Several studies (e.g., Nevonen & Broberg, 2000; Tozzi et al., 2003) have identified positive and negative life events as risk factors (i.e., events that lead to the development of eating disorders) and protective factors (i.e., events that lead to recovery in different psychopathologies). Positive and negative life events may, therefore, play an essential role in the etiology, maintenance, and recovery of psychological disorders, including eating disorders (Schmidt et al., 1997).
Several quantitative studies with eating disorder patients have identified different adverse life events as risk factors: physical or sexual abuse, bereavement, adverse family experiences (e.g., moves or changes in the family, fights or arguments -Hilbert et al., 2014 -), ending of significant relationships and experiences of stress at school or work (Pike et al., 2006) and some positive life events (e.g., participation in self-help groups, getting a stable job, or having a partner or children) as critical to recovery (Pettersen & Rosenvinge, 2002).
Qualitative studies have also been conducted in this area since qualitative methodology allows an understanding of experiences from the patient's perspective, which offers invaluable insights for healthcare professionals treating people with eating disorders (Patching & Lawler, 2009). For instance, in a study by Tozzi et al. (2003), the participants identified various events leading to the development of eating disorders: adverse family experiences (e.g., dysfunctional families: family very controlling, fights, divorce); weight loss and dieting; specific stressful experiences (e.g., exams, a close friend being very ill, losing one's job); and loss (e.g., the sudden death of someone close or a family member). In another study (Nevonen & Broberg, 2000), interpersonal problems (e.g., separations, conflicts, teasing, and comments) and psychosocial problems (e.g., school problems) were also identified as adverse life events related to the development of eating disorders. On the other hand, some of the mentioned factors contributing to recovery were supportive relationships, therapy, increased self-esteem, and maturation (Tozzi et al., 2003). These studies have, thus, provided new insights into causal and protective factors for eating disorders (Patching & Lawler, 2009).
Although the risk factors identified in these studies are negative events (Nevonen & Broberg, 2000; Tozzi et al., 2003), positive events can also be considered risk factors. For example, events such as entering high school, graduating from college, getting engaged, and getting married, although they are not negative events, can contribute to feeling overwhelmed, stressed, and less capable of coping effectively (Pike et al., 2006). Therefore, more important than identifying the events, it is essential to clarify the emotional experiences triggered by them, that is, the feelings and emotions associated with these specific events. As previously shown, some positive experiences can have a negative emotional impact and vice versa. Additionally, the same experience/event can have different feelings and meanings for different people. So far, few studies have evaluated the emotional meaning of these experiences from patients' perspectives.
Patching and Lawler (2009) found that the development of eating disorders was attributed to a lack of control, a sense of disconnection from family and peers, and extreme conflict with significant others (family and peers). In the clinical context, it is critical to promote events that convey feelings associated with a gain of control, facilitate connectedness with family and peers, and build strategies for conflict resolution. Patients in the recovery process also reported some of these emotional experiences. For instance, according to the patient's view, stronger perceived social support, greater sense of autonomy, and better capacity to handle problems are essential for recovery (Vanderlinden et al., 2007).
On the other hand, some authors (e.g., Nordbo et al., 2006) believe that some eating disorder symptoms are related to specific emotional experiences that are responsible for the maintenance of the disorder. These emotional experiences are, in a way, positive or coping functions of the eating disorder. Consequently, the emotional experience associated with the disorder is so important that it can be related to the development and maintenance of the disorder per se. For example, we know that patients with anorexia nervosa have a sense of stability and security (the eating disorder helped the patients organize their everyday lives) and an inner sense of mastery and strength (they achieved a sense of mastery and self-control) related to their eating disorder experience. These emotional experiences associated with anorexia nervosa may contribute to their development and maintenance (Nordbo et al., 2006). In bulimia nervosa, binge eating may play a critical emotion-regulatory function for the individual, namely reduced self-awareness ofnegative emotions (Cooper et al., 2004). In the clinical context, understanding emotions and their functions is crucial, and developing healthier behaviours than the eating disorder symptoms that can achieve the same value and emotional experiences (e.g., a sense of stability and security) is vital.
The literature is scarce concerning the study of the emotional experiences associated with eating disorder behaviors and symptoms from the patient's perspective. As previously discussed, more important than identifying the events, which has already been done in other studies, is to evaluate the related emotional experiences. Specifically because, as mentioned before, positive events can lead to negative emotional experiences and, therefore, be identified as risk factors. Not all the positive events can be considered as protective factors. Hence, it is essential to identify meaningful positive emotional experiences for women with eating disorders to know whether and which other life experiences and emotions should be promoted in the clinical context (Nordbo et al., 2006). Additionally, by identifying negative emotional experiences, the emotional regulatory strategies can be increased in the clinical context to deal with these reported negative emotional experiences.
The aims of this study are twofold. First, we intend to identify positive and negative life events in female patients with eating disorders, more specifically, young women with anorexia and bulimia nervosa. Second, we aim to determine the value/ meaning and the emotional experiences related to these specific life events. Our general purpose is to understand which emotional experiences are most valued by women with anorexia and bulimia nervosa. To do so, we asked women with anorexia and bulimia nervosa to recall the happiest and saddest events of their lives and the emotions and feelings associated with them. We performed a qualitative study using a semi-open structured interview format. It was assumed that by analyzing the transcribed interviews, we could detect a valid and reproducible set of constructs expressing which events women with eating disorders verbalize when they have to describe their happiest and saddest memories and which emotions are associated with them.
The sample included 18 female participants with eating disorders, with ages ranging between 16-21 years (M = 18.00; SD = 1.53). The clinical diagnoses of our sample were determined by the psychiatrist at the health care institution where the data was collected and recruited -women diagnosed with anorexia nervosa and bulimia nervosa-. All participants were outpatients who spoke European Portuguese as their first language.
The qualitative semi-structured interview was a Portuguese translation of the Emotions Interview (Rottenberg et al., 2005), in which the participants are asked to remember separately the saddest and happiest events of their lives and describe them in a detail. During the interview, questions are formulated to facilitate a detailed retrieval, such as when this event occurred. Questions are also applied to emphasize the emotionality of the event, such as why this event stands out.
The interviews were conducted in two central hospitals in northern Portugal by a researcher. After the participants signed the informed consent form, they completed the demographic questionnaire. Then, the interview was conducted and recorded for subsequent transcription. Half of the participants first recalled their sad events and then their happy events, while the other half recalled happy events and then sad events. The duration of the entire procedure was approximately 15 minutes.
Several studies (Hilbert et al., 2014; Pike et al., 2006; Tozzi et al., 2003) have asked patients with eating disorders to talk about the events that led to the development of their eating disorders and the events that led to recovery. As we wanted to evaluate which events and emotional experiences were most valued by women with eating disorders, we asked them to remember their happiest and saddest life events. As far as we know, no previous study has asked for these specific memories.
Only the researchers had access to the participants' data. The study was reviewed and approved by the local Ethics Committee and is in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.
The interviews were transcribed verbatim, and text analyses were performed using the software QSR-N*Vivo. After repeated readings of each interview, the coders applied thematic coding according to the "bottom-up principle." In the inductive analysis, data is coded without trying to fit it into a pre-existing coding frame. In this sense, this form of thematic analysis is data-driven. The first two authors used the same method to conduct the bottom-up analyses. The correspondence between the coders was high, and deviations were corrected through discussion. We used inductive thematic analysis, following the guidelines established by Braun and Clarke (2006).
Different strategies were adopted to ensure the validity and credibility of the results, including constant comparative analysis of the data. This process involves identifying significant topics, recurring ideas, and interesting features or patterns that were highlighted, and for this reason, a continuous comparison of data occurred throughout the study. All participant responses were read several times to enhance the researchers' familiarity with the transcriptions of the interviews. After, we developed a coding frame from the first set of responses, which involved identifying meaningful units of text (sentences, paragraphs) and assigning descriptive labels or codes to these units. This initial coding helps break down the data into manageable parts, constituting the coding frame used as a guide to systematically code all the data, which was reviewed in response to new data. The analysis progressed until data saturation occurred (when no new information was discovered from the data), and consistent patterns emerged. During this process, the coding frame was repeatedly discussed among the research team as a way to achieve consensus/agreement. To ensure the credibility of the data, we implemented a detailed illustration of each category with excerpts from the participants' speeches.
The analysis of the interviews through inductive thematic analysis yielded the following four topics: (1) events reported in the description of happy memories; (2) events reported in the description of sad memories; (3) emotional experiences associated with positive memories; and (4) emotional experiences associated with negative memories. Each topic has several subordinate themes (Table 1).
All participants described a set of happy events, integrated into seven themes: (a) Beginning an intimate relationship; (b) Birth of a sibling; (c) Academic achievement; (d) Obtaining something very much desired; (e) Simple everyday events; (f) Family gatherings; and (g) Travel. Some of these events can be grouped as events related to personal life: the beginning of an intimate relationship, the birth of a sibling, simple everyday events (like going to the beach), family gatherings, travels, and the obtention of something very much desired. The rest of the events can be grouped as events related to professional life: academic achievement.
a. Beginning an intimate relationship: Four participants described the beginning of an intimate relationship as their happiest event. Two of the participants mentioned the relationship started after the development of eating disorders, and the relationship has contributed to better self-esteem and well-being, helping them to deal with the disorder.
b. Birth of a sibling: One participant described the birth of a brother, something she wanted very much, as her happiest positive event. This event was particularly important and noteworthy for the patient because the birth of a sibling symbolizes the birth of unconditional love.
c. Academic achievement: Some participants described their happiest events as those that contributed to their academic achievement, such as beginning a desired career, earning a good grade average, and being transferred to a desired university.
d. Obtaining something very much desired: Some participants described events in which they obtained something they had desired for a long time as their happiest event, such as moving to a different city and, consequently, to a different house; getting a cat; receiving a much-desired birthday gift (e.g., an iPhone); and reconciling parents.
e. Simple everyday events: One participant described going to the beach as her happiest event. This day was remarkable for the patient because it was characterized by being a calm and peaceful day without any kind of worry or disturbance.
| “A very happy day for me is a beach day, and I think that’s it, a beach day, very calm, everything serene” (P3, 20 years old). |
f. Family gatherings: Three participants described family gatherings as their happiest events, where they reunited in festive times. In these examples, participants highlight the importance of happy gatherings on special occasions with not only the nuclear family but also with a large number of family members (e.g., aunts and cousins).
g. Travel: A participant described a trip, that is, when she traveled for the first time alone, as her happiest event. This highlights the role of autonomy, detachment, and the ability to live in the present moment, which was described as a significantly positive moment for this participant.
All participants described a set of sad events, integrated into five themes: (a) extreme case of conflict with the peer group / bullying; (b) extreme case of family conflict; (c) death and loss; (d) impact/impairment of the eating disorder; and (e) unexpected negative events. These themes can be grouped in several areas of the participants' lives. For example, the extreme case of conflict with the peer group / bullying and the extreme case of family conflict can be examples of disruptive personal relationships. The death and loss of family members and relatives, and the unexpected negative events like the end of a relationship and the unexpected loss of someone can be considered as events relating to grief. Lastly, the impact/ impairment of eating disorders, for example, the isolation by peer groups and family conflicts due to illness, are related to the disease, in this case, with the eating disorder.
a. Extreme case of conflict with the peer group / bullying: Some participants described episodes in which they were victims of discrimination/ bullying by colleagues/friends/peers or conflict with partners as their saddest events. The discrimination and conflicts described were not related to eating disorder impairments or consequences but to other reasons. Nevertheless, it seems that these events are relevant in the lives of these participants, being identified as the saddest events of their lives.
b. Extreme case of family conflict: Some participants described moments in which there were family conflicts as their saddest events. Those did not occur due to eating disorders. It is not surprising that these events are highly relevant in these participants, as eating disorders are often the result of a complex set of factors, including a disruptive, abusive, or neglectful family environment.
c. Death and loss: Some participants described the death of family members as their saddest event. One participant's father died during her childhood, and she, therefore, had to grow up without him; other participants described how relatives or close friends had been sick and eventually died, and the participants had to experience the whole disease process and death.
d. Impact/impairment of eating disorders: Some participants described situations or episodes that had occurred because they were ill, that is, because they had eating disorders, as their saddest events. Some women with eating disorders lose weight and have concerns about weight and health; others have negative thoughts and make very negative self-evaluations. Sometimes, they are excluded and isolated by their peer groups. Eating disorders may impact academic life and create family conflicts. Additionally, sometimes, women with eating disorders need to be hospitalized. All of these consequences of eating disorders were listed when participants described their saddest events.
e. Unexpected negative events: Some participants described unexpected negative events, such as the death of relatives or close friends, not being able to pursue the intended career, or the end of a relationship, as their saddest events. These events were noted mainly because they were not expected to happen, highlighting the unpredictability and lack of psychological and emotional preparation to deal with them.
We identified several emotional experiences associated with memories of positive events, that is, the emotional experiences that make the events so remarkable and important. For this topic, the following five themes emerged: (a) increased social support and affection; (b) increased personal valuation; (c) feelings of gratitude; (d) support and family unity; and (e) autonomy and independence.
a. Increased social support and affection: Several positive events were associated with increased social support and greater affection. Those events were important because they allowed the person to gain additional support and greater affection from other people. Among the positive events, we highlight starting a relationship and the birth of a brother.
b. Higher personal valuation: Several positive events were associated with academic achievement and personal valuation, where participants worked hard and dedicated themselves to obtaining something. Within the positive events, we highlight beginning a desired career, achieving a good grade, and transferring to the desired university. Participants reported happiness, pride, euphoria, and greater self-esteem.
c. Feeling of gratitude: Several positive events were associated with significant people, particularly family members, making concessions regarding long-standing requests. Participants described these concessions as putting them first and genuinely caring about them, which showed the participants that their families were accepting and recognizing their needs. The concessions ranged from simple requests, such as asking for an iPhone or a pet, to more complex requests, such as moving to a new house. Participants reported happiness, euphoria, acknowledgment, belonging, and, mainly, gratitude and appreciation.
d. Support and family unity: Several positive events were associated with family support and gatherings, including events in which the whole family met. We highlight events such as Christmas parties, New Year's Eve parties, and birthday parties. Despite these being moments when food issues, often without major restrictions and rules, arise, as we previously saw, these participants once again describe positive feelings and emotions related to festive moments, such as happiness, love, and unity.
e. Autonomy/Independence: One positive event was associated with autonomy and independence. For this participant, her most important, happy event was traveling because she did it alone for the first time. The participant reported happiness and euphoria. Although only one patient reported a positive experience related to autonomy/independence, we thought it important to highlight this finding. The happiness related to traveling alone for the first time was empowering for the patient.
We identified several emotional experiences associated with memories of negative events, that is, the emotional experiences that make these events remarkable and important. For this topic, the following four themes emerged: (a) lack of support and loneliness, (b) loss of support, and (c) fear of judgment and fear of not achieving goals.
a. Lack of support and loneliness: Several negative events were associated with lack of support and can be grouped into different areas: events related to family (lack of parental protection and situations in which family conflicts occurred), related to society in general (lack of support and isolation), and related to peers (absence of friends and conflict with the group of peers). In some cases, conflicts were related to the disease, while in other cases, they were not. Participants reported a lack of protection and fear, as well as sadness, loneliness, fragility, and vulnerability.
b. Loss of support: Several negative events were associated with a loss of support. In some cases, a family member or someone close had died, and in other cases, a relationship had ended. Both involved a loss of support previously present. The loss may have occurred during childhood, a long time ago, or more recently, and the participant may have been close to the person during the entire process of illness and death. Participants reported sadness, despair, and longing.
"It seems that a little bit of my childhood was emptier. It's strange to know that I will not see him again" (P16, 16 years old).
c. Fear of judgment by others and fear of not achieving goals: Some participants identified negative events associated with the fear ofjudg-ment and of not achieving goals due to the presence of the disease. Participants reported frustration, anxiety, worry, self-criticism, disappointment, frustration, and hopelessness.
In this study, we asked eighteen female patients with anorexia and bulimia nervosa to recall the happiest and saddest life events of their lives. Additionally, we identified the values or emotional experiences, that is, the feelings and emotions related to these specific life events. We identified the following four main topics: (1) events reported in the description of happy memories, (2) events reported in the description of sad memories, (3) emotional experiences associated with positive memories, and (4) emotional experiences associated with negative memories.
Women with eating disorders identified their saddest events, which can be grouped into (1) disruptive personal relationships marked by a conflict within the group of peers (bullying) or with the family; (2) grief, which includes events concerning the death or loss of relatives or close friends and some unexpected negative events, such as the unexpected death of relatives or close friends or the end of a relationship; and (3) impact/impairment of eating disorders, which includes events that occurred as a result of the participants having eating disorders. For example, weight loss, isolation by their peers, family conflicts due to illness, and hospitalization.
Some of the sad events reported in this study have been identified in previous studies as risk factors, such as adverse family experiences (e.g., fights and discussions). Indeed, results indicate that open communication between family members may offset eating disorders (Botta & Dumlao, 2002) and that adolescents with eating disorders have less trust in their parents, worse communication, and alienation with their parents and peers (Laporta-Herrero et al., 2021). Other risk factors identified were weight loss and dieting, interpersonal problems (e.g., separations, conflicts, teasing, and comments), and a sudden loss of someone close to or a family member (Nevonen & Broberg, 2000; Tozzi et al., 2003).
We observed the saddest events identified by participants resulted in or were related to loneliness and feelings of a lack ofsupport, loss of support, and a sense of lack of self-worth. Some of these emotional experiences, such as a lack of support and isolation, have been reported in other studies (Patching & Lawler, 2009) as events and emotions that can contribute to the development and maintenance of eating disorders.
Concerning their happiest events, the women with eating disorders reported events related to their personal life, such as the beginning of an intimate relationship, the birth of a brother, receiving something they strongly desired (e.g., a gift), events in which the entire family was reunited, travel, or simple/everyday events. Also, some of the happiest events were related to professional life, like academic achievements, such as obtaining a good grade average. It is also important to note that some of these happiest events, like the beginning of an intimate relationship, academic achievement, and family gatherings, are events that the presence of an eating disorder can disrupt. The intimate relationships in patients with eating disorders can be characterized by poor quality (Evans & Wertheim, 2005), and the presence of an eating disorder can provoke a higher level of stress and disrupt academic achievement (Yanover & Thompson, 2008) and family gatherings (Dannibale, 2014). This can be a possible reason why they are so important and were identified as the happiest events by women with eating disorders. Also, these events can be important for women with eating disorders because they convey social and emotional support, personal valuation, feelings of priority and importance, a sense of support and family unity, and autonomy and independence. Some of these emotional experiences, such as social support and a sense of autonomy, have been reported in other studies by women with eating disorders as important for the recovery process (Vanderlinden et al., 2007).
Regarding social support, the presence and lack of perceived social support have emerged as major emotional experiences related to the happiest and saddest life events, respectively. In fact, social support seems to be critical in the development and maintenance of eating disorders -anorexia nervosa and bulimia nervosa patients reported lower levels of social support or reduced satisfaction (Adenzato et al., 2012; Aimé et al., 2006) and (lack) social support can potentiate and mitigate the effects of other risk factors. For instance, social support is closely related to loneliness. Some of the participants in our study reported a lack of social support and loneliness in the experience of some specific negative life events. Previous studies (e.g., Richardson et al., 2017) have indicated that the relationship between loneliness and eating disorders is bi-directional -loneliness is a risk factor for eating disorders, and loneliness exacerbates eating disorder symptoms. Another interesting aspect of social support is its relation to self-evaluation -interaction in support contexts permits healthy personal development and growth and positive perceptions about self. So, our results highlight the relevance of perceived social support (in past and current emotional experiences) in anorexia and bulimia nervosa and inform the design of more effective prevention and treatment interventions focused on positive experiences related to higher perceived social support (e.g., focus on fostering connection and support from peers).
Autonomy, on the other hand, can be characterized as the person's ability to live a meaningful life of their own making. In developmental psychology, movement toward greater autonomy is considered a hallmark of optimal development, and it is central to healthy psychological development and functioning. In contrast, the disturbance of autonomy could impact the risk of onset, the severity of symptoms, as well as the maintenance of mental disorders such as eating disorders (Bergamin et al., 2022). In addition, autonomy seems to be related to hope and optimism, identity, meaning of life, and empowerment, and it is relevant to recovery (van Weeghle et al., 2019). Our findings support the importance of the patient's perception of autonomy in positive life experiences, which may help strengthen the person's self-efficacy and self-worth. Therefore, participation in valued activities and social roles may be relevant in recovery and may be integrated within clinical interventions that aim to promote personal autonomy.
Our results are in line with previous studies (e.g., Patching and Lawler, 2009; Vanderlinden et al., 2007) and highlight the importance of promoting emotional experiences related to positive life events, such as social support and affection, personal valuation, feelings of priority and importance, a sense of support and family unity, and autonomy and independence. These positive emotional experiences are meaningful and valued by patients with eating disorders and thus need to be promoted. Clinicians must be aware of these positive emotional experiences and how to encourage them using life experiences. Additionally, it is crucial to focus on specific negative emotional experiences, such as feelings of a lack of support and isolation, feelings of a loss of support, and a sense of lack of self-worth. Several studies (e.g., Anderson et al., 2018; Czaja et al., 2009; Harrison et al., 2010) have shown that patients with eating disorders have greater difficulty in regulating their emotions and an inability to cope effectively with their negative emotions. As such, clinicians should promote adequate strategies for emotional regulation to help patients deal with the specific emotional experiences identified in this study that seem valuable from patients' perspective.
One limitation of our study, which should be addressed in future studies, was that we did not ask participants about the timing regarding the occurrence of these life events, that is, if they occurred before or during the course of their eating disorders, to verify whether the participants' saddest events corresponded to events that led to the development of eating disorders and whether their happiest events corresponded to events that led to their recovery. Since the duration of the entire procedure was approximately 15 minutes, in a more profound interview format, more reflections might have been shared. Therefore, this study can serve as a basis for future studies that can delve deeper into the emotional events and experiences identified.
Another limitation of our study is the diagnosis (only women with anorexia and bulimia nervosa). It will be interesting, in future studies, to recruit a higher number of women with different eating disorders. This will also allow for identifying possible differences in the events and the emotional experiences reported by women with different diagnoses. However, more important than identifying the risk factors and protective factors that have already been identified (Hilbert et al., 2014; Pike et al., 2006; Tozzi et al., 2003), we aimed to observe which events were most valued by women with eating disorders and why they were important, that is, what were the emotional experiences associated with them. As previously discussed, it is important to evaluate the related emotional experiences. Positive emotional experiences related to perceived social support and a sense of autonomy are valued by women with anorexia and bulimia nervosa and, on the other hand, lack of support and isolation and a sense of lack of self-worth were reported as negative feelings related to major negative life events. With this work, we could identify important positive emotional experiences for women with eating disorders to know which life experiences and emotions should be promoted in therapy (Nordbo et al., 2006). Enhancing positive emotional events can be done, for instance, by using behavioral activation scheduling (e.g., cultivating positive emotions in everyday life), using relaxation therapies, and guided meditation practices that require participants to engage in thematic imagery exercises that can induce and extend the duration of pleasant experiences (Tugade & Fredrickson, 2007). Furthermore, by identifying negative emotional experiences in therapy, the emotional regulatory strategies can be increased to deal with these reported negative emotional experiences.
In sum, these findings propose that the study of emotional experiences, in particular from the patient's perspective, would enrich our understanding of eating pathology and provide new tools that might positively impact the prevention and treatment of eating disorders. Given these potential clinical implications, these findings represent a call for more research in this area. In addition, at a clinical level, an intervention focused on the person and their close relationships stands out as an area to be strengthened in the therapeutic environment, which could perhaps also include family members and close friends, who are trying to help their loved ones with eating disorders. In this way, we will not only be strengthening and helping the patient but also the whole surrounding environment, which, as we have seen, is fundamental to feelings of belonging, autonomy, control, and power over their schools, conditions, and lives.
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[1] This study was conducted at the Psychology Research Centre (PSI/01662), University of Minho, and supported by the Portuguese Foundation for Science and Technology (FCT) through the Portuguese State Budget (UIDB/PSI/01662/2020).
[2] Pinto, R., Albuquerque, P. B., Sousa, B., & Gonçalves, S. (2024). The emotional meaning of life events: A qualitative study of eating disorders patient's perspective. Avances en Psicología Latinoamericana, 42(1), 1-16. https://doi.org/10.12804/revistas.urosario.edu.co/apl/a.10130