Accepted Manuscript

Effects of emotional acceptance and rumination on media-induced body

dissatisfaction in anorexia and bulimia nervosa

Eva Naumann, Brunna Tuschen-Caffier, Ulrich Voderholzer, Johanna Schäfer,

Jennifer Svaldi

PII: S0022-3956(16)30163-7
DOI: 10.1016/j.jpsychires.2016.07.021
Reference: PIAT 2917

To appear in: Journal of Psychiatric Research

Received Date: 1 March 2016

Revised Date: 22 July 2016
Accepted Date: 22 July 2016

Please cite this article as: Naumann E, Tuschen-Caffier B, Voderholzer U, Schäfer J, Svaldi J, Effects
of emotional acceptance and rumination on media-induced body dissatisfaction in anorexia and bulimia
nervosa, Journal of Psychiatric Research (2016), doi: 10.1016/j.jpsychires.2016.07.021.

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 ACCEPTED MANUSCRIPT
Running head: Effects of Acceptance and Rumination on Body Dissatisfaction in Eating

Disorders.

Article title: Effects of Emotional Acceptance and Rumination on Media-Induced Body

Dissatisfaction in Anorexia and Bulimia Nervosa.

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Eva Naumanna, Brunna Tuschen-Caffierb, Ulrich Voderholzerc, Johanna Schäferd & Jennifer

Svaldie

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a
Corresponding author; University of Tübingen, Department of Clinical Psychology and

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Psychotherapy, Schleichstraße 4, 72076 Tübingen, Germany, Email: eva.naumann@uni-

tuebingen.de, Phone: +49 7071 2977199, Fax: +49 7071 295219

U
AN
University of Freiburg, Department of Clinical Psychology and Psychotherapy,

Engelbergerstrasse 41, 79106 Freiburg, Germany, Email: tuschen@psychologie.uni-

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freiburg.de, Phone: +49 761 2033014, Fax: +49 761 2033022

c
Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien, Germany, Email:
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uvoderholzer@schoen-kliniken.de, Phone: +49 8051 68100102, Fax: +49 8051 68100103

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d
University of Freiburg, Department of Clinical Psychology and Psychotherapy,
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Engelbergerstrasse 41, 79106 Freiburg, Germany, Email:

johanna.schaefer@psychologie.uni-freiburg.de, Phone: +49 761 2033010, Fax: +49 761

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2033022
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e
University of Tübingen, Department of Clinical Psychology and Psychotherapy,

Schleichstraße 4, 72076 Tübingen, Germany, Email: jennifer.svaldi@uni-tuebingen.de,

Phone: +49 7071 2975024, Fax: +49 7071 295219

 ACCEPTED MANUSCRIPT
Running head: Effects of Acceptance and Rumination on Body Dissatisfaction in Eating

Disorders.

Article title: Effects of Emotional Acceptance and Rumination on Media-Induced Body

Dissatisfaction in Anorexia and Bulimia Nervosa.

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Abstract

Introduction: Body dissatisfaction is an important risk and maintaining factor for eating

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disorders. The aim of the present study was to experimentally test the effects of two emotion

regulation strategies - acceptance and rumination - on media-induced body dissatisfaction in

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eating disorders. Method: After watching pictures of thin models, women with anorexia

nervosa (AN; n=39) and bulimia nervosa (BN; n=39) were encouraged to either use

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emotional acceptance or rumination to cope with their feelings. Body dissatisfaction and
AN
mood were repeatedly assessed. Results: Acceptance significantly improved body

dissatisfaction in women with BN. Rumination led to a significant increase of body

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dissatisfaction in both eating disorder groups. Results were independent from mood
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changes. Discussion: Findings highlight the importance ruminative thinking may have in the
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aggravation of dissatisfaction with the own body in AN and BN. Results suggest that

emotional acceptance is a useful strategy to regulate body dissatisfaction after exposure to

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thin-ideal media in BN.

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Keywords: eating disorders; body dissatisfaction; rumination; acceptance; emotion

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regulation; media.
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 1
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Introduction

Beyond being a main diagnostic feature of anorexia nervosa (AN) and bulimia

nervosa (BN), severe body image disturbances have been shown to play a decisive role in

the onset and maintenance of eating disorders (ED; for a review see Stice and Shaw, 2002).

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Previous research also points to the positive association between a negative body image at

the end of treatment and relapse rates in ED (Freeman et al., 1985; Keel et al., 2005). Thus,

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it is crucial to conduct research on factors that influence body image in ED as this may hold

implications for the improvement of current prevention and treatment programs.

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Results from an experimental study by Wade et al. (2009) provide compelling

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evidence that body dissatisfaction – defined as the affective component of body image

disturbances – can be modulated by certain emotion regulation (ER) strategies. In this study,
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female college students were allocated to different ER techniques following a body
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dissatisfaction induction by the exposure to media images of thin women. Findings suggest

that emotional acceptance is the most effective strategy to cope with media-induced
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appearance dissatisfaction, while emotional rumination has an attenuated effect on the

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recovery of body satisfaction.

To this date, only two studies experimentally assessed effects of ER on body image
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disturbance in patients with AN. In one study, women with AN reported significantly lower

estimations of weight following an imaginary meal task when they were encouraged to
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engage in an experiential-mindful compared to an analytical-ruminative self-focus (Rawal et

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al., 2011). In another experimental approach (Cowdrey et al., 2013), females with AN were

asked to listen to a mindfully breathing, rumination or distraction CD-guided exercise before

their evening meal. In this study, no differences between the ER conditions were found

regarding feelings of fatness after meal time. However, eating the meal might have blurred

possible effects of ER on feelings of fatness. Notably, a substantial number of participants in

these two studies (Cowdrey et al., 2013; Rawal et al., 2011) were partially remitted, and both

studies focused on different body image aspects, with no information on body dissatisfaction.
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 2
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Taken together, the mentioned experimental data suggest that ER strategies – in

particular emotional acceptance and rumination – have an influence on the experience of

body image problems. However, it must be stressed that these studies were either

conducted in non-ED samples or partially recovered AN patients. Therefore, we do not know

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if these results are transferable to the severe body dissatisfaction found in full-syndrome ED.

In light of this, the goal of the present study was to examine the effects of emotional

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acceptance and rumination on body dissatisfaction in patients with AN and BN. In line with

former studies (Svaldi and Naumann, 2014; Wade et al., 2009), participants were at first

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exposed to media images of thin models serving as a body-related stressor. Thereafter,

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participants were randomly allocated to either use acceptance or rumination to cope with

their feelings. Participants repeatedly rated their current body dissatisfaction. General mood
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was additionally measured, because it is closely associated with body dissatisfaction (Paxton
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et al., 2006; Stice and Shaw, 2002), and because it can be affected by acceptance and

rumination (Broderick, 2005; Singer and Dobson, 2009). It was predicted that acceptance
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would improve and rumination worsen media-induced body dissatisfaction and negative
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mood in patients with ED. Given the scant literature focusing on differences in effects of

induced acceptance and rumination across ED diagnoses, no specific hypotheses for AN

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and BN were made. ED groups were analyzed separately for exploratory reasons.
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Method
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Participants

The study sample consisted of women with AN (n = 39) and BN (n = 39). The main

recruitment source for the AN (n=31) and BN (n=25) group was an ED inpatient clinic. The

other participants were recruited through advertisements in local newspapers. Differences in

recruitment style between the two ED groups or ER conditions did not reach significance,
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 3
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χ2(1, N=78) < 2.37, p <.131. In order to avoid potential confounding treatment effects, ED

inpatients were only included if they were newly admitted.

The Eating Disorder Examination Interview (Hilbert and Tuschen-Caffier, 2006) was

conducted by a trained masters-level or doctoral student in clinical psychology to ensure that

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participants fulfilled the required DSM-IV-TR criteria. Comorbid disorders were assessed with

the Structured Clinical Interview for DSM-IV Axis I and the borderline personality section of

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the Axis II interview (Wittchen et al., 1997). We found a high inter-rater reliability for ED

(ĸ=.98) and comorbid diagnoses (ĸ=.93) in a subsample of 42 participants.

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Participants were excluded from the study if they (a) were aged below 16 years, (b)

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pregnant, (c) suffered from current substance abuse or addiction (except sustained full

remission), (d) bipolar disorder, (e) current or past psychosis, (f) schizophrenia, or (g)
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suicidality.
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There were no significant differences between ED groups or ER conditions regarding

demographic variables and comorbidities. As expected, analyses showed that patients with
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AN had significantly lower BMIs than the BN group. Descriptive data and statistics are shown
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in Table 1.

The local ethical committee approved the study. All participants provided informed
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consent before their participation. If subjects were younger than 18 years, a parent had to

additionally sign the consent form.

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------------------------------- Please insert Table 1 about here -------------------------------

Questionnaires

The following questionnaires were used to collect information on the comparability of

ED patients’ level of psychopathology.

The Eating Disorder Examination Questionnaire (EDE-Q) is a 36-item self-report

questionnaire with good psychometric properties that measures severity of ED pathology

Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 4
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(Hilbert et al., 2007). The EDE-Q global score had excellent internal consistency in the

present study (α=.93).

The Body Shape Questionnaire (BSQ) is a 34-item self-report questionnaire with

good psychometric properties that measures trait body dissatisfaction (Waadt et al., 1992).

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Internal consistency in the present study was excellent (α=.96).

The Beck Depression Inventory-II (BDI-II) was used to assess severity of depression.

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The high internal consistency, stability and validity of the BDI-II have been documented in a

number of studies (Hautzinger et al., 2006). Internal consistency in the present study was

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excellent (α=.90).

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The adapted version (Wade et al., 2009) of the Consumer Response Questionnaire

(CRQ) (Mills et al., 2002) was used during the experimental presentation of the thin-idealized
AN
media images. The CRQ encourages participants to compare themselves with the presented
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model pictures. The following items are answered on a 5-point response scale from 1

(strongly disagree) to 5 (strongly agree): (a) I would like my body to look like this woman’s
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body, (b) This woman is more attractive than me, and (c) I would not like to try on bathing
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suits if this woman was also trying on bathing suits in the same change room. In previous

studies the CRQ was used to strengthens the impact of the body dissatisfaction induction
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(Svaldi and Naumann, 2014; Wade et al., 2009), as social comparisons processes were

shown to mediate the effects of media images on body dissatisfaction (Tiggemann and
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McGill, 2004). Internal consistency in the present study was excellent (α=.95).
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There were no differences in questionnaires between ED groups and ER conditions.

Descriptive data and statistics for the questionnaires are displayed in Table 1.

Subjective Ratings

State body dissatisfaction was computed by the mean of the following 100 mm visual

analogue scales (VASs) ranging from “not at all” to “very much”: At the moment… 1) how

satisfied do feel about your body? (reverse scoring), 2) how satisfied do you feel about your
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 5
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body appearance? (reverse scoring), 3) how much do you hate your body?, and 4) how

much do you loathe your body?. The internal consistency for the body dissatisfaction scale

was excellent with Cronbach's α reaching from .89 to .92 (depending on the test interval).

Participants mood was measured with the following word-anchored (very-bad – very

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good) 100 mm VAS: “How do you feel at the moment?”.

To measure compliance with the ER instructions, participants were asked how

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strongly they agreed or disagreed with the statement “I have tried to carry out the instruction”

on a 100 mm VAS ranging from “not at all” to “very much”.

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Emotion Regulation Instructions

The instruction for acceptance was adapted from Singer and Dobson (2007).
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Participants were encouraged to take a non-judgmental attitude towards their body-related
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emotions and thoughts (e.g., This technique entails experiencing and perceiving things

without immediately judging or evaluating them. The aim of this technique is to try to accept
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one’s own emotions and let them be without trying to influence them). The induction of
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rumination was based on the well-established procedure of Nolen-Hoeksema and Morrow

(1993). First a short definition of ruminative coping was provided (e.g., This technique
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requires thinking about events and questions repeatedly and focusing on thoughts and

emotions without immediately trying to work out solutions). Then, participants were asked to
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repeatedly think about a set of 12 questions (e.g., Think about what your actual feelings tell
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you about yourself; Think about the way you feel right now). It is noteworthy that none of

these ruminative questions explicitly prompt body-related comparison with the model images.

Instructions for acceptance and rumination were comparable with regard to lengths and

references to topics involving body image. The exact wording for both ER instructions is

reported in the study of Svaldi et al. (2013).

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Experimental Procedure

Upon arrival at the experimental session, the participant was led into a sound-

attenuated laboratory room, and seated in front of a 17-inch monitor. The examiner started

the stimuli-generating computer program (Presentation; Neurobehavioral Systems, Inc.

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Albany, CA, USA), and left the laboratory room that was connected to an adjoining control

room.

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At baseline (T0) and after (T1) the induction of body dissatisfaction, participants

assessed their state body dissatisfaction and mood. The procedure to induce body

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dissatisfaction was based on Wade et al. (2009). The participant was instructed to carefully

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watch a set of 17 magazine advertisements portraying thin and attractive female models for

15 minutes1. Each image was presented separately on a computer screen for 55 seconds,
AN
while an acoustic signal indicated the beginning of the next picture. The participant filled out
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the CRQ after every image.

After the induction of body dissatisfaction, the participant received the instruction of
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either emotional acceptance or rumination. Randomization to one of the two ER conditions

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was done separately for each ED group using computer-generated random tables. The

participant listened to an audio-recording of the respective ER instruction. Instructions were

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additionally handed out in written form, so that the participant could read along silently. The

examiner entered the laboratory room to ensure that the participant had understood the ER
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instructions. Once the examiner left, the participant applied either acceptance or rumination
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for 5 minutes. A note card with the main aspects of the allocated ER strategy serving as a

memory aid was provided to the participant during the application phase. After applying the

ER strategy (T2), state body dissatisfaction and mood were assessed once more.

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The construction of the picture set was based on results of a pre-test, in which 40 thin-

idealized media images were shown to 8 healthy undergraduate female students, 6 women with BN

and 2 with AN. Pictures that induced the highest body dissatisfaction were selected for the study.
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 7
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Participants additionally reported on their compliance with the ER instruction. A flow diagram

of this experimental procedure is displayed in Figure 1.

To take participants’ minds off the ER task, a 5-min presentation of non-emotional

landscape images was shown at the end of the experimental session. Before leaving the

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laboratory, participants were debriefed and reimbursed with 25€.

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------------------------------- Please insert Figure 1 about here -------------------------------

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Data Analyses

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In line with the recommendations of Van Breukelen (2006), Group x Condition x Time

repeated measures analyses of covariance (ANCOVAs) with the baseline as covariate were
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conducted to analyze the effects of the media images as well as the main hypotheses on the
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ER effects. Mood changes were also entered as a covariate in the analyses on body

dissatisfaction to ensure that results were independent from mood. The item on the
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compliance with the ER instructions was analyzed by a Group x Condition ANOVA. Being
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exceedingly robust against violation of normality (Tabachnick and Fidell, 2007), ANOVAs

were also adopted for variables deviating from normal distribution. Effect sizes of the main
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effects and interactions are reported by partial eta squared (ηp2), whereby values larger than

.01 refer to small, .06 to moderate, and .14 to large effect sizes (Cohen, 1988). Effect sizes
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for post-hoc analyses are reported by Cohen’s d (Cohen, 1988), whereby values larger than
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.20 refer to small, .50 to moderate, and .80 to large effect sizes.
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 8
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Results

Induction of Body Dissatisfaction

A Group (AN, BN) x Condition (acceptance, rumination) x Time (T0, T1) repeated

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measures ANCOVA conducted on state body dissatisfaction yielded a significant main

effect of Time, F(1, 72) = 15.05, p < .000, ηp2 = .173, with significantly higher scores after the

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media image exposure than at baseline. No other main effect or interaction reached

significance, F(1, 72) < .69, p > .793, ηp2 < .001. A Group x Condition x Time repeated

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measures ANCOVA conducted on mood yielded no significant effects, F(1, 73) < 2.71, p >

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.104, ηp2 < .036. Means (Ms) and standard errors (SEs) for state body dissatisfaction and
AN
mood are displayed in Figure 2 and 3.
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Compliance with Emotion Regulation Instruction

Scores on the compliance item “I have tried to carry out the instruction” were
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generally high in both groups (AN: M/SD=82.76/18.74; BN: M/SD=83.58/16.07). A Group x

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Condition ANOVA yielded no significant main effects, F(1, 74) < .67, p > .797, ηp2 < .001, or

interaction, F(1, 74) = .04, p = .844, ηp2 < .001.

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Effects of Acceptance and Rumination on Body Dissatisfaction

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A Group (AN, BN) x Condition (acceptance, rumination) x Time (T1, T2) repeated
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measures ANCOVA on state body dissatisfaction yielded a significant main effect of Group,

F(1, 72) = 5.18, p = .026, ηp2 = .067, of Condition, F(1, 72) = 22.25, p < .001, ηp2 = .236, and

of Time, F(1, 72) = 25.30, p < .001, ηp2 = .260. All two-way interactions, F(1, 72) > 5.18, p <

.026, ηp2 > .067, and the three-way Time x Group x Condition interaction were significant,

F(1, 72) = 4.33, p = .041, ηp2 = . 057.

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Paired t-tests were conducted separately for the groups and ER conditions, to follow-

up on the significant interactions. State body dissatisfaction significantly decreased in

patients with BN instructed to use emotional acceptance, t(19) = 3.27, p = .004, d = .769,

while no significant changes were found in the acceptance condition in patients with AN,

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t(19) = .16, p = .870, d = .038. A significant increase of body dissatisfaction in response to

ruminative coping was found in BN, t(18) = -2.23, p = .038, d = -.650, and AN, t(18) = -2.28,

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p = .035, d = -.514. The Ms and SEs are displayed in Figure 2.

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------------------------------- Please insert Figure 2 about here -------------------------------

Effects of Acceptance and Rumination on Mood

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A Group (AN, BN) x Condition (acceptance, rumination) x Time (T1, T2) repeated
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measures ANCOVA on mood yielded a significant main effect of Condition, F(1, 73) = 9.13, p

= .003, ηp2 = .111, and of Time, F(1, 73) = 5.12, p = .027, ηp2 = .066. The interaction Time x
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Condition was significant, F(1, 73) = 9.13, p = .003, ηp2 = .111, with no other significant
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effect, F(1, 73) < 1.85, p > .178, ηp2 < .025.

To further explore the significant interaction, paired t-tests were conducted separately
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for the two ER conditions. It was found that mood significantly decreased in response to

ruminative ER, t(38) = 2.95, p = .005, d = .510, whereas no changes were found in the
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acceptance condition, t(40) = -.06, p = .953, d = -.009; see Figure 3 for Ms and SEs).
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------------------------------- Please insert Figure 3 about here -------------------------------

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Discussion

As predicted, we found that the application of emotional acceptance significantly

improved body dissatisfaction in response to thin-ideal media images in women with BN.

Therefore, extending previous data in non-ED samples (Dijkstra and Barelds, 2011; Wade et

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al., 2009; Wood-Barcalow et al., 2010), our finding suggests that the mindful processing of

emotions is a useful and effective strategy to cope with body dissatisfaction in BN.

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In contrast to our hypothesis, we found that the usage of acceptance did not

significantly change media-induced body dissatisfaction in patients with AN. One explanation

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for this could be that patients with AN might have struggled to adequately deploy emotional

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acceptance. Results from a qualitative study by Rawal et al. (2009) indicate that exercises

involving awareness and acceptance of body-related emotions are too overwhelming for
AN
severely disturbed AN. Furthermore, in contrast to studies in recovered depression (Singer
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and Dobson, 2009), we did not find a mood-elevating effect of acceptance. In this context,

we must point out that acceptance in the present study might not have been optimally
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operationalized as it only relied on verbal instructions and notes, albeit video instructions of
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acceptance have shown to be associated with higher compliance rates (Atkinson and Wade,

2012). Furthermore, given that we did not include a follow-up assessment of subjective
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ratings, we cannot rule out that improvement of body dissatisfaction in the AN group and

mood in general would have occurred at a later time point. In fact, one experimental study
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(Campbell-Sills et al., 2006) found that the beneficial effects of induced emotional
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acceptance in the down-regulation of negative affect were apparent not directly after the

emotion-evoking event but in the recovery phase. Thus, it will be necessary for future studies

to measure the effects of acceptance on body dissatisfaction and mood in ED over longer

periods of time.

In correspondence with the hypotheses, we found that rumination further aggravated

media-induced body dissatisfaction in patients with ED. Although rumination also led to a

significant decline of participants´ negative mood, it is important to note that the effects on
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 11
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body dissatisfaction were independent from participants’ mood levels. In line with research

on the negative effects of ruminative thinking on body image in healthy individuals (Etu and

Gray, 2010; Svaldi et al., 2013), our results provide evidence that rumination can be

considered as a maladaptive ER strategy in the context of body dissatisfaction also in

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women with AN and BN. This is of particular interest, given that patients with ED are

characterized not only by a reduced use of adaptive ER strategies, but also by a more

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frequent use of maladaptive ER strategies such as rumination (Aldao et al., 2010; Cowdrey

and Park, 2011). Thus, it is possible that the high body dissatisfaction in AN and BN may in

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part be due to a deficient ER when confronted with body-related stimuli and concerns. From

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a theoretical perspective this would converge with recent ED models that propose

dysfunctional ER (Fairburn et al., 2003; Haynos and Fruzzetti, 2011) and in particular
AN
rumination (Nolen-Hoeksema et al., 2008; Park et al., 2011, 2012) to play a key role in ED
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maintenance.

Notably, we found that the exposure to thin-idealized model pictures specifically

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induced body dissatisfaction with little influence on general mood. This is in sharp contrast to
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many previous reports in which the experimental presentation of thin-ideal female images led

to an exacerbation of both body dissatisfaction and negative mood (Hausenblas et al., 2013;
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Loeber et al., 2016; Wyssen et al., 2016). An explanation for the non-significant mood

change in the present study might be that the viewing of thin-idealized body images can be a
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source of social comparison but also “thinness fantasies” in women at high risk for
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developing an ED (Mills et al., 2002). Those thinness fantasies after thin-ideal model pictures

are associated with an improvement of mood (Tiggemann et al., 2009), and thus might have

been responsible for an alleviation of the negative effect of the thin-idealized media on

participants’ mood. In line with this argumentation, Joshi et al. (2004) found that women with

ED pathology felt generally better about themselves (but not their appearance) after

watching thinness-promoting images. From a methodological point of view, another

explanation for the non-significant decrease of negative mood might be that we measured
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 12
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mood very broadly using only one item. Single item measures have been shown to be of low

specificity and sensitivity to change (Jenkinson et al., 1994), and thus not ideal for use in

repeated measures studies. Future studies on the effect of thin-idealized media images in

ED would benefit from assessing general mood as well as a wider range of emotions with

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multiple items to better and more reliable distinguish between different emotional states.

Several limitations apply to the present study. First of all, although a power analysis

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indicated that the sample size was sufficient to detect medium to large effects, the study did

not have enough power to discern small effects. Thus, the presented data awaits replication

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in larger samples, especially given the non-significant result for acceptance in patients with

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AN.

Secondly, the study lacks a healthy or clinical control group. As serious ER

AN
disturbances have been reported in a number of mental disorders (Aldao et al., 2010), future
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studies are warranted that provide information about the ED-specific or transdiagnostic

importance of different ER strategies.

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Another concern of the current study is the absence of a control condition in which
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participants received no specific ER instruction. As such, no conclusion can be drawn about

the effects of acceptance and rumination in comparison to participants’ natural ER

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behaviours. Furthermore, it must be critically mentioned that only the effects of two ER

strategies on body dissatisfaction were investigated. Future studies are warranted that
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include an ER control condition as well as the induction of a wider range of ER strategies

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(including strategies like distraction or reappraisal), in order to be able to put the influence of

acceptance and rumination on body dissatisfaction into better perspective. This could also

help to determine if there are ER strategies that are easier to learn or more beneficial in the

reduction of body dissatisfaction than emotional acceptance, especially in populations with

AN.

As another limitation it must be stressed that we only focused on one specific

component of the body image (with no information about the influence of ER on other
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 13
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important body image parameters like perceptual size estimations or body image concerns;

Thompson, 2004), and that results can only be interpreted in the context of body

dissatisfaction in response to thin-ideal media images. As such, we have no information

about the effects of acceptance and rumination on non-manipulated body image or toxic

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effects of other body-related environmental stimuli (e.g., weighing, mirror exposure).

Furthermore, notwithstanding the correlation between thinness-promoting media, body

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dissatisfaction and ED symptomatology (Grabe et al., 2008; Stice and Shaw, 2002), the

laboratory-controlled, massed thin-idealized media exposure raises issues of external

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validity. While a laboratory experimental approach minimizes effects of confounding

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variables and allows to address questions on cause, it does adequately reflect the

complexity of real-world environments and does not provide insight into real-life experiences.
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Thus, generalization of our results to patients’ everyday life is limited by the artificial setting
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in which the study was carried out (e.g., unnatural presence of experimenter, concentrated

exposure to model pictures, provided instructions on how to deal with one´s emotions).
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Future studies would benefit from using a more ecological valid methodology like the
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ecological momentary assessment (EMA) for a naturalistic evaluation of ER and body

dissatisfaction in ED (Heron and Smyth, 2013; LePage and Crowther, 2010). In this context,
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it must be critically mentioned that the cross-sectional design of the present study limits the

meaning of the results. Longitudinal data assessments will be necessary in the future to
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determine the importance of specific ER strategies in the etiology of AN and BN.

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Moreover, caution is needed in extrapolating our findings to trait body dissatisfaction.

Although there is a close linkage between body dissatisfaction on a state and trait level,

there is a clear distinction between those two concepts (Cash et al., 2002).

Last but not least, inferences can only be made about the brief usage of acceptance

and rumination. For future studies it will be interesting to explore the potential that an

intensive acceptance-focused intervention holds for the reduction of deeply-rooted body

image problems. In fact, for the treatment of general and eating-related ED symptoms in ED
Effects of Acceptance and Rumination on Body Dissatisfaction in Eating Disorders 14
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patients there already is preliminary evidence on the high efficacy of mindfulness-based

programs (Masuda and Hill, 2013). Furthermore, the results of a recently published study

indicate that a mindfulness-based intervention reduces shape and weight concerns in

adolescent females, and therefore may be a useful tool in ED prevention (Atkinson and

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Wade, 2015).

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Acknowledgements

We want to thank the Scientific Society of Freiburg for their generous grant, which enabled

us to pay participants a small honorarium. We gratefully acknowledge the excellent support

of the staff of the Schoen Clinic Roseneck in Germany. We thank all the participants for their

commitment and dedication.

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Table 1. Means (standard deviations)/ frequencies and statistics for demographics, comorbidities and questionnaires.

Anorexia nervosa Bulimia nervosa Statistics1

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Acceptance Rumination Acceptance Rumination

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(n=20) (n=19) (n=20) (n=19) F or χ2 p

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Age 25.95 (12.31) 22.79 (7.25) 24.85 (8.10) 28.37 (9.09) 2.45 .122

Marital status 2.09 .554

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single 15 7 6 11

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partnership 5 12 14 8

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Educational level 1.83 .400

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low-middle 10 8 10 7

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high 10 11 10 12

BMI 15.35 (1.96) 14.77 (1.54) 20.79 (3.39) 22.96 (4.44) 97.01 .001*
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EDE-Q global 4.08 (1.35) 4.49 (1.25) 4.16 (.96) 4.62 (0.90) 2.85 .095
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BSQ 122.72 (36.13) 136.16 (32.11) 133.89 (31.19) 138.21 (24.75) 1.59 .216
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BDI-II 27.47 (8.03) 30.12 (11.23) 23.23 (10.07) 27.84 (9.94) 2.64 .108

CRQ 3.81 (0.63) 4.12 (0.54) 3.73 (0.69) 3.98 (0.79) 3.49 .066

Comorbidities2 2.46 .116

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depression 15 13 13 16

anxiety disorder 6 3 8 5

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OCD 2 3 1 2

BPD - 2 2 4

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BDD - 1 - 1

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Note. 1= Statistics are reported for the lowest p-value in the Group x Condition ANOVA/ χ2-Test; *= significant Group effect with no

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other effect or interaction being significant; 2= Lifetime diagnoses; BMI= body mass index (weight/height2); EDE-Q global= Eating Disorder

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Examination Questionnaire – global score; BSQ= Body Shape Questionnaire; BDI-II = Beck Depression Inventory-II; CRQ= Consumer

Response Questionnaire; OCD= obsessive-compulsive disorder; BPD= borderline personality disorder; BDD= body dysmorphic disorder.

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Figure 1. Flow Diagram of the Experimental Procedure.

T0 – Subjective Ratings:

Body Dissatisfaction and Mood

Induction of Body Dissatisfaction:

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Thin-Ideal Media Images

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T1 – Subjective Ratings:
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Body Dissatisfaction and Mood
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Instructions for Emotion Regulation Strategy:

Acceptance vs. Rumination

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5-Min Application of Emotion Regulation Strategy:
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Acceptance vs. Rumination

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T2 – Subjective Ratings:
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Body Dissatisfaction, Mood and Compliance

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Figure 2. Means on body dissatisfaction at baseline (T0), after the presentation of thin-

ideal media images (T1), and after the application of either acceptance or rumination (T2). Bars

represent standard errors. The star indicates statistical significance (p < .050).

ANOREXIA NERVOSA BULIMIA NERVOSA

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Rumination Acceptance Rumination Acceptance
100 100

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90 90

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*
BODY DISSATISFACTION
BODY DISSATISFACTION

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80 * 80

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70 70
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*
60 60
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*
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50 50
*
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40 40
T0 T1 T2 T0 T1 T2
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Figure 2. Means on mood at baseline (T0), after the presentation of thin-ideal media

images (T1), and after the application of either acceptance or rumination (T2). Bars represent

standard errors. The star indicates statistical significance (p < .050).

ANOREXIA NERVOSA BULIMIA NERVOSA

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Rumination Acceptance Rumination Acceptance
70 70

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60 60

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50 50

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40 40
MOOD

MOOD

30 30
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20
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* *
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10 10
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0 0
T0 T1 T2 T0 T1 T2
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Running head: Effects of Acceptance and Rumination on Body Dissatisfaction in Eating

Disorders.

Article title: Effects of Emotional Acceptance and Rumination on Media-Induced Body

Dissatisfaction in Anorexia and Bulimia Nervosa.

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Authors: Eva Naumann, Brunna Tuschen-Caffier, Ulrich Voderholzer, Johanna Schäfer, &

Jennifer Svaldi

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Contributors

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All authors have approved the final article. Eva Naumann developed the study design, was
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responsible for collection, analysis and interpretation of data, and wrote the paper. Brunna

Tuschen-Caffier, Ulrich Voderholzer and Jennifer Svaldi contributed substantially to the study
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design and intellectual content of the paper. Johanna Schäfer contributed substantially to the
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data analysis.
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 ACCEPTED MANUSCRIPT
Running head: Effects of Acceptance and Rumination on Body Dissatisfaction in Eating

Disorders.

Article title: Effects of Emotional Acceptance and Rumination on Media-Induced Body

Dissatisfaction in Anorexia and Bulimia Nervosa.

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Authors: Eva Naumann, Brunna Tuschen-Caffier, Ulrich Voderholzer, Johanna Schäfer, &

Jennifer Svaldi

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Role of the funding source

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We received a grant (2000 Euro) from the Scientific Society of Freiburg, which enabled us to
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pay participants a small honorarium. The corresponding authors received a state-funded

doctoral scholarships from the International Graduate Academy Freiburg. The funding
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sources had no involvement in study design, in the collection, analysis and interpretation of
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data, in the writing of the report, and in the decision to submit the article for publication.
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