttoPlanTreatment 18 8 Stage 3:Maintaining Mechanisms inOrder
of Priority 70
4 Cognitive-Behavioral Model ofARFID 20
Continuingto Support Weight
Sensory Sensitivity Formulation 21
Gain inStage 3(underweight
Fear of Aversive Consequences patients only) 70
Formulation 22
MaintainingMechanism #1:Sensory
ApparentLack of Interest in Eating or Sensitivity 71
Food Formulation 23
MaintainingMechanism #2:Fear of Aversive
Putting It All Together 25 Consequences 88
5 Overview of CBT-AR 26 MaintainingMechanism #3:Apparent
Family-Supported vs. Individual Lack ofInterest inEating or
Formats 26 Food 94
Four Stagesof CBT-AR 27 Troubleshooting Stage 3 101
Variable Treatment Length 29 Checklistfor Moving on to Stage 4 102
Outline ofaTypicalCBT-AR Session 30 9 Stage 4:Relapse Prevention 103
CBT-AR Treatment Goals 31 Stage 4, Session 1 103
CBT-AR Therapist Stance 31 Stage 4, Session 2 112
Conclusion 32 Troubleshooting Stage 4 115
vii
Contents
10 CBT-AR CaseExamples 116 Apparent Lack ofInterest inEating or
Case Example #1: An11-Year-Old Girl Food, and Low Weight(family-supported
with Sensory Sensitivity (family-supported CBT-AR) 127
CBT-AR) 116 Case Example #5: A32-Year-Old Man
Case Example #2: A13-Year-Old Boy with with Sensory Sensitivity (individual
Sensory Sensitivity, Apparent Lack of CBT-AR) 132
Interest inEatingor Food, and Low Weight
11 Conclusionand Future Directions 136
(family-supported CBT-AR) (Guest case
by Kendra R. Becker,Ph.D.) 119
Case Example #3: A16-Year-Old Girl with
Sensory Sensitivity, Lack of Interest in
Eatingor Food, Comorbid Binge Eating, Appendix 1: CBT-AR Competence Ratings 138
and Obesity (individualCBT-AR) (Guest case Appendix 2: CBT-AR Adherence:
by Kendra R. Becker,Ph.D.) 123 Session-by-Session Ratings 140
Case Example #4: A20-Year-Old Man References 170
with Fear of Aversive Consequences, Index 176
viii
Foreword
This book starts with a very simple premise: If you principles, which have been honed and refined. In
give people a diagnostic label, it helps them identify yourhands,youhave:astagedmodelthatisadaptable
that they or their loved ones have a legitimate prob- to the nature of the individual case; clearly laid out
lem, and they feel justified in seeking help. However, psychoeducationalmaterials;andamanualforparents
then you hit a quandary. You need a way of helping thatwillhelpthemgetinvolvedasactiveagentsinthe
those people deal with that problem when there has treatmentprocess.Thestagesoftherapyandthetasks
not been time to come up with solutions. So, when withineachstagearecleartothereader.Thepenulti-
Avoidant/restrictive food intake disorder (ARFID) mate chapter gives vivid case material, showing the
was launched onto the world stage in 2013, it was thinking that we need to do as we deliver CBT-AR.
great to have a label, but we had to face individuals Anyone who has trouble in understanding how to
with ARFIDandtheir familieswiththenews thatwe make CBT-AR work in routine practice can learn
were not ready with any evidence-based treatment. fromtheseexcellentcaseexamples.
All that we could offer were best guesses, and they The authors are very clear: The work of our field
were often farfrom adequate. to understand and treat ARFID is not yet complete,
The cognitive-behavioral therapy for eating dis- andwillbethesubjectofresearchandclinicalinnov-
orders(CBT-ED)approachthatworkswellwithmany ation for decades to come. However, this book is the
adults with eating disorders has not proven suitable most significant step to date – a bringing together of
forthisgroup.However,nowwehaveawell-thought- research and clinical knowledge in order to provide
out treatment approach that can bring real hope to clinicianswiththeknowledgeandskillsthattheyneed
those with ARFID, whatever their age. The authors tobeabletoworkwiththischallengingclinicalpopu-
have given us a form of CBT that is adapted for lation.Sonow,whenaparentorpersonwithARFID
ARFID – for Avoidant/Restrictive Food Intake Dis- says,‘Ihavebeengiventhisdiagnosis,sowhatcanyou
order (CBT-AR). In this book, it is made clear how do about it?,’ we will have an answer and the tools
CBT-AR differs from CBT-ED, as well as how they that we need. We should be delighted, and I believe
overlap. that you will be by the time you have read what
This book is a true trailblazer, with its com- followsinthismanualandtrieditwithyourpatients.
bination of clinical knowledge, sound theoretical This manual is written to be immediately access-
reasoning, empirical support, and plenty of case ible. It is certainly not going to spend much time on
material. It is no exaggeration to say that only this my shelves. It will be where it belongs – on my desk,
team could have produced such an excellent clinical and getting used. This manual deserves to be on the
protocol at this time. They have worked at multiple desksofallclinicianswhoworkwithsucheatingand
levels to understand ARFID, and have used that feeding problems. Jennifer Thomas, Kamryn Eddy,
research and clinical evidence to develop the therapy and their team are a formidable group of clinical
that youare going to read about here. researchers. This book demonstrates not only their
What Jennifer Thomas and Kamryn Eddy have skills but also their dedication to the care of their
done here (along with their redoubtable team) is to patientsand families.
find ways of doing this work with the person with
ARFID or their family, according to what is most Glenn Waller, DPhil
likely to fit the individual case. Their CBT-AR Professor of Clinical Psychology
protocol is soundly based on cognitive-behavioral University of Sheffield,UK
ix
