RESEARCH ARTICLE

An Experimental Investigation of Verbal Expression of Emotion inAnorexia and Bulimia NervosaHelen Davies*, Nicola Swan, Ulrike Schmidt & Kate Tchanturia

King’s College, Division of Psychological Medicine and Psychiatry, Section of Eating Disorders, Institute of Psychiatry, London, UK

Abstract

Objective: This study aims to use an experimental design to investigate verbal expression of emotion in anorexia nervosa (AN) and bu-limia nervosa (BN).Method: Forty-two patients with AN, 26 patients with BN and 34 healthy controls (HCs) were videoed talking about discrete emotionalexperiences. Talks were analysed using the Linguistic Inquiry and Word Count. Participants also completed the Emotion RegulationQuestionnaire (ERQ).Results: People with AN used fewer words when describing their emotional experiences and fewer positive affect words than HCs. Peoplewith BN were indistinguishable from HCs. Both ED groups had higher scores on the suppression subscale of the ERQ compared withHCs. Suppression was negatively correlated with negative verbal expression.Discussion: This study highlights differences between AN and BN in emotion expression. It supports a model of AN, which highlightsemotion inhibition as a maintaining factor of the illness. Methods of emotion regulation in EDs may contribute to increased negativemood and poorer social functioning. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords

anorexia nervosa; bulimia nervosa; emotion; expression; verbal

*Correspondence

Helen Davies, PhD, PO59, Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK. Tel: +44 (0) 207 848 0250; Fax: +44 (0) 207 848 0182.

Email: helen.davies@kcl.ac.uk

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1157

Introduction

Numerous studies have demonstrated the health benefits associ-ated with emotional expression, as well as the costs associatedwith its inhibition (Pennebaker, 1993; Fredrickson, 1998). Inhibi-tion of emotion has been described as a key feature of anorexianervosa (AN) (Bruch, 1973) and is thought to contribute to themaintenance of the disorder (Schmidt & Treasure, 2006). Onephenomenon, which potentially underpins inhibition of emotion,is alexithymia or the inability to communicate emotions, which ishighly present in people with AN (Miyake et al., 2009; Parling,Mortazavi & Ghaderi, 2010) and less so in bulimia nervosa(BN) (Schmidt, Jiwany & Treasure, 1993). Beliefs surroundingthe expression of emotions may also be implicated, as self-reportstudies have shown that individuals with AN and BN fear the con-sequences of expressing positive and negative emotion (Geller,Cockell, Hewitt, Goldner & Flett, 2000; Lawson, Emanuelli, Sines& Waller, 2008; Ioannou & Fox, 2009; Hambrook et al., 2011).

Models of treatment for eating disorders (ED) are beginning tofocus on emotional and interpersonal processes (Wonderlich,Mitchell, Peterson & Crow, 2001; Cooper, Wells & Todd, 2004;Schmidt & Treasure, 2006; Waller, Kennerley & Ohanian, 2007;Fairburn, Cooper & Shafran, 2008; Rieger et al., 2010; Wildes &Marcus, 2010). However, the precise nature of these processesand their contribution to the maintenance of the ED still requires

Eur. Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

empirical exploration in order to refine these treatments. In thiscontext, one important deficit in our knowledge concerns thebehavioural features that characterise interpersonal processes,for example, facial and verbal expressiveness in ED (Zuckeret al., 2007; Oldershaw et al., 2010a).

Recently, two studies have investigated facial emotion expres-sion in AN, finding an attenuation of positive (Soussignan, Jiang,Rigaud, Royet & Schaal, 2010) and negative affect (Davies,Schmidt, Stahl & Tchanturia, 2010). The purpose of the presentstudy is to extend the research on emotion expression in ED tothe domain of verbal expression and investigate this in an ecolog-ically meaningful way.

The study of verbal expression is significant, as language is thecurrency of most human social processes—we use words to conveyour emotions and thoughts and to understand the world (Chung &Pennebaker, 2007). Furthermore, translating our impulses and needsinto verbal language is important in helping to get our emotionalneeds met (Buhl, 2002); particularly, being able to convey basicemotional needs in the therapeutic setting is very important.

In addition to the self-report literature highlighting alexithymiain ED (e.g. Schmidt et al., 1993; Miyake et al., 2009; Parling et al.,2010), experimental studies using autobiographical recall testsprovide some insight into verbal expression of emotional experi-ences in ED. For example, ED patients recall more general mem-ories than healthy controls (HCs) (Dalgleish et al., 2003). This

1The DASS-21 is a short form of the 42-item measure. Therefore, when the final

score for each subscale is calculated, it is multiplied by 2.

Verbal Expression in Eating Disorders H. Davies et al.

pattern has been observed for both positive and negative cues andincreases with illness duration (Nandrino, Doba, Lesne, Christophe& Pezard, 2006). Additionally, the autobiographical speech of peoplewith AN is characterised by negative emotional perseveration with re-duced positive speech (Doba et al., 2007).

Studies in ED have also explored emotion word use in writtensamples (Lyons, Mehl & Pennebaker, 2006; Wolf, Sedway, Bulikand Kordy, 2007; Oldershaw, Hambrook, Tchanturia, Treasure& Schmidt, 2010b). For example, Wolf et al. (2007) used the Lin-guistic Inquiry and Word Count (LIWC) (Pennebaker, Francis &Booth, 2001) to explore the content of therapeutic essays writtenby AN inpatients. LIWC analyses showed that AN inpatients usedmore self-related words and negative emotion words and lesspositive emotion words than a student HC and recovering ANgroup (who scored in between the former two groups).

To date, linguistic studies of emotion have used self-reports orfocussed on specificity of autobiographical recall or on writtentext. Furthermore, the literature is limited in terms of experimen-tal studies with BN patients. Given that this group have demon-strated higher levels of alexithymia compared with HCs (usingself-report methods) (Schmidt et al., 1993), it will be beneficialto investigate verbal expression of emotion in this group.

The aim of the current study is to use a novel paradigm toexplore verbal expression of discrete emotions in people withAN and BN and HCs to address differences between groups asparticipants recount a happy, sad and angry experience in realtime in a pseudo-social environment (speaking to a camera).Strategies of emotion regulation employed by each group willbe investigated to see how these relate to emotional verbalexpression.

Hypotheses

Based on previous studies, our first hypothesis was that peoplewith AN would use fewer words than people with BN andHCs to describe emotional experiences with relatively fewerpositive but more negative emotion words, as measured bythe LIWC. As there are fewer data relating to verbal expressionin BN, our investigation had an explorative character for thisgroup. However, because alexithymia is not as severe in peoplewith BN compared with AN, we expected total word count(TWC) and relative use of positive and negative emotionwords to be less altered in people with BN than people withAN compared with HCs. Finally, it was expected that aberrantemotion regulation strategies would relate to more impairedverbal expression.

Method

Participants

One hundred and two participants took part in this study (AN=42, BN= 27, HCs = 34). Data from one BN participant had tobe removed as data recording was corrupted. AN and BN partici-pants were recruited from the South London and MaudsleyNational Health Service Foundation Trust Eating Disorders Ser-vice (inpatient and outpatient units) and had to fulfil a Diagnosticand Statistical Manual (DSM-IV) (APA, 1994) diagnosis for anED. Patients responded to posters put up in the units, and

Eur.

inpatients were also asked at their initial assessment on the wardif they would like to take part. This explains why there are moreAN than BN participants.

To meet the criteria for AN or BN, participants had to be diag-nosed as meeting the DSM-IV criteria for AN or BN (APA, 1994)either by a clinician or through the use of the Eating Disorder Ex-amination (EDE) (Fairburn and Cooper, 1993).

Inclusion criteria for HCs included a body mass index (BMI) ofbetween 19 and 25, no personal or family history of psychiatric ill-ness and DSM-IV Axis I disorder (including ED). HC participantswere recruited via advertisements in the local community andfrom university students and employees at King’s CollegeLondon.

Exclusion criteria for all groups included poor literacy, nonflu-ent English and a history of head injury or neurological disease.

Ethical approval was gained through the Oxfordshire Rec NHSethics committee (ref. 08/H0606/58). All participants gave writ-ten, informed consent to take part.

Measures and procedure

Demographic and clinical measures

The Structured Clinical Interview for DSM disorders (First,Spitzer, Gibbon & Williams, 2002) detected current and lifetimecomorbidity of psychiatric pathology and was used as a screeningtool in HCs.

All participants were weighed at assessment and had theirheight recorded in order to obtain BMI. Duration of illness (forpatients), medication status and age were also recorded. EstimatedIQ was also assessed using the National Adult Reading Test(NART) (Nelson and Willison, 1991). The following self-reportmeasures were completed by all participants.

Eating Disorder Examination Questionnaire (Fairburn &Beglin, 1994)

This 36-item self-report questionnaire is a measure of psycho-pathological and behavioural indicators of disordered eating. It isderived from and scored in the same way as the EDE interviewschedule (Fairburn and Cooper, 1993). The EDE Questionnaire(EDE-Q) has acceptable case detection and concurrent validityin community samples. In the current study, the overall Cronbachalpha coefficient was .93. To reduce the number of dependentvariables, the global score was used as the outcome measure inthis study.

Depression, Anxiety and Stress Scale (Lovibond &Lovibond, 1995)

This is a 21-item measure with seven items in each of the threesubscales.1 Each subscale has a maximum score of 21. The De-pression, Anxiety and Stress Scale-21 (DASS-21) uses a three-point scale, which ranges from 0, did not apply to me over thepast week, to 2, applied to me very much or most of the time overthe past week. HC participants were excluded if they scored abovethe normal range of 9 for depression and 7 for anxiety. Only

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H. Davies et al. Verbal Expression in Eating Disorders

depression and anxiety scores were included in the current studyas these are comorbid factors in ED. Internal consistency for thecurrent study using Cronbach alpha coefficient was .87.

Emotion Regulation Questionnaire (Gross & John, 2003)

The ERQ measures two emotion regulation strategies: reap-praisal and suppression. Cognitive reappraisal involves changingthe way one thinks about a potentially emotion-eliciting event(e.g. ‘when I am faced with a stressful situation, I make myselfthink about it in a way that helps me stay calm’). Suppressioninvolves changing the way one responds behaviourally to an emo-tion-eliciting event (e.g. ‘I control my emotions by not expressingthem’). Experimental findings demonstrate that reappraisal has ahealthier profile of short-term affective, cognitive and social con-sequences than suppression. The maximum score on the reap-praisal subscale is 42 and for the suppression subscale 28. Highinternal consistency for reappraisal (.79) and suppression (.73)has been reported (Gross & John, 2003), and in the current study,Cronbach alpha coefficient was .75.

Experimental task—emotion talk

This task investigates verbal, self generated, emotion expressionwhen participants were asked to talk about emotional experiences.The participant responds to prompts via the computer askingthem to talk about something neutral ‘please tell me what theweather has been like this week’, positive ‘please tell me aboutsomething which has made you feel happy’ and negative ‘pleasetell me about something which has made you feel sad’ and ‘pleasetell me about something which has made you feel angry’. The ex-act instructions given to participants were

We would like to hear you talking about different feelings youexperience and this will involve asking you a few questions.Because we think it is easier for people to do this when the re-searcher isn’t in the room, I shall leave whilst you are doing thetask. However, to help make your experience of talking aboutfeelings more realistic, imagine you are talking to me whenyou talk to the camera.Each question will appear separately on the computer screenand once you have given your verbal response to the question,hit the space bar for the next question to appear. As a guide tohow long to make your response, we suggest about a minute.You are not being judged on what you say and I’d like you tofeel as comfortable as you can.Before you start, do you haveany questions? Do you feel comfortable?

In between each of the individual talks, the participant was re-quired to undertake a number task (e.g. count backwards in oddnumbers from 30) serving as an interference measure. The partic-ipant was knowingly recorded throughout the task, via a smallvideo camera attached to the top of the computer, and their talkswere then transcribed.

Transcripts of participants’ verbal responses were analysed usingthe LIWC (Pennebaker, Booth & Francis, 2007a). The LIWC is a textanalysis computer programme designed to assess various componentsof verbal and written language (e.g. emotional, cognitive, structuralcomponents). On the basis of the hypotheses of this study, the catego-ries chosen for analysis (and which are used as the outcome variables)

Eur. Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

were TWC; percentage of positive words (e.g. happy, nice, good) andpercentage of negative words (e.g. hate, worthless). With the excep-tion of TWC, all LIWC output is expressed as a percentage of theTWC; this is to control for the number of words. On average, theLIWC2007 captures 91.5% of words used in transcribed speech (Pen-nebaker, Chung, Ireland, Gonzales & Booth, 2007b). The constructvalidity of the LIWC as ameasure of emotion expression has been val-idated for both the written and verbal expression of emotion (Kahn,Tobin, Massey & Anderson, 2007).

Data analysis

All analyses were carried out using SPSS version 15 (Chicago,Illinois, USA). Repeated measures analyses of variance (ANOVA)were used to assess verbal expression for the main effect of talk typeand diagnoses. For significant interactions, planned pair-wise testswere performed for between-group comparisons. ANOVA wasused for the ERQ and certain demographic and clinical characteris-tics with means and standard deviations presented in Table 1.Spearman’s rank correlation coefficient was used to investigatethe relationships between task performance and demographicsand clinical symptomatology. p-values were adjusted for multiplecomparison using Bonferroni correction (p= .05/5) and set at .01.Correlations were conducted separately for each group.

Results

Demographic and clinical characteristics

As shown in Table 1, there was no significant difference in agebetween groups, but there was a significant difference betweengroups in IQ (NART), with the AN group having a significantlylower score than the HCs. As expected, clinical characteristicsdiffered significantly between the ED groups and the HC group(except BMI, which was significantly lower for AN participantscompared with the BN group, and anxiety measured with theDASS, which was significantly higher in the AN group). Forty-two per cent of the AN group and 31% of the BN group weretaking antidepressant medication.

Experimental paradigm results

Table 2 presents means and standard deviations from the resultsof each talk. Table 3 illustrates an example of each emotion talkfrom each of the three groups (selected as the first talk transcribedfrom each group participant).

A 3 (AN versus BN versus HCs)� 4 (neutral, happy, sad,angry) repeated measures ANOVA was conducted separately forTWC, percentage of positive words and percentage of negativewords with group as a between-subjects factor and talk type as awithin-subjects factor. Given the linguistic nature of the task,IQ, as measured by the NART, was included in the analysis as acovariate. Depression, as measured by the DASS-21, was alsoincluded as a covariate.

For TWC, there was a significant main effect for talk type [F(3,297) = 66.62, p< .001, partial e2 = .40] and for group [F(1,99) = 3.21, p< .001, partial e2 = .06]. There was a significant talktype� group interaction [F(6, 297) = 3.5, p< .01, partiale2 = .06]. Planned post hoc comparisons showed that there was asignificant difference in TWC in the sad talk between the ANand HC groups [mean difference 42.2, 95% confidence interval

Table 1 Demographic, clinical and emotion questionnaire data for anorexia nervosa (AN), bulimia nervosa (BN) and healthy control (HC)

AN (n= 42) BN (n= 26) HC (n= 34) Test statistic p Post hoc

Age† 25.6 (6.5) 25.9 (8.0) 26.3 (8.4) F= .074 .92 NS

NART{ 110.0 (14) 112.0 (8) 113.0 (7.7) x2 = 9.9 .007 AN<HC**

BMI† 14.8 (1.8) 21.5 (2.0) 21.6 (1.4) F= 126.92 .001 AN<BN**

AN<HC**

Length of

illness†10.0 (6.1) 7.8 (5.6) Not applicable F= 2.02 .15 NS

EDE-Q global{ 3.7 (1.7) 4.0 (1.1) 0.6 (0.7) x2 = 53.72 .001 AN>HC**

BN>HC**

DASS anxiety† 21.0 (10.7) 15.9 (8.1) 1.8 (2.4) F= 48.69 .001 AN>BN*

AN>HC** BN>HC**

DASS depression{ 27.1 (11) 22.2 (13.4) 1.9 (2.5) x2 = 58.70 .001 AN>HC**

BN>HC**

ERQ reappraisal† 25.6 (8.3) 24.3 (9.5) 29.1 (6.0) F= 3.68 .03 AN<HC**

Suppression† 16.1 (5.3) 14.5 (5.0) 10.8 (5.0) F= 9.92 .001 AN>HC** BN>HC*

Mean scores with standard deviations are presented. Median and interquartile range is presented for the nonparametric data.†Age, body mass index (BMI), length of illness, Depression, Anxiety and Stress Scale (DASS) and Emotion Regulation Questionnaire (ERQ) data met assumptions of homo-

geneity; therefore, ANOVAs were used.{National Adult Reading Test (NART), DASS depression, Eating Disorder Examination Questionnaire (EDE-Q) did not meet assumptions of homogeneity; therefore, non-

parametric Kruskal–Wallis test was employed with post hoc Mann–Whitney U test.

*p<.01

**p< .001.

Verbal Expression in Eating Disorders H. Davies et al.

(CI) 14.6 to 69.7, p= .003] and a significant difference in the an-gry talk between the AN and HC groups (mean difference 43.9,95% CI 10.8 to 76.9, p= .01). There were no significant differ-ences in TWC between the BN and HC groups or between theBN and AN groups. NART-estimated IQ did not have a signifi-cant impact on the main outcome [F(1, 95) = 1.7, p= .83] neitherdid depression [F(1, 91) = .009, p= .92], and the results remainedsignificant, p= .05 and p= .02, respectively.

For percentage of positive words, there was a significant main ef-fect for talk type [F(3, 297) = 44.6, p< .001 partial e2 = .31] and forgroup [F(1, 99) = 6.1, p= .003, partial e2 = 0.1]. There was also asignificant talk type� group interaction [F(6, 297)= 2.2, p= .03,partial e2 = .04]. Planned post hoc comparisons showed that therewas a significant difference in positive word use in the happy talkbetween the AN and HC groups (mean difference 2.7, CI 0.8 to4.6, p= .006) and a significant difference in the sad talk betweenthe AN and HC groups (mean difference 1.1, 95% CI 0.2 to 2.0,p= .01). There was a significant difference between the BN andAN groups in the sad talk with the BN group using more positivewords (mean difference 0.8, 95% CI �1.3 to 0.9, p= .01). Therewere no significant differences between the BN and HC group.When adding the covariates NART and depression to the model,NART-estimated IQ did not have a significant impact on the mainoutcome [F(1, 95) = 0.23, p= .59], and depression [F(1, 91) = 1.1,p= .28] also had no significant impact on the regression. Theresults remained significant, p= .03 and p= .006, respectively.

For percentage of negative words, there was a significant maineffect for talk type [F(3, 297)=36.89, p< .001, partial e2 = .30], butthere was no main effect for group [F(1, 99)= .80, p= .45], andneither was there a talk type� group interaction [F(6, 297)= .55,p= .78]. As there was not a significant difference for group ora significant interaction, no further planned post hoc tests werecarried out.

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Emotion Regulation Questionnaire

On the ERQ, there was a significant difference on the reappraisalsubscale [F(2, 95) = 3.67, p= .02] with post hoc tests showing thatthe HC group scored significantly higher than the AN group(p= .05, d= 0.7). On the suppression subscale, there was a signif-icant main effect [F(2, 95) = 9.92, p= .001], and post hoc testsshowed that AN and BN participants scored significantly higherthan HC participants (p= .001, d= 1.4 and p= .019, d= 0.8, re-spectively), but there was no significant difference between theAN and BN groups.

Medication

The analyses for the experimental outcomes were run comparingmedicated with unmedicated participants in each clinical group toexplore the effects of antidepressants based on previous findings(Harmer, Shelley, Cowen & Goodwin, 2004). In the AN group, 19people were taking antidepressants. No significant differences werefound between medicated and unmedicated participants (p= .07 top= .46). In the BN group, eight people were taking antidepressants.No significant differences were found between medicated and un-medicated participants (p= .07 to p= .76).

Correlational analysis

Relationships between demographic and clinicalvariables and emotion talk variables

In order to explore relationships between the LIWC experimentalvariables and demographic and clinical measures, correlational anal-yses were undertaken. No significant correlations were found be-tween age, IQ and emotion talk variables across groups. There wereno significant relationships between clinical variables (depression,anxiety, BMI, length of illness and EDE-Q) with TWC or with posi-tive word use in any of the four talks. However, a significant negative

Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Table

2Re

sults

foreach

emotiontalk

foran

orexia

nervosa(AN),bu

limia

nervosa(BN)an

dhe

althycontrol(HC)grou

ps

Neutraltalk

Happy

talk

Sadtalk

Angrytalk

AN

(n=42)

BN

(n=26)

HC

(n=34)

Post

hoc

AN

(n=42)

BN

(n=26)

HC

(n=34)

Posthoc

AN

(n=42)

BN

(n=26)

HC

(n=34)

Posthoc

AN

(n=42)

BN

(n=26)

HC

(n=34)

Posthoc

Totalword

count

22.4(24.8)

20.1(14.3)

30.1(23.4)

NS

46.9(45.2)

59.0(47.0)

59.4(45.6)

NS

51.1(49.4)

75.2(48.6)

93.3(74.2)

AN<HC**

64.1(70.5)

84.2(57.3)

107.9(83.3)

AN<HC**

%po

sitive

words

4.6(5.5)

10.4(15.3)

8.3(5.7)

NS

5.4(4.2)

7.0(4.3)

8.1(4.0)

AN<HC**

0.9

(1.6)

1.8

(1.7)

2.1

(2.3)

AN<HC**

AN<BN**

1.2(1.9)

1.4(1.6)

2.0(2.0)

NS

%negative

words

2.3(6.1)

0.8(2.8)

2.1(4.1)

NS

0.2(0.6)

0.4(1.0)

0.1(0.4)

NS

5.7

(5.1)

4.6

(5.2)

4.8

(3.0)

NS

4.8(4.0)

4.8(3.6)

4.4(2.8)

NS

Meanspresentedwithstandard

deviationsin

brackets;Coh

en’sd=

**(d

≤0.8)

medium

effect;NS=not

significant.

H. Davies et al. Verbal Expression in Eating Disorders

Eur. Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Assoc

iation.

correlation was shown in the BN group between anxiety and negativewords in the sad talk (rs =�0.52, p= .01).

Relationships between the emotion regulation scale andemotion talk variables

There were no significant correlations between TWC or posi-tive word use in any of the talks and the emotion regulation sub-scales. There was, however, a significant positive correlationbetween negative word use and reappraisal in AN participantsfor the sad talk (rs = 0.45, p< .001), suggesting that reappraisalof emotion is linked to higher negative word use in AN partici-pants. There was also a significant negative correlation betweennegative word use and suppression in BN participants for the an-gry talk (rs =�0.49, p< .001), which potentially suggests thathigher suppression leads to less negative word use in BN partici-pants; however, given the cross-sectional design of this study, di-rection of causality can only be inferred.

Discussion

Main findings

This study used a quantitative text analysis to assess verbal ex-pression of discrete emotional experiences in people with AN andBN. It was predicted that the AN group would be more inhibitedin their verbal expression of emotion than the BN group, whichwas the case. The AN group showed attenuated verbal expressionand used less positive words compared with HCs. It was predictedthat the BN group would show some impairment in expression ofemotion; however, this was not the case, and the BN group wereindistinguishable from HCs in terms of TWC and relative use ofpositive words. Both ED groups used a similar number of negativewords to HCs but reported using suppression strategies toregulate their emotion compared with HCs who reported usingreappraisal methods. Furthermore, the ED group reported experi-encing high levels of negative affect compared with HCs, with ANexperiencing more anxiety than BN participants. Clinical severitydid not relate to the main findings in the AN group; however,anxiety related to negative affect when participants were talkingabout something sad in the BN group.

Differences between anorexia and bulimia nervosa inverbal expression

A question arising from these results is, What are the reasons forthe markedly reduced word count in AN? One possibility is that thismay be due to impaired verbal fluency, secondary to impaired cogni-tion in the underweight state. However, this seems unlikely as previ-ous studies have shown that AN participants do not differ from HCsin tests of verbal fluency (e.g. Godley, Tchanturia, MacLeod &Schmidt, 2001; Tchanturia et al., 2004). Moreover, BMI did not havea relationship with verbal expression in this study.

A second possibility is that AN participants talked less because oftheir difficulties accessing specific emotional memories (Dalgleishet al., 2003; Nandrino et al., 2006) However, in the study by Dalgleishet al. (2003), the participants were a mixture of AN and BN indivi-duals, and there were no differences between the two groups as bothdemonstrated lack of specificity in autobiographical memory.

A third potential explanation is that the reduced word count in ANmay have been a defensivemanoeuvre as participants were knowingly

Table 3 Examples of emotion talks for anorexia nervosa (AN), bulimia nervosa (BN) and healthy control (HC) groups

AN BN HC

Happy: Happy: Happy:

Going out with my boyfriend on Monday went to the

eye clinic and then went for a coffee.

Finding out that I’d passed my degree, that made me

very happy. Getting back with my boyfriend, (laugh),

no, umm, coming home from uni, finding out I’d got

umm, finally got my placement sorted and it’s a good

placement and I think it’s going to help me with my

future and stuff so that’s made me feel happy.

Something that has made me feel happy is um yesterday

getting my hair done made me feel very happy but

more than that um seeing my friends after failing my

exam yesterday made me feel really happy um

something else that has made me feel happy is

hanging around with my brother and my sister the

other weekend having family dinner that always

makes me feel happy.

Sad: Sad: Sad:

Recently I think um seeing um seeing my mum quite

sad about me coming in here for treatment because

it has upset her quite a lot and it’s um quite

upsetting to think that I’ve upset my mum and made

her worry about something.

Um, something that’s made me feel sad was um I had

to cancel seeing one of my friends last night because

it got to late afternoon and I felt really uncomfortable

about going out and eating and drinking in public

and I was really sad to let him down and also I wasn’t

going to do something I was looking forward to for a

long time.

Something that has made me feel sad was when my dog

died, um, and I was at Uni at the time and something

else that makes me feel sad and something else that

has made me feel sad was failing my exams is because

I felt really disappointed as well as sad and its like a

massive let down which deflates you so knocking my

confidence makes me feel sad I suppose.

Angry: Angry: Angry:

Um things that make me angry are rrlike when people

lie um or um I don’t know try to lie him or when I felt

something’s been really unfair by someone and they’ve

been horrible I don’t like it when people are horrible

to each other not unnecessarily it’s nasty.

Made me feel angry, angry, umm, the only time I really

feel angry is when people let me down, umm, people

say they say they are going to help me and they don’t

or they say they’re going to come round and they

don’t or go out and they don’t, apart from that I

don’t really get angry.

Something that’s made me feel angry I don’t tend to get

angry I get frustrated with things I can’t do anything

about so I wouldn’t say I feel angry I suppose I get

things that grind my gears are when people don’t

listen to each other especially if people don’t listen to

what you say it makes me very angry because you

especially if it’s something you think and feel wouldn’t

say it unless you mean it but I suppose it’s more

frustrating than it is anger really.

Verbal Expression in Eating Disorders H. Davies et al.

being recorded and negative beliefs about expressing emotion toothers could have curtailed their verbal expression (e.g. Hambrooket al., 2011). Interestingly, relative to their TWC, AN participantsused a similar number of negative emotion words as the HCs, whichcontrasts with the findings ofWolf et al. (2007) who, in a study asses-sing patterns of language in journal articles, found that the AN groupused more negative words than HCs. The reason for this may be thatparticipants found it safer to express negative emotions in writtenform rather than speaking in front of a camera or may be the resultof other differences such as study populations, design and power dif-ferences. For example, in the study by Wolf et al. (2007), the ANgroup were inpatients, seven of which were AN, and four were diag-nosed with ED not otherwise specified. In our study, 29% of the ANgroup were outpatients; however, they did not differ in their fre-quency of negative word use compared with the inpatients. There-fore, the presence of the camera could have been a factor inattenuated expression in the AN group.

The impact of emotion suppression on verbal expression

Intriguingly, in the present study, both AN and BN patientsreported greater use of emotion suppression (on the ERQ) com-pared with HCs. This suggests that AN and BN patients use ratherdifferent suppression strategies, perhaps on the basis of personal-ity differences (e.g. Diaz-Marsa, Carrasco & Saiz, 2000) or thatanxiety, which was significantly higher in the AN group, impactedgreater on their verbal expression.

Eur.

That both groups use suppression strategies to regulate theirexpression and yet experience high levels of negative affect (asmeasured by the DASS) is significant and fits with a model ofemotion regulation proposed by Gross and John (2003). Thismodel suggests that cognitive reappraisal is a regulation strategy,which occurs before emotions have been fully generated and thusreduces their experience. Suppression, however, is effective inchanging only the expression but not the experience of negativeemotion. Outcomes from the correlational analysis in the presentstudy support this model, as it showed that higher negative worduse in the AN group was associated with reappraisal; however,suppression was associated with fewer words.

Limitations

As this study had an exploratory character, it was not possible toundertake a power calculation using outcomes from prior EDsstudies. The sample size was slightly small, and thus the likelihoodof making type II errors is increased. It would be advantageous forfuture studies to increase sample sizes.

Asking participants to talk about the weather was included as a‘neutral condition’. However, talking about the weather evoked asimilar percentage of positive words as talking about somethinghappy, that is, there was a similar percentage of positive wordsused in both conditions. A verbal fluency task, such as thatdeveloped by Lezak (1976), would be a more appropriate neutralmeasure in future.

Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

H. Davies et al. Verbal Expression in Eating Disorders

The talks were kept in the same order for all participants tolimit carry over effects from negative to positive talk. However,the results show that the number of words used increased as thetalks proceeded. This may highlight a practice effect; however, itcould be due to valence of the talk (Habermas, Meier & Mukhtar,2009). In future, randomisation or counterbalancing of the talkswould be advised.

Speaking to a camera rather than using a ‘real’ social situationmay be seen as a limitation of the study as it is not a natural for-mat in which to recount emotional experiences. However, thismethod was chosen to reduce the number of dependent variables,which could arise from a ‘real’ social situation.

Other limitations are that only background levels of anxietyand depression were measured and that current mood state atthe time of testing was not assessed. Measures of positive affector anger were also not included. Moreover, the LIWC is a basicmeasure of the valence of emotion expression and does not allowfor a more nuanced assessment of the type and intensity of theemotions expressed. For example, HCs may have had a broaderrepertoire of ‘negative’ words such as frustrated, annoyed, irri-tated and angry—the BN group may only have used greater inten-sity words, for example, angry. It is possible that there werebetween group differences in these features.

Future studies could explore the impact of social context onemotion expression, for example, through the use of social inter-action paradigms or imagined presence of others.

The strength of this study is that it used an ecological andquantitative approach to directly investigate verbal expression ofemotion in people with ED, which to date has relied much onself-report questionnaires.

Eur. Eat. Disorders Rev. (2011)© 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Conclusion

Poor treatment outcomes in AN have been noted in recent guide-lines [National Institute of Clinical Excellence (NICE), 2004] andsystematic reviews (e.g. Steinhausen, 2002; Bulik, Berkman,Brownley, Sedway & Lohr, 2007; Lock & Fitzpatrick, 2009). Amodel by Schmidt and Treasure (2006) proposed that intraper-sonal and interpersonal problems are maintaining factors in AN.The findings from this experimental study support this modelby showing that verbal expression in general and expression ofpositive emotion in particular are limited in people with AN.These limitations make engagement in talking therapies difficultas they require the ability to access and talk about thoughts andfeelings. In addition, both AN and BN groups use suppressionstrategies to regulate emotion and should be helped to learn touse reappraisal strategies, which are associated with healthierpatterns of expression, social functioning and well-being(Gross & John, 2003).

Acknowledgements

This article presents independent research commissioned bythe NIHR Biomedical Research Centre for Mental Health,South London and Maudsley NHS Foundation Trust andInstitute of Psychiatry, King’s College London, and theNational Institute for Health Research (NIHR) under itsProgramme Grants scheme (RP-PG-0606-1043). The viewsexpressed in this publication are those of the author(s) andnot necessarily those of the NHS, the NIHR or the Depart-ment of Health. We would like to thank BIAL foundation(grant number 57/10).

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