Treating dysfunctional interoceptive awareness in eating disorders
One approach that has been suggested to help weaken conditioned associations between interoceptive and environmental cues is interoceptive exposure therapy. Although originally developed for treatment of anxiety, it has been conceptually extended towards eating disorders.16 Using the process of extinction learning, patients are engaged in activities intended to elicit physiological sensations that are disorder-related, associated with negative affective states, and trigger maladaptive behavioral responses.
Patients may be repeatedly confronted with the sight and smell of foods, during which they closely attend to the associated sensations of hunger, salivation, or disgust. Over time, this weakens the conditioned association between the sensory signal and negative affective state, in hopes of reducing food avoidance behaviors.
Consumption of food can be incorporated into interoceptive exposure therapy. One prominent clinician utilizes a chocolate frog as an exposure exercise, with a goal of successfully engaging the patient to examine, smell, and eventually eat this high-calorie food by the end of several sessions. Other potential interoceptive exposures involve gulping water (to elicit sensations of fullness or bloating), bouncing up and down (to elicit sensations of feeling body fat, or the movement of skin and muscles on the body), pushing the belly out (to elicit sensations of a tight belly), or sitting in a bean bag chair (to elicit sensations of sinking body weight).
An acceptance-based interoceptive exposure therapy has been recently described for children. Using playful cartoons to engage their curiosity about interoceptive sensations (eg, Gassy Gus, or Henry Heartbeat), the treatment trains children to increase their attention in a positive manner in order to decrease aversiveness, increase self-awareness, and increase food approach behaviors.17 However, the clinical efficacy of these techniques has not been systematically studied. There are currently no randomized controlled trials that have examined the efficacy of interoceptive exposure therapy for eating disorders, and further research is needed to determine the viability of such approaches.
We still have much to learn about the mechanisms driving food avoidance-approach behaviors in eating disorders. Studying interoception may provide new insights by characterizing how these individuals actively infer meaning about missing or ambiguously perceived interoceptive signals. For example, colleagues and I recently found that when anticipating a meal, individuals with AN tend to report false perceptions of interoceptive sensation, in the absence of any physiological changes.18 The presence of these visceral illusions during the premeal state, a time marked by strong food-related feelings of fear and anxiety, suggests that closer attention to patients’ responses to environmental cues and behaviors leading up to a meal is warranted. It may be that the selection of maladaptive actions in response to these expectations (eg, self-starvation to avoid the actual sensing of visceral sensations) is an underlying core feature of eating disorders and represents a transdiagnostic target for clinical intervention.
Dr Khalsa is Director of Clinical Studies, Laureate Institute for Brain Research, University of Tulsa, Tulsa, OK. Dr Khalsa reports no conflicts of interest concerning the subject matter of this article.
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