Emotional responding and distress tolerance in women at high vs. low risk for eating disorders in response to physical and cognitive stress

Eleni Iasonidou, Elena Constantinou, Nuno Ferreira, Maria Koushiou


Background: Disordered eating has been theorised to function as a maladaptive way of coping with negative affect. The current study aimed to comprehensively assess emotional responding and distress tolerance to a cognitive and a physical distress tolerance task using physiological (heart rate), self-report and behavioural measures (latency to quit task).

Methods: 56 women at high vs. 58 at low eating disorder risk completed the “Paced Auditory Serial Addition Task-Computerised” (PASAT-C) and the “Breath-holding Task” (BHT) and provided their affective ratings upon completion of the tasks. Heart rate was recorded during both tasks. Distress tolerance was assessed via a self-report measure, while latency to quit each task was used as a behavioural index of distress tolerance.

Results: Participants at high risk for eating disorders had higher heart rate during both tasks and reported significantly more unpleasantness and less control after the PASAT-C compared to the low-risk group. Shorter latency to quit the PASAT-C was evidenced in the high vs. low-risk group suggesting lower tolerance for cognitive distress. Breath-holding duration did not differ between the two groups.

Conclusions: Greater physiological and subjective arousal to distressing situations in high-risk individuals indicates a potential hypersensitivity to negative affect, possibly increasing eating disorder vulnerability. Potential implications for eating disorder prevention and management are discussed.


Eating disorder risk; Distress tolerance; Emotional responding; PASAT-C; BHT; Clinical Psychology.

Full Text:



Anestis, M. D., Selby, E. A., Fink, E. L., & Joiner, T. E. (2007). The multifaceted role of distress tolerance in dysregulated eating behaviors. International Journal of Eating Disorders, 40(8), 718-726. https://doi.org/10.1002/eat.20471

Beroš, K., Brajković, L., & Kopilaš, V. (2021). Psychological resilience and depression in women with anorexia nervosa. Mediterranean Journal of Clinical Psychology, 9(1). https://doi.org/10.6092/2282-1619/mjcp-2662

Biolcati, R., Mancini, G., Andrei, F., & Trombini, E. (2021). Trait emotional intelligence and eating problems in adults: associations with alexithymia and substance use. Mediterranean Journal of Clinical Psychology, 9(2), 1-16. https://doi.org/10.13129/2282-1619/mjcp-2983

Bradley, M. M., & Lang, P. J. (1994). Measuring emotion: the self-assessment manikin and the semantic differential. Journal of behavior therapy and experimental psychiatry, 25(1), 49-59. https://doi.org/10.1016/0005-7916(94)90063-9

Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour research and therapy, 35(1), 79-89. https://doi.org/10.1016/S0005-7967(96)00068-X

Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 24(2), 187-194. https://doi.org/10.1097/00006842-196203000-00009

Chen, E. Y., Matthews, L., Allen, C., Kuo, J. R., & Linehan, M. M. (2008). Dialectical behavior therapy for clients with binge‐eating disorder or bulimia nervosa and borderline personality disorder. International Journal of Eating Disorders, 41(6), 505-512. https://doi.org/10.1002/eat.20522

Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress tolerance in the eating disorders. Eating behaviors, 8(1), 91-97. https://doi.org/10.1016/j.eatbeh.2006.02.003

Critchley, H. D., Wiens, S., Rotshtein, P., Öhman, A., & Dolan, R. J. (2004). Neural systems supporting interoceptive awareness. Nature neuroscience, 7(2), 189. https://doi.org/10.1038/nn1176

Dapelo, M. M., Hart, S., Hale, C., Morris, R., Lynch, T. R., & Tchanturia, K. (2015). Facial expression of positive emotions in individuals with eating disorders. Psychiatry Research, 230(1), 70–77. https://doi.org/10.1016/j.psychres.2015.08.019

Daughters, S. B., Lejuez, C. W., Kahler, C. W., Strong, D. R., & Brown, R. A. (2005). Psychological distress tolerance and duration of most recent abstinence attempt among residential treatment- seeking substance abusers. Psychology of Addictive Behaviors, 19(2), 208. https://doi.org/10.1037/0893-164X.19.2.208

Davies, H., Schmidt, U., Stahl, D., & Tchanturia, K. (2011). Evoked facial emotional expression and emotional experience in people with anorexia nervosa. International Journal of Eating Disorders, 44(6), 531-539. https://doi.org/10.1002/eat.20852

Davies, H., Schmidt, U., & Tchanturia, K. (2013). Emotional facial expression in women recovered from anorexia nervosa. BMC psychiatry, 13(1), 1-9. https://doi.org/10. 1186/1471-244X-13-291

Di Nardo, M., Marchetti, D., Fulcheri, M., & Verrocchio, M. C. (2020). Understanding the link between interoceptive deficits and binge eating symptoms among adolescents: A serial mediation analysis. Mediterranean Journal of Clinical Psychology, 8(3). https://doi.org/10.6092/2282-1619/mjcp-2564

Eichen, D. M., Chen, E., Boutelle, K. N., & McCloskey, M. S. (2017). Behavioral evidence of emotion dysregulation in binge eaters. Appetite, 111, 1–6. https://doi.org/10.1016/j.appet.2016.12.021

Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour research and therapy, 41(5), 509-528. https://doi.org/10.1016/S0005-7967(02)00088-8

Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175191. https://doi.org/10.3758/bf03193146

Hajek, P., Belcher, M., & Stapleton, J. (1987). Breath-holding endurance as a predictor of success in smoking cessation. Addictive Behaviors, 12(3), 285-288. https://doi.org/10.1016/0306-4603(87)90041-4

Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2009). Emotion recognition and regulation in anorexia nervosa. Clinical Psychology & Psychotherapy, 16(4), 348–356. https://doi.org/10.1002/cpp.628.

Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2010). Emotional functioning in eating disorders: Attentional bias, emotion recognition and emotion regulation. Psychological Medicine, 40(11), 1887–1897. https://doi.org/10.1017/ S0033291710000036.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2009). Acceptance and commitment therapy. Washington, DC: American Psychological Association.

Haynos, A. F., & Fruzzetti, A. E. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science and Practice, 18(3), 183-202. https://doi.org/10.1111/j.1468-2850.2011.01250.x

Heatherton, T. F., & Baumeister, R. F. (1991). Binge eating as escape from self-awareness. Psychological bulletin, 110(1), 86. https://doi.org/10.1037/0033-2909.110.1.86

Herbert, C., Kübler, A., & Vögele, C. (2013). Risk for eating disorders modulates startle-responses to body words. PloS one, 8(1), e53667. https://doi.org/10.1371/journal.pone.0053667

Hilbert, A., Vögele, C., Tuschen-Caffier, B., & Hartmann, A. S. (2011). Psychophysiological responses to idiosyncratic stress in bulimia nervosa and binge eating disorder. Physiology & behavior, 104(5), 770-777. https://doi.org/10.1016/j.physbeh.2011.07.013

Holdwick Jr, D. J., & Wingenfeld, S. A. (1999). The subjective experience of PASAT testing: Does the PASAT induce negative mood?. Archives of Clinical Neuropsychology, 14(3), 273-284. https://doi.org/10.1093/arclin/14.3.273

Jacobi, C., Abascal, L., & Taylor, C. B. (2004). Screening for eating disorders and high‐risk behavior: Caution. International Journal of Eating Disorders, 36(3), 280-295. https://doi.org/10.1002/eat.20048

Karekla, M., Nikolaou, P., & Merwin, R. M. (2022). Randomized Clinical Trial Evaluating AcceptME—A Digital Gamified Acceptance and Commitment Early Intervention Program for Individuals at High Risk for Eating Disorders. Journal of Clinical Medicine, 11(7), 1775. https://doi.org/10.3390/jcm11071775

Katkin, E. S., Wiens, S., & Ohman, A. (2001). Nonconscious fear conditioning, visceral perception, and the development of gut feelings. Psychological Science, 12, 366–370. https://doi.org/10.1111/1467-9280.00368

Killen, J. D., Taylor, C. B., Hayward, C., Haydel, K. F., Wilson, D. M., Hammer, L., ... & Strachowski, D. (1996). Weight concerns influence the development of eating disorders: a 4-year prospective study. Journal of consulting and clinical psychology, 64(5), 936. https://doi.org/10.1037/0022-006X.64.5.936

Killen, J. D., Taylor, C. B., Hayward, C., Wilson, D. M., Haydel, K. F., Hammer, L. D., ... & Kraemer, H. (1994). Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: A three‐year prospective analysis. International Journal of Eating Disorders, 16(3), 227-238. https://doi.org/10.1002/1098-108X(199411)16:3<227::AID-EAT2260160303>3.0.CO;2-L

Klaperski, S., von Dawans, B., Heinrichs, M., & Fuchs, R. (2013). Does the level of physical exercise affect physiological and psychological responses to psychosocial stress in women?. Psychology of Sport and Exercise, 14(2), 266-274. https://doi.org/10.1016/j.psychsport.2012.11.003

Klatzkin, R. R., Gaffney, S., Cyrus, K., Bigus, E., & Brownley, K. A. (2015). Binge eating disorder and obesity: Preliminary evidence for distinct cardiovascular and psychological phenotypes. Physiology & behavior, 142, 20-27. http://dx.doi.org/10.1016/j.physbeh.2015.01.018

Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & Tyson, E. (2009). Academy for eating disorders position paper: eating disorders are serious mental illnesses. International Journal of Eating Disorders, 42(2), 97-103. https://doi.org/10.1002/eat.20589

Koushiou, M., Kapatais, A., Iasonidou, E., Adonis, M., & Ferreira, N. (2021). The moderating role of body image inflexibility in the relation between weight concerns and symptoms of eating disorders in Cypriot University students. Mediterranean Journal of Clinical Psychology, 9(2). https://doi.org/10.13129/2282-1619/mjcp-2977

Koushiou, M., Merwin, R. M., Anderson, D., & Karekla, M. (2019). An investigation of the affective experience of females at high risk for eating disorders in general and pathology-specific contexts. Appetite, 141, 104306. https://doi.org/10.1016/j.appet.2019.05.037

Koushiou, M., Nicolaou, K., & Karekla, M. (2018). Inducing negative affect using film clips with general and eating disorder-related content. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 23(6), 775-784. https://doi.org/10.1016/j.appet.2019.05.037

Lavender, J. M., Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Engel, S. G., Mitchell, J. E., ... & Berg, K. C. (2014). Dimensions of emotion dysregulation in bulimia nervosa. European Eating Disorders Review, 22(3), 212-216. https://doi.org/10.1002/erv.2288

Lejuez, C. W., Kahler, C. W., & Brown, R. A. (2003). A modified computer version of the Paced Auditory Serial Addition Task (PASAT) as a laboratory-based stressor. The Behavior Therapist.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Publications.

Mallorquí‐Bagué, N., Vintró‐Alcaraz, C., Sánchez, I., Riesco, N., Agüera, Z., Granero, R., ... & Fernández‐Aranda, F. (2018). Emotion regulation as a transdiagnostic feature among eating disorders: Cross‐sectional and longitudinal approach. European Eating Disorders Review, 26(1), 53-61. https://doi.org/10.1002/erv.2570

Mathôt, S., Schreij, D., & Theeuwes, J. (2012). OpenSesame: An open-source, graphical experiment builder for the social sciences. Behavior Research Methods, 44(2), 314-324. https://doi.org/10.3758/s13428-011-0168-7

Merwin, R. M. (2011). Anorexia nervosa as a disorder of emotion regulation: Theory, evidence, and treatment implications. Clinical Psychology: Science and Practice, 18(3), 208–214. https://doi.org/10.1111/j.1468-2850.2011.01252.x.

Merwin, R. M., Zucker, N. L., Lacy, J. L., & Elliott, C. A. (2010). Interoceptive awareness in eating disorders: Distinguishing lack of clarity from non-acceptance of internal experience. Cognition & Emotion, 24(5), 892–902. https://doi.org/10.1080/ 02699930902985845.

Miller, S. P., Erickson, S. J., Branom, C., & Steiner, H. (2009). Habitual response to stress in recovering adolescent anorexic patients. Child psychiatry and human development, 40(1), 43-54. https://doi.org/10.1007/s10578-008-0112-y

Miller, S. P., Redlich, A. D., & Steiner, H. (2003). The stress response in anorexia nervosa. Child Psychiatry and Human Development, 33, 295-306. https://doi.org/10.1023/A:1023036329399

Mitchell, J. E., & Crow, S. (2006). Medical complications of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 19(4), 438-443. http:/doi.org/10.1097/01.yco.0000228768.79097.3e

Nagl, M., Jacobi, C., Paul, M., Beesdo-Baum, K., Höfler, M., Lieb, R., & Wittchen, H. U. (2016). Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults. European child & adolescent psychiatry, 25, 903-918. https://doi.org/10.1007/s00787-015-0808-z

Nikolaou, P., Merwin, R. M., & Karekla, M. (2021). Acceptability And Feasibility of a Gamified Digital Eating Disorder Selective Prevention Program (AcceptME) Based On Acceptance And Commitment Therapy (ACT). https://doi.org/10.21203/rs.3.rs-871736/v1

Pace, C. S., & Muzi, S. (2019). Binge-eating symptoms, emotional-behavioral problems and gender differences among adolescents: a brief report. Mediterranean Journal of Clinical Psychology, 7(2). https://doi.org/10.6092/2282-1619/2019.7.2161

Pollatos, O., Kirsch, W., & Schandry, R. (2005). On the relationship between interoceptive awareness, emotional experience, and brain processes. Cognitive Brain Research, 25(3), 948-962. https://doi.org/10.1016/j.cogbrainres.2005.09.019

Pollatos, O., Kurz, A. L., Albrecht, J., Schreder, T., Kleemann, A. M., Schöpf, V., ... & Schandry, R. (2008). Reduced perception of bodily signals in anorexia nervosa. Eating behaviors, 9(4), 381-388. https://doi.org/10.1016/j.eatbeh.2008.02.001

Puttevils, L., Vanderhasselt, M. A., Horczak, P., & Vervaet, M. (2021). Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis. Comprehensive psychiatry, 109, 152262. https://doi.org/10.1016/j.comppsych.2021.152262

Rawal, A., Park, R. J., & Williams, J. M. G. (2010). Rumination, experiential avoidance, and dysfunctional thinking in eating disorders. Behaviour research and therapy, 48(9), 851-859. https://doi.org/10.1016/j.brat.2010.05.009

Schmidt, U., Jiwany, A., & Treasure, J. (1993). A controlled study of alexithymia in eating disorders. Comprehensive Psychiatry, 34(1), 54–58. https://doi.org/10.1016/0010- 440X(93)90036-4

Silva, W. R. D., Santana, M. D. S., Maroco, J., Maloa, B. F. S., & Campos, J. A. D. B. (2017). Body weight concerns: cross-national study and identification of factors related to eating disorders. PLoS One, 12(7), e0180125. https://doi.org/10.1371/journal.pone.0180125

Simons, J. S., & Gaher, R. M. (2005). The Distress Tolerance Scale: Development and validation of a self- report measure. Motivation and Emotion, 29(2), 83-102. https://doi.org/10.1007/s11031-005-7955-3

Soet, J., & Sevig, T. (2006). Mental health issues facing a diverse sample of college students: Results from the College Student Mental Health Survey. NASPA journal, 43(3), 410-431. https://doi.org/10.2202/1949-6605.1676

Stice, E., Marti, C. N., & Durant, S. (2011). Risk factors for onset of eating disorders: Evidence of multiple risk pathways from an 8-year prospective study. Behaviour research and therapy, 49(10), 622-627. https://doi.org/10.1016/j.brat.2011.06.009

Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: a brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological assessment, 12(2), 123. https://doi.org/10.1037/1040-3590.12.2.123

Striegel‐Moore, R. H., Rosselli, F., Perrin, N., DeBar, L., Wilson, G. T., May, A., & Kraemer, H. C. (2009). Gender difference in the prevalence of eating disorder symptoms. International Journal of Eating Disorders, 42(5), 471-474. https://doi.org/10.1002/eat.20625

Sütterlin, S., Schroijen, M., Constantinou, E., Smets, E., Van den Bergh, O., & Van Diest, I. (2013). Breath holding duration as a measure of distress tolerance: examining its relation to measures of executive control. Frontiers in psychology, 4, 483. https://doi.org/10.3389/fpsyg.2013.00483

Taylor-Piliae, R. E., Norton, L. C., Haskell, W. L., Mahbouda, M. H., Fair, J. M., Iribarren, C., ... & Fortmann, S. P. (2006). Validation of a new brief physical activity survey among men and women aged 60–69 years. American journal of epidemiology, 164(6), 598-606. https://doi.org/10.1093/aje/kwj248

Tolsa, M. D., & Malas, O. (2022). Re-exploring the connection between Emotional Intelligence, Anxiety, Depression, and Stress in adult population. Mediterranean Journal of Clinical Psychology, 10(1). https://doi.org/10.13129/2282-1619/mjcp-3291

van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current opinion in psychiatry, 34(6), 515. https://doi.org/10.1097/YCO.0000000000000739

van Hoeken, D., & Hoek, H. W. (2020). Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Current opinion in psychiatry, 33(6), 521. https://doi.org/10.1097/YCO.0000000000000641

Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of personality and social psychology, 54(6), 1063. https://doi.org/10.1037/0022-3514.54.6.1063

Wiens, S., Mezzacappa, E. S., & Katkin, E. S. (2000). Heartbeat detection and the experience of emotions. Cognition & Emotion, 14(3), 417-427. https://doi.org/10.1080/026999300378905

Yiu, A., Christensen, K., Arlt, J. M., & Chen, E. Y. (2018). Distress tolerance across self-report, behavioral and psychophysiological domains in women with eating disorders, and healthy controls. Journal of behavior therapy and experimental psychiatry, 61, 24-31. https://doi.org/10.1016/j.jbtep.2018.05.006

Zucker, N. L., Merwin, R. M., Bulik, C. M., Moskovich, A., Wildes, J. E., & Groh, J. (2013). Subjective experience of sensation in anorexia nervosa. Behaviour research and therapy, 51(6), 256-265. https://doi.org/doi:10.1016/j.brat.2013.01.010

Zvolensky, M. J., Vujanovic, A. A., Bernstein, A., & Leyro, T. (2010). Distress tolerance: Theory, measurement, and relations to psychopathology. Current Directions in Psychological Science, 19(6), 406-410. https://doi.org/10.1177/0963721410388642

DOI: https://doi.org/10.13129/2282-1619/mjcp-3796


  • There are currently no refbacks.