Testing virtual reality-based cue-exposure software: Which cue-elicited responses best discriminate between patients with eating disorders and healthy controls?

PURPOSE: Virtual reality (VR) technologies have been proposed as a new tool able to improve on in vivo exposure in patients with eating disorders. This study assessed the validity of a VR-based software for cue exposure therapy (CET) in people with bulimia nervosa (BN) and binge eating disorder (BED). METHODS: Fifty eight outpatients (33 BN and 25 BED) and 135 healthy participants were exposed to 10 craved virtual foods and a neutral cue in four experimental virtual environments (kitchen, dining room, bedroom, and cafeteria). After exposure to each VR scenario, food craving and anxiety were assessed. The frequency/severity of episodes of uncontrollable overeating was also assessed and body mass index was measured prior to the exposure. RESULTS: In both groups, craving and anxiety responses when exposed to the food-related virtual environments were significantly higher than in the neutral-cue virtual environment. However, craving and anxiety levels were higher in the clinical group. Furthermore, cue-elicited anxiety was better at discriminating between clinical and healthy groups than cue-elicited craving. CONCLUSIONS: This study provides evidence of the ability of food-related VR environments to provoke food craving and anxiety responses in BN and BED patients and highlights the need to consider both responses during treatment. The results support the use of VR-CET in the treatment of eating disorder patients characterized by binge-eating and people with high bulimic symptoms.

A Randomized Trial of Virtual Reality-Based Cue Exposure Second-Level Therapy and Cognitive Behavior Second-Level Therapy for Bulimia Nervosa and Binge-Eating Disorder: Outcome at Six-Month Followup.

This article reviews the 6-month followup data of a randomized, multicenter, parallel-group study conducted at five clinical sites in three European cities, which compared two second-level treatments for bulimia nervosa (BN) and binge eating disorder (BED): virtual reality-based cue exposure therapy (VR-CET) versus additional cognitive behavioral therapy (A-CBT). Post-treatment outcomes of this study were previously published and details of its design can be found at clinicaltrials.gov (identifier: NCT02237300). This article focuses on the evolution of symptoms assessed after 6 months of followup in a subgroup of 58 patients from the original study. In this study 64 patients with eating disorders (EDs) (35 with BN and 29 with BED), who still showed active episodes of binge eating by the end of a structured CBT program (first-level treatment), were randomly assigned to one of two second-level treatments (A-CBT or VR-CET). Frequency of binge and purge episodes, and attitudinal features of binge-related EDs (bulimia, drive for thinness, and body dissatisfaction) were assessed before starting the second-level treatment (n = 64), at the end (n = 64), and at 6-month followup (n = 58). Mixed between-within subject analyses of variance were used to compare outcomes of both second-level treatments over time. Although both treatment conditions showed statistically significant improvements at the end and after 6-month followup, obtained reductions were greater after VR-CET, regarding binge and purge episodes, as well as the decrease of self-reported tendency to engage in overeating episodes. Accordingly, abstinence from binge episodes were higher in VR-CET than A-CBT at followup (70 percent vs. 26 percent, respectively; χ2 = 11.711, p = 0.001). These results provide further support for the use of VR-CET as an effective second-level intervention for BN and BED treatment-resistant patients.

A Randomised Controlled Comparison of Second-Level Treatment Approaches for Treatment-Resistant Adults with Bulimia Nervosa and Binge Eating Disorder: Assessing the Benefits of Virtual Reality Cue Exposure Therapy.

A question that arises from the literature on therapy is whether second-level treatment is effective for patients with recurrent binge eating who fail first-level treatment. It has been shown that subjects who do not stop binge eating after an initial structured cognitive-behavioural treatment (CBT) programme benefit from additional CBT (A-CBT) sessions; however, it has been suggested that these resistant patients would benefit even more from cue exposure therapy (CET) targeting features associated with poor response (e.g. urge to binge in response to a cue and anxiety experienced in the presence of binge-related cues). We assessed the effectiveness of virtual reality-CET as a second-level treatment strategy for 64 patients with bulimia nervosa and binge eating disorder who had been treated with limited results after using a structured CBT programme, in comparison with A-CBT. The significant differences observed between the two groups at post-treatment in dimensional (behavioural and attitudinal features, anxiety, food craving) and categorical (abstinence rates) outcomes highlighted the superiority of virtual reality-CET over A-CBT. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Eating behavior style predicts craving and anxiety experienced in food-related virtual environments by patients with eating disorders and healthy controls.

Eating behavior style (emotional, restrictive, or external) has been proposed as an explanation for the differences in response to food-related cues between people who overeat and those who do not, and has been also considered a target for the treatment of eating disorders (EDs) characterized by lack of control over eating and weight-related (overweight/obesity) conditions. The aim of this study was to analyze the relationship between eating behavior style and psychophysiological responses (self-reported food craving and anxiety) to food-related virtual reality (VR) environments in outpatients with bulimia nervosa (BN) and binge eating disorder (BED) and to compare them with healthy participants. Fifty-eight outpatients and 135 healthy participants were exposed to palatable foods in four experimental everyday real-life VR environments (kitchen, dining room, bedroom and café). During exposure, cue-elicited food craving and anxiety were assessed. Participants also completed standardized instruments for the study purposes. ED patients reported significantly higher levels of craving and anxiety when exposed to the virtual food than healthy controls. Eating behavior styles showed strong associations with cue-elicited food craving and anxiety. In the healthy group, external eating was the only predictor of cue-elicited craving and anxiety. In participants with BN and BED, external and emotional eating were the best predictors of cue-elicited craving and anxiety, respectively.

Predicting onset and maintenance of men's eating disorders / Predictores de inicio y desarrollo de patología alimentaria en hombres

Background/Objective: Eating disorders (EDs) represent serious yet understudied mental health issues, particularly amongst young adult men attending colleges, who are at the average age of onset. Despite this and recent evidence that in young adult men the core ED symptoms are prevalent and remain relatively stable over the college period, little is known about factors associated with both the onset and maintenance of diagnosable EDs in this population. This work sought to address these research gaps. Method: Logistic regression analyses were conducted using data from an on-going longitudinal study of eating and mental health issues to examine the influence of theoretically relevant factors in predicting the onset and maintenance of men's (DSM-5) EDs at 4-year follow-up (N=2,507). Results: Body dissatisfaction, self-objectification, appearance-ideal internalization, dieting, and negative affectivity were all predictors of ED onset and maintenance. Self-objectification was the largest contributor to both ED onset and maintenance. Conclusions: The findings highlight potentially similar psychosocial foci for prevention and treatment efforts. Implications for improving existing preventive and treatment approaches are discussed (AU)

Antecedentes/Objetivo: Los trastornos de la conducta alimentaria (TCAs) representan graves, aunque poco estudiados, problemas de salud mental en las universidades, especialmente en hombres jóvenes, quienes se encuentran en la edad media de inicio. A pesar de la evidencia de que en hombres adultos jóvenes los principales síntomas de TCA son frecuentes y se mantienen relativamente estables durante el período universitario, poco se sabe sobre los factores asociados con la aparición y el mantenimiento de los TCAs en esta población. Este trabajo trata de abordar estas lagunas de investigación. Método: Se realizaron análisis de regresión logística utilizando datos de un estudio longitudinal en curso sobre alimentación y salud mental para examinar la influencia de factores teóricamente relevantes para predecir la aparición y el mantenimiento de los TCAs (DSM-5) en hombres durante 4 años de seguimiento (N=2.507). Resultados: La insatisfacción corporal, la auto-objetivación, la internalización de la apariencia ideal, las dietas, y la afectividad negativa fueron predictores de inicio y mantenimiento de TCA. La auto-objetivación fue el mayor contribuyente a la aparición y mantenimiento de TCA. Conclusiones: Los resultados destacan focos similares para su prevención y tratamiento. Se discuten las implicaciones para mejorar los enfoques preventivos y de tratamiento existentes (AU)

Cue-exposure software for the treatment of bulimia nercosa and binge eating disorder / Programa de exposición a señales para el tratamiento de la bulimia nerviosa y del trastorno por atracón

BACKGROUND: Cue-exposure therapy (CET) has proven its efficacy in treating patients with bulimia nervosa and binge eating disorder who are resistant to standard treatment. Furthermore, incorporating virtual reality (VR) technology is increasingly considered a valid exposure method that may help to increase the efficacy of standard treatments in a variety of eating disorders. Although immersive displays improve the beneficial effects, expensive technology is not always necessary. METHOD: We aimed to assess whether exposure to food related virtual environments could decrease food craving in a non-clinical sample. In addition, we specifically compared the effects of two VR systems (one non-immersive and one immersive) during CET. We therefore applied a one-session CET to 113 undergraduate students. RESULTS: Decreased food craving was found during exposure to both VR environments compared with pre-treatment levels, supporting the efficacy of VR-CET in reducing food craving. We found no significant differences in craving between immersive and non-immersive systems. CONCLUSIONS: Low-cost non-immersive systems applied through 3D laptops can improve the accessibility of this technique. By reducing the costs and improving the usability, VR-CET on 3D laptops may become a viable option that can be readily applied in a greater range of clinical contexts

ANTECEDENTES: la terapia de exposición a señales (TES) se ha mostrado eficaz en el tratamiento de pacientes con bulimia nerviosa y trastorno por atracón. Por otra parte, la incorporación de tecnologías de realidad virtual (RV) se considera cada vez más un método de exposición válido que puede ayudar a aumentar la eficacia de los tratamientos. Aunque los dispositivos inmersivos mejoran los efectos beneficiosos, no siempre es necesario el uso de tecnología costosa. MÉTODO: el objetivo de este estudio es evaluar si la exposición a entornos virtuales relacionados con la comida puede disminuir el deseo de comer en una muestra no clínica. Además, se comparan los efectos de dos sistemas (uno no inmersivo y otro inmersivo) durante la TES. Se aplicó un modelo de TES en una única sesión a 113 participantes. RESULTADOS: los resultados indicaron una disminución del deseo de comer como efecto de la exposición. No se encontraron diferencias significativas entre los dos sistemas. CONCLUSIONES: los resultados sugieren que con sistemas de bajo coste y alta facilidad de uso, la TES mediante RV puede llegar a ser una opción aplicable en un mayor rango de contextos clínicos

Cue-exposure software for the treatment of bulimia nervosa and binge eating disorder.

BACKGROUND: Cue-exposure therapy (CET) has proven its efficacy in treating patients with bulimia nervosa and binge eating disorder who are resistant to standard treatment. Furthermore, incorporating virtual reality (VR) technology is increasingly considered a valid exposure method that may help to increase the efficacy of standard treatments in a variety of eating disorders. Although immersive displays improve the beneficial effects, expensive technology is not always necessary. METHOD: We aimed to assess whether exposure to food related virtual environments could decrease food craving in a non-clinical sample. In addition, we specifically compared the effects of two VR systems (one non-immersive and one immersive) during CET. We therefore applied a one-session CET to 113 undergraduate students. RESULTS: Decreased food craving was found during exposure to both VR environments compared with pre-treatment levels, supporting the efficacy of VR-CET in reducing food craving. We found no significant differences in craving between immersive and non-immersive systems. CONCLUSIONS: Low-cost non-immersive systems applied through 3D laptops can improve the accessibility of this technique. By reducing the costs and improving the usability, VR-CET on 3D laptops may become a viable option that can be readily applied in a greater range of clinical contexts.

Predicting onset and maintenance of men's eating disorders.

BACKGROUND/OBJECTIVE: Eating disorders (EDs) represent serious yet understudied mental health issues, particularly amongst young adult men attending colleges, who are at the average age of onset. Despite this and recent evidence that in young adult men the core ED symptoms are prevalent and remain relatively stable over the college period, little is known about factors associated with both the onset and maintenance of diagnosable EDs in this population. This work sought to address these research gaps. METHOD: Logistic regression analyses were conducted using data from an on-going longitudinal study of eating and mental health issues to examine the influence of theoretically relevant factors in predicting the onset and maintenance of men's (DSM-5) EDs at 4-year follow-up (N = 2,507). RESULTS: Body dissatisfaction, self-objectification, appearance-ideal internalization, dieting, and negative affectivity were all predictors of ED onset and maintenance. Self-objectification was the largest contributor to both ED onset and maintenance. CONCLUSIONS: The findings highlight potentially similar psychosocial foci for prevention and treatment efforts. Implications for improving existing preventive and treatment approaches are discussed.

Antecedentes/Objetivo: Los trastornos de la conducta alimentaria (TCAs) representan graves, aunque poco estudiados, problemas de salud mental en las universidades, especialmente en hombres jóvenes, quienes se encuentran en la edad media de inicio. A pesar de la evidencia de que en hombres adultos jóvenes los principales síntomas de TCA son frecuentes y se mantienen relativamente estables durante el período universitario, poco se sabe sobre los factores asociados con la aparición y el mantenimiento de los TCAs en esta población. Este trabajo trata de abordar estas lagunas de investigación. Método: Se realizaron análisis de regresión logística utilizando datos de un estudio longitudinal en curso sobre alimentación y salud mental para examinar la influencia de factores teóricamente relevantes para predecir la aparición y el mantenimiento de los TCAs (DSM-5) en hombres durante 4 años de seguimiento (N = 2.507). Resultados: La insatisfacción corporal, la auto-objetivación, la internalización de la apariencia ideal, las dietas, y la afectividad negativa fueron predictores de inicio y mantenimiento de TCA. La auto-objetivación fue el mayor contribuyente a la aparición y mantenimiento de TCA. Conclusiones: Los resultados destacan focos similares para su prevención y tratamiento. Se discuten las implicaciones para mejorar los enfoques preventivos y de tratamiento existentes.

Mechanisms of influence of body checking on binge eating / Mecanismos de influencia de las conductas de comprobación del cuerpo en los atracones

Despite the theorized role of body checking behaviours in the maintenance process of binge eating, the mechanisms by which they may impact binge eating remain unclear. Using objectification model of eating pathology as a theoretical framework, the authors examined the potential intervening roles of body shame, appearance anxiety, and dietary restraint in the pathway between body checking and binge eating. Data collected from a large sample of treatment-seeking people with Bulimic-type Eating Disorders (N = 801) were analysed trough structural equation modelling. Results showed that, regardless of specific DSM-5 diagnostic categories, body checking behaviours were indirectly associated with binge eating and dietary restraint through body shame and appearance anxiety, whereas dietary restraint was directly linked to binge eating. The findings have clinical utility as they contribute to gaining insight into how critical scrutiny of one's body may act in several indirect ways to affect binge eating. We discuss practical implications of the findings (AU)

A pesar del papel teórico que desempeñan las conductas de comprobación corporal en el proceso de mantenimiento de la conducta de atracón, los mecanismos por los que pueden afectar a los atracones siguen sin estar claros. Tomando el modelo de la objetivación de la patología alimentaria como marco teórico, los autores examinaron las posibles funciones que desempeñan la vergüenza corporal, la ansiedad por la apariencia y la restricción alimentaria en la comprobación del cuerpo y los atracones. Los datos recogidos en una amplia muestra de pacientes con trastorno de tipo bulímico en busca de tratamiento (N = 801) se analizaron a través de modelos de ecuaciones estructurales. Los resultados mostraron que, independientemente de las categorías diagnósticas específicas del DSM-5, las conductas de comprobación estaban asociadas indirectamente con los atracones y la restricción alimentaria a través de la vergüenza corporal y la ansiedad por la apariencia, mientras que la restricción alimentaria estaba directamente asociada con los atracones. Los resultados aportan utilidad clínica dado que contribuyen a la idea de cómo el examen crítico del propio cuerpo puede afectar de forma indirecta a las conductas de atracón. Se discuten las implicaciones prácticas de los hallazgos (AU)

External Eating as a Predictor of Cue-reactivity to Food-related Virtual Environments.

The objective of this study was to assess the association between external eating style and food craving experienced during exposure to food cues in virtual reality (VR) environments in both clinical and non-clinical samples. According to the externality theory, people with external eating experience higher reactivity when exposed to food cues, which in turn increases the probability of overeating. Forty patients with eating disorders (23 with bulimia nervosa and 17 with binge eating disorder) and 78 undergraduate students were exposed to 10 different food cues in four VR environments (kitchen, dining room, bedroom, and café). After 30 seconds of exposure to each VR environment, food craving was assessed using a visual analog scale. External, emotional and restrictive eating styles were also assessed using the DEBQ. The results showed a strong association between external eating and cue-elicited food craving. After controlling for the presence of eating disorder diagnosis, external eating was the best predictor of reported food craving. The results lend support to the externality theory but highlight the need for further research in specific patterns of functioning in patients with bulimia nervosa and binge eating disorder.

Trait and State Craving as Indicators of Validity of VR-based Software for Binge Eating Treatment.

The aim of this study was to establish whether virtual reality (VR) exposure to food cues is able to produce craving levels consistent with state-craving and trait-craving as assessed by the Spanish and Italian versions of the State and Trait Food Craving Questionnaires (FCQ-T/S). The results were compared in 40 patients with eating disorders (17 with binge eating disorder, 23 with bulimia nervosa) and 78 healthy control subjects without eating disorders. Controls and patients with higher levels of trait-craving and state-craving both showed a greater desire to eat during VR exposure. Results also showed that trait and state craving assessed by FCQ-T/S were able to predict the total mean craving experienced during exposure to the VR software in both clinical and control samples. These findings present preliminary evidence about the validity of a new virtual reality-based application for cue-exposure treatment in patients with eating disorders.

Development Of A Virtual Environment Based On The Perceived Characteristics Of Pain In Patients With Fibromyalgia.

Fibromyalgia (FM) is a disorder characterized by chronic physical pain. The perception of this pain has psychological effects on mood, anxiety, and the degree of perceived control. In turn, these factors may increase the experience of pain. This study aims to develop a new virtual environment for the treatment of FM in order to enhance the therapeutic effects of traditional interventions. The first phase included a sample of 19 patients in order to identify common characteristics of the representation of pain and absence of pain, through drawing. The results showed that patients used different colors and different physical states to depict pain (red, motionless) and the absence of pain (blue, in motion). These features were then included in a 3D representation of the human body. ANOVA analysis showed that the degree of anxiety and depression influenced the perceived characteristic of movement.

Mechanisms of influence of body checking on binge eating.

Despite the theorized role of body checking behaviours in the maintenance process of binge eating, the mechanisms by which they may impact binge eating remain unclear. Using objectification model of eating pathology as a theoretical framework, the authors examined the potential intervening roles of body shame, appearance anxiety, and dietary restraint in the pathway between body checking and binge eating. Data collected from a large sample of treatment-seeking people with Bulimic-type Eating Disorders (N = 801) were analysed trough structural equation modelling. Results showed that, regardless of specific DSM-5 diagnostic categories, body checking behaviours were indirectly associated with binge eating and dietary restraint through body shame and appearance anxiety, whereas dietary restraint was directly linked to binge eating. The findings have clinical utility as they contribute to gaining insight into how critical scrutiny of one's body may act in several indirect ways to affect binge eating. We discuss practical implications of the findings.

A pesar del papel teórico que desempeñan las conductas de comprobación corporal en el proceso de mantenimiento de la conducta de atracón, los mecanismos por los que pueden afectar a los atracones siguen sin estar claros. Tomando el modelo de la objetivación de la patología alimentaria como marco teórico, los autores examinaron las posibles funciones que desempeñan la vergüenza corporal, la ansiedad por la apariencia y la restricción alimentaria en la comprobación del cuerpo y los atracones. Los datos recogidos en una amplia muestra de pacientes con trastorno de tipo bulímico en busca de tratamiento (N = 801) se analizaron a través de modelos de ecuaciones estructurales. Los resultados mostraron que, independientemente de las categorías diagnósticas específicas del DSM-5, las conductas de comprobación estaban asociadas indirectamente con los atracones y la restricción alimentaria a través de la vergüenza corporal y la ansiedad por la apariencia, mientras que la restricción alimentaria estaba directamente asociada con los atracones. Los resultados aportan utilidad clínica dado que contribuyen a la idea de cómo el examen crítico del propio cuerpo puede afectar de forma indirecta a las conductas de atracón. Se discuten las implicaciones prácticas de los hallazgos.

Identifying specific cues and contexts related to bingeing behavior for the development of effective virtual environments.

BACKGROUND: Binge eating behavior constitutes a central feature of both bulimia nervosa (BN) and binge eating disorder (BED). Cue exposure therapy (CET) has been proposed as an effective intervention. OBJECTIVE: To determine which situations and specific cues trigger higher levels of binge craving and to use the results in the development of virtual reality scenarios in which CET could be applied with BN and BED patients. METHOD: Participants were 101 outpatients, 50 with BED and 51 with BN, according to DSM-5 criteria, and 63 healthy undergraduate students who completed a self-administered questionnaire to assess binge craving. RESULTS: The likelihood of binge craving in the clinical group was greater when alone at home, during the afternoon/early evening and in the late evening/at night, at weekends, and at dinner time or between meals. Higher levels of craving were produced in the kitchen, bedroom, dining room, and bakery situations. With regard to the specific cues reported, the presence of and access to high calorie food and snacks was the most commonly reported cue. Although some gender differences regarding triggering factors were obtained, no statistical differences were observed between ED subtypes. BN and BED patients showed significantly higher levels of binge craving than controls in all the contexts except when feeling positive affect; in this situation, levels of craving were low in both groups. CONCLUSIONS: This information regarding trigger contexts and specific cues can be used to create valid and reliable virtual environments for CET. Indeed, the data from this study may serve to develop a wide range of situations with different levels of binge craving, in which the therapeutic aim is to extinguish conditioned responses and facilitate the generalization of craving extinction.