Prevalence & Features of Eating Disorders in Males – Part 5

Doctor discussing Anorexia Research

Exposure-Based Therapy & Eating Disorders – Functional Assessment

Below are a few different treatment steps that we use in implementing Exposure-Based Therapy.

First is the Functional Assessment. This is very important as it kicks off treatment and gets things started and moving in the right direction.

Our major objective in completing the functional assessment is to gain a good working understanding, with help from the patient, of some of the specific cognitive and behavioral features relating to their eating disorder.

What this gets at is trying to understand three key areas:

  1. What are the types of cues or triggers that evoke fear in the patient? In other words, what stimuli evoke eating disorder related anxiety or fear.
  2. What are the consequences or feared outcomes that the patient anticipates upon exposure to those feared cues?
  3. Finally, how does the patient try to cope with their fear ineffectively?
  4. What are they doing desperately to try to prevent those consequences from occurring

What I’m getting at here is:

What are the eating disorder specific safety behaviors that the patient engages in?

We start with assessing what the specific feared cues are.

Some common areas that we look to assess this can include a variety of certain foods or eating scenarios that the patient might fear.

Again, body image related activities or cues, even something as straightforward as seeing one’s reflection in the mirror, wearing more form-fitting clothing items, engaging in athletic activities that one might perceive as putting body image or physique under the microscope, even just having the body in a certain unflattering posture or position such as sitting slouched over in a way that might let the flesh on the stomach roll or collect a little bit more.

One of the things we’ve come to learn about using Exposure-Based Treatment in individuals with eating disorders is that we might need to do a lot of exposure to the internal private stimuli that a patient might experience.

This stimuli is really distressing and can include feelings of fullness, feeling hunger cues, even something as simple as warmth can be a significant fear cue for these patients.

We’ve had patients tell us that they construe warmth as an indication that they have over-eaten and will subsequently gain too much weight.

In terms of assessing the anticipated consequences of exposure to these feared cues, we then ask follow-up questions such as:

  • What is it that concerns you about that specific feared cue?
  • What is it that concerns you about eating fried foods?
  • What do you fear will happen if you go to the beach and wear a swimming suit and hang out with your friends?
  • What do you fear will happen if you experience intense hunger or feel particularly full after a larger meal?

Man with his dog playing in the park

Finally, when we’ve gotten the patient to articulate what are some of the feared consequences that they anticipate, we assess the safety behavior.

So, what are the types of things that you do to try to prevent the onset or the realization of this feared consequence? How do you try to make yourself less anxious if you’re in that type of situation?

So, those are the three key areas that we address in the context of the functional assessment.

Doing a careful a functional assessment is so important because, as you’ll see, it’s going to directly contribute to the types of Exposure-Based therapeutic activities that you encourage the patient to engage in throughout the course of the rest of the treatment

Developing the Exposure Hierarchy

Once the functional assessment is complete, we move on to developing what we call an “exposure hierarchy.”

Our goal here is to create a rank-ordered list of different exposure activities that the patient will be completing in succession throughout the course of his treatment.

Therapist discussing the patients functional assessment with the husband and wife.This creates a nice systematic roadmap that will be traveled throughout the course of treatment arranged in order from activities that evoke lower levels of fear and anxiety to activities that the patient anticipates to evoke higher levels of fear anxiety.

What these exposure activities need to be directly designed to target are the very feared cues that were identified in the course of your functional assessment with the patient such as the feared foods that you may have identified in the course of the functional assessment.

What that leads to in developing the exposure hierarchies is creating exposure activities that will see the patient gradually introduced to increasing fear of Oken foods into his diet.

From a body image perspective, Exposure Based activities that would be included in the hierarchy might include prolonged exposure to one’s body shape or physique in the mirror, engaging in a number of fears evoking activities such wearing a swimming suit to a public beach or a swimming pool, something of that nature.

In terms of how we do exposure to binge eating cues, this might include things like the types of food items that one has typically had difficulty with binging on in the past.

It can often include a lot of the environmental antecedents to binge eating, which, in many cases, is a lot of the intense negative emotions that are often present immediately prior to the occurrence of a binge eating episode.

However, it can include any environmental cue that serves to contribute to an individual’s binge eating cravings.

One specific example of this came from a recent patient of ours, albeit a female patient.

A significant queue for her that contributed to the onset of her binge eating episodes, given that she wanted to do a lot of this binge eating in secret due to the shame she experienced, she would often wait until the evening, before her husband was going to go into the shower.

As such, the environmental cue that started to provoke binge eating cravings for her was something as simple as seeing her husband going to get a fresh towel from a towel closet or something like that.

Just that environmental cue of seeing, “okay, my husband is about to begin his shower routine,” is what evoked pretty intense binge eating cravings for this patient.

So, binge eating cues can really include just about anything under the Sun but the key is that these are the environmental cues that are present immediately prior to the onset of a binge eating episode.

Please See

Prevalence & Features of Eating Disorders in Males – Part 1
Prevalence & Features of Eating Disorders in Males – Part 2
Prevalence & Features of Eating Disorders in Males – Part 3
Prevalence & Features of Eating Disorders in Males – Part 4


Virtual Presentation by Dr. Nicholas Farrell in the Dec. 7, 2017 Eating Disorder Hope Inaugural Online Conference & link to the press release at

Nicholas FarrellAbout the Presenter: Dr. Nicholas R. Farrell, Ph.D. is a licensed clinical psychologist who directs and supervises the treatment of patients in eating disorder programs at Rogers Memorial Hospital. Dr. Farrell specializes in the use of empirically-supported cognitive behavioral therapy (CBT) treatment strategies that are used to help patients in our eating disorders programs.

Additionally, Dr. Farrell is a regular contributor to scientific research on the effectiveness and dissemination of CBT for eating, anxiety, and mood disorders and has published over 20 peer-reviewed journal articles and book chapters. Dr. Farrell has been the gracious recipient of federal grant funding to study the role of social stigma in the context of eating disorders.

Image of Margot Rittenhouse.About the Transcript Editor: Margot Rittenhouse is a therapist who is passionate about providing mental health support to all in need and has worked with clients with substance abuse issues, eating disorders, domestic violence victims, and offenders, and severely mentally ill youth.

As a freelance writer for Eating Disorder and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on June 10, 2018.
Reviewed by Jacquelyn Ekern, MS, LPC on June 10, 2018.

Published on

About Baxter Ekern

Baxter is the Vice President of Ekern Enterprises, Inc. He is responsible for the operations of Eating Disorder Hope and ensuring that the website is functioning smoothly.