How To Use Exposure Therapy To Tackle Eating Disorders?

Recently, I’ve been wanting to expand my knowledge of eating disorder interventions. This desire led to me finding several ways exposure therapy, something I really like using, is used in the treatment of eating disorders. I wanted to share that knowledge, so I created this article. I hope you find it educational.

 

 

What Are Eating Disorders?

 

An eating disorder is a mental health issue that can develop when somebody has an unhealthy relationship with food which can take over their life (MQ: Transforming Mental Health). There are several types of eating disorders, which are: anorexia nervosa, bulimia nervosa, binge eating disorder (BED), other specified feeding and eating disorder (OSFED), orthorexia nervosa, pica, avoidant restrictive food intake disorder (ARFID; formally know as selective eating disorder or SED), rumination disorder (rumination syndrome), and diabulimia (also known as ED-DMT1 in and T1ED).

 

 

What Is Exposure Therapy?

 

Exposure therapy, the most common approach of which is graded exposure, is a type of therapy most commonly used to tackle mental health issues like anxiety and phobias. A typical exposure plan would be to order the things that cause you anxiety by how much anxiety they cause (a fear hierarchy). Then, starting with the least anxiety-causing item, you’d work to become comfortable with it before moving on to the next item.

 

 

Exposure Therapy And Eating Disorders

 

Exposure therapy has been proven time and again to be an effective intervention in the treatment of anxiety-related disorders. So, you might wonder how this approach might work in tackling eating disorders. Well, there are many aspects of an eating disorder where a slow and safe exposure to cues can be extremely useful in overcoming an eating disorder (Within).

 

In fact, exposure therapy has a fairly long history in treating eating disorders, having been used in the treatment of eating disorders since the 1980s (Reilly, Anderson, Gorrell, Schaumberg, and Anderson, 2017).

 

According to Butler and Heimberg (2020), exposure therapy can assist people with eating disorders in developing new and healthier associations with food and eating. One way this can be done is by utilising exposure therapy to extinguish or inhibit negative associations with cues and feared outcomes. This helps people build tolerance for what was once feared to be intolerable.

 

Interoceptive exposure, a version of exposure therapy whereby you try to mimic the physical sensations associated with a person’s fear (spinning around to mimic dizziness), can be useful in overcoming eating disorders (Lee et al., 2006). Eating/digestion-specific and emotion-based body-related cues are all viable targets for interoceptive exposure therapy (Boswell, Anderson, and Anderson, 2015).

 

Support for this comes from a study by Levinson et al. (2020). Their study was a four-week trial of interoceptive exposure therapy for eating disorders conducted online with 229 participants. They found that there was a significant decrease in eating disorder symptoms and eating disorder-related fears. These changes were found to either have been maintained or strengthened at a six-month follow-up.

 

Another study, this time by Farrell et al. (2019), sought to test the effectiveness of exposure therapy in reducing eating-related fears and avoidance of people with eating disorders, using 106 participants. The study used a mix of people with different eating disorder diagnoses, whereby the participants were provided with psychoeducation on the treatment approach, helped to create their exposure hierarchy, and guided through their exposure plan.

 

The study showed a significant reduction in eating-related fears and avoidant behaviours. The study also experienced a low discontinuation rate and received positive feedback about the treatment experience from the participant satisfaction survey.

 

 

How To Overcome Eating Disorders With Exposure Therapy

 

People with eating disorders can experience a range of fears, such as a fear of weight gain, loss of control, and appearing disgusting, all of which will drive their compulsive and avoidant behaviours, which will maintain their unhealthy relationship with food (Butler and Heimberg, 2020).

 

In eating disorders like anorexia nervosa, anxiety and avoidance can be maintaining factors (Melles, Duijvis, and Jansen, 2023). It’s these avoidance strategies and other safety behaviours that reinforce the fear of gaining weight, further highlighting the importance of evading this feared outcome (Butler and Heimberg, 2020).

 

Body exposure

Body image concerns are common among those with an eating disorder (Eating Disorder Solutions). Thus, an exposure plan might focus on helping people get used to looking at feared body parts and their body shape (Boswell, Anderson, and Anderson, 2015).

 

For example, people with anorexia nervosa can engage in several avoidance behaviours when it comes to their bodies, such as wearing baggy clothing, avoiding touching their bodies, and showering or changing with the lights off (Glashouwer and de Jong, 2021). Therefore, an exposure plan might comprise wearing clothes they wouldn’t otherwise wear, changing with the lights on, touching the body areas they avoid, and/or mirror exposure therapy.

 

Boswell, Anderson, and Anderson (2015) state that mirror exposure therapy can be an effective treatment on its own or as part of a broader treatment package for eating disorders and body image issues. Mirror exposure therapy is a version of exposure which involves a person looking at their supposed negatives in a mirror.

 

Feared foods

For conditions like ARFID, exposure therapy can be used to help people eat their feared food by eating something similar, but not the same foods they consider safe (Within). For example, if white bread is considered safe, then maybe eating 50/50 white and wholemeal bread would be a good place to start. Then moving on to whole grain bread.

 

According to (Within), if it’s children, this can also be approached by getting the child to draw pictures of their feared foods or playing with toys that look like their feared foods.

 

 

With eating disorders like anorexia nervosa and orthorexia nervosa where there might be a fear of carbohydrates, they could build an exposure plan to help extinguish that fear. For example, they might start with pictures of carbohydrates, moving on to touching and smelling foods high in carbohydrates, and then eventually eating carbohydrates (Eating Disorder Solutions). This might be to start by eating one chip with their meal, adding to that as their tolerance to carbohydrates grows.

 

However, according to Melles, Duijvis, and Jansen (2023), it’s a misconception that mere confrontation with food during weight restoration with anorexia nervosa is sufficient to tackle their fears. That’s because the fear of weight gain may cause them to think they’ll do nothing other than keep putting on weight. After all, it’s one of their core fears. Such people need to adopt the formation of a safer belief, so collecting as much detailed information about their maladaptive beliefs can be vital.

 

For example, what factors are involved in their belief? Does the time of day matter when they eat their feared food? How much weight do they think they’ll put on for eating their feared food? When do they believe this weight gain will be detectable after eating their feared food? Testing these expectations and demonstrating that their beliefs are wrong can be an important part of supporting someone with anorexia nervosa using exposure therapy. It’s also important to know about the person’s safety behaviours, so they don’t engage in these compensatory behaviours.

 

So, if someone with anorexia nervosa believed that if they ate carbohydrates like chips would mean they’d put on weight by the next day and people would notice this weight change, then weigh them the following day to show them that’s not how it works. You’d also need to weigh them before they ate the chips so they’d have something to compare it to.

 

However, given that the point of anorexia nervosa treatment is for them to gain weight, this kind of work would need to be coupled with tackling their fear of gaining weight and challenging that belief as well.

 

 

Feeling full

There are a lot of physiological sensations associated with eating disorders that can be targeted by exposure therapy, but it’s not possible to go through them all. One of the more common physiological sensations is feeling full, evoking fear. This can lead to behaviours to remedy that feeling, such as purging.

 

One way to become used to the feeling of being full could be to take the interoceptive exposure approach to mimic being full. This could be done by drinking a lot of water (Boswell, Anderson, and Anderson, 2015), so they feel full, and trying to stick with the aversive internal experience, building tolerance to it. They could then move on to something like jelly, which will have calories but not many, and is another quick and easy way to feel full so they can further build on their tolerance.

 

Eating in front of others

For some people with an eating disorder, they can become unable to eat in public or in front of others for fear of how people will judge them (Within). Thus, using an exposure therapy approach, they could work out a step-by-step exposure plan to tackle this. For example, the first step might be to eat something small in front of someone they feel most safe around, another step might be to have someone over for dinner at their home so it’s still a safe environment, and the last step might be to go to a restaurant to eat during its busiest hours.

 

Thought challenges

Exposure therapy is often well paired with thought challenges. So, get the person with an eating disorder to consider creating a list of negative thoughts and beliefs that are part of their eating disorder, and apply thought challenges like ‘reframing‘ and ‘putting your thoughts on trial‘ to help tackle those unwanted thoughts (Central Coast Treatment Center).

 

Fear of being judged

People with an eating disorder, through fear of being judged, will avoid scales, and dress a certain way so they can cover certain body parts (Melles, Duijvis, and Jansen, 2023). For example, I’ve always worn baggy clothes, which I did to hide my skinny body, but now I do to hide my fat belly. Through the use of exposure therapy, they can challenge the belief that someone will judge them if they wear tight or revealing clothes.

 

The reason we can develop such beliefs is because of the spotlight effect when really we’re nothing but NPCs in other people’s stories and main characters only in our own. This can be especially important in the treatment of anorexia nervosa in aiding them to gain weight.

 

 

Another way to tackle this fear of being judged is to use exposure therapy to help them get used to being weighed, and people seeing them being weighed on a scale (Melles, Duijvis, and Jansen, 2023). They might want to first get used to weighing themselves on their own, then with someone they trust, and then with that trusted person actively looking at the reading on the scale. If this is part of a treatment programme, then the person running their treatment might get strangers in to watch the person being weighed as well.

 

The same thing can be applied to their food choices, as someone with an eating disorder might fear being judged for eating specific foods, like chocolate and cakes, but would be ok being seen eating a salad. Again, an exposure therapy plan can be worked out for this as well.

 

Disgust

Disgust might not be what you first think of when it comes to treating eating disorders, but according to Reilly, Anderson, Gorrell, Schaumberg, and Anderson (2017), it does play a role. They highlighted that research has shown that a feeling of disgust motivates behaviours like food rejection, which doesn’t surprise me. After experiencing being force-fed baked beans as a child, I was so utterly disgusted by those food items that even them touching my finger would trigger an extreme disgust response.

 

Disgust is that feeling of revulsion and the overwhelming urge to avoid the cause of that disgust, and people with conditions like anorexia nervosa can find themselves having this response even at the thought of eating (Glashouwer and de Jong, 2021).

 

Social norms and attitudes, as well as diet culture, have led to our collective associations between disgust and food and body image (Anderson, Berg, Brown, Menzel, and Reilly, 2021). I know my attempt at dieting led to troubling and obsessive beliefs that made me miserable.

 

Thus, an exposure plan created to tackle that feeling of disgust through exposure to the disgusting stimuli will hopefully lead to tolerance of that feeling, reducing avoidance (Rast, Woronko, Jessup, and Olatunji, 2023).

 

 

Without knowing I was using an exposure method on myself, I eventually overcame a lot of my avoidance and disgust associated with baked beans, as it had also affected all other beans as well. I started by blending beans in dishes like chilli con carne. I still don’t eat baked beans, but I no longer have that disgust response when people eat them in front of me.

 

A six-session family-based interoceptive exposure treatment was created by Hildebrandt, Peyser, and Sysko (2021) to target and modify a person with an eating disorder’s disgust response to food and eating. Their approach also used in vivo exposure (exposure to feared items, activities, or situations). Each session was designed to help them tolerate the visceral sensations associated with their disgust. They did this by providing a meal replacement shake with unknown content and caloric density.

 

Although this approach shows promise, one of the takeaways from this therapy was how they felt people could benefit from having additional sessions, as they found the six sessions weren’t enough.

 

If disgust isn’t included as part of a person’s treatment for their eating disorders, then Anderson, Berg, Brown, Menzel, and Reilly (2021) believe this leaves them at risk of relapsing. They also believe this could cause them to be classed as resistant to exposure therapy when they’re not.

 

Thought challenges can be useful here as well, whereby using cognitive reappraisal to target disgust can be effective. This is why I included a cognitive reappraisal section in my updated exposure workbook.

 

 

Summary

 

Exposure therapy has a decent history of being effective in supporting people to overcome their eating disorders. The use of exposure therapy would complement any treatment for eating disorders, as well as for issues with body image like body dysmorphic disorder (BDD).

 

The examples I’ve given in this article on how to use exposure therapy to tackle eating disorders aren’t an extensive list, so there are many other ways exposure therapy could be used. But the ones I selected I thought gave the best example of how it could be used to treat eating disorders. If you’re aware of other examples of how exposure therapy can be used to treat eating disorders, please let me know in the comments section below.

 

As always, leave your feedback in the comments section below. Also, please share your experiences with using exposure therapy to tackle an eating disorder in the comments section below. Don’t forget, if you want to stay up-to-date with my blog, you can sign up for my newsletter below. Alternatively, click the red bell icon in the bottom right corner to get push notifications for new articles.

 

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References

 

Boswell, J. F., Anderson, L. M., & Anderson, D. A. (2015). Integration of interoceptive exposure in eating disorder treatment. Clinical Psychology: Science and Practice, 22(2), 194. Retrieved from https://www.researchgate.net/publication/269102619_Integration_of_Interoceptive_Exposure_in_Eating_Disorder_Treatment.

Butler, R. M., & Heimberg, R. G. (2020). Exposure therapy for eating disorders: A systematic review. Clinical Psychology Review, 78, 101851. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0272735820300398.

Farrell, N. R., Bowie, O. R., Cimperman, M. M., Smith, B. E., Riemann, B. C., & Levinson, C. A. (2019). Exploring the preliminary effectiveness and acceptability of food-based exposure therapy for eating disorders: A case series of adult inpatients. Journal of Experimental Psychopathology, 10(1), 2043808718824886. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/2043808718824886 and https://journals.sagepub.com/doi/full/10.1177/2043808718824886.

Glashouwer, K. A., & de Jong, P. J. (2021). The revolting body: Self-disgust as a key factor in anorexia nervosa. Current Opinion in Psychology, 41, 78-83. Retrieved from https://www.sciencedirect.com/science/article/pii/S2352250X21000348.

Hildebrandt, T., Peyser, D., & Sysko, R. (2021). Lessons learned developing and testing family-based interoceptive exposure for adolescents with low-weight eating disorders. The International Journal of Eating Disorders, 54(11), 2037–2045. Retrieved from https://doi.org/10.1002/eat.23605 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8712094.

Lee, K., Noda, Y., Nakano, Y., Ogawa, S., Kinoshita, Y., Funayama, T., & Furukawa, T. A. (2006). Interoceptive hypersensitivity and interoceptive exposure in patients with panic disorder: specificity and effectiveness. BMC Psychiatry, 6(1), 1-9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1559685, https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-6-32, and https://dx.doi.org/10.1186%2F1471-244X-6-32.

Levinson, C. A., Christian, C., Ram, S. S., Vanzhula, I., Brosof, L. C., Michelson, L. P., & Williams, B. M. (2020). Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders. Journal of Affective Disorders, 276, 585-591. Retrieved from https://doi.org/10.1016/j.jad.2020.07.075.

Melles, H., Duijvis, S., & Jansen, A. (2023). Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide. Behavioral Sciences (Basel, Switzerland), 13(5), 370. Retrieved from https://doi.org/10.3390/bs13050370, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10215383, and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10215383/pdf/behavsci-13-00370.pdf.

Rast, C., Woronko, S., Jessup, S. C., & Olatunji, B. O. (2023). Treatment of disgust in specific emotional disorders. Bulletin of the Menninger Clinic, 87(Supplement A), 5-30. Retrieved from https://guilfordjournals.com/doi/pdf/10.1521/bumc.2023.87.suppA.5.

Reilly, E. E., Anderson, L. M., Gorrell, S., Schaumberg, K., & Anderson, D. A. (2017). Expanding exposure-based interventions for eating disorders. The International Journal of Eating Disorders, 50(10), 1137–1141. Retrieved from https://doi.org/10.1002/eat.22761 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814124.