Factor structure and clinical correlates of the original and 16-item version of the Difficulties In Emotion Regulation Scale in adolescent girls with eating disorders.

OBJECTIVES: The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. METHODS: Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. RESULTS: A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. CONCLUSION: The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales.

Emotion dysregulation and suicidality in eating disorders.

OBJECTIVE: Suicidality in eating disorders (EDs) is high, and identification of therapeutically targetable traits associated with past, current, and future suicidality is of considerable clinical importance. We examined overall and ED subtype-specific associations among suicidal ideation, suicide attempts, and general and specific aspects of emotion dysregulation in a large sample of individuals with ED, at presentation for treatment and 1-year follow-up. METHOD: Using registry data from 2,406 patients, scores on the Difficulties in Emotion Dysregulation Scale (DERS) at initial registration were examined as predictors of recent suicidal ideation and self-report lifetime suicide attempts. Associations were examined in the full sample and in each ED subtype. In 406 patients, initial DERS scores were examined as predictors of suicidality at 1-year follow-up. RESULTS: Overall DERS was associated with suicidal ideation and suicide attempts, even when adjusting for ED psychopathology and current depression. Perceived lack of emotion regulation strategies showed unique associations with suicidal ideation and suicide attempts, both in the full sample and in most ED subtypes. Initial DERS was also associated with follow-up suicidal ideation and suicide attempts, although this association did not remain when adjusting for past suicidality. DISCUSSION: Results suggest that emotion dysregulation may be a potential mechanism contributing to suicidality in EDs, beyond the effects of ED psychopathology and current depression. Although the prevalence of suicidality differs across ED subtypes, emotion dysregulation may represent a risk trait for future suicidality that applies transdiagnostically. Results support addressing emotion dysregulation in treatment in order to reduce suicidality.

Taking the LEAP: study protocol for a randomized, multicentre, naturalistic, efficacy trial of the compuLsive Exercise Activity theraPy (LEAP) - a cognitive behavioral program specifically targeting compulsive exercise in patients with eating disorders.

BACKGROUND: About half of Swedish eating disorder patients report exercising compulsively and compulsive exercise (CE) is prevalent in all diagnoses and both genders. Yet there are no systematic treatments targeting CE in specialist care. This study aims to evaluate the effects of The CompuLsive Exercise Activity TheraPy (LEAP) - a promising group treatment targeting compulsive exercise, in Swedish eating disorder patients. METHOD: One hundred twenty-eight adult females and males suffering from anorexia nervosa, bulimia nervosa or other specified feeding and eating disorders (type 1, 2, or 4) with CE will be recruited via four specialist eating disorder treatment units. Participants will be randomized to receive treatment as usual (control group) or treatment as usual plus LEAP (intervention group). The groups will be assessed on key variables (e.g., BMI, eating disorder symptoms, exercise cognitions and behaviors) at three occasions: initially, after 3 months and after 6 months. DISCUSSION: The project takes place in a clinical setting, including both male and female patients with different eating disorder diagnoses with CE, enabling a good indication of the efficacy of LEAP. If our results are positive, LEAP has the potential of benefiting about half of the eating disorder population, with remission and recovery hopefully improving as a result. TRIAL REGISTRATION: The trial is registered with the ISRCTN registry (registration date 2020-03-25), trial ID: ISRCTN80711391 .

Emotion dysregulation and eating disorders-Associations with diagnostic presentation and key symptoms.

OBJECTIVE: Emotion dysregulation seems involved in the development, maintenance, and outcome of eating disorders (EDs). The present study aimed to differentiate patients with EDs from a comparison group on emotion dysregulation, and to examine emotion dysregulation in relation to ED diagnostic presentation and ED symptoms. METHOD: Participants, patients with EDs (N = 999) and a student comparison group (N = 252), completed the Difficulties in Emotion Regulation Scale and the Eating Disorder Examination Questionnaire. Patients were compared to the comparison group and compared by diagnosis regarding emotion dysregulation, and unique associations between emotion dysregulation aspects and ED symptoms were examined. RESULTS: Patients reported greater general emotion dysregulation than the comparison group, especially poorer emotional awareness and clarity. There were very few diagnostic differences. In both patients and the comparison group, limited access to emotion regulation strategies was associated with cognitive ED symptoms, and presence of binge eating in the comparison group. In patients, poor emotional awareness and emotional non-acceptance were additionally associated with cognitive symptoms, and difficulties in impulse control and emotional non-acceptance were associated with binge eating. DISCUSSION: Emotion dysregulation is an important transdiagnostic characteristic of ED. Results suggest interventions that enhance emotional awareness and acceptance, as well as emotion regulation skills training, in both ED treatment and prevention.

Validation of the eating pathology symptoms inventory (EPSI) in Swedish adolescents.

BACKGROUND: Eating disorders (ED) are associated with symptoms across body image, disordered eating, and exercise-related domains, and while predominantly affecting females, ED in males is also a significant concern. However, popular self-report methods insufficiently capture male presentations. This study aimed (1) to validate the first Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome limitations in previous measures, and (2) compare genders gender-specific manifestations of eating pathology, depression, and anxiety in Swedish high-school students. METHODS: Participants were 359 high-school students (47% males) aged 17.0 years (range 15-21). RESULTS: Confirmatory factor analysis and correlation patterns showed support for the 8-factor structure and convergent validity, but poorer discriminant validity may suggest caution in interpreting single scales as evidence of ED pathology. Gender comparisons were broadly consistent with previous research. CONLUSIONS: The Swedish EPSI may be used to asses ED symptoms, but caution is suggested in interpreting some scales in isolation as indicative of ED pathology.

Indivudals with eating disorders (ED) experience symptoms that have to do with body image, disordered eating, and physical exercise. Most who get an ED are female, but males are also affected. However, many symptom questionnaires do not capture how males experience their illness very well. In this study, we wanted to (1) test a Swedish translation of the Eating Pathology Symptoms Inventory (EPSI), which was designed to overcome some limitations in other questionnaires, and (2) compare male and female Swedish high-school students on ED symptoms, depression, and anxiety. Participants were 359 students (47% males) aged ≈ 17 years (range 15­21). Statistical analysis showed that the 8 suggested scales of the EPSI overall function as expected, and that the EPSI seems to measure ED symptoms well, but that it also has some overlap with depressive and anxiety symptoms. Males and females differed from one another in ways that resembled what other researchers have found. We conclude that the Swedish EPSI works well, but that some of the scales might not, on their own, suggest that a person has problems with ED, unless other more ED-specific scales also indicate such symptoms.

"To exercise sustainably" - Patients' experiences of compulsive exercise in eating disorders and the Compulsive Exercise Activity Therapy (LEAP) as a treatment: a qualitative interview study.

BACKGROUND: Compulsive exercise is common in eating disorders (EDs), but a systematic treatment model is lacking. The CompuLsive Exercise Activity TheraPy (LEAP) is a cognitive behavioral therapy treatment for compulsive exercise in EDs, delivered by trained therapists in groups over four consecutive weeks (8 groupsessions and 1 individual session), aiming to promote healthy physical activity. LEAP is currently evaluated in a randomized efficacy trial. In parallel, it is crucial to learn more about how it is perceived by qualitatively investigating participants' subjective experiences. METHODS: Nine patients with various EDs participating in the LEAP trial were interviewed about their experiences of taking part in LEAP and about compulsive exercise as an ED symptom using a semi-structured interview guide. The interview transcripts were analyzed according to thematic analysis. RESULTS: The informants expressed that compulsive exercise had not been addressed in their standard ED treatment and that LEAP as such provided an important complement, spurring reflection, awareness, and changed feelings and behaviors in relation to compulsive exercise. Initially, increased PA was triggered for some, but this side effect was transitory. A wish for more treatment time, in terms of longer or additional sessions, was expressed. CONCLUSIONS: Overall, LEAP seemed to fill an important treatment need and seemed both acceptable and feasible to patients. However, treatment time and the initial increase in PA may need further investigation and attention in order to optimize this treatment. TRIAL REGISTRATION: The trial is registered with the ISRCTN registry (registration date 20200325), trial ID ISRCTN80711391.

Compulsive exercise (CE) is very common in individuals with eating disorders (EDs) often tightly connected with the eating pathology. Even so, most standard treatments do not specifically target CE, leaving patients without strategies to normalize their exercise. The CompuLsive Exercise Activity TheraPy (LEAP) is delivered as an adjunctive treatment to standard ED treatment (targeting CE in patients with EDs. In this study, nine former LEAP patients were interviewed about their experiences of taking part in LEAP and about CE as an ED symptom. The informants were in general satisfied with LEAP and indicated that participation had positive effects on their exercise-related thoughts and attitudes, as well as actual exercise behaviors. They all experienced that CE was not addressed in their standard treatment, although they were motivated to work towards changing it. LEAP was therefore viewed as an important complement. Participating in LEAP initially triggered some informants to exercise more, which fortunately ceased over time and is similar to the temporal negative effect (increased food occupation) often observed initially in cognitive behavioral therapy for eating disorders. The content of LEAP was experienced as valid, informative, and eye-opening, and being able to discuss CE-related topics in a group setting was for many a positive experience. The experiences expressed in this study are very useful for continued development of LEAP. Although preliminary, the results also suggest that LEAP may be a valuable add-on treatment within ED care.

Maladaptive exercise in eating disorders: lifetime and current impact on mental health and treatment seeking.

BACKGROUND: Many patients with eating disorders report exercise as a central symptom of their illness-as a way to compensate for food intake, prevent weight-gain, and/or reduce negative affect. Previous findings show associations between maladaptive exercise and more severe eating disorder pathology, higher risk for relapse, other co-morbid symptoms, and worse treatment outcome. METHODS: In this study, we included 8252 participants with eating disorders and investigated associations between maladaptive exercise (both lifetime and current) and ED pathology, illness duration, depression, anxiety, self-harm and suicidal ideation, and treatment seeking patterns in individuals with lifetime maladaptive exercise. Participants were included via the Swedish site of the large global study The Eating Disorders Genetics Initiative (EDGI) and completed measures of both lifetime and current symptomatology. RESULTS: Results indicate that lifetime maladaptive exercise is associated with higher prevalence of lifetime depression and anxiety and with patients more often receiving treatment, although these results need to be investigated in future studies. Current maladaptive exercise was associated with more severe ED symptoms, and higher levels of depression, anxiety, obsessive-compulsive traits, and suicidal ideation. CONCLUSIONS: Our findings point to the complexities of exercise as an eating disorder symptom and the need for clearly assessing and acknowledging this, as well as tailoring interventions to treat this symptom to achieve sustainable recovery.

Many individuals with eating disorders view exercise as a crucial aspect of their illness, often using it to control weight and emotions. Research suggests that maladaptive exercise correlates with more severe eating disorder symptoms, increased risk of relapse, and poorer treatment outcomes. Analyzing data from 8252 participants with eating disorders, this study from the Swedish site of The Eating Disorders Genetics Initiative (EDGI) found that lifetime maladaptive exercise is linked to higher rates of depression and anxiety and increased treatment seeking behaviors. Current maladaptive exercise was associated with heightened eating disorder severity, depression, anxiety, obsessive-compulsive traits, and suicidal thoughts. These findings underscore the importance of recognizing exercise as a symptom of eating disorders and tailoring interventions accordingly for sustainable recovery.

Emotion dysregulation and eating disorder outcome: Prediction, change and contribution of self-image.

OBJECTIVES: Eating disorders (EDs) are severe disorders with unsatisfactory outcome. Emotion dysregulation and self-image are suggested maintenance factors; this study examined emotion dysregulation as potential predictor and/or mechanism of change in relation to ED outcome, and associations between change in emotion dysregulation and self-image in relation to outcome. DESIGN: Registry data from initial and 1-year follow-up assessments for 307 patients with a wide range of EDs in specialized ED treatment were used. METHODS: Initial and change (∆) in emotion dysregulation were examined as predictors of 1-year outcome. Direct and indirect associations between ∆emotion dysregulation and ∆self-image as either independent variable or mediator in relation to ∆ED psychopathology as dependent were also examined. RESULTS: Higher initial emotion dysregulation was weakly associated with higher follow-up ED psychopathology, but not remission, while relative increase in emotion dysregulation was associated with both higher follow-up psychopathology and increased risk of still having a diagnosis. Change in emotion dysregulation primarily had an indirect effect (through change in self-image), while change in self-image had a direct effect, on change in ED psychopathology improvement (such that improvement in one was associated with improvement in the other). CONCLUSIONS: Results identify emotion dysregulation as a potential mechanism of change in relation to ED outcome. However, this association was mainly mediated by change in self-image. Results indicate that, in order to improve emotion regulation as a means to reduce ED psychopathology, improving self-image is essential.

Binge Eating and Addictive-Like Behaviours in Males and Females.

INTRODUCTION: Binge eating is a common behaviour that is strongly linked to both obesity and eating disorder. There is evidence that binge eating commonly co-occurs with other problematic and addictive-like behaviours; however, this has not been explored systematically. The present study aimed to examine the relationship between binge eating, body weight, disordered eating behaviours and associated addictive-like behaviours, with particular attention paid to gender differences. METHOD: A community sample (N = 500; 75% female, Mage = 32.5 years) reported disordered eating behaviours (i.e. binge eating, purging, restriction of eating, compulsive exercise), body mass index (BMI), food addiction, starvation addiction, exercise dependence, tobacco use and alcohol consumption. RESULTS: 42% of females and 21% of males reported binge eating during the past four weeks. Binge eating was significantly associated with all investigated behaviours in females, and with purging, compulsive exercise and overweight/obesity in males. Controlling for BMI, self-starvation predicted binge eating in males (OR = 1.07), while food addiction (OR = 1.73) and alcohol dependence (OR = 1.11) predicted binge eating in females. CONCLUSIONS: The multiple associations between binge eating and addictive-like behaviors supports broad screening and generalized prevention efforts. Prevention efforts should reflect gender differences.

Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise.

INTRODUCTION: Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). METHOD: A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. RESULTS: Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. DISCUSSION: Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.

Initial self-blame predicts eating disorder remission after 9 years.

BACKGROUND: Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. AIM: To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. RESULTS: Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. CONCLUSION: In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

Self-directed behaviors differentially explain associations between emotion dysregulation and eating disorder psychopathology in patients with or without objective binge-eating.

BACKGROUND: Emotion dysregulation and negative self-directed behaviors are key characteristics of eating disorders (EDs), but their interaction in relation to ED psychopathology is insufficiently explored, and empirically robust and clinically relevant models are needed. METHODS: This study examined whether the association between emotion dysregulation and ED psychopathology was mediated by different negative self-directed behaviors in 999 ED patients divided into two sub-samples based on absence or presence of objective binge-eating episodes (OBE). Several simple and extended mediation models were examined using the Difficulties in Emotion Regulation Scale (DERS) as independent variable, the Structural Analysis of Social Behavior (SASB) as mediator, and the Eating Disorder Examination Questionnaire (EDE-Q) as dependent variable. RESULTS: An associational pathway was found where higher emotion dysregulation was associated with more negative self-directed behaviors, which in turn was associated with higher ED psychopathology. Self-directed behaviors of importance differed between patient groups. In participants without OBE, lower self-love and higher self-attack were influential, whereas in participants with OBE, lower self-affirmation and higher self-blame were influential. CONCLUSIONS: Self-directed behaviors may help to explain the association between emotion dysregulation and ED psychopathology. Our findings have both theoretical and clinical implications that are pathology-specific. Addressing specific self-directed behaviors could be an important way of helping patients deal with their emotions in relation to ED psychopathology.

Running on empty - a nationwide large-scale examination of compulsive exercise in eating disorders.

BACKGROUND: Compulsive exercise (CE) has been the neglected "Cinderella" among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample. METHODS: CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined. RESULTS: CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males. CONCLUSIONS: At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment.

Exercise Caution: Questions to Ask Adolescents Who May Exercise Too Hard.

When the primary goal of exercise is to compensate for food intake and to alter body shape and weight, it is considered compulsive and may be harmful. Compulsive exercise (CE) is important in the pathogenesis of eating disorders (EDs). Many healthy adolescents engage in CE too, and this may indicate a risk for EDs. Our aim was to learn more about ED risk factors tied to CE and to try to isolate questions to ask in order to probe for high ED risk in adolescents engaging in CE. Using two well-established instruments (the Structural Analysis of Social Behavior and the Eating Disorders Examination Questionnaire), we studied associations between ED variables and CE in healthy adolescent boys and girls. We examined gender-specific items to generate the best possible fit for each gender. Individuals with CE displayed significantly greater ED pathology and more self-criticism, and this pattern was stronger in girls than in boys. Risk factors for ED among individuals with CE differed slightly for boys and girls. We put forward a set of gender-specific questions that may be helpful when probing for ED risk among adolescents engaging in CE.

Emotion dysregulation, self-image and eating disorder symptoms in University Women.

BACKGROUND: We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms. METHODS: 252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise. RESULTS: Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise. CONCLUSIONS: Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus.