Effectiveness of cognitive behavioral therapy supported by virtual reality in the treatment of body image in eating disorders: One year follow-up Jose ´ H. Marco a,n , Conxa Perpin ˜a ´ b,d , Cristina Botella c,d a Department of Personality, Assessment and Treatment in Health Science, Catholic University of Valencia, Valencia, Spain b Department of Personality, Assessment and Psychological Treatment, University of Valencia, Valencia, Spain c Department of Basic Psychology, Clinic and Psychobiology, Universitat Jaume I, Castello ´n, Spain d CIBER Fisiopatologia Obesidad y Nutricio ´n (CB06/03), Instituto Salud Carlos III, Spain article info Article history: Received 1 February 2012 Received in revised form 23 July 2012 Accepted 14 February 2013 Keywords: Cognitive-behavioral-treatment Anorexia Bulimia nervosa Virtual systems Outpatient Personality disorders Randomized controlled trial abstract Body image disturbance is a significant maintenance and prognosis factor in eating disorders. Hence, existing eating disorder treatments can benefit from direct intervention in patients’ body image. No controlled studies have yet compared eating disorder treatments with and without a treatment component centered on body image. This paper includes a controlled study comparing Cognitive Behavioral Treatment (CBT) for eating disorders with and without a component for body image treatment using Virtual Reality techniques. Thirty-four participants diagnosed with eating disorders were evaluated and treated. The clinical improvement was analyzed from statistical and clinical points of view. Results showed that the patients who received the component for body image treatment improved more than the group without this component. Furthermore, improvement was maintained in post-treatment and at one year follow-up. The results reveal the advantage of including a treatment component addressing body image disturbances in the protocol for general treatment of eating disorders. The implications and limitations of these results are discussed below. & 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Body image disturbance is one of the most prominent clinical characteristics of eating disorders (Garner, 2002; Stice, 2002; Schwartz and Brownell, 2004; Nye and Cash, 2006). Body image is also one of the most relevant prognostic factors in the treatment of bulimia nervosa (BN) (Fairburn et al., 1993; Stice and Shaw, 2002) and anorexia nervosa (AN) (Thompson, 1992; Gleaves et al., 1993). Dissatisfaction with one’s body as well as body image disturbance is associated with problematic behaviors and attitudes toward food, such as lack of control over eating, adopting restric- tive diets, and demonstrating bulimic symptomatology. Therefore, the persistence of body dissatisfaction after treatment of eating disorders is a reliable predictor of relapse in AN and BN patients (Shisslak and Crago, 2001; Stice, 2002; Cash and Hrabosky, 2004). Despite the relevance of body image in eating disorder treatment, most studies fail to evaluate or treat body image (Rosen, 1996). In cases where body image is a treatment target, the effect of the treatment on patients’ body image is not analyzed (Farrell et al., 2006). Psychoeducational treatment for BN, pure behavioral treat- ments, pharmacological treatments, interpersonal therapy, and psychodynamic therapy are ineffective in terms of global body image improvement (Cash and Grant, 1996). Some treatments for eating disorders (Thompson et al., 1996) include educational components addressing body image in BN (Fairburn, 2002) and AN (Vitousek, 2002); however the effect of these interventions on body image is unknown (Nye and Cash, 2006). From a transdiagnostic perspective (Fairburn et al., 2003), body image intervention must prevent the maintenance of eating dis- order psychopathology. Fairburn et al. (2009) enhanced Cognitive Behavioral Treatment (CBT) for eating disorders with other com- ponents addressing important aspects of these disorders including perfectionism, interpersonal problems, and self-esteem. Several studies (Rosen 1996; Farrell et al., 2006; Nye and Cash, 2006) suggest that interventions based on body image distortion could improve evidence-based treatments for eating disorders (NICE, 2004) However, there has been no controlled study proving the effectiveness of body image treatment in eating disorders (Nye and Cash, 2006). Hence, it would be illuminating to compare the statistical and clinical effectiveness of treatments with or without a component focused on body image (Cash and Hrabosky, 2004; Farrell et al., 2006). A previous study conducted by our group with participants diagnosed with eating disorders showed that treatment for body Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/psychres Psychiatry Research 0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.02.023 n Correspondence to: Department of Personality, Assessment and Treatment in Health Science, Catholic University of Valencia, C/Guillem de Castro, 175, Valencia 46008, Spain. Tel.: þ34 963637412; fax: þ34 963919827. E-mail addresses: joseheliodoro.marco@ucv.es, jh.marco@hotmail.com (J.H. Marco). Psychiatry Research 209 (2013) 619–625