Eating Disorders and Emotion Regulation

A well-known driving force in eating disorders is a desire to change one’s body, but people also engage in eating disorder behaviors with a desire to change their emotions. People sometimes restrict food intake to dull painful feelings, binge eat to lift their mood, or exercise excessively to distract themselves from feeling unworthy. These types of clinical observations led to the creation of eating disorder treatments that teach people to cope with their emotional experiences in healthy ways (also called emotion regulation). Interventions with emotion regulation components include integrative cognitive-affective therapy, enhanced cognitive-behavioral therapy and dialectical behavior therapy.

In 2015, Lavender and colleagues took a look at the research on emotion regulation in people with eating disorders. Specifically, they conducted a comprehensive review of anorexia nervosa and bulimia nervosa research through the lens of Gratz and Roemer’s (2004) multidimensional model of emotion regulation. The four types of emotion regulation in the model are assessed with the Difficulties in Emotion Regulation Scale (DERS) and are described in detail below.

1) The ability to use adaptive emotion regulation strategies flexibly to change emotional responses in order to meet individual goals or situational demands

This dimension is measured on the DERS by asking people to rate how frequently they have certain experiences from 1 (almost never) to 5 (almost always). For example, one statement says, “When I’m upset, it takes me a long time to feel better.” People with anorexia nervosa or bulimia nervosa tend to see themselves as being less skilled on this dimension as compared to people without these eating disorders. For example, they tend to report having a harder time changing negative moods by pivoting toward helpful, positive thoughts.

There are some scientifically-informed self-help books available that teach skills relevant to this dimension. These include Overcoming Binge Eating by Christopher Fairburn, Women Who Think Too Much by Susan Nolen-Hoeksema, and Feeling Good: The New Mood Therapy by Dr. David Burns. Some of the strategies include looking for useful ways to reframe hurtful or inaccurate thoughts, problem-solving instead of overthinking, and taking a break for pleasant activities (e.g., talking to a friend, watching a funny movie) before returning to the distressing issue.

2) The ability to stop impulses and remain goal-directed when distressed

An example of a DERS question for this dimension (rated from 1 almost never to 5 almost always) is, “When I’m upset, I have difficulty controlling my behaviors.” Lavender suggested that people with eating disorders struggle with this dimension but emphasized the need for additional research in this area. Eating disorder treatments teach coping strategies that aim to prevent impulsive behaviors during times of distress. For example, people can benefit from learning to distract themselves through activities (e.g., crossword puzzles), self-soothe through positive experiences (e.g., listening to calming music, relaxation exercises), and/or tolerate the urge to act impulsively by waiting for urges to pass/decrease. The goals of these skills are to 1) prevent unhealthy behaviors that would make the situation worse and 2) to re-focus attention on reaching longer-term goals through adaptive self-care.

3) Emotional awareness, understanding, and acceptance

The DERS measures this dimension with items such as, “I have difficulty making sense out of my feelings,” and “When I’m upset, I feel angry with myself for feeling that way,” (rating scale from 1 almost never to 5 almost always). Research on this dimension is somewhat mixed, but suggests that people with eating disorders may struggle with identifying, interpreting, and approving of their emotions. This may be particularly true for those who also struggle with symptoms of anxiety or depression. Therapeutic approaches that target this dimension include increasing emotional awareness (e.g., by being mindful of one’s feelings), educating and discussing the meanings and functions of emotions (e.g., anger can be a signal that a situation is unfair and requires action), and fostering acceptance (e.g., pushing back against the thought that it’s not okay to have certain types of feelings).

4) Willingness to experience emotional distress to pursue meaningful activities

Lavender also examined whether people with eating disorders have tendencies to avoid situations that evoke unpleasant emotions. An example of this would be someone skipping a party due to social anxiety despite the possibility of good outcomes (e.g., having fun, making new friends). Preliminary evidence suggests that people with eating disorders feel more driven to avoid emotionally distressing situations and less compelled by rewards than people without eating disorders. Eating disorder treatments typically encourage people to pursue meaningful activities by helping them tolerate unwanted emotional states. By repeatedly facing feared situations, people tend to experience decreased anxiety and develop a sense of accomplishment.

In summary, people with anorexia nervosa and bulimia nervosa often struggle with emotion regulation difficulties. Future work is needed to understand the role of emotion regulation in other eating disorders, such as binge eating disorder). Research in this area is mostly cross-sectional, which means that emotion regulation difficulties were measured while people had anorexia nervosa or bulimia nervosa. Therefore, it is currently unknown whether these emotion regulation difficulties were present before the onset of an eating disorder (perhaps serving as risk factors), if they develop during the onset of an eating disorder, or a combination of both. Scientists and therapists alike are working hard to develop a deeper understanding of the role of emotion regulation in eating disorders, so that we can empower people with the tools to cope effectively with their emotions.


Return To Getting Eating Disorder Help

Return To Home Page



About The Author:

Dr. Kathryn Gordon is a licensed clinical psychologist who has published research on eating disorders, suicidal behavior and other mental health topics.


Burns, D. (2008). Feeling good: The new mood therapy. New York, NY: Harper.

Collins, R.L. (2007). Relapse prevention for eating disorders and obesity. In G.A. Marlatt &
D.M. Donovan (Eds.), Relapse prevention: Maintenance strategies in the treatment of
addictive behaviors. New York, NY: Guilford Press.

Fairburn, C.G. (2013). Overcoming binge eating: The proven program to learn why you binge
and how you can stop. New York, NY: Guilford Press.

Fairburn, C.G., Cooper, Z., Doll, H.A., O’Connor, M.E., Bohn, K., Hawker, D.M., Wales, J.A.,
& Palmer, R.W. (2009). Transdiagnostic cognitive-behavioral therapy for patients with
eating disorders: A two-site trial with 60-week follow-up. The American Journal of
Psychiatry, 166(3), 311-319.

Gratz, K.L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the difficulties in
emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1),

Lavender, J.M., Wonderlich, S.A., Engel, S.G., Gordon, K.H., Kaye, W.H., & Mitchell, J.E.
(2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A
conceptual review of the empirical literature. Clinical Psychology Review, 40, 111-122.

Nolen-Hoeksema, S. (2004). Women who think too much: How to break free of overthinking and
reclaim your life. New York, NY: Holt & Co.

Safer, D.L., Telch, C.F, & Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa.
The American Journal of Psychiatry, 158(4), 632-634.

Safer, D.L., Telch, C.F, & Chen, E.Y. (2017). Dialectical behavior therapy for binge eating and
bulimia. New York, NY: Guilford Press.

Wonderlich, S.A., Peterson, C.B., Crosby, R.D., Smith, T.L., Klein, M.H., Mitchell, J.E., &
Crow, S.J. (2014). A randomized controlled comparison of integrative cognitive-affective
therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa.
Psychological Medicine, 44(3), 543-553.

Wonderlich, S.A., Peterson, C.B., Crosby, R.D., Smith, T.L., Klein, M.H., Mitchell, J.E., &
Crow, S.J. (2015). Integrative cognitive-affective therapy for bulimia nervosa: A
treatment manual. New York, NY: Guilford Press.

Written – 2019