Emotion regulation, emotion recognition, and empathy in adolescents with anorexia nervosa

  • Kevser NalbantEmail author
  • Bilge Merve Kalaycı
  • Devrim Akdemir
  • Sinem Akgül
  • Nuray Kanbur
Original Article
Part of the following topical collections:
  1. Personality and Eating and Weight disorders



Emotional functions may play an important role in anorexia nervosa (AN). The onset of the disorder generally occurs during adolescence, which is a critical period of emotional development. However, most studies that evaluated emotional functions in AN were conducted in adult patients. The aim of this study was to evaluate emotion regulation, emotion recognition, and empathy skills in adolescent girls with AN by controlling for the effects of depression and anxiety symptoms, childhood traumatic experiences, and attachment security on emotional functions.


Thirty-two adolescent girls with AN and 32 healthy counterparts completed the Difficulties in Emotion Regulation Scale, the Reading the Mind in the Eyes Test, Toronto Alexithymia Scale-20, and the Child and Adolescent KA-SI Empathic Tendency Scale-Adolescent Form.


The results revealed that adolescents with AN were found to have more difficulties in emotion regulation, higher alexithymic tendencies, and lower empathy skills compared with the control group. However, emotion recognition was not found to be significantly different between the two groups. These results were the same when controlling for the effects of depression and anxiety symptoms, childhood traumatic experiences, and attachment security except for empathy skills. Alexithymia and depressive symptoms were significantly related to emotion regulation difficulties in adolescents with AN.


Considering the results, it seems that emotion regulation and alexithymia may play a crucial role in the development and maintenance of AN. Accordingly, it is necessary to focus on the improvement of these skills during the treatment of AN. Furthermore, interventions promoting these skills during adolescence may be preventive.

Level of evidence

Level III, case–control study.


Adolescent Anorexia nervosa Emotion regulation Emotion recognition Alexithymia Empathy 


Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This research was approved by the Ethics Committee of the Hacettepe University, Medical Faculty.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Smink FR, van Hoeken D, Hoek HW (2012) Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep 14(4):406–414. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR (2011) Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry 68(7):714–723. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Bulik CM (2014) The challenges of treating anorexia nervosa. Lancet 383(9912):105–106. CrossRefPubMedGoogle Scholar
  4. 4.
    Lavender JM, Wonderlich SA, Engel SG, Gordon KH, Kaye WH, Mitchell JE (2015) Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: a conceptual review of the empirical literature. Clin Psychol Rev 40:111–122. CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Oldershaw A, Startup H, Lavender T (2019) Anorexia nervosa and a lost emotional self: a psychological formulation of the development, maintenance, and treatment of anorexia nervosa. Front Psychol 10:219. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Sloan E, Hall K, Moulding R, Bryce S, Mildred H, Staiger PK (2017) Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: a systematic review. Clin Psychol Rev 57:141–163. CrossRefPubMedGoogle Scholar
  7. 7.
    Aldao A, Nolen-Hoeksema S, Schweizer S (2010) Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev 30(2):217–237. CrossRefPubMedGoogle Scholar
  8. 8.
    Gross JJ (1998) Antecedent-and response-focused emotion regulation: divergent consequences for experience, expression, and physiology. J Pers Soc Psychol 74(1):224CrossRefGoogle Scholar
  9. 9.
    Mendes AL, Ferreira C, Marta-Simoes J (2017) Experiential avoidance versus decentering abilities: the role of different emotional processes on disordered eating. Eat Weight Disord 22(3):467–474. CrossRefPubMedGoogle Scholar
  10. 10.
    Svaldi J, Griepenstroh J, Tuschen-Caffier B, Ehring T (2012) Emotion regulation deficits in eating disorders: a marker of eating pathology or general psychopathology? Psychiatry Res 197(1–2):103–111. CrossRefPubMedGoogle Scholar
  11. 11.
    Harrison A, Tchanturia K, Treasure J (2010) Attentional bias, emotion recognition, and emotion regulation in anorexia: state or trait? Biol Psychiat 68(8):755–761CrossRefGoogle Scholar
  12. 12.
    Brockmeyer T, Skunde M, Wu M, Bresslein E, Rudofsky G, Herzog W, Friederich H-C (2014) Difficulties in emotion regulation across the spectrum of eating disorders. Compr Psychiatry 55(3):565–571CrossRefGoogle Scholar
  13. 13.
    Weinbach N, Sher H, Bohon C (2018) Differences in emotion regulation difficulties across types of eating disorders during adolescence. J Abnorm Child Psychol 46(6):1351–1358. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kolar DR, Hammerle F, Jenetzky E, Huss M, Burger A (2016) Aversive tension in female adolescents with Anorexia Nervosa: a controlled ecological momentary assessment using smartphones. BMC Psychiatry 16:97. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Adolphs R (2003) Cognitive neuroscience of human social behaviour. Nat Rev Neurosci 4(3):165–178. CrossRefPubMedGoogle Scholar
  16. 16.
    Hall JA, Andrzejewski SA, Yopchick JE (2009) Psychosocial correlates of interpersonal sensitivity: a meta-analysis. J Nonverbal Behav 33(3):149–180CrossRefGoogle Scholar
  17. 17.
    Oldershaw A, Hambrook D, Stahl D, Tchanturia K, Treasure J, Schmidt U (2011) The socio-emotional processing stream in Anorexia Nervosa. Neurosci Biobehav Rev 35(3):970–988. CrossRefPubMedGoogle Scholar
  18. 18.
    Schmidt U, Treasure J (2006) Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol 45(Pt 3):343–366CrossRefGoogle Scholar
  19. 19.
    Caglar-Nazali HP, Corfield F, Cardi V, Ambwani S, Leppanen J, Olabintan O, Deriziotis S, Hadjimichalis A, Scognamiglio P, Eshkevari E (2014) A systematic review and meta-analysis of ‘systems for social processes’ in eating disorders. Neurosci Biobehav Rev 42:55–92CrossRefGoogle Scholar
  20. 20.
    Zonnevijlle-Bender MJ, van Goozen SH, Cohen-Kettenis PT, van Elburg A, van Engeland H (2002) Do adolescent anorexia nervosa patients have deficits in emotional functioning? Eur Child Adolesc Psychiatry 11(1):38–42CrossRefGoogle Scholar
  21. 21.
    Hatch A, Madden S, Kohn MR, Clarke S, Touyz S, Gordon E, Williams LM (2010) Emotion brain alterations in anorexia nervosa: a candidate biological marker and implications for treatment. J Psychiatry Neurosci 35(4):267–274CrossRefGoogle Scholar
  22. 22.
    Lule D, Schulze UM, Bauer K, Scholl F, Muller S, Fladung AK, Uttner I (2014) Anorexia nervosa and its relation to depression, anxiety, alexithymia and emotional processing deficits. Eat Weight Disord 19(2):209–216. CrossRefPubMedGoogle Scholar
  23. 23.
    Laghi F, Pompili S, Zanna V, Castiglioni MC, Criscuolo M, Chianello I, Baumgartner E, Baiocco R (2015) Are adolescents with anorexia nervosa better at reading minds? Cogn Neuropsychiatry 20(6):489–501. CrossRefPubMedGoogle Scholar
  24. 24.
    Sfarlea A, Greimel E, Platt B, Dieler AC, Schulte-Korne G (2018) Recognition of emotional facial expressions in adolescents with anorexia nervosa and adolescents with major depression. Psychiatry Res 262:586–594. CrossRefPubMedGoogle Scholar
  25. 25.
    Peres V, Corcos M, Robin M, Pham-Scottez A (2018) Emotional intelligence, empathy and alexithymia in anorexia nervosa during adolescence. Eat Weight Disord. CrossRefPubMedGoogle Scholar
  26. 26.
    Parker JD, Michael Bagby R, Taylor GJ, Endler NS, Schmitz P (1993) Factorial validity of the 20-item Toronto Alexithymia Scale. Eur J Pers 7(4):221–232CrossRefGoogle Scholar
  27. 27.
    Nowakowski ME, McFarlane T, Cassin S (2013) Alexithymia and eating disorders: a critical review of the literature. J Eat Disord 1:21. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Russell TA, Schmidt U, Doherty L, Young V, Tchanturia K (2009) Aspects of social cognition in anorexia nervosa: affective and cognitive theory of mind. Psychiatry Res 168(3):181–185. CrossRefPubMedGoogle Scholar
  29. 29.
    Gillberg IC, Billstedt E, Wentz E, Anckarsäter H, Råstam M, Gillberg C (2010) Attention, executive functions, and mentalizing in anorexia nervosa eighteen years after onset of eating disorder. J Clin Exp Neuropsychol 32(4):358–365CrossRefGoogle Scholar
  30. 30.
    Baron-Cohen S, Jaffa T, Davies S, Auyeung B, Allison C, Wheelwright S (2013) Do girls with anorexia nervosa have elevated autistic traits? Mol Autism 4(1):24. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Jennissen S, Holl J, Mai H, Wolff S, Barnow S (2016) Emotion dysregulation mediates the relationship between child maltreatment and psychopathology: a structural equation model. Child Abuse Negl 62:51–62. CrossRefPubMedGoogle Scholar
  32. 32.
    Monteleone AM, Ruzzi V, Patriciello G, Pellegrino F, Cascino G, Castellini G, Steardo L Jr, Monteleone P, Maj M (2019) Parental bonding, childhood maltreatment and eating disorder psychopathology: an investigation of their interactions. Eat Weight Disord. CrossRefPubMedGoogle Scholar
  33. 33.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub, ArlingtonCrossRefGoogle Scholar
  34. 34.
    Kreipe RE, Golden NH, Katzman DK, Fisher M, Rees J, Tonkin RS, Silber TJ, Sigman G, Schebendach J, Ammerman SD et al (1995) Eating disorders in adolescents. A position paper of the Society for Adolescent Medicine. J Adolesc Health 16(6):476–479PubMedGoogle Scholar
  35. 35.
    Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N (1997) Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36(7):980–988CrossRefGoogle Scholar
  36. 36.
    Gökler B, Ünal F, Pehlivantürk B, Kültür EÇ, Akdemir D, Taner Y (2004) Okul Çaği Çocuklari için Duygulanim Bozukluklari ve Şizofreni Görüşme Çizelgesi -Şimdi ve Yaşam Boyu Şekli - Türkçe Uyarlamasinin Geçerlik ve Güvenirliği [Reliability and Validity of Schedule for Affective Disorders and Schizophrenia for School Age Children--Present and Lifetime Version--Turkish Version (K-SADS-PL-T)]. Çocuk ve Gençlik Ruh Sağliği Dergisi 11(3):109–116Google Scholar
  37. 37.
    Garner DM, Garfinkel PE (1979) The eating attitudes test: an index of the symptoms of anorexia nervosa. Psychol Med 9(02):273–279CrossRefGoogle Scholar
  38. 38.
    Savaşır I (1989) Erol N. Yeme tutum testi: Anoreksiya nervoza belirtiler indeksi Psikoloji Dergisi 7:19–25Google Scholar
  39. 39.
    Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess 26(1):41–54CrossRefGoogle Scholar
  40. 40.
    Neumann A, van Lier PA, Gratz KL, Koot HM (2010) Multidimensional assessment of emotion regulation difficulties in adolescents using the Difficulties in Emotion Regulation Scale. Assessment 17(1):138–149. CrossRefPubMedGoogle Scholar
  41. 41.
    Sarıtaş D, Gençöz T (2011) Ergenlerin duygu düzenleme güçlüklerinin, annelerinin duygu düzenleme güçlükleri ve çocuk yetiştirme davranışları ile ilişkisi. Çocuk ve Gençlik Ruh Sağlığı Dergisi 18(2):117–126Google Scholar
  42. 42.
    Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I (2001) The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J Child Psychol Psychiatry 42(2):241–251CrossRefGoogle Scholar
  43. 43.
    Baron-Cohen S, Wheelwright S, Spong A, Scahill V, Lawson J (2001) Are intuitive physics and intuitive psychology independent? A test with children with Asperger Syndrome. J Dev Learn Dis 5(1):47–78Google Scholar
  44. 44.
    Girli A (2014) Psychometric properties of the Turkish child and adult form of “Reading the Mind in the Eyes Test”. Psychology 5:1321–1337. CrossRefGoogle Scholar
  45. 45.
    Bagby RM, Parker JD, Taylor GJ (1994) The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. J Psychosom Res 38(1):23–32CrossRefGoogle Scholar
  46. 46.
    Bagby RM, Taylor GJ, Parker JD (1994) The twenty-item Toronto Alexithymia Scale—II. Convergent, discriminant, and concurrent validity. J Psychosom Re 38(1):33–40CrossRefGoogle Scholar
  47. 47.
    Güleç H, Köse S, Güleç MY, Çitak S, Evren C, Borckardt J, Sayar K (2009) Reliability and factorial validity of the Turkish version of the 20-item Toronto alexithymia scale (TAS-20). Klinik Psikofarmakol Bulteni 19(3):214–220Google Scholar
  48. 48.
    Kaya A, Siyez DM (2010) KA-Sİ çocuk ve ergenler için empatik eğilim ölçeği: Geliştirilmesi geçerlik ve güvenirlik çalışması. Eğitim ve Bilim 35(156).
  49. 49.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4(6):561–571CrossRefGoogle Scholar
  50. 50.
    Hisli N (1989) Beck Depresyon Envanterinin üniversite öğrencileri için geçerliği, güvenirliği. Psikoloji dergisi 7(23):3–13Google Scholar
  51. 51.
    Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, Neer SM (1997) The screen for child anxiety related emotional disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry 36(4):545–553. CrossRefPubMedGoogle Scholar
  52. 52.
    Karaceylan Çakmakçı F (2004) Çocuklarda Anksiyete Bozukluklarını Tarama Ölçeği geçerlik ve güvenirlik çalışması. Unpublished Expertise Thesis, Department of child and adolescent psychiatry Kocaeli University, Faculty of Medicine, KocaeliGoogle Scholar
  53. 53.
    Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, Sapareto E, Ruggiero J (1994) Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry 151(8):1132CrossRefGoogle Scholar
  54. 54.
    Sar V, Ozturk E, Ikikardes E (2012) Çocukluk çağı ruhsal travma ölçeğinin Türkçe uyarlamasının geçerlilik ve güvenirliği. Turkiye Klinikleri J Med Sci 32(4):1054–1063CrossRefGoogle Scholar
  55. 55.
    Armsden GC, Greenberg MT (1987) The inventory of parent and peer attachment: individual differences and their relationship to psychological well-being in adolescence. J Youth Adolesc 16(5):427–454CrossRefGoogle Scholar
  56. 56.
    Raja SN, McGee R, Stanton WR (1992) Perceived attachments to parents and peers and psychological well-being in adolescence. J Youth Adolesc 21(4):471–485CrossRefGoogle Scholar
  57. 57.
    Günaydın G, Selçuk E, Sümer N, Uysal A (2005) Ebeveyn ve arkadaşlara bağlanma envanteri kısa formu’nun psikometrik açıdan değerlendirilmesi. Türk Psikoloji Yazıları 8(16):13–23Google Scholar
  58. 58.
    Torres S, Guerra MP, Miller K, Costa P, Cruz I, Vieira FM, Brandao I, Roma-Torres A, Rocha M (2019) Factorial validity of the toronto alexithymia scale (tas-20) in clinical samples: a critical examination of the literature and a psychometric study in anorexia nervosa. J Clin Psychol Med Settings 26(1):33–46. CrossRefPubMedGoogle Scholar
  59. 59.
    Speranza M, Loas G, Wallier J, Corcos M (2007) Predictive value of alexithymia in patients with eating disorders: a 3-year prospective study. J Psychosom Res 63(4):365–371. CrossRefPubMedGoogle Scholar
  60. 60.
    Davies H, Schmidt U, Stahl D, Tchanturia K (2011) Evoked facial emotional expression and emotional experience in people with anorexia nervosa. The International journal of eating disorders 44(6):531–539. CrossRefPubMedGoogle Scholar
  61. 61.
    Davies H, Swan N, Schmidt U, Tchanturia K (2012) An experimental investigation of verbal expression of emotion in anorexia and bulimia nervosa. Eur Eat Disord Rev 20(6):476–483. CrossRefPubMedGoogle Scholar
  62. 62.
    Harrison A, Sullivan S, Tchanturia K, Treasure J (2009) Emotion recognition and regulation in anorexia nervosa. Clin Psychol Psychother 16(4):348–356. CrossRefPubMedGoogle Scholar

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Authors and Affiliations

  1. 1.Department of Child and Adolescent Psychiatry, Medical FacultyHacettepe UniversityAnkaraTurkey
  2. 2.Department of Child and Adolescent Psychiatry, Medical Faculty, Training and Research HospitalYildirim Beyazıt UniversityAnkaraTurkey
  3. 3.Division of Adolescent Medicine, Department of Pediatrics, Medical FacultyHacettepe UniversityAnkaraTurkey

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