1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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

9. 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 = )
Primarily female (n = 79/82)
Average age = (SD = 8.48)
Primarily European American (68/82)
In treatment weekly on average = 8.64 hours (Range = 0 to 168 hours)

10. 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

11. 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”

12. Online Imaginal Exposure

13. Online Imaginal Exposure

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

15. 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

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

17. 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….

18. 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.” 

19. Question 3
Will anxiety decrease across the intervention?

20. Preliminary Results
Anxiety During Imaginal Exposure Sessions

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

22. Preliminary Results

23. Preliminary Results *
* p = .035

24. Preliminary Results

25. 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

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

27. 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?

28. QUESTIONS? Contact: Cheri A. Levinson Assistant Professor
Director, Eating Anxiety Treatment Lab
Clinical Director, Louisville Center for Eating Disorders
Clinical Treatment & Research Opportunities for Individuals with Eating Disorders are Available!