Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 16, 237–239 (2009)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.625

Editorial Eating Disorders

and Emotions
John R. E. Fox1,2,3
1
Division of Health Research, Lancaster University, Lancaster, UK
2
Clinical Psychology, School of Health in Social Science, The University of
Edinburgh, Edinburgh, UK
3
Eating Disorders Unit, Russell House, Affinity Healthcare, Cheadle Royal
Hospital, Cheadle, Cheshire, UK

This special edition deals with one of the core
dimensions of understanding eating disorders,
namely, emotions and emotional processing. Only
recently has psychological theory started to con-
sider the role of emotions within an eating disorder
presentation. This has often been a bewildering
fact to the ‘coal face’ clinician, as they are often
faced by a client who either appears to be devoid
of emotion, or at the mercy of her own emotions.
Strober (2004) eloquently described a host of emo-
tions that are often present in anorexia nervosa,
from the quiet anger to the perpetual fear of gaining
weight. Strober also described the emotions that
are often found in carers and professionals who
work with this client group, namely, fear and irri-
tation that the client refuses to change despite the
therapist’s best efforts. The pioneering work of
Hilde Bruch (1962, 1978) was pivotal in starting to
piece together information about anorexia nervosa.
Through her detailed analysis of her own cases,
Bruch came to develop the hypothesis that anorexia
nervosa was a condition that grew out of the inabil-
ity to experience or express one’s own emotions.
She proposed that the experience of ‘being fat’ was
directly connected to an inability to distinguish or
express one’s own emotional states.
Psychological therapies took a while to develop
theories that began to account for the emotional
difficulties present in eating disorders. The empha-
sis prior to these developments was on behavioural
and eating changes, as within cognitive behavioural
therapy for bulimia nervosa (CBT-BN; Fairburn,
Marcus, & Wilson, 1993). Although these theories
showed a lot of promise by helping nearly 50% of
patients with bulimia improve, they clearly had
a long way to go. One of the key factors that was
not accounted for by the early CBT models was
apparent difficulties that the people with eating
disorders had with their mood. Indeed, Fairburn
revised his original theory of CBT-BN to incor-
porate mood intolerance in the late 1990s (Fair-
burn, 1997). The use of particular eating disorder
behaviours to moderate or suppress emotion has
started to gain momentum within the literature.
Crisp (1980) discussed how the anorexic girl will
use restriction (also knows as anorexia nervosa)
to reverse the pubertal/maturation process, and
avoid the associated emotions that ensue. Indeed,
he argued very strongly that recovery from anorexia
nervosa is associated with the worsening of mood,
and periods of depression. Crisp (1997) coined the
phrase that the ‘anorexic’ needs to be at a ‘sadder,
but wiser position’ to make a recovery. Heather-
ton and Baumeister (1991) undertook some pio-
neering research that examined how binge eating
was associated with reduced self-awareness. This
finding opened the door to considering how binge
eating may play an important emotion regulatory
function for the individual, and this led to further
postulations about the role of bingeing and vomit-
ing in bulimia nervosa.
The role of binge eating in decreased self-aware-
ness and how restriction can reduce emotional
awareness have now been incorporated into con-
temporary cognitive therapy models of eating dis-
orders. Cooper, Wells and Todd (2004) proposed
a model that argued that positive and negative
beliefs about bingeing, in response to negative
core belief activation, are pivotal in understanding
bulimia nervosa. The key dynamic in this model
is the knowledge that bingeing helps the self to
dissociate from painful emotions. Equally, Waller,
Kennerley and Ohanian (2007) argued that both
bingeing–vomiting and restriction are emotion
suppression strategies, but they are just utilized
at different times. For example, restriction is used
to pre-empt any emotion activation, while binge-
ing–vomiting is used after an emotion has been
activated. Although these models are a useful start,
they leave both the theorist and the clinician with a

Copyright © 2009 John Wiley & Sons, Ltd.

238
number of questions about the role of emotions in
eating disorders. Which emotions are important?
Do people with eating disorders experience higher
levels of emotions, or do they have difficulty with
everyday levels of emotions? Finally, what is the
relation of depression to these difficulties and what
are the best ways to work with the actual emotions
generated?
As editor of this special edition, I have often con-
sidered the need for further theory development in
understanding not only the actual eating disorder
behaviours, but also the connection with other asso-
ciated symptoms that are present within people
who have eating disorders. For example, within the
second-generation cognitive models, there is often
a lack in the consideration of the marked body
dissatisfaction that accompanies every case of an
eating disorder. In my clinical position, it is impos-
sible not to see the lengths that people with eating
disorders will go to to prevent weight gain and
how much difficulty and loathing they feel for their
own bodies. I have wondered about this in relation
to both the recent CBT models and the writings of
Hilde Bruch (as discussed above). Moreover, there
is a wealth of literature research that has examined
normal emotional processes without psychological
disorder, and I have also wondered if this gives
us any further clues in understanding emotions
within eating disorders. In compiling this special
edition, I have sought papers that offer some
insights into the questions raised above. None of
the papers adequately answer all the questions as
the evidence base is still in need of further research,
but it is my hope that these special edition papers
generate thought, further theory and research.
In the first paper, I present a review of the litera-
ture on emotional processes in eating disorders. On
the basis of this review, Mick Power and I present
a model that attempts to understand eating disor-
ders from a basic emotion perspective. It is argued
that eating disorders need to be understood from
a developmental perspective, where the role of
anger and disgust are the important emotions. A
key construct of this model is that it proposes that
co-morbid patterns of presentation in eating disor-
ders, such as eating disorders and depression, can
be understood from a basic emotions perspective.
In this instance, the role of self-disgust would be
seen as pivotal in understanding depression and
eating disorders. This theoretical perspective is
contrary to the second paper, within this special
edition, by Davey and Chapman. In this paper,
they argue that disgust, although an important
emotion, is actually part of the anxiety that is often
Copyright © 2009 John Wiley & Sons, Ltd.
J. R. E. Fox
a feature of eating disorders. These differing views
have a ‘chicken and egg’ angle to them, as it may
be that anxiety is actually comprised of disgust,
as they both are emotions of avoidance and both
create a ‘psychological distance’ between the self
and the stimulus. Also, Davey and Chapman’s
paper is based on analogue data and therefore,
it is not known about these proposed processes
within a clinical group. The third paper looks
at the perception of emotions within a group of
people with a diagnosis of anorexia nervosa. It
is the only qualitative study within this special
edition and it provides very rich data. The findings
suggest that anger is a key problematic emotion
for people with anorexia nervosa, and it also offers
some very interesting insights into the potential
developmental pathways for this client group. The
conflicting emotions and feelings associated with
these histories give some important clues as to how
complex and powerful the messages given about
emotions are through childhood. It also introduces
the finding that it is not only the beliefs about the
emotion that are significant, but also the lack of
meta-emotional skills that are of importance in for-
mulating the difficulties that people with anorexia
nervosa potentially face. This special edition then
introduces two papers on shame in eating disor-
ders. Goss and Allan offer an excellent review of
the literature that pertains to shame in eating dis-
orders. They discuss how shame is an important
emotion in understanding eating disorders, and
how these emotions are linked to pervasive self-
worth beliefs. Goss and Allan offer a very informa-
tive discussion on how levels of shame are often
linked to adverse experiences while growing up,
and this discussion has many commonalities with
the review offered by Fox and Power, and the
qualitative paper. Many of these issues of shame
are echoed by the Keith et al. paper, where they
connect schema beliefs with levels of shame and
parental bonding styles.
The special edition goes on to present two papers
that address both the actual levels of specific emo-
tions in eating disorders and the perception of
threat that is perceived from emotional states.
The consistency of these findings is fascinating,
with one demonstrating that levels of anger and
sadness uniquely predict disordered eating, and
the other paper reporting that perception of threat
from anger and depression uniquely predicted
poor emotional expression in people with dis-
ordered eating. Taking these results together, it
appears that people with eating disorders have the
‘double whammy’ of experiencing high levels of
Clin. Psychol. Psychother. 16, 237–239 (2009)
DOI: 10.1002/cpp
Editorial
anger and perceiving this anger as being threaten-
ing. Both of these papers discuss how these find-
ings resonant with the findings of Geller, Cockell,
Hewitt, Goldner and Flett (2000), Hayaki, Fried-
man and Brownell (2002), and Fox and Harrison
(2008). All of these papers argue that threatening
emotions (e.g., anger) are directed away from the
self and onto the body, via body dissatisfaction. It
is interesting how the literature has started to come
round in a circle, with similar themes being dis-
cussed by Hilde Bruch nearly 30 years ago. Related
to the writings of Bruch, Harrison et al.’s paper
discusses results that highlight how people with
a diagnosis of anorexia nervosa have difficulties
with emotional regulation and emotion percep-
tion. It is noteworthy that they discuss how these
difficulties may actually be weight related, and if
one considers the potential function of weight loss
to suppress emotions, this would make theoretical
sense. However, Schmidt, Jichwany and Treasure
(1993) undertook a controlled study of alexithymia
and found that increased weight did not lead to
an improvement in emotion recognition/expres-
sion difficulties. On the back of these results,
these authors argued that alexithymia should be
regarded more as a trait rather than state-type
phenomena. However, the findings of Fox in this
special edition challenge this notion of monolithic
difficulties with emotion, as the participants spoke
clearly about their own emotions and they felt sig-
nificant difficulty in expressing their emotions (in
keeping with Ioannou and Fox). It may be time for
a deconstruction of alexithymia in the literature,
along emotion identification and emotion expres-
sion lines.
The final two papers of this special edition are
written by colleagues from North America. Presnell
and Stice discuss the relation between depression
and bulimic symptoms, and they found further evi-
dence of a bilateral relationship between these two
variables. Lastly, Dolhanty and Greenberg present
a paper that discusses emotion-focused therapy for
anorexia nervosa. This clinically focused paper is a
fascinating example of the challenges that the clini-
cian faces in working with this client group, and it
also provides an excellent insight into the applica-
tion of emotion-focused therapy for someone with
anorexia nervosa.
Across all the studies presented in this special
edition, the importance of understanding emo-
tions and their functioning has been emphasized.
As discussed in the beginning of this editorial, I
undertook the editing of this special edition with
a number of questions in mind about the nature
Copyright © 2009 John Wiley & Sons, Ltd.
239
of emotion, co-morbidity and role of emotions in
the psychological treatment of eating disorders. I
do feel that this collection of papers offers some
answers to these questions, but, in keeping with
good scientific enquiry, they also generate further
questions for future research.
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Clin. Psychol. Psychother. 16, 237–239 (2009)
DOI: 10.1002/cpp