Exposure therapy is a form of cognitive behavioral therapy (CBT) that is often used in the treatment of anxiety disorders including generalized anxiety disorder, panic disorder, phobias, obsessive-compulsive disorders, and eating disorders. Excessive anxiety is also a significant psychological component of eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and avoidant restrictive food intake disorder (ARFID). In AN, BN, and BED the fear centers around eating, food, weight and/or shape. In ARFID, body weight and shape are not a factor. Instead there is a fear of eating unfamiliar foods or of aversive consequences such as gagging and/or vomiting when eating.
Exposure therapy works through exposing you to a feared or anxiety producing thought, image, object, activity or situation in a safe controlled environment. Although it may seem counter intuitive to expose someone to something they fear, the more the person avoids their fear the stronger that fear becomes. In exposure therapy, the therapist sets up a safe controlled environment to expose you to the feared stimulus in order to reduce fear and avoidance of the stimulus. Repeating the exposure over time causes you to become less fearful, anxious and avoidant which is a psychological process called habituation. In individuals with eating disorders habituation fosters a greater ability to tolerate uncomfortable feelings and stop engaging in compulsive behaviors.
Exposure therapy is used in eating disorders to address multiple areas of concern including:
- Feared foods
- Fearful eating situations
- Clothing: wearing appropriate and/or form fitting
- Body image
- Weighing and/or body checking
- Social situations and activities
There are multiple variations to exposure therapy. After your therapist evaluates you, your therapist will work with you to determine which one(s) best fit your needs.
One such variation is in vivo exposure therapy. In vivo is Latin for “within the living” which means the exposure is conducted in real life. For example, an individual with bulimia nervosa may be asked to bring in a lunch that they’d normally binge and purge on and eat it without using any rituals and to avoid purging after they finished it.
Another variation of exposure therapy is imagined exposure where you are asked to write a detailed narrative of being exposed to your feared object, activity or situation. Using this narrative, the therapist can guide you in imagining the scenario to help reduce your fear. This can also be done without the use of a written narrative and the therapist guiding you through the experience. For example, someone with AN may be asked to imagine eating dinner then having a feared food such as an ice cream cone for dessert.
In exposure therapy the pace at which you are exposed can be varied; graded exposure; systematic desensitization; and flooding. You and your therapist can work together to develop a “fear hierarchy.” A list of fears from the least intense to the most intense is created and each of these fears are addressed with exposure therapy. After being repeatedly exposed to these fears, you become less fearful, anxious and avoidant and eventually you might actually come to enjoy them. Again this process is called habituation.
Using the fear hierarchy list you created, your therapist will start with the least feared item and work your way up the list. For example, John who has ARFID, has had an intense fear of gagging and possibly vomiting if he ate an unfamiliar food. He made a list with the least fearful food, eggs, all the way up to the most feared, chicken. There was no rhyme or reason to the fear he attributed to his fear foods. John’s repertoire of food has been exceedingly limited as his food aversion began in childhood.
We started with eggs as he ranked them lowest on his list. When presented with a portion of eggs he was asked to rate his level of anxiety on a scale of 0 to 10 with 0 being none (calm) and 10 extreme (panic). John rated his anxiety at a 5 when he looked at the eggs; it rose to a 6 as he brought the plate to his face to smell it; and it further increased to an 8 when asked to take a bite of it. When he took a bite the anxiety stayed at an 8. It didn’t rise past an 8 as he continued to chew it but did go to a 9 when he was about to swallow it. John felt like he was going to gag as he felt the food going down his throat. The next bite was very similar to the first but as he continued to eat the eggs his anxiety began to decline. During this process, I continued to check in with him after each bite to describe his thoughts and feelings and to check his anxiety level. He was able to reduce his anxiety to a 2 when we decided to stop eating the eggs. We then spent some time discussing this experience. John’s homework was to continue eating eggs at least 5 times over the course of the next week to continue his exposure to eggs. When he came in for his next session he reported that he practiced exposing himself to eggs each day and now his anxiety to eggs was gone. He stated he now enjoys them and plans to eat them on a regular basis. John habituated to the eggs. John’s next session was with black beans as that was next on his hierarchy list. With this experience John rated his anxiety initially at a 5 ½, slightly higher than his anxiety with eggs. Similar to his first experience with eggs, John was able to significantly reduce his level of anxiety this time to 0 through the exposure activity. John continues to come in and work on exposing himself to new foods. Over the course of the year, John has incorporated and enjoys 15 new foods.
Systematic Desensitization was developed by Joseph Wolpe in 1958. Wolpe helped anxious people develop a hierarchy of stressful scenes ranging from situations that cause no anxiety to those that created terror within them. He then had them trained in the relaxation technique, progressive muscle relation (PMR). Once trained he paired PMR with their scary scenes to desensitize them. Systematic desensitization is a form of graduated exposure so you create a hierarchy list of fears; learn the relaxation techniques; and then begin exposure therapy to overcome anxiety.
Katie who had been suffering from anorexia nervosa for many years used this process to help her normalize her relationship with food. This approach is often used as part of Family-based treatment (FBT). Initially, Katie’s parents were in control of managing her food which included everything from purchasing the foods to cooking to plating her food at meals and snacks. As Katie progressed in her recovery, which included progression in weight restoration, she was gradually given back the responsibility of being in charge of her food. This was a very gradual process. Katie initially began with breakfast as this was her least stressful meal. Over time, she was given responsibility for her morning snack, then her afternoon snack, then her lunch and finally dinner. With this approach, the goal is to reduce the fear and anxiety associated with food, eating and weight restoration while building confidence, competence, capability, responsibility and good self-care.
In Flooding, the individual is exposed to the highest fear that is listed on their hierarchy. It was developed by psychologist Thomas Stampfl in 1967 to address phobias. Flooding is thought to be a faster method of treating fears than systematic desensitization. Flooding is performed in vivo and like systematic desensitization, relaxation is used to manage the anxiety prompted by the experience. In the treatment of eating disorders, many programs and private practice therapists will use flooding via experiential experiences. For example, oftentimes individuals with eating disorders will isolate and not participate in activities with others that may trigger their anxiety such as wearing a swimsuit and going to the beach. As the clinical director at a local eating disorder program, as well as in my private practice, I often set up activities with patients that has some combination of food, activity and possibly body image. For instance, during the summer in Southern California, we had our patients go on therapeutic outings to one of the local beaches. They were asked to dress in appropriate clothes such as shorts and a t-shirt over their swimsuit. We then went to the beach where we had them eat a packed lunch that we had the kitchen prepare. They did not get to choose or know ahead of time what was packed for them. Often times we would pack a challenging meal for them that included dessert. They would be directed to remove their outerwear, play at the beach, and then have their lunch. They were flooded with this extremely anxiety provoking experience. Repeated exposures to these and similar types of experiences promotes habituation.
Exposure Response Prevention (ERP)
Another method of exposure therapy is ERP which was originally developed for individuals with obsessive-compulsive disorders (OCD). Eating disorder individuals like OCD individuals participate in ritualistic and/or obsessive-compulsive behaviors to alleviate their anxiety. In ERP, you are exposed to a thought, image, object, situation, or activity that makes you anxious and/or start an obsession. With ERP, the RP – response prevention- means you are asked to make a choice to do something else other than engage in your ritual or obsessive behavior that alleviates the anxiety. For someone with bulimia nervosa, this could mean not vomiting, exercising, using laxatives or diuretics or restricting their next meal/snack after eating an uncomfortable food or meal. For example, Jane who has BN, has the compulsion to vomit any time she consumes a food that she is not comfortable with and believes will cause weight gain. Jane agreed to do a session of ERP with a lunch that she normally vomits. Jane brought in a fast food 6-piece chicken tender meal that included French fries and a shake. Prior to starting the meal, we agreed that she would not practice any rituals and she would work to eat mindfully. We also agreed to extend her session so that she would sit with her food without purging it. She agreed. She did not ritualistically tear her chicken into small pieces or take extremely small bites of her fries to feel more control and lower her anxiety. After eating her food, Jane was extremely anxious and had strong urges to vomit. She did not purge; instead, she talked about her underlying fears and concerns that fueled her eating disorder.
As you can see there are many ways an individual with an eating disorder can use exposure therapy to help them in their recovery. It’s important to stress that no matter which method of exposure therapy is used, it’s vital that you are repeating the exposure to the stimulus consistently and repeatedly for this to be effective. The avoidance is reduced. You habituate. You are recovering.
About the Author:
Anne H. Lee is a licensed therapist, registered dietitian and a certified eating disorder specialist. Anne has been working with eating disorders since 1996 and was the manager of the eating disorder program at Mission Hospital Laguna Beach for over 17 years. She currently has a private practice in Orange County, Ca, where she continues to specialize in treating eating disorders, addictions, and trauma.
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Burns, D. (1999). The Feeling Good Handbook. New York, New York. Penguin Putnam.
What is Exposure Therapy? (2018, October 26)
Exposure and Response Prevention (ERP). (2018 October 26)
Written – 2019