Blog of the UNC Center of Excellence for Eating Disorders.Blog seek to provide outstanding education and training in eating disorders detection and care to medical students and other health profession trainees at UNC.
CEED is a world leader in eating disorders treatment, research, and training. The training we offer encompasses a range of training levels, including undergraduate and postgraduate research trainees, undergraduate and graduate interns, summer fellows, graduate students, and post-doctoral fellows, and international visiting scholars. Since 2003, CEED has trained over 150 rising individuals who are actively involved in treatment, research, and/or administration, or are pursuing further graduate training! CEED’s founding director, Dr. Cynthia Bulik, spearheads much of this training, although all faculty are involved in supervising and mentoring trainees and fellows. Here, we profile a CEED alum who has made amazing strides in providing access to eating disorder treatment in her home state.
Cheri Levinson came to CEED as a clinical psychology intern in the summer of 2014. During her year here, Cheri was involved in both research and treatment in our inpatient, partial hospitalization, and outpatient programs. She continues to work closely with Drs. Bulik and Stephanie Zerwas to elucidate associations between eating disorders and anxiety disorders. After completing her internship, Dr. Levinson completed post-doctoral training at Washington University in St. Louis, where she excelled as both a clinician and researcher.
Since 2016, Dr. Levinson has been an Assistant Professor in the Department of Psychological & Brain Sciences at the University of Louisville in Louisville, Kentucky. She is the director of the EAT Lab (Eating Anxiety Treatment Laboratory and Clinic), where she supervises a research team dedicated to developing novel treatments for eating disorders, treating individuals with co-occurring eating disorders and anxiety disorders, and personalizing eating disorder treatment. Through her work with the Behavioral Wellness Clinic and Louisville OCD Clinic, she founded the Louisville Center for Eating Disorders in October 2017, which provides outpatient and intensive outpatient services to the community. The establishment of this center is critical as Kentucky lacks treatment services for individuals with eating disorders, and information gathered through research at this center will undoubtedly provide necessary evidence-based treatment to individualsin need. We are proud of Dr. Levinson’s accomplishments and all she is doing for the state of Kentucky and the field of eating disorders!
If you are a CEED alum—volunteer (VHP), honors student, intern, summer fellow, graduate student, or postdoc—we would love to hear from you! Please contact Dr. Melissa Munn-Chernoff (firstname.lastname@example.org) so we know what wonderful things you are doing!
Some people just sparkle. You take one look at them and you realize that they, “have the right stuff.”
Perth is really far away. It is sitting out there on the far Western coast of Australia. Even so, it’s home to some incredible academics, including a Nobel Prize winner. Hunna Watson was also in Perth, doing superb work one eating disorders, but she wanted a chance to learn and do even more. Truthfully, we get inquiries all the time from people all over the world who want to come work with us, but there is no way we can accommodate everyone. Occasionally, however, you realize that if you say no, you will kick yourself forever.
Hunna first came to CEED for a few months in 2011 as a summer fellow (albeit in the fall!). Two years later when she had accumulated too much leave time, she was forced to take it. Although she did get a few fun weeks traveling around the States, the majority of her leave was spent with us at CEED absorbing whatever we had to offer. Combined, those two experiences made it clear to both of us that we needed to continue this somehow and the wheels were set in motion to bring Hunna to North Carolina for more than a few weeks or months!
When she first came to us, she was an SPSS user (yes, we judged a little), but it was clear that she was a hardworking dynamo who could learn just about anything. What we really needed at the time was more biostatistics help and Hunna loved stats. But, often, you work with statisticians who know very little about the topics or disorders that you are studying. In contrast, Hunna had a wealth of experience with eating disorders and was one of the driving forces and a steering committee member of the Australian National Eating Disorders Collaboration. So, she was the complete package! On her own initiative. Hunna enrolled in an MBiostats course to get a formal biostats degree, which she competed with flying colors.
In her first years at CEED, she apprenticed herself to Bob Hamer who was our chief statistician and wonderful friend until he was taken from this life far too soon in 2015. Hunna absorbed all the knowledge and wisdom she could from Bob and took over analyses of a very complicated data set from the Norwegian Mother and Child Study (MoBa). She has also provided guidance for all CEED faculty and trainees on statistical analysis and data interpretation.
All of this is awesome, but not the reason that I am awarding her the Order of the Chocolate Fish. Hunna basically knew nothing about genetic analysis. None of her previous work had anything to do with genetics. As our work in that area took off, we desperately needed someone to analyze the complicated genetic data. We had a choice to make—advertise for someone with expertise in statistical genetics (who would likely know nothing about eating disorders) or see if Hunna would like to get trained up for the task. Never one to shy away from a challenge, Hunna was game and so were we. True to form (in one of her first emails to me she said “My working style is very self-directed. Once an idea is in place, I can run with it mostly independently. So long as I have the right skills of course,” she dove into upskilling in statistical genetics. Some people take a lifetime to learn these skills, but Hunna basically had to cram everything into a year. She attended courses, read like crazy, did an intensive on-site learning visit to Gerome Breen’s lab at King’s College London and then ended up being the primary analyst for the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and also led the analytic charge for the Anorexia Nervosa Genetics Initiative (ANGI)!
Doing this kind of statistical work is hard…period. Plus, Hunna was working under the watchful eye of people who have been doing this for decades who happily critiqued her every keystroke. It was at this point that I realized how her leisure time passion (ultra-marathoner) and work converge. Hunna has an enormous capacity to persevere. I am sure that at times the genetic analyses felt like an ultra-marathon through mud. But she came through in the end with her trusted Raleigh by her side. Soon, we will see a major fruit of her labor when we reveal the results of ANGI and the next wave of PGC-ED results!
My thanks to Perth for the long-term loan of Hunna and my thanks to Hunna for all she does for CEED and PGC-ED!
After note: Dr. Watson hasn’t completely abandoned her native Australia! In addition to her position at CEED, is Adjunct Research Fellow at the University of Western Australia and Adjunct Lecturer at Curtin University.
April 18-21 marked the 25th annual International Conference on Eating Disorders. Highlights of this year’s conference included talks on how to reach more individuals in the prevention and treatment of eating disorders, including the Keynote address by Dr. Alan Kazdin, who discussed reducing the burdens of eating disorders by using the media, social networks, and other large-scale projects, along with plenary presentation that focused specifically on for developing community-based partnerships in eating disorder research and influencing policy.
Another highlight of the conference was a plenary session focused on our understanding of the microbiome in eating disorders (also see https://uncexchanges.org/2016/09/01/microbiome-a-new-direction-in-understanding-anorexia-nervosa/ and https://uncexchanges.org/2017/04/03/leaky-gut-a-potential-contributor-to-the-brain-gut-microbiota-axis/), which featured CEED director Dr. Cynthia Bulik. Speakers in this session noted how much is still unknown about the microbiome, and how understanding gut microbiota may lead to advances in treatment of eating disorders and an increased understanding of how gastrointestinal disorders and eating disorders may interact. For example, a study from CEED provides initial indication that diversity of gut microbiota is limited in patients who present with anorexia nervosa, and that it increases over the course of inpatient treatment (Kleiman et al., 2015). Next steps of this line of research include testing clinical applications that promote healthy gut microbiota as a component of treatment for eating disorders.
Other presenters from the CEED team included Dr. Zeynep Yilmaz, who spoke on a panel regarding moving the field forward through biological research, and Dr. Jessica Baker, who presented on the shared genetic association between anorexia nervosa and temperament. Leigh Brosof, a summer fellow at CEED in 2017, also presented a poster that highlighted work she completed last summer which identified a cross-disorder symptom network of obsessive-compulsive disorder and eating disorder symptoms in a large, epidemiological cohort of children from the UK.
Overall, this year’s ICED was lively, with spirited debates and passionate participation from individuals representing a range of backgrounds. Many individuals in recovery from an eating disorder shared their experiences and discussed how the research that was being presented fit or did not fit with their lived experience. Clinicians, researchers, advocates, and parents continued to engage in difficult dialogues in the service of moving the field forward, so that eating disorder prevention and treatment will ultimately be more effective.
Kleiman SC, Watson HJ, Bulik-Sullivan EC, Huh EY, Tarantino LM, Bulik CM, Carroll IM. The intestinal microbiota in acute anorexia nervosa and during renourishment: relationship to depression, anxiety, and eating disorder psychopathology. Psychosom Med. 2015;77(9):969-981. PMID:26428446
The Academy for Eating Disorders (AED) recently held its 25th annual International Conference on Eating Disorders (ICED) in Chicago, Illinois from April 18th – 21st. The theme of this year’s conference was “Expanding Our Community and Perspectives,” and the content was aimed at broadening the evidence base and clinical perspectives within the eating disorders field. The conference kicked off with a stimulating keynote address from the renowned clinical psychologist Alan Kazdin (Yale University) during which he stressed the importance of reducing the burden of eating disorders by focusing on interventions (and research paradigms) that are scalable, reach the greatest number of people, and incorporate the patient perspective.
In keeping with this theme, there were several plenary sessions that were geared toward expanding our perspectives on both scientific research and clinical interventions. For example, the first plenary session highlighted the importance of employing strategic science to improve our ability to influence eating disorder-related policy. Although many in the eating disorder field are invested in advocacy work, the presenters encouraged us to do so with a data-driven approach. The second plenary encouraged us to expand our definition of eating disorder recovery. The presenters (including UNC’s Anna Bardone-Cone) helped us improve our understanding of the current state of the science, and also encouraged us to consider that recovery may or may not be an appropriate goal, particularly in the case of severe, and enduring anorexia nervosa. That perspective is certainly not without its challenges, but the presenter (Phillipa Hay) eloquently argued that shifting the treatment focus to improving quality of life (over explicit weight gain, for example), may allow for a more person-centered approach.
The final two plenary sessions aimed to improve our engagement in and knowledge of leading-edge science in the field. The third plenary focused on community-based participatory research and encouraged researchers to involve community stakeholders in both the design and implementation of eating disorder studies. Such efforts can provide crucial insights into how interventions and research methods can be improved and can expedite the implementation of research findings into the communities who need them most. In doing so, community-based participatory research allows for eating disorder communities to be an active and reciprocal part of the research process. The final plenary was centered on the role of the microbiome in eating disorders. Our own Cynthia Bulik and Ian Carroll were notable members of the plenary panel and helped us better understand how the microbiome-gut-brain axis can influence the weight continuum and the extent to which current research can inform clinical care.
Throughout the conference, participants were exposed to many opportunities to educate themselves and also to network with a community of peers. In addition to the keynote and plenaries above, there were daily workshops and paper/poster sessions during which participants could obtain in-depth knowledge on clinical interventions, innovative scientific investigations, and efforts to close the research-practice gap. In sum, ICED 2018 was an interactive opportunity to learn, engage in dialogue, and advance the study and treatment of eating disorders.
On Wednesday April 4 at the iconic Varsity Theater in Chapel Hill, CEED was honored to sponsor a screening of the powerful documentary Going Sane. Director Josh Sabey was in attendance and joined Christine Peat from CEED, Cynthia and Ed Binanay, and myself in a discussion panel after the movie to address questions from the audience on the topic of evidence-based mental health care.
The documentary is particularly powerful for me as several of my former mentors (Stephen Hinshaw, PhD from UC Berkeley and Walt Kaye, MD from UC San Diego) and colleagues (Bill Pelham, PhD) spoke passionately about the importance of delivering evidence-based care in psychiatry and psychology. They were joined by powerful voices of patients and family advocates who had been through the complicated labyrinth of finding evidence-based care—some with tragic outcomes. Unfortunately, the mental health field lags far behind other areas of medicine in requiring evidence-based practices. This makes it incredibly difficult for parents and caregivers to sift through available information to make informed decisions about the best treatment for their loved ones.
Part of the evening was spent clarifying terms related to evidence-based practice.
Evidence-based treatment: Evidence-based treatment (also known as empirically supported treatment) refers to those psychological interventions that have demonstrated efficacy for a specific condition through rigorous, high quality research of (e.g., the collective evidence of multiple randomized controlled trials).
Evidence-based practice: Evidence-based practice is a method of clinical decision-making that combines the research evidence for a particular treatment (i.e., is the treatment empirically supported?) with patient characteristics and clinical expertise. The American Psychological Association defines evidence-based practice as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” Thus, evidence-based treatment is a component of evidence-based practice but does not solely determine the clinical decision making. (The interested reader can find more information here).
Evidence-informed treatment: This phrase often gets used when therapists pick and choose features of various evidence-based treatments, but don’t actually deliver the treatment in a format that reflects how it was developed and tested in randomized controlled trials. For example, a therapist might use “a little bit of CBT” but not actually deliver a comprehensive course of the treatment as it was meant to be delivered.
Cynthia and Ed Binanay brought a wealth of both professional and personal information to the panel, via their work in the health care system, and the challenges they faced in finding care for their son who in addition to a congenital heart condition was also diagnosed with schizoaffective disorder. Together with audience members, they illustrated how critically important it is to advocate on behalf of your ill loved ones. The Binanays also emphasized how important it is to talk about mental illness, even though you might find that some of your friends may distance themselves from you. By speaking about mental illness, you destigmatize it, and you’ll make new friends—ones who are understanding and supportive.
Christine Peat from CEED helped describe some of the evidence-based treatments that are available for mental illnesses, in specific how cognitive-behavioral therapy is applied to the treatment of eating disorders.
A core message of the film and the panel was to be informed consumers of mental health care. Ask questions. Be involved. Advocate. If you missed the screening, or would like to watch it again or share it with someone who could benefit from the messages, you can rent or buy it on Amazon. Additionally, if you are interested in hearing more about the documentary and the importance of its message, we encourage you to listen to Josh being interviewed on WCHL and Dr. Bulik being interviewed on WUNC’s The State of Things.
We ran out of time for questions during the panel and promised to address any unanswered ones in our blog. Here are a few of the questions that we did not get to on the eve of the screening.
1. Please give examples of evidence-based treatment other than CBT and family involvement when treating mental illness.
a. This is a great question! There is a fantastic publicly-available resource from The Society of Clinical Psychology that has compiled all of the various evidence-based treatments for mental illnesses. The website allows you to search for treatments by name or by mental health diagnosis. Another excellent source for learning about mental health evidence-based practices is the website of the Substance Abuse and Mental Health Services Administration (SAMHSA) https://www.campbellcollaboration.org/
2. Support group at UNC Oasis charges money…via deductible on insurance. This should be changed. Money seems to be the motivating component even for a family support group.
a. We agree that mental health services are far too limited in terms of their scope and availability, particularly for those who are underinsured or uninsured. Many of us in the mental health field continue to advocate for broadening this scope and are active in politics to help enact these changes. In the meantime, there are free resources available to those living in specific counties (see list of NC county managed care organizations) and some practices do offer free services. For example, local eating disorder specialist Tammy Holcomb offers a free support group for those with eating disorders and the Carolina House offers a free support group for families of those with eating disorders.
3. Is there a newsletter for this area consolidating protests for mental health, fundraisers, workshops, etc.
a. While we are currently unaware of any specific newsletters that consolidate this type of information, we encourage our readers to learn more about various mental health efforts through the following well-respected organizations:
We invite you to join our founding director, Dr. Cynthia Bulik, on Wednesday, April 4th, for a special screening of the film Going Sane, at The Varsity Theater in Chapel Hill. Doors open at 6:30pm, and the 65-minute film will begin at 7pm. Following the film will be a panel discussion, moderated by Dr. Bulik. Read on to learn more about Going Sane, and the featured panelists.
Going Sane, a documentary film featured as a selection in several festivals, is a deeply personal exploration of the mental healthcare industry. Lisa Sabey, the film’s producer, experienced the difficulty in navigating treatment options firsthand as she struggled to find effective, safe mental healthcare for her daughter, who suffered from anorexia nervosa. Now, Lisa has teamed with her son Josh, a talented director, to share the lessons she learned over many years, most significantly the importance of seeking a provider who can deliver evidence-based care.
Going Sane features expert clinicians and researchers, as well as other parents like Lisa, who share valuable insight gleaned from personal experiences. The panelists who will discuss the film following its screening offer a similar mix of viewpoints. In addition to Dr. Bulik, CEED’s own Dr. Christine Peat will take part in the discussion, lending her expertise as a researcher and clinician. Ed and Cynthia Binanay share the unique role of being both professionals in the mental healthcare industry, and parents of a child who has suffered from mental illness. Ed is the Director of Development for UNC Center for Excellence in Community Mental Health, and Cynthia serves as Chair of Board of Directors for Alliance Behavioral Healthcare. Rounding out the group is Josh Sabey, the film’s director, an accomplished writer and filmmaker.
The documentary has wide appeal and is recommended for parents, loved ones, individuals seeking treatment, mental healthcare providers, those considering a career in mental healthcare, or anyone with a vested interest in improving mental healthcare in America. The screening is sponsored by the UNC Center of Excellence for Eating Disorders and is free to the public. Downtown Chapel Hill offers ample public parking. We look forward to sharing this valuable film and opening the floor for an informed discussion. We hope to see you there!
The National Eating Disorders Association encourages awareness, conversation, and involvement in eating disorders activism and outreach. Every spring, the National Eating Disorders Awareness Week (#NEDAwareness) is an opportunity to focus a national discussion on the importance of identifying, treating, and preventing eating disorders and to provide resources for these often stigmatized and underdiagnosed conditions. The NEDAwareness Week 2018 (February 26th – March 4th) theme was “Let’s Get Real” with the goal of expanding the conversation about eating disorders to highlight stories that are not always heard. For example, stereotypes about how eating disorders present (i.e., in thin, white, female bodies) often prevent individuals from seeking the treatment they need. Many individuals who do not fit this profile may not be screened for eating disorder symptoms and/or may not reach out for help if they need it. This year’s NEDAwareness Week theme reminds us that stigma and erroneous stereotypes prevent people from seeking help, and NEDA encourages us to bust myths to help get people screened and into treatment.
NEDAwareness Week 2018 encouraged individuals to get involved and stay involved—after all, eating disorder awareness and advocacy are essential and relevant year-round. If you want to join these efforts, here are a few ways to get started:
Take the NEDAwareness Quiz. This quiz is designed to assess your thoughts and feelings about food, body image, exercise, and social media. It also allows you to learn about what perspectives others have on these same issues and will hopefully generate meaningful discussion about the influence these factors have on our daily lives.
Get Screened: Last year, NEDA launched their free and confidential online screening for eating disorders and this screening tool has been lauded as an important resource for those who might be questioning whether they are dealing with disordered eating thoughts or behaviors. Participants are connected with a volunteer at the end of the quiz who can help funnel identified individuals toward crucial treatment.
Get Connected: NEDA has Facebook, Instagram, YouTube, and Twitter accounts that you can follow to join the conversation. You can share the Faces of Recovery video and stories which help remind everyone that although eating disorders do not discriminate based on age, race, weight, or socioeconomic status, recovery is possible with appropriate treatment and the consistent support of loved ones.
Although NEDAwareness Week may technically be over, let’s have 2018 be NEDAwareness Year! “Let’s get real” and challenge common myths and stereotypes about eating disorders, have real conversations about how food, body image, and exercise affect our lives, and increase awareness of how eating disorders can affect anyone regardless of gender, age, or race and ethnicity. With your help, NEDAwareness 2018 has the potential to be an inclusive movement with the power to make a significant, positive change in the lives of those affected by eating disorders.
Eating disorders affect people of all genders and sexual orientations. However, people with certain identities experience higher rates of disordered eating than others.1 It is important that we talk about these differences, so we can better understand and support individuals at high risk of developing an eating disorder.
Research on the lesbian, gay, bisexual, and transgender (LGBT) population shows that this group is at heightened risk of disordered eating.1,2 LGB and transgender individuals (people whose gender identity does not match their sex assigned at birth) face similar stressors, such as stigma, that increase eating disorder risk.3,4 Other factors are unique to each group. For example, transgender individuals who experience gender dysphoria may engage in eating disorder behaviors, such as fasting or excessive exercise, in attempts to alter their body shape or size to achieve a desired physique.5
Most people in eating disorder research samples are cisgender (a person whose gender identity matches their sex assigned at birth), and even among LGBT studies, the number of transgender individuals included is often small.4 In fact, most studies still only allow binary responses for sex/gender questions, in which you can click “Male” or “Female.” Occasionally, respondents are given the option of clicking “Other” or “Prefer not to answer.” It is critical that transgender people are identified and represented in research so that we can understand how to best prevent and treat eating disorders in this vulnerable population.
Through a survey of 923 Canadian transgender youth, Watson and colleagues compared 14 – 18 year olds and 19 – 25 year olds across five disordered eating behaviors: binge eating, fasting, diet pill use, laxative use, and vomiting.4 The researchers also explored factors that may increase or decrease risk of disordered eating.
Main takeaways from the study:
Binge eating and fasting were highly prevalent, with 35 to 45% of individuals reporting each behavior.
Roughly half of the 14 – 18 year olds reported disordered eating in the last year: 42% reported binge eating, 48% fasted, 7% used diet pills, 5% used laxatives, and 18% vomited. Among the 19 – 25 year olds, almost a third reported disordered eating, with 29% reporting binge eating, 27% reporting fasting, 4% using diet pills, 3% using laxatives, and 5% vomiting.
Transgender youth frequently experience violence and harassment, which is often linked to gender-based stigma.6,7 Watson and colleagues call this “enacted stigma.” Youth who experienced more enacted stigma were at higher risk of binge eating, fasting, and vomiting.
Those with greater social connectedness and support were less likely to binge eat, fast, or vomit. For the 19 – 25 year olds, social support was negatively associated with vomiting. In 14 – 18 year olds, family connectedness, and to a lesser extent school connectedness and perception of friends as caring, were associated with lower risk of disordered eating.
Those with the lowest number of protective factors and the most enacted stigma experiences had the highest risk of disordered eating.
Transgender adolescents and young adults are at heightened risk for disordered eating.1,3,4 In a large population-based sample of U.S. college students, 15.82% of transgender students reported having a diagnosed eating disorder in the past year, compared to .55 to 3.52% of cisgender students.1 Clearly eating disorders are a serious concern for the transgender community, and it is important for parents, teachers, and clinicians to be aware of this. Those of us close to transgender people need to be familiar with the signs and symptoms of eating disorders. Families and schools should strive to create an environment that helps transgender youth feel connected to others and provides protection from enacted stigma. By offering our support and fighting back against stigma, we may help protect transgender youth from developing disordered eating and other mental health problems.
Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144-149.
Watson, R. J., Adjei, J., Saewyc, E., Homma, Y., & Goodenow, C. (2017). Trends and disparities in disordered eating among heterosexual and sexual minority adolescents. International Journal of Eating Disorders, 50(1), 22-31.
Testa, R. J., Rider, G. N., Haug, N. A., & Balsam, K. F. (2017). Gender confirming medical interventions and eating disorder symptoms among transgender individuals. Health Psychology, 36(10), 927.
Watson, R. J., Veale, J. F., & Saewyc, E. M. (2017). Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors. International Journal of Eating Disorders, 50(5), 515-522.
Murray, S. B., Boon, E., & Touyz, S. W. (2013). Diverging eating psychopathology in transgendered eating disorder patients: A report of two cases. Eating Disorders, 21(1), 70-74.
Kwon, P. (2013). Resilience in lesbian, gay, and bisexual individuals. Personality and Social Psychology Review, 17(4), 371-383.
Saewyc, E., Konishi, C., Poon, C., & Smith, A. (2011). 2. Is it Safer to be Gay in High School Today? Trends in Sexual Orientation Identity and Harassment in Canada. Journal of Adolescent Health, 48(2), S8-S9.
In Lighter than My Shadow, author Katie Green shares her personal experience in living with an eating disorder, starting from the time that she was a young girl. This novel is unique in that it is not comprised of chapter after chapter of words on a page, telling the story of her experiences; instead, she tells us about her experience with eating disorders in the form of a graphic novel.
More than 500 pages are filled with illustrations, simply but artfully sketched, depicting Green’s journey through adolescence into adulthood. The words that accompany these sketches narrate her life, thoughts, and conversations as she navigates the development of and treatment for her eating disorder.
These sketches deliver the very powerful and raw portrayals of Katie’s experience. For instance, her destructive, disordered thoughts surrounding food, her body, and her peers are depicted by dark and messy scribbles above her head. They start out small, but as the thoughts get darker, messier, and more destructive, so do the scribblings—sometimes growing so large that they take over the whole page until they swallow Green whole. In watching this progression, the reader is confronted with what so many people with mental health issues face: pervasive negative thoughts that can feel as though they have entirely engulfed one’s life.
The introduction page of the book holds a short letter from the author to the person holding her novel. There Green expresses her intent to, “be honest about how hard recovery is, and how long it takes, at the same time proving that it is possible.” She encourages readers who are also suffering from an eating disorder or other mental illness and acknowledges the challenges of seeking treatment by saying that “getting better is so inherently personal, and everyone must choose it for themselves”. This book is her promise that “it can and does get better”. If you or someone you know is dealing with an eating disorder, this book can be a powerful insight into the realities of the illness and a reminder that no one is alone in illness, no matter how isolating it may feel.
According to theories of emotion regulation in eating disorders, unpleasant emotions, like sadness, anger, and anxiety, can precipitate eating disorder symptoms. Eating disorder symptoms, in turn, can distract from or even temporarily alleviate unpleasant emotions. Coping with unpleasant emotions by binge eating, purging, restricting, or compulsively exercising, may make these symptoms become more entrenched.
Researchers have used scientific strategies to study emotion regulation within the context of eating disorders. Many questions have been investigated: Do people with an eating disorder feel negative emotions more intensely than those without an eating disorder? Do their coping methods differ from people without an eating disorder? Can teaching skills to cope with strong emotions reduce eating disorder symptoms? Here, we look at the research findings on emotion regulation in the past year and present a snapshot of up-to-the-minute research.
Recent Research Findings on Emotion Regulation
The data suggest that people with eating disorders report greater difficulties with emotion regulation than people without eating disorders, and tend to engage in less healthy emotion regulation strategies, such as worry, rumination, and self-punishment, than cognitive reappraisal (i.e., re-interpretation of the situation) or acceptance of uninvited emotion1,2,3,4. People with anorexia nervosa (AN) and bulimia nervosa (BN) were found to have a bias where they rated neutral facial expressions as expressing more anger than controls did and were less likely than controls to express positive emotion in their own facial expressions5,6.
People with eating disorders engage in eating disorder behaviors to regulate their moods. In one study, individuals with BN carried digital devices and were asked periodically during the day, over 2 weeks, to record their emotion and binge-eating, purging, or combined binge-purge episodes. Acute increases in unpleasant emotions preceded eating disorder behaviors, and after these behaviors odes mood was boosted, although there was also greater instability in unpleasant emotions7. Likewise, for individuals with AN, guilt peaked before restrictive eating periods and decreased afterward8.
According to emotion regulation theory, enabling individuals to better regulate their moods and emotional reactions to stressors could reduce eating disorder symptoms. In one study, improvement in one’s ability to regulate emotions during psychotherapy for BN was linked to greater improvement in eating disorder-related cognitive symptoms and binge eating frequency, but not purging frequency9. Other studies found that improvements in emotion regulation during treatment were correlated with treatment gains10,3. Sloan and colleagues tested the idea that emotion regulation difficulties underlie a range of mental health problems11. Results supported emotion regulation as a “transdiagnostic” construct. They suggested that when targeted for improvement in treatment, emotion regulation may help with a range of symptoms associated with anxiety, depression, eating disorders, and substance use.
People with acute eating disorders may have an internal world where positive emotions (e.g., joy) seem harder to tap, while negative emotions (e.g., distress, anxiety, disappointment, sadness) are closer to the surface and more frequently experienced. Their strategies for dealing with these emotions may be ineffective and may be compounded by problems with social communication, such as misreading others’ emotional states (in a negatively biased way). Enhancing the ability to manage emotions is incorporated into several psychotherapies (e.g., cognitive-behavior therapy) and is one way in which disordered eating behaviors can be addressed therapeutically. A deeper understanding of the role of emotion regulation in eating disorders and how best to enhance emotion regulation strategies are important topics in both basic research and in treatment development and refinement.
Crino, N., Touyz, S. & Rieger, E. (2017) How eating disordered and non-eating disordered women differ in their use (and effectiveness) of cognitive self-regulation strategies for managing negative experiences. Eat Weight Disord. 1-8.
Kenny T.E., Singleton C., & Carter J.C. (2017) Testing predictions of the emotion regulation model of binge eating disorder. Int J Eat Disord. 50, 1297-1305.
Mallorquí-Bagué, N., Vintró-Alcaraz, C., Sánchez, I., Riesco, N., Agüera, Z., et al.(2018) Emotion Regulation as a Transdiagnostic Feature Among Eating Disorders: Cross-sectional and Longitudinal Approach. Eat. Disorders Rev., 26: 53–61.
Westwood, H., Kerr-Gaffney, J., Stahl, D., & Tchanturia, K. (20**) Alexithymia in eating disorders: Systematic review and meta-analyses of studies using the Toronto Alexithymia Scale. Journal of Psychosomatic Research, 99, 66-81.
Dapelo, M. M., Surguladze, S., Morris, R., & Tchanturia, K.(2017) Emotion recognition in face and body motion in bulimia nervosa. Eat. Disorders Rev., 25, 595–600.
Leppanen, J., Dapelo, M.M., Davies, H., Lang, K., et al. (2017) Computerised analysis of facial emotion expression in eating disorders. PLOS ONE 12(6): e0178972.
Berner, L., ***et? (20**) Temporal associations between affective instability and dysregulated eating behavior in bulimia nervosa. Journal of Psychiatric Research, 92, 183-190.
Haynos, A. F., Berg, K. C., Cao, L., Crosby, R. D., et al. (2017). Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa. Journal of Abnormal Psychology, 126(5), 495-505.
Peterson, C.B., Berg, K.C., Crosby, R.D., Lavender, J.M., et al. (2017). The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self-directed behavior, and self-discrepancy within the mediation model. Int J Eat Disord. 50, 636-647.
MacDonald, D.E., Trottier, K., Olmsted, M.P. (2017) Rapid improvements in emotion regulation predict intensive treatment outcome for patients with bulimia nervosa and purging disorder. Int J Eat Disord.50, 1152-1161.
Sloan, E., Hall, K., Moulding, R., Bryce, S., et al. (2017) Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: A systematic review. Clinical Psychology Review. 57, 141-163.