Purpose This study assessed (1) the experience of the eating disorder voice in people with anorexia nervosa or in remission, and (2) the feasibility of creating and interacting with a computerised representation (i.e., avatar) of this voice. Methods Twenty-one individuals with anorexia nervosa and 18 individuals who were in remission participated in the study. They reported on the characteristics of their eating disorder voice and created a personalised avatar (a visual and auditory representation of the eating disorder voice), using a computerised software. Participants assessed closeness of match between the voice and the avatar, perceived distress and acceptability of re-exposure to the avatar. Results Patients felt less powerful than their eating disorder voice and unable to disregard the voice's commands. The experience of the voice was associated with negative, as well as some positive emotions, reflecting the prototypical ambivalence towards the illness. Individuals in remission had an opposite pattern of responses. They attributed only negative emotions to the voice, felt more powerful than the voice, and able to disregard its commands. Overall participants reported that there was a good match between the voice and the sound of the avatar. Patients expressed willingness to repeat exposure to the avatar. Conclusion Individuals with anorexia can create personalised digital avatars representing the eating disorder voice and are willing to engage therapeutically with the avatar. The next step is to test the feasibility of repeated exposure to the avatar to address the power and distress associated with the eating disorder voice. Level of evidence Level III.
Background. Patients with anorexia nervosa often describe the experience of living with the “eating disorder” voice. They struggle to recognise and assert their own identity over the illness’s identity and relate to it from a powerless and subordinate position. AVATAR therapy was developed to help patients with psychosis to gain greater power and control over distressing voices. The goal of this study was to test the feasibility, acceptability, safety and preliminary efficacy of an adaptation of AVATAR therapy for anorexia nervosa. Methods. Twelve adult patients with anorexia nervosa were recruited. Ten completed an assessment session and between five to seven therapy sessions. The assessment session consisted in the creation of a visual and auditory representation of the “eating disorder” (“the avatar”) through specialist computer software. During the therapy sessions, patients engaged in a dialogue with the avatar to assert their power and control over it. Patients completed baseline, end of intervention and follow-up (4-week) online questionnaires. A non-concurrent multiple baselines single case experimental design (SCED) was used (A1BA2). Feasibility, acceptability, safety and preliminary efficacy of the intervention were assessed. Results. The therapy met pre-specified criteria relating to: Feasibility: sample recruited within three months; retention rate at the end of the treatment phase= 81.9%; therapy completion rate= 90.1%. Safety: no serious adverse experiences associated with the intervention. Acceptability: mean ratings= 7.5 (SD = 2.61) out of ten on a 0-10 scale of acceptability (10= complete satisfaction). With respect to preliminary indications of efficacy, participants reported significantly lower levels of distress associated with the eating disorder voice and higher levels of self-compassion post-therapy. No other significant changes were observed with regards to frequency of the eating disorder voice, voice’s characteristics, such as omnipotence and malevolence, eating disorder symptoms and symptoms of anxiety, depression and stress. Patients’ feedback indicated that the therapy had helped with their ability to stand up to the illness, make positive changes around eating, and increase their motivation to recover and their self-compassion. Conclusion. AVATAR therapy for anorexia nervosa is feasible, acceptable and safe for patients. Larger studies are needed to test clinical efficacy. Registration The study was pre-registered on the clinicaltrials.gov registry (https://clinicaltrials.gov/ct2/show/NCT04778423).
Purpose: This study assessed (1) the experience of the eating disorder voice in people with anorexia nervosa or recovered from the illness, and (2) the feasibility of creating and interacting with a computerised representation (i.e., avatar) of this voice.Methods: Twenty-one individuals with anorexia nervosa and 18 individuals who had recovered from the illness participated in the study. They reported on the characteristics of their eating disorder voice and created a personalised avatar (a visual and auditory representation of the eating disorder voice), using a computerised software. Participants assessed closeness of match between the voice and the avatar, perceived distress and acceptability of re-exposure to the avatar. Results: Patients felt less powerful than their eating disorder voice and unable to disregard its commands. The experience of the voice was associated with negative, as well as some positive emotions, reflecting the prototypical ambivalence towards the illness. Recovered individuals had an opposite pattern of responses. They attributed only negative emotions to the voice, felt more powerful than the voice, and able to disregard its commands. Overall participants reported that there was a good match between the voice and the sound of the avatar. Patients expressed willingness to repeat exposure to the avatar.Conclusion: Individuals with anorexia can create personalised digital avatars representing the eating disorder voice and are willing to engage therapeutically with this avatar. The next step is to test the feasibility of repeated exposure to the avatar to address the power and distress associated with the eating disorder voice.Level of evidence: Level III
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