Academic journal article Journal of Eating Disorders

Emotion Regulation Difficulties in Anorexia Nervosa: Associations with Improvements in Eating Psychopathology

Academic journal article Journal of Eating Disorders

Emotion Regulation Difficulties in Anorexia Nervosa: Associations with Improvements in Eating Psychopathology

Article excerpt

Author(s): Marsha Rowsell[sup.1], Danielle E. MacDonald[sup.2,3] and Jacqueline C. Carter[sup.1]


In her seminal writings, Bruch [1, 2] asserted that problems with emotion regulation, particularly difficulties differentiating and describing emotions, are a core deficit in anorexia nervosa (AN). Recently, a growing body of theoretical and empirical evidence suggests that emotion regulation deficits may play a key role in both the development and maintenance of AN [3-7]. Indeed, several authors have theorized that AN is a disorder of emotion regulation and that the symptoms of AN, such as dietary restriction, excessive exercise, and binge/purge behaviors, represent maladaptive attempts to regulate aversive emotional states [8-10].

In a recent review article, Lavender and colleagues [11] examined the research evidence for applying Gratz and Roemer's [12] multidimensional model of emotion dysregulation in conceptualizing emotion regulation difficulties in AN. This review uncovered the following findings: considerable evidence to support the application of this model in AN including evidence of broad deficits in adaptive emotion regulation skills in AN; some evidence of impulse control and distress tolerance difficulties in AN; substantial evidence of emotion awareness deficits in AN; and some evidence of emotional avoidance in AN.

Indeed, a number of studies have found that difficulties with emotion regulation are associated with eating disorder psychopathology [7, 13]. High levels of negative emotionality have been shown to prospectively increase the risk of eating pathology [14, 15] and, in a recent meta-analysis, lack of adaptive emotion regulation strategies - particularly deficits in problem-solving skills, and greater use of avoidance, rumination and suppression - was associated with greater eating disorder psychopathology [16]. Further, there is evidence that characteristic anxious avoidance, both of emotions and of interpersonal situations that may trigger emotional experiences in AN, often predates the illness and persists after recovery [7, 17, 18].

Several recent studies have found evidence that emotion regulation difficulties may also play a role in the maintenance of AN. It has been consistently found that individuals with AN report greater impairments in emotion regulation compared to controls [19]. Specifically, AN has been shown to be associated with high vulnerability to dysregulated emotions including impaired abilities to experience and differentiate emotions, as well as difficulties with the attenuation and modulation of negative emotional states [19-21]. Individuals with AN have also been found to report higher levels of alexithymia (i.e., difficulty identifying and describing emotions) compared to healthy controls [22, 23]. Further, some research has shown that individuals with AN have greater levels of alexithymia than individuals with other eating disorders such as bulimia nervosa and binge eating disorder [23], suggesting a specific emotion-related deficit in AN rather than a general impairment related to eating disorders more broadly. In addition, several studies have found evidence of distress intolerance, that is, the inability to accept and withstand negative emotional experiences, particularly among those with the restricting subtype of AN [4, 17]. As observed by Lynch and colleagues [24], emotional overcontrol has been linked with social withdrawal, cognitive rigidity, reward insensitivity, strong needs for structure and symmetry, and clinical perfectionism - traits which have been shown to be common among individuals with AN, and which may function to perpetuate the disorder [6, 25, 26].

Studies that have examined differences in emotion regulation deficits between the two subtypes of AN have produced mixed results. In the restricting subtype of AN (AN-R), emotion regulation deficits tend to be characterized by emotional overcontrol, such as emotional inhibition and lack of emotion expression [27]. …

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