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Citation: Ascione, M.; Carulla-Roig,
M.; Miquel-Nabau, H.; Porras-Garcia,
B.; Meschberger-Annweiler, F.-A.;
Serrano-Troncoso, E.; Ferrer-Garcia,
M.; Moreno-Sánchez, M.;
Gutierrez-Maldonado, J. Attentional
Bias Modification Training Based on
Virtual Reality and Eye Tracking in
Anorexia Nervosa Patients. J. Clin.
Med. 2023,12, 5932. https://doi.org/
10.3390/jcm12185932
Academic Editor: Denis Bourgeois
Received: 11 August 2023
Revised: 4 September 2023
Accepted: 8 September 2023
Published: 12 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Journal of
Clinical Medicine
Article
Attentional Bias Modification Training Based on Virtual Reality
and Eye Tracking in Anorexia Nervosa Patients
Mariarca Ascione 1, Marta Carulla-Roig 2, Helena Miquel-Nabau 1, Bruno Porras-Garcia 3,
Franck-Alexandre Meschberger-Annweiler 1, Eduardo Serrano-Troncoso 2, Marta Ferrer-Garcia 1,
Manuel Moreno-Sánchez 4and Jose Gutierrez-Maldonado 1, *
1Department of Clinical Psychology and Psychobiology, Institute of Neurosciences, University of Barcelona,
Passeig de la Vall d’Hebron 171, 08035 Barcelona, Spain; ascione.m@ub.edu (M.A.);
helena.mn29@gmail.com (H.M.-N.); franck.meschberger@ub.edu (F.-A.M.-A.); martaferrerg@ub.edu (M.F.-G.)
2Department of Child and Adolescent Psychiatry and Psychology, Hospital Sant Joan de Déu of Barcelona,
Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950 Barcelona, Spain;
marta.carulla@sjd.es (M.C.-R.); eduardo.serrano@sjd.es (E.S.-T.)
3Department of Population Health Science, University of Utah School of Medicine, 295 Chipeta Way,
Salt Lake City, UT 84112, USA; brnopg91@gmail.com
4Department of Cognition, Development and Educational Psychology, University of Barcelona,
Passeig de la Vall d’Hebron 171, 08035 Barcelona, Spain; manelsg@gmail.com
*Correspondence: jgutierrezm@ub.edu
Abstract:
Anorexia nervosa (AN) patients exhibit attentional bias (AB) related to the body, which is
the tendency to pay greater attention to weight-related body areas compared to non-weight-related
ones. This phenomenon has been linked to elevated levels of body dissatisfaction (BD) and may
potentially reduce the effectiveness of body exposure therapy. The purpose of this pilot study is
to assess the efficacy of a single session of a new body-related AB modification task (ABMT) that
combines virtual reality with eye tracking in patients with AN. The goals of the ABMT are to reduce
body-related AB by balancing attention between weight and non-weight-related body areas and to
reduce BD levels. Twenty-three adolescent patients with AN were embodied in a virtual avatar and
immersed in a virtual environment where they completed the ABMT. Body-related AB measures and
BD levels were assessed before and after the training. A paired samples t-test showed statistically
significant differences between pre-assessment and post-assessment; the complete fixation time on
weight-related body parts was reduced and BD levels decreased. The initial evidence of the efficacy
of this ABMT has important clinical implications, since AB and BD are considered risk factors for
developing and maintaining eating disorder symptomatology among patients with AN.
Keywords: anorexia nervosa; attentional bias modification; body dissatisfaction
1. Introduction
Anorexia nervosa (AN) is a serious eating disorder with high mortality rates [
1
] and is
often diagnosed in early adolescence or adolescence [
2
]. Neurocognitive deficits including
attentional bias (AB) are implicated in developing and maintaining eating disorders [
3
,
4
].
AB is a phenomenon that is defined as the tendency to focus attention to information
perceived as threatening over other types of information in response to a stimulus related
to the disease [
5
,
6
]. It has been found that most patients with AN show an AB toward their
body, focusing more attention on disliked body parts or weight-related body parts (e.g.,
stomach, thighs) and ignoring body parts not related to weight (e.g., neck, arms) [
7
]. A
cognitive approach to psychopathology identifies AB as the result of maladaptive cognitive
processes and schemas related to appearance, shape, and weight [
5
,
8
]. The patient’s way
of thinking and behaving is constantly determined by such schemas. They automatically
process only body information that is consistent with their dysfunctional self-schema
(related to “fat”) and ignore the schema with inconsistent information (related to “thin”) [
5
].
J. Clin. Med. 2023,12, 5932. https://doi.org/10.3390/jcm12185932 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2023,12, 5932 2 of 12
Body-related AB is an important causal and maintenance factor in body dissatisfaction
(BD) [9–11] and is one of the prominent risk and maintenance factors for AN [12]. Indeed,
numerous findings indicate that AB to body-related stimuli is moderated by the degree to
which an individual self-reports BD [
13
]. Additionally, it has been found that dysfunctional
body-related AB could interfere with and reduce the efficacy of exposure-based treatment,
such as mirror exposure therapy, which is generally used in patients with AN to treat body
image disturbances and improve the results of classic cognitive-behavioral therapy [
14
].
One study shows that patients who had higher AB toward weight-related body parts were
those who benefited least from MET (Mirror exposure therapy) [
15
]. The objective of MET
is to look at all parts of the body for the same amount of time. However, these patients may
tend to look excessively at weight-related body areas and neglect other parts of the body,
which makes MET less effective [15].
Reducing body-related AB is clinically important for preventing and treating eating
disorders [
16
]. Cognitive theories suggest that incorporating AB modification training
(ABMT) into the treatment of AN can improve attentional control [
16
,
17
]. Repeated practice
of ABMT leads to neuroplasticity-mediated changes in the brain, modifying automatic
cognitive processes [
16
]. ABMT has shown effectiveness in various psychological condi-
tions, including anxiety disorders, depression, addictive disorders, obsessive compulsive
disorders, and eating disorders [
18
]. While ABMT has been used to reduce AB toward
food-related stimuli in eating disorders [
19
–
21
], no studies have explored its use with
body-related stimuli. Currently, five studies have utilized traditional ABMT to address
body image concerns in non-clinical samples [
22
–
26
]. The most utilized technique is the
modified probe detection task, originally adapted from MacLeod et al. [
27
] and coupled
with eye-tracking (ET) devices [
26
] in some instances. However, this traditional technique,
often conducted on desktop computers or smartphones, may lack ecological validity [
28
].
The probe detection task is based on the repetitive presentation of single pairs of stimuli or
relatively complex patterns of stimuli, like images of self-defined attractive and unattractive
body parts [
26
] or words that concern appearance, body shape, and food [
22
–
25
] to divert
attention away from disorder-related stimuli. The nature of these stimuli may not fully
capture the complexity of real-life situations [
28
]. Additionally, the repetitive nature of
these tasks may lead to decreased participant engagement and reduced attentional control,
potentially diminishing their effectiveness in modifying biases or symptoms [29].
To overcome these limitations, one potential solution is to integrate virtual reality (VR)
and eye-tracking (ET) technologies. VR is increasingly used in eating disorder treatment to
improve dysfunctional eating behaviors and body image disturbances [
30
,
31
] by immersing
patients in realistic simulations that replicate their bodies and real-life situations [
32
,
33
],
evoking emotions and reactions similar to real-life experiences while providing a safe and
controlled setting [
30
]. ET technology facilitates accurate and continuous measurement of
eye positions and movement throughout tasks. This technology provides a high level of
precision, allowing for detailed tracking and analysis of gaze patterns [
34
]. VR and ET are
often used separately. However, integrating them provides a whole new way to interact
with VR content and improve the overall virtual experience.
Given the documented effectiveness of VR and ET-based ABMT in reducing body-
related AB in healthy women [
35
,
36
], it is reasonable to explore the potential benefits of
applying this approach to adolescents with AN. Early treatment is crucial for adolescents
with AN due to their increased risk of long-term health complications and higher suicide
risk, as it leads to improved long-term outcomes and a higher likelihood of achieving full
recovery [
37
]. This study proposes the hypothesis that implementing ABMT aimed at
promoting balanced attention towards the entire body will effectively reduce body-related
AB. It is anticipated that this reduction in AB will correspond to lower levels of BD.
J. Clin. Med. 2023,12, 5932 3 of 12
2. Materials and Methods
2.1. Clinical Sample
This study included twenty-three female adolescent patients (age = 15.30
±
1.29 years;
BMI = 18.28
±
1.62 kg/m
2
) from the eating disorders unit of Hospital Sant Joan de Déu
of Barcelona. Inclusion criteria consisted of a primary diagnosis of AN according to the
DSM-5 [
38
], an age between 12 and 17 years and 11 months, and classification as under-
weight based on body mass index (BMI) for age and sex growth references charts [
39
]. Ex-
clusion criteria were severe mental disorders with manic or psychotic symptoms, epilepsy,
sensory complications preventing exposure, pregnancy, and clinical cardiac arrhythmia.
All of the patients received a multidisciplinary approach treatment, including biological
management, nutritional rehabilitation, behavioral programs to improve eating habits and
weight, cognitive therapy (individual and group), and counseling for both individuals and
parents. The majority received an intensive day program for 11 h a day (sleeping at home),
while only one was in outpatient care, which is suitable for patients with good compliance
and no significant risk factors. Intensive day hospital care is usually reserved for cases
where there is no improvement in weight or eating behavior, especially when physical
health is severely compromised or comorbid psychopathology is present.
2.2. Measures
Body dissatisfaction. BD was assessed using the Body Image Assessment Scale-Body
Dimensions (BIAS-BD) [
40
]. This figural drawing scale questionnaire consists of a series
of 17 silhouettes that depict a range of body sizes, spanning from 60 to 140 percent of
the average female BMI. The pre- and post-training assessments utilized two different
test-retest versions (A and B), with randomized silhouettes to mitigate any potential order
effect bias. Participants chose the silhouette that best represented their current body size
and the one that reflected their ideal body size. BD was determined by calculating the
difference between the perceived body size and the self-defined ideal body size. Scores
close to 0 represent no desired body change, and larger scores represent larger desired body
change. This scale exhibits good psychometric properties, demonstrating robust test-retest
reliability (r = 0.86) and substantial concurrent validity (r = 0.76) [40].
Body-related attentional bias measures. Visual fixation on the virtual body served
as a measure of AB. The body was divided into two areas of interest (AOIs) based on a
categorization derived from the Physical Appearance State and Trait Anxiety Scale [
41
] (see
Figure 1):
•
Weight-related AOIs encompassed body regions commonly associated with measures
of eating disorders, including the stomach, hips, waist, thighs, and legs.
•
Non-weight-related AOIs included body parts less correlated with eating disorders:
neck, chest, shoulders, arms, and feet.
In this study, the participant’s head was not taken into account as the avatar’s head
was covered by a head-mounted display, which was also worn by the participant. Visual
fixation, defined as the behavior of sustaining one’s gaze on a specific location for a mini-
mum duration, typically 100–200 ms [
42
], was assessed using two reliable and continuous
measures [
33
,
43
,
44
]: the number of fixations, which represents the total count of fixations on
the specified group of the AOI, and complete fixation time, which refers to the cumulative
duration of fixations on the specified AOI group in milliseconds.
2.3. Instruments
Hardware. The VR system utilized in this study consisted of an HTC Vive Pro Eye
head-mounted display (HTC Corporation, Taoyuan, Taiwan) equipped with a built-in
Tobii eye tracker (Tobii Technology, Stockholm, Sweden). The system also included two
base stations, two VR controllers, and two additional body trackers affixed to the feet for
comprehensive full-body motion tracking.
Software. The VR environment was developed using Unity 3D 5.6.1 software (Unity
Technologies, San Francisco, CA, USA) and featured a room with a mirror placed 1.5 virtual
J. Clin. Med. 2023,12, 5932 4 of 12
meters in front of the patient, along with two boxes placed on the floor. The patients
were able to observe their entire body from a first-person perspective and their reflec-
tion in the mirror, even while they were in motion. The avatars, created using Blender
version 2.78 software, were outfitted with a head-mounted display similar to what the
patients wore. They also wore a tank top paired with jeans, allowing for customization of
the clothing color to match that of the participants, and black trainers. To minimize the
impact of hairstyle, they wore a grey hat covering their hair.
J.Clin.Med.2023,12,xFORPEERREVIEW4of13
Figure1.Weight- re latedareasofinterestaredelineatedinyellow,whilenon-weight-relatedareas
ofinterestaredemarcatedinblueonthefemalevirtualavataremployedbyOGAMAsoftware(Ver-
sion5.1)toanalyzeaentionalbiasrelatedtothebody.
2.3.Instruments
Hardware.TheVRsystemutilizedinthisstudyconsistedofanHTCViveProEye
head-mounteddisplay(HTCCorporation,Taoyu a n,Taiwa n )equippedwithabuilt-inTo-
biieyetracker(TobiiTechno log y,Stockholm,Sweden).Thesystemalsoincludedtwobase
stations,twoVRcontrollers,andtwoadditionalbodytrackersaffixedtothefeetforcom-
prehensivefull-bodymotiontracking.
Software.TheVRenvironmentwasdevelopedusingUnity3D5.6.1software(Unity
Technologies,SanFrancisco,CA,USA)andfeaturedaroomwithamirrorplaced1.5vir-
tualmetersinfrontofthepatient,alongwithtwoboxesplacedonthefloor.Thepatients
wereabletoobservetheirentirebodyfromafirst-personperspectiveandtheirreflection
inthemirror,evenwhiletheywereinmotion.Theavatars,createdusingBlenderversion
2.78software,wereoutfiedwithahead-mounteddisplaysimilartowhatthepatients
wore.Theyalsoworeatanktoppairedwithjeans,allowingforcustomizationofthecloth-
ingcolortomatchthatoftheparticipants,andblacktrainers.Tominimizetheimpactof
hairstyle,theyworeagreyhatcoveringtheirhair.
2.4.Procedure
ThisstudyreceivedapprovalfromtheethicscommieesofboththeUniversityof
BarcelonaandtheHospitalSantJoandeDéuofBarcelona.Wrieninformedconsentwas
obtainedfromboththeparticipantsandtheirlegalguardians.Personalizedavatarswere
craftedbyoverlayingfrontalandlateralphotographsofeachpatientontoavirtualsilhou-
ee.Theavatar’sheightandbodyproportionswerethenadjustedtomatchthoseofthe
respectivepatient’ssilhouee.
Duringthisprocess,thepatientinitiallycompletedversionAoftheBIAS-BDques-
tionnaire.Followingquestionnairecompletion,thepatientwasthenimmersedinthevir-
tualenvironment.Uponenteringtheroom,afive-minutevisuo-motorandvisuo-tactile
stimulationprotocol,adaptedfrompreviousstudies[7,45,46],wasappliedtoinducea
full-bodyownershipillusion(FBOI),increasingparticipants’identificationwiththevir-
tualbody[47].Patientsweregiveninstructionstomaintaintheirgazeontheirownreflec-
tioninthemirrorwithoutmakinganymovementsfor30s,duringwhichtheireyemove-
mentswererecorded.Tomitigatepotentialbiasarisingfromknowledgeofthetrueobjec-
tive,thispre-trainingABassessmentwaspresentedtothepatientsasasensorcalibration
Figure 1.
Weight-related areas of interest are delineated in yellow, while non-weight-related areas
of interest are demarcated in blue on the female virtual avatar employed by OGAMA software
(Version 5.1) to analyze attentional bias related to the body.
2.4. Procedure
This study received approval from the ethics committees of both the University of
Barcelona and the Hospital Sant Joan de Déu of Barcelona. Written informed consent
was obtained from both the participants and their legal guardians. Personalized avatars
were crafted by overlaying frontal and lateral photographs of each patient onto a virtual
silhouette. The avatar ’s height and body proportions were then adjusted to match those of
the respective patient’s silhouette.
During this process, the patient initially completed version A of the BIAS-BD ques-
tionnaire. Following questionnaire completion, the patient was then immersed in the
virtual environment. Upon entering the room, a five-minute visuo-motor and visuo-tactile
stimulation protocol, adapted from previous studies [
7
,
45
,
46
], was applied to induce a
full-body ownership illusion (FBOI), increasing participants’ identification with the virtual
body [
47
]. Patients were given instructions to maintain their gaze on their own reflection in
the mirror without making any movements for 30 s, during which their eye movements
were recorded. To mitigate potential bias arising from knowledge of the true objective, this
pre-training AB assessment was presented to the patients as a sensor calibration task. The
true purpose of the assessment was only disclosed after the session had concluded.
The next step was the ABMT, which was derived from a modified version of the
attention bias induction procedure introduced by Smeets et al. [
26
] and developed through
the visual selection of geometric figures with various colors that fitted specific body areas.
Participants were explicitly informed of the real goal of the training (learning to pay
attention to all body parts), because this could potentially enhance the learning process
by engaging both implicit and explicit aspects of the task [
48
,
49
]. Specifically, participants
were asked to stare for 4 s at the specific body part where the geometrical figures appeared
on the avatar, while it was progressively illuminated until the end of the 4 s, and then to
J. Clin. Med. 2023,12, 5932 5 of 12
move on to the next figure presentation. To ensure that all patients had spent the same
amount of time on all parts of the body by correctly completing the entire task, if the patient
deviated their gaze from the stimulus, the system blocked the elapsing of seconds until the
participant returned the gaze to the stimulus. To make the ABMT more interactive and to
maintain the motivation to perform the task, participants were asked to detect and identify
the geometric figures through a figure discrimination task based on naming the figure’s
shape in half of the trials and naming the figure’s color in the remaining trials. During the
training, the geometric figures were displayed in 45% of the trials on body parts related to
weight. In another 45% of the trials, the figures were presented on body parts related to
non-weight. The remaining 10% of the trials featured the figures appearing on two neutral
stimuli located adjacent to the avatar (Figure 2).
J.Clin.Med.2023,12,xFORPEERREVIEW5of13
task.Thetruepurposeoftheassessmentwasonlydisclosedafterthesessionhadcon-
cluded.
ThenextstepwastheABMT,whichwasderivedfromamodifiedversionoftheat-
tentionbiasinductionprocedureintroducedbySmeetsetal.[26]anddevelopedthrough
thevisualselectionofgeometricfigureswithvariouscolorsthatfiedspecificbodyareas.
Participantswereexplicitlyinformedoftherealgoalofthetraining(learningtopayat-
tentiontoallbodyparts),becausethiscouldpotentiallyenhancethelearningprocessby
engagingbothimplicitandexplicitaspectsofthetask[48,49].Specifically,participants
wereaskedtostarefor4satthespecificbodypartwherethegeometricalfiguresappeared
ontheavatar,whileitwasprogressivelyilluminateduntiltheendofthe4s,andthento
moveontothenextfigurepresentation.Toensurethatallpatientshadspentthesame
amountoftimeonallpartsofthebodybycorrectlycompletingtheentiretask,ifthepa-
tientdeviatedtheirgazefromthestimulus,thesystemblockedtheelapsingofseconds
untiltheparticipantreturnedthegazetothestimulus.TomaketheABMTmoreinterac-
tiveandtomaintainthemotivationtoperformthetask,participantswereaskedtodetect
andidentifythegeometricfiguresthroughafigurediscriminationtaskbasedonnaming
thefigure’sshapeinhalfofthetrialsandnamingthefigure’scolorintheremainingtrials.
Duringthetraining,thegeometricfiguresweredisplayedin45%ofthetrialsonbody
partsrelatedtoweight.Inanother45%ofthetrials,thefigureswerepresentedonbody
partsrelatedtonon-weight.Theremaining10%ofthetrialsfeaturedthefiguresappearing
ontwoneutralstimulilocatedadjacenttotheavatar(Figure2).
Figure2.Aentionalbiasmodificationtrainingvisualrepresentation:geometricfiguresappearing
onaweight-relatedbodypart(a),onanilluminatedweight-relatedbodypart(b),onanon-weight-
relatedbodypart(c),andonneutralstimulus(d).
ThedivisionoftargetstimuliintospecificpercentagesintheABMTservesseveral
purposes.TheprimarygoalofABMTwastoachieveabalancedallocationofaention
betweenweight-relatedandnon-weight-relatedbodyparts.Toensurethisequilibrium,
thestimuliweredistributedalmostequally,with45%allocatedtoeachofthesetwocate-
gories.Thisdistributionguaranteesthatparticipantsreceivetrainingingivingequalat-
tentiontobothtypesofbodyparts.Theinclusionof10%neutralstimuliinABMTextends
itseffectsbeyondtraining,promotingthetransferofbalancedaentionallocationfroma
trainingcontexttoreal-worldsituationsbyintroducingvariability.Also,itservestomain-
tainengagementandfocusduringthetraining.Whenstimuliareheavilybiasedtoward
onecategory,participantsmightanticipatethelocationofthenextstimulus,influencing
trainingoutcomes.Bydistributingstimulibetweenweight-related,non-weight-related
bodyparts,andneutralstimuli,ABMTkeepsparticipantsengagedandaentivethrough-
outthetraining.
Thepatientsperformedthesearch-and-staretaskforatotalof150figures,which
weresplitintotwoblocksof75figureseach.Aone-minutebreakwasprovidedbetween
thetwoblocks,resultinginatotaltaskdurationofapproximately10to15min.Thedura-
tionofthetaskinthisstudywasdeterminedbasedonthefindingsfromapreviousstudy
thatexaminedtheoptimaltaskdurationfortheABMTinhealthywomen.Theestablished
Figure 2.
Attentional bias modification training visual representation: geometric figures appearing
on a weight-related body part (
a
), on an illuminated weight-related body part (
b
), on a non-weight-
related body part (c), and on neutral stimulus (d).
The division of target stimuli into specific percentages in the ABMT serves several
purposes. The primary goal of ABMT was to achieve a balanced allocation of attention
between weight-related and non-weight-related body parts. To ensure this equilibrium, the
stimuli were distributed almost equally, with 45% allocated to each of these two categories.
This distribution guarantees that participants receive training in giving equal attention to
both types of body parts. The inclusion of 10% neutral stimuli in ABMT extends its effects
beyond training, promoting the transfer of balanced attention allocation from a training
context to real-world situations by introducing variability. Also, it serves to maintain
engagement and focus during the training. When stimuli are heavily biased toward one
category, participants might anticipate the location of the next stimulus, influencing train-
ing outcomes. By distributing stimuli between weight-related, non-weight-related body
parts, and neutral stimuli, ABMT keeps participants engaged and attentive throughout
the training.
The patients performed the search-and-stare task for a total of 150 figures, which were
split into two blocks of 75 figures each. A one-minute break was provided between the two
blocks, resulting in a total task duration of approximately 10 to 15 min. The duration of
the task in this study was determined based on the findings from a previous study that
examined the optimal task duration for the ABMT in healthy women. The established dura-
tion aimed to ensure effectiveness while aligning with the previous research’s findings [
36
].
Finally, during the post-training assessment, ET measures were taken again with the same
cover story as before, and, once the VR headset and trackers were removed, the participant
completed version B of the BIAS-BD.
2.5. Statistical Analyses
The Open Gaze and Mouse Analyzer (OGAMA; Freie Universität, Berlin, Germany)
analysis software was used to convert raw ET data into appropriate quantitative data.
Additional data processing involved the calculation of the difference between weight-
related and non-weight-related AOIs. For example, in terms of the fixations number, it
resulted in 25 (30 fixations to weight-related AOIs—5 fixations to non-weight-related AOIs).
J. Clin. Med. 2023,12, 5932 6 of 12
Therefore, a score close to 0 indicates balanced attention between weight and non-weight-
related body parts, while a positive score indicates greater attention to weight-related
body parts, and a negative score indicates greater attention to non-weight-related body
parts. The outcomes of the intervention were analyzed by the statistical software IBM
SPSS Statistics v.28. The Shapiro–Wilk test did not show evidence of non-normality for
both body dissatisfaction and complete fixation time variables. Based on these results, a
paired samples t-test was used to determine whether there was a statistically significant
difference in the BD and complete fixation time measures between pre- and post-treatment
assessments. However, the distribution of the number of fixation variables departed signif-
icantly from normality at the pre-treatment assessment but not for the post-treatment
assessment. Therefore, a Wilcoxon signed-rank test was used to determine whether
there was a statistically significant difference in the number of fixations before and after
the training.
3. Results
The clinical sample consisted of 23 AN female adolescents. Table 1provides the clinical
characteristics of the patients, including the subtype of anorexia nervosa, comorbidities,
and the types of pharmacological treatment received.
Table 1. Clinical characteristics of patients.
Clinical Characteristic Number of Patients
Subtype of anorexia nervosa
Restrictive Anorexia Nervosa 22
Purgative Anorexia Nervosa 1
Comorbidities
Major Depressive Disorder 2
Major Depressive Disorder and Mild Intellectual Disability 1
Post-Traumatic Stress Disorder 1
Social Anxiety Disorder 2
Obsessive Compulsive Disorder 1
Pharmacological Treatment
Antipsychotics 2
Antidepressants 11
Anxiolytics 2
Antipsychotics and Antidepressants 8
Antipsychotics and Anxiolytics 1
Antidepressants and Anxiolytics 4
Antidepressants, Anxiolytics, and Antipsychotics 4
Figure 3a–c displays the mean values and 95% confidence intervals for BD and body-
related AB measures at both the pre-training assessment and post-training assessment
time points.
A one-tailed paired samples t-test was performed to analyze whether patients had
lower complete fixation time and BD levels after the ABMT (see Table 2).
Table 2.
Paired samples t-test comparing complete fixation time and body dissatisfaction between
pre-assessment and post-assessment time.
Pre-Assessment Time Post-Assessment Time Paired Samples
t-Test Effect Size
Mean (SD) Mean (SD) t p Cohen’s d *
Complete fixation time
(in ms) 3269.88 (5837.05) −94.88 (7988.81) 1.863 * 0.040 0.452
Body dissatisfaction 42.83 (26.14) 33.26 (32.14) 1.880 * 0.037 0.392
Note: Significant differences. * p< 0.05; Cohen’s d effect sizes: small (
≥
0.20), medium (
≥
0.50), and large (
≥
0.80).
J. Clin. Med. 2023,12, 5932 7 of 12
J.Clin.Med.2023,12,xFORPEERREVIEW7of13
Figure3a–cdisplaysthemeanvaluesand95%confidenceintervalsforBDandbody-
relatedABmeasuresatboththepre-trainingassessmentandpost-trainingassessment
timepoints.
(a)(b)
(c)
Figure3.Meansofthepatientsatthetwoassessmentconditions(pre-assessment,post-assessment)
incompletefixationtime(a),numberoffixations(b),andbodydissatisfaction(c).Errorbarsrepre-
sent95%confidenceintervals(+/−2SE).Note:“Wvs.NWAOIs”=weightvs.non-weightareasof
interest;“BIAS-BD”=BodyImageAssessmentScale-BodyDimensions.
Aone-tailedpairedsamplest-testwasperformedtoanalyzewhetherpatientshad
lowercompletefixationtimeandBDlevelsaftertheABMT(seeTable 2).
Tab le2.Pai redsamplest-testcomparingcompletefixationtimeandbodydissatisfactionbetween
pre-assessmentandpost-assessmenttime.
Pre-AssessmentTimePost-AssessmentTimePairedSamples
t-TestEffectSize
Mean(SD)Mean(SD)tpCohen’sd*
Completefixationtime(inms)3269.88(5837.05)−94.88(7988.81)1.863*0.0400.452
Bodydissatisfaction42.83(26.14)33.26(32.14)1.880*0.0370.392
Note:Significantdifferences.*p<0.05;Cohen’sdeffectsizes:small(≥0.20),medium(≥0.50),and
large(≥0.80).
AWilcoxonsigned-ranktestwasusedtodeterminewhethertherewasastatistically
significantreductioninthenumberoffixationsfollowingthetraining(seeTab l e3).
Tab le3.Wilcoxonsigned-ranktestcomparingthenumberoffixationsbetweenpre-assessmentand
post-assessmenttime.
Pre-AssessmentTimePost-AssessmentTimeWilcoxonSigned-RankTestEffectSize
Mean(SD)Mean(SD)zpr
2
*
Numberoffixations2.00(20.80)−3.41(18.56)−0.5920.554
−0.100
Figure 3.
Means of the patients at the two assessment conditions (pre-assessment, post-assessment) in
complete fixation time (
a
), number of fixations (
b
), and body dissatisfaction (
c
). Error bars represent
95% confidence intervals (+/
−
2 SE). Note: “W vs. NW AOIs” = weight vs. non-weight areas of
interest; “BIAS-BD” = Body Image Assessment Scale-Body Dimensions.
A Wilcoxon signed-rank test was used to determine whether there was a statistically
significant reduction in the number of fixations following the training (see Table 3).
Table 3. Wilcoxon signed-rank test comparing the number of fixations between pre-assessment and
post-assessment time.
Pre-Assessment Time Post-Assessment Time Wilcoxon Signed-Rank Test Effect Size
Mean (SD) Mean (SD) z p r2*
Number of fixations 2.00 (20.80) −3.41 (18.56) −0.592 0.554 −0.100
Note: * R-squared effect size: small (≥0.10), medium (≥0.30) and large (≥0.50).
Attentional bias measures. There was a significant reduction in the complete fixation
time on the weight-related AOIs at the post-training assessment compared to the pre-
training assessment, resulting in a balanced complete fixation time between the weight-
related and non-weight-related AOIs. There was no statistically significant change in the
number of fixations.
Body dissatisfaction. A significant decrease in BD was observed in the post-training
assessment time compared to the pre-training assessment time.
4. Discussion
The main goal of this study was to investigate the effectiveness of a single session of
ABMT using VR and ET technology in reducing body-related AB and BD in adolescent
patients with AN.
This study confirmed that patients with AN had AB towards weight-related body parts, as
indicated by a higher fixation time on these areas. This aligns with previous research [
7
,
44
,
50
]
suggesting that AB can act as a maintaining factor in disorders through cognitive and emotional
mechanisms [
8
]. Selective processing of symptom-relevant stimuli leads to disregarding
conflicting information [
51
], especially when those stimuli are perceived as threatening,
J. Clin. Med. 2023,12, 5932 8 of 12
triggering a vicious circle of hypervigilance and exclusion of disconfirming stimuli [
52
,
53
].
As expected, the ABMT restored balanced attention between weight- and non-weight-
related body areas by reducing the complete fixation time on weight-related body parts.
These findings align with previous studies that demonstrated the effectiveness of ABMT in
reducing appearance bias [
22
,
24
] but contrast with a study that did not elicit AB change [
23
].
The contrasting results with this other study may be attributed to methodological differ-
ences. This study was carried out by combining VR and ET technologies, and the ABMT
was more focused on balancing attention between positive (non-weight-related body parts)
and negative (weight-related body areas) stimuli using a virtual representation of the
patient’s real body parts, while the other study used a computer dot-probe task to induce
AB towards a specific stimuli valence using words related to appearance, body shape, and
food in a positive, negative, or neutral connotation.
In contrast to the complete fixation time measure, AN patients showed no body-related
AB when the fixations number measure was considered a measure of AB, as participants
exhibited a balanced number of fixations between weight and non-weight-related body
parts at baseline, which remained unchanged after the ABMT, indicating that the ABMT
did not impact the fixations number due to the absence of bias to correct.
The measures of the complete fixation time and fixations number were both used to
assess the level of attention and cognitive processing in the AOIs, but their interpretation
may differ. While the fixations number reflects the semantic importance of stimuli [
54
,
55
],
complete fixation time is influenced by the complexity and level of interest in the AOI [
56
,
57
].
Therefore, participants may distribute their fixations number between weight and non-
weight-related body parts because both belong to the semantic category of the body, which
is clinically significant for patients with AN. The higher complete fixation time spent
on weight-related areas at baseline may be attributed to their emotional relevance and
complexity, suggesting a deeper processing of information related to those areas.
The interpretation of the change in the complete fixation time pattern after ABMT must
be considered carefully, as these changes may depend on the interplay between automatic
attentional processes, higher-order attentional control mechanisms, and goal-directed
behavior [
58
–
60
]. Threat stimuli might be predominantly processed through automatic
processes, whereas neutral stimuli may necessitate a certain level of attentional control for
sufficient processing [
61
,
62
]. ABMT aims to teach attention control [
63
], and it is possible
that patients, knowing the goal of the training, voluntarily chose to allocate attention to
non-weight-related body areas in addition to automatic attention to weight-related areas.
The development of attention control abilities involves dedicated neural architecture and
multiple neural pathways, which are influenced by repeated exposure to specific tasks,
such as ABMT [
64
–
66
]. However, further information is needed to determine whether the
balanced complete fixation time after the ABMT reflects learned attention control, changes
in emotional and cognitive relevance of non-weight-related body areas, or a combination
of these factors.
Furthermore, this study demonstrated a reduction in BD levels reported by patients
after ABMT. These findings align with previous research by Smith and Rieger [
24
], who ob-
served that inducing AB towards negative body-related stimuli increased BD and induced
an AB towards the respective target stimuli. Our findings are also consistent with those
reported by Smeets et al. [
26
], who found that inducing an AB for self-defined unattractive
body parts led to a reduction in body satisfaction, whereas inducing an AB for self-defined
attractive body parts led to an increase in body satisfaction. These findings highlight the
role of body-related AB in maintaining body image disturbances [
5
,
9
] and suggest that body
image-related AB and levels of BD can be manipulated. If AB exacerbates levels of BD, AB
could be an appropriate target for interventions aimed at reducing BD. Redirecting attention
towards both weight- and non-weight-related body parts could be beneficial for improving
BD and developing alternative cognitive and behavioral patterns. In contrast with our
study, studies by Loughnan et al. [
23
] and Allen et al. [
22
], using neutral and positive
appearance-based ABMT, respectively, did not effectively reduce BD nor elicit AB towards
J. Clin. Med. 2023,12, 5932 9 of 12
specific targets. These results support the hypothesis that changes in AB can influence
symptom changes: when bias was successfully modified, symptomatology also changed;
conversely, unsuccessfully modifying bias resulted in no symptom change [67–69].
Based on previous studies, it is hypothesized that AB plays a significant role in the
development and maintenance of BD in individuals with AN and healthy women [
5
,
9
,
50
].
ABMT has important clinical implications, since it holds the potential for the prevention and
treatment of eating disorders by modifying AB [
6
,
16
]. Additionally, ABMT has the potential
to directly influence subcortical attentional processes and cognitive operations that operate
beyond conscious control, making it a potentially effective approach for patients with
persistent forms of the disease who may not benefit from traditional “top-down” cognitive
therapies [16].
Implementing VR equipment in eating disorder services can present challenges due
to the costs and logistical considerations involved. However, the use of VR technology in
ABMT offers advantages in terms of flexibility and acceptability. The virtual nature of the
task allows for the incorporation of diverse threat stimuli, enhancing the customization
of interventions. Moreover, the immersive and interactive nature of VR increases patient
engagement and motivation, contributing to more effective training outcomes. Despite
the challenges, the benefits of using VR in ABMT make it a promising approach to eating
disorder treatment [70].
Although the significant efficacy of the ABMT developed and analyzed in this study
is noteworthy, several limitations need to be addressed. These include a small sample
size and the absence of a control group. Additionally, this study only measured acute
effects without assessing long-term outcomes. Participants reported that ABMT was
repetitive in nature, suggesting the potential for enhancing user engagement by introducing
gamified features such as rewards and animations [
71
]. Future research should replicate
this study with a larger sample size, evaluate the long-term effects of ABMT through
follow-up assessments, and investigate whether multiple sessions or combining ABMT
with traditional psychological therapy, such as mirror exposure therapy, can improve its
effectiveness. Furthermore, it is important to acknowledge that the clinical heterogeneity
within our sample could have influenced the results. AN is characterized by a spectrum of
clinical presentations, including differences in symptom severity, duration of illness, and
the presence of comorbid conditions. Future research should consider stratifying samples
based on clinical phenotypes to explore potential differential treatment responses. Finally,
it would be valuable to explore the preventive potential of ABMT for women at risk of
developing eating disorders and extend the research to include the male population, who
are also experiencing an increase in body image disturbances and eating disorders [
72
,
73
].
5. Conclusions
This study showcases the promising potential of a novel ABMT based on VR and
ET as a valuable clinical tool in reducing body-related AB and BD in adolescent patients
diagnosed with AN. By simulating the image of the patient reflected in a mirror and utiliz-
ing objective measurements of visual attention patterns, this ABMT offers a meaningful
and effective approach to address these core challenges in AN treatment. The findings
suggest that this intervention can enhance therapeutic outcomes and contribute to the
overall well-being of adolescent patients with AN.
Author Contributions:
Conceptualization, M.A., M.C.-R., H.M.-N., B.P.-G., F.-A.M.-A., E.S.-T.,
M.F.-G., M.M.-S. and J.G.-M.; methodology, M.A., M.C.-R., H.M.-N., B.P.-G., F.-A.M.-A., E.S.-T.,
M.F.-G., M.M.-S. and J.G.-M.; software, M.A., B.P.-G. and M.M.-S.; validation, M.A., M.C.-R., H.M.-N.,
B.P.-G., F.-A.M.-A., E.S.-T., M.F.-G., M.M.-S. and J.G.-M.; formal analysis, M.A.; investigation, M.A.,
M.C.-R., H.M.-N. and J.G.-M.; resources, M.F.-G. and J.G.-M.; data curation, M.A.; writing—original
draft preparation, M.A.; writing—review and editing, M.A., F.-A.M.-A., B.P.-G., M.M.-S., M.F.-G. and
J.G.-M.; visualization, M.A., F.-A.M.-A. and B.P.-G.; supervision, M.F.-G. and J.G.-M.; project admin-
istration, J.G.-M.; funding acquisition, J.G.-M. All authors have read and agreed to the published
version of the manuscript.
J. Clin. Med. 2023,12, 5932 10 of 12
Funding:
This study was funded by the Spanish Ministry of Science and Innovation (Agencia Estatal
de Investigación, Ministerio de Ciencia e Innovación, Spain). Grant PID2019-108657RB-I00 funded
by MCIN/AEI/10.13039/501100011033. This study also has the support of “FundacióLa Maratóde
TV3”, Grant 202217-10.
Institutional Review Board Statement:
This study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Bioethics Commission of University of Barcelona
(CBUB), IRB00003099.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in
the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest:
The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.
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