Emotion Acceptance Behavior Therapy

In a pilot study, modest weight gains and improvement in anxiety and depression followed this outpatient approach.

Emotion acceptance behavior therapy (EABT) is an outpatient psychotherapeutic intervention designed for older adolescents and adults with anorexia nervosa (AN). EABT emphasizes the role anorexic symptoms might play in facilitating the patient’s avoidance of emotions. That is, the model postulates that people with AN often are characterized by inhibited or harm-avoidant personality traits and problems with anxiety and mood disturbance, all of which shape their experience of emotion as aversive or uncontrollable, and that their AN-related thoughts and behaviors, in turn, help them avoid these emotions.

Jennifer E. Wildes, PhD and Marsha D. Marcus PhD of Western Psychiatric Institute and Clinic, Pittsburgh, recently tested the value of EABT in study of 5 AN patients 17 to 43 years of age.

As the authors reported in the International Journal of Eating Disorders (2011;45:421), the EABT model assumes that emotion avoidance poses two main problems for persons with AN. First, although AN symptoms may be effective at reducing emotions over the short term, long-term efforts to avoid emotion may have the paradoxical result of increasing the frequency and intensity of aversive emotional reactions. In their efforts to avoid emotion, patients with AN may find themselves trapped in a cycle of emotional vulnerability, avoidance, and disordered eating. Second, because patients spend so much time focused on AN symptoms, valued goals in other parts of their lives are often neglected.

How treatment is structured

EABT combines standard behavioral inventions central to clinical management of AN (weight monitoring and prescription of regular and nutritionally balanced eating, for example), with psychotherapeutic techniques designed to help patients increase emotion awareness, decrease avoidance of emotion, and encourage resumption of valued activities and relationships. Cognitive strategies focused on altering the frequency or form of AN symptoms (identifying, challenging, and restructuring dysfunctional thoughts and attitudes about eating weight and shape) are not used.

In Drs. Marcus and Wildes’ study, EABT was provided in 24 one-hour sessions conducted individually over 22 weeks. Patients met with their therapist twice a week for the first 4 weeks (sessions 1-8), followed by weekly sessions from weeks 5 through 18 (sessions 9-22), and every other week for the last 4 weeks of treatment. Patient were monitored medically at each appointment by a nurse or nurse practitioner and met monthly with one of the study physicians. Finally, patients had up to 2 sessions of nutrition counseling with a registered dietitian. At pre- and post-treatment sessions, all the participants were interviewed with the Eating Disorder Examination (EDE-16.0D), the Beck Anxiety Inventory, Acceptance and Action Questionnaire, and Eating Disorder Quality of Life Questionnaire.

Results

Of the first 5 patients who were offered EABT, 4 completed at least 90% of the therapy sessions and 3 showed modest weight gain without need for hospitalization or intensive treatment (one patient dropped out because she lived too far away to complete the sessions). The women who responded to EABT also showed improvement on several secondary outcomes, including depressive and anxiety symptoms.

The authors concluded that EABT is feasible and acceptable, and may be efficacious for treating older adolescents and adults with AN. As a result of feedback from the participants and their therapists, the authors have made several changes to the original EABT program. For example, they expanded the length of the program to 40 sessions and attempted to make the program more flexible, so therapists can increase the frequency of sessions when patients are struggling with weight loss or other eating disorder behaviors, such as purging. They also are evaluating factors that may predict outcome following EABT. For example, it is possible that sustained weight loss early in treatment, as opposed to maintaining weight or gaining weight, may signal a poor response to the intervention. It may also be that EABT is less effective for patients with chronic AN. A larger pilot study will explore these very questions.