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Emotions and Anorexia
Malvi Bipin Savani
Emotions are a fundamental part of the human experience that both affect and shape our views of the world around us. Emotions help us communicate our core values and beliefs, which in turn help mend or break relationships with our surroundings. There have been countless studies conducted on emotions and its affect on practically every facet of our life—how we think and interact with the world. Out of these studies, the pattern of emotions in individuals diagnosed with anorexia nervosa (AN) offer a particularly interesting relationship in how emotions are distorted due to the adverse circumstances presented with this eating disorder. These studies ultimately pave the way to answer the effects of AN disease in emotions.
What are emotions and how can they be measured?
The term emotion is very subjective in the sense that one well-educated scientist’s definition of emotion may vary from another. More importantly, the word “emotion” is used colloquially to the extent that it has become almost synonymous to the word “feeling.” Countless scientific definitions by “scholars from all disciplines” have been proposed over the years with each definition varying from the other (www.affective-sciences.org). A concise, scientific definition of the term ‘emotion’ is crucial for the “advancement in [various] field and collaborative research between different disciplines” (www.affective-sciences.org). While numerous studies concerning emotions have been conducted, it is often difficult to interpret the results and measure “how to use this evidence” from the study (www.affective-sciences.org). Using a component process model, Scherer—a scientist from the Geneva Emotion Research Group—defines emotion as “an episode of interrelated, synchronized changes in the states of all or most of the five organismic subsystems in response to the evaluation of an external or internal stimulus event as relevant to major concerns of the organism” (www.affective-sciences.org).
While there is no “gold-standard method for” measuring emotions, some studies measure “individual components such as appraisal (Scherer et al., 2001), brain mechanism (Davidson et al., 2003a), psychological response patterns (Stemmler, 2003), and expressive behavior (Harrigan et al., 2005)” (www.affective-sciences.org).
Perception of Emotion in AN Patients
Alexithymia is “the person’s difficulty in describing, recognizing, and expressing their own emotional status” (http://www3.interscience.wiley.com). There has been a strong link between patients with AN and alexithymia, and alexithymia and depression. One clear relation between AN and eating disorders include the idea that those in the restrictive subtype avoid food, which is associated with an avoidance of emotion, while the binging/purging subtype indulge in food and then purge to suppress “negative emotions once it has been activated” (http://www3.interscience.wiley.com).
A study conducted by JR Fox from the Division of Clinical Psychology at the University of Manchester explored accounts of 11 individuals with AN and focused on “their experiences of emotion and their management from a basic emotions and developmental perspective” (http://www3.interscience.wiley.com). The grounded theory methodology was used in conducting the research. This theory takes into account the “role of the researcher in the analyses of the data” and the “researcher’s perspective on how the emotions were displayed and acknowledged by the participant would need to be interpreted by the researcher” (http://www3.interscience.wiley.com). This approach could present certain biases or misinterpretations of how the patients with AN might actually experience certain emotions. And this factor may gauge the effectiveness of the study. The study was conducted by a 38-year old male clinical psychologist. This could present a few problems in the study for numerous reasons; if there was more than one researcher, then the different responses each researcher received could be merged or serve as a better representation of what the 11 individuals are actually experiencing emotionally. The small sample used in this study might not be sufficient to make generalizations about individuals with AN and how different individuals react to or express emotions. Another factor that could affect the results is that the researcher is a male, which could, in turn, affect the type of responses received.
Questions concerning the “participant’s experiences, including beliefs about expression and developmental histories of emotional expression in the family” were recorded through means of a qualitative data analysis software package as well as field notes and a research diary (http://www3.interscience.wiley.com). Specific questions that were asked include: “What do you understand about emotions?” “How do you express these emotions?” “Do you ever feel angry? Examples” “If the person denies feeling any of the emotions ask, what would it be like to experience—emotions?” (http://www3.interscience.wiley.com). The last question seems to present a bias since it questions the replies of the individuals with AN, and could potentially force the patients to come up with an answer that the researcher might be looking for.
Results revealed that patients had two overarching themes including “experiencing anger as too overwhelming” and “too much emotion” (http://www3.interscience.wiley.com). A number of these patients reported the prevalence of violence ranging from abusive relationships to parents who were abusive towards each other. Almost half of the patients developed “a narrative about anger being overwhelming and almost toxic emotion that needed to be avoided at all costs” (http://www3.interscience.wiley.com). Moreover, factors such as divorces, loss of a loved one, and bullying played an important role in increasing “their levels of emotion” especially anger and sadness, “which were often suppressed in order to protect them or another key individual in their life” (http://www3.interscience.wiley.com). This build-up of emotions, especially anger, is correlated with an increase in the “eating disorder symptoms” (http://www3.interscience.wiley.com).
Furthermore, a study conducted at the Eating Disorders Unit in Italy asked 112 female patients with almost 50% with AN & the other 50% with bulimia nervosa (BN) to fill out a Buss-Perry Aggressiveness Questionnaire (AQ). The results revealed that “in patients with anorexia nervosa, difficulties in expressing anger and outward-directed aggressiveness can be a prevailing” (http://www.ncbi.nlm.nih.gov). Some of the factors of the study that could have affected the results include the fact that controls included an age group younger than the patients, and “exclusive reliance of self-report measures” (http://www.ncbi.nlm.nih.gov).
Emotion Avoidance in AN Patients
Emotion avoidance is often linked with anorexia nervosa as these patients often “report feeling emotionally ‘numb’” (http://www3.interscience.wiley.com). This is important since most symptoms for anorexia including constant preoccupation with food and body image, is prevalent since these individuals want to avoid dealing with emotions and directly facing the problems in their life. Hence, they use preoccupation with food to “avoid thinking about or confronting other potentially aversive stimuli such as adolescent conflicts, interpersonal problems, and stress and failure experiences” (http://www3.interscience.wiley.com). Another theory for this emotion avoidance includes the idea that those who have AN are more prone to emotion avoidance “resulting from traits characteristic of avoidant personality disorder (e.g. shyness, inhibition, harm avoidance)” (http://www3.interscience.wiley.com). Furthermore, emotion disorders such as mood and anxiety disorders also play an important role in the emotion avoidance in patients with AN. Many reports have shown depression and anxiety symptoms in those with AN. It has been found that “many mood and anxiety disorder presentations are characterized by efforts to avoid experiencing intense emotions” (http://www3.interscience.wiley.com).
A group of psychiatrists from the Western Psychiatric Institute and Clinic at the University of Pittsburg Medical Center hypothesized that an “increased levels of emotion avoidance…help explain the relationship between depressive and anxiety symptoms and [eating disorder] psychopathology” and eating disorder “psychopathology may serve to help individuals with AN cope with or regulate comorbid depressive and anxiety symptoms…driven… by emotion avoidance” (http://www3.interscience.wiley.com). To test this hypothesis, seventy-five patients receiving “inpatient or day hospital treatment for AN” consented to participate in the study by completing a “one-time assessment consisting of a battery of self-report questionnaires” and were compensated with $25. Emotion avoidance was assessed through means of an Emotion Avoidance Questionnaire, which is a “20-item self-report measure that evaluates…(1) Avoidance of Positive Emotions; (2) Avoidance of Negative Emotions; (3) Negative Beliefs about Emotion; and (4) Social Concerns about Displaying Emotion” (http://www3.interscience.wiley.com). A potential flaw is the validity of one test with only 20 questions to effectively measure emotion avoidance. Since the study was voluntary and compensated, there is also the factor that some may not have been able to completely assess their own emotions effectively since the EAQ was a self-assessment. Similarly, depressive symptoms were assessed using a Beck Depression Inventory, while anxiety symptoms were measured using a Beck Anxiety Inventory. The eating disorder psychopathology was measured using 91-item self-assessment questionnaire called the Eating Disorder Inventory-3. According to the results, “individuals with AN endorsed levels of emotion avoidance that were similar to or higher than those reported by individuals with avoidant personality disorder and social phobia and exceeded community controls” (http://www3.interscience.wiley.com). Furthermore, the regression analyses revealed a positive correlation between depressive symptoms and eating disorder psychopathology and emotion avoidance in patients with AN. Moreover, the regression analyses also showed a positive correlation between anxiety symptoms and eating disorder psychopathology and emotion avoidance.
While there was a variation in the AN subtype with the study including an even number of those with both Restricting and Binge eating/purging subtype, one of the flaws of the study included the fact that 100% of those being studied were Caucasian. This raises the question whether this study is a comprehensive evaluation that can provide generalization of all patients diagnosed with anorexia nervosa. Further research concerning emotion avoidance could evaluate the biological factors associated with the reported emotional numbness that is associated with AN patients.
Neuropsychological Factors in AN and Emotion
One of the traits of those with AN is the distortion of what one looks like and the overestimation of one’s weight. A study conducted at the Università ‘La Sapienza’ in Rome, Italy tested whether this overestimation of “their size despite being severely underweight…echoes an underlying emotional disturbance or also reflects a genuine body-representation deficit” (http://www.ncbi.nlm.nih.gov). Using the fact that “disorders of body representation also emerge following damage to the right parietal lobe,” the researchers applied “a behavioral task to compare body knowledge in severe anorexics, healthy volunteers and stroke patients with focal damage to the left/right parietal lobe” (http://www.ncbi.nlm.nih.gov). A psychophysical procedure “based on perception, in the dark, of an approaching visual stimulus that was turned off before reaching the observer” was used, and the participants had to determine if the stimulus would hit them if the stimulus had continued to project linearly (http://www.ncbi.nlm.nih.gov). The results showed that while healthy volunteers and left parietal patients could predict accurately whether the visual stimulus would hit them or not, anorexics and right parietal patients “underestimated [the] eccentricity of their left body boundary” (http://www.ncbi.nlm.nih.gov). While this study could pave the way for the discovery of neuropsychological components of anorexia, the study only used eight anorexics and only four patients with damage to their left/right parietal lobe, which does not present a representative sample that can make conclusions of anorexics in general. Further study needs to be conducted with a larger sample in order to test the significance of the temporal lobe in emotional disturbance or deficits n body-representation.
Emotions in Recovered AN vs. Healthy Individuals
Various studies have been conducted comparing the ability to recognize one’s own emotions and that of others for anorexic patients and healthy patients. Researchers at the Department of Experimental Psychology at the University of Oxford conducted a study in which they tested emotional processing in both patients with AN and the healthy volunteers “using self-reported questionnaires and processing tasks” (http://www.ncbi.nlm.nih.gov). According to the data, patients with AN “had lowered levels of self reported emotional awareness and expression” and “they also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words” (http://www.ncbi.nlm.nih.gov). The study clearly establishes the idea that many patients with AN have a deficit in expressing emotion effectively, and this can be linked to the suppression of emotion as a coping mechanism of not dealing with any conflicts. Factors that could have led to unrepresentative generalizations include the inclusion of both medicated and unmedicated anorexics, and the fact that some were suffering from depression and others were not, which could be difficult to compare with the healthy volunteer group.
In another study conducted in King’s College London at the Institute of Psychiatry, a group of researchers tested “whether an impaired ability to infer emotion in people with autism spectrum disorder (ASD) and difficulty with emotional theory of mind (eToM) are limited to the ill state or if this condition is a stable deficit” in recovering AN patients (http://www.ncbi.nlm.nih.gov). In this study, “twenty-four participants fully recovered from AN were compared against” forty AN patients and forty-seven healthy volunteers on “forced-choice tasks assessing emotion recognition, basic or advanced eToM in other people, using sensory stimuli and on a written task measuring eToM ability for the self as well as for others” (http://www.ncbi.nlm.nih.gov). The results concluded that although for the recovering AN, there was a slight impairment in recognizing emotions in comparison to the healthy control, they were able to better distinguish emotions in themselves and others in comparison to the AN group.
It is evident that there is a strong link between individual with AN and deficit in emotional expression in themselves and others. An Eating Disorders Program in Credit Valley Hospital treated one individual with emotion focused therapy (EFT) and monitored the “weights and scores on self-report measures” both before the treatment and 18 months after treatment (http://www3.interscience.wiley.com). The EFT proposes the idea that “the existence of innate emotions…are shaped and organized through interactions with the environment into basic emotional meaning structures or meaning schemes” (http://www3.interscience.wiley.com). EFT focuses on dealing directly with painful emotions and transforming these maladaptive methods of dealing with emotions to “the activation of healthy innate emotions” (http://www3.interscience.wiley.com). The Case Formulation outlined eight steps towards enabling the patient to self-acceptance, and “recognizing, understanding and overcoming the avoidance of internal experiences” (http://www3.interscience.wiley.com). A 24-year-old woman with restrictive anorexia nervosa received the emotion focused treatment once she had discharged herself from the hospital. After unfolding the problem, why the woman is there for treatment, the therapist attempts to resolve the patient’s “self-criticism, self-interruption or blocking of feelings, and unfinished business with a significant other” (http://www3.interscience.wiley.com). After 18 months of treatment, the patient had reported laughing spontaneously with feelings of happiness, and “her total score on the Toronto Alexithymia Scale was reduced from 54 (intermediate) to 49(non-alexithymic)…[and] her depression as measured by the Beck Depression Inventory…was reduced from 35 (severely depressed) to 22 (moderately depressed)” (http://www3.interscience.wiley.com). This individual’s significant improvement clearly indicate the value of this kind of treatment for her, but more studies need to be conducted with this promising approach before it can be considered an effective approach to treating patients with AN. And while an emotion focused therapy might be useful for some, others might find it hard to confront their problems or even begin to recognize any emotion or how to express what they’re experiencing in words. Hence, the time spent in confronting problems and dealing with emotions might be too long while another approach might be more promising for a particular individual.
Based on current research being conducted in the emotional responses of AN patients, the difference in emotional recognition in AN patients in comparison to healthy individuals, and the introduction of emotional therapies, it is clear that our emotion plays a key role in how we interact with the environment. It is our emotions that help us adapt to the various situations and confront our problems and deal with them effectively. Individuals diagnosed with AN use food as a coping mechanism to shut themselves off from any aversive stimuli around them to the point where they become emotionally numb. Avoidant emotion is prevalent in cases of both restrictive and binging/purging subtypes of AN with the first using avoidant emotion to not deal with emotions at all, and the latter binging and purging in order to suppress any negative emotions. Although more research needs to be conducted in the role of the right parietal lobe in determining whether the patients actually think they are fat when in fact they are severely underweight or if it is a body-representation deficit. Further research in this field could pave the way for a new mode of treatment that takes neuropsychological components into account. Furthermore, based on emotion expression and recognition comparison studies between AN patients, recovered AN and healthy individuals, it is evident that there is some permanent damage in emotional recognition due to AN. And the emotion focused therapy seems very promising in that it carefully unfolds the problem that is the underlying cause of AN and helps patients recognize and confront their emotions in a more healthy, adaptive manner. However, the study mentioned only included the effects of this form of treatment in one individual and because it showed significant improvement in the patient, more research needs to be conducted with this treatment in order to evaluate the effectiveness of this approach.
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