Journal Pre-proof

Exposure therapy for eating disorders: A systematic review

Rachel M. Butler, Richard G. Heimberg

PII: S0272-7358(20)30039-8
DOI: https://doi.org/10.1016/j.cpr.2020.101851
Reference: CPR 101851

To appear in: Clinical Psychology Review

Received date: 17 September 2019

Revised date: 7 March 2020
Accepted date: 10 March 2020

Please cite this article as: R.M. Butler and R.G. Heimberg, Exposure therapy for eating
disorders: A systematic review, Clinical Psychology Review (2019), https://doi.org/
10.1016/j.cpr.2020.101851

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Exposure Therapy for Eating Disorders: A Systematic Review

Rachel M. Butler & Richard G. Heimberg

Department of Psychology, Temple University

Correspondence concerning this article should be addressed to Richard G. Heimberg,

Adult Anxiety Clinic of Temple, Department of Psychology, Temple University, 1701 North

13th Street, Philadelphia, PA, 19122-6085, United States. Email: heimberg@temple.edu. Tel:

(215) 204-1575. Fax: (215) 204-5539.

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Abstract

Exposure therapy is a potential method for the treatment of eating disorders. The current

paper reviews the literature on exposure interventions for eating disorders, including studies (N =

60) on exposure and response prevention (ERP), in vivo feared food exposure, mirror exposure,

family-based treatment with exposure, and virtual reality exposure therapy. Mirror exposure

alone or in the context of cognitive-behavioral therapy (CBT) can decrease body dissatisfaction.

The few controlled trials on ERP for binge and purge cues show only marginal benefit of ERP

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for binge or purge cues over and above other treatment methods such as CBT. In vivo exposure

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to feared foods may decrease state anxiety and increase caloric intake and body mass index, but

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research is limited. Virtual reality exposure could improve accessibility and feasibility of
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exposures in the clinical setting. A significant portion of the trials incorporated exposures into an

overarching treatment such as CBT, body image therapy, or inpatient treatment, so the effects of
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exposure itself are difficult to parse apart. We discuss the state of the current literature in the
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context of learning theory and offer insights into new approaches to the application of exposure

therapy in an eating disordered population.

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Keywords: exposure therapy; eating disorder; anorexia nervosa; bulimia nervosa; binge eating

disorder
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Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), binge-eating

disorder (BED), and other specified or unspecified eating disorders, are accompanied by

significant physical and psychological distress (Berkman, Lohr, & Bulik, 2007). Although the

literature on treatment of eating disorders supports the use of cognitive behavioral therapy or

interpersonal psychotherapy for adults (Fairburn et al., 2015; Kass, Kolko, & Wilfley, 2013) and

family-based treatment for adolescents (Lock, 2015), there are a significant number of

individuals who do not improve during treatment (Wilson, Grilo, & Vitousek, 2007). In

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particular, the rates of recovery for those with AN are low, and even specialized treatments do

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not have long-term effects on weight gain or psychological symptoms for AN (Murray et al.,

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2019). Rates of recovery for BN or BED are higher, but there is still considerable inconsistency
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in terms of treatment efficacy (Berkman et al., 2007). Thus, examination of the literature on

specific treatment approaches for eating disorders that could lead to modification or extension of
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these approaches is warranted.

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Eating disorders are conceptualized as disorders of feeding and weight or shape, and they

can be considered on a spectrum of under- to over-eating (Wade, Bergin, Martin, Gillespie &
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Fairburn, 2006). A transdiagnostic, cognitive behavioral model of eating disorders suggests that
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an underlying over-valuation of weight and shape drives disordered eating behavior (Fairburn,

Cooper, & Shafran, 2003). This over-valuation of weight and shape may be linked to a strong

fear of negative outcomes related to violating the thin ideal. In fact, there is some evidence for an

anxiety-driven model of eating disorders. For example, in an ecological momentary assessment

study, disordered eating behavior (e.g., self-induced vomiting, binge eating, food restriction)

tended to occur at times of high anxiety, and anxiety tended to decrease following disordered

eating behaviors, maintaining their function as methods of reducing anxiety (Lavender et al.,
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2013). Researchers have posited that increased learning of fear associations between food and

the perceived negative outcome of weight gain results in avoidance of food in AN (Strober,

2004). Beliefs that eating or weight gain will lead to catastrophic outcomes are accompanied by

the use of safety behaviors, such as body checking and compulsive behaviors surrounding food,

eating, and body shape or weight. In AN, restriction may be conceptualized as avoidance of food

to reduce the fear of weight gain, whereas in BN, compensatory behaviors such as purging or

excessive exercise serve this purpose. Thus, through these avoidance strategies or safety

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behaviors, individuals with eating disorders maintain the core fear of weight gain by reinforcing

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the fear and the importance of evading the feared outcome. Persons with eating disorders exhibit

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severe anxiety surrounding food and eating, likely because these stimuli are linked to the core
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fear of significant weight gain (Steinglass, Eisen, Attia, Mayer, & Walsh, 2007). Other core fears

may be at play in eating disorders, such as loss of control or fear of feeling or appearing
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disgusting (Cardi et al., 2019; Murray, Loeb, & Le Grange, 2016). Thus, fear and anxiety
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processes are influential in driving compulsive or avoidant behaviors that maintain disordered

eating.
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One avenue for intervention focused on the role of anxiety in eating disorders is exposure
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therapy. Often administered in the context of cognitive behavioral therapy (CBT), exposure

therapy is widely regarded as the gold standard treatment for anxiety and related disorders,

including specific phobia (Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008), panic disorder

and agoraphobia (Gloster et al., 2011), social anxiety disorder (Kaplan, Swee, & Heimberg,

2018), obsessive-compulsive disorder (Greist et al., 2003; Olatunji, Davis, Powers, & Smits,

2013), and posttraumatic stress disorder (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010).

Based on the principles of fear extinction, exposure therapy involves confronting the individual
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with a feared (conditioned) stimulus without the occurrence of the feared outcome

(unconditioned stimulus). Over time, the conditioned stimulus no longer results in anxiety or fear

(conditioned response; Foa & Kozak, 1986; Lovibond, 2004). Alternatively, inhibitory learning

theory suggests that exposure therapy functions to create a new, non-threat association with the

conditioned stimulus, which serves to reduce anxiety and disconfirm the expectation of the

feared outcome (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). In the inhibitory

learning model, exposure is designed to maximize the retrieval of the newly learned non-threat

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association when the feared stimulus is presented.

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Applied to eating disorders, exposure therapy may be utilized to extinguish (or inhibit)

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the association between the feared stimulus and the feared outcome. Traditionally, researchers
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have considered food to be the feared stimulus and changes in weight and shape as the feared

outcome. However, an alternative conceptualization of eating disorders suggests that weight gain
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may be the feared stimulus (CS) paired with feared outcomes (US) such as embarrassment,
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rejection, abandonment, loss of control, or appearing/feeling disgusting (Murray et al., 2016;

Reilly, Anderson, Gorrell, Schaumberg, & Anderson, 2017). Using exposure to break down self-
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concept-related CS-US associations could be key to long-term change in eating disorders.

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Additionally, exposure therapy may assist individuals with eating disorders to develop new

associations to food and eating. Individuals may learn that the feared loss of control does not

occur or that the feelings associated with weight gain are tolerable (Cardi et al., 2019).

Exposure therapy has been investigated as an intervention for eating disorders over the

past several decades (Koskina et al., 2013). However, there is renewed interest in exposure

therapy for eating disorders based on advances in the field, both in the use of exposure therapy

itself and in the conceptualization of how it may be best applied for eating disorders (Murray et
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al., 2016; Reilly et al., 2017). We review the extant literature on exposure therapy for eating

disorders to best understand how it has been implemented in eating disorder treatment to date.

The intention of the current review is to establish the types of feared stimuli exposure therapy

has been used to target in the treatment of eating disorders and to determine whether these

methods have been efficacious. In particular, we are interested in examining whether core fears

in eating disorders have been confronted through appropriate application of exposure therapy.

Recommendations for future research directions based on gaps in the current literature, advances

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in understanding the role of fear in eating disorders, and potential new methodologies are

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delineated.

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Methods
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The present review focuses on the use of exposure therapy in the context of DSM-5

eating disorders including AN, BN, and BED. We utilized PsycINFO, Pubmed, and Google
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Scholar to identify appropriate studies through February 2020. Our search terms included
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combinations of ‘exposure’, ‘exposure therapy’, ‘eating disorders’, ‘anorexia’, ‘anorexia

nervosa’, ‘bulimia’, ‘bulimia nervosa’, and ‘binge eating’. Additionally, we reviewed reference
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sections to identify relevant articles. We included empirical studies published in peer-reviewed

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journals, specifically experimental or clinical trials examining exposure therapy in a sample with

any type of eating disorder. Our original search resulted in 1009 studies. Sources from a previous

review were scanned and included if relevant. Of these, we removed duplicate versions of studies

(n = 502). After examination of abstracts, we selected 165 studies for further screening.

Ultimately, we excluded articles that did not involve the use of exposure techniques (n = 52), did

not include an eating disorder sample or included only avoidant restrictive food intake disorder

(n = 16), were reviews or commentaries (n = 22), or were not published in English (n = 7).
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Uncontrolled case studies (n = 8) were also excluded, although some are cited in text for

historical context or if they provide important basis for the conceptualization of a new type of

exposure therapy for eating disorders. Case series and open trials were included in the review.

The final number of publications included in the systematic review was 60. See the PRISMA

diagram (Figure 1) and supplementary Table A.1 for more information about studies included in

the systematic review.

Results

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Exposure and Response Prevention - Purge

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Early studies sought to examine the effects of exposing individuals with BN to a binge, in

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other words, eating typical binge foods in large quantities, and preventing purging behaviors
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(ERP-purge). The theory was that engaging in purging behaviors maintains the binge eating

episodes by removing the threat of weight gain associated with binge eating. Inhibiting purging
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should reduce or eliminate binge episodes by removing the relief from anxiety that vomiting
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allows and reinstating the fears associated with binge episodes (Rosen & Leitenberg, 1982). In

the first report of this treatment, Rosen and Leitenberg (1982) described the case of a 21-year-old
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woman who underwent 18 total sessions of exposure to a large and uncomfortable amount of
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food, intended to induce the urge to vomit, and then was prevented from vomiting. After a course

of ERP-purge for each type of food (large meal, junk food, snack food), the amount of food eaten

increased, distress decreased, and urge to vomit decreased. Several small single-case design

studies used this approach, finding some reduction in bingeing and purging following ERP-purge

(e.g., Leitenberg, Gross, Peterson, & Rosen, 1984; Rossiter & Wilson, 1985). For example,

Leitenberg et al. (1984) used a multiple baseline design to administer ERP-purge to five women

with BN. ERP-purge was administered in three blocks of six sessions, each block focusing on a
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different type of binge food. Within-session, there was a decrease in patients’ distress and urge to

vomit over time once eating concluded, and there was a significant reduction in binge eating and

vomiting at posttreatment. Another study randomized 45 women with BN to either ERP-purge in

one setting, ERP-purge in multiple settings, CBT without ERP (i.e., self-monitoring of eating

and vomiting, emphasis on importance of regular meals and exercise), or a wait list condition

and found that both ERP-purge conditions outperformed CBT in terms of decrease in vomiting

frequency and increase in amount of food eaten without vomiting at posttreatment and follow-up

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laboratory test meals (Leitenberg, Rosen, Gross, Nudelman, & Vara, 1988). However, these

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findings must be interpreted cautiously due to the small number of participants in each condition.

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Another open trial of ERP-purge was conducted with 34 participants (33 females, 1 male)
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with BN (Giles, Young, & Young, 1985). To our knowledge, this was the first examination of

ERP for binge and purge symptoms to include a male participant. At the end of treatment (M =
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11.6 sessions), 20 participants were classified as significantly improved (> 80% reduction in
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purging) and 2 were classified as improved (> 50% reduction in purging). Six participants were

non-responders to ERP-purge methods, and six dropped out of the study. Thus, for some, ERP-
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purge reduced symptoms of purging, but for others the approach was not as useful. Interestingly,
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in an uncontrolled case series, ERP-purge was associated with significant reductions in vomiting

(> 90%) in three individuals with BN and Type I diabetes (Spurdle & Giles, 1990).

Research has endeavored to determine whether the addition of ERP to other approaches

such as CBT (i.e., self-monitoring, cognitive restructuring, and behavioral experiments to

challenge dysfunctional beliefs) enhances outcomes. A randomized controlled trial (RCT)

compared cognitive restructuring, a component of CBT, to cognitive restructuring plus ERP-

purge for 17 women with BN. The addition of ERP-purge improved binge/purge abstinence rates
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(33% abstinence for cognitive restructuring; 71% for cognitive restructuring plus ERP-purge),

and the difference between conditions grew larger at one-year follow- up (Wilson, Rossiter,

Kleinfield, & Lindholm, 1986). However, the sample was too small for appropriate between-

group comparisons. Wilson, Eldredge, Smith, and Niles (1991) compared CBT, including self-

monitoring of eating behaviors and cognitive restructuring, to CBT with ERP-purge in a sample

of 22 participants with BN. CBT and CBT plus ERP-purge conditions performed similarly in

that both groups demonstrated reductions in frequency of binge eating and purging, eating

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concerns, attitudes toward body weight and shape, restrained eating, self-esteem, and depression.

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In this study, however, ERP-purge did not have an additive effect beyond CBT, but again the

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small sample size is limiting. Agras, Schneider, Arnow, Raeburn, and Telch (1989) randomized
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77 women with BN to either self-monitoring of caloric intake and purging behaviors, CBT, CBT

plus ERP-purge, or a wait list control condition. Although purging decreased in all groups, CBT
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resulted in greater reductions in purging at 6-month follow-up than CBT plus ERP-purge. ERP-
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purge may be implied in the instructions of CBT (but not cognitive restructuring; Wilson et al.,

1986) because in CBT, participants are encouraged to eat regular meals and to resist the urge to
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purge at home. If so, ERP-purge may still be an active component implicit in CBT.
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Additionally, researchers have combined ERP-purge with other interventions such as

energy balance training, which limits the ability to determine the specificity of ERP-purge’s

effects on BN symptoms. Johnson, Schlundt, Kelley, and Ruggiero (1984) examined the effects

of an intervention of ERP and energy balance training (i.e., teaching balanced eating and

exercise habits for weight control) on purging behaviors in a sample of women with BN (N = 6).

Qualitative inspection of the reduction of vomiting frequency before and after the intervention

suggests that four of the five treatment completers’ symptoms improved. Similarly, Johnson,
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Schlundt, and Jarrell (1986) administered an intervention comprising 16 weeks of ERP-purge,

energy balance training, and personal social problem solving to 12 women with BN. Overall, the

eight treatment completers reported an 89.9% reduction in vomiting frequency and demonstrated

significant improvements on self-report measures of psychosocial functioning. However, the

study did not examine treatment components, so it is impossible to conclude whether

improvements resulted from ERP-purge, energy balance training, personal social problem

solving, or some combination thereof. Additionally, the researchers collected data on number of

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food intakes per day rather than binge eating episodes, which limits conclusions about the effects

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of the treatment on binge eating.

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Exposure and response prevention for bulimia has also been investigated in a group
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therapy setting. Gray and Hoage (1990) conducted a 6-week, 12 session ERP-purge group

intervention for BN in a sample of eight women compared to wait list controls (n = 4). All but
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one of the participants in the ERP-purge group experienced a reduction in binge and purge
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frequency to under 25% of their baseline as well as reductions in depression. The wait list group

experienced no changes in the same time period.

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Exposure and Response Prevention - Binge

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The previous studies focused on exposure to eating binge food and the prevention of

purging. Others have examined the efficacy of cue exposure to typical binge foods (conditioned

stimulus) but with an emphasis on the prevention of bingeing (conditioned response; ERP-

binge). The intention of ERP-binge is to attenuate the urge to binge on typical binge foods by

breaking the association between the conditioned stimulus and response. In ERP-binge,

participants are instructed to smell or taste the typical binge food, but they are prevented from

eating it. Urges to binge often decrease from one session to the next in ERP-binge, suggesting
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that between-session habituation of urges to binge occurs (Neudeck, Floren, & Tuschen-Caffier,

2001). Schmidt and Marks (1988) exposed four women with BN to typical binge foods and

prevented them from bingeing. Two patients experienced large reductions in the frequency of

binge episodes during treatment, a third patient improved following treatment, and the fourth

dropped out. When comparing ERP-binge (n = 7) to a self-control treatment condition (n = 7)

focused on cognitive restructuring and coping with stress, both treatment conditions resulted in

decreased frequency of binges, depression, and belief in irrational thoughts at posttreatment

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(Jansen et al., 1992). However, at follow-up, the proportion of participants abstaining from binge

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eating was higher in the ERP-binge condition. The only study to implement ERP-binge for

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females with BN (n = 13) and AN-binge/purge subtype (AN-B/P; n = 7) found that the urge to
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vomit, guilt, tension, and lack of control decreased within individual sessions and from pre- to

posttreatment, and there were few differences between the AN-B/P and BN groups (Kennedy,
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Katz, Neitzert, Ralevski, & Mendlowitz, 1995).

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Researchers have also endeavored to use ERP-binge methods as a second line of

treatment for treatment-resistant individuals with BN. In an open trial, Martinez-Mallen et al.
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(2007) administered ERP-binge to adolescent girls (N = 25) who were non-responsive to six to
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eight months of treatment as usual (i.e., CBT and pharmacological treatment). ERP-binge

prompted reductions in binge episodes at 6-month follow-up, but no changes in the frequency of

purging were found. Additionally, disordered eating symptoms, trait anxiety, and depression

decreased from pre- to posttreatment and were maintained at 6-month follow-up. Further, ERP-

binge shows promise for treatment-resistant adults with BN; a case series reported that five of six

women who underwent ERP-binge had decreases in frequency of binge and purge episodes at

posttreatment, and all six patients reported binge and purge abstinence at four to 20-month
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follow-up (Toro et al., 2003). ERP-binge may be a useful approach for those with BN who are

non-responsive to other types of treatment.

ERP-Binge and ERP-Purge

Whereas the prior studies examined ERP-binge and ERP-purge as separate interventions,

some researchers have administered courses of treatment including both ERP-binge and ERP-

purge. Cooper and Steere (1995) compared CBT (n = 13) to an intervention which included four

sessions of ERP-purge followed by four sessions of ERP-binge (n = 14) for women with BN.

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Both conditions resulted in large reductions in binge/purge frequency, but CBT and ERP did not

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differ on magnitude of reduction at posttreatment. At 12-month follow-up, vomiting frequency

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tended to increase in ERP and decrease in CBT. Although the authors did not analyze baseline
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differences in severity by condition, they report that in the month prior to treatment, binge

episode frequency was 30.4 for ERP and 21.9 for CBT, and vomiting frequency was 79.9 for
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ERP and 36.1 for CBT, suggesting that baseline severity in the ERP condition was greater. This
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may account for the greater tendency toward relapse in the ERP condition at follow-up. It is also

possible that combining the ERP-purge and ERP-binge conditions diluted the effects of the
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interventions because fewer sessions were devoted to each.

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Researchers have also endeavored to compare the outcomes of ERP-binge and ERP-

purge interventions to determine which would be most successful at reducing binge eating and

purging behaviors in BN. Schmidt and Marks (1989) compared ERP-binge and ERP-purge for

women with BN (N = 11). Patients crossed over and received both ERP variations, but only 5 of

the 11 patients completed both phases of the treatment, making the second phase of the crossover

design uninterpretable. First phase results suggested that both ERP-binge and ERP-purge

produced within-session reductions in urges to binge or purge as well as actual binge/purge

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behaviors at home (Schmidt & Marks, 1989). In an RCT, Bulik, Sullivan, Carter, McIntosh, and

Joyce (1998) administered 8 sessions of CBT to 135 women with BN and then randomized

participants to receive 8 sessions of ERP-binge, ERP-purge, or a relaxation control condition. At

posttreatment, ERP-binge and ERP-purge produced rates of binge/purge abstinence comparable

to the relaxation training group, and all three conditions led to decreases in the rates of binge and

purge behaviors beyond that produced by the initial 8 sessions of CBT. At 3-year follow-up,

those receiving ERP-binge or ERP-purge did not clearly outperform those in the relaxation

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training condition, although treatment effects were stable and 85% of participants no longer met

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criteria for BN (Carter, McIntosh, Joyce, Sullivan, & Bulik, 2003). However, at 5-year follow-

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up, the ERP-binge and ERP-purge groups demonstrated greater increases in rates of binge
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abstinence from pretreatment to 5-year follow-up and lower rates of purging behaviors over the

course of the 5-year period than the relaxation group (McIntosh et al., 2011). No other
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differences on measures of psychological symptoms were found between treatment conditions at

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follow-up periods. It is possible that the 8-weeks of CBT prior to randomization led to

improvements in all conditions, but ERP-binge and ERP-purge resulted in longer-term reduction
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in symptoms of BN.
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ERP-binge and ERP-purge are feasible and acceptable interventions for bulimia and

possibly for AN-B/P. In some cases, ERP-binge and ERP-purge outperform other interventions

for BN (e.g., Leitenberg et al., 1988). In other cases, ERP-binge and ERP-purge seem to produce

improvements comparable to other interventions for BN in the short-term (e.g., Cooper & Steere,

1995) and sometimes outperform other interventions at long-term follow-up (McIntosh et al.,

2011). ERP-binge may enhance outcomes for those who are not responsive to other modalities of

treatment for binge and purge symptoms and could be applied as a second-line treatment.
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Finally, other interventions including CBT sometimes resulted in greater improvements than

ERP-binge or ERP-purge (e.g., Agras et al., 1989). The shortage of RCTs investigating ERP-

binge and ERP-purge that are appropriately powered is of concern. Given that most of the

research reviewed above relied on small sample sizes, evidence for the efficacy of ERP-binge

and ERP-purge for BN and AN-B/P is mixed. It should be noted that ERP-binge and ERP-purge

are treatments targeting symptoms of BN, binge eating and purging, but they do not directly

address any underlying fears or beliefs that may be maintaining the disorder, such as a fears of

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weight gain, loss of control, or rejection. This may account for some of the mixed findings on the

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efficacy of ERP-binge and ERP-purge.

Feared Food Exposures

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AN is characterized by restriction and avoidance of feared foods. AN can be

conceptualized as resulting from learning to associate food with catastrophic feared outcomes
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such as weight gain or loss of control, thus developing an intense fear and avoidance of food and
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eating situations (Steinglass et al., 2011). Those with AN often employ safety behaviors to

reduce anxiety surrounding food and eating (Cardi et al., 2019). These safety behaviors (e.g.,
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restriction, calorie counting, cutting food into small bites, avoiding “forbidden foods”) result in
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low weight and maintenance of the disorder. Exposure and response prevention has been an

effective method of reducing distress and use of safety behaviors or avoidance in anxiety

disorders by weakening the association between the conditioned stimulus and the conditioned

response (Rupp, Doebler, Ehring, & Vossbeck‐Elsebusch, 2017). Thus, exposure and response

prevention may be a useful treatment for AN, specifically by extinguishing the association

between the feared stimulus (e.g., food and eating) and the feared outcome (e.g., weight gain,

discomfort, rejection). Ostensibly, weakening the fear learning for patients with AN would lead
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to reductions in anxiety and safety behaviors such as restriction and food avoidance as well as

increased weight gain.

In vivo exposure to feared foods and response prevention (AN-ERP) may be a promising

route for addressing the role of fear of food on maintenance of AN. In a case study, a woman

attending inpatient treatment underwent AN-ERP and exhibited increased caloric intake,

decreased eating disorder-related rituals and preoccupations, and qualitative changes in her

thoughts during the meals (Glasofer, Albano, Simpson, & Steinglass, 2016). A case series

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demonstrated that state anxiety and food avoidance ratings decreased over the course of AN-

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ERP, and this predicted an increase in caloric intake at posttreatment (Steinglass et al., 2012);

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however, this was found in a very small sample (N = 9), and patients were simultaneously in
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inpatient treatment. In an RCT comparing AN-ERP (n = 16) to cognitive remediation therapy (n

= 16), which focuses on increasing cognitive flexibility, AN-ERP produced greater increases in
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caloric intake in a laboratory test meal from pre- to posttreatment, and decreases in state anxiety
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predicted increases in caloric intake in the AN-ERP condition (Steinglass et al., 2014). However,

the mean caloric intake increase in AN-ERP at the posttest meal was only 49 kcal, which may
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not be clinically meaningful. The above studies provide preliminary evidence that AN-ERP may
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decrease anxiety and promote greater caloric intake in patients with AN, but further research is

needed with larger sample sizes.

Researchers have also examined ways to augment learning during in vivo food

exposures. D-cycloserine (DCS), a drug which has been found to promote learning during

exposure therapy by expediting fear extinction (Norberg, Krystal, & Tolin, 2008), has been

implemented during exposure to feared foods in patients with AN. A small sample of inpatients

(N = 11) with AN or eating disorder not otherwise specified (EDNOS) were randomized to
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receive either DCS or placebo during four laboratory exposure meals. Overall, patients’ caloric

intake increased from pre- to posttest, and post-meal fear decreased; however, there were no

differences between the DCS and placebo conditions (Steinglass et al., 2007). Inclusion of a

small sample and concurrent inpatient treatment make the findings difficult to interpret.

Levinson et al. (2015) randomized patients in partial hospitalization to receive either DCS (n =

20) or placebo (n = 16) during mealtime exposures and found that those receiving DCS

experienced a greater increase in body mass index (BMI) across four sessions of exposure. Thus,

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DCS may assist learning during mealtime exposures and enhance weight gain in those with AN.

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Patients with AN have learned fear associations toward food and eating situations, and DCS may

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help disrupt these associations to promote learning of new associations in these situations.
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The aforementioned research on feared food exposure was conducted concurrently with

inpatient or partial hospitalization, making the effects of in vivo food exposure difficult to parse
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apart from contemporaneous treatments. Additionally, patients undergoing in vivo exposure for
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AN have all been weight restored (BMI > 18.5), indicating that they are at a later stage of

treatment. Cardi et al. (2019) sought to address these factors by examining in vivo feared food
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exposure for individuals with AN who were not otherwise in treatment (N = 18). Instead of
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focusing on habituation of fear, the exposure sessions focused on violating expected feared

outcomes (e.g., fear of losing control, fear of changing shape quickly), consistent with an

inhibitory learning approach to exposure therapy (Craske et al., 2014). In this open trial, patients’

BMI increased significantly, and anxiety and eating disorder psychopathology, such as restraint,

eating concern, and preoccupations, decreased through treatment. Furthermore, patients

expressed a desire to continue exposure to feared foods and a greater confidence in their ability

to change. Similarly, in a case series of adults with any eating disorder in an inpatient hospital
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setting (N = 106), food-based exposure therapy resulted in decreases in anxiety about eating,

feared outcomes of eating, and compensatory behaviors (Farrell, Bowie et al., 2019). Increased

self-efficacy surrounding eating and the ability to tolerate the feared outcome may be one

mechanism for change in eating disorder-related cognitive processes.

Future research using RCTs for individuals with AN who are not in another form of

treatment is needed to determine whether AN-ERP is an effective form of treatment for AN.

However, initial studies suggest that exposure to feared foods assists in reducing state anxiety

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(Cardi et al., 2019; Steinglass et al., 2012; Steinglass et al., 2014) and can result in increases in

ro
caloric intake (Steinglass et al., 2012; Steinglass et al., 2014) and weight gain (Cardi et al.,

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2019). More research is needed to determine whether the effects of AN-ERP are a result of a
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reduction in safety behaviors, which in turn promotes weight gain and reduces food-related

anxiety. Additionally, as fear of food is essentially derived from negative beliefs about the
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consequences of eating (e.g., weight gain, loss of control, disgust, rejection), research is needed
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to clarify whether reducing fear of food through in vivo food exposure will translate into changes

in the core fears maintaining eating disorders.

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Body Image Exposures

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A core feature shared by AN and BN is the presence of body image disturbance, or a

distorted, highly negative perception of one’s own body shape or weight (Cash & Deagle, 1997;

Forrest, Jones, Ortiz, & Smith, 2018). Additionally, it has been posited that BED is maintained

by dissatisfaction or embarrassment about one’s body, as individuals with BED have poorer

body image than weight-matched controls (Ahrberg, Trojca, Nasrawi, & Vocks, 2011; Lewer,

Nasrawi, Schroeder, & Vocks, 2016). For example, Naumann, Trentowska, and Svaldi (2013)

found that individuals with BED had increases in salivation and desire to binge in response to
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viewing their own body, whereas controls did not, suggesting that body dissatisfaction plays a

role in the maintenance of food cravings or urges to binge eat. Body image disturbance and body

dissatisfaction are risk factors for the development of eating disorders, suggesting that they are

important aspects to target during interventions for eating disorders (Stice & Shaw, 2002). Often,

body image disturbance is associated with feelings of fear or disgust toward one’s body (Stasik-

O’Brien & Schmidt, 2018). Furthermore, dissatisfaction with body shape and weight can lead

individuals to avoid viewing their body in the mirror or avoid looking at the parts of their body

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with which they are most dissatisfied or disgusted (Shafran, Fairburn, Robinson, & Lask, 2004).

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On the other hand, it can also lead to body-related safety behaviors such as compulsive body

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checking (e.g., pinching fat on the body, repeatedly checking waist size, etc.; Shafran et al.,
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2004). In fact, body checking may be a core transdiagnostic symptom of eating disorders

(Forbush, Siew, & Vitevitch, 2016). By improving body image and addressing body-related
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safety behaviors, interventions may subsequently reduce eating disorder pathology.

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Interventions such as mirror or video exposure are designed to help individuals confront

their body image and acquaint themselves with the discomfort, tension, and negative emotions
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that may be experienced when viewing their bodies (for a review, see Griffen, Naumann, &
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Hildebrandt, 2018). In systematic mirror exposure, individuals view their body in a full- length or

tri-fold mirror so as to view the body from all angles (Tuschen-Caffier, Pook, & Frank, 2001). In

theory, systematic body image exposure should allow negative emotions such as fear of ones’

body and the associated avoidance of body or body-related activities to diminish over repeated

exposure sessions. In fact, within-session and between-session decreases in negative thoughts

and emotions as well as increases in positive emotions occurred during body image video

exposure for those with BN (Trentowska, Svaldi, Blechert, & Tuschen-Caffier, 2017). Likely,
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the mirror or video exposure experience presents disconfirming evidence regarding overly

negative body-related thoughts and emotions.

Research has compared the effects of mirror exposure for individuals with eating

disorders and controls in an attempt to determine whether those with eating disorders respond

differently to confronting their body image. One session of video exposure to one’s body

allowed 18 women with AN to appraise their body size more realistically (Rushford &

Ostermeyer, 1997). In fact, women with AN show the greatest changes in body size estimation

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following mirror or video exposures when compared to those with BN or controls (Norris, 1984;

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Rushford & Ostermeyer, 1997). During two mirror exposure sessions, individuals with BED (n =

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30) experienced more negative mood and higher frequency of negative cognitions than controls
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(n = 30), but both groups experienced a decline in negative mood and cognitions between

sessions one and two (Hilbert, Tuschen-Caffier, & Vögele, 2002). Similarly, those with BED (n
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= 60) vocalized more negative body-related cognitions and fewer positive or neutral cognitions
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than controls (n = 60) during a 5-minute mirror exposure (Baur, Krohmer, Tuschen-Caffier, &

Svaldi, 2019). In one session of mirror confrontation separated into four 10-minute exposures,
ur

women with an eating disorder (n = 21) experienced greater increases in negative emotions after
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the first 10-minute exposure compared to controls (n = 28), and both groups experienced

increased skin conductance response (Vocks, Legenbauer, Wächter, Wucherer, & Kosfelder,

2007). Nevertheless, a decrease in negative emotions occurred for both groups from pre- to

posttest. Across four sessions of mirror exposure in which participants had to describe different

areas of their bodies nonjudgmentally, 19 women with BN and EDNOS experienced a greater

decrease in negative thoughts and emotions and a greater increase in positive emotions than 19

controls (Trentowska, Bender, & Tuschen-Caffier, 2013). It appears that, although both controls
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and individuals with eating disorders tend to experience decreases in negative mood, emotions,

and thoughts, and increases in positive emotions during body image exposure, changes may be

greater for those with eating disorders. This suggests that individuals with eating disorders have

capacity for improvement in the experience of their bodies during body image exposure.

Experimental research has also investigated whether different methods of body image

exposure differentially activate negative emotions and thoughts. Tuschen-Caffier, Vögele,

Bracht, and Hilbert (2003) compared body image exposure via video-recording to an imagery

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task in which women gave a detailed, realistic description of their own body. For both women

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with BN (n = 20) and controls (n = 20), negative emotions increased during both exposure types;

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those with BN experienced greater increases in tension, anxiety and insecurity than controls
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during video confrontation but not the imagery task. In both imagery and video exposure, those

with BN reported more sadness compared to controls, and video exposure elicited higher sadness
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ratings than the imagery task for both groups. Importantly, participants with BN gave shorter
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descriptions of hips, waist, and bottom areas than controls during video exposure, suggesting

more avoidance of these difficult body areas. Video exposure may help those with BN approach
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rather than avoid the difficult thoughts and emotions tied to their body image.
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In clinical samples of individuals with BN and EDNOS, guided video and mirror

exposure have led to declines in body shape concerns, eating concerns, and restraint

(Trentowska, Svaldi, & Tuschen-Caffier, 2014). Additionally, pure mirror exposure (i.e., mirror

exposure focused on self-directed observation of the body and its parts without resisting it, while

verbalizing thoughts or feelings that come up) has been compared to guided exposure, during

which attention is directed to specific body areas that participants are asked to describe in

detailed, nonjudgmental language. In a sample of women with BN and high body dissatisfaction,
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pure mirror exposure (n = 14) outperformed guided mirror exposure (n = 15) in increasing body

satisfaction at the end of exposure sessions, and within-session decrease in subjective discomfort

ratings occurred during pure but not guided exposure (Díaz-Ferrer et al., 2015). In pure mirror

exposure, participants may be attending to feared body areas on their own and thus habituating

more quickly. Guiding participants to benign areas first (e.g., the head) may result in a lack of

habituation by end of session and poorer outcomes when compared to pure mirror exposure.

Other factors such as visual attention or body checking may affect whether mirror

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exposure is effective. Research demonstrates that individuals with eating symptomatology

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exhibit biased direction of visual attention toward self-defined unattractive body parts compared

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to attractive body parts, whereas controls exhibit bias in the opposite direction (Freeman et al.,
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1991; Jansen, Nederkoorn, & Mulkens, 2005). Body checking may also affect whether exposure

reduces negative emotions. One study found that for women with an eating disorder (N = 21),
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higher baseline rates of habitual body checking predicted slower declines in negative emotions
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during mirror exposure (Vocks, Kosfelder, Wucherer, & Wächter, 2008). Visual attention to self-

defined unattractive body parts and body checking could be conceptualized as a safety behavior
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that, if engaged in, might diminish the efficacy of mirror exposure.

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Mirror exposure has also been compared to non-directive body image therapy, focused on

discussion of one’s development of body image, cultural influences on body image, and body-

related thoughts and feelings. An acceptance-based mirror exposure protocol focused on

nonjudgmental appraisal of the body as a whole, rather than honing in on distress-inducing body

parts, was originally tested against non-directive body image therapy in a nonclinical sample and

demonstrated improvements for body dissatisfaction (Delinsky & Wilson, 2006). Hildebrandt,

Loeb, Troupe, and Delinsky (2012) extended this research by comparing acceptance-based
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mirror exposure (n = 17) to a non-directive body image therapy (n = 16) in a weight restored,

transdiagnostic sample of women and men with any eating disorder. Those in the acceptance-

based mirror exposure condition showed improvements in eating disorder symptoms, especially

body checking, shape and weight concerns, and eating-related obsessions. Based on this

research, an acceptance-based approach to mirror exposures may be a more efficacious method

of improving body image than non-directive body image therapy.

Mirror exposure has also been integrated into CBT treatment programs. A case study of

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CBT with an emphasis on mirror exposure for a patient with BN showed promising reductions in

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binge and purge symptoms as well as decreases in body checking and body shape concerns to

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levels comparable to non-eating disordered college age women (Delinsky & Wilson, 2010).
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Another case series incorporated mirror exposure into an ACT intervention for anorexia,

showing improvements in symptoms and quality of life (Berman, Boutelle, & Crow, 2009).
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Hilbert and Tuschen-Caffier (2004) randomized a sample of women with BED to either group
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CBT with body image exposure (n = 14) or group CBT with cognitive restructuring related to

body image (n = 14). Participants in both conditions experienced substantial reductions in

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negative body-related cognitions, weight and shape concerns, body dissatisfaction, restraint,
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eating concerns, and depression across treatment, but no differences were found between

conditions on any outcomes. However, only four of the 19 therapy sessions were dedicated to

body exposure or body-related cognitive restructuring, which may have diluted the ability to

detect differences between treatments. Body image therapy incorporating mirror exposure into a

ten-session group for 53 women and two men with AN produced decreases in body-related

checking and avoidance and improvements in eating disorder symptoms (Morgan, Lazarova,

Schelhase, & Saeidi, 2014). Because there was no control condition, we cannot determine
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whether the effects of body image therapy for AN go beyond adjustment to the body that occurs

with time. Mirror exposure focused on negatively and positively appraised body parts was

incorporated into group CBT for individuals with AN, BN, and EDNOS (n = 17); individuals

experienced reductions in negative emotions and cognitions during exposure sessions compared

to non-eating disordered controls who had not undergone therapy (Vocks, Wächter, Wucherer, &

Kosfelder, 2008). Further, group CBT incorporating exposure to appearance (i.e., mirror

exposure) and body image triggers improved body image, decreased body avoidance, and

of
promoted more realistic body size ideals for 22 women with eating disorders compared to those

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in a wait list condition (n = 24; Bhatnagar, Wisniewski, Solomon, & Heinberg, 2013). Although

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this research supports the feasibility of incorporating mirror exposure into CBT for eating
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disorders, we cannot distinguish the effect of mirror exposure from that of CBT in these studies.

Body image group therapy, incorporating in-session mirror exposure as well as at-home
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exposure to body-related feared situations, has been implemented in diverse samples, including
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those with BED, AN, BN, and EDNOS. Lewer et al. (2017) randomized women with BED to ten

sessions of body image group therapy (n = 15) or a wait list condition (n = 21). Compared to the
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wait list, body image therapy was associated with greater reductions in drive for thinness, body
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dissatisfaction, and eating, weight, and shape concerns. After completion of a partial

hospitalization program, Trottier, Carter, MacDonald, McFarlane, and Olmsted (2015) compared

maintenance treatment as usual, which involved 2-5 group therapy sessions per week (n = 23) to

maintenance treatment as usual plus five sessions of body image exposure therapy (n = 22) in a

transdiagnostic sample of women with eating disorders in partial remission. Body image

exposure therapy produced greater reductions in body image avoidance than maintenance

treatment as usual. Key et al. (2002) found that, in a sample of women with AN, a group therapy
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incorporating mirror exposure (n = 9) was more efficacious for reducing body dissatisfaction and

body avoidance than a group therapy focused on challenging thoughts and avoidance behaviors

(n = 6). Treatments incorporating both mirror exposure and at-home exposures related to body

image avoidance and body checking produce promising results for reduction of body image-

related difficulties (Lewer et al., 2017; Trottier et al., 2015). Farrell et al. (2019) used an

inhibitory learning approach by incorporating body-image-related exposures with feared food

exposures to created hierarchies of mixed exposure types, and extinction learning was deepened

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by combining hierarchy items. After four weeks, patients reported lower eating disorder

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symptoms, body checking, and fear of food.

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Mirror and video exposure for body image distortion improves body image, reduces body
re
checking, avoidance, and dissatisfaction, and promotes more realistic perception of body size for

those with eating disorders. There is research on the application of mirror exposure in samples
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with BN, AN, BED, and EDNOS; however, there are few studies in samples with AN alone.
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Further research is needed given that perceptions of body weight and shape are severely distorted

in those with AN (Mölbert et al., 2017). Additionally, there are almost no studies including male
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participants, which limits our understanding of whether mirror exposure can improve body
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image in men with eating disorders. Body image exposure therapy also reduces behavioral

avoidance of body image-related triggers, which may help break the cycle of maintaining fear

through avoidance. Mirror and video exposure as well as exposure to body image-related cues

are appropriate components of CBT for treatment of body image disturbance.

Family-Based Exposure and Response Prevention

Exposure therapy for eating disorders has largely been studied in adult populations.

However, because the onset of eating disorders often occurs during middle or late adolescence
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(Stice, Marti, & Rohde, 2013), it is crucial to tailor exposure-based interventions to the

adolescent population. Research shows that family-based treatment, a manualized treatment for

AN which involves the adolescent’s family in therapy, is efficacious (Lock, Agras, Bryson &

Kraemer, 2005) and may even out-perform CBT when considering short-term outcomes (Le

Grange, Lock, Agras, Bryson, & Jo, 2015). This suggests that the incorporation of family

members in therapy for adolescents with AN adds important value. In particular, for exposure-

based interventions, parents may be trained in the principles of exposure therapy and may

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facilitate at-home exposures, which may increase the frequency of exposures in which an

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adolescent may engage, increasing the dose of treatment the adolescent receives.

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Family based treatment has been modified to include explicit exposure therapy
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components (FBT-E) and has been piloted in small samples of girls with AN. In a case series, 10

outpatients with AN designed food-related fear and avoidance hierarchies with their parents and
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engaged in at-home food exposures with parents as facilitators while also eliminating avoidance
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behaviors (Hildebrandt, Bacow, Grief, & Flores, 2014). Additionally, Iniesta Sepúlveda et al.

(2017) augmented CBT for adolescents by requiring parental involvement in a case series of
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eight adolescent girls with AN in which ERP (e.g., in vivo food exposure, mirror exposures,
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cooking) was the primary focus of treatment. In both family-based exposure interventions for

AN, decreases in eating psychopathology and anxiety and increases in measures of body weight

occurred (Hildebrandt et al., 2014; Iniesta Sepúlveda et al., 2017). Further, Iniesta Sepúlveda et

al. (2017) found that body checking, eating disorder-related preoccupations and compulsions,

and quality of life improved following treatment. These initial studies of exposure-based

interventions with family members for AN are promising in terms of feasibility and potential for

reduction in symptoms of AN. However, RCTs are needed to determine whether there is added
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benefit of parental involvement in exposure therapy, and adolescents with diagnoses of BN and

BED must also be included.

Virtual Reality Exposures

The use of virtual reality (VR) software to facilitate exposure therapy for eating disorders

has garnered attention in the past two decades (see Ferrer-Garía & Guttierez-Maldonado, 2012,

for a review). Researchers have proposed that VR-based exposures increase ecological validity

by creating realistic environments in which the person might normally experience a binge

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episode or food-related anxiety (e.g., a kitchen). For those with eating disorders, food in VR

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elicits emotional responses comparable to real food (Gorini, Griez, Petrova, & Riva, 2010), and

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high calorie foods in specific VR environments can provoke food cravings, anxiety, and even
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body image dissatisfaction (Ferrer‐García et al., 2013; Gutiérrez-Maldonado, Ferrer-García,

Caqueo-Urízar, & Moreno, 2010). Even the presence or absence of other people in a VR
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environment can affect craving in response to food cues (Pla-Sanjuanelo et al., 2015).
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Researchers have used information about eliciting cravings and anxiety in VR environments to

design realistic VR interventions for eating disorders (e.g., kitchen settings, high calorie foods;
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Ferrer‐García et al., 2017).

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VR exposure therapy has been utilized for treatment of body image disturbances through

exposure to body shape and weight stimuli, replicating interventions such as mirror or video

exposure (Ferrer-García & Gutiérrez-Maldonado, 2012). In a small RCT, Perpiñá et al. (1999)

administered standard body image group therapy plus either a VR condition of exposure to body

shape/weight (n = 8) or a relaxation condition (n = 5). The VR exposure condition was more

efficacious than relaxation; individuals who underwent VR exposures for body image

experienced greater improvements in body satisfaction, body avoidance, and depression (Perpiñá
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et al., 1999). Marco, Perpiña, and Botella (2013) compared standard CBT (n = 9), which varied

depending on the type of eating disorder a participant had, to a VR-augmented condition (n = 10)

which involved five virtual environments in which participants were confronted with a scale,

kitchen, mirror, and other tasks intended to demonstrate discrepancies between perceived and

actual body weight. The CBT plus VR condition outperformed the standard CBT condition in

terms of improvements in body dysphoria, attitudes toward the body, and bulimia symptoms at

posttreatment and one-year follow-up (Marco et al., 2013). Given the small sample sizes and the

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number of dimensions along which the experimental and comparison conditions differed in

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Marco et al. (2013), these studies should be considered preliminary tests of concept. Well-

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powered RCTs are needed to clarify the potential of VR exposure for body image disturbance.
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Riva and colleagues (2000) have developed a virtual reality exposure protocol, called

experiential cognitive therapy (ECT), which incorporates exposure to both eating and body
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image-related situations in virtual environments. Initial findings on this multidimensional VR

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exposure therapy approach were promising, including a study showing that, compared to CBT-

based psychonutritional groups, VR exposure for body image disturbance resulted in decreased
ur

body avoidance and increased body satisfaction in a sample of 20 overweight females with BED
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(Riva, Bacchetta, Baruffi, & Molinari, 2002). Further, in an RCT comparing ECT (i.e. 10

sessions of VR exposure therapy and 5 group therapy sessions focused on assertiveness and

motivation to change), CBT, nutritional support group, and WL conditions for 36 women with

BED, ECT promoted improvements in body image and assertiveness. At 6-month follow-up,

binge eating abstinence was highest in the ECT condition (77%) as was body satisfaction (Riva,

Bacchetta, Cesa, Conti, & Molinari, 2003). However, Riva, Bacchetta, Cesa, Conti, and Molinari

(2004) found few differences in outcomes between ECT, CBT, and a nutritional support group;
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patients with BED (N = 36) experienced decreases in weight and binge eating frequency in all

three treatment conditions. Similarly, Cesa et al. (2013) compared ECT, CBT, and inpatient

treatment for 90 women with BED. Based on the 66 women who completed the study, they

found scarce notable differences in outcome between conditions, but significant attrition makes it

difficult to interpret the results of this study. Riva and colleagues’ RCTs provide some

preliminary support for the incorporation of VR into the treatment of binge eating and body

image disturbance. However, the combination of VR exposure therapy with psychotherapy and

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nutritional groups makes it difficult to parse apart the efficacy of the VR exposure therapy itself

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in prompting changes in body image and eating behaviors. Additionally, it is difficult to

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determine how much exposure therapy occurred in the context of ECT based on methods
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described, so the dosage of exposure in these studies is unclear.

In VR cue exposure therapy, individuals are exposed to typical binge foods in the VR
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environment. For BN or BED, a hierarchy of common binge foods and binge-related

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environments is created based on individual ratings (Ferrer‐García et al., 2017), and individuals

are then exposed to binge foods in VR scenarios. VR cue exposure is meant to simulate the
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experience of ERP-binge in which typical binge foods are presented to the client but they are
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prevented from eating the foods. VR cue exposures have been used to augment more traditional

CBT for BN or BED as a second-level treatment for non-responders. After a course of CBT for

BN or BED, Ferrer-García et al. (2017) randomized male and female non-responders to either

receive additional sessions of CBT (n = 32) or VR cue exposures (n = 32). VR cue exposures

resulted in greater rates of binge abstinence at posttreatment as well as greater decreases in binge

episode frequency, lower anxiety, and less intense food cravings, suggesting that VR cue

exposure can be efficacious among CBT non-responders. Further, rates of binge abstinence were
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not far off of those found in in vivo exposure to binge foods (53% and 64%, respectively; Bulik

et al., 1998) showing that VR exposure could be as successful as in vivo exposure at reducing

binge eating. At 6-month follow-up, patients in the VR cue exposure condition continued to

demonstrate higher rates of binge abstinence and lower tendencies to engage in binge behaviors

compared to patients in the CBT condition (Ferrer-García et al., 2019).

Researchers have also endeavored to use VR exposure to target other eating disorder

symptoms such as the urge to exercise compulsively. Paslakis et al. (2017) found that a VR

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exposure to a jogging scene promoted an initial spike followed by habituation of the urge to be

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physically active in a sample of 30 inpatient females with AN and BN. The research on VR

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exposure therapy as a next-step for eating disorders is promising, but there are significant gaps in
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the literature. We found no research comparing the efficacy of interventions for eating disorders

using VR exposure paradigms to in vivo exposures such as those to feared foods, binge-related
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cues, or body image. Research on VR exposure therapy should compare VR exposure therapy to
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corresponding methods of in vivo therapy to determine whether VR exposure is a satisfactory

alternative to in vivo exposure.

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Discussion
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We reviewed the literature on exposure therapy for eating disorders, which included

exposure and response prevention to binge and purge cues, in vivo feared food exposures, body

image exposure (i.e., mirror and video exposure), and exposure through virtual reality. We found

considerable support for the use of mirror exposure alone or in the context of CBT to target body

image disturbance, especially for those with BN or BED (e.g., Trentowska et al., 2014). Mirror

exposure may also be helpful for improving body image in AN (Morgan et al., 2014), but more

research is needed using controlled methods. Support for the use of ERP for binge and purge
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cues is more mixed; the few RCTs show only marginal benefit of ERP-binge or ERP-purge over

and above other treatment methods such as CBT (e.g., Bulik et al., 1998). Research on in vivo

food exposure for AN is still in the initial stages, but some evidence shows that state anxiety

decreases and caloric intake and BMI increases through food exposure (e.g., Cardi et al., 2019;

Steinglass et al., 2014). VR exposure to feared foods, eating situations, and body image may be a

mechanism to improve accessibility and feasibility of exposures in the clinical setting.

Additionally, VR exposure could be more approachable than actual food or mirror exposures.

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Some evidence suggests that pairing pharmacological agents such as DCS with exposure therapy

ro
may boost extinction as shown by increased weight gain in those with anorexia (Levinson et al.,

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2015), but replication is needed. Overall, exposure therapy may be a tolerable intervention for
re
eating disorders. However, the actual efficacy of exposure therapy itself is somewhat difficult to

determine, given that a significant portion of the RCTs reviewed herein incorporated exposures
lP

into an overarching treatment such as CBT, body image therapy, or inpatient treatment; the
na

effects of exposure within a broader course of treatment may be diluted. Additionally, sample

sizes in many of the studies were small, making overarching conclusions difficult to draw. More
ur

research using large RCTs is needed to discern the efficacy of exposure therapy for the treatment
Jo

of eating disorders.

One major limitation of the current body of research on exposure therapy for eating

disorders is the exclusive focus on exposure to stimuli (e.g. food, body image) that may not be

targeting the actual core fear that is maintaining the eating disorder. If we conceptualize fear of

weight gain or fatness as the core fear in eating disorders, then mirror exposures may be

approaching exposure to this fear by exposing the individual to the image of their body.

However, in vivo food exposure, ERP-binge, and ERP-purge are essentially exposing the
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individual to the prevention of their safety behavior (i.e., purging, restricting, bingeing) that is

used to reduce the anxiety surrounding the fear of becoming fat. In this instance, the person is

not being directly exposed to the core fear of becoming fat; instead, they are being exposed to a

symptom of that fear. Moreover, if we conceptualize the core fear as something consequential to

becoming fat, such as rejection, abandonment, loss of control, or feeling disgusting, then are we

missing the mark with current exposure techniques? More research is needed to understand core

feared stimuli and feared outcomes in eating disorders in order to properly design exposure

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therapy methods that will directly target them (Murray et al., 2016).

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Clinically, it may be most beneficial to determine core fears on an individual basis. More

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research is needed to determine whether individualizing exposures to directly target a person’s
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ideographically determined core fear may be most beneficial. As reported by Cardi et al. (2019),

core feared consequences of eating ranged from appearing disgusting, experiencing disgust or
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intense distress, changing shape very quickly, and losing control. Designing exposures to directly
na

target these fears on an individual basis could be most useful in promoting change in beliefs and

fears. Further, fear may not be the only potential target of exposures. Reilly et al. (2017)
ur

suggested that exposure to interoceptive cues (e.g. fullness, bloating) or feelings of disgust may
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be appropriate for some individuals with eating disorders, depending on what is driving the

maladaptive eating behavior. In fact, two case studies examining exposure-based approaches to

targeting feelings of disgust while eating as well as distressing interoceptive cues have

demonstrated the feasibility of applying these exposure methods for eating disorders in a clinical

setting (Boswell et al., 2019; Plasencia, Sysko, Fink, & Hildebrandt, 2019).

How do we directly target individual’s core fears? Core fears such as rejection,

abandonment, feeling or appearing disgusting, or losing control have not been directly focused
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on using exposure therapy in any RCTs. One potential method of exposing individuals to these

core fears is through imaginal exposure, which is typically used in the treatment of obsessive-

compulsive disorder or during prolonged exposure for posttraumatic stress disorder

(Abramowitz, 1996; Powers et al., 2010). In imaginal exposure, the individual imagines their

worst fears and learns to tolerate and approach rather than avoid these fears. One promising case

study utilized imaginal exposure to target the core fear of loss of identity after becoming fat in a

woman with AN. In this case, CBT included 5 sessions of imaginal exposure and led to clinically

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significant change in disordered eating and impairment, and weight gain (Levinson, Rapp, &

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Riley, 2014). Simultaneous treatment in a partial hospitalization program complicates any

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specific conclusions about imaginal exposure in this case, so further research on imaginal
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exposure for core fears in eating disorders is needed.

Another limitation in the current literature on exposure therapy for eating disorders is the
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lack of research with male participants. The majority of the studies reviewed include no male
na

participants, while others include only a small proportion. In fact, of the 60 studies included in

the systematic review, only eight had any male participants, totaling 51 men across all studies
ur

(19 came from a single study). Although lifetime prevalence rates are lower in men,
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approximately 16-25% of persons with eating disorders are men (Madden, Morris, Zurynski,

Kohn, & Elliot, 2009; Smink, van Hoeken, Oldehinkel, & Hoek, 2014). Testing exposure-based

interventions for men with eating disorders is crucial, especially given the potential differences

in male and female eating disorder pathology. Men with eating disorders may place more

emphasis on drive for muscularity or an idealized masculine body shape rather than thinness

(Murray, Griffiths, & Mond, 2016), and shape and weight concerns for men appear to be less

pronounced than for women matched on percent median body weight (Darcy et al., 2012). The
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presentation of male eating disorder pathology may result in different core fears to target with

exposure than is the case for women. Future research on exposure for eating disorders must

include male participants, and exposure should be designed to target core fears and feared

consequences specific to men.

Finally, future research on exposure therapy for eating disorders should explore the use of

inhibitory learning principles in order to augment changes in fear learning (Craske et al., 2014).

Researchers should explore ways to maximize the violation of expectancies during exposure. For

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example, if individuals believe that weight gain will lead to rejection, exposure should be

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designed to disprove this belief. Research is also needed to determine whether exposure to eating

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disorder related fears in multiple contexts will improve the generalization of new learning and
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thus lead to a greater reduction in eating disorder pathology. Additionally, the feared stimuli

should be varied to consolidate learning; in in vivo food exposure, a variety of foods (rather than
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one feared food type) should be exposed. Incorporating inhibitory learning principles should
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facilitate the retrieval of the new non-fear association. To date, only a few studies have

intentionally applied inhibitory learning principles to exposure for eating disorders (Cardi et al.,
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2019; Farrell et al., 2019), so the need for research on this topic is critical.
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Conclusions

Exposure therapy for eating disorders has demonstrated some efficacy, but large RCTs

isolating exposure therapy from other treatments are needed. Following advancements in the

understanding of extinction learning as well as improvements in the understanding of core fears

in eating disorders, changes to the application of exposure therapy for eating disorders are

warranted. Recent research has begun to adopt new methods for exposure therapy that intend to

directly address core fears and the feared consequences of eating. Individualized methods should
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be applied to directly address the core fear rather than addressing symptoms. This new

conceptualization of exposure therapy for eating disorders is an exciting direction for a future

line of research and for clinical application.

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Identification

Records identified through Additional records identified

database searching through other sources
(n = 1009) (n = 17)

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Records after duplicates removed
Screening

(n = 524)

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Records screened Records excluded
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(n = 524) (n = 359)
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Eligibility

Full-text articles excluded (n =

Full-text articles assessed 105)
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for eligibility Not exposure intervention

(n = 165) (n = 52)
Not eating disorder sample,
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or includes only avoidant

restrictive food intake
disorder (n = 16)
Included

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Studies included in Non-English language (n = 7)

qualitative synthesis Uncontrolled case study
(n = 60) (n = 8)
Review (n = 22)

Figure 1. PRISMA Diagram of articles selected for review.

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Author Disclosures

Role of Funding Sources

This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Contributors
Authors R.M.B. and R.G.H. collaborated on the design and aims of the current review.
Author R.M.B. conducted literature searches and wrote the first draft of the manuscript.
Both authors contributed to and have approved the final manuscript.

Conflict of Interest
The authors declare that they have no conflicts of interest.

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Highlights

 There is considerable need for advancement of treatments for eating disorders.

 Exposure therapy could be used to target underlying fears driving eating

disorders.

 Feared food exposure and mirror exposure are somewhat efficacious.

 With few randomized controlled trials, the current research is inconclusive.

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Author Biographies

Rachel M. Butler is an advanced doctoral student in clinical psychology at Temple

University. Her research interest focus on the intersection of eating disorders and anxiety.

Richard G. Heimberg is the Thaddeus L. Bolton Professor of Psychology and Director of

the Adult Anxiety Clinic of Temple University. He is past president of the Association
for Behavioral and Cognitive Therapies and the Society for a Science of Clinical
Psychology and recipient of the Lifetime Achievement Award from the Philadelphia
Behavior Therapy Association. He has devoted much of his career to the study and
development of cognitive behavioral treatments for anxiety, mostly social anxiety
disorder. He has published over 475 articles and chapters and a dozen books on these
topics.

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