Difficulties regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect?

Explicating the role of emotion dysregulation in risky behaviors: A review and synthesis of the literature with directions for future research and clinical practice

Extant literature provides support for emotion dysregulation as a transdiagnostic construct with relevance to the pathogenesis and treatment of numerous psychiatric difficulties and maladaptive behaviors, including risky, self-destructive, and health-compromising behaviors (e.g., substance use, risky sexual behavior). The aim of the present review is to synthesize theory and empirical research on the relationship between emotion dysregulation and risky behaviors. In addition, we highlight cutting-edge approaches for investigating the emotion dysregulation-risky behavior, including examination of the role of positive emotional experiences and inclusion of context-dependent and physiological assessments. Finally, we note the relevance of the emotion dysregulation-risky behavior relation to intervention efforts aimed at reducing risky behaviors.

A Preliminary Experimental Investigation of Emotion Dysregulation and Impulsivity in Risky Behaviours

This prospective experimental study sought to examine the unique effects of emotion dysregulation and impulsivity on risky behaviors over time. To this end, 20 African American women enrolled in a historically black university in the southern United States were randomly assigned to receive one of two brief empirically-supported skills training modules (i.e., emotion modulation [EM] or impulsivity reduction [IR]). Participants completed measures of emotion dysregulation, impulsivity, and past-week risky behaviors before (pre-) and one week after (post-) the experimental manipulation. Participants assigned to the EM condition reported significant improvements from pre- to post-manipulation in overall emotion dysregulation (as well as all specific dimensions of emotion dysregulation other than lack of emotional awareness), as well as two dimensions of impulsivity: negative and positive urgency. Participants assigned to the IR condition reported a significant decrease in one dimension of impulsivity (lack of premeditation) from pre- to post-manipulation. Findings also revealed a significant effect of time on risky behaviors, with participants reporting significantly fewer past-week risky behaviors at the post- (vs. pre-) manipulation assessment. Finally, changes in emotion dysregulation from pre- to post-manipulation accounted for the observed reduction in risky behaviors over time (above and beyond changes in impulsivity dimensions). Results highlight the relevance of emotion dysregulation to risky behaviors and suggest that treatments targeting emotion dysregulation may be useful in reducing risky behaviors.

The role of sensation seeking and motivations for eating in female and male adolescents who binge eat

OBJECTIVES

Although different personality traits have been associated with the onset and maintenance of binge eating, the role of sensation seeking is still not well documented. The aim of the present study was to investigate the role of sensation seeking and motivations for eating in male and female adolescents who binge eat.

METHODS

336 adolescents (196 boys and 140 girls, mean age 17.48) completed a survey composed of Binge Eating Scale, Motivation for Eating Scale, and Brief Sensation Seeking Scale.

RESULTS

Our results showed that for female adolescents, binge eating was significantly correlated with age, body mass index (BMI), Environmental and Emotional Eating. Hierarchical multiple regression analysis indicated that BMI was a significant positive predictor of binge eating; Emotional and Physical Eating accounted for 34% of the variance. For male adolescents, binge eating was significantly correlated with age, BMI, Boredom susceptibility, Experience seeking, environmental, Social and Emotional Eating. The most significant variables that contribute to binge symptoms, were age and BMI (that accounted for 16% of the variance), Experience seeking and Boredom susceptibility (11%) and emotional eating (18%).

CONCLUSIONS

Our results provided support for emotional motivations as significant triggers for binge eating behavior in both male and female adolescents. Although two sensation seeking dimensions were significant predictors of binge eating in males, sensation seeking was not associated to binge eating in the female subsample.

Investigating the moderating role of emotional awareness in the association between urgency and binge eating

Binge eating has been found to be associated with urgency (the tendency to act impulsively in response to negative affect) and emotional awareness (i.e., attention to emotions, clarity of emotions). The present study tested the hypothesis that the relation between binge eating and urgency would be moderated by emotional awareness, over and above negative affect. Participants were 249 female college students. Items from the Trait Meta Mood Scale (TMMS), the Urgency subscale of the UPPS Impulsive Behavior Scale, and the Bulimia (B) subscale of the Eating Disorders Inventory (EDI-3) were administered. As predicted, emotional awareness moderated the link between urgency and binge eating. Both Urgency×Attention to emotions and Urgency×Clarity of emotions significantly predicted binge eating scores, even after taking into account negative affect. Consistent with past research, higher levels of urgency were associated with higher levels of binge eating, even after taking negative affect into account. However, the associations were particularly strong among individuals with low levels of attention to emotions and low levels of clarity of emotions. The findings from this study have implications for future research examining binge eating.

Integrating fundamental concepts of obesity and eating disorders: implications for the obesity epidemic

Physiological mechanisms promote weight gain after famine. Because eating disorders, obesity, and dieting limit food intake, they are famine-like experiences. The development of the concept of meeting an ideal weight was the beginning of increasing obesity. Weight stigma, the perception of being fat, lack of understanding of normal growth and development, and increased concern about obesity on the part of health providers, parents, and caregivers have reinforced each other to promote dieting. Because weight suppression and disinhibition provoke long-term weight increase, dieting is a major factor producing the obesity epidemic. The integrated eating disorder-obesity theory included in this article emphasizes that, contrary to dieters, lifetime weight maintainers depend on physiological processes to control weight and experience minimal weight change.

Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation

Binge eating has a high prevalence among bariatric patients and is associated with post-surgical weight gain. This study examined the potential mediating role of emotion regulation difficulties in the relation between attachment insecurity and binge eating among this population. Participants were 1388 adult pre-bariatric surgery candidates from an accredited bariatric surgery assessment centre in Toronto, Ontario. Participants completed measures of psychological functioning, including attachment style and emotion regulation. Mediation analyses revealed that difficulties with emotion regulation mediated a positive association between insecure-anxious attachment and binge eating. An insecure-avoidant attachment was found to have a non-significant association with binge eating when examining the total effect. However, when difficulties with emotion regulation were controlled for in the model to examine its role as a mediator, this association became significant, and emotion regulation difficulties also mediated the relationship between attachment avoidance and binge eating. These findings suggest that difficulties in emotion regulation may be an important clinical issue to address in order to reduce binge eating in adult bariatric surgery candidates.

Maintenance of parasympathetic inhibition following emotional induction in patients with restrictive type anorexia nervosa

This study aimed to explore changes in heart rate variability (HRV), a proxy for parasympathetic activity characterizing emotion regulation processes before, during and after negative emotional induction in patients suffering from restrictive type anorexia nervosa (AN-RT). We compared two methods of HRV analysis, the Fast Fourier Transform high frequency (FFT-HF) and a specific HRV high frequency analysis technique, namely, the wavelet transform HRV (WT-HRV). A sample of 16 inpatients with AN-RT was compared to 24 control participants. Heart rate (HR) was continuously recorded for 5 min before the beginning of the video until 5 min after the video. The participants answered questionnaires concerning their eating behaviors, mood disorders and difficulties in emotion regulation. During the entire procedure, the FFT-HF in patients was lower than that in controls. Using the WT-HRV, the patients did not differ from the controls at baseline, and only the controls showed a decrease during emotional induction. After the video, the WT-HRV in patients began to decrease during the first 2 min of emotional recovery although the WT-HRV in controls was already increased. These results highlighted the disturbances in the physiological dynamics of emotion regulation processes in patients with AN-RT.

Hoarding and eating pathology: the mediating role of emotion regulation

Hoarding disorder is characterized by persistent difficulty discarding possessions resulting in clutter that precludes one from using living areas for their intended purposes. The limited empirical work available has suggested a strong link between hoarding and various non-psychiatric conditions, including obesity. Despite these associations, no research has examined the link between hoarding and other forms of eating pathology including symptoms associated with binge eating. Moreover, little is known about mechanisms that may account for this relationship. The current study examined the associations between hoarding severity, obesity, and symptoms associated with binge eating in a sample (N=97) of individuals with elevated hoarding symptoms. Results revealed that hoarding severity was associated with increased body mass index (BMI) and symptoms of binge eating. In addition, difficulties regulating emotions mediated the association between hoarding and eating concerns. Considering the lack of information on hoarding behaviors, as well as its classification as a new diagnosis within DSM-5, these findings add considerably to a growing body of literature on hoarding disorder.

An Update on Evidence-Based Psychosocial Treatments for Eating Disorders in Children and Adolescents

Eating disorders are relatively common and serious disorders in adolescents. However, there are few controlled psychosocial intervention studies with this younger population. This review updates a previous Journal of Clinical Child and Adolescent Psychology review published in 2008. The recommendations in this review were developed after searching the literature including PubMed/Medline and employing the relevant medical subject headings. In addition, the bibliographies of book chapters and treatment guideline articles were reviewed; last, colleagues were asked for suggested additional source materials. Psychosocial treatments examined include family therapy, individual therapy, cognitive behavioral therapy, interpersonal psychotherapy, cognitive training, and dialectical behavior therapy. Using the most recent Journal of Clinical Child and Adolescent Psychology methodological review criteria, family treatment-behavior (FT-B) is the only well-established treatment for adolescents with anorexia nervosa. Family treatment-systemic and insight oriented individual psychotherapy are probably efficacious treatments for adolescents with anorexia nervosa. There are no well-established treatments for adolescents with bulimia nervosa, binge eating disorder, or avoidant restrictive food intake disorder. Possibly efficacious psychosocial treatments for adolescent bulimia nervosa include FT-B and supportive individual therapy. Internet-delivered cognitive behavioral therapy is a possibly efficacious treatment for binge eating disorder. Experimental treatments for adolescent eating disorders include enhanced cognitive behavioral therapy, dialectical behavioral therapy, cognitive training, and interpersonal psychotherapy. FT-B is the only well-established treatment for adolescent eating disorders. Additional research examining treatment for eating disorders in youth is warranted.

Emotional Openness in Overweight and Normal-Weight Adolescents

Obesity is common among adolescents and is associated with a number of medical complications. As maladaptive emotional processing is assumed to influence obesity, this research investigated emotional openness (EO), a general model of emotional processing, in normal-weight versus overweight adolescents, with consideration of gender differences. The goal was to determine whether a particular EO profile is characteristic of overweight adolescents. This research also explored the psychometric characteristics of the Dimensions of Openness to Emotions Questionnaire (DOE-20), a comprehensive multifactorial instrument that assesses emotional processing. The DOE-20 and the Positive and Negative Affect Schedule (PANAS) short form were completed by 160 adolescents (mean age: 14.36 ± 0.61 years), 39 of which were overweight. A multivariate analysis of variance showed no difference with respect to overweight status, but boys had a better ability to recognize and regulate emotions than girls. The original five-factor structure of the DOE-20 was confirmed by confirmatory factor analysis, although internal consistency was modest. Because this research did not replicate the EO profile previously found in obese adults, we discuss the adequacy of the DOE-20 to evaluate EO in adolescents as well as the ability of the construct of EO to assess emotional processing in obesity. Further research should examine the links between EO, problematic eating behaviors, and obesity.

Emotion-focused group therapy for women with symptoms of bulimia nervosa

This study provides outcome pilot data for an outpatient emotion-focused therapy group for 12 women with DSM-IV diagnoses of binge-eating disorder, bulimia nervosa, or eating disorder not otherwise specified. The emotion-focused therapy group involved 16 weekly sessions that targeted problematic emotions connected to eating disorder symptoms. Semi-structured clinical interviews were conducted pre- and post-treatment and self-report questionnaires were administered. From pre- to post-treatment, changes in binge eating and scores on self-report measures were statistically significant. Participants reported a decrease in the frequency of binge episodes, improvements in mood, and improvements in emotion regulation and self-efficacy.

Emotion regulation model in binge eating disorder and obesity--a systematic review

Deficits in emotion regulation processes are a common and widely used explanation for the development and maintenance of binge eating disorder (BED). It is assumed that BED patients - as they have difficulty regulating their negative emotions - use binge eating to cope with these emotions and to find relief. However, the number of experimental studies investigating this assumption is scarce and the differentiation of obese individuals with and without BED regarding the emotion regulation model is not verified. We reviewed literature for experimental studies investigating the emotion regulation model in obese patients (OB) with and without BED. Our search resulted in 18 experimental studies examining the triggering effect of negative emotions for binge eating or its effects on subsequent relief. We found evidence indicating that negative emotion serves as a trigger for binge eating in the BED group unlike the obese group without BED. Considering the small number of studies, we found evidence for a (short-term) improvement of mood through food intake, irrespective of group.

Interpersonal dysfunction and affect-regulation difficulties in disordered eating among men and women

Although several studies suggest that negative affect and interpersonal problems serve as important contributors for eating-related problems, much of this research has been conducted among women and less is known about their roles in precipitating and maintaining eating problems among men. Previous studies with undergraduate men suggest that difficulties in emotion regulation are associated with disordered eating even after controlling for differences in body mass index (BMI) and negative affect. The present study sought to replicate these findings and extend them to assess any unique variance explained by problems in interpersonal functioning among both men and women. Participants were men (n=213) and women (n=521) undergraduates at a large Midwestern university who completed a demographic information form, the Eating Disorder Examination-Questionnaire (EDE-Q), the Difficulties in Emotion Regulation Scale (DERS), the Positive and Negative Affect Schedule, and the Inventory of Interpersonal Problems-Short Circumplex Form (IIP-SC). A series of hierarchical regression analyses indicated that DERS and IIP-SC significantly predicted EDE-Q global scores after controlling for variability in BMI and negative affect and that the results were similar for men and women. Our findings offer preliminary support for models that highlight emotional vulnerability and interpersonal problems for disordered eating for young adult men. Future research extending these findings among treatment-seeking samples and employing multi-method assessment would serve to further clarify the tenability of these theoretical models for both men and women.

Repertoires of emotion regulation: A person-centered approach to assessing emotion regulation strategies and links to psychopathology

Despite growing research on emotion regulation (ER) strategies and psychopathology, research has primarily focused on identifying one-to-one associations between ER strategies and symptoms. Thus, little is known about how patterns in the repertoires of ER strategies are associated with different mental disorders. We utilised latent class analysis to identify distinct repertoires of ER strategies, and their links with various psychopathology domains (i.e., anxiety, depression, disordered eating, borderline personality). Participants (N = 531) reported on their use of seven ER strategies in six recalled stressful contexts, as well as on their symptoms of psychopathology. We identified five classes of ER strategies: Low Regulators (n = 168), High Regulators (n = 140), Adaptive Regulators (n = 99), Worriers/Ruminators (n = 96) and Avoiders (n = 28). Generally, High Regulators and Worriers/Ruminators endorsed greater levels of psychopathology, relative to Low and Adaptive Regulators. Our findings underscore the importance of characterising the dynamics of ER repertoires when seeking to understand links between ER strategies and psychopathology.

A preliminary experimental examination of the effect of emotion dysregulation and impulsivity on risky behaviors among women with sexual assault-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is associated with a wide range of risky behaviors (e.g., substance use and risky sexual behaviors); however, few studies have examined mechanisms that may underlie risky behaviors in this population. The present study utilized a prospective experimental design to examine the effects of emotion dysregulation and impulsivity on risky behaviors across time. Thirty women with sexual assault-related PTSD were randomly assigned to receive emotion modulation (EM), impulsivity reduction (IR), or healthy living (HL; comparison condition) skills trainings. Participants completed measures of emotion dysregulation, impulsivity, and risky behaviors pre-manipulation and 1-month post-manipulation. Participants in the EM and IR conditions reported a significant reduction in risky behaviors from pre- to post-manipulation relative to the HL condition. Changes in emotion dysregulation from pre- to post-manipulation fully accounted for reductions in risky behaviors over time. Results provide preliminary experimental support for the role of emotion dysregulation in risky behaviors.

Expanding and clarifying the role of emotion regulation in nonsuicidal self-injury

OBJECTIVE

Deficits in emotion regulation have been implicated in nonsuicidal self-injury (NSSI) by both theory and research. Research indicates that NSSI is commonly performed as an emotion regulation strategy, as it often decreases the experience of negative affect. People who engage in NSSI often report greater emotion dysregulation than those without an NSSI history. Further, interventions that have demonstrated effectiveness in reducing NSSI involve a focus on emotion regulation skills. Given the important role of emotion regulation in NSSI, research should continue to develop our understanding of this construct.

METHODS

We conducted a review of relevant research in emotion regulation and dysregulation and specific emotion regulation strategies in NSSI.

RESULTS

First, we provide an overview of current research on emotion regulation and dysregulation in NSSI. Second, we discuss the application of a specific emotion regulation model to NSSI research, and review research on NSSI supporting the use of this model.

CONCLUSION

NSSI has been associated with an emotion regulation function and trait emotion dysregulation among people who self-injure. Relevant research provides initial support for the applicability of a specific model of emotion regulation to NSSI. We suggest directions for future research to continue to cultivate our understanding of emotion regulation in NSSI.

Examination of the difficulties in emotion regulation scale and its relation to disordered eating in a young female sample

OBJECTIVE

Difficulties with emotion regulation is considered an important maintaining factor of disordered eating. One of the most commonly used measures of this construct is the Difficulties in Emotion Regulation Scale (DERS). The aim of this study was to explore the factor structure of this measure in young females and to examine its reliability and validity with respect to disordered eating.

METHOD

Females aged 17-25 years (M age = 19.6 years, N = 486) were examined in the analyses. Confirmatory factor analyses were conducted followed by regression analyses examining the DERS subscales as predictors of eating disorder severity and disordered eating behaviors.

RESULTS

The original 6-factor 36-item model did not fit well and analyses indicated a 6-factor 30-item solution was a more suitable fit for our population. Validity and reliability of the 30-item solution were found to be acceptable. Regression analyses also indicated the 36- and 30-item models were able to adequately predict eating disorder severity and disordered eating behaviors with the "Awareness" and "Goals" subscales being predictors of the former, and the "Impulsivity" subscale being a significant predictor of the latter.

DISCUSSION

The overall findings suggest that an abbreviated version of the DERS might be more appropriate than the original version with young females and that this measure exhibits stronger relationships with eating disorder severity and disordered eating behaviors than the longer version. Further examinations of the psychometric properties of the DERS with clinical populations are indicated.

The impact of maternal overweight and emotion regulation on early eating behaviors

Empirical data indicate that the risk for childhood obesity and overweight increases when one or both parents are overweight or obese. Such an association, however, cannot be entirely explained only by biological factors. Based on available literature, we hypothesized that maternal emotion regulation might play a role in explaining the intergenerational transfer of overweight and obesity. We conducted a quasi-experimental, longitudinal study: (step I) during the third trimester of pregnancy of 65 Italian women (33 overweight and 32 non-overweight), the Difficulties in Emotion Regulation Scale were administered to assess the quality of their emotion regulation strategies; and (step II) seven months after the delivery, the feeding interactions between the participants and their babies were evaluated in a 20-minute video-recording, by using the Italian version of the Observational Scale for Mother-Infant Interaction during Feeding. When compared to the non-overweight group, the overweight group had more difficulties in emotion regulation, was more psychologically distressed, and had poorer feeding interactions with their babies. Perhaps more importantly, the extent to which the participants were suffering difficulties in emotion regulation during pregnancy predicted, significantly, and beyond the effects of pre-pregnancy maternal weight, the quality of the mother-child feeding interactions 7months after the delivery.

Mediterranean diet and emotion regulation

BACKGROUND

Mediterranean dietary patterns have been associated with cardiovascular and psychological health, including positive affect. Emotion regulation has not been linked to this pattern.

OBJECTIVE

The present study prospectively examined the relationship between Mediterranean diet and later emotion regulation and whether positive or negative affect mediated any such relationship.

METHODS

Data was derived from the Adventist Health Study-2 (2002-6), and Biopsychosocial Religion and Health Substudy (2006-7; 2010-11). We assessed adherence to Mediterranean diet using the Trichopoulou score at baseline, and responses to Positive and Negative Affect Schedule (2006-7) and Difficulties in Emotion Regulation Scale (2010-11) in 1,699 men and 3,293 women. Statistical analyses were performed using multiple linear regression and Hayes PROCESS SPSS macros.

RESULTS

Mediterranean dietary adherence scores were inversely related to difficulty with clarity of emotional responses (B =-0.013, p = 0.006, 95% CI [-0.23, -0.004]) but unrelated to difficulty with awareness of emotional responses or lack of access to strategies for regulating emotions. Positive and negative affect fully mediated the diet and clarity relationship by respectively decreasing and increasing difficulty with clarity (effect scores -0.007 [95% CI -0.009, -0.005] and -0.005 [95% CI -0.008, -0.003]).

CONCLUSIONS

Mediterranean diet adherence showed association with emotional clarity via increasing positive and decreasing negative affect.

Can the impact of body dissatisfaction on disordered eating be weakened by one's decentering abilities?

Decentering has been defined as the ability to deal with thoughts and emotions as subjective and ephemeral inner events. Since it implies a non-judging and present focused attitude towards thoughts and emotions, decentering has been considered as an important protective process against psychopathology, as it has been empirically shown to decrease depressive relapse rates. Nevertheless, its role in eating disordered attitudes and behaviours has not been fully uncovered. Therefore, the aim of the present study is to explore the moderator effect of decentering on the relationship between eating psychopathology and one of its main risk factors, body image dissatisfaction. The sample comprised 279 female students, aged between 14 and 21 years-old. Results revealed that decentering abilities were negatively linked to body image dissatisfaction and to the global score of eating psychopathology. Through a path analysis, the buffer effect of decentering was confirmed. The findings suggest that the ability to take a non-judgmental and accepting stance towards internal experiences diminishes the impact of one's body dissatisfaction on disordered eating attitudes and behaviours. This study seems especially pertinent since it uncovers a mechanism to lessen the pervasive impact of body image dissatisfaction, which is highly prevalent in women from Western societies.

Emotionsregulation: Überblick und kritische Reflexion des aktuellen Forschungsstandes

Die Forschung zum Thema Emotionsregulation erfreut sich auch im Bereich der Klinischen Psychologie einer zunehmenden Beliebtheit. Allerdings stellt sich die Frage, inwieweit die Popularität des Konstrukts im Einklang mit dessen Validität und tatsächlicher heuristischer Fruchtbarkeit steht. Vor diesem Hintergrund ist es Ziel der vorliegenden Arbeit, einen aktuellen Überblick über Konzeptualisierungen, Erfassungsmethoden, Befunde zum Zusammenhang mit psychischen Störungen sowie Möglichkeiten der therapeutischen Nutzung des Konzeptes Emotionsregulation zu geben. Aufbauend auf einer kritischen Reflexion bisheriger Konzepte, Vorgehensweisen und Befunde werden Vorschläge gemacht, wie die Validität und die heuristische Fruchtbarkeit des Emotionsregulationsparadigmas weiter gefördert werden können.

Exploring health-related quality of life in eating disorders by a cross-sectional study and a comprehensive review

BACKGROUND

People with eating disorders (ED) often report poor health-related quality of life (HRQoL), which is explicitly correlated to illness' severity and its effects on cognitive performance. We aimed to analyze health-related quality of life (HRQoL) in subgroups of eating disorder (ED) patients by using the brief version of WHOQoL questionnaire (WHOQoL-BREF) before treatment administration. Moreover, in order to compare our findings with other published data, we carried out a comprehensive review of the literature on HRQoL in ED patients.

METHODS

Our review was carried out by means of an accurate data mining of PsychInfo and Medline databases and other available sources. In our cross-sectional study, eighty female ED patients (26 with bulimia nervosa, 33 with anorexia nervosa, 7 with binge eating disorder and 14 with ED not otherwise specified) completed the WHOQoL-BREF. HRQoL scores were compared among ED subgroups and clinical information (presence of previous contacts, length of illness, psychiatric comorbidity) was considered in the analysis.

RESULTS

Our review shows that with few exceptions ED patients have a poorer HRQoL than the healthy population of control and sometimes the mental component of HRQoL is the most involved dimension. Moreover, there are no differences in the HRQoL among ED groups, even if AN patients in some studies have a lower HRQoL scores. Furthermore, BED patients have a poorer HRQoL than obese patients who do not have binge episodes. Finally, all treatments were positively correlated with an improvement on general and specific QoL dimensions. In our sample, ED subgroups differed only for Psychological Health HRQoL scores (F = 4.072, df = 3; p = 0.01). No differences were found between inpatients and outpatients, treatment naïve and previously treated patients and patients with or without psychiatric comorbidity. Moreover, HRQoL scores were not correlated to length of illness within each ED subgroup.

CONCLUSIONS

The analysis of the literature adds some relevant information on HRQoL in ED and may address the future research toward the exploration of specific questions. One of these may be the prominent role of Psychological Health domain in HRQoL, since our study confirms that this component is able to differentiate eating disorders.

Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial

Difficulties with emotions are common across mood and anxiety disorders. Dialectical behavior therapy skills training (DBT-ST) reduces emotion dysregulation in borderline personality disorder (BPD). Preliminary evidence suggests that use of DBT skills mediates changes seen in BPD treatments. Therefore, we assessed DBT-ST as a stand-alone, transdiagnostic treatment for emotion dysregulation and DBT skills use as a mediator of outcome. Forty-four anxious and/or depressed, non-BPD adults with high emotion dysregulation were randomized to 16 weeks of either DBT-ST or an activities-based support group (ASG). Participants completed measures of emotion dysregulation, DBT skills use, and psychopathology every 2 months through 2 months posttreatment. Longitudinal analyses indicated that DBT-ST was superior to ASG in decreasing emotion dysregulation (d = 1.86), increasing skills use (d = 1.02), and decreasing anxiety (d = 1.37) but not depression (d = 0.73). Skills use mediated these differential changes. Participants found DBT-ST acceptable. Thirty-two percent of DBT-ST and 59% of ASG participants dropped treatment. Fifty-nine percent of DBT-ST and 50% of ASG participants complied with the research protocol of avoiding ancillary psychotherapy and/or medication changes. In summary, DBT-ST is a promising treatment for emotion dysregulation for depressed and anxious transdiagnostic adults, although more assessment of feasibility is needed.

A Preliminary Examination of the Role of Emotion Differentiation in the Relationship between Borderline Personality and Urges for Maladaptive Behaviors

BACKGROUND AND OBJECTIVES

Impulsive, maladaptive, and potentially self-damaging behaviors are a hallmark feature of borderline personality (BP) pathology. Difficulties with emotion regulation have been implicated in both BP pathology and maladaptive behaviors. One facet of emotion regulation that may be particularly important in the relation between BP pathology and urges for maladaptive behaviors is emotion differentiation.

METHODS

Over one day, 84 participants high (n = 34) and low (n = 50) in BP pathology responded to questions regarding state emotions and urges to engage in maladaptive behaviors using handheld computers, in addition to a measure of emotion-related difficulties controlling impulsive behaviors.

RESULTS

Results revealed that individuals high in BP pathology reported greater emotion-related impulsivity as well as daily urges to engage in maladaptive behaviors. However, the association between BP group and both baseline emotion-related impulsivity and daily urges for maladaptive behaviors was strongest among individuals who had low levels of positive emotion differentiation. Conversely, negative emotion differentiation did not significantly moderate the relationships between BP group and either emotion-related difficulties controlling impulsive behaviors or state urges for maladaptive behaviors.

LIMITATIONS

Limitations to the present study include the reliance upon an analogue sample and the relatively brief monitoring period.

CONCLUSIONS

Despite limitations, these results suggest that, among individuals with high BP pathology, the ability to differentiate between positive emotions may be a particularly important target in the reduction of maladaptive behaviors.

Development and validation of the eating loss of control scale

Recurrent objective bulimic episodes (OBE) are a defining diagnostic characteristic of binge eating disorder (BED) and bulimia nervosa (BN). OBEs are characterized by experiencing loss of control (LOC) while eating an unusually large quantity of food. Despite nosological importance and complex heterogeneity across patients, measurement of LOC has been assessed dichotomously (present/absent). This study describes the development and initial validation of the Eating Loss of Control Scale (ELOCS), a self-report questionnaire that examines the complexity of the LOC construct. Participants were 168 obese treatment-seeking individuals with BED who completed the Eating Disorder Examination interview and self-report measures. Participants rated their LOC-related feelings or behaviors on continuous Likert-type scales and reported the number of LOC episodes in the past 28 days. Principal component analysis identified a single-factor, 18-item scale, which demonstrated good internal reliability (α = .90). Frequency of LOC episodes was significantly correlated with frequency of OBEs and subjective bulimic episodes. The ELOCS demonstrated good convergent validity and was significantly correlated with greater eating pathology, greater emotion dysregulation, greater depression, and lower self-control but not with body mass index. The findings suggest that the ELOCS is a valid self-report questionnaire that may provide important clinical information regarding experiences of LOC in obese persons with BED. Future research should examine the ELOCS in other eating disorders and nonclinical samples.

Food for love: the role of food offering in empathic emotion regulation

The present article examines the interpersonal and intrapersonal antecedents and consequences of food offering. Food offering is one of the earliest biobehavioral regulatory interactions between parent and child. It ensures survival of the child who is fully dependent on food provision by others. The quality of these early interactions influences how people respond to situations later in life, and food offering in particular may be closely related to emotion regulation throughout the lifespan. While research has examined other forms of emotion regulation, and food consumption has been studied from an intrapersonal perspective, we know little about the interpersonal effects of food offering. After reviewing literature from a wide range of disciplines, we propose that one mechanism underlying these effects is empathic emotion regulation (EER). We conceptualize EER as an interpersonal regulation system in which an empathic response to another person’s emotional state aims to regulate both emotion within the provider and across interaction partners. We suggest that the offer of food by an empathic provider is motivated by the emotional state of one’s interaction partner (recipient). By offering food, the provider not only aims to attenuate the recipient’s negative affect but also her own. Food offering thereby becomes a means to increase positive affect for both recipient and – when the offer has the desired effect – provider. We further propose that the sharing of food resources as well as the use of food as a support behavior increases interpersonal closeness. Finally, we frame the process of food offering within a developmental perspective. If the regulatory success of food offering becomes a replacement for other support behaviors, children will learn from an early age to use food as a primary means to soothe self and others, possibly resulting in eating disorders and a restricted range of coping behavior.

Differences in features of non-suicidal self-injury according to borderline personality disorder screening status

Given that non-suicidal self-injury (NSSI) disorder is being considered for the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is important to consider how NSSI occurs with and without borderline personality disorder (BPD). Participants were 480 undergraduates who completed online questionnaires and were assigned to 4 groups based on NSSI and BPD status. Analyses revealed BPD-positive self-injurers had higher self-punishment, anti-suicide, and anti-dissociation functions of NSSI and higher rates of cutting and burning than BPD-negative self-injurers. Furthermore, difficulty in emotion regulation, not distress tolerance, was most critical in distinguishing between groups. Differences between BPD-positive and BPD-negative self-injurers provide preliminary support for NSSI as a distinct disorder. However, more research in this area is needed.

Pilotstudie zur Effektivität eines Emotionsregulationstrainings bei Frauen mit Binge-Eating-Störung

Negative Emotionen sind ein häufiger Auslöser von Essanfällen bei Personen mit Binge-Eating-Störung (BES). Erste Untersuchungen haben gezeigt, dass Defizite in der Emotionsregulation (ER) den Zusammenhang von negativen Emotionen und Essanfällen mediieren. Vor diesem Hintergrund erhielten im Rahmen einer Pilotstudie 14 Frauen mit BES ein ER-Training in der Gruppe. Indikatoren für die Effektivität des Trainings waren Anzahl der Episoden und Tage mit objektiven Essanfällen, Körperunzufriedenheit, sowie Depressivität vor Studienbeginn (T0), nach 8 Wochen Wartezeit (T1) und nach dem 8-wöchigen ER-Training (T2). Während es keine Veränderungen von T0 zu T1 gab, zeigte sich eine signifikante Reduktion der Symptomatik in allen erhobenen Variablen von T1 zu T2. Die Ergebnisse der Pilotstudie unterstützen die Relevanz der ER bezüglich der Reduktion von Essanfällen und damit die Notwendigkeit gut implementierter Therapiestudien, die die Effektivität von ER-Trainings in der Veränderung der Psychopathologie der BES untersuchen. Zudem sind weitere Studien, die die Rolle der ER bei der Aufrechterhaltung der BES klären, notwendig.

Emotionally focused group therapy and dietary counseling in binge eating disorder. Effect on eating disorder psychopathology and quality of life

OBJECTIVE

To test the effect on psychopathology and quality of life of Emotionally Focused Therapy (EFT), Dietary Counseling (DC), and Combined Treatment (CT) in treatment-seeking patients with Binge Eating Disorder (BED) and obesity.

METHODS

Utilizing an observational study design, 189 obese adult patients with BED were treated by manualized therapy protocols. An independent assessment of health-related quality of life (Obesity-Related Well-Being questionnaire - ORWELL-97), attitudes toward eating (Eating Inventory - EI), binge eating (Binge Eating Scale - BES) and body uneasiness (Body Uneasiness Test - BUT) was performed at baseline, end-of-treatment, and six-month follow-up. These data are the secondary outcomes of a previously published treatment study.

RESULTS

A higher dropout rate was observed in the DC compared to the EFT and CT groups, while body weight decreased significantly in all three groups. Pre-post scores on the BES, BUT Global Severity Index, and EI Hunger subscale significantly decreased in the CT and EFT groups (but not the DC group). At six-month follow-up, 71% of participants in CT and 46% of participants in EFT had a BES score below the threshold of attention for BED (≤16), whereas no participants in the DC group reached this target. Finally the ORWELL-97 score decreased significantly in all groups, but significantly more so in the CT and EFT groups.

CONCLUSION

Results support the utility of combining EFT and DC in the treatment of patients with BED and obesity, emphasizing the usefulness of techniques focused on cognitive emotional processing for changing eating disorder psychopathology and quality of life.

Eating pathology, emotion regulation, and emotional overeating in obese adults with Binge Eating Disorder

OBJECTIVE

The purpose of the current study was to examine the relationship among emotional regulation, emotional overeating, and general eating pathology in a treatment seeking sample of adults with Binge Eating Disorder (BED).

METHOD

The sample was composed of 326 adults (248 women, 78 men) who were obese and met DSM-IV-TR criteria for BED. Prior to treatment, participants completed the Difficulties in Emotion Regulation Scale (DERS), Emotional Overeating Questionnaire (EOQ), Beck Depression Inventory (BDI), and Eating Disorder Examination-Questionnaire (EDE-Q) as part of a larger assessment battery.

RESULTS

A series of hierarchical regression analyses indicated that difficulties with emotion regulation accounted for unique variance in both emotional overeating and general eating pathology above and beyond sex and negative affect.

DISCUSSION

Emotion regulation may play a significant role in the maintenance of emotional overeating and eating pathology in obese adults with BED.

Influence of negative affect on choice behavior in individuals with binge eating pathology

Research suggests that individuals with binge eating pathology (e.g., bulimia nervosa (BN) and binge eating disorders (BED)) have decision making impairments and particularly act impulsively in response to negative affect. The aim of this study was to examine the influence of negative affect on choice behavior in women with BN and BED. Ninety women (59 with BN or BED and 31 healthy controls) watched a sad or control film fragment and were subsequently asked to complete a choice behavior task (as measured by a variation of the Bechara Gambling Task (BGT)). Results showed that negative affect influenced choice behavior differently in healthy controls and in women with BN and BED after punishment (but not after reward). In the context of increased negative affect, punishment was associated with more disadvantageous choice behavior in both BN and BED women but not in healthy controls, while the effect was the exact opposite in both groups after a decrease in negative affect. Levels of sadness were not found to influence choice behavior after reward in either groups. These findings suggest that emotional states may have a direct impact on choice behavior of individuals with binge eating pathology and are not only related to pathological behavior itself.

Evaluating the indirect effect of self-compassion on binge eating severity through cognitive-affective self-regulatory pathways

Current theory and evidence point to disruptions in self-concept and difficulties with emotion regulation as contributing to the severity of binge eating. Alternatively, contemporary perspectives on self-compassion suggest that individual differences in this adaptive approach to self-regulation may serve to counteract these cognitive-affective triggers presumably resulting in reductions in binge eating severity. Accordingly, the present cross-sectional analysis examined an indirect effect model of positive dimensions of self-compassion on binge eating severity through both emotional tolerance and unconditional self-acceptance pathways. Two hundred fifteen undergraduate students (78% female) completed self-report measures of the variables of interest; BMI was calculated from self-reported heights and weights. Pearson's correlations revealed a positive linear association between self-compassion and unconditional self-acceptance; negative links were observed between self-compassion and emotional intolerance along with the severity of binge eating symptoms. A subsequent multiple mediator analysis utilizing both normal test theory and robust non-parametric bootstrap resampling procedures confirmed the presence of a significant total indirect effect of self-compassion on binge eating severity (-.15, p<0.001) through the combined mediators along with yielding specific indirect effects for both emotional tolerance (-.05, p<0.05) and unconditional self-acceptance (-.11, p<0.01) which were preserved in a model adjusted for BMI. Preliminary results underscore the need to further evaluate the tenability of this model in both prospective cohort and intervention-based research. Findings additionally invite considering the value of integrating self-compassion training into college health promotion efforts towards mitigating the appreciable levels of binge eating behavior prevalent in this at-risk population.

The clinical obesity maintenance model: an integration of psychological constructs including mood, emotional regulation, disordered overeating, habitual cluster behaviours, health literacy and cognitive function

Psychological distress and deficits in executive functioning are likely to be important barriers to effective weight loss maintenance. The purpose of this paper is twofold. First, in the light of recent evidence in the fields of neuropsychology and obesity, particularly on the deficits in the executive function in overweight and obese individuals, a conceptual and theoretical framework of obesity maintenance is introduced by way of a clinical obesity maintenance model (COMM). It is argued that psychological variables, that of habitual cluster Behaviors, emotional dysregulation, mood, and health literacy, interact with executive functioning and impact on the overeating/binge eating behaviors of obese individuals. Second, cognizant of this model, it is argued that the focus of obesity management should be extended to include a broader range of maintaining mechanisms, including but not limited to cognitive deficits. Finally, a discussion on potential future directions in research and practice using the COMM is provided.

A Condensed Dialectical Behavior Therapy Skills Group for Binge Eating Disorder: Overcoming Winter Challenges

Although binge eating disorder (BED) is a recent diagnostic category, research for efficacious and effective treatment is well underway. This case study describes a dialectical behavior therapy (DBT) skills group for BED implemented in an outpatient community clinic. Although based on Safer, Telch, and Chen’s (2009) manual for BED and bulimia nervosa (BN), notable adaptations included shortening the group’s duration from 20 to 12 weeks, adding an interpersonal effectiveness module and DBT-informed “Holiday Plan” worksheets, and providing inclement weather alternatives. Despite the added challenges associated with winter treatment of BED (e.g., holiday meals, weather-related schedule interruptions), the 3 women who completed treatment no longer met criteria for BED at termination and their feedback suggested that the treatment was highly acceptable. Group members demonstrated clinically significant reductions in disordered eating behavior and improvements in self-esteem, emotion regulation, and quality of life. Treatment gains were maintained at 1-year follow-up. Our discussion includes treatment implications and recommendations for future research.

Trajectories of eating and clinical symptoms over the course of a day hospital program for eating disorders

Although it is well-established that day hospital programs for eating disorders significantly reduce clinical symptoms, the pre-test/post-test designs that were previously used do not provide information regarding the trajectory of symptoms during treatment. This study observed, on a weekly basis, the evolution of symptoms of 61 women suffering from eating disorders engaged in a day hospital program, and compared the trajectories of specific subgroups of patients. Results show that (a) the first half of the program was crucial for symptom changes; (b) although completers and non-completers presented similar initial improvement, their trajectories rapidly differentiated; and (c) poorer respondents initially reported more symptoms, showed a slower improvement, and never reached the non-clinical zone, whereas better-respondents reached the non-clinical cut-off point more rapidly.