Emotion dysregulation, self-image, and eating disorders

Background: Eating disorders (EDs) are complex psychiatric disorders that entail great suffering, high prevalence of comorbid psychiatric and somatic conditions, and increased mortality. The understanding of how EDs develop and are maintained is unclear, although emotion- and self-related themes are highlighted in several theoretical models of EDs. This thesis focuses on two psychological traits in relation to EDs: emotion dysregulation (difficulties in understanding and managing one’s emotions) and self-image (habitual self-directed evaluations and behaviors). Higher emotion dysregulation and more negative self-image may differentiate those suffering from EDs from controls, and independently, both concepts are associated with ED symptom severity and outcome. However, previous studies have generally been conducted in smaller samples and/or with only some ED diagnoses represented, and the impact of specific aspects of emotion dysregulation on symptoms remains unclear. Also, no prior research has concurrently examined both emotion dysregulation and self-image in relation to ED psychopathology and outcome in order to clarify potential pathways whereby these traits affect each other in relation to symptoms. Doing so could present an opportunity to integrate models, disentangle association pathways, and increase specificity. Aims: This thesis aimed to examine aspects of emotion dysregulation in relation to diagnostic presentation, specific ED symptoms, and ED outcome. It also aimed to examine direct and indirect associations between emotion dysregulation, self-image, and ED psychopathology, in ways that may inform both risk and potentially pathology-specific maintenance models. Lastly, it aimed to clarify if, and in that case how, these concepts may impact on ED outcome. Methods: Participants were patients with a range of EDs presenting to specialized ED treatment units (Studies I and III: N=999; Study IV: N=307) and comparison participants (female university students; Studies I and II: N=252). Emotion dysregulation was measured by the Difficulties in Emotion Regulation Scale (DERS), self-image by the Structural Analysis of Social Behavior (SASB), and ED symptoms by the Eating Disorder Examination Questionnaire (EDE-Q). Study I examined differences in DERS between patients and the comparison group, and between patients with different EDs. It also examined unique associations between DERS subscales and ED psychopathology and behavioral symptoms. Study II examined direct and indirect associations between emotion dysregulation, self-image, and ED symptoms in the comparison group using mediation analysis. Study III aimed to replicate the main Study II findings, and additional analyses extended previous work by exploring direct and indirect associations using particular emotion dysregulation dimensions and distinct self-image aspects. Study IV examined if initial DERS, or one-year change in DERS, could predict ED outcome in a subset of patients with complete follow-up data using multiple regression. It also examined pathways whereby change in emotion dysregulation and self-image might influence change in ED psychopathology over one year using mediation analysis. Results: Patients generally reported higher emotion dysregulation than the comparison group, but emotion dysregulation generally did not differ between diagnoses. Higher perceived lack of emotion regulation strategies was uniquely associated with ED psychopathology in both patients and comparison participants. In patients, higher difficulties in impulse control and emotional non-acceptance showed unique associations with binge-eating, while lower difficulties in goal-directed behavior was associated with compulsive exercise. Emotion dysregulation was strongly associated with negative self-image in both comparison participants and patients. When examined concurrently in relation to ED psychopathology, emotion dysregulation was only indirectly associated with symptoms through self-image. More finegrained analyses in patients with and without binge-eating characterized by loss of control, respectively, showed differentiating indirect effects through specific self-image aspects. Initial emotion dysregulation only weakly predicted ED outcome, while less improvement (or worsening) in emotion dysregulation was strongly associated with both higher follow-up ED psychopathology and an increased risk of still having an ED, even when initial severity was taken into consideration. Lastly, less emotion dysregulation improvement only was indirectly associated with less ED psychopathology improvement, through less self-image improvement. Conclusions: Emotion dysregulation seems to differentiate individuals suffering from EDs from comparison groups but generally not diagnoses from each other, indicating emotion dysregulation as a potential transdiagnostic risk factor. Although both emotion dysregulation and self-image independently may function as maintenance factors for ED psychopathology and mechanisms of change in relation to better ED outcomes, results from mediation analyses particularly suggest self-image as the influential factor whereby emotion dysregulation influences ED psychopathology. Thus, although results confirm considerable associations between emotion dysregulation and symptoms that would benefit from clinical attention, they particularly highlight the importance of addressing self-image when doing so. That is, helping patients to respond to themselves with acceptance and protection rather than harsh blame and neglect, even in the presence of unwanted, undifferentiated, and ‘unmanageable’ emotions, may provide patients with necessary tools for reducing ED symptoms

Exercise caution : Questions to ask adolescents who may exercise too hard

When the primary goal of exercise is to compensate for food intake and to alter body shape and weight, it is considered compulsive and may be harmful. Compulsive exercise (CE) is important in the pathogenesis of eating disorders (EDs). Many healthy adolescents engage in CE too, and this may indicate a risk for EDs. Our aim was to learn more about ED risk factors tied to CE and to try to isolate questions to ask in order to probe for high ED risk in adolescents engaging in CE. Using two well-established instruments (the Structural Analysis of Social Behavior and the Eating Disorders Examination Questionnaire), we studied associations between ED variables and CE in healthy adolescent boys and girls. We examined gender-specific items to generate the best possible fit for each gender. Individuals with CE displayed significantly greater ED pathology and more self-criticism, and this pattern was stronger in girls than in boys. Risk factors for ED among individuals with CE differed slightly for boys and girls. We put forward a set of gender-specific questions that may be helpful when probing for ED risk among adolescents engaging in CE

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

BACKGROUND: We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms. METHODS: 252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise. RESULTS: Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise. CONCLUSIONS: Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus

Running on empty – a nationwide large-scale examination of compulsive exercise in eating disorders

Abstract Background Compulsive exercise (CE) has been the neglected “Cinderella” among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample. Methods CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined. Results CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males. Conclusions At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment

Running on empty : a nationwide large-scale examination of compulsive exercise in eating disorders

BACKGROUND: Compulsive exercise (CE) has been the neglected "Cinderella" among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample. METHODS: CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined. RESULTS: CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males. CONCLUSIONS: At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment

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.Funding Agencies|None Funding Source: Medline</p

Factor Structure of the Difficulties in Emotion Regulation Scale in Treatment Seeking Adults with Eating Disorders

The Difficulties in Emotion Regulation Scale (DERS) is extensively used as a measure of emotion (dys-)regulation ability in both clinical and nonclinical populations. This is the first study to examine the factor structure of both the original 36-item and short 16-item version of the DERS in adults with eating disorders and to test measurement invariance across diagnostic subgroups. The factor structure of the scale was examined using confirmatory factor analysis in a psychiatric sample of adults with eating disorders (N = 857). Four primary factor structures were fitted to the data: (1) a unidimensional model, (2) a six-factor correlated-traits model, (3) a higher-order factor solution, and (4) a bifactor model. Measurement invariance was tested for diagnostic subgroups of anorexia nervosa and bulimia nervosa and associations between factors and eating pathology were examined in each diagnostic group. Results indicated that a modified bifactor solution fitted the data adequately for both the 36-item and 16-item version of the DERS. A general factor explained most of the variance (86%) and reliability was high for the general factor of DERS (total) but lower for the subscales. Measurement invariance of the bifactor model was supported across diagnostic subgroups and test of factor means reveled that bulimia nervosa had a higher factor mean than anorexia nervosa on the general factor. The general factor accounted for a significant proportion of variance in eating pathology. Our results support the use of the total scale of both the 36-item and 16-item version among adults with eating disorders

Exercise Caution: Questions to Ask Adolescents Who May Exercise Too Hard

When the primary goal of exercise is to compensate for food intake and to alter body shape and weight, it is considered compulsive and may be harmful. Compulsive exercise (CE) is important in the pathogenesis of eating disorders (EDs). Many healthy adolescents engage in CE too, and this may indicate a risk for EDs. Our aim was to learn more about ED risk factors tied to CE and to try to isolate questions to ask in order to probe for high ED risk in adolescents engaging in CE. Using two well-established instruments (the Structural Analysis of Social Behavior and the Eating Disorders Examination Questionnaire), we studied associations between ED variables and CE in healthy adolescent boys and girls. We examined gender-specific items to generate the best possible fit for each gender. Individuals with CE displayed significantly greater ED pathology and more self-criticism, and this pattern was stronger in girls than in boys. Risk factors for ED among individuals with CE differed slightly for boys and girls. We put forward a set of gender-specific questions that may be helpful when probing for ED risk among adolescents engaging in CE

Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise

INTRODUCTION: Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). METHOD: A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. RESULTS: Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. DISCUSSION: Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied

Initial self-blame predicts eating disorder remission after 9 years

Background Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. Aim To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. Results Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. Conclusion In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. Plain English summary It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of recovery, with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.Funding Agencies|Kalmar Regional Council, Sweden</p