Social anxiety and weight interact with body salience to affect experiences of social exclusion.

BACKGROUND: Individuals at a higher weight experience greater victimization and exclusion by peers, and limited research suggests that the salience of one's body image may increase negative emotional reactions to social rejection. Additionally, social exclusion is related to higher levels of social anxiety (SA). We examined how body salience interacts with SA and weight to predict anxiety, self-esteem, and negative affect following social rejection. METHODS: Participants were undergraduate women (N = 186). We explored the interactive effects of SA, body mass index (BMI), and body salience (i.e., face versus body photo condition) on emotional response to exclusion in a social ostracism paradigm, Cyberball. BMI and self-reported SA were collected at baseline. One week later, participants played Cyberball and reported state affect, anxiety, and self-esteem before and after the game. RESULTS: The 3-way interaction of BMI, SA, and photo condition did not significantly predict post-exclusion state measures. Photo condition moderated the relationship between SA and post-exclusion anxiety and between BMI and post-exclusion anxiety. CONCLUSIONS: Those with higher SA were particularly anxious following exclusion if their bodies were visible to others. Additionally, those with lower BMI experienced greater anxiety after exclusion when their body was visible than those with higher BMI.

Re-assessing the assessment of fears of positive and negative evaluation: Scale development and psychometric evaluation of the Bivalent Fear of Evaluation Scale (BFOES).

The bivalent fear of evaluation (BFOE) model of social anxiety divides fear of evaluation into two distinct valences: fear of positive evaluation (FPE) and fear of negative evaluation (FNE). However, there is evidence that the two most widely utilized and psychometrically supported measures of FNE and FPE contain items which are ambiguous with regard to valence of evaluative fear. To formally address this, the BFOE Scale (BFOES) was developed, by merging items from measures of FNE and FPE into a single scale with an integrated response format. The present studies examined the psychometric profile of the BFOES across a large pooled archival dataset (N = 2216), which included approximately 10 % (n = 224) patients with social anxiety disorder (SAD). The factorial validity, internal consistency, and construct validity of the BFOES were examined. Additionally, item response theory analyses were employed for the purpose of merging items from self-report scales which utilized different Likert-type response formats. Results from both studies provided support for the psychometric profile of the BFOES. The implications of the BFOES for the assessment of social anxiety, and theoretical models of fear of evaluation and SAD, are discussed.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives.

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

A Brief Self-Compassionate Letter-Writing Intervention for Individuals with High Shame.

Objectives: Over the last decade, the mental health of undergraduate students has been of increasing concern and the prevalence of psychological disorders among this population has reached an unprecedented high. Compassion-based interventions have been used to treat shame and self-criticism, both of which are common experiences among undergraduate students and transdiagnostic vulnerability factors for an array of psychological disorders. This randomized controlled study examined the utility of a brief online self-compassionate letter-writing intervention for undergraduate students with high shame. Method: Participants were 68 undergraduates who scored in the upper quartile on shame. Individuals were randomly assigned to a 16-day self-compassionate letter-writing intervention (n = 29) or a waitlist control group (n = 39). Participants completed baseline, post-assessment, and one-month follow-up measures. Results: Participants who practiced self-compassionate letter writing evidenced medium-to-large reductions in global shame, external shame, self-criticism, and general anxiety at post-assessment, and gains were sustained at follow-up. Additionally, there were trend-level effects for increases in self-compassion and decreases in depression for those who participated in the intervention. Conclusions: This study examined the efficacy of self-compassionate letter-writing as a stand-alone intervention for undergraduate students with high shame. This brief, easily accessible, and self-administered practice may be beneficial for a host of internalizing symptoms in this population and may support university counseling centers as they navigate high demand for mental health services.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial.

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Optimized short-forms of the Cognitive Distortions Questionnaire.

INTRODUCTION: The Cognitive Distortions Questionnaire (CD-Quest) is a self-report questionnaire that assesses common cognitive distortions. Although the CD-Quest has excellent psychometric properties, its length may limit its use. METHODS: We attempted to develop short-forms of the CD-Quest using RiskSLIM - a machine learning method to build short-form scales that can be scored by hand. Each short-form was fit to maximize concordance with the total CD-Quest score for a specified number of items based on an objective function, in this case R2, by selecting an optimal subset of items and an optimal set of small integer weights. The models were trained in a sample of US undergraduate students (N = 906). We then validated each short-form on five independent samples: two samples of undergraduate students in Brazil (Ns = 182, 183); patients with depression in Brazil (N = 62); patients with social anxiety disorder in the US (N = 198); and psychiatric outpatients in Turkey (N = 269). RESULTS: A 9-item short-form with integer scoring was created that reproduced the total 15-item CD-Quest score in all validation samples with excellent accuracy (R2 = 90.4-93.6%). A 5-item ultra-short-form had good accuracy (R2 = 78.2-85.5%). DISCUSSION: A 9-item short-form and a 5-item ultra-short-form of the CD-Quest both reproduced full CD-Quest scores with excellent to good accuracy. These shorter versions of the full CD-Quest could facilitate measurement of cognitive distortions for users with limited time and resources.

Frontoparietal and Default Mode Network Contributions to Self-Referential Processing in Social Anxiety Disorder.

Social anxiety disorder (SAD) is characterized by negative self-referential processing, which triggers excessive emotional reactivity. In healthy individuals, positive self-views typically predominate and are supported by regions of the default mode network (DMN) that represent self-related information and regions of the frontoparietal control network (FPCN) that contribute to metacognitive awareness and emotion regulation. The current study used functional magnetic resonance imaging (fMRI) to examine patterns of DMN and FPCN activation during positive and negative self-referential judgments in SAD patients (N = 97) and controls (N = 34). As expected, SAD patients demonstrated a striking difference in self-beliefs compared with non-anxious healthy controls, endorsing fewer positive traits and more negative traits. However, SAD patients and controls demonstrated largely similar patterns of DMN and FPCN recruitment during self-referential judgements. No significant group differences were observed. However, equivalence testing identified numerous regions demonstrating effect sizes that were not small enough to conclude that they were practically equivalent to zero, despite the nonsignificant null hypothesis test. These regions may be key targets to investigate in future studies using larger samples.

Examining the relationship between shame and social anxiety disorder: A systematic review.

This paper is the first systematic review of the literature on the relationship between shame and social anxiety (SA). We reviewed a total of 60 peer-reviewed empirical articles that met criteria for inclusion. We begin by summarizing literature investigating the empirical association between shame and SA and review literature on whether this association is impacted by cultural or diagnostic differences. Next, we briefly describe the updated version of Rapee and Heimberg's (1997) cognitive-behavioral model of social anxiety disorder (SAD; Heimberg, Brozovich, & Rapee, 2014) and propose how shame may interact with five processes described therein: environmental experiences, observations/images of the self, perceived negative evaluation by others, post-event cognitive processes, and behavioral manifestations of SA. We review the current literature on shame and SA as it relates to each of these domains. Thereafter, we discuss existing research on the role of shame in the treatment of SAD and the implications of the research discussed in this review. Finally, we conclude with a discussion of some key limitations in the existing literature and areas for future research.

Evaluation of Cognitive Behavioral Therapy vs Mindfulness Meditation in Brain Changes During Reappraisal and Acceptance Among Patients With Social Anxiety Disorder: A Randomized Clinical Trial.

Importance: Cognitive behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR) are thought to help patients with social anxiety disorder (SAD) via distinct emotion-regulation mechanisms. However, no study has compared the effects of CBGT and MBSR on brain and negative emotion indicators of cognitive reappraisal and acceptance in patients with SAD. Objective: To investigate the effects of CBGT and MBSR on reappraisal and acceptance in patients with SAD and to test whether treatment-associated brain changes are associated with social anxiety symptoms 1 year posttreatment. Design, Setting, and Participants: In this randomized clinical trial, a total of 108 unmedicated adults diagnosed with generalized SAD were randomly assigned to 12 weeks of CBGT, MBSR, or waitlist. The final sample included 31 patients receiving CBGT, 32 patients receiving MBSR, and 32 waitlist patients. Data were collected at the psychology department at Stanford University from September 2012 to December 2014. Data were analyzed from February 2019 to December 2020. Interventions: CBGT and MBSR. Main Outcomes and Measures: Changes in self-reported negative emotion and functional magnetic resonance imaging (fMRI) blood oxygen level-dependent (BOLD) signal within an a priori-defined brain search region mask derived from a meta-analysis of cognitive reappraisal and attention regulation 1 year posttreatment. Results: Of 108 participants, 60 (56%) were female. The mean (SD) age was 32.7 (8.0) years. Self-reported race and ethnicity data were collected to inform the generalizability of the study to the wider population and to satisfy the requirements of the National Institutes of Health. From the categories provided by the National Institutes of Health, 47 participants selected White (43.5%), 42 selected Asian (38.9%) 10 selected Latinx (9.3%), 1 selected Black (1%), 1 selected Native American (1%), and 7 selected more than 1 race (6.5%). CBGT and MBSR were associated with a significant decrease in negative emotion (partial η2 range, 0.38 to 0.53) with no significant between-group differences when reacting (ß, -0.04; SE, 0.09; 95% CI, -0.11 to 0.08; t92 = -0.37; P = .71), reappraising (ß, -0.15; SE, 0.09; 95% CI, -0.32 to 0.03; t92 = -1.67; P = .10), or accepting (ß, -0.05; SE, 0.08; 95% CI, -0.20 to 0.11; t92 = -0.59; P = .56). There was a significant increase in BOLD percentage signal change in cognitive and attention-regulation regions when reappraising (CBGT = 0.031; MBSR = 0.037) and accepting (CBGT = 0.012; MBSR = 0.077) negative self-beliefs. CBGT and MBSR did not differ in decreased negative emotion and increased reappraisal and acceptance BOLD responses. Reappraisal-associated MBSR (vs CBGT) negative emotions and CBGT (vs MBSR) brain responses were associated with social anxiety symptoms 1 year posttreatment. Conclusions and Relevance: The results of this study suggest that CBGT and MBSR may be effective treatments with long-term benefits for patients with SAD that recruit cognitive and attention-regulation brain networks. Despite contrasting models of therapeutic change, CBT and MBSR may both enhance reappraisal and acceptance emotion regulation strategies. Trial Registration: ClinicalTrials.gov Identifier: NCT02036658.

The Impact of Brief Mindfulness Training on Postevent Processing Among Individuals With Clinically Elevated Social Anxiety.

Postevent processing (PEP), the engagement in detailed and repetitive self-focused review of one's performance in social situations, is theorized to maintain pathological social anxiety. However, little is known about interventions that may impact this maintenance factor. The current study examined the impact of brief mindfulness training (BMT) on PEP among socially anxious individuals. There were 77 participants (75.32% female, 63.64% non-Hispanic/Latinx White) with clinically elevated social anxiety who attended one appointment in the laboratory during which they were randomized to receive a brief mindfulness-based training (n = 37) or no training (i.e., thinking as usual control group; n = 40). After the training period, participants underwent a 3-minute social anxiety induction task, after which they were instructed to apply their thinking strategy. Participants were then asked to complete 2 weeks of daily online surveys that included a PEP induction task, instructions to use their thinking strategy following PEP induction, and a measure of state PEP. Individuals in the BMT condition reported a significant reduction in state anxiety posttraining compared to individuals in the control condition. Conditions did not differ on state PEP after the social anxiety induction task. However, compared to those in the control condition, participants in the BMT condition reported significantly greater decreases in state PEP over the 14-day follow-up period. Thus, this brief mindfulness-based strategy may be useful for individuals with clinically elevated social anxiety who engage in PEP, a cognitive vulnerability factor implicated in the maintenance of social anxiety.

From psychological to physical health: Exploring temporal precedence throughout emotion regulation therapy.

OBJECTIVE: Generalized anxiety disorder (GAD) is characterized, in part, by physical symptoms such as muscle tension and gastrointestinal (GI) distress. To date, little research has examined how changes in psychological symptoms associated with GAD may impact physical symptoms. This study investigated if reductions in worry, anxiety, and depression precede changes in muscle tension and GI distress throughout psychotherapy. METHODS: Participants with GAD (N = 85) completed 20 weeks of emotion regulation therapy (ERT) in addition to assessments pre, mid, and post treatment. They completed a physical symptom questionnaire, evaluating muscle tension and GI distress. Participants also completed psychological symptoms questionnaires, including the State Trait Anxiety Inventory (STAI-7), Penn State Worry Questionnaire (PSWQ), and Beck Depression Inventory (BDI-II). Control participants (N = 44) completed these measures at baseline. RESULTS: Participants with GAD had significantly greater muscle tension (p < .001) and GI distress (p < .001) compared to control participants without GAD. Reductions in worry, depression, and trait anxiety did not precede changes in muscle tension (range of effect size (r): .05-.12). Reductions in both depression (p = 0.04) and trait anxiety (p < 0.01) preceded reductions in GI distress. Reductions in worry did not precede reductions in GI distress (p = 0.25). CONCLUSION: These data provide preliminary evidence for the temporal effect of reductions in psychological symptoms on reductions in GI distress in GAD, highlighting the potential of psychotherapy to improve physical outcomes.

The moderating effects of anger suppression and anger expression on cognitive behavioral group therapy and mindfulness-based stress reduction among individuals with social anxiety disorder.

BACKGROUND: . Cognitive-behavioral therapy and mindfulness-based stress reduction (MBSR) are two prominent evidence-based treatments for social anxiety disorder (SAD). It is not clear, however, whether outcomes of these two treatments are moderated by similar factors. For example, whereas anger suppression and anger expression each predict outcomes in cognitive- behavioral group therapy (CBGT), it is unknown whether they differentially influence outcomes in CBGT versus MBSR. METHODS: . One hundred eight participants with SAD were randomized to CBGT, MBSR or Waitlist (WL). WL participants were later randomized to CBGT or MBSR, and their data were combined with data from those originally randomized to CBGT or MBSR. Anger suppression and anger expression were assessed at pre-treatment, and social anxiety was assessed at pre-treatment, post-treatment, and every 3 months throughout a 12-month follow-up period. RESULTS: . From pre- to post-treatment, higher anger suppression was associated with significantly greater reduction in social anxiety in CBGT compared with MBSR. From post-treatment through follow-up, higher anger expression was associated lesser reduction in social anxiety in MBSR but not in CBGT. LIMITATIONS: . Data are limited by sole reliance on self-report and it is unclear whether these findings generalize beyond group-based interventions. CONCLUSIONS: . Individuals with SAD who are higher in anger suppression and/or expression might be better suited to CBGT than MBSR.

Cognitive Behavioral Therapy for Social Anxiety Disorder: Predictors of Treatment Outcome in a Quasi-Naturalistic Setting.

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients' social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.

Reductions in social anxiety during treatment predict lower levels of loneliness during follow-up among individuals with social anxiety disorder.

INTRODUCTION: Individuals with social anxiety disorder (SAD) are at elevated risk of loneliness, yet little research has examined loneliness in this population. Cognitive-behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR) have demonstrated efficacy in treating SAD, yet research has not examined whether they lead to reductions in loneliness. METHODS: This sample comprised 108 individuals with SAD who were randomized to CBGT, MBSR, or a waitlist control (WL); WL participants were re-randomized to CBGT or MBSR following WL. Assessments were completed pre- and post-treatment, and 3-, 6-, 9-, and 12-month follow-up assessments. RESULTS: Compared to WL, individuals in CBGT and MBSR were less lonely at post-treatment; there was no difference between treatments after treatment or during follow-up. Greater reductions in social anxiety from pre- to post-treatment predicted lower levels of loneliness during follow-up. Greater reductions in loneliness from pre- to post-treatment also predicted lower levels of social anxiety during follow-up. DISCUSSION: Individuals who experience reductions in their social anxiety during treatment may also feel less lonely following treatment. Reductions in loneliness also lead to improvements in social anxiety. Future research should continue to examine the relationship between social anxiety and loneliness and how interventions for SAD may help reduce loneliness.

The benefits of a longer course of cognitive behavioral therapy for some patients with social anxiety disorder.

Historically, cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) has been evaluated in randomized-controlled trials as a 12-16 session treatment and has demonstrated response rates ranging from 58% to 75%. Despite these promising results, some patients do not improve substantially after this short course of CBT. It is unclear whether non-responding patients would make substantial improvements in social anxiety with further treatment. In a university outpatient clinic specializing in CBT for SAD, we compared outcomes for patients who ended treatment after approximately 20 sessions of CBT (n = 38) to those who continued treatment for a variable number of additional sessions (n = 34). We found no between-group differences in demographic characteristics, number of comorbid diagnoses, comorbid generalized anxiety disorder or major depressive disorder, or severity of depression at baseline. Patients who ended treatment after 20 sessions experienced greater improvements in SAD over those 20 sessions compared to those who continued treatment. Both groups experienced changes in depression and quality of life over the first 20 sessions. Those who continued treatment showed additional decreases in social anxiety beyond session 20. For those who initially appear to be non-responsive to CBT for SAD, a longer course of treatment may elicit significant improvements.

Social anxiety moderates the relationship between body mass index and motivation to avoid exercise.

Higher weight individuals experience frequent weight-related discrimination, which is associated with exercise avoidance. Exercise is a health behavior with multiple physical and mental health benefits and should be accessible to all. The current study examined another factor that might influence exercise in addition to weight stigma: social anxiety (SA). Given the often public nature of exercise, individuals with SA may feel scrutinized when exercising, which may lead to avoidance. This study examined whether SA moderates the relationship between body mass index (BMI) and exercise and whether SA and its interaction with BMI predict exercise behavior after accounting for weight stigma. We administered an online survey to 603 undergraduates (72 % female, 60 % White). SA was not significantly associated with BMI, but it was positively associated with weight stigma and exercise-avoidance motivation and negatively associated with self-reported exercise. SA moderated the relationship between BMI and exercise-avoidance motivation; individuals with higher BMIs were motivated to avoid exercise, but only if they reported higher SA. This interaction predicted exercise-avoidance motivation after accounting for weight stigma and its interaction with BMI. However, SA did not moderate the relationship between BMI and self-reported exercise. SA may be associated with exercise avoidance among higher weight individuals.

Targeting fear of positive evaluation in patients with social anxiety disorder via a brief cognitive behavioural therapy protocol: a proof-of-principle study.

BACKGROUND: Our aim was to develop a brief cognitive behavioural therapy (CBT) protocol to augment treatment for social anxiety disorder (SAD). This protocol focused specifically upon fear of positive evaluation (FPE). To our knowledge, this is the first protocol that has been designed to systematically target FPE. AIMS: To test the feasibility of a brief (two-session) CBT protocol for FPE and report proof-of-principle data in the form of effect sizes. METHOD: Seven patients with a principal diagnosis of SAD were recruited to participate. Following a pre-treatment assessment, patients were randomized to either (a) an immediate CBT condition (n = 3), or (b) a comparable wait-list (WL) period (2 weeks; n = 4). Two WL patients also completed the CBT protocol following the WL period (delayed CBT condition). Patients completed follow-up assessments 1 week after completing the protocol. RESULTS: A total of five patients completed the brief, FPE-specific CBT protocol (two of the seven patients were wait-listed only and did not complete delayed CBT). All five patients completed the protocol and provided 1-week follow-up data. CBT patients demonstrated large reductions in FPE-related concerns as well as overall social anxiety symptoms, whereas WL patients demonstrated an increase in FPE-related concerns. CONCLUSIONS: Our brief FPE-specific CBT protocol is feasible to use and was associated with large FPE-specific and social anxiety symptom reductions. To our knowledge, this is the first treatment report that has focused on systematic treatment of FPE in patients with SAD. Our protocol warrants further controlled evaluation.

Anxiety disorders and healthcare utilization: A systematic review.

Anxiety disorders and related traits have become increasingly relevant to the study of physical health and health behaviors over the years. One important health behavior is healthcare utilization, and both over- and under-use have important implications within both personal and public health domains. Anxiety disorders are associated with reassurance-seeking, avoidance behaviors, and other characteristics and traits that may impact patterns of healthcare utilization. The current paper reviews the literature on the known associations between anxiety disorders and healthcare utilization, including studies (N = 70) that examined the association of healthcare utilization with generalized anxiety disorder, social anxiety disorder, panic disorder and agoraphobia, dental and blood-injection-injury phobias, and illness anxiety disorder/health anxiety. Overall, the majority of the studies reviewed indicate that anxiety disorders and health anxiety are associated with increased healthcare utilization across multiple care settings. In addition, there is preliminary but limited evidence that, in some cases, anxiety can be associated with delayed, irregular, or inconsistent use of healthcare services. More work is needed to fine-tune our understanding of the impact of anxiety disorders in healthcare settings.

Self-Stigma Toward Nonsuicidal Self-Injury: An Examination of Implicit and Explicit Attitudes.

OBJECTIVE: Evidence suggests that individuals without a history of nonsuicidal self-injury (NSSI) are likely to view NSSI as a stigmatized behavior. However, there is limited evidence evaluating the presence of self-stigma among individuals who have engaged in NSSI. METHODS: We recruited a university sample (n = 351) and employed implicit and explicit measures to examine the degree of stigmatization toward those with NSSI scarring, as compared to nonintentional disfigurement (i.e., accidental scarring) and to tattoos (i.e., a culturally sanctioned form of intentional tissue alteration). We examined the extent to which bias is related to indicators of NSSI severity among those with a history of NSSI. RESULTS: We provide evidence that negative biases toward NSSI may represent the effects of self-stigma. However, findings suggest that biases were generally attenuated among participants with a history of NSSI as compared to those without. Participants who had lower levels of NSSI explicit bias were more likely to have a history of more severe engagement in NSSI; however, no significant relationships were found between implicit bias and NSSI severity indicators. CONCLUSIONS: We present a theoretical rationale for attenuated biases among individuals with a history of NSSI and discuss implications of this research for NSSI recovery.

Exposure therapy for eating disorders: A systematic review.

Exposure therapy is a potential method for the treatment of eating disorders. The current paper reviews the literature on exposure interventions for eating disorders, including studies (N = 60) on exposure and response prevention (ERP), in vivo feared food exposure, mirror exposure, family-based treatment with exposure, and virtual reality exposure therapy. Mirror exposure alone or in the context of cognitive-behavioral therapy (CBT) can decrease body dissatisfaction. The few controlled trials on ERP for binge and purge cues show only marginal benefit of ERP for binge or purge cues over and above other treatment methods such as CBT. In vivo exposure to feared foods may decrease state anxiety and increase caloric intake and body mass index, but research is limited. Virtual reality exposure could improve accessibility and feasibility of exposures in the clinical setting. A significant portion of the trials incorporated exposures into an overarching treatment such as CBT, body image therapy, or inpatient treatment, so the effects of exposure itself are difficult to parse apart. We discuss the state of the current literature in the context of learning theory and offer insights into new approaches to the application of exposure therapy in an eating disordered population.