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. Author manuscript; available in PMC: 2011 Jul 1.
Published in final edited form as: Int J Eat Disord. 2010 Jul;43(5):398–404. doi: 10.1002/eat.20730

Emotion Avoidance in Patients with Anorexia Nervosa: Initial Test of a Functional Model

Jennifer E Wildes 1, Rebecca M Ringham 1, Marsha D Marcus 1
PMCID: PMC2882494  NIHMSID: NIHMS147102  PMID: 19670226

Abstract

Objective

This study aimed to evaluate emotion avoidance in patients with anorexia nervosa (AN) and to examine whether emotion avoidance helps to explain (i.e., mediates) the relation between depressive and anxiety symptoms and eating disorder (ED) psychopathology in this group.

Method

Seventy-five AN patients completed questionnaires to assess study variables. Rates of emotion avoidance were compared to published data, and regression models were used to test the hypothesis that emotion avoidance mediates the relation between depressive and anxiety symptoms and ED psychopathology in AN.

Results

AN patients endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls. As predicted, emotion avoidance significantly explained the relations of depressive and anxiety symptoms to ED psychopathology.

Discussion

Findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states.

Close observers of eating disorder psychopathology long have noted that anorexia nervosa (AN) is associated with emotion avoidance, defined here as the desire to avoid experiencing or expressing physical sensations, thoughts, urges, and behaviors related to intense emotional states. Indeed, several clinical scholars have articulated that anorexic symptoms function, in part, to help individuals cope with or avoid aversive emotions. For example, Slade (1) hypothesized that preoccupation with food, eating, weight, and shape enables individuals with AN to avoid thinking about or confronting other potentially aversive stimuli such as adolescent conflicts, interpersonal problems, and stress and failure experiences. Similarly, Schmidt and Treasure (2) have proposed a model of AN maintenance that emphasizes the role of anorexic symptoms in facilitating avoidance of negative emotions, as well as interpersonal relationships that may trigger these emotions. Specifically, these theorists assert that the exclusive mental focus on food and eating that characterizes AN is associated with emotions becoming less salient, noting that many individuals with AN report feeling emotionally “numb” (p. 347).

Several lines of research provide support for the notion that emotion avoidance is pertinent to anorexic psychopathology. For example, studies using qualitative methodology (3, 4) or self-report questionnaires (5, 6) to assess AN patients' perceptions of the functions served by disordered eating symptoms have reported that the illness helps affected individuals to avoid or control emotions. Research also has documented that individuals seeking treatment for AN and other eating disorders are more likely than non-psychiatric controls to endorse emotion avoidance. Specifically, Corstorphine and colleagues (7) found that women with AN, bulimia nervosa (BN), or eating disorder not otherwise specified were significantly more likely than non-psychiatric control women to report avoidance of situations that might provoke positive (i.e., excitement, enthusiasm, enjoyment), as well as negative (i.e., anger, sadness, nervousness) emotional states. Moreover, emotion avoidance was associated with increased levels of body dissatisfaction in the disordered eating group (7).

Less is known about the factors that contribute to emotion avoidance in patients with AN. Some scholars have theorized that individuals with AN have a temperamental predisposition to emotion avoidance resulting from traits characteristic of avoidant personality disorder (e.g., shyness, inhibition, harm avoidance) (2). There is evidence that emotion avoidance is salient to individuals with avoidant personality traits. For example, using a multi-dimensional measure of emotion avoidance (i.e., the Emotional Avoidance Questionnaire), Taylor and colleagues (8) found that individuals with avoidant personality disorder reported more negative beliefs about experiencing emotions, greater avoidance of positive emotions, and more social concerns about displaying emotions than did community controls.

Another factor that may contribute to emotion avoidance in patients with AN is co-morbid “emotional disorder” (i.e., mood and anxiety disorder, p. 529) (9) symptomatology. It is well-documented that depressive and anxiety symptoms are prevalent in patients with AN [for reviews, see (10, 11); also see (12)] and are associated with increased severity of eating disorder psychopathology in this group (13, 14). Furthermore, there is evidence that many mood and anxiety disorder presentations are characterized by efforts to avoid experiencing intense emotions [for reviews, see (15, 16)]. For example, Campbell-Sills and colleagues (17) found that individuals seeking treatment for mood and anxiety disorders rated their emotions as less acceptable and were more likely to report that they attempted to suppress their emotions in response to watching an aversive film clip than individuals with no history of emotional disorder.

Thus, we hypothesize that depressive and anxiety symptoms may be associated with increased levels of emotion avoidance in patients with AN. Moreover, we speculate that emotion avoidance may help to explain the relation between depressive and anxiety symptoms and eating disorder psychopathology in this group. In particular, we theorize that eating disorder psychopathology may serve to help individuals with AN cope with or regulate co-morbid depressive and anxiety symptoms, and that this functional link between emotional disorder symptoms and eating disorder symptoms is driven, in part, by emotion avoidance (see Figure 1). Heatherton and Baumeister (18) have proposed a similar model to explain the processes underlying binge eating among restrictive dieters and individuals with BN. Specifically, these theorists assert that binge eating functions, in part, to help individuals escape from aversive self-awareness, which includes negative self-perceptions and emotional distress. We agree with Heatherton and Baumeister that disordered eating behaviors (i.e., extreme dietary restriction, binge eating, purging) may help to facilitate emotion avoidance in patients with AN. However, we also hypothesize that disordered eating thoughts (i.e., ruminative thoughts about eating, weight, and shape) serve a similar purpose, which is consistent with previous models focusing on the functions of AN symptomatology (1). Thus, in the present study, we aimed: 1) to characterize emotion avoidance in patients with AN using Taylor et al.'s (8) Emotional Avoidance Questionnaire; and 2) to conduct a preliminary test of the hypothesis that emotion avoidance helps to explain (i.e., mediates) the relation between co-morbid depressive and anxiety symptoms and eating disorder psychopathology in AN.

Figure 1.

Figure 1

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Hypothesized model in which emotion avoidance helps to explain the relation between depressive and anxiety symptoms and eating disorder psychopathology in anorexia nervosa

Methods

Participants

Eighty-three patients age ≥ 17 years receiving inpatient or day hospital treatment for AN were invited to participate in the present research. After we provided a complete description of the study, 77 patients (92.8% of those approached) signed written informed consent forms approved by the University of Pittsburgh Institutional Review Board. Two patients withdrew consent prior to completing the study procedures, resulting in a final sample of 75. Participant characteristics are reported in Table 1.

Table 1.

Demographic and Clinical Characteristics of the Sample (N = 75)

Variable M SD n %
Age (in years) 26.3 8.6
Sex
 Female 74 98.7
Race
 Caucasian 75 100
Anorexia Nervosa Subtype
 Restricting 27 36.0
 Binge eating/purging 48 64.0
Level of Care
 Inpatient 60 80.0
 Day hospital 15 20.0
Body Mass Index
 At treatment presentation 15.8 1.8
 At time of study 16.8 1.7
Depressive Symptoms (BDI Total) 29.1 11.9
Anxiety Symptoms (BAI Total) 24.6 12.3
Eating Disorder Psychopathology (EDRC)* 49.4 8.8
Emotion Avoidance (EAQ Total) 60.1 12.6
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*

Data missing for one participant (N = 74)

BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; EDRC = Eating Disorder Risk Composite from the Eating Disorder Inventory-3; EAQ = Emotional Avoidance Questionnaire

Procedure

All procedures were reviewed and approved by the University of Pittsburgh Institutional Review Board prior to initiation. Study participants completed a one-time assessment consisting of a battery of self-report questionnaires. Information about eating disorder diagnosis, level of care (i.e., inpatient or day hospital), height, and weight was collected by chart review. To maximize study participation, participants received $25 for completing the questionnaires.

Measures

Diagnostic information

AN diagnoses were assigned based on information obtained from structured interviews conducted for other research studies at our site, or clinical evaluations completed by experienced treatment staff. The majority of participants (76%; n = 57) were interviewed by trained assessors using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I) (19) and the Eating Disorder Examination (EDE 16.0D) (20), both psychometrically sound and widely used diagnostic instruments. For the 18 patients (24%) who did not complete research interviews, diagnoses were made by experienced clinicians using clinical interviews based on DSM-IV (21) diagnostic criteria. In addition, participants were required to have a body mass index (BMI) < 18.5 at admission for treatment.

Demographics

Demographic data (i.e., age, sex, race/ethnicity) were collected using an investigator-designed self-report questionnaire. Information about height and weight was obtained from chart review. All participants had their height measured using a stationary stature board prior to initiating treatment; weight was assessed daily (inpatients) or three times per week (day hospital patients) using a digital scale. BMI was calculated by formula, i.e., weight in kilograms divided by height in meters squared.

Emotion avoidance

Emotion avoidance was assessed using the Emotional Avoidance Questionnaire (EAQ) (8), a 20-item self-report measure that evaluates four aspects of emotion avoidance: 1) Avoidance of Positive Emotions (e.g., “I don't let myself get really happy about things because it's better to keep your feelings under control”); 2) Avoidance of Negative Emotions (e.g., “When I feel anxious or worried about something, I try to ignore it as much as I can”); 3) Negative Beliefs about Emotion (e.g., “I cannot tolerate feeling sad”); and 4) Social Concerns about Displaying Emotion (e.g., “I don't like expressing anger in front of others because I don't want them to think badly of me”). Items are rated on 5-point Likert scale, where 1 = not true of me and 5 = very true of me. The EAQ has demonstrated reliability and validity in clinical, community, and college student samples (8). Internal consistencies for the 20-item measure and the four subscales in the current sample were as follows: EAQ Total: α = 0.84, Avoidance of Positive Emotions: α = 0.85, Avoidance of Negative Emotions: α = 0.71, Negative Beliefs about Emotion: α = 0.79, Social Concerns about Displaying Emotion: α = 0.71.

Depressive symptoms

Depressive symptoms were assessed by the Beck Depression Inventory (BDI) (22), a 21-item self-report questionnaire that evaluates the severity of depressive symptomatology during the week prior to administration. Because all participants in the current study were receiving acute weight restoration treatment, one item focusing on recent weight loss was eliminated. The BDI has demonstrated strong reliability and validity in numerous samples (23). Coefficient α for the modified, 20-item version of the instrument used in the present study was 0.91.

Anxiety symptoms

Severity of anxiety symptoms was measured using the Beck Anxiety Inventory (BAI) (24), a 21-item self-report questionnaire that focuses on symptoms of anxiety experienced during the week prior to administration. The BAI has shown good reliability and validity in psychiatric patients (24). Coefficient α in the present sample was 0.92.

Eating disorder psychopathology

Eating disorder psychopathology was assessed using the Eating Disorder Inventory-3 (EDI-3) (25), a revision of Garner's 91-item self-report measure. The EDI-3 includes several changes designed to improve the psychometric properties of the EDI including a 0-4 point scoring system and the calculation of age- and diagnosis-adjusted T scores for the instrument's 12 subscales and 6 composite scales. The Eating Disorder Risk Composite (EDRC), a sum of the Drive for Thinness (DT), Bulimia (B), and Body Dissatisfaction (BD) scales, was used as an index of eating disorder psychopathology in the present study. 1 Following the guidelines presented by Garner (25), EDRC scores were calculated as follows: 1) raw scores for the DT, B, and BD scales were converted to age- (i.e., 11-17 years vs. ≥ 18 years) and diagnosis- (i.e., AN-restricting [AN-R] vs. AN-binge eating/purging [AN-BP]) adjusted T scores using normative data from clinical samples of adolescents and adults seeking treatment for eating disorders in the United States; 2) a sum of the T scores for the DT, B, and BD scales was calculated; and 3) this T score sum was then converted to a final age- and diagnosis-adjusted T score, i.e., the EDRC. Research has provided support for the psychometric properties of the EDRC including excellent internal consistency (α =0.90-0.97) and test-retest reliability (r = 0.98) in clinical samples of eating disorder patients (25). Coefficient α for the EDRC in the present sample was 0.93.

Data Analyses

Initial examination of the distribution properties of the variables included in the present study showed no evidence of significant skew or kurtosis, and only two cases (2.6%) with missing data. One participant was missing two items on the BDI and one item on the BAI; scale totals for these measures were imputed using person-mean substitution. The other participant did not complete the EDI-3; thus, her data were excluded from the hypothesis testing analyses.

We used descriptive statistics to characterize emotion avoidance in the current sample relative to the data presented in the study by Taylor et al. (8). Means and standard deviations also were calculated for the variables included in the hypothesis testing analyses (i.e., total scores on the BDI, BAI, and EAQ; EDRC scores from the EDI-3). Pearson correlations and independent samples t-tests were used to determine whether there were any associations of age, BMI, AN subtype, or level of care with the hypothesized outcome (i.e., EDRC score) and mediator (i.e., EAQ total score) variables.

To evaluate the hypothesis that emotion avoidance helps to explain (i.e., mediates) the relation between depressive and anxiety symptoms and eating disorder psychopathology in AN, we estimated a series of regression models corresponding to the following criteria for mediation (26): 1) The hypothesized predictor must be significantly related to the outcome of interest (i.e., BDI/BAI Total → EDRC). 2) The hypothesized predictor must be significantly related to the hypothesized mediator (i.e., BDI/BAI Total → EAQ Total). 3) When the hypothesized mediator is added to the initial model (i.e., BDI/BAI Total + EAQ Total → EDRC), it must be significantly related to the outcome. And, 4) when the hypothesized mediator is added to the initial model, the strength of the relation between the predictor and the outcome should decline. We used Sobel's test (27) to evaluate the significance of the mediation effects observed in the present study. All tests were two-tailed with α level set at p < 0.05.

Results

Emotion Avoidance in Patients with AN

Table 2 presents means and standard deviations for the EAQ subscales in the current sample and in the groups included in the study by Taylor et al. (8). Examination of the data reveals that individuals with AN endorsed levels of emotion avoidance that were similar to or higher than those reported by individuals with avoidant personality disorder and social phobia and exceeded community controls.

Table 2.

EAQ Subscale Scores in the Current Sample Relative to Participants in the Study by Taylor et al. (8)

EAQ Subscale Anorexia Nervosa Avoidant PD* Social Phobia* Community Control*
M SD M SD M SD M SD
Avoidance of Positive Emotions 11.0 4.9 10.8 4.2 9.0 4.2 7.7 3.8
Avoidance of Negative Emotions 15.1 4.2 13.8 3.5 14.8 3.1 12.2 5.3
Negative Beliefs about Emotion 16.7 4.8 14.4 4.6 11.4 4.1 9.1 3.8
Social Concerns about Displaying Emotion 17.3 4.4 16.9 3.7 16.7 4.6 11.4 4.1
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*

Data from Taylor et al. (8)

EAQ = Emotional Avoidance Questionnaire; PD = personality disorder

Test of the Hypothesized Model

Preliminary analyses

There were no significant associations of age (p = 0.47), BMI (either at presentation for treatment [p = 0.30] or at the time of the current study [p = 0.29]), AN subtype (p = 0.17), or level of care (p = 0.39) with the hypothesized outcome variable (i.e., EDRC score). Scores on the hypothesized mediator (i.e., EAQ total) also were unrelated to age (p = 0.80), BMI (treatment presentation: p = 0.22; current study: p = 0.27), and AN subtype (p = 0.22). However, because at a trend level, inpatients had higher EAQ total scores than did individuals in the day hospital program (M[SD] = 61.7[12.7] vs. 54.7[10.7]; t[72] = 1.98, p = 0.052), level of care was included as a covariate in the mediation analyses.

Test of the hypothesis that emotion avoidance mediates the relation between depressive and anxiety symptoms and eating disorder psychopathology in AN

The top half of Table 3 presents results of regression analyses to evaluate the hypothesized associations among depressive symptoms, eating disorder psychopathology, and emotion avoidance in the present study. As predicted, depressive symptoms were positively associated with eating disorder psychopathology and emotion avoidance in patients with AN. Moreover, emotion avoidance was positively related to severity of eating disorder psychopathology in this group. Finally, results indicate that emotion avoidance partially mediated the relation between depressive symptoms and eating disorder psychopathology in the current sample. Specifically, the unstandardized regression coefficient (B) for the BDI decreased from 0.425 to 0.335 when EAQ total scores were added to the model predicting scores on the EDRC (z = 1.98, p < 0.05).

Table 3.

Results of Regression Analyses to Test the Hypothesis that Emotion Avoidance Mediates the Relation between Depressive and Anxiety Symptoms and Eating Disorder Psychopathology in Patients with Anorexia Nervosa*

Regression Model B SE B t p pr
Depressive Symptoms
1. BDI Total → EDRC 0.425 0.072 5.90 <0.001 0.57
2. BDI Total → EAQ Total 0.526 0.106 4.97 <0.001 0.51
3a. EAQ Total → EDRC, controlling for BDI Total 0.171 0.079 2.17 0.033 0.25
3b. BDI Total → EDRC, controlling for EAQ Total 0.335 0.082 4.11 <0.001 0.44
Anxiety Symptoms
1. BAI Total → EDRC 0.213 0.084 2.52 0.014 0.29
2. BAI Total → EAQ Total 0.458 0.110 4.16 <0.001 0.44
3a. EAQ Total → EDRC, controlling for BAI Total 0.305 0.084 3.63 0.001 0.40
3b. BAI Total → EDRC, controlling for EAQ Total 0.073 0.087 0.84 0.404 0.10
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*

Level of care (inpatient versus day hospital) included as a covariate in the regression analyses

pr = partial correlation; BDI = Beck Depression Inventory; EDRC = Eating Disorder Risk Composite from the Eating Disorder Inventory-3; EAQ = Emotional Avoidance Questionnaire; BAI = Beck Anxiety Inventory

Results of regression analyses to evaluate the hypothesized relations among anxiety symptoms, eating disorder psychopathology, and emotion avoidance in patients with AN are presented in the bottom half of Table 3. As expected, anxiety symptoms were positively associated with eating disorder psychopathology and emotion avoidance in the current sample. Furthermore, emotion avoidance was positively related to severity of eating disorder psychopathology in this group. Finally, results document that emotion avoidance almost fully mediated the relation between anxiety symptoms and eating disorder psychopathology in the current study. As shown in Table 3, the unstandardized regression coefficient (B) for the BAI decreased from 0.213 to 0.073 when EAQ total scores were added to the model predicting scores on the EDRC (z = 2.74, p < 0.007).

Discussion

This study sought to evaluate emotion avoidance in patients with AN and to examine whether emotion avoidance helps to explain the relation between depressive and anxiety symptoms and severity of eating disorder psychopathology in this group. Overall, our findings indicate that emotion avoidance in AN is worthy of additional investigation. First, our data lend support to the notion that emotion avoidance is salient to individuals with AN. In particular, we found that AN patients endorsed levels of emotion avoidance that were similar to or higher than those reported by individuals with avoidant personality disorder and social phobia and exceeded community controls (8). These findings converge with previous research (7) in documenting that avoidance of emotion characterizes the phenomenology of eating disorders. Furthermore, our data showing that AN patients seek to avoid positive, as well as negative, emotional states are consistent with descriptions of this population as exhibiting constrained, conforming, and inhibited personality traits (28). Several theorists have postulated that abnormalities in fear conditioning and discomfort experiencing novelty or change, which emerge early in development, may signal an “emotional endophenotype” (p. 216) (29) of AN characterized, in part, by phobic avoidance (29-31). Although this avoidance is linked most directly to weight gain and body fat in AN, it also may extend to intense emotions. Thus, one task for future research will be to determine the extent to which emotion avoidance in patients with AN reflects a broader tendency towards fear-based learning and avoidance of harm in this group.

The second aim of this study was examine whether emotion avoidance helps to explain the relation between co-morbid depressive and anxiety symptoms and eating disorder psychopathology in AN. To this end, we tested the plausibility of a theoretical model in which depressive and anxiety symptoms are hypothesized to produce increased levels of emotion avoidance in patients with AN, which, in turn, leads to greater severity of eating disorder psychopathology as a means of regulating aversive emotion (see Figure 1). Our results provide initial support for this conceptualization. As predicted, depressive and anxiety symptoms were positively associated with emotion avoidance in the current sample. Moreover, emotion avoidance partially explained the relations between depressive and anxiety symptoms and severity of eating disorder psychopathology. These findings are consistent with clinical observations (1, 2) and patient reports (3-6) that anorexic symptoms function, in part, to help individuals avoid aversive emotional states. However, the cross-sectional approach to data collection in the current study precludes us from drawing inferences about causality. It is possible that eating disorder symptoms may lead to depressive and anxiety symptoms in patients with AN. Or, there may be a bi-directional relation between eating disorder symptoms and emotional disorder symptoms in this group. Future research using experimental and prospective longitudinal methodology is needed to disentangle causal relationships. Finally, there are a number of additional factors besides emotion avoidance (e.g., neurobiological similarities, family history, relations with stress and trauma) that may mediate or moderate the association between emotional disorder symptoms and eating disorder psychopathology in AN.

In this study, emotion avoidance almost fully accounted for the relation between anxiety symptoms and eating disorder psychopathology, but only partially explained the relation between depressive symptoms and eating disorder psychopathology. These findings suggest that emotion avoidance may be more salient to the association of anxiety with anorexic symptoms than it is to the association of depression with AN. However, it also is possible that the current results are an artifact resulting from a weaker relation of anxiety symptoms than depressive symptoms with eating disorder psychopathology in the present sample. Given that anxiety symptoms are a well-established correlate of anorexic symptomatology (10, 11), future research is needed to determine whether the present pattern of results can be replicated.

Several limitations must be noted when evaluating the results of the current study. First, participants were patients age 17 years and older receiving acute weight restoration treatment at a tertiary care facility and, therefore, may not be representative of the population of individuals with AN. Second, depressive and anxiety symptoms were assessed using self-report questionnaires, and we do not know to what extent threshold-level psychiatric co-morbidity might have influenced the study findings. Third, although we were able to descriptively compare EAQ scores in the present sample to scores reported by Taylor et al. (8), this study did not include a control group to which AN patients' scores could be compared statistically. Finally, as noted above, the cross-sectional approach to data collection in the current study prevents us from drawing conclusions about directional relations among the variables.

Clinical Implications

Limitations notwithstanding, this study confirms that emotion avoidance is present in patients with AN and provides preliminary support for a theoretical model in which emotion avoidance helps to explain the relation between depressive and anxiety symptoms and severity of eating disorder psychopathology in this group. These findings contribute to a growing body of literature emphasizing the function of anorexic symptoms in helping individuals avoid aversive emotions (2-6). Such work may have important implications for the development of effective interventions for AN. Indeed, as detailed by Vitousek and colleagues (32), addressing the functions served by anorexic symptoms is a critical component of treatment for this illness. Thus, if anorexic symptoms serve to facilitate emotion avoidance, then strategies designed to increase emotion acceptance and decrease emotion avoidance (e.g., mindfulness, exposure, validation) may have considerable utility in psychotherapeutic interventions for AN patients. We are in the process of developing an outpatient treatment for older adolescents and adults with AN that incorporates these strategies (33).

Acknowledgments

Research supported by R01 MH082685 and K01 MH080020 from the National Institute of Mental Health. We thank Yu Cheng, Ph.D. for her feedback on an earlier draft of this manuscript.

Footnotes

1

We considered focusing only on the DT scale in the present study, but concluded that the EDRC more accurately captures our model's emphasis on the association of disordered eating thoughts, as well as behaviors, to emotion avoidance in patients with AN. Moreover, preliminary analyses showed that T-scores on both the DT (r = 0.37, p = 0.001) and BD (r = 0.50, p < 0.001) scales were positively correlated with emotion avoidance, as measured by the EAQ total score. There was no significant association between scores on the B scale and emotion avoidance in the current sample (r = 0.22, p = 0.06).

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