Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Eating disorders are associated with high mortality, poor treatment outcomes, and few empirically supported treatment options.

“due to the high mortality, poor treatment outcomes, and lack of empirically supported treatment options for this population (Arcelus, 2011)”

• cites Arcelus, 2011 sourcePartly supported

  The Introduction describes poor long-term outcomes for anorexia nervosa, and Limitations and Future Studies reports high mortality across anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. Summary of Relevant Studies says the included studies could not establish treatment effects, but the paper does not assess whether empirically supported treatment options are scarce. Its poor-outcome discussion is also specific to anorexia nervosa rather than all eating disorders. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Evidence supports that exposure therapy is highly effective for reducing anxiety, clinical symptoms, and disorder-related impairment across anxiety-based disorders, including eating disorders.

“Evidence supports that exposure therapy treatments are highly effective for reducing anxiety, clinical symptoms, and disorder-related impairment across a range of anxiety-based disorders, including EDs”

• cites Butler & Heimberg, 2020 sourceNot checked — no full text of the source
• cites Cardi et al., 2019 sourcePartly supported

  The introduction (p. 7) describes exposure-based treatments as evidence-based, first-line interventions for anxiety disorders. The Summary of findings (p. 15) reports reduced anxiety and eating-disorder symptoms in a small anorexia nervosa case series. It does not establish that exposure therapy is highly effective across eating disorders or show a reduction in disorder-related impairment. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites Levinson et al., 2020 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Other studies have found no effect of within-session or between-session distress reduction on anxiety changes after exposure therapy.

“Other studies have demonstrated no effect of within- or between-session distress reduction on changes in anxiety following exposure therapy (Baker et al., 2010; Peterman et al., 2019).”

• cites Baker et al., 2010 sourcePartly supported

  The Discussion reports no relationship between within-session habituation and treatment outcomes. But the Results report that between-session reductions in distress predicted some anxiety improvements, including changes measured immediately after exposure, although the findings were inconsistent at the later assessment. The claim's unqualified 'no effect' for between-session distress reduction is therefore not supported. (LLM, conf=0.90)

  Experimental — accuracy not yet measured
• cites Peterman et al., 2019 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Exposure therapy has recently been used for eating disorders to target fear and anxiety processes thought to maintain eating pathology.

“Exposure therapy has more recently been applied to the treatment of eating disorders (EDs; for a review see Butler & Heimberg, 2020) to target fear and anxiety-related processes theorized to maintain eating pathology”

• cites Butler & Heimberg, 2020 sourceNot checked — no full text of the source
• cites Christian & Levinson, 2022 sourceNot checked — no full text of the source
• cites Schaumberg et al., 2021 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Habituation theories propose that during exposure to a feared stimulus, a person becomes used to it and it no longer elicits fear.

“habituation theories of exposure therapy propose that during exposure to a feared stimulus, a person will habituate or “get used to” the stimulus, and it will no longer elicit a fear response (Benito & Walther, 2015).”

• cites Benito & Walther, 2015 sourcePartly supported

  The Overview defines habituation as reduced anxiety in the presence of a feared stimulus and says repeated exposure elicits lower anxiety. It does not say the stimulus will no longer elicit any fear response, so that part of the paraphrase overstates the model. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim. May combine two claims.

Essayli et al. (2023) found that between-session, but not within-session, distress reduction occurred during daily food exposure for adolescents in an eating disorder partial hospitalization program, and greater between-session reduction was related to improved weight gain and symptom change.

“Essayli et al. (2023) found that between-session, but not within-session, distress reduction, occurred during the course of daily food exposure for adolescents in an ED-focused partial hospitalization program, and higher between-session distress reduction was related to improved weight gain and symptom change.”

• cites Essayli et al. (2023) sourceSupported

May combine two claims.

In Study 2, distress reduction between sessions occurred but was not related to treatment outcomes.

“In Study 2, between-session distress reduction occurred but was not related to outcomes.”

May combine two claims.

In Study 1, a significantly negative between-session time slope for state anxiety corresponded to a FOFM reduction of 0.30 or more; a significantly positive slope corresponded to a FOFM increase of 0.89 or more.

“A significantly negative slope of between-session time (e.g., reduction) was associated with experiencing a reduction of 0.30 or more on the FOFM, and a significantly positive slope (e.g., increase) was associated with experiencing an increase of 0.89 or more on the FOFM.”

May combine two claims.

In Study 2, for the average participant, subjective distress ratings tended to increase over the course of each session, suggesting within-session distress reduction did not occur.

“Additionally, for the average participant, subjective distress ratings tended to increase over the course of each session, suggesting that within-session distress reduction did not occur.”

May combine two claims.

In Study 1, participants with average FOFM change (decrease of 0.20) had some between-session decrease in session-level SUDS; greater FOFM reduction accompanied greater decreases across sessions; increasing FOFM accompanied stable SUDS.

“As depicted in Figure 3, participants with an average amount of change in FOFM (i.e., a decrease of 0.20 points) had some between-session decrease in session-level SUDS, whereas participants with more reduction in FOFM had session-level SUDS scores that decreased even more across sessions and participants with increasing FOFM had session-level SUDS scores that remained stable across sessions.”

May combine two claims.

In Study 1, participants with average EDE-Q change (decrease of 0.33) had some between-session decrease in session-level SUDS; greater EDE-Q reduction accompanied greater decreases across sessions; increasing EDE-Q accompanied relatively flat SUDS.

“As depicted in Figure 4, participants with an average amount of change in EDE-Q (i.e., a decrease of 0.33 points) also had some between-session decrease in session-level SUDS, whereas participants with more reduction in EDE-Q had session-level SUDS scores that decreased to a greater degree across sessions and participants with increasing EDE-Q had session-level SUDS scores that were relatively flat”

May combine two claims.

In Study 2, SUDS scores tended to increase within each session and decrease between sessions regardless of change in FOFM.

“Thus, SUDS scores tended to increase over time within each session and decrease over time between sessions (regardless of the change in FOFM scores).”

May combine two claims.

In Study 2, SUDS scores tended to increase within each session and decrease between sessions regardless of change in EDE-Q.

“Thus, SUDS scores tended to increase over time within each session and decrease over time between sessions (regardless of the change in EDE-Q scores).”

May combine two claims.

In Study 1, a significantly negative between-session time slope for SUDS corresponded to a FOFM reduction of 0.09 or more; a significantly positive slope corresponded to a FOFM increase of 2.65 or more.

“A significantly negative slope of between-session time (e.g., reduction) was associated with experiencing a reduction of 0.09 or more on the FOFM and a significantly positive slope of between-session time was associated with experiencing an increase of 2.65 or more on the FOFM.”

May combine two claims.

In Study 1, between-session decreases in state anxiety were linked to greater improvements in eating-disorder fears and symptoms, while increases were linked to worsening of those fears and symptoms.

“Between-session reduction in state anxiety was associated with larger improvements in ED fears and symptoms, whereas the opposite effect (e.g., anxiety increase) was associated with worsening ED fears and symptoms.”

May combine two claims.

In both studies, subjective distress during single online and in vivo imaginal exposure sessions did not habituate for the average participant and actually tended to increase during exposures.

“Subjective distress rated during single online and in vivo imaginal exposure sessions did not habituate (i.e., decrease) for the average participant and actually tended to increase during the exposures in both studies for the average participant, although visual inspection of the data suggests that participants scores tended to increase and then slightly decrease.”

May combine two claims.

In Study 1, a significantly negative between-session time slope for state anxiety corresponded to an EDE-Q reduction of 0.45 or more; a significantly positive slope corresponded to an EDE-Q increase of 0.78 or more.

“Applying these same methods to Model 1b, a significantly negative slope of between-session time (e.g., reduction) was associated with experiencing a reduction of 0.45 or more on the EDE-Q and a significantly positive slope of between-session time (e.g., increase) was associated with experiencing an increase of 0.78 or more on the EDE-Q.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Earlier research has focused on anxiety or arousal reductions occurring over minutes or hours, such as within a single treatment session.

“Prior research has focused on reductions in anxiety or arousal that may occur over minutes or hours, such as during the course of one treatment session.”

Classified as probably not a substantial claim.

Inhibitory learning theory holds that exposure therapy builds new learning through repetition and time, which inhibits the feared association and response.

“This idea is part of inhibitory learning theory, which posits that exposure therapy builds new learning with repetition and time, which inhibits the feared association and response (Craske et al., 2014, 2018).”

• cites Craske et al., 2014, 2018Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Several types of exposure therapy exist for eating disorders, including exposure and response prevention, interoceptive exposure, and imaginal exposure.

“There are several types of exposure therapy for EDs, including exposure and response prevention (ERP), interoceptive exposure, and imaginal exposure (Butler & Heimberg, 2020).”

• cites Butler & Heimberg, 2020 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Habituation, a diminished response to repeated stimuli, is a long-studied mechanism that may explain how exposure therapy changes fear and anxiety.

“Habituation (i.e., diminished response to repeated stimuli) is a long-studied mechanism that may explain how exposure therapy treatments affect change in fear and anxiety (Rankin et al., 2009).”

• cites Rankin et al., 2009 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some evidence indicates that exposure therapy can target eating disorder symptoms, but more research is needed to identify which exposure types best reduce specific symptoms.

“There is some evidence to show that exposure therapy can target ED symptoms, but more research is needed to understand which types of exposure might be most helpful at reducing specific symptoms (Butler & Heimberg, 2020).”

• cites Butler & Heimberg, 2020 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Imaginal exposure therapy, derived from prolonged exposure for PTSD, is an emerging exposure-based treatment with initial efficacy for eating disorders.

“Imaginal exposure therapy, which is derived from prolonged exposure therapy for posttraumatic stress disorder (PTSD), is one emerging exposure-based treatment that has shown initial efficacy for EDs (Levinson et al., 2020; Butler et al., 2023).”

• cites Levinson et al., 2020 sourceNot checked — no full text of the source
• cites Butler et al., 2023 sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

In 14 veterans with PTSD, Sripada et al. (2015) found that symptom change was associated with between-session distress reduction but not with within-session reduction.

“Sripada et al. (2015) examined associations between changes in distress and treatment outcomes in 14 veterans with PTSD, finding associations between symptom change and between-session distress reduction, but not within-session reduction”

• cites Sripada et al. (2015) sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Findings on whether distress reduction matters during exposure therapy are mixed.

“Given that findings on the importance of distress reduction during exposure therapy are mixed”

Probably not a substantial claim: may not pass S3 (load-bearing).

Exposure therapy is an evidence-based treatment for anxiety-related disorders.

“Exposure therapy is an evidence-based treatment for anxiety-related disorders”

• cites Abramowitz et al., 2019Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Habituation theory has long been the main theoretical basis of exposure therapy and is central to theories such as emotional processing theory.

“Habituation theory has long been the primary theoretical basis of exposure therapy and has been integral to theories of exposure such as emotional processing theory (Foa & Kozak, 1986).”

• cites Foa & Kozak, 1986 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The SCID-5-RV Eating Disorder Modules were administered by trained students and clinicians to determine eligibility and eating disorder diagnosis.

“The SCID-5-RV Eating Disorder Modules (First et al., 2015) were administered by trained students and clinicians and were used to determine eligibility and ED diagnosis.”

• cites First et al., 2015Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The clinical trial design was preregistered on ClinicalTrials.gov, and the current study was preregistered as a secondary data analysis.

“Clinical trial design was preregistered on ClinicalTrials.gov (NCT03712748) and the current study was preregistered as a secondary data analysis”

Classified as probably not a substantial claim.

Initial fear activation is thought to indicate that exposure is appropriately targeting the core fear.

“Initial fear activation is thought to be an indication that the exposure is appropriately targeting the core fear.”

• cites Foa & Kozak, 1986 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Eating Disorder Fear Interview subscales have shown good internal consistency, factor structure, and convergent and divergent validity.

“The subscales have demonstrated good internal consistency, factor structure, convergent and divergent validity (Levinson et al., 2019).”

• cites Levinson et al., 2019 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The preregistered plan handled missing data with score-level multiple imputation using chained equations and the linear mixed-models method.

“Our preregistered plan was to account for this missing data using score-level multiple imputation (via chained equations and the linear mixed-models method).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In Study 1, BSAM and SUDS scores were missing for 9 to 10 percent of observations, and symptom change scores were missing for 27 percent of participants.

“Scores on the BSAM and SUDS were missing for 9–10% of observations and change in symptom scores were missing for 27% of participants.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Brief State Anxiety Measure had good internal consistency at baseline in this sample, with Cronbach's alpha of .85.

“Internal consistency was good at baseline (Cronbach’s α = .85).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Eating Disorder Examination Questionnaire had good internal consistency at baseline in this sample, with Cronbach's alpha of .87.

“Internal consistency was good at baseline (Cronbach’s α = .87).”

Probably not a substantial claim: may not pass S2 (checkable).

The two-study format allows somewhat stronger conclusions for findings that replicated across samples.

“The two-study format allows us to make somewhat stronger conclusions for findings which replicated across samples.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Prior research in anxiety and eating disorders tends to show an initial peak in subjective distress followed by within-session reduction.

“This finding is partially consistent with prior research in anxiety and EDs, which tends to demonstrate an initial peak in subjective distress followed by within-session reduction (Butler & Heimberg, 2023; Rupp et al., 2017).”

• cites Butler & Heimberg, 2023 sourceNot checked — no full text of the source
• cites Rupp et al., 2017 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The test-retest reliability of the BSAM has not been determined, which may affect the reliability of findings.

“Further, the test-retest reliability of the BSAM has not been determined, which may affect the reliability of findings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Fear of Food Measure had excellent internal consistency at baseline in this sample, with Cronbach's alpha of .94.

“Internal consistency was excellent at baseline (Cronbach’s α = .94).”

Classified as probably not a substantial claim. May combine two claims.

Between-session distress reduction may be a mechanism of exposure therapy or simply an indicator of progress from session to session during imaginal exposure therapy.

“Between-session distress reduction may be a mechanism of exposure therapy or simply an indicator of progress from session to session during a course of imaginal exposure therapy.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims. The quote only partly states this claim.

Two changes were made to the preregistration to speed model fitting: more regularizing priors and fewer Markov chains.

“Two changes were made to the preregistration to make the models quicker to fit (which was important for feasibility given the multiple imputation procedure described below).”

Classified as probably not a substantial claim.

Emotional processing theory assumes an initial peak in fear during exposure (initial fear activation).

“This pattern partially matches the assumptions of emotional processing theory, which posits that there should be an initial peak in fear during exposure (i.e., initial fear activation; Foa & Kozak, 1986).”

• cites Foa & Kozak, 1986 sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

Fifteen imputed datasets were generated, models were fit to each, and results were pooled by combining posterior distributions for each parameter.

“Fifteen imputed datasets were generated, models were fit to each, and the results were pooled by combining the posterior distributions of each parameter.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The MINI was used to assess exclusionary criteria for participation.

“The MINI was used to assess for exclusionary criteria for participation.”

• cites Sheehan et al., 1998Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

Emotional processing theory assumes that within-session decreases in distress represent consolidation of learning and allow integration of new information into fear structures.

“This finding opposes the assumptions of emotional processing theory, which posits that within-session decreases in distress represent a consolidation of learning during the session and allow for the integration of new information into fear structures (Foa & Kozak, 1986).”

• cites Foa & Kozak, 1986 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The Brief State Anxiety Measure is highly correlated with the full 20-item state anxiety measure.

“The BSAM shows high correlation with the full 20-item state measure (Marteau & Bekker, 1992).”

• cites Marteau & Bekker, 1992 sourceNot checked — no full text of the source

May combine two claims.

The association between between-session state anxiety decrease and symptom decrease was not found in Study 2, likely due to power.

“This effect was not found in Study 2, likely due to power.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The preregistered analysis plan used Bayesian generalized linear mixed-effects models to test the study hypotheses.

“Our preregistered data analysis plan was to use Bayesian generalized linear mixed-effects models (GLMMs) to test the study hypotheses”

Probably not a substantial claim: may not pass S3 (load-bearing).

Self-report measures of subjective distress and state anxiety may be less predictive of outcomes during exposure than physiological markers of activation.

“We used self-report measures of subjective distress and state anxiety, which may be less predictive of outcomes during exposure than physiological markers of activation (Rupp et al., 2017).”

• cites Rupp et al., 2017 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

A meta-analysis of habituation research in anxiety disorders found that between-session distress reduction was associated with better treatment outcomes.

“These findings are in line with a meta-analysis of research on “habituation” during exposure therapy for anxiety disorders, which found that between-session distress reduction was associated with better treatment outcomes (Rupp et al., 2017).”

• cites Rupp et al., 2017 sourceNot checked — no full text of the source