Overcoming fear of eating: A case study of a novel use of exposure and response prevention

Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa

BACKGROUND

Anxiety is a core characteristic of anorexia nervosa and a potential target of exposure therapy, which requires a profound understanding of the patients' fears in order to be successful. The knowledge about fears in anorexia nervosa that should be targeted during exposure therapy can be enriched by laboratory research to the precise emotional and behavioral responses of anorexia nervosa patients when they are exposed to disorder relevant fear stimuli.

METHODS

In the laboratory, patients with anorexia nervosa (n = 15) and healthy controls (n = 51) were exposed to 1. their own body weight and a 10% higher body weight on the scale, 2. a standardized lab breakfast, and 3. five virtual bodies with different BMIs ranging from extreme underweight to lower healthy weight. The participants emotional (anxiety, disgust, satisfaction, acceptance) and behavioral responses (calorie consumption) were assessed. Patients with anorexia nervosa but not the healthy controls then received an intensive exposure treatment (~ 30 individual exposure sessions) targeting their individual fears, next to standard care. After the exposure treatment, it was investigated whether the patients' responses to the laboratory tasks changed.

RESULTS

Across all tasks, the patients reported more anxiety than healthy controls. The patients also consumed less calories during the breakfast and accepted the different body weights on the scale less than healthy controls. During the virtual body exposure, the patients' emotional responses did not differ per avatar but they reacted more negatively towards avatars with healthier weights than did healthy controls. After the exposure treatment, the patients reported less fears and they consumed more calories while their BMIs had increased. They were also more accepting of healthier weights.

CONCLUSIONS

Exposure to food-, body- and weight-related stimuli in the laboratory induces emotional reactions in patients with anorexia nervosa that are informative for the identification of exposure therapy treatment targets. In addition, exposure therapy targeting individual fears in patients with anorexia nervosa led to symptom reduction and is a promising intervention for the treatment of anorectic fears, though more research is needed to optimize its efficacy.

Adolescent activity-based anorexia has a substantial and prolonged impact on social behavior in young adult female rats

Activity-based anorexia (ABA) is a rodent model of anorexia nervosa (AN) that induces several key components of AN, including voluntary reduction in food intake, reduced body weight, hyperactivity, and alterations to the hypothalamic-pituitary-adrenal (HPA) axis. Previous research has demonstrated persistently increased anxiety-like behavior in the elevated plus maze (EPM), a test measuring avoidance of novel and open areas in adult female rats that experienced ABA during adolescence and are weight-restored in adulthood. Whether the same behavioral effects of two bouts of adolescent ABA emerge in response to different anxiety-provoking stimuli, however, has not been explored. We used the social partition (SP), novelty suppressed feeding (NSF), marble burying, and EPM tests to explore whether two bouts of adolescent ABA have persistent effects on anxiety-like behavior in weight restored young adult female rats. One-way ANOVA analyses revealed that female rats that experienced two bouts of ABA during adolescence had increased anxiety-like behavior in the EPM and SP tests in young adulthood following weight restoration compared with controls. These data demonstrate that the enduring behavioral effects of two bouts of adolescent ABA are specific to particular anxiety-provoking stimuli and suggest that adolescent ABA has enduring effects on social relationships.

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.

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.

Psychometric properties of the fear of food measure in Japanese women

PURPOSE

The aim of the present study was to investigate the psychometric properties of the fear of food measure (FOFM) in Japanese women.

METHODS

This study was a cross-sectional, observational, and multicenter study conducted at the University of Tokyo and Kyushu University. Participants were comprised of 169 healthy women and 149 patients with eating disorders. First, the present study explored the factor structure of FOFM in Japanese women using exploratory factor analyses. Then, the Cronbach's alpha and McDonald's omega were calculated to assess reliability. Concurrent validity was examined by calculating correlation coefficients with the Eating Attitudes Test, negative affect of Positive and Negative Affect Schedule, and Hospital Anxiety and Depression Scale. Additionally, the Wilcoxon rank-sum test was used to compare scores between the healthy control and patient group.

RESULTS

The final model had four subscales. The subscales, thus, had high reliability and showed significant positive correlations with the questionnaires. The scores of subscales in the patient group were significantly higher than those in the healthy control group.

CONCLUSIONS

The FOFM had a four-factor structure in Japanese women. Its reliability and validity were verified and it could be used as a tool to assess fear of food.

LEVEL OF EVIDENCE

III, case-control analytic study.

Changes in meal-related anxiety predict treatment outcomes in an intensive family-based treatment program for adolescents with anorexia nervosa

Meal-related anxiety in individuals with eating disorders is associated with reduced caloric intake and persisting eating-disordered behaviors, which may reduce the likelihood of attaining or sustaining remission. The current study is the first to examine changes in meal-related anxiety as a predictor of outcomes in the context of a family-based partial hospitalization program. A sample of 51 adolescents with anorexia nervosa or atypical anorexia rated anxiety before and after all treatment meals using the Subjective Units of Distress Scale (SUDS). Regression analyses suggested that participants experiencing a greater reduction in meal anxiety endorsed fewer eating disordered symptoms on the EDE at the end of treatment. Reductions in meal anxiety did not predict EBW at end of treatment, which could be because family-based treatment (FBT) supports adequate food intake regardless of meal anxiety (i.e., parents ensure food intake). Findings suggest that reductions in meal-related anxiety may be an important predictor of outcomes in family-based interventions, and future research is needed to examine if directly targeting meal anxiety may enhance outcomes.

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.

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.

Manipulating the theoretical framing of exposure therapy for eating disorders impacts clinicians' treatment preferences

BACKGROUND

Exposure therapy is the most effective treatment for anxiety and related disorders and its efficacy in the eating disorders is rapidly gaining support. Despite the strong evidence behind exposure therapy, many anxiety disorder providers do not endorse the usage of exposure therapy. Limited research has explored the use of exposure therapy in eating disorder providers, as well as the impact of framing on likelihood to use exposure therapy.

OBJECTIVE

The current study (N = 125 eating disorder providers) manipulated the framing of exposure to feared foods (pizza).

METHODS

We framed the treatment as an exposure, behavioral experiment, or acceptance/mindfulness-based intervention. We also tested attitudes towards exposure therapy in eating disorder providers.

RESULTS

Participants were more likely to endorse willingness to use a treatment framed as a behavioral experiment over exposure and acceptance-based framing. This effect did not vary by degree type, type of provider, years in practice, experience, or training. We also found that providers with more training, specifically in eating disorder exposure, were more likely to use exposure over acceptance-based framed intervention (and vice versa). Finally, we found that eating disorder providers had a somewhat positive view of exposure therapy.

CONCLUSION

Framing of the intervention impacts likelihood that providers will endorse using specific interventions. Therefore, intervention development and dissemination efforts should consider the language around the description of evidence-based treatments. Furthermore, enhanced training and education specifically with eating disorder exposure therapy may enhance the likelihood of providers utilizing exposure therapy. Level I: experimental study.

Exposure with response prevention (ERP) for body dissatisfaction in a group therapy format: an exploratory study

PURPOSE

The aim of this exploratory study was to examine patient satisfaction and outcomes from exposure with response prevention (ERP) delivered in a group therapy format. The group was aimed at addressing eating disorder symptoms associated with body dissatisfaction in the later stages of outpatient treatment.

METHODS

33 adults with a DSM-5 diagnosis of an eating disorder participated in the ERP group. Participants completed pre- and post-ERP group measures of depression, anxiety, self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, upward and downward appearance comparisons, and patient satisfaction.

RESULTS

Involvement in the ERP group was associated with significant decreases in self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, and upward physical appearance comparisons post-group treatment. This adjunct treatment group was well received and viewed as being helpful by participants.

CONCLUSIONS

ERP in a group therapy format for addressing body dissatisfaction may represent a complimentary approach to current evidence-based treatments for an eating disorder, and warrant further investigation.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.