Exposure therapy for eating disorders: A systematic review

Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders

OBJECTIVE

Imaginal exposure is a novel intervention for eating disorders (EDs) that has been investigated as a method for targeting ED symptoms and fears. Research is needed to understand mechanisms of change during imaginal exposure for EDs, including whether within- and between-session distress reduction is related to treatment outcomes.

METHOD

Study 1 tested four sessions of online imaginal exposure (N = 143). Study 2 examined combined imaginal and in vivo exposure, comprising six imaginal exposure sessions (N = 26). ED symptoms and fears were assessed pre- and posttreatment, and subjective distress and state anxiety were collected during sessions.

RESULTS

Subjective distress tended to increase within-session in both studies, and within-session reduction was not associated with change in ED symptoms or fears. In Study 1, between-session reduction of distress and state anxiety was associated with greater decreases in ED symptoms and fears pre-to posttreatment. In Study 2, between-session distress reduction occurred but was not related to outcomes.

CONCLUSIONS

Within-session distress reduction may not promote change during exposure for EDs, whereas between-session distress reduction may be associated with better treatment outcomes. These findings corroborate research on distress reduction during exposure for anxiety disorders. Clinicians might consider approaches to exposure-based treatment that focus on distress tolerance and promote between-session distress reduction.

Cross-sectional and longitudinal changes in body composition, anxiety, and depression in a clinical sample of adolescents with anorexia nervosa

OBJECTIVE

Eating disorders among children and adolescents have increased in prevalence, and mortality rates for anorexia nervosa are among the highest for any psychiatric disorder. Our current study aimed to (a) examine the cross-sectional relationship between body composition and anxiety/depressive symptoms among 97 adolescents and young adults who have been diagnosed with anorexia nervosa, (b) examine the longitudinal changes in body composition and anxiety/depressive symptoms over three months (from baseline to follow-up visit), and (c) examine the longitudinal relationship between change in body composition and change in anxiety/depression over three months.

METHOD

A retrospective chart review was conducted within an interdisciplinary eating disorder clinic between August 2019 and December 2021. In total, 97 adolescents aged 11-20 years old with diagnoses of anorexia nervosa were included in the analyses. Body composition data were collected at each visit along with parent- and youth-report measures of symptoms of anxiety/depression symptoms.

RESULTS

Findings indicated adolescents demonstrated some improvement in body composition, as well as parent-reported reductions in anxiety/depression symptoms. Based on parent reports, increased BMI percentile was associated with improvements in anxiety/depression symptoms. On the other hand, youth did not report significant changes in anxiety/depressive symptoms. Additionally, there were no associated improvements with body composition measures, which may be associated with continued body dissatisfaction or symptoms of anxiety and depression predating the eating disorder.

CONCLUSIONS

These results suggest the importance of including interventions addressing depression, anxiety, and body image as part of treatment.

Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study

ABSTRACT

Hoarding disorder (HD) is marked by difficulty discarding possessions. Many refuse treatment or drop out, which may be due to treatment's incorporation of in-home decluttering, which is feared and avoided. Thus, strategies to prepare patients for decluttering/discarding are needed. Imaginal exposure (IE), or imagining one's worst fears about discarding, could be one such strategy. This pilot preliminarily tested a short-duration IE intervention compared with a control intervention. Over 3 days, adults diagnosed with HD (n = 32) were randomly assigned to either write about and imagine their worst fears about discarding (IE condition) or a neutral topic (control writing [CW] condition). The IE condition showed significant improvements in HD symptoms from preintervention to 1-week follow-up, with medium to large effects; however, the CW condition did as well. Comparing change scores between conditions, the IE condition's improvements were not significantly different than the CW condition's. Overall, IE was helpful in improving HD symptoms, but this pilot did not indicate that it was more helpful than CW. This raises important questions about possible demand characteristics, placebo effects, or regression to the mean, and it has implications for the design and methodology of other studies assessing IE's utility.

State mechanisms of change in eating disorder symptoms and fears during an online imaginal exposure treatment for eating disorders

Anxiety and fear are key characteristics of eating disorders (EDs). Exposure therapy is a specific type of intervention aimed at reducing fear and anxiety and is efficacious in treating a variety of anxiety and related disorders. A growing body of research suggests that exposure therapy is also efficacious for the treatment of EDs. However, there is currently little research investigating mechanisms of change during exposure therapy for EDs. The current study (N = 143) expanded on an open series trial of imaginal exposure for EDs that found significant reductions in ED symptoms and core ED fears. In the current study we investigated change in state drive for thinness, body dissatisfaction, and anxiety as mechanisms underpinning change in ED symptoms and core ED fears during four sessions of online imaginal exposure treatment for EDs. We found that state body dissatisfaction, but not state drive for thinness or anxiety, was a mechanism of change for ED symptoms and some core ED fears. Our findings suggest that body dissatisfaction may be a mechanism driving change during exposure therapy for EDs. Optimizing exposure treatments to focus on body dissatisfaction may improve treatment outcomes for EDs.

Development and Validation of a Broad and Fear-Adaptable Measure of Fear Approach and Application to Common Eating Disorder Fears

Fear approach is a theorized mechanism of exposure treatment for anxiety-based disorders. However, there are no empirically established self-report instruments measuring the tendency to approach feared stimuli. Because clinical fears are heterogeneous, it is important to create a measure that is adaptable to person- or disorder-specific fears. The current study (N = 455) tests the development, factor structure, and psychometric properties of a self-report instrument of fear approach broadly and the adaptability of this measure to specific eating disorder fears (i.e., food, weight gain). Factor analyses identified a unidimensional, nine-item factor structure as the best fitting model. This measure had good convergent, divergent, and incremental validity and good internal consistency. The eating disorder adaptations retained good fit and strong psychometric properties. These results suggest that this measure is a valid, reliable, and adaptable measure of fear approach, which can be used in research and exposure therapy treatment for anxiety-based disorders.

Facing Eating Disorder Fears: An Open Trial Adapting Prolonged Exposure to the Treatment of Eating Disorders

Eating disorders (EDs) are maintained by core fears, which lead to avoidance behaviors, such as food avoidance or compensatory behaviors. Previously tested exposure-based treatments for EDs have generally focused on proximal outcomes (e.g., food), rather than addressing core fears (e.g., fear of weight gain and its consequences). The current study tested the feasibility and initial clinical efficacy of 10 sessions of imaginal and in vivo exposure for core ED fears (termed "Facing Eating Disorder Fears"), mainly fear of weight gain and its associated consequences. Participants were 36 adults with anorexia nervosa (AN), bulimia nervosa, or other specified feeding and eating disorders determined by semistructured diagnostic interviews. ED symptoms, fears, and body mass index (BMI) were assessed at pretreatment, posttreatment, and 1-month follow-up. Treatment involved 10 sessions of imaginal and in vivo exposure to ED fears in combination with in vivo exposures to feared and avoided situations as homework. ED symptoms and fears decreased from pre- to posttreatment and at 1-month follow-up. BMI increased significantly from pre- to posttreatment, particularly for those with AN. Effect sizes ranged from small to very large. ED symptoms and fears decreased and BMI increased following exposure. Increases in BMI occurred without any direct intervention on eating, suggesting that weight gain can be achieved without a specific focus on food during ED treatment. Facing Eating Disorder Fears may be a feasible stand-alone intervention for EDs. Future research must test comparative efficacy through randomized controlled trials.

An Intensive time series investigation of the relationships across eating disorder-specific fear responses and behavior urges in partially remitted anorexia nervosa

Anorexia nervosa (AN) is a serious and persistent psychiatric illness. Many individuals with AN cycle between stages of remission (i.e., relapse), with research documenting that cognitive remission generally lags behind nutritional/weight restoration. Yet, little is known about which mechanisms promote movement from partial remission in AN (defined as nutritional, but not cognitive, recovery) to full remission. Fear-based processes, including avoidance and approach behaviors, likely contribute to the persistence of cognitive-behavioral AN symptoms after nutritional restoration. The current study used intensive longitudinal data to characterize these processes during partial remission (N = 41 participants with partially remitted AN; 4306 total observations). We aimed to a) characterize frequency of fear-based processes in real-time, b) investigate associations across fear-based processes and behavioral urges, and c) test if real-time associations among symptoms differed across commonly feared stimuli (e.g., food, social situations). On average, participants endorsed moderate fear and avoidance, with weight-gain fears rated higher than other feared stimuli. Momentary fear, avoidance, approach, and distress were all positively associated with AN behavior urges at one time-point and prospectively. Central symptoms and symptom connections differed across models with different feared stimuli. These findings provide empirical support for the theorized fear-avoidance-urge cycle in AN, which may contribute to the persistence of eating pathology during partial remission. Fear approach may be associated with temporary increases in urges, which should be considered during treatment. Future research should explore these associations in large, heterogeneous samples, and test the effectiveness of exposure-based interventions during partial remission.

Virtually possible: strategies for using telehealth in eating disorder treatment learned from the COVID-19 pandemic

The COVID-19 pandemic resulted in an abrupt shift from in-person to virtual treatment, and clinicians continue to offer telehealth due to its advantages. Telehealth may be a viable, effective, and safe treatment modality for many clients with eating disorders. We consider contemporary issues regarding the use of telehealth in eating disorder treatment and identify strategies to enhance its delivery. First, we emphasize key factors when choosing therapy delivery (telehealth, in-person, or hybrid). Second, we address telehealth-specific planning, preparation, safety, and privacy considerations. Third, we discuss how eating disorder assessment and evidence-based interventions can be adapted for telehealth delivery. Fourth, we raise telehealth-specific challenges related to group-based delivery and the therapeutic alliance offering alternative avenues for connection and engagement. We conclude with a discussion of how additional research is needed to refine the presented strategies, develop new strategies, and assess their efficacy and effectiveness.

Traditional versus virtual partial hospital programme for eating disorders: Feasibility and preliminary comparison of effects

OBJECTIVE

Minimal research has examined teletherapy for group or intensive eating disorder (ED) treatment, particularly partial hospital programme (PHP). This study compared treatment outcomes for individuals treated before and after a pandemic-driven implementation of virtual PHP.

METHOD

Patients received care at ED treatment centres using the Renfrew Unified Treatment for Eating Disorders and Comorbidity. Patients treated with virtual PHP were compared to patients treated with traditional PHP. Measures of ED symptomology and behaviours, depressive symptoms, anxiety severity, anxiety sensitivity, experiential avoidance, mindfulness, and body mass index (BMI; reported for anorexia nervosa [AN] patients only) were collected at intake and discharge. Multiple regression analyses were conducted to examine the effect of treatment group on outcomes, controlling for intake score, comorbidity, discharge status, AN diagnosis, and step-down status.

RESULTS

Differences in treatment type were only found for binge eating frequency, with those in virtual PHP reporting significantly lower binge eating episodes at discharge than those in traditional PHP. Body mass index showed significantly less improvement in virtual PHP than in traditional PHP.

CONCLUSIONS

Preliminary results suggest virtual PHP is feasible and effective, potentially increasing access to evidence-based, intensive ED treatment. However, additional research is needed to establish efficacious support for weight gain among individuals with AN in virtual programs.

A multi-modal assessment of fear conditioning in adolescent anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a pernicious psychiatric disorder which is principally characterized by a fear of weight gain. Notwithstanding the centrality of fear in the psychopathology of AN, controlled assessments of negative valence systems are lacking. Herein we assess fear conditioning in adolescent females with AN.

METHOD

Adolescent girls (Mage  = 14.6 years, ±1.57) with DSM-5 diagnoses of AN (N = 25) and age-matched control girls (Mage  = 14.8 years, ±1.46) with no DSM-5 diagnoses (N = 25) completed structured clinical interviews and participated in a classical three-phase Pavlovian fear conditioning paradigm. Participants with comorbid anxiety disorders were excluded. Skin conductance response (SCR) was measured, alongside self-reported fear, valence, and fear expectancy ratings.

RESULTS

Both groups demonstrated significant differential acquisition across all four measures. Regarding group comparisons, no differences emerged for self-reported fear, valence, and fear expectancy ratings during acquisition, although for SCR, those with AN demonstrated reduced physiological arousal relative to controls. Both groups demonstrated significant differential extinction for unconditioned stimuli (US) expectancy, self-report fear, and self-report valence. No statistically significant group differences were evident during extinction to the conditioned stimuli (CS)+, on any outcome measure. However, controls reported more positive valence to the CS- than those with AN.

CONCLUSIONS

Contrary to our hypotheses, our preliminary assessment did not find support for elevated fear responding among adolescent girls with AN with regards to fear acquisition or extinction. These data suggest that AN in adolescent girls may not be associated with a heightened propensity to acquire fear, but conversely, may suggest that exposure treatments for AN may be helpful, since extinction learning is intact in AN.

PUBLIC SIGNIFICANCE

AN is characterized by fear-related symptoms, including food and weight-related fear, and behavioral avoidance, yet controlled studies assessing fear learning are limited. Our preliminary assessment of adolescent AN indicates no abnormalities in fear learning among adolescents with AN. These findings may inform existing mechanistic models of AN psychopathology, and the development of exposure-based treatments for AN.

Eating disorders among queer and trans individuals: Implications for conceptualization, assessment, and treatment

Eating disorders (EDs) have been traditionally viewed as a disorder affecting cisgender, heterosexual women. Yet, the prevalence of EDs among queer and trans (QnT) individuals, coupled with the lack of interventions that attend to contextual factors related to sexual orientation and gender identity, underscore a critical health disparity issue requiring urgent attention. Here, we first review factors pertaining to QnT individuals' minoritized sexual and gender identities that are important to consider in ED conceptualization for this population (e.g., minority stressors, identity-based body image standards). Next, we describe problematic assumptions present in existing ED assessment and propose more inclusive approaches. Lastly, we provide suggestions for practices that providers can implement within their treatment of EDs among QnT individuals.

Testing anxiety and reward processing in anorexia nervosa as predictors of longitudinal clinical outcomes

Anorexia nervosa (AN) is a psychiatric disorder with a tenuous longitudinal course marked by a high risk of relapse. Previous studies suggest that aberrant threat perception and reward processing operate in many with AN, and may produce obstacles to treatment engagement; therefore, these could potentially represent predictors for longitudinal clinical outcomes. In this study, anxiety and reward symptoms, behaviors, and neural circuit connectivity were measured in intensively treated AN-restrictive subtype patients (n = 33) and healthy controls (n = 31). Participants underwent an fMRI experiment using a monetary reward task in combination with either overlapping individually tailored anxiety-provoking words or neutral words. Behavioral/psychometric measures consisted of reaction times on the monetary reward task and self-ratings on anxiety symptoms at study entry. We tested multimodal, multivariate models based on neural, behavioral, and psychometric measures of reward and anxiety to predict physiological (Body Mass Index; BMI) and psychological (eating disorder symptom severity) longitudinal outcomes in AN over six months. Our results indicated that higher anxiety symptom psychometric scores significantly predicted BMI reductions at follow-up. Untreated anxiety after intensive treatment could put individuals with AN at heightened risk for weight loss. This represents a potentially modifiable risk factor that could be targeted more aggressively to help reduce the chance of future clinical worsening.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Differences in Telomere Length between Adolescent Females with Anorexia Nervosa Restricting Type and Anorexia Nervosa Binge-Purge Type

Physiological and psychological distress may accelerate cellular aging, manifested by shortening of telomere length (TL). The present study focused on TL shortening in anorexia nervosa (AN), an illness combining physiological and psychological distress. For that purpose, we measured TL in 44 female adolescents with AN at admission to inpatient treatment, in a subset of 18 patients also at discharge, and in 22 controls. No differences in TL were found between patients with AN and controls. At admission, patients with AN-binge/purge type (AN-B/P; n = 18) showed shorter TL compared with patients with AN-restricting type (AN-R; n = 26). No change in TL was found from admission to discharge, despite an improvement in body mass index standard deviation score (BMI-SDS) following inpatient treatment. Older age was the only parameter assessed to be correlated with greater TL shortening. Several methodological changes have to be undertaken to better understand the putative association of shorter TL with B/P behaviors, including increasing the sample size and the assessment of the relevant pathological eating disorder (ED) and non-ED psychological correlates in the two AN subtypes.

The Impact of Anorexia Nervosa and the Basis for Non-Pharmacological Interventions

Anorexia nervosa is a psychiatric disorder with an unknown etiology that is characterized by an individual's preoccupation with their weight and body structure while denying the severity of their low body weight. Due to the fact that anorexia nervosa is multifaceted and may indicate the coexistence of genetic, social, hormonal, and psychiatric disorders, a description of non-pharmacological interventions can be used to ameliorate or reduce the symptoms of this condition. Consequently, the purpose of the present narrative review is to describe the profile's context in the anorexic person as well as the support they would require from their family and environment. In addition, it is aimed at examining preventative and non-pharmacological interventions, such as nutritional interventions, physical activity interventions, psychological interventions, psychosocial interventions, and physical therapy interventions. To reach the narrative review aims, a critical review was conducted utilizing both primary sources, such as scientific publications, and secondary sources, such as bibliographic indexes, web pages, and databases. Nutritional interventions include nutritional education and an individualized treatment for each patient, physical activity interventions include allowing patients to perform controlled physical activity, psychological interventions include family therapy and evaluation of the existence of other psychological disorders, psychosocial interventions include management of the relationship between the patient and social media and physical therapy interventions include relaxation massages and exercises to relieve pain. All these non-pharmacological interventions need to be individualized based on each patient's needs.

Modification of Body-Related Attentional Bias through Virtual Reality and Eye-Tracking in Healthy Participants: Implications for Anorexia Nervosa Treatments

Cognitive biases have a significant impact on the etiology and treatment of eating disorders (EDs). These biases, including selective attentional bias (AB) to disliked body parts, may reinforce concerns about body shape, fear of gaining weight and body image disturbances and may contribute to dietary restriction and restraint. Decreasing AB could reduce core symptoms in anorexia nervosa (AN). This study represents a preliminary exploration aiming to assess whether AB towards weight-related (WR) and non-weight-related (NW) body parts could be reduced through an AB modification task in a virtual reality (VR) environment in healthy participants. A total of 54 female participants, aged 22.98 ± 1.89, were recruited. The task consisted of directing the participants' attention towards all body parts equally in a VR setting. Eye-tracking (ET) measurements (complete fixation time [CFT] and number of fixations [NF]) were made before and after the task. The results showed a significant reduction of the AB in the two groups with an initial AB towards WR body parts or towards NW body parts. Participants showed a tendency to more balanced (non-biased) attention after the intervention. This study provides evidence of the usefulness of AB modification tasks in a non-clinical sample.

PTSD symptoms as a potential mediator of associations between military sexual assault and disordered eating

Despite increasing rates of sexual assault in the military and high rates of disordered eating and post-traumatic stress disorder (PTSD) among veterans, little is known about how these constructs are related. This study examined whether PTSD symptoms mediate the relation between military sexual assault and disordered eating among female veterans. United States female veterans (N = 98) completed self-report measures assessing military sexual assault, PTSD, and disordered eating. Results indicated that military sexual assault was associated with higher PTSD symptoms and disordered eating. PTSD symptoms did not mediate the relation between military sexual assault and overall levels of disordered eating. However, PTSD symptoms fully mediated the relation between military sexual assault and the Bulimia and Food Preoccupation subscale of the Eating Attitudes Test-26. Findings suggest that military sexual assault may contribute to the development of bulimia nervosa symptoms indirectly through PTSD symptoms. Thus, the findings do not support a global relationship between trauma and all facets of disordered eating, but demonstrate a relationship between PTSD and bulimia nervosa symptoms, with purging potentially functioning as an emotion regulation strategy. Future longitudinal studies are needed to establish temporal precedence of these associations.

Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.

An examination of eating disorder fears in imaginal exposure scripts

OBJECTIVE

Eating disorders (EDs) are maintained by fear and anxiety, which lead to disordered eating behaviors thought to prevent the occurrence of feared outcomes. Fear of weight gain and food are among the most common fears present in the EDs. However, theory and clinical observation suggest that the feared consequences of eating or weight gain are diverse and individualized. Further research is needed to delineate specific fears underlying ED pathology.

METHOD

167 participants with any ED participated in an online four-session imaginal exposure intervention. Imaginal exposure scripts were rated by trained coders using items derived from the Eating Disorder Fear Interview to identify fears present. Frequencies of fears present in scripts were quantified.

RESULTS

Two-thirds of scripts mentioned fears of food and weight or body-related fears. In over half of scripts, fear of judgment and fear of loss of control were identified. Diagnostic differences were found, including that those with anorexia nervosa (AN) and bulimia nervosa (BN) had highest fears of food, whereas those with AN and other specified feeding and eating disorder (OSFED) had higher weight gain/body-focused fears.

LIMITATIONS

We were underpowered to make comparisons between ED diagnoses other than AN, BN, and OSFED.

CONCLUSIONS

Imaginal exposure scripts contained a large number of fears related to food, weight/shape, judgment, and loss of control, among others. These findings extend the current understanding of ED fears and provide evidence for the individualized and varied nature of fears. Identification of ED fears can further inform research on designing personalized, exposure-based treatment approaches.

Fear of weight gain during cognitive behavioral therapy for binge-spectrum eating disorders

PURPOSE

Fear of weight gain may play a central role in maintaining eating disorders (EDs), but research on the role of fear of weight gain during cognitive behavioral therapy (CBT-E) for binge-spectrum EDs is sparse. We examined changes in fear of weight gain during CBT-E for binge-spectrum EDs. We investigated whether fear of weight gain predicted loss of control (LOC) eating or weight change.

METHODS

Participants (N = 63) were adults of any gender recruited as part of a larger trial. Participants received 12 sessions of CBT-E, completed diagnostic assessments at pre-, mid-, and post-treatment, and completed brief surveys before sessions.

RESULTS

Fear of weight gain decreased across treatment, moderated by diagnosis. Those with bulimia nervosa spectrum EDs (BN-spectrum), compared to binge eating disorder, reported higher fear of weight gain at baseline and experienced a larger decrease in fear across treatment. Those reporting higher fear of weight gain at a given session experienced more frequent LOC episodes the following week. Fear of weight gain was not associated with session-by-session changes in BMI.

CONCLUSION

CBT-E results in decreases in fear of weight gain, but levels remain high at post-treatment, especially for those with BN-spectrum EDs. Future interventions should consider targeting fear of weight gain as a maintaining factor for LOC episodes TRIAL REGISTRATION: NCT04076553.

LEVEL OF EVIDENCE

Level II controlled trial without randomization.

Eating Disorder Symptom and Fear Change Trajectories During Imaginal Exposure Therapy: A Slope Network Analysis

Eating disorders (EDs) are characterized by fears related to food, body image, and social evaluation. Exposure-based interventions hold promise for targeting a range of ED fears and reducing ED psychopathology. We investigated change mechanisms and optimal fear targets in imaginal exposure therapy for EDs using a novel approach to network analysis. Individuals with an ED (N = 143) completed up to four online imaginal exposure sessions. Participants reported ED symptoms and fears at pretreatment, posttreatment, and 6-month follow-up. We constructed networks of symptoms (Model 1), fears (Model 2), and combined symptoms and fears (Model 3). Change trajectory networks from the slopes of symptoms/fears across timepoints were estimated to identify how change in specific ED symptoms/fears related to change in other ED symptoms/fears. The most central changing symptoms and fears were feeling fat, fear of weight gain, guilt about one's weight/shape, and feared concerns about consequences of eating. In Model 3, change in ED fears bridged to change in desire to lose weight, desiring a flat stomach, following food rules, concern about eating with others, and guilt. As slope networks present averages of symptom/fear change slopes over the course of imaginal exposure therapy, further studies are needed to examine causal relationships between symptom changes and heterogeneity of change trajectories. Fears of weight gain and consequences of eating may be optimal targets for ED exposure therapy, as changes in these fears were associated with maximal change in ED pathology. Slope networks may elucidate change mechanisms for EDs and other psychiatric illnesses.

Transdiagnostic fears and avoidance behaviors in self-reported eating disorders

BACKGROUND

Fears and avoidance behaviors are common symptoms of eating disorders. It was investigated whether different eating disorder diagnoses are equally characterized by similar fears and avoidance behaviors.

METHODS

Individuals with self-reported eating disorders (n = 250) and healthy controls (n = 95) completed online questionnaires assessing general fears, eating related fears, and avoidance behaviors.

RESULTS

All self-reported eating disorder diagnoses showed more eating related fears, general fears, and avoidance behaviors than healthy controls. Individuals with binge eating disorder showed less specific and general fears on some but by no means all scales, yet they showed less food avoidance behaviors than all other eating disorders and less eating restraint than anorexia nervosa and bulimia nervosa.

CONCLUSIONS

Eating related fears, general fears, and food avoidance behaviors were found to be transdiagnostic symptoms in self-reported eating disorders. Individuals with binge eating disorder also exhibit more fears and avoidance behaviors than healthy controls, but to a lesser extent than the other eating disorders. Specialized interventions targeting fears and avoidance may be promising add-on interventions not only in the treatment of anorexia nervosa, but in the treatment of all eating disorders.

Food Restriction in Anorexia Nervosa in the Light of Modern Learning Theory: A Narrative Review

Improvements in the clinical management of anorexia nervosa (AN) are urgently needed. To do so, the search for innovative approaches continues at laboratory and clinical levels to translate new findings into more effective treatments. In this sense, modern learning theory provides a unifying framework that connects concepts, methodologies and data from preclinical and clinical research to inspire novel interventions in the field of psychopathology in general, and of disordered eating in particular. Indeed, learning is thought to be a crucial factor in the development/regulation of normal and pathological eating behaviour. Thus, the present review not only tries to provide a comprehensive overview of modern learning research in the field of AN, but also follows a transdiagnostic perspective to offer testable explanations for the origin and maintenance of pathological food rejection. This narrative review was informed by a systematic search of research papers in the electronic databases PsycInfo, Scopus and Web of Science following PRISMA methodology. By considering the number and type of associations (Pavlovian, goal-directed or habitual) and the affective nature of conditioning processes (appetitive versus aversive), this approach can explain many features of AN, including why some patients restrict food intake to the point of life-threatening starvation and others restrict calorie intake to lose weight and binge on a regular basis. Nonetheless, it is striking how little impact modern learning theory has had on the current AN research agenda and practice.

Cognitive-affective reactions to a non-judgmental and judgmental mirror gazing task in individuals with body dysmorphic concerns

BACKGROUND AND OBJECTIVES

The look into the mirror represents a typical trigger situation for people with body dysmorphic concerns. Mirror exposure on the other hand is commonly used in the treatment of Body Dysmorphic Disorder even though little is known about its precise effects. This study aimed to investigate cognitive-affective processes related to mirror gazing.

METHODS

A total of 125 individuals (screening for body dysmorphic concerns: N_BDD+ = 56, negative N_BDD- = 69) participated in a laboratory study using a guided 10-min mirror gazing task. Participants were randomized to one of two experimental conditions, a non-judgmental and judgmental description of the own body during mirror gazing. Distress, self-hostile cognitions and post-event processing were assessed after the task and at follow-up.

RESULTS

Participants with body dysmorphic concerns showed higher values regarding subjective appearance distortion, stress induced by the exposure, distress, self-hostile cognitions and post-event processing compared to the symptom negative group. The two conditions did not yield differential effects.

LIMITATIONS

The short duration of the mirror gazing and the only internal description of the body may have contributed to a missing effect for the approach.

CONCLUSIONS

The results indicate the importance of cognitive and affective processes in reaction to mirror exposure. They support the cognitive model of BDD and suggest post-event processing as a relevant factor requiring further investigation in future research.

The mirror and obesity: A systematic review on the effects of mirror exposure on behaviour and obese individuals

AIMS AND OBJECTIVES

To review the literature regarding the effects of mirror exposure on behaviour and obese patients. The review explored how mirror exposure influences behaviour in obese patients in terms of activity level, psychology and eating habits.

BACKGROUND

Obesity is a major epidemic that affects people worldwide but is more predominant in the Western world. Many health issues are directly linked to obesity, and current therapies have failed to provide a sustainable resolution to this problem. Mirror exposure has been used in eating disorders such as anorexia nervosa, bulimia and binge eating; however, there exists a gap in the use of mirrors in obese patients. The literature review focuses on the effects of mirror exposure on behaviour and obese patients.

METHOD

A literature review of articles published between 2006 and 2020 related to mirror exposure in obese patients and the related effects.

RESULTS

Literature that explicitly discussed mirror exposure in obese patients was included; five research articles were reviewed.

CONCLUSIONS

Mirror exposure can influence behaviour modification in obese patients. Therefore, the use of mirrors should be considered as an adjunct therapy in this group of patients.

RELEVANCE TO CLINICAL PRACTICE

Mirror exposure can positively alter behaviour in obese patients and can be used as an intervention in clinical practice to assist in weight loss and improve health outcomes.

Core eating disorder fears: Prevalence and differences in eating disorder fears across eating disorder diagnoses

OBJECTIVE

Fear and anxiety are key maintaining factors for eating disorder (ED) pathology. Maladaptive fears lead to ED behaviors and avoidance, which provide temporary relief, but ultimately reinforce the fear and contribute to a cycle that maintains the ED. To date, fears of food and weight gain are the most explored fears underlying ED pathology. However, recently other important ED fears have been identified, including fears of social consequences and personal consequences.

METHOD

The current study (N = 229 individuals with an ED) aimed to better characterize ED fears. Specifically, this study examined which ED fears were most endorsed across and within ED diagnoses, and if there were differences in ED fears by diagnosis and by weight status.

RESULTS

Overall, fear of gaining weight was the most frequently endorsed fear, followed by fear of food, and fear of judgment. Individuals with anorexia nervosa (AN) most frequently endorsed fear of food, individuals with atypical AN and bulimia nervosa: fear of gaining weight, and those with other specified feeding and eating disorder: fear of judgment. Limited differences were found between diagnoses. When examining by weight category, participants with underweight most frequently endorsed fear of food, participants with normal weight: fear of gaining weight, and participants with overweight and obesity: fear of judgment.

DISCUSSION

These findings suggest ED fears are heterogenous. Given such high heterogeneity, this work highlights the importance of assessing for specific ED fears at the beginning of treatment, which could be used to deliver personalized exposure treatment.

PUBLIC SIGNIFICANCE STATEMENT

Eating disorders (EDs) are serious mental illnesses with high rates of medical and psychiatric comorbidities. Fear plays an important role in the development and maintenance of EDs. The present study found fear of food, weight gain, and judgment are the most frequently endorsed fears for individuals with EDs and found few differences in fears based on ED diagnosis. These findings highlight the importance of assessing individuals' specific ED fears for treatment.

What happens in the course of positive mirror exposure? Effects on eating pathology, body satisfaction, affect, and subjective physiological arousal in patients with anorexia and bulimia nervosa

OBJECTIVE

Mirror exposure (ME) is a therapeutic technique to improve body image disturbance. However, evidence on the effectiveness of different forms of ME in clinical populations is lacking. The present study therefore analysed effects of ME on trait-like and state measures of body image in patients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

The present study therefore analysed effects of ME on trait-like and state measures of body image in patients with anorexia nervosa (AN) and bulimia nervosa (BN). In total, 47 inpatients underwent 3 ME sessions guided by a therapist, with instructions to exclusively verbalise positively about their whole body. Participants completed questionnaires on trait-like eating pathology and body image at the start and end of the study, and instruments on state affect and body satisfaction were administered directly before and after each ME session. Subjective physiological arousal and emotional valence relating to each body part were assessed within each session.

RESULTS

The results indicate significant improvements in eating pathology and body image regarding trait-like measures in patients with AN and BN. Concerning state measures, negative affect significantly decreased and body satisfaction increased during ME. Physiological arousal decreased and positively valenced emotions relating to the various body parts increased.

CONCLUSIONS

These findings suggest that positively verbalising about one's body during ME improves eating pathology, body image, affect, and subjective physiological arousal, and thus seems to be an effective form of ME.

It's all in the name: why exposure therapy could benefit from a new one

Exposure therapy for anxiety and related disorders is the psychological intervention with the strongest support for its efficacy and effectiveness to date. Yet, it is the least used evidence-based intervention in routine clinical practice, with a long-acknowledged public relations problem. Despite a wealth of research aimed at improving uptake of exposure, exposure's marketing and branding remains an untapped target. We first introduce principles from the marketing literature to propose that the field take steps toward a rebranding and repackaging of exposure therapy to support efforts to implement it widely. Second, we present preliminary data on clinician preferences for the use of alternative terminology developed to be more palatable and marketable - "Supported Approach of Feared Experiences - Cognitive Behavioral Therapy (SAFE-CBT)" - compared to traditional terminology. This initial survey indicated that most clinicians preferred use of the SAFE-CBT term when talking to patients, whereas only a minority preferred it for use among training clinicians. We conclude by discussing implications of these results for future efforts to implement exposure therapy more widely and set an agenda for future research in this space.

Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Sensor technology in eating disorders research: A systematic review

OBJECTIVE

Sensor technologies offer exciting potential to objectively measure psychopathological correlates of eating pathology and eating disorder (ED) research utilizing sensors has rapidly proliferated in the past several years. The aims of the present review are: (1) characterize the types of sensors that have been utilized in ED research, (2) identify the psychopathological factors relevant to EDs that have been assessed using sensors, (3) describe the data supporting the validity and reliability of these sensors, (4) discuss limitations associated with these sensors, and (5) identify gaps that persist within the ED literature with regard to use of sensor technologies.

METHOD

A systematic search was conducted of PubMed, PsycINFO, Web of Science, ProQuest, and "gray" literature sources. Eligible publications were empirical studies that utilized sensors to measure at least one psychological variable among clinical ED populations.

RESULTS

Sensors have been utilized with ED samples to measure eating behaviors, physical activity, sleep, autonomic nervous system activity, eyeblink startle response, visual attention, and visual-haptic object integration. The reliability and validity of these sensors varies widely and there are a number of significant gaps that remain in the literature with regard to the types of sensors utilized, context in which sensors have been used, and populations studied.

DISCUSSION

The existing literature utilizing sensors within ED research largely support the feasibility and acceptability of these tools. Sensors should continue to be utilized within the field, with a specific focus on examining the reliability and validity of these tools within ED samples and increasing the diversity of samples studied.

PUBLIC SIGNIFICANCE STATEMENT

Sensor technologies, such as those included in modern smartwatches, offer new opportunities to measure factors that may maintain or contribute to symptoms of eating disorders. This article describes the types of sensors that have been used in eating disorders research, challenges that may arise in using these sensors, and discusses new applications of these sensors that may be pursued in future research.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Novel Approaches to Tackling Emotional Loss of Control of Eating Across the Weight Spectrum

Emotional overeating is a process that is particularly relevant to people within the binge spectrum of eating disorders. Approximately a third of people with overweight share this phenotype. In addition, this behaviour may occur in neurodevelopmental disorders (attention-deficit hyperactivity disorder (ADHD)) and other psychiatric disorders. The biopsychosocial underpinnings of emotional eating include a genetic vulnerability to a higher weight and various cognitive and emotional traits. The environment also plays a key role. For example, the commodification of food and beauty and exposure to weight stigma, unpleasant eating experiences and general adversity can set the scene. The majority of people with binge-eating disorder do not seek treatment (perhaps related to internalised stigma and shame). Hence opportunities for early intervention and secondary prevention are lost. Most guidelines for binge-eating disorder (based on the limited available research) recommend forms of cognitive psychotherapies and antidepressants. However, novel treatments that target underlying mechanisms are in development. These include interventions to improve emotional regulation and inhibitory control using neuromodulation and/or brain training. New technologies have been applied to talking therapies, including apps which can offer ‘just-in-time interventions’ or virtual reality or avatar work which can deliver more personalised interventions using complex scenarios. Drugs used for the treatment of ADHD, psychiatric and metabolic disorders may have the potential to be repurposed for binge-eating disorder. Thus, this is an area of rapid change with novel solutions being applied to this problem.

A Case for Translation From the Clinic to the Laboratory

Laboratory procedures have been used for decades as analogues for clinical processes with the goal of improving our understanding of psychological treatments for emotional disorders and identifying strategies to make treatments more effective. This research has often focused on translation from the laboratory to the clinic. Although this approach has notable successes, it has not been seamless. There are many examples of strategies that work in the laboratory that fail to lead to improved outcomes when applied clinically. One possible reason for this gap between experimental and clinical research is a failure to focus on translation from the clinic to the laboratory. Here, we discuss potential benefits of translation from the clinic to the laboratory and provide examples of how this might be implemented. We first consider two well-established laboratory analogues (extinction and cognitive reappraisal), identify critical aspects of the related clinical procedures (exposure and cognitive restructuring) that are missing from these analogues, and propose variations to better capture the clinical process. Second, we discuss two clinical procedures that have more recently been brought into the laboratory (eye-movement desensitization and reprocessing and imagery rescripting). We conclude by highlighting potential implications of this proposed shift in focus for translational research.

Anorexia Nervosa, Body Image Perception and Virtual Reality Therapeutic Applications: State of the Art and Operational Proposal

Anorexia Nervosa (AN) patients exhibit distorted body representation. The purpose of this study was to explore studies that analyze virtual reality (VR) applications, related to body image issues, to propose a new tool in this field. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, Scopus, and Web of Science databases were explored; the review included 25 studies. Research has increased over the last five years. The selected studies, clinical observational studies (n = 16), mostly concerning patients' population with AN (n = 14) or eating disorders (EDs) diagnosis, presented multiple designs, populations involved, and procedures. Some of these studies included healthy control groups (n = 7). Studies on community sample populations were also selected if oriented toward clinical applications (n = 9). The VR technologies in the examined period (about 20 years) have evolved significantly, going from very complex and bulky systems, requiring very powerful computers, to agile systems. The advent of low-cost VR devices has given a big boost to research works. Moreover, the operational proposal that emerges from this work supports the use of biofeedback techniques aimed at evaluating the results of therapeutic interventions in the treatment of adolescent patients diagnosed with AN.

Comparing self-compassion versus body exposure for adult women with moderate to severe body dissatisfaction: A feasibility and pilot trial

This study assessed the feasibility and effectiveness of two brief online interventions for body shame for women with moderate to severe negative body image, to inform the design of a future randomized controlled trial. The primary feasibility outcomes were recruitment, measure completion rates, retention rates and internet connection failure rates. The secondary pilot outcomes were change on clinical measures and state shame ratings during the interventions. Participants were randomized to either online (40‐min single session) body exposure or self‐compassion interventions. Five validated nomothetic outcome measures (body dissatisfaction, appreciation, eating disorder, external shame and anxiety) were taken at three time points (preintervention, postintervention and 2‐week follow‐up). Subjective units of body shame (SUBS 0–100 scale) were rated every 5 min during the interventions. The target of recruiting 30 participants in 60 days was successfully achieved. The measure completion rate was high (100%), and retention rates (80% to 100%) showed moderate‐to‐high acceptability of the interventions. Online delivery was moderately viable with a 12.5% session disconnection rate. The self‐compassion intervention significantly reduced SUBS ratings during the course of the intervention, but there was no significant improvement or difference between the interventions on nomothetic outcome measures. Findings suggest that a fully powered trial is viable, and sample size calculation and methodological requirements are provided.

The Good, the Bad, and the Ugly-Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

Avoidance behaviors are shaped by associative learning processes in response to fear of impending threats, particularly physical harm. As part of a defensive repertoire, avoidance is highly adaptive in case of acute danger, serving a potent protective function. However, persistent or excessive fear and maladaptive avoidance are considered key factors in the etiology and pathophysiology of anxiety- and stress-related psychosomatic disorders. In these overlapping conditions, avoidance can increase the risk of mental comorbidities and interfere with the efficacy of cognitive behavioral treatment approaches built on fear extinction. Despite resurging interest in avoidance research also in the context of psychosomatic medicine, especially in conditions associated with pain, disturbed interoception, and disorders of the gut-brain axis, current study designs and their translation into the clinical context face significant challenges limiting both, the investigation of mechanisms involved in avoidance and the development of novel targeted treatment options. We herein selectively review the conceptual framework of learning and memory processes, emphasizing how classical and operant conditioning, fear extinction, and return of fear shape avoidance behaviors. We further discuss pathological avoidance and safety behaviors as hallmark features in psychosomatic diseases, with a focus on anxiety- and stress-related disorders. Aiming to emphasize chances of improved translational knowledge across clinical conditions, we further point out limitations in current experimental avoidance research. Based on these considerations, we propose means to improve existing avoidance paradigms to broaden our understanding of underlying mechanisms, moderators and mediators of avoidance, and to inspire tailored treatments for patients suffering from psychosomatic disorders.

The transdiagnostic role of food craving: An application of substance use models

Food craving is a transdiagnostic process underlying clinically significant disordered eating behaviors and eating disorder diagnoses. However, the lack of literature examining the role of food craving as it relates to the full spectrum of disordered eating behaviors, including restrictive eating and compensatory behaviors, may be due to the traditional definition of food craving as the desire to consume particular foods. Applying motivational models of substance use craving to food craving may help to explain inconsistencies within existing literature. Three motivational models of craving from the substance use literature may be particularly applicable to (1) provide a clear definition of food craving as a motivational process, (2) understand the role of that motivational process as it underlies the full spectrum of disordered eating behavioral patterns, (3) provide insight for the most appropriate ways in which to accurately assess food craving, and (4) establish ways in which food craving may represent a useful motivational process to target in eating disorder treatments. This narrative review describes three models of substance use craving and provides suggestions for utilizing motivational models to understand the transdiagnostic role of food craving as it relates to the full spectrum of disordered eating behaviors in both research and clinical work.

ARFID Parent Training Protocol: A randomized pilot trial evaluating a brief, parent-training program for avoidant/restrictive food intake disorder

Evidence-based treatment approaches for avoidant/restrictive food intake disorder (ARFID) remain limited and may be inaccessible to families due to geographic, financial, and/or time constraints. This study aims to establish the acceptability and feasibility of a brief ARFID Parent Training Program (ARFID-PTP), modified from other evidence-based approaches, using a randomized controlled trial design. Participants (n = 30) will be children aged 5-12 who meet diagnostic criteria for ARFID and their parents/guardians. Participants will be randomized to receive treatment immediately or following a 4-week wait (waitlist control). Treatment consists of two, 2-hr virtual treatment sessions with the family and a therapist plus an optional booster session. Primary aims include evaluating the (a) feasibility of ARFID-PTP as indicated by recruitment and retention rates, as well as treatment adherence at home and (b) acceptability as determined by ratings on the Credibility and Expectancy Questionnaire and satisfaction questions. A secondary aim is to assess the preliminary efficacy of ARFID-PTP via changes in scores on the Pica, ARFID, and Rumination Disorder Interview. If results indicate appropriate feasibility and acceptability, the proposed protocol will form the basis for larger scale trials of treatment efficacy in efforts to increase accessibility of evidence-based treatment for ARFID.

Exposure-enhanced cognitive behavioral therapy for adolescents with binge eating: An initial case series

Binge eating (BE) often develops during adolescence and is associated with deleterious psychological and physical consequences. Current treatments for adolescents achieve suboptimal results, likely due to failure to adequately address fear of weight gain (FOWG) which maintains BE. Thus, exposure treatment (the most powerful intervention for fear) may be a promising approach. However, exposure treatment has only minimally tested in adults with BE and never tested in adolescents. Thus, the current study is the first to evaluate a 4-session exposure module within a 12-session standard cognitive behavioral therapy for adolescents with BE. We recruited adolescents with BE (N = 5) and examined treatment feasibility, acceptability, and preliminary effects on FOWG and eating pathology. Overall, the 4-session exposure module was feasible and acceptable and showed preliminary evidence that it could reduce FOWG. However, several participants did not endorse significant fears of weight gain; rather, these participants reported that fears of deprivation or social judgment were more related to their BE. Future research should test higher doses of exposure and further examine the role of fear of deprivation/social judgment. Finally, future iterations of this treatment could include more parent involvement or test exposure in combination with treatments other than cognitive behavioral therapy, such as family-based treatment.

A novel 'practical body image' therapy for adolescent inpatients with anorexia nervosa: a randomised controlled trial

PURPOSE

To determine the potential effectiveness of a novel 10-week manualised Practical Body Image therapy (PBI) with mirror exposure (ME), when used as an adjuvant to an intensive treatment package (TAU) in adolescent inpatients with Anorexia Nervosa (AN). To evaluate the effectiveness of ME in an adolescent population.

METHODS

Using a randomised control design, 40 girls aged 11-17 years with AN were assigned to PBI with TAU (n = 20) and TAU alone (n = 20). Both groups completed self-report measures of body image at week 1 and week 10 of the study to measure the potential effectiveness of PBI. The PBI group completed measures at week 7 to evaluate the ME component.

RESULTS

31 participants completed the study; 16 TAU, 15 PBI. PBI participants had greater improvement in all outcomes than TAU participants. Medium effect sizes were seen for self-reported weight concern, body image avoidance in terms of clothing and body image anxiety. ME produced effect sizes in self-reported body image avoidance in terms of clothing and grooming that were greater than 0.40, n = 14.

CONCLUSION

The findings demonstrate that PBI supports an intensive inpatient treatment package and addresses elements of negative body image. PBI was beneficial for addressing body image dissatisfaction with improvements in weight concerns, body image avoidance and physical appearance trait anxiety following the ME component. The magnitude of the effect sizes is comparable to previous studies. Positive qualitative feedback indicated the intervention was acceptable to users. PBI is a promising new adjuvant treatment for AN.

EMB RATING

Level I: randomized controlled trial.

Avoidance in Anorexia Nervosa: Towards a research agenda

Anorexia Nervosa is a severe and disabling mental disorder and a huge challenge to treat. Intense fears of e.g., food, eating, weight gain and social evaluation are core features of anorexia nervosa and obstacles during treatment. The perceived threats trigger avoidance and safety behaviors like highly restrictive eating, strict eating rules, vomiting and body checking, to minimize feared outcomes. The role of avoidance in anorexia nervosa is however hardly studied experimentally. In the present article, the focus is on a new transdiagnostic research agenda featuring both basic and clinical experimental research into avoidance as a most important mechanism maintaining the eating disorder. Avoidance learning and the generalization of learned avoidance behaviors are discussed, as well as safety behaviors and the need for inhibitory learning as a treatment target during exposure therapy.

The drive for thinness: Towards a mechanistic understanding of avoidance behaviors in a non-clinical population

Fear of weight gain is a cardinal feature of eating disorders, including Anorexia Nervosa (AN). This fear motivates behaviors aimed at avoiding weight gain, such as restricting food intake. Of note, avoidance in AN is not confined to food-related items but extends to intense emotional states. Despite the presence of several forms of excessive avoidance in AN, little is known about the mechanisms underpinning avoidance behavior in AN. In the present exploratory study, we investigated whether university students with an elevated desire to avoid weight gain (as measured through self-reported Drive for Thinness, DT) show deficits in generic avoidance learning. Two-hundred and seventy-five female students filled in the Eating Disorder Inventory-II (EDI-II) and performed a food-unrelated avoidance task. Generalized and linear mixed models (GLMM) revealed that students scoring higher on the DT scale of the EDI-II showed more ineffective avoidance, suggesting a tendency for excessive avoidance in at-risk individuals for AN. Similar results might extend to other eating disorders.

Virtual reality in the treatment of eating disorders

Over the last 25 years, virtual reality (VR) has offered innovative solutions for targeting different key symptoms of eating disorders: from craving to negative emotions, from attentional biases to body dissatisfaction. The present narrative review assesses the existing literature in these areas trying to identify their different levels of clinical evidence. Specifically, the review presents four clinical approaches based upon VR and their implications in the treatment of eating disorders: VR cue exposure, VR reference frame shifting, VR for correcting body distortions and attentional biases. In general, existing findings demonstrate the clinical value of VR. On one side, the present review suggests that two VR-based techniques-VR exposure and reference frame shifting-have a significant research support and provide a possible advantage over traditional cognitive-behavioural therapy (CBT) for bulimia nervosa and binge eating disorder. On the other side, two emerging VR applications-multisensory body illusions and the use of VR for the modification of attentional biases-even if supported by preliminary data still need further research.

Changes in brain and behavior during food-based decision-making following treatment of anorexia nervosa

BACKGROUND

Anorexia nervosa is a severe illness with a high mortality rate, driven in large part by severe and persistent restriction of food intake. A critical challenge is to identify brain mechanisms associated with maladaptive eating behavior and whether they change with treatment. This study tested whether food choice-related caudate activation in anorexia nervosa changes with treatment.

METHODS

Healthy women (n = 29) and women hospitalized with anorexia nervosa (n = 24), ages 18 to 40 years, completed a Food Choice Task during fMRI scanning at two timepoints. Among patients, procedures occurred upon hospital admission (Time 1) and again after patients had gained to normal weight (Time 2). Healthy controls were tested twice at an interval group-matched to patients. Choice-related caudate activation was assessed at each timepoint, using parametric analyses in an a priori region of interest.

RESULTS

Among patients, the proportion of high-fat foods selected did not change over time (p's > 0.47), but decreased neural activity in the caudate after treatment was associated with increased selection of high-fat foods (r₂₃ = - 0.43, p = 0.037). Choice-related caudate activation differed among women with anorexia nervosa vs healthy control women at Time 1 (healthy control: M = 0.15 ± 0.87, anorexia nervosa: M = 0.70 ± 1.1, t₅₁ = - 2.05, p = 0.045), but not at Time 2 (healthy control: M = 0.18 ± 1.0, anorexia nervosa: M = 0.37 ± 0.99, t₅₁ = - 0.694, p = 0.49).

CONCLUSIONS

Caudate activity was more strongly associated with decisions about food among individuals with anorexia nervosa relative to healthy comparison individuals prior to treatment, and decreases in caudate engagement among individuals with anorexia nervosa undergoing treatment were associated with increases in high-fat food choices. The findings underscore the need for treatment development that more successfully alters both eating behavior and the neural mechanisms that guide it.

Motivation to recover for adolescent and adult eating disorder patients in residential treatment

OBJECTIVE

This study aimed to assess how baseline motivation to recover impacts eating disorder (ED) and comorbid symptoms at end-of-treatment (EOT) for adolescents and adults in inpatient/residential treatment.

METHOD

Two hundred and three adolescent (M = 15.90) and 395 adult (M = 25.45) patients with a Diagnostic Statistical Manual, 5th edition ED diagnosis completed the Decisional Balance Scale (DBS) at baseline, and psychosocial measures (ED symptoms, anxiety, depression, obsessive-compulsive disorder symptoms), and %body mass index (kg/m² ; BMI) or median %BMI (for adolescents) at baseline and EOT.

RESULTS

The DBS Avoidance Coping and Burdens subscales at baseline were significantly lower for adolescents than adults (p < 0.001), whereas the DBS Benefits subscale at baseline did not significantly differ between subsamples (p = 0.06). Motivation to recover via DBS subscales was a more reliable predictor of EOT outcomes for both ED and comorbid psychopathology in adults (significant predictor in 19 of 54 total analyses, and 4 significant associations post-Bonferroni correction) than adolescents (significant predictor in 5 of 54 total analyses, and 1 significant association post-Bonferroni correction).

CONCLUSIONS

Baseline motivation to recover may be an important predictor of outcome for adult patients in inpatient/residential treatment but does not appear associated with outcomes for adolescent patients.

Registered report: Initial development and validation of the eating disorders safety behavior scale

Anxiety and eating disorders (EDs) often co-occur, prompting calls to explore anxiety-related maintenance processes in ED samples. Safety behaviors, which function to prevent a feared outcome from occurring or to reduce anxiety associated with a feared stimulus, are observed across anxiety disorders and, along with overt avoidance behaviors, are an important target in treatment. Data suggest that individuals with EDs also engage in safety behaviors. However, no existing assessments provide a comprehensive measure of eating-disorder-specific overt avoidance and safety behaviors. The goal of this Stage 1 Registered Report is to develop a comprehensive self-report measure of ED-specific safety behaviors. In Study 1, we will recruit 50 women with EDs to complete the scale and provide feedback on the response scale. Feedback from these participants will be used to refine the measure. In Study 2, we will evaluate the psychometric properties of the measure in a large sample of women with EDs (n dependent on the size of measurement) and a community sample without current or a history of ED symptoms. We will explore the measure factor structure, known-groups validity by comparing scores from women with EDs to healthy controls, internal consistency, and convergent and divergent validity with other psychological instruments.