آیا تنظیم احساسات پنهان در اختلال پرخوری افراطی اهمیت دارد؟

Abstract Objective To examine if implicit emotion regulation (occurring outside of awareness) is related to binge eating disorder (BED) symptomatology and explicit emotion regulation (occurring within awareness), and can be altered via intervention. Methods Implicit emotion regulation was assessed via the Emotion Conflict Task (ECT) among a group of adults with BED. Study 1 correlated BED symptomatology and explicit emotion regulation with ECT performance at baseline (BL) and after receiving BED treatment (PT). Study 2 generated effect sizes comparing ECT performance at BL and PT with healthy (non-eating disordered) controls (HC). Results Study 1 yielded significant correlations (p < .05) between both BED symptomatology and explicit emotion regulation with ECT performance. Study 2 found that compared to BL ECT performance, PT shifted (d = − .27), closer to HC. Preliminary results suggest a) BED symptomatology and explicit emotion regulation are associated with ECT performance, and b) PT ECT performance normalized after BED treatment. Conclusions Implicit emotion regulation may be a BED treatment mechanism because psychotherapy, directly or indirectly, decreased sensitivity to implicit emotional conflict. Further understanding implicit emotion regulation may refine conceptualizations and effective BED treatments.

1. Introduction Emotion regulation can be defined as goal directed processes that function to influence the intensity, duration, and type of emotion experienced (Gross & Thompson, 2007). Such emotion regulation can occur both explicitly and implicitly (Bargh and Williams, 2007, Gross and Thompson, 2007 and Mauss et al., 2006). Explicit emotion regulation includes processes which demand conscious effort for initiation and require some form of monitoring throughout implementation (Gyurak, Gross, & Etkin, 2011). In contrast, implicit emotion regulation (IER) is a process evoked automatically by a stimulus, completed without monitoring, and occurs without awareness and insight. There has been substantial interest in explicit emotion regulation and IER within psychiatric research. Similar to cognitive control (Miller & Cohen, 2001), effective explicit emotion regulation requires an ability to detect emotional content and subsequently adjust action (i.e., approach or avoid the stimulus) accordingly (Lang and Davis, 2006 and LeDoux, 2000). Traditional psychological interventions have targeted both cognitive regulation strategies, such as in thought challenging tasks in Cognitive Behavioral Therapy (Persons, 1989), and explicit emotion regulation strategies, such as in distress tolerance skills in Dialectical Behavior Therapy (Linehan, 1993a and Linehan, 1993b). Preliminary data suggest that IER may be related to psychiatric functioning in individuals with Generalized Anxiety Disorder (GAD) and Depression (Etkin et al., 2010 and Etkin and Schatzberg, 2011), yet IER remains unexplored among many other psychiatric conditions. If IER is indeed related to psychiatric conditions, then perhaps interventions can be developed that purposefully target IER, potentially improving the overall efficacy of current treatment approaches which solely target cognitive and explicit emotion regulation strategies. In regards to eating disorders (ED) specifically, there similarly has been an exponential research growth on the role of emotion regulation in binge eating (Gianini et al., 2013 and Whiteside et al., 2007). Such research consistently links greater difficulties with explicit emotion regulation, including deficits in emotion recognition, among individuals with ED compared to those without ( Brockmeyer et al., 2014, Gilboa-Schechtman et al., 2006, Harrison et al., 2010, Haynos and Fruzzetti, 2011, Oldershaw, 2009 and Racine and Wildes, 2013). Indeed, compared to individuals without binge eating disorder (BED), those with BED report both increased experiences of negative affect and lowered ability to both identify and describe their emotional states ( Zeeck, Stelzer, Linster, Joos, & Hartmann, 2010). In addition, extensive data document associations specifically between explicit emotion regulation and binge eating ( Lilenfeld et al., 2006, Whiteside et al., 2007 and Womble et al., 2001). Limited research on IER in ED has been conducted within anorexia nervosa (AN) or bulimia nervosa (BN). For example, compared to healthy controls, women with AN or BN demonstrated more attentional biases (yielding a large effect size) to a Stroop Task presentation of angry faces ( Stroop, 1935). To date, it is unknown whether IER processes differ between individuals with and without BED. Similarly, no data exist regarding the existence, strength, and direction of associations between IER and specific BED symptomatology (i.e., binge eating frequency, weight and shape concerns) within a BED population, either before or after a BED manualized treatment. Such knowledge would be useful, for example, by potentially refining current theoretical models of binge eating, such as Escape Theory ( Heatherton & Baumeister, 1991) and/or the Affect Regulation Model ( Polivy and Herman, 1993 and Wiser and Telch, 1999). Escape Theory proposes that binge eating is used as an attempt to escape self-awareness. The Affect Regulation Model conceptualizes binge eating as an attempt to alter painful emotional states, maintained via negative reinforcement through provision of temporary relief from aversive emotions. Moreover, such knowledge may indicate if IER is indeed related to binge eating and can be altered via intervention. Thus, it would serve as an important yet currently overlooked intervention target which might ultimately improve treatment outcomes. One of the few assessments of IER is the use of a behavioral task called the Emotional Conflict Task (ECT; 28). The ECT has been validated for use in healthy control and psychiatric populations (Etkin et al., 2006, Etkin and Schatzberg, 2011 and Etkin et al., 2010) and is the only emotion regulation task now supported by lesion evidence (Algom, Chajut, & Lev, 2004). The ECT is a variant of the classic Stroop paradigm (Haynos & Fruzzetti, 2011) in which words are presented in colors either congruent with the word itself (red in red ink) or incongruent with the word (red in blue ink) to provide a measure of cognitive, rather than emotional, conflict (MacLeod, 1991). In the ECT, emotional conflict arises from incompatibility between the task-relevant and task-irrelevant emotional dimensions of a stimulus, hence representing an emotional analog to the color-word Stroop task (First, Spitzer, Gibbon, & Williams, 2002). Specifically, participants in the ECT are presented with photographs of emotional faces (fearful or happy) with a word (“fear” or “happy”) written over them. The word written on the photo either matches the facial expression (e.g., in a no-conflict trial the happy face has the word “happy”), or is incongruent with it (e.g., in a conflict trial the happy face has the word “fear”). The task is for participants to indicate whether the facial expression is happy or fearful by pressing a button, and not to respond based upon the overlaying word. Implicit emotion regulation is evidenced by trial-to-trial changes in one's ability to respond to conflicting sequential presentations. The emotion regulation process is implicit because individuals are unaware of the modulation of the emotional control elicited by the stimuli on their behavioral response (Maier & di Pellegrino, 2012). Relatedly, despite careful probing, participants do not report any awareness of the task's key processes. To date, ECT studies in clinical populations showed slowed ECT performance. For example, individuals with GAD and comorbid GAD and depression demonstrate slower ECT performance compared to healthy controls and depression-only patients (Etkin and Schatzberg, 2011 and Etkin et al., 2010). Although exaggerated ECT performance has not yet been demonstrated by a particular clinical population, it is nonetheless plausible and would indicate abnormal IER (i.e., prolonged heightened sensitivity; inability to down-regulate). Indeed, assessing IER may provide additional detail regarding symptom manifestation and differentiation from healthy controls. The present study sought to address these gaps in the literature and investigate the nature of ECT measured IER within BED. Specifically, a two part study was conducted to explore both IER's associations with explicit emotion regulation and BED symptomatology, and potential differences in IER between adults with and without BED.

5. Conclusion In summary, there are several benefits to incorporating IER measurement in BED research. First, and as these results demonstrate, IER is linked to BED symptomatology and explicit emotion regulation both before and after BED treatment. As such, IER may facilitate differentiation of those with BED from healthy controls. In addition, IER changes may be the means by which BED improves in treatment because psychotherapy, directly or indirectly, influenced it. In addition, because IER in BED is currently understudied, it is important to better understand how it does or does not play a role in binge eating (in the way that research has demonstrated explicit emotion regulation does Brockmeyer et al., 2014, Whiteside et al., 2007 and Womble et al., 2001) and further elucidate its role in AN and BN (Davidson and Wright, 2002, Dobson and Dozois, 2004, Fairburn et al., 1991 and Miller and Cohen, 2001). Together, such data may potentially inform and refine existing and/or novel theories and interventions focusing on the role IER plays in the etiology and maintenance of binge eating, and ideally augment current rates of treatment response.