Jessica Werthmann

Purpose: Body image disturbances (BID) are central to anorexia nervosa (AN), influencing its development, maintenance and relapse. While mirror exposure (ME) has been shown to reduce BID in adults, research in adolescents is limited. This pilot randomized controlled trial examined the feasibility and effects of ME, added to treatment as usual (TAU), in adolescent inpatients with AN. In addition, we explored changes in body-related attentional bias as a potential mechanism of change. Methods: Adolescent female inpatients with AN were randomized to receive either 12 ME sessions over 4 weeks (ME group, n = 11) or TAU ( n = 13) in a pre-post design. Primary outcomes were global measures of BID and eating disorder (ED) pathology. Attentional bias was assessed using two eye-tracking paradigms. Results: Relative to TAU, ME did not improve BID or ED pathology. Both groups showed reductions in BID over time. Exploratory post-hoc analyses indicated reductions in body control and avoidance behaviors in the ME but not the TAU group. An attentional bias toward self-defined unattractive body parts was present but did not change over time in either group. Discussion: In this pilot trial, ME did not provide additional benefits over TAU in improving global BID or ED pathology in adolescent inpatients with AN. Improvements in BID may reflect general therapeutic effects of inpatient treatment. Exploratory analyses indicated potential effects on specific body-related behaviors but require cautious interpretation due to limited power. Future research should examine for whom and at what stage body image–focused interventions may be beneficial. Level of evidence: Level I, randomized controlled trial. Trial registration: The study is registered on the German Clinical Trial Register (DRKS; registration number: DRKS0019104).

Introduction: Disordered eating behaviors (DEBs), including restrictive eating, binge eating and purging, are associated with mental health problems and an increased risk of eating disorders (EDs), which often occur in adolescence and can have serious health consequences. In addition, the increasing rates of overweight and obesity among children and adolescents raise concerns about their associated physical and mental health risks. Attentional biases (ABs) to food- and body-related cues have been proposed as cognitive mechanisms that contribute to the development and maintenance of EDs and are also discussed in the etiology of overweight and obesity. While theoretical models suggest that ABs may contribute to the maintenance of EDs, DEBs, and obesity, empirical evidence in young populations is still limited. Method: This systematic review (PROSPERO: CRD42023399292) examined literature from PsycINFO, PubMed, and Scopus on ABs to food- and body-related stimuli in children and adolescents with overweight, obesity, or ED symptoms, compared to healthy comparisons. A total of 30 peer-reviewed studies published in English since 2003 were included. Results: The evidence on AB for food in young people with overweight and obesity remains inconclusive, and studies provide conflicting results. Similarly, studies in adolescents with AN show heightened attention to low-calorie foods and inconsistent attentional patterns toward high-calorie foods, indicating a complex and heterogeneous picture. Evidence on AB for food in young people with BED is scarce, with one study reporting an attentional bias towards food. For LOC eating, findings were mixed and less conclusive. This suggests that body-related AB may serve as a relevant marker for the psychopathology of EDs, particularly in AN. Conclusion: This review underscores the role of ABs in EDs and overweight/obesity and highlights methodological inconsistencies as well as research gaps, particularly in samples beyond AN and overweight/obesity. Future studies should therefore employ standardized methods, diverse samples, and developmental perspectives to improve understanding of AB in the etiology of these pathologies and inform targeted interventions for at-risk youth.

Background: The dissemination of evidence-based techniques is critical for the successful treatment of eating disorders in clinical practice. A growing number of studies suggests that body exposure is an effective technique to treat body image disturbance in eating disorders. However, the dissemination of body exposure among psychotherapists in clinical practice remains unclear. Methods: An online survey was conducted among licensed psychotherapists in Germany. The dissemination of body exposure in clinical practice, psychotherapists’ characteristics (such as clinical training, attitudes towards exposure, confidence), and therapists’ experiences with benefits and side-effects of body exposure were assessed. Results: Data of 230 psychotherapists were analysed. More than half of them (58.3%) applied body exposure in their clinical practice. Yet, body exposure was only offered to 37.3% of their eating disorder patients. Moreover, 56.7% of psychotherapists delivering body exposure indicated that they have not received any training in this technique. Self-reported confidence in delivering body exposure correlated significantly with the number of patients treated with body exposure. Psychotherapists who applied body exposure reported minor side-effects and that the majority of their patients profited from this technique. Conclusions: Our results offer insights into the dissemination of body exposure in clinical practice in Germany. Overall, body exposure is still underused considering the empirical evidence demonstrating the potential of body exposure to treat body image disturbances effectively. Moreover, with regard to potential barriers of using body exposure, our data suggest that training opportunities for clinicians may facilitate the dissemination of this technique in clinical practice.

Background: Anorexia Nervosa (AN) is a severe mental illness, which typically develops in adolescence and, if left untreated, often becomes chronic. Body dissatisfaction is a core characteristic of AN. Mirror exposure (ME) is an effective therapeutic technique to tackle body dissatisfaction in adult patients with eating disorders, but there is limited evidence for the effects of ME in adolescence. One potential mechanism underlying effects of ME on body dissatisfaction is change in body-related attention bias. However, this mechanism remains to be empirically tested. Accordingly, the aim of the current study is twofold: primarily, we aim to test if ME can reduce body dissatisfaction and associated symptoms in adolescent patients with AN. Additionally, we aim to investigate whether change in biased body-related attention due to ME is a possible mechanism of action. Method: Adolescent patients with AN are randomized to either 12 sessions of ME (3 ME-sessions/week) or wait-list within four weeks. Main outcomes include body dissatisfaction and associated symptoms of AN. Moreover, body-related attention bias is assessed at baseline and post-treatment by means of eye-tracking with two paradigms. Further, process variables are collected weekly. In addition, 12 weeks after end of the study, the acceptability of the ME is assessed. Discussion: The main aim of the study is to evaluate high-frequency and high-intense ME for treating body dissatisfaction in adolescents with AN. In addition, we would like to clarify whether change in attentional bias for body stimuli is a mechanism underlying change in body dissatisfaction due to ME.

Background: In a feasibility randomised controlled trial in people with overweight/obesity with and without binge eating disorder (BED) symptoms, we assessed eight weekly sessions of attention bias modification training (ABMT) and mindfulness training (MT) versus waiting list (WL) and explored potential mechanisms. Methods: 45 participants were randomly allocated to one of three trial arms. Primary outcomes were recruitment, retention and treatment adherence rates. Secondary outcomes included measures of eating behaviour, mood, attention and treatment acceptability. Assessments were conducted at baseline, post-intervention (week 8), and follow-up (week 12). Results: Participant retention at follow-up was 84.5% across groups. Session completion rates in the laboratory were 87% for ABMT and 94% for MT, but home practice was much poorer for ABMT. Changes in BMI and body composition were small between groups and there was a medium size BMI reduction in the MT group at follow-up. Effect sizes of eating disorder symptom changes were not greater for either intervention group compared to WL, but favoured ABMT compared to MT. Hedonic hunger and mindful eating scores favoured MT compared to ABMT and WL. ABMT reduced attention biases towards high-calorie food cues, which correlated with lower objective binge eating days at post-intervention. No significant changes were observed in the MT, or WL conditions. Conclusions: Both ABMT and MT have potential value as adjuncts in the treatment of obesity and BED, and a larger clinical trial appears feasible and indicated. Trial registration: ISRCTN Registry, ISRCTN15745838. Registered on 22 May 2018.

Positively imagined activities may capture visual attention due to an increase in positive value. Increasing attention toward activities, in turn, may prove useful for clinical interventions aiming to motivate behavioral engagement. Employing a within-subject experimental design, we examined the effect of positive imagery on attention using a visual probe task with concurrent eye tracking. Adults from the general population (N = 54) imagined performing activities involving visually presented objects in a positive (focusing on the positive emotional impact) or neutral (focusing on a neutral circumstance) manner. They then completed a visual probe task using picture stimuli depicting one object per type of imagery. Positive compared to neutral imagery increased self-reported behavioral motivation and biased the direction, but not the duration, of gaze toward objects associated with the imagined activities. An exploratory analysis showed a positive association between the direction bias and depressive symptoms. Our findings build on existing literature on positive imagery as a motivational amplifier by highlighting early attention as an underlying cognitive mechanism.