EMPIRICAL ARTICLE

Adjunctive Graded Body Image Exposure for Eating Disorders: A Randomized Controlled Initial Trial in Clinical Practice Kathryn Trottier, PhD1,2* Jacqueline C. Carter, D Phil3 Danielle E. MacDonald, MA1,4 Traci McFarlane, PhD1,2,4 Marion P. Olmsted, PhD1,2

ABSTRACT Objective: Graded body image exposure is a key component of CBT for eating disorders (EDs). However, despite being a highly anxiety-provoking intervention, its specific effectiveness is unknown. The aims of this initial study were to investigate the feasibility and preliminary effectiveness of individualized graded body image exposure to a range of feared/ avoided body image-related situations in a sample of partially remitted ED patients. Method: Forty-five female adult participants were randomly assigned to maintenance treatment as usual (MTAU) only or MTAU plus five sessions of graded body image exposure. Results: The graded body image exposure intervention led to large improvements in body avoidance as measured by two different methods. In addition,

Introduction Although individually administered, cognitivebehavioural therapy (CBT) is the leading evidencebased treatment for bulimia nervosa (BN), only half of individuals with BN experience remission with this treatment.1 There are few randomized controlled trials (RCTs) of treatments for anorexia nervosa (AN) or other eating disorder (ED) sympAccepted 16 July 2014 Additional Supporting Information may be found in the online version of this article. Supported by Ontario Mental Health Foundation Postdoctoral (Fellowship (to K.T.); Department of Psychiatry and Allied Health, University Health Network. *Correspondence to: Kathryn Trottier, Eaton Wing South 7-414A, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada. E-mail: [email protected] 1 Department of Psychiatry, University Health Network, Toronto, Canada 2 Department of Psychiatry, University of Toronto, Toronto, Canada 3 Department of Psychology, Memorial University, St. Johns, Canada 4 Department of Psychology, Ryerson University, Toronto, Canada. Published online 19 August 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22341 C 2014 Wiley Periodicals, Inc. V

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there was evidence of a significant impact of body image exposure on the overvaluation of shape, but not weight, 5 months after treatment. Discussion: Taken together, the current results provide evidence of the feasibility of adjunctive individualized graded body image exposure within a clinical treatment program and suggest that graded body image exposure reduces body avoidance behaviors in partially remitted ED patients. Our findings suggest that individualized graded body image exposure shows promise as an intervention targeting the overvaluation of shape in C 2014 Wiley Periodicals, Inc. EDs. V Keywords: body exposure; image; CBT; eating disorders

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tom profiles. However, based on the available research, CBT appears to be a promising approach for those who are able to complete treatment.2–7 The post-treatment outcomes of intensive treatments appear to be similar to individual CBT with respect to binge eating and self-induced vomiting symptoms and may be somewhat better with respect to weight restoration, although these data are primarily based on nonrandomized studies.8–11 For those who do experience remission, relapse rates are significant.12–15 Overvaluing weight and/ or shape—that is judging one’s self-worth based primarily on perceptions of weight and/or shape— has been associated with relapse across diagnostic groups14–16 and is considered the core cognitive psychopathology across all ED diagnoses.17 Recently there has been more interest and attention paid to body checking and avoidance behaviors and their relation to the overvaluation of weight and/or shape. According to Fairburn and colleagues’ expanded cognitive-behavioral (CB) model, body checking and body avoidance are direct behavioral expressions of the overvaluation of weight and/or shape.18,19 Body checking refers to the tendency to examine or scrutinize aspects of International Journal of Eating Disorders 48:5 494–504 2015

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one’s body weight and/or shape (e.g., repeated selfweighing, measuring body parts, pinching the flesh on one’s body, scrutinizing one’s figure in the mirror). In contrast, body avoidance describes the tendency to avoid looking at, learning information about, or allowing others to see one’s body (e.g., covering mirrors, refusing to be weighed, wearing baggy clothes). Body avoidance is believed to contribute to the maintenance of EDs in some individuals by: (1) preventing opportunities to learn new information about the body, its importance, and that feared outcomes do not come true18 and (2) contributing to avoidance of social interactions and consequent social isolation.19 Body checking may maintain an ED by leading the person to draw negative and incorrect conclusions about their bodies due to pre-existing cognitive biases. In line with this, Shafran et al.20 experimentally demonstrated that body checking leads to increased body dissatisfaction, feelings of fatness, and increased critical thinking about the body. Body checking and avoidance behaviors are highly prevalent among ED individuals relative to women without a history of an ED, and frequency of avoidance and checking have been found to be related to ED severity.18 Both body checking and body avoidance have also been found to be uniquely and significantly related to the overvaluation of weight and/or shape in overweight patients with binge eating disorder,21 AN, BN, and eating disorder not otherwise specified (EDNOS; Trottier et al., submitted). Historically, psychotherapies for EDs have included a component addressing body image disturbance. However, these interventions were typically poorly specified and do not appear to have been major components of treatment. The therapeutic effects of these treatments on weight and shape concerns were modest,22 and it is unknown to what extent the improvements were due to the specific body image interventions versus the rest of the ED treatment package. Psychosocial treatments specifically addressing body image disturbance have also been developed and tested. However, for the most part, these studies have used nonclinical samples, have not involved individualized formulations, and were not designed to specifically target the overvaluation of weight and/or shape. Given that many people fail to recover following a course of CBT for BN, Wilson23 called for the development of interventions to more specifically and potently target the core cognitive psychopathology of the disorder (weight and/or shape overvaluation)—that could be easily integrated into existing CBTs. International Journal of Eating Disorders 48:5 494–504 2014

Since then several relevant studies have been conducted and published, most of which have evaluated the efficacy of mirror exposure. Mirror exposure involves having participants look at their bodies in a mirror while describing their physical appearance with the goal of habituation to negative thoughts and feelings about the body. For example, a recent study compared four sessions of graded mirror exposure in women with EDNOS and BN, and healthy controls. Distress decreased within sessions and from session to session with the effects being most pronounced in ED participants.24 Unfortunately body checking, body avoidance, and overvaluation of weight and/or shape were not reported outcome variables. In another study, individuals with EDs received either five sessions of mirror exposure or nondirective body image therapy as an adjunct to ED treatment. Mirror exposure resulted in improvements in body checking, body dissatisfaction, and ED symptoms, compared to nondirective therapy.25 Similar findings were obtained in a comparison of mirror exposure versus nondirective body image therapy for AN, which demonstrated that mirror exposure resulted in more pronounced improvements in body dissatisfaction and body avoidance.26 Another recent study investigated a 10-session CBT intervention for body image in AN, using an uncontrolled pre-post design.27 Seven of the sessions included mirror exposure, and other interventions included mindfulness and cognitive restructuring. From pretreatment to post-treatment, participants made significant improvements in body checking, body avoidance, weight and shape concerns, and physical appearance state trait anxiety. In summary, the literature indicates that mirror exposure is efficacious in ED individuals, in that it reduces distress related to viewing their bodies in the mirror, and there is some evidence of positive effects on body checking and avoidance. Qualitative research indicates that even non-ED women describe real-world situations involving body exposure (e.g., swimming) as among the most uncomfortable body-related situations.28 ED individuals not only avoid looking at their bodies in mirrors but also avoid situations that trigger body image distress and/or that they fear their bodies will be evaluated in, such as going to social functions and buying new clothes. Presumably, it is their avoidance of these situations that prevents them from learning that feared outcomes related to body weight and/or shape are unlikely and contributes to their social isolation. Importantly, it is unlikely that mirror exposure would generalize to the host 495

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of situations that ED individuals fear and avoid related to body image. Furthermore, mirror exposures do not allow for the testing of many negative predictions related to the body (e.g., “If I wear a tshirt, people will stare at my fat arms.”). In line with these potential shortcomings, some mirror exposure protocols have included homework assignments intended to target individualized body checking and avoidance behaviors.29 Individualized graded body image exposure using a hierarchy of feared and/or avoided situations has been suggested as a treatment strategy for body image disturbance30 and has been shown to have efficacy in the treatment of body dysmorphic disorder.31 In EDs, body avoidance has become a key target for change in CBT-Enhanced19 (CBT-E), and the treatment protocol notes that exposure is the therapeutic strategy to be used, although a specific procedure is not described. (This study was designed and began in 2007, before publication of the CBT-E protocol.) Dismantling trials have not yet been conducted to examine the relative efficacy of its various components. An uncontrolled study tested Cash’s program in a guided self-help group format for ED individuals and reported improvements in body image, although only one session of eight included graded body image exposure, and body avoidance and overvaluation of weight and/or shape were not reported outcome variables.32 Another intervention for EDs also showed significant improvements in body avoidance compared to a control group.33 However, similar to the previous study, body image exposure was only one treatment component of several, and the exposure exercises used in this intervention involved both mirror exposure and exposure to feared and/or avoided body imagerelated situations. In these multicomponent intervention studies, the extent to which improvements were due to graded exposure versus the other components is not clear. To our knowledge, the specific efficacy or effectiveness of individualized graded exposure to a range of feared and avoided body image-related situations has not been tested in ED individuals. Knowledge about the feasibility and effectiveness of this particular strategy in EDs is important given that it is a highly anxiety-provoking intervention that is currently being recommended and administered.19 The primary aims of this study were: (1) to determine the feasibility of graded body image exposure as an adjunct to maintenance treatment as usual (MTAU) within our clinical treatment centre, and (2) 496

to gather initial evidence of the specific effectiveness of graded exposure to a range of feared and/or avoided body image-related situations in EDs. Hypotheses

Our primary hypothesis was that ED participants who received the body image exposure intervention as an adjunct to MTAU would experience a significant reduction in body avoidance over the course of the body image exposure intervention period, compared with the MTAU only condition. Our secondary hypothesis was that adjunctive graded body image exposure would also result in reductions in overvaluation of weight and/or shape. However, we expected this change to occur later, in the period following the body exposure intervention to allow enough time for schema-level cognitive change to occur in line with the behavioral change of decreased body avoidance. Exploratory Research Question

What is the effect of graded body image exposure on body checking in individuals with EDs? Although body avoidance and checking appear to be related behaviors, the relationship between them has yet to be elucidated and thus, we did not make a specific prediction about the impact of the intervention on body checking.

Method Design An additive randomized study design with comparison to MTAU was used as recommended by Wilson23 for the investigation of novel treatment strategies. Following intensive day hospital (DH) treatment, patients who had at least partially remitted from their ED behaviors (i.e., binge eating, vomiting, laxative use, and weight restoration, as applicable) were randomly assigned to (1) MTAU or to (2) MTAU plus five sessions of concurrent individual therapy targeting body image avoidance. The study intervention was administered following (rather than concurrently with) DH treatment to enable participants to first establish a pattern of regular eating and to interrupt ED symptoms. This time line for initiating body image exposure is similar to what was subsequently prescribed in the CBT-E protocol (maintaining factors related to weight and/or shape are addressed following the establishment of regular eating).19 Outcome measures were administered at post-DH/ pre-MTAU/pre-body image exposure therapy (hereafter referred to as pre-body image exposure), at post-body image exposure intervention period, and at 6 months International Journal of Eating Disorders 48:5 494–504 2014

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post-DH treatment (approximately 5 months post-body image exposure). This study was approved by the first author’s institutional ethics review board. Participants/Recruitment A total of 45 participants gave their informed consent to participate and were enrolled in this study. To be eligible to participate, participants met diagnostic and statistical manual of mental disorders-IV-text revision DSMIV-TR34 diagnostic criteria for an ED prior to admission to the DH. In addition, potential participants were considered partially remitted from their ED behaviors (including weight restoration for those with a pretreatment diagnosis of AN) at the time of discharge from the DH. Partial behavioral remission was defined as weight restoration to a minimum body mass index (BMI; kg/m2) of 19 and no more than two binge and/or purge episodes in total over the last 2 weeks of DH treatment. It is acknowledged that using DSM-5 criteria, two binge and/ or purge episodes over 2 weeks could be consistent with meeting the symptom frequency threshold for BN, rather than partial remission. Participants were to be excluded in the case of: (1) pregnancy, (2) current psychosis, (3) male sex, and/or (4) unwillingness to participate in body image exposure exercises. Treatment Intensive Treatment. The DH and its effectiveness have been described in detail in the literature.8,35 Briefly, it is a group-based, CB program for adults aged 17 and older. The key targets for change are dietary restriction and restraint, low body weight, binge eating, and compensatory behaviors. The target BMI for those requiring weight restoration is 20. Distorted thoughts related to eating as well as distorted thoughts and other behaviors related to weight and/or shape are secondary targets for change. Formalized interventions for body avoidance were not included as part of DH treatment during the period of recruitment for this study. All patients in the DH are encouraged to reduce body-checking behaviors and are provided with psychoeducation about the potential negative consequences of body checking, as well as strategies to help them not act on urges for body checking. MTAU. MTAU involved attending the aftercare treatment program offered by our treatment centre and/or receiving individual therapy in the community. Fortyfour of the participants elected to attend the aftercare program. Over the course of this study, the aftercare treatment consisted of 90-min group therapy sessions on 2–5 days per week. A staff-supported meal was provided on each program day. Similar to DH treatment, no formalized body avoidance interventions were included in MTAU during the course of this study. Planned length of treatment was for 4–16 weeks. NumInternational Journal of Eating Disorders 48:5 494–504 2014

ber of treatment days attended and length of treatment were individually tailored. Other treatments sought out by participants in the community following DH included individual psychotherapy, group psychotherapy, medication management, nutritional counseling, and ED support center. Participants in both conditions agreed not to undertake any formalized body image therapy over the course of the body image exposure intervention period. Body Image Exposure Intervention. Participants randomized to the body image exposure condition received five individual therapy sessions over a 4-week period concurrent with the first 4 weeks of MTAU. The first session was 90 min in duration and covered psychoeducation about the overvaluation of weight and/or shape and body avoidance as potential maintaining factors in EDs. Psychoeducation about the CB model of anxiety maintenance and graded exposure as a treatment strategy was also provided. Additionally, the therapist and patient worked collaboratively to develop an individualized body image exposure hierarchy (see Table 1 for an example), and instruction was given about how to complete exposure practices between sessions. See Supporting Information Appendix A for a detailed description of the content of Session 1. The remaining four sessions focused on reviewing exposure practices, providing guidance and feedback, and planning future exposure practices. Therapists reviewed exposure-monitoring forms and helped participants to consider new information or evidence obtained through the practice, as well as to highlight successes with respect to coping with distress without escape and/ or avoidance, and reductions in distress over time. Therapists asked about potentially counterproductive behaviors including escape and/or avoidance (e.g., putting a jacket over exposed arms; distracting oneself in a way that prevents gathering evidence and learning new information about one’s body) and body checking, and helped participants to develop individualized strategies to address these behaviors and plans to implement them as needed. Therapists were free to review any of the psychoeducational material and to use the motivational strategy of decisional balance (i.e., weighing the pros and cons of body image avoidance versus body image exposure) as needed. Additionally, in the fifth and final session, progress made across the whole of the 4 weeks was reviewed. Participants were told (as appropriate) that they had the tools and strategies needed to address body avoidance and were encouraged to continue the work on their own, either by continuing to work on their remaining hierarchy items, developing a new more challenging hierarchy and/or continuing to prevent avoidance and escape behaviors in their everyday lives.

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The first author or one of three Ph.D. level clinical psychology students with clinical training in CBT for EDs administered the body exposure intervention. To ensure therapist competence and enhance treatment integrity, all therapy sessions were recorded and therapists received clinical supervision with one of the first or second authors. Assessment Protocol and Measures Participants were assessed pre-DH, pre-body image exposure intervention, post-body image exposure intervention period, and at 6-months post DH. The assessors were blind to treatment condition. Consistent with intentto-treat philosophy, participants were asked to complete the study assessments even if they dropped out of treatment. Several constructs were assessed. Body avoidance was assessed using hierarchy ratings of avoidance (for those in the intervention group only as the ratings were a product of therapy), and the Body Image Avoidance Questionnaire (BIAQ).36 Body checking was assessed using the Body Checking Questionnaire (BCQ).37 Overvaluation of weight and shape were assessed using the two relevant items from the Eating Disorder Examination (EDE).38 Finally, ED symptom frequencies were assessed via the EDE, and demographic variables were collected. Hierarchy Ratings of Avoidance. Participants who received body image exposure therapy rated their degree of avoidance of each item on their individualized hierarchy during the development of the hierarchies and thereafter before the start of each session. Ratings were on a scale of 0–100, where 0 represented no avoidance and 100 represented complete avoidance. Average avoidance ratings were calculated for session 1 and at the end of treatment (i.e., session 5). Change in average avoidance scores from the first to final body image exposure therapy sessions served as an outcome variable. This change score is only available for the body image exposure group because hierachy construction was a key body image exposure therapy component and thus the control group did not construct hierarchies. BIAQ. The BIAQ is a 19-item questionnaire that measures avoidance of situations that provoke concern about physical appearance. It has four factors including clothing, social activities, eating restraint, and grooming and weight. Scores on the BIAQ have been shown to be reliable and valid.37 We used an adapted version of this scale for the purposes of this study. In particular, the eating restraint subscale was excluded because these items do not assess avoidance of body weight and/or shape; and a five-point scale ranging from “never” to “always” was used. The BIAQ is scored by summing the item scores to obtain a total, with higher scores indicating greater body avoidance. Internal consistency in the present sample at pre-body image exposure was a 5 0.85.

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BCQ. The BCQ is a 23-item self-report questionnaire that measures the frequency with which individuals engage in a variety of body checking behaviors.38 Respondents indicate on a five-point Likert scale ranging from “never” to “very often” the frequency with which they engage in each behavior. The BCQ is scored by summing the item scores to obtain a total, with higher scores indicating more frequent body checking. The BCQ has been shown to be relaible and valid.38 Internal consistency in the present sample was a 5 0.92 at pre-body image exposure. EDE. The EDE38 is a semistructured interview and is considered the gold-standard method of assessing ED symptomatology. We abbreviated it to contain diagnostic items only. The abbreviated EDE was administered at pre-DH to assign a diagnosis and at pre-body image exposure to determine eligibility for the study. The relevant items from the Weight Concerns and Shape Concerns subscales were used to measure overvaluation of weight and shape. This item is as follows for the Shape Concerns subscale: “Over the past 4 weeks has your shape been important in influencing how you feel about yourself as a person? If you imagine the things that influence how you feel about yourself—such as (performance at work or school, relationships with others, being a parent, etc.)—and put these in order of importance, where does shape fit in?” The item for the Weight Concerns subscale is similar but shape is replaced with weight. These items are scored on a scale from 0 to 6, with 0 indicating no importance of shape or weight and 6 indicating supreme importance of shape or weight. Demographic Variables. Demographic information including age, marital status, ethnic origin, education level, socioeconomic status, and duration of illness were collected at preintensive treatment. Statistical Analyses Data were analyzed using SPSS version 19.0, and p values of

Adjunctive graded body image exposure for eating disorders: A randomized controlled initial trial in clinical practice.

Graded body image exposure is a key component of CBT for eating disorders (EDs). However, despite being a highly anxiety-provoking intervention, its s...
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