Eating Disorders Handbook – Psious Professionals

Index Eating Disorders

Disorders of the Eating Behavior and Virtual Reality
Psychological evaluation/intervention protocol proposed by Psious
1. Evaluation of the Eating Behavior Disorders
2. Proposal of Intervention in the presence of Eating Disorders
Recommendations for use
Recommended Bibliography
Annexes
1. Self-registration of body image (situation/thought/emotion)
2. Self-report hierarchy for Eating Disorders: Restaurant (Psious)

1. Disorders of the Eating Behavior and Virtual Reality

Virtual Reality (VR) is a beneficial tool for the treatment of Eating Disorders, also known as Eating Behavior Disorders (EBD), especially Bulimia Nervosa (BN), Nervous Anorexia (AN) and Binge Eating Disorder (BED).

Several studies demonstrate the effectiveness of VR as an exposure therapy to reduce the desire or impulse towards food and to normalize eating patterns, as well as to help patients to be aware of their distortion of their own body image, to confront and correct such distortion, get a more realistic perception and reduce dissatisfaction with one’s own body (Gutiérrez-Maldonado et al., 2016; Lafond, Riva, Gutierrez-Maldonado, & Wiederhold, 2016; Lozano et al, 2002; Marco, Perpiñá & Botella, 2013; Manzoni et al, 2013; Manzoni et al, 2016; Perpiñá, Botella & Baños, 2003; Perpiñá et al., 2013; Pla-Sanjuanelo et al., 2015; Riva, 2011: Riva et al, 1999; Wiederhold, Riva, & GutiérrezMaldonado, 2016).

2. Psychological evaluation/ intervention protocol proposed by Psious

*All the information contained in this section is indicative. The Psious environments are therapeutic tools that must be used by the healthcare professional within a process of evaluation and intervention designed according to the characteristics and needs of the user. Also remember that you have the General Clinical Guide where you have more information on how to adapt psychological intervention techniques (exposure, DS, cognitive restructuring, etc.) to Psious environments.

2.1. Evaluation of the Eating Behavior Disorders

2.1.1 Objectives of the evaluation

Evaluate the concern for body image, eating habits, diet and physical exercise, the perception of one’s body figure, self-image and self-esteem.

Evaluate the presence of altered eating behaviors (food restriction, binge eating, compensatory behavior…).

Evaluate the presence of distorted thoughts in relation to food / body image.

Evaluate possible comorbidities (depression, anxiety, self-injurious behavior, etc.).

Define stimulation configurations feared by the patient and to what degree: Elaboration of the exposure hierarchy.

2.1.2 Some useful instruments for the Eating Behavior

Disorders evaluation

Taking into account the objectives of the evaluation, we will list some tools and instruments that may be useful to obtain relevant information about the characteristics of your user. Remember that a good definition of objectives, characterization of the patient and planning of the intervention are important for the efficiency and therapeutic efficacy, as well as for the satisfaction of your patients. In the bibliography you will find the articles in which to review the characteristics of the instruments proposed below:

Structured Clinical Interview for disorders of Axis I of the DSM-IV (First, Spitzer, Williams, Gibbon, 1997)

Diagnostic Interview for Children and Adolescents (Shaffer, Fisher, Lucas, Dulcan, Schwab, 2000; Bravo et al, 2001; Ezpeleta L, et al., 1997)

Autoreports:

Body Image:

Gardner’s Body Image Evaluation Scale (Gardner, Stark, Jackson, Friedman, 1999).

(Body Weight, Image and Self-Esteem Evaluation Scale, B-WISE (Awad, Voruganti, 2004)..

Body Attitude Test (BAT) (Probst, 1995; Gila, et al., 1999).

Body Shape Questionnaire (BSQ) (Cooper, et al.,1988; Raich, et al., 1996).

Body Image Avoiding Questionnaire (BIAQ) (Rosen, Srebrik, Saltzberg y Wendt, 1991)

Nuclear psychopathology: Common symptoms and behaviors in

eating behavior disorders

Eating Disorders Inventory -3 (EDI-3) (Garner, 2004).

Eating Attitudes Test (EAT-40) (Garner and Garfinkel, 1979; Castro, Toro, Salmero, Guimera, 1991).

Eating Disorders Exam – Quetionnaire (EDE-Q) (Fairburn y Beglin, 1994; Elder y Grilo, 2007).

Edinburgh Bulimia Test (BITE) (Henderson and Freeman, 1987).

Bulimia Test (BULIT) (Smith and Thelen, 1984; Vázquez-Morejón et aL, 2007)

Desire / impulse towards food

State and Trait Food Cravings Questionnaires (FCQ-S, FCQ-T)(Cepeda et al, 2000).

Motivation for the treatment

Attitudes Questionnaire against Change in Eating Disorders (ACTA) (Beato Fernández, Rodríguez Cano, 2003).

3.2. Proposal of Intervention in the presence of Eating

Disorders

It is important to note that in this section we will only show and suggest some points to guide the intervention with our patient through the two virtual environments available to Psious for the treatment of EDs. However, we must not forget that the intervention proposal presented below only shows a part of it, because the full treatment of the EDs also requires other procedures (diagnostic interview, psychometric evaluation, structuring of dietary guidelines, prevention of relapse, etc.) and will be more extensive.

SESSIONS TO WORK ON THE DISTORTION OF THE BODY IMAGE: “DRESSING ROOM” SCENE

The intervention sessions described below do not necessarily have to be consecutive, but may be spaced throughout the treatment according to the phase of the treatment (at the beginning, in the middle and at the end). This is so because the perception of one’s body image is hardly going to be modified week by week, so it would make more sense to evaluate their changes according to the phase of treatment in which the patient is located.

SESSION 1: At the beginning of the therapy process

Provide the necessary basic information on concepts related to body image (ideal of beauty, how it has evolved throughout history …).

Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied and which ones he likes the most.

Assess the fear / discomfort felt by the patient before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.

Present and justify the use of VR in this context. Give instructions on how the environment works and let the patient become familiar with the tool.

Start experience through VR:

Measure the patient’s BMI and select the corresponding category for each part of the body (“slim”, “very slim”, etc.) according to the table of equivalences provided in this handbook.

Ask the patient to adjust the dimensions of each part of the body of the avatar that appears in the VR glasses, as perceived by himself. You may ask: “What parts of your body do you perceive as different from those of the avatar and, therefore, are you going to modify?”

When the patient has established the dimensions of the avatar, we can formulate and record the answers to the following questions:

“Is this how you see yourself?”

“What is your level of discomfort with this image (from 0 to 10)?”

“What is your level of satisfaction with this image (from 0 to 10)?”

“To what degree do you think your body is really like that (from 0 to 10)?”

“To what degree do you think others see you this way too (from 0 to 10)?”

Activate the event “Avatars comparison”.

Discuss with the patient the distortion of his own image, which he can now observe objectively through the real silhouette. This will lead to a process of cognitive restructuring. We can ask questions like:

“This is your real body, what do you think?”

“What is your level of discomfort with this image (from 0 to 10)?”

“What is your level of satisfaction with this image (from 0 to 10)?”

“Are both figures (avatar and silhouette) the same?”

“What differences do you see between the two?”, “What body parts do you have distorted?”

“What makes you believe that you / they (to mention the distorted part of the body) are / are bigger / bigger than they really are / are?”

“How does this affect you emotionally?”

“How does this affect your behavior (avoidance, diets …)?”

“To what degree do you accept that you overestimate the dimensions of your body and that your perception of your own body image is different from that of your real body (from 0 to 10)?”

“Could we assume that the parts of your body that least match reality are those that dislike you the most?”

“What have you learned or what conclusions have you drawn today?”

Explain how to perform a self-registration of situations, thoughts and emotions related to body image (see appendix) (ex .: Situation: “I went to buy clothes and there were no pants of my size.” Thought: “Surely not they make fat pants like me.” Emotion: “Frustration, anger, shame”).

Explain, if deemed necessary, how to practice a guided SD with an audio tape to work the exposure in imagination to bodily areas (to reduce discomfort to one’s body).

Tasks between sessions:

Do daily self-registration of situations, thoughts and emotions related to body image.

Practice the guided SD with an audio tape to work the exposure in imagination to corporal areas, if applicable.

SESSION 2: Around the halfway of the therapy process

Review the daily self-registrations made to date and perform the relevant cognitive restructuring.

Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.

Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible

Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette.

Tasks between sessions:

Continue with self-registration of situations, thoughts and emotions related to body image.

Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if necessary.

SESSION 3: At the end of the therapy process

Review the daily self-registrations made to date and perform the relevant cognitive restructuring

Ask the patient to what degree (from 0 to 10) he is satisfied with his body in general, with which parts of it he is most dissatisfied, and which ones he likes the most, at this moment of treatment.

Assess the fear / discomfort felt by the patient in this phase of treatment before having to see his own body and to what extent he would avoid it (or feel the need to do so) if this were possible.

Start the experience by VR following the same steps described above in points 5 and 6 of Session 1. Note: In this phase of treatment it is possible that the actual body size of the patient has changed (whether the patient has gone up or down in weight, etc.). If so, the patient’s current BMI should be taken into account to introduce the new dimensions of each part of the body to the platform, in order to generate its new real silhouette. The final objective will be for the patient to adjust as much as possible the estimated figure (avatar with subjective measures) to his real measures (silhouette with real measurements).

Emphasize and reinforce the improvements achieved: Reduction of distortion (show how the avatar with the subjective measures of the patient and the real silhouette have increasingly seemed more) and decrease in levels of anxiety / discomfort (SUDs), if proceeds.

Tasks:

Follow with self-registration of situations, thoughts and emotions related to body image, with the aim that the patient himself who from now on is able to restructure their own thoughts / emotions about it. the learned.

Continue practicing the SD guided with an audio tape to work the exposure in imagination to corporal areas, if it continues to agree.

SESSIONS TO WORK ON THE EXPOSURE TO THE FOOD:

“RESTAURANT” SCENE

SESSION 1:

The objective of this first session will be to present and justify the use of VR in the treatment, and for the patient to get used to the tool.

Present and justify the techniques that will be used throughout the treatment: exposure with VR and live exposure, etc.

Show the VR “Restaurant” environment, explain how it works, and what will the work’s dynamics be like.

Elaborate an exposure hierarchy (see appendix) ordered by Subjective Units of Distress (SUDs) from 0 to 100. Note:

If we wish to work on the fear of consuming certain foods: Elaborate a hierarchy considering feared or “forbidden” foods and the situations that accompany 18 Eating Disorders Handbook them (eating with people, eating alone, etc.), arranging the items from those producing lesser anxiety to those generating more anxiety.

. If we wish to work on the intake control (desire/”craving” or impulse towards food): Build a hierarchy considering foods and situations that produce a greater desire/impulse to eat, arranging the items from those which cause less urgency/impulse to those causing more urgency/impulse.

Begin the gradual and systematic exposure to the “Restaurant” environment: Propose to begin by exposing the patient to one of the hierarchy’s items that is close to 20-30 SUDs (see example of items below).

Explain that the same will be done in the following sessions, progressively increasing the difficulty (advancing in the hierarchy’s items):

For fear of consuming certain foods: Trying foods and situations that produce greater fear

To control the intake and compensatory behaviors: Trying foods and situations that produce a greater desire or impulse to eat, without the possibility of binge eating or compensatory behavior.

Note: From now on, using the present intervention example, we will work on a hypothetical case of exposure due to fear of consuming certain foods (option “a”).

Item	SUDs	Configuration V.:	Event
At the restaurant, alone, eating the diuretic/hypocaloric menu:	20	Company: Alone	Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about a neutral topic:	25	Company: Accompanied. Conversation: Neutral (examples of phrases: “I have a lot of free time lately, and I like to use it to watch movies, one of my favorite hobbies”; “Yesterday, I saw a movie I really liked, I think it was called The Magic of Belle Island”).	Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while they are silent:	30	Company: Accompanied Conversation: Silence	Events: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)

SESSION 2:

Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance.

Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 35-50 SUDs (see example item below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat,” “to talk about these subjects while eating generates a lot of anxiety for me”…).

Using the platform reports, show the patient the clinical advances achieved

Homework between sessions: Try to eat together with other people (friends, coworkers, family…), even if the patient still does not dare to eat a normalized diet with them.

ítem	USAs	V. Configuración	Evento
At the restaurant, accompanied, eating the diuretic/hypocaloric menu, while talking about topics related to food/physical appearance:	50	Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Mmmm… how good is this!”; “You know that I brought you here because I’ve been told you can eat very well in this restaurant.”)	Event: Menu + Menu 2 (diuretic)/ Menu 4 (hypocaloric)

SESSION 3:

Review the achievements of the previous session and establish objectives for this session: To be in the restaurant, accompanied, eating the standard menu, while talking about a neutral topic.

Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 55-70 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this”…).

Using the platform reports, show the patient the clinical advances achieved

Homework between sessions: Try to eat together with other people (friends, coworkers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only).

ítem	USAs	V. Configuración	Evento
At the restaurant, alone, eating the standard menu:	65	Company: Alone	Menu + Menu 3 (standard)
At the restaurant, accompanied, eating the standard menu, while talking about a neutral topic:	70	Company: Accompanied Conversation: Neutral (examples of phrases: “I like films a lot, almost all genres, and even though I watch many movies at home, I believe there is nothing quite like going to the movies”; “I think a movie they have been promoting for some time will be released this weekend, I don’t remember what it’s called, but I think it’s a scary one”).	Menu + Menu 3 (standard)

SESSION 4:

Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance.

Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 75-80 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “to talk about these subjects while eating generates a lot of anxiety for me”…).

Using the platform reports, show the patient the clinical advances achieved.

Homework between sessions: Try to eat together with other people (friends, co-workers, family…) dishes and quantities belonging to a normalized diet (without restrictions or consuming low-calorie foods only), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety

ítem	USAs	V. Configuración	Evento
: At the restaurant, accompanied, eating the standard menu, while silent:	75	Company: Accompanied Conversation: Silence	Event: Menu + Menu 3 (standard)
At the restaurant, accompanied, eating the standard menu, while talking about topics related to food/physical appearance:	80	Company: Accompanied Conversation: Uncomfortable (examples of phrases: “Now that I think about it, maybe tomorrow afternoon I won’t be able to meet you because I want to go to the gym, I have not been there for days…”; “I believe I haven’t told you I’m thinking of going to the Islands in summer… I would have to buy a new swimsuit, but I can’t find one that I like how it makes me look…”).	Events: Menu + Menu 3 (standard)

SESSION 5:

Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic.

Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 85-90 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,” “if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food…”).

Using the platform reports, show the patient the clinical advances achieved.

Homework between sessions: Try to eat, both alone and with other people (friends, co-workers, family, both at home and at a family/friends meal…), some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…).

ítem	USAs	V. Configuración	Evento
At the restaurant, alone, eating the hypercaloric menu	85		Menu + Menu 1 (hypercaloric)
At the restaurant, accompanied, eating the hypercaloric menu, while talking about a neutral topic	90	Company: Accompanied Conversation: Neutral (examples of phrases: “Next month, there will be a 2×1 promo in all the city’s cinemas, I saw it on the internet”; “I’ve noticed that the more films I watch, the more I notice the amount of good stories you can write about”).	Menu + Menu 1 (hypercaloric)

SESSION 6:

Review the achievements of the previous session and establish objectives for this session: To be at the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance.

Continue with the gradual and systematic exposure to the “Restaurant” environment: Expose the patient to any of the hierarchy’s items close to 95-100 SUDs (see example items below). Cognitive restructuring, if applicable: while the patient is being exposed, ask him/her about his/her thoughts, emotions and the difficulties he/she is experiencing (e.g., “I will not be able to eat this,” “this food has a lot of fat,” “I feel I’m going to put on weight if I eat this,“” if there is someone with me, I get more distracted while I eat, but if I’m alone, I’m more focused on the food “, ”when somebody tells me I look better, I think it’s because I gained weight right away”…).

Show the clinical advances achieved using the platform reports, analyze the improvements achieved (reduction of anxiety when compared to the first exposures), and provide the final feedback to the patient regarding the results obtained.

Homework: Eat together with other people (friends, coworkers, family, both at home and at a family/friends meals…) some “forbidden” foods (with higher caloric content) that generate discomfort (e.g., pizza, pasta, chocolate, soft drinks with high sugar content…), while the patient start (if not done by others) a talk regarding physical appearance/food topics that generates some discomfort (e.g., “What is your favorite food? I have always liked macaroni with tomato”, etc.) with the aim of talking about these topics normally and without feeling so much anxiety, while being capable of incorporating previously “forbidden” foods to his/her diet.

ítem	USAs	V. Configuración	Evento
At the restaurant, accompanied, eating the hypercaloric menu, while silent:	95	Company: Accompanied Conversation: Silence	Menu + Menu 1 (hypercaloric)
At the restaurant, accompanied, eating the hypercaloric menu, while talking about topics related to food/physical appearance:	100	Company: Accompanied Conversation: Uncomfortable (examples of phrases: “You know, I think you look much better”; “Oh! I forgot to tell you that we have organized a barbecue next week, I’m counting on you to come…”).	Carta + Menu + Menu 1 (hypercaloric)

3. Recommendations for use

It is important to accompany the exhibition with comments, questions or indications so that the patient becomes more in a situation and experiences the exhibition more realistically. For example, in the Dressing Room scene, comments like “Imagine that this is your real body, that you are the one in this costume right now,” etc. as they could be useful. In the Restaurant scene, we could also make interventions such as “Try to imagine you are eating these foods as if they were real, try to focus on their flavor, texture, temperature…”, “What thoughts come to your mind when you eat in this restaurant while surrounded by other people?”, etc.

4. Recommended Bibliography

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5. Annexes

5.1 Self-registration of body image

(situation/thought/emotion)

Date/Time	Situation	Thought	Emotion

5.1 Self-report hierarchy for Eating Disorders: Restaurant

(Psious)

ÍTEM	Anxiety/Urgency Level (0-100)
Being in a restaurant, alone, drinking a green tea and eating green salad and a fruit (e.g., kiwi) as desert.
Being in a restaurant, alone, drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking green tea and eating a green salad and a fruit (e.g., kiwi) as desert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am drinking water and eating grilled chicken breast with a salad, and natural yogurt as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant, alone, drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and drinking water and eating a tortilla as a first course, a dish of steamed vegetables as second course, and natural yogurt as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).
Being in a restaurant, alone, having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion and I remain silent.
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion talks to me about topics that have nothing to do with food or physical appearance (e.g., films).
Being in a restaurant accompanied (by a friend, family member, partner…) where there are more tables with people surrounding me, and I am having a soft drink (e.g., Coca-Cola) and eating a hamburger with chips and a piece of cake as dessert, while my companion talks to me about topics that are more directly or indirectly related to food and physical appearance (e.g., going to the gym, buying clothes, organizing a barbecue…).