Facing Fears: Exposure and Response Prevention for Anorexia Nervosa

When faced with a meal to eat, what is it that makes the experience so devastatingly challenging for individuals with anorexia nervosa? Patients on our inpatient unit agreed to help us better understand this by having a meal with us, in the research setting. In our initial study, we learned that even at healthier weights mealtimes were very challenging, it was hard to eat adequately, and the fear and anxiety that emerged was observable.

Faced with these results, we next asked, “How can we help?” In light of our findings about mealtime anxiety, we decided to apply the psychotherapy tools that are known to help with anxiety – Exposure and Response Prevention – to the treatment of anorexia nervosa. In our most recent study, we found that taking an Exposure and Response Prevention approach in the treatment of anorexia nervosa led to improvements in eating.

Study Specifics

What was our approach? In Exposure and Response Prevention for Anorexia Nervosa, our study therapists worked with patients to help them describe their fears around eating, going beyond the foods themselves and thinking about all aspects of eating a meal. For example, some individuals with anorexia nervosa described fears of touching foods, or of eating in front of people – or of eating alone. Together, patients and therapists worked to organize these fears in order of difficulty. Over several meetings, therapists guided patients through exposure sessions and created individually-tailored homework assignments allowing them to practice confronting – rather than avoiding – fear and anxiety in a systematic way.  The treatment allowed individuals with anorexia nervosa to have the experience that their worst fears did not come to pass when they challenged themselves in this particular way, and to experience that anxiety can improve over time without avoidance.

How would our approach measure up? To know, we needed to compare it to something. We chose Cognitive Remediation Therapy as our second study treatment. Quite unique from Exposure and Response Prevention, Cognitive Remediation Therapy focuses more on thought patterns than behaviors. In this treatment, patients did a variety of therapist-guided mental exercise to learn about their unique thinking style and how these processes may be limiting them.

Everyone who came to our inpatient unit was offered the opportunity to participate in this study, as an add-on to our standard inpatient clinical program. Those who wanted to participate received 4 weeks of additional individual therapy as part of the study. The specific treatment they got (Exposure and Response Prevention or Cognitive Remediation Therapy) was chosen at random. To see if and how the treatments worked, participating patients ate a meal in our research setting at the start and end the study. We found that the people who had received the Exposure and Response Prevention therapy were able to eat better in this meal than those who had received the Cognitive Remediation Therapy.

Study Results

What do we learn from this study? We learned that changing eating behavior is enormously challenging. We learned that to change behavior, therapy needs to target that behavior directly. For those who struggle with fears about eating, we think we have one new way to help. We were happy to find that patients also felt this approach to treatment was important and helpful. One individual described it well: “This [treatment] is hard, but it’s good. Facing my anxiety about eating while I eat is what I’m going to need to know how to do.”

Still, we know that anorexia nervosa is a very tough illness to treat, and we are not done looking for more and better treatment options.

What are the next steps? As we studied eating behavior in anorexia nervosa more closely, we also learned about the things that patients do automatically. We are now seeking to strengthen our treatment approach by developing methods of targeting those behaviors that may be habitual. Stay tuned!

To read more about the study described above, check out:

Steinglass JE, Albano AM, Simpson HB, Wang Y, Zou J, Attia E, Walsh BT. (2014). Confronting fear using exposure and response prevention for anorexia nervosa: A randomized controlled pilot study. International Journal of Eating Disorders, 47(2),174-80.

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  1. […] Exposure therapy is a psychotherapy known to be highly effective in treating obsessive-compulsive disorder, anxiety disorders, and PTSD. In exposure therapy, therapists coach patients to lean into fears and discomfort – rather than avoiding these experiences – and to learn, through a series of in-session experiments and homework sessions, that they can manage these feelings. With repeated practice, the intensity of the distress may diminish or become easier to experience. At the Columbia Center for Eating Disorders, we have previously adapted this approach to eating- and food-related fears for patients with anorexia nervosa. […]

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