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A question that arises from the literature on therapy is whether second-level treatment is effective for patients with recurrent binge eating who fail first-level treatment. It has been shown that subjects who do not stop binge eating after an initial structured cognitive-behavioural treatment (CBT) programme benefit from additional CBT (A-CBT) sessions; however, it has been suggested that these resistant patients would benefit even more from cue exposure therapy (CET) targeting features associated with poor response (e.g. urge to binge in response to a cue and anxiety experienced in the presence of binge-related cues). We assessed the effectiveness of virtual reality-CET as a second-level treatment strategy for 64 patients with bulimia nervosa and binge eating disorder who had been treated with limited results after using a structured CBT programme, in comparison with A-CBT. The significant differences observed between the two groups at post-treatment in dimensional (behavioural and attitudinal features, anxiety, food craving) and categorical (abstinence rates) outcomes highlighted the superiority of virtual reality-CET over A-CBT. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Purpose: Virtual reality (VR) technologies have been proposed as a new tool able to improve on in vivo exposure in patients with eating disorders. This study assessed the validity of a VR-based software for cue exposure therapy (CET) in people with bulimia nervosa (BN) and binge eating disorder (BED). Methods: Fifty eight outpatients (33 BN and 25 BED) and 135 healthy participants were exposed to 10 craved virtual foods and a neutral cue in four experimental virtual environments (kitchen, dining room, bedroom, and cafeteria). After exposure to each VR scenario, food craving and anxiety were assessed. The frequency/severity of episodes of uncontrollable overeating was also assessed and body mass index was measured prior to the exposure. Results: In both groups, craving and anxiety responses when exposed to the food-related virtual environments were significantly higher than in the neutral-cue virtual environment. However, craving and anxiety levels were higher in the clinical group. Furthermore, cue-elicited anxiety was better at discriminating between clinical and healthy groups than cue-elicited craving. Conclusions: This study provides evidence of the ability of food-related VR environments to provoke food craving and anxiety responses in BN and BED patients and highlights the need to consider both responses during treatment. The results support the use of VR-CET in the treatment of eating disorder patients characterized by binge-eating and people with high bulimic symptoms

This article reviews the 6-month followup data of a randomized, multicenter, parallel-group study conducted at five clinical sites in three European cities, which compared two second-level treatments for bulimia nervosa (BN) and binge eating disorder (BED): virtual reality-based cue exposure therapy (VR-CET) versus additional cognitive behavioral therapy (A-CBT). Post-treatment outcomes of this study were already published in Ferrer- Garcia et al. (2017) and details of its design can be found at clinicaltrials.gov (identifier: NCT02237300, https:// clinicaltrials.gov). This article focuses on the evolution of symptoms assessed after 6 months of followup in a subgroup of 58 patients from the original study. In this study (Ferrer-Garcia et al., 2017) 64 patients with eating disorders (EDs) (35 with BN and 29 with BED), who still showed active episodes of binge eating by the end of a structured CBT program (first-level treatment), were randomly assigned to one of two second-level treatments (A-CBT or VR-CET). Frequency of binge and purge episodes, and attitudinal features of binge-related EDs (bulimia, drive for thinness, and body dissatisfaction) were assessed before starting the second-level treatment (n = 64), at the end (n = 64), and at 6-month followup (n = 58). Mixed between-within subject analyses of variance were used to compare outcomes of both second-level treatments over time. Although both treatment conditions showed statistically significant improvements at the end and after 6-month followup, obtained reductions were greater after VR-CET, regarding binge and purge episodes, as well as the decrease of selfreported tendency to engage in overeating episodes. Accordingly, abstinence from binge episodes were higher in VR-CET than A-CBT at followup (70 percent vs. 26 percent, respectively; v2 = 11.711, p = 0.001). These results provide further support for the use of VR-CET as an effective second-level intervention for BN and BED treatment-resistant patients.

article i nfo Article history: Achieving social functioning and achieving social competence are two main objectives of psychosocial interven- tions for people suffering from schizophrenia. The present preliminary study presents a novel approach of social skills training (SST) based on the proposals of Kopelowicz et al. (Kopelowicz, A., Liberman, R. P., and Zarate, R., 2006. Schizophr. Bull. 32 (1): S12-23) that link the treatment to seven specific target behaviours: social percep- tion, social information processing, responding and sending skills, affiliative skills, interactional skills, and behav- iour governed by social norms. Thirty-one stabilised outpatients were randomly assigned to one of two groups, SST (n=13) or treatment-as-usual (n=18) (TAU;case management, medication adherence, psychotherapy, lei- sure engagement, and familysupport) and were assessedat baseline incognitive performance,clinical symptom- atology, social cognition, and psychosocial functioning. These outcomes were evaluated across post-treatment and at the 6-month follow-up appointment. SST subjects showed improvements in psychopathology, social dis- comfort, social cognition (self-regulation statements during interactions), social withdrawal, interpersonal com- munication, and quality of life compared with theTAU group. At the6-month follow-up, results were maintained for negative symptoms, social discomfort, and some functioning outcomes. Neuropsychological variables were also examined, as mediators of benefit from skills training. Results support the efficacy of the brief SST for outpa- tients with schizophrenia and show the need to implement empirically supported interventions in mental health services to enhance patients' social functioning and quality of life.

Background: Binge eating behavior constitutes a central feature of both bulimia nervosa (BN) and binge eating disorder (BED). Cue exposure therapy (CET) has been proposed as an effective intervention. Objective: To determine which situations and specific cues trigger higher levels of binge craving and to use the results in the development of virtual reality scenarios in which CET could be applied with BN and BED patients. Method: Participants were 101 outpatients, 50 with BED and 51 with BN, according to DSM-5 criteria, and 63 healthy undergraduate students who completed a self-administered questionnaire to assess binge craving. Results: The likelihood of binge craving in the clinical group was greater when alone at home, during the afternoon/early evening and in the late evening/at night, at weekends, and at dinner time or between meals. Higher levels of craving were produced in the kitchen, bedroom, dining room, and bakery situations. With regard to the specific cues reported, the presence of and access to high calorie food and snacks was the most commonly reported cue. Although some gender differences regarding triggering factors were obtained, no statistical differences were observed between ED subtypes. BN and BED patients showed significantly higher levels of binge craving than controls in all the contexts except when feeling positive affect; in this situation, levels of craving were low in both groups. Conclusions: This information regarding trigger contexts and specific cues can be used to create valid and reliable virtual environments for CET. Indeed, the data from this study may serve to develop a wide range of situations with different levels of binge craving, in which the therapeutic aim is to extinguish conditioned responses and facilitate the generalization of craving extinction.

Patients with psychosis exhibit a wide range of cognitive deficits which are associated with poor functioning and poor outcomes in psychosocial interventions. Recently, virtual reality (VR) has been demonstrated to be a useful tool for treatment and rehabilitation of these patients. We have developed and applied an integrated VR programme to improve social skills in people with schizophrenia: the Soskitrain. The aim of the present study is to evaluate the relationship between patients' cognitive deficits, their sense of presence and their ratings of the programme's acceptability. Twelve clinically stabilized outpatients with a well-established diagnosis of schizophrenia or schizoaffective disorder underwent neuropsychological assessment prior to treatment, while after the intervention they completed a questionnaire about their sense of presence and the acceptability of the VR programme. Post-treatment results revealed a high sense of presence among patients, as well as good verisimilitude and high acceptance of the virtual environments. In addition, there were significant negative correlations between sense of presence and deficits in both delayed verbal learning and processing speed. The paper discusses the implications of cognitive impairment for the experience and acceptance of VR when treating psychotic patients.

Background and objectives Social skills training (SST) intervention has shown its efficacy to improve social dysfunction in patients with psychosis; however the implementation of new skills into patients' everyday functioning is difficult to achieve. In this study, we report results from the application of a virtual reality (VR) integrated program as an adjunct technique to a brief social skills intervention for patients with schizophrenia. It was predicted that the intervention would improve social cognition and performance of patients as well as generalisation of the learned responses into patient's daily life. Methods Twelve patients with schizophrenia or schizoaffective disorder completed the study. They attended sixteen individual one-hour sessions, and outcome assessments were conducted at pre-treatment, post-treatment and four-month follow-up. Results The results of a series of repeated measures ANOVA revealed significant improvement in negative symptoms, psychopathology, social anxiety and discomfort, avoidance and social functioning. Objective scores obtained through the use of the VR program showed a pattern of learning in emotion perception, assertive behaviours and time spent in a conversation. Most of these gains were maintained at four-month follow-up. Limitations The reported results are based on a small, uncontrolled pilot study. Although there was an independent rater for the self-reported and informant questionnaires, assessments were not blinded. Conclusions The results showed that the intervention may be effective for improving social dysfunction. The use of the VR program contributed to the generalisation of new skills into the patient's everyday functioning.

Eating behavior style (emotional, restrictive, or external) has been proposed as an explanation for the differences in response to food-related cues between people who overeat and those who do not, and has been also considered a target for the treatment of eating disorders (EDs) characterized by lack of control over eating and weight-related (overweight/obesity) conditions. The aim of this study was to analyze the relationship between eating behavior style and psychophysiological responses (self-reported food craving and anxiety) to food-related virtual reality (VR) environments in outpatients with bulimia nervosa (BN) and binge eating disorder (BED) and to compare them with healthy participants. Fifty-eight outpatients and 135 healthy participants were exposed to palatable foods in four experimental everyday real-life VR environments (kitchen, dining room, bedroom and café). During exposure, cue-elicited food craving and anxiety were assessed. Participants also completed standardized instruments for the study purposes. ED patients reported significantly higher levels of craving and anxiety when exposed to the virtual food than healthy controls. Eating behavior styles showed strong associations with cue-elicited food craving and anxiety. In the healthy group, external eating was the only predictor of cue-elicited craving and anxiety. In participants with BN and BED, external and emotional eating were the best predictors of cue-elicited craving and anxiety, respectively.