Broadening the conceptualization of panic disorder to include the fear presentation of avoidant/restrictive food intake disorder: The legacy of panic control therapy

Abstract

The presentation of avoidant/restrictive food intake disorder (ARFID) characterized by fear of aversive consequences of eating (fear-ARFID) has both phenomenological and mechanistic similarities to panic disorder. In this narrative review, we propose a shared model of the pathogenesis of the two disorders, centered on interoceptive sensitivity as the key maintenance mechanism. We review the evidence that fear-ARFID, which involves restrictive eating motivated by a desire to avoid aversive events (e.g., choking, vomiting, abdominal pain) related to the gastrointestinal tract, onsets with an unexpected event and develops through catastrophic misinterpretation of the probability or significance of the event reoccurring, heightened awareness of minor interoceptive sensations associated with the feared event (i.e., interoceptive sensitivity), escalating anxiety and increasingly frequent experience of minor interoceptive sensations, and increasingly extensive avoidant behavior. Given the support for shared maintenance mechanisms with panic disorder, we suggest a program of clinical research evaluating the adaptation of elements of Panic Control Therapy (PCT), a well-established empirically supported treatment for panic disorder, to treat fear-ARFID. Developing and testing new intervention strategies based on PCT could expand ARFID patients’ access to appropriate care by enabling anxiety-experienced clinicians to use their existing competencies to treat fear-ARFID using a disorder-specific evidence-based treatment.