Journal Pre-proof

An exploratory component analysis of emotion regulation strategies for improving

emotion regulation and emotional eating

Adrienne S. Juarascio, Megan N. Parker, Stephanie M. Manasse, Jennifer L. Barney,

Emily P. Wyckoff, Cara Dochat

PII: S0195-6663(19)31277-2
DOI: https://doi.org/10.1016/j.appet.2020.104634
Reference: APPET 104634

To appear in: Appetite

Received Date: 6 October 2019

Revised Date: 17 February 2020
Accepted Date: 18 February 2020

Please cite this article as: Juarascio A.S., Parker M.N., Manasse S.M., Barney J.L., Wyckoff E.P. &
Dochat C., An exploratory component analysis of emotion regulation strategies for improving emotion
regulation and emotional eating, Appetite (2020), doi: https://doi.org/10.1016/j.appet.2020.104634.

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1 An exploratory component analysis of emotion regulation strategies for improving emotion

2 regulation and emotional eating

4 Adrienne S. Juarascioa,b, Megan N. Parkerc, Stephanie M. Manasseb, Jennifer L. Barneyd, Emily

5 P. Wyckoffe, Cara Dochatf

6
a
7 Department of Psychology, Drexel University, Philadelphia, PA, USA
b
8 Center for Weight, Eating and Lifestyle Science (WELL Center), Drexel University,

9 Philadelphia, PA, USA

c
10 Department of Medical and Clinical Psychology, Uniformed Services University of the Health

11 Sciences, Bethesda, MD, USA

d
12 Department of Psychology, Utah State University, Logan, UT, USA
e
13 Department of Psychological Sciences, University of Connecticut, Storrs, CT, USA
f
14 San Diego State University/University of California, San Diego Joint Doctoral Program in

15 Clinical Psychology, San Diego, CA, USA

16

17 Corresponding Author: Adrienne Juarascio, Department of Psychology, Drexel University,

18 Stratton Hall, 3141 Chestnut Street, Philadelphia, PA 19104, USA Email: asj32@drexel.edu

19

20 Declarations of interest: The opinions and assertions expressed herein are those of
21 the authors and are not to be construed as reflecting the views of the Uniformed Services
22 University of the Health Sciences (USUHS), or the U.S. Department of Defense.
23

24 Financial Disclosure: none.

25
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26 Abstract

27 Emotion-focused treatments are generally efficacious for improving emotion regulation

28 and consequently, improving clinical symptoms across numerous disorders. However, emotion-

29 focused treatment approaches often contain numerous treatment components, limiting our ability

30 to identify which are most efficacious. As such, the current pilot study sought to isolate three

31 components common across a range of emotion-focused treatments (i.e. emotional awareness,

32 emotion down-regulation, and distress tolerance) and test the impact of each component on (1)

33 emotion regulation and (2) emotional eating behavior. Adults (N = 76) who reported four or

34 more emotional eating episodes in the past month were assigned to attend a one-time, three-hour

35 workshop focused on either awareness, down-regulation or tolerance of emotions, and were

36 subsequently evaluated at one-week and two-weeks follow-up. All groups experienced

37 equivalent improvements in emotional eating at two-weeks follow-up (F [1.47, 85.38 ]=7.60, p <

38 .01). However, groups showed differential patterns of change across facets of emotion

39 regulation. Improvements in access to healthy emotion regulation strategies was moderately

40 related to improvements in emotional eating in Down-Regulation and Distress Tolerance groups

41 (r [18] = 0.40, r [20] = 0.63, respectively). In the Distress Tolerance group, improvements in

42 emotional eating were moderately related to improvements in acceptance of emotions

43 (r[20]=0.33) and ability to refrain from impulses (r[20]=0.41). In the Emotional Awareness

44 group, improvements in emotional acceptance (r[20]=0.30), awareness (r[20]=0.38) and clarity

45 (r[20]=0.39) were moderately related to improvements in emotional eating. While several

46 components of emotion-focused treatments may improve outcomes, each component may

47 demonstrate a unique mechanism of action. Further study is needed to isolate these treatment

48 components in fully powered clinical trials to better understand the mechanisms of action for
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49 emotion-focused treatments and ultimately develop more efficient and effective treatment

50 approaches.

51 Key words: component analysis; emotional eating; emotion regulation

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73 An exploratory component analysis of emotion regulation strategies for improving emotion

74 regulation and emotional eating

75 1. Introduction

76 Emotion dysregulation (i.e., low levels of awareness, understanding, and acceptance of

77 emotions, and the tendency to engage in maladaptive behaviors when in a negative emotional

78 state) is a broad, transdiagnostic risk and maintenance factor for numerous psychological

79 disorders (e.g. substance abuse disorders, eating disorders, anxiety disorders; Baker, Piper,

80 McCarthy, Majeskie, & Fiore, 2004; Lavender, Happel, Anestis, Tull, & Gratz, 2015; Richard et

81 al., 2008; Schmidt, Zvolensky, & Maner, 2006). Higher levels of emotion dysregulation are

82 associated with dropout from treatment, poor compliance with treatment recommendations, and

83 worse treatment outcomes from a variety of behavioral treatment approaches (Álvarez-Moya et

84 al., 2011; Daughters et al., 2005; Lima, Peckham, & Johnson, 2018; Moeller et al., 2001; Peake,

85 Limbert, & Whitehead, 2005; Waller, 1997). Poor outcomes may occur due to difficulty

86 adhering to behavioral treatment recommendations when experiencing strong negative emotions

87 and due to continuing urges to engage in maladaptive coping behaviors (e.g., substance use,

88 binge eating) that provide immediate, though short-term, reductions in negative affect, and often

89 increase positive affect (Álvarez-Moya et al., 2011; Bell & Newns, 2002; Dawe et al., 2007;

90 Nederkoorn, Jansen, Mulkens, & Jansen, 2007; Pinna, Sanna, & Carpiniello, 2014; Taylor,

91 Abramowitz, & McKay, 2012). Because individuals with high emotion dysregulation often have

92 limited access to healthier or more adaptive coping strategies, reliance on maladaptive behaviors

93 to modulate negative affect persists.

94 Given the clinical relevance of emotion dysregulation in the maintenance and treatment
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95 of a wide array of maladaptive behaviors and psychological disorders, a growing number of

96 emotion-focused psychological treatments have been designed to target emotion dysregulation

97 and related constructs. Emotion-focused treatments like Dialectical Behavioral Therapy (DBT)

98 and Acceptance and Commitment Therapy (ACT) have proven effective for a wide range of

99 problems including mood (Van Aalderen et al., 2012) and anxiety disorders (Bluett, Homan,

100 Morrison, Levin, & Twohig, 2014; Evans et al., 2008; Roemer & Orsillo, 2007; Strauss,

101 Cavanagh, Oliver, & Pettman, 2014; Vøllestad, Sivertsen, & Nielsen, 2011), chronic pain

102 (Cederberg, Cernvall, Dahl, von Essen, & Ljungman, 2016; Chiesa & Serretti, 2011; Veehof,

103 Oskam, Schreurs, & Bohlmeijer, 2011), smoking (Brewer et al., 2011; Bricker, Wyszynski,

104 Comstock, & Heffner, 2013; Gifford et al., 2011; Rogojanski, Vettese, & Antony, 2011; Singh et

105 al., 2013) and obesity (Butryn, Forman, Hoffman, Shaw, & Juarascio, 2011; Forman et al., 2016;

106 Lillis et al., 2016; Wadden & Berkowitz, 2016), with rates of efficacy typically comparable to

107 traditional Cognitive Behavioral Therapies (CBTs). Although few existing studies have assessed

108 mechanisms of action through formal mediation analyses, improvements in emotion regulation

109 or related constructs (e.g., psychological acceptance, distress tolerance, and mindfulness) have

110 been associated with improvements in clinical symptoms across a range of emotion-focused

111 treatments (French, Golijani-Moghaddam, & Schröder, 2017; Graham, Gouick, Krahé, &

112 Gillanders, 2016; Hann & McCracken, 2014; Kohl, Rief, & Glombiewski, 2012; Levin,

113 Hildebrandt, Lillis, & Hayes, 2012; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006;

114 Neacsiu, Rizvi, & Linehan, 2010; Sharp, 2012; Sparapani, 2015) .

115 While emotion-focused treatments appear to be generally efficacious for improving

116 emotion regulation and related constructs (and in turn, improving clinical symptoms), to date

117 there exists minimal research examining which specific treatment components of these
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118 comprehensive programs drive the observed improvements in emotion regulation. Emotion-

119 focused treatments are typically delivered as comprehensive treatment packages with many

120 components that have a hypothesized impact on patients’ abilities to cope with emotional

121 distress. Understanding the varying ability of individual treatment components to both improve

122 emotion dysregulation and reduce use of maladaptive coping behaviors can help isolate the most

123 effective ingredients of emotion regulation treatments and thus lead to the development of more

124 concise and disseminable treatment approaches (Manasse, Clark, Juarascio, & Forman, 2019).

125 Isolating treatment components and evaluating each component’s impact on symptom

126 reduction and hypothesized mechanisms is a crucial next step for optimizing treatments that

127 target emotion dysregulation. The use of a component analysis design allows for a controlled

128 evaluation of a specific treatment component on both a hypothesized target or mechanism and

129 the outcome (Levin et al., 2012). Component analyses are also consistent with recent NIH

130 initiatives that have called for decreased focus on the effectiveness of comprehensive treatment

131 packages and increased focus on the development and evaluation of treatment components that

132 operate on an a priori specified mechanism of action (National Institute of Mental Health, 2014,

133 2017a, 2017b). The use of component analyses to identify the most effective treatment

134 components could facilitate the development of highly efficient and maximally effective

135 interventions.

136

137 1.1 Current Study

138 We conducted a component analysis of three treatment components commonly used in emotion-

139 focused treatments. Components were identified by first conducting a literature review of third-

140 wave behavioral therapies for eating disorders. As reported in (Linardon, Fairburn, Fitzsimmons-
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141 Craft, Wilfley, & Brennan, 2017), the most commonly used treatments have been Acceptance

142 and commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), which emphasize

143 mindfulness and emotion regulation skills. Manuscripts and treatment manuals, referenced in

144 Linardon et al. (2017) were then reviewed and three distinct treatment components were

145 identified for testing in an initial component analysis: Emotional Awareness (i.e., the ability to

146 recognize, label, and make sense of one’s current emotional experiences); Emotion Down-

147 regulation (i.e., the ability to adaptively reduce the intensity of an emotional experience in the

148 moment), and Distress Tolerance (i.e., the ability to tolerate an emotional experience without

149 altering or reducing it).

150 Although emotion dysregulation is a maintenance factor for a number of maladaptive

151 behaviors and psychological disorders, we conducted our initial component analysis on one

152 specific maladaptive behavior (i.e. emotional eating) to allow for a more focused test in a single

153 population. Emotional eating (i.e., the tendency to eat in response to negative emotional

154 experiences) is strongly linked to obesity, eating disorders, and poor long-term health outcomes

155 (Arnow, Kenardy, & Agras, 1995; Frayn & Knäuper, 2017; H. Konttinen, Haukkala, Sarlio-

156 Lahteenkorva, Silventoinen, & Jousilahti, 2009; Masheb & Grilo, 2006; Ricca et al., 2009) and

157 numerous theories have proposed a negative reinforcement-based function for emotion-driven

158 eating (Bennett, Greene, & Schwartz-Barcott, 2013; Ganley, 1989; Heatherton & Baumeister,

159 1991; Hanna Konttinen, Männistö, Sarlio-Lähteenkorva, Silventoinen, & Haukkala, 2010; Pine,

160 1985; Rommel et al., 2012). Studies utilizing ecological momentary assessment (Haedt-Matt &

161 Keel, 2011), naturalistic recalls and diaries (Deaver, Miltenberger, Smyth, Meidinger, & Crosby,

162 2003; Johnson, Schlundt, Barclay, Carr-Nangle, & Engler, 1996; Lynch, Everingham, Dubitzky,

163 Hartman, & Kasser, 2000), and laboratory-based studies (Cools, Schotte, & McNally, 1992;
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164 Tuschen-Caffier & Vögele, 1999) have all demonstrated that negative affect prospectively

165 increases the likelihood of overeating episodes. Additionally, negative mood decreases

166 temporarily during and/or after such episodes, suggesting a negative reinforcement function of

167 emotional eating (Hayaki, 2009).

168 Given the preliminary nature of this research, we chose to utilize a proof-of-concept

169 analog design exploring the preliminary efficacy of three different one-day workshops, with

170 emotion regulation and emotional eating episodes assessed at both one- and two-weeks follow-

171 up. We aimed to evaluate the independent, initial efficacy of (1) Emotional Awareness, (2)

172 Down-Regulation, and (3) Distress Tolerance treatment components on emotional eating

173 symptoms (at two-weeks follow-up). We also investigated whether each treatment component

174 impacted 1) its intended target (e.g., if the Distress Tolerance intervention improved distress)

175 and 2) other emotion regulation targets (e.g., if the Distress Tolerance intervention improved

176 emotional awareness and down-regulation of negative emotions). Finally, we explored whether

177 changes in facets of emotion regulation were differentially associated with improvements in

178 emotional eating for each treatment component.

179

180 2. Materials and Methods

181 2.2 Participants

182 Participants were adults (N = 82) with four or more emotional eating episodes in the past

183 month, as assessed by the Emotional Overeating Questionnaire (EOQ; Masheb & Grilo, 2006).

184 Cut-offs have not been established for the EOQ (Gianini, White, & Masheb, 2013), therefore,

185 frequency criteria for eating disorders diagnoses including bulimia nervosa and binge eating

186 disorder were used to guide inclusion criteria(American Psychological Association, 2013).
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187 Participants were excluded if they currently met or had previously received a diagnosis of

188 anorexia nervosa, bulimia nervosa, bipolar disorder, post-traumatic stress disorder, a substance

189 use disorder, a psychotic disorder, or a pervasive development disorder, or previously received

190 an emotion regulation focused treatment. Specifically, participants were excluded if they

191 reported previously receiving ACT or a structured DBT program.

192
193 2.3 Procedures

194 Participants were recruited from an urban area using flyers and online postings that

195 advertised a workshop for reducing emotional eating. Participants were enrolled across 6 waves

196 of recruitment. Individuals initially attended a baseline assessment where they provided written

197 informed consent and completed self-report questionnaires and a behavioral eating paradigm

198 designed to measure disinhibited eating. After completion of the baseline assessment participants

199 were assigned to attend the next available group. Six participants dropped out of the study prior

200 to attending a workshop. Participants (n = 78) attended one of the three emotion regulation

201 treatment groups comprised of a one-time, three-hour workshop that taught skills and strategies

202 specific to either Emotional Awareness, Down-Regulation, or Distress Tolerance. Participants in

203 all groups were instructed to keep a self-monitoring record of their eating behavior (including

204 any emotional eating episodes) and spend approximately one hour each week practicing specific

205 skills they learned during the workshop. Out of the participants who completed baseline

206 assessments and attended the workshops, 83% (n = 65) completed a one-week follow-up

207 assessment and 79% (n = 62) completed a two-week follow-up assessment. The one-week

208 follow-up assessment contained self-report measures that were sent via a survey link that the

209 participants completed at home. The two-week follow-up assessment was identical to the
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210 baseline assessment. The study was approved by the Institutional Review Board of Drexel

211 University (protocol number 1505003644).

212

213 2.4 Measures

214 Participants characteristics. Participants self-reported their age, sex, and race on a

215 demographic questionnaire.

216 Body Mass Index (BMI; kg/m2). During the baseline assessment height and weight was

217 measured twice. Average height and weight was used to calculate BMI.

218 Emotional eating. The Emotional Overeating Questionnaire (EOQ; Masheb & Grilo,

219 2006) is a measure of the frequency of emotional overeating, which has been found to have high

220 internal consistency in overweight individuals and individuals who binge eat (Gianini et al.,

221 2013; Masheb, Dorflinger, Rolls, Mitchell, & Grilo, 2016; Woolhouse, Knowles, & Crafti,

222 2012). The measure asks participants to report the number of days in the past month he or she ate

223 in response to six emotions: sadness, anxiety, anger, boredom, tiredness, and happiness. The

224 current pilot study only focused on the 5 negative emotions and did not include emotional eating

225 episodes in response to feelings of happiness. We modified the time frame of the measure to be

226 usable at all study time points. As such, at one- and two-week follow-up assessments,

227 participants were asked how many days in the past seven (rather than 28) they ate in response to

228 each of the six emotions. The number of emotional eating episodes prior to the workshop (i.e.,

229 from the past 28 days) were divided by four in order to derive a weekly average so as to be

230 comparable to the follow-up assessment of emotional eating over the past seven days. The

231 average number of days each participant had an emotional eating episode due to negative affect
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232 was calculated from the five negative emotion questions. This scale measures frequency of a

233 behavior and so the lowest possible score is zero, but there are no maximum scores.

234 Disinhibited eating. Participants were administered a behavioral measure of disinhibited

235 eating, a bogus taste test, at baseline and two-week follow-up assessments. The bogus taste test

236 has been used in previous studies to test factors that affect food intake (Robinson et al., 2017).

237 Prior to the taste test, participants completed the computerized Paced Serial Auditory Task

238 (PASAT; Lejuez, Kahler, & Brown, 2003) a behavioral task that is designed to produce

239 frustration in participants and has been used in previous studies to induce and measure a person’s

240 willingness to tolerate distress (Eichen, Chen, Boutelle, & McCloskey, 2017; Feldner, Leen-

241 Feldner, Zvolensky, & Lejuez, 2006; Lejuez et al., 2003; Yiu, Christensen, Arlt, & Chen, 2018) .

242 The task shows a new single digit number on the screen every 3 seconds. Participants are

243 instructed to add the number on the screen and the number shown immediately prior. They then

244 have to select the correct sum (between 1 and 18). If the wrong answer is chosen, participants

245 receive a loud buzz that persists until they chose a correct answer. Participants were told they

246 could end the task at any point during the assessment. Immediately after completing the PASAT

247 participants were taken to another room to complete the taste test. They were asked to taste and

248 rate their liking of several different snack foods: 50 grams of potato chips, 80 grams of pretzels,

249 85 grams of sandwich cookies, and 135 grams of chocolate peanut butter cups. Participants were

250 told they could taste and eat as much as they would like, since the uneaten food would be thrown

251 out, and were left alone for five minutes to complete the task. Afterward, the amount of each

252 snack food remaining was measured and the total amount (in grams) of food eaten was

253 calculated. Total possible food consumption ranged from zero to 345 grams.
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254 Emotion regulation. The Difficulties in Emotion Regulation Scale (DERS; Gratz &

255 Roemer, 2004) is a widely used self-report measure of emotion dysregulation that assesses six

256 different domains of emotion dysregulation: emotional awareness, emotional clarity, acceptance

257 of emotional responses, ability to engage in goal-directed behaviors when distressed, ability

258 refrain from engaging in impulsive behaviors, and perceived access to healthy strategies for

259 regulating emotions. The DERS has strong internal consistency and test-retest reliability (Gratz

260 & Roemer, 2004). Possible scores for each subscale are as follows: emotional awareness 6-30,

261 emotional clarity 5-25, acceptance of emotional responses 6-30, ability to engage in goal-

262 directed behaviors when distressed 5-25, ability refrain from engaging in impulsive behaviors 6-

263 30, and perceived access to healthy strategies for regulating emotions 8-40, total score 36-180. In

264 the current pilot study, the six DERS domains were coded such that higher scores indicated

265 better emotion regulation.

266

267 2.5 Workshop structure

268 All groups were led by an advanced graduate student and another graduate student co-

269 leader. Workshops lasted three hours and consisted of four to eight participants. Each workshop

270 began with personal introductions, presentation of workshop expectations, and a review of study

271 procedures. All workshops included an emotional eating psychoeducation component, which

272 defined emotional eating (“Overeating or utilizing eating as a way to cope with difficult

273 emotions”; Arnow et al., 1995) and discussed the negatively reinforcing nature of emotional

274 eating. After presenting the negative reinforcement cycle, each group introduced the specific

275 component targeted in that group by identifying how use of skills and strategies consistent with

276 that treatment component could be used to disrupt this cycle. The majority of session time was
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277 spent teaching participants how to utilize the skills and strategies consistent with their assigned

278 treatment component to regulate emotions and reduce emotional eating (described in greater

279 detail for each individual workshop below). Each workshop concluded with a summary, review,

280 and assignment of homework.

281 2.5.1 Emotional Awareness workshop

282 The goal of the Emotional Awareness workshop was to teach participants how to

283 mindfully observe and give labels to their emotional experience. Participants were taught the

284 purpose of emotional experiences, the importance of enhancing emotional awareness in order to

285 understand how emotions can drive behaviors, and how to become more aware of the connection

286 between emotions and eating behavior. Participants were also taught to identify unhelpful

287 interpretations of emotional reactions that elicit secondary emotional responses. The largest

288 section of the workshop focused on understanding and naming emotions. Adapted directly from

289 DBT, participants were introduced to the function and range of emotional experience. Group

290 leaders provided step-by-step instructions on how to increase emotional awareness by:

291 identifying and interpreting events that trigger emotions; noticing thoughts, physiological

292 changes, and urges that accompany emotions; recognizing how one expresses emotions; and

293 finally, naming the emotion. The workshop included two mindfulness exercises: a body scan and

294 mindfully eating a raisin. During the first mindfulness exercise, highly palatable snack foods

295 were placed on the table to better replicate the challenges of practicing mindfulness in a

296 naturalistic environment where food is easily accessible. To address emotional eating

297 specifically, a section on differentiating hunger from negative emotions was included in the

298 workshop. This section involved observing and describing the nature of their hunger (i.e.,

299 specific cravings, a desire to continue eating highly palatable food even when not physically
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300 hungry) and distinguishing these experiences from their current emotional state. The workshop

301 did not include any instructions to alter or accept negative emotional experiences, but instead

302 simply focused on creating additional awareness of emotional experiences. For homework,

303 participants were instructed to practice identifying emotions prior to eating episodes at least two

304 times over each of the next two weeks and were encouraged to try at least two mindfulness

305 exercises a week from the handouts provided.

306 2.5.2 Down-Regulating emotions workshop

307 The Down-Regulation workshop aimed to provide participants with more adaptive

308 behavioral strategies for reducing negative emotional experiences. Down-regulating emotions

309 was defined as using adaptive strategies to lessen the intensity or duration of negative emotions

310 (Linehan, 2015b). The unique workshop components for this condition were primarily adapted

311 from existing DBT resources (Linehan, 2015b). Checking the facts and opposite action (Linehan,

312 2015a, 2015b) were presented as complementary exercises which (1) examine the validity of

313 one’s interpretations about a situation in order to (2) change the intensity of the emotion

314 experience if the emotion is due to a biased or distorted interpretation of the situation, and then

315 (3) act in opposition to the emotion in order to reduce distress. When checking the facts,

316 participants were instructed to identify a prompting event and their interpretations of it, examine

317 the bidirectional influence between thoughts and feelings, challenge irrational thought patterns,

318 and determine whether the emotion and its intensity “fit the facts” of the situation (similar to the

319 process of cognitive reappraisal). When using opposite action, participants were instructed to act

320 in opposition to the emotion experienced. The process of checking the facts was designed to

321 provide an intervention point for intentional selection of an adaptive coping strategy. Participants

322 practiced “checking the facts” in session in the presence of highly palatable snack foods, which
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323 were presented to induce cravings analogous to those in naturalistic settings in which participants

324 may be tempted to eat. Participants were provided handouts with other ideas for adaptive coping

325 strategies, drawn from existing DBT resources, that they could try using when experiencing a

326 negative emotion. These included self-soothing activities, momentary distraction, and pleasant

327 activities (Linehan, 2015a, 2015b), which could alter a current negative emotional experience. In

328 order to practice self-soothing experientially, participants submerged their faces in a bowl of ice

329 water and held their breath for approximately 15 seconds. Afterwards. participants described

330 their initial experience using this strategy. For homework, participants were instructed to use

331 checking the facts and opposite action as down-regulation strategies, and to practice pleasant

332 activities, self-soothing techniques, or opposite action at least two times each over the upcoming

333 two weeks.

334 2.5.3 Distress Tolerance workshop

335 The goal of the Distress Tolerance workshop was to provide participants with a set of

336 skills and strategies designed to increase acceptance of emotionally distressing situations while

337 emphasizing one’s ability to choose not to engage in maladaptive eating behaviors when urges

338 arise. The concept of distress tolerance was introduced and described to participants as the ability

339 to fully experience internal events (e.g., thoughts, emotions, urges) without attempting to modify

340 them (e.g., through eating). Distress tolerance skills were adapted from both DBT and ACT

341 (Hayes, Stroshal, & Wilson, 1999; Linehan et al., 2015). A key message of this workshop was

342 that the urge to eat is likely to occur in response to negative emotions, but it is possible to “ride

343 the wave” (Linehan, 2015b) of the urge to eat until the urge passes on its own, rather than giving

344 into the urge (by emotionally eating). The “tug of war with a monster” metaphor from ACT

345 (Hayes et al., 1999) was provided to increase participants’ willingness to accept negative
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346 internal experiences without trying to alter them or engage in behaviors to change them.

347 Defusion techniques and exercises such as the ‘hands over your face’ metaphor (Hayes et al.,

348 1999) were presented as methods for obtaining psychological distance from distressing thoughts

349 and feelings. This distance in turn counteracts a perceived need to directly change the content of

350 the thought or feeling.

351 In order to practice distress tolerance experientially, a negative mood induction was

352 completed within the group setting. To illicit distressing emotions and to target urges similar to

353 those felt when one might engage in emotional eating, participants were asked to take one bite of

354 a snack food and then spend the next five minutes writing about a recent memory that was

355 emotionally salient to them and brought up negative emotions they might have eaten to suppress.

356 While doing this activity, the snack foods they had just eaten remained in the room (in large

357 quantities) but participants were told to use the distress tolerance skills they had just learned to

358 navigate any urges to continue eating. A similar in-session practice attempt was also conducted

359 using the PASAT to induce frustration while participants practiced using distress tolerance

360 techniques to ride out any urges to eat snack foods. For homework, participants were asked to

361 complete two mood induction writing exercises each week followed by the use of distress

362 tolerance techniques learned in session to “ride out” the negative emotion and any subsequent

363 urges to eat.

364

365 2.6 Statistical analyses

366 Consistent with recommendations for pilot clinical trials with continuous outcomes and small

367 effect sizes approximately 25 participants were recruited for each workshop condition

368 (Whitehead, Julious, Cooper, & Campbell, 2016). The current pilot study tested hypotheses that
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369 were specified before the data were collected. The study was exploratory in nature, as such,

370 effect sizes, rather than statistical significance was interpreted. To explore the independent

371 preliminary efficacy of each workshop component we conducted repeated measures ANOVA to

372 examine changes in emotional eating and emotion regulation for each separate group across time

373 (i.e., baseline, one-week follow-up, two-week follow-up). We then ran a 3 (condition) x 3 (time

374 point) factorial ANOVA, including interactions between time and workshop condition, to

375 examine differential changes in outcome measures by condition. Because Mauchly’s test of

376 sphericity was violated, Greenhouse-Geisser corrections were used to decrease the odds of Type

377 I error. Partial eta squared was used as a measure of effect size indicating weak (010 to .059),

378 moderate (.060 to .139), or strong (≥.14) relationships between time, condition and outcomes

379 (Cohen, 1988).

380 To explore if changes in emotion regulation were differentially associated with

381 improvements in emotional eating for each condition we examined Pearson correlation

382 coefficients between changes in emotion regulation from baseline to one-week follow-up and

383 residual change in emotional eating from baseline to two-weeks follow-up, for each workshop

384 separately. Before the data were collected, formal mediation analyses were considered, but

385 ultimately forgone due to the small sample sizees of the groups, and the nature of running

386 mediation analyses with a multi-categorical predictor variable (i.e., three treatment groups

387 instead of two). Running mediation analyses with a multi-categorical predictor would have

388 prohibited us from testing the effects of each group independently on outcomes compared to the

389 other two groups (Hayes & Preacher, 2014). As such, independently examining correlations

390 among change in process variables and residual change in outcome variables allowed us to more

391 directly explore if change in process variables were differentially related to outcomes for each
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392 condition. Effect size of Pearson correlations coefficients were determined to be weak (.100 to

393 .299), moderate (.300 to .499), or strong ( ≥ .500) (Cohen, 1988) . Change in outcome variables

394 from baseline to two-week follow-up were calculated such that positive change indicated

395 improvements in outcome variables. Residual change scores of process variables were calculated

396 by regressing emotion regulation scores at one-week follow-up on emotion regulation scores at

397 baseline.

398

399 3. Results
400 3.1 Descriptive statistics and baseline comparisons

401 Individuals who completed workshops were 58% white (n = 45), 17% African American

402 (n = 13), 13% Asian (n = 10), 6% other: African, Latino, Native American, Multicultural (n = 5),

403 and 6% unspecified (n = 5). Ethnicity of the three groups were not significantly different (X2 [6]

404 = 1.14, p =.98). Additional sample demographics are presented in in Table 1. Prior to the

405 workshop, the average number of emotional eating episodes participants reported was 10.41

406 monthly (SD = 6.59) and 2.51 weekly (SD = 1.64). Group comparisons of demographics and

407 baseline emotional eating episodes, disinhibited eating, and emotion regulation are presented in

408 Table 1.

409

410
411 Table 1. Group demographics and comparison of outcome measures at baseline
Emotional Down- Distress F or X2 p

Awareness Regulation Tolerance

(n=30) (n=23) (n=25)

M(SD) M(SD) M(SD)

 19

Age (years) 33 (15) 40 (16) 34 (13) 1.39 .26

BMI 29.6 (7.6) 27.4 (6.8) 28.4 (6.0) 0.71 .49

Sex (n,% Female) 26 (86.7%) 15 (68.2%) 17 (68.0%) 3.40 .18

Disinhibited eating a 64.41 (37.83) 81.14 (53.34) 75.38 (44.12) 1.21 .31

Average EE episodes b 2.75 (1.94) 1.98 (1.43) 2.67 (1.39) 1.40 .25

Emotional acceptance 21.37 (5.73) 21.22 (6.39) 19.4 (8.37) 0.66 .52

Goal directed behavior 14.30 (5.63) 14.43 (3.76) 13.28 (5.62) 0.38 .69

Refrain from impulses 22.40 (5.73) 24.17 (5.00) 22.32 (5.84) 0.86 .43

Emotional awareness 20.30 (5.15) 20.78 (4.63) 21.12 (6.55) 0.16 .86

Perceived access to 0.22 .80

28.33 (6.90) 28.52 (7.13) 27.24 (7.91)
strategies

Emotional clarity 18.07 (3.77) 18.43 ( 3.47) 18.24 (4.72) 0.06 .95

Overall emotion 124.77 (24.70) 127.57 (22.22) 121.60 (29.18) 0.33 .72

regulation

412
413 Note. BMI= Body mass index (kg/m2); EE= Emotional eating; a grams of food consumed during
414 the bogus taste test; b weekly averages.
415
416
417 3.2 Changes in outcomes and emotion regulation
418
419 Changes in emotional eating, disinhibited eating, and emotion regulation across time and

420 by workshop condition can be found in Table 2. Overall, all three workshops produced decreases

421 in emotional eating episodes, but there were not differences in amount of change across groups.

422 There were no changes in food consumed during a laboratory taste test. All three workshops

423 produced changes in overall emotion regulation abilities, and perceived access to strategies.

424 Groups differed on improvements in overall emotion regulation ability, ability to refrain from
 20

425 impulses and emotional acceptance.

426
427 Table 2. Changes in emotional eating. disinhibited eating, and emotion regulation across and by

428 workshop condition.

Baseline One-week follow-up Two-week

M(SD) M(SD) follow-up
(n=63) M(SD)
(n=76) (n=62)
a
Disinhibited eating t, p
Overall 74.17 (40.07) 69.25 (47.80) 0.80, .43
2
F,p
ηp
Time*Condition 0.01, .99 <.01

Emotional 62.10 (39.59) 61.35 (40.81)

Awareness
Down-Regulation 71.76 (28.44) 61.59 (43.97)
Distress Tolerance 82.25 (43.87) 77.35 (47.49)
Emotional eating
Overall 2.58 (1.70) 1.75 (1.53) 1.83 (1.68) 7.60, <.01* 0.12
Time x condition 0.72, .54 0.03
Emotional 2.49 (1.83) 2.10 (1.92) 1,88 (1.91)
Awareness
Down-Regulation 1.97 (1.57) 1.29 (1.05) 1.39 (1.36)
Distress Tolerance 2.77 (1.33) 1.73 (1.48) 2.05 (1.75)
Overall emotion regulation
Overall 123.85 (25.03) 130.86 (26.25) 132.71 (27.29) 3.52, <.05* 0.06
Time x Condition 3.16, .03* 0.10
Emotional
Awareness 124.77 (24.70) 129.17 (22.53) 131.38(22.861)
Down-Regulation 127.57 (22.22) 127.67 (26.26) 133.60 (25.51)
Distress Tolerance 121.60 (29.18) 135.52 (30.50) 133.19 (33.58)
Emotional acceptance
Overall 20.60 (6.72) 22.41 (6.07) 21.94 (6.58) 1.78, .18 0.03
Time x Condition 3.71, .02* 0.12
Emotional 21.37 (5.73) 21.67 (5.64) 21.00 (6.20)
 21

Awareness
Down-Regulation 21.22(6.39) 22.00 (5.41) 23.10 (4.61)
Distress Tolerance 19.40 (8.37) 23.62 (7.11) 21.76 (8.43)
Refrain from impulses
Overall 22.80 (5.49) 23.44 (4.96) 24.46 (5.54) 3.26, .05 0.05
Time x Condition 2.71, .04* 0.09
Emotional
Awareness 22.40 (5.73) 24.00 (4.04) 24.67 (4.99)
Down-Regulation 24.17 (5.00) 22.17 (4.76) 24.75 (5.42)
Distress Tolerance 22.32 (5.84) 23.90 (6.02) 23.95 (6.34)
Emotional awareness
Overall 20.51 (5.51) 21.56 (5.23) 21.44 (4.88) 0.97, .38 0.02
Time x Condition 0.65, .63 0.02
Emotional
Awareness 20.30 (5.15) 21.25 (5.01) 22.00 (4.17)
Down-Regulation 20.78 (4.63) 20.78 (4.82) 20.50 (5.05)
Distress Tolerance 21.12 (6.55) 22.57 (5.88) 21.76 (5.44)
Perceived access to
strategies
Overall 27.84 (7.24) 29.22 (7.35) 30.37 (7.65) 5.23, .01* 0.08
Time x Condition 2.21, .09 0.07
Emotional
Awareness 28.33 (6.90) 28.83 (6.57) 30.33 (6.21)
Down-Regulation 28.52(7.13) 28.61 (8.68) 30.80 (8.28)
Distress Tolerance 27.24 (7.91) 30.19 (7.23) 30.00 (8.63)
Emotional clarity
Overall 18.12 (3.91) 18.92 (3.92) 18.81 (3.97) 0.90, .41 0.02
Time x Condition 1.91, .11 0.07
Emotional
Awareness 18.07 (3.77) 19.08 (3.22) 18.48 (3.47)
Down-Regulation 18.43 (3.47) 18.17 (3.19) 18.40 (3.73)
Distress Tolerance 18.24 (4.72) 19.38 (5.13) 19.52 (4.70)
Goal directed behavior
Overall 13.98 (5.03) 15.30 (5.00) 15.71 (5.56) 3.01, .06 0.05
Time x Condition 1.98, .12 0.07
Emotional
Awareness 14.30 (5.63) 14.33 (5.47) 14.90 (6.11)
Down-Regulation 14.43 (3.76) 15.94 (4.47) 16.05 (4.67)
 22

Distress Tolerance 13.28 (5.62) 15.86 (4.93) 16.19 (5.93)

429 Note. *p < .05; t= paired samples t-test; F= repeated measures ANOVAs;, ηp2 = partial eta
430 squared; a participants only completed the disinhibited eating task at baseline and two-week
431 follow-up.
432
433
434
435
436 Figure 1. Differential change in overall emotion regulation across conditions

180

168

156

144
Overall emotion regulation

132

120

108

96

84

72

60

48

36
Pre- workshop One-week post workshop Two-weeks post
workshop

Emotional Awareness Down Regulation Distress Tolerance

437
438
439 Note. Emotion regulation measured by the Difficulties in Emotion Regulation Scale. The overall
440 repeated measures ANOVA was significant, however, Tukeys-b post-hoc tests did not reveal any
441 differences between groups.

442 Figure 2. Differential change in emotional acceptance across conditions

 23

36
34
32
Acceptance of emotional responses

30
28
26
24
22
20
18
16
14
12
10
8
6
Pre- workshop One-week post workshop Two-weeks post
workshop

Emotional Awareness Distress Tolerance Down Regulation

443
444 Note. Emotional acceptance measured by the Difficulties in Emotion Regulation Scale. The
445 overall repeated measures ANOVA was significant, however, Tukeys-b post-hoc tests did not
446 reveal any differences between groups.

447

448 Figure 3. Differential change in ability to refrain from impulses across conditions

36
Ability to refrain from engaging in

34
32
30
impulsive behavior

28
26
24
22
20
18
16
14
12
10
8
6
Pre- workshop One-week post workshop Two-weeks post
workshop

Emotional Awareness Down Regulation Distress Tolerance

449
 24

450

451 Note. Impulsivity measured by the Difficulties in Emotion Regulation Scale. The overall
452 repeated measures ANOVA was significant, however, Tukeys-b post-hoc tests did not reveal any
453 differences between groups.

454

455
456 3.3 Relationships between changes in process variables and changes in outcomes

457 Overall, for the three workshop groups there were medium to small correlations between

458 improvement in facets of emotion regulation and improvement in emotional eating and

459 disinhibited eating. See Table 3. for correlations by condition.

460

461 Table 3. Correlations among improvements in emotion regulation and outcomes from each
462 workshop
463
Condition Emotional Awareness Down-regulation Distress Tolerance

r, p r, p r, p

Facets of Emotional Disinhibited Emotional Disinhibite Emotional Disinhibited

emotion Eating Eating Eating d Eating Eating Eating
regulation (n=20) (n=20) (n=18) (n=17) (n=20) (n=19)
Emotional 0.30, 0.20 -0.12, 0.61 0.21, 0.42 0.34, 0.18 0.33, 0.16 0.16, 0.50
acceptance

Ability to 0.28, 0.23 -0.14, 0.56 0.15, 0.56 0.01, 0.97 0.41, 0.08 0.34, 0.15
refrain
from
impulses

Emotional 0.38, 0.10 0.10, 0.68 0.01, 0.97 0.28, 0.27 0.20, 0.41 -0.03, 0.91
awareness

Perceived 0.22, 0.35 <0.01, 0.99 0.40, 0.10 0.11, 0.68 .63, <0.01 0.23, 0.35
access to
strategies

Emotional 0.39, 0.09 0.05, 0.84 -0.18, 0.48 0.04, 0.89 0.26, 0.27 0.08, 0.76
clarity
 25

Ability to 0.22, 0.36 0.05, 0.83 0.22, 0.37 -0.27, 0.29 0.16, 0.49 0.35, 0.14
engage in
goal
directed
behaviors

Overall 0.38, 0.10 0.14, 0.95 0.26, 0.30 0.16, 0.54 0.21, 0.38 0.36, 0.13
emotion
regulation

464
465 Note. p < .05; Emotional eating and disinhibited eating reflect changes from baseline to two-
466 week follow-up. DERS domains reflect residual change in facets of emotion regulation from
467 baseline to one-week follow-up.
468

469 4. Discussion

470 The present study was an exploratory component analyses of three commonly used

471 emotion-focused treatment components. All three workshops were associated with reductions in

472 the frequency of emotional eating episodes and with improvements in emotion regulation.

473 Overall, weak to moderate effects of treatment condition on changes in emotion regulation and

474 emotional eating were observed. Given the pilot nature of the current study, moderate effect

475 sizes suggest that even a one-time workshop focused on improving one specific facet of emotion

476 regulation may be effective for improving emotional eating, at least in the short term. However,

477 workshops did not produce reductions in lab-based disinhibited eating.

478 The current pilot study also evaluated 1) whether treatment components impacted

479 different facets of emotion regulation and 2) whether changes in emotion regulation were

480 differentially associated with improvements in emotional eating for each treatment component.

481 While all three groups were associated with broad improvements in emotion regulation, the

482 specific facets of emotion regulation most strongly associated with improvements in emotional
 26

483 eating varied by workshop. Specifically, in the Down-Regulation workshop improvements in

484 perceived access to healthy emotion regulation strategies was the only facet of emotion

485 regulation moderately associated with improvements in emotional eating. In the Emotional

486 Awareness workshop, improvements in emotional acceptance, awareness and clarity were

487 moderately related to improvements in emotional eating. Finally, in the Distress Tolerance

488 workshop, improvements in emotional acceptance, ability to refrain from impulses, and

489 perceived access to strategies were moderately or strongly associated with improvements in

490 emotional eating.

491 Some emotion regulation treatment components impacted emotional eating behaviors

492 through several pathways. For the Emotional Awareness group and Distress Tolerance group,

493 improvements in three out of six facets of emotion regulation were moderately associated with

494 improvements in emotional eating. On the other hand, for the Down-Regulation group, only

495 improvements in perceived access to strategies had moderate associations with improvements in

496 emotional eating. Additionally, the three treatment conditions had minimal overlap in their

497 effects on individual facets of emotion regulation and emotional eating. There was no overlap

498 between the facets of emotion regulation most strongly associated with improvements in

499 emotional eating for the Emotional Awareness and Down-Regulation groups. Further, only one

500 facet overlapped between the Emotional Awareness and Distress Tolerance groups (emotional

501 acceptance) and between the Down-Regulation and Distress Tolerance groups (perceived access

502 to strategies). Together, these findings potentially suggest that each workshop component

503 impacts emotional eating through different mechanisms.

504 Although participants experienced a decrease in self-reported emotional eating frequency,

505 there were no changes in amount of food consumed during a laboratory disinhibited eating
 27

506 paradigm. It is possible that improvements in different facets of emotion regulation are more

507 effective in preventing emotional eating episodes from occurring than they are for reducing the

508 amount of food consumed during a disinhibited eating episode. However, improvements in

509 emotional acceptance were moderately related to decreases in disinhibited eating in for Down

510 Regulation group. Improvements in ability to control impulses and engage in goal directed

511 behavior were moderately associated with decreases in disinhibited eating in for the Distress

512 Tolerance group. Changes in disinhibited eating were only weakly related to improvements in

513 emotional acceptance, awareness, and ability to refrain from impulses among the Emotional

514 Awareness group. Together, this pattern of findings may suggest that one-time emotion focused

515 workshops, especially those solely aiming to increase emotional awareness, may not be

516 sufficient for reducing the amount of food consumed during an emotional eating episode. It is

517 also possible that the in-lab paradigm was not sufficiently representative of the scenarios that

518 trigger emotional eating outside of laboratory settings. Notably, the current pilot study did not

519 conduct a manipulation check to confirm that the stress induction paradigm produced significant

520 increases in negative affect prior to the disinhibited eating task. Therefore, it is possible that

521 participants did not experience a level of affective change necessary for inducing emotionally

522 driven disinhibited eating.

523 This pilot study addressed gaps in the literature by independently implementing and

524 assessing the impact of different types of emotion regulation skills on emotion regulation and

525 emotional eating. Previous studies have been limited in their ability to make mechanistic

526 conclusions about which components (e.g., emotional awareness, down-regulation, distress

527 tolerance, etc.) drive change in emotion-focused treatments given that these components are

528 rarely, if ever, delivered in isolation. The design of the current pilot study allowed us to explore
 28

529 the effects of a single emotion regulation component in absence of other components. Results

530 demonstrated that the provision of skills designed to increase emotional awareness may be

531 sufficient for improving emotional eating. Similarly, the provision of skills designed to facilitate

532 distress tolerance and down-regulation of negative emotions, without first increasing emotional

533 awareness, may also be sufficient for improving emotional eating. Interestingly, these findings

534 suggest that it may not be necessary to target multiple emotion regulation constructs to facilitate

535 change in emotional eating.

536 On the other hand, each treatment workshop varied in which specific facet of emotion

537 regulation, as assessed by the DERS, was associated with change in emotional eating. As such,

538 there may be added benefit to learning emotional awareness skills in combination with either

539 down-regulation or distress tolerance skills to foster improvements in all emotion regulation

540 domains. It is unknown whether improving more facets of emotion regulation (e.g., emotional

541 clarity, ability to refrain from impulses) leads to greater improvements in clinical outcomes.

542 Future treatment studies may choose to implement more complex factorial designs to test the

543 independent efficacy of treatment components compared to combinations of treatment

544 components. For example, the Multiphasic Optimization Strategy (MOST) approach can help

545 identify the most effective combinations of treatment components (Collins, Murphy, & Strecher,

546 2007). Utilizing more complex designs to test the main and interactive effects of various

547 treatment components will advance the development of optimized treatments that contain the

548 most effective combination of components which can improve treatment efficacy, efficiency and

549 disseminability (Manasse et al., 2019).

550 While there are many strengths of the current pilot study, some limitations must be

551 considered. The study conducted multiple statistical analyses to identify which facets of emotion
 29

552 regulation were most strongly associated with improvements in emotional eating for each

553 workshop. Given the small sample size and analog nature of the study, we did not utilize

554 multiple comparison corrections as this would have increased our risk of Type 2 error. However,

555 it is important to note that the number of statistical tests run increases the likelihood of making a

556 Type 1 error and is a limitation of the current pilot study. Fully powered clinical trials are

557 needed to detect statistically significant relationships among different treatment components and

558 facets of emotion regulation. The pilot study also relied on retrospective self-reports of emotion

559 regulation and emotional eating. Given the well-established problems of retrospective self-

560 reported measures (e.g, subject to recall bias, recency bias), especially in individuals who have

561 deficits in identifying and reporting emotions, future research should aim to use other

562 measurements of emotional eating (e.g., ecological momentary assessment) that combat these

563 limitations.

564 There were also limitations related to the workshops. Teaching down-regulation and

565 distress tolerance skills may also bring more awareness to emotions in the moment, future

566 studies will need to test for treatment contamination to ensure the delivery of distinct treatment

567 components. Additionally, while the current pilot study isolated treatment components, it did not

568 evaluate the use of individual skills within those treatment components. Multiple skills specific

569 to the relevant treatment component were taught in each workshop. Future work should identify

570 which specific strategies are necessary and effective for improving emotion regulation and

571 decreasing emotional eating to even further isolate the most effective components of emotion

572 focused interventions. Unfortunately, due to the short follow-up period, we are unable to

573 examine longer-term effects of each component. It is possible that improvements in emotional

574 awareness may be sufficient in the short-term changes in emotional eating but having access to
 30

575 healthy emotions regulations strategies is necessary for sustaining improvements long term.

576 Future trials should examine both main and interactive effects of each treatment component in

577 trials that measure emotion regulation and emotional eating over a longer follow-up period.

578 Finally, while delivering emotion regulation strategies in a one-time workshop format is both

579 time- and cost-effective, individuals may have further benefited from, and preferred, to attend

580 multiple sessions. This study is analog in nature and extension and replication is necessary.

581

582 4.1 Conclusions

583 Teaching specific emotion regulation skills in isolation (e.g., emotional awareness, down-

584 regulation of emotions, or tolerance of emotions) appears to be acceptable and effective for

585 reducing emotional eating. Each component had independent and equal preliminary efficacy in

586 improving emotional eating, although each component differentially impacted individual facets

587 of emotion regulation. However, future studies should examine if certain combinations of

588 emotion regulation components confer the greatest benefit.

589

590

591 Funding: This research did not receive any specific grant from funding agencies in the public,

592 commercial, or not-for-profit sectors.

593

594 Author Contributions: ASJ was the principle investigator of the study, responsible for data

595 collection, and contributed to the manuscript. MNP conducted analyses, contributed to the

596 manuscript, and created tables and figures. SMN helped conceptualize the study and contributed
 31

597 to the manuscript. JLB, CD, and EPW assisted in data collection and critically reviewed and

598 revised the manuscript. All authors have approved the final.

599

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720 Kohl, A., Rief, W., & Glombiewski, J. A. (2012). How effective are acceptance strategies? A
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