Virtual Reality-Based Running Exposure to Target the Acute Urge to Be Physically Active in Anorexia Nervosa: A Case Series

Introduction: Anorexia nervosa (AN) is a severe and complex eating disorder (ED), whose incidence has increased following the COVID-19 pandemic, straining specialized healthcare systems worldwide. Although patients often resort to compulsive exercise as a means of weight control, prolonged fasting intensifies the urge to move, leading to increased motor restlessness. Despite progress in understanding AN, interventions often overlook the crucial role that the urge to be physically active plays in reinforcing the ED itself. This case series tested the feasibility of a Virtual Reality-based Running Exposure (VR-RE) protocol to target the acute urge to be physically active in inpatients with severe AN undergoing rehabilitation. Methods: Three female inpatients with severe AN (body mass index ≤15 kg/m2), aged 21, 23, and 26, participated in a 4-week VR-RE protocol, involving four sessions of simulated jogging in a VR environment. Pre- and post-intervention assessments evaluated ED symptoms and traits characteristics, such as compulsive exercise and physical activity addiction. Results: Although treatment outcomes were only partially achieved and there was little change observed in clinical parameters such as weight and body mass index, reductions in the acute urge to move were observed for all after each VR session. Additionally, reliable and clinically relevant changes were observed in drive for thinness, body image dissatisfaction, interoceptive deficits, and emotional regulation. Two patients also reported a decrease in both trait and addictive physical activity at the end of the protocol and rehabilitation program. Qualitative feedback revealed perceived synchronization with the avatar and endorsed the protocol’s potential for outpatient settings. No cybersickness was reported. Conclusion: This study presents a structured VR-based protocol targeting the acute urge to be physically active in severe AN, integrated into a rehabilitation setting. Future research with longer, personalized, and controlled trials is needed to validate its clinical utility.