Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications

Associations between emotion regulation difficulties, eating disorder symptoms, non-suicidal self-injury, and suicide attempts in a heterogeneous eating disorder sample

BACKGROUND

This study examined the associations between specific dimensions of emotion dysregulation and eating disorder (ED) symptoms and behaviors, non-suicidal self-injury (NSSI), and suicide attempts in a heterogeneous ED sample.

METHODS

Participants (N=110) completed the Difficulties in Emotion Regulation Scale (DERS), the Eating Disorder Examination Questionnaire (EDE-Q), and self-reported the presence of lifetime NSSI and a lifetime suicide attempt.

RESULTS

The EDE-Q global score, a primarily cognitive measure of ED symptoms, was significantly positively correlated with DERS strategies, clarity, and awareness subscale scores and DERS total score (ps<0.01). Only the strategies subscale was uniquely positively associated with EDE-Q global score in a multivariate regression analysis. There was no association between the frequency of binge eating or frequency of driven exercise and any of the DERS subscale scores or total score (ps>0.01). Frequency of purging was significantly, positively associated with DERS impulse subscale score and total score (p<0.01). None of the DERS subscale scores were significantly different between those with and without NSSI or between those with and without a lifetime suicide attempt (ps>0.01).

CONCLUSIONS

Findings indicate that in a heterogeneous ED sample, emotion regulation deficits are more strongly associated with cognitively-oriented symptoms of EDs than behavioral symptoms such as a binge eating, purging, driven exercise, NSSI, or suicide attempts.

Anorexia Nervosa and EMDR: A Clinical Case

Numerous studies have identified links between psychopathology and a history of traumatic life events and dysfunctional attachment relationships. Hence, given the possible traumatic origins of this pathology, it may be useful to provide a trauma-focused intervention such as the eye movement desensitization and reprocessing (EMDR) therapy. This article illustrates a clinical case by describing the positive results of the EMDR therapy in the recovery of unremitting anorexia nervosa in a 17-year-old inpatient. She had previously been hospitalized on 4 occasions in the previous 4 years and received both psychodynamic and cognitive-behavioral therapy. At pretreatment, the client weighed (28 kg, 62 lb) and had a body mass index of 14. She was designated with a dismissing attachment style on the Adult Attachment Interview. EMDR therapy was provided for 6 months in hospital, in twice weekly 50-minute sessions and consisted of standard procedures primarily focusing on her relational traumas, interspersed with psychoeducational talk therapy sessions, and integrated with ego state therapy. At the end of treatment, the client weighed (55 kg, 121 lb) and had a body mass index of 21.5. She no longer met diagnostic criteria for anorexia nervosa, and her attachment style had changed to an earned free-autonomous state of mind. She reported an increase in self-confidence and in her ability to manage various social challenges. Results were maintained at 12 and 24 months follow-up. The treatment implications of this case study are discussed.

'I can't accept that feeling': Relationships between interoceptive awareness, mindfulness and eating disorder symptoms in females with, and at-risk of an eating disorder

Mindfulness based therapies (MBTs) for eating disorders show potential benefit for outcomes yet evidence is scarce regarding the mechanisms by which they influence remission from symptoms. One way that mindfulness approaches create positive outcomes is through enhancement of emotion regulation skills. Maladaptive emotion regulation is a key psychological feature of all eating disorders. The aim of the current study was to identify facets of emotion regulation involved in the relationship between mindfulness and maladaptive eating behaviours. In three cross-sectional studies, clinical (n=39) and non-clinical (n=137 and 119) female participants completed: 1) the Eating Disorder Inventory (EDI) eating specific scales (drive-for-thinness and bulimia) and the EDI psychological symptom scales (emotion dysregulation and interoceptive deficits); and 2) mindfulness, impulsivity, and emotion regulation questionnaires. In all samples mindfulness was significantly and inversely associated with EDI eating and psychological symptom scales, and impulsivity. In non-clinical samples interoceptive deficits mediated the relationship between mindfulness and EDI eating specific scales. Non-acceptance of emotional experience, a facet of interoceptive awareness, mediated the relationship between mindfulness and eating specific EDI scores. Further investigations could verify relationships identified so that mindfulness based approaches can be optimised to enhance emotion regulation skills in sufferers, and those at-risk, of eating disorders.

A naturalistic examination of negative affect and disorder-related rumination in anorexia nervosa

In anorexia nervosa (AN), volitional inhibition of rewarding behaviors, such as eating, involves a conflict between the desire to suppress appetite and the inherent motive to consume. This conflict is thought to have costs that carry over into daily life, e.g., triggering negative affect and/or recurring ruminations, which may ultimately impact long term outcome. Hence, increasing research effort is being dedicated to understand the link between emotional and ruminative processes in the etiology and maintenance of AN. We investigated whether affective states influence disorder-related rumination in AN applying "ecological momentary assessment", a method which allows the experimenter to gain insight into psychological processes in the natural environment and assess data in real time. Participants (AN = 37, healthy controls = 33) were given a smartphone for 14 days. A ringtone signaled at six random time-points each day to fill in a questionnaire, which gauged disorder-typical thoughts about food and weight as well as affective state. Analyses, applying hierarchical linear models confirmed that AN patients spend more time thinking about food, body shape and weight than controls (p < 0.001). Additionally, the results support the hypothesis that momentary negative affect (but not baseline depression (p = 0.56) or anxiety symptoms (p = 0.60) are positively associated with a higher amount of disorder-related rumination in patients (p < 0.001). Our findings are in line with theories which claim that ruminative thinking induces a vulnerability to negative stimuli which, in turn, fosters heightened negative affect. Thus, therapeutic interventions could be improved by implementing modules that specifically target disorder-related rumination.

Effects of emotional acceptance and rumination on media-induced body dissatisfaction in anorexia and bulimia nervosa

INTRODUCTION

Body dissatisfaction is an important risk and maintaining factor for eating disorders. The aim of the present study was to experimentally test the effects of two emotion regulation strategies - acceptance and rumination - on media-induced body dissatisfaction in eating disorders.

METHOD

After watching pictures of thin models, women with anorexia nervosa (AN; n = 39) and bulimia nervosa (BN; n = 39) were encouraged to either use emotional acceptance or rumination to cope with their feelings. Body dissatisfaction and mood were repeatedly assessed.

RESULTS

Acceptance significantly improved body dissatisfaction in women with BN. Rumination led to a significant increase of body dissatisfaction in both eating disorder groups. Results were independent from mood changes.

DISCUSSION

Findings highlight the importance ruminative thinking may have in the aggravation of dissatisfaction with the own body in AN and BN. Results suggest that emotional acceptance is a useful strategy to regulate body dissatisfaction after exposure to thin-ideal media in BN.

An Integrative Bio-Psycho-Social Theory of Anorexia Nervosa

The need for novel approaches to understanding and treating anorexia nervosa (AN) is well recognized. The aim of this paper is to describe an integrative bio-psycho-social theory of maintaining factors in AN. We took a triangulation approach to develop a clinically relevant theory with face validity and internal consistency. We developed theoretical ideas from our clinical practice and reviewed theoretical ideas within the eating disorders and wider bio-psycho-social literature. The synthesis of these ideas and concepts into a clinically meaningful framework is described here. We suggest eight key factors central to understanding the maintenance and treatment resistance of anorexia nervosa: genetic or experiential predisposing factors; dysfunctional feelings processing and regulation systems; excessive vulnerable feelings; 'feared self' beliefs; starvation as a maladaptive physiological feelings regulation mechanism; maladaptive psychological coping modes; maladaptive social behaviour; and unmet physical and psychological core needs. Each of these factors serves to maintain the disorder. The concept of universal physical and psychological core needs can provide an underpinning integrative framework for working with this distinctly physical and psychological disorder. This framework could be used within any treatment model. We suggest that treatments which help address the profound lack of trust, emotional security and self-acceptance in this patient group will in turn address unmet needs and improve well-being. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

The concept of unmet physical and psychological needs can be used as an underlying integrative framework for understanding and working with this patient group, alongside any treatment model. A functional understanding of the neuro-biological, physiological and psychological mechanisms involved in anorexia nervosa can help patients reduce self-criticism and shame. Fears about being or becoming fat, greedy, needy, selfish and unacceptable ('Feared Self') drive over-compensatory self-depriving behaviour ('Anorexic Self'). Psychological treatment for anorexia nervosa should emphasize a focus on feelings and fostering experiences of acceptance and trust. Treatment for patients with anorexia nervosa needs to be longer than current clinical practice.

The reinforcing effect of exercise in anorexia nervosa: Clinical correlates and relationship to outcome

The purpose of the current study was to examine the relative reinforcing effect of exercise compared to a non-monetary alternative reinforcer (leisure activity), and to money, before and after weight restoration in an inpatient population with anorexia nervosa (AN). Sixty-two inpatients with AN completed a progressive ratio (PR) task to earn exercise, leisure activities, or cash at low weight and after weight restoration. Measures of pathology and motivation to exercise were completed and post-treatment discharge weights were collected. Patients worked harder for exercise at low weight than after weight restoration (df = 46, t = 5.50, p < .001). PR task performance was weakly associated with a measure of commitment to exercise (low weight: r = 0.31, weight restored: r = 0.36, p < .05), but not with other clinical measures or follow-up weights. Contrary to prior suggestions, measurement of the reinforcing value of exercise among individuals with AN via a PR task does not appear valuable in assessing clinical severity or outcome. Other, simpler, self-report measures of commitment to exercise may have greater value in assessing these outcomes.

Cultural Adaptation of Dialectical Behavior Therapy for a Chinese International Student With Eating Disorder and Depression

Limited information exists on the application of evidence-based treatments for eating disorders among diverse populations. An increasing number of international and immigrant clients provides a pressing need for culturally responsive treatments. This case study highlights an eating disorder treatment that incorporates dialectical behavior therapy and cultural adaptation guidelines. This study explicates a culturally adapted dialectical behavior therapy (DBT) treatment of a 24-year-old female Chinese international student suffering from an eating disorder, depression, and cultural adjustment issues. In particular, this case addresses Chinese cultural values, including conformity, interdependence, and filial piety, and how these values intersect with the client’s presenting issues and treatment. Cultural modifications made to the case conceptualization and dialectical behavior therapy are discussed. The client reported a significant decrease in distress, an increase in the quality of social relationships, and an increase in satisfaction with social roles. These results provide support for the effectiveness and importance of integrating cultural adaptation and evidence-based treatment. Clinical implications and recommendations for clinicians and students are provided.

FBT With Adjunctive Parent Emotion Coaching in an Adolescent Male With Anorexia Nervosa

Family-based therapy (FBT) is the gold standard of treatment for adolescents with anorexia nervosa (AN) and has shown to be more effective than other forms of treatment in several randomized controlled trials. However, FBT is a behaviorally based intervention that does not explicitly address emotional distress often exhibited by patients and their parents. This case study describes the treatment of a 14-year-old adolescent male with AN using FBT as the primary treatment modality. We also implemented an adjunctive treatment designed to address parents’ emotion communication skills (ECSs) to reduce emotion dysregulation and family conflict in the implementation of FBT and in the process of AN recovery. Over the course of 29 sessions, the adolescent has evidenced an increase in weight from 84 pounds to 110.25 pounds and significant decreases in weight and shape concerns. This case provides preliminary support for the feasibility and effectiveness of an adjunct parent emotion coaching intervention combined with FBT for an adolescent male with AN.

Development and Validation of a State-Based Measure of Emotion Dysregulation

Existing measures of emotion dysregulation typically assess dispositional tendencies and are therefore not well suited for study designs that require repeated assessments over brief intervals. The aim of this study was to develop and validate a state-based multidimensional measure of emotion dysregulation. Psychometric properties of the State Difficulties in Emotion Regulation Scale (S-DERS) were examined in a large representative community sample of young adult women drawn from four sites ( N = 484). Exploratory factor analysis suggested a four-factor solution, with results supporting the internal consistency, construct validity, and predictive validity of the total scale and the four subscales: Nonacceptance (i.e., nonacceptance of current emotions), Modulate (i.e., difficulties modulating emotional and behavioral responses in the moment), Awareness (i.e., limited awareness of current emotions), and Clarity (i.e., limited clarity about current emotions). S-DERS scores were significantly associated with trait-based measures of emotion dysregulation, affect intensity/reactivity, experiential avoidance, and mindfulness, as well as measures of substance use problems. Moreover, significant associations were found between the S-DERS and state-based laboratory measures of emotional reactivity, even when controlling for the corresponding original DERS scales. Results provide preliminary support for the reliability and validity of the S-DERS as a state-based measure of emotion regulation difficulties.

Alterations in emotion generation and regulation neurocircuitry in depression and eating disorders: A comparative review of structural and functional neuroimaging studies

Major depression and eating disorders (EDs) are highly co-morbid and may share liability. Impaired emotion regulation may represent a common etiological or maintaining mechanism. Research has demonstrated that depressed individuals and individuals with EDs exhibit impaired emotion regulation, with these impairments being associated with changes in brain structure and function. The goal of this review was to evaluate findings from neuroimaging studies of depression and EDs to determine whether there are overlapping alterations in the brain regions known to be involved in emotion regulation, evidence of which would aid in the diagnosis and treatment of these conditions. Our review of the literature suggests that depression and EDs exhibit common structural and functional alterations in brain regions involved in emotion regulation, including the amygdala, ventral striatum and nucleus accumbens, anterior cingulate cortex, insula, and dorsolateral prefrontal cortex. We present preliminary support for a shared etiological mechanism. Future studies should consider manipulating emotion regulation in a sample of individuals with depression and EDs to better characterize abnormalities in these brain circuits.

EEG neurofeedback effects in the treatment of adolescent anorexia nervosa

A pre-post design including 22 females was used to evaluate the effectiveness of neurofeedback in the treatment of adolescent anorexia nervosa. Resting EEG measures and a psychological test-battery assessing eating behavior traits, clinical symptoms, emotionality, and mood were obtained. While both the experimental (n = 10) and control group (n = 12) received their usual maintenance treatment, the experimental group received 10 sessions of individual alpha frequency training over a period of 5 weeks as additional treatment. Significant training effects were shown in eating behavior traits, emotion regulation, and in relative theta power in the eyes closed condition. Although the results are limited due to the small sample size, these are the first empirical data demonstrating the benefits of neurofeedback as a treatment adjunct in individuals with anorexia nervosa.

New Insights in Anorexia Nervosa

Anorexia nervosa (AN) is classically defined as a condition in which an abnormally low body weight is associated with an intense fear of gaining weight and distorted cognitions regarding weight, shape, and drive for thinness. This article reviews recent evidences from physiology, genetics, epigenetics, and brain imaging which allow to consider AN as an abnormality of reward pathways or an attempt to preserve mental homeostasis. Special emphasis is put on ghrelino-resistance and the importance of orexigenic peptides of the lateral hypothalamus, the gut microbiota and a dysimmune disorder of neuropeptide signaling. Physiological processes, secondary to underlying, and premorbid vulnerability factors-the "pondero-nutritional-feeding basements"- are also discussed.

Emotion-focused treatments for anorexia nervosa: a systematic review of the literature

PURPOSE

The present review explores emotion-focused treatments for anorexia nervosa (AN).

METHODS

We conducted a systematic literature search across key databases (PsychINFO, PubMed/Medline, and Web of Science) prior to September 2015. Twenty studies were selected for systematic review.

RESULTS

The present review found initial evidence supporting the acceptability and feasibility of emotion-focused treatments for AN. Although preliminary results are promising, further controlled studies are necessary to establish the efficacy of emotion-focused treatments for AN.

CONCLUSIONS

Future controlled trials should compare emotion-focused treatments against each other and against other AN treatments. Future studies should also examine the mechanisms of action for the emotion-focused treatments and treatment moderators.

Voluntary emotion regulation in anorexia nervosa: A preliminary emotion-modulated startle investigation

Emotion regulation difficulties are implicated in the development and maintenance of anorexia nervosa (AN). However, research has been limited by an almost exclusive reliance on self-report. This study is the first to use the emotion-modulated startle paradigm (EMSP) to investigate emotional reactivity and voluntary emotion regulation in individuals with AN. Twenty women with AN viewed negative, positive, neutral, and food images and were asked to enhance, suppress, or maintain their emotional responses mid-way through picture presentation. Startle eyeblink magnitudes in response to startle probes administered prior, and subsequent, to regulation instructions indexed emotional reactivity and regulation, respectively. On emotional reactivity trials, startle magnitudes were greater for negative, positive, and food images, compared to neutral images. Participants had difficulty suppressing startle responses to negative and food images, as indicated by non-significant suppress-maintain comparisons. In contrast, startle responses to enhance and suppress cues during presentation of pleasant images were comparable and significantly lower than maintain cues. Findings converge with self-report data to suggest that patients with AN have difficulties with voluntary emotion regulation. The EMSP may be a promising trans-diagnostic method for examining emotion regulation difficulties that underlie risk for eating disorders and other psychiatric conditions.

Emotional Intolerance and Core Features of Anorexia Nervosa: A Dynamic Interaction during Inpatient Treatment? Results from a Longitudinal Diary Study

OBJECTIVE

The role of emotion dysregulation with regard to the psychopathology of anorexia nervosa (AN) is increasingly discussed. It is both assumed that AN symptoms have an impact on difficulties in tolerating aversive emotions and that-conversely-emotion dysregulation influences AN. To date, such conclusions are drawn on the basis of cross-sectional data not allowing for inferences on the temporal dynamics. The current study investigates the longitudinal interaction between emotional intolerance and core AN symptoms over the course of inpatient treatment by comparing patients with high (BMI<15 kg/m2) vs. low symptom severity (HSS vs. LSS).

METHOD

The study adopted a longitudinal, process-oriented design with N = 16 analysed electronic diaries. Throughout the course of their inpatient treatment, the patients answered questions daily about emotional intolerance and their AN-specific cognitions and behaviours. The temporal dynamics between emotional intolerance and these variables were analysed using a multivariate time series approach.

RESULTS

The time series of the processes under investigation adequately reflected the individual treatment courses. The majority of significant linear time trends was found for HSS patients. Most importantly, analysis revealed significant temporal interactions between emotional intolerance and AN symptoms in almost 70% of HSS patients. Thereby, up to 37% of variance in eating restraint and up to 23% in weight concern could be attributed to changes in emotional intolerance.

CONCLUSIONS

The findings support the notion that intolerable unpleasant emotions in severely affected AN patients influence their psychopathology. Additionally, time series analysis outlined the inter-individual heterogeneity of psychosomatic treatment courses of AN patients.

Emotion regulation training to reduce problematic dietary restriction: An experimental analysis

Evidence suggests that emotion regulation may be a process relevant to problematic dietary restriction. However, emotion regulation has not been evaluated as an intervention target across a range of restriction severity. This study utilized an experimental design to examine whether targeting emotion regulation reduced problematic dietary restriction. Within a self-identified restrictive sample (n = 72), the effects of an emotion regulation condition (i.e., emotion regulation training) were compared to those of a control condition (i.e., nutrition information training) on dietary restriction indices (i.e., effort to reduce intake on a progressive ratio task, work towards an alternate reinforcer on a progressive ratio task, intake by dietary recall) following a stressor. Exploratory analyses of potential moderators (i.e., restraint, BMI, binge eating and purging status, emotion regulation difficulties) were conducted to examine whether these factors affected the impact of training on dietary restriction. No significant main effects of condition were detected on any outcome measure. However, results were moderated by BMI status. Participants with lower BMIs exerted less effort towards dietary restriction following the emotion regulation condition versus the control condition (p = 0.02). Results suggest that targeting emotion regulation may help to reduce problematic dietary restriction among lower weight individuals.

Aversive tension in female adolescents with Anorexia Nervosa: a controlled ecological momentary assessment using smartphones

BACKGROUND

Current models of Anorexia Nervosa (AN) emphasize the role of emotion regulation. Aversive tension, described as a state of intense arousal and negative valence, is considered to be a link between emotional events and disordered eating. Recent research focused only on adult patients, and mainly general emotion regulation traits were studied. However, the momentary occurrence of aversive tension, particularly in adolescents with AN, has not been previously studied.

METHOD

20 female adolescents with AN in outpatient treatment and 20 healthy adolescents aged 12 to 19 years participated in an ecological momentary assessment using their smartphones. Current states of aversive tension and events were assessed hourly for two consecutive weekdays. Mean and maximum values of aversive tension were compared. Multilevel analyses were computed to test the influence of time and reported events on aversive tension. The effect of reported events on subsequent changes of aversive tension in patients with AN were additionally tested in a multilevel model.

RESULTS

AN patients showed higher mean and maximum levels of aversive tension. In a multilevel model, reported food intake was associated with higher levels of aversive tension in the AN group, whereas reported school or sport-related events were not linked to specific states of aversive tension. After food intake, subsequent increases of aversive tension were diminished and decreases of aversive tension were induced in adolescents with AN.

CONCLUSIONS

Aversive tension may play a substantial role in the psychopathology of AN, particular in relation with food intake. Therefore, treatment should consider aversive tension as a possible intervening variable during refeeding. Our findings encourage further research on aversive tension and its link to disordered eating.

TRIAL REGISTRATION

German register of clinical trials (DRKS): DRKS00005228 (Date of registration: September 2, 2013).

Associations between negative affect and binge/purge behaviors in women with anorexia nervosa: Considering the role of negative urgency

OBJECTIVE

Evidence implicates negative affect in the occurrence of binge/purge behaviors, although the extent to which theoretically relevant individual difference variables may impact this association remains unclear. Negative urgency, the dispositional tendency to engage in rash action when experiencing negative affect, is a unique facet of impulsivity that may play a key role. Moreover, it was hypothesized that women with anorexia nervosa (AN) who are higher on measures of negative urgency, relative to those lower on negative urgency, would exhibit: 1) greater binge eating and purging frequencies on high negative affect days, and 2) a greater change in negative affect prior to and following binge eating and purging episodes.

METHOD

Women with AN (n=82) completed a self-report measure of negative urgency and a 2-week ecological momentary assessment protocol in which they recorded binge eating, purging, and negative affect ratings.

RESULTS

Women with higher levels of negative urgency exhibited a greater frequency of binge eating and purging; however, in comparison to women low on negative urgency, they: 1) were more likely to binge eat on days corresponding with low-to-moderate negative affect (similar rates of binge eating were observed on high negative affect days), and 2) displayed substantially elevated levels of negative affect across time, and thus, smaller degrees of change in negative affect prior to and following binge eating and purging episodes.

DISCUSSION

Negative urgency underlies individual differences in the daily experience of negative affect. Women with AN who are high on negative urgency may have an increased propensity for binge eating and purging via a relatively persistent and heightened state of negative emotions.

Sexual violence, weight perception, and eating disorder indicators in college females

OBJECTIVE

To examine the relationships between sexual violence experiences, inaccurate body weight perceptions, and the presence of eating disorder (ED) indicators in a sample of female US college students.

PARTICIPANTS

Participants were 6,090 college females 25 years of age and younger.

METHODS

A secondary analysis of National College Health Assessment data gathered annually at one institution from 2004 to 2013 was utilized. A model predicting ED indicators was tested using logistic regression analyses with multiple categorical variables representing severity of sexual violence, accuracy of body weight perception, and an interaction between the two.

RESULTS

Sexual violence and inaccurate body weight perception significantly predicted ED indicators; sexual violence was the strongest predictor of purging behavior, whereas inaccurate body weight perception was best predicted by underweight status.

CONCLUSIONS

Findings provide support to the relationship between purging behavior and severity of sexual violence and also to the link between inaccurate body weight perception and being underweight.

Emotion regulation difficulties in anorexia nervosa: associations with improvements in eating psychopathology

BACKGROUND

Difficulties with emotion regulation have been established as a core deficit in anorexia nervosa (AN). However, limited research has evaluated whether weight gain is associated with improvements in emotion regulation difficulties in AN and whether improvements in emotion regulation are associated with reductions in eating disorder psychopathology. The aims of this study were threefold: 1) to examine the nature and extent of emotion regulation difficulties in AN; 2) to determine whether these difficulties improved during intensive treatment for the eating disorder; and 3) to study whether improvements in emotion regulation were associated with improvements in eating disorder psychopathology.

METHOD

The participants were 108 patients who met DSM-IV-TR criteria for AN and were admitted to a specialized intensive treatment program. Self-report measures of eating disorder symptoms and difficulties with emotion regulation were administered at admission to and discharge from the program.

RESULTS

Patients with the binge-purge subtype of AN reported greater difficulties with impulse control when upset and more limited access to emotion regulation strategies when experiencing negative emotions than those with the restricting subtype. Among those who completed treatment and became weight restored, improvements in emotion regulation difficulties were observed. Greater pre-to-post treatment improvements in emotional clarity and engagement in goal directed behaviours when upset were associated with greater reductions in eating disorder psychopathology during treatment.

CONCLUSIONS

These findings add to growing evidence suggesting that eating disorder symptoms may be related to emotion regulation difficulties in AN and that integrating strategies to address emotion regulation deficits may be important to improving treatment outcome in AN.

A naturalistic examination of the temporal patterns of affect and eating disorder behaviors in anorexia nervosa

OBJECTIVE

Evidence supports the presence of significant variability in the timing of affective experiences and eating disorder (ED) behaviors across ED populations. This study examined the naturalistic timing of affective states and ED behaviors in anorexia nervosa (AN).

METHODS

Women (N = 118) with full or subthreshold DSM-IV AN completed 2 weeks of ecological momentary assessment (EMA) involving self-reports of affect and ED behaviors. Patterns of positive affect, negative affect, and tension/anxiety across hours of the day and days of the week were examined using linear mixed models. Variation in ED behavior occurrence (i.e., binge eating, vomiting, exercise, meal skipping, and self-weighing) across hours of the day and days of the week was examined using general estimating equations.

RESULTS

Results revealed significant variation in tension/anxiety across hours of the day; there were no significant associations between time of day and negative or positive affect. All affective variables significantly varied across days of the week, with both negative affect and tension/anxiety highest in the middle of the week and lowest on the weekends. The ED behaviors all significantly varied across hours of the day, with binge eating and vomiting most common in later hours, exercise and self-weighing most common in earlier hours, and meal skipping most common at times corresponding to breakfast and lunch. ED behaviors did not significantly vary across days of the week.

CONCLUSION

The significant patterns of variation in the timing of affective experiences and ED behaviors may have utility in informing theories and interventions for AN.

Initial test of an emotional avoidance model of restriction in anorexia nervosa using ecological momentary assessment

It has been hypothesized that restrictive eating allows individuals with anorexia nervosa (AN) to avoid contact with negative emotions; however, this presumption has not been directly tested. In this study, we conducted an initial investigation examining whether restrictive eating serves an emotional avoidance function among individuals with AN. Females with AN (n = 118) reported on negative and positive affect, anxiety/tension, and eating behaviors at multiple time points daily over a 2-week period using ecological momentary assessment methodology. Affective patterns were compared using generalized estimating equation models between days in which participants reported either: (1) relatively high restriction (without binge eating); (2) relatively low restriction (without binge eating); (3) binge eating; or (4) no restriction or binge eating. We hypothesized that, if restriction were functioning to avoid negative affect, average negative affect and anxiety/tension, as well as average negative and positive affect lability, would be lower and average positive affect would be higher on days characterized by high levels of restriction compared to other eating patterns. Contrary to hypotheses: (1) average negative affect, anxiety/tension, and positive affect were not significantly different between days characterized by high restriction and those characterized by low or no restriction; (2) Negative affect and anxiety/tension lability were higher on days characterized by high restriction compared to no restriction or binge eating days; (3) Anxiety/tension lability was higher on days characterized by high versus low levels of restriction. This patterns of findings does not support an avoidance model of restrictive eating for individuals with AN.

Examining the associations between emotion regulation difficulties, anxiety, and eating disorder severity among inpatients with anorexia nervosa

OBJECTIVE

There is growing interest in the role of emotion regulation in anorexia nervosa (AN). Although anxiety is also hypothesized to impact symptoms of AN, little is known about how emotion regulation, anxiety, and eating disorder symptoms interact in AN. In this study, we examined the associations between emotion regulation, anxiety, and eating disorder symptom severity in AN.

METHODS

Questionnaires and interviews assessing emotion regulation difficulties, anxiety, eating disorder symptoms, and eating disorder-related clinical impairment were collected from group of underweight individuals with AN (n=59) at admission to inpatient treatment. Hierarchical linear regressions were used to examine the associations of emotion regulation difficulties, anxiety, and the interaction of these constructs with eating disorder symptoms and eating disorder-related clinical impairment.

RESULTS

Emotion regulation difficulties were significantly positively associated with eating disorder symptoms and related clinical impairment only when anxiety levels were low and anxiety was significantly positively associated with eating disorder symptoms and related clinical impairment only when emotion regulation problems were not elevated.

CONCLUSIONS

This study adds to a growing literature suggesting that emotion regulation deficits are associated with eating disorder symptoms in AN. Certain individuals with AN may especially benefit from a focus on developing emotion regulation skills in the acute stages of illness.

Emotion dysregulation, self-image and eating disorder symptoms in University Women

BACKGROUND

We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms.

METHODS

252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise.

RESULTS

Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise.

CONCLUSIONS

Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus.

Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration

OBJECTIVE

This study examined: (1) changes in emotion regulation difficulties in underweight inpatients with anorexia nervosa (AN) following weight restoration, (2) differences in emotion regulation between AN subtypes at acute and weight-restored stages of illness.

METHOD

Repeated measure analyses of variance examined changes in scores on the Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, J Psychopathol Behav Assess, 26, 41-54, 2004) and other clinical variables in a group of inpatients with AN from hospital admission (N = 65) to weight restoration (N = 51). Correlations between BMI and DERS scores at both time points were examined. Emotion regulation difficulties were compared between individuals with AN, restricting type (AN-R) and AN, binge/purge type (AN-BP) at both time points using multivariate analysis of covariance.

RESULTS

All clinical variables, except for the DERS, significantly improved with weight restoration (p < .001). There were no associations between BMI and DERS prior to or after weight restoration and AN subtypes did not significantly differ in emotion regulation difficulties.

DISCUSSION

Unlike other clinical variables, emotion regulation difficulties in AN did not improve with weight restoration. In addition, both subtypes of AN appear to have similar difficulties with emotion regulation. The treatment of AN might be enhanced by focusing on improving emotion regulation abilities.

Difficulties in emotion regulation across the spectrum of eating disorders

Theoretical models consider difficulties in emotion regulation (ER) as central trans-diagnostic phenomena across the spectrum of eating disorders (ED). However, there is a lack of studies directly comparing ED subtypes regarding ER problems. Furthermore, patients with anorexia nervosa-restricting type (AN-R) and patients with AN-binge/purge type (AN-BP) have usually been merged into one overall AN group in previous research on ER. In order to overcome these limitations of previous studies, the present study investigated specific ER difficulties in 120 patients with different ED subtypes, including AN-R, AN-BP, bulimia nervosa (BN), and binge-eating disorder (BED). As compared to 60 healthy normal-weight controls (NWC) and 29 healthy over-weight controls (OWC), all ED subtypes reported greater difficulties in ER. ED subtypes did not differ regarding most domains of ER except BED showing less severe ER difficulties in some domains. In addition, AN-BP but not BN reported greater impulse control difficulties than AN-R and BED. The findings underscore the relevance of ER difficulties in ED and support the trans-diagnostic view of ER difficulties being present across the whole spectrum of ED. In addition, the present results suggest that certain domains of ER may be linked more closely to certain ED subtypes than to others.

Neurocircuitry of limbic dysfunction in anorexia nervosa

Anorexia Nervosa (AN) is a serious psychiatric condition marked by firmly entrenched and maladaptive behaviors and beliefs about body, weight and food, as well as high rates of psychiatric comorbidity. The neural roots of AN are now beginning to emerge, and appear to be related to dysfunctional, primarily limbic, circuits driving pathological thoughts and behaviors. As a result, the significant physical symptoms of AN are increasingly being understood at least partially as a result of abnormal or dysregulated emotional processing. This paper reviews the nature of limbic dysfunction in AN, and how structural and functional imaging has implicated distinct emotional and perceptual neural circuits driving AN symptoms. We propose that top-down and bottom-up influences converge on key limbic modulatory structures, such as the subcallosal cingulate and insula, whose normal functioning is critical to affective regulation and emotional homeostasis. Dysfunctional activity in these structures, as is seen in AN, may lead to emotional processing deficits and psychiatric symptoms, which then drive maladaptive behaviors. Modulating limbic dysregulation may therefore be a potential treatment strategy in some AN patients.

Lower body weight is associated with less negative emotions in sad autobiographical memories of patients with anorexia nervosa

Food restriction and weight-loss have been proposed to represent pathogenic mechanisms of emotion regulation in anorexia nervosa (AN). However, there is a lack of studies empirically examining this hypothesis. Therefore, the present study compared 25 women with AN and 25 healthy control women (HC) regarding spontaneous emotional processing of autobiographic memories. Participants' idiographic memories of sad autobiographic events were analyzed using computerized, quantitative text analysis as an unobtrusive approach of nonreactive assessment. Compared to HC, AN patients retrieved more negative but a comparable number of positive emotions. Moreover, the lesser the body weight in AN patients, the lesser negative emotions they retrieved, irrespective of current levels of depressive symptoms and duration of illness. No such association was found in HC. These preliminary findings are in line with models of AN proposing that food restriction and weight-loss may be negatively reinforced by the alleviation of aversive emotional responses.

Emotion dysregulation and symptoms of anorexia nervosa: the unique roles of lack of emotional awareness and impulse control difficulties when upset

OBJECTIVE

Extant research suggests that individuals with anorexia nervosa (AN) have deficits in emotion regulation across a variety of domains. The current study investigated associations between specific difficulties with emotion regulation and the core symptoms of AN.

METHOD

Participants were 192 patients with AN presenting to an intensive eating disorder treatment facility. Emotion regulation was assessed using the multidimensional Difficulties in Emotion Regulation Scale, and associations with body mass index (BMI) at admission, eating disorder cognitions, objective binge eating, subjective binge eating, and purging were examined.

RESULTS

Eating disorder cognitions were significantly associated with multiple forms of emotion dysregulation; however, only lack of emotional awareness was independently related to these symptoms. In contrast, impulse control difficulties when upset was the only emotion regulation impairment associated with the presence of recurrent objective binge eating and recurrent purging in AN. No significant relationships between emotion regulation and BMI or subjective binge eating were detected.

DISCUSSION

Results point to differential associations between specific emotion regulation deficits and core symptoms of AN. These findings suggest that parsing the construct of emotion regulation as well as the AN phenotype can help to identify the unique ways in which eating disorder symptoms may function to regulate emotions.

Body regard as a moderator of the relation between emotion dysregulation and nonsuicidal self-injury

Despite research documenting a strong association between emotion dysregulation and nonsuicidal self-injury (NSSI), the moderators of this association have received little attention. Thus, it remains unclear why some individuals with heightened emotion dysregulation engage in NSSI and others do not. Body regard (i.e., how one perceives, experiences, and cares for the body) may be one such moderator, explaining the risk for NSSI among some individuals with emotion dysregulation. The current study used structural equation modeling within a sample of 398 undergraduates (26% reporting NSSI, mean frequency = 25.16, SD = 40.5) to test the interactive effect of emotion dysregulation and body regard on NSSI frequency when controlling for negative affect and borderline personality disorder symptoms. The interaction model provided a strong fit to the data and showed that emotion regulation was associated with NSSI only when low levels of body regard were present. Results suggest that body regard may be important to understanding who engages in NSSI within the context of emotion dysregulation. Possible mechanisms underlying the interaction between body regard and emotion dysregulation are discussed along with treatment and prevention implications.

A system of evidenced-based techniques and collaborative clinical interventions with a chronically ill patient

Although evidence-based treatments (EBTs) exist for both bulimia nervosa and binge eating disorder, there is far less evidence underpinning the treatment of anorexia nervosa (AN). Furthermore, there is no clearly defined standardized approach to patients who have not responded to treatment over an extended period of time. Chronic eating disorder patients in particular might need long-term engagement with treatment providers offering a wide range of interventions. This case study highlights how an experienced private practitioner systematically employed a variety of EBT techniques for a patient with a severe, long-term eating disorder and its comorbidities, within a model of attachment and collaboration. The practice of utilizing a wide variety of EBT techniques in a systematic manner guided by clinical expertise and supported by a therapy relationship of collaboration and attachment may prove to be a fruitful avenue for future research.

Moderators of post-binge eating negative emotion in eating disorders

The purpose of this study was to test the impact of two variables on post-binge eating negative emotion in a combined sample of women with anorexia nervosa (AN; n = 47) and bulimia nervosa (BN; n = 121). Participants completed two weeks of an ecological momentary assessment protocol during which they provided multiple daily ratings of overall negative affect and guilt and reported eating disorder behaviors including binge eating and self-induced vomiting. The results indicate that both overall negative affect and guilt exhibited a statistically significantly decrease in the hour immediately following binge eating episodes. The decrease in guilt, but not overall negative affect, was moderated by eating disorder diagnosis and the tendency to engage in self-induced vomiting. Specifically, individuals with BN reported a greater reduction in guilt than those with AN, and individuals who did not typically engage in self-induced vomiting reported more decreases in guilt than those who typically engaged in self-induced vomiting. This study extends the existing literature on the relationship between negative affect and eating disorder behaviors, suggesting guilt as a potentially relevant facet of negative affect in the maintenance of binge eating. In addition, the findings indicate that two individual differences, eating disorder diagnosis and self-induced vomiting, may influence the trajectory of guilt following binge eating episodes.

Temporal relationships of emotional avoidance in a patient with anorexia nervosa--a time series analysis

OBJECTIVE

Anorexia nervosa (AN) is a serious eating disorder marked by self-induced underweight. In patients with AN, the avoidance of emotions appears to be a central feature that is reinforced during the acute state of the disorder. This single case study investigated the role of emotional avoidance of a 25-year-old patient with AN during her inpatient treatment.

METHOD

Throughout the course of 96 days, the patient answered questions daily about her emotional avoidance, pro-anorectic beliefs, perfectionism, and further variables on an electronic diary. The patient's daily self-assessment of emotional avoidance was described in terms of mean value, range, and variability for the various treatment phases. Temporal relationships between emotional avoidance and further variables were determined using a time series approach (vector autoregressive (VAR) modelling).

RESULTS

Diary data reflect that the patient's ability to tolerate unpleasant emotions appeared to undergo a process of change during inpatient treatment. Results of the time series analysis indicate that the more the patient was able to deal with negative emotions on any one day (t-1), the less she would be socially avoidant, cognitively confined to food and eating, as well as feeling less secure with her AN, and less depressive on the following day (t).

CONCLUSIONS

The findings show that for this patient emotional avoidance plays a central role in the interacting system of various psychosocial variables. Replication of these results in other patients with AN would support the recommendation to focus more on emotional regulation in the treatment of AN.

Emotion regulation difficulties in anorexia nervosa: Relationship to self-perceived sensory sensitivity

Changes in sensation (e.g., prickly skin) are crucial constituents of emotional experience, and the intensity of perceived changes has been linked to emotional intensity and dysregulation. The current study examined the relationship between sensory sensitivity and emotion regulation among adults with anorexia nervosa (AN), a disorder characterised by disturbance in the experience of the body. Twenty-one individuals with AN, 20 individuals with AN who were weight-restored, and 23 typical controls completed self-report measures of sensory sensitivity and emotion regulation. AN participants reported heightened sensory sensitivity and greater difficulty regulating emotions relative to controls. Self-perceived sensory sensitivity was associated with greater emotion dysregulation. Weight-restored AN participants reported greater ability to regulate emotions than their currently underweight counterparts, despite heightened sensitivity. Findings suggest that hypersensitivity may be a persisting feature in AN, and that weight restoration may involve improved ability to cope with sensation.