Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome

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British Journal of Clinical Psychology (2011), 50, 310–325C© 2010 The British Psychological Society

TheBritishPsychologicalSociety

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Emotional expression, self-silencing, and distresstolerance in anorexia nervosa and chronic fatiguesyndrome

David Hambrook1,2,4, Anna Oldershaw1, Katharine Rimes2,Ulrike Schmidt1, Kate Tchanturia1, Janet Treasure1,Selwyn Richards3 and Trudie Chalder2∗1Division of Psychological Medicine and Psychiatry, Section of Eating Disorders,King’s College London, Institute of Psychiatry, UK

2Division of Psychological Medicine and Psychiatry, Section of General of HospitalPsychiatry, King’s College London, Institute of Psychiatry, UK

3Poole Hospital NHS Foundation Trust, UK4Doctorate in Clinical Psychology, Department of Psychology, Royal Holloway,University of London, UK

Objectives. Difficulties in processing emotional states are implicated in the aetiologyand maintenance of diverse health conditions, including anorexia nervosa (AN) andchronic fatigue syndrome (CFS). This study sought to explore distress tolerance, self-silencing, and beliefs regarding the experience and expression of emotions in individualsdiagnosed with AN and CFS. These conditions were chosen for this study because theirclinical presentation is characterized by physical symptoms, yet cognitive behaviouralmodels suggest that emotional processing difficulties contribute to the aetiology andmaintenance of both.

Design. A between-subjects cross-sectional design was employed.

Methods. Forty people with AN, 45 with CFS, and 48 healthy controls (HCs)completed the Distress Tolerance Scale (DTS), Silencing the Self Scale (STSS), Beliefsabout Emotions Scale (BES), and measures of clinical symptomatology.

Results. Initial group comparisons found that both AN and CFS participants scoredhigher than HCs on a subscale measuring difficulties in distress tolerance. AN andCFS participants were also more likely to judge themselves by external standards,endorse statements reflecting a tendency to put the needs of others before themselves,and present an outwardly socially compliant image of themselves whilst feeling hostilewithin. Relative to HCs, AN participants reported more maladaptive beliefs regardingthe experience of having negative thoughts and feelings and revealing these emotions to

∗Correspondence should be addressed to Professor Trudie Chalder, Academic Department of Psychological Medicine, King’sCollege London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK (e-mail: [email protected]).

DOI:10.1348/014466510X519215

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others, with CFS participants showing a non-significant trend in the same direction. Aftercontrolling for differences in age, anxiety, and depression the only significant difference toremain was that observed for the STSS care as self-sacrifice subscale. More maladaptivebeliefs about the experience and expression of emotions were associated with greaterdegree of eating disorder symptomatology in the AN group.

Conclusions. Differences in emotional processing are present in AN and CFScompared to HCs, with some disorder-specific variation, and may be associated withgreater clinical symptomatology. These findings support current explanatory models ofboth AN and CFS, and suggest that emotional processing should be addressed in theassessment and treatment of individuals with these illnesses.

There is growing evidence to suggest that difficulties in processing emotional states areimplicated in the aetiology and maintenance of diverse health conditions, including butnot limited to eating disorders (e.g., Schmidt & Treasure, 2006), chronic fatigue syndrome(CFS; e.g., Surawy, Hackman, Hawton, & Sharpe, 1995), major depression (Saarijarvi,Salminen, Tamminen, & Aarela, 1993), anxiety disorders (e.g., Baker, Holloway, Thomas,Thomas, & Owens, 2004), impulse control disorders (Fox, Hong, & Shina, 2008; Nock& Mendes, 2008), hypertension (Todarello, Taylor, Parker, & Fanelli, 1995), and irritablebowel syndrome (Ali et al., 2000; Jones, Wessinger, & Crowell, 2002). It has beensuggested that these emotion processing difficulties are therefore transdiagnostic, oper-ating across psychiatric and physical illness, and important to consider when attemptingto construct valid explanatory and treatment models for different conditions (Baker,Thomas, Thomas, & Owens, 2007; Coughlin & Selva, 2006). This study seeks to exploreselected aspects of emotional processing in individuals with anorexia nervosa (AN)and CFS. AN is a severe mental illness characterized by self-starvation and weight loss,and extreme concerns about weight, body shape, and/or eating (American PsychiatricAssociation [APA], 1994). CFS is characterized by persistent, medically unexplainedfatigue of new or definite onset lasting for at least 6 months also accompanied by a rangeof somatic (e.g., musculoskeletal pain) and neurocognitive complaints (e.g., impairedmemory/concentration) (Fukuda et al., 1994). These conditions were chosen for thisstudy because their overt clinical presentation is characterized by physical symptoms, yetcognitive behavioural models suggest that emotional processing difficulties contributeto the aetiology and maintenance of both problems (e.g., Schmidt & Treasure, 2006;Surawy et al., 1995).

Cognitive-behavioural models of CFS (e.g., Surawy et al., 1995) suggest that for somevulnerable individuals, during development the child’s expression of negative emotionis met with punishment or lack of helpful attention. Displays of negative affect are nottolerated, whilst high value is attached to being happy, never giving up, and believing inthe power of ‘positive mental attitude’ in overcoming adversity. This leads to problems inthe development of emotional processing skills and the belief that negative emotions are‘bad’, unacceptable, have adverse interpersonal consequences, and therefore should beavoided or at least not overtly expressed. At times of stress, such beliefs lead individualsto avoid seeking help, suppress, or ignore emotional difficulties, and to focus on somaticsensations associated with stress. Once CFS has developed, it is thought to be maintainedby a range of unhelpful cognitive, emotional, and behavioural responses includinginactivity/avoidance, self-critical thoughts, and frustration (Browne & Chalder, 2009;Surawy et al., 1995).

Whilst there is growing evidence to suggest that adverse childhood environmentsmay increase the risk for later development of CFS (e.g., Fisher & Chalder, 2003; Heim

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et al., 2009), empirical studies exploring the specific emotional processing styles ofpeople with CFS per se are sparse. However, there is some evidence that individualswith CFS score highly in the trait of alexithymia, denoting difficulties in the abilityto recognize, label, and describe emotions, and problems in linking feelings withphysiological correlates (e.g., Johnson, Lange, Tiersky, Deluca, & Natelson, 2001; vande Putte, Engelbert, Kuis, Kimpen, & Uiterwaal, 2007). Furthermore, Rimes and Chalder(2010) have found that relative to healthy controls (HCs), people with CFS are morelikely to believe that they should be able to control their emotions, that experiencingnegative emotion is a sign of weakness, and that others will react unfavourably to anydisplay of emotion.

In summary, the limited available evidence suggests that people with CFS doexperience difficulties in identifying their own emotions, a desire to suppress theirown emotions, and possess negative beliefs about the experience and expression ofnegative emotions. To date, there has been no attempt to directly assess these constructssimultaneously in CFS samples, or to examine the associations with emotional processingdifficulties and the central symptom of fatigue.

Recent research has also suggested that emotionally invalidating early environmentsmay contribute to difficulties with emotional processing in AN. It has long beenargued that emotional disturbance is a core feature of AN (e.g., Bruch, 1985). Indeed,people with AN experience difficulties identifying other people’s affective states(e.g., Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004; Oldershaw, HambrookTchanturia, Treasure, & Schmidt, 2010; Russell, Schmidt, Doherty, Young, & Tchanturia,2009), as well as their own (e.g., Lawson, Emanuelli, Sines, & Waller, 2008; Schmidt,Jinawy, & Treasure, 1993). AN sufferers also report difficulty in tolerating strong emotions(Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007; Waller, Corstorphine, &Mountford, 2007), and will often try to avoid potential triggers of these states (Serpell,Treasure, Teasdale, & Sullivan, 1999), or use impulsive behaviours to cope with them.For example, Corstorphine et al. (2007) explored distress tolerance in AN and bulimianervosa (BN) patients. Compared to HCs, eating disorder (ED) patients were more likelyto report a tendency to avoid situations that might trigger negative affect and wereless likely to report an ability and willingness to accept distress and manage it throughadaptive behavioural strategies. Avoidance of affect was also associated with both bulimicsymptomatology and body dissatisfaction, suggesting that individuals with EDs may usemaladaptive behavioural strategies (e.g., bingeing, vomiting) as a way of coping withintolerable emotions.

Several authors (e.g., Buchholz et al., 2007; Forbush & Watson, 2006; Geller, Cockell,Hewitt, Goldner, & Flett, 2008) have argued that people with AN are particularly highin self-silencing; a tendency to avoid expressing negative emotions due to an over-anticipation of distress and discomfort, a heightened sensitivity to the reactions of others,and a preference for stable and emotionally calm environments (Jack & Dill, 1992).One reason suggested as to why people with AN inhibit the expression of negativeemotions and minimize their own needs is in order to prevent conflict and preserveclose relationships (Schmidt & Treasure, 2006). A number of studies have demonstratedan association between emotional inhibition and ED symptomatology, including weightand shape concern, dietary restraint, and binge eating (Ross & Wade, 2004; Smolak &Munstertieger, 2002; Zaitsoff, Geller, & Srikameswaran, 2002).

Just as Surawy et al. (1995) described in their cognitive-behavioural model of CFS,Mountford, Corstorphine, Tomlinson, and Waller (2007) proposed that Linehan’s (1993)concept of emotionally invalidating childhood environments might provide a framework

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within which to understand the emotional difficulties that people with EDs oftenexperience. Such an environment can be defined as one where the child’s early personalexperiences are not validated by caregivers, and where communication of emotions iseither ignored or punished. Growing up in such an environment teaches the child thattheir view and experience of emotions is incorrect and can lead to the developmentof emotional dysregulation (as the child may not have been taught how to label his orher feelings appropriately) and difficulties in distress tolerance – the ability to endureand accept negative affect, so that problem-solving can take place (Linehan, 1993).Individuals who struggle to tolerate such distress will seek to avoid potential triggersor use impulsive behaviours to cope with negative emotional states. Individuals withEDs do report difficulty in tolerating strong affect (Corstorphine et al., 2007), and makeefforts to avoid experiencing intense emotional states (Serpell et al., 1999). There isalso substantial clinical and empirical evidence recognizing a direct and immediate linkbetween emotional states and eating behaviour (McManus & Waller, 1995; Meyer et al.,1998). Furthermore, people with AN are more likely to report invalidating childhoodenvironments compared to HCs, and that these experiences are associated with EDpsychopathology and measures of distress tolerance (Haslam, Mountford, Meyer, &Waller, 2008; Mountford et al., 2007).

As in the CFS literature, no attempt has previously been made to explore distresstolerance, emotional suppression, and beliefs about emotions concurrently in AN, and toexamine their associations with functional ED symptoms. For both disorders, emotionalprocessing difficulties are important clinical phenomena to explore as they may predictsuccessful therapeutic outcomes. For example, emotional processing difficulties in ANhave been found to predict outcome at 3 years (Speranza, Loas, Wallier, & Corcos,2007). In a recent randomized controlled trial comparing counselling and cognitivebehavioural therapy (CBT) for chronic fatigue, patients’ ability to acknowledge, express,and accept emotional distress was the key predictor of good outcome irrespective oftreatment modality (Godfrey, Chalder, Ridsdale, Seed, & Ogden, 2007). It is clear thatbeing able to report on and express one’s emotional experiences are central skillsrequired to engage successfully in psychological therapy. Therefore, understandingthe emotional experience of individuals with CFS and AN, and working specificallyto improve difficulties, may be important to encourage positive treatment outcomes.

Study aimsIt has been suggested that an invalidating environment in childhood might result inemotional processing difficulties in both AN and CFS. These difficulties include poordistress tolerance, emotional suppression or avoidance, and maladaptive beliefs aboutemotions. It is also possible that these difficulties may be functionally associated withsymptomatology in these disorders. The aim of the current study was to exploreconcurrently how people with AN and CFS tolerate, express, and manage emotionsrelative to HCs and each other. We also examined relationships between these variablesand clinical symptoms in both disorders. We hypothesized that people with AN andCFS would report lower distress tolerance, higher self-silencing, and endorse moremaladaptive beliefs about the experience and expression of emotions relative to HCs.Based on clinical observations that general psychopathology is more prominent inindividuals with AN than CFS, and the likely negative impact of malnutrition andstarvation, we expected that there would be more pronounced emotional processingdifficulties in the AN group compared to the CFS group, but that the CFS group

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would report difficulties compared to HCs. Regarding the associations between emotionprocessing variables and symptomatology, it was predicted that there would be a positivecorrelation between measures of symptomatology (ED symptoms, fatigue) and measuresof distress tolerance, self-silencing, and beliefs about emotions. We chose to comparepeople with AN and CFS because both disorders are associated with a physical symptompresentation yet similar emotional processing difficulties have been proposed to beimportant in their aetiology and maintenance. Investigating them simultaneously allowedthe examination of the proposed emotional processing difficulties from a transdiagnosticperspective and investigation of the hypothesis that the emotional processing difficultieswould be more severe in AN than in CFS.

MethodParticipantsThree groups of participants were recruited: AN, CFS, and HCs. Participants wererecruited over 12 months as part of a larger study exploring social and emotionalfunctioning in AN and CFS (e.g., Oldershaw et al., 2010). Participants from all groupswere excluded for poor literacy, non-fluent English, or a history of head injury orneurological illness. Forty adults with AN (37 females) were recruited form a specialistout-patient ED service in London. For eligibility, AN participants were required to havebody mass index (BMI) below 18.5 kg/m2 and be diagnosed using DSM-IV (APA, 1994)criteria as having restricting (N = 12) or binge eating/purging (N = 9) AN subtype orEating Disorder Not Otherwise Specified, AN type (N = 19). Forty-five adults with CFS (35females) were recruited from two specialist out-patient CFS treatment units in the Southof England. Trained clinicians confirmed diagnoses using the operational case definitionof CFS described by the United States Centre for Disease Control and Prevention (Fukudaet al., 1994). HC participants were recruited via public advertisement and throughpersonal contacts. Fifty-six HC participants were screened for inclusion in the study.Participants were also excluded from this group if their scores on the Eating DisorderExamination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) exceeded one standarddeviation (SD) above healthy norms (for norms, see Fairburn, Cooper, & O’Connor,2008), if their BMI was less than 18.5 kg/m2, if there was evidence of a DSM-IV AxisI disorder, or a personal/family history of AN or CFS. The additional exclusion criteriaapplied to this group resulted in a final sample of 47 HCs (37 females).

Measures and procedureThe study was approved by the local ethics committee and participants had theopportunity to ask any questions before giving their informed consent to take part.Self-report measures were posted to participants in advance of a face-to-face interviewin which they met with a researcher to complete a number of other measures whichwere administered as part of the larger study (see above). Questionnaire completiontook approximately 40 min per participant.

DemographicsParticipants provided information regarding their age, gender, ethnicity, and educationalbackground. AN and CFS participants were also asked about the duration of their illness

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and their age at onset of illness. All participants provided their height and weight tocalculate BMI (see Table 1).

Table 1. Between-groups comparisons for demographic variables

Structured Clinical Interview for DSM-IV-TR Axis 1 DisordersThe Structured Clinical Interview for DSM-IV-TR Axis 1 Disorders (SCID; First, Spitzer,Gibbon, & Williams, 2002) is a semi-structured interview used to screen for DSM-IV AxisI diagnoses. All participants were administered the screening module of the SCID toidentify possible co-morbid Axis I disorder.

Eating Disorder Examination QuestionnaireThe Eating Disorder Examination Questionnaire (EDEQ; Fairburn & Beglin, 1994) is ameasure of psychopathological and behavioural indicators of disordered eating. This36-item self-report questionnaire is derived from the ED examination interview schedule(Fairburn & Cooper, 1993). The EDE-Q provides a global score and has four subscalesmeasuring dietary restraint, eating concern, weight concern, and shape concern.Subscale and global scores range from zero to six, with higher scores representinggreater pathology. The EDE-Q has acceptable case detection and concurrent validity incommunity samples (Mond, Hay, Rodgers, Owen, & Beumont, 2004). In the currentstudy, internal consistency for each subscale was high (restraint � = .92; eating concern� = .89; weight concern � = .89; shape concern � = .95).

Fatigue ScaleThe Fatigue Scale (FS; Chalder et al., 1993) is an 11-item questionnaire measuring physicaland mental fatigue symptoms. Participants rate the extent to which they feel fatiguedcompared to usual during the past month, ranging from 0 (Less than usual) to 3 (Muchmore than usual). The scale has good clinical validity in the general population (Loge,Ekeberg, & Kaasa, 1998) and in patients diagnosed with CFS (e.g., Deale, Chalder, Marks,& Wessely, 1997; Quarmby, Rimes, Deale, Wessely, & Chalder, 2007). In the currentstudy, internal consistency for the FS was high (� = .96).

Hospital Anxiety and Depression ScaleThe Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) is a widelyused self-report measure consisting of 14 items, 7 tapping depression and 7 anxiety.Based on feelings and behaviour during the previous week, items are scored 0–3, leadingto a maximum score of 21 for each subscale. The HADS has been recommended as a

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screening tool in CFS (Deale & Wessley, 2000) and is widely used in research involvingAN participants. In the current study, internal consistency for both anxiety (� = .91)and depression (� = .88) subscales was high.

Distress Tolerance ScaleThe Distress Tolerance Scale (DTS; Corstorphine et al., 2007) is a 20-item self-reportmeasure of distress tolerance, defined as the ability to endure and accept negativeaffect so that problem-solving can take place (Linehan, 1993). The items of the DTSload onto three separate but correlated subscales: (1) anticipate and distract, reflectsresponses that anticipate distress and distract from negative affect; (2) avoidance of affect,measures the extent to which respondents report avoiding situations that might triggeran emotional response; (3) accept and manage, reflects the extent to which individualsare able to accept distress in their life and manage it through adaptive behaviours.Higher scores on the anticipate and distract and avoidance of affect subscales representmore pathological responses. The accept and manage subscale is reverse-scored so thatlower scores represent more pathological responses. Corstorphine et al. report adequateinternal consistency for the DTS and this was replicated in the current study (anticipateand distract � = .70; avoidance of affect � = .81; accept and manage � = .68). It shouldbe noted that whilst the original DTS consisted of 20 items, Corstorphine et al. (2007)found that only 14 items loaded onto any of the three subscales. As such, the remaining6 items are not included in this analysis.

Silencing the Self ScaleThe Silencing the Self Scale (STSS; Jack & Dill, 1992) is a 31-item questionnaire designedto tap schemata concerning the suppression of emotions in the context of establishingand maintaining intimate relationships. Each item is rated for agreement on a five-pointscale (1 = strongly disagree; 5 = strongly agree), with higher scores representing greaterself-silencing. The STSS is divided into four subscales: (1) externalized self-perception,the extent to which respondents judge themselves by external standards; (2) care as self-sacrifice, the extent to which respondents put the needs of others before themselvesto secure relationships; (3) silencing the self, the extent to which respondents inhibitfulfilling their own needs and expressing themselves to preserve relationship harmony;and (4) divided self, the extent to which respondents attempt to present an outwardlycompliant self at all costs. Psychometric investigations of the STSS have generallysupported its reliability and validity (e.g., Stevens & Galvin, 1995). In the current study,internal consistency for each of the STSS subscales was acceptable (externalized self-perception � = .83; care as self-sacrifice � = .71; silencing the self � = .85; divided self� = .87).

Beliefs about Emotions ScaleThe Beliefs about Emotions Scale (BES; Rimes & Chalder, 2010) is a 12-item self-reportscale that measures beliefs about the experience and expression of emotions (e.g., ‘IfI lose control of my emotions in front of others, they will think less of me’, ‘I shouldnot let myself give in to negative feelings’). Items are rated on a Likert-type scale from0 to 6, with higher scores representing more maladaptive beliefs. The BES items havebeen found to load onto one single factor with good internal consistency (� = .91) inindividuals with CFS (Rimes & Chalder, 2010). In the current study, internal consistency

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was also excellent (� = .93). The BES has demonstrated good construct validity, beingcorrelated significantly with measures of perfectionism and self-sacrificing. Furthermore,the BES has demonstrated sensitivity to change as a result of therapeutic intervention(Rimes & Chalder, 2010).

Data analysisAn a priori power calculation was conducted to estimate the required sample size. Thiswas based on the experimental measures used as part of the protocol for the wider study(Oldershaw et al., 2010). Based on this power calculation, the required sample size wassuccessfully recruited.

All data were analysed using SPSS Version 15. All significance test results are quotedas two-tailed probabilities. An alpha level of .05 was used for all statistical tests unlessotherwise specified. If assumptions required for parametric tests were violated then non-parametric tests were carried out. When the same results were obtained from parametricand non-parametric tests, only the former are reported. Demographic variables for eachgroup were compared using one-way analyses of variance (ANOVA), followed-up withTukey’s HSD post hoc tests. Independent samples t tests were used to compare AN andCFS groups in terms of duration of illness and age of onset. Differences between thegroups in terms of their scores on the symptomatology measures (EDE-Q, FS, HADS)were also explored using one-way ANOVAs with Tukey’s HSD. Initial one-way ANOVAswere also used to explore differences between the three groups on each of the emotionalprocessing measures. Given the significant differences between the groups in terms oftheir age and scores on the HADS (see below), further analyses of covariance (ANCOVA)were carried out on the emotional processing variables to assess the influence of thesefactors on test scores. Age, depression, and anxiety scores were entered as covariates.These results are reported only where significant effects of covariates occurred. Finally,partial correlations were calculated to explore relationships between symptomatology(EDE-Q, FS) and emotional processing variables, while controlling for age, anxiety, anddepression. Correlations including the EDE-Q were calculated for the AN group only andcorrelations including the FS were calculated for the CFS group only.

ResultsDemographic variablesMeans (M), standard deviations (SD), and results of statistical tests for demographicvariables are presented in Table 1. Post hoc analyses revealed that CFS participantswere significantly older than HCs, who were significantly older than people with AN. Asexpected, the AN group had significantly lower BMIs than both CFS and HC groups, whodid not differ from one another. AN and CFS participants did not differ from each otherin terms of their illness duration, however, AN participants had a significantly earlier ageof onset.

Anxiety and depressionSignificant group differences emerged for self-reported anxiety and depression (seeTable 2). The AN group were more anxious than both CFS and HC groups, and the CFSgroup were more anxious than HCs. Both AN and CFS participants were more depressedthan HCs, but did not differ from each other.

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Table 2. Between-groups comparisons for symptomatology measures

Between-group comparisons for disorder-specific symptomatologySignificant differences were observed on all of the EDE-Q subscales and on the FS(Table 2). For each EDE-Q subscale, AN participants scored significantly higher than CFSand HC groups, who did not differ from one another. The CFS group were significantlymore fatigued than either AN or HC participants, with AN participants intermediate andsignificantly different to both.

Between-group comparisons for emotional processing scalesThe results of the initial ANOVAs comparing the three groups on the DTS, STSS, and BESare presented in Table 3. Bonferroni’s correction for multiple comparisons was appliedfor each measure (0.05/4 subscales = 0.01 for STSS; 0.05/3 subscales = 0.02 for DTS).On the DTS, significant group differences were observed on the avoidance of affectsubscale only, with AN and CFS participants scoring significantly higher than HCs, butnot different from each other. Significant group differences were observed for each ofthe STSS subscales (all p < .01), except for the Silencing the Self subscale. AN participantsreported the greatest level of externalized self-perception, with CFS participant scores

Table 3. ANOVA comparisons for emotional processing measures

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intermediate between AN and HCs. AN and CFS participants had significantly higherscores than the HCs on the care as self-sacrifice subscale, but were not different fromeach other. AN and CFS participants rated themselves more highly on the divided selfsubscale than HCs, but did not differ from each other. The AN group had significantlyhigher BES scores than both CFS and HC groups, and there was a non-significant trendfor the CFS group to have higher scores than HCs (p = .07).

Following the initial ANOVAs, further one-way between-groups ANCOVAs wereconducted to control for the effects of differences in age, anxiety, and depression.After adjusting for age and HADS scores, the only group difference to remain significantwas that observed for the STSS care as self-sacrifice subscale [F(2, 116) = 3.11, p < .05,partial �2 = .05], with AN and CFS groups scoring significantly higher than HCs, but notdifferent from each other.

Correlations between Symptomatology and Emotional Processing ScalesPartial correlation was used to explore the relationship between ED symptomatology(EDE-Q subscales) and emotional processing variables in the AN group while controllingfor age, depression, and anxiety. Bonferroni’s correction was applied resulting in r

coefficients being significant at p < .004 (0.05/13 subscales). There were significantstrong, positive partial correlations between BES scores and the EDE-Q global score (r =.62, p < .001), eating concern (r = .55, p = .001), weight concern (r = .6, p < .001),and shape concern (r = .59, p < .001) subscales. Due to the more stringent alpha levelimposed by the Bonferroni correction, no other significant correlations were observedbetween the EDE-Q and other emotional processing measures.

Partial correlations also explored the relationship between fatigue and emotionalprocessing variables in the CFS group while controlling for age, anxiety, and depression.Bonferroni’s correction resulted in alpha being set at p < .006 (0.05/9 subscales). FSscores did not correlate significantly with any of the emotional processing variables aftercontrolling for age, anxiety, and depression.

DiscussionThis study aimed to examine self-reported distress tolerance, self-silencing and beliefsabout emotions in samples of individuals diagnosed with AN and CFS. These constructshave not previously been simultaneously explored in either CFS or AN. Relative toHCs, individuals with AN and CFS reported greater suppression of their own emotionsand needs, with AN participants particularly endorsing beliefs about the utility of thisapproach in securing successful attachments to others. Both AN and CFS participantswere more likely to evaluate themselves with reference to external rather than internalstandards and report that they strive to present an outwardly compliant self whilstsubjectively growing angry and hostile. AN and CFS participants struggled with distresstolerance and reported a tendency to avoid affect, further suggesting that both of thesegroups actively try to inhibit their own experience of emotion. Consistent with ourprediction, the AN participants showed more pronounced global emotional processingdifficulties than the CFS group.

The current study failed to detect group differences on the anticipate and distract orthe accept and manage subscales of the DTS, which is in contrast to a previous study(Corstorphine et al., 2007). This discrepancy between our own findings and those ofCorstorphine et al. might be explained by the fact that their sample comprised both ANand BN cases, whereas the present study included people with AN only.

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AN participants reported more maladaptive beliefs than HCs about experiencingnegative thoughts and feelings, the acceptability of expressing emotions to others, andthe perceived consequences of revealing their emotions to others. These findings aresupportive of previous suggestions that AN sufferers experience negative emotions asunacceptable and believe that they should not be expressed for fear of being criticizedand/or rejected (e.g., Schmidt & Treasure, 2006). There was also a trend for CFSparticipants to report more maladaptive beliefs than HCs, and with greater numbersof participants this difference may have reached significance.

The preliminary findings described above should also be interpreted cautiously. Whencontrolling for group differences in age, anxiety, and depression, most of the significantgroup differences in emotion processing disappeared. The only difference to remainsignificant was that observed for the STSS care as self-sacrifice subscale. Participants inthe AN and CFS groups were more likely than HCs to endorse items on this scale whichmeasures the tendency to put the needs of others before oneself in order to securerelationships. This finding is important in two respects. Firstly, it suggests that bothpeople with AN and CFS are particularly likely to place others needs before their own,even when differences in their age and levels of anxiety and depression are controlledfor. Secondly, the lack of significant effects for the other emotional processing variablessuggests that comorbid anxiety and depression are important factors to consider. It islikely that the difficulties with distress tolerance and other aspects of emotion processingobserved in AN and CFS are mediated by the heightened anxiety and depressionseen in these conditions, and therefore not solely related to the disorders (AN, CFS)themselves. With larger samples it would have been interesting to have completed moresophisticated path analyses in order to explore this question further. This would be a keyrecommendation for future research. From a clinical perspective, this finding suggeststhat a detailed assessment of the role of anxiety and depression in mediating emotionaldifficulties is also something which should be considered in the overall formulation ofindividuals with AN and CFS.

When examining associations between disorder-specific symptomatology and emo-tional processing variables in AN, the only variable found to correlate with EDE-Q scoreswas the BES. That is, negative beliefs about emotions were associated with greater eating,weight, and shape concerns. Due to the correlational nature of the data it is impossibleto make conclusions about causality here. However, the current findings do point toa strong link between the core psychopathology of AN and the possession of negativebeliefs about experiencing and expressing emotions. This would make sense in thecontext of recent models of AN which suggest such a link between emotion and coreED symptomatology (e.g., Schmidt & Treasure, 2006). Interestingly, after controlling forage, anxiety, and depression, our measure of fatigue did not correlate significantly withany of the emotion processing variables. Associations between fatigue and either distresstolerance or self-silencing have not previously been explored. A previous study (Rimes &Chalder, 2010) did find fatigue to be significantly positively associated with BES scores.However, that study recruited larger samples who were matched for age, suggesting thatthe null findings in the current study may be due to reduced power imposed by smallersample sizes and the fact that we had to control for differences in age.

LimitationsThere are several limitations to the current study. Firstly, the design was cross-sectionaland therefore definitive conclusions regarding causality cannot be made. Second, our

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relatively small sample sizes limited the analyses that could be conducted and alsoplaced constraints on the power to detect differences. With larger sample sizes it ispossible that some of the group differences found for emotional processing variablesmay have remained even after covarying for age, anxiety, and depression. Third, thestudy employed self-report measures only, which are inherently biased towards sociallydesirable responding. Future research might benefit from including both self-report andexperimental or observer-rated measures of emotional processing. Fourth, our threesamples were not matched for age and as a result we had to control for this our analyses,which may have reduced power. Given the later onset of CFS to AN, it is difficult tomatch these groups for both age and illness duration, the latter of which was achievedin the current study. Finally, the conclusions drawn here may have been strengthenedhad we also included a measure of invalidating childhood environments in our protocol.This would have allowed for a more direct examination of the links between suchenvironments, later emotion processing difficulties, and the respective symptomatologyassociated with AN and CFS.

ImplicationsIn spite of these limitations, this study adds an important message to previous researchwhich has linked impaired emotional processing with deleterious health outcomes(Esterling, L’Abate, Murray, & Pennebaker, 1999). It provides tentative evidence sug-gestive of disturbed emotional processing strategies in two disabling, but very distinctillnesses which have previously been underexplored. Taken together, our findings doprovide some support for current explanatory models for both disorders (Schmidt &Treasure, 2006; Surawy et al., 1995) and there may be some diagnostic overlap in thespecific emotional processing difficulties experienced by people suffering with AN andCFS. By studying the two disorders simultaneously, it was possible to test the hypothesisthat the emotional processing difficulties would be more severe in the AN group thanthe CFS group, and this was confirmed. The results improve our understanding of thesimilarities and differences in emotional processing across disorders. This study designis consistent with a developing trend in psychopathological processes research to takea transdiagnostic perspective rather than looking at each disorder in isolation (e.g.,Mansell, Harvey, Watkins, & Shafran, 2009).

The tendency of both groups to suppress and avoid emotions, and to hold mal-adaptive beliefs about the consequences of emotional expression, suggests a target forintervention in both of these disorders. There is currently limited evidence to supportpsychological or pharmacological treatments for AN (National Institute for Health andClinical Excellence [NICE], 2004), and whilst CBT is suggested as a first-line interventionfor CFS (NICE, 2007), existing cognitive behavioural interventions are limited in theirconsideration of emotional processing. Recent advances in developing more tailored,empirically driven interventions which focus on the role of emotional functioning andits link with cognition and behaviour in AN and CFS may provide positive outcomes.For example, Corstorphine (2006) presents the rationale and outline for an innovativecognitive–emotional–behavioural therapy (CEBT) for EDs, including AN. It aims to enablepeople with EDs to understand the experience and expression of emotions, so thatthey can identify and challenge their beliefs and attend and respond to their emotionsadaptively. Such skills are intended to reduce the need for maladaptive emotional copingand compensatory behaviours. CEBT draws on a range of models and techniques,including CBT, dialectical behavioural therapy (Linehan, 1993), mindfulness approaches

322 David Hambrook et al.

and experiential work. The aim of CEBT is not to present an entirely original therapy, butto reconfigure existing material in a way that is useful in the treatment of EDs specifically.Similarly, a combination of CBT and mindfulness approaches which encourage healthyemotional processing are being developed and tested for use with people who haveCFS with some promising preliminary outcomes (e.g., Rimes & Wingrove, 2010; Surawy,Roberts, & Silver, 2005).

Future research might also consider exploring comparisons between AN, CFS, andother clinical conditions in order to clarify the specifity of the observed emotionalprocessing difficulties in these groups. It might be particularly interesting to examinecomparisons with people experiencing mood and anxiety disorders, and a physical illnessgroup such as fibromyalgia or rheumatoid arthritis. The role of comorbid depression andanxiety in influencing emotional processing has been highlighted by the current studyand it has demonstrated the importance of taking these variables into account whenresearching emotional processing.

AcknowledgementsThis work was supported by the NIHR Biomedical Research Centre for Mental Health, SouthLondon and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s CollegeLondon and by a Department of Health NIHR Programme Grant for Applied Research (Ref.number RP-PG-0606-1043; ARIADNE – Applied Research into Anorexia Nervosa and NotOtherwise Specified Eating Disorders). The views expressed herein are not necessarily thoseof DoH/NIHR. Anna Oldershaw was supported by a PhD studentship from the PsychiatryResearch Trust and Research into Eating Disorders (RIED).

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Received 4 August 2009; revised version received 11 June 2010