Attachment, Emotion Regulation Difficulties, and Disordered Eating Among College Women and Men

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1 744884TCPXXX / The Counseling PsychologistHan and Kahn research-article2017 Regular Manuscript Attachment, Emotion Regulation Difficulties, and Disordered Eating Among College Women and Men The Counseling Psychologist 2017, Vol. 45(8) The Author(s) 2017 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: journals.sagepub.com/home/tcp Suejung Han 1 and Jeffrey H. Kahn 1 Abstract In this study, we examined a structural equation model in which attachment anxiety and avoidance were associated with binge eating and restricted eating behaviors through distinct emotion regulation difficulties of emotional reactivity and emotional cutoff among college women (n = 744) and men (n = 200). As predicted, attachment anxiety was associated with emotional reactivity which, in turn, was associated with binge eating. Attachment avoidance was associated with emotional cutoff which, in turn, was associated with restricted eating, both in college women and men. Two gender differences were found: the association between emotional cutoff and binge eating was statistically significant only for women, and the association between emotional reactivity and binge eating was stronger for men than for women. Clinical implications are suggested, specifically the importance of addressing attachment insecurities and distinct emotion regulation difficulties related to serving college women and men with binge eating and/or restricted eating behaviors. Keywords attachment insecurity, emotion regulation, binge eating, restricted eating, gender 1 Illinois State University, Normal, IL, USA Corresponding Author: Suejung Han, Department of Psychology, Illinois State University, Campus Box 4620, Normal, IL , USA. shan3@ilstu.edu The Division 17 logo denotes that this article is designated as a CE article. To purchase the CE Test, please visit

2 Han and Kahn 1067 Disordered eating behaviors such as binge eating and restricted eating among college students are highly prevalent, carrying serious physical and mental health consequences. For example, 25% to 48% of college women and 6% to 17% of college men binge eat (e.g., Matthews, 2004), and 44% of college women and 27% of college men are on a diet to lose weight (American College Health Association, 2010). Even at a subclinical level, binge eating is associated with obesity and illnesses such as diabetes (Schwarze, Oliver, & Handal, 2003); excessive restricted eating is associated with gastrointestinal issues and amenorrhea (Selzer, Caust, Hibbert, Bowes, & Patton, 1996). Both binge eating and restricted eating are also associated with mental health concerns such as depression and anxiety, and may precede the development of eating disorders at a clinical level (Agras, 2001). Attachment theory (Bowlby, 1988; Mikulincer & Shaver, 2007) may explain why some individuals engage in disordered eating. It has been suggested that people with insecure attachment may have emotion regulation difficulties that are associated with disordered eating (e.g., Tasca et al., 2009). Thus, in this study we examined how insecure attachment is distinctively related to binge eating and restricted eating through two emotion regulation difficulty pathways: emotional reactivity and emotional cutoff. In addition, we examined whether these interrelationships differed between college women and men. Insecure Attachment and Disordered Eating Attachment security develops among children if the primary caregiver reliably responds to the children s need for protection and soothing (Bowlby, 1988). These securely attached children subsequently internalize how the caregiver soothed them and develop their own distress regulating capacity. Children who perceive the caregiver to be inconsistent in responsiveness learn to exaggerate distress to seek proximity to their caregiver; this is known as attachment anxiety because the child feels anxiety about rejection and abandonment, and therefore engages in a hyperactivating emotion regulation strategy (Fraley & Shaver, 2000; Mikulincer & Shaver, 2007). Children who perceive the caregiver to be consistently rejecting or unavailable learn to suppress distress (i.e., a deactivating emotion regulation strategy) and avoid proximity to the caregiver to prevent rejection; these children develop attachment avoidance, or discomfort with, and avoidance of, attachment figures (Fraley & Shaver, 2000; Mikulincer & Shaver, 2007). The attachment security or insecurity that develops in childhood persists as a trait-like quality into adult relationships (e.g., romantic relationships) with relative stability (Fraley, 2002), internalized as mental representations of self, others, interpersonal relationships, and distress regulation strategies (Bowlby, 1988).

3 1068 The Counseling Psychologist 45(8) Attachment anxiety and attachment avoidance are two forms of attachment insecurity; in the past several decades, attachment insecurity has been investigated in relation to disordered eating. Some clinicians have suggested that disordered eating (e.g., binge eating) could be a symbolic way of seeking comfort from foods rather than from unavailable or rejecting attachment figures (e.g., parents, partner; Orzolek-Kronner, 2002) or is a direct reflection of underlying attachment patterns (e.g., restricted eating as distancing from the self, and binge eating as underregulated affects; Ringer & Crittenden, 2007). A meta-analysis of 154 empirical studies on the link between psychosocial factors and disordered eating showed that insecure attachment was the second strongest correlate of disordered eating with a large effect size (d = 1.31), with negative self-evaluation being the strongest correlate (d = 2.27) among 11 psychological variables, such as perceived low parental care and sensitivity to social dominance (Caglar-Nazali et al., 2013). In a review of 50 empirical studies, Tasca and Balfour (2014) reported that 80% to 100% of individuals with eating disorders had an insecure attachment style. These two reviews did not specify the gender of the participants in the studies reviewed. Although the link between insecure attachment and disordered eating is well established, the distinct relationships between the two dimensions of insecure attachment attachment anxiety and attachment avoidance and disordered eating are less clear. When general disordered eating symptoms were examined, attachment anxiety was associated with disordered eating consistently, whereas attachment avoidance showed mixed findings. For example, attachment anxiety was strongly associated with disordered eating symptoms among a community sample of women (Eggert, Levendosky, & Klump, 2007) and a clinical sample of women (Tasca et al., 2009), yet the association between attachment avoidance and disordered eating symptoms was weak for women in the clinical sample (Tasca et al., 2009) and nonsignificant among community women (Eggert et al., 2007). Findings were also mixed when eating disorder diagnoses were examined. A review article reported distinct associations between attachment anxiety and bulimic-spectrum disorders, and between attachment avoidance and restricting-type anorexia nervosa (Zachrisson & Skarderud, 2010) in women with eating disorders, although other research found no such associations among clinical samples of women (Broberg, Hjalmers, & Nevonen, 2001; Zachrisson & Kulbotten, 2006). Perhaps these mixed findings may be because attachment anxiety and avoidance are distinctively associated with different disordered eating behaviors, not diagnostic categories (Zachrisson & Skarderud, 2010). Thus, we hypothesized that attachment anxiety would be associated with binge eating behavior and that attachment avoidance would be associated with restricted eating behavior because of the distinct emotion regulation difficulties associated with attachment anxiety versus avoidance.

4 Han and Kahn 1069 The Role of Emotion Regulation Difficulties Emotion regulation theorists have conceptualized disordered eating behaviors as efforts to regulate dysfunctional emotions. For example, binge eating could be viewed as an effort to escape from negative self-consciousness (Heatherton & Baumeister, 1991), self-medication for distress with foods (Schlundt & Johnson, 1990), or the replacement of painful emotions with less painful emotions (Kenardy, Arnow, & Agras, 1996). Research supports these perspectives. For example, a review reported that state negative affect tended to precede binge eating episodes among women, suggesting that when some people feel overwhelmed by negative emotions they binge eat as an immediate emotion regulatory effort (Haedt-Matt & Keel, 2011). Also, emotion regulation difficulties, such as finding it hard to stay goal directed when feeling emotionally overwhelmed, and having difficulty gaining a clear understanding of one s feelings, have been associated with binge eating among a combined sample of college men and women (Han & Pistole, 2014). Thus, a tendency to feel intense negative emotions may be related to binge eating. Anorexic symptoms (e.g., restricted eating), on the other hand, have been conceptualized as an effort to avoid experiencing emotions (Wildes & Marcus, 2011). Clinical observations and research suggest that restricted eating may serve to numb negative emotions (Harrison, Sullivan, Tchanturia, & Treasure, 2009), avoid experiencing or expressing emotional states (Wildes & Markus, 2011), or soothe anxiety (Strober, 2004) among women. Consistently, anorexic symptoms have been associated with low interoceptive awareness (Pollatos et al., 2008), difficulty recognizing emotions in oneself and others (Bydlowski et al., 2005), alexithymia (Rastam, Gillberg, Gillberg, & Johansson, 1997), and emotional inhibition (Holliday, Uher, Landau, Collier, & Treasure, 2006), in samples of women. Thus, whereas emotional reactivity (i.e., underregulated emotions and difficulty controlling overwhelming emotions) may be associated with binge eating, emotional cutoff (i.e., overregulated emotions and difficulty experiencing and expressing emotions) may be associated with restricted eating, at least among women. These two emotion regulation difficulties emotional reactivity and emotional cutoff correspond to attachment anxiety s hyperactivating strategy and attachment avoidance s deactivating strategy, respectively (Mikulincer & Shaver, 2007). Thus, attachment anxiety is conceptually related to emotional reactivity, which is also related to binge eating; by contrast, attachment avoidance is conceptually related to emotional cutoff, which is also related to restricted eating. A few studies have examined the mediating roles of emotion regulation difficulties between attachment insecurity and disordered eating, but they either did not compare binge eating versus restricted eating

5 1070 The Counseling Psychologist 45(8) separately or did not distinguish emotional reactivity from emotional cutoff. For example, general emotion regulation difficulties mediated the link between both attachment anxiety and avoidance and binge eating in a combined sample of college men and women (Han & Pistole, 2014), and another study found mediation with general disordered eating symptoms as the dependent variable among college women (Ty & Francis, 2013). In the only study of which we are aware that examined distinct mediators of emotional reactivity and emotional cutoff for attachment anxiety and avoidance, emotional reactivity mediated the link between attachment anxiety and disordered eating symptoms, but emotional cutoff did not mediate the link between attachment avoidance and disordered eating among a clinical sample of women (Tasca et al., 2009). Thus, we aimed to extend this research to different forms of disordered eating (i.e., binge eating and restricted eating). Gender Differences in the Proposed Model As reviewed previously, most research on the links among attachment, emotion regulation, and disordered eating has focused on women. Research on men s disordered eating has increased recently, however, demonstrating that a substantial minority of men report disordered eating behaviors (Wade, Keski-Rahkonen, & Hudson, 2011). The current literature on disordered eating in men has largely focused on their unique body image issues of desire for muscularity (vs. thinness in women) and associated behaviors such as excessive protein consumption or exercise (O Dea & Abraham, 2002). Thus, scholars have argued that symptom constellations of eating disorder diagnoses may be different for men from women, and thus current eating disorder measures may not validly capture eating disorders among men (e.g., Strother, Lemberg, Stanford, & Turberville, 2012). However, men and women may be similar in how specific behaviors (i.e., not symptom constellations for diagnoses) of binge eating and restricted eating are manifested. Research also shows that it is not dissatisfaction with less muscle but the fear of gaining fat that was associated with disordered eating among men (Smith, Hawkeswood, Bodell, & Joiner, 2011). This suggests that men may engage in fasting and binge eating in a similar manner to women to avoid gaining fat. There have been inconclusive findings among the few existing studies that examined gender differences on the association between attachment and disordered eating. In one study, the authors found gender similarity in that insecure attachment was associated with pathological eating behaviors and attitudes among both college men and women (Huprich, Stepp, Graham, & Johnson, 2004). Other researchers reported some gender differences. For example, fearful attachment (characterized by both high attachment anxiety

6 Han and Kahn 1071 and high attachment avoidance) was associated with bulimic symptoms in college women, whereas secure attachment (characterized by both low attachment anxiety and low attachment avoidance) was associated with drive for thinness in college men (Elgin & Pritchard, 2006). Attachment anxiety was also associated with dieting in men and with general disordered eating symptoms, dieting, and bulimia in women, whereas attachment avoidance was associated with general disordered eating symptoms in men and with only dieting in women (Koskina & Giovazolians, 2010). In sum, attachment anxiety and avoidance seem to be associated with disordered eating in both women and men, but it is far from clear whether attachment anxiety and avoidance are distinctively associated with binge eating versus restricted eating behaviors between genders. Gender differences on the association between emotion regulation difficulties and disordered eating are not conclusive either. Some researchers have reported gender similarities. For example, general emotion regulation difficulties were associated with disordered eating among college men (Lavender & Anderson, 2010) and college women (Ty & Francis, 2013). Impulsivity was associated with disordered eating behaviors and attitudes both in college men and women (Lundahl, Wahlstrom, Christ, & Stoltenberg, 2015). Similarly, negative urgency the propensity to act rashly when distressed was associated with binge eating in both men and women (e.g., Davis-Becker, Peterson, & Fischer, 2014). In contrast, Perry and Hayaki (2014) found that alexithymia difficulty recognizing and describing one s feelings, similar to emotional cutoff was associated with bulimic symptoms among college men, whereas emotional impulse strength (similar to emotional reactivity) was associated with bulimic symptoms among college women. Given the inconclusive findings related to gender differences in emotion regulation difficulties and disordered eating, it is necessary for future work to further clarify these relationships. The Present Study Using the proposed model, we hypothesized that attachment insecurity and disordered eating would be associated through emotion regulation difficulties (i.e., emotional reactivity and emotional cutoff; see Figure 1). We tested all possible pathways but were particularly interested in two pathways. Specifically, we predicted that (a) attachment anxiety would be associated with emotional reactivity which, in turn, would be associated with binge eating, and that (b) attachment avoidance would be associated with emotional cutoff which, in turn, would be associated with restricted eating, as the primary indirect relations based on attachment theory. To test the model, we

7 1072 The Counseling Psychologist 45(8) Figure 1. Structural equation model of the relations among attachment insecurities, emotion regulation, and disordered eating. Coefficients for women (n = 744) are not italicized above, and coefficients for men (n = 200) are in italicized typeface below. Standardized coefficients are displayed. *p <.05. **p <.01. ***p <.001. used nonclinical samples of college women and men because binge eating and restricted eating are highly prevalent in nonclinical populations, yet affect mental and physical health negatively (Stice, Marti, Shaw, & Jaconis, 2009). Also, subclinical disordered eating behaviors appear to be similar in their repercussions and correlates except for the severity (e.g., Jansen, van den Hout, & Griez, 1990), and warrant psychological intervention and preventive efforts. We also explored potential gender differences in this model. We could not find a consistent conceptual or empirical rationale for a gender difference between insecure attachment and binge eating versus restricted eating. However, based on Perry and Hayaki s (2014) finding that emotional expressivity and alexithymia were associated with disordered eating in men and women, respectively, we predicted that emotional reactivity may be more strongly associated with disordered eating for women than men, whereas emotional cutoff may be more strongly associated with disordered eating for men than women. Method Participants A total of 1,048 college students at a U.S. Midwestern university who took psychology courses were recruited from the psychology department research participation pool. Among the initial respondents, 104 who either did not

8 Han and Kahn 1073 complete more than half of the survey, did not provide sufficient demographic information, or appeared to respond randomly (e.g., reporting age as 2) were removed. The final sample of 944 included 744 (79%) women and 200 (21%) men with a mean age of (SD = 2.38) for women and (SD = 3.56) for men. The majority of participants identified as European American (76%; 577 women, 143 men), with African American individuals comprising 11% (80 women, 22 men), Latinos 7% (52 women, 16 men), Asian Americans 2% (10 women, six men), and the remaining 4% endorsing other or multiple ethnic identities. The sample reflected the ethnic composition of the student population at the university. Instruments Attachment. The 12-item Experiences in Close Relationships-Short Form (Wei, Russell, Mallinckrodt, & Vogel, 2007) measured adult attachment. It includes attachment anxiety (6 items; e.g., I need a lot of reassurance that I am loved by my partner ) and attachment avoidance (6 items; e.g., I am nervous when partners get too close to me ) dimensions. Participants rate each item on a 7-point Likert-type scale ranging from 1 (disagree strongly) to 7 (agree strongly). Higher scores indicate higher levels of attachment anxiety and attachment avoidance. Cronbach s alpha coefficients for this study were.76 for men and.78 for women on attachment anxiety, and.80 for men and.86 for women on attachment avoidance. Emotion regulation difficulties. Two subscales of the Differentiation of Self Inventory (Skowron & Friedlander, 1998) measured emotion regulation difficulties. The 11-item emotional reactivity subscale measures the degree to which a person responds to environmental stimuli with emotional flooding, emotional lability, or hypersensitivity (e.g., At times I feel as if I m riding an emotional roller-coaster ). The 12-item emotional cutoff subscale measures the degree to which a person feels threatened by intimacy and avoids intense experiences (e.g., I have difficulty expressing my feelings to people I care for ). Each item is rated on a 6-point scale ranging from 1 (not at all true of me) to 6 (very true of me). Higher scores indicate higher levels of emotional reactivity and emotional cutoff, respectively. Cronbach s alpha coefficients were reported as.88 and.79 for scores on emotional reactivity and emotional cutoff, respectively (Skowron & Friedlander, 1998). In this study, Cronbach s alpha coefficients were.87 for men and.86 for women on emotional reactivity and.92 for men and.90 for women on emotional cutoff, respectively. Binge eating. The 16-item Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982) measured binge eating behaviors and associated

9 1074 The Counseling Psychologist 45(8) feelings and cognitions (e.g., feeling a lack of control). Each of the 16 items lists three to four statements that range from normal to problematic eating. For example, an item has four statements such as: (a) I rarely eat so much food that I feel uncomfortably stuffed afterwards (weighted 0); (b) Usually about once a month, I eat such a quantity of food, I end up feeling very stuffed (weighted 1); (c) I have regular periods during the month when I eat large amounts of food, either at mealtime or at snacks (weighted 2); and (d) I eat so much food that I regularly feel quite uncomfortable after eating and sometimes a bit nauseous (weighted 3). Scores of the 16 items are summed such that higher scores indicate more severe binge eating. The BES demonstrated concurrent validity by differentiating people with severe binge eating from people with mild or no binge eating (Gormally et al., 1982). Cronbach s alpha coefficient for this study was.88 for men and.89 for women. Restricted eating. The 10-item Restrained Eating subscale of the Dutch Eating Behavior Questionnaire (van Strien, Frigters, Bergers, & Defareds, 1986) measured a restricted-eating tendency to control weight (e.g., Do you deliberately eat less in order not to become heavier? ). The response format is a 5-point scale ranging from 1 (never) to 5 (very often). The internal consistency of scores from the subscale has been reported to range from.92 to.95 among various samples (van Strien et al., 1986). The subscale scores also have high factorial validity and concurrent validity as indicated by correlations with other restrained eating scales (e.g., the restraint scale of the Three Factor Eating Questionnaire; Stunkard & Messick, 1985). Cronbach s alpha coefficient was.93 for men and.94 for women in this study. Procedure A brief study description and URL to the online survey were posted on the research participation management site as an option for students to complete for research credit. After reading the consent form on the first page of the survey, participants clicked the agree to participate button to proceed to complete the survey. Results Preliminary Analyses Means, standard deviations, and correlation coefficients of the study variables are presented in Table 1. The strongest correlations for both women and men were between attachment anxiety and emotional reactivity and between attachment avoidance and emotional cutoff. Based on Gormally et al. s

10 Han and Kahn 1075 Table 1. Means, Standard Deviations, and Correlations Variable M SD 1. Attachment.18 *.51 ***.32 ***.32 *** anxiety 2. Attachment.28 *** ***.28 ***.17 * avoidance 3. Emotional.54 *** ***.31 *** reactivity 4. Emotional cutoff.33 ***.62 ***.25 ***.41 *** Binge eating.30 ***.18 ***.28 ***.30 ***.49 *** Restricted eating.19 ***.15 ***.18 ***.27 ***.47 *** M SD Possible range Note. Data for men (n = 200) are above the diagonal; data for women (n = 744) are below the diagonal. *p <.05. ***p <.001. (1982) cutoffs, 26.8% of college women (n = 199) and 18.5% of college men (n = 37) in our study reported mild to severe binge eating. Although there is no cutoff score provided for restricted eating, restricted eating scores were significantly higher than the mean score reported for the community samples with which the scale was developed, t = 4.37, p <.001, d =.24, for women, t = 6.19, p <.001, d =.52, for men (van Strien et al., 1986). Given our use of structural equational modeling (SEM), we created item parcels for each of the variables in our hypothesized model. The item-toconstruct method was used to create four parcels as indicators of binge eating and three parcels for all the other latent variables (Little, Cunningham, Shahar, & Widaman, 2002). There were some missing data at the parcel level, yet nearly all participants (97%) had no more than one missing parcel; the maximum number of missing parcels for any given participant was six (out of 19). Little et al. s missing completely at random test was not significant, χ 2 (745) = , p =.11, thus supporting the possibility that the data were missing completely at random. We used the Mplus MLR estimator, which accounts for missing data using full-information maximum likelihood. Minimum covariance coverage was.95, further suggesting that missing data were not problematic.

11 1076 The Counseling Psychologist 45(8) Distributions of the item parcels showed neither univariate skewness nor kurtosis, with maximum skewness of 1.18 and maximum kurtosis of Nevertheless, the MLR estimation method provides standard errors and a chisquare statistic that are robust to nonnormality (Muthén & Muthén, 2010). Sizes of the two samples were adequate to detect a medium effect size with six latent variables with 19 indicators (minimum required sample size = 177; Westland, 2010). Overview of Model Testing We first tested the fit of the measurement model both separately by gender and in a multiple-groups model. This allowed us to examine measurement invariance, that is, whether the indicator variables mapped onto the latent variables in the same way for women as for men. We also included a test of latent mean structures to assess whether the means of the latent variables differed by gender. We then assessed the fit of the structural model in Figure 1 to data from women and men separately, and we determined which indirect effects were statistically significant. We also tested this structural model in a multiple-groups analysis that allowed us to determine whether the structural paths differed by gender. In all cases, acceptable model fit was indicated by values of.95 or greater on the Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI), values of.06 or lower on the Root Mean Square Error of Approximation (RMSEA), and values of.08 or lower on the Standardized Root Mean Square Residual. Difference in fit between pairs of nested models was determined with the chi-square difference test as well as the difference in the values of the other fit indices. Measurement Model In the measurement model, all latent variables were allowed to correlate with one another. The fit indices for the measurement model for the sample of women indicated that the 19 indicators mapped onto the six latent constructs very well (see Table 2). Standardized factor loadings ranged from.59 to.96, p <.001. Correlations among latent variables ranged from.10 to.67. For the sample of college men, the measurement model s fit to the data was marginally adequate (see Table 2). Standardized factor loadings among men ranged from.61 to.97, and correlations among latent variables ranged from.10 to.65. Measurement invariance. To compare the fit of the measurement model as a function of gender, we followed Byrne s (2012) recommended procedures

12 Han and Kahn 1077 Table 2. Structural Equation Model Fit Indices Model χ 2 df CFI TLI RMSEA 90% CI SRMR Measurement models Women only (n = 744) [.05,.06].04 Men only (n = 200) [.06,.08].07 Configural [.05,.06].05 Constrained factor [.05,.06].05 loadings Prior model [.05,.05].06 constrained factor covariances Prior model [.05,.06].06 constrained intercepts Prior model + varying [.05,.06].06 factor means and variances Structural models Women only (n = 744) [.05,.06].05 Men only (n = 200) [.06,.08].07 Configural [.05,.06].05 Constrained factor [.05,.06].06 loadings, intercepts, covariances, and structural coefficients Prior model + two varying structural paths (post hoc) [.05,.06].06 Note. df = degrees of freedom; CFI = comparative fit index; TLI = Tucker-Lewis Index; RMSEA = root mean square error of approximation; CI = confidence interval; SRMR = standardized root mean square residual. for conducting multiple groups analyses. First, we tested a configural model in which the same pattern of fixed and free parameters was specified for both groups. Except for fixing all factor variances to 1 (to facilitate model identification), no equivalence constraints were imposed on any parameters. This configural measurement model provided a good fit to the data (see Table 2). Next, we tested a model with equality constraints on the factor loadings such that the associations between the 19 indicator variables and the six latent variables were the same for women as for men. This constrained model also provided a good fit to the data (see Table 2), and the other fit indices were no worse than in the prior model. Moreover, a chi-square difference test, which accounts for the scaling correction factor given the robust estimation method,

13 1078 The Counseling Psychologist 45(8) indicated that the model with constrained factor loadings did not provide a significantly worse fit to the data than the configural model, Δχ 2 (19) = 10.74, p =.93. Thus, the fit of indicators to latent variables did not differ by gender. The next model added additional between group constraints, this time for factor covariances. Because testing the invariance of the error covariances is considered unnecessary (Byrne, 2012), residual variances of indicators were allowed to vary. Intercepts were also free to vary between groups. This model also provided a good fit to the data (see Table 2) and did not provide a significantly worse fit than either the previous model, Δχ 2 (15) = 20.26, p =.16, nor the configural model, Δχ 2 (34) = 30.99, p =.62. The CFI, TLI, and RMSEA indicated as good of a fit in this new model as in the configural model. Thus, measurement invariance was supported. Structured means modeling. Because the fit of the measurement model did not differ by gender, the meaning of the latent variables likely did not differ by gender. We therefore examined whether the means of these latent variables differed. We estimated a model that, in addition to specifying equal factor loadings and factor covariances, specified that the intercepts of the indicator variables were equal. This model also provided a good fit to the data (Table 2). Moreover, we concluded that it did not provide a significantly worse fit to the data than the previous model based on the chi-square difference test, Δχ 2 (19) = 25.24, p =.15, and the fact that other fit indices did not change. Latent variable means and variances were constrained to be equal between groups in all prior models. Thus, we next allowed these six means and six variances to differ between groups. Comparing this model to the prior model tested the null hypothesis that the means and variances of the latent variables did not differ by gender. Once again, this was a good-fitting model (see Table 2). Moreover, it did not provide a significantly worse fit to the data than the previous model, Δχ 2 (12) = 9.41, p =.67, and the other fit indices did not change from the previous model. The differences in means (whereby negative differences indicate higher means for women) were estimated to be -.04 for attachment anxiety, p =.64; -.17 for attachment avoidance, p =.06; -.11 for emotional reactivity, p =.25; -.03 for emotional cutoff, p =.71; -.03 for binge eating, p =.74; and -.02 for restricted eating, p =.79. Thus, there was no reason to believe that the means of the latent variables differed between genders. Structural Model Our primary goal was to test the fit of the hypothesized model in Figure 1 for women and men. Among women, the hypothesized model fit the data well (see Table 2), yet the structural model fit significantly worse than the

14 Han and Kahn 1079 Table 3. Estimates of Standardized Bias-Corrected Bootstrapped Indirect Effects Women Men Independent variable Mediator variable Dependent variable Indirect effect 99% CI Indirect effect 99% CI Attachment anxiety Attachment anxiety Attachment anxiety Attachment anxiety Attachment avoidance Attachment avoidance Attachment avoidance Attachment avoidance Emotional Binge eating.16* [.07,.23].31* [.14,.48] reactivity Emotional cutoff Binge eating.04* [.01,.08].01 [.03,.04] Emotional reactivity Restricted eating.09* [.02,.17].09 [.08,.25] Emotional cutoff Restricted.03* [.00,.05].03 [.03,.09] eating Emotional Binge eating.03* [.06,.00].07 [.17,.02] reactivity Emotional cutoff Binge eating.20* [.13,.27].03 [.10,.16] Emotional reactivity Emotional cutoff Restricted eating Restricted eating.02 [.04,.00].02 [.07,.03].11* [.05,.18].15* [.02,.28] Note. CI = confidence interval. *p <.01. measurement model, Δχ 2 (4) = 12.36, p =.01. Nevertheless, other fit indices were virtually identical between the measurement and structural models. Standardized coefficients are displayed in Figure 1. Attachment anxiety was positively associated with emotional reactivity, and attachment avoidance was negatively associated with emotional reactivity, R 2 =.38. Emotional cutoff (R 2 =.47) was positively associated with both attachment anxiety and attachment avoidance. The stronger paths by far were between (a) attachment anxiety and emotional reactivity and (b) attachment avoidance and emotional cutoff. Binge eating (R 2 =.20) was positively associated with both emotional reactivity and emotional cutoff. Finally, restricted eating (R 2 =.07) was positively associated with both emotional cutoff and emotional reactivity. Eight indirect effects are implied by the structural model (see Table 3). We tested the significance of these indirect effects by bootstrapping 10,000 samples with replacement. Table 3 displays the bias-corrected estimates of the standardized indirect effects. Because of the large number of indirect effects, we used a conservative alpha level of.01 to report the 99% confidence intervals of the indirect effects in Table 3. Seven of the eight indirect effects were statistically significant among women (with the exception being the indirect

15 1080 The Counseling Psychologist 45(8) effect from attachment avoidance to restricted eating via emotional reactivity). Three of these indirect effects were substantial in size (i.e., larger than.10), and two of these were the primary pathways we hypothesized: (a) attachment anxiety to binge eating via emotional reactivity and (b) attachment avoidance to restricted eating via emotional cutoff. The third substantial indirect effect was attachment avoidance to binge eating via emotional cutoff. For men, the structural model provided a reasonable, if not ideal, fit (see Table 2). The structural model did not provide a significantly worse fit to the data than the measurement model based on the values of the other fit indices and the chi-square difference test, Δχ 2 (4) = 1.97, p =.74. Standardized coefficients are displayed in Figure 1 (italicized typeface). Attachment anxiety was positively, and attachment avoidance was negatively, associated with emotional reactivity, R 2 =.45. Emotional cutoff (R 2 =.43) was positively associated with attachment avoidance, but attachment anxiety was not associated with emotional cutoff. Binge eating (R 2 =.20) was positively associated with emotional reactivity but not with emotional cutoff. Finally, restricted eating (R 2 =.10) was associated with emotional cutoff but not emotional reactivity. As with the sample of women, we tested the significance of the eight possible indirect effects via bootstrapping (see Table 3). Only two indirect effects were significant among men, and these were the two that we hypothesized would be primary pathways between attachment and disordered eating: (a) attachment anxiety to binge eating via emotional reactivity and (b) attachment avoidance to restricted eating via emotional cutoff. The substantial indirect effect between attachment avoidance and binge eating (via emotional cutoff) that was significant among women was not significant among men. Our final step was to determine whether the model in Figure 1 provided a similar fit to women and men. We estimated a configural model in which the same pattern of coefficients was specified for both women and men, but the estimates of these parameters were allowed to vary across gender. The configural structural model provided a good fit to the data (see Table 2). Thus, the multigroup representation of the model in Figure 1 was empirically supported. The comparison model constrained the 19 factor loadings, 19 intercepts, eight structural paths (i.e., betas), and three factor covariances to be equal between groups. This heavily constrained model also provided a good fit to the data with fit indices that were comparable to those from the configural model, and it did not provide a significantly worse fit to the data than the structural configural model, Δχ 2 (49) = 51.48, p =.38. Thus, the model in Figure 1 provided a similar fit for both women and men. Nevertheless, an

16 Han and Kahn 1081 inspection of the structural paths indicated potentially meaningful differences in the magnitude of the paths between emotional reactivity and binge eating (.23 for women,.43 for men) and between emotional cutoff and binge eating (.32 for women,.05 for men). We therefore tested an additional, post hoc model similar to the fully constrained structural model but in which these two paths were allowed to vary by gender. This model provided a good fit to the data (with comparable fit indices as compared to the prior model), and it also provided a significantly better fit to the data than the fully constrained model, Δχ 2 (2) = 13.83, p <.001. Thus, although the model as a whole did not differ across gender, these two structural paths did. Discussion We examined the differential associations between (a) attachment anxiety and avoidance and (b) binge eating and restricted eating, via distinct emotion regulation difficulties of emotional reactivity and emotional cutoff, among college women and men. Our results revealed that, as hypothesized, attachment anxiety was associated with binge eating via emotional reactivity, and attachment avoidance was associated with restricted eating via emotional cutoff, in both college women and men. Theoretically, attachment anxiety s hyperactivating strategy of intensifying emotional reactions (Mikulincer & Shaver, 2007) may demand immediate regulatory efforts such as binge eating. One the other hand, attachment avoidance s deactivating strategy of suppressing emotional reactions and maintaining restricted emotionality could contribute to restricted eating motivations and behaviors. Our results may explain some mixed findings on the associations between attachment and different eating disorder diagnoses. Some researchers reported the distinct associations between attachment anxiety and bulimia nervosa and between attachment avoidance and anorexia nervosa (e.g., Zachrisson & Skarderud, 2010), whereas others did not find such distinct associations between insecure attachment dimensions and eating disorder diagnostic categories (Broberg et al., 2001; Zachrisson & Kulbotten, 2006). We showed that it might not be the diagnostic categories but the disordered eating behaviors that are distinctively associated with attachment anxiety and avoidance (Orzolek-Kronner, 2002; Ringer & Crittenden, 2007). Also, Tasca et al. (2009) did not find the indirect role of emotional cutoff between attachment avoidance and general disordered-eating symptoms among a clinical sample of women. By differentiating binge eating and restricted eating, we were able to show that, consistent with the theory, emotional cutoff did mediate the association between attachment avoidance and restricted eating, in addition to replicating the mediating role of emotional

17 1082 The Counseling Psychologist 45(8) reactivity in the association between attachment anxiety and binge eating. This was the first study, to our knowledge, that demonstrated the distinct indirect pathways by emotional reactivity and cutoff between insecure attachment and disordered eating. It is noteworthy that our results supported the hypothesized paths among both college women and men. Despite the dearth of research on men, these results are consistent with the few existing studies reporting that negative affect (McCabe & Ricciardelli, 2003) and insecure attachment (Elgin & Pritchard, 2006; Huprich et al., 2004; Koskina & Giovazolians, 2010) are associated with disordered eating among men. However, we did find several important gender differences on the links between emotion regulation difficulties and disordered eating. In addition to the distinct pathways that were hypothesized, other indirect pathways were significant in only women. Specifically, attachment anxiety was associated with binge eating also via emotional cutoff and with restricted eating via emotional reactivity. Attachment avoidance was also associated with binge eating via emotional cutoff. Perhaps attachment insecurity is a general risk factor for various emotion regulation difficulties and disordered eating among women, whereas attachment anxiety versus avoidance serves distinct contributions to binge eating versus restricted eating. The generalized pathways partly came from the significant association between emotional cutoff and binge eating among women. Based on Perry and Hayaki s (2014) finding that showed alexithymia as being associated with disordered eating among men, we had predicted that emotional cutoff would be more strongly associated with disordered eating in men than in women. Emotional cutoff was associated with restricted eating in women and men to a similar degree, but it was not associated with binge eating in men. Binge eating has been conceptualized as an effort to escape from negative emotions such as painful self-awareness (Heatherton & Baumeister, 1991), which may be related to the tendency to avoid confronting negative emotions (i.e., emotional cutoff). This speculation was supported only for women, perhaps because relying on binge eating to regulate negative emotions is more culturally acceptable for women than for men. Men may be more likely to engage in other ways of suppressing negative emotions, such as drinking, that are more socially acceptable (Capraro, 2000). Also, attachment avoidance is associated with low levels of self-reported distress (Mikulincer, Florian, & Tolmacz, 1990) but high physiological indicators of distress (e.g., Sonnby-Borgstrom & Jonsson, 2004). It is possible that women with attachment avoidance cut off their emotional distress at the explicit level, but the suppressed emotional distress may still demand regulatory effort of binge eating at the implicit level. In other words, emotional

18 Han and Kahn 1083 suppression might not be as effective of a coping strategy for women as for men because they experience more intense negative emotions compared to men (Nolen-Hoeksema, 2012). Based on Perry and Hayaki s (2014) finding that impulse strength was associated with disordered eating in women, we had predicted that emotional reactivity would be more strongly associated with disordered eating in women than in men. Emotional reactivity was associated with both binge eating and restricted eating in women, but emotional reactivity was more strongly associated with binge eating in men than in women. Noteworthy was that there was no significant mean difference on emotional reactivity between men and women, which is inconsistent with the previous research that shows that women tend to experience more intense emotions than men (Nolen- Hoeksema, 2012). Perhaps the level of emotional reactivity between men and women is not the critical difference; instead, the important gender difference may be the implication that emotional reactivity has for disordered eating. In other words, because men are usually less reactive emotionally than women, when men do experience emotional reactivity, they are at greater risk for engaging in binge eating than women (Perry & Hayaki, 2014). Because there are mixed findings on whether men are less emotionally reactive than women, future research may investigate the ways men experience emotional reactivity and the relationship to various disordered eating behaviors. Clinical Implications More than 20% of our nonclinical participants reported mild to severe levels of binge eating, and the mean level of restricted eating among our samples was higher compared to that in the sample (van Strien et al., 1986) used in previous research. Although the cutoff score for clinical levels of restricted eating is not available, and the sample size of those with a clinical level of binge eating did not allow for group comparisons, the apparent high prevalence of disordered eating in our samples warrants discussion of clinical implications of our findings. Counseling psychologists who serve college men and women with disordered eating may address attachment insecurity, different emotion regulation difficulties, and their contributions to different disordered eating behaviors. First, for people who binge eat, it may be useful to explore their attachment anxiety issues (e.g., fear of rejection in their attachment relationship), resulting negative emotions, and subsequent compelling urges to binge eat to soothe those negative emotions. Second, for people who restrict their eating, it may be useful to explore attachment avoidance issues (e.g., anticipated rejection and fear for intimacy in their attachment relationship), resulting

19 1084 The Counseling Psychologist 45(8) emotional and interpersonal suppression, and subsequent generalization of such suppressive tendencies in the form of restricted eating. Third, for people who engage in both binge eating and restricted eating alternately, it may be useful to explore distinct attachment-related antecedents for these two disordered eating behaviors (e.g., perceived rejection versus anticipated rejection) and intervening dysfunctional emotion regulation (e.g., intensifying versus suppressing). As such, clients may (a) gain insight about potential attachment meaning of foods and eating behaviors, (b) develop a more functional and realistic view of and relationship with foods that do not reflect their underlying attachment relationship (e.g., appreciating foods without feeling guilty but not overindulging in them like they want affection from the attachment figure; Bacon, 2010), and (c) learn how to address negative emotions resulting from perceived insecurity in the attachment relationships. Working on their attachment relationships and emotion regulation strategies directly may also help. Establishing the therapeutic alliance as a secure attachment relationship, improving romantic and family relationships, or developing secondary secure attachment relationships (e.g., friendships) may be useful by reducing the need for excessive proximity seeking to, or avoidance of, foods (e.g., Mallinckrodt, Daly, & Wang, 2010). Also, helping clients with becoming aware of their emotions, confronting them, naming them, understanding and accepting them, and therefore not being overwhelmed by them may be useful (e.g., Robinson, Dolhanty, & Greenberg, 2015) in reducing the emotion regulatory needs for disordered eating behaviors. In particular, addressing different mental health implications of emotional reactivity versus emotional cutoff for men and women would provide a gender-sensitive intervention for disordered eating. Limitations and Future Research Ideas There are limitations in this study that warrant future research. First, in this study we did not examine gender-specific body image issues or the sociocultural factor of body objectification (Fredrickson & Roberts, 1997) as contributing factors to disordered eating. Future research should address interrelationships between these variables and the current study s variables to provide a comprehensive picture for how disordered eating arises. Perhaps the larger social context that presses objectification of one s body may increase body dissatisfaction and body image issues, which, in turn, may lead to disordered eating. In doing so, internalizing the thin body ideal may lead someone to engage in disordered eating behavior (e.g., dieting and then rebound binge eating) to compensate for the felt insecurity in the adult attachment relationship (e.g., perceived rejection by the partner). Future studies

20 Han and Kahn 1085 should test these speculations. Second, we did not assess disordered eating behaviors typically associated with men, such as protein consumption or excessive exercise. Future research should address whether the proposed path model is supported when examining these disordered eating behaviors among men. Third, this study was cross-sectional and correlational. No interpretations of causal relationships among the variables should be made. Future research using experience sampling or daily diary methods should test the temporal or causal order of these relationships. Such designs would also allow for the examination of possible within-person variations of binge eating and restricted eating as a function of attachment anxiety versus avoidance and various emotion regulation difficulties and emotional states. For example, within one individual, with some situational changes (e.g., perceived rejection), attachment anxiety could exacerbate emotional distress, compelling that person to seek quick self-medication of binge eating as symbolic proximity seeking. On the other hand, with other situational changes (e.g., anticipated rejection), attachment avoidance could exacerbate the discomfort with intimacy and suppression efforts, leading to restricted eating. Fourth, we used a nonclinical sample of college students. The study results may not be generalized to clinical or community samples nor college samples with different demographic factors. Demographic factors such as social status, race, or ethnicity need to be examined as potential moderators. Conclusion This study showed that attachment anxiety and avoidance were associated with binge eating and restricted eating through distinct emotion regulation difficulties. This result suggests that clinicians may consider how specific attachment insecurities and emotional reactivity or suppression tendencies contribute to binge eating or restricted eating distinctively among their women and men clients. Importantly, clinicians and researchers could attend to disordered eating behaviors (versus diagnostic categories) and how they manifest themselves over time depending on situationally activated attachment insecurities and emotion regulation difficulties. Authors Note Portions of this paper were presented at the 2016 Annual Convention of the Association for Psychological Science. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.