A Pilot Open Trial of a Text Message Safety Behavior Fading Intervention for Appearance Concerns Among Women

Appearance concerns are a key feature in body dysmorphic disorder and eating disorders, and they have been found to be a common feature of social anxiety disorder. Given the lack of transdiagnostic treatments for appearance concerns, we developed a preliminary text-based intervention targeting appearance-related safety behaviors (ARSBs; i.e., maladaptive behavioral strategies that seek to mitigate the feared consequences of the evaluation of appearance). The intervention utilized a daily text-message protocol where individuals are asked to fade their behaviors, provided encouragement, and log ARSB use in the past day. We evaluated the efficacy of ARSB fading in two successive cohorts of women with elevated appearance concerns (Study 1 N = 38, Study 2 N = 39). We found that across both studies participants experienced large reductions in appearance concerns (d = .93-1.36) and eating disorder symptoms (d = 1.06-1.20) that were maintained 1 month after treatment. Further, participants experienced small-to-medium reductions in social anxiety (d = 0.38-0.58) and depression (d = 0.52-0.96) from pre- to posttreatment. Notably, there were missing data in both studies (31%-50%), but multiple imputation was used to observe stability of effects. We also collected and incorporated feedback on the treatment to optimize the treatment before conducting the second trial. While these changes did not lead to significant differences in study outcomes, the second cohort demonstrated greater adherence to treatment and found the treatment to be more credible than the first cohort. Further, we found that greater baseline ARSBs predicted greater pre- to follow-up changes in appearance concerns. Taken together, text-based ARSB fading appears to be a promising treatment, and further research on the treatment appears warranted.