Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

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Journal of Behavior Therapy and Experimental Psychiatry

journal homepage: www.elsevier.com/locate/jbtep

Distress tolerance across self-report, behavioral and psychophysiological T

domains in women with eating disorders, and healthy controls
Angelina Yiua, Kara Christensenb, Jean M. Arlta, Eunice Y. Chena,∗
a
TEDp (Temple Eating Disorders program), Department of Psychology, Temple University, 1701 North 13th Street, Philadelphia, PA, 19122, United States
b
Cognition and Emotion Lab, Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Background and objectives: The tendency to engage in impulsive behaviors when distressed is linked to dis-
Eating disorders ordered eating. The current study comprehensively examines emotional responses to a distress tolerance task by
Distress tolerance utilizing self-report, psychophysiological measures (respiratory sinus arrhythmia [RSA], skin conductance re-
Psychophysiology sponses [SCRs] and tonic skin conductance levels [SCLs]), and behavioral measures (i.e., termination of task,
PASAT-C
latency to quit task).
Methods: 26 healthy controls (HCs) and a sample of treatment-seeking women with Bulimia Nervosa (BN), Binge
Eating Disorder (BED) and Anorexia Nervosa (AN) (N = 106) completed the Paced Auditory Serial Addition
Task- Computerized (PASAT-C). Psychophysiological measurements were collected during baseline, PASAT-C,
and recovery, then averaged for each time period. Self-reported emotions were collected at baseline, post-
PASAT-C and post-recovery.
Results: Overall, we found an effect of Time, with all participants reporting greater negative emotions, less
happiness, lower RSA, more SCRs and higher tonic SCLs after completion of the PASAT-C relative to baseline.
There were no differences in PASAT-C performance between groups. There was an effect of Group for negative
emotions, with women with BN, BED and AN reporting overall higher levels of negative emotions relative to
HCs. Furthermore, we found an effect of Group for greater urges to binge eat and lower RSA values among BED,
relative to individuals with BN, AN and HCs.
Limitations: This study is cross-sectional and lacked an overweight healthy control group.
Conclusion: During the PASAT-C, individuals with eating disorders (EDs) compared to HCs report higher levels of
negative emotions, despite similar physiological and behavioral manifestations of distress.

Eating disorders (EDs) affect up to 4.64% of adults (Le Grange, those without a history of ED (Corstorphine et al., 2007), and that self-
Swanson, Crow, & Merikangas, 2012) and have significant negative reported emotional distress tolerance, but not behavioral and physical
medical and psychosocial outcomes (Baiano et al., 2014). Disordered forms of distress tolerance, was negatively associated with symptoms of
eating, in general, has been conceptualized as a maladaptive response BN (Anestis et al., 2012). A study examining self-reported discomfort
to alleviate distress (Aldao, Nolen-Hoeksema, & Schweizer, 2010; induced by hot or cold temperatures did not find differences in hot or
Anestis, Smith, Fink, & Joiner, 2009; Corstorphine, Mountford, cold thresholds between individuals with BN and healthy controls
Tomlinson, Waller, & Meyer, 2007; Fischer, Smith, & Cyders, 2008; (HCs) after a stress induction task (Schmahl et al., 2010), suggesting
Haynos & Fruzzetti, 2011; Leyro, Zvolensky, & Bernstein, 2010). A similar distress tolerance between BN and HCs. While these studies
number of studies use multiple methodologies to examine individuals' expand our understanding of the utility of self-report and behavioral
with EDs experience of and abilities to withstand negative emotions measures of distress tolerance in EDs, there is still a lack of literature
and/or aversive states, termed distress tolerance. For example, it was using psychophysiological measures to assess affective responding in
found that individuals with Bulimia nervosa (BN) experience greater EDs before, during, and after a stressor (Anestis et al., 2007; Anestis,
self-reported sadness in response to stress tasks within achievement and Peterson, et al., 2009; Claes, Vandereycken, & Vertommen, 2005;
interpersonal domains compared to controls and restrained eaters Peterson & Fischer, 2012; Wenzel, Weinstock, Vander Wal, & Weaver,
(Tuschen-Caffier & Vögele, 1999). Another study found that a history of 2014; Wu et al., 2013).
an ED was associated with greater avoidance of affect compared to Research suggests that affective responses encompass subjective

∗
Corresponding author.
E-mail address: [email protected] (E.Y. Chen).

https://doi.org/10.1016/j.jbtep.2018.05.006
Received 1 August 2017; Received in revised form 19 May 2018; Accepted 28 May 2018
Available online 29 May 2018
0005-7916/ © 2018 Elsevier Ltd. All rights reserved.
A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

experience, physiology and behavior (Gross, 2013), and that multiple between women with BN and BED in response to different stressors
methods of assessment are needed in order to gain a comprehensive (Hilbert, Vögele, Tuschen-Caffier, & Hartmann, 2011). SCLs are also
understanding of affective response when engaged in distress tolerance similar between women with BN, women with self-reported restrained
in EDs. An understanding of the relationship between these three eating and HCs (Tuschen-Caffier & Vögele, 1999). Taken together, there
components of an affective response in EDs is particularly important is some evidence to suggest that there is a relationship between EDs and
due to the behavioral dysregulation observed in EDs (e.g., fasting, decreased RSA when psychological stress is induced, and limited evi-
purging, excessive exercise, binge eating). However, there are few dence pointing to a relationship between EDs and sympathetic re-
studies that utilize this approach, and any relationship between the sponses as indexed through skin conductance. The concurrent ex-
psychophysiological components of emotional responding and the be- amination of parasympathetic and sympathetic responses is warranted,
havioral components in EDs remains unclear (Gross, 2013; Lang, as there is evidence to suggest that sympathetic responses are asso-
Greenwald, Bradley, & Hamm, 1993). ciated with negative affect following exposure to emotional stimuli;
The psychophysiological component of emotional response is com- even when cardiac measures did not change significantly (Boucsein
prised of parasympathetic and sympathetic nervous system activity. et al., 2012; Salters-Pedneault, Gentes, & Roemer, 2007).
Parasympathetic nervous system activity can be indexed by examining Thus far, the evidence base for the psychophysiological component
vagal activity, which includes heart rate variability (HRV) and re- of emotional response while distressed across the range of EDs has been
spiratory sinus arrhythmia (RSA), which consists of HRV in conjunction mixed, limited by small sample sizes, and there is a lack of research
with respiration. Neuroimaging studies show that there is a positive utilizing multiple ED diagnoses. The current study extends past research
relationship between vagal activity and increased activation in neural (Leehr et al., 2015; Naumann, Tuschen-Caffier, Voderholzer, Caffier, &
structures implicated in effective emotion processing and physiological Svaldi, 2015; Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012a;
aspects of emotional responses (e.g., right pregenual anterior cingulate, Svaldi, Tuschen-Caffier, Lackner, Zimmermann, & Naumann, 2012b)
right subgenual anterior cingulate and right rostral medial prefrontal through the multi-modal assessment of emotional responses across
cortex and the left sublenticular extended amygdala or ventral three common ED diagnoses and HC participants to a commonly used
striatum) (Thayer, Åhs, Fredrikson, Sollers, & Wager, 2012). Low behavioral distress tolerance task. The Paced Auditory Serial Addition
resting vagal activity, decreased vagal activity when emotionally Task-Computerized (PASAT-C) (Lejuez, Kahler, & Brown, 2003) was
aroused, and a slow return to baseline after emotional arousal are as- used as a behavioral measure of distress tolerance (Feldner, Leen-
sociated with greater symptoms of psychopathology (Beauchaine, Feldner, Zvolensky, & Lejuez, 2006; Gratz, Rosenthal, Tull, Lejuez, &
2015). Although reduced resting vagal activity is theorized as a risk Gunderson, 2006) and self-reported emotions and psychophysiological
factor for psychopathology (Crowell, Beauchaine, & Linehan, 2009), measures of arousal were measured in response to the PASAT-C. As
systematic reviews and meta-analysis suggest that higher resting vagal individuals with EDs have been argued to have, “shared, but distinctive,
activity is paradoxically associated with both BN (Peschel et al., 2016) clinical features […] maintained by similar psychopathological pro-
and Anorexia Nervosa (AN) (Mazurak, Enck, Muth, Teufel, & Zipfel, cesses,” utilizing a transdiagnostic approach that includes three ED
2011) compared to controls. Current research suggests that higher groups may be most useful in identifying the proposed “similar psy-
resting vagal activity in BN and AN may reflect the physiological chopathological processes” (Fairburn, Cooper, & Shafran, 2003).
changes associated with disordered eating behaviors (Peschel et al., We predicted a main effect of time, such that self-reported negative
2016), though further research is needed to clarify the contributions of emotions would be greater, happiness would be lower, and urges to
psychological symptoms and physiological consequences of disordered binge eat would be greater after the PASAT-C, in comparison to base-
eating. line and at recovery. Based on prior research (Anestis et al., 2007;
Experimental work examining RSA response to stressors among in- Corstorphine et al., 2007; Tuschen-Caffier & Vögele, 1999), we ex-
dividuals with EDs has produced mixed findings. Two separate studies pected that diagnostic group would moderate this effect. Specifically,
found that women with Binge Eating Disorder (BED) and obesity we expected that HCs would demonstrate less significant changes in
(Friederich et al., 2006) and women with BN (Messerli-Bürgy, Engesser, negative emotions, happiness, and urges to binge eat during the PASAT-
Lemmenmeier, Steptoe, & Laederach-Hofmann, 2010) showed de- C, compared to individuals with BN, BED, or AN. As the PASAT-C is
creased RSA levels with a slow return to baseline following a psycho- used as a behavioral distress tolerance measure (Gratz et al., 2006;
logical stress induction task. The observed decrease in RSA levels with a Sauer & Baer, 2012), we expected that individuals with BN, BED, and
slow return to baseline suggests difficulty in modulating emotional AN would be more likely to prematurely terminate the PASAT-C and
arousal both during and after a stressor. However, there is contrary exhibit shorter latency to terminate the PASAT-C than HCs. Given the
evidence that RSA levels among women with BED and obesity remain proposed role of negative affect in EDs during distress (Anestis et al.,
unchanged after psychological stress was induced (Messerli-Bürgy 2007; Anestis, Smith, et al., 2009; Peterson & Fischer, 2012), we ex-
et al., 2010) and that RSA levels of women without EDs who are obese pected that RSA values would be lower and SCRs and tonic SCL values
return to baseline levels after stress exposure (Messerli-Bürgy et al., would be higher during the PASAT-C in ED groups compared to HC,
2010). This suggests that women without EDs who are obese exhibit relative to baseline and recovery.
physiological emotion modulation as evidenced by a return of RSA le-
vels to baseline levels after stress exposure, but that women with BED 1. Methods
and obesity are physiologically unresponsive to stress exposure. Addi-
tional research points to engagement in clinically significant levels of 1.1. Participants
binge eating, rather than weight status, for decreased RSA after psy-
chological stress (Udo et al., 2014). Participants were self-referred from the community using flyers,
The sympathetic nervous system response can be indexed by skin referred from local eating disorder clinics and student health and
conductance, which measures the time it takes for a current to pass counseling services, and recruited in a University-based outpatient
through the skin (Boucsein et al., 2012). Higher skin conductance re- eating disorder program as part of several clinical trials. Participants
sponses (SCRs) and levels (SCLs) are associated with greater emotional were invited to participate in the study if, after undergoing a clinical
arousal (Kreibig, 2010; Lang et al., 1993). SCRs reflect the number of interview (described below) they met for a diagnosis of BN, BED, or AN
times emotional arousal changes from baseline within a given time (typical or atypical), without current drug or alcohol dependence or
period and SCLs reflects an individual's overall level of emotional symptoms of psychosis. HCs were self-referred from the community,
arousal within a given period of time. In contrast to the mixed re- student health and counseling services, and the University Hospital, and
lationship between RSA and EDs, evidence suggests that SCL are similar were eligible to participate if, after undergoing the same clinical

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A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

interview as individuals with EDs, they did not meet diagnosis for Hopkins Symptom Checklist (Watson et al., 1988). In the present study,
current psychopathology, and did not have a history of serious mental internal consistency of the negative emotion composite score at each
illness. time point ranged from α = 0.84 to 0.90.
The sample consisted of 106 females with an ED and 26 female HCs Psychophysiological measures. Psychophysiological measures
with no history of psychiatric disorders from the community. Of the included respiratory sinus arrhythmia (RSA) as a measure of para-
participants with an ED, 34.90% of the sample was diagnosed with BN sympathetic activity (Grossman & Taylor, 2007; Thayer et al., 2012)
(n = 37), 51.89% with BED (n = 55), and 13.21% with typical or aty- and skin conductance responses (SCRs) and tonic skin conductance le-
pical AN (n = 14). The sample identified predominantly as non- vels (tonic SCL) as measures of sympathetic activity (Boucsein, 2011).
Hispanic (91.70%) and was 64.4% Caucasian, 13.60% African- Psychophysiological measures were assessed during the baseline,
American, 4.50% Asian, and 9.1% of mixed race. The mean age of during the PASAT-C, and during the recovery period. Electro-
participants was 35.06 years (SD = 11.47), and the mean body mass cardiogram (ECG) data were collected from two Biopac Ag-AgCl spot
index (BMI) was 29.55 kg/m2 (SD = 9.50). electrodes placed on the bottom of the palm of the non-dominant hand,
using a modified Lead II configuration (Boucsein, 2011). We derived
1.2. Measures RSA by using a band pass filter on the ECG signal and spectral analysis
to extract the high-frequency component (> 0.15 hz) of heart rate
Psychiatric symptoms. The Structured Clinical Interview for variability. Skin conductance was recorded from two electrodes at-
Diagnostic and Statistical Manual of Mental Disorders – IVe Text tached to the palm of the non-dominant hand. Increases in SCRs have
Revision (DSM – IV – TR) Axis I Disorders (SCID – I) (First, Spitzer, been associated with negative affect following exposure to emotional
Gibbon, & Williams, 2002) was used to assess for psychiatric symptoms. stimuli, even when cardiac measures did not change significantly
The SCID I was used to confirm ED diagnoses and to assess for exclu- (Boucsein et al., 2012; Salters-Pedneault et al., 2007). Tonic SCL re-
sionary psychiatric symptoms. The SCID I is considered the gold-stan- ferred to the level of skin conductance per data collection period.
dard measure for psychiatric diagnoses (Lobbestael, Leurgans, & Arntz,
2011). 1.3. Diagnostic and laboratory procedures
Eating disorder behaviors. The Eating Disorder Examination 16.0
(EDE) (Fairburn, Cooper, & O'Connor, 2008) is an investigator-based The present study was reviewed and approved by the university
interview that assesses DSM– IV-TR (American Psychiatric Association, institutional review board and took place over two separate testing
2000) ED symptoms. The EDE – 16.0 was used to diagnosis AN, BN, and sessions, with each session taking 2–4 hours. During the first session,
BED The EDE – 16.0 has good discriminant validity, such that in- eligibility screening and informed consent were completed, followed by
dividuals with AN, BN, and BED are distinguished from controls an assessment of psychiatric and ED symptoms by Masters-level clin-
(Cooper, Cooper, & Fairburn, 1989; Wilfley, Schwartz, Spurrell, & icians using the measures described above. Individual participant di-
Fairburn, 1999; Wilson & Smith, 1989). In the current study, the EDE agnoses were agreed upon and finalized with the licensed clinical
total score demonstrated an internal consistency of α = 0.94. psychologist supervisor at weekly best-estimate meetings (Klein,
Current subjective emotional state. A visual analogue scale (VAS) Ouimette, Kelly, Ferro, & Riso, 1994; Kosten & Rounsaville, 1992),
with an abbreviated Positive and Negative Affect State (PANAS) where all structured interview data were presented. Height and weight
(Watson, Clark, & Tellegen, 1988) measured current subjective emo- were measured with a medical stadiometer and scale by the interviewer
tional state prior to the baseline, after the PASAT-C, and after recovery to calculate BMI. During the second session, participants completed the
from the PASAT-C (see Fig. 1). Self-report negative and positive affec- laboratory procedures for the PASAT-C, described below. Diagnostic
tive adjectives that assessed anxiety, fear, frustration, happiness, sad- and psychophysiological assessments occurred prior to outpatient
ness, and tension were scored on a 100-point Likert scale. A single treatment for individuals with EDs.
question to assess urges to binge eat was added due to its relevance in Behavioral distress tolerance task. The Paced Auditory Serial
the current ED sample. Higher scores indicated greater intensity of the Addition Task-Computerized (PASAT-C) (Lejuez et al., 2003) is a be-
response. In the present study, we created a composite for negative havioral distress tolerance task that has been shown to induce negative
emotions using an average of scores from anxiety, fear, frustration, affect (Daughters, Lejuez, Kahler, Strong, & Brown, 2005; Eichen, Chen,
sadness and tension. Urge to binge eat and happiness were assessed Boutelle, & McCloskey, 2017; Feldner et al., 2006; Holdwick &
separately. The original PANAS shows good convergent validity, with Wingenfeld, 1999; Schloss & Haaga, 2011) and short-term anxiety,
correlations ranging from 0.51 to 0.74 with the Beck Depression In- frustration, and irritability (Gratz et al., 2006; Lejuez et al., 2003). The
ventory, the State-Trait Anxiety Inventory State Anxiety Scale and PASAT-C is a computer-based task that requires the participant to add a

Fig. 1. Schematic of the procedure and time periods assessed.

Visual Analogue Scale: self-reported negative emotions, happiness, urges to binge eat.
Psychophysiology: respiratory sinus arrhythmia, skin conductance response, tonic skin conductance levels.

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A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

visually presented digit to the previous visually presented digit. Ex- 2. Results
plosion sounds followed incorrect answers or when the participant
failed to respond quickly enough. The PASAT-C was presented for a 2.1. Preliminary analyses
maximum of 12 min, consisting of four levels that lasted for 3 min each.
With each successive level of the PASAT-C, the latency between trials As expected, there were significant group differences on presence of
was decreased and negative feedback of “go faster,” “do better,” and “go a lifetime mood disorder (p < .001), anxiety disorder (p < .001),
faster, do better” was present. The additional worded feedback was de- medical co-morbidities (p = .006), and medication use (p = .002),
veloped by Linehan (unpublished). By the fourth level (PASAT-C Level which were driven by the lack of psychiatric and medical co-morbid-
4), there was a 1 s latency of trials with negative feedback. Participants ities among HCs. There were no significant differences between BN,
were provided written instructions at the beginning of the task that they BED, and AN on presence of a lifetime mood disorder, medical co-
had the option to quit the task after completion of Level 2. If partici- morbidities, or medication use, although AN were significantly more
pants terminated the task early, they went on to complete the recovery likely to have an anxiety disorder relative to BN (p < .05). Due to the
period, detailed below. Distress tolerance on the PASAT-C was beha- lack of significant systematic differences in psychiatric and medical co-
viorally operationalized dichotomously and continuously as termina- morbidities between BN, BED, and AN, these variables were not in-
tion of the task when given the option and latency to quit, respectively. cluded as covariates. Please see Table 1 for a description of the severity
Psychophysiology Capture Procedure. Psychophysiological mea- of ED symptoms, demographic information and clinical characteristics
sures were collected during baseline, PASAT-C, and the recovery of the sample.
period. Average RSA, SCR, and tonic SCL values were computed from
the 5-min baseline, up to 12 min of the PASAT-C, and the 5-min re- 2.2. Main analyses1
covery period, respectively. Please see Fig. 1 for a schematic of the
procedure. Once sensors were attached, participants completed a
baseline VAS and were asked to sit quietly without moving for a 5-min
baseline period (Laborde, Mosley, & Thayer, 2017). Following this, Hypothesis 1. Self-reported emotions. Overall, there was a main
participants were instructed to begin the PASAT-C. Upon completion of effect of Time, such that participants reported higher negative
the PASAT-C, participants completed a second VAS and were asked to emotions, F(2, 107) = 47.61, p < .001, η2 = .31, and lower happiness,
sit quietly for an additional 5-min without moving for a recovery period F(2, 107) = 39.10, p < .001, η2 = .27, after completion of the PASAT-C,
(Laborde et al., 2017). Participants completed a final VAS rating after in comparison to baseline and recovery (ps < .05). There was a main
the recovery period. effect of Group for negative emotions, F(3, 107) = 12.09, p < .001,
η2 = .25, but not happiness (p = .07). Specifically, HC participants
reported lower negative emotions (ps < .001) in comparison to
1.4. Statistical treatment individuals with BN, BED, or AN across all measurement periods.
There were no Time × Group interactions (ps = .12 - .27) for negative
Chi-square tests were conducted to assess for group differences in all emotions or happiness.
demographic variables, and medical and psychiatric comorbidities, For urges to engage in binge eating, there was a main effect of
with the exception of age, which was assessed using an ANOVA. Group, F(3, 107) = 16.51, p < .001, η2 = 0.32, such that across all
Variables related to presence of medication use (e.g., stimulant medi- measurement periods individuals with BED demonstrated significantly
cation, anxiolytics) and medical co-morbidities were included as cov- greater urges to binge eat compared to BN, AN, and HCs (ps < .04),
ariates in the analyses if there were significant differences between ED individuals with BN demonstrated significantly greater urges to binge
groups (BN, BED, AN) due to their effects on psychophysiological re- eat compared to HCs (p < .001), and individuals with AN did not differ
sponses (Grossman, Stemmler, & Meinhardt, 1990; Masi, Hawkley, significantly from BN or HC (ps > .06). There was no effect of Time
Rickett, & Cacioppo, 2007). As it was expected that HCs would exhibit (p = .56) or an interaction between Time x Group (p = .93), but in-
significantly fewer medical co-morbidities and medication use relative dividuals with AN exhibited a trend for decreased urge to binge eat
to the ED groups (Hudson, Hiripi, Pope, & Kessler, 2007; Johnson, after completion of the PASAT-C. See Table 2 for a summary of findings.
Spitzer, & Williams, 2001; Kessler et al., 2013; Padierna, Quintana,
Arostegui, Gonzalez, & Horcajo, 2000), medical co-morbidities and Hypothesis 2. PASAT-C termination and latency to quit. A chi
medication use were only included as covariates if there were sig- square test indicated that there were no differences between groups on
nificant differences between BN, BED, and AN. PASAT-C completion versus non-completion, χ2(3) = 3.85, p = .28. A
For analyses involving self-reported emotions and psychophysiolo- univariate ANOVA suggested that there were no differences between
gical measures, independent variables were Time (baseline, PASAT-C, groups on PASAT-C latency to quit, F(3,129) = 1.39, p = .25, η2 = .03.
recovery) and Group (BN, BED, AN, and HC). A repeated measures See Table 3 for means and standard deviations.
ANOVA was chosen as it allows for individual differences in baseline Hypothesis 3. Psychophysiological measures. There was a
scores to be accounted (Field, 2013). Six repeated measures Time x significant effect of Time for RSA values, F(2,128) = 11.87, p < .001,
Group ANOVAs were conducted with the self-reported negative emo- η2 = .09, such that all participants exhibited lowered RSA during the
tion composite score, happiness, urge to binge eat, RSA, SCRs, and PASAT-C, in comparison to baseline (p = .05) and recovery
Tonic SCL as dependent variables. Planned simple effects analyses were (p < .001). There was a significant effect of Group, F(3,128) = 6.10,
conducted to probe significant interactions. To examine group differ- p = .001, η2 = .13, such that individuals with BED exhibited lowered
ences in PASAT-C completion vs. non-completion, a chi square test was RSA levels in comparison to individuals with BN or HCs (ps ≤ .006) but
conducted. To examine group differences in PASAT-C latency to quit, a not AN (p = .33) across all measurement periods. There was no
univariate ANOVA was conducted. A power analysis indicated that we Time × Group interaction (p = .87) for RSA values.
were powered to detect medium to large interaction effects (f = .25 to
.40) with a power of .95 (Faul, Erdfelder, Lang, & Buchner, 2007). There was a significant effect of Time for tonic SCL values,
Partial η2 was used to report effect sizes for repeated measures AN- F(2,109) = 50.57, p < .001, η2 = 0.32, and SCR values, F(2,107) = 32.85,
OVAs and ANOVAs, with the following cut-off conventions: small
(0.01), medium (0.06) and large (0.14) (Cohen, 1988, pp. 20–26). 1
Analyses were re-run with BMI as a covariate, with some differences in findings.
Specifically, there was no longer an effect of Time for negative emotions (p = .70) or RSA
(p = .83). All other findings remained the same.

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A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

Table 1
Severity of eating disorder symptoms, demographic information, and clinical characteristics of participants at baseline.
Anorexia Binge Eating Bulimia Healthy Total Sample
Nervosa Disorder Nervosa Controls

n = 14 n = 55 n = 37 n = 26 N = 132

Variable M SD M SD M SD M SD M SD

Body Mass Index1 18.82 3.67 36.42 9.47 25.45 5.88 26.68 4.61 29.56 9.50
EDE Global2 3.27 1.69 3.12 0.9 3.22 1.04 0.39 0.52 2.63 1.48
EDE Eating Concern2 3.27 1.94 2.82 1.42 2.76 1.15 0.04 0.08 2.30 1.69
EDE Dietary Restraint 3 3.40 1.91 2.19 1.26 3.09 1.33 0.48 0.89 2.24 1.62
EDE Weight Concern2 2.90 1.83 3.59 1.07 3.42 1.41 0.48 0.67 2.85 1.69
EDE Shape Concern2 3.49 1.70 3.9 1.25 3.62 1.35 0.55 0.79 3.12 1.79
Objective Binge Episodes (3 months)4 1.21 2.51 4.58 4.11 6.29 6.04 0 0 3.80 4.82
Compensatory Behaviors Episodes (3 months)5 3.54 4.96 0.32 1.13 8.37 8.41 0 0 2.85 5.95
Age in years 34.64 11.47 41.65 9.49 29.81 9.77 28.81 10.59 35.06 11.47

N % N % N % N % N %

Ethnic minority 2 14.3 23 41.8 11 29.7 11 42.3 49 36.84

Single 9 64.3 24 43.6 22 59.5 15 62.5 70 52.63
Employed or Full-Time Student 13 92.9 51 92.7 33 89.2 25 96.2 122 91.73
Completed 4-year college 11 78.6 43 78.2 23 62.2 14 53.8 91 68.42
Low Income 10 71.4 16 29.1 20 54.1 17 65.4 61 45.86
(< 25 000)
Mood Disorder 7 50 35 63.6 27 73 0 0 69 51.88
Anxiety Disorder 9 64.3 20 36.4 12 32.4 0 0 41 30.83
Medical Comorbidity 7 50 26 47.3 22 59.5 4 15.4 59 44.36
Medications 6 42.9 28 50.9 18 48.6 2 7.7 54 40.6

Notes:
1
HCs had significantly lower BMI relative to the BED group (p < .001) and significantly higher BMI relative to the AN group (p < .01), but did not differ significantly
from the BN group.
2
Scores from the EDE Eating Concern subscale, Weight Concern subscale, Shape Concern subscale, or Global scores did not differ significantly between the BN, BED,
or AN groups (ps > .23) but were significantly higher relative to HCs (ps < .001).
3
AN and BN groups did not differ significantly on the EDE Dietary Restraint subscale (p = .47), but the BED group reported significantly lower dietary restraint
relative to AN, and BN, and significantly greater dietary restraint relative to HCs (ps < .001).
4
BED and BN reported significantly greater frequency of binge eating episodes than AN (ps < .008). BED and BN did not differ significantly on frequency of binge
eating episodes (p = .15).
5
BN and AN reported significantly greater frequency of compensatory behaviors (ps < .001) than BED, BN and AN did not differ significantly on frequency of
compensatory behaviors (p = .84).

Table 2 Table 3
Self-reported negative emotions, happiness and urges to binge eat at baseline, Completion time and latency to quit on the Paced Auditory Serial Addition Task
during the Paced Auditory Serial Addition Task – Computerized (PASAT-C), and – Computerized (PASAT- C) among women with Bulimia Nervosa, Binge Eating
during recovery from PASAT-C among women with Bulimia Nervosa, Binge Disorder, Anorexia Nervosa, and Healthy Controls.
Eating Disorder, Anorexia Nervosa, and Healthy Controls.
PASAT-C Completion PASAT-C
Baseline PASAT-C Recovery N (%) Latency to Quit (seconds)
M (SD) M (SD) M (SD) M (SD)

Negative Emotions Anorexia Nervosa 10 (71.4%) 678.64 (103.62)

Binge Eating Disorder 38 (69.1%) 683.84 (89.32)
Anorexia Nervosa 48.99 (22.51) 60.80 (26.58) 47.53 (21.66) Bulimia Nervosa 23 (62.2%) 643.84 (128.05)
Binge Eating Disorder 39.40 (22.82) 57.24 (20.20) 30.55 (18.25) Healthy Control 22 (84.6%) 690.85 (110.35)
Bulimia Nervosa 38.90 (22.83) 58.38 (20.22) 35.90 (20.33)
Healthy Control 8.91 (13.18) 37.07 (24.47) 15.40 (16.38)
p < .001, η2 = 0.24, such that all participants exhibited greater tonic
Happiness SCL and SCR values during the PASAT-C in comparison to baseline
(ps < .001), but not recovery (ps = .45 - 0.75). There was no effect of
Anorexia Nervosa 37.56 (25.16) 22.47 (26.08) 17.68 (24.51)
Group (ps > .51) or Time × Group interaction (ps > .30) for tonic
Binge Eating Disorder 40.85 (18.05) 23.52 (25.07) 29.20 (21.58)
Bulimia Nervosa 43.98 (18.74) 21.03 (21.58) 29.50 (23.21) SCL or SCR values. See Table 4 for means and standard deviations.
Healthy Control 59.41 (19.40) 28.51 (28.71) 39.42 (28.14)

3. Discussion
Urge to Binge

Anorexia Nervosa 21.70 (29.03) 11.42 (25.86) 20.41 (33.67) The current study extends the current literature on affective re-
Binge Eating Disorder 46.87 (27.10) 42.41 (36.48) 44.21 (32.50) sponse in EDs by integrating self-report, behavioral, and psychophy-
Bulimia Nervosa 33.15 (28.48) 31.84 (36.86) 34.77 (32.55) siological measures (RSA, SCRs, and tonic SCLs) of response to a dis-
Healthy Control .77 (1.97) 2.98 (11.41) .34 (.71) tress tolerance task (Daughters et al., 2005; Feldner et al., 2006;
Holdwick & Wingenfeld, 1999; Schloss & Haaga, 2011). Despite similar
psychophysiological responding (RSA, SCRs, and tonic SCL) to the
PASAT-C and PASAT-C termination and latency to quit across all

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A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

Table 4 explore factors that influence whether one will or will not act upon
Respiratory sinus arrhythmia, skin conductance responses and tonic skin con- urges to binge eat when experiencing negative affect (Haedt-Matt &
ductance levels for Bulimia Nervosa, Binge Eating Disorder, Anorexia Nervosa, Keel, 2011; Hilbert & Tuschen-Caffier, 2007).
and Healthy Controls at baseline, during PASAT-C, and during recovery from The PASAT-C achieved the desired result of increasing distress as
PASAT-C.
evidenced by increased negative emotions, decreased happiness, de-
Baseline PASAT-C Recovery creased RSA values and increased SCRs and tonic SCLs across the
M (SD) M (SD) M (SD) sample, without differences in termination or latency to quit. This
suggests that regardless of baseline level of negative emotions or di-
Respiratory sinus arrhythmia (in ms2)
agnostic group, the PASAT-C was distress inducing, which is consistent
Anorexia Nervosa 5.81 (1.20) 5.69 (1.16) 6.15 (1.17) with past research utilizing samples with clinically significant psycho-
Binge Eating Disorder 5.25 (1.36) 5.16 (1.39) 5.40 (1.32) pathology (Gratz et al., 2006). The success of the PASAT-C to induce
Bulimia Nervosa 6.25 (1.16) 6.05 (1.06) 6.32 (1.09)
distress may have produced a ceiling effect on performance, such that
Healthy Control 6.21 (1.36) 6.06 (1.30) 6.38 (1.27)
all participants were equally sensitive to its effects regardless of diag-
nosis. However, the lack of significant group differences is counter to
Skin conductance response
another study that found significantly shorter latency to quit the
Anorexia Nervosa 1.80 (2.42) 3.96 (4.15) 3.91 (2.69) PASAT-C among undergraduate students who endorsed binge eating
Binge Eating Disorder 2.13 (1.90) 3.78 (3.02) 3.88 (2.75) behaviors relative to controls (Eichen et al., 2017). The difference in
Bulimia Nervosa 1.24 (1.70) 3.54 (3.45) 2.77 (2.39) findings may be due to sampling differences between the two studies.
Healthy Control 1.83 (1.72) 2.90 (2.54) 3.94 (2.94)
The current study recruited treatment-seeking patients with a range of
EDs; the other study recruited non-treatment seeking college students.
Tonic skin conductance levels (in μs)

Anorexia Nervosa 2.19 (2.11) 6.38 (6.58) 6.72 (5.67) 3.1. Future directions
Binge Eating Disorder 2.94 (2.27) 5.14 (4.06) 5.06 (4.05)
Bulimia Nervosa 2.35 (3.89) 5.28 (6.51) 4.98 (6.40) The option to terminate the PASAT-C allowed for distress tolerance
Healthy Control 2.40 (3.11) 5.37 (6.04) 5.77 (6.76) to be measured behaviorally in the current study and participants who
chose to terminate the PASAT-C completed the recovery period earlier
than those who completed the entire PASAT-C task. The inclusion of
groups, individuals with BN, BED, and AN reported greater overall
multiple ED diagnostic groups can be considered a strength and a
negative emotions and lower overall happiness compared to HCs. The
limitation of the current study. Comparisons were possible between ED
discrepancy between psychophysiological responding and PASAT-C
diagnoses and HCs, however the smaller group of individuals with AN
termination and latency to quit with self-report of emotional experience
may have hindered detecting differences between that group and
suggests that individuals with EDs experience disproportionately
others. For example, individuals with AN exhibited a trend for de-
greater subjective distress relative to HCs when presented with the
creased urges to binge eat after completion of the PASAT-C in com-
same stimuli. Overall, this may suggest that while physiological and
parison to baseline, which is in contrast to individuals with BED and BN
behavioral experience of distress manifests similarly across groups, it is
who exhibited similar urges to binge eat at baseline and after the
the interpretation of experiences during both baseline and when dis-
PASAT-C. This may reflect an increased desire for control over eating
tressed that best distinguish between groups with EDs and HCs.
when experiencing negative affect among individuals with AN
Although HCs reported significantly lower negative emotions and
(Fairburn, Shafran, & Cooper, 1999). A larger sample of individuals
greater happiness relative to all other groups, individuals with BED
with AN may clarify the urge to binge eat in response to stress among
were differentiated from other ED groups and HCs by exhibiting sig-
different ED diagnoses. Furthermore, as the PASAT-C generated similar
nificantly lower RSA values across all time periods without concomitant
levels of negative affect across the entire sample, future research could
differences from other groups in tonic SCL or SCR values. Research has
utilize emotion inductions that may be more salient to EDs, such as cues
demonstrated an association between BMI and RSA and suggests that
involving body shape/weight concerns or food. Such disorder-related
cardiovascular autonomic function changes as a function of weight loss
stimuli may produce differential results between groups with EDs and
(Karason, Mølgaard, Wikstrand, & Sjöström, 1999; Rissanen, Franssila-
HCs and offer increased insight into the negative affect states that are
Kallunki, & Rissanen, 2001). Consistent with past research (Dingemans
posited to maintain disordered eating behaviors. For example, partici-
& van Furth, 2012; Hudson et al., 2007), HCs had significantly lower
pants could complete behavioral approach/avoidance tasks that involve
BMI relative to the BED group and significantly higher BMI relative to
examining the body in a mirror or observing images of high-caloric
the AN group, but did not differ significantly from the BN group;
food. In terms of behavioral assessments, future research could utilize
however, BMI was not controlled for in the current study, as 92% of
distress tolerance measures that more closely map onto eating disorder
participants diagnosed with BED were overweight or obese, likely due
concerns, such as sampling foods.
to the cumulative effects of objective binge episodes on weight gain
Finally, the current study's group of individuals with BED primarily
over time (Hudson et al., 2010). Therefore, participants with BED are
consisted of individuals who are also overweight. Although individuals
“doubly diagnosed” with BED and obesity, making it difficult to dis-
with BED are at a higher risk for obesity (e.g., de Zwaan, 2001), the
sociate diagnosis and weight status. Future studies may wish to dis-
medical condition of obesity is not synonymous with the psychological
sociate diagnosis and weight status.
condition of BED (e.g., Klatzkin, Gaffney, Cyrus, Bigus, & Brownley,
Contrary to expectations, self-reported urges to binge eat did not
2015). There are multiple physiological, cognitive, and psychological
change over the course of all time periods, regardless of whether one
symptoms associated with obesity and there is a risk of falsely con-
had an ED or not. However, self-reported urges to binge eat differed as a
flating these symptoms with BED. Future studies may seek to disen-
function of ED diagnosis, such that individuals with BED and BN re-
tangle BED and obesity by examining whether similar patterns of
ported overall greater urges to binge eat across all timepoints in com-
findings are found for individuals with BED who are of normal weight,
parison to individuals with AN or HC. Perhaps individuals who engage
or for individuals without EDs who are of normal weight and over-
in habitual binge eating experience consistent urges to engage in binge
weight status.
eating, but only act on this urge when they experience negative affect
The current study is one of the first to examine emotional re-
(Hilbert & Tuschen-Caffier, 2007) or are under stress. As the current
sponding across individuals with EDs and HCs in response to a task that
study only assessed urges to binge eat, future research may seek to
induces distress. It provides a step towards enhancing our

29
A. Yiu et al. Journal of Behavior Therapy and Experimental Psychiatry 61 (2018) 24–31

understanding of the similarities and differences in emotional re- disorder patients. Personality and Individual Differences, 39, 739–749. http://dx.doi.
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BED exhibit overall reduced levels of RSA responding and experience Cooper, Z., Cooper, P. J., & Fairburn, C. G. (1989). The validity of the eating disorder
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treatment implications can be made. The finding that EDs are asso- Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress
ciated with overall greater subjective distress without deleterious ef- tolerance in the eating disorders. Eating Behaviors, 8, 91–97. http://dx.doi.org/10.
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Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental
treatment implications for the function of disordered eating to decrease model of borderline personality: Elaborating and extending Linehan's theory.
distress (Corstorphine et al., 2007). Overall, performance on the Psychological Bulletin, 135, 495–510. http://dx.doi.org/10.1037/a0015616.
PASAT-C was comparable across groups, suggesting there are not dif- 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
ferences in the cognitive functioning required for the task, thus clinical
among residential treatment-seeking substance abusers. Psychology of Addictive
intervention for EDs may prioritize managing strong, negative emotion. Behaviors, 19, 208–211. http://dx.doi.org/10.1037/0893-164X.19.2.208.
Individuals with EDs may benefit from treatments that focus on fos- Dingemans, A. E., & van Furth, E. F. (2012). Binge eating disorder psychopathology in
tering greater acceptance of one's emotional experiences, such as Dia- normal weight and obese individuals. International Journal of Eating Disorders, 45,
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lectical Behavior Therapy (Chen et al., 2015; Safer, Robinson, & Jo, Eichen, D. M., Chen, E., Boutelle, K. N., & McCloskey, M. S. (2017). Behavioral evidence
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Crow, 2009; Juarascio, Forman, & Herbert, 2010; Juarascio et al., 1016/j.appet.2016.12.021.
Fairburn, C. G., Cooper, Z., & O'Connor, M. (2008). Eating disorder examination (edition
2013). Our study supports the proposed model that negative emotions 16.0D). Cognitive behavior therapy and eating disorders (pp. 309–314). New York, NY:
may perpetuate and maintain EDs, with the caveat that the experience Guilford Press.
of distress may manifest physiologically and behaviorally similarly to Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating
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Conflicts of interest orexia nervosa. Behaviour Research and Therapy, 37, 1–13. http://dx.doi.org/10.
1016/s0005-7967(98)00102-8.
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* power 3: A flexible statistical
Funding: Funding: 1K23 MH081030-01 from NIMH and power analysis program for the social, behavioral, and biomedical sciences. Behavior
R21MH093932-01A1 from NIMH and NIDDK to Eunice Chen, Ph.D. Research Methods, 39, 175–191.
Feldner, M. T., Leen-Feldner, E. W., Zvolensky, M. J., & Lejuez, C. W. (2006). Examining
The funding body did not have any involvement in the conduct of the
the association between rumination, negative affectivity, and negative affect induced
research, the study design, preparation of the article or decision to by a paced auditory serial addition task. Journal of Behavior Therapy and Experimental
submit the article for publication. The Dr. Chen discloses annual roy- Psychiatry, 37, 171–187. http://dx.doi.org/10.1016/j.jbtep.2005.06.002.
alties from Guilford Press. All other authors declare no potential con- Field, A. (2013). Discovering statistics using IBM SPSS statistics. Thousand Oaks, CA: Sage
Publications.
flict of interest with the current work. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical
interview for DSM-IV-TR axis I disorders, research version, patient edition. New York, NY:
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