Emotional overload in bulimia nervosa: an ERP study of emotion processing and regulation

Abstract

Objective
People with bulimia nervosa (BN) self-report difficulties processing and regulating emotions. However, self-reports have been shown to be biased, particularly with people with BN who have difficulties describing their emotions. Self-reports also cannot easily disentangle between early processing and later regulatory stages, so it is not clear whether people with BN really do process their emotions more intensely or whether this is due to the aftermath of regulatory difficulties. This study aimed to use an objective way to measure (1) whether people with BN process their emotions with higher intensity compared to healthy controls (HC) and (2) whether they can successfully implement an emotion regulation strategy called cognitive reappraisal.

Methods
We developed a neuroimaging task using electroencephalography to answer these questions, using the Late Positive Potential (LPP) as an objective measure of emotional arousal at the processing and regulatory stages. We tested the task in females with BN (N = 32) and matched HC (N = 35).

Results
We found that our BN group showed higher LPP compared to our HC group when viewing emotional pictures, demonstrating increased emotional intensity at the processing stage. We also found that our BN group had difficulties successfully implementing cognitive reappraisal to reduce emotional arousal.

Discussion
This suggests that people with BN process their emotions with higher intensity and struggle to implement subsequent cognitive reappraisal strategies. This has direct implications for clinicians who should be aware that when evoking affect in treatment, people with BN may need greater support in understanding and managing their emotions.

Full text

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Emotional overload in bulimia nervosa: an ERP study of emotion
processing and regulation
Laura Vuillier
Bournemouth University
Ziyi Wang
Durham University
Sanjidha Hassan
Bournemouth University
Amy Harrison
University College London
Matthew P. Somerville
University College London
Xun He
Bournemouth University
Research Article
Keywords: Bulimia Nervosa, Eating Disorders, Emotion, Emotion Processing, Emotion Regulation, Neuroimaging, LPP
Posted Date: September 10th, 2024
DOI: https://doi.org/10.21203/rs.3.rs-4886296/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License
Additional Declarations: No competing interests reported.

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Abstract
Objective
People with bulimia nervosa (BN) self-report diculties processing and regulating emotions. However, self-reports have been shown to be biased,
particularly with people with BN who have diculties describing their emotions. Self-reports also cannot easily disentangle between early
processing
and later
regulatory
stages, so it is not clear whether people with BN really do process their emotions more intensely or whether this is due to the
aftermath of regulatory diculties. This study aimed to use an objective way to measure (1) whether people with BN process their emotions with
higher intensity compared to healthy controls (HC) and (2) whether they can successfully implement an emotion regulation strategy called cognitive
reappraisal.
Methods
We developed a neuroimaging task using electroencephalography to answer these questions, using the Late Positive Potential (LPP) as an objective
measure of emotional arousal at the processing and regulatory stages. We tested the task in females with BN (N = 32) and matched HC (N = 35).
Results
We found that our BN group showed higher LPP compared to our HC group when viewing emotional pictures, demonstrating increased emotional
intensity at the processing stage. We also found that our BN group had diculties successfully implementing cognitive reappraisal to reduce
emotional arousal.
Discussion
This suggests that people with BN process their emotions with higher intensity and struggle to implement subsequent cognitive reappraisal
strategies. This has direct implications for clinicians who should be aware that when evoking affect in treatment, people with BN may need greater
support in understanding and managing their emotions.
Plain English summary
Research has shown that people with bulimia nervosa (BN) often have trouble managing their emotions. We wanted to understand why this happens.
For example, we were wondering whether people with BN feel emotions more strongly than others, or do they just have trouble nding ways to cope
with their feelings? Or maybe both? We created a new task to look at what the brain is doing when people with BN experience and manage their
emotions. We tested the task in 32 females with BN and 35 healthy females with no eating disorders. The results showed two main things. First, we
showed that women with BN tend to feel emotions more intensely than those without BN. Second, we showed that women with BN tend to have
diculties using cognitive reappraisal, a strategy that involves looking at situations from different angles to nd more positive aspects. These ndings
are important because they suggest that people with BN might need extra help in two areas: they may need support in dealing with the strength of
their emotions, and in nding better ways to manage their feelings and reduce distress. This research could lead to better ways to support people with
BN in the future.
Introduction
Eating disorders (EDs) are serious mental health conditions that have among the highest morbidity and mortality rates of all psychiatric illnesses, with
suicide a major cause of death (Smith et al., 2018; Treasure et al., 2020). Bulimia nervosa (BN) is one of the most common EDs and is characterised
by bingeing episodes followed by inappropriate compensatory behaviours such as excessive exercise, purging, fasting, and laxatives (American
Psychiatric Association., 2013). There is ample literature showing that people with BN have diculties processing and regulating emotions (Pret et
al., 2019). However, most research looking at emotions in EDs relies on questionnaires, which is problematic because questionnaires are often not
able to disentangle
frequency
of use vs success in
implementing
a strategy, or diculties in
processing
vs
regulating
emotions (Gross, 2015; Sheppes,
2014). Moreover, people with BNs are known to have high levels of alexithymia (Westwood et al., 2017) characterised by diculties identifying and
describing emotions, making the use of self-reports questionable. This study aims to use EEG as an objective approach to explore the underlying
neural mechanisms behind the self-reported diculties with emotion processing and regulation in BN. This is important because it could help develop
innovative treatments that address these emotional diculties. Currently, over 60% of patients with BN do not obtain complete abstinence from core
ED symptoms after treatment (Linardon & Wade, 2018), possibly because current evidence-based treatments principally focus on the symptoms (e.g.
the bingeing and purging episodes), rather than what is driving them, such as diculties processing and regulating emotions (Ben-Porath et al., 2020;
Lavender et al., 2015; MacDonald et al., 2017). There is now a growing body of evidence that shows an association between emotions and EDs,
particularly with binge-eating and purging which are thought to be used as an attempt to lower negative affect in BN (Lavender et al., 2016; Smyth et
al., 2007).

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Ample literature has also shown that people with BN tend to under-use commonly called ‘adaptive’ strategies, such as cognitive reappraisal (Danner et
al., 2012; Vuillier et al., 2022), which has been linked to many positive physical and mental health outcomes (Gross & John, 2003; Riepenhausen et al.,
2022)(J. J. Gross & John, 2003) such as increased resilience in periods of stress (Riepenhausen et al., 2022). The reason behind this under-use of
cognitive reappraisal in people with EDs is, however, currently unknown. It is generally assumed that people with EDs are not using this strategy
because they do not select it from their emotion regulation repertoire, preferring instead to rely on other strategies instead such as rumination,
suppression, or even ED behaviours such as bingeing and purging (Pret et al., 2019). However, it remains a possibility that they do not use this
strategy because they cannot successfully
implement
it (i.e. it does not work to reduce their distress). Much of the existing research examining
emotion regulation strategy relies on self-report methods, an approach which does not differentiate between frequency and success (or failure) of
implementation and mainly looks at habitual use (e.g. the Emotion Regulation Questionnaire (Gross & John, 2003)).
People with BN have also been shown to experience emotions with high intensity and have elevated levels of emotional reactivity (Nock et al., 2008;
Svaldi et al., 2012). However, whilst perceptual and regulatory processes are theoretically independent (Gross, 2015), they are in practice dicult to
disentangle using questionnaires. Indeed, the process model of emotion regulation suggests that early perceptual diculties such as increased
intensity can
cause
diculties at the regulation stage (e.g. see Gross, 2015 for further detail on the process model), but the literature also suggests
that emotion dysregulation may
lead to
increased emotional intensity (Gross & Barrett, 2011; Gross & Jazaieri, 2014; Nock et al., 2008). Specically,
the literature is not yet clear whether the self-reported emotional intensity arises from decits at the regulation stage, or whether people with BN suffer
from a double emotional burden of increased emotional intensity at the processing stage, as well as diculties at the regulating stage.
Electroencephalography (EEG), with the use of Event-Related Potentials (ERPs) opens a new avenue to explore and disentangle perceptual and
regulatory processes. For example, the Late Positive Potential (LPP), a positive-going component maximal at parietal-occipital sites (PoZ), reects the
amount of processing resources, or emotional arousal, a person allocates to a stimulus (Bradley, 2009; Hajcak et al., 2010) making it a great tool to
evaluate emotion processing. For example, viewing emotional images evokes stronger LPP than neutral ones (Hajcak et al., 2010; Schindler et al.,
2020). The LPP can also be modulated by emotion regulation instructions such that re-evaluating an image in a more positive light (i.e. using cognitive
reappraisal) leads to a diminished LPP in adults with and without psychopathology (Foti & Hajcak, 2008; Hajcak et al., 2010; MacNamara et al., 2022).
This makes the LPP an excellent neurophysiological marker to measure emotion processing and regulation.
Whilst no research so far has specically investigated the processing and regulation of emotional responses in EDs, some research has used the LPP
in response to food stimuli. Sarlo et al (2013) found that healthy women with bulimic tendencies showed enhanced LPP amplitudes when asked to
reappraise pictures of high-caloric food, suggesting they found it harder to reappraise pictures of food as less tempting. Another study (Svaldi et al.,
2010) found that in people with Binge Eating Disorder, pictures of food created more emotional arousal (i.e. higher emotional reactivity), as depicted
by higher LPP, compared to healthy controls, although they did not look at reappraisal processes. It is however important to note that looking at the
perception and reappraisal of food items using LPP may not generalise to emotional scenes. One study did look at emotion processing and down-
regulation of emotional pictures in people with anorexia nervosa (AN) (Mallorquí-Bagué et al., 2020) and found no signicant differences in LPP, both
in terms of emotion processing and emotion regulation in their AN vs healthy control group. However, their instruction for down-regulating emotions
was to “
reduce the emotional response that it might elicit
” so it is not clear what strategy their participants used, which may not have been
reappraisal. Also, whilst diculties with emotion regulation are thought to be transdiagnostic (Pret et al., 2019), differences between ED categories
can be observed, such that dysfunctional emotion regulation is associated with different outcomes in AN vs BN (Meule et al., 2021) and there may
also be differences in the use of adaptive strategies such as reappraisal between AN and BN (Puttevils et al., 2021).
This study aimed to explore the underlying mechanisms behind the self-reported emotional intensity and low usage of cognitive reappraisal in people
with BN. Specically, it aimed to determine whether females with BN experience emotions with high intensity, and whether they can successfully
implement cognitive reappraisal (i.e does it work to reduce distress). We developed a task based on Foti and Hajcak’s (2008) which allowed us to
separately study the neural bases of emotion processing and regulation and tested it in females with BN (N = 32) and matched healthy controls (HC;
N = 35). We rst hypothesised (H1) that our females with BN would self-report using less reappraisal than our healthy controls (as per Vuillier et al.
(2022) for example) and self-report experiencing their emotions with more intensity (as per Svaldi et al. (2012) for example). Given the lack of clarity in
the literature, we were unsure what to expect regarding the LPP when processing (H2) and reappraising (H3) emotions; therefore, these hypotheses
were exploratory.
Methods
Participants
The study sample consisted of N = 35 female healthy controls (HC) recruited via media advertisements and university campus outreach between
August 2019 and August 2023. They took part in a pre-selection survey and only those scoring below two on the EDEQ and reporting no ED behaviour
and no current mental health diagnosis were included. We also recruited N = 32 females with symptoms of Bulimia Nervosa (BN). Out of these, n = 4
were recruited from an ED service. The rest (n = 28) were recruited via media advertisements and university campus outreach, and all met the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for a diagnosis of BN, although not all had a diagnosis at the time
of recruitment1. Groups were matched in terms of age, ethnicity, and education level. See Table1 for the demographic descriptions of the sample.

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Data analysis excluded two healthy participants and two participants with BN due to excessive muscular movements.
Note 1
This was partly due to the COVID pandemic which saw an increase in ED service use and help seeking behaviours, creating long waiting list for
assessments.
Table 1
Sample description.
BN group (N = 32) HC group (N = 35) Test of group differences
EDEQ - total 4.5 (0.76) 0.6 (0.43) t(65)= -826.5, p < .001
EDEQ- binge 11.8 (7.8) 0.2 (0.87) t(64)= -8.7, p < .001
EDEQ- compensatory behaviours 15.7 (16.6) 0.9 (2.8) t(65)= -5.2, p < .001
Age 23.4 (6.8) 24.4 (5.6) t(63) = 0.63, p = .529
Ethnicity Asian (n = 3)
Black (n = 1)
Mixed (n = 1)
White (n = 27)
Other (n = 0)
Asian (n = 5)
Black (n = 1)
Mixed (n = 0)
White (n = 25)
Other (n = 2)
X2(4,N=67)=3.7p=.444
Education level College (n = 3)
Further education (n = 16)
Undergraduate level (n = 10)
Postgraduate level (n = 3)
College (n = 3)
Further education (n = 13)
Undergraduate level (n = 14)
Postgraduate level (n = 5)
X2(3,N=67) =1.35,p=.718
Note
: Numbers represent Mean, with SD in brackets, unless specied.
Questionnaires
Eating Disorder Examination Questionnaire (EDE-Q)
The EDE-Q (Fairburn & Beglin, 2008) contains 28 questions referring to the past 28 days, such that high scores indicate severe ED psychopathology.
Questions are scored from 0–6 with a maximum possible total average score of 6. A score equal to or above 4 is commonly used to classify
individuals within the clinical range (e.g. Mond et al., 2006), with a score of 2 or below considered representative of a community sample without ED
behaviours (Carey et al., 2019). The EDE-Q also contains six questions measuring binge eating; purging; laxative uses; and excessive exercise as a
means of controlling their shape or weight. The EDE-Q total score has good internal consistency which was conrmed in our sample (BN α = .84; HC α
= .88).
Emotional Regulation Questionnaire (ERQ)
The ERQ (Gross & John, 2003) is a 10-item scale designed to measure respondents’ tendency to regulate their emotions using Cognitive Reappraisal
or Expressive Suppression. The six questions to measure cognitive reappraisal are scored on a 7-point Likert-type scale, with a maximum score of 42
(a higher score means more tendency to use this strategy). The ERQ has good internal consistency which was also conrmed in our sample (BN α
= .87 ; HC α = .92 for cognitive reappraisal).
Emotional Reactivity Scale (ERS)
The ERS (Nock et al., 2008) is a 21-item scale that measures emotional sensitivity, intensity and persistence. We only used the seven questions to
measure intensity (Items 3, 4, 6, 17, 19, 20, 21). Questions are scored on a 5-point Likert-type scale (0–4), with a maximum score of 28 for intensity
(higher score means more intensity). The ERS has good internal consistency which was conrmed in our sample (BN α = .90 ; HC α = .82).
The Emotion Regulation Task
Participants were seated in a dimly illuminated testing booth. The visual stimuli were displayed in the centre of a 17-inch PC monitor at a viewing
distance of 60 cm. The emotion regulation task had three conditions: Neutral, Maintain, and Reappraisal. Each of these conditions featured 46 unique
pictures from the IAPS (Lang et al., 2008), so that each picture was only presented once. Pictures and conditions were randomised across three
blocks of 46 trials each. A trial began with a 1000 ms xation display, succeeded by a neutral or negative picture shown for 1500 ms. Following the
picture, participants encountered a text prompt for 5000 ms, with the content varying based on the (randomised) condition. For the neutral condition,
the instruction asked participants to observe the image without any specic emotional engagement. For the maintain condition, the instruction

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encouraged participants to fully engage with their emotional responses (e.g.
“The ambulance crew arrived too late and could not save the driver”
following the picture of a car accident). For the reappraisal condition, the instructions aimed to guide participants to cognitively reframe the negative
image, either through focusing on a more positive outcome of the emotional scene (e.g.
“All people were saved thanks to the ambulance crew's hard
work”
following the picture of a car accident), or through objectifying the situation by viewing it as fake, from a movie for example. They were told to
specically reframe their interpretation using the description and to not think of something else2. See Supplementary Material for the full list of the
IAPS pictures and corresponding descriptions. After the text prompt, there was a subsequent 800 ms xation period, followed by the re-presentation
of the identical image for another 1500 ms. Following this second image display, participants were required to assess and report the strength of their
emotional response (i.e. arousal), utilising the Self-Assessment Manikin scale for arousal.
Note 2
Our paradigm differs from other paradigms in the eld on this important point. Most paradigms ask participants to come up with their own alternative
explanation for reappraising the emotional picture. Whilst this may be closer to real life situations, such paradigms cannot differentiate whether a
participant cannot come up with an alternative explanation or whether they do but it does not work to reduce distress. Our design specically provided
participants with an alternative explanation to remove the untestable possibility that they may not have been following instructions.
EEG recording and data analysis
EEG recording
. Continuous EEG data were captured using an active electrode system (ActiCHamp, Brain Products, GmbH, Gilching, Germany) from 32
scalp electrodes. These electrodes were positioned according to the 10–20 system (Jasper, 1958) at designated sites including AFz, Fz, FCz, Cz, CPz,
Pz, POz, F3, F4, F7, F8, FC3, FC4, FT7, FT8, CP3, CP4, CP5, CP6, P3, P4, P7, P8, PO3, PO4, PO7, PO8, O1, and O2. Additionally, two electrodes were
placed on the mastoid bones behind each ear. The vertical electrooculogram (VEOG) was recorded from electrodes below the left eye, and the
horizontal electrooculogram (HEOG) from electrodes adjacent to the outer canthi of both eyes.
EEG data were recorded using Brain Vision Recorder (RRID: SCR_016331; www.brainproducts.com) at a sampling rate of 1000 Hz. The raw EEG data
were band-pass ltered from 0.01 to 30 Hz. All channels were referenced online to the left mastoid electrode and re-referenced oine to an average of
both left and right mastoids. Independent component analysis (ICA) was performed on the continuous data to identify and remove eyeblink and eye
movement (Jung, et al., 2000). Artifact rejection was performed for individual channel with trials contaminated with muscular movement artefacts
(exceeding ± 80
µ
V in all other channels) being removed as artefacts from EEG analysis.
To analyse the ERP components, the remaining EEG was segmented into 1600 ms epochs ranging from 100 ms before to 1500 ms after the onset of
the image display to capture the full image presentation. The 100 ms pre-stimulus interval was used for baseline correction. EEG was averaged
separately for each group (BN or HC) and for each condition for emotion processing (rst presentation of the picture) and emotion regulation (second
presentation after the instructions to maintain or reappraise the emotion). All EEG data processing was performed with BrainVision Analyzer software
(Brain Products GmbH, Gilching, Germany).
ERP and statistical analysis
. Based on a collapsed localisers approach (Luck and Gaspelin, 2017), the late positive potential (LPP) was quantied as
the average activity where it was maximal on the scalp at POz electrode. Statistical evaluations were performed using JASP statistical software
(version 0.18.1.0, www.jasp-stats.org), with independent sample t-test for H1, One-way between-subject Analyses of Variance (ANOVA) for H2, and 2 ×
2 mixed ANOVA supplemented by permutation-based FDR analyses for H3. Permutation-based false discovery rate (FDR) estimates (Fields &
Kuperberg, 2020) were performed using RStudio (Version 2022-02-03-492, RStudio, 2022, based on the R programming language Version 4.2.0, R Core
Team, 2022).
Results
Hypothesis 1: Self-report use of cognitive reappraisal and emotional reactivity
As predicted, we found that the BN group (M = 24.6, SD = 1.6) reported less use of reappraisal on the ERQ compared to the HC group (M = 29.4, SD =
7.3;
t
(62) = 2.4,
p =
.009). We also found that the BN group self-reported experiencing their emotions with higher intensity (M = 17.8, SD = 6.9)
compared to the HC group (M = 10.9, SD = 5.0;
t
(62)= -4.7,
p <
.001).
Hypothesis 2: LPP for emotion processing
Differences in emotion processing were assessed using a one-way between-subject ANOVA to examine whether the BN group experienced higher
arousal level than the HC group when negative images were presented. The result revealed that LPP amplitudes were signicantly larger (F(1, 61) =
4.47, p = .039, ηp2 = .068) in the BN group (M = 4.26, SD = 4.60), compared to those in HC group (M = 1.86, SD = 4.39), which can be seen in Fig.1. The
results were supported by permutation-based t-tests with FDR correction, suggesting that the LPP components of the HC group fell back to baseline
at around 924ms, while the BN LPPs remained signicantly larger than the baseline through the whole time period (from 400 to 1500 ms).
Hypothesis 3: LPP for emotion regulation

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The BN group (M = 4.2, SD = 1.3) showed higher arousal self-ratings after being instructed to reappraise their emotions compared to the HC group (M
= 3.5, SD = 1.2, t (62)= -2.1,
p
= .038), suggesting diculties successfully implementing reappraisal.
The LPP mean amplitudes were subjected to a mixed ANOVA with the within-factor Condition (maintain vs reappraisal) and between-factor Group (BN
vs HC). A signicant mean effect of Group (F(1, 61) = 5.63, p = .021, ηp2 = .066), revealed that BN group (M = 2.62, SD = 3.61) showed higher LPP
amplitudes compared to the HC group (M = 0.70, SD = 2.78), as seen in Fig.2.
Estimates by permutation-based one-sample t-tests with FDR correction further identied that the BN group’s LPP component for the reappraisal
condition remained signicantly different from baseline until 1476 ms, whereas the HC group’s LPP component returned to baseline from 640 ms.
This demonstrates that the BN group took longer than the HC group to reappraise their emotions, and they still showed high arousal until right before
the picture disappeared.
The same permutation-based analyses for the maintain condition showed that the BN group’s LPP returned to baseline more quickly than in the
reappraisal condition, as the cluster became insignicant from 916 ms, suggesting that using reappraisal led to more arousal than simply maintaining
the emotional impact of the negative pictures in the BN group. The HC group’s LPP in the maintain condition returned to baseline at 632 ms, which is
around the same time as for the reappraisal condition.
Discussion
This study aimed to explore the neural bases of emotion processing and regulation in people with bulimia nervosa. We developed an EEG task which
we tested in females with BN (N = 32) and matched HC (N = 35). We rst conrmed that our BN group reported experiencing their emotions with
higher intensity and reported lower use of reappraisal compared to our HC group, conrming H1. We also found that our BN group showed higher LPP
compared to our HC group when viewing emotional pictures (H2). Our results also showed that participants with BN showed large LPP in the
reappraisal condition, whilst the LPP returned to baseline early on for our control participants, suggesting diculties implementing cognitive
reappraisal in our BN participants (H3). We discuss these results in turn.
It was no surprise to nd that our participants self-reported more emotional intensity and low usage of cognitive reappraisal compared to our HC as
this has been reported in the literature (Pret et al., 2019; Svaldi et al., 2012). However, it was interesting to see that the self-reported emotional
reactivity was reected in the more objective measure using the LPP. The literature is unclear as to whether emotional reactivity and emotion
regulation are one or two processes, as some authors suggest that emotional reactivity may
cause
diculties regulating emotions while others
suggest that emotion dysregulation may
lead to
emotional reactivity, while yet others suggest that these concepts are actually indistinguishable
(Gross & Barrett, 2011; Gross & Jazaieri, 2014; Nock et al., 2008; Zhang et al., 2023). Our experimental paradigm allowed us to separate these
processes by looking at emotional arousal during the processing stage, independently of the regulatory stage, and we found that people with BN do
seem to process their emotions with higher intensity. This is important because it suggests that new interventions working on emotions for people
with BN should target emotional intensity. For example, training could help them identify and label their emotions - which is something this group nds
challenging (Westwood et al., 2017) - because alexithymia is associated with emotional reactivity (Preece et al., 2020). A recent study showed that
helping people with EDs identify and label their emotions (amongst others) was linked to reduced alexithymia and ED behaviours (Vuillier et al., 2024).
Whilst the authors did not measure whether this improvement was mediated by reduced emotional reactivity, it is a possibility that future research
should explore.
Our study also reported on diculties successfully
implementing
cognitive reappraisal, which had not yet been explored in people with BN. The
extended process model (Gross, 2015) denes emotion regulation as the dynamic ways in which people detect emotions, determine that they want to
regulate them, and attempt to do so through selecting and implementing a strategy, forming an iterative cycle constantly in need of updating. For
example, if the existing selection and implementation decisions result in the desired outcome (for example reduced negative affect), then the person
can continue relying on these decisions in the future. But if the emotion does not change (or changes in undesirable ways), then the person may
decide to select a different strategy in the future (Gross & Ford, 2023). Here, we showed that reappraisal does not seem to work well to reduce distress
in people with BN, which may explain why they do not select this strategy in their daily life. Cognitive reappraisal is part of cognitive-behavioural
approaches that are frequently employed to challenge thoughts and feelings in Cognitive Behavioural Therapy (CBT), the current psychological gold
standard treatment for BN (NICE guideline, 2020). Our ndings show that simply telling people with BN to change the way they think about an
emotional situation will not actually result in lower distress.
Whilst this is the rst study demonstrating diculties implementing cognitive reappraisal in BN, this was not completely surprising. For example, it is a
well-known nding that people tend to refrain from using cognitive reappraisal in high-intensity emotion situations, for example preferring to use
distraction instead (McRae, 2016; Shar et al., 2015, 2016; Sheppes & Gross, 2011; Van Bockstaele et al., 2020). Cognitive reappraisal relies on
cognitive resources in working memory (Gan et al., 2017), so when cognitive resources are already recruited to
attend to
an emotional event, there
may not be enough left to
regulate
the emotion. This suggests that offering people other strategies such as distraction to disengage from the
emotional event at an early attentional stage may be more helpful. And indeed, Shar et al (2016) showed that when healthy participants exhibited
enhanced emotional intensity (measured by enhanced LPP) they were more likely to choose distraction over reappraisal, compared to low-intensity
trials. Distraction has an ambiguous status in the emotion regulation literature because it essentially does not help deal with the emotion; it simply
distracts the person whilst the emotion passes, but next time a similar emotional event comes back, the person will not be better equipped to deal

Page 7/12
with it. However, because distraction is helpful when the cognitive load is too intense, it could potentially be suggested as an alternative to the urge to
binge-eat or purge. A recently developed psycho-educational intervention on emotion regulation seems to support the use of distraction as an
effective strategy to help “ride the emotional wave”, before returning to the emotional situation and use other strategies such as reappraisal once
people are less emotionally aroused (Vuillier et al., 2024). We did not look at the effect of distraction on the LPP but future research should explore
whether in people with BN, distraction may reduce the LPP more than reappraisal.
Our study has many strengths, starting with the fact we used an objective measure of emotion intensity and regulation instead of relying on self-
reports which can be biased. Our sample with close to 70 participants is also large for an EEG study. However, our study has some limitations. First,
we only tested female participants for convenience purposes, despite the fact we know males with EDs also have diculties identifying and regulating
their emotions (Vuillier et al., 2022). There does also seem to be sex differences in the association between reappraisal and EDs, such that low
reappraisal use seems associated with higher ED cognition in females but not in males (Vuillier et al., 2022). It therefore remains to be tested whether
males with EDs can implement reappraisal successfully. We also only tested females with BN and whilst diculties with emotion regulation are
thought to be transdiagnostic (Pret et al., 2019), differences between ED categories have been observed (Meule et al., 2021; Puttevils et al., 2021). A
recent study found that people with AN found reappraisal less effective than control participants in a body exposure task (Crino et al., 2019), but it
remains to be seen whether this would also apply to emotional situations more generally, and across the ED spectrum. It is also important to note that
whilst we combined people with BN as one group to compare against a ‘healthy’ group, EDs are heterogeneous. A recent paper looking at an emotion-
based intervention for example found some variation in people’s preferences for reappraisal, with one participant saying they found reappraisal
“
particularly useful […] it helped calm me down and let me see things in perspective
”, whilst another said they have “
always struggled with reappraisal
because my mind feels like it gets tied in knots and jams up with questioning everything, and doesn’t know where to stop, and I end up not having a
clue how I feel
”. Incidentally the rst participant was male and the second female so it could be indeed due to sex differences although this would
need to be examined in more detail in future research.
Conclusion
Our paper showed that females with BN experience their emotions with more intensity and are not as successful in using cognitive reappraisal to
reduce emotional arousal compared to a healthy control group. These ndings have implications for adapting current evidence-based treatment, and
developing new emotion-based treatments for BN.
Abbreviations
AN
Anorexia Nervosa
ANOVA
Analyses of Variance
BN
Bulimia Nervosa
CBT
Cognitive Behaviour Therapy
DSM-5
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
ED
Eating Disorder
EDE-Q
Eating Disorder Examination Questionnaire
EEG
Electroencephalography
ERP
Event-Related Potential
ERS
Emotion Reactivity Scale
FDR
False Discovery Rate
HC
Healthy Control
IAPS
International affective Picture System
LPP
Late Positive Potential

Page 8/12
NHS
National Health Service
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki, and received ethical approval from the Research Ethics Panel at
Bournemouth University (Ref: 26501) as well as NHS ethical approval (IRAS ID: 254746; REC Ref: 19/NI/0086). All participants provided fully-informed
consent to take part in the study.
Consent for publication
Consent to publish anonymised data was granted by participants when consenting to take part in the study.
Competing interests
The authors declare that they have no competing interests.
Funding
LV received funding from the British Academy for this project (Ref: SRG1819190146). LV and XH are salaried staff at Bournemouth University, and SH
conducted her MSc at Bournemouth University. ZW is a PhD student at Durham University. AH and MPS are salaried staff at University College
London. The views expressed are those of the authors and not necessarily those of their aliations.
Author Contribution
LV designed the study and received funding from the British Academy. ZW and SH collected the data under the supervision of LV. AH conrmed
diagnosis of patients with BN. ZW analysed the data under the supervision of LV and XE. LV wrote the introduction and discussion sections. LV and
ZW wrote the methods section. ZW wrote the result section and prepared the Figures. All authors read and approved the nal manuscript.
Acknowledgement
We would like to thank all students who helped collect this data, namely: Samantha Sewell, Daniel Pearson, Lauren Mose, Bridget Greenslade, Nicola
Travis, and Isabel Green, as well as Itunuoluwa Oladokun. We would also like to thank all our participants for their generous time and help with this
research: thank you!
Data Availability
The datasets generated and/or analysed during the current study are available in the Bournemouth Online Research Data Depository (BORDaR)
repository (https://bordar.bournemouth.ac.uk/) or are available from the corresponding author.
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Figures

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Figure 1
ERG grand average for emotion processing, with the healthy control group (HC) in blue and the Bulimia Nervosa group (BN) in blue).
Figure 2
ERG grand average for emotion regulation, with the healthy control group (HC) in blue and the Bulimia Nervosa group (BN) in blue). The grand average
ERP for the maintain condition are presented in full lines, while the reappraisal condition is presented in dashed lines.

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