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

Emotional Dysregulation in Anorexia Nervosa: Scoping Review of Psychological Treatments

Eating disorders are complex psychiatric disorders characterized by compensatory and restrictive behavior and a preoccupation with one's body. Eating and purging behaviors are considered dysfunctional emotional regulation strategies. Therefore, psychological treatment is essential. The most common psychological interventions are dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), family therapy (FBT), multi-family group therapy (MFTG) and mentalization-based treatment (MBT). The aim of this study was to summarize the current evidence on the impact of psychological treatments on emotional regulation difficulties and psychological symptoms in patients with eating disorders, especially anorexia nervosa. A search was conducted on PubMed and Web of Science using the terms "anorexia nervosa" and "emotion dysregulation". Of the 278 initial articles, we included 15 publications. The results indicate that the acquisition of coping strategies, through DBT, leads to an improvement in anxiety and alexithymia. DBT, CBT and MBT lead to a reduction in the use of dysfunctional emotional regulation strategies too. Eating disorders involve both physical and mental health; therefore, it is desirable for future research to focus on the mutual synergy between the mental and physical components by evaluating various factors, such as biomarkers and the most appropriate therapeutic approach, with respect to the treatment setting.

Risk and resilience in eating disorders: differentiating pathways among psychosocial predictors

OBJECTIVE

Eating disorders (EDs) represent a rising global health concern. The current study takes a multivariate approach to examine psychological (i.e., perfectionism, anxiety sensitivity [AS], emotion dysregulation) and sociocultural factors (i.e., body dissatisfaction) that may relate to risk and resilience in EDs.

METHODS

Participants were 698 undergraduate students (Mage = 21, SDage = 4.02), mainly female (71%) and Hispanic (61.6%), who participated in an online survey assessing perfectionism, emotion dysregulation, AS, body dissatisfaction, and eating behaviors.

RESULTS

The results from structural equation model analyses revealed differential associations with disordered eating (DE) outcomes. Self-oriented perfectionism and dysmorphic appearance concerns were associated with increased dieting/carb restriction, desire for thinness, and binging tendencies. Specifically, emotional nonacceptance and lack of emotional awareness showed associations with elevated risk for dieting/carb restriction and purging tendencies, respectively. Conversely, lack of emotional clarity showed a protective pathway to these risk behaviors. Anxiety sensitivity cognitive concerns related to higher purging tendencies, while AS social concerns related to lower purging and binging tendencies.

DISCUSSION

Findings highlight the differential pathways of psychosocial risk and resilience for EDs. Subscales of emotional dysregulation and AS showed risk as well as resilience associations with DE outcomes. This information is key for advancing transdiagnostic prevention and intervention to reduce the rising rates of EDs.

Perceptual Dysfunction in Eating Disorders

Eating disorders (EDs) are characterized by abnormal responses to food and weight-related stimuli and are associated with significant distress, impairment, and poor outcomes. Because many of the cardinal symptoms of EDs involve disturbances in perception of one's body or abnormal affective or cognitive reactions to food intake and how that affects one's size, there has been longstanding interest in characterizing alterations in sensory perception among differing ED diagnostic groups. Within the current review, we aimed to critically assess the existing research on exteroceptive and interoceptive perception and how sensory perception may influence ED behavior. Overall, existing research is most consistent regarding alterations in taste, visual, tactile, and gastric-specific interoceptive processing in EDs, with emerging work indicating elevated respiratory and cardiovascular sensitivity. However, this work is far from conclusive, with most studies unable to speak to the precise etiology of observed perceptual differences in these domains and disentangle these effects from affective and cognitive processes observed within EDs. Further, existing knowledge regarding perceptual disturbances in EDs is limited by heterogeneity in methodology, lack of multimodal assessment protocols, and inconsistent attention to different ED diagnoses. We propose several new avenues for improving neurobiology-informed research on sensory processing to generate actionable knowledge that can inform the development of innovative interventions for these serious disorders.

Tension and disordered eating behaviors in the daily lives of adolescents and young adults from the general population: Associations and moderating role of trait emotion regulation

Experiences of tension and difficulties in emotion regulation have been linked to eating pathology in clinical samples and are targeted in respective treatment approaches. The present study aimed to investigate the impact of tension on engagement in disordered eating behaviors (DEBs) and potential moderating effects of trait emotion regulation in young people from the general population. A subsample of 971 adolescents and young adults from an epidemiological cohort study reported on levels of tension and four different DEBs (skipping eating, restrained eating, eating large amounts of food, loss-of-control-eating) via ecological momentary assessment (EMA), as well as on trait emotion regulation via questionnaire. In multilevel models, momentary tension did not predict levels of subsequent DEBs. However, higher average levels of tension across the EMA period predicted higher levels of all DEBs. No interactions with emotion regulation emerged. Individuals experiencing overall higher levels of tension appear to be more prone to engaging in DEBs.

[Sports and Physical Exercise Therapy in the Treatment of Mental Health Issues in Children and Adolescents]

Sports and Physical Exercise Therapy in the Treatment of Mental Health Issues in Children and Adolescents Abstract: Mental disorders are among the most common chronic diseases in childhood and adolescence in Germany and worldwide. The health benefits of a physically active lifestyle during adolescence are well documented. Furthermore, a growing body of evidence suggests a positive impact of physical activity on mental health and emotional well-being. Longitudinal studies also show an association between physical activity and reduced risk of developing a mental disorder. Therefore, therapeutic exercise plays an important role in child and adolescent psychiatry. High-quality randomized-controlled trials are needed to substantiate the described effects.

The role of mindfulness on the psychological aspects of anorexia nervosa

OBJECTIVE

Emotion regulation, perfectionism, and rumination are perpetuating factors in anorexia nervosa (AN). Mindfulness can be protective and therapeutic. We aimed to understand the relationship between these factors and mindfulness in AN.

METHODS

20 adolescent girls in the acute phase of the AN, 16 in remission, and 40 in the control group were evaluated.

RESULTS

Mindfulness was lowest in the acute AN group. The difference in the acute AN group regarding body dissatisfaction, emotion dysregulation, perfectionism, and mindfulness disappeared after controlling for the effects of depression and anxiety. The predictors of disordered eating in the entire study population were body dissatisfaction and depressive symptoms. Emotion regulation and perfectionism were the predictors of mindfulness in the acute AN group and the entire study population. When mindfulness decreased, concerns about body shape increased in both acute AN and remission groups, while dietary restriction and disordered eating behaviors increased only in the remission group.

DISCUSSION

Emotion regulation difficulties in acute AN could be related to depression and anxiety. Mindfulness interventions for emotion regulation could be used for depression during the acute phase while for perfectionism in remission. Early intervention for depression and body dissatisfaction seems protective, and mindfulness could be an appropriate intervention.

Premature termination of inpatient eating disorder treatment: Does timing matter?

BACKGROUND

Premature termination of treatment is a serious problem in the treatment of eating disorders. Prior research attempting to differentiate patients who are able to complete treatment from those who terminate early has yielded mixed results. One proposed explanation for this is a failure to examine the time course of treatment termination. This study was designed to explore associations between baseline patient characteristics and timing of treatment termination.

METHODS

Participants were 124 eating disorder patients admitted voluntarily to the inpatient program at Toronto General Hospital between 2009 and 2015. At admission, all patients completed measures of eating disorder symptoms, eating disorder cognitions, depressive symptoms and emotional dysregulation. Body weight was measured weekly. Data analyses were completed using one-way ANOVAs and Chi Square tests.

RESULTS

Results showed significant associations between timing of treatment termination and eating disorder diagnosis, severity of eating disorder cognitions and severity of depressive symptoms. Post-hoc analyses revealed that patients who left treatment early had more severe depressive symptoms, eating disorder cognitions related to eating and difficulties engaging in goal directed behaviors when emotionally dysregulated.

CONCLUSIONS

Patients who terminated inpatient treatment early in their admissions differ from patients who terminated later and those who completed treatment. These differences have potential clinical implications for the clinical management of patients with severe eating disorders requiring inpatient admission. Trial registration This paper is not associated with a clinical trial.

Relation between increasing attachment security and weight gain: a clinical study of adolescents and their parents at an outpatient ward

PURPOSE

We wanted to evaluate the impact of a relational focus in the treatment of adolescent ED-patients and their parents at an intensive outpatient ward, based on attachment theory, combined with a family approach and psychodynamic principles. Our aim was to investigate the distribution of different attachment styles among the adolescent ED-patients and their parents, and to find out if they could change by the treatment.

METHODS

Swedish adolescents (n = 33; 3 boys, 30 girls) and their parents (n = 60; 34 mothers, 26 fathers) participated.

MEASURES

Attachment Style Questionnaire (ASQ), Body Mass Index (BMI) and Children's Global Assessment Scale (CGAS) before and after treatment.

RESULTS

The adolescents were high on Need for Approval (ASQ4) of the Insecure/Anxious scale before treatment (in contrast to the parents). The patients had a significant decrease in ASQ4 after treatment, which correlated inversely to the increase in BMI but not to CGAS. The mothers showed features of the Secure/Confident style, fathers of the Insecure/Avoidant with elevated Relationships as Secondary (ASQ2).

CONCLUSIONS

Treatment with a relational and a family focus has impact on attachment insecurity in adolescent ED-patients and outcomes in terms of BMI. It is important to engage the parents, who need to help the adolescents to separate at that developmental stage. A secure therapeutic context, which enables mentalizations and allows new relational experiences, is essential. The ASQ-instrument is useful in indicating how the treatment of ED-adolescents is proceeding.

LEVEL OF EVIDENCE

Level IV: evidence obtained from multiple time series with the intervention.

A prospective study on body image disturbances during pregnancy and postpartum: the role of cognitive reappraisal

Background

During pregnancy, body size rapidly modifies over a relatively short period. Literature emphasizes the need to identify the factors that influence body image during peripartum as the extent of women's adaptation to these changes has significant repercussions on both mother's and newborn's health. Emotion regulation strategies (i.e., expressive suppression and cognitive reappraisal) were linked to body image in the general and clinical population, but no studies were conducted in the peripartum. The present study aims to investigate the longitudinal impact of prepartum body image disturbances on postpartum body image disturbances and to evaluate the mediational role of emotional regulation strategies.

Methods

A total of 133 pregnant women completed a three-phase longitudinal study. Women answered online questionnaires during the second (T1) and the third (T2) trimesters of pregnancy, and at about 6 months postpartum (T3).

Results

Findings indicated that body image disturbances at T1 were a significant predictor of body image disturbances in the postpartum (1 year after the first assessment). Moreover, cognitive reappraisal measured at T2 partially mediated this relationship: body image disturbances in the second trimester of pregnancy were linked to less use of cognitive reappraisal in the third trimester of pregnancy, and this, in turn, was associated with worse body image disturbances at 6 months after birth.

Conclusion

Findings of this longitudinal study highlight the importance of assessing body image disturbances during pregnancy to early identify women at risk, and suggest cognitive reappraisal as a possible target intervention.

Temporal associations between experiential avoidance and disordered eating behaviors in adolescents and young adults: findings from an epidemiological cohort study with ecological momentary assessment

PURPOSE

Previous studies linking experiential avoidance (EA) and eating pathology have largely relied on single measurements based on traditional retrospective questionnaires. Taking advantage of available repeated assessments of EA and disordered eating behaviors (DEBs) in the everyday lives of young people from an epidemiological cohort, we aimed to investigate ecologically valid temporal associations between these constructs.

METHODS

A random population sample of N = 1180 14-21-year-olds from Dresden, Germany, participated at baseline (2015/2016). As part of smartphone-based ecological momentary assessment (EMA), participants reported on engagement in EA and four DEBs (skipping eating, eating large amounts of food, loss-of-control eating, and restrained eating) up to eight times per day for four days. Multilevel modeling of concurrent and time-lagged associations between EA and DEBs, was conducted among those with at least 50% EMA-compliance (n = 1069).

RESULTS

EA was associated with higher concurrent levels of all four types of concurrent DEBs. In addition, EA significantly predicted subsequent levels of restrained eating. Only loss-of-control eating significantly predicted subsequent EA, and this effect depended on the timespan between consecutive assessments. When this timespan was short, higher Loss-of-control eating predicted lower subsequent EA, while it predicted higher subsequent EA when the timespan was longer.

CONCLUSION

The present findings suggest that EA is temporally closely linked to greater engagement in DEBs, supporting theoretical assumptions that DEBs may serve an attempted avoidance function in the context of unpleasant inner experiences. Future studies may benefit from examining samples with more pronounced eating pathology.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Predictors of current suicidal ideation in a multi-diagnostic sample of individuals with eating disorders

BACKGROUND

Individuals with eating disorders (EDs) have high rates of suicidal ideation (SI) and attempts (SA). Fasting, body dissatisfaction, binge eating and purging have been associated with SI in non-clinical samples, individuals with anorexia nervosa or low-weight EDs, and a multi-diagnostic sample. However, few studies have examined how ED symptoms contribute to risk for SI in conjunction with other well-established risk factors, such as nonsuicidal self-injury (NSSI) and past SA. The aim of this study was to examine which ED symptoms contribute unique risk for current SI in a multi-diagnostic, clinical sample when statistically adjusting for gender, NSSI, past SA, and past SI.

METHODS

We conducted a chart review of 166 individuals who presented for ED treatment at an outpatient facility and signed informed consent. Initial intake interviews were coded for the presence versus absence of fasting, fear of weight gain, binge eating, purging, excessive exercise, restriction, body checking, self-weighing, and body dissatisfaction, as well as NSSI, past SA, past SI, and current SI.

RESULTS

A total of 26.5% of the sample endorsed current SI. In a logistic regression analysis, identifying as male (n = 17) or having a non-binary gender identity (n = 1), the presence of fasting, and past SI were all significantly associated with increased odds of current SI, whereas excessive exercise significantly decreased odds of current SI. Fasting was equally common across all diagnostic groups.

CONCLUSIONS

Future research should establish the temporal relationship between fasting and SI to better inform intervention.

Learned industriousness as a translational mechanism in anorexia nervosa

It remains unexplained why some behaviours persist despite being non-hedonic and ostensibly aversive. This phenomenon is especially baffling when such behaviours are taken to excess in the form of psychopathology. Anorexia nervosa is one psychiatric disorder in which effortful behaviours that most people find unpleasant (suchas restrictive eating) are persistently performed. We propose thatthe social psychology theory of learned industriousness providesa novel mechanistic account for such phenomena. This theoryposits that high-effort behaviour can be conditioned to acquire secondary reinforcing properties through repeated pairing with reward. Accordingly, effort sensations become less aversive andmore appetitive, increasing willingness to engage in effortful behaviour. In this Perspective, we review pre-clinical behaviouraland biological data that support learned industriousness, contrast learned industriousness with other models of non-hedonic persistence (such as habit learning), highlight evidence that supports learned industriousness in individuals with anorexia nervosa and consider implications of the model, including translation to other psychiatric presentations.

Executive dysfunction in eating disorders: Relationship with clinical features

Eating disorders (ED) are severe mental disorders that may result in significant functional impairment and disability. Neuropsychological studies have consistently found impaired executive function (EF) among ED patients. EF is particularly involved in fundamental skills of daily living and in behavioral and emotional regulation. In this study, impairment of executive functioning is investigated in patients with eating disorders and the associations with clinical features and clinical subtypes are analyzed.

METHOD

75 female patients (m = 22.01 years, sd = 9.15) with eating disorder (43 restrictive anorexia, 30 binge-eating anorexia and 13 bulimia nervosa) and 37 healthy controls (m = 18.54 years, sd = 4.21) were included in the study. An extensive assessment of executive function domains (verbal fluency, set shifting, attention span, selective attention, working memory, inhibitory control and processing speed) was carried out in both groups. Clinical scales for food intake restriction, binge-eating/purging, depression, anxiety and impulsivity were also administered and correlated with scores on executive function tests.

RESULTS

Patients with an ED had significantly lower scores than healthy controls in performance of several executive function tests, particularly in set shifting, interference control and processing speed (p < .01, in all three domains). Executive function impairment was related to anxious, depressive and eating disorder symptoms (p < .05), regardless of clinical subtype.

CONCLUSIONS

Executive function impairment in eating disorders is associated with greater ED symptomatic severity and might involve a negative treatment outcome. Therefore, cognitive remediation techniques should probably be considered in a number of severe patients with ED.

Risk and protective factors for new-onset binge eating, low weight, and self-harm symptoms in >35,000 individuals in the UK during the COVID-19 pandemic

OBJECTIVE

The disruption caused by the COVID-19 pandemic has been associated with poor mental health, including increases in eating disorders and self-harm symptoms. We investigated risk and protective factors for the new onset of these symptoms during the pandemic.

METHOD

Data were from the COVID-19 Psychiatry and Neurological Genetics study and the Repeated Assessment of Mental health in Pandemics Study (n = 36,715). Exposures were socio-demographic characteristics, lifetime psychiatric disorder, and COVID-related variables, including SARS-CoV-2 infection/illness with COVID-19. We identified four subsamples of participants without pre-pandemic experience of our outcomes: binge eating (n = 24,211), low weight (n = 24,364), suicidal and/or self-harm ideation (n = 18,040), and self-harm (n = 29,948). Participants reported on our outcomes at frequent intervals (fortnightly to monthly). We fitted multiple logistic regression models to identify factors associated with the new onset of our outcomes.

RESULTS

Within each subsample, new onset was reported by: 21% for binge eating, 10.8% for low weight, 23.5% for suicidal and/or self-harm ideation, and 3.5% for self-harm. Shared risk factors included having a lifetime psychiatric disorder, not being in paid employment, higher pandemic worry scores, and being racially minoritized. Conversely, infection with SARS-CoV-2/illness with COVID-19 was linked to lower odds of binge eating, low weight, and suicidal and/or self-harm ideation.

DISCUSSION

Overall, we detected shared risk factors that may drive the comorbidity between eating disorders and self-harm. Subgroups of individuals with these risk factors may require more frequent monitoring during future pandemics.

PUBLIC SIGNIFICANCE

In a sample of 35,000 UK residents, people who had a psychiatric disorder, identified as being part of a racially minoritized group, were not in paid employment, or were more worried about the pandemic were more likely to experience binge eating, low weight, suicidal and/or self-harm ideation, and self-harm for the first time during the pandemic. People with these risk factors may need particular attention during future pandemics to enable early identification of new psychiatric symptoms.

Emotional dysregulation and linguistic patterns as a defining feature of patients in the acute phase of anorexia nervosa

PURPOSE

This research aims to analyze the relationship between emotional regulation and the symbolic process in autobiographical narratives of a group of individuals diagnosed with restrictive anorexia nervosa (AN), compared to a non-clinical group. The study is framed within multiple code theory (MCT) (Bucci, 1997; 2021), which considers mind-body integration. The purposes of this study are to investigate whether participants of the AN group will show greater alexithymia and emotional dysregulation than the non-clinical group; and whether the specific linguistic and symbolic features, such as somato-sensory words, affect words, and difficulty in the symbolizing process will predict the AN group.

METHODS

Twenty-nine female participants hospitalized with AN during an acute phase (mean age 19.8 ± 4.1) and 36 non-clinical female participants (mean age 21 ± 2.4) were selected through snow-ball sampling. The participants completed the Toronto Alexithymia Scale (TAS-20), the Profile of Mood of State (POMS), the Emotion Regulation Questionnaire (ERQ), and the Relationship Anecdotes Paradigm Interview (RAP). The RAP interview was audio-recorded and transcribed to apply the Referential Process (RP) Linguistic Measures. A T test for paired samples and a logistic binary regression was performed.

RESULTS

AN presented a significantly higher emotional dysregulation through the ERQ, TAS20 and POMS measures. Specifically, AN showed higher ER expression/suppression strategies, fewer functional cognitive strategies, higher alexithymia, and higher mood dysregulation. Specific linguistic features such as sensory-somatic, word affect, and difficulty in RP symbolizing predict the AN group (R2 = 0.349; χ2 = 27,929; df = 3; p = .001).

CONCLUSIONS

Emotional dysregulation is connected to AN symptoms and autobiographical narratives. The results can help a clinical assessment phase showing specific linguistic features in AN patients.

LEVEL OF EVIDENCE

Level II, controlled trial without randomization.

Emotion Dynamics and Emotion Regulation in Anorexia Nervosa: A Systematic Review of Ecological Momentary Assessment Studies

Altered emotion dynamics and emotion regulation (ER) have been indicated in theoretical descriptions of abnormal emotional functioning, which contributes to the development and maintenance of anorexia nervosa (AN). Ecological momentary assessment (EMA) has recently become popular in research on eating disorders. It is a source of new insights into the psychopathology of AN as it enables intensive long-term tracking of everyday experiences and behaviours of individuals through repeated self-reports. The following systematic review aims to synthesize research on the use of EMA when evaluating emotion dynamics and ER in AN. Specific studies were identified with the use of MEDLINE, PsycINFO, and Scopus databases. A supplemental search was performed in reference lists of the relevant publications. As a result, 27 publications were identified and included in the systematic review. The findings from the reviewed studies point to various disturbed components of emotion dynamics as well as to unique associations of maladaptive ER strategies with specific abnormalities in emotion dynamics in AN. Limitations of the studies were discussed as well. An outlook for further research in the field was provided in the last section of the paper.

Disordered eating as a repercussion of sexual assault: a consequence to consider

PURPOSE

This study aims at clarifying the links between sexual violence and disordered eating (DE).

METHODS

In a sample of 12,638 victims of self-reported sexual violence, we analyzed the situation of 546 victims that declared having developed DE. We assessed the characteristics of the assault (age, type of aggression) and the medical consequences (PTSD, depression, suicide attempts, anxiety disorders, etc.).

RESULTS

DE prevalence was 4.3% in the victim sample. The age of the first assault in DE victims was significantly lower than that of the whole population (12 years vs 16 years for median; p < 0.001). A much higher prevalence of sexual assault consequences was present in victims developing DE with odd ratios (OR) for: self-mutilation (OR = 11.5 [8.29-15.95], p < 0.001); depression (OR = 5.7 [4.81-6.86], p < 0.001); self-medication (OR = 5.3 [3.86-7.19], p < 0.001); suicide attempts (OR = 4.5 [3.59-5.67], p < 0.001); post-traumatic stress disorder (OR = 3.8 [2.99-4.78], p < 0.001); anxiety troubles (OR = 5.2 [4.11-6.47], p < 0.001); alcoholism (OR = 4.0 [2.81-5.58], p < 0.001).

CONCLUSION

This study confirms the link between DE and sexual violence, especially in childhood, leading to severe psychological consequences. In this context, DE should be envisaged as a coping strategy accompanying emotional dysregulation due to traumatic events, and be treated as such.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series analysis such as case studies.

Real-Life Self-Control Conflicts in Anorexia Nervosa: An Ecological Momentary Assessment Investigation

Background

Individuals with anorexia nervosa (AN) are often thought to show heightened self-control and increased ability to inhibit desires. In addition to inhibitory self-control, antecedent-focused strategies (e.g., cognitive reconstrual—the re-evaluation of tempting situations) might contribute to disorder maintenance and enable disorder-typical, maladaptive behaviors.

Methods

Over a period of 14 days, 40 acutely underweight young female patients with anorexia nervosa (AN) and 40 healthy control (HC) participants reported their affect and behavior in self-control situations via ecological momentary assessment during inpatient treatment (AN) and everyday life (HC). Data were analyzed via hierarchical analyses (linear and logistic modeling).

Results

Conflict strength had a significantly lower impact on self-control success in AN compared to HC. While AN and HC did not generally differ in the number or strength of self-control conflicts or in the percentage of self-control success, AN reported self-controlled behavior to be less dependent on conflict strength.

Conclusions

While patients with AN were not generally more successful at self-control, they appeared to resolve self-control conflicts more effectively. These findings suggest that the magnitude of self-control conflicts has comparatively little impact on individuals with AN, possibly due to the use of antecedent-focused strategies. If confirmed, cognitive-behavioral therapy might focus on and help patients to exploit these alternative self-control strategies in the battle against their illness.

Interpersonal, affective and compulsive features of driven exercise in anorexia nervosa

BACKGROUND

This preregistered (https://osf.io/g9ajb) analysis sought to integrate the current literature on trait compulsivity into maintenance models of driven exercise in anorexia nervosa (AN). We tested whether compulsivity increases the likelihood of driven exercise via interpersonal and affect-regulatory pathways.

METHODS

We used multilevel structural equation modeling to test the hypothesis that trait compulsivity predicts a stronger within-person link between affect-regulatory difficulties or interpersonal sensitivity and driven exercise in female adolescents and adults with AN. We used data from five assessments across inpatient treatment and 6-months follow-up of 207 adult and adolescent patients with AN (1035 datapoints).

RESULTS

In line with our hypotheses, patients who generally experienced more affect-regulatory difficulties or stronger interpersonal sensitivity tended to engage in driven exercise more strongly. Moreover, high levels of trait compulsivity amplified the effect of interpersonal sensitivity on driven exercise across time. Contrary to our hypotheses, the link between affect regulation and driven exercise was not moderated by compulsivity. Similar effects on general eating disorder psychopathology were found, but no cross-level moderation effect of compulsivity.

LIMITATIONS

Due to sample size, potential AN subtype-dependent effects were not analyzed.

CONCLUSION

Our results suggest that driven exercise coincides with self-reported experiences of interpersonal sensitivity and that this link varies as a function of compulsivity such that the within-person coupling is stronger among those scoring high on compulsivity. To derive clinically useful functional models of driven exercise, future studies might use intensive longitudinal data to investigate its momentary associations with affect and interpersonal sensitivity in the context of compulsive traits.

Evaluation of the Affect School as supplementary treatment of Swedish women with eating disorders: a randomized clinical trial

BACKGROUND

Despite solid research there remains a large group of patients with eating disorders who do not recover. Emotion dysregulation has been shown to be a feature in the different eating disorders. A manualized group intervention developed in Sweden, the Affect School, aims to enhance emotional awareness and the ability to perceive and express emotions.

AIM

This study aimed to test the hypothesis that participation in the Affect School as a complement to ordinary eating disorder treatment would enhance awareness and regulation of emotions and reduce alexithymia and cognitive eating disorder symptoms in a sample of patients with eating disorders at a Swedish specialized outpatient clinic.

METHOD

Forty patients with various eating disorders were randomized to either participation in the Affect School as a supplement to treatment as usual (TAU), or to a TAU control group. Participants were assessed with the Eating Disorder Examination Questionnaire, the Deficits in Emotion Regulation Scale-36, and the Toronto Alexithymia Scale-20 at start, end of intervention, and at the 6- and 12-month follow-ups.

RESULTS

No significant differences were observed post-treatment but Affect School participants had improved significantly more than controls on eating disorder cognitions and behaviours and emotion dysregulation at the 6- and 12-month follow-ups and had significantly less alexithymia at the 6-month follow-up.

CONCLUSION

Difficulties with emotion recognition and/or regulation can complicate fulfilment of personal needs and obstruct communication and relationships with others. The present study indicates that adding Affect School group sessions to regular treatment enhances emotional awareness and emotion regulation and decreases eating disorder symptoms and alexithymia. Patients with eating disorder diagnoses have described problems with emotional management, for example: lower emotional awareness and difficulties in using adaptive emotional regulatory strategies compared to people without eating disorders. It has been suggested that interventions aiming at enhancing emotional awareness and acceptance would be beneficial in treatment. In the present study we explored whether adding the Affect School to regular treatment would enhance awareness and regulation of emotions and decrease eating disorder symptoms. Forty women with an eating disorder were randomly allocated to either an additional participation in a group treatment for 8 weeks or usual treatment only. The treatment contained education on different affects such as joy, fear, interest, shame, anger, disgust, and worry. The education was followed by discussions on own experiences. Participants filled in self-assessment forms that measured eating disorder symptoms, emotional recognition, and emotion regulation before the start and at the end of the group treatment, and after 6 and 12 months respectively. The results when comparing the two groups suggested that the Affect School could be an effective additional treatment. Participants in the Affect School improved their scorings but the change took time and did not show until at the 6- and 12 months follow-ups.

The mediating role of self-criticism, experiential avoidance and negative urgency on the relationship between ED-related symptoms and difficulties in emotion regulation

OBJECTIVE

Difficulties in emotion regulation are thought to play a transdiagnostic role across eating disorders (ED). In the current study, we explored with a path analysis the mediating role of self-criticism, experiential avoidance and negative urgency on the relationship between ED-related symptoms and dimensions of difficulties in emotion regulation.

METHOD

Participants were 103 female outpatients recruited at a Portuguese ED hospital unit, diagnosed with an ED, aged 14-60 years old (M = 28.0, SD = 10.5), body mass index (BMI) ranging from 11.72 to 39.44 (M = 20.1, SD = 5.4).

RESULTS

The path analysis resulted in a model with an adequate fit to the data (SRMR = 0.05; RMSEA = 0.07 [0.00, 0.12], PCLOSE = 0.269; TLI = 0.97; IFI = 0.99; GFI = 0.95). A final model in which the relationship between ED-related symptoms and dimensions of difficulties in emotion regulation was mediated by self-criticism, experiential avoidance and negative urgency, accounted for a variance of 71% for strategies, 57% for non-acceptance, 62% for impulses, 56% for goals and 20% for clarity.

CONCLUSION

Results suggest that self-criticism, experiential avoidance and negative urgency, combined, are relevant in the relationship between ED-related symptoms and difficulties in emotion regulation. ED treatment and emotion regulation skills may be enhanced through the inclusion of specific components that target self-criticism, experiential avoidance and negative urgency, as they become prominent during the therapeutic process.

Revisiting alexithymia as an important construct in the treatment of anorexia nervosa: a proposal for future research

Consistent research supports altered emotional processing in adult patients with anorexia nervosa (AN), including elevations in alexithymia, or deficits in identifying and describing emotions and other internal experiences. Despite increasing interest in emotion-focused therapies for AN, alexithymia is often not directly addressed within many existing treatments, and little empirical work has moved beyond descriptive, cross-sectional research. In this paper, we propose that refining the field's understanding of alexithymia may provide insights into poor outcomes in existing psychological treatments for AN. First, we provide a brief overview of existing work exploring alexithymia in AN, and then describe several next steps in treatment-relevant research, including differentiating alexithymia from related constructs, considering neurobiological correlates of alexithymia, testing the link between alexithymia and outcome across treatment modalities, and piloting adjunctive treatment techniques focused on emotional identification and description. Altogether, exploring adjunctive treatment approaches targeting alexithymia may offer one promising possibility for improving long-term outcomes.

Modified Dual Pathway Model for Binge Eating: The Role of Emotion Dysregulation

We tested a modification of the dual pathway model using two sequential mediators between body dissatisfaction and binge eating: restricted eating and difficulties in emotion regulation replacing negative affect. A total of 435 college students completed an online survey. Results from path analyses indicated that the relationship between body dissatisfaction and binge eating was not mediated by restricted eating for neither women nor men. However, this relationship was mediated first by restricted eating and then by difficulties in emotion regulation for women only. Moreover, this relationship was mediated by difficulties in emotion regulation for both women and men. A post hoc analysis indicated that the above mediation results were still significant after adding negative affect into the model. No mediations through negative affect were significant. Clinical implications include the conceptualization and intervention of eating concerns within an emotion dysregulation framework.

Morphing analysis of facial emotion recognition in anorexia nervosa: association with physical activity

PURPOSE

Anorexia Nervosa (AN) has been linked to emotion processing inefficiencies, social cognition difficulties and emotion dysregulation, but data on Facial Emotion Recognition (FER) are heterogenous and inconclusive. This study aims to explore FER in patients with AN using a dynamic and ecological evaluation, and its relationship with Physical Activity (PA), an important aspect of AN that could impact emotional processing.

METHODS

Sixty-six participants (33 patients with AN and 33 healthy controls) performed a morphed facial emotional recognition task and 49 of them wore an accelerometer during seven days to assess PA. Axis-I disorders and depressive symptoms have been assessed.

RESULTS

No difference was found regarding time to recognize facial emotions. However, patients with AN correctly recognize emotions more frequently than controls. This was specific to disgust, although there was also a tendency for sadness. Among patients, higher depressive scores are associated with a faster and more accurate recognition of disgust, while a higher level of PA is associated to decreased accuracy in recognizing sadness.

CONCLUSION

Patients with AN are capable of recognizing facial emotions as accurately as controls, but could have a higher sensitivity in recognizing negative emotions, especially disgust and sadness. PA has opposite effects and, thus, could be considered as an emotional regulation strategy against negative affect.

LEVEL OF EVIDENCE II

Controlled trial without randomization.

Biased and inflexible interpretations of ambiguous social situations: Associations with eating disorder symptoms and socioemotional functioning

BACKGROUND

Research indicates that difficulties across multiple socioemotional functioning domains (e.g., social emotion expression/regulation, response to social elicitors of emotion) and negatively biased interpretations of ambiguous social situations may affect eating disorder symptoms. The impact of inflexible interpretations of social situations on eating disorder symptoms is less clear. The present study therefore examined relations between inflexible and biased social interpretations, socioemotional functioning, and eating disorder symptoms.

METHOD

A total of 310 participants from the general population, recruited from an online crowdsourcing platform, completed measures of socioemotional functioning (e.g., rejection sensitivity, negative social exchange), eating disorder symptoms, and positive and negative interpretation bias and inflexibility on a single measurement occasion.

RESULTS

Socioemotional functioning impairments (Pillai's trace = 0.11, p < .001), but not negative (β = .07, p = .162) or positive (β = -.01, p = .804) interpretation bias or inflexible interpretations (β = .04, p = .446), were associated with eating disorder symptoms in multiple regression models. In network analyses controlling statistically for multiple markers of socioemotional functioning, eating disorder symptoms were directly associated with negative (but not positive) interpretation bias. Inflexible interpretations were indirectly linked to symptoms via co-dampening of positive emotions. Exploratory causal discovery analyses suggested that several socioemotional functioning variables (social anxiety, depression, negative social exchange) may cause eating disorder symptoms.

CONCLUSIONS

Consistent with cognitive-interpersonal models of disordered eating, our results suggest that less accurate (biased, inflexible) interpretations of social information contribute to patterns of cognition (anxious anticipation of rejection) and emotion regulation (down-regulation of positive social emotion) thought to encourage disordered eating.

PUBLIC SIGNIFICANCE

This study suggests that less accurate interpretations of ambiguous social information encourage anxious anticipation of rejection and downregulation of positive social emotions, both of which are thought to promote eating disorder symptoms. Knowledge provided by this study about the likely relations between interpretive processes, social/emotional functioning, and eating disorder symptoms may help inform treatments for eating disorders, particularly those that attempt to modify patterns of interpretation.

Changes in unhealthy exercise in outpatient eating disorder treatment: examining emotion avoidance mechanisms

Unhealthy exercise (UE) is a common symptom of eating disorders (EDs) associated with elevated chronicity and relapse. Previous research suggests that UE serves an emotion regulation function, especially to reduce negative affect. UE may be especially prevalent among individuals with anorexia nervosa (AN), as UE and restrictive eating may be used to avoid unpleasant emotions. It is unclear whether changes in emotion avoidance (EA) can lead to changes in UE over time. The current study examined whether month 1 EA mediated the relation between baseline UE and month 2 UE in a clinical sample of 127 patients (M_age = 22.52 [SD = 11.75], 92.9% female) recruited from an ED outpatient treatment program. The current study also explored whether this mediation was stronger for individuals with AN than other ED diagnoses. Findings revealed that changes in EA significantly mediated the relation between changes in UE from baseline to month 2 of treatment. ED diagnosis did not moderate this relation. Findings suggest that improvements in EA may reduce UE over time. Treatment should target UE through cultivation of increased emotion acceptance.Level of evidence Level III: evidence obtained from well-designed cohort study.

The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach

Background

Previous theoretical models and reviews have documented a strong connection between emotion dysregulation eating disorder (ED) psychopathology among the general and clinical populations. The aim of this review was to build on this previous work by conducting a network meta-analysis to explore associations between adaptive and maladaptive emotion regulation strategies and ED psychopathology trans-diagnostically across the ED spectrum to identify areas of emotion dysregulation that have the strongest association with symptomatology.

Methodology

A total of 104 studies were included in the meta-analysis and correlation coefficient representing the associations between specific emotion regulation strategies and ED symptomatology were extracted. We ran a Bayesian random effects network meta-analysis and the initial network was well-connected with each emotion regulation strategy being linked to at least one other strategy. We also conducted a network meta-regression to explore whether between-study differences in body mass index (BMI), age, and whether the sample consisted of solely female participants explained any possible network inconsistency.

Results

The network meta-analysis revealed that ruminations and non-acceptance of emotions were most closely associated with ED psychopathology. There was no significant network inconsistency but two comparisons approached significance and thus meta-regressions were conducted. The meta-regressions revealed a significant effect of BMI such that the associations between different emotion regulation strategies and ED symptomatology were weaker among those with low BMI.

Discussion

The present findings build on previous work and highlight the role of rumination and difficulties with accepting emotions as key emotion regulation difficulties in EDs. Additionally, the finding that the associations were weaker among ED patients with low BMI may point toward a complex relationship between ED behaviors and emotion regulation. Taken together, our findings call for interventions that target emotion regulation, specifically rumination and difficulties accepting emotions, in the treatment of EDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249996, PROSPERO, identifier: CRD42021249996.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Behavioral reinforcement of pathological exercise in anorexia nervosa

Pathological exercise in anorexia nervosa (AN) is a harmful behavior associated with a chronic course and poor prognosis. To date, no comprehensive theoretical model exists to describe pathological exercise in the context of AN, and as such, few treatments are effective at promoting direct and sustained pathological exercise extinction. Using a framework put forth by Wise & Koob (2014), debating the relative importance of positive and negative reinforcement in substance use, we present three hypotheses of behavioral reinforcement of exercise, encompassing biological, psychological, and environmental influences. Specifically, we argue that exercise is positively reinforced through receipt of biological and behavioral rewards, negatively reinforced through avoidance of aversive emotions, and that these two systems work in tandem over time to engrain pathological exercise as a habit. We then present suggestions for testing each of these hypotheses as future directions for the field.

Explaining reinforcement and erroneous beliefs in pathological exercise: A commentary and expansion on Coniglio et al. (in press) using the pathways model of disordered gambling

Coniglio, Cooper, and Selby proposed that behavioral reinforcement may be critical for understanding the etiology and maintenance of pathological exercise among people living with anorexia nervosa. They presented three competing hypotheses about why exercise can become problematic: (a) positive reinforcement via biological and behavioral rewards, (b) negative reinforcement via avoidance of aversive states, or (c) a synergistic interplay between positive and negative reinforcement. Herein, we extend Coniglio and colleagues' framework by drawing on theory and research from the field of disordered gambling-a behavior in which reinforcement is an etiological and maintaining mechanism. We applied the pathways model of disordered gambling to the study of pathological exercise and made the following two proposals. First, pathological exercise may be driven by positive reinforcement, negative reinforcement, or both (they are not mutually exclusive), depending on the presence or absence of specific co-occurring psychopathologies. Second, erroneous beliefs about the safety and efficacy of maladaptive exercise for weight control may help maintain pathological exercise regardless of the type of reinforcement. We conclude by calling for research that assesses Coniglio and colleagues' novel hypotheses and our supposition that the pathways model can help provide a framework for those hypotheses.

Examining weekly relationships between obsessive-compulsive and eating disorder symptoms

BACKGROUND

Despite the severity and high rate of co-occurrence between eating disorders (ED) and obsessive-compulsive disorder (OCD), less is known regarding the longitudinal sequencing of their comorbidity and whether and how their symptoms may influence one another over time. The current study sought to answer these questions by testing if a bidirectional, longitudinal relationship exists between ED symptoms and OCD obsessions and compulsions.

METHODS

We examined the relationship between ED symptoms, obsessions and compulsions across five time points, each one week apart using auto-regressive cross-lagged panel modeling. The final sample consisted of 358 individuals from the community with moderate levels of ED and OCD symptoms, the majority of whom identified as White and male.

RESULTS

Bivariate correlations revealed that ED symptoms, obsessions and compulsions were associated with one another across the five weeks. Two cross-lagged panel models indicated that ED symptoms predicted OCD symptoms at numerous time points and vice versa. However, we found this significant longitudinal associations across only certain weeks. Notably, the models found that only ED symptoms and OCD obsessions predicted one another across different time points across the five weeks; ED symptoms and OCD compulsions did not predict one another.

LIMITATIONS

Due to the non-clinical nature of the sample, there is limited generalizability to clinical populations.

CONCLUSIONS

Our results provide preliminary evidence that there is a bidirectional, longitudinal relationship between ED symptoms and OCD symptoms among a community sample, particularly with respect to cognitive as opposed to behavioral symptoms.

Emotion regulation difficulties, perceived parenting and personality as predictors of health-risk behaviours among adolescents

Health-Risk Behaviours (HRBs) are significant antecedent conditions of adverse health outcomes among adolescents, and their prevention requires an in-depth understanding of associated factors. Like any other behaviour, HRBs may be an outcome of a complex interplay between personal and situational factors that determines our responses. Among other factors, emotional tendencies, specific behavioural patterns, and psychosocial environment may be the significant factors working at different hierarchical positions within a system and guiding human behaviours, including HRBs. Previous studies have explored the role of these specific factors in developing and maintaining HRBs, but mainly among the adult population, and no conclusive results could be observed regarding their contribution to HRBs in adolescents. The present study explored the predictability of adolescents' engagement in HRBs with regard to three representations of the mentioned factors, i.e., emotion regulation difficulties, perceived parenting practices and personality traits. A total of 723 (Males = 440) adolescents (Mage = 16.05, SD = 1.1) provided relevant information on the standardized questionnaires. Structural equation modelling was applied to test the stated hypotheses. Analysis revealed that the adolescents who reported more difficulty regulating one's emotions, perceived parenting practice as maladaptive, scored high on neuroticism and low on conscientiousness, showed more engagement in HRBs than their counterparts. Further, the findings indicated that emotion regulation difficulties and perceived parenting practices are stronger predictors of HRBs than personality traits. Interventional programs targeting HRBs among adolescents should address specific facets of emotional dysregulation and sensitise parents about their role in moderating adolescents' HRBs.

A 1-year follow-up study of the longitudinal interplay between emotion dysregulation and childhood trauma in the treatment of anorexia nervosa

OBJECTIVE

The study aimed to investigate the complex relationship between eating disorder (ED) specific psychopathology, emotion dysregulation, and their longitudinal variations in patients with anorexia nervosa (AN) treated with a multidisciplinary approach including enhanced cognitive-behavior therapy (CBT-E), and to provide an integrated model which includes childhood trauma as a predictor of worse treatment outcomes.

METHOD

In total, 120 female patients with AN were evaluated at admission (T0), and 105 were re-evaluated after 1 year (T1) of treatment. At T0, patients underwent a clinical assessment and filled the Symptom Checklist 90-Revised (SCL90-R), the Eating Disorders Examination Questionnaire (EDE-Q), the Difficulties in Emotion Regulation Scale (DERS), and the Childhood Trauma Questionnaire (CTQ). SCL-90-R, EDE-Q, and DERS were readministered at T1. Variations between T0 and T1 were evaluated, and the proposed model was investigated using bivariate latent change score analysis in a structural equation modeling (SEM) framework.

RESULTS

An overall significant clinical amelioration was observed after treatment. A unidirectional effect of DERS scores on EDE-Q variations was outlined by SEM: patients with higher baseline DERS scores achieved less EDE-Q improvements, and EDE-Q latent change score was significantly predicted by longitudinal variations of DERS-but not vice versa. Higher CTQ scores predicted reduced treatment efficacy for ED-specific psychopathology through the mediating effect of higher baseline DERS scores.

DISCUSSION

The present study sheds light on the mechanism by which early trauma compromises treatment outcome in patients with AN, underlining the crucial role of emotional dysregulation.

Seeing Through the Façade of Anorexia: A Grounded Theory of Emotional Change Processes Associated With Recovery From Anorexia Nervosa

OBJECTIVES

Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia.

METHODS

Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants' experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed.

RESULTS

The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants' journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships.

CONCLUSION

These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development.

Is decision-making impairment an endophenotype of anorexia nervosa?

Background

Patients with anorexia nervosa (AN) show impaired decision-making ability, but it is still unclear if this is a trait marker (i.e., being associated with AN at any stage of the disease) or a state parameter of the disease (i.e., being present only in acutely ill patients), and if it has endophenotypic characteristics. The aim of this study was to determine the endophenotypic, and state- or trait-associated nature of decision-making impairment in AN.

Methods

Ninety-one patients with acute AN (A-AN), 90 unaffected relatives (UR), 23 patients remitted from AN (R-AN), and 204 healthy controls (HC) carried out the Iowa gambling task (IGT). Prospective valence learning (PVL) model was employed to distinguish the cognitive dimensions underlying the decision-making process, that is, learning, consistency, feedback sensitivity, and loss aversion. IGT performance and decision-making dimensions were compared among groups to assess whether they had endophenotypic (i.e., being present in A-AN, UR, and R-AN, but not in HC) and/or trait-associated features (i.e., present in A-AN and R-AN but not in HC).

Results

Patients with A-AN had lower performance at the IGT (p < 0.01), while UR, R-AN, and HC had comparable results. PVL-feedback sensitivity was lower in patients with R-AN and A-AN than in HC (p < 0.01).

Conclusions

Alteration of decision-making ability did not show endophenotypic features. Impaired decision-making seems a state-associated characteristic of AN, resulting from the interplay between trait-associated low feedback sensitivity and state-associated features of the disease.

Factor structure and clinical correlates of the original and 16-item version of the Difficulties In Emotion Regulation Scale in adolescent girls with eating disorders

OBJECTIVES

The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders.

METHODS

Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined.

RESULTS

A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms.

CONCLUSION

The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales.

Emotion regulation in adolescents with anorexia and bulimia nervosa: Differential use of adaptive and maladaptive strategies compared to healthy adolescents

OBJECTIVE

Adolescents with anorexia (AN) and bulimia nervosa (BN) often struggle with emotion regulation (ER). These difficulties have predominantly been assessed across emotions, without considering adaptive and maladaptive ER separately. We compared adolescents with AN or BN to healthy adolescents (HCs) regarding the adaptive and maladaptive ER of three emotions.

METHOD

A treatment-seeking sample of 197 adolescents (atypical/full-threshold AN: N = 118, atypical/full-threshold BN: N = 32; HC: N = 47) reported emotion-specific ER with the FEEL-KJ questionnaire. Mixed models were calculated for adaptive and maladaptive ER to assess differences between emotions (anxiety, anger, and sadness) and groups (AN, BN, and HC).

RESULTS

Main effects of emotion (p < .001) and group (p < .001) were found, but no interaction effects were found (p > .05). Post hoc tests showed lower maladaptive and higher adaptive ER for anxiety than anger or sadness (p < .001). AN and BN reported lower adaptive (p < .001) and higher maladaptive ER than HCs (p < .001). BN showed the highest levels of maladaptive ER (p = .009).

DISCUSSION

The differences between AN and BN in adaptive and maladaptive ER should be considered. Furthermore, investigating differences in ER of other emotions in eating disorders might be promising.

The ethereal bodies of pro-Ana blogs: emotional communities and spaces of sociability on the web

The study presented in this paper aimed at understanding how anorexic young women use virtual environments as spaces of sociability in order to construct a narrative about anorexia, anchor their experiences through emotional mutuality and validate discourses. To do so, an analysis of the content found in the commenting and posting sections of pro-anorexia blogs was carried out. Three thematic categories were identified: body, personal identity and sociability on the web. It was observed that blogs are virtual spaces of sociability and construction of identity groups. The representations and the experiences lived by the corporal materiality feed cyberspace and are the starting point for understanding a phenomenon particular to the contemporaneity, that is the virtual exchanges. In blogs, one can find body narratives that seek to give coherence to an individual and to his or her existence as well as narratives that aim at anchoring and legitimizing personal experiences and validating pro-anorexia attitudes. Social ties are strengthened within the group, which becomes an emotional community. The meanings of the spreading discourses allow us to infer that in these groups, the materiality of anorexic bodies emancipates itself from the social stigmas of a disease.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Association of Emotion Regulation Trajectories in Childhood With Anorexia Nervosa and Atypical Anorexia Nervosa in Early Adolescence

IMPORTANCE

People with anorexia nervosa often experience difficulties regulating their emotions. There is no longitudinal evidence as to whether these differences are already present in childhood or when they begin to emerge.

OBJECTIVE

To investigate the association between emotion regulation trajectories from 3 to 7 years of age and symptoms of anorexia nervosa and atypical anorexia nervosa in adolescence.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all children with complete exposure data in the Millennium Cohort Study, a UK general population birth cohort. Data were acquired from June 2001 to March 2016 and analyzed from June to November 2020.

EXPOSURES

Mothers reported on their children's emotion regulation skills at 3, 5, and 7 years of age using the Children's Social Behavior Questionnaire. Multilevel models were used to derive early childhood emotion regulation scores (ie, predicted intercept) and within-child changes in emotion regulation scores from 3 to 7 years of age (ie, predicted slope).

MAIN OUTCOME AND MEASURES

Symptoms consistent with a DSM-5 diagnosis of anorexia nervosa or atypical anorexia nervosa at 14 years of age, defined using a range of questions relative to body image, weight perception, and dieting behaviors (hereinafter referred to as broad anorexia nervosa). Univariable and multivariable logistic regression models tested the association between exposures and outcome. Regression models were adjusted for child and family sociodemographic and socioeconomic characteristics and mental health difficulties, prenatal and perinatal factors, child's cognitive development, and maternal attachment.

RESULTS

A total of 15 896 participants (85.7% of total sample; 51.0% boys; 84.5% White individuals) had complete data on the exposure and were included in the main analyses. Among those with complete exposure and outcome data (9912 of the analytical sample [62.4%]), 97 participants (1.0%; 86 [88.7%] girls and 85 [87.6%] White individuals) had symptoms consistent with a diagnosis of broad anorexia nervosa at 14 years of age. No evidence suggested that children with lower emotion regulation ability at 3 years of age had greater odds of later reporting symptoms of broad anorexia nervosa (odds ratio [OR], 1.21; 95% CI, 0.91-1.63). However, children whose emotion regulation skills did not improve over childhood and who had greater problems regulating emotions at 7 years of age had higher odds of having broad anorexia nervosa at 14 years of age (OR, 1.45; 95% CI, 1.16-1.83).

CONCLUSIONS AND RELEVANCE

These findings suggest that difficulties in developing age-appropriate emotion regulation skills in childhood are associated with experiencing broad anorexia nervosa in adolescence. Interventions to support the development of emotion regulation skills across childhood may help reduce the incidence of anorexia nervosa.

Stress appraisal prospectively predicts binge eating through increases in negative affect

PURPOSE

Ecological momentary assessment (EMA) studies preliminarily support the transactional model of emotion regulation in eating disorders, such that heightened stress appraisal (i.e., the cognitive evaluation of an event's demands) results in increased negative affect (NA) and subsequent binge eating (BE). However, the temporal relationships between these variables and the magnitude of stress appraisal that is clinically significant require clarification. The current study aimed to extend previous research by (1) examining the temporal relationship between stress appraisal, changes in NA, and BE using three timepoints, (2) exploring what magnitude of momentary stress appraisal results in clinically significant increases in NA and BE, and (3) characterizing what stressors are associated with clinically significant stress appraisal.

METHODS

37 adult females completed an EMA protocol assessing momentary stressors, stress appraisal, NA, and BE over 2 week duration. Multilevel mediation models were used to test the study aims.

RESULTS

Momentary increases in stress appraisal significantly predicted binge eating through increases in NA. Stress appraisal ratings of 0.50 SD higher relative to one's average stress appraisal began to significantly predict the likelihood of BE through increases in NA, and the likelihood of BE occurrence increased with every 0.25 increments in momentary stress appraisal. Work/school stressors and interpersonal stressors were the most commonly endorsed stressors of clinically significant stress appraisal.

CONCLUSION

The current study supported the transactional model of emotion dysregulation in a binge eating sample and supports the use of momentary interventions at times of clinically significant stress appraisal to reduce BE risk.

LEVEL OF EVIDENCE

Level II, controlled trial without randomization.

Inflammatory dysregulation in women with an eating disorder: Relationships with altered emotional reactivity

BACKGROUND

Some studies suggest that inflammatory signaling dysregulation may contribute to eating disorder (ED) pathophysiology. However, little is known about the influence of inflammatory response on altered processes seen among patients with ED, such as emotional processing and reactivity.

OBJECTIVES

The objectives were: (a) to investigate the systemic inflammatory response in ED women; and (b) to analyze the role of inflammatory markers in emotional reactivity.

METHOD

Concentrations of several intercellular and intracellular inflammatory mediators (cytokines, prostaglandin by-products and enzymes, TBARS, and MAPK proteins) were quantified in plasma and PBMCs from 68 women with an ED (m = 22.01 years, SD = 9.15) and 35 healthy controls (m = 18.54 years, SD = 4.21). Moreover, emotional reactivity to affective pictures (those without either food or thinness content) was studied using the adult (>18 years old) sample (n = 41).

RESULTS

Between-group differences were revealed for most markers (TNF-α, PGE₂ , COX2, and ratio of activated MAPK proteins), pointing to increased inflammatory response in patients (p < .01). Women with ED showed heightened emotional reactivity, regardless of picture valence. Principal components derived from inflammatory markers showed an explanatory loading on patient's emotional reaction, in terms of valence and arousal.

CONCLUSION

This study corroborates the altered systemic inflammatory response in patients with ED. The inflammatory dysregulation may contribute to ED phenotype, as seen by its relationship with heightened emotional reactivity, even though the inflammatory markers were not evaluated throughout the emotional reactivity protocol.

Smartphone application for adolescents with anorexia nervosa: an initial acceptability and user experience evaluation

BACKGROUND

Anorexia Nervosa (AN) is a key target for E-Health programs considering the many barriers hindering patients' access to care and the disorder's severity. Although these programs have become more common and effective, they often have low adherence, especially among youth. This can hinder their implementation and effectiveness in real-world settings. User experience partly overlaps with the acceptability field and may provide insight into factors affecting adherence and adoption of E-Health programs. This study aimed to explore early acceptability and user experience of a companion app prototype for adolescents with AN using user-centered design methods.

METHODS

We developed a prototype containing self-help material and emotions and behaviors evaluation and management features. Then we conducted a mixed evaluation combining semi structured focus group interviews and questionnaires in a clinician group and an AN patient group. We analyzed data using thematic analysis and descriptive statistics.

RESULTS

The app's overall appeal was adequate. The user experience questionnaire revealed the weakest dimensions, including novelty, dependability, and efficiency versus stimulation (i.e., ability to induce motivation to use the product) and perspicuity (i.e., easy to understand, to get familiar with). The qualitative data analysis revealed three central axes: acceptability, features, and use. We identified acceptability barriers and facilitators such as the importance of design and customization, especially for adolescents. Psychoeducation was a major feature for participants, as patients highlighted the difficulties they encountered when seeking disorders-related information.

CONCLUSIONS

This study shows the importance of including users in the different stages of an e-health intervention development, in order to identify their needs, general use and compliance patterns, to improve adherence and adoption of the program and its effectiveness.

From Deficits in Emotional Intelligence to Eating Disorder Symptoms: A Sequential Path Analysis Approach Through Self-Esteem and Anxiety

Past studies have reported emotional intelligence (EI) as a relevant factor in development and maintenance of eating disorders (ED), as well as in increasing self-esteem and reducing anxiety. Similarly, research has showed that anxiety and self-esteem are positively and negatively associated to ED criteria, respectively. However, no prior studies have yet tested the multiple intervening roles of both self-esteem and anxiety as potential mediators of the association between EI and ED symptomatology. The present study aims to bridge these gaps by testing a sequential path model. Specifically, we examine the potential sequential mediation effects of self-esteem-anxiety on the link between EI and ED. A sample composed of 516 Spanish undergraduate students and community adults completed measures of EI, self-esteem, anxiety, and ED symptomatology. The results show that high levels of EI were positively associated with self-esteem and negatively associated with anxiety and ED symptoms. Anxiety was positively associated to ED symptoms, while self-esteem levels were negatively linked to ED symptoms. Moreover, path analyses showed that self-esteem and anxiety fully mediated the relationship between EI and ED symptoms in sequence. These findings suggest that EI plays a key role in reducing symptomatology of ED through increased self-esteem and reduced anxiety symptoms, providing novel evidence regarding psychological mechanisms through which EI contributes to a reduction of ED symptomatology. Implications for assessing and improving these psychological resources in ED preventive programs are discussed.

Emotional processing in recovered anorexia nervosa patients: A 15 year longitudinal study

OBJECTIVE

This 15 years longitudinal study aimed to examine whether difficulties in cognitive processing of emotions persisted after long-term recovery from anorexia nervosa (AN), and its link to anxiety and depression.

METHOD

Twenty-four females, who were tested longitudinally during their acute and recovered AN phases, and 24 healthy control (HC) women, were screened for anxiety, depression, alexithymia, emotion regulation difficulties (ER; only assessed in recovery phase), and completed an experimental task to analyse emotional experience.

RESULTS

In spite of significant improvement in alexithymia, anxiety, and depression with AN recovery, some emotion functioning difficulties did not normalize. The occurrence of comorbid anxiety and depression explained the reduced ability to identify, understand, and accept emotions in long-term recovery (relative to controls), but not the increased global difficulty in using ER strategies, which revealed a more stable nature of deficit. With recovery, negative emotions linked to situations addressing food and body weight are felt more intensely.

CONCLUSIONS

Managing emotions, especially the negative ones, remains a challenge for individuals recovered from AN. Under this circumstance, maladaptive eating behaviour can serve as an affect regulatory function, increasing the risk of relapse. Emotional education is an important avenue in protecting long-term AN relapse.

Mindfulness-based interventions for eating disorders: The potential to mobilize multiple associative-learning change mechanisms

Mindfulness is a two-component skill that includes mindful awareness (attentional monitoring of present moment experience) and mindful acceptance (adopting an attitude of acceptance toward this experience). Although mindfulness-based interventions (MBIs) are efficacious for many conditions, there is a lack of research on MBIs for eating disorders (EDs). We propose that MBIs may be promising for EDs given their potential to mobilize not one, but multiple associative-learning change mechanisms in EDs-defined as adaptive processes of change involving one of two forms of associative-learning: Pavlovian and operant learning. We hypothesize how MBIs-via increasing either mindful awareness or mindful acceptance-may mobilize up to eight associative-learning change mechanisms, two involving Pavlovian learning, and six involving operant learning. We also elaborate on similarities and differences between MBIs and CBT approaches for EDs, as well as opportunities for synergy. Finally, we present recommendations for future research related to the development and evaluation of novel MBI interventions for EDs and the testing of mechanisms and patient-treatment matching hypotheses.

Mental Pain in Eating Disorders: An Exploratory Controlled Study

Mental pain (MP) is a transdiagnostic feature characterized by depression, suicidal ideation, emotion dysregulation, and associated with worse levels of distress. The study explores the presence and the discriminating role of MP in EDs in detecting patients with higher depressive and ED-related symptoms. Seventy-one ED patients and 90 matched controls completed a Clinical Assessment Scale for MP (CASMP) and the Mental Pain Questionnaire (MPQ). ED patients also completed the Beck Depression Inventory-II (BDI-II), Clinical Interview for Depression (CID-20), and Eating Attitudes Test (EAT-40). ED patients exhibited significantly greater severity and higher number of cases of MP than controls. Moreover, MP resulted the most important cluster predictor followed by BDI-II, CID-20, and EAT-40 in discriminating between patients with different ED and depression severity in a two-step cluster analysis encompassing 87.3% (n = 62) of the total ED sample. Significant positive associations have been found between MP and bulimic symptoms, cognitive and somatic-affective depressive symptoms, suicidal tendencies, and anxiety-related symptoms. In particular, those presenting MP reported significantly higher levels of depressive and anxiety-related symptoms than those without. MP represents a clinical aspect that can help to detect more severe cases of EDs and to better understand the complex interplay between ED and mood symptomatology.

Psychosocial etiology of maladaptive exercise and its role in eating disorders: A systematic review

OBJECTIVE

Although maladaptive exercise (ME) is widely recognized as a clinical feature in transdiagnostic eating disorders, less is known about psychosocial factors that give rise to and perpetuate this behavior. This systematic review aimed to examine the empirical status of this association.

METHOD

We reviewed 46 full text articles examining longitudinal associations between psychosocial variables and ME.

RESULTS

Eighteen studies met full inclusion criteria. Based on our qualitative synthesis, evidence suggests reasonably consistent associations between early concern with weight and shape, and negative affect on later development of ME.

DISCUSSION

Inconsistent and insufficient assessment of ME across a majority of studies underscores caution in interpretation of results, but guides important discussion for future clinical and research efforts.