Introduction

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by unrelenting self-starvation and life-threatening weight loss with concomitant brain anomalies as a consequence of malnutrition [1]. This relentless pursuit of starvation is associated with negative physical, emotional, and social consequences [2]. It has been found, that negative affect was increased significantly before loss of control eating, purging, the combination of loss of control eating/and purging, and weighing behavior in a sample of 118 adult females presenting AN. Furthermore, negative affect decreased significantly after the occurrence of these behaviors [3]. Some studies imply that negative affect may offer a critical maintenance mechanism of some AN symptoms. For example, in a study of 116 anorexic women measuring personality, clinical variables, and eating disorder symptoms [4], three subtypes, under-regulated (1), over-regulated (2), and low psychopathology (3), emerged. Under-regulated subtypes (1), characterized by high Stimulus-Seeking, Self-Harm, and Oppositional behavior presented higher baseline eating disorder symptoms, lower positive affect, higher negative affect, self-discrepancy, and binge eating. Over-regulated subtypes (2), characterized by high Compulsivity and low Stimulus-Seeking were more likely to have a lifetime obsessive-compulsive disorder diagnosis and showed higher levels of perfectionism, whereas negative affect, positive affect, and self-discrepancy in this group were intermediary between the other subtypes. Low psychopathology subtypes (3), characterized by normative personality, and presented the lowest levels of baseline eating disorder symptoms, co-occurring disorders, and eating disorder behaviors. Nevertheless, in a group of clinically diagnosed Estonian patients presenting eating disorders, compared with healthy volunteers, assessed on Estonian versions of the Eating Disorder Inventory-2, positive affect and negative affect (measured by the Positive Affect and Negative Affect Schedule), and Neuroticism made the largest contribution to Eating Disorder-2 subscales, with Openness to Experience and Conscientiousness (measured by the NEO Personality Inventory), predisposing individuals to eating problems [5]. It has been shown also that patients with AN inhibit expressions of both positive and negative emotions, even after controlling for neuroticism, with higher levels of hostility and neuroticism; they were less aware of their inner thoughts and feelings, “private self-consciousness”, and had a heightened awareness of the thoughts and expectations of others, “public self-consciousness”, [6]. Patients presenting eating disorders often report alexithymia, an inability to identify and describe their emotions and affective status [7,8]. They show a paucity of words expressing feelings and demonstrate difficulties in identifying and distinguishing feeling of physical sensations. Alexithymia and personal distress seem to predict the vulnerability features of Anorexia Nervosa (AN) with higher levels of personal distress in the latter linked to poor self-regulation and emotional awareness [9].

There is a high comorbidity between AN and anxiety and/or alexithymia disorders [10], moreover, AN patients display certain features similar to those abusing substances/exercise, through a ‘narrowed' behavioral repertoire such that weight loss, food intake restriction, and excessive exercise interfere with other activities in a similar fashion to substance/exercise abuse [11]. Further, comorbidity between AN, anxiety, depression and psychoactive substance use has been described [12]. It is likely that the disorder elevates anxiety, depression with stress presenting a predisposing factor to poorer health-related quality-of-life and social support [13]. It was observed that patients presenting eating disorders, AN and bulimia nervosa, showed markedly more alexithymia and a comparable group of female students. Clinical evidence indicates that these patients have major problems with attachment anxiety and negative affect [14]. The core affective processes that evolve into the development and maintenance of AN remain relatively unknown although the contributions of alexithymia suggest an affective basis [15]. It has been observed that AN participants displayed significantly greater implicit positive affect toward pleasant images and significantly greater implicit negative affect toward unpleasant, high-calorie food, and overweight body type images. Recovered participants did not differ significantly from controls on any implicit affect measure [16]. The notion of AN, as a motivated behavioral disorder in which compulsiveness may contribute to the persistence of abnormal eating habits and excessive exercise behaviors, seems warranted in view of evidence implicating anxiety, stress, fear and avoidance learning factors [17,18].

Affect is suggested to be composed of two systems, positive affect and negative affect, which reflect relatively stable cognitive emotional profiles as dispositions or signal sensitivity systems [19,20]. Negative affect and emotion among individuals presents a trait associated with both anxiety [21] and depression [22-24]. Conversely, positive affect is negatively associated with depression [24]. Attachment anxiety was associated with eating disorder symptom severity, and this relationship may be mediated by perfectionism and affect regulation strategies [25]. Affective profiles expressing high negative affect have been shown to report a higher degree of stress and a lower degree of coping and control than those with high positive affect [26-28]. Moreover, both adolescents and young and older adults with “Self-destructive” affective profile, i.e. high negative affect and low positive affect, typically report a higher degree of depression than people with any of the other profiles, i.e. “self-fulfilling”, “high affective” and “low affective” [19,26]. Negative affect has also been associated with pessimism [29]. Negative affect predicted stress, which in turn predicted general and situational depressiveness [30]. In this context, [24], suggest that positive affect is a dimension that varies from pleasant engagement (e.g., enthusiastic and active) to unpleasant disengagement (e.g., sad and bored), while the negative affect dimension moves from unpleasant engagement (e.g., angry and fearful) to pleasant disengagement (e.g., calm and serene). However, there is evidence that rather than being completely independent, the two affective dimensions might be interrelated in a two-dimensional circumflex model containing not only arousal (vertical axis), but also a valence dimension (horizontal axis). In other words, in order to get a full range of a persons' emotional well-being we need to assess not only high arousal affect, but also to assess the whole range of emotions we humans can experience.

Several implications of decreased emotional well-being are related to mental health concerns such as stress, depression and anxiety which may in turn lead to expressions of physical ill-health. Deterioration in health status, for instance, is associated with reduced levels of emotional and physical well-being [31]. The notion of affectivity presents a confluence of emotions and attributes – psychological, biological and social – that determine individuals' perceptions and experiences of situations [32]. Thus, the purpose of the present study was to examine AN patients' emotional well-being and background health information in comparison to age-matched healthy control subjects.

Materials and Methods

Participants and procedure

Ninety female patients (age range: 24 to 42 years) presenting eating disorders at diagnosis but here exclusively AN, with a history of unsuccessful treatment and referred from the Department of General Psychiatry, Sahlgrenska University Hospital (Gothenburg, Sweden) participated in the study. All the patients were ethnic Scandinavians from higher socioeconomic groups and well-educated. They had all undergone further education, following high-school graduation, for at least three years, had affluent-level economic status and upper-middle social-family backgrounds. They had all been afflicted with the symptoms for over five on arrival at the Anorexia & Bulimia Clinic for Adults (Sahlgrenska University Hospital), and described themselves as “well-behaved girls”. The healthy volunteer participants (i.e., 114 Controls) were selected from a larger sample collected in another study using the same instruments to measure affect [32].

The ethics protocol of the University Hospital Sahlgrenska was applied and maintained. All the patients who were contacted agreed to participate (N = 90). On arrival at the clinic, each patient described her type of eating disorder and completed the Eating Disorder Inventory-2 to measure symptoms of eating disorder and was then given their diagnosis by the presiding staff. Thereafter, were allowed to complete the questionnaire. Specifically, on arrival each patient was met by the respective professional workers, nurse, psychologist, physician, and after a preliminary discussion was asked whether or not she would be willing to complete a questionnaire in order for the health staff to obtain further insights into the AN condition. Following this, each patient received instructions and was allowed 30-45 min to respond to the instruments.

Instruments

Background health information. Background variables, such as age, years of education, smoking and drinking habits, pain, use of mood-enhancing drugs and analgesics, and frequency and duration of exercise, etc, were completed according to the description and procedure outlined in [33].

Positive Affect Negative Affect Schedule. This is one of the most commonly used instruments to measure high arousal affect and was developed on the premise that positive affect and negative affect represent two orthogonal independent dimensions: high positive affect versus low positive affect and high negative affect versus low negative affect. The instrument instructs participants to rate to what extent they generally have experienced 20 different feelings or emotions (10 positive affect and 10 negative affect) during the last week, using a 5-point Likert scale (1 = very slightly, 5 = extremely). The 10–item positive affect scale includes adjectives such as strong, proud, and interested. The 10–item negative affect scale includes adjectives such as afraid, ashamed, and nervous. In their study [30], reported a Cronbach's alpha of .88 for the positive affect scale and .83 for the negative affect scale. In the present study the scales had similar internal reliability (.93 for positive affect and .91 for negative affect).

Emotional Well-Being Scale. This a 16-item questionnaire includes eight items to assess positive feelings and eight items to assess negative feelings. For both the positive and negative items, three of the items are general (e.g., positive, negative) and three per subscale are more specific (e.g., joyful, sad). In contrast to the Positive Affect Negative Affect Schedule, this instrument includes low arousal emotions [34]. In the present study the Cronbach's alpha were .90 for the positive emotion scale and .92 for the negative emotion scale. Two single items form these scales were also used to assess depression and stress.

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   Table 1:

   Means and SD (±)Self-reported positive and negative affect, positive and negative emotions, stress and depression levels, sleeping problems, pain, use of analgesics and mood-affecting drugs, and exercise frequency by AN patients (90) and healthy controls (n = 114).
   

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   Table 1: Means and SD (±)Self-reported positive and negative affect, positive and negative emotions, stress and depression levels, sleeping problems, pain, use of analgesics and mood-affecting drugs, and exercise frequency by AN patients (90) and healthy controls (n = 114).
   Factor	F	AN Patients	Healthy Age-Matched Controls
   Positive affect	111.17*	2.81 ± 0.82	3.63 ± 0.71
   Negative affect	65.04*	3.14 ± 0.74	2.08 ± 0.62
   Positive emotions	27.77*	2.98 ± 1.08	3.71 ± 0.89
   Negative emotions	36.98*	3.60 ± 1.00	2.76 ± 0.93
   Stress	84.34*	4.23 ± 0.88	2.95 ± 1.05
   Depression	40.29*	3.25 ± 1.36	2.07 ± 1.25
   Sleeping problems	98.87*	3.84 ± 1.10	2.39 ± 0.96
   Pain	63.69*	3.69 ± 1.07	2.45 ± 1.11
   Analgesics	32.27*	2.38 ± 1.22	1.58 ± 0.78
   Mood-enhancing drugs	41.81*	2.66 ± 1.97	1.28 ± 1.00
   Exercise frequency	4.60***	3.92 ± 1.18	3.59 ± 1.07
   *p < 0.001, ***p < 0.05. Bonferroni comparisons.

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