Emotion and Eating Disorder Symptoms in Patients with Anorexia Nervosa: An Experimental Study

An accumulating body of research has documented that negative emotions influence the expression of disordered eating symptoms. Much of this work has focused specifically on the role of negative affect (viz., anxiety, depression, anger, distress) in the onset and maintenance of bulimic syndromes. For example, prospective longitudinal data have demonstrated that increases in negative affect predict the onset of bulimic symptoms in adolescent females (1, 2). Similarly, studies using ecological momentary assessment (EMA) to examine state-specific associations between mood and bulimic symptoms have shown that increases in negative affect precede episodes of binge eating and purging [for review, see (3); also see (4)], and that the highest rates of binge eating and purging occur on days characterized by stable levels of high negative affect or increasing negative affect over the course of the day (5). Finally, experimental studies have found that exposure to a negative mood induction leads to increases in urges to binge (6) and feelings of loss of control over eating (7, 8) in women with binge eating problems [but see, (9)]. Less is known about the effect of emotion on eating disorder symptoms in individuals with anorexia nervosa (AN). One pilot study using EMA found a positive association between daily mood lability and restrictive eating behaviors in females with AN, suggesting that fluctuations in emotion may be related to disordered eating symptoms in this group (10). Indeed, Engel and colleagues (10) postulate that increases in negative emotion may lead to restrictive eating behaviors in individuals with AN, which are followed by a decrease in negative affect. However, no research to our knowledge has used experimental or longitudinal methodology to evaluate the impact of emotions on eating disorder symptoms in AN patients. There are compelling reasons to hypothesize that increases in negative affect might precipitate the expression of dietary restriction and other symptoms of disordered eating in individuals with AN. For example, clinical observers long have noted that individuals with AN have difficulty construing or tolerating emotions (11, 12). Moreover, descriptive studies have documented a range of emotional difficulties in AN patients, including deficits in emotion recognition (13, 14), high levels of alexithymia (15, 16), and comorbidity with mood and anxiety disorders (17). Several theoretical models of AN psychopathology have emphasized the role of anorexic symptoms in facilitating avoidance of aversive emotions (18–21). Furthermore, data from quantitative and qualitative research studies provide support for the notion that emotion avoidance is salient to individuals with AN (22–26). Finally, treatments designed to increase the willingness of AN patients to tolerate negative emotional states without engaging in disordered eating behaviors have shown promising initial results (21, 27). In summary, several lines of research provide support for the idea that negative emotions may influence disordered eating symptoms in individuals with AN, but no study to our knowledge has used experimental methodology to examine the effect of emotion on eating disorder symptoms in this group. Thus, the overall aim of the current investigation was to evaluate the effect of experimentally-induced negative emotion on self-reported eating disorder symptoms and objectively-measured eating behavior in women with AN. We hypothesized that AN patients randomized to a negative emotion condition would report greater increases in subjective eating disorder symptoms and consume fewer calories during a standardized meal session than AN patients randomized to a neutral emotion condition.