Emotion regulation as a transdiagnostic factor in eating disorders and gambling disorder: Treatment outcome implications Journal of Behavioral CRISTINA VINTRÓ-ALCARAZ1,2† , LUCERO MUNGUÍA1† , Addictions ROSER GRANERO2,3 , ANAHI GASPAR-PÉREZ1 , NEUS SOLÉ-MORATA1 , ISABEL SÁNCHEZ1,2 , 11 (2022) 1, 140–146 JÉSSICA SÁNCHEZ-GONZÁLEZ1, JOSÉ M. MENCHÓN1,4,5 , DOI: 10.1556/2006.2022.00004 SUSANA JIMÉNEZ-MURCIA1,2,4p and © 2022 The Author(s) FERNANDO FERNÁNDEZ-ARANDA1,2,4pp 1 Department of Psychiatry, Bellvitge University Hospital-IDIBELL, 08907 Barcelona, Spain 2 Ciber Physiopathology, Obesity and Nutrition (CIBERObn), Instituto de Salud Carlos III, 08907 Barcelona, Spain BRIEF REPORT 3 Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain 4 Department of Clinical Sciences, School of Medicine, University of Barcelona, 08907 Barcelona, Spain 5 CIBER de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, L’Hospitalet de Llobregat, 08907 Barcelona, Spain Received: July 13, 2021 • Revised manuscript received: December 19, 2021; February 6, 2022 • Accepted: February 9, 2022 Published online: March 7, 2022 ABSTRACT Background: A first approach addressed to ascertain whether emotion regulation (ER) could be a transdiagnostic construct between eating disorders (EDs) and gambling disorder (GD) (through a joint clinical clustering analysis of both disorders) was performed by Munguía et al. (2021). Both conditions were represented by a severe, moderate, and low ER profile subgroups, according to the degree of ER difficulties. Results showed a linear relationship between the severity of ER difficulties and the severity of the disorder and the psychopathological state. Aims: Based on the aforementioned cross-sectional study, the objective of this longitudinal research was to explore the treatment response of the different ER subgroups. Methods: 459 adult patients (n 5 277 ED; n 5 182 GD) were included. Several clinical variables, as well as outcome indicators (after completing 16 weeks of cognitive-behavioral therapy), were evaluated. Results: The three subgroups found in the previous cross-sectional study were taken for the performance of the present research. ED and GD distribution in each subgroup replicates the one exposed by Munguía et al. (2021), as well as their characterization, considering psychopathology, disorder severity and personality traits. The low ER subgroup reported a better response to treatment, whereas the severe group had the highest rates of non-remission and dropouts. Conclusions: Our results y suggest that greater difficulties in ER lead to poorer treatment outcomes. Therefore, tailored treatments for Shared first authorship: Cristina patients with poor ER abilities would be recommended to improve adherence and treatment outcomes. Vintró-Alcaraz and Lucero Munguía. p Corresponding author. Tel.: þ34 932607227; fax þ34-93-2607193. KEYWORDS E-mail: sjimenez@bellvitgehospital.cat gambling disorder, eating disorder, emotion regulation, transdiagnostic, treatment outcome, longitudinal pp Corresponding author. Tel.: þ34 932607227; fax þ34-93-2607193. E-mail: ffernandez@bellvitgehospital. cat INTRODUCTION Emotion regulation (ER) is the ability to identify, modulate and use specific strategies for an adequate emotional experience and expression (Gross, 2015). Difficulties in ER have been Journal of Behavioral Addictions 11 (2022) 1, 140–146 141 related to the etiology and maintenance of several psycho- They were n 5 277 ED patients (n 5 68 anorexia nervosa logical disorders, including eating disorders (EDs) and [AN], n 5 96 bulimia nervosa [BN], n 5 41 binge eating gambling disorder (GD). Even though there is no high disorder [BED], and n 5 72 other specified feeding or eating prevalence of the co-occurrence of both disorders (Potenza disorders [OSFED]) and n 5 182 GD patients (n 5 95 non- et al., 2019), several commonalities in risk and maintaining strategic gamblers, n 5 48 strategic gamblers, and n 5 39 factors have been emphasized (Lemón, Fernández-Aranda, mixed gamblers). The upper part of Table S1 (supplemen- Jiménez-Murcia, & Håkansson, 2021). Behaviors such as tary material) includes the subgroup distribution of the binge eating, restrictive eating, and betting have been different categories in this study. postulated as coping strategies to deal with negative emotional states (Aldao, Nolen-hoeksema, & Schweizer, Instruments 2010; Velotti, Rogier, Beomonte Zobel, & Billieux, 2021). In The Spanish adaptations of the Difficulties in Emotion Regu- this sense, ER difficulties have been suggested as an under- lation Scale (DERS), Symptom Checklist-Revised (SCL-90-R) lying transdiagnostic factor (Sloan et al., 2017). and Temperament and Character Inventory-Revised (TCI-R) Munguía et al. (2021) explored ER as a transdiagnostic questionnaires were used. A detailed description of them can construct between EDs and GD through a joint clinical be found in the previous study (Munguía et al., 2021). clustering analysis. The ER severity profile followed a linear relationship with the general psychopathology and severity Treatment of the disorder: subgroup-1 (Sg1) corresponds to the “severe profile”, subgroup-2 (Sg2) to the “moderate profile”, and subgroup-3 (Sg3) to the “low profile”. In addition, more Eating disorders. Patients received CBT treatment carried out functional personality traits (high reward dependence, by experienced psychologists at Bellvitge University Hospital persistence, self-directedness, and cooperativeness) were (HUB). The treatment for BN, BED and OSFED patients was found in Sg3, while more impaired ones, as high harm 16 weekly outpatient group sessions of 90 min each. Patients avoidance, were found in Sg1 (Munguía et al., 2021). with AN completed a day hospital treatment program with two However, the relationship between ER and treatment daily group CBT sessions during 3 months. A detailed expla- outcome was not explored in this previous study. nation could be found in Mallorquí-Bagué et al. (2018). ER also plays an important role in the response to Not attending three consecutive sessions of CBT was treatment in ED (MacDonald, Trottier, & Olmsted, 2017) considered a dropout. Patients who completed treatment and GD (Sancho et al., 2018). Improvements in ER during were categorized as follows: full remission (total absence of cognitive-behavioral therapy (CBT) led to a better response ED symptoms for a sustained period of time), partial- to treatment in ED populations (MacDonald et al., 2017). remission (substantial symptomatic improvement but with Treating emotion dysregulation has been highlighted in GD residual symptoms) and non-remission (still meeting full to maintain abstinence (Daughters et al., 2005). However, no criteria for an ED) (American Psychiatric Association, previous research has demonstrated if the transdiagnostic 2013). Prior published studies have also used these cate- role of ER could also have an impact on treatment outcome gories (Mallorquí-Bagué et al., 2018). or, specifically, if treatment response would follow the Gambling disorder. Participants with GD received 16 severity of the ER profile found in the cross-sectional weekly outpatient CBT sessions of 90 min each at HUB, with transdiagnostic approach (Munguía et al., 2021). the main objective of achieving full abstinence. Aims Despite that to date no consensus about how to define treatment outcomes based on relapses exists (Ledgerwood & The present longitudinal study aims to explore the treatment Petry, 2006), the following criteria have been established. outcomes of the different ER subgroups reported by Mun- They were based on the consensus judgment of senior guía et al. (2021). We hypothesize that the low profile sub- clinical psychologists who considered all aspects of the pa- group will present lower rates of dropouts and higher tient’s relapses, such as the number of them and gambling remission rates than the moderate and, especially, the severe activity. Following the same classification categories of EDs profile subgroups. treatment outcome (American Psychiatric Association, 2013), patients with GD were labeled as dropouts if they missed 3 consecutive sessions. It was considered full METHODS remission if there was one or no relapse during the treat- ment; partial remission implied two or more relapses of their Sample problem gambling activity during the treatment, and finally, non-remission implied active gambling behavior at the end The participants of this study (n 5 459; GD-age: M 5 39.68, of the treatment. SD 5 13.08; ED-age M 5 28.77, SD 5 10.32) constitute a subsample of the previous cross-sectional study conducted Procedure by Munguía et al. (2021), recruited between January-2017 and July-2019. Patients who underwent group treatment and Exclusion criteria for the study were being under 18 years whose response to treatment was available were included. old, the presence of a severe mental disorder or intellectual 142 Journal of Behavioral Addictions 11 (2022) 1, 140–146 disability, and having received individual treatment. All total sample, with the comparison between the subgroups and patients were screened via a structured interview by expe- between the diagnostic subtypes (see also Table S1, appendix). rienced clinical psychologists. Sg3 was associated with the best treatment effectiveness, fol- lowed by Sg2 and Sg1. The highest risk of bad treatment Statistical analysis. Statistical analysis was carried out with outcome (dropout or non-remission) was associated with Sg1 Stata17 for Windows (Stata-Corp, 2021). First, the descrip- (55.2%). Post-hoc comparison between the subgroups showed tive indexes for the sample were obtained. Next, analysis of differences between Sg1 versus Sg3 (P 5 0.018), while no variance (ANOVA), for comparing quantitative measures differences were obtained comparing Sg2 to Sg3 (P 5 0.183). and chi-square test (c2) for categorical variables compared Compared with GD, ED patients also increased the likelihood the groups defined by the subgroups and the diagnostic of a bad treatment outcome (P < 0.001). The lower part in subtype. The effect size was estimated with Cohen’s-d for the Fig. 1 includes the 100% stacked bar charts with the com- mean differences and Cohen’s-h for the proportion differ- parison of the CBT outcomes between the subgroups within ences (null effect size was considered for estimates < 0.20, each diagnostic subtype (GD and ED). No statistical differ- low-poor for estimates > 0.20, moderate-medium for esti- ences were obtained in the stratified analyses. mates > 0.50 and large-high for estimates > 0.80) (Cohen, 1988). Finner-procedure was also used for controlling the increase in Type-I error due to the use of multiple statistical significance tests (Finner & Roters, 2001). DISCUSSION Ethics. The present study was carried out in accordance The goal of the present study was to explore the treatment with the latest version of the Declaration of Helsinki. The outcome of individuals with GD or ED diagnosis based on University Hospital Clinical Research Ethics Committee the ER profiles defined in the study by Munguía et al. (2021). approved the study, and signed informed consent was ob- Women showed higher difficulties in regulating their tained from all participants. affective states, while most of the men belonged to the low profile (Sg3). Previous findings have shown greater ER im- RESULTS pairments in females with EDs (Agüera et al., 2019), while a recent study revealed that men with GD presented more ER difficulties compared to women (Sancho et al., 2019). Our Description of the sample findings also showed that patients included in the severe Compared to GD, the ED subsample included a higher profile (Sg1) were younger and presented an earlier onset of proportion of women (91.3% versus 9.3%, P < 0.001), the disorder. While in the general population ER skills are younger age patients (M 5 28.8 versus M 5 39.7 yrs, P < usually related to older age (Aldao, Gee, De Los Reyes, & 0.001), earlier onset of the disorder (M 5 19.6 versus Seager, 2016). Sancho et al. (2019) observed that older pa- M 5 24.4 yrs, P < 0.001) and shorter duration of it (M 5 9.2 tients with GD presented more difficulties in regulating versus M 5 15.3 yrs, P < 0.001). affect. Regarding ED population, younger age was associated The upper part of Table S1 displays the distribution of the with a higher risk of dropout in men (Agüera et al., 2017). clinical diagnoses between the subgroups. Statistical differ- Nevertheless, the age of onset of the disorder does not ences appeared within the total sample (P < 0.001): most appear to be determinant for treatment outcome (Jiménez- patients within Sg1 (77.0%) were diagnosed with ED, while Murcia et al., 2010; Vall & Wade, 2015), whereas other Sg2 included 57.4% of ED patients and Sg3 44.1% of ED characteristics, such as ER skills (MacDonald et al., 2017), do patients. Among the GD subsample (n 5 182), no statistical play a key role in determining the rate of remission, number difference was found for the distribution of the gambling of dropouts and relapses. preference into subgroups (P 5 0.872). Within the ED sub- The dropout and remission rates in the present work are sample (n 5 277), statistical differences appeared (P < 0.001): similar to those described in previous studies (Agüera et al., Sg1 was characterized by the presence of BN (37.9%) and 2019; Toneatto & Ladouceur, 2003). As hypothesized, the OSFED (31.5%), Sg2 by BN (37.6%), and Sg3 by AN (46.7%); severe profile was characterized by a higher number of the lowest proportion of BED was registered for Sg3. dropouts compared to the rest of the subgroups, which agrees with previous research stating that greater psycho- Description of the subgroups at baseline pathology predicts a worsened treatment response (Accurso et al., 2016; Jiménez-Murcia et al., 2007). Regarding per- Table 1 includes the distribution of the clinical measures at sonality, severe profile presented the highest score in harm baseline and the comparison between subgroups. The best avoidance (related to a more anxious, pessimistic, and functional profile was observed for Sg3 whereas Sg1 reported insecure profile), whereas elevated scores in reward depen- the worst functional profile. dence, persistence, self-directedness, and cooperativeness characterized the low profile, meaning they are more Comparison of CBT outcomes between subgroups friendly, more empathic and with a tendency to set and The upper part in Fig. 1 includes the first 100% stacked bar achieve goals. These findings are in agreement with previous charts with the distribution of the CBT outcomes among the studies reporting altered personality traits affecting Journal of Behavioral Addictions 11 (2022) 1, 140–146 Table 1. Comparison between the subgroups at baseline Subgroup-1 Subgroup-2 Subgroup-3 Subgroup-1 vs Subgroup-1 vs Subgroup-2 vs (n 5 161) (n 5 162) (n 5 136) Subgroup-2 Subgroup-3 Subgroup-3 Global test n % n % n % P P |h| P |h| P |h| y Sex Women 122 75.8% 94 58.0% 54 39.7% <0.001p 0.001p 0.38 <0.001p 0.75 0.002p 0.37 Men 39 24.2% 68 42.0% 82 60.3% Mean SD Mean SD Mean SD P P |d| P |d| P |d| Age (yr) 30.66 11.44 34.17 12.78 34.68 13.53 0.010p 0.013p 0.29 0.006p 0.32 0.724 0.04 Onset of dis. (yrs) 19.94 7.84 21.85 9.61 22.94 10.37 0.018p 0.064 0.22 0.006p 0.33 0.316 0.11 Duration dis. (yrs) 10.73 10.23 12.31 10.45 11.75 10.30 0.379 0.169 0.15 0.397 0.10 0.638 0.05 DERS Non-acceptance 23.93 4.65 18.11 5.60 12.08 5.53 <0.001p <0.001p 1.13y <0.001p 2.32y <0.001p 1.08y DERS Goals 20.47 2.88 15.72 3.99 11.43 3.64 <0.001p <0.001p 1.36y <0.001p 2.76y <0.001p 1.12y DERS Strategies 17.76 4.81 18.56 4.63 16.07 4.80 <0.001p 0.134 0.17 0.002p 0.35 <0.001p 0.53y DERS Awareness 30.94 5.00 21.79 4.64 13.94 4.15 <0.001p <0.001p 1.90y <0.001p 3.70y <0.001p 1.78y DERS Impulse 21.76 4.62 14.19 3.92 10.20 3.04 <0.001p <0.001p 1.77y <0.001p 2.96y <0.001p 1.14y DERS Clarity 17.15 4.00 14.09 3.98 9.53 2.92 <0.001p <0.001p 0.77y <0.001p 2.18y <0.001p 1.31y Total DERS score 132.0 13.57 102.4 13.04 73.3 13.60 <0.001p <0.001p 2.22y <0.001p 4.32y <0.001p 2.18y SCL-90R GSI 2.24 0.54 1.37 0.49 0.71 0.49 <0.001p <0.001p 1.69y <0.001p 2.98y <0.001p 1.36y SCL-90R PST 73.27 10.58 57.44 16.34 36.61 18.33 <0.001p <0.001p 1.15y <0.001p 2.45y <0.001p 1.20y SCL-90R PSDI 2.72 0.45 2.10 0.47 1.60 0.45 <0.001p <0.001p 1.36y <0.001p 2.47y <0.001p 1.07y TCI-R Novelty seeking 105.4 17.96 105.1 15.84 104.6 13.59 0.905 0.845 0.02 0.655 0.05 0.795 0.03 TCI-R Harm avoidance 125.8 18.31 110.5 16.41 92.1 14.51 <0.001p <0.001p 0.88y <0.001p 2.04y <0.001p 1.19y TCI-R Reward depend. 98.5 16.57 99.0 14.32 103.9 14.04 0.003p 0.764 0.03 0.002p 0.36 0.005p 0.35 TCI-R Persistence 103.6 20.88 105.8 18.43 116.1 17.64 <0.001p 0.300 0.11 <0.001p 0.65y <0.001p 0.57y TCI-R Self-directedness 105.3 15.77 119.2 14.17 144.8 15.99 <0.001p <0.001p 0.92y <0.001p 2.49y <0.001p 1.70y TCI-R Cooperativeness 128.3 16.98 130.6 15.14 138.6 14.08 <0.001p 0.165 0.15 <0.001p 0.66y <0.001p 0.54y TCI-R Self-transcende. 67.1 14.01 62.5 13.40 59.8 13.47 <0.001p 0.003p 0.34 <0.001p 0.53y 0.086 0.20 Note. SD: standard deviation. p Bold: significant comparison (0.05). y Bold: effect size into the ranges mild-moderate to the high-large. 143 144 Journal of Behavioral Addictions 11 (2022) 1, 140–146 Fig. 1. Distribution of the CBT outcomes within the diagnoses and the subgroups Note. GD: gambling disorder. ED: eating disorder. Sg1: Subgroup 1. Sg2: Subgroup 2. Sg3: Subgroup 3. Full-rem.: full remission. Partial-rem.: partial remission. Non-rem.: non-remission. treatment outcomes in individuals with EDs (Agüera et al., variables that may influence emotion regulation as comor- 2017) and GD (Ramos-Grille, Gomà-i-Freixanet, Aragay, bidity and medication intake. Finally, the transdiagnostic Valero, & Vallès, 2015). approach only examined two associated disorders; other In conclusion, our hypotheses were confirmed since the conditions related to difficulties in ER should be examined. low profile subgroup presented a higher number of patients with full remission outcomes, while the highest percentage of Conclusions non-remission corresponded to the severe profile as well, and This research supports a growing literature highlighting ER the highest percentage of partial remission was associated impairments as a transdiagnostic feature across psychiatric with the moderate profile. Based on the present findings, we disorders (Aldao et al., 2010; Sloan et al., 2017). One of the could postulate that higher emotion dysregulation is associ- most significant findings of the present study indicated that ated with higher psychological distress and may be related to greater difficulties in regulating emotions may lead to poorer lower rates of remissions and higher taxes of dropouts. In treatment outcomes, suggesting the relevance of considering this regard, deficits in ER have been linked to poorer treat- ER to carry out individualized treatment approaches. ment outcomes in both disorders (Mallorquí-Bagué et al., 2018; Velotti, Rogier, BeomonteZobel, & Billieux, 2021). Thus, interventions aimed at improving emotion dysregula- Funding sources: Financial support was received through the tion are necessary to obtain better treatment outcomes. Ministerio de Ciencia, Innovación y Universidades (grant Certain treatments that focus on ER have been applied in RTI2018-101837-B-100). FIS PI14/00290, FIS PI17/01167 both the GD (Sancho et al., 2018) and ED populations (Safer, received aid from the Ministerio de Sanidad, Servicios Telch, & Agras, 2001; Wanden-Berghe, Sanz-Valero, & Sociales e Igualdad. The research was also funded by the Wanden-Berghe, 2011) with favorable results. Delegación del Gobierno para el Plan Nacional sobre Drogas (2017I067 and 2019I47), CIBER Fisiología Obesidad y Limitations Nutrición (CIBERobn) and CIBER Salud Mental (CIBER- The present study should be evaluated within the context of SAM), both of which are initiatives of ISCIII. We thank several limitations. The classification of treatment outcome CERCA Programme/Generalitat de Catalunya for institu- in GD has been established based on the consensus judgment tional support. Fondo Europeo de Desarrollo Regional of the senior clinical psychologist of the unit, not used in (FEDER) “Una manera de hacer Europa”/”A way to build earlier studies, which compromises the generalization of the Europe”. The researchers are members of the “Clinical, results. What is more, future research should consider biological and psychological Psychiatry group”, consolidated Journal of Behavioral Addictions 11 (2022) 1, 140–146 145 research group by the Research University Grants Man- attempt. Journal of Gambling Studies, 21(4), 363–378. https:// agement Agency of Catalonia (2017 SGR 1247). CVA is doi.org/10.1007/s10899-005-5554-6. supported by a predoctoral grant awarded by the Ministerio Finner, H., & Roters, M. (2001). On the false discovery rate and de Educación, Cultura y Deporte (FPU16/01453). AGP is expected type I errors. 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Distribution of the diagnostic subtypes within the empirical subgroups and comparison of the CBT outcomes Subgroup-1 Subgroup-2 Subgroup-3 Subgroup-1 vs Subgroup-1 vs Subgroup-2 vs Global (n 5 161) (n 5 162) (n 5 136) Subgroup-2 Subgroup-3 Subgroup-3 test Sample n % n % n % P P |h| P |h| P |h| p p p y p Total GD 37 23.0% 69 42.6% 76 55.9% <0.001 <0.001 0.42 <0.001 0.69 0.022 0.27 (n 5 459) ED 124 77.0% 93 57.4% 60 44.1% 0.42 0.69y 0.27 Total GD 37 23.0% 69 42.6% 76 55.9% <0.001p 0.001p 0.42 <0.001p 0.69y 0.003p 0.27 (n 5 459) AN 19 11.8% 21 13.0% 28 20.6% 0.04 0.24 0.21 BN 47 29.2% 35 21.6% 14 10.3% 0.17 0.51y 0.31 BED 19 11.8% 17 10.5% 5 3.7% 0.04 0.32 0.27 OSFED 39 24.2% 20 12.3% 13 9.6% 0.31 0.40 0.09 ED AN 19 15.3% 21 22.6% 28 46.7% <0.001p 0.292 0.19 <0.001p 0.70y 0.010p 0.51y (n 5 277) BN 47 37.9% 35 37.6% 14 23.3% 0.01 0.32 0.31 BED 19 15.3% 17 18.3% 5 8.3% 0.08 0.22 0.30 OSFED 39 31.5% 20 21.5% 13 21.7% 0.23 0.22 0.00 GD Non-strategic 19 51.4% 37 53.6% 39 51.3% 0.872 0.704 0.05 0.577 0.00 0.928 0.05 (n 5 182) Strategic 8 21.6% 18 26.1% 22 28.9% 0.10 0.17 0.06 Mixed 10 27.0% 14 20.3% 15 19.7% 0.16 0.17 0.01 Outcomes Dropout 68 42.2% 65 40.1% 47 34.6% 0.039p 0.130 0.04 0.018p 0.16 0.183 0.12 (n 5 459) Non- 21 13.0% 10 6.2% 12 8.8% 0.24 0.14 0.10 remission Partial- 26 16.1% 28 17.3% 15 11.0% 0.03 0.15 0.18 remission Full- 46 28.6% 59 36.4% 62 45.6% 0.17 0.35 0.19 remission Note. GD: gambling disorder. ED: eating disorders. AN: anorexia nervosa. BN: bulimia nervosa. BED: binge eating disorder. OSFED: other specified feeding eating disorder. p Bold: significant comparison (0.05). y Bold: effect size into the ranges mild-moderate to the high-large. Open Access. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited, a link to the CC License is provided, and changes – if any – are indicated.