Abstract
Attachment and emotion regulation affect various aspects of an individual’s life throughout the lifespan and into adulthood, and are known to be associated with various psychopathologies. Based on a review of the literature, attachment styles and the management of negative emotions have a significant role in the development and maintenance of Binge Eating Disorder (BED). Previous studies have found that insecure attachment styles increase the risk of developing BED, but the role of emotion regulation difficulties has not been assessed. The aim of the current study is to examine the role of emotion regulation difficulties in the relationship between insecure attachment styles and symptoms of BED. The sample of the current study consisted of 364 participants (238 females, 126 males) aged 18–65 years (M = 35.27, SD = 10.00) residing in different provinces of Turkey. Sociodemographic information form, Binge Eating Disorder Scale (BEDS), Difficulty in Emotion Regulation Scale-Short Form (DERS-16), and Inventory of Experiences in Close Relationships-2 were administered to the participants. The results of the present study showed that difficulties in emotion regulation played a mediating role in the relationship between symptoms of BED and avoidant and anxious attachment styles. The results of the current study highlight the importance of clinicians assessing attachment styles and emotion regulation difficulties, examining the interaction of these variables together, and providing interventions accordingly when faced with symptoms of BED.
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Introduction
Eating behaviour is known as a situation that includes psychological and social dimensions, as well as meeting the needs for biological development and physiological functions. In addition, Ünlü (2011) stated that eating behaviour is affected by both physiological and psychological factors. Match and Simon (2000) stated that stress and negative mood can increase or decrease eating behaviour. Considering the individual factors that are effective in the emergence of disordered eating attitudes and behaviours, it can be seen that positive and negative emotions can shape the eating attitudes and behaviours of individuals, and the disordered eating attitudes and behaviours found in individuals can increase in relation to maladaptive strategies used in emotion regulation (Leblebicioğlu, 2018). Binge Eating Disorder (BED) is a well-established eating disorder that is characterized by recurrent episodes of binge eating (Dingemans et al., 2002). Individuals with BED tend to eat alone, experience loss of control while eating, and feel shame, guilt, or depression about the amount of food they consume (Hilbert, 2019). It is important to note that this description is based on objective criteria and has been thoroughly researched. Individuals with BED tend to eat alone, experience loss of control while eating, and feel shame, guilt, or depression about the amount of food they consume (Wilson, 2011). Individuals who struggle with impulsive eating behavior often have difficulty regulating their emotions in response to negative life events (Pike et al., 2006). Poor emotion regulation can lead to binge eating episodes, perpetuating a cycle (Hilbert, 2019).
Emotion regulation is most commonly defined as changing an individual’s emotions according to external demands (Gross, 2002). Emotion regulation skills in which the person is aware of emotions, maintains psychological well-being, and makes sense of the emotions that are challenging the person are known as successful emotion regulation (Gratz & Roemer, 2004). However, it is thought that a high level of this condition may reveal BED, which is known as abnormal eating behaviour (Aytin, 2014). Individuals with eating disorders are known to have lower levels of emotional openness and awareness, lower levels of emotional acceptance, and higher levels of emotion regulation difficulties and emotion regulation intensity than healthy individuals (Fairburn & Harrison, 2003). Many previous studies have shown that people with eating disorders lack strategies for coping with negative mood and have difficulties in emotion regulation, and it is thought that deficits in emotion regulation may lead to impairments in eating behaviour (Aytin, 2014; Sim & Zeman, 2006).
In addition to emotion regulation difficulties, attachment styles are also predictive of eating behaviours (Sim & Zeman, 2005). Attachment is known as the relationship between the caregiver and the child that begins, continues and is shaped before the child is born (Siegel, 2012). There is a large number of studies on attachment theories, and much of the research data suggests a relationship between psychopathologies and eating disorders (Aytin, 2014; Zimmerman & Becker-Stoll, 2002). Attachment styles, such as eating attitudes, are thought to be formed in infancy and influence emotion regulation processes and affect all of the individual’s close relationships throughout life (Aytin, 2014). According to the common findings of studies in the literature, people focus on their own bodies in early adolescence, when intense biological developments are observed (Zimmerman & Becker-Stoll, 2002). In eating disorders, attention shifts to the body through externalising behaviours as the body changes, and eating disorders can occur with the behaviours of starving, purging and binge eating (Alantar & Maner, 2008). In this regard, it can be predicted that attachment styles will be shaped by emotion regulation strategies and eating disorders from childhood and adolescence. In this regard, it is thought that addressing the variables across a broad age range will reveal the age range in which these behaviours are more prevalent.
Objectives and hypotheses
As a result of the present study, the contribution to the literature by identifying the role of emotion dysregulation in the relationship between insecure attachment styles and levels of binge eating disorder is considered to shed light on future research. The problematic attachment that develops between the caregiver and the infant may lead to problems in emotion regulation processes and, consequently, to many psychopathologies such as eating disorders (Aytin, 2014). Bowlby and Ainsworth (1978) proposed the Attachment Theory, which suggests that attachment styles developed in early childhood can have an impact on adult relationships. The theory also explains how emotion regulation processes can be affected in adult relationships. Problematic attachment styles, such as avoidant and anxious attachment, can lead to emotional dysregulation in adulthood, which may result in behavioral issues, such as eating disorders (Tasca, 2019). For this reason, the current study provides important details by examining attachment styles, levels of BED and emotion regulation difficulties of individuals. The present study aimed to examine the relationship between the level of binge eating disorder and attachment styles and emotion dysregulation difficulties in adult individuals. Therefore, this study examined whether the level of emotion dysregulation difficulties has a mediating role in the relationship between avoidant and anxious attachment styles and BED.
H1
Emotion dysregulation plays a mediating role in the relationship between anxious attachment style and BED.
H2
Emotion dysregulation plays a mediating role in the relationship between avoidant attachment style and BED.
Method
Sample
The sample of the current study consisted of 364 participants (238 females, 126 males), aged between 18 and 65 years (M = 35.27, SD = 10.00), living in different provinces of Turkey, who voluntarily agreed to participate in the study. It was found that the majority of the participants had a university or higher education, were employed and were in a romantic relationship or married. In addition, the BMI status of the participants ranged from 14.98 to 38.28, and the sample mean was found to be within the limits of normal BMI values (M = 25.01, SD = 4.17). The socio-demographic information of the participants is shown in Table 1.
Data collection tools
Sociodemographic information form
The form prepared by the researchers included questions about participants’ age, gender, employment status, educational status, weight, height, smoking and alcohol use, and whether they were taking psychiatric medication.
Binge eating disorder scale (BEDS)
It was first developed by Gormally et al. (1982) as the Binge Eating Scale (BES) to determine the level of BED symptoms. The validity and reliability study the Turkish sample was conducted by Tosyalı (2021). The scale consists of a single factor and 16 items as in the original form. It was found that the internal consistency coefficient of the original scale (α = 0.85) and the Turkish form (α = 0.83) were similar. Although the scale consists of a single dimension, it assesses both cognitive and behavioural factors. In this measurement tool, there are items such as “I avoid communicating with people because of this self-awareness”, “I have a habit of swallowing food without chewing”, “Eating when I am bored is a constant habit of mine”. High scores on the scale indicate an increase in BED symptoms.
Difficulty in emotion regulation scale-short form (DRE-16)
The scale was developed by Gratz and Roemer (2004) to measure the difficulties that individuals experience in emotion regulation. The short form of the scale was developed by Bjureberg and colleagues (2016). The validity and reliability study of the short form of the scale the Turkish sample was conducted by Yiğit and Guzey-Yiğit (2019), and the Cronbach alpha internal consistency value was found to be α = 0.92. The measurement tool consists of 5 sub-dimensions named as “openness“, “goals”, “impulse”, “strategies” and “non-acceptance” and a total of 16 items. This measurement tool includes items such as “I have difficulty making sense of my emotions”, “I have difficulty finishing my work when I feel bad”, “I have difficulty focusing on other things when I feel bad”. High scores on the scale indicate a high level of difficulty in emotion regulation.
Inventory of experiences in close relationships-2 (inventory of experiences in close relationships-2)
The scale developed by Franley et al. (2000) to determine the level of avoidant and anxious attachment styles consists of a total of 36 items and 2 sub-dimensions. The reliability and validity study of the scale the Turkish sample was conducted by Selçuk et al. (2005). The developed scale has a similar number of questions and factors to its original structure, and the internal consistency coefficients were calculated as α = 0.86 for the anxiety factor and α = 0.90 for the avoidance factor. The extent to which the items in the scale reflect participants’ feelings and thoughts in their romantic relationships is rated on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree), and the two factors are scored separately, making it impossible to obtain a total score the scale. For both sub-dimensions, the lowest score that can be obtained from the scale is 18 and the highest score is 126. An increase in the scores obtained from the scale indicates an increase in the levels of anxious and avoidant attachment styles. This measurement tool includes items such as “I am afraid of losing the love of the person I am in a romantic relationship with”, “I am very comfortable being close to the people I am in a romantic relationship with”, “I feel uncomfortable when the person I am in a romantic relationship with wants to be very close to me”.
Procedure
The present study was conducted using a quantitative and cross-sectional research method. Ethical committee approval was obtained from Istanbul Arel University (date: 30.03.2023-261,382, decision number: E-52857131-050.06.04-261382). In addition to the socio-demographic information form, an informed voluntary consent form was presented to the participants before presenting the questionnaire consisting of three scales that were psychometrically suitable for use and whose validity and reliability studies were conducted the Turkish sample, and the study continued with the participants who voluntarily agreed to participate in the study. The prepared questionnaire form was delivered to the participants residing in different provinces of Turkey via online surveys, and in this context, the sample of the study was selected by random sampling. It took an average of 15 min to complete the questionnaire form.
Statistical analyses
Prior to data analysis, the data were examined and it was determined that the kurtosis and skewness values of the scores were within the range of +/− 1.5 (Tabachnick & Fidell, 2013), which is known to be accepted as a normal distribution. Descriptive and correlational analyses of the data were performed using IBM SPSS v.26 software. The examination of the role of emotion dysregulation in the relationship between BED symptoms and attachment styles was tested using the PROCESS macro v.3.1 plug-in (Hayes, 2013).
Results
The sample of the study was grouped into two as low and high BED level on the basis of the cut-off score of BEDS (BEDS cut-off point = 17). In this context, it was determined that there were 126 participants with low and 238 participants with high BED symptoms. Then, an independent sample t-test was conducted to determine how attachment styles and difficulties in emotion dysregulation differed in terms of BED level. There was a significant difference in anxious attachment style between low level BED (M = 49.1, SD = 16.58) and high level BED (M = 53.0, SD = 16.79); t(362) = − 2.10, p =.03, d = − 0.23. There was a significant difference in avoidant attachment style between low level BED (M = 49.7, SD = 16.85) and high level BED (M = 54.2, SD = 16.51); t(362) = − 2.23, p =.02, d = − 0.25. Finally, there was a significant difference in emotion dysregulation between low level BED (M = 28.9, SD = 8.61) and high level BED (M = 34.7, SD = 9.93); t(362) = − 5.58, p <.001, d = − 0.61.
In the present study, Pearson correlation analysis was used to determine the relationships between symptoms of BED and adult attachment styles and emotion regulation difficulties. The relationships between the variables used in the study are shown in Table 2. Analysis of the table shows that there is a positive and significant relationship between BED symptoms and avoidant attachment style (r =.27; p <.01) and a positive and significant relationship with anxious attachment style (r =.24; p <.01). In addition, there was a positive and significant relationship between BED symptoms and emotion regulation difficulties (r =.47; p <.01).
Figure 1 presents the results of the process analysis examining the mediating role of emotion dysregulation in the relationship between BED and anxious attachment levels. As can be seen in the figure, while the level of anxious attachment positively and significantly predicts the level of emotion dysregulation (B = 0.29, SE.= 0.006, t = 5.87, p <.001), the level of emotion dysregulation positively and significantly predicts the level of BED symptoms (B = 0.30, SE.= 0.21, t = 5.97, p <.001). When the emotion regulation difficulties variable was added to the model, the overall effect of anxious attachment level on the level of BED (B = 0.24, SE.= 0.02, t = 4.70, CI.= 0.07 − 0.16, p <.001) decreased (B = 0.15, SE.= 0.02, t = 2.94, CI.= 0.02 − 0.12, p <.001). According to Preacher and Hayes (2004), if the relationship between two variables decreases when a third variable is added, provided that it is different from zero, this variable has a mediating role. In this direction, it was found that the indirect effect of anxious attachment level on BED symptoms through emotion dysregulation level was significant (B = 0.24, SE.= 0.02, t = 4.70, CI.= 0.07 − 0.16, p <.001). Furthermore, when the variables were evaluated within the model, the model was found to be significant (F(2, 361) = 30.95, p <.001) and explained 24% of the variance.
Figure 2 shows the results of the process analysis examining the mediating role of levels of emotion dysregulation in the relationship between BED and levels of avoidant attachment. Analysis of Fig. 2 shows that the level of avoidant attachment positively and significantly predicts the level of emotion dysregulation (B = 0.14, SE.= 0.007, t = 2.65, p <.001), and the level of emotion dysregulation positively and significantly predicts the level of BED symptoms (B = 0.34, SE.= 0.20, t = 6.76, p <.001). When the emotion regulation difficulty variable was included in the model, the overall effect of avoidant attachment level on the level of BED symptoms (B = 0.24, SE.= 0.02, t = 4.70, CI.= 0.07 − 0.16, p <.001) decreased (B = 0.14, SE.= 0.02, t = 3.14, CI.= 0.06 − 0.20, p <.001). According to Preacher and Hayes (2004), if the relationship between two variables decreases when a third variable is added, this variable has a mediating role. In this regard, it was found that the indirect effect of avoidant attachment level on BED symptoms through emotion dysregulation level was significant (B = 0.24, SE.= 0.02, t = 4.70, CI.= 0.07 − 0.16, p <.001). Finally, the model analysed was found to be significant (F(2, 361) = 29.70, p <.001) and explained 22% of the variance.
Discussion
Emotional factors play an important role in the development and maintenance of binge eating disorder (Keski-Rahkonen, 2021). Difficulties in emotional regulation may lead to the onset of binge eating episodes. This is because individuals may turn to food to cope with negative emotions or to calm themselves (Dingemans et al., 2017). Furthermore, insecure attachment styles, such as avoidant or anxious attachment, may increase the risk of developing binge eating disorder by influencing difficulties in emotion regulation (Tasca et al., 2011; Tasca & Balfour, 2014; Ward et al., 2000). The current study examined the role of emotion regulation difficulties in the relationship between BED symptoms and adult attachment styles. The present study found that there was a relationship between BED symptoms and avoidant and anxious attachment styles and emotion regulation difficulties. This finding suggests that adults who develop avoidant and anxious attachment styles and who have difficulties in emotion regulation may have more symptoms of BED.
The relationship between emotion regulation difficulties and BED is known to be bidirectional. Huseynbalayeva and Emek-Savaş (2023) found in their study that symptoms of BED may lead to negative emotions such as shame and sadness, and the individual may have difficulties in emotion regulation, and at the same time, the individual’s difficulties in emotion regulation may lead to binge eating when faced with negative situations. Furthermore, they may also have difficulty in controlling impulsive behaviours in response to emotional stress (Svaldi et al., 2019). Furthermore, the results of the current study show that difficulties in emotion regulation play a mediating role in the relationship between BED symptoms and anxious and avoidant attachment styles. This finding suggests that individuals who develop avoidant and anxious attachment styles may experience emotion regulation difficulties, which may increase BED symptoms. This finding of the study confirms both the nature of BED and the findings of studies in the relevant literature. In light of the literature, individuals with anxious attachment styles may experience high levels of emotional reactivity and struggle with emotion regulation. Studies suggest that individuals with symptoms of BED are more likely to have anxious attachment patterns (Hertz et al., 2012; Troisi et al., 2006). These individuals may turn to binge eating as a way of coping with feelings of anxiety and distress, or to regulate feelings related to attachment-related insecurities (O’Shaughnessy & Dallos, 2009; Troisi et al., 2005; Tasca et al., 2011). Individuals with an avoidant attachment style tend to avoid emotional intimacy and may have difficulty trusting others, preferring to rely on themselves. Studies suggest that individuals with symptoms of BED may also exhibit avoidant attachment patterns (Cameron et al., 2019; Salzman, 1997; Tasca & Balfour, 2014). Moreover, it shows that individuals with avoidant attachment style may be more prone to emotional dysregulation and accordingly have a higher risk of developing BED (Tasca & Balfour, 2014). With avoidant attachment style, individuals may engage in binge eating behaviour as a way of coping with emotional problems or to create emotional distance with others. For these individuals, binge eating may function as a way to create a physical barrier or suppress emotions, providing temporary relief from fears related to emotional closeness and attachment (Cameron et al., 2019). This attachment avoidance behaviour may lead to difficulties in emotion regulation (Shakory et al., 2015). In other words, binge eating behaviours may serve as a way of coping with anxiety, regulating emotions or seeking comfort. However, since this feeling of relief occurs after a maladaptive emotion regulation strategy, it lasts for a very short time and is followed by feelings of shame, sadness and guilt. It is suggested that this vicious cycle plays a role in the maintenance of BED (O’Shaughnessy & Dallos, 2009).
Limitations
The present study has some limitations. Firstly, in this study, symptoms of BED were assessed in a non-clinical sample. In addition, considering the complex nature of BED and the possibility of other comorbid disorders, it may be important to address the psychiatric history of the participants. In terms of the generalisability of the findings, it is recommended that future studies should work with clinical samples or conduct their research within the scope of a comparative model of two samples when they examine the relationship between attachment styles and symptoms of BED. In addition, early experiences are very important in the development of attachment styles. Attachment styles are thought to develop through interactions with primary caregivers in early childhood (McLeod, 2009). Adverse childhood experiences such as neglect, abuse or inconsistent caregiving behaviours may affect attachment development and increase the risk of developing both TIP and insecure attachment styles. For this reason, it is thought to be important to evaluate early experiences in research. In addition, another limitation of the current study is related to the research design. Since the current study is a cross-sectional (relational) study, the measurements were taken in a single time period and limited to this. For this reason, instead of causal inferences, the findings obtained were interpreted relationally. Since these variables are participant variables, it is thought that conducting qualitative and longitudinal studies will provide a deeper perspective.
An examination of the related literature revealed that there were no studies examining the role of emotion regulation difficulties in the relationship between BED symptoms and adult attachment styles. The current study is unique in this respect. In addition, it is thought that the wide age range of the study sample increases the generalisability of the study. Finally, since the sample of the current study consisted of individuals living in different provinces of Turkey and differing in terms of socio-demographic characteristics, the findings cannot be generalised to the Turkish sample.
Conclusion
Besides having limitations, the present study is unique in that it is the first study to examine the role of emotion regulation difficulties in the relationship between symptoms of BED and insecure attachment styles. In this respect, it is thought that the study contributes to the related literature in scientific terms. The findings of the current study reveal that individuals with symptoms of BED may have insecure attachment styles and may experience emotion regulation difficulties. For this reason, it is thought that it is important to examine attachment styles and emotion regulation difficulties in individuals who apply to therapy with symptoms of BED, to evaluate which areas of the individual’s life they affect, and to evaluate behavioural interventions and cognitive restructuring.
Data availability
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
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Bekmezci, Z., Çağatay, S.E. Investigation of the role of difficulty in emotion regulation in the relationship between attachment styles and binge eating disorder. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-05968-9
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DOI: https://doi.org/10.1007/s12144-024-05968-9