Using Exposure and Response Prevention Therapy to Address Fear in Anorexia Nervosa

by Joanna Steinglass MD and Sarah Parker PhD
New York State Psychiatric Institute, New York, NY
Reprinted from Eating Disorders Review
September/October 2011 Volume 22, Number 5
©2011 Gürze Books

Anorexia nervosa (AN) is characterized by severe restriction of food intake, resulting in inappropriately low body weight, intense fear of gaining weight, and self-evaluation closely linked to body shape and weight. Acute treatment focuses on weight restoration,1 and structured, behaviorally oriented programs can be highly successful for helping patients achieve normal weights. 2,3 Unfortunately, the rate of relapse following acute treatment is substantial, and as many as 30% to 50% of adult hospitalized patients must be re-hospitalized within one year of discharge.4  Acute weight restoration, then, is a critical first step in treatment, but it is not enough to achieve remission or recovery.

One possibility is that when the incentives provided by structured treatment are removed, the individual will not have the motivation and skills to pursue healthy eating. New treatments are needed that address the eating disorder symptoms that persist after weight restoration and that likely contribute to relapse. One potentially useful treatment target is fear and anxiety around eating.

Fear and Anxiety in AN

AN is a complex, multifaceted disorder in which the fear of fat, food, and eating situations is one of many salient features of the illness. Anxiety has long been noted as a prominent feature of AN, and a high rate of comorbidity between AN and anxiety disorders has frequently been reported. 5,6 Though generalized anxiety improves as weight is restored, it does not necessarily normalize.7  Instead, most AN patients continue to show significant psychopathology after successful weight restoration, including abnormal eating behavior, over-concern with weight, and fear of fat.

Individuals who have shown improvement in many psychological symptoms still significantly restrict their eating when observed in a laboratory situation.8 Furthermore, restrictive eating patterns consisting of a monotonous low-energy, low-density diet have been shown to predict relapse.9 These restrictive eating patterns may be driven by underlying fear and avoidance of foods, along with fear of certain eating situations, which may in turn be the manifestation of underlying traits of high anxiety and high obessionality.10

Exposure and Response Prevention for AN

Fear and anxiety around eating, which are so clearly present and so distressing to patients, are important treatment targets that can be addressed through Exposure and Response Prevention Therapy for AN (AN-EXRP). AN-EXRP is a new approach to treating AN that emphasizes the central importance of improving eating behavior in order to achieve and maintain healthy eating and healthy weight. The techniques were developed specifically for patients with AN, based on exposure and response prevention techniques that are the treatment of choice for most anxiety disorders. One study comparing intake in a series of observed settings demonstrated a significant inverse relationship between caloric intake and eating-related anxiety.11 This suggests that reducing fear and anxiety in eating situations could improve eating behavior, as was seen in an open series study of AN-EXRP.12

AN-EXRP is currently an area of active study, and may improve eating behavior and thereby reduce the morbidity and mortality related to starvation and hospitalization. Our research program continues to evaluate the active components and optimal delivery of this new psychotherapy for AN.

The overarching goal of AN-EXRP is for patients to approach situations and phenomena that cause them anxiety in ways that are deliberate, controlled, and manageable. By confronting their fears in this way, patients are able to disconfirm irrational beliefs about the dangers of food and eating situations and disprove their distorted beliefs about the potency and intolerability of anxiety.

The rationale for AN-EXRP is repeatedly reviewed collaboratively with the patient during treatment, and framed in the following way: Exposure work is done to reduce the power of such beliefs over a person’s behavior, thereby improving functioning and reducing distress. This is achieved not only in sessions, but also by having patients practice their own exposures between sessions and closely monitoring their patterns of anxiety, rituals, and avoidance.

Initial phase of treatment: Introduction and Initiation

BOX A: Case Illustration
K.W. reports that she fears feeling full. She might be helped to identify the kinds of thoughts that she associates with this feeling (e.g., ‘If I feel full, then I’ve eaten too much’). She might then explore what the fears are that lie underneath these thoughts (‘If I eat too much, then everything I eat will turn to fat and I will be obese’). The therapist then might help her identify some experiences that might bring up feelings of fullness that would evoke SUDs at different levels: i.e., drinking a half-cup of seltzer (level 3); drinking a cup of seltzer (level 4); drinking a smoothie (level 5); eating a large salad (level 6); eating a large salad and drinking a cup of seltzer (level 7); eating a bowl of pasta (level 8); eating a bowl of pasta with seltzer (level 9); eating dessert after a meal (level 10).

Treatment begins by eliciting the patient’s individual experience of the role of anxiety in the eating disorder, helping him or her identify feared eating situations and avoidance behaviors or rituals. The therapist educates the patient about the natural course of anxiety (Figure 1) and establishes the expectation that, with repeated challenges, anxiety peaks will decrease in intensity and duration.

The therapist and the patient develop a common language to describe anxiety, or using a subjective units of distress (SUDs) scale. Together they review an inventory of foods and situations that trigger anxiety about eating and/or body image, and rank them in order of difficulty using the SUDs scale. This hierarchy of feared eating situations (see box) serves as the basis for planning in-session exposures. Initial sessions involve situations that create minimal to low-moderate patient anxiety. The goals for these initial exposures are to increase the patient’s comfort with being exposed to situations that provoke anxiety and then rating her distress, and in doing so to increase her sense of self-confidence about confronting anxiety and experiencing habituation.

During exposure sessions, the patient engages in the fear-inducing activity, and the therapist regularly makes SUDs ratings and asks the patient about the ways that anxiety changes her physical and mental states. Opportunities for disconfirming irrational beliefs are highlighted and discussed after the exposure itself is finished. At the end, the therapist helps the patient compare what occurred in the session to the session goals, and to develop one or two “take-home messages” that can act as references between sessions. The therapist and patient then develop ways of practicing the exposure between sessions.

Middle Phase: Exploration and Intensification

After the initial exposures, when the patient indicates that she or he is increasingly familiar with and adept at the processes of self-monitoring, between-session practice, and doing in-session exposures, the therapist and patient work to intensify and broaden the challenges they take on both during and between sessions. As the process of exposure enfolds, the therapist helps the patient systematically take on more challenging tasks with each exposure session. When a patient is unwilling to fully engage in an exposure task during a particular session, the therapist helps the patient repeat the work until she has mastered it.

End phase: Consolidation and Relapse Prevention

During the last phase of treatment, the patient will have ideally achieved at least 85% of her goals, and the therapist can now urge her to take more responsibility for identifying and initiating exposures and explicitly notes how the patient can apply take-home messages from the sessions to everyday life. The therapist focuses on helping the patient adopt an EXRP-oriented approach in many different food-related situations. The therapist also helps the patient develop exposure-based strategies for relapse prevention, including specific, concrete ways that they will approach foods and situations that bring up anxiety.


Cognitive Behavior Therapy (CBT) has long been considered a mainstay of treatment of eating disorders, and behavior therapy is a well-established, empirically supported treatment in the weight restoration treatment phase of AN.1 This approach has rarely been extended to the use of exposure therapy techniques. There are data supporting the use of EXRP with bulimia nervosa (BN), 12, 13, although this approach has been less utilized given the success of other, less therapist-intensive treatments. One small trial describes “exposure therapy” as a part of the treatment of AN, but the details are unclear.14 Another case report clearly describes food exposure in the successful treatment of a male with AN, 15again highlighting the face validity of this approach in the field.

Our group has provided AN-EXRP to a series of acutely weight-restored patients in a structured treatment program, and has demonstrated a significant association between change in eating-related anxiety and caloric intake after 12 sessions. 16   Naturalistic data from a clinical program that treats AN comorbid with anxiety disorders shows improvement in eating disorder symptoms with a program of EXRP that is very similar to the treatment described here. 17  Understanding AN as a fear-related disorder, where eating behavior is significantly influenced by anxiety in anticipation of a meal, fear of foods and eating situations, as well as avoidance of distress and avoidance of eating suggests that exposure and response prevention techniques may be useful. These techniques have been developed to meet the specific challenges of AN through the creation of AN-EXRP. This treatment warrants continued study, and continued dissemination to the community.

About the Authors

Dr. Steinglass is Assistant Professor of Clinical Psychiatry at the Eating Disorders Research Clinic New York State Psychiatric Institute, New York, NY. Dr. Parker is Instructor of Clinical Psychology at New York State Psychiatry Institute.

Recommended Reading:

Kozak, M, Foa, E. Mastery of Obsessive-Compulsive Disorder, New York, Oxford University Press, 1997.

Steinglass JE, Sysko R, Glasofer D, Albano AM, Simpson HB, Walsh BT. 2011. Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int J Eat Disord. 2011. 44: 134.

Steinglass, J. E., A. Albano, et al. (EPub May 2011). Fear of Food as a Treatment Target: Exposure and Response Prevention for Anorexia Nervosa in an Open Series.  Int J Eat Disord. 2011 May 3. doi: 10.1002/eat.20936.


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