Emotional functioning in eating disorders: attentional bias, emotion recognition and emotion regulation

Exploring changes in alexithymia throughout intensive dialectical behavior therapy for eating disorders

OBJECTIVE

Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time.

METHOD

A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months).

RESULTS

Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms.

CONCLUSIONS

Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.

Negative affect and binge eating: Assessing the unique trajectories of negative affect before and after binge-eating episodes across eating disorder diagnostic classifications

OBJECTIVE

Ecological momentary assessment (EMA) studies suggest that among individuals who binge eat, emotional states and binge eating are functionally related. However, it is unclear whether the trajectory of negative affect (NA) is the same across diagnostic groups or if specific changes in affect are unique to each diagnostic category. This study examined the moderating effect of diagnosis on the trajectory of negative affect before and after binge eating.

METHOD

Adults with eating disorder diagnoses (anorexia nervosa [AN] = 118, bulimia nervosa [BN] = 133, binge-eating disorder [BED] = 112) completed an EMA where they reported binge eating and negative affect throughout the day. Generalized estimating equation analyses were used to model the trajectories of NA before and after binge eating.

RESULTS

For all individuals, the linear trajectory of NA significantly increased before (B = 0.044, p < .001) and decreased following the binge-eating episode (B = -0.054, p < .001). However, diagnosis moderated this trajectory. Specifically, individuals with BN had a greater change in linear trajectories of NA before (B = 2.305, p < .001) and after (B = -4.149, p < .001) binge eating compared to those with BED, but not those with AN. There were no differences in the trajectory of NA between individuals with BED or AN.

DISCUSSION

These findings suggest that binge-eating episodes in BN may be more strongly associated with NA than in BED, but similar to binge-eating episodes in AN.

Direct and indirect effects of alexithymia on disordered eating in a non-clinical female sample: Determining the role of negative affect

BACKGROUND

Alexithymia is an independent predictor of symptoms of eating disorders, but also influences disordered eating in clinical samples indirectly via negative affect (depression and anxiety). The aim of the current work was to establish if alexithymia predicts disordered eating in a non-clinical sample directly and indirectly (via negative affect).

METHODS

A sample of healthy females (n = 248) completed measures of depression, anxiety, alexithymia, and disordered eating (drive for thinness, bulimia, and body dissatisfaction). Bias-corrected bootstrapping was used to conduct parallel mediation analyses to determine if negative affect (depression and anxiety) mediated the influence of alexithymia on disordered eating.

RESULTS

The relationship between alexithymia (difficulty identifying feelings) and drive for thinness was mediated by depression but not anxiety. The link between difficulty identifying feelings and bulimia was mediated by anxiety but not depression. The correlation between alexithymia (difficulty describing feelings) and body dissatisfaction was mediated by both depression and anxiety. However, after controlling for negative affect, difficulty identifying feelings remained an independent predictor of drive for thinness, and difficulty describing feelings remained an independent predictor of body dissatisfaction.

CONCLUSION

Facets of alexithymia (DIF and DDF) directly predict disordered eating in healthy participants as well as indirectly via depression and anxiety. These findings suggest that targeted interventions to improve the ability of individuals to identify and describe their feelings could be beneficial in reducing disordered eating, particularly in those "at risk" of developing eating disorders.

Rumination, emotional intensity and emotional clarity

It has been suggested that a high tendency to ruminate presents a deficient emotion regulation. Past research found that people with high tendency to ruminate show sustained attention for negative stimuli and increased negative thinking, which may result in intensified experiences of negative emotions. Moreover, high level of rumination was associated with low emotional understanding. Accordingly, we hypothesized (1) high ruminators (HR) experience more intense emotional reactions than low ruminators (LR) for negative but not positive emotions, (2) LR have higher emotional clarity than HR, and (3) there would be the same pattern of results for brooding but not for reflective pondering. Participants completed a demographic questionnaire, a rumination response style questionnaire, and the Beck Depression Inventory-II. They also rated emotional intensity and identified emotion type for scene pictures from the CAP-D (Categorized Affective Pictures Database). The highest (HR) and lowest (LR) quarters of ruminators were compared on levels of emotional intensity and emotional clarity. We found HR experienced negative emotions more intensely than LR, with no difference for positive emotions. In contrast to our hypothesis, the two groups did not differ in their emotion understanding. This pattern of results was found for brooding but not for reflective pondering. Our research sheds light on the mechanism underlying rumination and emotion regulation.

Social cognition in female adults with Anorexia Nervosa: A systematic review

Deficits in interpersonal and social functioning are well established in females with Anorexia Nervosa (AN), and are thought to be key features involved in the onset and maintenance of the disease. Growing literature suggests these may be attributed to poor social cognitive processes. This systematic review evaluates whether differences in social cognition exist in adult females with AN. A total of 32 studies that compared females with AN against a healthy control group using social cognitive measures and/or questionnaires were analysed. The majority of studies were deemed to have a low or moderate risk of bias. Overall, empathy appears to be intact in AN, however greater emotion regulation difficulties, elevated alexithymia and reduced emotional awareness are evident in AN. Findings relating to emotion recognition and emotional Theory of Mind were inconsistent. The nature of the task appeared to influence the domains of cognitive ToM and social perception, warranting further research. These findings are discussed within the broader context of social cognitive models and AN rehabilitation.

Shame and eating disorders symptoms: A meta-analysis

OBJECTIVE

Numerous empirical studies and theoretical models posit that shame is a common experience among individuals across the eating disorder spectrum. In this study we aim to investigate the association between shame and eating disorders symptoms using a meta-analytical approach.

METHOD

In this meta-analysis, we synthesized findings from 195 studies to examine the proposed association between shame and eating disorders symptoms. We looked at the associations with both general eating disorders symptoms and with specific eating disorders symptoms (i.e., anorexic, bulimic, and binge-eating symptoms). Moderation analyses testing for the effect of type of shame, type of eating symptoms, clinical status, quality of the study, age, and gender were conducted.

RESULTS

Shame was significantly associated with a medium to large effect size with all types of eating disorders symptoms (rs between .40 and .52). Body shame (r = .55) and shame around eating (r = .59) were more strongly related with eating disorders pathology. Type of eating disorders symptoms did not moderate the relationship between shame and disturbed eating.

DISCUSSION

Overall, the magnitude of the effect size of the association between shame and eating disorders symptoms is a medium to large one. Body shame and shame around eating seem to be the types of shame most closely tied with eating disorders symptoms, suggesting that directly targeting them in interventions might be highly beneficial. Findings highlight current gaps in the literature (e.g., mostly correlational studies, low quality studies) with implications for future research.

Emotion dysregulation across the span of eating disorder symptoms: Findings from a community sample of adolescents

OBJECTIVE

Emotion dysregulation is proposed as a key factor within eating disorder pathology. However, less is known about specific emotion regulation difficulties experienced by adolescents with varying levels of eating disorders symptoms. The present study examined the relationship between eating disorder behaviors and specific facets of emotion dysregulation, and differences in emotion dysregulation between eating disorder diagnostic groups.

METHOD

Participants were 2,783 adolescents, 11-19 years (M = 14 years, 9 months, SD = 1 year, 6 months), who completed self-report measures as part of the EveryBODY study. Adolescents were identified as not having eating disorder symptoms (n = 2,122) or meeting diagnostic criteria for symptoms of specific eating disorder, including: anorexia nervosa or atypical anorexia nervosa (n = 57), bulimia nervosa (n = 136), binge-eating disorder (n = 57), other specified feeding or eating disorder characterized by binge eating or purging (n = 381), and unspecified feeding or eating disorder (n = 30).

RESULTS

Binge eating, driven exercise, and fasting were each uniquely associated with emotion dysregulation, whereas purging was not. Similar findings were obtained within specific domains of emotion dysregulation. Findings from diagnostic groups showed a significant main effect of diagnosis on overall emotion dysregulation and most domains of emotion dysregulation. Adolescents with eating disorder symptoms consistently reported higher emotion dysregulation compared to those without these symptoms.

DISCUSSION

Findings indicate that emotion dysregulation is a key factor across eating disorder pathology, and potential treatment target across the spectrum of eating disorder diagnoses in adolescents.

Depression and anxiety mediate the relationship between insomnia and eating disorders in college women

Objective: This study examined the associations between insomnia, anxiety, and depression in college women with eating disorders (EDs). Participants: Six hundred and ninety women from 28 US colleges who screened positive for an ED were assessed for psychiatric comorbidities. Women were, on average, 22.12 years old, mostly White (60.1%) and undergraduates (74.3%). Methods: Two mediation models were tested to determine if depression and/or anxiety mediated the relationship between insomnia and ED symptomatology. Results: One-fifth of the sample (21.7%) reported clinically moderate and severe levels of insomnia. Both depression (B = .13, p <. 001) and anxiety (B = .13, p <. 001) significantly mediated the relationship between insomnia and ED psychopathology. Conclusions: Insomnia is relatively common in college-age women with EDs. Findings suggest that this association between ED and sleep disturbances can be explained, in part, by changes in depression and anxiety. Clinicians should consider incorporating mental health assessments for insomnia, depression, and anxiety into current ED prevention, intervention, and screening efforts on college campuses.

The KOALA-study: study protocol for a comprehensive study of cognitive biases in adolescent anorexia nervosa patients compared to healthy and clinical controls

BACKGROUND

Anorexia nervosa (AN) is characterized by dysfunctional cognitions including cognitive biases at various levels of information processing. However, less is known about the specificity of these biases, i.e., if they occur for eating-disorder-related information alone or also for non-eating-disorder-related emotional information in AN patients (content-specificity) and if they are unique to individuals with AN or are also shown by individuals with other mental disorders (disorder-specificity).

METHODS

The present study systematically assesses cognitive biases in 12-18-year-old female adolescents with AN on three levels of information processing (attention, interpretation, and memory) and with regard to two types of information content (eating-disorder-related, i.e., stimuli related to body weight and shape, and non-eating-disorder-related). To address not only content- but also disorder-specificity, adolescents with AN will be compared not only to a healthy control group but also to a clinical control group (adolescents with major depression or particular anxiety disorders). Cognitive biases are assessed within a single experimental paradigm based on the Scrambled Sentences Task. During the task eye movements are recorded in order to assess attention biases while interpretation biases are derived from the behavioural outcome. An incidental free recall test afterwards assesses memory biases. We expect adolescents with AN to show more pronounced negative cognitive biases on all three levels of information processing and for both types of content compared to healthy adolescents. In addition, we expect the specificity of biases to translate into differential results for the two types of content: AN patients are expected to show stronger biases for disorder-related stimuli but similar or less pronounced biases for non-disorder-related stimuli compared to the clinical control group.

DISCUSSION

This is the first study to comprehensively assess cognitive biases in adolescents with AN. It will have essential implications not only for cognitive-behavioural models of AN but also for subsequent studies aiming to modify cognitive biases in this population, thereby addressing important maintaining factors already at an early stage of the disorder.

Interactional Effects of Multidimensional Perfectionism and Cognitive Emotion Regulation Strategies on Eating Disorder Symptoms in Female College Students

Given the inconclusive findings regarding the relation between perfectionism and eating disorder symptoms, it is important that we determine whether this relation is modulated by emotion dysregulation, which is a prominent risk factor for eating disorders. We sought to identify specific cognitive emotion regulatory strategies—rumination, self-blame, and catastrophizing—that interact with multidimensional perfectionism to shape eating disorder symptoms (i.e., shape, weight, eating concerns, and dietary restraint). Using latent moderated structural equation modeling, we analyzed data from 167 healthy young female adults. We found that only rumination significantly moderated the relation between socially prescribed perfectionism and eating disorder symptoms. However, this was not observed for self-oriented perfectionism or other regulatory strategies. These findings held true when a host of covariates were controlled for. Our findings underscore the crucial role of rumination, a modifiable emotion regulatory strategy, in augmenting the relation between socially prescribed perfectionism and eating disorder symptoms in young women.

Functional assessment of restrictive eating: A three-study clinically heterogeneous and transdiagnostic investigation

Restrictive eating is common and associated with negative psychological outcomes across the life span and eating disorder (ED) severity levels. Little is known about functional processes that maintain restriction, especially outside of narrow diagnostic categories (e.g., anorexia nervosa). Here, we extend research on operant four-function models (identifying automatic negative, automatic positive, social negative, and social positive reinforcement functions) that have previously been applied to nonsuicidal self-injury (NSSI), binge eating, and purging to restricting. We assessed restrictive eating functions in three samples: clinically heterogeneous adolescents (Study 1: N = 457), transdiagnostic adults (Study 2: N = 145), and adults with acute or recently weight-restored anorexia nervosa (Study 3: N = 45). Study 1 indicated the four-function model was a good fit for restricting (root mean square error of approximation [RMSEA] = .06, Tucker-Lewis index [TLI] = .88). This factor structure replicated in Study 2 (comparative fit index [CFI] = .97, RMSEA = .07, TLI = .97, standardized root mean square residual [SRMR] = .09). Unlike NSSI, binge eating, and purging, which have been found to primarily serve automatic negative reinforcement functions, all three present studies found automatic positive reinforcement was most highly endorsed (by up to 85% of participants). In Studies 1 and 3, automatic functions were associated with poorer emotion regulation (ps < .05). In Study 1, social functions were associated with less social support (ps < .001). Across studies, automatic functions were associated with greater restriction ps < .05). Functions varied slightly by ED diagnosis. Across ED presentation, severity, and developmental stage, restrictive eating may be largely maintained by automatic positive reinforcement, with some variability across presentations. Continued examination of restrictive eating functions will establish processes that maintain restriction, allowing more precise treatment targeting for these problematic behaviors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Reduced emotion recognition from nonverbal cues in anorexia nervosa

OBJECTIVE

Recent models of anorexia nervosa (AN) emphasise the role of reduced emotion recognition ability (ERA) in the development and maintenance of the disorder. However, methodological limitations impede conclusions from prior research. The current study tries to overcome these limitations by examining ERA with an audio-visual measure that focuses strictly on multimodal nonverbal cues and allows to differentiate between ERA for different emotion categories.

METHOD

Forty women with AN and 40 healthy women completed the Geneva Emotion Recognition Test. This test includes 83 video clips in which 10 actors express 14 different emotions while saying a pseudo-linguistic sentence without semantic meaning. All clips contain multimodal nonverbal cues (i.e., prosody, facial expression, gestures, and posture).

RESULTS

Patients with AN showed poorer ERA than the healthy control group (d = 0.71), particularly regarding emotions of negative valence (d = 0.26). Furthermore, a lower body weight (r = 0.41) and longer illness duration (ρ = -0.32) were associated with poorer ERA in the AN group.

CONCLUSIONS

Using an ecologically valid instrument, the findings of the study support illness models emphasising poor ERA in AN. Directly addressing ERA in the treatment of AN with targeted interventions may be promising.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

Attentional bias in eating disorders: A meta-review

OBJECTIVE

This meta-review summarizes and synthesizes the most reliable findings regarding attentional bias in eating disorders across paradigms and stimulus types and considers implications for theory and future research.

METHOD

Four databases were systematically searched, along with reference lists of included reviews, yielding 15 systematic reviews (four of which were also meta-analyses). The quality of each review was appraised using the AMSTAR-2.

RESULTS

Key findings from systematic reviews are summarized, organized by paradigm and stimulus type.

DISCUSSION

The authors synthesize evidence from the highest-quality studies. There is evidence for attentional avoidance and vigilance in eating disorders depending on stimulus properties (low vs. high-calorie food; high-body mass vs. low-body mass index photos of others) and attentional avoidance of food stimuli in those with anorexia nervosa. Sad mood induction may generate attentional bias for food in those with binge-eating disorder. There may also be attentional bias to general threat in eating disorder samples. This meta-review concludes that most systematic reviews in this field are low in quality and summarizes the main areas that could be improved upon in future reviews. Implications of this study's findings for theory and intervention research are also discussed.

Altered social cognition in a community sample of women with disordered eating behaviours: a multi-method approach

Prior work suggests that individuals with an eating disorder demonstrate task-based and overall differences in sociocognitive functioning. However, the majority of studies assessed specifically anorexia nervosa and often employed a single experimental paradigm, providing a piecemeal understanding of the applicability of various lab tasks in denoting meaningful differences across diverse individuals. The current study was designed to address these outstanding issues. Participants were undergraduate females who self-identified as having an official (n = 18) eating disorder diagnosis or disordered eating behaviours with no diagnosis (n = 18), along with a control group (n = 32). Participants completed three social tasks of increasing complexity with different outcome measures, namely a gaze cueing task, passive video-watching using eyetracking, and a task to measure preferred social distance. Results diverged as a function of group across tasks; only the control group produced typical social attention effects, the disordered eating group looked significantly more at faces, and the eating disorder group demonstrated a significantly larger preferred social distance. These results suggest variations in task efficacy and demonstrate that altered sociocognitive functioning extends beyond official eating disorder diagnosis.

Implementation of mentalization-based treatment in a day hospital program for eating disorders-A pilot study

OBJECTIVE

Aim of the pilot study was to evaluate the effectiveness of a day hospital program for eating disorders (EDs) after implementation of mentalization-based treatment (MBT), including a comparison to a historical matched control group.

METHOD

All consecutively admitted patients with an ED were included in a prospective, observational study over a period of 2 years. Main outcome criteria were eating and overall psychopathology. Furthermore, changes in the capacity to mentalize (reflective functioning [RF]), difficulties with affect regulation and interpersonal problems were assessed at admission, discharge and a three months follow-up.

RESULTS

Thirty-eight out of fourty patients could be included. The program led to significant reductions in eating and general pathology. There was significant improvement in RF, difficulties in emotion regulation and interpersonal functioning. However, there was no advantage in comparison to a matched control group (main outcomes). ED symptoms showed a slight renewed increase after discharge, while body mass index further increased. RF change was predictive of change in overall psychopathology, but not ED symptoms. Drop-out rate was 13.2%.

CONCLUSION

The program showed no advantage in comparison to a historical control group concerning a reduction in eating and overall psychopathology. However, it was associated with low drop-out rates, and changes which MBT targets: An increase in RF and a reduction of interpersonal problems as well as difficulties in emotion regulation.

The Mediator Effect of Personality on the Relationship Between Symptomatic Impairment and Treatment Outcome in Eating Disorders

Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The "pathoplasty model" of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)-a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.

Relationships between Non-Suicidal Self-Injury and Other Maladaptive Behaviors: Beyond Difficulties in Emotion Regulation

Non-suicidal self-injury (NSSI) co-occurs with both other maladaptive behaviors (e.g., aggression) and emotion dysregulation. However, the extent to which these maladaptive behaviors are linked to NSSI independent of emotion dysregulation is unclear. The present study examined relationships between NSSI and six other maladaptive behaviors among university undergraduates. When controlling for demographic variables, emotion dysregulation, and other maladaptive behaviors, binge eating, purging, illicit drug use, and physical aggression were each related to lifetime NSSI history and/or severity. No maladaptive behaviors were significantly related to the presence of current diagnostic-level NSSI in these multivariate analyses. Results suggest that some maladaptive behaviors may relate uniquely to NSSI risk independent of emotion dysregulation, highlighting the importance of considering such behaviors in self-injury assessment and treatment.

Autistic Traits Mediate Reductions in Social Attention in Adults with Anorexia Nervosa

Anorexia nervosa (AN) is associated with difficulties in social and emotional functioning. A significant proportion of individuals with AN show autistic traits, which may influence social attention. This study examined attention to faces and facial features in AN, recovered AN (REC), and healthy controls, as well as relationships with comorbid psychopathology. One hundred and forty-eight participants' eye movements were tracked while watching a naturalistic social scene. Anxiety, depression, alexithymia, and autistic traits were assessed via self-report questionnaires. Participants with AN spent significantly less time looking at faces compared to REC and controls; patterns of attention to individual facial features did not differ across groups. Autistic traits mediated the relationship between group and time spent looking at faces.

Hunger games: Associations between core eating disorder symptoms and responses to rejection by peers during competition

OBJECTIVE

Individuals with eating disorder (ED) symptoms are sensitive to social threat and report maladaptive interpersonal styles that may contribute to and exacerbate negative evaluation from others. Research in this area has relied primarily on self-report. The current study examined associations between behavioral responses to social threat and core ED symptoms using a behavioral paradigm. Based on previous findings that individuals with binge-eating report being more reactive and confrontational, whereas individuals with dietary restriction tend to be more submissive and avoidant of conflict, we hypothesized that binge eating would be associated with a greater tendency to retaliate against rejection perpetrators, whereas dietary restriction would be associated with a lower tendency to retaliate when rejected.

METHOD

Undergraduate women (N = 132) completed a self-report measure of ED symptoms and participated in an online "Survivor"-type game in which they voted to either accept or reject computerized coplayers, while also receiving acceptance or rejection feedback from others.

RESULTS

Neither ED symptom was associated with how often participants retaliated against coplayers who rejected them. However, dietary restriction was related to more rejection votes overall (i.e., the tendency to reject others regardless of how others voted).

DISCUSSION

Findings suggest that individuals with dietary restriction may rely on a maladaptive defensive strategy aimed at pre-empting rejection, or alternatively, have difficulty shifting from habitual self-isolating behavior that results from over-involvement with restricting symptoms. Interventions targeting hypersensitivity to social threat or interpersonal flexibility may help reduce interpersonal stress and mitigate its impact on restricting symptoms.

Believing emotions are uncontrollable is linked to eating disorder psychopathology via suppression and reappraisal

OBJECTIVE

Research suggests that beliefs about emotional controllability influence the use of emotion regulation strategies, which in turn impact psychological health and illness. However, no research has yet investigated whether emotional controllability is linked to eating psychopathology. The current study investigates whether these concepts are related, as individuals with eating disorders have problems with emotion regulation.

METHOD

We collected self-report data from 718 participants from a community sample using validated questionnaires, and ran mediational analyses to assess the relationship between emotional controllability and eating psychopathology, via reappraisal and suppression, two emotion regulation strategies.

RESULTS

Our mediational analyses suggest that believing emotions to be uncontrollable relates to high levels of suppression (β = -.08), low levels of reappraisal (β = .19) and poorer eating disorder psychopathology (β = -.11). Reappraisal and suppression were found to partially mediate the relationship between emotional controllability and eating psychopathology.

DISCUSSION

The current study has demonstrated relationships that support investigations relating emotional controllability, emotion regulation and psychological health. This research has potential implications for developing interventions to target beliefs about emotions in order to help improve emotion regulation skills and eating psychopathology.

The emotional face of anorexia nervosa: The neural correlates of emotional processing

Social-emotional processing difficulties have been reported in Anorexia Nervosa (AN), yet the neural correlates remain unclear. Previous neuroimaging work is sparse and has not used functional connectivity paradigms to more fully explore the neural correlates of emotional difficulties. Fifty-seven acutely unwell AN (AAN) women, 60 weight-recovered AN (WR) women and 69 healthy control (HC) women categorised the gender of a series of emotional faces while undergoing Functional Magnetic Resonance Imaging. The mean age of the AAN group was 19.40 (2.83), WR 18.37 (3.59) and HC 19.37 (3.36). A whole brain and psychophysical interaction connectivity approach was used. Parameter estimates from significant clusters were extracted and correlated with clinical symptoms. Whilst no group level differences in whole brain activation were demonstrated, significant group level functional connectivity differences emerged. WR participants showed increased connectivity between the bilateral occipital face area and the cingulate, precentral gyri, superior, middle, medial and inferior frontal gyri compared to AAN and HC when viewing happy valenced faces. Eating disorder symptoms and parameter estimates were positively correlated. Our findings characterise the neural basis of social-emotional processing in a large sample of individuals with AN.

The Renfrew Unified Treatment for Eating Disorders and Comorbidity: Long-Term Effects of an Evidence-Based Practice Implementation in Residential Treatment

Background: The Renfrew Unified Treatment for Eating Disorders and Comorbidity (UT) is a transdiagnostic, emotion-focused treatment adapted for use in residential group treatment. This study examined the effect of UT implementation across five years of treatment delivery. Methods: Data were collected by questionnaire at admission, discharge (DC), and 6-month follow-up (6MFU). Patient outcomes were measured by the Eating Disorder Examination-Questionnaire, Center for Epidemiologic Studies-Depression Scale, Brief Experiential Avoidance Questionnaire (BEAQ), Anxiety Sensitivity Index, and Southampton Mindfulness Scale. Data were analyzed for N = 345 patients treated with treatment-as-usual (TAU), and N = 2,763 treated with the UT in subsequent years. Results: Results from multilevel models demonstrated a significant interaction between implementation status (TAU vs. UT) and time, both linear and quadratic, for the depression, experiential avoidance, anxiety sensitivity, and mindfulness variables. Patients treated with the UT showed more improvement in these variables on average, as well as more rebound between DC and 6MFU. Results from multilevel models examining eating disorder outcome showed no significant difference between the TAU and UT for the full sample, but a significant three-way interaction indicated that the UT produced more improvement in the EDE-Q relative to the TAU particularly for patients who entered treatment with high levels of experiential avoidance (BEAQ score). Conclusion: This long-term study of a transdiagnostic, evidence-based treatment in residential care for eating disorders and comorbidity suggests implementation was associated with beneficial effects on depression and emotion function outcomes, as well as eating disorder severity for patients with high levels of baseline emotion regulation problems. These effects did not appear to diminish in the 5 years following initial implementation.

The Relationship between Emotional Intelligence, Obesity and Eating Disorder in Children and Adolescents: A Systematic Mapping Review

Eating and weight disorders often develop early in life and cause a long-standing significant health burden. Given the documented role of emotional intelligence (EI) in shaping the body image and predicting the onset of eating disorders, knowledge of the mechanisms involved in EI among youth is fundamental to designing specific interventions for screening and prevention of obesity and eating disorders (EDs). The present systematic mapping review was aimed to explore and quantify the nature and distribution of existing research investigating the impact of EI on EDs in young people. A systematic search for relevant articles was conducted using PubMed, Scopus, PsycINFO and Web of Science databases. The Appraisal tool for Cross-Sectional Studies (AXIS) was used to assess the included studies’ methodological quality. The included studies’ results were mapped based on stratification by age groups (children, preadolescents, and adolescents), population (clinical vs. non-clinical) and disordered eating outcomes. Nine studies were included, supporting the association between EI and body image dissatisfaction, ED risk and bulimic symptomatology, but not with anorexic symptoms. Research on children and clinical populations was scant. Further studies are needed to deepen the role of EI in the genesis and maintenance of EDs.

Just like fireworks in my brain - a Swedish interview study on experiences of emotions in female patients with eating disorders

BACKGROUND

Patients with eating disorders have reported poorer emotional awareness, more emotional suppression, less use of adaptive emotional regulation strategies, and more use of maladaptive emotional regulation strategies compared to people in healthy control groups.

AIM

To explore experiences of emotions by a transdiagnostic sample of patients with eating disorders.

METHOD

Nine patients with different eating disorder diagnoses at an eating disorder outpatient clinic in Sweden were interviewed for their thoughts on emotions. The interviews were analyzed with Thematic Analysis.

RESULT

Four themes were constructed: "Not knowing what one feels", "Switch off, run away, or hide behind a mask", "Emotions in a lifelong perspective", and "Using eating behaviours to regulate emotions". The patients described uncertainty regarding whether they experienced emotions correctly. They described how they tried to avoid difficult emotions through suppressive strategies and eating disorder behaviour. All described strategies were inefficient and all emotions were experienced as problematic, even joy. Since joy was used as a mask, the real experience of happiness was lost and mourned.

CONCLUSION

All kinds of emotions were considered problematic to experience, but shame, fear, and sadness were considered worst. It is difficult to know if the emotional difficulties preceded an eating disorder, however such difficulties may have increased as a result of the eating disorder.

Revisiting the relationship between body dissatisfaction and eating disorder symptoms in Chinese adolescents: the mediating roles of regulatory emotional self-efficacy and depression symptoms

PURPOSE

Even though many studies have investigated the relationship between body dissatisfaction and eating disorder symptoms, the relationship is still far from being clear, especially about what factors that could potentially mediate such relationship. This study aimed to examine the direct pathway in the relationship between body dissatisfaction and eating disorder symptoms, and possible mediation pathways between the two via regulatory emotional self-efficacy and depression symptoms.

METHODS

A sample of 654 adolescents from central China completed questionnaires for a set of study variables. Modeling analysis was conducted that examined the direct pathway between body dissatisfaction and eating disorder symptoms, and the mediating roles of regulatory emotional self-efficacy and depression symptoms between these two constructs. Multi-group modeling analysis was conducted to assess model invariance across gender and age groups.

RESULTS

The results showed that, in addition to the direct pathway between body dissatisfaction and eating disturbances, regulatory emotional self-efficacy and depression symptoms partially mediated the relationship between these two constructs. Results of multi-group invariance analysis showed that the mediation model was consistent across gender and age groups.

DISCUSSION

These results indicated that management of regulatory emotional self-efficacy and appropriate intervention for depression could potentially buffer against the negative impact of body dissatisfaction on eating disorder symptoms. Finally, some potential clinical implications are discussed, and possible preventions for eating disorder symptoms are suggested.

LEVEL OF EVIDENCE

V, Cross-sectional descriptive study.

Exploring Neural Mechanisms Related to Cognitive Control, Reward, and Affect in Eating Disorders: A Narrative Review of FMRI Studies

Studies using functional magnetic resonance imaging (fMRI) have contributed to our understanding of possible neural abnormalities among individuals with eating disorders. Many of these studies have focused on three domains: 1) cognitive control, 2) reward processing, and 3) affective processing. This review attempts to summarize the recent fMRI findings across these domains among the most well-characterized eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Though the literature is a bit murky, a few major themes have emerged. Cognitive control systems are affected among individuals across eating disorder diagnoses, but effects seem least pronounced in AN. Specifically, individuals with all eating disorders appear to show decreased prefrontal activation during cognitive control, but there is less evidence in AN linking decreased prefrontal activation with behavior. There is some evidence that the reinforcing value of food is reduced in AN, but individuals with BN and BED show hyperactivation to rewarding food-related stimuli, suggesting the reinforcing value of food may be enhanced. However, more complex reward processing paradigms show that individuals with BN and BED exhibit hypoactivation to reward anticipation and provide mixed results with regards to reward receipt. There are fewer neuroimaging findings related to affective processing, yet behavioral findings suggest affective processing is important in understanding eating disorders. Though the extant literature is complicated, these studies represent a foundation from which to build and provide insight into potential neurobiological mechanisms that may contribute to the pathophysiology of eating disorders.

The interaction of negative psychological well-being and picky eating in relation to disordered eating in undergraduate students

The extant literature on picky eating focuses on children, leaving adults understudied. A sparse and mixed evidence base suggests relationships exist between picky eating and disordered eating in adults. The present study furthered this research by examining shared negative psychological correlates as moderators that may strengthen relationships between picky eating and disordered eating in undergraduate students. Participants (N = 509; 76.3% female) completed a cross-sectional survey assessing picky eating (Adult Picky Eating Questionnaire), disordered eating (Binge Eating Scale and Eating Disorder Examination-Questionnaire), and negative psychological correlates including anxiety, depression, and stress (Depression, Anxiety and Stress Scale - 21 Items), inflexible eating (Inflexible Eating Questionnaire), obsessive compulsive disorder (Short Obsessive Compulsive Disorder Screener), and social eating anxiety (adapted Social Phobia Scale) symptoms. Positive relationships were observed between picky eating and binge eating, dietary restraint, eating concerns, overall eating pathology, and all negative psychological correlates. Moderation analyses examined if negative psychological correlates strengthened relationships between picky eating and disordered eating. Higher inflexible eating and anxiety and stress symptoms interacted with higher picky eating in relation to disordered eating, specifically eating concerns. Interactions between picky eating and negative psychological correlates did not explain variance in binge eating, dietary restraint, and overall eating pathology. Findings complement research demonstrating overlap between picky eating and disordered eating and highlight specific negative psychological correlates that may strengthen relationships between picky eating and disordered eating. Researchers and clinicians interested in concurrent picky eating and disordered eating should consider these negative psychological correlates given their potential to worsen disordered eating.

Examining heart rate variability as an indicator of top-down inhibitory control over emotions and eating behaviors among individuals with and without binge eating

OBJECTIVE

Guilt increases prior to objective binge-eating episodes (OBE) and decreases following OBE, suggesting that OBE may function to regulate negative affective states. Rapid eating, a common feature of OBE, may be an observable indication of difficulty regulating eating. Heart rate variability (HRV), a measure of parasympathetic activity, is an indicator of top-down inhibitory control and indicates emotion regulation attempts. We aimed to test the effect of guilt on consumption rate and change in HRV among individuals with (+) and without (-) OBE.

METHOD

Participants (N = 86) underwent a mood induction (randomized to either a neutral mood or a guilt condition) and were then provided with 32 ounces (0.95 L) of Boost® meal replacement shake (960 kcal) and instructed to consume until they felt satisfied. Guilt was measured at baseline, prior to consumption, and following consumption. HRV was measured throughout.

RESULTS

Participants in the guilt condition reported higher guilt prior to consumption than individuals in the neutral mood condition, primarily driven by individuals with low HRV. Guilt decreased following consumption among individuals with low HRV in the guilt condition. The OBE+ individuals did not consume more or at an overall faster rate than OBE- individuals. Guilt prior to consumption did not lead to faster initial rates among OBE+ individuals; although, OBE+ individuals who experienced an increase in HRV from prior to during consumption demonstrated faster initial rates and greater changes in rate over time.

DISCUSSION

When experiencing negative emotions, individuals with OBE may experience increases in parasympathetic functioning while eating, reinforcing OBE as a facilitator of emotion regulation.

Negative bias and reduced visual information processing of socio-emotional context in borderline Personality Disorder: A support for the hypersensitivity hypothesis

BACKGROUND AND OBJECTIVES

Current studies on emotional dysregulation in BPD suggest that it might be manifested by altered appraisal and biased attentional mechanisms, rather than by hyperreactivity. The aim of this study was to acquire more evidence on this topic by testing the hypothesis that BPD patients are characterized by a negative evaluation bias and reduced visual exploration in response to socio-emotional content. Moreover, the association between the previous conceptualizations and typical dysfunctional processes in BPD were evaluated.

METHODS

Fifty-four socio-emotional pictures were administered to 20 female BPD patients and 20 healthy controls (HCs) divided into three blocks characterized by different stimulus durations (500 ms, 3s, 18s). Self-reported and eye-tracking data were collected during the experiment.

RESULTS

BPD patients showed lower valence ratings and reduced visual exploration of socio-emotional pictures compared to HCs. Visual exploration in BPD was affected by exposure time with reduced exploration in response to prolonged stimuli presentation. Dysfunctional features and pre-task negative affectivity level in BPD were correlated with self-reported evaluations and eye-tracking data.

LIMITATIONS

Possible effects of gender on emotional responsivity could not be addressed given the female composition of our sample. Moreover, the role of psychiatric symptoms and medications should be addressed in future research.

CONCLUSIONS

This study presented evidence on dysfunctional mechanisms sustaining emotional dysregulation in BPD. This construct seemed supported by a well-established negative bias towards emotional stimuli together with a reduced processing of social information as manifestations of emotional hypersensitivity.

The potential use of N-methyl-3,4-methylenedioxyamphetamine (MDMA) assisted psychotherapy in the treatment of eating disorders comorbid with PTSD

Despite advances in the field, eating disorders (EDs) remain very challenging disorders to treat, especially when comorbid with posttraumatic stress disorder (PTSD). N-methyl-3,4-methylenedioxyamphetamine (MDMA)-assisted psychotherapy for treatment refractory PTSD shows great promise, with two-thirds of participants achieving full remission at 1 year or more at follow-up. PTSD is a common comorbidity associated with EDs, and patients with EDs and PTSD (ED-PTSD) are reported to have higher severities of illness, greater comorbidities, higher treatment dropouts, and poorer outcomes. We hypothesize that MDMA-assisted psychotherapy will be efficacious in the ED-PTSD population for both ED and PTSD symptoms. The rationales for and proposed mechanisms of MDMA-assisted psychotherapy for ED-PTSD are considered from neurobiological, psychological and social perspectives. MDMA is associated with unique psychopharmacological effects, including: 1) reduced fear, 2) enhanced wellbeing, 3) increased sociability/extroversion, 4) reduced self-criticism, 5) increased compassion for self/others, 6) increased interpersonal trust, and 7) alert state of consciousness. These anxiolytic and prosocial effects may counteract avoidance and hyperarousal in the context of psychotherapy for those with ED-PTSD. Other clinical features of EDs that may be amenable to MDMA-assisted psychotherapy include body image distortion, cognitive rigidity, and socio-emotional processing difficulties. To illustrate its potential, personal accounts of individuals with ED-PTSD symptoms reporting benefit from MDMA adjunctive to psychotherapy are described. In addition, the possible risks and challenges in conducting this work are addressed, and future implications of this proposal are discussed.

Emotion and overeating behavior: effects of alexithymia and emotional regulation on overweight and obesity

PURPOSE

Obesity and overweight are significant risk factors for many serious diseases. Several studies have investigated the relationship between emotional regulation and overweight or obesity in people with eating disorders. Although a few studies have explored alexithymia in individuals with severe obesity without eating disorders, no attention has been paid to individuals with overweight and preclinical form of obesity. This study aims to assess whether overweight and obesity are related to emotional dysregulation and alexithymia.

METHODS

The study involved 111 undergraduate students who had not been diagnosed with an eating disorder. The sample was divided into two groups according to their body mass index (BMI): normal weight (N = 55) and overweight (N = 56). All of them completed the Toronto Alexithymia Scale (TAS-20), the Emotional Regulation Questionnaire (ERQ), and the Eating Disorder Inventory-2 (EDI-2).

RESULTS

Results showed higher levels of alexithymia, and specifically higher difficulty in identifying feelings and an externally oriented thought, in participants with overweight. Multiple correlation analysis highlighted the positive relations between some EDI-2 subscales and both alexithymia and emotional regulation scores. Linear regressions revealed a significant relationship between body BMI and both alexithymia and emotional regulation strategies.

CONCLUSIONS

The condition of overweight/obesity seems to be associated with higher emotional dysregulation compared to normal weight condition. It is essential to study this relationship because it could represent a risk factor for the worsening of problems related to overeating and excessive body weight. These findings suggest that an integrated approach aimed at considering the promotion of emotional regulation could contribute to the effectiveness of a program designed to reduce overweight and obesity.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Selective attentional bias to food-related stimuli in healthy individuals with characteristics towards orthorexia nervosa

PURPOSE

It has been argued that orthorexia nervosa (ON) is a unique type of disordered eating of food considered by the individual to be healthy. Given that in other eating disorder populations attentional preference for food-related cues influences eating behaviours, is it also likely that these biases may be a characteristic of ON tendency.

METHODS

Eighty healthy individuals completed the ORTO-15 questionnaire (ON tendency), a modified Stroop task containing words related to healthy and unhealthy foods and perceived hunger levels pre- and post-testing. The ORTO-15 was used to identify participants within this sample who demonstrated more or less of the characteristics of ON.

RESULTS

Results suggest that the presence of attentional bias to healthy, but not for unhealthy food-related stimuli independently predict increased ON tendency. Increased attentional bias towards healthy food-related stimuli is associated with increased scores on the ORTO-15.

CONCLUSION

Attentional bias, as a deficit in information processing, towards healthy food-related stimuli accounts for variability in ON characteristics.

LEVEL OF EVIDENCE

Level I, experimental study.

Nonsuicidal self-injury, difficulties in emotion regulation, negative urgency, and childhood invalidation: A study with outpatients with eating disorders

OBJECTIVES

Among outpatients with eating disorders (ED), we compared participants without nonsuicidal self-injury (non-NSSI group), with NSSI over a year ago (past NSSI group) and with NSSI in the previous year (current NSSI group) regarding different variables, and examined whether difficulties in emotion regulation and negative urgency moderated the relationship between maternal/paternal invalidation and NSSI.

METHOD

The sample included 171 outpatients (94.2% female; M_age  = 28.78, SD_age  = 11.19).

RESULTS

Fifty-four participants (31.6%) had NSSI in the previous year. This group showed higher eating pathology, difficulties in emotion regulation, negative urgency, and maternal/paternal invalidation than the non-NSSI group. Analyses revealed an adequate fit to the data for the model that included moderating effects of emotional awareness and negative urgency in the relationship between maternal/paternal invalidation and increased likelihood of NSSI in the previous year.

CONCLUSIONS

Interventions for NSSI and ED should include emotion regulation, impulse control, and validation strategies.

Patterns of negative emotional eating among Chinese young adults: A latent class analysis

There is ample evidence suggesting that negative emotional eating is closely related to disordered eating behaviors. However, most previous studies on the topic focused only on emotional over-eating, but neglected emotional under-eating. Moreover, previous studies also mainly used variable-oriented methods by reducing negative emotional eating to a single dimension, which limits our understanding of individual differences in negative emotional eating. In this study, we used a person-oriented approach, latent class analysis (LCA), to examine the negative emotional eating patterns and to characterize these patterns in a sample of 1,068 Chinese young adults (52.6% females, aged 17-24 years). Negative emotional eating was measured by the Emotional Over-Eating and Emotional Under-Eating subscales of the Adult Eating Behavior Questionnaire. Four patterns, namely, "non-emotional eating" (38.9%), "emotional over- and under-eating" (15.4%), "emotional over-eating" (14.7%), and "emotional under-eating" (31.0%), were identified. Sex and BMI were found to be statistically significant predictors for negative emotional eating patterns. The identified four patterns showed significant differences in eating disorder symptoms and psychological distress. Particularly, participants in emotional over- and under-eating exhibited the highest level of eating disorder symptoms and psychological distress. Overall, this study identified four distinct negative emotional eating patterns, among which, the emotional over- and under-eating was the most problematic. Future studies regarding negative emotional eating and its impact on mental health may benefit from focusing not only on individuals with emotional over-eating, but also on those showing a mixed pattern of negative emotional eating.

Illness Perception in Adolescent Patients With Anorexia: Does It Play a Role in socio-Emotional and Academic Adjustment?

People’s beliefs about their illness have been shown to affect their adjustment. The aim of this study was to describe illness perception in adolescent patients with anorexia nervosa (AN) and assess its relationship with socio-emotional and academic adjustment following Leventhal’s Self-Regulation Model. Thirty-four female AN patients, with a mean age of 15.76 (SD = 2.00), completed the Revised Illness Perception Questionnaire (IPQ-R), the Psychosocial Adjustment to Illness Scale (PAIS) and the Hospital Anxiety and Depression Scale (HAD). Adolescent anorexia patients perceived that they had control over their illness and treatment would improve their condition. However, they also believed that it was highly distressing, going to last a long time and would have serious consequences. As for the causes of the disorder, they were attributed primarily to a specific eating disorder and psychological factors. The results showed that anorexia patients’ illness perceptions were related to socio-emotional and academic adjustment. In this sense, identity with the illness was associated with a worse academic adjustment, while emotional representation was associated with a worse emotional and social adjustment. These findings highlight how important it is for patients’ beliefs about their disease to be considered in the treatment of anorexia. In this respect, clinicians treating these patients should consider how certain beliefs affect their academic and socio-emotional adjustment. It would be interesting for patients to become aware of how these beliefs influence the strategies they use to cope with their disease as well as their adjustment to it.

Heightened affective response to perturbation of respiratory but not pain signals in eating, mood, and anxiety disorders

Several studies have recently suggested that an abnormal processing of respiratory interoceptive and nociceptive (painful) stimuli may contribute to eating disorder (ED) pathophysiology. Mood and anxiety disorders (MA) are also characterized by abnormal respiratory symptoms, and show substantial comorbidity with ED. However, no studies have examined both respiratory and pain processing simultaneously within ED and MA. The present study systematically evaluated responses to perturbations of respiratory and nociceptive signals across the levels of physiology, behavior, and symptom report in a transdiagnostic ED sample (n = 51) that was individually matched to MA individuals (n = 51) and healthy comparisons (HC; n = 51). Participants underwent an inspiratory breath-holding challenge as a probe of respiratory interoception and a cold pressor challenge as a probe of pain processing. We expected both clinical groups to report greater stress and fear in response to respiratory and nociceptive perturbation than HCs, in the absence of differential physiological and behavioral responses. During breath-holding, both the ED and MA groups reported significantly more stress, feelings of suffocation, and suffocation fear than HC, with the ED group reporting the most severe symptoms. Moreover, anxiety sensitivity was related to suffocation fear only in the ED group. The heightened affective responses in the current study occurred in the absence of group differences in behavioral (breath hold duration, cold pressor duration) and physiological (end-tidal carbon dioxide, end-tidal oxygen, heart rate, skin conductance) responses. Against our expectations, there were no group differences in the response to cold pain stimulation. A matched-subgroup analysis focusing on individuals with anorexia nervosa (n = 30) produced similar results. These findings underscore the presence of abnormal respiratory interoception in MA and suggest that hyperreactivity to respiratory signals may be a potentially overlooked clinical feature of ED.

Improving emotion recognition in anorexia nervosa: An experimental proof-of-concept study

OBJECTIVE

Previous research has found increasing evidence for difficulties in emotion recognition ability (ERA) and social cognition in anorexia nervosa (AN), and recent models consider these factors to contribute to the development and maintenance of the disorder. However, there is a lack of experimental studies testing this hypothesis. Therefore, the present proof-of-concept study examined whether ERA can be improved by a single session of a computerized training in AN, and whether this has short-term effects on eating disorder symptoms.

METHOD

Forty inpatients (22.20 ± 7.15 years) with AN were randomly assigned to receive a single session of computerized training of ERA (TERA) or a sham training (training the recognition of different types of clouds). ERA, self-reported eating disorder symptoms, and body mass index (BMI) were assessed within 3 days before and after training.

RESULTS

After training, both groups showed improved ERA, reduced self-reported eating disorder symptoms, and an increased BMI. As compared to patients in the control group, patients who received TERA showed greater improvements in ERA and self-reported eating disorder symptoms.

DISCUSSION

ERA can be effectively trained in patients with AN. Moreover, short-term improvements in self-reported eating disorder symptoms provide tentative support for the hypothesis that difficulties in ERA contribute to the maintenance of AN, and that specific trainings of ERA hold promise as an additional component in AN treatment. Future studies are needed to replicate these findings in larger samples, and to investigate long-term effects and transfer into real-world settings.

The mentalization profile in patients with eating disorders: a systematic review and meta-analysis

Context: Patients with eating disorders (EDs) may have a lower mentalization ability. To the best of our knowledge, no meta-analysis has so far addressed the multidimensional mentalization profile within these patients.Objective: To summarize the existing evidence of the mentalization profile and its association with EDs.Data sources: We searched for articles in PsychINFO, Embase and PubMed using the search terms mentalization, reflective function, adult attachment interview, alexithymia, Toronto Alexithymia Scale, eye test, Reading the Mind in the Eyes Test, Theory of Mind, mind-mindedness, mind-blindness, facial expression recognition, metacognition, ED, anorexia nervosa (AN) and bulimia nervosa (BN).Studies included: Quantitative studies including diagnosed patients with an ED, healthy controls (HCs) and relevant test methods.Data synthesis: Forty-four studies were included. Nine studies were eligible for the meta-analysis. Significantly lower mentalization ability about oneself was found in patients with an ED when compared to HCs. Groups were more comparable when dealing with mentalization ability of others. Non-significant but clinically relevant results include a tendency for a lower mentalization ability in patients with AN compared to patients with BN.Conclusion: The mentalization profile is complex and varies across dimensions of mentalization in patients with an ED. Different degrees of mentalization between various EDs were found, implying the necessity for further research on mentalization profiles in different ED diagnoses. The sparse existing literature was a limitation for this meta-analysis, emphasizing that further research on the mentalization profile in patients with EDs is needed.

Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders

Emotion regulation deficits are associated with eating disorder (ED) symptoms, regardless of eating disorder diagnosis. Thus, recent treatment approaches for EDs, such as dialectical behavior therapy (DBT), have focused on teaching patients skills to better regulate emotions. The present study examined changes in emotion regulation among adult patients with EDs during DBT-oriented partial hospital treatment, and at follow-up (M[SD] = 309.58[144.59] days from discharge). Exploratory analyses examined associations between changes in emotion regulation and ED symptoms. Patients with anorexia nervosa, restricting (AN-R, n = 77), and binge-eating/purging subtype (AN-BP, n = 46), or bulimia nervosa (BN, n = 118) completed the Difficulties in Emotion Regulation Scale (DERS) at admission, discharge, and follow-up. Patients with BN demonstrated significant improvements across all facets of emotion dysregulation from admission to discharge and maintained improvements at follow-up. Although patients with AN-BP demonstrated statistically significant improvements on overall emotion regulation, impulsivity, and acceptance, awareness, and clarity of emotions, from admission to discharge, these improvements were not significant at follow-up. Patients with AN-R demonstrated statistically significant improvements on overall emotion dysregulation from treatment admission to discharge. Changes in emotion regulation were moderately correlated with changes in ED symptoms over time. Results support different trajectories of emotion regulation symptom change in DBT-oriented partial hospital treatment across ED diagnoses, with patients with BN demonstrating the most consistent significant improvements.

Empathy, mentalizing, and cognitive functioning in anorexia nervosa and bulimia nervosa

The existing evidence on the specific profile and the determinants of empathic and mentalizing abilities in anorexia nervosa (AN) and bulimia nervosa (BN) is not conclusive. Moreover, it is not clear whether patients with eating disorders also exhibit diminished ability to accurately appraise their own empathic skills. We examine in AN and BN: (a) the impairments in various aspects of empathy and theory of mind (ToM), while accounting for the effect of other cognitive functions and (b) the accuracy of self-appraisal of empathy. Self-reported and performance-based empathy, ToM, and cognitive functions were assessed in 46 patients with AN, 30 patients with BN, and 42 healthy controls (HC). Both AN and BN patients reported diminished overall empathic abilities, whereas only BN patients reported reduced cognitive empathy compared to HC. Deficits in performance-based empathy were found in both patient groups. Cognitive ToM was impaired only in AN. Significant correlations between self-reported and performance-based empathy were found in BN and HC but not in AN. Cognitive deficits negatively affected the self-appraisal of empathy in AN but not empathic skills per se. Our findings highlight a double deficit related to empathic responding in AN: diminished performance and inaccurate self-appraisal of empathic abilities, indicating dysfunctional self-reflection.