Emotion dysregulation, self-image, and eating disorders

Abstract

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.