Table 1.

Anxiety-relevant eating disorder symptoms, potential behavioral treatment approaches, current evidence for these approaches, questions for future research, and clinical considerations.

Potential Behavioral Treatment Approach(es)	Current Evidence	Questions of Interest for Future Research	Clinical Considerations
Fear of Weight Gain
• Imaginal: scripts focusing on significant and substantial (as defined by patient) weight gain • Imaginal: scripts focused on uncertain and/or volatile weight trajectory • In vivo: Graphing expected vs. actual weight trajectory week by week during treatment • In vivo: exposure to “number on the scale” via addition of unknown amounts of weight	• One case study indicated that imaginal exposme targeting fear of potential weight gain/”fatness” significantly reduced eating disorder symptoms at end of treatment and 1 month post-treatment follow-up (Levinson et al., 2014). • A 4-session trial of online imaginal exposme therapy for EDs significantly reduced ED fears and global ED symptoms at end of treatment and 6-month follow-up (Levinson et al., 2020). • While part of a larger intervention. Waller and colleagues (2020) report use of in-vivo exposme to weights and tracking of expectancy violation and have reported promising effects on eating disorder symptoms (Waller et al., 2019)	• Timing to target this fear in treatment is under debate (i.e. before vs. after weight restoration) • Exploring relative utility of exposure to current weight versus exposure to “control” over weight/weight gain	• Weight gain may be expected. Therefore, the likelihood of the feared outcome (i.e., weight gain) may not be unrealistic; challenging fear of weight gain in individuals with low weight may aim to develop distress tolerance skills and highlight new learning that “I can gain weight, and I can tolerate the distress.” • Distinguish fear of weight gain itself from anticipated consequences of/associations with weight gain • Validation of actual consequences of weight gain (i.e., negative social comments), while highlighting the disproportion of the negative reaction to these consequences, or the ability to tolerate these negative reactions
Fear of Objective Fatness
• Imaginal & virtual-reality: Heavier self • Interoceptive: Wearing clothing that increases sensed size of body • In Vivo: Engaging in weight activism activities	• A non-dieting intervention among college students has shown to reduce anti-fat attitudes (Wilson et al., 2020) • Fear of objective fatness also targeted in Levinson et al., 2014 and Levinson et al., 2020 (see Fear of Wight Gain)	• Increased investigation of imaginal and virtual-reality based exposures related to fear or fatness	• Validation of societal forces reinforcing fear of fatness (i.e., stigma towards higher weight bodies), while highlighting the disproportion of the negative reaction to these consequences, ability to tolerate negative reactions, or incompatibility of these societal pressmes and personally held values
Fear of Fullness
• Interoceptive: water loading, lie on left side; wearing tight clothing across stomach. Induce fullness and sit with/focus on internal sensations (e.g., feeling full, GI activity) and anxiety related to lack of empty stomach	• Acceptance-based interoceptive exposme for ARFID includes exposures to unpleasant visceral sensations (Zucker et al., 2019). • Gulping water and wearing tight clothing are endorsed as feared behaviors in some individuals with EDs and has been used initial case-series trials of exposme for EDs (Boswell et al., 2019). • After an overnight fast, individuals with AN drank significantly less water than healthy individuals but reported greater increases in negative affect and greater fullness post-water loading. Lower water intake was associated with greater visceral hypersensitivity, anxiety sensitivity, negative affect, body vigilance, pre-task feelings of fullness, feeling fat, fear of gaining weight/becoming fat, clothing feeling tight on the stomach, and urges to restrict, body check, and weigh oneself (Brown et al., 2020).	• Currently unclear the degree to which fear of fullness operates independently from fear of fat or weight gain	• Some patients may drink excessive water as an ED behavior to mimic fullness in order to reduce hunger. Water loading would not be appropriate for these individuals. • The amount of water should not be excessive (e.g. < 1.5 liters), and such exposme should not be conducted in populations at risk for hyponatremia or seizmes. Medical clearance is essential prior to engaging in these exposures. • Assess and identify whether patients endorse fears of gastric distension and fullness separate from food. • Hunger and fullness cues may vary with nutritional status, dietary restriction, and binge eating symptoms, and may not be nonnative for several months. • Some EDs (e.g., ARFID) can include fear of negative consequences of fullness such as vomiting, independent of shape and weight concerns
Gastric Sensitivity (Nausea; Discomfort)
• In vivo: smell rotten things; spinning, reading while spinning; ‘disgusting’ foods	• Acceptance-based interoceptive exposure for ARFID includes exposures to unpleasant visceral sensations (Zucker et al., 2019). • A recent case study of acceptance-based interoceptive exposure included milkshake ingestion to build tolerance to aversive physical sensations associated with disgust (Plasencia et al., 2019). • A clinical case series of interoceptive exposure for EDs included spinning in a chair to induce nausea (Boswell et al., 2019) • Emetophobia exposure exercises include spinning (Hunter & Antony, 2009).	• Investigation of whether heightened gastric sensitivity is related to elevations in fear, disgust, or other affective states.	• Some EDs (e.g., ARFID) include increased sensory sensitivity. • Assessment of this gastric sensitivity should include a comprehensive medical assessment to rule out Gl-related abnormalities. • Individuals who are malnourished and/or underweight may experience increased dizziness at baseline; medical clearance and procurement of a safe environment is recommended. • If disgust if the primary emotion driving gastric sensitivity, knowledge of differential extinction for disgust versus fear and proposed disgust-centric exposure [e.g., OCD (Knowles et al., 2018)] is recommended
Intolerance of Uncertainty
• Imaginal: uncertain outcomes • In vivo: soot weighing; meal exposure involving unknown calorie content, amount of food, type of food; surprise exposures in other domains	• A non-clinical sample of women (N = 85) were randomized to groups where knowledge of the contents of chocolate consumed (i.e., IU) was experimentally manipulated. Results suggest both trait and state IU may be important clinical targets (Kesby et al., 2019).	• Currently unclear whether intolerance is greater for uncertainty or uncontrollability among individuals with EDs (Haynos et al., 2020). Future research would benefit from differentiating expected uncertainty (e.g., the potential for unclear outcomes is known) versus unexpected uncertainty (e.g., the potential for unclear outcomes is a surprise)	•Increased uncertainty may motivate/increase urge to engage in safety behaviors, due to elevated perception of potential or unknown threat; therefore, successful exposures will likely require therapeutic intervention to identify and interrupt/prevent related safety behavior
Perfectionism
• In vivo: purposefully making mistakes; practicing routines or normal activities without perfectionism-based safety behaviors	• A group treatment for perfectionism was evaluated across settings (inpatient, PHP, outpatient) that includes use of a perfection-oriented exposure hierarchy. In addition to demonstrating feasibility, the intervention led to decreases in high standards (C. A. Levinson et al., 2017)	• Perfectionism can be broken into different facets, including evaluative concern and high personal standards. More research is needed to determine which aspects of perfectionism may warrant intervention, and if different facets of perfectionism necessitate different interventions (Haynos et al., 2018)	• Achievement orientation can augment striving for therapeutic gains in treatment (i.e., success at recovery); therefore, certain facets of perfectionism may be a useful tool for a clinician in other domains
Body Checking
• In vivo: Wearing clothing that provokes discomfort without checking self, wearing clothing a size too small in a social situation; not wearing makeup • Self-monitoring: Tracking urges to body check	• Females high in body dissatisfaction (N = 22) were randomized to exposure conditions that were “negative” (asked to engage in body checking of disliked body parts) or “positive” (asked to engage in body checking of self-defined attractive body parts). Those in the “negative” condition demonstrated significantly greater increases in the perceived attractiveness of loathed body parts and decreased avoidance behavior over time compared to those in the “positive” condition (Jansen et al., 2016).	• Improved understanding of both the immediate and delayed impact of in vivo, experimentally induced body checking is necessary in order to better understand its function, and develop and improve interventions aimed at reducing this behavior	• As it does not provide immediate relief, body checking may serve alternate functions in the context of eating pathology than typical safety behaviors • Body checking often occurs below the level of awareness, which may increase difficulty in identifying its presence, and in intervening in a timely manner • Inducing critical body checking as an in vivo exposure may serve to reduce cognitive and affective response over time.
Body Image Avoidance
• In vivo: Mirror exposure: wearing revealing clothing in social situations, during mirror exposures • Interoceptive: body-related mindfulness	• Mirror exposure exercises reduce body dissatisfaction ((Delinsky & Wilson, 2006; Griffen et al., 2018). • Both pure (unguided) and guided mirror exposure have demonstrated reductions in body image avoidance	• Unclear whether mirror exposure that involves nonjudgmental vs. positive prompts is superior (if disgust-based, then positive may be more appropriate counterconditioning) • Severity of interoceptive and perceptual distortions should be examined as potential moderators of outcome • Unclear when during treatment that body image exposure exercises may be most beneficial	• Body avoidance is strongly associated with body dissatisfaction; body dissatisfaction is one of the most pernicious symptoms in transdiagnostic eating disorders, and one of the last to subside in the context of treatment (Tomba et al., 2019)
Food Avoidance (Specific Foods)
• In vivo: meal and food exposures • Chaining: add onto already consumed feared food (e.g., adding pepperoni to feared cheese pizza)	• Feared-food-specific EXRP protocols have been associated with greater caloric intake (Steinglass et al., 2012; Steinglass et al., 2014) and obsessive-compulsive ED symptoms among individuals with AN (Glasofer et al., 2016).	• Research that monitors therapeutic process variables (therapist and client willingness, avoidance, and escape (safety behaviors)) may assist in identifying therapeutic engagement and response	• Cognitive or behavioral avoidance/safety behaviors may undermine learning and enhance fear • Introduction of feared foods during weight restoration may perpetuate expectation that these foods lead to weight gain
Eating-related Rituals
• Exposure and resopnse prevention (EXRP): removal of rituals during meals			• Exposures should be conducted in multiple settings/contexts to address potential context-specific conditioning processes
Compulsive Weighing
• Environmental manipulation: removal of scale access • Restriction of weighing to specific days and times of day (e.g., session)		• The structure (blind vs. unblind) and utility of in-session weights may be dismantled empirically.	• Distinguish for patient, the importance of regular weighing in the context of treatment vs. compulsively alone
Compulsive Exercise
• Environmental manipulation: removal of exercise tracking devices • In vivo: Exercise Cue Exposure • Exposure and response prevention: engage in low levels of exercise to promote exposure to urges to continue and counter urges	• A program specifically designed to target compulsive exercise in patients with eating disorders includes graded exposures with response management. A recent pilot trial (N = 32) demonstrated initial feasibility and acceptability (Dittmer et al., 2018).	• The extent to which exercise is positively vs. negatively reinforcing in the context of EDs, and the degree to which this varies across patients, is currently unclear	• Exercise may serve very specific and idiographic functions in the context of eating pathology, which should be carefully assessed prior to intervening • Athlete identity/sport participation may both positively and negatively impact response to intervention • For some patients (e.g., elite athletes), strategic return to exercise may increase motivation for recovery
Binge Eating
• In vivo: Binge Cue Exposure	• Early EXRP protocols targeting anxiety and negative affective responses to feared or avoided “binge” foods demonstrated mixed findings (Leitenberg et al., 1984; Leitenberg & Rosen, 1989; Martinez-Mallén et al., 2007; Schmidt & Marks, 1989; Toro et al., 2003), with evidence that EXRP is associated with greater reductions in eating disorder symptoms at 3- and 5-year follow-up (Carter et al., 2003; McIntosh et al., 2011).
Purging (Laxative Use; Vomiting)
• In vivo: Purge Cue Exposure • Interoceutive: Induce fullness and sit with/focus on internal sensations (e.g., feeling full, GI activity, throat tightening)	• Initial evaluations of EXRP for vomiting suggest that EXRP for vomiting in BN may be associated with reductions in urge to vomit among individuals with BN (Schmidt & Marks, 1989).		• Ensure that participant does not engage in alternate weight loss/compensatory behaviors (e.g., excessive exercise) in response to blocked availability of purging
Dietary Restriction/Fasting
• In vivo: meal exposure with known caloric intake; sit with anxiety related to caloric consumption; scheduling eating at regular intervals			• Increased use of intermittent fasting within the larger social context may complicate planned exposure • May require patient to have reached a point where he/she is no longer engaging in other compensatory behaviors and will adhere to meal plan prior to and following the exposure
Calorie Counting
• In vivo: eatine in situations where caloric content is unknown • Uncertainty: exposure to facts regarding lack of precision in traditional calorie information			• Calorie content is posted in many public spaces • Individuals may engage in a mental tallying and approximation of calories as a safety behavior
Social Appearance Anxiety/ Fear of Negative Appearance Evaluation
• In vivo: wearing revealing clothing in social situations; being judged based on appearance by therapy confederates; therapist or other confederate commenting on body in the context of another type of exposure	• Among those with body dysmorphic symptoms, those instructed to decrease safety behaviors (e.g. reduce instances of concealing appearance) for 1 week showed less reactivity to in-vivo appearance-related task compare with those instructed to increase safety behaviors (Summers & Cougle, 2018)	• While anecdotally incorporated into exposure-based interventions for EDs at multiple levels of treatment, little guidance is currently available on how and when to incorporate exposures for social appearance anxiety.	• With weight restoration for those who had been underweight, comments from innocent bystanders (e.g., “you look so much healthier”) will augment planned exposures
Fear of Eating in Social Situations
• In vivo: eatine with friends, family, at restaurants, alone at a restaurant; eating out with therapist and ordering filing food while therapist makes judgmental comments, comments about dieting			• For individuals whose fears include strangers watching them eat, it may be a realistic observation that strangers direct more attention to them while eating – particularly if the individual has specific rituals or specific eating processes that are outside the norm of routine mealtime behavior patterns • In vivo exposures that involve commenting on the client’s food require clear and thorough rationale and debriefing to ensure that the client is clear that the therapist is not actually judging intake.