Eating disorders (EDs) are serious mental health conditions with a rising incidence. They have among the highest morbidity and mortality rates of all psychiatric illnesses, with suicide a major cause of death (Smith et al., 2018; Treasure et al., 2020). They typically have a chronic course, resulting in many years lived with disability, annual healthcare costs almost double those of the general population, and 3.3 million healthy life years lost annually (van Hoeken & Hoek, 2020). The scale of this problem is startling - EDs are estimated to affect 7.8% of the worldwide population (Galmiche et al., 2019), though their true prevalence is likely higher and apparently increasing (Treasure et al., 2020): the last four years showed a 21% increase in referrals in south-east England alone (Ayton et al., 2022). In addition, psychological treatment for EDs is suboptimal. Using the current empirically-supported evidence-based treatment (i.e. Cognitive Behavioural Therapy, CBT), over 60% of patients with Bulimia Nervosa (BN) (Linardon & Wade, 2018) and 50% of patients with Binge Eating Disorders (BED) (Linardon, 2018) do not obtain complete abstinence from core eating disorder symptoms. Similarly, relapse rates are high, for example with up to 53% of patients with Anorexia Nervosa (AN) relapsing (Khalsa et al., 2017), further demonstrating the limitations of current evidence-based treatments. Part of the answer may lie in the fact that current evidence-based treatments principally focus on the symptoms themselves, rather than what is driving them. Some evidence is however accumulating regarding a third wave of treatment that focuses on emotions as an underlying cause for these symptoms, such as dialectical behavioural therapy (DBT, e.g. Ben-Porath et al., 2020). We developed an online self-paced intervention based on DBT that draws on a body of knowledge concerning the relationship between difficulties with emotions and eating psychopathology (Kukk & Akkermann, 2022; McClure et al., 2022; Nordgren et al., 2021; Trompeter et al., 2021; Westwood et al., 2017). This paper reports the findings from the pilot study evaluating the intervention in a group of 39 people with an ED.
A multifaceted link between difficulties with emotions and EDs is now widely established. Firstly, people with EDs struggle to identify and describe their emotions, a tendency known as alexithymia (Westwood et al., 2017). Secondly, they often struggle to regulate their emotions (Prefit et al., 2019), seeming to over-rely on maladaptive emotion regulation strategies such as suppression or rumination while under-utilising adaptive strategies such as acceptance (Prefit et al., 2019; Vuillier, May, et al., 2021) or cognitive reappraisal (Petersson et al., 2021); indeed, lower use of cognitive reappraisal appears to be associated with higher severity of restrictive symptoms (Vuillier et al., 2022). Thirdly, people with EDs also differ in their beliefs about emotions, such as whether emotions are controllable or uncontrollable, and whether they are good or bad which both have implications for emotion regulation strategies (Ford & Gross, 2019). As such, people with EDs tend to believe that emotions are not something they can control or manage, with stronger beliefs around the uncontrollability of emotions being linked to greater ED psychopathology (Vuillier, Joseph, et al., 2021), as well as higher levels of anxiety and depression (Deplancke et al., 2022). The other dimension of beliefs about emotions concerns the extent to which they are good or bad, or perceived as acceptable or threatening. Maladaptive beliefs about the threat posed by emotions leads to emotional non-acceptance and can incur secondary emotions which have both been associated with EDs (Corstorphine, 2006; Leppanen et al., 2021). While primary emotions are natural and adaptive responses to the environment (e.g. feeling sad when losing something or someone you care about), secondary emotions (e.g. feeling guilty for feeling sad because feeling sad is ‘bad’) are learnt responses which do not always make sense (e.g. the lingering emotion of guilt rather than sadness when losing something or someone you care about) and are known to be associated with ED behaviours (Corstorphine, 2006).
There is evidence to support that at least some of these emotion difficulties, such as emotion regulation problems, are premorbid longitudinal predictors of disordered eating and EDs (Henderson et al., 2021; Warne et al., 2023). Moreover, these concepts and difficulties are linked: for instance, being unable to identify emotions makes it harder to know how to regulate unpleasant feelings (Brown et al., 2018; Sfärlea et al., 2019), and believing emotions are uncontrollable influences the ways in which people attempt to regulate their emotions, if they try at all (Ford & Gross, 2019; Gutentag et al., 2017). However, these processes are also distinguishable. For example, alexithymia or maladaptive beliefs about emotions are not a prerequisite for difficulties with emotion regulations, which can happen at any and all stages of the emotion regulation cycle (Gross, 2015). Therefore, we believe that interventions developed to help people with EDs better understand and manage their emotions should address all these concepts.
The foremost treatment recommended for EDs is Cognitive Behavioural Therapy (NICE guideline, 2020), which principally works by directly targeting ED thoughts and behaviours (Murphy et al., 2010). However, newer therapies such as DBT aim to address underlying emotion difficulties, which are believed to give rise to and maintain ED thoughts and behaviours, as well as treating co-occurring psychopathologies (e.g. anxiety, depression) that also contribute to the development and maintenance of EDs (Elran-Barak & Goldschmidt, 2021). DBT treatment focuses principally on emotional non-acceptance and offers strategies to help manage emotions. It has been shown to work well to improve emotion regulation skills and reduce eating psychopathology in EDs (Rozakou-Soumalia et al., 2021) and seems at least equally efficacious and less associated with relapse at 6-month follow-up compared to CBT (Lammers et al., 2022). However, it does not always resolve more fine-grained, underlying emotion processes, such as beliefs about emotions or alexithymia which can maintain ED behaviours and seem to act as a negative prognostic factor in ED recovery (Speranza et al., 2007). There is emerging evidence that interventions specifically targeting beliefs about emotions (Glisenti et al., 2023) or alexithymia (Becker-Stoll & Gerlinghoff, 2004) are effective for people with EDs and may lead to a higher probability of patients’ recovery (Pinna et al., 2015). As of yet, however, these emotion-focused approaches are not yet recognised or recommended by the National Institute for Health and Care Excellence (NICE); nor, to the best of our knowledge, has an intervention including all these significant aspects of emotional functioning, including beliefs about emotions, been developed.
The current study aims to evaluate a self-help online intervention that was developed by a team of clinicians and researchers, with input from lived-experience experts at multiple points. This intervention aims to increase awareness of the link between emotions and eating psychopathology. Through five short online self-paced videos (5–9 minutes long), it aims to normalise emotions, provide help to identify and regulate emotions as well as self-care strategies, all the while using techniques known to improve therapeutic alliance through providing genuineness, unconditional positive regard, and empathic understanding (Rogers, 1957). We delivered this intervention to 39 people with EDs with the aim of answering the following research questions, using quantitative and qualitative methods:
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Is our intervention linked with qualitative and/or quantifiable changes in emotion processes and psychopathology?
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Do changes in emotional awareness and processing and regulating abilities predict changes in ED psychopathology?