Emotion generation and regulation in anorexia nervosa: A systematic review and meta-analysis of self-report data Anna Oldershaw a,b, ⁎, Tony Lavender a , Hannah Sallis c , Daniel Stahl c , Ulrike Schmidt b a Centre for Applied Psychology, Canterbury Christ Church University, Salomons Centre at Tunbridge Wells, Broomhill Road Southborough, Tunbridge Wells, Kent TN3 0TG, UK b Section of Eating Disorders, Division of Psychological Medicine, King's College London, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK c Department of Biostatistics, King's College London, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK HIGHLIGHTS • A comprehensive review and meta-analysis of emotional processing in AN. • People with AN report less emotional awareness/clarity but more emotionality than HCs. • People with AN employ maladaptive emotion regulation strategies more than HCs. • People with AN employ adaptive emotion regulation strategies less than HCs. • Findings inform cognitive-affective AN models and therapeutic interventions. abstract article info Article history: Received 29 August 2014 Received in revised form 18 April 2015 Accepted 27 April 2015 Available online 2 May 2015 Keywords: Anorexia nervosa Eating disorders Emotion Affect Regulation Review This systematic review sought to examine the generation and regulation of emotion in people with Anorexia Nervosa (AN). Key databases (Medline, Embase, PsychINFO and Web of Science) were searched for peer- reviewed articles published by March 2015 yielding 131 studies relevant to emotion generation and emotion reg- ulation (ER) processes as defined by Gross (1998). Meta-analyses determined pooled group differences between AN and healthy control (HC) groups. More maladaptive schemata were reported by people with AN than HCs, with largest pooled effects for defective- ness/shame (d = 2.81), subjugation (d = 1.59) and social isolation (d = 1.66). Poorer awareness of and clarity over emotion generated and some elevated emotionality (disgust and shame) were reported. A greater use of ‘maladaptive’ ER strategies was reported by people with AN than HCs, alongside less use of ‘adaptive’ strategies. Pooled differences of particularly large effect were observed for: experiential avoidance (d = 1.00), negative problem-solving style (d = 1.06), external/social comparison (d = 1.25), submissiveness (d = 1.16), attention concentration (worry/rumination; d = 1.44) and emotion suppression (d = 1.15), particularly to avoid conflict (d = 1.54). These data support the notion that emotion regulation difficulties are a factor in AN and support use of associated cognitive–affective models. The implications of these findings for further understanding AN, and de- veloping models and related psychological interventions are discussed. © 2015 Elsevier Ltd. All rights reserved. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 1.1. Emotion generation, regulation & psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 1.2. Emotion generation, regulation & anorexia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 1.3. The present review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2.1. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2.2. Information sources and searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 2.3. Study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Clinical Psychology Review 39 (2015) 83–95 ⁎ Corresponding author at: Centre for Applied Psychology, Canterbury Christ Church University, Salomons Campus at Tunbridge Wells, Broomhill Road, Southborough, Tunbridge Wells, Kent TN3 0TG, UK. E-mail address: annaoldershaw@hotmail.com (A. Oldershaw). http://dx.doi.org/10.1016/j.cpr.2015.04.005 0272-7358/© 2015 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect Clinical Psychology Review