Cited by 512Eating Disorders and BehaviorsAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPersonality Disorders and Psychopathology

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Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature

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Lavender, Jason M., Wonderlich, Stephen A., Engel, Scott G., Gordon, Kathryn H., Kaye, Walter H., Mitchell, James E.·2015·Clinical Psychology Review

DOI 10.1016/j.cpr.2015.05.010PMC PMC4537813

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Abstract

Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer's (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.

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The Role of Affect in the Maintenance of Anorexia Nervosa: Evidence from a Naturalistic Assessment of Momentary Behaviors and Emotion
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Facets of Negative Affect Prior to and Following Binge-Only, Purge-Only, and Binge/Purge Events in Women With Bulimia Nervosa
Berg, K. C., Crosby, R., Cao, L., Peterson, C., Engel, S., Mitchell, J., & Wonderlich, S. (2012) · Journal of Abnormal Psychology · doi:10.1037/a0029703 · Cited by 236 · cited 1×
“Some studies examining trajectories of momentary affect have reported a pattern in which negative affect increases prior to ED behaviors, and decreases after the behaviors (e.g., Berg et al., 2013; Smyth et al., 2007).”
Background
The Relationship Between Emotion Dysregulation and Deliberate Self-Harm Among Inpatients with Substance Use Disorders
Gratz, K. L., & Tull, M. T. (2009) · Cognitive Therapy and Research · doi:10.1007/s10608-009-9268-4 · Cited by 225 · cited 1×
“…following treatment (e.g., Gratz, Tull, & Levy, 2013; Safer, Robinson, & Jo, 2010; Wonderlich et al., 2014); and (c) the dimensions have displayed differential associations with various psychopathological symptoms (e.g., Gratz & Tull, 2010; Racine & Wildes, 2013; Williams & Grisham, 2012).”
Background
Rumination, experiential avoidance, and dysfunctional thinking in eating disorders.
Rawal, A., Park, R. J., & Williams, J. M. G. (2010) · Behaviour Research and Therapy · doi:10.1016/j.brat.2010.05.009 · Cited by 223 · cited 1×
“Evidence of elevated experiential avoidance in those with AN compared to controls (Rawal et al., 2010) is also consistent with this notion.”
Result
Aspects of social cognition in anorexia nervosa: Affective and cognitive theory of mind
Russell, T. A., Schmidt, U. H., Doherty, L., Young, V., & Tchanturia, K. (2009) · Psychiatry Research · doi:10.1016/j.psychres.2008.10.028 · Cited by 217
A risk and maintenance model for bulimia nervosa: From impulsive action to compulsive behavior.
Pearson, C. M., Wonderlich, S. A., & Smith, G. T. (2015) · Psychological Review · doi:10.1037/a0039268 · Cited by 217
Attentional Bias, Emotion Recognition, and Emotion Regulation in Anorexia: State or Trait?
Harrison, A., Tchanturia, K., & Treasure, J. L. (2010) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.04.037 · Cited by 215 · cited 5×
“A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript al., 2005 [mixed ED sample]; Harrison et al., 2010; Legenbauer, Vocks, & Ruddel, 2008; Sim & Zeman, 2004; Svaldi et al., 2012).”
BackgroundInfluential
Maintenance of binge eating through negative mood: a naturalistic comparison of binge eating disorder and bulimia nervosa.
Hilbert, A., & Tuschen-Caffier, B. (2007) · International Journal of Eating Disorders · doi:10.1002/eat.20401 · Cited by 215 · cited 1×
“In contrast, other studies have found elevated negative emotional states prior to binge eating that further increase after the behavior (e.g., Hilbert & Tuschen-Caffier, 2007).”
Result
Deficits in emotion regulation associated with pathological gambling
Williams, A. D., Grisham, J. R., Erskine, A., & Cassedy, E. (2011) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.2011.02022.x · Cited by 207
The “Reading the Mind in Films” Task: Complex emotion recognition in adults with and without autism spectrum conditions
Golan, O., Baron-Cohen, S., Hill, J. J., & Golan, Y. (2006) · Social Neuroscience · doi:10.1080/17470910600980986 · Cited by 200
Emotional Theory of Mind and Emotional Awareness in Recovered Anorexia Nervosa Patients
Oldershaw, A., Hambrook, D. G., Tchanturia, K., Treasure, J. L., & Schmidt, U. H. (2009) · Psychosomatic Medicine · doi:10.1097/psy.0b013e3181c6c7ca · Cited by 197 · cited 1×
“A related line of research has utilized theory of mind-based tasks, with results further suggesting deficits in the recognition of complex emotions in AN versus controls (Harrison et al., 2010; Oldershaw et al., 2010; Russell, Schmidt, Doherty, Young, & Tchanturia, 2009).”
Emotional processing in eating disorders: specific impairment or general distress related deficiency?
Gilboa‐Schechtman, E., Avnon, L., Zubery, E., & Jeczmien, P. (2006) · Depression and Anxiety · doi:10.1002/da.20163 · Cited by 195 · cited 5×
“, 2013; Sureda, Valdes, Jodar, & de Pablo, 1999), although results are less consistent when controlling for depression and/or anxiety (e.g., Eizaguirre et al., 2004; Gilboa-Schechtman et al., 2006; Montebarocci et al., 2006; Rozenstein et al., 2011; Speranza et al., 2005).”
BackgroundResultInfluential
Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder
Gratz, K. L., Tull, M. T., & Levy, R. (2014) · Psychological Medicine · doi:10.1017/s0033291713002134 · Cited by 194
Impulsiveness and lack of inhibitory control in eating disorders.
Claes, L., Nederkoorn, C., Vandereycken, W., Guerrieri, R., & Vertommen, H. (2006) · Eating Behaviors · doi:10.1016/j.eatbeh.2006.05.001 · Cited by 192 · cited 1×
“Evidence more clearly indicates that avoidance tendencies and punishment sensitivity are elevated in AN (Claes et al., 2006, 2010; Glashouwer et al., 2014; Harrison, et al., 2011; Jappe et al., 2011).”
Background
Deficient Activity in the Neural Systems That Mediate Self-regulatory Control in Bulimia Nervosa
Marsh, R., Steinglass, J. E., Gerber, A. J., Graziano O’Leary, K., Wang, Z., Murphy, D., Walsh, B. T., & Peterson, B. S. (2009) · Archives of General Psychiatry · doi:10.1001/archgenpsychiatry.2008.504 · Cited by 190 · cited 1×
“Moreover, recent studies have revealed abnormal functioning in neurocircuitry underlying executive processes in AN and BN (e.g., Lock et al., 2011; Marsh et al., 2009, 2011; Wagner et al., 2007; Zastrow et al., 2009), which is relevant to dysregulated behaviors in BN and overregulated behaviors in…”
Background
The Beliefs about Emotions Scale: Validity, reliability and sensitivity to change
Rimes, K. A., & Chalder, T. (2010) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2009.09.014 · Cited by 188
The recognition of emotion in the faces and voice of anorexia nervosa
Kucharska‐Pietura, K., Nikolaou, V., Masiak, M., & Treasure, J. L. (2003) · International Journal of Eating Disorders · doi:10.1002/eat.10219 · Cited by 187
Hunger Does Not Motivate Reward in Women Remitted from Anorexia Nervosa
Wierenga, C. E., Bischoff‐Grethe, A., Melrose, A. J., Irvine, Z., Torres, L. A., Bailer, U. F., Simmons, A. N., Fudge, J. L., McClure, S. M., Ely, A. V., et al. (2014) · Biological Psychiatry · doi:10.1016/j.biopsych.2014.09.024 · Cited by 184 · cited 2×
“, anterior ventral striatum), consistent with a shared trait for emotion dysregulation (e.g., Wagner et al., 2007; Wagner, 2010; Wierenga et al., 2015).”
Background
Personality traits after recovery from eating disorders: Do subtypes differ?
Wagner, A., Barbarich-Marsteller, N. C., Frank, G., Bailer, U. F., Wonderlich, S. A., Crosby, R. D., Henry, S. E., Vogel, V., Plotnicov, K. H., McConaha, C. W., et al. (2006) · International Journal of Eating Disorders · doi:10.1002/eat.20251 · Cited by 181 · cited 5×
“Findings from studies with recovered ED samples suggest that these propensities may persist with recovery (e.g., Harrison et al.; Wagner et al., 2006), although other results suggest differences between ill and recovered groups (e.”
BackgroundResultInfluential
Alexithymia and facial emotion recognition in patients with eating disorders
Kessler, H., Schwarze, M., Filipic, S., Traue, H. C., & von Wietersheim, J. (2006) · International Journal of Eating Disorders · doi:10.1002/eat.20228 · Cited by 177
Aberrant Brain Activation During a Response Inhibition Task in Adolescent Eating Disorder Subtypes
Lock, J., Garrett, A. S., Beenhakker, J., & Reiss, A. L. (2010) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2010.10010056 · Cited by 172 · cited 2×
“Moreover, recent studies have revealed abnormal functioning in neurocircuitry underlying executive processes in AN and BN (e.g., Lock et al., 2011; Marsh et al., 2009, 2011; Wagner et al., 2007; Zastrow et al., 2009), which is relevant to dysregulated behaviors in BN and overregulated behaviors in…”
BackgroundResult
Alexithymia and depression in eating disorders
Corcos, M., Guilbaud, O., Speranza, M., Paterniti, S., Loas, G., Stéphan, P., & Jeammet, P. (2000) · Psychiatry Research · doi:10.1016/s0165-1781(00)00109-8 · Cited by 164 · cited 3×
“Findings from numerous studies using self-report measures suggest that those with AN exhibit greater alexithymia compared to controls (Corcos et al., 2000; Nandrino, Doba, Lesne, Christophe, & Pezard, 2006; Nowakowski, McFarlane, & Cassin; 2013; Schmidt, Jiwany, & Treasure, 1993; Taylor, Parker,…”
BackgroundInfluential
Evoked facial emotional expression and emotional experience in people with anorexia nervosa
Davies, H. A., Schmidt, U. H., Stahl, D. R., & Tchanturia, K. (2010) · International Journal of Eating Disorders · doi:10.1002/eat.20852 · Cited by 160 · cited 4×
“…Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et al., 2014; Davies et al., 2011; Geller, Cockell, Hewitt, Goldner, & Flett, 2000; Jansch et al., 2009; Oldershaw et al., 2012; Svaldi et al., 2012).”
BackgroundMethodInfluential
Impulsivity, Emotion Regulation, and Mindful Attentional Focus in Compulsive Buying
Williams, A. D., & Grisham, J. R. (2011) · Cognitive Therapy and Research · doi:10.1007/s10608-011-9384-9 · Cited by 153 · cited 1×
“…following treatment (e.g., Gratz, Tull, & Levy, 2013; Safer, Robinson, & Jo, 2010; Wonderlich et al., 2014); and (c) the dimensions have displayed differential associations with various psychopathological symptoms (e.g., Gratz & Tull, 2010; Racine & Wildes, 2013; Williams & Grisham, 2012).”
Background
Daily mood patterns and bulimic behaviors in the natural environment
Crosby, R. D., Wonderlich, S. A., Engel, S. G., Simonich, H. K., Smyth, J. M., & Mitchell, J. E. (2008) · Behaviour Research and Therapy · doi:10.1016/j.brat.2008.11.006 · Cited by 149 · cited 1×
“Finally, daily patterns of negative affect have been found to be associated with binge eating and purging in BN (Crosby et al., 2009), suggesting the importance of considering variability, in addition to intensity, of negative affect.”
Background
Starvation and emotion regulation in anorexia nervosa
Brockmeyer, T., Holtforth, M. G., Bents, H., Kämmerer, A., Herzog, W., & Friederich, H. (2011) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2011.09.003 · Cited by 147 · cited 2×
“A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript groups (Harrison, Tchanturia, & Treasure, 2010), and others finding no significant differences (e.g., Brockmeyer et al., 2012).”
BackgroundMethod
Emotion Dysregulation and Symptoms of Anorexia Nervosa: The Unique Roles of Lack of Emotional Awareness and Impulse Control Difficulties when Upset
Racine, S., & Wildes, J. (2013) · International Journal of Eating Disorders · doi:10.1002/eat.22145 · Cited by 143 · cited 3×
“…(2004) measure of emotion dysregulation suggest that overall emotion dysregulation is positively associated with ED severity in both AN and BN, with various emotion dysregulation dimensions differentially related to ED symptoms in each disorder (Lavender et al., 2014; Racine & Wildes, 2013).”
BackgroundMethod
Alexithymia and its relationships with anxiety and depression in eating disorders
Eizaguirre, A. E., Ortego, A., de Apellániz, I. O. D. A. M., Olariaga, L. J., & Juaniz, M. (2003) · Personality and Individual Differences · doi:10.1016/s0191-8869(03)00099-0 · Cited by 143 · cited 1×
“…1994; Nowakowski et al., 2013; Sureda, Valdes, Jodar, & de Pablo, 1999), although results are less consistent when controlling for depression and/or anxiety (e.g., Eizaguirre et al., 2004; Gilboa-Schechtman et al., 2006; Montebarocci et al., 2006; Rozenstein et al., 2011; Speranza et al., 2005).”
Result
An FMRI study of self-regulatory control and conflict resolution in adolescents with bulimia nervosa
Marsh, R., Horga, G., Wang, Z., Wang, P., Klahr, K. W., Berner, L. A., Walsh, B. T., & Peterson, B. S. (2011) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2011.11010094 · Cited by 142
Does the tendency to act impulsively underlie binge eating and alcohol use problems? An empirical investigation
Kane, T. A., Loxton, N. J., Staiger, P. K., & Dawe, S. (2003) · Personality and Individual Differences · doi:10.1016/s0191-8869(03)00070-9 · Cited by 140
Alexithymia ratings in bulimia nervosa: clinical correlates
Jimerson, D. C., Wolfe, B. E., Franko, D. L., Covino, N. A., & Sifneos, P. E. (1994) · Psychosomatic Medicine · doi:10.1097/00006842-199403000-00002 · Cited by 138
Anger and core beliefs in the eating disorders
Waller, G., Babbs, M., Milligan, R., Meyer, C., Ohanian, V., & Leung, N. (2003) · International Journal of Eating Disorders · doi:10.1002/eat.10163 · Cited by 132 · cited 6×
“…AN and control groups or find greater suppression but not lower expression (Breaux & Moreno, 1994; Fassino, Daga, Piero, Leombruni, & Rovera, 2001; Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et…”
BackgroundResultInfluential
Depressive personality dimensions and alexithymia in eating disorders
Speranza, M., Corcos, M., Loas, G., Stéphan, P., Guilbaud, O., Pérez-Díaz, F., Vénisse, J.-L., Bizouard, P., Halfon, O., Flament, M. F., et al. (2005) · Psychiatry Research · doi:10.1016/j.psychres.2005.04.001 · Cited by 129 · cited 3×
“Other investigations have reported greater alexithymia in AN versus controls even when controlling for relevant affective constructs (Montebarocci et al., 2006; Speranza et al., 2005).”
BackgroundResult
Daily patterns of anxiety in anorexia nervosa: Associations with eating disorder behaviors in the natural environment.
Lavender, J. M., Young, K. P. D., Wonderlich, S. A., Crosby, R. D., Engel, S. G., Mitchell, J. E., Crow, S. J., Peterson, C. B., & Grange, D. L. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0031823 · Cited by 128
Altered Temporal Difference Learning in Bulimia Nervosa
Frank, G., Reynolds, J. R., Shott, M. E., & O’Reilly, R. C. (2011) · Biological Psychiatry · doi:10.1016/j.biopsych.2011.05.011 · Cited by 128
Emotional expression, self‐silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome
Hambrook, D. G., Oldershaw, A., Rimes, K. A., Schmidt, U. H., Tchanturia, K., Treasure, J. L., Richards, S., & Chalder, T. (2010) · British Journal of Clinical Psychology · doi:10.1348/014466510x519215 · Cited by 126
The importance of distinguishing between the different eating disorders (sub)types when assessing emotion regulation strategies
Danner, U. N., Sternheim, L. C., & Evers, C. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.01.005 · Cited by 124 · cited 6×
“…2001; Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et al., 2014; Davies et al., 2011; Geller, Cockell, Hewitt, Goldner, & Flett, 2000; Jansch et al., 2009; Oldershaw et al., 2012; Svaldi et…”
BackgroundMethodInfluential
Anorexia nervosa and the insula
Nunn, K., Frampton, I., Fuglset, T. S., Törzsök-Sonnevend, M., & Lask, B. (2011) · Medical Hypotheses · doi:10.1016/j.mehy.2010.10.038 · Cited by 122
Psychometric evaluation of the behavioral inhibition/behavioral activation system scales and the sensitivity to punishment and sensitivity to reward questionnaire in a sample of eating disordered patients
Beck, I. M. E., Smits, D., Claes, L., Vandereycken, W., & Bijttebier, P. (2009) · Personality and Individual Differences · doi:10.1016/j.paid.2009.04.007 · Cited by 120
Anger and personality in eating disorders
Fassino, S., Daga, G. A., Pierò, A., Leombruni, P., & Rovera, G. G. (2001) · Journal of Psychosomatic Research · doi:10.1016/s0022-3999(01)00280-x · Cited by 120
Exploring the relationship between negative urgency and dysregulated eating: Etiologic associations and the role of negative affect.
Racine, S. E., Keel, P. K., Burt, S. A., Sisk, C. L., Neale, M. C., Boker, S. M., & Klump, K. L. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0031250 · Cited by 120 · cited 1×
“, 2009); (2) the preponderance of cross-sectional studies, with a smaller body of prospective/longitudinal studies (e.g., Combs, Pearson, & Smith, 2011; Haynos et al., 2014; Racine & Wildes, in press; Racine et al., 2013), and (3) a variety of issues related to sampling.”
Background
Heightened sensitivity to reward and punishment in anorexia nervosa
Jappe, L. M., Frank, G. K. W., Shott, M. E., Rollin, M. D. H., Pryor, T., Hagman, J. O., Yang, T. T., & Davis, E. (2011) · International Journal of Eating Disorders · doi:10.1002/eat.20815 · Cited by 119 · cited 3×
“Evidence more clearly indicates that avoidance tendencies and punishment sensitivity are elevated in AN (Claes et al., 2006, 2010; Glashouwer et al., 2014; Harrison, et al., 2011; Jappe et al., 2011).”
Background
Development of emotion acceptance behavior therapy for anorexia nervosa: a case series
Wildes, J. E., & Marcus, M. D. (2011) · International Journal of Eating Disorders · doi:10.1002/eat.20826 · Cited by 118
Emotion Awareness and Identification Skills in Adolescent Girls With Bulimia Nervosa
Sim, L. A., & Zeman, J. L. (2004) · Journal of Clinical Child & Adolescent Psychology · doi:10.1207/s15374424jccp3304_11 · Cited by 107 · cited 2×
“A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript al., 2005 [mixed ED sample]; Harrison et al., 2010; Legenbauer, Vocks, & Ruddel, 2008; Sim & Zeman, 2004; Svaldi et al., 2012).”
BackgroundResult
Alexithymia and emotional awareness in anorexia nervosa: Time for a shift in the measurement of the concept?
Parling, T., Mortazavi, M., & Ghaderi, A. (2010) · Eating Behaviors · doi:10.1016/j.eatbeh.2010.04.001 · Cited by 106 · cited 1×
“Some findings suggest deficits in the ability to infer emotions in the self in acute AN (but not recovered AN; Oldershaw, Hambrook, Tchanturia, Treasure, & Schmidt, 2010), whereas other findings suggest no apparent deficits (Parling et al., 2010).”
Background
Is Avoidant Personality Disorder More Than Just Social Avoidance?
Taylor, C. T., Laposa, J. M., & Alden, L. E. (2004) · Journal of Personality Disorders · doi:10.1521/pedi.18.6.571.54792 · Cited by 105
Impaired Central Processing of Emotional Faces in Anorexia Nervosa
Pollatos, O., Herbert, B. M., Schandry, R., & Gramann, K. (2008) · Psychosomatic Medicine · doi:10.1097/psy.0b013e31817e41e6 · Cited by 104
Negative reinforcement eating expectancies, emotion dysregulation, and symptoms of bulimia nervosa.
Hayaki, J. (2009) · International Journal of Eating Disorders · doi:10.1002/eat.20646 · Cited by 104
Well-being and morbid obesity in women: A controlled therapy evaluation
Tanco, S. A., Linden, W., & Earle, T. L. (1998) · International Journal of Eating Disorders · doi:10.1002/(sici)1098-108x(199804)23:3 · Cited by 103
Dimensions of Emotion Dysregulation in Bulimia Nervosa
Lavender, J. M., Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Engel, S. G., Mitchell, J. E., Crow, S. J., Smith, T. L., Klein, M. H., Goldschmidt, A. B., et al. (2014) · European Eating Disorders Review · doi:10.1002/erv.2288 · Cited by 103 · cited 2×
“Results from research using Gratz and Roemer’s (2004) measure of emotion dysregulation suggest that overall emotion dysregulation is positively associated with ED severity in both AN and BN, with various emotion dysregulation dimensions differentially related to ED symptoms in each disorder (Lavender et al., 2014; Rac…”
BackgroundMethod
The role of negative urgency and expectancies in problem drinking and disordered eating: Testing a model of comorbidity in pathological and at-risk samples.
Fischer, S. F., Settles, R. E., Collins, B., Gunn, R. L., & Smith, G. T. (2011) · Psychology of Addictive Behaviors · doi:10.1037/a0023460 · Cited by 99 · cited 1×
“…of emotioneliciting situations, negative urgency, and distress tolerance, particularly in clinical populations (e.g., Corstorphine et al., 2007; Fischer et al., 2007; 2012; Hambrook et al., 2011; Raykos et al., 2009); (2) the preponderance of cross-sectional studies, with a smaller body of…”
Background
The relationship of momentary anger and impulsivity to bulimic behavior
Engel, S. G., Boseck, J. J., Crosby, R. D., Wonderlich, S. A., Mitchell, J. E., Smyth, J. M., Miltenberger, R. G., & Steiger, H. (2006) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.03.014 · Cited by 96 · cited 1×
“Additional EMA research has shown that individual difference variables (e.g., personality traits, co-occurring psychopathology) may impact the association between affect and ED behaviors (e.g., Engel et al., 2007; Selby et al., 2012).”
Background
Untitled work
(2010) · Cited by 96
Altered striatal response to reward in bulimia nervosa after recovery
Wagner, A., Aizenstein, H., Venkatraman, V. K., Bischoff‐Grethe, A., Fudge, J., May, J. C., Frank, G. K., Bailer, U. F., Fischer, L., Putnam, K., et al. (2010) · International Journal of Eating Disorders · doi:10.1002/eat.20699 · Cited by 93
Self-citation
Dynamic longitudinal relations between emotion regulation difficulties and anorexia nervosa symptoms over the year following intensive treatment.
Racine, S. E., & Wildes, J. E. (2014) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000011 · Cited by 90
Emotional processing in women with anorexia nervosa and in healthy volunteers
Jänsch, C., Harmer, C. J., & Cooper, M. J. (2009) · Eating Behaviors · doi:10.1016/j.eatbeh.2009.06.001 · Cited by 89 · cited 2×
“…Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et al., 2014; Davies et al., 2011; Geller, Cockell, Hewitt, Goldner, & Flett, 2000; Jansch et al., 2009; Oldershaw et al., 2012; Svaldi et al., 2012).”
Background
Negative feelings and the desire to eat in bulimia nervosa.
Alpers, G., & Tuschen-Caffier, B. (2001) · Eating Behaviors · doi:10.1016/s1471-0153(01)00040-x · Cited by 88 · cited 1×
“However, findings also suggest that negative emotions may decrease following purging (Alpers & Tuschen-Caffier, 2001).”
Background
Reward and punishment sensitivity in dysfunctional eating and hazardous drinking women: Associations with family risk
Loxton, N. J., & Dawe, S. (2006) · Appetite · doi:10.1016/j.appet.2006.05.014 · Cited by 87 · cited 1×
“…M anuscript A uthor M anuscript Regarding approach and avoidance motivation in AN, processes consistent with those described in Reinforcement Sensitivity Theory (see Corr, 2004) may be involved in the etiology and/or maintenance of EDs (Harrison, Treasure, & Smillie, 2011; Loxton & Dawe, 2006).”
Method
Current status of functional imaging in eating disorders
Frank, G., & Kaye, W. H. (2012) · International Journal of Eating Disorders · doi:10.1002/eat.22016 · Cited by 84 · cited 9×
“Overall, preliminary findings suggest EDs may be characterized by a heightened tendency to avoid emotion-eliciting situations, although the limited body of research with AN- and BN-specific samples limits the ability to make firm conclusions.”
BackgroundInfluential
Emotional functioning in adolescent anorexia nervosa patients
Zonnevylle-Bender, M. J. S., van Goozen, S. H. M., Cohen‐Kettenis, P. T., van Elburg, T. A., & van Engeland, H. (2004) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-004-0351-9 · Cited by 81
Dysregulated Eating and Distress: Examining the Specific Role of Negative Urgency in a Clinical Sample
Anestis, M. D., Smith, A. R., Fink, E. L., & Joiner, T. E. (2008) · Cognitive Therapy and Research · doi:10.1007/s10608-008-9201-2 · Cited by 81
Autobiographical memory deficit in anorexia nervosa: emotion regulation and effect of duration of illness.
Nandrino, J., Doba, K., Lesne, A., Christophe, V., & Pezard, L. (2006) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2006.02.008 · Cited by 80
Approach and avoidance motivation in eating disorders
Harrison, A., Treasure, J. L., & Smillie, L. D. (2011) · Psychiatry Research · doi:10.1016/j.psychres.2011.04.022 · Cited by 76
Clinical Handbook of Eating Disorders: An Integrated Approach
Gearhart, L. (2007) · Psychiatric Services · doi:10.1176/appi.ps.58.2.273 · Cited by 76
An Experimental Investigation of Verbal Expression of Emotion in Anorexia and Bulimia Nervosa
Davies, H. A., Swan, N., Schmidt, U. H., & Tchanturia, K. (2011) · European Eating Disorders Review · doi:10.1002/erv.1157 · Cited by 73 · cited 3×
“…Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et al., 2014; Davies et al., 2011; Geller, Cockell, Hewitt, Goldner, & Flett, 2000; Jansch et al., 2009; Oldershaw et al., 2012; Svaldi et al., 2012).”
BackgroundMethod
Social Cognition in Bulimia Nervosa: A Systematic Review
DeJong, H., den Eynde, F. V., Broadbent, H. J., Kenyon, M., Lavender, A., Startup, H. M., & Schmidt, U. H. (2011) · European Psychiatry · doi:10.1016/j.eurpsy.2011.07.002 · Cited by 73 · cited 1×
“…BN do not display substantial emotion recognition deficits compared to controls for most emotions using a variety of measures (e.g., Harrison et al., 2010; Kenyon et al., 2012; Legenbauer et al., 2008), although the limited number of studies precludes any firm conclusions (see DeJong et al., 2013).”
Background
A risk model for preadolescent disordered eating
Combs, J. L., Pearson, C. M., & Smith, G. T. (2010) · International Journal of Eating Disorders · doi:10.1002/eat.20851 · Cited by 67
The relationship of neuroticism and urgency to negative consequences of alcohol use in women with bulimic symptoms
Fischer, S. F., Smith, G. T., Annus, A. M., & Hendricks, M. (2007) · Personality and Individual Differences · doi:10.1016/j.paid.2007.03.011 · Cited by 67 · cited 2×
“…of emotioneliciting situations, negative urgency, and distress tolerance, particularly in clinical populations (e.g., Corstorphine et al., 2007; Fischer et al., 2007; 2012; Hambrook et al., 2011; Raykos et al., 2009); (2) the preponderance of cross-sectional studies, with a smaller body of…”
Background
Alexithymia in female patients with eating disorders
Montebarocci, O., Codispoti, M., Surcinelli, P., Franzonı, E., Baldaro, B., & Rossi, N. C. F. (2006) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/bf03327739 · Cited by 67 · cited 3×
“Other investigations have reported greater alexithymia in AN versus controls even when controlling for relevant affective constructs (Montebarocci et al., 2006; Speranza et al., 2005).”
BackgroundResult
Differentiating bingeing/purging and restrictive eating disorder subtypes: The roles of temperament, effortful control, and cognitive control
Claes, L., Robinson, M. D., Muehlenkamp, J. J., Vandereycken, W., & Bijttebier, P. (2009) · Personality and Individual Differences · doi:10.1016/j.paid.2009.09.016 · Cited by 62 · cited 1×
“Evidence more clearly indicates that avoidance tendencies and punishment sensitivity are elevated in AN (Claes et al., 2006, 2010; Glashouwer et al., 2014; Harrison, et al., 2011; Jappe et al., 2011).”
Background
Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration
Haynos, A. F., Roberto, C. A., Martinez, M. A., Attia, E., & Fruzzetti, A. E. (2014) · International Journal of Eating Disorders · doi:10.1002/eat.22265 · Cited by 62 · cited 4×
“Consistent with the latter findings, preliminary evidence also suggests no difference in emotion regulation between those with acute AN and weight-restored individuals (Haynos et al., 2014).”
BackgroundResultInfluential
Emotional expression and body dissatisfaction
Hayaki, J., Friedman, M. A., & Brownell, K. D. (2001) · International Journal of Eating Disorders · doi:10.1002/eat.1111 · Cited by 62
Emotion and Eating Disorder Symptoms in Patients with Anorexia Nervosa: An Experimental Study
Wildes, J., Marcus, M., Bright, A. C., Dapelo, M. M., & Psychol, M. C. (2012) · International Journal of Eating Disorders · doi:10.1002/eat.22020 · Cited by 60 · cited 1×
“In one study, women with AN were randomized to a negative or neutral mood induction and then completed a test meal (Wildes et al., 2012).”
Background
Out of control?: Inhibition processes in eating disorders from a personality and cognitive perspective
Claes, L., Mitchell, J. E., & Vandereycken, W. (2011) · International Journal of Eating Disorders · doi:10.1002/eat.20966 · Cited by 59
Emotional Processing Following Recovery from Anorexia Nervosa
Oldershaw, A., DeJong, H., Hambrook, D. G., Broadbent, H. J., Tchanturia, K., Treasure, J. L., & Schmidt, U. H. (2012) · European Eating Disorders Review · doi:10.1002/erv.2153 · Cited by 59 · cited 3×
“…Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and reduced expression of emotions in AN (Danner et al., 2014; Davies et al., 2011; Geller, Cockell, Hewitt, Goldner, & Flett, 2000; Jansch et al., 2009; Oldershaw et al., 2012; Svaldi et al., 2012).”
Background
Identification and Evaluation of Cognitive Affect-Regulation Strategies: Development of a Self-Report Measure
Kamholz, B. W., Hayes, A. M., Carver, C. S., Gulliver, S. B., & Perlman, C. A. (2006) · Cognitive Therapy and Research · doi:10.1007/s10608-006-9013-1 · Cited by 59
Heightened sensitivity to punishment and reward in anorexia nervosa
Glashouwer, K. A., Bloot, L., Veenstra, E. M., Franken, I. H. A., & de Jong, P. J. (2014) · Appetite · doi:10.1016/j.appet.2013.12.019 · Cited by 58 · cited 1×
“Evidence more clearly indicates that avoidance tendencies and punishment sensitivity are elevated in AN (Claes et al., 2006, 2010; Glashouwer et al., 2014; Harrison, et al., 2011; Jappe et al., 2011).”
Background
A study of patients with anorexia nervosa using ecologic momentary assessment.
Engel, S., Wonderlich, S., Crosby, R., Wright, T. L., Mitchell, J., Crow, S., & Venegoni, E. (2005) · International Journal of Eating Disorders · doi:10.1002/eat.20184 · Cited by 58 · cited 4×
“…AN and BN are characterized by elevated negative emotionality (e.g., depressive symptoms, overall negative affect, specific negative affective states; Allen, Scannell, & Turner, 1998; Engel et al., 2005; Pollice, Kaye, Greeno, & Weltzin, 1997; Stice, Nemeroff, & Shaw, 1996; Waller et al., 2003).”
BackgroundResultInfluential
Emotion recognition, emotional awareness and cognitive bias in individuals with bulimia nervosa
Legenbauer, T., Vocks, S., & Rüddel, H. (2008) · Journal of Clinical Psychology · doi:10.1002/jclp.20483 · Cited by 53 · cited 2×
“…BN do not display substantial emotion recognition deficits compared to controls for most emotions using a variety of measures (e.g., Harrison et al., 2010; Kenyon et al., 2012; Legenbauer et al., 2008), although the limited number of studies precludes any firm conclusions (see DeJong et al., 2013).”
BackgroundResult
Theory of mind in bulimia nervosa
Kenyon, M., Samarawickrema, N., DeJong, H., den Eynde, F. V., Startup, H. M., Lavender, A., Goodman‐Smith, E., & Schmidt, U. H. (2011) · International Journal of Eating Disorders · doi:10.1002/eat.20967 · Cited by 52 · cited 1×
“…BN do not display substantial emotion recognition deficits compared to controls for most emotions using a variety of measures (e.g., Harrison et al., 2010; Kenyon et al., 2012; Legenbauer et al., 2008), although the limited number of studies precludes any firm conclusions (see DeJong et al., 2013).”
Background
Emotional Functioning in Obsessive-Compulsive Personality Disorder: Comparison to Borderline Personality Disorder and Healthy Controls
Steenkamp, M. M., Suvak, M. K., Dickstein, B. D., Shea, M. T., & Litz, B. T. (2015) · Journal of Personality Disorders · doi:10.1521/pedi_2014_28_174 · Cited by 51
Anger expression in eating disorders: Clinical, psychopathological and personality correlates
Krug, I., Bulik, C. M., Vall-Llovera, O. N., Granero, R., Agüera, Z., Villarejo, C., Jiménez‐Múrcia, S., & Fernández‐Aranda, F. (2008) · Psychiatry Research · doi:10.1016/j.psychres.2007.10.003 · Cited by 50 · cited 1×
“…specifically have produced less consistent findings, with some research suggesting both greater anger suppression and outward anger expression (Krug et al., 2008 [mixed ED sample with mostly BN participants]), and other research suggesting greater anger suppression in BN versus controls, but…”
Result
Momentary emotion surrounding bulimic behaviors in women with bulimia nervosa and borderline personality disorder
Selby, E. A., Doyle, P., Crosby, R. D., Wonderlich, S. A., Engel, S. G., Mitchell, J. D., & Grange, D. L. (2012) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2012.08.014 · Cited by 47 · cited 2×
“Additional EMA research has shown that individual difference variables (e.g., personality traits, co-occurring psychopathology) may impact the association between affect and ED behaviors (e.g., Engel et al., 2007; Selby et al., 2012).”
Background
Avoidance of affect in the eating disorders
Lampard, A. M., Byrne, S. M., McLean, N. J., & Fursland, A. (2010) · Eating Behaviors · doi:10.1016/j.eatbeh.2010.11.004 · Cited by 44 · cited 1×
“One study found greater behavioral avoidance of positive affect, but not negative affect, in a mixed ED versus control group (Lampard et al., 2011).”
Background
Perception of emotion and bilateral advantage in women with eating disorders, their healthy sisters, and nonrelated healthy controls
Rozenstein, M. H., Latzer, Y., Stein, D. J., & Eviatar, Z. (2011) · Journal of Affective Disorders · doi:10.1016/j.jad.2011.06.009 · Cited by 43 · cited 2×
“…1994; Nowakowski et al., 2013; Sureda, Valdes, Jodar, & de Pablo, 1999), although results are less consistent when controlling for depression and/or anxiety (e.g., Eizaguirre et al., 2004; Gilboa-Schechtman et al., 2006; Montebarocci et al., 2006; Rozenstein et al., 2011; Speranza et al., 2005).”
Result
Facial Affect Recognition in Anorexia Nervosa: Is Obsessionality a Missing Piece of the Puzzle?
de Castro, L. C., Davies, H. A., Hale, L. S., Surguladze, S., & Tchanturia, K. (2010) · Australian & New Zealand Journal of Psychiatry · doi:10.3109/00048674.2010.524625 · Cited by 42
Impact of Fasting on Food Craving, Mood and Consumption in Bulimia Nervosa and Healthy Women Participants
Moreno‐Domínguez, S., Rodríguez‐Ruiz, S., Fernández‐Santaella, M. C., Ortega‐Roldán, B., & Antonio Cepeda-benito, A. (2012) · European Eating Disorders Review · doi:10.1002/erv.2187 · Cited by 41
Associations between Retrospective versus Ecological Momentary Assessment Measures of Emotion and Eating Disorder Symptoms in Anorexia Nervosa
Lavender, J. M., Young, K. D. D., Anestis, M., Wonderlich, S., Crosby, R., Engel, S., Mitchell, J., Crow, S., Peterson, C., & Grange, D. L. (2013) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2013.06.021 · Cited by 38
Factors related to severity of vomiting behaviors in bulimia nervosa
Daga, G. A., Pierò, A., Gramaglia, C. M., & Fassino, S. (2005) · Psychiatry Research · doi:10.1016/j.psychres.2004.01.013 · Cited by 35 · cited 1×
“Additionally, studies have typically reported findings suggesting elevated punishment sensitivity and/or harm avoidance in those with BN versus controls (e.g., Abbate-Daga et al., 2005; Frank et al., 2013; Wagner et al., 2006).”
Background
Confirmatory and exploratory factor analysis of the distress tolerance scale (DTS) in a clinical sample of eating disorder patients
Raykos, B. C., Byrne, S. M., & Watson, H. (2009) · Eating Behaviors · doi:10.1016/j.eatbeh.2009.07.001 · Cited by 26 · cited 3×
“certain important dimensions of emotion dysregulation such as avoidance of emotioneliciting situations, negative urgency, and distress tolerance, particularly in clinical populations (e.g., Corstorphine et al., 2007; Fischer et al., 2007; 2012; Hambrook et al., 2011; Raykos et al., 2009); (2) the preponderance of cros…”
BackgroundResult
Alexithymia, type A behaviour and bulimia nervosa
Sureda, B., Valdés, M., Jódar, I., & de Pablo, J. (1999) · European Eating Disorders Review · doi:10.1002/(sici)1099-0968(199908)7:4 · Cited by 22
Comparing Anorectics and Bulimics on Measures of Depression, Anxiety, and Anger
Breaux, C. A., & Moreno, J. K. (1994) · Eating Disorders · doi:10.1080/10640269408249111 · Cited by 13 · cited 2×
“Some studies suggest no differences between AN and control groups or find greater suppression but not lower expression (Breaux & Moreno, 1994; Fassino, Daga, Piero, Leombruni, & Rovera, 2001; Waller et al., 2003), but a larger number of studies indicate the presence of greater suppression and…”
BackgroundResult
Psychiatric Comorbidity Associated with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder
Lilenfeld, L. (2004) · doi:10.3109/9780203021767-16 · Cited by 11
Guilt and hostility as coexisting characteristics of bulimia nervosa
Allen, C., Scannell, E. D., & Turner, H. R. (1998) · Australian Psychologist · doi:10.1080/00050069808257396 · Cited by 10
Schizophrenia or epilepsy? A problem in differential diagnosis
Lohrenz, J. G., Levy, L., & Davis, J. F. (1962) · Comprehensive Psychiatry · doi:10.1016/s0010-440x(62)80030-3 · Cited by 2
Untitled work
Mussell (1997) · doi:10.1002/(sici)1098-108x(1997)21:4

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Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: a systematic review
Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.09.002 · Cited by 1,052
“…ER strategies that predominantly examine non-clinical samples, overall difficulties in ER are more frequently examined within clinical treatment-seeking populations, including individuals with eating related pathology (Lavender et al., 2015) and BPD (Bornovalova et al., 2008; Stepp et al., 2014).”
Background
Mindfulness and Emotion Regulation: Insights from Neurobiological, Psychological, and Clinical Studies
Guendelman, S., Medeiros, S., & Rampes, H. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.00220 · Cited by 577
“, 2015), and anorexia and bulimia nervosa (Lavender et al., 2015).”
Background
Can interoception improve the pragmatic search for biomarkers in psychiatry?
Khalsa, S. S., & Lapidus, R. C. (2016) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2016.00121 · Cited by 366
“Interoceptive dysfunction in AN can also be located within descriptions of “emotion dysregulation” (190), “poor distress tolerance,” (191) and perhaps most tellingly, “alexithymia” or the inability to discriminate between emotional states and bodily sensations (192, 193).”
Background
A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention
Sakiris, N., & Berle, D. (2019) · Clinical Psychology Review · doi:10.1016/j.cpr.2019.101751 · Cited by 369
Emotion regulation across eating pathology: A meta-analysis
Prefit, A.-B., Cândea, D. M., & Szentagotai-Tătar, A. (2019) · Appetite · doi:10.1016/j.appet.2019.104438 · Cited by 341

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Authors: Lavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., & Mitchell, J. E.
Affiliations: University of North Dakota (US)
North Dakota State University (US)
University of California San Diego (US)
Corresponding author: Lavender, Jason M.
ORCID: Lavender, Jason M.
Wonderlich, Stephen A.
Gordon, Kathryn H.
Kaye, Walter H.
Mitchell, James E.
Venue: Clinical Psychology Review
Publisher: Elsevier BV
Published: 2015-08
Volume: 40
Pages: 111-122
ISSN: 0272-7358 (ISSN-L)
DOI: 10.1016/j.cpr.2015.05.010
PMC: PMC4537813
OpenAlex: W585778545
Cited by: 512
References: 156
Citations by year: 2026: 45 · 2025: 45 · 2024: 45 · 2023: 38 · 2022: 58 · 2021: 69 · 2020: 52 · 2019: 50 · 2018: 40 · 2017: 38 · 2016: 26 · 2015: 5
FWCI: 5.22
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Clinical Psychology Review (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
eScholarship (California Digital Library) (submittedVersion)
Funders: U.S. Public Health Service (K23 101342)
National Institute of Mental Health (K23MH101342, T32MH082761)
Topics: Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Keywords: emotional dysregulation, anorexia nervosa, bulimia nervosa, eating disorders, emotion regulation, emotional awareness, emotional acceptance, emotional distress, goal-directed behavior, psychological intervention
MeSH terms: Self-Control, Anorexia Nervosa, Emotions, Humans, Bulimia Nervosa

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Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature

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