Emotion avoidance in patients with anorexia nervosa: initial test of a functional model.

Close observers of eating disorder psychopathology long have noted that anorexia nervosa (AN) is associated with emotion avoidance, defined here as the desire to avoid experiencing or expressing physical sensations, thoughts, urges, and behaviors related to intense emotional states. Indeed, several clinical scholars have articulated that anorexic symptoms function, in part, to help individuals cope with or avoid aversive emotions. For example, Slade (1) hypothesized that preoccupation with food, eating, weight, and shape enables individuals with AN to avoid thinking about or confronting other potentially aversive stimuli such as adolescent conflicts, interpersonal problems, and stress and failure experiences. Similarly, Schmidt and Treasure (2) have proposed a model of AN maintenance that emphasizes the role of anorexic symptoms in facilitating avoidance of negative emotions, as well as interpersonal relationships that may trigger these emotions. Specifically, these theorists assert that the exclusive mental focus on food and eating that characterizes AN is associated with emotions becoming less salient, noting that many individuals with AN report feeling emotionally “numb” (p. 347). Several lines of research provide support for the notion that emotion avoidance is pertinent to anorexic psychopathology. For example, studies using qualitative methodology (3, 4) or self-report questionnaires (5, 6) to assess AN patients' perceptions of the functions served by disordered eating symptoms have reported that the illness helps affected individuals to avoid or control emotions. Research also has documented that individuals seeking treatment for AN and other eating disorders are more likely than non-psychiatric controls to endorse emotion avoidance. Specifically, Corstorphine and colleagues (7) found that women with AN, bulimia nervosa (BN), or eating disorder not otherwise specified were significantly more likely than non-psychiatric control women to report avoidance of situations that might provoke positive (i.e., excitement, enthusiasm, enjoyment), as well as negative (i.e., anger, sadness, nervousness) emotional states. Moreover, emotion avoidance was associated with increased levels of body dissatisfaction in the disordered eating group (7). Less is known about the factors that contribute to emotion avoidance in patients with AN. Some scholars have theorized that individuals with AN have a temperamental predisposition to emotion avoidance resulting from traits characteristic of avoidant personality disorder (e.g., shyness, inhibition, harm avoidance) (2). There is evidence that emotion avoidance is salient to individuals with avoidant personality traits. For example, using a multi-dimensional measure of emotion avoidance (i.e., the Emotional Avoidance Questionnaire), Taylor and colleagues (8) found that individuals with avoidant personality disorder reported more negative beliefs about experiencing emotions, greater avoidance of positive emotions, and more social concerns about displaying emotions than did community controls. Another factor that may contribute to emotion avoidance in patients with AN is co-morbid “emotional disorder” (i.e., mood and anxiety disorder, p. 529) (9) symptomatology. It is well-documented that depressive and anxiety symptoms are prevalent in patients with AN [for reviews, see (10, 11); also see (12)] and are associated with increased severity of eating disorder psychopathology in this group (13, 14). Furthermore, there is evidence that many mood and anxiety disorder presentations are characterized by efforts to avoid experiencing intense emotions [for reviews, see (15, 16)]. For example, Campbell-Sills and colleagues (17) found that individuals seeking treatment for mood and anxiety disorders rated their emotions as less acceptable and were more likely to report that they attempted to suppress their emotions in response to watching an aversive film clip than individuals with no history of emotional disorder. Thus, we hypothesize that depressive and anxiety symptoms may be associated with increased levels of emotion avoidance in patients with AN. Moreover, we speculate that emotion avoidance may help to explain the relation between depressive and anxiety symptoms and eating disorder psychopathology in this group. In particular, we theorize that eating disorder psychopathology may serve to help individuals with AN cope with or regulate co-morbid depressive and anxiety symptoms, and that this functional link between emotional disorder symptoms and eating disorder symptoms is driven, in part, by emotion avoidance (see Figure 1). Heatherton and Baumeister (18) have proposed a similar model to explain the processes underlying binge eating among restrictive dieters and individuals with BN. Specifically, these theorists assert that binge eating functions, in part, to help individuals escape from aversive self-awareness, which includes negative self-perceptions and emotional distress. We agree with Heatherton and Baumeister that disordered eating behaviors (i.e., extreme dietary restriction, binge eating, purging) may help to facilitate emotion avoidance in patients with AN. However, we also hypothesize that disordered eating thoughts (i.e., ruminative thoughts about eating, weight, and shape) serve a similar purpose, which is consistent with previous models focusing on the functions of AN symptomatology (1). Thus, in the present study, we aimed: 1) to characterize emotion avoidance in patients with AN using Taylor et al.'s (8) Emotional Avoidance Questionnaire; and 2) to conduct a preliminary test of the hypothesis that emotion avoidance helps to explain (i.e., mediates) the relation between co-morbid depressive and anxiety symptoms and eating disorder psychopathology in AN. Figure 1 Hypothesized model in which emotion avoidance helps to explain the relation between depressive and anxiety symptoms and eating disorder psychopathology in anorexia nervosa