Emotion regulation among patients with obesity and food addiction

Emotion regulation among patients with obesity and food addiction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emotion regulation among patients with obesity and food addiction Lou Madieta, Amandine Scocard, Marine Rozet, Arnaud De Luca, François Kazour, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6682315/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Dec, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted 7 You are reading this latest preprint version Abstract Background: Emotion dysregulation, alexithymia and attentional biases toward food or emotional stimuli have been reported in patients with obesity and food addiction (FA), but the relative contribution of obesity or FA to these characteristics remains unclear. Methods: Our objectives were to compare patients with obesity and FA, patients with obesity without FA and patients without obesity regarding cognitive emotion regulation strategies, alexithymia, emotion regulation difficulties, and attentional biases.We included 37 patients seeking treatment for obesity (18 FA, 19 without FA) and 37 controls. We assessed food addiction (YFAS 2.0); emotional regulation strategies (CERQ), emotion regulation difficulties (DERS), alexithymia (TAS-20), and attentional biases (Stroop and Emotional Stroop tasks). Results: Among patients with obesity, those with FA differed from non-FA only in terms of cognitive emotion regulation strategies: less refocus on planning (p=.04), more catastrophizing (p=.02), and more positive refocusing (p<.001). Having an obesity (with or without FA) was associated with higher scores regarding emotion regulation strategies (p<.05), alexithymia (p<.001) and emotion regulation difficulties (p<.001). Conclusions: Among patients with obesity, having a FA was related to cognitive avoidance toward negative events, but not to change in the saliency of emotional or food stimuli. Alexithymia was more related to obesity than to FA. food addiction eating disorders obesity emotional regulation cognitive behavioral therapy Figures Figure 1 Figure 2 1 Introduction Obesity is a global pandemic concerning 13.1% of worldwide adults, a prevalence doubled since the 1990 [ 1 ]. Obesity is associated with an elevated risk of mortality, lower quality of life and higher prevalence for co-occurrent psychiatric disorders and general medical disorders[ 2 – 4 ]. Tackling obesity and its associated factors is one of the prioritized target of the World Health Organization [ 5 ]. To this end, identifying subgroups of vulnerable patients among persons with obesity help designing better tailored treatments. Obesity is associated with a wide range of biopsychosocial factors, including genetic aspects, limited physical activity, excessive calorie intake that may be due to high in fat and or sugar foods, and disordered eating [ 6 ]. In line with this later hypothesis, food addiction (FA) has been proposed as a risk factors for obesity in a subgroup of patients [ 7 , 8 ]. Approximately 25% of people with obesity or overweight suffer from FA [ 9 ]. FA is defined by the use of highly palatable food in a pattern similar to substance use in substance use disorder [ 10 ]. This includes the presence of tolerance, withdrawal symptoms, larger amounts consumed than intended, persistent desire or unsuccessful attempts to cut down, much time spent using or recovering from food usage, continual use despite knowledge of adverse consequences or activities given up due to use of food. In FA, part of the food intake may be emotionally driven [ 11 ], as it was already demonstrated in subgroups of patients with classical eating disorders [ 12 ] or substance use disorder [ 13 ]. As proposed in the self-medication theory, eating these foods may be a coping strategy [ 14 , 15 ]. As in substance abuse, difficulties in emotion regulation may increase the risk of regular high palatable food intake onset and maintenance leading to eating disorders including FA [ 16 – 18 ]. According to the model of emotional regulation processes [ 19 ], emotion regulation can occur at behavioral (situation modification), attentional (attentional deployment) and cognitive levels (cognitive change ) levels. Furthermore, when evaluating emotional regulation via subjective measure such as self-administered questionnaires, it is necessary to account for the capacity to identify and express emotion (i.e., alexithymia). Such a multilevel assessment of emotion regulation processes in obesity and FA may provide valuable insight to better design tailor-based treatment for these patients. On one hand, previous works showed that at the cognitive level, obesity was associated with more frequent use of cognitive emotion regulation strategy such as refocus on planning and catastrophizing [ 20 ]. Individuals with obesity also showed more intense alexithymia and difficulty in emotional awareness and emotion regulation strategies, namely, reduced cognitive reappraisal and acceptance, and greater suppression of emotion expression [ 21 ]. At the attentional level, while the literature is heterogenous, a majority of published studies showed an attentional bias against food cues [ 22 ]. These works did not account for the presence of FA in studied samples. On the other hand, previous work conducted among patients with FA showed that it was associated with more difficulty in emotion regulation in aspects of lack of awareness of emotional responses, non-acceptance of emotional responses, lack of clarity of emotional responses, limited access to emotion regulation strategies, impulse control difficulties, difficulties engaging in goal-directed behaviors [ 9 ]. FA was also associated with impulsivity both in terms of cognitive aspects and non-planning impulsivity[ 23 ], but also with alexithymia [ 24 ]. Attentional bias toward food-related cues in FA may be altered by emotional stimuli as it’s been shown that a sad mood increases attentional bias toward unhealthy highly palatable foods [ 25 ]. These works did not account for the presence of obesity in studied samples. In sum, obesity and FA are both associated with emotion dysregulation and alexithymia, but the relative contribution of these mechanisms to obesity and FA remains unclear. In addition, investigating attentional biases toward food or negative emotional stimuli may provide additional knowledge of the mechanisms underlying obesity or FA, but studies in this field are lacking. The main objective of our study was to compare patients with obesity and FA versus patients with obesity but no FA in terms of cognitive emotion regulation strategies. We hypothesized that among patients with obesity, having a FA may be associated with more non-adaptive and less adaptive cognitive emotion regulation strategies. Our secondary objectives were: (1) to compare patients with obesity and FA versus patients with obesity but no FA in terms of other emotion regulation-related variables (i.e., difficulties in emotion regulation, alexithymia, attentional bias toward food or negative emotion-related stimuli, cognitive inhibition); (2) to compare these patients with obesity (with or without FA) versus patients without obesity (control group) regarding the same emotion regulation-related variables. We hypothesized that there may be a gradient of increased severity between patients without obesity, patients with obesity but no FA, and patients with obesity and FA in terms of alexithymia, difficulties in emotion regulation, cognitive inhibition and attentional bias toward food or negative stimuli. 2 Material & Methods 2.1 Participants and Procedures In this cross-sectional study, we recruited persons from two groups: (1) a group of patients with obesity (BMI ≥ 30 kg/m 2 ) consulting in the Department of Psychiatry and Addiction at the University Hospital of Tours, France that were recruited between May 2022 and November 2022 (patients referred to psychiatrists from the Specialized Obesity Center of the same hospital), and (2) an unmatched control group constituted of adults without obesity (BMI ≤ 30 kg/m²) recruited between December 2022 and July 2023 from a non-clinical population (university members and students). Patients were eligible for the study if they were at least 18 years old, were willing to participate and had a BMI ≥ 30 kg/m². In both populations, exclusion criteria were similar: participants were excluded if they presented any bias inducing disability (including motor, perceptive or cognitive impairment), if French was not their native language or if they had significant difficulties in answering the self-administered questionnaire. In the patient group, the study inclusion was systematically proposed by the psychiatrists in charge of the patient follow-up (PB or AS), and patients were assessed during a research consultation scheduled in the following month. All groups underwent a single consultation assessment with the same physician (LM). This consultation included data collected from medical records, self-administered questionnaires as well as a neuropsychological task specifically designed for this study using the Psychopy software [ 26 ] (see Supplemental Material A for more details). 2.2 Measures 2.2.1 Sociodemographics and medical characteristics In both groups, we collected the following data using self-administered questionnaires or medical records: demographics (age, gender, marital and employment status), past and current medical and psychiatric disorders to assess for exclusion criteria and self-reported height and weight. 2.2.2 Food addiction We assessed FA diagnosis and the severity of FA using the Yale Food Addiction Scale 2.0 (YFAS 2.0) (original version [ 10 ]; French validation[ 27 ]). This self-administered questionnaire assesses addictive-like symptoms of eating high in fat and or sugar foods (especially highly processed) during the past 12 months, based on DSM-5 criteria for substance use disorder. The YFAS can be used both as a severity scale and a diagnostic scale with a dichotomous rating according to specifically defined cut-offs [ 28 ]. In this study, we assessed both the existence of a FA diagnosis as well as the number of FA symptoms experienced during the previous 12 months (score ranging from 0 to 11). In our study, Cronbach’s α was excellent at .96. 2.2.3 Cognitive emotion regulation strategies We assessed emotion regulation strategies using the French version of the Cognitive Emotional Regulation Questionnaire (CERQ) (original version : [ 29 ]; French validation : [ 30 ]). The CERQ is a self-report questionnaire evaluating nine distinct emotional regulation strategies in response to an adverse event [ 30 ]. A higher score reflects a more frequent use of this type of emotional strategy. These nine strategies were regrouped by the original authors as adaptive (acceptance, positive refocusing, refocus on planning, positive reappraisal, putting into perspective) or non-adaptive (self-blame, rumination, catastrophizing, blaming others). In our study, Cronbach’s α for the Adaptive subscore was .91, and .85 for the non-adaptive subscore. 2.2.4 Emotion regulation difficulties We assessed emotion regulation difficulties using the French version of Difficulty in Emotion Regulation Scale (DERS-16) (original long version : [ 31 ]; original short version : [ 32 ]; French validation :[ 33 ]). In this study, we used total DERS score as indicator of emotion regulation difficulties, a higher score indicating more difficulty in regulating emotions Cronbach’s α was excellent at .94. 2.2.5 Alexithymia We assessed alexithymia using the Toronto alexithymia scale (TAS-20) (Original version : [ 34 ] French validation : [ 35 ]). The TAS-20 provides a total score and three sub-scores: difficulty identifying emotions, difficulty describing emotions and operational thinking. A higher total score on the TAS-20 indicates higher alexithymia. In our study, Cronbach’s α for the total TAS-20 score was good at .85. More specifically, Cronbach’s α was at .76 for the subscale difficulty identifying emotions, .78 for difficulty describing emotions and .53 for operational thinking. 2.2.6 Cognitive inhibition, and attentional bias toward Food and negative emotional stimuli Participants cognitive inhibition and attentional biases were assessed using a neuropsychological assessment that included a Stroop task (Color-Word Interference Test) [ 36 ] and an emotional Stroop task [ 37 , 38 ] specifically designed for this study with evaluation of attentional bias toward negative emotional stimuli and food stimuli (the detailed procedure is available in the Supplemental Material A). The Stroop task enables the calculation of a difference in mean response time in congruent conditions (words written in the corresponding color) and non-congruent conditions (words written in a non-corresponding color) which reflect the ability to suppress contradictory information (e.g., the written word meaning). The emotional Stroop task enables the calculation of a difference in mean response time in emotional condition (food-related stimuli and emotion-related stimuli) and in mean response time in neutral condition, which reflect the ability to suppress emotional related information. 2.3 Statistical analysis Statistical analyses were performed using the JASP 0.17.3 software. All analyses were two-tailed; p-values < .05 were considered statistically significant. Missing data were excluded from the analysis. Descriptive statistics included percentages for ordinal variables and means and standard deviations for continuous variables. To test our main hypothesis, we used ANOVA tests or Kruskal-Wallis tests (according to Levene homoscedasticity test) to compare the three groups (patients with FA and obesity, patients with obesity and without FA, control group). Dependent variable was the group type, and independent variables were sociodemographic characteristics, CERQ sub-score, DERS total score, TAS total score and sub-scores, Stroop effect (cognitive inhibition measured by the difference in mean response time between congruent and non-congruent condition at the Stroop task), food valence (attentional bias toward food measured by the difference in mean response time between food related stimuli task and neutral stimuli at the emotional Stroop task) and emotional valence (attentional bias toward emotional stimuli measured by difference in mean response time between negative emotional stimuli and neutral stimuli at the emotional Stroop task). To test our secondary hypotheses, we used ANOVA tests or Kruskal-Wallis tests (depending on the results of Levene homoscedasticity test) when the independent variables were continuous, and we used chi-squared tests when the independent variables were ordinal. To assess the significant difference of Stroop effect, Food valence and Emotional valence tasks compared to a neutral reaction (mean reaction time would thus be equal to 0), we used a Wilcoxon-Mann-Whitney test with the null hypothesis being “there was no difference between the two respective conditions. 2.4 Ethics This study has been approved by the institutional review board of the University Hospital of Tours (N°:2022_028) for the clinical population and by the institutional review board of the University and Tours and Poitiers (Comité d’Éthique pour les Recherches sur la Personne Tours- Poitiers) (CER-TP 2022-09-01), prior to the beginning of the study. All procedures were performed in accordance with the ethical standards of the national and institutional research committee as well as with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All participants provided informed consent after the procedure had been fully explained and prior to their inclusion in the study. All collected data were in line with the French recommendation regarding use of personal data, with the approval of the French “Commission Nationale de l’Informatique et des Libertés”. 3 Results 3.1 Study flow chart Figure 1 presents the study flow chart. Among the eligible persons in the patient group n = 50), four patients refused to participate, nine presented an exclusion criterion. Among the eligible persons in the control group, one control presented an exclusion criterion. This led to a total sample of 74 included participants (i.e., 37 patients and 37 controls). 3.2 Descriptive statistics 3.2.1 Sociodemographic and medical characteristics The sociodemographic and medical characteristics of our sample are presented in Table 1 . Mean age was 40.0 ± 14.1; Mean BMI was 32.9 ± 13.9 kg/m 2 . 74.3% % (55) of participants were female. (Table 1 ) 3.2.2 Cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia Emotion regulation specificities and alexithymia are presented in Table 2 . For the patient group, concerning cognitive emotion regulation strategy use, mean use of adaptive emotional regulation strategy was 61.0 ± 19.6 for the OB + FA-; 52.72 ± 11.0 for the OB + FA+. Mean use of non-adaptive emotional regulation strategy was 33.3 ± 9.3 for the OB + FA- and 41.2 ± 8.3 for the OB + FA+. Concerning emotion regulation difficulties, mean total DERS score was 25.8 ± 15.4 for the OB + FA- and 30.1 ± 13.9 for the OB + FA. Concerning alexithymia, mean alexithymia intensity was 50.9 ± 11.4 for the OB + FA- and 55.9 ± 12.0 for the OB + FA+. For the control group, concerning cognitive emotion regulation strategy use, mean use of adaptive emotional regulation strategy was 63.2 ± 14.0. Mean use of non-adaptive emotional regulation strategy was 36.0 ± 10.2. Concerning emotion regulation difficulties, mean total DERS score was 15.5 ± 13.6. Mean alexithymia score was 44.1 ± 12.8. 3.2.3 Attentional bias and cognitive inhibition Results of the neuropsychological assessments are presented in Table 3 . Concerning attentional bias, mean Emotional Valence in the whole sample was − 1.2 ± 11.0 ms; it did not significatively differ from 0 (p = .35). Mean Food Valence was 1.3 ± 12.3 ms; it did not significatively differ from 0 (p = .35). Concerning cognitive inhibition, mean Stroop Effect was 10.4 ± 26.5 ms; it significatively differed from 0 (p < .001). 3.3 Comparison between the three groups in univariate analyses (Table 2 ) 3.3.1 Socio-demographics characteristics Our subgroups presented significant differences in terms of age (p < .001), BMI (p < .001), gender (p = 0,02), professional status (p < .001) and FA symptoms (p < .001). 3.3.2 Cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia In terms of main effects, univariate analyses showed differences between adaptive emotional regulation strategy and non-adaptive emotional regulation strategy between the three groups (significant main effects with p = 0.03 and p = 0.05, respectively), as well as significant differences in terms of difficulties in emotion regulation (p < .01) and alexithymia (p < .001). Our primary objective are illustrated in Fig. 2 (comparison between OB + FA + and OB + FA - patients), we found that OB + FA + patients reported significantly less frequently the use of refocus on planning (p = .04), and more frequently the use of catastrophizing (p = .02) and positive refocusing (p < .001) than OB + FA - patients. The two groups did not differ in terms of other cognitive emotion regulation strategies. The OB + FA + group did not differ from the OB + FA – group in terms of difficulty in emotion regulation (p = .44) or in terms of alexithymia (p = .29). When considering either all adaptive or all non-adaptive emotion regulation strategies altogether, post-hoc analyses showed that the OB + FA + subgroup used more frequently non-adaptive emotional regulation strategies than the OB- FA+ (p = .02) but no significant differences were observed in terms of use of adaptive emotional regulation strategies (p = .06). To answer our secondary objective (comparison between persons with obesity versus without obesity), we found that both patients from the OB + FA + and OB + FA – groups reported significant higher difficulties in emotion regulation, higher alexithymia and different use of some cognitive emotion regulation strategies than the normal weight group, namely lower refocus on planning, higher use of blaming others and lower self-blame. Patients from the three groups did not differ in terms of the other cognitive emotion regulation strategies, namely acceptance, positive reappraisal, putting into perspective, or rumination. When considering either all adaptive or non-adaptive emotion regulation strategies altogether, post-hoc analyses showed no significant differences in terms of non-adaptive strategies between the OB + FA + and OB – FA – subgroups (p = .06) or between the OB + FA – and OB – FA – subgroups (p = .40); there were no significant differences in terms of adaptive strategies between the OB + FA – and the OB – FA – subgroups (p = .68), but a lower use of adaptive strategies in the OB + FA + subgroup when compared to the OB – FA – subgroup (p < .001). 3.3.3 Cognitive inhibition and attentional biases toward Food or negative emotional stimuli There were no significant differences in attentional biases between the three subgroups both in terms of attentional bias toward negative emotional stimuli (Emotional valence were respectively 1.2 ± 14.9, -3.5 ± 10.0, -1.2 ± 9.3 for the OB + FA + group, OB + FA – group and OB- FA – group; p = 0.44) and attentional bias toward food stimuli (mean Food valence were respectively 0.7 ± 14.8, 2.3 ± 13.6, 1.1 ± 10.5 for the OB + FA + group, OB + FA – group and OB- FA – group; p = 0.91). There were no significant differences in Cognitive inhibition between the sub-groups (p = 0.97). 4 Discussion Our study main result was that among patients with obesity, having a FA was associated with some specific cognitive emotional regulation strategies (CERQ scores): less refocus on planning, more catastrophizing, and more positive refocusing. Counterintuitively, patients with obesity and FA did not differ from those without FA in terms of emotion regulation difficulties (DERS score) or alexithymia (TAS-20 scores). Emotion regulation difficulties and two dimensions of alexithymia (i.e., difficulties in identifying and in describing emotions) were associated with having an obesity rather than with FA. Finally, we found no significant differences between our three groups of patients in terms of attentional bias toward food or negative emotional stimuli and cognitive inhibition. To the best of our knowledge, our study was the first to explore cognitive emotion regulation strategies and its association with FA in patients with obesity. We found that among patients with obesity, having a FA was associated with two non-adaptive cognitive emotion regulation strategies: less refocus on planning and more catastrophizing. Previous study in obese sample also found similar variation of refocus on planning use and catastrophizing variation according to BMI without accounting for FA [ 20 ]. Catastrophizing has been shown to be the the sole cognitive strategy associated with binge eating disorder [ 39 ]. More catastrophizing and less refocus on planning may in fact be due to the same psychopathological mechanism: a cognitive avoidance of the thoughts associated with the exposition to negative events (i.e., catastrophizing refers to the terror of the experience related to negative events) as well as cognitive avoidance of the anticipation of the exposition to these events (i.e., refocus on planning refers to thinking about what steps to take in order to deal with the negative event). In both cases, the thoughts associated with the exposition or anticipation of the exposition to negative events may overtake the adaptative capacities of one’s individual and may lead to more cognitive avoidance, thus impeding the patient’s perceived self-efficacy to cope with all types of negative events. Our results are compatible with classical models of binge eating, namely some parts of the escape theory of binge eating (which postulates that some persons may develop binge eating because of a desire to escape from self-awareness; in this case, escape from self-awareness specifically related to negative events) [ 40 ] and the emotion regulation model of binge eating (which posits that patients with Binge Eating Disorder have deficits in emotion regulation processes and difficulty in regulating their negative emotions, binge eating being a way to cope with these emotions and to find relief) [ 41 ]. In FA, eating highly palatable foods may be one effective (short-term) coping strategy to avoid negative thoughts or negative emotions associated with the exposition (real or anticipated) to the thoughts associated with negative events meaning that FA is associated with cognitive avoidance toward negative events. In our study, we found that the other non-adaptive strategies (i.e., rumination, self-blame, blaming others) were not associated with FA. Studies conducted in patients with other addictive disorders found divergent associations with non-adaptive emotions (i.e., more frequent use of self-blame and blaming others) [ 42 , 43 ]. While these divergent results may be explained by the differences in included population; it may be due to a difference in nature of the cognitive emotion regulation strategies assessed: self-blame and blaming others refer to the attribution style of a person toward negative events ; catastrophizing and refocus on planning refer to a direct cognitive exposition to negative affective state or experience, which the patient with FA may try to avoid (avoiding self-awareness, as proposed in the escape theory of binge eating) [ 40 ]. In line with these findings, we may assume that FA may be more strongly linked to thoughts associated with the direct affective exposition to negative events rather than to indirect affective exposition such as attribution theory. Surprisingly, having a FA was associated with one adaptive strategy: more use of positive refocusing. Similar use of this strategy has also been demonstrated in patients with gambling disorder [ 42 , 44 ]. Two hypotheses may be proposed: as proposed by Ruiz de Lara, the short term efficacy of the strategies may reinforce biased beliefs about the outcomes of the addictive behavior (in the case of gambling, beliefs about gambling outcomes and controllability; in the case of food, biased beliefs about the positive outcomes of eating) [ 44 ]. Another explanation could be that in this case positive refocusing is a mean to avoid the exposition to thoughts and affect associated with negative events and these questions the adaptive nature of this cognitive strategy. When overused, positive refocusing might be another facet of lower focus on planning: cognitive avoidance toward negative events. Another interesting result of our study was that in our sample patients with obesity presented more difficulty in emotion regulation (DERS total score) than controls regardless of the presence of FA. These results are in line with complementary work showing that in general population, people at high FA risk (without accounting for BMI) or with a higher BMI (without accounting for FA) show more difficulty in emotion regulation [ 20 , 45 ]. A precedent work in pre-bariatric sample showed that people with obesity and FA presented more difficulty in emotion regulation that people with obesity without FA [ 11 ]. Altogether these results are in line with a separate association of obesity and FA to difficulty in emotion regulation with stronger relative association strength between obesity and difficulty in emotion regulation and advocate for specific work measuring relative correlation association on the subject. As observed for emotion regulation difficulties, patients with obesity had higher alexithymia than controls, without a significative difference between patients with or without FA. The association between obesity and alexithymia is in line with the literature as patient with obesity presented more alexithymia especially more difficulty in identifying emotions and an externally oriented thinking style [ 21 ]. Li et al. work found a significant correlation between alexithymia and FA severity [ 24 ]. Altogether theses works show that alexithymia may be more closely linked to obesity than to FA and as such may not be a direct therapeutic target when focusing FA. As our sample was constituted of patients with severe obesity (mean BMI was 45.6 and 39.9 in our FA and non-FA samples), future studies should be conducted in patients with less severe obesity before we may generalize our findings to the broader population of patients with obesity. In our study, cognitive inhibition was not specifically altered in OB + FA + when measured by the Stroop task. These results are in line with precedent studies in similar populations [ 46 , 47 ]: although literature is heterogenous, FA was not specifically associated with cognitive inhibition deficit in obese patients, and results from cross-sectional and longitudinal studies support the idea that inhibition deficits may be more due to obesity than FA [ 48 ]. This show a difference between FA and substance use disorders in which there seems to be a causal association between inhibition control deficit and the onset of chronic substance use [ 16 – 18 , 49 , 50 ]. Our work failed to demonstrate a specific attentional bias toward neither food nor negative emotion stimuli in patients with obesity and FA which. A precedent work using image cues showed a preference toward unhealthy food cues population of patient with FA without obesity [ 25 ] no other work explored attentional bias toward negative emotion in comparable population to our knowledge. We may assume that the deficits in emotion regulation observed in patients with obesity and FA may be more linked to explicit emotion regulation (i.e., as assessed by the CERQ) than implicit emotion regulation (as assessed by the Stroop and emotional Stroop task). Although our study provided some insights into the association between FA, emotion regulation and obesity, it had some methodological limitations. First, our samples sizes were small to moderate, and this could have led to non-significant results due to a lack of statistical power. This limitation underscores the statistical significance of our positive results such as association between FA status and use of maladaptive cognitive emotional regulation strategy. Second, our control population presented significant socio-demographic differences with our clinical population that could have led to a confusion bias which may have been explained by our recruitment method for the control group (i.e., university members and students), with the recruitment of younger persons with higher employment rate and higher level of education. Of note, there was, however, no correlation between age and cognitive emotion regulation strategy. Thirdly, the cross-sectional nature of our study precludes us from demonstrating a causal relationship between emotional regulation strategy and FA. To demonstrate whether these cognitive emotion regulation strategies happen before, during or after the onset of FA, prospective studies are warranted. Despite these limitations, our study has some clinical implications. Firstly, it demonstrates the need to explore emotion regulation mechanism in patients with FA through different and complementary methods such as cognitive emotion regulation (that can be reliably assessed using the CERQ), difficulties in emotion regulation (DERS), difficulties in identifying and describing emotions (TAS-20) and neuropsychological measures. Secondly, it brings support for the use of the CERQ, a self-administered tool rarely used in the field of addictive and eating disorder, but that may be contributive to explore the cognitive emotion regulation specificities in patients with obesity and FA. It brings insight into emotion regulation aspects that may be linked to obesity itself (i.e., higher alexithymia and higher difficulties in emotion regulation) and emotion regulation aspects that may be associated more specifically to FA and that may be specific targets (i.e., some specific cognitive emotion regulation strategies). In sum, our results are compatible with the hypothesis of a specific cognitive avoidance toward the exposition to negative emotions and its associated events in patients with obesity and FA. Therapeutic implications that may be helpful in these patients may include the use of psychotherapy to increase the patient’s perceived self-efficacy toward the exposition or anticipation of exposition to these emotionally charged events (i.e., Cognitive behavioral therapy including Acceptment & Commitment Therapy and Dialectical behavioral therapy, but also the use of pharmacological). In summary, our study demonstrates that the presence of FA among patients with obesity is associated with specific cognitive emotion regulation strategies but not with attentional biases toward food or negative emotion stimuli. Our study also adds to the knowledge of the links between obesity, emotion regulation difficulties, alexithymia, and cognitive inhibition or attentional biases toward food or negative emotion stimuli as assessed per the classical and emotional Stroop task. It confirms the reliability of the DERS and the TAS-20 to evaluate such deficits in patients with obesity and suggests that emotion regulation and cognitive strategy for emotion regulation may be potential therapeutic targets for FA as already demonstrated in patients with substance use disorder, for which psychotherapy targeting emotional regulation such as Dialectical behavioral therapy showed good efficacy [ 51 ]. Cognitive behavioral therapy based approach including emotion regulation ability and cognitive strategy restructuration may be a promising treatment in obese patients with FA. Declarations Ethics approval and consent to participate This study has been approved by the institutional review board of the University Hospital of Tours (N°:2022_028) for the clinical population and by the institutional review board of the University and Tours and Poitiers (Comité d’Éthique pour les Recherches sur la Personne Tours- Poitiers) (CER-TP 2022-09-01), prior to the beginning of the study. All procedures were performed in accordance with the ethical standards of the national and/or institutional research committee as well as with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All participants provided informed consent after the procedure had been fully explained and prior to their inclusion in the study. All collected data were in line with the French recommendation regarding use of personal data, with the approval of the French “Commission Nationale de l’Informatique et des Libertés” (CNIL). Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions LM: Conceptualization; Methodology ; Formal analysis; Investigation; Writing - Original Draft AS Methodology ; Resources; Writing - Review & Editing MR Writing - Original Draft ; Validation ADL Writing - Review & Editing FK Writing - Review & Editing SB Writing - Review & Editing NB Resources ; Supervision ; Writing - Review & Editing BG Supervision; Writing - Review & Editing PB Conceptualization; Methodology ; Formal analysis; Validation; Resources; Writing - Original Draft Acknowledgements Not applicable References World health statistics 2023: monitoring health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO n.d. Abdelaal M, le Roux CW, Docherty NG. Morbidity and mortality associated with obesity. Ann Transl Med 2017;5:161. https://doi.org/10.21037/atm.2017.03.107. Simon GE, Von Korff M, Saunders K, Miglioretti DL, Crane PK, van Belle G, et al. Association Between Obesity and Psychiatric Disorders in the US Adult Population. Archives of General Psychiatry 2006;63:824–30. https://doi.org/10.1001/archpsyc.63.7.824. Pi-Sunyer X. The Medical Risks of Obesity. Postgraduate Medicine 2009;121:21–33. https://doi.org/10.3810/pgm.2009.11.2074. NCD Global Monitoring Framework n.d. https://www.who.int/publications-detail-redirect/ncd-surveillance-global-monitoring-framework (accessed March 7, 2024). Safaei M, Sundararajan EA, Driss M, Boulila W, Shapi’i A. A systematic literature review on obesity: Understanding the causes & consequences of obesity and reviewing various machine learning approaches used to predict obesity. Computers in Biology and Medicine 2021;136:104754. https://doi.org/10.1016/j.compbiomed.2021.104754. Gearhardt AN, Schulte EM. Is Food Addictive? A Review of the Science. Annu Rev Nutr 2021. https://doi.org/10.1146/annurev-nutr-110420-111710. Lipsky LM, Cummings JR, Haynie DL, Nansel TR. The burden of overweight/obesity and weight-related behaviors attributable to food addiction in emerging adults. Appetite 2024;199:107399. https://doi.org/10.1016/j.appet.2024.107399. Praxedes DRS, Silva-Júnior AE, Macena ML, Oliveira AD, Cardoso KS, Nunes LO, et al. Prevalence of food addiction determined by the Yale Food Addiction Scale and associated factors: A systematic review with meta-analysis. European Eating Disorders Review 2022;30:85–95. https://doi.org/10.1002/erv.2878. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale Food Addiction Scale. Appetite 2009;52:430–6. https://doi.org/10.1016/j.appet.2008.12.003. Ahmadkaraji S, Farahani H, Orfi K, Fathali Lavasani F. Food addiction and binge eating disorder are linked to shared and unique deficits in emotion regulation among female seeking bariatric surgery. J Eat Disord 2023;11:97. https://doi.org/10.1186/s40337-023-00815-x. Leppanen J, Brown D, McLinden H, Williams S, Tchanturia K. The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach. Frontiers in Psychiatry 2022;13. Weiss NH, Kiefer R, Goncharenko S, Raudales AM, Forkus SR, Schick MR, et al. Emotion regulation and substance use: A meta-analysis. Drug and Alcohol Dependence 2022;230:109131. https://doi.org/10.1016/j.drugalcdep.2021.109131. Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 1985;142:1259–64. https://doi.org/10.1176/ajp.142.11.1259. Estévez A, Jáuregui P, Sánchez-Marcos I, López-González H, Griffiths MD. Attachment and emotion regulation in substance addictions and behavioral addictions. J Behav Addict n.d.;6:534–44. https://doi.org/10.1556/2006.6.2017.086. Tarter RE, Kirisci L, Mezzich A, Cornelius JR, Pajer K, Vanyukov M, et al. Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. Am J Psychiatry 2003;160:1078–85. https://doi.org/10.1176/appi.ajp.160.6.1078. Ivanov I, Schulz KP, London ED, Newcorn JH. Inhibitory control deficits in childhood and risk for substance use disorders: a review. Am J Drug Alcohol Abuse 2008;34:239–58. https://doi.org/10.1080/00952990802013334. Moffitt TE, Arseneault L, Belsky D, Dickson N, Hancox RJ, Harrington H, et al. A gradient of childhood self-control predicts health, wealth, and public safety. Proc Natl Acad Sci U S A 2011;108:2693–8. https://doi.org/10.1073/pnas.1010076108. Gross JJ. Handbook of Emotion Regulation, Second Edition. Guilford Publications; 2013. Willem C, Gandolphe M-C, Roussel M, Verkindt H, Pattou F, Nandrino J-L. Difficulties in emotion regulation and deficits in interoceptive awareness in moderate and severe obesity. Eat Weight Disord 2019;24:633–44. https://doi.org/10.1007/s40519-019-00738-0. Fernandes J, Ferreira-Santos F, Miller K, Torres S. Emotional processing in obesity: a systematic review and exploratory meta-analysis: Emotional processing in obesity. Obesity Reviews 2018;19:111–20. https://doi.org/10.1111/obr.12607. Hendrikse JJ, Cachia RL, Kothe EJ, McPhie S, Skouteris H, Hayden MJ. Attentional biases for food cues in overweight and individuals with obesity: a systematic review of the literature. Obesity Reviews 2015;16:424–32. https://doi.org/10.1111/obr.12265. Brunault P, Ducluzeau P-H, Courtois R, Bourbao-Tournois C, Delbachian I, Réveillère C, et al. Food Addiction is Associated with Higher Neuroticism, Lower Conscientiousness, Higher Impulsivity, but Lower Extraversion in Obese Patient Candidates for Bariatric Surgery. Subst Use Misuse 2018;53:1919–23. https://doi.org/10.1080/10826084.2018.1433212. Li R, Kajanoja J, Tuulari JJ, Karlsson L, Karlsson H, Karukivi M. Relationships between alexithymia and food addiction: The Finnish version of Yale Food Addiction Scale and preliminary test of its psychometric properties. Front Psychol 2023;14:1067872. https://doi.org/10.3389/fpsyg.2023.1067872. Frayn M, Sears CR, von Ranson KM. A sad mood increases attention to unhealthy food images in women with food addiction. Appetite 2016;100:55–63. https://doi.org/10.1016/j.appet.2016.02.008. Peirce J, Gray JR, Simpson S, MacAskill M, Höchenberger R, Sogo H, et al. PsychoPy2: Experiments in behavior made easy. Behav Res 2019;51:195–203. https://doi.org/10.3758/s13428-018-01193-y. Brunault P, Courtois R, Gearhardt AN, Gaillard P, Journiac K, Cathelain S, et al. Validation of the French Version of the DSM-5 Yale Food Addiction Scale in a Nonclinical Sample. Can J Psychiatry 2017;62:199–210. https://doi.org/10.1177/0706743716673320. Gearhardt AN, Corbin WR, Brownell KD. Development of the Yale Food Addiction Scale Version 2.0. Psychology of Addictive Behaviors 2016;30:113–21. https://doi.org/10.1037/adb0000136. Garnefski N, Kraaij V, Spinhoven P. Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences 2001;30:1311–27. https://doi.org/10.1016/S0191-8869(00)00113-6. Jermann F, Van der Linden M, D’acremont M, Acremont, Zermatten A. Cognitive Emotion Regulation Questionnaire (CERQ): Confirmatory Factor Analysis and Psychometric Properties of the French Translation. European Journal of Psychological Assessment 2006;22:126–31. https://doi.org/10.1027/1015-5759.22.2.126. Gratz KL, Roemer L. Multidimensional Assessment of Emotion Regulation and Dysregulation: Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment 2004;26:41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94. Bjureberg J, Ljótsson B, Tull MT, Hedman E, Sahlin H, Lundh L-G, et al. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. J Psychopathol Behav Assess 2016;38:284–96. https://doi.org/10.1007/s10862-015-9514-x. Côté G, Gosselin P, Dagenais I. Évaluation multidimensionnelle de la régulation des émotions : propriétés psychométriques d’une version francophone du Difficulties in Emotion Regulation Scale. Journal de Thérapie Comportementale et Cognitive 2013;23:63–72. https://doi.org/10.1016/j.jtcc.2013.01.005. Bagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23–32. https://doi.org/10.1016/0022-3999(94)90005-1. Loas G, Fremaux D, Marchand MP. Étude de la structure factorielle et de la cohérence interne de la version française de l’échelle d’alexithymie de Toronto à 20 items (TAS-20) chez un groupe de 183 sujets sains. [The factorial structure and internal consistency of the French version of the 20-item Toronto Alexithymia Scale (TAS-20): A study among 183 normal subjects.]. L’Encéphale: Revue de Psychiatrie Clinique Biologique et Thérapeutique 1995;21:117–22. Stroop JR. Studies of interference in serial verbal reactions. Journal of Experimental Psychology 1935;18:643–62. https://doi.org/10.1037/h0054651. Mathews A, MacLeod C. Selective processing of threat cues in anxiety states. Behaviour Research and Therapy 1985;23:563–9. https://doi.org/10.1016/0005-7967(85)90104-4. Williams JM, Mathews A, MacLeod C. The emotional Stroop task and psychopathology. Psychol Bull 1996;120:3–24. https://doi.org/10.1037/0033-2909.120.1.3. Walenda A, Bogusz K, Kopera M, Jakubczyk A, Wojnar M, Kucharska K. Emotion regulation in binge eating disorder. Psychiatr Pol 2021;55:1433–48. https://doi.org/10.12740/PP/OnlineFirst/122212. Heatherton TF, Baumeister RF. Binge eating as escape from self-awareness. Psychol Bull 1991;110:86–108. https://doi.org/10.1037/0033-2909.110.1.86. Leehr EJ, Krohmer K, Schag K, Dresler T, Zipfel S, Giel KE. Emotion regulation model in binge eating disorder and obesity - a systematic review. Neuroscience & Biobehavioral Reviews 2015;49:125–34. https://doi.org/10.1016/j.neubiorev.2014.12.008. Navas JF, Verdejo-García A, LÓpez-GÓmez M, Maldonado A, Perales JC. Gambling with Rose-Tinted Glasses on: Use of Emotion-Regulation Strategies Correlates with Dysfunctional Cognitions in Gambling Disorder Patients. J Behav Addict 2016;5:271–81. https://doi.org/10.1556/2006.5.2016.040. Kalantarkousheh SM, Doostian Y, Godini AA, Aazami Y. Cognitive Emotion Regulation Strategies among Regular Persons and Participants in Methadone or Narcotics Anonymous Treatment Programs. Studies in Social Sciences and Humanities 2015;2:131–8. Ruiz de Lara CM, Navas JF, Perales JC. The paradoxical relationship between emotion regulation and gambling-related cognitive biases. PLoS One 2019;14:e0220668. https://doi.org/10.1371/journal.pone.0220668. Innamorati M, Imperatori C, Harnic D, Erbuto D, Patitucci E, Janiri L, et al. Emotion Regulation and Mentalization in People at Risk for Food Addiction. Behav Med 2017;43:21–30. https://doi.org/10.1080/08964289.2015.1036831. Blume M, Schmidt R, Hilbert A. Executive Functioning in Obesity, Food Addiction, and Binge-Eating Disorder. Nutrients 2018;11. https://doi.org/10.3390/nu11010054. Rodrigue C, Ouellette A-S, Lemieux S, Tchernof A, Biertho L, Bégin C. Executive functioning and psychological symptoms in food addiction: a study among individuals with severe obesity. Eat Weight Disord 2018;23:469–78. https://doi.org/10.1007/s40519-018-0530-1. Favieri F, Forte G, Casagrande M. The Executive Functions in Overweight and Obesity: A Systematic Review of Neuropsychological Cross-Sectional and Longitudinal Studies. Frontiers in Psychology 2019;10. Stephan RA, Alhassoon OM, Allen KE, Wollman SC, Hall M, Thomas WJ, et al. Meta-analyses of clinical neuropsychological tests of executive dysfunction and impulsivity in alcohol use disorder. The American Journal of Drug and Alcohol Abuse 2017;43:24–43. https://doi.org/10.1080/00952990.2016.1206113. Figueiredo PR, Tolomeo S, Steele JD, Baldacchino A. Neurocognitive consequences of chronic cannabis use: a systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews 2020;108:358–69. https://doi.org/10.1016/j.neubiorev.2019.10.014. Azizi A, Borjali A, Golzari M. The Effectiveness of Emotion Regulation Training and Cognitive Therapy on the Emotional and Addictional Problems of Substance Abusers. Iran J Psychiatry 2010;5:60–5. Tables Table 1. Descriptive statistics of our study sample regarding sociodemographic and medical characteristics, and comparison between the three groups in univariate analyses Complete sample (n=74) OB+ FA+ Group (n=18) OB+ FA- Group (N= 19) OB- FA- Group (n=37) p Z statistics for Pair-wise comparaison (p-value) OB+ FA+ vs. OB+ FA- OB+ FA- vs. OB- FA- OB+ FA+ vs. OB- FA- Age (Year) 40.0±14.1 41.1±16.3 48.4±12.0 35.1±12.0 <.001 † 1.6(.11) 3.3(<.001) 1.4(.16) BMI (Kg/m²) 32.9±13.9 45.6±7.8 39.9±7.4 23.1±3.0 < .001 † -0.6(.57) 5.8(<.001) 6.3(<.001) Gender (Female) 74.3% (55) 100 % (18) 63.2% (12) 67.6% (25) .02 Familial status (relationship) 64.9% (48) 50 % (9) 69.6 % (39) 75.7% (28) .15 Professional status (employed) 64.9% (48) 44.4% (8) 42.1% (8) 86.5% (32) < .001 Number of FA symptoms (YFAS 2.0) 2.8±3.3 7.3±2.4 2.5±2.5 .8±1.4 < .001 † -3.6(<.001) 2.3(.02) 6.5(<.001) Note. Continuous variables were compared between the three groups using ANOVA test or Kruskal Wallis test depending on the Levene test ( † indicates results obtained from Kruskal Wallis test); ordinal variables were compared using chi-squared tests. YFAS 2.0 : Yale Food Addiction Scale 2.0 Table 2. Descriptive statistics of our study sample regarding cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia, and comparison between the three groups in univariate analyses Complete sample (n=74) OB+ FA+ Group (n=18) OB+ FA- group (n= 19) OB- FA- group (n=37) p-value Z statistics for pair-wise comparaison (p-value) OB+ FA+ vs. OB+ FA- OB+ FA- vs. OB- FA- OB+ FA+ vs. OB- FA- Adaptive emotional regulation strategy total score (CERQ) 60.1±15.4 52.72±11.0 61.0±19.6 63.2±14.0 .03 † 1.9(.06) -0.4(.68) -2.6(<.001) Acceptance (CERQ1) 13.4±3.8 12.4±3.9 13.6±5.0 13.8±3.0 .55† Positive refocusing (CERQ2) 10.8±4.2 13.8±3.6 9.3±4.3 10.0±3.9 .25 † Refocus on planning (CERQ3) 11.3±4.6 7.2±2.0 10.3±5.0 13.9±3.6 < .001 † 2.1(.04) -2.9(.004) -5.2(<.001) Positive reappraisal (CERQ4) 12.4±4.0 11.0±4.0 13.0±4.6 12.8±3.7 <.001 † -3.1(<.001) -0.6(.57) 3.0(<.001) Putting into perspective (CERQ5) 12.0±4.0 10.6±3.8 11.7±4.7 12.8±3.6 .17 † Non- adaptive emotional regulation strategy total score (CERQ) 36.6±9.9 41.2±8.3 33.3±9.3 36.0±10.2 .05 † -2.3(.02) -0.8(0.4) 1.9(0.06) Rumination (CERQ6) 11 .0±4.0 10.3±2.9 9.7±4.2 11.9±4.2 .06 † Self-blame (CERQ7) 8.9±3.6 8.0±3.53 7.2±3.4 10.2±3.2 < .001 † -0.8(0.4) -3.2(.001) -2.2(0.03) Blaming others (CERQ8) 9.6±4.5 11.6±4.2 12.5±4.8 7.2±3.1 < .001 † 0.3(0.8) 4.0(<.001) 3.6(<.001) Catastrophizing (CERQ9) 7.4±3.1 9.1±2.9 7.1±3.5 6.8±2.8 .01 † -2.3(0.02) 0.2(0.8) 2.8(.005) Difficulty in emotion regulation (DERS total score) 21.7±15.4 30.1±13.9 25.8±15.4 15.5±13.6 <.001 † -0.8(0.44) 2.6(<.01) 3.4(< .001) Alexithymia total score (TAS-20) 48.7±13.1 55.9±12.0 50.9±11.4 44.1±12.8 .0053 † -1.0(0.29) 1.9(0.05) 3.1(<.001) Difficulty identifying emotions (TAS-20) 17.4±6.0 21.0±5.0 18.7±5.2 15.0±5.8 .0013 † -1.2(0.22) 2.1(0.03) 3.5(<.001) Difficulty describing emotions (TAS-20) 13.8±5.0 16.3±5.2 13.8±4.6 12.5±4.8 0.03 † -1.5(0.14) 1.0(0.31) 2.7(.007) Operational thinking (TAS-20) 17.5±4.6 18.6±5.3 18.4±4.2 16.5±4.4 0.10 † Note. Continuous variables were compared between the three groups using ANOVA test or Kruskal Wallis test depending on the Levene test († indicates results obtained from Kruskal Wallis test); ordinal variables were compared using chi-squared tests. CERQ=Cognitive emotion regulation questionnaire; DERS = Difficulties in Emotion Regulation Scale; TAS-20=Toronto Alexithymia Scale, 20 items. Table 3. Descriptive statistics of our study sample regarding attentional biases and cognitive inhibition, and comparison between the three groups in univariate analyses Complete sample (n=74) OB+ FA+ group (n=18) OB + FA - group (n= 19) OB– FA - group (n=37) Difference from 0 U (p-value) Subgroup comparison H(p) Emotional valence (ms) - 1.2±11.0 1.2±14.9 -3.5±10.0 -1.2±9.3 1106. 00 (0.13) 0.32(0.85) † Food valence (ms) 1.3±12.3 0.7±14.8 2.3±13.6 1.1±10.5 1390.00(0.99) 0.22(0.89) † Stroop effect (ms) 10.4±26.5 6.9±35.2 6.8±29.1 14.0±19.8 2091.00(<.001) 0.07(0.97) † Note. Significant difference from 0 was calculated using Wilcoxon-Mann-Whitney test; Continuous variables were compared between the three groups using ANOVA tests or Kruskal Wallis test depending on the Levene test († indicates results obtained from Kruskal Wallis test Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Supplementary Material : specifications of creation regarding the neuropsychological task administered Graphicalasbtract.ppt.pptx Graphical Abstract Cite Share Download PDF Status: Published Journal Publication published 15 Dec, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 25 Jul, 2025 Reviews received at journal 15 Jun, 2025 Reviewers agreed at journal 10 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 20 May, 2025 Submission checks completed at journal 20 May, 2025 First submitted to journal 16 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6682315","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469110035,"identity":"36ed7ccf-a243-4297-9660-2fd0927d1160","order_by":0,"name":"Lou Madieta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIie3Ov0oDMRzA8d8ZyC3BWxMo9hXS5RxO6NuYJQXhlg6iKQdxsb6AT9HNsRCIyzm4RXSoFJx1KRwUMaegRc2hm0i+Q/6QfEgAYrE/2PbbhIgfkkWiPk6yEMHvBAPim4Sp7+5vkHaF6c9Iesq33GHRy/rVw7i5MJCdn1wvx2uguwGDSc2RtIIwjfObaW2A3tXl4EoD7c0DhEpPsCHcQn6baHOsnNxnEwVHNPSxV/JsyNCmq9IT6DspGuU/1klG2r+CSY5awp2wicIdhNgDMzoThFpZsqkWMHASsYmmQZKl1WwpV8Uwqy5nj40uYMeJ+ye13guStvmnPeF+6AJfSxe/uh6LxWL/vhfeAFEEOxHB+AAAAABJRU5ErkJggg==","orcid":"","institution":"CHU Angers Service de Psychiatrie – Addictologie","correspondingAuthor":true,"prefix":"","firstName":"Lou","middleName":"","lastName":"Madieta","suffix":""},{"id":469110036,"identity":"0a9085a9-6cf9-4864-aa31-d11493ce5164","order_by":1,"name":"Amandine Scocard","email":"","orcid":"","institution":"CHRU de Tours, Équipe de Liaison et de Soins en Addictologie","correspondingAuthor":false,"prefix":"","firstName":"Amandine","middleName":"","lastName":"Scocard","suffix":""},{"id":469110037,"identity":"e0c15eae-9a84-4c0e-962b-d6f500a1bf65","order_by":2,"name":"Marine Rozet","email":"","orcid":"","institution":"CHU Angers Service de Psychiatrie – Addictologie","correspondingAuthor":false,"prefix":"","firstName":"Marine","middleName":"","lastName":"Rozet","suffix":""},{"id":469110038,"identity":"5e6173cd-6a7e-4166-9a5f-a02d070e2be8","order_by":3,"name":"Arnaud De Luca","email":"","orcid":"","institution":"CHRU de Tours, Centre Spécialisé de l’Obésité","correspondingAuthor":false,"prefix":"","firstName":"Arnaud","middleName":"","lastName":"De Luca","suffix":""},{"id":469110039,"identity":"5228c30c-eb6a-455a-a03d-be49d72fe6d6","order_by":4,"name":"François Kazour","email":"","orcid":"","institution":"CHU Angers Service de Psychiatrie – Addictologie","correspondingAuthor":false,"prefix":"","firstName":"François","middleName":"","lastName":"Kazour","suffix":""},{"id":469110040,"identity":"e4be8fa0-9f84-461e-ad91-573507f07196","order_by":5,"name":"Servane Barrault","email":"","orcid":"","institution":"CHRU de Tours, Centre de Soins d’Accompagnement et de Prévention en Addictologie d’Indre-et-Loire (CSAPA-37)","correspondingAuthor":false,"prefix":"","firstName":"Servane","middleName":"","lastName":"Barrault","suffix":""},{"id":469110041,"identity":"4918a755-4b4c-4f68-8e6d-5da81cb9ed18","order_by":6,"name":"Nicolas Ballon","email":"","orcid":"","institution":"CHRU de Tours, Équipe de Liaison et de Soins en Addictologie","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Ballon","suffix":""},{"id":469110043,"identity":"3b58cc7e-3f05-4342-a4f1-1065445ebb76","order_by":7,"name":"Bénédicte Gohier","email":"","orcid":"","institution":"CHU Angers Service de Psychiatrie – Addictologie","correspondingAuthor":false,"prefix":"","firstName":"Bénédicte","middleName":"","lastName":"Gohier","suffix":""},{"id":469110045,"identity":"d5de6e80-5094-4e98-911a-383f897176fe","order_by":8,"name":"Paul Brunault","email":"","orcid":"","institution":"CHRU de Tours, Équipe de Liaison et de Soins en Addictologie","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Brunault","suffix":""}],"badges":[],"createdAt":"2025-05-16 16:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6682315/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6682315/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-025-01424-6","type":"published","date":"2025-12-15T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84545385,"identity":"5ad32e9d-d869-48d1-9d3f-b4f8de97bee6","added_by":"auto","created_at":"2025-06-13 09:13:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":174627,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow chart\u003c/p\u003e\n\u003cp\u003eNote. OB+ FA+: Patients with obesity and FA; OB+ FA-: Patients with obesity but without FA; OB-FA-: control group= participants without obesity and without FA\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6682315/v1/4ea054803cd25b546174e04e.png"},{"id":84545382,"identity":"0a831398-454e-4dc4-beee-435039034ae6","added_by":"auto","created_at":"2025-06-13 09:13:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65113,"visible":true,"origin":"","legend":"\u003cp\u003eAdaptative and non-adaptative cognitive emotional regulation strategy\u003c/p\u003e\n\u003cp\u003eNote. Acceptance (CERQ1); Positive refocusing (CERQ2); Refocus on planning (CERQ3); Positive reappraisal (CERQ4); Putting into perspective (CERQ5); Rumination (CERQ6); Self-blame (CERQ7); Blaming others (CERQ8); Catastrophizing (CERQ9)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6682315/v1/b30fbfa1c44e0af8a2b1973a.png"},{"id":98814587,"identity":"ee0d76f9-82b6-4bd1-8670-6f141a8494bc","added_by":"auto","created_at":"2025-12-22 16:12:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1737854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682315/v1/b3f2fa18-8fcc-4bc3-8b70-8b2ab38ff7c8.pdf"},{"id":84545387,"identity":"23beef88-2154-4b87-b4de-25fe45d514ef","added_by":"auto","created_at":"2025-06-13 09:13:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":76226,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Material : specifications of creation regarding the neuropsychological task administered\u003c/p\u003e","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6682315/v1/ea2c2807e5ca07e935f7c1f9.docx"},{"id":84546234,"identity":"6c534c3a-0708-4ff5-ab5e-9a3135357366","added_by":"auto","created_at":"2025-06-13 09:21:35","extension":"pptx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":649678,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical Abstract\u003c/p\u003e","description":"","filename":"Graphicalasbtract.ppt.pptx","url":"https://assets-eu.researchsquare.com/files/rs-6682315/v1/09d8e50ee1700f376af65dde.pptx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emotion regulation among patients with obesity and food addiction","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eObesity is a global pandemic concerning 13.1% of worldwide adults, a prevalence doubled since the 1990 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Obesity is associated with an elevated risk of mortality, lower quality of life and higher prevalence for co-occurrent psychiatric disorders and general medical disorders[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Tackling obesity and its associated factors is one of the prioritized target of the World Health Organization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To this end, identifying subgroups of vulnerable patients among persons with obesity help designing better tailored treatments.\u003c/p\u003e \u003cp\u003eObesity is associated with a wide range of biopsychosocial factors, including genetic aspects, limited physical activity, excessive calorie intake that may be due to high in fat and or sugar foods, and disordered eating [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In line with this later hypothesis, food addiction (FA) has been proposed as a risk factors for obesity in a subgroup of patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Approximately 25% of people with obesity or overweight suffer from FA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. FA is defined by the use of highly palatable food in a pattern similar to substance use in substance use disorder [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This includes the presence of tolerance, withdrawal symptoms, larger amounts consumed than intended, persistent desire or unsuccessful attempts to cut down, much time spent using or recovering from food usage, continual use despite knowledge of adverse consequences or activities given up due to use of food.\u003c/p\u003e \u003cp\u003eIn FA, part of the food intake may be emotionally driven [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], as it was already demonstrated in subgroups of patients with classical eating disorders [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] or substance use disorder [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As proposed in the self-medication theory, eating these foods may be a coping strategy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As in substance abuse, difficulties in emotion regulation may increase the risk of regular high palatable food intake onset and maintenance leading to eating disorders including FA [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to the model of emotional regulation processes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], emotion regulation can occur at behavioral (situation modification), attentional (attentional deployment) and cognitive levels (cognitive change ) levels. Furthermore, when evaluating emotional regulation via subjective measure such as self-administered questionnaires, it is necessary to account for the capacity to identify and express emotion (i.e., alexithymia). Such a multilevel assessment of emotion regulation processes in obesity and FA may provide valuable insight to better design tailor-based treatment for these patients.\u003c/p\u003e \u003cp\u003eOn one hand, previous works showed that at the cognitive level, obesity was associated with more frequent use of cognitive emotion regulation strategy such as refocus on planning and catastrophizing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Individuals with obesity also showed more intense alexithymia and difficulty in emotional awareness and emotion regulation strategies, namely, reduced cognitive reappraisal and acceptance, and greater suppression of emotion expression [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. At the attentional level, while the literature is heterogenous, a majority of published studies showed an attentional bias against food cues [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These works did not account for the presence of FA in studied samples.\u003c/p\u003e \u003cp\u003eOn the other hand, previous work conducted among patients with FA showed that it was associated with more difficulty in emotion regulation in aspects of lack of awareness of emotional responses, non-acceptance of emotional responses, lack of clarity of emotional responses, limited access to emotion regulation strategies, impulse control difficulties, difficulties engaging in goal-directed behaviors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. FA was also associated with impulsivity both in terms of cognitive aspects and non-planning impulsivity[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], but also with alexithymia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Attentional bias toward food-related cues in FA may be altered by emotional stimuli as it\u0026rsquo;s been shown that a sad mood increases attentional bias toward unhealthy highly palatable foods [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These works did not account for the presence of obesity in studied samples.\u003c/p\u003e \u003cp\u003eIn sum, obesity and FA are both associated with emotion dysregulation and alexithymia, but the relative contribution of these mechanisms to obesity and FA remains unclear. In addition, investigating attentional biases toward food or negative emotional stimuli may provide additional knowledge of the mechanisms underlying obesity or FA, but studies in this field are lacking.\u003c/p\u003e \u003cp\u003eThe main objective of our study was to compare patients with obesity and FA versus patients with obesity but no FA in terms of cognitive emotion regulation strategies. We hypothesized that among patients with obesity, having a FA may be associated with more non-adaptive and less adaptive cognitive emotion regulation strategies. Our secondary objectives were: (1) to compare patients with obesity and FA versus patients with obesity but no FA in terms of other emotion regulation-related variables (i.e., difficulties in emotion regulation, alexithymia, attentional bias toward food or negative emotion-related stimuli, cognitive inhibition); (2) to compare these patients with obesity (with or without FA) versus patients without obesity (control group) regarding the same emotion regulation-related variables. We hypothesized that there may be a gradient of increased severity between patients without obesity, patients with obesity but no FA, and patients with obesity and FA in terms of alexithymia, difficulties in emotion regulation, cognitive inhibition and attentional bias toward food or negative stimuli.\u003c/p\u003e"},{"header":"2 Material \u0026 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants and Procedures\u003c/h2\u003e \u003cp\u003eIn this cross-sectional study, we recruited persons from two groups: (1) a group of patients with obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) consulting in the Department of Psychiatry and Addiction at the University Hospital of Tours, France that were recruited between May 2022 and November 2022 (patients referred to psychiatrists from the Specialized Obesity Center of the same hospital), and (2) an unmatched control group constituted of adults without obesity (BMI\u0026thinsp;\u0026le;\u0026thinsp;30 kg/m\u0026sup2;) recruited between December 2022 and July 2023 from a non-clinical population (university members and students). Patients were eligible for the study if they were at least 18 years old, were willing to participate and had a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2;. In both populations, exclusion criteria were similar: participants were excluded if they presented any bias inducing disability (including motor, perceptive or cognitive impairment), if French was not their native language or if they had significant difficulties in answering the self-administered questionnaire. In the patient group, the study inclusion was systematically proposed by the psychiatrists in charge of the patient follow-up (PB or AS), and patients were assessed during a research consultation scheduled in the following month.\u003c/p\u003e \u003cp\u003eAll groups underwent a single consultation assessment with the same physician (LM). This consultation included data collected from medical records, self-administered questionnaires as well as a neuropsychological task specifically designed for this study using the Psychopy software [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] (see Supplemental Material A for more details).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Sociodemographics and medical characteristics\u003c/h2\u003e \u003cp\u003eIn both groups, we collected the following data using self-administered questionnaires or medical records: demographics (age, gender, marital and employment status), past and current medical and psychiatric disorders to assess for exclusion criteria and self-reported height and weight.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Food addiction\u003c/h2\u003e \u003cp\u003eWe assessed FA diagnosis and the severity of FA using the Yale Food Addiction Scale 2.0 (YFAS 2.0) (original version [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; French validation[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]). This self-administered questionnaire assesses addictive-like symptoms of eating high in fat and or sugar foods (especially highly processed) during the past 12 months, based on DSM-5 criteria for substance use disorder. The YFAS can be used both as a severity scale and a diagnostic scale with a dichotomous rating according to specifically defined cut-offs [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this study, we assessed both the existence of a FA diagnosis as well as the number of FA symptoms experienced during the previous 12 months (score ranging from 0 to 11). In our study, Cronbach\u0026rsquo;s α was excellent at .96.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Cognitive emotion regulation strategies\u003c/h2\u003e \u003cp\u003eWe assessed emotion regulation strategies using the French version of the Cognitive Emotional Regulation Questionnaire (CERQ) (original version : [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]; French validation : [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]). The CERQ is a self-report questionnaire evaluating nine distinct emotional regulation strategies in response to an adverse event [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A higher score reflects a more frequent use of this type of emotional strategy. These nine strategies were regrouped by the original authors as adaptive (acceptance, positive refocusing, refocus on planning, positive reappraisal, putting into perspective) or non-adaptive (self-blame, rumination, catastrophizing, blaming others). In our study, Cronbach\u0026rsquo;s α for the Adaptive subscore was .91, and .85 for the non-adaptive subscore.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Emotion regulation difficulties\u003c/h2\u003e \u003cp\u003eWe assessed emotion regulation difficulties using the French version of Difficulty in Emotion Regulation Scale (DERS-16) (original long version : [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]; original short version : [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]; French validation :[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]). In this study, we used total DERS score as indicator of emotion regulation difficulties, a higher score indicating more difficulty in regulating emotions Cronbach\u0026rsquo;s α was excellent at .94.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.5 Alexithymia\u003c/h2\u003e \u003cp\u003eWe assessed alexithymia using the Toronto alexithymia scale (TAS-20) (Original version : [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] French validation : [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]). The TAS-20 provides a total score and three sub-scores: difficulty identifying emotions, difficulty describing emotions and operational thinking. A higher total score on the TAS-20 indicates higher alexithymia. In our study, Cronbach\u0026rsquo;s α for the total TAS-20 score was good at .85. More specifically, Cronbach\u0026rsquo;s α was at .76 for the subscale difficulty identifying emotions, .78 for difficulty describing emotions and .53 for operational thinking.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.2.6 Cognitive inhibition, and attentional bias toward Food and negative emotional stimuli\u003c/h2\u003e \u003cp\u003eParticipants cognitive inhibition and attentional biases were assessed using a neuropsychological assessment that included a Stroop task (Color-Word Interference Test) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and an emotional Stroop task [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] specifically designed for this study with evaluation of attentional bias toward negative emotional stimuli and food stimuli (the detailed procedure is available in the Supplemental Material A). The Stroop task enables the calculation of a difference in mean response time in congruent conditions (words written in the corresponding color) and non-congruent conditions (words written in a non-corresponding color) which reflect the ability to suppress contradictory information (e.g., the written word meaning). The emotional Stroop task enables the calculation of a difference in mean response time in emotional condition (food-related stimuli and emotion-related stimuli) and in mean response time in neutral condition, which reflect the ability to suppress emotional related information.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the JASP 0.17.3 software. All analyses were two-tailed; p-values\u0026thinsp;\u0026lt;\u0026thinsp;.05 were considered statistically significant. Missing data were excluded from the analysis. Descriptive statistics included percentages for ordinal variables and means and standard deviations for continuous variables.\u003c/p\u003e \u003cp\u003eTo test our main hypothesis, we used ANOVA tests or Kruskal-Wallis tests (according to Levene homoscedasticity test) to compare the three groups (patients with FA and obesity, patients with obesity and without FA, control group). Dependent variable was the group type, and independent variables were sociodemographic characteristics, CERQ sub-score, DERS total score, TAS total score and sub-scores, Stroop effect (cognitive inhibition measured by the difference in mean response time between congruent and non-congruent condition at the Stroop task), food valence (attentional bias toward food measured by the difference in mean response time between food related stimuli task and neutral stimuli at the emotional Stroop task) and emotional valence (attentional bias toward emotional stimuli measured by difference in mean response time between negative emotional stimuli and neutral stimuli at the emotional Stroop task).\u003c/p\u003e \u003cp\u003eTo test our secondary hypotheses, we used ANOVA tests or Kruskal-Wallis tests (depending on the results of Levene homoscedasticity test) when the independent variables were continuous, and we used chi-squared tests when the independent variables were ordinal. To assess the significant difference of Stroop effect, Food valence and Emotional valence tasks compared to a neutral reaction (mean reaction time would thus be equal to 0), we used a Wilcoxon-Mann-Whitney test with the null hypothesis being \u0026ldquo;there was no difference between the two respective conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Ethics\u003c/h2\u003e \u003cp\u003eThis study has been approved by the institutional review board of the University Hospital of Tours (N\u0026deg;:2022_028) for the clinical population and by the institutional review board of the University and Tours and Poitiers (Comit\u0026eacute; d\u0026rsquo;\u0026Eacute;thique pour les Recherches sur la Personne Tours- Poitiers) (CER-TP 2022-09-01), prior to the beginning of the study. All procedures were performed in accordance with the ethical standards of the national and institutional research committee as well as with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All participants provided informed consent after the procedure had been fully explained and prior to their inclusion in the study. All collected data were in line with the French recommendation regarding use of personal data, with the approval of the French \u0026ldquo;Commission Nationale de l\u0026rsquo;Informatique et des Libert\u0026eacute;s\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 Study flow chart\u003c/h2\u003e\n \u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the study flow chart. Among the eligible persons in the patient group n\u0026thinsp;=\u0026thinsp;50), four patients refused to participate, nine presented an exclusion criterion. Among the eligible persons in the control group, one control presented an exclusion criterion. This led to a total sample of 74 included participants (i.e., 37 patients and 37 controls).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 Descriptive statistics\u003c/h2\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003e3.2.1 Sociodemographic and medical characteristics\u003c/h2\u003e\n \u003cp\u003eThe sociodemographic and medical characteristics of our sample are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Mean age was 40.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1; Mean BMI was 32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9 kg/m\u003csup\u003e2\u003c/sup\u003e. 74.3% % (55) of participants were female.\u003c/p\u003e\n \u003cp\u003e(Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n \u003ch2\u003e3.2.2 Cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia\u003c/h2\u003e\n \u003cp\u003eEmotion regulation specificities and alexithymia are presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. For the patient group, concerning cognitive emotion regulation strategy use, mean use of adaptive emotional regulation strategy was 61.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6 for the OB\u0026thinsp;+\u0026thinsp;FA-; 52.72\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0 for the OB\u0026thinsp;+\u0026thinsp;FA+. Mean use of non-adaptive emotional regulation strategy was 33.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 for the OB\u0026thinsp;+\u0026thinsp;FA- and 41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 for the OB\u0026thinsp;+\u0026thinsp;FA+. Concerning emotion regulation difficulties, mean total DERS score was 25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4 for the OB\u0026thinsp;+\u0026thinsp;FA- and 30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9 for the OB\u0026thinsp;+\u0026thinsp;FA. Concerning alexithymia, mean alexithymia intensity was 50.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4 for the OB\u0026thinsp;+\u0026thinsp;FA- and 55.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0 for the OB\u0026thinsp;+\u0026thinsp;FA+.\u003c/p\u003e\n \u003cp\u003eFor the control group, concerning cognitive emotion regulation strategy use, mean use of adaptive emotional regulation strategy was 63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0. Mean use of non-adaptive emotional regulation strategy was 36.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2. Concerning emotion regulation difficulties, mean total DERS score was 15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6. Mean alexithymia score was 44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003e3.2.3 Attentional bias and cognitive inhibition\u003c/h2\u003e\n \u003cp\u003eResults of the neuropsychological assessments are presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Concerning attentional bias, mean Emotional Valence in the whole sample was \u0026minus;\u0026thinsp;1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0 ms; it did not significatively differ from 0 (p\u0026thinsp;=\u0026thinsp;.35). Mean Food Valence was 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 ms; it did not significatively differ from 0 (p\u0026thinsp;=\u0026thinsp;.35). Concerning cognitive inhibition, mean Stroop Effect was 10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 ms; it significatively differed from 0 (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Comparison between the three groups in univariate analyses\u003c/h2\u003e\n \u003cp\u003e(Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.1 Socio-demographics characteristics\u003c/h2\u003e\n \u003cp\u003eOur subgroups presented significant differences in terms of age (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), BMI (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), gender (p\u0026thinsp;=\u0026thinsp;0,02), professional status (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and FA symptoms (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.2 Cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia\u003c/h2\u003e\n \u003cp\u003eIn terms of main effects, univariate analyses showed differences between adaptive emotional regulation strategy and non-adaptive emotional regulation strategy between the three groups (significant main effects with p\u0026thinsp;=\u0026thinsp;0.03 and p\u0026thinsp;=\u0026thinsp;0.05, respectively), as well as significant differences in terms of difficulties in emotion regulation (p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and alexithymia (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003cp\u003eOur primary objective are illustrated in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e (comparison between OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;and OB\u0026thinsp;+\u0026thinsp;FA - patients), we found that OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;patients reported significantly less frequently the use of refocus on planning (p\u0026thinsp;=\u0026thinsp;.04), and more frequently the use of catastrophizing (p\u0026thinsp;=\u0026thinsp;.02) and positive refocusing (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) than OB\u0026thinsp;+\u0026thinsp;FA - patients. The two groups did not differ in terms of other cognitive emotion regulation strategies. The OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;group did not differ from the OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; group in terms of difficulty in emotion regulation (p\u0026thinsp;=\u0026thinsp;.44) or in terms of alexithymia (p\u0026thinsp;=\u0026thinsp;.29). When considering either all adaptive or all non-adaptive emotion regulation strategies altogether, post-hoc analyses showed that the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;subgroup used more frequently non-adaptive emotional regulation strategies than the OB- FA+ (p\u0026thinsp;=\u0026thinsp;.02) but no significant differences were observed in terms of use of adaptive emotional regulation strategies (p\u0026thinsp;=\u0026thinsp;.06).\u003c/p\u003e\n \u003cp\u003eTo answer our secondary objective (comparison between persons with obesity versus without obesity), we found that both patients from the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;and OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; groups reported significant higher difficulties in emotion regulation, higher alexithymia and different use of some cognitive emotion regulation strategies than the normal weight group, namely lower refocus on planning, higher use of blaming others and lower self-blame. Patients from the three groups did not differ in terms of the other cognitive emotion regulation strategies, namely acceptance, positive reappraisal, putting into perspective, or rumination. When considering either all adaptive or non-adaptive emotion regulation strategies altogether, post-hoc analyses showed no significant differences in terms of non-adaptive strategies between the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;and OB \u0026ndash; FA \u0026ndash; subgroups (p\u0026thinsp;=\u0026thinsp;.06) or between the OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; and OB \u0026ndash; FA \u0026ndash; subgroups (p\u0026thinsp;=\u0026thinsp;.40); there were no significant differences in terms of adaptive strategies between the OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; and the OB \u0026ndash; FA \u0026ndash; subgroups (p\u0026thinsp;=\u0026thinsp;.68), but a lower use of adaptive strategies in the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;subgroup when compared to the OB \u0026ndash; FA \u0026ndash; subgroup (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.3 Cognitive inhibition and attentional biases toward Food or negative emotional stimuli\u003c/h2\u003e\n \u003cp\u003eThere were no significant differences in attentional biases between the three subgroups both in terms of attentional bias toward negative emotional stimuli (Emotional valence were respectively 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9, -3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0, -1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 for the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;group, OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; group and OB- FA \u0026ndash; group; p\u0026thinsp;=\u0026thinsp;0.44) and attentional bias toward food stimuli (mean Food valence were respectively 0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8, 2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6, 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 for the OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;group, OB\u0026thinsp;+\u0026thinsp;FA \u0026ndash; group and OB- FA \u0026ndash; group; p\u0026thinsp;=\u0026thinsp;0.91). There were no significant differences in Cognitive inhibition between the sub-groups (p\u0026thinsp;=\u0026thinsp;0.97).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eOur study main result was that among patients with obesity, having a FA was associated with some specific cognitive emotional regulation strategies (CERQ scores): less refocus on planning, more catastrophizing, and more positive refocusing. Counterintuitively, patients with obesity and FA did not differ from those without FA in terms of emotion regulation difficulties (DERS score) or alexithymia (TAS-20 scores). Emotion regulation difficulties and two dimensions of alexithymia (i.e., difficulties in identifying and in describing emotions) were associated with having an obesity rather than with FA. Finally, we found no significant differences between our three groups of patients in terms of attentional bias toward food or negative emotional stimuli and cognitive inhibition.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, our study was the first to explore cognitive emotion regulation strategies and its association with FA in patients with obesity. We found that among patients with obesity, having a FA was associated with two non-adaptive cognitive emotion regulation strategies: less refocus on planning and more catastrophizing. Previous study in obese sample also found similar variation of refocus on planning use and catastrophizing variation according to BMI without accounting for FA [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Catastrophizing has been shown to be the the sole cognitive strategy associated with binge eating disorder [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. More catastrophizing and less refocus on planning may in fact be due to the same psychopathological mechanism: a cognitive avoidance of the thoughts associated with the exposition to negative events (i.e., catastrophizing refers to the terror of the experience related to negative events) as well as cognitive avoidance of the anticipation of the exposition to these events (i.e., refocus on planning refers to thinking about what steps to take in order to deal with the negative event). In both cases, the thoughts associated with the \u003cem\u003eexposition\u003c/em\u003e or \u003cem\u003eanticipation of\u003c/em\u003e the exposition to negative events may overtake the adaptative capacities of one\u0026rsquo;s individual and may lead to more cognitive avoidance, thus impeding the patient\u0026rsquo;s perceived self-efficacy to cope with all types of negative events. Our results are compatible with classical models of binge eating, namely some parts of the escape theory of binge eating (which postulates that some persons may develop binge eating because of a desire to escape from self-awareness; in this case, escape from self-awareness specifically related to negative events) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and the emotion regulation model of binge eating (which posits that patients with Binge Eating Disorder have deficits in emotion regulation processes and difficulty in regulating their negative emotions, binge eating being a way to cope with these emotions and to find relief) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn FA, eating highly palatable foods may be one effective (short-term) coping strategy to avoid negative thoughts or negative emotions associated with the exposition (real or anticipated) to the thoughts associated with negative events meaning that FA is associated with cognitive avoidance toward negative events.\u003c/p\u003e \u003cp\u003eIn our study, we found that the other non-adaptive strategies (i.e., rumination, self-blame, blaming others) were not associated with FA. Studies conducted in patients with other addictive disorders found divergent associations with non-adaptive emotions (i.e., more frequent use of self-blame and blaming others) [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. While these divergent results may be explained by the differences in included population; it may be due to a difference in nature of the cognitive emotion regulation strategies assessed: self-blame and blaming others refer to the attribution style of a person toward negative events ; catastrophizing and refocus on planning refer to a direct cognitive exposition to negative affective state or experience, which the patient with FA may try to avoid (avoiding self-awareness, as proposed in the escape theory of binge eating) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In line with these findings, we may assume that FA may be more strongly linked to thoughts associated with the direct affective exposition to negative events rather than to indirect affective exposition such as attribution theory.\u003c/p\u003e \u003cp\u003eSurprisingly, having a FA was associated with one adaptive strategy: more use of positive refocusing. Similar use of this strategy has also been demonstrated in patients with gambling disorder [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo hypotheses may be proposed: as proposed by Ruiz de Lara, the short term efficacy of the strategies may reinforce biased beliefs about the outcomes of the addictive behavior (in the case of gambling, beliefs about gambling outcomes and controllability; in the case of food, biased beliefs about the positive outcomes of eating) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Another explanation could be that in this case positive refocusing is a mean to avoid the exposition to thoughts and affect associated with negative events and these questions the adaptive nature of this cognitive strategy. When overused, positive refocusing might be another facet of lower focus on planning: cognitive avoidance toward negative events.\u003c/p\u003e \u003cp\u003eAnother interesting result of our study was that in our sample patients with obesity presented more difficulty in emotion regulation (DERS total score) than controls regardless of the presence of FA. These results are in line with complementary work showing that in general population, people at high FA risk (without accounting for BMI) or with a higher BMI (without accounting for FA) show more difficulty in emotion regulation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A precedent work in pre-bariatric sample showed that people with obesity and FA presented more difficulty in emotion regulation that people with obesity without FA [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Altogether these results are in line with a separate association of obesity and FA to difficulty in emotion regulation with stronger relative association strength between obesity and difficulty in emotion regulation and advocate for specific work measuring relative correlation association on the subject. As observed for emotion regulation difficulties, patients with obesity had higher alexithymia than controls, without a significative difference between patients with or without FA. The association between obesity and alexithymia is in line with the literature as patient with obesity presented more alexithymia especially more difficulty in identifying emotions and an externally oriented thinking style [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Li et al. work found a significant correlation between alexithymia and FA severity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Altogether theses works show that alexithymia may be more closely linked to obesity than to FA and as such may not be a direct therapeutic target when focusing FA. As our sample was constituted of patients with severe obesity (mean BMI was 45.6 and 39.9 in our FA and non-FA samples), future studies should be conducted in patients with less severe obesity before we may generalize our findings to the broader population of patients with obesity.\u003c/p\u003e \u003cp\u003eIn our study, cognitive inhibition was not specifically altered in OB\u0026thinsp;+\u0026thinsp;FA\u0026thinsp;+\u0026thinsp;when measured by the Stroop task. These results are in line with precedent studies in similar populations [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]: although literature is heterogenous, FA was not specifically associated with cognitive inhibition deficit in obese patients, and results from cross-sectional and longitudinal studies support the idea that inhibition deficits may be more due to obesity than FA [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This show a difference between FA and substance use disorders in which there seems to be a causal association between inhibition control deficit and the onset of chronic substance use [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Our work failed to demonstrate a specific attentional bias toward neither food nor negative emotion stimuli in patients with obesity and FA which. A precedent work using image cues showed a preference toward unhealthy food cues population of patient with FA without obesity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] no other work explored attentional bias toward negative emotion in comparable population to our knowledge. We may assume that the deficits in emotion regulation observed in patients with obesity and FA may be more linked to explicit emotion regulation (i.e., as assessed by the CERQ) than implicit emotion regulation (as assessed by the Stroop and emotional Stroop task).\u003c/p\u003e \u003cp\u003eAlthough our study provided some insights into the association between FA, emotion regulation and obesity, it had some methodological limitations. First, our samples sizes were small to moderate, and this could have led to non-significant results due to a lack of statistical power. This limitation underscores the statistical significance of our positive results such as association between FA status and use of maladaptive cognitive emotional regulation strategy. Second, our control population presented significant socio-demographic differences with our clinical population that could have led to a confusion bias which may have been explained by our recruitment method for the control group (i.e., university members and students), with the recruitment of younger persons with higher employment rate and higher level of education. Of note, there was, however, no correlation between age and cognitive emotion regulation strategy. Thirdly, the cross-sectional nature of our study precludes us from demonstrating a causal relationship between emotional regulation strategy and FA. To demonstrate whether these cognitive emotion regulation strategies happen before, during or after the onset of FA, prospective studies are warranted.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study has some clinical implications. Firstly, it demonstrates the need to explore emotion regulation mechanism in patients with FA through different and complementary methods such as cognitive emotion regulation (that can be reliably assessed using the CERQ), difficulties in emotion regulation (DERS), difficulties in identifying and describing emotions (TAS-20) and neuropsychological measures. Secondly, it brings support for the use of the CERQ, a self-administered tool rarely used in the field of addictive and eating disorder, but that may be contributive to explore the cognitive emotion regulation specificities in patients with obesity and FA. It brings insight into emotion regulation aspects that may be linked to obesity itself (i.e., higher alexithymia and higher difficulties in emotion regulation) and emotion regulation aspects that may be associated more specifically to FA and that may be specific targets (i.e., some specific cognitive emotion regulation strategies). In sum, our results are compatible with the hypothesis of a specific cognitive avoidance toward the exposition to negative emotions and its associated events in patients with obesity and FA. Therapeutic implications that may be helpful in these patients may include the use of psychotherapy to increase the patient\u0026rsquo;s perceived self-efficacy toward the exposition or anticipation of exposition to these emotionally charged events (i.e., Cognitive behavioral therapy including Acceptment \u0026amp; Commitment Therapy and Dialectical behavioral therapy, but also the use of pharmacological).\u003c/p\u003e \u003cp\u003eIn summary, our study demonstrates that the presence of FA among patients with obesity is associated with specific cognitive emotion regulation strategies but not with attentional biases toward food or negative emotion stimuli. Our study also adds to the knowledge of the links between obesity, emotion regulation difficulties, alexithymia, and cognitive inhibition or attentional biases toward food or negative emotion stimuli as assessed per the classical and emotional Stroop task. It confirms the reliability of the DERS and the TAS-20 to evaluate such deficits in patients with obesity and suggests that emotion regulation and cognitive strategy for emotion regulation may be potential therapeutic targets for FA as already demonstrated in patients with substance use disorder, for which psychotherapy targeting emotional regulation such as Dialectical behavioral therapy showed good efficacy [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Cognitive behavioral therapy based approach including emotion regulation ability and cognitive strategy restructuration may be a promising treatment in obese patients with FA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study has been approved by the institutional review board of the University Hospital of Tours (N\u0026deg;:2022_028) for the clinical population and by the institutional review board of the University and Tours and Poitiers (Comit\u0026eacute; d\u0026rsquo;\u0026Eacute;thique pour les Recherches sur la Personne Tours- Poitiers) (CER-TP 2022-09-01), prior to the beginning of the study.\u003c/p\u003e\n\u003cp\u003eAll procedures were performed in accordance with the ethical standards of the national and/or institutional research committee as well as with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants provided informed consent after the procedure had been fully explained and prior to their inclusion in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll collected data were in line with the French recommendation regarding use of personal data, with the approval of the French \u0026ldquo;Commission Nationale de l\u0026rsquo;Informatique et des Libert\u0026eacute;s\u0026rdquo; (CNIL).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eConsent for publication\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eCompeting interests\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eFunding\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLM: Conceptualization; Methodology ; Formal analysis; Investigation; Writing - Original Draft \u0026nbsp;\u003cbr\u003e\u0026nbsp;AS Methodology ; Resources; Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;MR Writing - Original Draft ; Validation\u003cbr\u003e\u0026nbsp;ADL Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;FK Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;SB Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;NB Resources ; Supervision ; Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;BG Supervision; Writing - Review \u0026amp; Editing\u003cbr\u003e\u0026nbsp;PB Conceptualization; Methodology ; Formal analysis; Validation; Resources; Writing - Original Draft\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003ch2\u003eAcknowledgements\u003c/h2\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld health statistics 2023: monitoring health for the SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO n.d.\u003c/li\u003e\n\u003cli\u003eAbdelaal M, le Roux CW, Docherty NG. Morbidity and mortality associated with obesity. Ann Transl Med 2017;5:161. https://doi.org/10.21037/atm.2017.03.107.\u003c/li\u003e\n\u003cli\u003eSimon GE, Von Korff M, Saunders K, Miglioretti DL, Crane PK, van Belle G, et al. Association Between Obesity and Psychiatric Disorders in the US Adult Population. Archives of General Psychiatry 2006;63:824\u0026ndash;30. https://doi.org/10.1001/archpsyc.63.7.824.\u003c/li\u003e\n\u003cli\u003ePi-Sunyer X. The Medical Risks of Obesity. Postgraduate Medicine 2009;121:21\u0026ndash;33. https://doi.org/10.3810/pgm.2009.11.2074.\u003c/li\u003e\n\u003cli\u003eNCD Global Monitoring Framework n.d. https://www.who.int/publications-detail-redirect/ncd-surveillance-global-monitoring-framework (accessed March 7, 2024).\u003c/li\u003e\n\u003cli\u003eSafaei M, Sundararajan EA, Driss M, Boulila W, Shapi\u0026rsquo;i A. A systematic literature review on obesity: Understanding the causes \u0026amp; consequences of obesity and reviewing various machine learning approaches used to predict obesity. Computers in Biology and Medicine 2021;136:104754. https://doi.org/10.1016/j.compbiomed.2021.104754.\u003c/li\u003e\n\u003cli\u003eGearhardt AN, Schulte EM. Is Food Addictive? A Review of the Science. Annu Rev Nutr 2021. https://doi.org/10.1146/annurev-nutr-110420-111710.\u003c/li\u003e\n\u003cli\u003eLipsky LM, Cummings JR, Haynie DL, Nansel TR. The burden of overweight/obesity and weight-related behaviors attributable to food addiction in emerging adults. Appetite 2024;199:107399. https://doi.org/10.1016/j.appet.2024.107399.\u003c/li\u003e\n\u003cli\u003ePraxedes DRS, Silva-J\u0026uacute;nior AE, Macena ML, Oliveira AD, Cardoso KS, Nunes LO, et al. Prevalence of food addiction determined by the Yale Food Addiction Scale and associated factors: A systematic review with meta-analysis. European Eating Disorders Review 2022;30:85\u0026ndash;95. https://doi.org/10.1002/erv.2878.\u003c/li\u003e\n\u003cli\u003eGearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale Food Addiction Scale. Appetite 2009;52:430\u0026ndash;6. https://doi.org/10.1016/j.appet.2008.12.003.\u003c/li\u003e\n\u003cli\u003eAhmadkaraji S, Farahani H, Orfi K, Fathali Lavasani F. Food addiction and binge eating disorder are linked to shared and unique deficits in emotion regulation among female seeking bariatric surgery. J Eat Disord 2023;11:97. https://doi.org/10.1186/s40337-023-00815-x.\u003c/li\u003e\n\u003cli\u003eLeppanen J, Brown D, McLinden H, Williams S, Tchanturia K. The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach. Frontiers in Psychiatry 2022;13.\u003c/li\u003e\n\u003cli\u003eWeiss NH, Kiefer R, Goncharenko S, Raudales AM, Forkus SR, Schick MR, et al. Emotion regulation and substance use: A meta-analysis. Drug and Alcohol Dependence 2022;230:109131. https://doi.org/10.1016/j.drugalcdep.2021.109131.\u003c/li\u003e\n\u003cli\u003eKhantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 1985;142:1259\u0026ndash;64. https://doi.org/10.1176/ajp.142.11.1259.\u003c/li\u003e\n\u003cli\u003eEst\u0026eacute;vez A, J\u0026aacute;uregui P, S\u0026aacute;nchez-Marcos I, L\u0026oacute;pez-Gonz\u0026aacute;lez H, Griffiths MD. Attachment and emotion regulation in substance addictions and behavioral addictions. J Behav Addict n.d.;6:534\u0026ndash;44. https://doi.org/10.1556/2006.6.2017.086.\u003c/li\u003e\n\u003cli\u003eTarter RE, Kirisci L, Mezzich A, Cornelius JR, Pajer K, Vanyukov M, et al. Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. Am J Psychiatry 2003;160:1078\u0026ndash;85. https://doi.org/10.1176/appi.ajp.160.6.1078.\u003c/li\u003e\n\u003cli\u003eIvanov I, Schulz KP, London ED, Newcorn JH. Inhibitory control deficits in childhood and risk for substance use disorders: a review. Am J Drug Alcohol Abuse 2008;34:239\u0026ndash;58. https://doi.org/10.1080/00952990802013334.\u003c/li\u003e\n\u003cli\u003eMoffitt TE, Arseneault L, Belsky D, Dickson N, Hancox RJ, Harrington H, et al. A gradient of childhood self-control predicts health, wealth, and public safety. Proc Natl Acad Sci U S A 2011;108:2693\u0026ndash;8. https://doi.org/10.1073/pnas.1010076108.\u003c/li\u003e\n\u003cli\u003eGross JJ. Handbook of Emotion Regulation, Second Edition. Guilford Publications; 2013.\u003c/li\u003e\n\u003cli\u003eWillem C, Gandolphe M-C, Roussel M, Verkindt H, Pattou F, Nandrino J-L. Difficulties in emotion regulation and deficits in interoceptive awareness in moderate and severe obesity. Eat Weight Disord 2019;24:633\u0026ndash;44. https://doi.org/10.1007/s40519-019-00738-0.\u003c/li\u003e\n\u003cli\u003eFernandes J, Ferreira-Santos F, Miller K, Torres S. Emotional processing in obesity: a systematic review and exploratory meta-analysis: Emotional processing in obesity. Obesity Reviews 2018;19:111\u0026ndash;20. https://doi.org/10.1111/obr.12607.\u003c/li\u003e\n\u003cli\u003eHendrikse JJ, Cachia RL, Kothe EJ, McPhie S, Skouteris H, Hayden MJ. Attentional biases for food cues in overweight and individuals with obesity: a systematic review of the literature. Obesity Reviews 2015;16:424\u0026ndash;32. https://doi.org/10.1111/obr.12265.\u003c/li\u003e\n\u003cli\u003eBrunault P, Ducluzeau P-H, Courtois R, Bourbao-Tournois C, Delbachian I, R\u0026eacute;veill\u0026egrave;re C, et al. Food Addiction is Associated with Higher Neuroticism, Lower Conscientiousness, Higher Impulsivity, but Lower Extraversion in Obese Patient Candidates for Bariatric Surgery. Subst Use Misuse 2018;53:1919\u0026ndash;23. https://doi.org/10.1080/10826084.2018.1433212.\u003c/li\u003e\n\u003cli\u003eLi R, Kajanoja J, Tuulari JJ, Karlsson L, Karlsson H, Karukivi M. Relationships between alexithymia and food addiction: The Finnish version of Yale Food Addiction Scale and preliminary test of its psychometric properties. Front Psychol 2023;14:1067872. https://doi.org/10.3389/fpsyg.2023.1067872.\u003c/li\u003e\n\u003cli\u003eFrayn M, Sears CR, von Ranson KM. A sad mood increases attention to unhealthy food images in women with food addiction. Appetite 2016;100:55\u0026ndash;63. https://doi.org/10.1016/j.appet.2016.02.008.\u003c/li\u003e\n\u003cli\u003ePeirce J, Gray JR, Simpson S, MacAskill M, H\u0026ouml;chenberger R, Sogo H, et al. PsychoPy2: Experiments in behavior made easy. Behav Res 2019;51:195\u0026ndash;203. https://doi.org/10.3758/s13428-018-01193-y.\u003c/li\u003e\n\u003cli\u003eBrunault P, Courtois R, Gearhardt AN, Gaillard P, Journiac K, Cathelain S, et al. Validation of the French Version of the DSM-5 Yale Food Addiction Scale in a Nonclinical Sample. Can J Psychiatry 2017;62:199\u0026ndash;210. https://doi.org/10.1177/0706743716673320.\u003c/li\u003e\n\u003cli\u003eGearhardt AN, Corbin WR, Brownell KD. Development of the Yale Food Addiction Scale Version 2.0. Psychology of Addictive Behaviors 2016;30:113\u0026ndash;21. https://doi.org/10.1037/adb0000136.\u003c/li\u003e\n\u003cli\u003eGarnefski N, Kraaij V, Spinhoven P. Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences 2001;30:1311\u0026ndash;27. https://doi.org/10.1016/S0191-8869(00)00113-6.\u003c/li\u003e\n\u003cli\u003eJermann F, Van der Linden M, D\u0026rsquo;acremont M, Acremont, Zermatten A. Cognitive Emotion Regulation Questionnaire (CERQ): Confirmatory Factor Analysis and Psychometric Properties of the French Translation. European Journal of Psychological Assessment 2006;22:126\u0026ndash;31. https://doi.org/10.1027/1015-5759.22.2.126.\u003c/li\u003e\n\u003cli\u003eGratz KL, Roemer L. Multidimensional Assessment of Emotion Regulation and Dysregulation: Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment 2004;26:41\u0026ndash;54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94.\u003c/li\u003e\n\u003cli\u003eBjureberg J, Lj\u0026oacute;tsson B, Tull MT, Hedman E, Sahlin H, Lundh L-G, et al. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. J Psychopathol Behav Assess 2016;38:284\u0026ndash;96. https://doi.org/10.1007/s10862-015-9514-x.\u003c/li\u003e\n\u003cli\u003eC\u0026ocirc;t\u0026eacute; G, Gosselin P, Dagenais I. \u0026Eacute;valuation multidimensionnelle de la r\u0026eacute;gulation des \u0026eacute;motions : propri\u0026eacute;t\u0026eacute;s psychom\u0026eacute;triques d\u0026rsquo;une version francophone du Difficulties in Emotion Regulation Scale. Journal de Th\u0026eacute;rapie Comportementale et Cognitive 2013;23:63\u0026ndash;72. https://doi.org/10.1016/j.jtcc.2013.01.005.\u003c/li\u003e\n\u003cli\u003eBagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23\u0026ndash;32. https://doi.org/10.1016/0022-3999(94)90005-1.\u003c/li\u003e\n\u003cli\u003eLoas G, Fremaux D, Marchand MP. \u0026Eacute;tude de la structure factorielle et de la coh\u0026eacute;rence interne de la version fran\u0026ccedil;aise de l\u0026rsquo;\u0026eacute;chelle d\u0026rsquo;alexithymie de Toronto \u0026agrave; 20 items (TAS-20) chez un groupe de 183 sujets sains. [The factorial structure and internal consistency of the French version of the 20-item Toronto Alexithymia Scale (TAS-20): A study among 183 normal subjects.]. L\u0026rsquo;Enc\u0026eacute;phale: Revue de Psychiatrie Clinique Biologique et Th\u0026eacute;rapeutique 1995;21:117\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eStroop JR. Studies of interference in serial verbal reactions. Journal of Experimental Psychology 1935;18:643\u0026ndash;62. https://doi.org/10.1037/h0054651.\u003c/li\u003e\n\u003cli\u003eMathews A, MacLeod C. Selective processing of threat cues in anxiety states. Behaviour Research and Therapy 1985;23:563\u0026ndash;9. https://doi.org/10.1016/0005-7967(85)90104-4.\u003c/li\u003e\n\u003cli\u003eWilliams JM, Mathews A, MacLeod C. The emotional Stroop task and psychopathology. Psychol Bull 1996;120:3\u0026ndash;24. https://doi.org/10.1037/0033-2909.120.1.3.\u003c/li\u003e\n\u003cli\u003eWalenda A, Bogusz K, Kopera M, Jakubczyk A, Wojnar M, Kucharska K. Emotion regulation in binge eating disorder. Psychiatr Pol 2021;55:1433\u0026ndash;48. https://doi.org/10.12740/PP/OnlineFirst/122212.\u003c/li\u003e\n\u003cli\u003eHeatherton TF, Baumeister RF. Binge eating as escape from self-awareness. Psychol Bull 1991;110:86\u0026ndash;108. https://doi.org/10.1037/0033-2909.110.1.86.\u003c/li\u003e\n\u003cli\u003eLeehr EJ, Krohmer K, Schag K, Dresler T, Zipfel S, Giel KE. Emotion regulation model in binge eating disorder and obesity - a systematic review. Neuroscience \u0026amp; Biobehavioral Reviews 2015;49:125\u0026ndash;34. https://doi.org/10.1016/j.neubiorev.2014.12.008.\u003c/li\u003e\n\u003cli\u003eNavas JF, Verdejo-Garc\u0026iacute;a A, L\u0026Oacute;pez-G\u0026Oacute;mez M, Maldonado A, Perales JC. Gambling with Rose-Tinted Glasses on: Use of Emotion-Regulation Strategies Correlates with Dysfunctional Cognitions in Gambling Disorder Patients. J Behav Addict 2016;5:271\u0026ndash;81. https://doi.org/10.1556/2006.5.2016.040.\u003c/li\u003e\n\u003cli\u003eKalantarkousheh SM, Doostian Y, Godini AA, Aazami Y. Cognitive Emotion Regulation Strategies among Regular Persons and Participants in Methadone or Narcotics Anonymous Treatment Programs. Studies in Social Sciences and Humanities 2015;2:131\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRuiz de Lara CM, Navas JF, Perales JC. The paradoxical relationship between emotion regulation and gambling-related cognitive biases. PLoS One 2019;14:e0220668. https://doi.org/10.1371/journal.pone.0220668.\u003c/li\u003e\n\u003cli\u003eInnamorati M, Imperatori C, Harnic D, Erbuto D, Patitucci E, Janiri L, et al. Emotion Regulation and Mentalization in People at Risk for Food Addiction. Behav Med 2017;43:21\u0026ndash;30. https://doi.org/10.1080/08964289.2015.1036831.\u003c/li\u003e\n\u003cli\u003eBlume M, Schmidt R, Hilbert A. Executive Functioning in Obesity, Food Addiction, and Binge-Eating Disorder. Nutrients 2018;11. https://doi.org/10.3390/nu11010054.\u003c/li\u003e\n\u003cli\u003eRodrigue C, Ouellette A-S, Lemieux S, Tchernof A, Biertho L, B\u0026eacute;gin C. Executive functioning and psychological symptoms in food addiction: a study among individuals with severe obesity. Eat Weight Disord 2018;23:469\u0026ndash;78. https://doi.org/10.1007/s40519-018-0530-1.\u003c/li\u003e\n\u003cli\u003eFavieri F, Forte G, Casagrande M. The Executive Functions in Overweight and Obesity: A Systematic Review of Neuropsychological Cross-Sectional and Longitudinal Studies. Frontiers in Psychology 2019;10.\u003c/li\u003e\n\u003cli\u003eStephan RA, Alhassoon OM, Allen KE, Wollman SC, Hall M, Thomas WJ, et al. Meta-analyses of clinical neuropsychological tests of executive dysfunction and impulsivity in alcohol use disorder. The American Journal of Drug and Alcohol Abuse 2017;43:24\u0026ndash;43. https://doi.org/10.1080/00952990.2016.1206113.\u003c/li\u003e\n\u003cli\u003eFigueiredo PR, Tolomeo S, Steele JD, Baldacchino A. Neurocognitive consequences of chronic cannabis use: a systematic review and meta-analysis. Neuroscience \u0026amp; Biobehavioral Reviews 2020;108:358\u0026ndash;69. https://doi.org/10.1016/j.neubiorev.2019.10.014.\u003c/li\u003e\n\u003cli\u003eAzizi A, Borjali A, Golzari M. The Effectiveness of Emotion Regulation Training and Cognitive Therapy on the Emotional and Addictional Problems of Substance Abusers. Iran J Psychiatry 2010;5:60\u0026ndash;5.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Descriptive statistics of our study sample regarding sociodemographic and medical characteristics, and comparison between the three groups in univariate analyses\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete sample (n=74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB+ FA+ Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB+ FA- Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N= 19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB- FA- Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ statistics for Pair-wise comparaison (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eOB+ FA+ vs. OB+ FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eOB+ FA-\u0026nbsp;vs. OB- FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eOB+ FA+ vs. OB- FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e40.0\u0026plusmn;14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e41.1\u0026plusmn;16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e48.4\u0026plusmn;12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e35.1\u0026plusmn;12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1.6(.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e3.3(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e1.4(.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (Kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e32.9\u0026plusmn;13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e45.6\u0026plusmn;7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e39.9\u0026plusmn;7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e23.1\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e-0.6(.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e5.8(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e6.3(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (Female)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e74.3% (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e100 % (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e63.2% (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e67.6% (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamilial status\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(relationship)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e64.9% (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e50\u0026nbsp;% (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e69.6\u0026nbsp;% (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e75.7% (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional status\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(employed)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e64.9% (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e44.4% (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e42.1% (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e86.5% (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of FA symptoms (YFAS 2.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e2.8\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.3\u0026plusmn;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e2.5\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e.8\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e-3.6(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e2.3(.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e6.5(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. Continuous variables were compared between the three groups using ANOVA test or Kruskal Wallis test depending on the Levene test (\u003csup\u003e\u0026dagger;\u003c/sup\u003e indicates results obtained from Kruskal Wallis test); ordinal variables were compared using chi-squared tests. YFAS 2.0 : Yale Food Addiction Scale 2.0\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Descriptive statistics of our study sample regarding cognitive emotion regulation strategies, emotion regulation difficulties and alexithymia, and comparison between the three groups in univariate analyses\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete sample (n=74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB+ FA+\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003cbr\u003e\u0026nbsp;(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB+ FA- group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n= 19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB- FA-\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ statistics for pair-wise comparaison (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eOB+ FA+ vs. OB+ FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eOB+ FA-\u0026nbsp;vs.\u0026nbsp;OB- FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eOB+ FA+ vs.\u0026nbsp;OB- FA-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdaptive emotional regulation strategy total score (CERQ)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e60.1\u0026plusmn;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e52.72\u0026plusmn;11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e61.0\u0026plusmn;19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e63.2\u0026plusmn;14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.03\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1.9(.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-0.4(.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-2.6(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptance (CERQ1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13.4\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12.4\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.6\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.8\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.55\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive refocusing (CERQ2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10.8\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.8\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9.3\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.0\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.25\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRefocus on planning (CERQ3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11.3\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.2\u0026plusmn;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.3\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.9\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.1(.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-2.9(.004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-5.2(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive reappraisal (CERQ4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.4\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11.0\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.0\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12.8\u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-3.1(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-0.6(.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePutting into perspective (CERQ5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.0\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.6\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11.7\u0026plusmn;4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12.8\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.17 \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon- adaptive emotional regulation strategy total score (CERQ)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e36.6\u0026plusmn;9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e41.2\u0026plusmn;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e33.3\u0026plusmn;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e36.0\u0026plusmn;10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.05\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-2.3(.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-0.8(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRumination (CERQ6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11\u0026nbsp;.0\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.3\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9.7\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11.9\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.06\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-blame (CERQ7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8.9\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8.0\u0026plusmn;3.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.2\u0026plusmn;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.2\u0026plusmn;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-0.8(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-3.2(.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-2.2(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlaming others (CERQ8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9.6\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11.6\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12.5\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.2\u0026plusmn;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;\u0026nbsp;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.3(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4.0(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.6(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCatastrophizing (CERQ9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7.4\u0026plusmn;3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9.1\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.1\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.8\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.01\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-2.3(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.2(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8(.005)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty in emotion regulation (DERS total score)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e21.7\u0026plusmn;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e30.1\u0026plusmn;13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e25.8\u0026plusmn;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e15.5\u0026plusmn;13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-0.8(0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.6(\u0026lt;.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.4(\u0026lt;\u0026nbsp;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlexithymia total score (TAS-20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e48.7\u0026plusmn;13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55.9\u0026plusmn;12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50.9\u0026plusmn;11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e44.1\u0026plusmn;12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;.0053\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.0(0.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.9(0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.1(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty identifying emotions (TAS-20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e17.4\u0026plusmn;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e21.0\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e18.7\u0026plusmn;5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e15.0\u0026plusmn;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e.0013\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.2(0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.1(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.5(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty describing emotions (TAS-20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e13.8\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e16.3\u0026plusmn;5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13.8\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12.5\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.03 \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.5(0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.0(0.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7(.007)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperational thinking (TAS-20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e17.5\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e18.6\u0026plusmn;5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e18.4\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e16.5\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.10\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. Continuous variables were compared between the three groups using ANOVA test or Kruskal Wallis test depending on the Levene test (\u0026dagger; indicates results obtained from Kruskal Wallis test); ordinal variables were compared using chi-squared tests. CERQ=Cognitive emotion regulation questionnaire; DERS = Difficulties in Emotion Regulation Scale; TAS-20=Toronto Alexithymia Scale, 20 items.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Descriptive statistics of our study sample regarding attentional biases and cognitive inhibition, and comparison between the three groups in univariate analyses\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"650\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete sample (n=74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB+ FA+ group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB + FA - group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n= 19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOB\u0026ndash; FA - group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifference from 0\u003cbr\u003e\u0026nbsp;U (p-value)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubgroup comparison H(p)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional valence (ms)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e- 1.2\u0026plusmn;11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.2\u0026plusmn;14.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-3.5\u0026plusmn;10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e-1.2\u0026plusmn;9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1106. 00 (0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.32(0.85) \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood valence (ms)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e1.3\u0026plusmn;12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.7\u0026plusmn;14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2.3\u0026plusmn;13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.1\u0026plusmn;10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1390.00(0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.22(0.89) \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStroop effect (ms)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e10.4\u0026plusmn;26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6.9\u0026plusmn;35.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6.8\u0026plusmn;29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e14.0\u0026plusmn;19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2091.00(\u0026lt;.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e0.07(0.97)\u003csup\u003e\u0026nbsp;\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. Significant difference from 0 was calculated using Wilcoxon-Mann-Whitney test; Continuous variables were compared between the three groups using ANOVA tests or Kruskal Wallis test depending on the Levene test (\u0026dagger; indicates results obtained from Kruskal Wallis test\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"food addiction, eating disorders, obesity, emotional regulation, cognitive behavioral therapy","lastPublishedDoi":"10.21203/rs.3.rs-6682315/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6682315/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEmotion dysregulation, alexithymia and attentional biases toward food or emotional stimuli have been reported in patients with obesity and food addiction (FA), but the relative contribution of obesity or FA to these characteristics remains unclear.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eOur objectives were to compare patients with obesity and FA, patients with obesity without FA and patients without obesity regarding cognitive emotion regulation strategies, alexithymia, emotion regulation difficulties, and attentional biases.We included 37 patients seeking treatment for obesity (18 FA, 19 without FA) and 37 controls. We assessed food addiction (YFAS 2.0); emotional regulation strategies (CERQ), emotion regulation difficulties (DERS), alexithymia (TAS-20), and attentional biases (Stroop and Emotional Stroop tasks).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among patients with obesity, those with FA differed from non-FA only in terms of cognitive emotion regulation strategies: less refocus on planning (p=.04), more catastrophizing (p=.02), and more positive refocusing (p\u0026lt;.001). Having an obesity (with or without FA) was associated with higher scores regarding emotion regulation strategies (p\u0026lt;.05), alexithymia (p\u0026lt;.001) and emotion regulation difficulties (p\u0026lt;.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Among patients with obesity, having a FA was related to cognitive avoidance toward negative events, but not to change in the saliency of emotional or food stimuli. Alexithymia was more related to obesity than to FA.\u003c/p\u003e","manuscriptTitle":"Emotion regulation among patients with obesity and food addiction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 09:13:31","doi":"10.21203/rs.3.rs-6682315/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-25T10:28:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T16:05:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236325278763323634021729929730875467047","date":"2025-06-10T09:09:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T08:56:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-20T22:00:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T16:55:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2025-05-16T16:08:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"37e568ba-b837-4d26-b8df-d434a03e6f5f","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:08:11+00:00","versionOfRecord":{"articleIdentity":"rs-6682315","link":"https://doi.org/10.1186/s40337-025-01424-6","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2025-12-15 15:57:52","publishedOnDateReadable":"December 15th, 2025"},"versionCreatedAt":"2025-06-13 09:13:31","video":"","vorDoi":"10.1186/s40337-025-01424-6","vorDoiUrl":"https://doi.org/10.1186/s40337-025-01424-6","workflowStages":[]},"version":"v1","identity":"rs-6682315","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6682315","identity":"rs-6682315","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}