Virtual Reality Mirror Exposure Combined with Eye-Tracking Attentional Bias Modification in Adolescent Males with Anorexia Nervosa: A Feasibility Study
Restricted accessResearch articleFirst published online 2026
Virtual Reality Mirror Exposure Combined with Eye-Tracking Attentional Bias Modification in Adolescent Males with Anorexia Nervosa: A Feasibility Study
Male adolescents with anorexia nervosa (AN) remain markedly underrepresented in clinical and technological research, limiting understanding of the gender-specific mechanisms that may shape how they interact with virtual environments. The primary objective of this study was to evaluate the feasibility and acceptability of an integrated virtual reality (VR)-based mirror exposure therapy and eye-tracking-driven attentional bias (AB) modification training protocol—previously tested in a female-based randomized controlled trial—in two male adolescents with AN. Both participants received concurrent multidisciplinary care, with one case featuring comorbid muscle dysmorphia. Feasibility was assessed via protocol adherence and technical stability. Acceptability was measured using the System Usability Scale (SUS). Secondary exploratory measures included eye-tracking AB and clinical questionnaire outcomes (body dissatisfaction, drive for thinness, body anxiety, body appreciation) at pretreatment, posttreatment, and 3-month follow-up. Feasibility indicators were consistently positive: Both participants completed all sessions, reported high perceived usability (SUS > 80), and no technical incidents occurred. Exploratory clinical observations suggested improvements in body dissatisfaction, weight-related anxiety, and body appreciation, with effects maintained at the 3-month follow-up. Eye-tracking data revealed divergent attentional profiles: the patient with a typical AN presentation showed heightened attention to weight-related body areas, whereas the patient with muscle dysmorphia displayed a more complex pattern oriented toward muscular regions. Given the concurrent multidisciplinary treatment, clinical improvements cannot be attributed solely to the VR intervention; however, these cases show that the protocol is a viable and well-tolerated tool that warrants further investigation in a randomized controlled trial with AN male adolescents.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). American Psychiatric Association: Washington, DC; 2022.
2.
Van EedenAE, Van HoekenD, HoekHW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry2021;34(6):515–524; doi: 10.1097/YCO.0000000000000739
3.
Gutiérrez-MaldonadoJ, Ferrer-GarcíaM, DakanalisA, et al.Virtual Reality: Applications to Eating Disorders. In: The Oxford Handbook of Eating Disorders. (AgrasWS, RobinsonA, eds) Oxford University Press: Oxford, UK; 2018. pp. 470–491.
4.
RivaG, MalighettiC, SerinoS. Virtual reality in the treatment of eating disorders. Clin Psychol Psychother2021;28(3):477–488; doi: 10.1002/CPP.2622
5.
Porras-GarciaB, Ferrer-GarciaM, Serrano-TroncosoE, et al.AN-VR-BE. A randomized controlled trial for reducing fear of gaining weight and other eating disorder symptoms in anorexia nervosa through virtual reality-based body exposure. J Clin Med2021;10(4):682; doi: 10.3390/JCM10040682
6.
BauerA, SchneiderS, WaldorfM, et al.Selective visual attention towards oneself and associated state body satisfaction: An eye-tracking study in adolescents with different types of eating disorders. J Abnorm Child Psychol2017;45(8):1647–1661; doi: 10.1007/S10802-017-0263-Z
7.
JansenA, NederkoornC, MulkensS. Selective visual attention for ugly and beautiful body parts in eating disorders. Behav Res Ther2005;43(2):183–196; doi: 10.1016/J.BRAT.2004.01.003
8.
Kerr-GaffneyJ, HarrisonA, TchanturiaK. Eye-tracking research in eating disorders: A systematic review. Int J Eat Disord2018;52(1):3–27; doi: 10.1002/EAT.22998
9.
RodgersRF, DuBoisRH. Cognitive biases to appearance-related stimuli in body dissatisfaction: A systematic review. Clin Psychol Rev2016;46:1–11; doi: 10.1016/J.CPR.2016.04.006
10.
Tuschen-CaffierB, BenderC, CaffierD, et al.Selective visual attention during mirror exposure in anorexia and bulimia nervosa. PLoS One2015;10(12):e0145886; doi: 10.1371/JOURNAL.PONE.0145886
11.
SmeetsE, RoefsA, van FurthE, et al.Attentional bias for body and food in eating disorders: Increased distraction, speeded detection, or both? Behav Res Ther2008;46(2):229–238; doi: 10.1016/J.BRAT.2007.12.003
12.
Von WietersheimJ, KunzlF, HoffmannH, et al.Selective attention of patients with anorexia nervosa while looking at pictures of their own body and the bodies of others: An exploratory study. Psychosom Med2012;74(1):107–113; doi: 10.1097/PSY.0B013E31823BA787
13.
WilliamsonDA, WhiteMA, York-CroweE, et al.Cognitive-behavioral theories of eating disorders. Behav Modif2004;28(6):711–738; doi: 10.1177/0145445503259853
14.
RenwickB, CampbellIC, SchmidtU. Attention bias modification: A new approach to the treatment of eating disorders? Int J Eat Disord2013;46(5):496–500; doi: 10.1002/EAT.22107
15.
Bar-HaimY. Research Review: Attention bias modification (ABM): A novel treatment for anxiety disorders. J Child Psychol Psychiatry2010;51(8):859–870; doi: 10.1111/J.1469-7610.2010.02251.X
16.
SmeetsE, JansenA, RoefsA. Bias for the (un)attractive self: On the role of attention in causing body (dis)satisfaction. Health Psychol2011;30(3):360–367; doi: 10.1037/a0022095
17.
StottN, FoxJRE, WilliamsMO. Attentional bias in eating disorders: A meta-review. Int J Eat Disord2021;54(8):1377–1399; doi: 10.1002/EAT.23560
18.
Meschberger-AnnweilerFA, AscioneM, Porras-GarciaB, et al.An attentional bias modification task, through virtual reality and eye-tracking technologies, to enhance the treatment of anorexia nervosa. J Clin Med2023;12(6):2185; doi: 10.3390/JCM12062185
19.
Miquel-NabauH, Briseño-OlorizN, Porras-GarciaB, et al.Modification of body-related attentional bias through virtual reality and eye-tracking in healthy participants: Implications for anorexia nervosa treatments. Brain Sci2023;13(5):764; doi: 10.3390/BRAINSCI13050764
20.
AscioneM, Carulla-RoigM, Meschberger-AnnweilerFA, et al.Virtual reality body exposure and attentional bias modification in the treatment of adolescents with anorexia nervosa. Clin Psychol Psychother2026;33(2):e70273; doi: 10.1002/cpp.70273
21.
AscioneM, Serrano-TroncosoE, Carulla-RoigM, et al.Improving anorexia nervosa treatment with virtual reality body exposure and attentional bias modification: A single case study. Appl Sci2024;14(11):4340; doi: 10.3390/APP14114340
22.
DavisonKK, MarkeyCN, BirchLL. A longitudinal examination of patterns in girls’ weight concerns and body dissatisfaction from ages 5 to 9 years. Int J Eat Disord2003;33(3):320–332; doi: 10.1002/eat.10142
23.
Jiménez-MarínG, García MedinaI, Bellido-PérezE, et al.Advertising at the point of sale: Influence on children′s body image. Rev Lat Comun Soc2017;72:957–974; doi: 10.4185/RLCS-2017-1202
24.
Lavenne-CollotN, MaubantE, DéroulezS, et al.Self/other recognition and distinction in adolescents with anorexia nervosa: A pilot study using a double mirror paradigm. PLoS One2025;20(1):e0309548; doi: 10.1371/journal.pone.0309548
SchorrM, MillerKK. The endocrine manifestations of anorexia nervosa: Mechanisms and management. Nat Rev Endocrinol2017;13(3):174–186; doi: 10.1038/nrendo.2016.175
27.
TimkoCA, DeFilippL, DakanalisA. Sex differences in adolescent anorexia and bulimia nervosa: Beyond the signs and symptoms. Curr Psychiatry Rep2019;21(1):1–8; doi: 10.1007/S11920-019-0988-1
28.
NagataJM, BrownTA, MurraySB, et al.Eating disorders in boys and men. Eat Disord Boys Men2021;1–346; doi: 10.1007/978-3-030-67127-3
29.
OlivardiaR. Mirror, mirror on the wall, who’s the largest of them all? The features and phenomenology of muscle dysmorphia. Harv Rev Psychiatry2001;9(5):254–259; doi: 10.1080/10673220127900
30.
GilaA, CastroJ, CesenaJ, et al.Anorexia nervosa in male adolescents: Body image, eating attitudes and psychological traits. J Adolesc Health2005;36(3):221–226; doi: 10.1016/j.jadohealth.2004.02.039
31.
AlfanoL, HildebrandtT, BannonK, et al.The impact of gender on the assessment of body checking behavior. Body Image2011;8(1):20–25; doi: 10.1016/J.BODYIM.2010.09.005
32.
ChoA, LeeJH. Body dissatisfaction levels and gender differences in attentional biases toward idealized bodies. Body Image2013;10(1):95–102; doi: 10.1016/J.BODYIM.2012.09.005
33.
Porras-GarciaB, Ferrer-GarciaM, GhitaA, et al.The influence of gender and body dissatisfaction on body-related attentional bias: An eye-tracking and virtual reality study. Int J Eat Disord2019;52(10):1181–1190; doi: 10.1002/eat.23136
34.
Porras-GarciaB, Exposito-SanzE, Ferrer-GarciaM, et al.Body-related attentional bias among men with high and low muscularity dissatisfaction. J Clin Med2020;9(6):1736; doi: 10.3390/JCM9061736
35.
WaldorfM, VocksS, DüsingR, et al.Body-oriented gaze behaviors in men with muscle dysmorphia diagnoses. J Abnorm Psychol2019;128(2):140–150; doi: 10.1037/ABN0000403
36.
TalbotD, SalemeD. Evidence of attentional bias toward body stimuli in men. Atten Percept Psychophys2022;84(4):1069–1076; doi: 10.3758/S13414-022-02466-7
37.
GorrellS, HughesEK, SawyerSM, et al.Gender-based clinical differences in evidence-based treatment for adolescent anorexia nervosa: Analysis of aggregated randomized controlled trials. Eat Weight Disord2022;27(3):1123–1130; doi: 10.1007/S40519-021-01257-7
38.
WallinK, WallinU, WentzE, et al.A comparison between young males and females with anorexia nervosa in a clinical setting. Nord J Psychiatry2023;77(1):91–95; doi: 10.1080/08039488.2022.2127883
39.
StrobelC, QuadfliegN, VoderholzerU, et al.Short- and long-term outcome of males treated for anorexia nervosa: A review of the literature. Eat Weight Disord2018;23(5):541–552; doi: 10.1007/S40519-018-0538-6
40.
WattersS, HigginsA. Muscle dysmorphia: An under-recognised aspect of body dissatisfaction in men. Br J Nurs2024;33(12):584–588; doi: 10.12968/BJON.2023.0176
41.
World Health Organization. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 2nd ed, Vol. 2. World Health Organization: Geneva; 2004.
42.
Herpertz-DahlmannB, BorzikowskyC, AltdorfS, et al.‘Therapists in action’—Home treatment in adolescent anorexia nervosa: A stepped care approach to shorten inpatient treatment. Eur Eat Disord Rev2021;29(3):427–442; doi: 10.1002/ERV.2755
43.
García FernándezG, Krotter DíazA, UdeanuA. Effectiveness of psychological interventions for eating disorders in adolescence: An overview of systematic reviews. Rev Psicol Clínica Con Niños y Adolesc2023;10(1):11; doi: 10.21134/rpcna.2023.10.1.10
44.
PrestonC, Kuper-SmithBJ, Henrik EhrssonH. Owning the body in the mirror: The effect of visual perspective and mirror view on the full-body illusion. Sci Rep2015;5(1):18345; doi: 10.1038/srep18345
45.
BrookeJ. SUS: A “Quick and Dirty” Usability Scale. In: Usability Evaluation in Industry (JordanPW, ThomasB, WeerdmeesterBA, McClelland., eds) Taylor and Francis; London, UK; 1996; pp. 189–194.
46.
BangorA, KortumPT, MillerJT. An empirical evaluation of the system usability scale. Int J Human–Computer Interact2008;24(6):574–594; doi: 10.1080/10447310802205776
ElosuaP, López-JaúreguiA, Sánchez-SánchezF. EDI-3, Inventario de Trastornos de la Conducta Alimentaria-3, Manual. Tea Ediciones: Madrid, Spain; 2010.
49.
ElosuaP, López-JáureguiA. Internal structure of the spanish adaptation of the eating disorder inventory-3. Eur J Psychol Assess2012;28(1):25–31; doi: 10.1027/1015-5759/A000087
50.
ReedDL, ThompsonJK, BrannickMT, et al.Development and validation of the Physical Appearance State and Trait Anxiety Scale (PASTAS). J Anxiety Disord1991;5(4):323–332; doi: 10.1016/0887-6185(91)90032-O
51.
AvalosL, TylkaTL, Wood-BarcalowN. The Body Appreciation Scale: Development and psychometric evaluation. Body Image2005;2(3):285–297; doi: 10.1016/J.BODYIM.2005.06.002
52.
Jáuregui-LoberaI, RíosPB. Spanish version of the Body Appreciation Scale (BAS) for adolescents. Span J Psychol2011;14(1):411–420; doi: 10.5209/REV_SJOP.2011.V14.N1.37
53.
RoefsA, JansenA, MoresiS, et al.Looking good. BMI, attractiveness bias and visual attention. Appetite2008;51(3):552–555; doi: 10.1016/J.APPET.2008.04.008
54.
JacobRJK, KarnKS. Eye tracking in human-computer interaction and usability research: ready to deliver the promises. In: The Mind’s Eye: Cognitive and Applied Aspects of Eye Movement Research. Elsevier Science; 2003;573–605; doi: 10.1016/B978-044451020-4/50031-1
55.
JiangMYW, VartanianLR. A review of existing measures of attentional biases in body image and eating disorders research. Aust J Psychol2018;70(1):3–17; doi: 10.1111/AJPY.12161
56.
Porras-GarciaB, Ferrer-GarciaM, Serrano-TroncosoE, et al.Validity of virtual reality body exposure to elicit fear of gaining weight, body anxiety and body-related attentional bias in patients with anorexia nervosa. J Clin Med2020;9(10):3210; doi: 10.3390/jcm9103210
57.
SmithKE, MasonTB, MurraySB, et al.Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE-Q). Int J Eat Disord2017;50(7):769–775; doi: 10.1002/EAT.22716
58.
JacobsonNS, TruaxP. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol1991;59(1):12–19; doi: 10.1037//0022-006X.59.1.12
59.
MorleyS, DowzerCN. Manual for the Leeds Reliable Change Indicator: Simple Excel(tm) applications for the analysis of individual patient and group data. University of Leeds: Leeds, UK; 2014.
60.
SauroJ. A Practical Guide to the System Usability Scale: Background, Benchmarks & Best Practices. Measuring Usability LLC: Denver, CO; 2011.
61.
MurraySB, RiegerE, TouyzSW, et al.Muscle dysmorphia and the DSM-V conundrum: Where does it belong? A review paper. Int J Eat Disord2010;43(6):483–491; doi: 10.1002/EAT.20828
62.
McCrearyDR. The drive for muscularity scale: Description, psychometrics, and research Findings. Muscular Ideal Psychol Soc Med Perspect2008:87–106; doi: 10.1037/11581-004
63.
DownsDS, HausenblasHA, NiggCR. Factorial validity and psychometric examination of the exercise dependence scale-revised. Meas Phys Educ Exerc Sci2004;8(4):183–201; doi: 10.1207/S15327841MPEE0804_1
64.
TaranisL, TouyzS, MeyerC. Disordered eating and exercise: Development and preliminary validation of the compulsive exercise test (CET). Eur Eat Disord Rev2011;19(3):256–268; doi: 10.1002/ERV.1108
