Support for Pre-Eating Anxiety via EXRP and Meal Support

Our patients with anorexia consistently report high anxiety with significant and often irrational food-related fear (akin to phobias), avoidance behaviors, eating rituals, and other maladaptive behaviors that can resemble the various manifestations of OCD. While the connection between anxiety and anorexia was solidified long ago, there has been limited use of established methods for treating anxiety disorders – like exposure and response prevention techniques – in the treatment of AN.

Our esteemed colleagues up at New York State Psychiatric Institute wanted to look more closely at the use of exposure and response prevention interventions specifically for anorexia.  

The researchers hypothesized that these interventions would help address underlying fears and rituals that both caused and maintained low caloric intake and weight loss in anorexia.  

To evaluate the efficacy of traditional EXRP for AN, a pilot study was carried out over 12 sessions for 17 patients ages 16 to 45. During each of the 12 sessions, 90-minutes of treatment took place. Session one began with the development of a list of patient’s feared eating situations, avoidance behaviors and ritualized behaviors. Psychoeducation was provided to explain the theory behind the study and a distress scale was used to develop a feared eating hierarchy on a scale of 1-100. Each of the subsequent sessions included exposure to the feared eating situation and progressing up their fear ladder. The patient was to experience the anxiety during each hierarchical step, as opposed to avoiding it and in time, habituation of anxiety would occur. Over time, patients would reflect on their experiences and recognize that feared outcomes did not occur. Anxiety was measured with three scales: STAI-S, SUDS, FAH. While this small sample size makes it challenging to generalize results, effect sizes were medium to large. Key to the findings was that there was a decrease in pre-meal anxiety; pre-meal anxiety is particularly important to address in treatment, as it is highly correlated with decreased food intake.

In the Treatment Setting

As with any research protocol, it’s important to think about how valuable findings can translate into practice to benefit patients.  At Columbus Park, we target eating anxiety and avoidance both with individual exposure work and also in our supported meal service. In the context of actual dining, we can work with clients to develop food hierarchies and help them deliberately and systematically introduce feared foods back into their food repertories.  We pair the exposures with specific skills – like deep breathing and progressive muscle relaxation – to help our clients manage the distress that comes from confronted and pushing through the fear.    

My3square, a virtual meal support program recently launched by the Columbus Park team, is also designed to help participants address food fear, food-related rituals and avoidance.  Within the context of group meal support, participants work to increase food variety and adequacy (systematic exposure – steadily introducing feared foods) while concurrently learning and practicing skills for managing the distress associated with the feared situation.  Visit us at to learn more.


Steinglass, J., Albano, A., SImpson,B., Schebendach, J., Attia, E. (2013) Fear of Food as  Treatment Target: Exposure and Response Prevention for Anorexia Nervosa in an Open Series. Int J Eating Disorder (45) 615-621