Cheri A. Levinson

Objective: The purpose of this study was to investigate the reliability of change indices in exposure therapy. Method: We analyzed data from 119 adults with elevated social anxiety who participated in studies of public speaking exposures. Participants reported their distress using the Subjective Units of Distress Scale (SUDS) at regular intervals. The reliability of within-session habituation, between-session habituation, and expectancy change measures were estimated. Results: Commonly used measures of between-session habituation (BSH) typically demonstrated only moderate reliability, and commonly used measures of within-session habituation (WSH) typically demonstrated poor reliability. Exploratory tests in expectancy change indices suggests these findings apply to other measures of change during exposure. Conclusions: Our results indicate that measures underlying the study of habituation may be inadequate because of low reliability. This threatens the foundation of clinical and translational research, such that no substantive conclusions can be drawn from them.

Objective: Anorexia nervosa spectrum disorders (ANSD) are associated with high chronicity and mortality, with suicidality representing one of the most common and clinically significant comorbidities. Sleep disturbances are prevalent in individuals with ANSD and have independently been linked to both eating disorder (ED) symptom severity and suicidal ideation (SI), yet their temporal role in maintaining ANSD symptoms and SI remains poorly understood. This study examined sleep disturbances as a potential shared, transdiagnostic mechanism contributing to daily fluctuations in ANSD symptoms and SI. Method: Participants meeting diagnostic criteria for ANSD with current or past SI ( n = 128) completed daily ecological momentary assessment (EMA) surveys assessing sleep disturbances, ED symptoms, and SI. Analyses and hypotheses were pre‐registered. Results: Multilevel models tested within‐ and between‐person, temporally lagged, bidirectional associations among sleep disturbances, ANSD symptoms, and SI. Greater sleep disturbances predicted increased next‐day restriction, binge eating, compensatory behaviors, body checking, and SI. Bidirectional effects were also observed, such that elevations in restriction, binge eating, compensatory behaviors, body checking, and SI predicted greater sleep disturbances the following night. Discussion: These findings suggest that sleep disturbances are dynamically embedded in the daily maintenance of core ANSD symptoms and SI. Sleep may represent a shared, modifiable vulnerability process contributing to ANSD severity and SI, highlighting its potential as a transdiagnostic intervention target in both eating disorder treatment and suicide prevention.

Objective: Interoceptive processes have been implicated in the onset and progression of disordered eating and self‐injurious thoughts and behaviors (SITBs), but relatively little is known about how these relationships unfold in the short‐term. To clarify the influence of momentary interoception on self‐damaging behaviors, this study tested whether reactivity and volatility in interoceptive attention predicted disordered eating and SITBs in a high‐risk restrictive eating disorder sample. Method: One hundred and thirty adults with anorexia nervosa and atypical anorexia and current or lifetime suicidality completed 21 days of ecological momentary assessment evaluating disordered eating behaviors, SITBs, and interoceptive attention. We used dynamic structural equation modeling to test whether short‐term reactivity and trait‐level volatility in interoceptive attention conferred proximal risk for non‐suicidal self‐injury (NSSI), restriction, binge eating, purging, suicidal ideation, and suicidal behaviors. Results: At the within‐person level, greater reactivity in interoceptive attention was associated with increased risk for NSSI, binge eating, purging, and active suicidal ideation, whereas decreased reactivity in interoceptive attention was associated with increased risk for passive suicidal ideation. At the between‐person level, greater volatility in interoceptive attention, reflecting a larger amount of intraindividual residual variance in interoceptive processes, was also associated with increased risk for NSSI, binge eating, and purging. No significant effects were detected for restriction or suicidal behavior. Discussion: Impairments in interoception have transdiagnostic relevance for understanding eating disorders and SITB risk. Interventions that reduce the intensity of interoceptive fluctuations may help reduce certain eating disorder symptoms and SITBs in the context of anorexia nervosa and atypical anorexia.

Objective: Restrictive eating disorders are characterized by abnormalities in both HRV and interoception, yet the extent to which transient physiological changes are related to interoceptive sensibility in this population remains unclear. The present study examines the association between HRV and interoceptive sensibility among individuals with anorexia nervosa and atypical anorexia (i.e., Anorexia Nervosa Spectrum Disorders) in real‐time using a combination of biosensor and ecological momentary assessment data. Method: Seventy‐five adults with Anorexia Nervosa Spectrum Disorders and current or lifetime suicidality completed 21 days of ecological momentary assessment while wearing a sensor band that passively collected HRV data. Multilevel models examined the association between HRV and interoceptive sensibility at the within‐ and between‐person levels. Results: HRV was positively associated with interoceptive sensibility at the between‐person level, such that individuals with higher HRV demonstrated greater interoceptive sensibility. However, temporary changes in HRV (i.e., deviations from one's average) were not associated with corresponding changes in interoceptive sensibility. Discussion: Within Anorexia Nervosa Spectrum Disorders with co‐occurring suicidality, alterations in autonomic function are accompanied by differences in interoceptive sensibility at the trait, but not state, level. Both heightened HRV and irregularities in interoceptive sensibility may arise as a consequence of prolonged caloric restriction. Physiological processes distinct from HRV may be responsible for driving momentary fluctuations in interoceptive sensibility in this population. Further research is needed to continue parsing potential differences in physiological processes across specific diagnoses and illness stage.

RISE-ED is acceptable in intensive treatment settings and was associated with reductions in interoceptive deficits.To enhance feasibility, module delivery should be based on estimated length of sta...

Objective: Imaginal exposure therapy facilitates the approach of feared stimuli (e.g., fear of weight gain) not accessible in everyday life (e.g., rapidly gaining weight) and has initial promising data for the treatment of eating disorders (EDs). Methods: In the current randomized controlled trial (RCT) participants ( N = 130) were randomly assigned to a five‐session digital imaginal exposure condition or a control online journaling condition within 4 months of discharge from intensive (e.g., inpatient) treatment. We examined the feasibility and acceptability of the treatment conditions, target engagement, and initial clinical efficacy. This study was pre‐registered. Results: Imaginal exposure therapy significantly outperformed the control condition on our primary outcome and target mechanism: fear of weight gain. Imaginal exposure therapy also outperformed the control condition on overall ED symptoms, fear of food, food avoidance, clinical impairment, and PTSD symptoms, suggesting initial clinical efficacy. Discussion: This RCT suggests that the active ingredient (i.e., exposure to feared stimuli) in imaginal exposure leads to significant decreases in fear of weight gain and associated clinical outcomes. This work supports imaginal exposure therapy as an effective intervention for fear of weight gain, a primary maintenance factor of EDs. Trial Registration: NCT04862247

Background: Cognitive behavioral therapy (CBT) is the most effective treatment for binge eating disorder (BED) but is limited by modest efficacy and low reach of in-person delivery. Combining mindfulness training with CBT could enhance efficacy by targeting emotion dysregulation, a key factor in BED that CBT does not adequately target. Digital delivery can enhance the reach of treatment. Accordingly, we developed CBT-based Mindful Courage, a 16-session digital intervention combining CBT and mindfulness training for BED. Objective: The aim of this study is to conduct a pilot randomized controlled trial to evaluate the feasibility (intervention and assessment completion) and acceptability (usability, overall satisfaction, engagement, visual appeal of content, understandability of program content, desire to continue the program, perceived skill acquisition, perceived confidence in implementing skills, and perceived helpfulness) of CBT-based Mindful Courage. We will also evaluate changes in outcomes (binge eating frequency, eating disorder symptoms, clinical impairment, and depression symptoms) and mechanisms (emotion dysregulation, dietary overrestriction, and trait mindfulness). Methods: This is a parallel-group, single-blinded, randomized controlled trial with a 1:1 allocation ratio. It will be conducted from November 2025 to November 2026, with study assessments at baseline, midtreatment, end-of-treatment, and 2-month follow-up. We will recruit a volunteer sample of adults with BED (N=40) aged 18 to 75 years via online advertisements. Exclusion criteria include a BMI <18.5, current anorexia or bulimia nervosa, and current treatment for BED or weight loss. Participants will be randomly allocated to an active control that includes coached self-monitoring (self-monitoring of food intake in Recovery Record and coaching calls by a research assistant) or to CBT-based Mindful Courage+coached self-monitoring. Both conditions will have a duration of 18 weeks. All study sessions will take place over Zoom. Results: The study was funded in April 2023. Data collection began in November 2025, and we anticipate recruitment to be completed by November 2026. Results are expected to be analyzed by May 2027 and published by May 2028. Conclusions: This will be an important first step in creating a scalable and efficacious treatment for BED. Trial Registration: ClinicalTrials.gov NCT07212673; https://clinicaltrials.gov/study/NCT07212673 International Registered Report Identifier (IRRID): DERR1-10.2196/91761