A Trial of Online Imaginal Exposure Therapy for Eating Disorder Related Fears in Individuals with Anorexia Nervosa Cheri A. Levinson, Ph.D., Irina Vanzhula, B.A., Leigh Brosof, B.A. Lisa Michelson, B.A., Benjamin Calebs, B.A., Caroline Christian, Laura Fewell, B.A. University of Louisville Department of Psychological & Brain Sciences

Anorexia Nervosa (AN) Treatment AN has highest mortality rate of any mental illness No empirically-supported treatments in adults Many individuals treated in intensive treatment specialty centers During intensive treatment Multiple exposures to feared foods Learning behavioral strategies to facilitate eating They are receiving exposure! Klump et al., 2009

Exposure in the Eating Disorders Exposure therapy for mealtime anxiety in AN has been gaining support Increases caloric intake Increases body mass index Decreases anxiety Is learning happening during exposures in intensive treatment centers? 50% of individuals relapse Why then such high rates of relapse? Levinson et al., 2015; Steinglass et al., 2013

What can we learn from anxiety disorders? In treatment of anxiety disorders exposure to feared stimuli creates habituation or new associative learning Exposure may not be effective if we are not targeting the core fear Core fear in AN Food? Fear of weight gain? Consequences of weight gain? How do we target core fears? Craske et al., 2008; Otto et al., 2008; Levinson et al., 2017; Murray et al., 2016

Targeting Core Fears-Imaginal Exposure Fear cannot be created in ‘real life’ Prolonged Exposure Therapy for PTSD Also used in generalized anxiety disorder, OCD, social anxiety disorder etc…. Activates same area of brain as “in-vivo” exposures What is imaginal exposure? Patient identifies and imagines fear and learns to sit with associated emotions Creates an imaginal exposure script Foa, Hembree, Rothbaum, 2007

What about imaginal exposure in AN? Pilot case study showed imaginal exposure therapy was effective at decreasing anxiety and eating disorder symptoms Residential setting Targeted fear of weight gain Can we apply imaginal exposure on a larger scale? Levinson, Rapp, & Riley, 2014

Current Study Questions Can we target core fears with imaginal exposure therapy? What are the core fears? Can we implement imaginal exposure therapy online? Will participants learn from imaginal exposure in an online format? Will anxiety decrease across the intervention? Will eating disorder fears, cognitions, and behaviors decrease across the intervention?

Online Imaginal Exposure Study: Procedure Complete Diagnostic Phone Screening Complete Training on Exposure Therapy Identify Eating Related Fear Complete Online Questionnaires Four Sessions of Online Exposure Therapy with Weekly Feedback One Month Follow Up Questionnaires Re-imagine fear

Participants Assessed N = 130 Current n = 85 Completed n = 64 32 dropped after completing at least 1 exposure 13 after assessment before starting treatment Current n = 85 Completed n = 64 Diagnosis AN = 41 BN = 13 BED = 7 OSFED = 24 Body Mass Index (M = 21.51; Range = 13.89-54.91) Primarily female (n = 79/82) Average age = 28.12 (SD = 8.48) Primarily European American (68/82) In treatment weekly on average = 8.64 hours (Range = 0 to 168 hours)

Measures Structured Clinical Interview for DSM-5 Determine diagnosis Eating Disorder Diagnostic Inventory Eating Disorder Fear Screener (in development) Identify eating disorder fear Subjective Units of Distress Anxiety (0-100) during exposure Fear of Food Measure Cognitive-behavioral fears of food Eating Disorder Examination Questionnaire Eating disorder cognitions and behaviors Fairburn & Beglin, 2008; First et al., 2015; ; Levinson & Byrne, 2015 Stice et al., 2004; Wolpe, 1998

Identifying Eating Related Fear Yes No Scale (1-10) Check Top 3 Highest Fears Food, in general ☐   Food with Unspecified Calories (AKA Not Knowing How Many Calories Are in the Meal) Food Not Portioned Out Foods Containing a High Amount of Calories Specific Times of the Day (i.e. Meal time) Extra Food (i.e. Ketchup, Mustard) Desserts or Sweets Processed Foods Specific Foods (i.e. Red meat, Sugar--- Ask participant if they maintain a specific diet) Eating More Food Than You Can Burn Via Exercise Not Exercising Weighing More Than a Specific Number Tolerating Your Size/ Not Accepting Your Body Fatty Foods Gaining Weight Rejection Abandonment Judgment Laziness Making Mistakes Feeling Physically Uncomfortable Feeling Emotionally Uncomfortable Losing Control Being Compared Judgment on Appearance Judgment on Social Media Failing to Meet Expectations (i.e. Familial Expectations of What Your Size Should Be) Judgment of Self Failing to Meet Societal Expectations Embarrassment About Appearance Embarrassment/Discomfort SCREENING FOR ED FEARS NOTE: 1 = “No Fear At All”; 10 = “The Worst Fear Possibly Imagined”

Online Imaginal Exposure

Online Imaginal Exposure

Question 1 Can we target core fears with imaginal exposure therapy? What are the core fears?

Fears Identified Fear n Gaining Weight 27 Losing Control 15 Rejection (because of eating disorder/appearance) 12 Weighing more than a specific number 10 Judgment on appearance 8 Not being able to exercise Abandonment because of appearance/eating disorder 7 Failing to meet expectations 5 Feeling physically uncomfortable 4 Other fears

Question 2 Can we implement imaginal exposure therapy online? Will participants learn from imaginal exposure in an online format?

What do they write about? “I have gained weight over a short period of time and it is noticeable. I feel disgusted with myself and worry about losing my 'fit/thin' persona. I am in the car on the way to work. I hate the way I fit into my clothes now. They still fit, but they are tighter in places. I can't believe I have allowed myself to gain weight. I know it was healthy, I did it because I needed to for my recovery, but I went overboard. I gained more than I needed to and now I feel it everywhere. I look at myself in the mirror in the car, I look chubby. I am wearing my nice black pants, a button down shirt, and a cardigan. I can see every bit and curve of my thighs, I can see my stomach bulge, I glance at my arms and long for the muscle I used to have. I hate myself. I want to hide, go home and throw sweatpants on. I want to lose weight. I can't stand looking like this. How will I walk into work? People will notice the weight gain right away. It's so obvious. I pull into work and sigh. I know I have to go in and face the day. I'm scared to see anyone, even my friends. I'm ashamed of what I look like, what they will think. I walk in through the doors, my heart pounding, my chest tightening. Look down, don't let anyone see you. Walk fast, don't even let them see you from the back, they'll know who you are and wonder what happened to you….

What do they say they learn? "I felt my anxiety go up. I felt and could vividly see what was going on. I learned I could tolerate being uncomfortable without acting on things because eventually the imagination calms down and doesn't feel as powerful.” “This exposure helped me begin to not give weight and shape so much power in my life.” “It was scary. It’s what I have always feared. And to talk about it as if it had happened made it seem so real. Yeah, knowing that even if my worst fear came true, eventually I think I'd be ok. There is a weird kind of peace now.” “Thinking about being fearful may actually be worse than actually being fearful/anxious.” 

Question 3 Will anxiety decrease across the intervention?

Preliminary Results Anxiety During Imaginal Exposure Sessions

Question 4 Will eating disorder fears, cognitions, and behaviors decrease across the intervention?

Preliminary Results

Preliminary Results * * p = .035

Preliminary Results

Conclusions Online imaginal exposure is feasible to implement Most participants report fears having to do with weight gain Variability in “core” fear Participants are able to imagine core fears Report learning from exposures Anxiety decreases across the intervention Also at one month follow up Food avoidance and shape concerns significantly lower from pre to post therapy

Limitations No control group Small number of sessions No established measure of eating disorder fears No therapist assistance Primarily females Moderate drop-out rates

Future Directions Randomized Control Trial Online vs therapist-assisted vs control Predictors of treatment success Who benefits from this treatment? Expanded online protocol Including in-vivo exposures Can this be used at higher levels of care?

QUESTIONS? Contact: Cheri A. Levinson Assistant Professor Director, Eating Anxiety Treatment Lab Clinical Director, Louisville Center for Eating Disorders cheri.levinson@louisville.edu 502-852-7710 www.louisvilleeatlab.com www.louisvillecenterforeatingdisorders.com Clinical Treatment & Research Opportunities for Individuals with Eating Disorders are Available!