RESEARCH ARTICLE

The Relationship Among Compulsive Buying, Compulsive Internet

Use and Temperament in a Sample of Female Patients with
Eating Disorders
Laurence Claes1*, Astrid Mller2, Jan Norr3, Leen Van Assche4, Steve Wonderlich5,6 & James E. Mitchell5,6
1

Catholic University of Leuven, Leuven, Belgium

Department of Psychosomatic Medicine and Psychotherapy, University of ErlangenNuremberg, Erlangen, Germany
3
Free University of Brussels, Brussels, Belgium
4
CGG Andante, Berchem, Belgium
5
Neuropsychiatric Research Institute (NRI), University of North Dakota, School of Medicine and Health Sciences, Fargo, ND, USA
6
Department of Clinical Neuroscience, University of North Dakota, School of Medicine and Health Sciences, Fargo, ND, USA
2

Abstract
The aim of the present study was to investigate the association among compulsive buying (CB), compulsive internet use (CIU) and
reactive/regulative temperament in a sample of 60 female patients with eating disorders. All patients were assessed by means of the
Compulsive Buying Scale, the CIU scale, the Eating Disorder Inventory2, the Behavioral Inhibition System/Behavioral Activation
System scales, the Dimensional Assessment of Personality Pathology and the effortful control scale of the Adult Temperament
Questionnaire. The results showed a positive association between CB and CIU, both categorized as impulse control disorders, not
otherwise specied. Both CB and CIU showed signicantly positive correlations with emotional lability, excitement seeking and lack of
effortful control (more specically lack of inhibitory and lack of activation control). The implication of these ndings for the treatment
of both disorders will be discussed. Copyright 2011 John Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
anorexia nervosa; bulimia nervosa; comorbidity; personality
*Correspondence
Laurence Claes, KULeuven, Department of Psychology, Tiensestraat 102, B3000 Leuven, Belgium. Tel: +32(0)1631.61.33; Fax: +32(0)1632.59.16.
Email: Laurence.claes@psy.kuleuven.be
Published online 28 June 2011 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1136

In the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, impulse control disorders (ICD) are classied as
pathological gambling, kleptomania, intermittent explosive disorder, pyromania, trichotillomania and ICD not otherwise specied,
which may include compulsive internet use (CIU), compulsive
sexual behaviour, pathological skin picking and compulsive buying
(CB) (Dellosso, Altamura, Allen, Marazitti, & Hollander, 2006;
Kuzma & Black, 2005). FernandezAranda et al. (2006, 2008)
showed a prevalence of 18% of CB in patients with bulimia nervosa
(BN) and 12% in patients with other eating disorders (ED),
including anorexia nervosa (AN), BN and eating disorder not
otherwise specied (EDNOS). Shapira et al. (2003)reported a
lifetime prevalence between 0% and 5% of problematic
internet use in AN, between 10% and 15% in BN and about
20% in EDNOS. According to FernandezAranda et al. (2006,
2008), CB is the most prevalent ICD in patients with ED. Given the
high correlation between CB and excessive internet use (Mueller
et al., ), we decided to investigate the comorbidity between these
conditions and their associations with temperament in a sample of
patients with ED.
Claes, Bijttebier, Mitchell, de Zwaan, and Mueller (2011)
found a positive association between CB and the Eating Disorder
Inventory2 drive for thinness and bulimia scales in a sample of
126

female university students. Similarly, Tao and Liu (2009) found

that female individuals with internet dependence scored significantly higher on diet behaviour, bulimia and oral control
compared with female individuals without internet dependence.
Additionally, several studies reported a signicant association
between CB and internet use. For example, Lejoyeux, Mathieu,
Embouazza, Huet, and Lequen (2007) reported that individuals with
CB connect for a longer period of time and more often go to online
shopping sites than normal controls. KukarKinney, Ridgway, and
Monroe (2009) showed that individuals with higher CB tendencies
prefer shopping and buying online over traditional stores to avoid
social interactions. And nally, Mueller et al. (in press) found a
positive association between CB and excessive internet use.
Given the association between CB and excessive internet use, it
is possible that similar temperament characteristics underlie both
CB and excessive internet use. Rothbart, Ahadi, and Evans (2000)
dene temperament as individual differences in reactivity and self
regulation. Reactive temperament can be conceptualized in terms
of two separate neurobiological systems: the Behavioral Inhibition
System (BIS) and the Behavioral Activation System (BAS) (Gray,
1987). The BIS (anxiety and neuroticism) is sensitive to stimuli
that signal conditioned punishment and with the omission or
termination of reward and is involved in behavioural inhibition.

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L. Claes et al.

The BAS is sensitive to stimuli that signal unconditioned reward

and the relief from punishment and is involved in approach
behaviour (Bijttebier, Beck, Claes, & Vandereycken, 2009; Claes
et al., 2010). Earlier studies on reactive temperament showed that
CB is unrelated to BIS reactivity and positively related to BAS
reactivity (e.g. Claes et al. 2010, 2011); whereas excessive internet
use (Yang, Choe, Baity, Lee, & Cho, 2005), internet addiction
(Tsai et al., 2009) and CIU (van der Aa et al., 2009; Meerkerk,
van den Eijnden, Vermulst, & Garretsen, 2010) are positively
related to BIS reactivity/neuroticism and negatively to extraversion (van der Aa et al., 2009; Landers & Lounsbury, 2006; Petrie &
Gunn, 1998). The relationship between BAS fun seeking
(sensation seeking) and internet dependence is ambiguous. Some
studies found a positive relationship between internet dependence
and BAS fun seeking (Lin & Tsai, 2002), whereas others found a
negative relationship between internet dependence and BAS fun
seeking (e.g. Lavin, Marvin, McLarney, Nola, & Scott, 1999).
Besides reactive temperament (automatic, bottomup), self
regulation (controlled, topdown) can also play a role in human
behaviour. Selfregulation is often simultaneously used with
terms such as effortful control (Rothbart, 1989), selfcontrol
(Baumeister, Heatherton, & Tice, 1994) and conscientiousness
(Bijttebier et al., 2009). Lack of selfregulation, effortful control
or selfcontrol is associated with impulsive behaviours (Baumeister
et al., 1994). Several studies have found a negative relationship
between CB and selfcontrol (e.g. Faber, 2004; Vohs & Faber, 2007;
Claes et al., 2010, 2011) and CIU and selfcontrol/conscientiousness
(e.g. van der Aa et al., 2009; Meerkerk et al., 2010).
Reactivity is characterized by automatic processing, whereas
selfregulation is characterized by controlled processing. Automatic processing is a fast, parallel, fairly effortless process that
is not limited by shortterm memory capacity, is not under direct
subject control and performs skilled behaviours. Controlled
processing on the contrary is often slow, generally serial,
effortful, capacity limited, subject regulated and is used to deal
with novel or inconsistent information (Shiffrin & Schneider,
1984).
The goal of the present study was fourfold. (1) To investigate
the prevalence of CB/CIU symptoms in a sample of female
outpatients with ED. Based on the literature, we expected a
prevalence of CB between 12% and 18%, and a prevalence of
internet use between 0% and 5% for patients with restrictive
type of AN (ANR) and between 10% and 20% for patients
with bingeing/purging type of AN (ANBP, BN and EDNOS).
(2) Furthermore, to determine the association between CB/CIU
and bulimic/anorexic symptoms and (3) to determine the
association between CB and CIU. We expected bulimic
symptoms to correlate more strongly with CB and CIU. And
nally, (4) to investigate whether CB and CIU are characterized
by the same temperament prole. Based on the literature, we
expected that both CB and CIU would be characterized by low
levels of effortful control, whereas CB would be positively related
to BAS reactivity, and CIU would be positively related to BIS
reactivity/neuroticism and negatively to extraversion. The
relationship between CIU and BAS reactivity (fun seeking and
sensation seeking) is hard to predict as the literature is rather
ambiguous. Investigating the presence of comorbid (impulse
control) symptoms/disorders in patients with ED is important,

CB, CIU and temperament in patients with ED

given the fact that the presence of impulsive traits/symptoms

increase the risk of poor treatment outcome and a worse long
term prognosis for patients with ED (Claes, Vandereycken, &
Vertommen, 2002).

Method
Participants and procedure
The sample of ED consists of 60 female outpatients with ED. The
patients were diagnosed according to the criteria in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (American
Psychiatric Association, 1994) on the basis of a standardized
clinical interview and the Eating Disorder Inventory2 (EDI2;
Garner, 1991; Dutch version: van Strien & Ouwens, 2003): 23 (38.3%)
patients were diagnosed as suffering from ANR; 4 (6.7%), ANBP; 16
(26.7%), BN; and 17 (28.3%), EDNOS. The age of the sample of ED
ranged from 15 to 57 years with a mean of 27.82 years (SD = 9.76).
Patients with ANR (M = 23.33, SD = 6.87) were signicantly younger
than patients with EDNOS (M = 34, SD = 11.68) [F(3, 52) = 4.06,
p < 0.01]. Almost 25% (24.5%) of the patients with ED followed
secondary education, and 75.5% followed tertiary education (34.7%
college; 40.8% university). There were no signicant differences
between the subgroups with ED with respect to educational level
[(6)2 = 5.13, ns].
All patients were provided with an envelope holding informed
consent documents and questionnaires via their individual
therapist. Patients who were willing to participate provided written
informed consent and completed the questionnaires individually at
home. The documents were returned to the researcher in a sealed
envelope via their individual therapist, who had no access to
participant responses. The study procedures were approved by the
University Institutional Review Board of the rst author.
Instruments
Compulsive buying was assessed by means of the Compulsive
Buying Scale (CBS) (Faber & OGuinn, 1992). The CBS consists
of seven items representing specic behaviours and feelings
associated with CB ( = 0.72 in the present study). Six items
(e.g. Bought myself something in order to make myself feel
better) are answered on a vepoint scale ranging from 1 (very
often) to 5 (never). One item, If I have any money left at
the end of the pay period, I just have to spend it, is answered on a
vepoint scale ranging from 1 (strongly agree) to 5 (strongly
disagree). Faber and OGuinn (1992) developed a scoring system
involving a regression equation with item weighting to determine
the cutoff score for CB. Lower scores indicate a higher level of CB.
Faber and OGuinn (1992) reported that the CBS correctly
classied 89.9% of a general population sample and 85.3% of a CB
group. With regard to a recent German populationbased survey, a
cutoff score equal to 1.09 or lower indicates the person has CB
(Mueller et al., 2010). The German version of the CBS correctly
classied 91.1% of a clinical CB group (treatmentseeking patients
who where all interviewed and dened as suffering from clinically
signicant CB) (Mueller et al., 2010). In the present study,
the original version of the CBS was translated into Dutch and
retranslated into English by ofcial translators. We performed a
factor analysis on the seven items of the CBS in the present sample

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127

L. Claes et al.

CB, CIU and temperament in patients with ED

and found support for a onefactor solution, which explained

38.26% of the variance. All items had a loading of less than 0.51 on
this onefactor scale. The internal consistency of the onefactor
scale was equal to 0.72.
Compulsive internet use was assessed by means of the Dutch
Compulsive Internet Use Scale (Meerkerk et al., 2010). This scale
consists of 14 items which have to be answered on a vepoint
Likert scale ranging from 1 (never) to 5 (very often). The scale
(n = 14; = 0.94 in the present) taps into the dimensions loss of
control, preoccupation, withdrawal symptoms, coping and
conicts about internet use (e.g. How often do you nd it
difcult to stop using the internet?) (van der Aa et al., 2009).
Meerkerk et al. reasoned that for internet use to be called
compulsive, the behaviour specied in the 14 CIU items should
play an important role in the life of the internet user. This occurs
when the behaviour occurs on average more than sometimes
which implicates a cutoff score of 14 items 2 (sometimes) >28
(p. 731).
Eating disorder symptoms were assessed by means of the EDI2
(Garner, 1991; Dutch version: van Strien & Ouwens, 2003). The
EDI2 is a 91item, sixpoint forcedchoice inventory assessing
several behavioural and psychological traits common in BN and
AN. The EDI2 consists of 11 subscale scores, of which two are
used in the present study: drive for thinness (n = 7; = 0.91; Im
terried of gaining weight) and bulimia (n = 7; = 0.91; e.g.
I stuff myself with food).
Reactivity temperament was assessed by means of the BIS/BAS
scales (Carver & White, 1994; Dutch version: Beck, Smits, Claes,
Vandereycken, & Bijttebier, 2009). The BIS/BAS scales consist
of 24 items to be rated on a fourpoint scale ranging from 1
(I strongly agree) to 4 (I strongly disagree). The BIS scale assesses
worry concerning potential punishments in the future [n = 7;
= 0.80 in the present study; e.g. I have very few fears compared
to my friends (reversed)]. The BAS scale assesses enthusiasm in
the pursuit of potentially rewarding outcomes (n = 13; = 0.78).
The BAS scale has three subscales, being drive (n = 4; = 0.74;
e.g. When I want something, I usually go allout to get it), fun
seeking (n = 4; = 0.52; e.g. I often act on the spur of the
moment) and reward responsiveness (n = 5; = 0.63; e.g. It
would excite me to win a contest). Besides the BIS/BAS scales,
we also administered the affective lability scale (n = 8, = 0.86,
e.g. I often have often emotional ups and downs) and the
stimulus seeking scale (n = 8, = 0.78, e.g. I often act at the
spur of the moment, although I know that I will regret it later)
of the Dimensional Assessment of Personality Pathology
Short Form (DAPP; Livesley & Jackson, 2002; Dutch version:
van Kampen, De Beurs, & Adrea, 2008) to have an additional
measure of BIS reactivity and BAS reactivity. The DAPP affective
lability scale measures the variability of affect (ups and downs)
instead of the presence of negative affect (like the BIS scale),
whereas DAPP stimulus seeking scale contains more forms of
stimulus seeking compared with the BAS fun seeking scale.
Regulative temperament was measured by means of the
19item effortful control scale from the Adult Temperament
QuestionnaireShort Form (Evans & Rothbart, 2007; Dutch
version: Hartman & Rothbart, 2001). Participants reported on the
extent to which high or low levels of effortful control generally
characterize their interactions with the environment (1 = not at
128

all applicable; 7 = completely applicable) (n = 19; = 0.83).The

effortful control scale has three subscales being, attentional
control [n = 5; = 0.65; e.g. Its often hard for me to alternate
between two different tasks (reversed)], activation control [n = 7;
= 0.72; e.g. I hardly ever nish things on time (reversed)] and
inhibition control (n = 7; = 0.67; e.g. It is easy for me to hold
back my laughter in a situation where is not appropriate).
Analyses
All analyses were performed by means of SPSS 17 (SPSS Inc.,
Chicago, IL, USA). To calculate the associations among the
intervalscaled variables CB, CIU, eating disorder symptoms and
temperament, we made use of the Pearson correlation coefcients. To compare ANR and binge/purge subtypes of ED with
respect to CB and CIU, we made use of ANOVAs. And nally, to
predict CB and CIU scale scores by means of the temperament
variables, we used regression analyses. For all analyses, the critical
pvalue was p < 0.05.

Results
Prevalence of compulsive buying and compulsive
internet use
With respect to CB symptoms, 10% (n = 6; one ANR and ve
binge/purge ED patients) of the 60 patients with ED scored below
the cutoff score of the CBS, indicating a lifetime prevalence of
10% of CB in female patients with ED. With respect to CIU
symptoms, 11.7% (n = 7; two ANR and ve binge/purge ED
patients) of the 60 patients with ED scored above the cutoff score
of the Internet Use Scale, indicating a lifetime prevalence of
11.7% of CB in female patients with ED. Two (3.3%) of the 60
patients with ED scored above the cutoff score of both the
CBS and Internet Use Scale, and both patients belonged to the
binge/purge ED group.
Association among compulsive buying,
compulsive internet use and eating disorder
symptoms/diagnoses
As can be seen in Table 1, CB was signicantly related to the drive
for thinness and bulimia, but the correlation between CB and
bulimia was the strongest. CIU was only signicantly related to
the drive for thinness. Finally, we found a strong positive
correlation between CB and CIU (r = 0.47, p < 0.001).
We also compared patients with ANR with patients with
ANBP, BN and EDNOS with respect to CB and CIU scale scores.
The binge/purge ED patients scored signicantly higher on the
CBS compared with ANR [F(1,58) = 6.25, p < 0.01]. We did not
nd signicant differences between the subtypes of ED with respect
to CIU [F(1,58) = 1.08, ns].
Association among compulsive buying,
compulsive internet use and temperament
We also investigated the association among CB, CIU and reactive
and regulative temperament (Table 2). With respect to reactive
temperament, CB and CIU were not signicantly related with BIS
reactivity, but both showed positive correlations with DAPP
emotional lability. Furthermore, CB and CIU were positively

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L. Claes et al.

CB, CIU and temperament in patients with ED

Table 1 Correlations among CB, CIU and eating disorder symptoms (N = 59)
CBS

CBS
CIU
EDIDT
EDIB

CIU

EDIDT

0.47***

0.28*
0.29*

Table 3 Predictions of CB and CIU based on reactive/regulative temperament

CBS

EDIB
0.34**
0.19
0.45**

CB, compulsive buying; CIU, compulsive internet use; CBS, Compulsive Buying
Scale; EDIDT, Eating Disorder Inventory2 drive for thinness; EDIB, Eating
Disorder Inventory2 bulimia.

Scores on the CBS were reversed: higher scores on the CBS indicate a higher level
of CB.
*p < 0.05.
**p < 0.01.
***p < 0.001.

related to BAS fun seeking (p < 0.08) and BAS drive, respectively,
and both showed positive correlations with DAPP excitement
seeking.
With respect to regulative temperament (effortful control or
selfregulation), CB and CIU were both related to a lack of
effortful control, more specically to a lack of inhibitory control
and a lack of activation control. Contrary to CB, CIU was also
signicantly related to a lack of attentional control.
Finally, we performed regression analyses, with the ztransformed
temperament scales that showed signicant association with DAPP

DAPP emotional lability

DAPP excitement seeking
EC total

IUS
2

R = 0.21**

R = 0.24**

0.15
0.12
0.32**

0.19
0.02
0.39**

CB, compulsive buying; CIU, compulsive internet use; CBS, Compulsive Buying
Scale; IUS, Internet Use Scale; DAPP emotional lability, emotional lability scale in
the Dimensional Assessment of Personality PathologyShort Form; DAPP
excitement seeking, excitement seeking scale in the Dimensional Assessment of
Personality PathologyShort Form; EC total, total score in the effortful control
scale of the Adult Temperament Questionnaire.

Scores on the CBS were reversed: higher scores on the CBS indicate a higher level
of CB.
**p < 0.01.

emotional lability, DAPP excitement seeking and EC total as

independent variables and CB and CIU as dependent variables
(Table 3). The regression models with interaction terms were not
displayed because they did not reveal signicant results. Overall,
the results showed that neither emotional instability nor
excitement seeking contributed signicantly to CB and CIU after
controlling for the lack of effortful control.

Discussion
Table 2 Correlations among CB, CIU and reactive/regulative temperament

BIS total
BAS total
BASDR
BASFS
BASRR
DAPP affective lability
DAPP stimulus seeking
EC total
ECINH
ECACT
ECATT

CBS

IUS

0.06
0.19
0.11
0.23
0.12
0.29*
0.30*
0.43**
0.41**
0.43**
0.17

0.02
0.07
0.27*
0.02
0.09
0.33*
0.25*
0.46**
0.29**
0.51**
0.31**

CB, compulsive buying; CIU, compulsive internet use; CBS, Compulsive Buying
Scale; IUS, Internet Use Scale; BIS total, total score in the Behavioral Inhibition
Scale; BAS total, total score in the Behavioral Activation Scale; BASDR, drive scale
of BAS; BASFS, fun seeking scale of BAS; BASRR, reward responsiveness scale of
BAS; DAPP affective lability scale, affective lability scale in the Dimensional
Assessment of Personality PathologyShort Form; DAPP stimulus seeking scale,
stimulus seeking scale in the Dimensional Assessment of Personality Pathology
Short Form; EC total, total score in the effortful control scale of the Adult
Temperament Questionnaire (ATQ); ECINH, inhibitory control scale in the
effortful control scale of the ATQ; ECACT, activation control scale in the effortful
control scale of the ATQ; ECATT, attentional control scale in the effortful control
scale of the ATQ.

Scores on the CBS were reversed: higher scores on the CBS indicate a higher level
of CB.
*p < 0.05.
**p < 0.01.

In the present study, we investigated the relationship between CB

and CIU, both considered as ICD not otherwise specied, in a
sample of 60 patients with ED. The prevalence of both CB and
CIU was about 10%, which is similar to the ndings of previous
studies that reported prevalence rates of 12% to 18% of CB in
patients with ED (FernandezAranda et al., 2008) and between
0% to 20% of problematic internet use in samples of ED (Shapira
et al., 2003). Both CB and CIU were signicantly related to
restrictive eating behaviours, as previously found by Claes et al.
(2011) and Tao and Liu (2009). However, CB was also significantly related to both bulimic symptoms and the diagnosis of
binge/purge diagnoses of ED (BN and EDNOS) (see e.g. Claes
et al.; Faber, Christenson, de Zwaan, & Mitchell, 1995; Mitchell
et al., 2002; Mueller et al., 2009). This nding is also in line with
our experience that individuals seeking treatment for CB are binge
eating and purging rather than dieting.
Furthermore, we found a signicant association (r = 0.47)
between CB and CIU, results that are comparable to Mueller et al.
(in press), who reported a correlation of 0.38 between CB and
excessive internet use in a sample of consumers. We can hypothesize that patients with ED often use the internet to buy things
while avoiding interpersonal contacts (KukarKinney et al., 2009).
However, in the present study, we did not explicitly ask what
the patients with ED were doing while using the internet. It is
possible that they were visiting proAN/BN sites, chatting, gaming
or buying, which needs to be addressed in future studies.
Given the high association between CB and CIU, we
investigated whether similar temperament characteristics underlie
both CB and CIU in patients with ED. With respect to reactive

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CB, CIU and temperament in patients with ED

temperament, we did not nd a signicant association between

CB/CIU and BIS. Also, previous studies (e.g. Claes et al., 2010,
2011) did not report a signicant association between CB and
BIS; however, Meerkerk, van den Eijnden, Franken, & Garretsen
(2010) reported a signicant positive association between CIU
and BIS in students. With respect to the BAS scales, CIU was
signicantly related to BAS drive (i.e. the persistent pursuit of
desired goals), whereas CB was almost (p < 0.08) signicantly
positive related to BAS fun seeking (i.e. the willingness to
approach a potentially rewarding event on the spur of the
moment). Furthermore, both CB/CIU were signicantly related
to emotional lability (i.e. mood swings) and excitement seeking.
The latter conrming the association between CB/CIU and fun
seeking/sensation seeking (e.g. Claes et al., 2011; Lin & Tsai,
2002). This may raise the hypotheses that both CB and CIU can
be considered emotionregulation strategies, to stabilize the mood
swings and to gain more positive/excitement feelings, which
needs to be addressed in future studies.
Finally, with respect to regulative temperament (selfregulation
or effortful control), both CB and CIU were characterized by lack
of effortful control, more specically by low levels of inhibitory
control (i.e. the capacity to suppress inappropriate approach
behaviour) and activation control (i.e. the capacity to perform an
action, when there is a strong tendency to avoid it) (Evans &
Rothbart, 2007). However, while taking into account emotional
lability, excitement seeking and lack of effortful control at the
same time (regressions), only lack of effortful control remained
signicantly related to CB/CIU in patients with ED. Brain
dopamine which innervates the limbicstriatal and frontostriatal brain circuits has often been implicated in impulsive
behaviours, which may reect failures of motivational and
cognitive controls (Cools, 2008 for an overview). Several studies
found that striatal dopamine may be associated with cognitive
capacity and executive functioning (Chen et al., 2005; Cropley,
Fujita, Innis, & Nathan, 2006; Guo et al., 2006; Hsieh et al., 2010),
whereas other studies found signicant relationships between
particular frontal brain activity and addiction (e.g. for online

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whether the term compulsive needs to be replaced by
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Finally, given the association between CB and CIU and given
that both are driven by lack of effortful control or topdown
control, the treatment of both symptoms could benet from
training in effortful control. Today, several studies have already
shown that effortful or executive or topdown control can be
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with ED (e.g. bulimic behaviours, gambling, alcohol abuse).
As far as we know, our study is the rst study that investigated
to associations among CB, CIU and temperament in patients with
ED. Besides the strengths of the study, some limitations need to
be addressed. First, the results of our study need to be replicated
in larger samples of patients with ED, including higher numbers
of different subtypes of ED. Secondly, besides assessing the
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is essential to assess the degree of effortful control while
confronted with patients who show different types of ICD and
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