porate mood intolerance in the late 1990s (Fair- burn, 1997). The use of particular eating disorder behaviours to moderate or suppress emotion has started to ...
Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 16, 237–239 (2009) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.625
Editorial
Eating Disorders and Emotions John R. E. Fox1,2,3 1
Division of Health Research, Lancaster University, Lancaster, UK Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK 3 Eating Disorders Unit, Russell House, Affinity Healthcare, Cheadle Royal Hospital, Cheadle, Cheshire, UK 2
This special edition deals with one of the core dimensions of understanding eating disorders, namely, emotions and emotional processing. Only recently has psychological theory started to consider the role of emotions within an eating disorder presentation. This has often been a bewildering fact to the ‘coal face’ clinician, as they are often faced by a client who either appears to be devoid of emotion, or at the mercy of her own emotions. Strober (2004) eloquently described a host of emotions that are often present in anorexia nervosa, from the quiet anger to the perpetual fear of gaining weight. Strober also described the emotions that are often found in carers and professionals who work with this client group, namely, fear and irritation that the client refuses to change despite the therapist’s best efforts. The pioneering work of Hilde Bruch (1962, 1978) was pivotal in starting to piece together information about anorexia nervosa. Through her detailed analysis of her own cases, Bruch came to develop the hypothesis that anorexia nervosa was a condition that grew out of the inability to experience or express one’s own emotions. She proposed that the experience of ‘being fat’ was directly connected to an inability to distinguish or express one’s own emotional states. Psychological therapies took a while to develop theories that began to account for the emotional difficulties present in eating disorders. The emphasis prior to these developments was on behavioural and eating changes, as within cognitive behavioural therapy for bulimia nervosa (CBT-BN; Fairburn, Marcus, & Wilson, 1993). Although these theories showed a lot of promise by helping nearly 50% of patients with bulimia improve, they clearly had a long way to go. One of the key factors that was not accounted for by the early CBT models was apparent difficulties that the people with eating disorders had with their mood. Indeed, Fairburn revised his original theory of CBT-BN to incorCopyright © 2009 John Wiley & Sons, Ltd.
porate mood intolerance in the late 1990s (Fairburn, 1997). The use of particular eating disorder behaviours to moderate or suppress emotion has started to gain momentum within the literature. Crisp (1980) discussed how the anorexic girl will use restriction (also knows as anorexia nervosa) to reverse the pubertal/maturation process, and avoid the associated emotions that ensue. Indeed, he argued very strongly that recovery from anorexia nervosa is associated with the worsening of mood, and periods of depression. Crisp (1997) coined the phrase that the ‘anorexic’ needs to be at a ‘sadder, but wiser position’ to make a recovery. Heatherton and Baumeister (1991) undertook some pioneering research that examined how binge eating was associated with reduced self-awareness. This finding opened the door to considering how binge eating may play an important emotion regulatory function for the individual, and this led to further postulations about the role of bingeing and vomiting in bulimia nervosa. The role of binge eating in decreased self-awareness and how restriction can reduce emotional awareness have now been incorporated into contemporary cognitive therapy models of eating disorders. Cooper, Wells and Todd (2004) proposed a model that argued that positive and negative beliefs about bingeing, in response to negative core belief activation, are pivotal in understanding bulimia nervosa. The key dynamic in this model is the knowledge that bingeing helps the self to dissociate from painful emotions. Equally, Waller, Kennerley and Ohanian (2007) argued that both bingeing–vomiting and restriction are emotion suppression strategies, but they are just utilized at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing–vomiting is used after an emotion has been activated. Although these models are a useful start, they leave both the theorist and the clinician with a
238 number of questions about the role of emotions in eating disorders. Which emotions are important? Do people with eating disorders experience higher levels of emotions, or do they have difficulty with everyday levels of emotions? Finally, what is the relation of depression to these difficulties and what are the best ways to work with the actual emotions generated? As editor of this special edition, I have often considered the need for further theory development in understanding not only the actual eating disorder behaviours, but also the connection with other associated symptoms that are present within people who have eating disorders. For example, within the second-generation cognitive models, there is often a lack in the consideration of the marked body dissatisfaction that accompanies every case of an eating disorder. In my clinical position, it is impossible not to see the lengths that people with eating disorders will go to to prevent weight gain and how much difficulty and loathing they feel for their own bodies. I have wondered about this in relation to both the recent CBT models and the writings of Hilde Bruch (as discussed above). Moreover, there is a wealth of literature research that has examined normal emotional processes without psychological disorder, and I have also wondered if this gives us any further clues in understanding emotions within eating disorders. In compiling this special edition, I have sought papers that offer some insights into the questions raised above. None of the papers adequately answer all the questions as the evidence base is still in need of further research, but it is my hope that these special edition papers generate thought, further theory and research. In the first paper, I present a review of the literature on emotional processes in eating disorders. On the basis of this review, Mick Power and I present a model that attempts to understand eating disorders from a basic emotion perspective. It is argued that eating disorders need to be understood from a developmental perspective, where the role of anger and disgust are the important emotions. A key construct of this model is that it proposes that co-morbid patterns of presentation in eating disorders, such as eating disorders and depression, can be understood from a basic emotions perspective. In this instance, the role of self-disgust would be seen as pivotal in understanding depression and eating disorders. This theoretical perspective is contrary to the second paper, within this special edition, by Davey and Chapman. In this paper, they argue that disgust, although an important emotion, is actually part of the anxiety that is often Copyright © 2009 John Wiley & Sons, Ltd.
J. R. E. Fox a feature of eating disorders. These differing views have a ‘chicken and egg’ angle to them, as it may be that anxiety is actually comprised of disgust, as they both are emotions of avoidance and both create a ‘psychological distance’ between the self and the stimulus. Also, Davey and Chapman’s paper is based on analogue data and therefore, it is not known about these proposed processes within a clinical group. The third paper looks at the perception of emotions within a group of people with a diagnosis of anorexia nervosa. It is the only qualitative study within this special edition and it provides very rich data. The findings suggest that anger is a key problematic emotion for people with anorexia nervosa, and it also offers some very interesting insights into the potential developmental pathways for this client group. The conflicting emotions and feelings associated with these histories give some important clues as to how complex and powerful the messages given about emotions are through childhood. It also introduces the finding that it is not only the beliefs about the emotion that are significant, but also the lack of meta-emotional skills that are of importance in formulating the difficulties that people with anorexia nervosa potentially face. This special edition then introduces two papers on shame in eating disorders. Goss and Allan offer an excellent review of the literature that pertains to shame in eating disorders. They discuss how shame is an important emotion in understanding eating disorders, and how these emotions are linked to pervasive selfworth beliefs. Goss and Allan offer a very informative discussion on how levels of shame are often linked to adverse experiences while growing up, and this discussion has many commonalities with the review offered by Fox and Power, and the qualitative paper. Many of these issues of shame are echoed by the Keith et al. paper, where they connect schema beliefs with levels of shame and parental bonding styles. The special edition goes on to present two papers that address both the actual levels of specific emotions in eating disorders and the perception of threat that is perceived from emotional states. The consistency of these findings is fascinating, with one demonstrating that levels of anger and sadness uniquely predict disordered eating, and the other paper reporting that perception of threat from anger and depression uniquely predicted poor emotional expression in people with disordered eating. Taking these results together, it appears that people with eating disorders have the ‘double whammy’ of experiencing high levels of Clin. Psychol. Psychother. 16, 237–239 (2009) DOI: 10.1002/cpp
Editorial anger and perceiving this anger as being threatening. Both of these papers discuss how these findings resonant with the findings of Geller, Cockell, Hewitt, Goldner and Flett (2000), Hayaki, Friedman and Brownell (2002), and Fox and Harrison (2008). All of these papers argue that threatening emotions (e.g., anger) are directed away from the self and onto the body, via body dissatisfaction. It is interesting how the literature has started to come round in a circle, with similar themes being discussed by Hilde Bruch nearly 30 years ago. Related to the writings of Bruch, Harrison et al.’s paper discusses results that highlight how people with a diagnosis of anorexia nervosa have difficulties with emotional regulation and emotion perception. It is noteworthy that they discuss how these difficulties may actually be weight related, and if one considers the potential function of weight loss to suppress emotions, this would make theoretical sense. However, Schmidt, Jichwany and Treasure (1993) undertook a controlled study of alexithymia and found that increased weight did not lead to an improvement in emotion recognition/expression difficulties. On the back of these results, these authors argued that alexithymia should be regarded more as a trait rather than state-type phenomena. However, the findings of Fox in this special edition challenge this notion of monolithic difficulties with emotion, as the participants spoke clearly about their own emotions and they felt significant difficulty in expressing their emotions (in keeping with Ioannou and Fox). It may be time for a deconstruction of alexithymia in the literature, along emotion identification and emotion expression lines. The final two papers of this special edition are written by colleagues from North America. Presnell and Stice discuss the relation between depression and bulimic symptoms, and they found further evidence of a bilateral relationship between these two variables. Lastly, Dolhanty and Greenberg present a paper that discusses emotion-focused therapy for anorexia nervosa. This clinically focused paper is a fascinating example of the challenges that the clinician faces in working with this client group, and it also provides an excellent insight into the application of emotion-focused therapy for someone with anorexia nervosa. Across all the studies presented in this special edition, the importance of understanding emotions and their functioning has been emphasized. As discussed in the beginning of this editorial, I undertook the editing of this special edition with a number of questions in mind about the nature Copyright © 2009 John Wiley & Sons, Ltd.
239 of emotion, co-morbidity and role of emotions in the psychological treatment of eating disorders. I do feel that this collection of papers offers some answers to these questions, but, in keeping with good scientific enquiry, they also generate further questions for future research.
REFERENCES Bruch, H. (1962). Perceptual and conceptual disturbance in anorexia nervosa. Psychosomatic Medicine, 24, 187– 194. Bruch, H. (1978). The golden cage: The enigma of anorexia nervosa. Cambridge, MA: Harvard University Press. Cooper, M.J., Wells, A., & Todd, G. (2004). A cognitive theory of bulimia nervosa. British Journal of Clinical Psychology, 43, 1–16. Crisp, A.H. (1980). Anorexia nervosa: Let me be. London: Academic Press. Crisp, A.H. (1997). Anorexia as a flight from growth: Assessment and treatment based upon the model. In D.M. Garner, & P.E. Garfinkel (Eds), Handbook of treatment for eating disorders (pp. 248–278). New York: The Guildford Press. Fairburn, C.G. (1997). Eating disorders. In D.M. Clark, & C.G. Fairburn (Eds), Science and practice of cognitivebehaviour therapy (pp. 209–243). Oxford, UK: Oxford University Press. Fairburn, C.G., Marcus, M.D., & Wilson, G.T. (1993). Cognitive-behavioural therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C.G. Fairburn, & G.T. Wilson (Eds), Binge eating: Nature, assessment, and treatment (pp. 361–405). New York: Guildford Press. Fox, J.R.E., & Harrison, A. (2008). The relation of anger to disgust: The potential role of coupled emotions within eating pathology. Clinical Psychology and Psychotherapy, 15(2), 86–95. Geller, J., Cockell, S.J., Hewitt, P.L., Goldner, E.M., & Flett, G.L. (2000). Inhibited expression of negative emotions and interpersonal orientation in anorexia nervosa. International Journal of Eating Disorders, 28(1), 8–19. Hayaki, J., Friedman, M.A., & Brownell, K.D. (2002). Emotional expression and body dissatisfaction. International Journal of Eating Disorders, 31, 57–62. Heatherton, T.F., & Baumeister, R.F. (1991). Binge-eating as an escape from awareness. Psychological Bulletin, 110, 86–108. Schmidt, U., Jichwany, A., & Treasure, J. (1993). A controlled study of alexithymia in eating disorders. Comprehensive Psychiatry, 34, 54–58. Strober, M. (2004). Managing the chronic, treatmentresistant patient with anorexia nervosa. International Journal of Eating Disorders, 36, 245–255. Waller, G., Kennerley, H., & Ohanian, V. (2007). Schema focused cognitive-behaviour therapy with eating disorders. In L.P. Riso, P.T. du Poit, & J.E. Young (Eds), Cognitive schemas and core beliefs in psychiatric disorders: A scientist-practitioner guide (pp. 139–175). New York: American Psychiatric Association.
Clin. Psychol. Psychother. 16, 237–239 (2009) DOI: 10.1002/cpp
