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Published:February 23, 2021DOI:https://doi.org/10.1016/j.jaci.2020.11.038
      To the Editor:
      We appreciate that Shemesh and Sicherer
      • Shemesh E.
      • Sicherer S.H.
      Addressing anxiety and avoidance in food-induced anaphylaxis.
      state they agree with the premise and many of the conclusions and recommendations of our recent Paradigms and Perspectives article, “New issue of food allergy: phobia of anaphylaxis in pediatric patients,”
      • Dahlsgaard K.K.
      • Lewis M.O.
      • Spergel J.M.
      New issue of food allergy: phobia of anaphylaxis in pediatric patients.
      in which we addressed how allergists and other medical providers best recognize when a patient’s anxiety in the context of food allergies surpasses that which is expected and adaptive and may qualify for a diagnosis of a separate anxiety disorder and require a full course of treatment by a mental health provider.
      We would also like to add a few clarifications. First, we disagree with Shemesh and Sicherer’s contention that posttraumatic stress disorder (PTSD), rather than specific phobia of anaphylaxis, is the “better designation” in such cases because anaphylaxis is an event, “not an object or situation.” Although a diagnosis of PTSD in some cases may be appropriate, we frequently evaluate food-allergic children who have never experienced anaphylaxis or who experienced it so early in infancy or toddlerhood that they do not remember it. Nonetheless, these children present with an intense fear of a severe allergic reaction, as well as prolonged, impairing avoidance of very low risk situations and objects that they inaccurately predict will lead to anaphylaxis—in other words, a diagnosis of specific phobia is appropriate per Diagnostic and Statistical Manual of Mental Disorders Fifth Edition.
      American Psychiatric Association
      Specific phobia, Differential diagnosis.
      For example, the peanut-allergic child who has “for years” avoided being in the same room as others who are eating peanut products, and has difficulty attending school or social events without great distress. In these cases, imaginal exposure to peanut in the room is less likely to lead to symptom relief as would in vivo exposure.
      We would also note that, even in cases in which a traumatic event did occur and full criteria for PTSD are also met, prolonged imaginal exposure alone is not the evidence-based treatment. Rather, the well-established treatment for PTSD is prolonged exposure (and, in children, trauma-focused–cognitive-behavioral therapy), which incorporates as key active ingredients both imaginal exposure of the traumatic event and in vivo exposure to safe objects or situations that trigger distress, avoidance, and functional impairment.
      • Powers M.B.
      • Halpern J.M.
      • Ferenschak M.P.
      • Gillihan S.J.
      • Foa E.B.
      A meta-analytic review of prolonged exposure for posttraumatic stress disorder.
      ,
      • Dorsey S.
      • McLaughlin K.
      • Kerns S.
      • Harrison J.P.
      • Lambert H.K.
      • Briggs E.C.
      • et al.
      Evidence base update for psychosocial treatments for children and adolescents exposed to traumatic events.
      We also disagree with Shemesh and Sicherer’s recommendation that, “unless closely paired with the allergist,” the mental health professional’s role be restricted to imaginal exposure techniques only. Their contention inaccurately suggests that in vivo exposures are somehow dangerous to the food-allergic patient. By definition, in vivo exposures to benign triggers of fearful expectations do not “compromise” safety; rather, they serve to provide experiential proof that what has been unnecessarily avoided is, indeed, safe. To reference Sicherer and colleagues’ excellent previous work, peanut-allergic individuals do not have significant allergic reactions to causal contact to peanuts, which is one type of in vivo exposure we describe in our article.
      • Simonte S.J.
      • Ma S.
      • Mofidi S.
      • Sicherer S.H.
      Relevance of causal contact with peanut butter in children with peanut allergy.
      Although we highly recommend that exposure therapists consult regularly with a patient’s allergist, we fear that a restriction on their ability to treat this population via in vivo exposure will result in additional patient burden to accessing a highly evidence-based treatment and further marginalize this population.
      • Manassis K.
      Managing anxiety related to anaphylaxis in childhood: a systematic review.
      The example of Specific Phobia of Choking, listed in both the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and International Classification of Diseases, Tenth Revision, Clinical Modification, is instructive here. Choking is indeed a life-threatening event, but many patients present to treatment without having experienced it. For instance, in McNally’s
      • McNally R.J.
      Choking phobia: a review of the literature.
      classic review article of choking phobia, only 10 of the 25 cases described had a sudden onset after an experience of choking. Patients with specific phobia of choking typically limit their intake to liquid or soft foods, engage in the unnecessary safety behaviors of extremely slow eating with laborious overchewing, and rapidly lose weight. Imaginal exposure might be a potential intervention in the treatment package, but unlikely (given the lack of a choking episode) to be as helpful as in vivo exposures to swallowing an increasing array of solid foods. If the patient has indeed experienced choking and meets full criteria for PTSD, in vivo exposures will serve as a crucial part of the treatment package until the patient has habituated to swallowing various foods swiftly and without fear. Because eating is by definition a low-risk activity, a mental health provider is certainly capable of assigning and guiding such in vivo exposures and should do so in consult with medical providers as appropriate.

      References

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        • Sicherer S.H.
        Addressing anxiety and avoidance in food-induced anaphylaxis.
        J Allergy Clin Immunol. 2021; 147: 1524
        • Dahlsgaard K.K.
        • Lewis M.O.
        • Spergel J.M.
        New issue of food allergy: phobia of anaphylaxis in pediatric patients.
        J Allergy Clin Immunol. 2020; 146: 780-782
        • American Psychiatric Association
        Specific phobia, Differential diagnosis.
        in: Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition (DSM-5). American Psychiatric Publishing, Washington, DC2013: 202
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        • Halpern J.M.
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        A meta-analytic review of prolonged exposure for posttraumatic stress disorder.
        Clin Psychol Rev. 2010; 30: 635-641
        • Dorsey S.
        • McLaughlin K.
        • Kerns S.
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        Evidence base update for psychosocial treatments for children and adolescents exposed to traumatic events.
        J Clin Child Adolesc Psychol. 2017; 46: 303-330
        • Simonte S.J.
        • Ma S.
        • Mofidi S.
        • Sicherer S.H.
        Relevance of causal contact with peanut butter in children with peanut allergy.
        J Allergy Clin Immunol. 2003; 112: 180-182
        • Manassis K.
        Managing anxiety related to anaphylaxis in childhood: a systematic review.
        J Allergy (Cairo). 2012; 2012316296
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        Compr Psychiatry. 1994; 35: 83-89

      Linked Article

      • Addressing anxiety and avoidance in food-induced anaphylaxis
        Journal of Allergy and Clinical ImmunologyVol. 147Issue 4
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          We read the article by Dahlsgaard et al1 with interest and appreciate the authors’ focus on “unhelpful avoidance” in the context of excessive anxiety as an underrecognized response to allergic reactions to food in children. We agree with the premise of the article and many of its recommendations and conclusions. We especially agree that some forms of exposure therapy may be valuable in alleviating unhelpful avoidance. Under the aegis of the EMPOWER (Enhancing, Managing, and PrOmoting WEll-being and Resiliency) program at the Jaffe Food Allergy Institute, we have undertaken randomized trials of self-injection exposure to relieve anxiety and avoidance associated with self-injection of epinephrine, and of education and allergen contact exposure to reduce anxiety about casual allergen exposure, both with positive outcomes.
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