BY: Cheri Levinson, PhD
DATE: August 24, 2015
Anyone who has received treatment for an eating disorder knows that treatment often involves facing fears: whether it is facing feared foods, calories, scales, eating in public, talking about difficult experiences, the list goes on! Although it can be incredibly hard, the good news is that facing feared situations can help with recovery. But why does facing fears help?
Researchers have known for many years that to successfully treat intense anxiety (or anxiety disorders) it is necessary to use a type of intervention called exposure therapy. Exposure therapy is a behavioral intervention that teaches an individual to systematically and gradually face their fears. For example, someone who has a fear of spiders (arachnophobia) would start by looking at pictures of a spider, then work their way up to standing across the room from a spider, and eventually work towards having the spider crawl on them. Exposure therapy works because individuals learn that what they are afraid of is not as scary as they might have thought and that they can tolerate the anxiety that occurs when facing their fears.
What does this have to do with eating disorders? We know that most people (up to two thirds) with eating disorders struggle with heightened anxiety or an anxiety disorder (Kaye et al., 2004). People with eating disorders often struggle with all types of anxiety not related to their eating disorder (social anxiety, worry, OCD, panic attacks) in addition to anxiety about body image, food, and appearance. Given the high rates of anxiety in individuals with eating disorders, it seems likely that exposure therapy might be a promising intervention.
Until recently, there had been minimal research on exposure therapy and eating disorders. However, that is rapidly changing. Researchers have shown that body image anxiety can be successfully treated with mirror exposure, reducing body image distress and increasing body satisfaction (Jansen et al., 2015). In this type of exposure therapy patients create a hierarchy of least to most distressing body parts. Beginning with the least distressing area, and working up to the most distressing area, patients are instructed to view and talk about their body while facing a mirror.
Researchers have also shown that in patients diagnosed with anorexia nervosa, mealtime food exposures are effective at increasing food intake (Steinglass et al., 2014), decreasing anxiety around food, and in exposures facilitated with learning medication, increased weight regain (Levinson et al., 2015). In this type of exposure therapy patients are exposed to feared foods. During the exposure, patients are encouraged to experience (instead of avoid) the resulting anxiety and to refrain from engaging in any avoidance or ritualistic behaviors that serve to temporarily reduce the anxiety.
Some additional types of exposures therapies that are beginning to be investigated are virtual reality exposure and imaginal exposure therapy (imagining a feared scenario). Ultimately, the evidence is beginning to suggest that exposure therapy is an effective intervention to help work toward recovery from an eating disorder. We hope that the future will bring much more research on exposure and its application to eating disorders.
Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., Masters, K., & Price Foundation Collaborative Group. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161:2215-2221.
Jansen, A., Voorwinde, V., Hoebink, Y., Rekkers, M., Martijn, C., & Mulkens, S. (2015). Mirror exposure to increase body satisfaction: Should we guide the focus of attention towards positively or negatively evaluated body parts?. Journal of Behavior Therapy and Experimental Psychiatry, 50:90-96.
Levinson, C.A., Rodebaugh, T.L., Fewell, L., Kass, A., Riley, E.N., Stark, L., McCallum, K., Lenze. E.J. (2015). A pilot randomized control trial of D-cycloserine facilitation of exposure therapy in patients with Anorexia Nervosa. The Journal of Clinical Psychiatry, 76: 787-793.
Steinglass, J. E., Albano, A. M., Simpson, H. B., Wang, Y., Zou, J., Attia, E., & Walsh, B. T. (2014). Confronting fear using exposure and response prevention for anorexia nervosa: a randomized controlled pilot study. International Journal of Eating Disorders, 47: 174-180.