Distress tolerance is linked to unhealthy eating through pain catastrophizing
Introduction
There is a complex and well-documented link between emotions and eating (Macht, 2008). Difficulty regulating emotions has been associated with eating in obese (Gluck, Geliebter, Hung, & Yahav, 2004) and normal-weight individuals (Macht, Haupt, & Ellgring, 2005). Eating to regulate emotions can become a maladaptive coping strategy and contribute to binge eating, obesity, and other eating disorders (Gianini et al., 2013, Svaldi et al., 2012). It has also been shown that individuals diagnosed with an eating disorder (i.e., anorexia-nervosa, bulimia-nervosa, and binge-eating disorder) demonstrate higher levels of emotion intensity, lower acceptance of emotions, less emotional awareness and clarity, as well as decreased use of functional and increased use of dysfunctional emotion regulation strategies when compared to healthy controls (Svaldi et al., 2012). Furthermore, difficulty regulating emotion has also been shown to be a risk factor for unhealthy eating-related behaviors, such as emotional eating (Evers, Marijn Stok, & de Ridder, 2010), binging, purging, fasting, and compulsive exercise (Lavender & Anderson, 2010) in nonclinical samples.
Low distress tolerance (i.e., the inability to withstand negative emotions) is an important component of emotion regulation difficulty (Gratz & Roemer, 2004) and is also linked to dysregulated eating (Anestis et al., 2007, Corstorphine et al., 2007, Kozak and Fought, 2011). Low distress tolerance has been shown to predict bulimic tendencies (Anestis et al., 2007), as well as factors that contribute to obesity: higher levels of emotional eating, external eating (i.e., overeating on the basis of environmental food cues such as smell), and general overeating (Kozak & Fought, 2011). The findings of the aforementioned studies demonstrate the importance of prevention and treatment techniques that address deficits in emotion regulation, and in particular, low distress tolerance, with the ultimate goal of improving emotion regulation skills among at-risk and clinical populations.
Psychological approaches to understanding behavior typically address thoughts and emotions. Identifying thoughts proximal to negative emotions and subsequent maladaptive behaviors are an important component of cognitive behavioral therapy (Beck, 2011). In the cognitive behavioral model, cognitions are a focal point of treatment through the identification and restructuring of unhelpful thoughts (Beck, 2011). Catastrophizing is a specific type of distorted thinking involving an exaggerated negative filter leading to over-estimation of adverse outcomes (Vowles, McCracken, & Eccleston, 2007). Catastrophizing is a feature of mental health issues such as depression (Pössel & Black, 2014) and anxiety (Brown, O'Leary, & Barlow, 2001), and is often targeted in their treatment (Beck, 2011, Brown et al., 2001). The link between catastrophizing and eating disorders is not as consistent as with other mental health issues, with a significant association in some studies (Cohen and Petrie, 2005, Sternheim et al., 2012) and not others (Kelly et al., 2012, Moller and Bothma, 2001). Nonetheless, addressing catastrophizing is common in cognitive behavioral treatment for eating disorders (Abbott and Goodheart, 2012, Collins, 2005).
Pain catastrophizing is a specific type of catastrophic thinking involving the negative amplification of pain-related thoughts. Pain catastrophizing can involve repetitive thoughts about pain (rumination), exaggerated concern about negative consequences of pain (magnification), and the belief that nothing will change the pain (helplessness). Pain catastrophizing is a central contributing factor to pain perception, and is modifiable through cognitive behavior techniques (Pulvers & Hood, 2013). Individuals who catastrophize about their pain may exhibit maladaptive eating behaviors in order to cope with their pain. Pain has been linked to eating issues surrounding obesity (Janke and Kozak, 2012, Stone and Broderick, 2012) and other eating disorders (Coughlin et al., 2008), suggesting the importance of understanding the link between pain catastrophizing and unhealthy eating for the prevention and treatment of obesity and eating disorders.
Studies that have examined the relationship between pain catastrophizing with unhealthy eating behaviors and weight has primarily focused on clinical samples, such as individuals utilizing inpatient psychological services for eating disorder treatment (Coughlin et al., 2010, Coughlin et al., 2008). In one study of individuals seeking eating disorder treatment, psychiatric inpatients with moderate and severe pain were more likely to catastrophize about their pain, have a binging and/or purging diagnosis, experience greater body dissatisfaction, and have a greater drive for thinness than those who reported mild or no pain. In addition, pain intensity was related to more time spent in inpatient hospitalization, even after controlling for degree of underweight, depressive symptoms, and neurotic personality features (Coughlin et al., 2010). These findings imply that pain catastrophizing may play an influential role in the development, maintenance, and treatment process of eating disorders. However, these findings are difficult to generalize to a nonclinical sample, such as college students. Given that unhealthy eating behaviors (e.g., binging and over restricted dieting) are prevalent and persistent throughout the college years, there is a need to assess the role that pain catastrophizing plays in the development of unhealthy eating behaviors among a nonclinical sample of college students (Eisenberg, Nicklett, Roeder, & Kirz, 2011).
In addition, the link between pain catastrophizing and eating and weight has been examined with overweight and obese samples of individuals, who also suffer from chronic pain conditions (Shelby et al., 2008; Somers, Keefe, Carson, Pells, & Lacaille, 2008). Among individuals considered borderline morbidly obese and morbidly obese, pain catastrophizing has been shown to be a predictor of intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling one's eating, and lower weight-related quality of life (Somers et al., 2008). However, the issue of generalizability is also relevant here, given that these results cannot be extended to a college student sample. Examining pain catastrophizing among college students without chronic pain is important given the potential impact of pain on students' lives (e.g., having to miss classes, work commitments, club meetings, or collegiate sports events because of pain episodes). Although individuals in the college years are at a lower risk for developing chronic pain conditions, research has shown that they do experience temporary episodes of pain. College students report psychosocial stressors (e.g., feeling very sad, exhausted/chronically fatigued, and overwhelmed), which in turn, can manifest into lower back pain (Gilkey et al., 2010, Kennedy et al., 2008). Unable to miss classes and extracurricular activities because of a pain episode, college students may turn to negative coping techniques, including catastrophizing (Buenaver, Edwards, Smith, Gramling, & Haythornthwaite, 2008) and the use and abuse of prescription pain medications (Garnier et al., 2010, McCabe et al., 2006), to deal with their pain. The present study examines the role of pain catastrophizing in unhealthy eating among a nonclinical sample by testing whether pain catastrophizing mediates the link between distress tolerance with unhealthy eating. It is expected that pain catastrophizing will explain the link between distress tolerance and unhealthy eating after controlling for body mass index (BMI), ethnicity, age, and gender. BMI, ethnicity, age, and gender were chosen as control variables to reduce the effects of these influential variables on the main outcome variable (unhealthy eating) (Eisenberg et al., 2011, Olsen et al., 2015, Quick and Byrd-Bredbenner, 2014, Rich and Thomas, 2008).
The conceptual model for the main study was Cognitive Theory of Addiction, which maintains that addictive behaviors become habitual ways of dealing with stress or managing negative affect, or compensating for deficiencies in distress tolerance (i.e., self-medication) (Beck, Wright, Newman, & Liese, 1993). The study utilized a broad frame of reference in considering compulsive health behaviors such as unhealthy eating within this framework. It was expected that psychological deficits (i.e., distress tolerance and pain catastrophizing) would be associated with health risk behaviors (e.g., unhealthy eating). The study also attempted to measure deficits in distress tolerance through two behavioral tasks, the cold pressor task (a measure of physical distress tolerance) and the mirror tracing task (i.e., a measure of psychological distress tolerance) (for a review on physical and psychological distress tolerance tasks see Leyro, Zvolensky, & Bernstein, 2010). The patterns of associations revealed that the self-report measure of distress tolerance was a more robust marker of the target construct than the behavioral measure. Given that the behavioral measures were found to be less predictive markers, this information is not included in the current paper.
Section snippets
Participants and procedure
Healthy adults (N = 171; 62.6% female) from a research pool signed up electronically in partial fulfillment of a course requirement at a university in the southwestern region of the United States. Participants ranged in age from 18 to 54 years (M = 20.91, SD = 5.02) and predominantly identified as Caucasian (38.6%) and Hispanic (28.1%) (see Table 1). The present study was part of a larger investigation on psychological deficits and health behaviors.
The study contained related medical exclusion
Bivariate correlations
Bivariate correlations assessed the strength of associations between distress tolerance, pain catastrophizing, unhealthy eating, and body mass index (see Table 2). There was a negative correlation between DTS and PCS scores (r[169] = −0.49, p < 0.001), such that lower distress tolerance scores were related to higher levels of pain catastrophizing. Likewise, DTS and DEBQ scores were negatively correlated (r[169] = −0.24, p < 0.01), such that lower distress tolerance scores were related to higher
Discussion
The current study is the first to establish that pain catastrophizing connects distress tolerance with unhealthy eating. Individuals low in distress tolerance reported higher pain catastrophizing. These individuals also reported higher levels of unhealthy eating. Although distress tolerance was associated with unhealthy eating, there was not a significant direct effect of distress tolerance on unhealthy eating. Current treatment approaches for eating disorders often incorporate a focus on
Conflict of interest statement
No authors have conflicts of interest.
Funding
This study was funded by a University Professional Development award from California State University San Marcos.
Acknowledgements
We are grateful to the following individuals for their assistance with data collection: Jennifer Bachand, Brittany Basora, Marissalyn Gonzales, Michelle Hackbardt, Jeffrey Olson, Nick Roome, Jackie Schroeder Brady, Marlene Strege, and Cassandra Volpe, and Grant Brady for database management.
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