JMIR Publications

ABSTRACT

Background:

There is a growing interest in developing novel psychological interventions for eating disorders, with an emphasis on targeting maintaining factors. One hypothesized mechanism of illness maintenance is the experience of an inner eating disorder voice which reinforces unhelpful thoughts, emotions and behaviors. Preliminary studies suggest that the eating disorder voice is common among patients and linked to greater illness severity.

Objective:

This single-arm, mixed-method pilot feasibility study evaluated a novel virtual reality (VR)-based therapy to target the eating disorder voice. The intervention was adapted from AVATAR therapy for psychosis and examined as an adjunct to treatment as usual in individuals with eating disorders. In this adaptation participants engaged with a therapist-controlled avatar representing their inner eating disorder voice in virtual reality. The primary objectives were to assess the feasibility, acceptability, and safety of the intervention, and to provide preliminary estimates of its clinical efficacy.

Methods:

Adults with anorexia nervosa (n=9) or bulimia nervosa (n=1) took part in a seven-session VR-based therapy course at Mental Health Center, Copenhagen University Hospital in Denmark, alongside their treatment as usual. Quantitative measures of feasibility (recruitment, retention rates and satisfaction scores), safety, and eating disorder-related outcomes were collected at baseline and post-treatment between June 2023 and January 2024. Qualitative interviews post intervention (October 2023 to November 2023) explored participants’ experiences. Descriptive statistics, paired t-tests, and thematic analysis were applied and finalized October 2025.

Results:

Recruitment targets were met: 14 individuals were referred and 11 provided consent well within the prespecified timeframe. Treatment completion (n=10) was 80% and no serious adverse events occurred. Participants reported high satisfaction (n=7) (mean 9/10 on a Likert scale; median 9; range 3) and qualitative data (n=8) suggested that they valued the immersive virtual representation of their eating disorder voice. Exploratory analyses indicated improvements in eating disorder symptoms (P = .011; Hedges’ g = -0.99 [95% CI: -1.74, -0.24]), power dynamics associated with the eating disorder voice (P = .002; Hedges’ g = -1.63 [95% CI: -2.59, -0.67]), and emotion regulation via cognitive reappraisal (P = .039; Hedges’ g = 0.87 [95% CI: 0.08, 1.66]).

Conclusions:

VR-based avatar intervention for eating disorders was feasible, acceptable, and safe, with signals of some clinical change. These findings support further development and evaluation of the intervention, in a randomized clinical trial. This study was funded by the Independent Research Fund Denmark (reference-number: 2096-00078B) and Research Fund of the Mental Health services - Capital Region of Denmark.