Implications for the present thesis

Findings from this review reveal that research into the attentional processing of emotion within eating-related psychopathology is relatively limited. Although previous work has looked into the presence of attentional bias in eating disorder patients, little is known about the specific attention deficits in those with non-clinical disordered eating. Clearly, future work exploring the attentional processing of emotional stimuli among those with high levels of non-clinical disordered eating is needed to uncover the specific processing deficits which may precede an eating disorder diagnosis.

In addition, a variety of different measures of attention processing have been utilised, which makes it difficult to draw conclusions from the research that has been carried out. For example, do those with eating disorders display an increased orienting of attention towards emotion, do they find it difficult to engage from emotional stimuli, do they avoid it, or could it be a combination of all three mechanisms? Consequently, further research which aims to delineate the temporal characteristics of attention processing would be beneficial. Specifically, future work examining orientation, disengagement and avoidance in response to emotional stimuli is necessary. In light of the limitations of frequently used measures of attention such as the Stroop and dot- probe tasks, further research should also seek to use more objective, ecologically valid measures of attention processing (e.g. eye-tracking technology).

Finally, previous work on attention processing within anxiety patients has shown that training individuals to attend to emotion (if they avoid it) or avoid (if they have a bias) may help to reduce previously observed attentional deficits (Koster et al., 2009). Within eating disorder patients, attention training to remove attentional biases towards emotional information may help to reduce accompanying emotional deficits and hence the need for eating disordered behaviour (which is often used to distract from negative emotional states that cannot be adequately processed). As a result, future research

31 testing the efficacy of a single session attention training intervention for reducing biases towards emotional stimuli in participants with non-clinical disordered eating attitudes and behaviours would be valuable. If successful, attention training would have the potential not only to reduce eating disorder-related symptoms before a diagnosis is made (i.e. prevention) but could possibly be incorporated into current eating disorder treatments.

Part 2

The recognition, regulation and expression of emotion within eating-

related psychopathology: A systematic review

Part 2 of this chapter will outline and evaluate the current literature relating to the recognition, regulation and expression of emotion in females with both non-clinical and clinical levels of disordered eating. Impairments in emotional functioning are thought to play a crucial role in both the development and maintenance of eating disorders. Specifically, individuals with high eating-related psychopathology have been shown to experience a number of difficulties when recognising (e.g. Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004), regulating (e.g. Harrison, Sullivan, Tchanturia, & Treasure, 2010a; Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012) and expressing (e.g. Meyer, Leung, Barry, & De Feo, 2010) emotion. Recent evidence suggests that emotion processing deficits frequently found within disordered eating affect both clinical and non-clinical populations. However, the role of emotion among those with non-clinical disordered eating has rarely been acknowledged, and earlier work has focused primarily on those with a clinical diagnosis. As emotional functioning deficits may represent a risk factor for the onset of eating disorders, targeting emotional difficulties expressed in those most vulnerable may ultimately help to prevent the onset of more serious eating-related psychopathology. Consequently, the aim of this literature review was to uncover the nature of emotion processing deficits observed in individuals with eating-related psychopathology by comparing eating disorder patients, those recovered from an eating disorder and those with non-clinical levels of disordered eating. Indeed, the research questions articulated in the present thesis are formed on the basis of findings from this review.

32 1.6. Introduction

Emotion processing deficits have previously been shown to play an important role in both the onset and maintenance of disordered eating and social dysfunction (Schmidt & Treasure, 2006). However, the specific aspects of emotion processing implicated in the development of eating-related psychopathology are often overlooked.

Earlier work on emotion recognition has demonstrated that eating disorder patients display significant deficits in the recognition of emotion from faces (Kucharska-Pietura et al., 2004) and in their ability to interpret social events (Bydlowski et al., 2005). The ability to accurately interpret the emotional intentions of others is crucial for successful functioning in social situations. Therefore, it may be argued that a reduced sensitivity in recognising the emotional expressions of others could lead to misunderstandings during social interactions, which may undermine or inhibit the formation of significant social bonds with others. Research has shown that those who go on to develop eating disorders are frequently shy with few friends (Fairburn & Harrison, 2003), and often experience social isolation or inadequate interpersonal relationships (Jackson, Weiss, Lunquist, & Soderlind, 2005; McClintok & Evans, 2001). Consequently, the presence of emotion recognition deficits may represent a risk factor for the future development of more serious eating disorders in those with poor social functioning or social phobia. Individuals with eating disorders have also been shown to experience a number of difficulties when regulating their emotions (e.g. Harrison et al., 2010a; Svaldi et al., 2012). Specifically, recent research has emphasised the role of maladaptive or ineffective emotion regulation in initiating pathological eating behaviour (Smyth et al., 2007; Danner, Evers, Stok, van Elburg, & de Riffer, 2012; Racine & Wildes, 2013). In addition, much of the previous work on emotion regulation has suggested that individuals with eating disorders lack access to effective or adaptive emotion regulation strategies (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Danner, Sternheim, & Evers, 2014; Svaldi et al., 2012). As a result, those with high levels of disordered eating often turn to regulation strategies that they do have access to such as bingeing or dietary restraint. These techniques are used with the intention of alleviating negative feelings but are usually considered to be a highly ineffective way of regulating emotion (Heatherton & Baumeister, 1991). In fact, the frequent use of such maladaptive regulation strategies is often associated with increased eating disorder symptom severity (Forbush & Watson, 2006; Aldao et al., 2010; Harrison et al., 2010a).

Previous findings also highlight the maladaptive core beliefs held by those with eating disorders about the nature and value of emotions (e.g. Leung, Waller, & Thomas, 1999;

33 Fox, 2009). Beliefs such as “emotional expression is a sign of weakness” and “emotional experience has aversive consequences” are therefore likely to contribute to the perceived need to avoid or moderate their experience of negative emotion. Often, such attitudes are thought to prevent or ‘block’ the processing of emotionally salient information (Root & Fallon, 1989; Waller, Kennerley, & Ohanian, 2007).

Furthermore, longitudinal follow-up studies have indicated that low levels of emotional functioning not only prevent the successful treatment of eating disorders, but can predict poor treatment adherence and application (e.g. Speranza, Loas, Johnsson, & Franck, 2007). Alexithymia (a deficiency in the understanding, processing or description of emotion; Sifneos, 1996) is also shown to facilitate both the chronic nature of eating disorders and increase the potential for relapse or further complications following recovery (De Groot, Rodin, & Olmstead, 1995; Schmidt, Jiwany, & Treasure, 1993). Combining the findings from various studies investigating aspects of emotion processing may therefore help to characterize and better understand how emotional impairments may interfere with treatment outcomes in eating disorder patients.

Although the role of emotion and social cognition with anorexia nervosa has recently been reviewed (e.g. Zucker et al., 2007; Oldershaw et al., 2011), emotion processing within non-clinical disordered eating is rarely examined. Consequently, the present review aims to assimilate the current research on emotion processing in females with both clinical and non-clinical disordered eating to explore the relationship between emotion recognition, regulation, expression and eating-related psychopathology in greater depth. Overall, it is hoped that a greater knowledge of the specificity of the emotional deficits associated with disordered eating attitudes and behaviours could guide clinicians in choosing the most efficient therapeutic strategy and may help to inform the development of future eating disorder prevention and treatment strategies. 1.7. Method

This systematic review was performed according to the PRISMA guidelines (Moher et al., 2010). A comprehensive literature search was conducted using Web of Science, PubMed and PsychInfo, Medline and Web of Science electronic search engines. In addition, key eating disorder journals were examined for relevant articles from January 1966 to January 2015. For each database search, search terms relating to emotion processing (emotion processing, emotional functioning, emotion, emotion recognition, emotion regulation, emotional expression) were combined with terms relating to eating- related psychopathology (eating-related psychopathology, eating disorder, anorexia nervosa, bulimia nervosa, disordered eating) using the “AND” operator. In addition to

34 electronic searches, the reference lists of relevant review papers, as well as identified articles were examined to ensure all articles missed by on-line searches were included. 1.8. Results