Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology?

Abstract

Preliminary evidence indicates that individuals with eating disorders (ED) show emotion regulation (ER) difficulties. However, it is yet unclear whether different types of ED differ in their ER profile and whether certain ER difficulties are specific for ED or rather a transdiagnostic factor. Twenty women with anorexia nervosa (AN), 18 with bulimia nervosa (BN), 25 with binge eating disorder (BED), 15 with borderline personality disorder (BPD), 16 with major depressive disorder (MDD) and 42 female healthy controls (HC) were administered the Emotion Regulation Questionnaire, the Inventory of Cognitive Affect Regulation Strategies, the Difficulties in Emotion Regulation Scale and the Affect Intensity Measure. The ED groups reported significantly higher levels of emotion intensity, lower acceptance of emotions, less emotional awareness and clarity, more self-reported ER problems as well as decreased use of functional and increased use of dysfunctional emotion regulation strategies when compared to HC. No significant differences between the ED groups emerged for most ER variables. However, there were indications that the BED group may show a slightly more adaptive pattern of ER than the two other ED groups. As a whole, all clinical groups performed very similar on most ER variables and reported more difficulties regulating their emotions than HC. The findings suggest that ER difficulties are not linked to a particular diagnostic category. Instead, ER difficulties appear to be a transdiagnostic risk and/or maintenance factor rather than being disorder-specific.

Introduction

With respect to eating disorders (ED), a great amount of theoretical and empirical attention so far has been devoted to cognitive biases and their relevance for the maintenance of pathological eating behavior (Lee and Shafran, 2004). In recent years, however, there has been a proliferation of research focusing on the dispositional use of emotion regulation (ER) strategies in individuals with ED. This research interest was triggered by empirical findings showing that negative mood is a reliable antecedent of binge eating in binge eating disorder (BED; Wegner et al., 2002, Chua et al., 2004, Hilbert et al., 2007, Stein et al., 2007) and binge/purging behavior in bulimia nervosa (BN; Stice, 2001, Waters et al., 2001, Smyth et al., 2007, Crosby et al., 2009, Smyth et al., 2009). A key hypothesis in this context is that individuals with ED display deficits in ER and lack the skills required to adaptively and effectively cope with negative affective states. Binge attacks and/or purge behavior are then seen as attempts to cope with negative affect by providing short term comfort or distraction (Smyth et al., 2007, Wild et al., 2007).

Although most theoretical accounts on ER deficits in ED have focused on BN or BED, some theorists have suggested problems with ER to be present in other ED, too. For example, in their transdiagnostic model of ED, Fairburn, Cooper and Shafran (2003) suggest mood intolerance to be a process involved in the maintenance of ED in general. More specifically, excessive exercising in anorexia nervosa (AN) has been suggested to serve as an ER strategy and thereby replace the binge/purge cycle and binge behavior typical for BN and BED respectively (Penas-Lledo et al., 2002).

Preliminary evidence for the assumed lack of effective ER skills in ED comes from self-report studies comparing eating disordered individuals with healthy controls (HC). Several of these studies focused on the concept of alexithymia, which refers to the difficulty in identifying and describing feelings (Taylor et al., 1992, Bagby et al., 1994, Taylor et al., 1996). Using the Toronto Alexithymia Scale (TAS; Taylor et al., 1988), increased difficulties with respect to emotional awareness have been reported both for AN and BN (Bydlowski et al., 2005, Carano et al., 2006) and BED (Svaldi et al., 2010) when compared to HC. Furthermore, compared to HC and girls with unipolar depression, young women with BN show inferior interoceptive awareness and greater reluctance to express emotions (Sim and Zeman, 2004). In another study (Sim and Zeman, 2005), negative affect, poor awareness of emotions and nonconstructive coping with negative emotions were shown to partially mediate the link between body dissatisfaction and bulimic symptoms in a sample of early adolescent girls. Corstorphine et al. (2007) found women with AN, BN and ED not otherwise specified (EDNOS) to self-report greater avoidance of emotions and lower capacity to accept and manage emotions on the Distress Tolerance Scale (Corstorphine et al., 2007), an instrument which assesses adaptive and maladaptive means of coping with affect. In BED, the frequency of binge eating in a large sample of college students could be predicted by the total score, as well as by all the subscales of the Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) including non-acceptance of emotions, difficulties with engaging in goal-directed activities, impulsiveness, lack of awareness of emotions and non-availability of effective ER strategies (Whiteside et al., 2007). Similarly, Harrison et al. (2009) found women with AN to have significantly more difficulties in all the subscales of the DERS compared to HC. In a recent meta-analysis on the dispositional use of ER strategies (Aldao et al., 2010), rumination and suppression were positively and problem solving was negatively associated with ED symptoms. While effect sizes for rumination and suppression were medium, effect sizes for reappraisal were only small and non-significant. Hence, some ER strategies may be more important than others.

In sum, there is preliminary evidence supporting the hypothesis that individuals with ED show ER difficulties. However, a number of limitations regarding past research in this area are noteworthy. First, ER is a broad concept that has been defined as “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one's goals” (Thompson, 1994, pp. 27–28). Conceptualized in this way, ER encompasses a number of different processes involving not only “the modulation of emotional arousal, but also the awareness, understanding, and acceptance of emotions, and the ability to act in desired ways regardless of emotional state” (Gratz and Roemer, 2004, p. 41). It is yet unclear, which of these processes are involved in the maintenance of ED. Past studies have tended to focus on only a few variables at a time. In order to get a more complete picture of ER difficulties in ED, it appears important to assess ER in a more comprehensive way. Second, it is as yet unclear whether different types of eating disorders differ in their ER profile. In an earlier study using the Negative Mood Regulation Scale (Catanzaro and Mearns, 1990), no differences between different ED were found with regard to individuals' sense of competence in using various strategies of negative mood regulation (Gilboa-Schechtman et al., 2006). Although participants with AN reported lower levels of emotional awareness than individuals with BN, this difference disappeared when controlling for levels of depression and anxiety. Similarly, in another study TAS differences between AN and BN disappeared when taking depression into account as a confounding variable (Corcos et al., 2000). In a third study, no differences between AN and BN were found on the TAS, but AN females reported significantly lower levels of emotional awareness by means of the Level of Emotional Awareness Scale (LEAS; Lane et al., 1990) than participants with BN (Bydlowski et al., 2005).

The current study aimed to systematically investigate ER difficulties across different ED using a large range of ER variables. Most studies to date have compared eating disordered participants to HC only. It therefore remains unclear in which ways ER may be specific for eating pathology or rather a transdiagnostic maintenance factor. In fact, ER difficulties have been found across a large range of emotional disorders (Campbell-Sills and Barlow, 2006, Kring, 2008) and feature prominently in current theoretical models of psychopathology (Barlow et al., 2004, Mennin and Fresco, 2010). In the previously mentioned meta-analysis on the dispositional use of ER (Aldao et al., 2010), maladaptive strategies such as rumination, avoidance and suppression were associated with higher levels of depression, anxiety, substance abuse and eating pathology. Likewise, more adaptive strategies as acceptance, reappraisal and problem solving were associated with lower psychopathology. However, in contrast to adaptive ER strategies, maladaptive strategies were more strongly related to psychopathology. Furthermore, the relationship between certain ER strategies and psychopathology differed depending on the type of disorder examined. For example, effect sizes for rumination were large for anxiety and depression, but only medium for eating disturbances and substance abuse. Effect sizes for avoidance were large for depression, medium to large for anxiety, and medium for eating and substance problems. Finally, effect sizes for reappraisal were small to medium for depression and anxiety, but only small for eating pathology and substance abuse. A subsequently conducted study (Aldao and Nolen-Hoeksema, 2012) found the relationship between adaptive ER strategies and symptoms of depression, anxiety and alcohol problems to be moderated by levels of maladaptive strategies. Specifically, adaptive strategies were negatively associated with psychopathology symptoms only at high levels of maladaptive strategies. Moreover, maladaptive, but not adaptive ER strategies were prospectively associated with symptoms of psychopathology.

Based on the limitations of earlier research, the aims of the current study were threefold. It was firstly aimed to replicate earlier findings showing that ED are related to ER difficulties. In line with existing conceptualizations (Gratz and Roemer, 2004, Berking et al., 2008), a range of different characteristics of ER were examined. It was hypothesized that compared to healthy controls, participants with ED would (1) report a higher intensity of emotions, (2) be less acceptant of negative emotions, (3) report less awareness, clarity and understanding of their emotions, (4) report more ER problems, (5) report using less functional ER strategies, and (6) report using more dysfunctional ER strategies. The study further aimed to investigate whether different types of eating disorders (AN, BN and BED) differ regarding their ER profile. For most ER variables, the three groups of ED were expected to show elevated levels when compared to HC, but not to significantly differ from each other. However, based on preliminary earlier findings described above individuals with AN were hypothesized to show lower levels of emotional awareness, but also lower levels of impulse control difficulties than those with BN or BED. Finally, we aimed to investigate whether ER difficulties are specific of ED or rather a general distress deficiency also common to other psychological disorders. In order to test this important issue, we compared our ED groups to a group of women with major depressive disorder (MDD) and a group of women with borderline personality disorder (BPD). There is extensive evidence that BPD is related to ER difficulties (Levine et al., 1997, Ebner-Priemer et al., 2007) and deficient ER is a key feature of theoretical models of the disorder (Linehan, 1993, Gratz et al., 2009). Similarly, there is emerging evidence linking depression to difficulties in ER (Ehring et al., 2010, Joormann, 2010). In line with a transdiagnostic view of ER, we expected all patient groups to differ from HC on all ER variables with only few differences between the different diagnostic categories. However, we hypothesized that BPD, BN and BED would show higher levels of impulse control difficulties than all other groups. In addition, individuals with MDD were expected to report the lowest levels of using functional cognitive ER strategies.