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Comparing views of patients,

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Comparing views
of patients, parents,
and clinicians on Journal of Health Psychology
Copyright © 2009 SAGE Publications
emotions in anorexia Los Angeles, London, New Delhi, Singapore
and Washington DC
www.sagepublications.com

A qualitative study Vol 14(7) 843–854

DOI: 10.1177/1359105309340977

Abstract
O. K YR I AC O U , A . E A S T E R
AND K . T C H A N TU R I A Patients with anorexia nervosa (AN)
Institute of Psychiatry, UK may experience difficulties in
emotional processing that can
adversely affect treatment and
maintenance of the illness. Focus
groups or questionnaires were
undertaken with patients with AN,
parents and clinicians, with the aim to
explore the most salient issues
pertaining to emotions and social
cognition in AN. Qualitative thematic
analysis was used to analyse the data.
Seven primary themes were identified
showing congruence across groups:
‘emotional awareness and
understanding’; ‘emotional
intolerance’; ‘emotional avoidance’;
‘emotional expression and negative
beliefs’; ‘extreme emotional
responses’; ‘social interactions and
relationships’; and ‘lack of empathy’.
Clinical and empirical implications
are discussed.

AC K N OW L E D G E M E N T S . This work was part of the ARIADNE programme

(Applied Research into Anorexia Nervosa and Not Otherwise Specified
Eating Disorders), funded by a Department of Health NIHR Programme
Grant for Applied Research (Reference number RP-PG-0606–1043) to
U. Schmidt, J. Treasure, K. Tchanturia, H. Startup, S. Ringwood, S..Landau,
M. Grover, I. Eisler, I. Campbell, J. Beecham, M. Allen, G. Wolff.
The views expressed herein are not necessarily those of DH/NIHR.
Keywords
COMPETING INTERESTS: None declared.
■ anorexia
ADDRESS. Correspondence should be directed to:
■ eating disorders
A. EASTER, Section of Eating Disorders, Division of Psychological Medicine
■ emotions
and Psychiatry, PO59, Institute of Psychiatry, De Crespigny Park, ■ focus groups
London SE5 8AF, UK. [Tel. +44 20 7848 0160; Fax +44 20 7848 0182; ■ qualitative research
email: abigail.easter@iop.kcl.ac.uk] ■ social cognition

843
JOURNAL OF HEALTH PSYCHOLOGY 14(7)
Introduction
Psychopharmacological treatment outcomes for
adults with anorexia nervosa (AN) are poor (Lock &
Fitzpatrick, 2009) and have shown little improve-
ment to date (Agras & Robinson, 2008). There is yet
no empirically supported treatment of choice for AN
according to NICE guidelines (NICE, 2004). Several
explanations have been posited as to why AN patients
are difficult to treat and why prognosis and outcome
are so disappointing. These have included: patients’
ambivalence towards change; resistance to treatment;
comorbidity and personality traits; reduced effec-
tiveness of psychotropic medication and psycho-
therapy in severely underweight patients (Schmidt
& Treasure, 2006); and, compromised cognitive
abilities (e.g. Tchanturia, Davies, Lopez, Schmidt,
Treasure, & Wykes, 2008). In addition, clinical expe-
rience suggests that individuals with AN are often
resistant to engaging in treatment that focuses on emo-
tions and personal experiences. Possible links have
been made between problems with emotional pro-
cessing and eating disorders (ED) by a number of
researchers (e.g. Jones, Harmer, Cowen, & Cooper,
2008; Zucker, Losh, Bulik, LaBar, Piven, & Pelphrey,
2007). However, the exact nature of such problems
and, essentially, how they can be targeted in treatment
remains unclear.
Studies of emotional processing difficulties in AN
are gradually increasing, in particular research has
indicated that rates of alexithymia appear to be ele-
vated in individuals with AN (Bydlowski, Corcos,
Jeammet, Paterniti, Berthoz & Laurier, 2005;
Gilboa-Schechtman, Avnon, Zubery, & Jeczmien,
2006; Schmidt, Jiwany, & Treasure, 1993). Studies of
emotional perception also indicate that individuals
with AN may have an impaired ability to recognize
emotionally expressive faces (Zonnevijlle-Bender,
van Goozen, Cohen-Kettenis, van Elburg, & van
Engeland, 2002, 2004). However, such studies
have shown some contradictory findings (Kessler,
Schwarze, Filipic, Traue, & von Wietersheim, 2006)
and there is a need for replication. Much research
to date has focused on how negative emotions are
processed and tolerated in individuals with ED.
For example, people suffering from AN have been
found to be more sensitive to negative emotions such
as shame and disgust in particular (Troop, Murphy,
Bramon, & Treasure, 2000). Bruch (1985) noted
that people with AN not only show impaired differ-
entiation between hunger and satiety but find it hard
to distinguish their physical sensations from their
844
intimate emotions, which they often cannot describe.
Clinical observations also suggest that individuals
suffering from this illness display impairments in the
processing of their own emotions and the emotional
states of others.
Emotions may play an important role in the
maintenance of AN, as well as being antecedents
and triggers of some eating-disordered behaviours
(e.g. Arnow, Kenardy, & Stewart, 1995; Fairburn,
Cooper, & Shafran, 2003). Maintenance factors
are particularly important for developing treatment
strategies as they predict symptom persistence over
time among initially symptomatic individuals.
Schmidt and Treasure (2006) propose an intraper-
sonal maintenance model of AN, which highlights
the role of emotions in maintaining the disorder.
They suggest that suppression and avoidance of
emotions is often highly valued by patients suffer-
ing with AN and manifested in perfectionism, over
time this becomes intrinsically linked with avoid-
ance of eating. Eating ‘forbidden’ foods not only
arouses unwanted negative feelings in such patients
but also becomes a threat to emotional stability.
Corstorphine (2006) describes this as a vicious
cycle where patients use eating behaviours to avoid
emotions, as a result they become increasingly out
of touch with experiencing emotions.
Empirical research in this area is limited and we
have found no qualitative studies on the views of
patients and parents on emotional processing in AN.
Before we can develop effective interventions to
address emotions in the treatment of ED there is
a need to identify the most relevant problems that
people with ED face. This in turn may help guide
quantitative research into emotional processing
difficulties in AN in the future.
The aims of this study are to establish what the
most commonly experienced problems are relating
to emotional processing in patients with AN from
the perspective of patients with AN, their parents
and clinicians. Specifically, we aim to explore what
patients, parents, and clinicians identify as the most
salient issues regarding emotions and social cogni-
tion and find possible similarities and differences in
accounts across these groups.
Methods
Participants
In accordance with qualitative methods and focus
group guidelines, a purposive sample of ‘expert’
 KYRIACOU ET AL.: A QUALITATIVE STUDY

informers was sought. A demographics questionnaire Table 2. Demographic information on patients (N = 6)

was administered to all participants. Information was
Participant Duration of
collected from three distinct groups of participants
ID Gender Age illness (years) BMI
(described later) in order to gain a detailed under-
standing of the experiences of emotional processing Patient 1 Female 21 6 16.10
difficulties from a number of sources. The authors Patient 2 Female 36 22 15.20
felt that it was important to gain a detailed narrative Patient 3 Female 31 15 12.00
of such experiences from different perspectives, in Patient 4 Female 22 4 15.40
order to both increase the validity of accounts and, Patient 5 Female 20 5 12.30
to gain an insight into areas of concurrence and Patient 6 Female 31 12 14.80
divergence in the descriptions from each group.

Patients The patient group (N = 6) consisted The average duration of illness was 10.7 years
of current AN inpatients with a mean age of 26.8 (SD = 7), and the average BMI was 14.3 (1.7).
(SD = 6.7); four of the patients suffered from
restricting AN and two from binge/purge AN. Parents Carers (N = 12) taking part in the focus
group were recruited from the Carers Volunteer
Database maintained by the eating disorder unit
Table 1. Demographic information on clinicians (N = 12) (EDU). All carers were parents who were currently
and nurses (N = 7) caring for a patient with AN, all of whom had
received inpatient treatment. Parents’ mean age was
Participant How long
ID Gender Grade worked in
52.5 years (SD = 7.11); mean age of persons cared
ED (years) for was 20.3 years (SD = 3.7), with mean duration
of illness of 4.8 years (SD = 2.4).
Clinician 1 Female Consultant 20
Psychiatrist Clinicians The group consisted of nurses (N = 7),
Clinician 2 Female Clinical 10 psychiatrists (N = 3), and psychologists (N = 9)
Psychologist working in the EDU. Nurses had an average length
Clinician 3 Female Consultant 20 of ED work experience of 7 years (SD = 5) while the
Psychiatrist psychiatrists and psychologists had worked for an
Clinician 4 Male Consultant 10 average of 10.5 (SD = 5.7) years with ED patients.
Psychiatrist
Clinician 5 Female Counselling 5
Psychologist Data collection
Clinician 6 Female Clinical 4 The study was approved by the local ethics com-
Psychologist mittee. Informed written consent was sought and
Clinician 7 Female Counselling 6 obtained from all participants.
Psychologist
The following were used to guide the focus
Clinician 8 Female Clinical 10
Psychologist
groups:
Clinician 9 Female Clinical 5 1. What are the most common problems related
Psychologist
to emotions and emotional processing in AN?
Clinician 10 Male Counselling 15
Psychologist
2. What problems do people with AN have in
Clinician 11 Female Counselling 8 social situations, in interpersonal interactions
Psychologist and in relationships?
Clinician 12 Female Counselling 8
Psychologist
The above open-ended and general topics relating
Nurse 1 Female Charge Nurse 12 to possible emotional difficulties and their implica-
Nurse 2 Female Ward Nurse 16 tions were selected in order to encourage an unbiased
Nurse 3 Female Charge Nurse 4 and open discussion among participants, regarding
Nurse 4 Female Ward Nurse 3 these issues.
Nurse 5 Female Ward Nurse 5 All focus groups were conducted by the first and
Nurse 6 Female Ward Nurse 6 corresponding authors and were audio recorded,
Nurse 7 Female Ward nurse 3
with participants’ permission. The transcripts of all

845
JOURNAL OF HEALTH PSYCHOLOGY 14(7)

Table 3. Demographic information on carers (N = 12; missing demographic information on one carer)

Participant Duration of Age of Currently living Patient ever received

ID Gender illness (years) patient w/ patient inpatient care

Mother 1 Female 3 23 yes yes

Mother 2 Female 2 18 yes yes
Mother 3 Female 8 25 yes yes
Mother 4 Female 6 18 no yes
Mother 5 Female 2 16 yes yes
Mother 6 Female 6 25 no yes
Father 1 Male 2 16 yes yes
Father 2 Male 6 18 no yes
Mother 7 Female 4 18 yes yes
Father 3 Male 9 26 no yes
Mother 8 Female 5 21 yes yes
Mother 9 Female – – – –

groups were analysed individually by the first (OK)
and second author (AE). Due to the impracticalities
of gathering all psychologists and psychiatrists
to take part in a focus group at a specified time, a
parallel questionnaire was given to this group of
participants, who supplied information on the same
questions asked at the focus groups, via email.
Thematic analysis:
description and suitability
The authors adopted a post-positivist epistemologi-
cal stance to research. This approach asserts that the
complexity and unpredictability of human behav-
iour makes it difficult to determine cause-and-effect
relationships of behaviour. It is therefore concerned
with exploring the meaning of human experience.
Inductive thematic analysis was undertaken to under-
stand the difficulties associated with emotional pro-
cessing in those suffering with ED, from multiple
perspectives. Thematic analysis as described by
Braun and Clarke (2006) was used to distil themes
and disseminate findings. Thematic analysis is a
widely applied and flexible method within and
beyond psychology. It was considered suitable for
the exploratory purposes of this study because of
its flexibility and theoretical freedom, and for its
descriptive rather than interpretative function,
making it preferable to other methods, such as
Interpretative Phenomenological Analysis (IPA;
e.g. Smith & Osborn, 2003) and Grounded Theory
(Glaser & Strauss, 1967).
Analysis
Each group transcript was repeatedly examined in
depth and coded for the presence of references to
846
emotions and social cognition. The preliminary
themes were continuously reviewed for salience and
importance and for clustering or grouping of themes
by content. The authors used the method of constant
comparison in order to reduce and condense the
themes into the most important categories. Through
this iterative, cyclical process, the most salient
themes were identified while others were discarded.
Validation process and reliability
Standards for the conduct of good qualitative research
as delineated by Henwood and Pidgeon (1992) and
Elliot and colleagues (Elliott, Fischer, & Rennie,
1999) were followed in this study. Triangulation,
an attempt to increase reliability and validity of
qualitative results, was pursued by combining differ-
ent sources of information (e.g. understanding the
research question from multiple perspectives), as
well as using two qualitative researchers to analyse
the data. The first and second authors coded the focus
groups and clinicians’ responses separately and then
jointly, using the procedures described to derive a
master table of themes. In addition to triangulation,
validity and reliability were pursued as follows: a
research diary was maintained during the course of
analysis to ensure transparency and credibility of
the themes identified; joint discussions were held
between the authors to ensure that the analysis was
true to the raw data; the master table of themes was
continuously updated throughout analysis; the iden-
tification and inclusion of contradictory or negative
cases and accounts were sought; participant theme
validation was pursued as participants were offered
transcripts and drafts of the thematic analysis
throughout the preparation of the report.

Results
Due to the substantial amount of information gener-
ated from the focus groups, the emphasis of this paper
is placed on the most salient themes, i.e. problems
relating to emotions and social cognition in AN. There
was, however, one additional major theme, which is
not discussed any further in the current article, con-
cerning the priorities and format of treatment of emo-
tional problems in AN. This theme consisted of six
distinct subthemes: psycho-education of emotions,
practical and graduated treatment, safe and appropri-
ate therapeutic environment, increased availability of
treatment, broader skills training and interactive group
work. These findings will be reported elsewhere.
Emotional awareness
and understanding
People with AN were described by parents and clin-
icians as highly functional on an intellectual level
but as showing substantial emotional difficulties. A
lack in awareness of emotional experiences in peo-
ple with eating disorders (ED) was described by all
groups of participants. This was described as an
inability to recognize, identify and label emotions.
Patient 4: I think it’s also an issue of identify-
ing emotions, and other people I’ve
talked to as well, if you ask them
how they feel they just don’t know,
and I’m like that quite a lot.
In contrast to an apparent absence of self-awareness
of own emotions and needs, across all groups there
was some feeling that perception of emotions in
others was intact, or even superior.
Table 4. Theme Occurrence and Overlap across groups
Themes
Problems with emotions & social cognition
Emotional Awareness & Understanding:
Of Self
Of Others
Inability to tolerate, contain and cope
with emotions
Emotional Avoidance
Expression of Emotions & Negative
Beliefs about Emotions
Extreme emotional responses & Erratic
oscillation of Emotions
Social Interaction & Interpersonal Relationships
Lack of empathy
* denotes conflicting views within group; x denotes absence of theme in group; √ denotes presence of theme in group
KYRIACOU ET AL.: A QUALITATIVE STUDY
Father 3: ... she’s extremely perceptive,
highly intelligent; she can read
other people and their emotions
perfectly. She can read what I’m
thinking or feeling from miles
away. But she is not perceptive
when it comes to herself ...
Clinician 9: Patients know very well how other
people think but sometimes are
confused with their own emotions.
Patient 5: I would like to think I was aware
of other people and how they feel,
yeah, just by looking at people’s
expressions, I don’t really have a
problem with that.
An over-sensitivity to the emotions of others was
reflected in comments from both patients and par-
ents. They described a tendency for their daughters
to become preoccupied with the responses and
behaviours of other people; patients were likely to
over-analyse behaviours as well as attribute respon-
sibility to themselves for any perceived negative
reaction or non-verbal cue.
Patient 2: I mean possibly, and this is also
the case for other people I’ve spo-
ken to, I might be too inclined to
put myself at the root of other peo-
ple’s problems, and accept respon-
sibility for other people that you
don’t actually have.
Father 2: Someone doesn’t say good morning
to you, there’s all sorts of things
that could be going on but our
daughter will rapidly interpret that
as everybody hates her.
Clinicians Nurses Patients Carers
* √ * *
* √ √ *
√ √ √ √
√ √ √ √
√ √ √ √
√ √ √ √
√ √ √ √
* x x √
847
JOURNAL OF HEALTH PSYCHOLOGY 14(7)
This exaggeration of significance of others’ emotions
may be compounded by what clinicians described
as failure to understand the complexity of emotions,
e.g. ‘being angry with someone we love’ (Clinician 7).
In other words, although people with AN were per-
ceived as showing preoccupation and exerting great
effort in reading other people, they were not neces-
sarily seen as able to understand or accurately ‘assess’
emotional responses of others.
The impact of poor self-awareness of emotions
and over sensitivity to others’ emotions was reflected
upon by all groups of participants. A lack of one’s
own emotional and self-awareness often led to
sufferers of ED displaying ‘pleasing behaviour’ or
acting in accordance with what they felt other
people wanted or expected of them.
Clinician 8: As people are often cut off from
their own emotional states, and
partly as a result, may find it dif-
ficult to be fully in touch with
others’ states, authentic, genuine
and spontaneous interaction and
connection with others may be
more difficult. This may make the
formation and retention of rela-
tionships problematic ... people
with AN often feel bad about
themselves, then try to compen-
sate by being goody-goodies,
pleasing, placating others.
Inability to tolerate, contain
and cope with emotions
All groups spoke about an inability to cope with,
tolerate and contain emotions. This was particularly
the case with negative or strong emotions and feel-
ings; although positive emotions also appeared to
be considerably cumbersome they were motioned
less frequently by participants.
Clinician 12: Difficulty in tolerating negative
emotions and even experiencing
positive ones.
In response to positive emotions, it was identified
by clinicians, that patients tended to sabotage such
emotions as a result of guilt and intolerability, as
well as a consequence of feeling undeserving and
unable to justify having them.
Nurse 1: There’s always a backlash, like if
someone has a really good day,
and they’re happy and smiling,
then the next couple of days
they’re miserable and guilt-ridden,
I shouldn’t have done it, so they
848
act out, so yes they do it but then
they feel so bad because they’ve
had a good day that they feel
they must sabotage it.
The inability to tolerate emotions was not only true
of one’s own emotions but was identified by clini-
cians and parents as an intolerance of other people’s
emotional states, where emotions could be viewed
as a currency of psychological control. Emotional
blackmailing and manipulation of close others were
reported by parents, where intolerance of their emo-
tional expressions would be responded to by threats
of not eating. Parents talked of feeling trapped as a
result, of having to tread on eggshells and constantly
be vigilant of controlling their own emotional
responses to the patient for sheer terror of being met
by refusal to eat. Normal, interpersonal interactions
and emotional expression within the family were
therefore curtailed and ultimately encumbered.
Mother 7: I find it very difficult to have any
normal emotions with my daugh-
ter because if I am cross with her
about something she’s not going
to eat the next meal at all. Whether
I’m cross with her about her eat-
ing, which I try very hard not to
do, or anything else at all, what-
ever it is, if I display any emotion
or appear cross she will withdraw
and refuse to eat anything and
then it becomes even more of a
battle and it makes things even
harder. So I’m treading on
eggshells all the time not to upset
her emotionally for fear she will
not eat …
Emotional avoidance
There was a strong agreement that many individuals
suffering from ED have a tendency to avoid emotions
all together. Emotions were described by patients
as painful and uncomfortable, leading to attempts to
avoid or suppress them and ultimately to emotional
numbness.
Patient 1: For me, it’s just avoiding feeling
emotions that will be painful,
that’s what the anorexia did for
me, it’s avoidance, not just of
food, but emotions that are quite
painful and quite scary ... so
that’s what I feel I need help with,
just learning, like [patient 6] said,
to identify emotions, but also to
not be afraid to feel them either.

Clinicians described a sense that their patients were
shut down from both feeling and emotional expres-
sion due to a fear of allowing themselves to be vul-
nerable to attack from others. Clinicians and parents
identified that having an ED was a way to channel
or numb emotions that were perceived as over-
whelming and threatening.
Clinician 10: AN is valued for lots of reasons
and some of the emotions and
thoughts clients have are viewed
as shameful, such as envy, com-
petitiveness, which leads to
concealment and deceit about
feelings, needs and behaviours.
Father 1: Recognising that her emotions
should not terrify her, and learn-
ing how to cope with them, she
just cannot contain them, cannot
cope to good or bad emotions, she
just responds in the most destruc-
tive manner to any pressure, any
emotion at all.
Clinicians discussed how emotional avoidance in
ED can be seen in terms of primary and secondary
avoidance. Primary avoidance was described as a
complete lack of any emotional experience, where
emotions instead became somatic:
Clinician 8: (Difficulties) in experiencing
emotions at all – sometimes these
are somatised as an alternative to
an authentic emotional or psycho-
logical experience.
Secondary avoidance was seen as an escape from
emotions, particularly negative ones, once they were
activated:
Clinician 8: People have difficulty coping
with any emotional stressor ...
and they respond through avoid-
ance and with poor coping strate-
gies including intensification of
their food restriction.
Patients articulated the corrosive ‘cause and effect’
impact of the illness on emotional avoidance. They
described using their AN as a way of avoiding and
numbing the experience of emotions, as well as
emotional numbing as a result of AN. Often high-
lighting the loss of identity that being cut off from
your emotional states leads to.
Patient 6: … I base my entire life around
the anorexia, so the problem was
my daily life, everything I did was
KYRIACOU ET AL.: A QUALITATIVE STUDY
geared towards the anorexia so
that just ruled out any sort of
emotional processing at all, I
mean I don’t have a cause with a
capital C but I think the main
thing for me about all this stuff is
that it does prevent you having
any emotions at all. That’s what
I found useful so I’ve cultivated
all the habits and my huge long
walks and I’ve avoided any sort
of social life, so it will just be me
and IT.
This intense avoidance and emotional difficulty was
implicated by clinicians as obstructing the recovery
process. They discussed how avoiding emotions
altogether did not allow for effective resolution of
problems, and consequently learning, therefore
hindering the ability to move forward.
Nurse 2: This rigidity, this avoidance also
affects them, stops them learning
about themselves and understand-
ing why they feel what they feel,
they don’t try something different,
so they get stuck.
Expression of emotions
and negative beliefs
Given that all groups identified difficulties in the
ability of people with ED to identify and tolerate
their emotions it is not surprising that a subsequent
difficulty in expressing emotions was also described.
An uncertainty surrounding how to express emotions
was voiced.
Patient 4: Frustration, and not knowing
how or if you should express it,
and to who.
Problems with emotional expression were often
linked to strong negative beliefs about emotions held
by those suffering with ED. A number of underlin-
ing negative beliefs about emotions were discussed,
e.g. ‘emotions are terrifying, or to express them is a
sign of weakness’ (Clinician 9), emotions are ‘unac-
ceptable and not allowed’ (Clinician 5). In the con-
text of such beliefs it is perhaps unsurprising that
their expression is limited.
Indeed, expressing emotions was often consid-
ered a weakness by patients and likely to leave one
‘exposed to being exploited and seen as vulnerable’
(Patient 5). Patients were therefore suspicious and
untrusting of disclosing anything of a personal
nature to others.
849
JOURNAL OF HEALTH PSYCHOLOGY 14(7)
Patient 1: You find it hard to believe that
someone would commit to you, so
it’s difficult to commit to other
people as well, it’s difficult to
really open up, like do you really
want to invest a lot of energy or
emotion in case you get slapped in
the face and then left feeling very
vulnerable.
Clinicians described patients’ fear of the consequences
of experiencing and expressing emotions as being
‘ ... catastrophic, e.g. that their upset/anger will
destroy either themselves or others’ (Clinician 11).
Clinician 1: Some people with AN have really
strong beliefs about the dangers
or undesirability of showing emo-
tions, that it somehow makes you
weak, vulnerable, unacceptable,
selfish to show what you feel or
need. Or the beliefs are tied in with
their perfectionism, i.e. if you were
a truly good person you wouldn’t
be having such ‘ugly, nasty’ feel-
ings. That immediately leads to
guilt, shame and self-criticism.
Parents also articulated this negative belief about
emotions as putting one in danger of being exposed
or exploited.
Mother 5: We’ve noticed that someone who
was very emotionally expressive
and communicative has stopped
being that. It’s just a blank, what
she says when we ask her about
this is, if I talk about my feelings
they will be used against me ... she
won’t discuss anything else for
fear it opens her up to a weakness,
or it will be used in some way
against her ...
Extreme emotional responses
Many identified that this difficulty in managing
emotions often manifested itself in oscillations in
both the experience and expression of emotions,
with no balance or flexibility.
Clinician 6: Emotions are either bottled up or
all pour out or people with AN have
states in which they are cut off
from emotions vs. a state in which
they are powerfully in touch with
them but unable to moderate or
make use of them.
850
This appeared to be true not only in the experience of
emotions but as a reaction to many other areas of
patients’ lives, and in illness perception. Absolute and
dichotomous thinking, the lack of a ‘happy medium’
and difficulty tolerating ambiguity or change, were
articulated. Patients described the confusion that this
oscillation in emotion caused them and expressed
how they felt they could quickly and unpredictably
fluctuate between being angry and numb, happy and
sad, often resulting in guilt and self-denigration.
Patients and clinicians talked about patients’ percep-
tions of ‘staying ill as bad’ (Nurse 2), and ironically
also of recovering as bad, illustrating how patients
become trapped in polarised perceptions.
Patient 2: ... And then suddenly something
happens and it’s like AAGGH, and
then it’s back to absolutely nothing
again. So I think if I could identify
it at the time, it wouldn’t explode,
and I wouldn’t be numb, you know,
I could find something in between,
that would be helpful ...
Nurse 2: It’s almost an inability to tolerate
fluctuations and see that as normal.
Clinician 6: Or emotions get in the way of intel-
lectualising and being organised
and perfect. There are often devel-
opmental origins where families
tended not to share emotions or to
model extremes, one parent being
cut off and the other explosive.
From the parents’ point of view, the extreme and
unpredictable oscillation between intense emotional
outbursts and numbness were also described as
disruptive and draining for family.
Mother 1: With our younger daughter, it’s
hard as well, she cannot cope with
her sister, she’s too emotional, she
said they’ll be talking about
school or television or whatever
and then she shrieks at me. So then
I go outside, maybe for a walk,
and then I come up and she just
says oh would you like a cup of
tea? So it’s so extreme! ...
Social interactions and interpersonal
relationships
As touched upon above, the culmination of the
aforementioned emotional problems was associated
with problematic relationships and the perpetuation
of obstacles in social situations.

Patient 6: So, I know there are people who
do have other aspects to their life
as well as the anorexia, and I won-
der how come they can do it and I
can’t, how come I have to dedicate
absolutely everything to it while
other people just seem to dedicate
a wee bit to it, and that’s probably
a superficial reading of it, I don’t
know whether underneath it all
that’s their reality, I don’t know
what sort of detrimental effects it
may have for their families and
their social life, but they do have
something that can identifiably be
called a social life ... whereas I
have nothing ...
Some clinicians compared the profound difficulties
faced by people with AN to a social phobia, while
one described the impaired ability to process and
understand emotions as inextricably hindering
interpersonal relationships. Interestingly, difficul-
ties were identified across all groups as occurring in
a range of social interactions, from casual, everyday
exchanges, to intimate relationships.
Clinician 1: It’s hard for them to function in
any interpersonal relationship or
encounter, particularly if there is
any conflict, competition or uncer-
tainty. For some this can include
very basic encounters, such as
what happens in a shop or with
workmen if they treat you badly,
but it is not like that for all. Often
it is in relationships with people
they know and are close to where
there is conflict or competition or
uncertainty (e.g. threat of loss)
that can’t be expressed.
Patients spoke about their tremendously obstructed
daily life and an inability to cope with everyday
living as an inextricable consequence of suffering
from an ED.
Patient 2: I’m really surprised actually
(animated) when people talk
about their friends and all that
because I have no friends! For the
past 10–12 years, I haven’t done
anything, I haven’t gone out with
anyone, I haven’t spoken to any-
body, in a social context, so like
people with families (patients),
that absolutely astounds me!
KYRIACOU ET AL.: A QUALITATIVE STUDY
Clinicians and parents also spoke of patients lacking
the social skills to manoeuvre every day life with
other people, leading to social paralysis, compounded
by difficulties in understanding others’ perspectives
as well as their tendency for rigid and inflexible
behaviours.
Clinician 1: They may feel different or a misfit
or they may put on a happy front
to cope which leaves them and
others feeling disconnected. There
is a lack of spontaneity and cre-
ativity in their interactions leaving
them rather wooden and awkward.
Rigidity will mean they struggle
to consider alternative perspec-
tives and the bigger picture that
are involved in negotiating the
social world.
Social contexts and interactions were subsequently
seen as threatening and intimidating, leading to a per-
petuation of avoidance and isolation. Consequently,
accounts described a self-fulfilling prophecy, where
poor self-esteem and inability to self-assert con-
tribute to a cycle of negative experiences in social
interactions that can be difficult to break.
Mother 5: … (friends) all got better things
to do, I mean she’s not good
company, I don’t know if they
invite her or not, but why would
you want someone weighing you
down like that.
Mother 8: I think also, this inability to
express themselves emotionally,
and the self-esteem issue, it some-
how makes any situation they are
in socially fire back at them. Our
daughter, for example, she seems
to be bullied by any females she
comes across, they pick up on her
low self-esteem and they use it
against her because she doesn’t
know how to fight back, she’s
always at the bottom of the pile ...
Parents identified a tendency for increasing and
inappropriate dependence by their loved ones. Their
accounts suggest a regression or a suspended psy-
chosocial development as patients become over-
attached on mothers in particular while severing
their relationships with other people as the course of
the illness progresses. Parents also described feel-
ing controlled and their own personal space and
lifestyle dictated by the illness.
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JOURNAL OF HEALTH PSYCHOLOGY 14(7)
Mother 6: She attaches herself to me, which
is nice, I mean at least now we get
along as compared to before, but
that’s not good either in a way
because I’m becoming her best
friend, because she’s isolated her-
self from her school friends.
The only exception was in a minority of cases
where loved ones preferred to form relationships
with other people with AN, as they felt safer and
more able to relate to them. Other parents described
the opposite in that their daughters were avoidant
and wary of other people with ED.
Father 2: Our daughter said something to us
the other day, how she felt much
happier with people who were ill
than with people who were well,
because these people hurt you
whereas those who are ill don’t,
and she had this real fear of inter-
action with people outside the
hospital, who were not ill, I suppose
to avoid any of the emotional or
social things that can go wrong for
all of us really but that she thinks
she cannot cope with. She needs to
be with people who understand
her, or are perceived not to pose a
threat to her.
Father 3: That’s really, really interesting,
ours is the complete reversal of
that. She is just very unhappy with
other people, particularly if they
are anorexic, and based on all the
experiences she has had, she just
doesn’t want to be with another
anorexic.
Lack of empathy
There was a discrepancy in that parents and clini-
cians described a lack of empathy and an inability
to understand the perspective of other people,
which was not identified in accounts of patients.
Clinicians described a difficulty in their patients to
‘be in touch’ with or to understand other peoples’
emotional states (Clinician 8). Some parents
described their loved ones as completely oblivious
to or, unable to comprehend the impact that their
illness had on their families. Others, in contrast,
described their loved ones as emotionally astute
when it came to other people yet oblivious to their
own emotions and needs.
852
Mother 7: My daughter’s completely lost
the ability to put herself in other
people’s situation, she is so
focused on herself she cannot see
what it’s like on other people...
For example, she spends 5 hours
eating dinner and I’m desperate
to go to bed, I’m so tired, and I
can’t go to bed because she hasn’t
eaten, and I tell her please, I need
to go to bed, and she says oh yeah,
and still, she cannot put herself in
anyone else’s shoes.
Clinician 11: Sometimes an impaired ability to
understand others’ feelings and
points of view due to an inability
to process what that person’s
experience might be like, rather
like autism. Not being sure how
to respond in certain situations,
or if they do know how to
respond feeling unable to do so.
Interestingly, many of the parents and clinician
described patients as very good at reading other
peoples emotions. This suggests that the difficulty
is not in recognizing emotional states in others but
may lie in the ability to view the world from others
perspective.
Discussion
This qualitative study endeavoured to compare the
views of patients, clinicians and parents on the topic
of emotions and social cognition in anorexia ner-
vosa. Our approach adheres to Clinical Governance
guidelines, which call for user involvement in the
planning and provision of care, as well as the NICE
specifications for ED, which emphasize the impor-
tance of involving family members in treatment.
There was overall high congruence across all focus
groups and considerable difficulties were identified
in the areas of: recognition, understanding, expres-
sion and tolerance of emotions. These were highly
associated with impaired social experiences and
interpersonal relationships in people with AN.
Table 4 shows the main themes identified through
thematic analysis, indicating their response from
each group of participants involved in the study.
The finding that there are many similarities in the
views of both patients with AN and those caring for
and treating them are in line with previous research,
which suggests that the view of ED patients and

their relatives are predominantly similar (Marcos,
Weinman, Cantero, & Vazquez, 2009). The prob-
lems identified for individuals with AN in under-
standing and coping with emotions, accompanied
by negative beliefs around emotions, suggest that
people with AN struggle to negotiate the demands
of everyday life and to function appropriately, both
socially and emotionally. These results corroborate
previous observations of alexithymia in AN, (e.g.
Kessler et al., 2006), however, further empirical
work is needed to identify and assess these social
and emotional difficulties, and clinically, they will
need to be addressed as part of a comprehensive
approach to treatment. Based on the main themes to
emerge from our qualitative analyses we are now
developing an emotion and social cognition module
for inpatient treatment for AN.
The Cognitive Remediation and Emotional
Skills Training (CREST) combines features of
Cognitive Remediation for AN (Tchanturia et al.,
2008) and aims improve cognitive and emotional
processing in a similar format. Through the use of
simple exercises patients are encouraged to reflect
their emotions; specifically it aims to aid patients
to recognize and label their own and others’ emo-
tions, as well as encouraging emotional expres-
sion in a safe way combined with plan behavioural
experiments.
Strengths and limitations
As a qualitative study using a small sample, the cur-
rent work is subject to certain limitations, and war-
rants caution with interpretation. For example, the
patients in this study may differ in terms of motiva-
tion for change and recovery. The parents’ focus
group is a self-selected sample and may be skewed
in terms of over-representation of actively involved
and ‘empowered’ parents. Additionally, it is possi-
ble that certain participants may be referring to co-
morbid features, which are high in AN, that may not
be generalizable to other individuals suffering with
AN. The patients that participated in this study were
all inpatients, being treated for their ED and the
experience of most clinicians was within this set-
ting. More research is needed to determine if these
findings are transferable to a wider group of indi-
viduals with AN. Despite the limitations, the study
yielded significant information regarding the emo-
tional and social difficulties of people with AN,
with interestingly high convergence across different
participant groups.
KYRIACOU ET AL.: A QUALITATIVE STUDY
Conclusion
The emotional difficulties experienced by those
suffering from AN as described by patients, parents
and clinicians produces a complex, multifaceted
and interrelated profile of problems. Research into
emotions in ED is in its infancy and this study not
only emphasises the importance of addressing these
problems in treatment, but also the need for more
research in this area, which was described aptly by
one of the nurses in this study as ‘uncharted waters’
(Nurse 2). Based on the thematic analyses of focus
groups and the high degree of congruence in themes
identified across groups, we are confident that these
are the most significant issues relating to emotions
and social cognition in AN and they should be
targeted in psychological interventions.
References
Agras, W. S., & Robinson, A. H. (2008). Forty years of
progress in the treatment of the eating disorders. Nordic
Journal of Psychiatry, 62 Suppl. 47, 19–24.
Arnow, B., Kenardy, J., & Stewart, A. (1995). The
emotional eating scale: The development of a measure
to assess coping with negative affect by eating.
International Journal of Eating Disorders, 18(1),
79–90.
Braun, V., & Clarke, V. (2006). Using thematic analysis
in psychology. Qualitative Research in Psychology, 3,
77–101.
Bruch, H. (1985). Four decades of eating disorder. In
D. M. Garner & P. E. Garfinkel (Eds.), Handbook of
psychotherapy for anorexia nervosa and bulimia
(pp. 7–18). New York: Guildford.
Bydlowski, S., Corcos, M., Jeammet, P., Paterniti, S.,
Berthoz, S., & Laurier, C. (2005). Emotion-processing
deficits in eating disorders. International Journal of
Eating Disorders, 37(4), 321–329.
Corstorphine, E. (2006). Cognitive-Emotional-Behavioural
Therapy for the eating disorders: Working with beliefs
about emotions. European Eating Disorders Review,
14(6), 448–461.
Elliott, R., Fischer, C. T., & Rennie, D. L. (1999).
Evolving guidelines for publication of qualitative
research studies in psychology and related fields.
British Journal of Clinical Psychology, 38(3), 215–229.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003).
Cognitive behaviour therapy for eating disorders: a
‘transdiagnostic’ theory and treatment. Behaviour
Research and Therapy, 41(5), 509–528.
Gilboa-Schechtman, E., Avnon, L., Zubery, E., &
Jeczmien, P. (2006). Emotional processing in eating dis-
orders: specific impairment or general distress related
deficiency? Depression and Anxiety, 23(6), 331–339.
853
JOURNAL OF HEALTH PSYCHOLOGY 14(7)
Glaser, B. G., & Strauss, A. L. (1967). The discovery of
grounded theory: strategies for qualitative research.
Chicago: Aldine.
Henwood, K., & Pidgeon, N. (1992). Qualitative research &
psychological theorising. British Journal of Psychology,
83(1), 97–112.
Jones, L., Harmer, C., Cowen, P., & Cooper, M. (2008).
Emotional face processing in women with high and
low levels of eating disorder related symptoms. Eating
Behaviours, 9(4), 389–397.
Kessler, H., Schwarze, M., Filipic, S., Traue, H. C., & von
Wietersheim, J. (2006). Alexithymia and facial emotion
recognition in patients with eating disorders. International
Journal of Eating Disorders, 39(3), 245–251.
Lock, J. D., & Fitzpatrick, K. K. (2009). Anorexia ner-
vosa. British Medical Journal, Clinical Evidence,
01(1011), 1–19.
Marcos, Q. Y., Weinman, J., Cantero, C. T., & Vazquez, M. B.
(2009). The dissimilarity between patients’ and relatives’
perception of eating disorders and its relation to patient
adjustment. Journal of Health Psychology, 14(2), 306–312.
NICE. (2004). National Institute for Health & Clinical
Excellence – National Collaborating Centre for Mental
Health Leicester. London: British Psychological
Society and Royal College of Psychiatrists.
Schmidt, U., Jiwany, A., & Treasure, J. (1993). A controlled
study of alexithymia in eating disorders. Comprehensive
Psychiatry, 34(1), 54–58.
Author biographies
OLIVIA KYRIACOU has worked as a research
psychologist in eating disorders in the US and the
UK since 1999. She completed her PhD at the
Eating Disorders Research Unit, Institute of
Psychiatry, King’s College London, in 2008,
exploring the role of fathers and carers’
experiences in eating disorders.
ABIGAIL EASTER has worked as a research
psychologist at the Institute of Psychiatry, Kings
College London for the past four years. She is
854
Schmidt, U., & Treasure, J. (2006). Anorexia nervosa:
Valued and visible. A cognitive-interpersonal mainte-
nance model and its implications for research and
practice. British Journal of Clinical Psychology,
45(3), 343–366.
Smith, J. A., & Osborn, M. (2003). Interpretative phenom-
enological analysis. In J. A. Smith (Ed.), Qualitative
psychology: A practical guide to methods. London:
SAGE.
Tchanturia, K., Davies, H., Lopez, C., Schmidt, U.,
Treasure, J., & Wykes, T. (2008). Neuropsychological
task performance before and after cognitive remediation
in anorexia nervosa: a pilot case-series. Psychological
Medicine, 38(9), 1371–1373.
Troop, N. A., Murphy, F., Bramon, E., & Treasure, J. L.
(2000). Disgust sensitivity in eating disorders: a pre-
liminary investigation. International Journal of Eating
Disorders, 27(4), 446–451.
Zonnevijlle-Bender, M. J., van Goozen, S. H., Cohen-
Kettenis, P. T., van Elburg, A., & van Engeland, H.
(2002). Do adolescent anorexia nervosa patients have
deficits in emotional functioning? European Child and
Adolescent Psychiatry, 11(1), 38–42.
Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven,
J., & Pelphrey, K. A. (2007). Anorexia nervosa and
autism spectrum disorders: guided investigation of
social cognitive endophenotypes. Psychological Bulletin,
133(6), 976–1006.
currently undertaking her PhD at the Eating
Disorders Research Unit, investigating the effects
of maternal eating disorders on fetal and infant
development.
KATE TCHANTURIA is a Consultant Clinical
Psychologist and Senior Lecturer at the Institute
of Psychiatry King’s College London at
Maudsley. She obtained her PhD in experimental
psychology. For last 12 years she has focused her
research and clinical work in ED.