1. Introduction
Binge Eating Disorder (BED) is a severe eating disorder characterized by food intake in a larger amount in a short time (<2 hours, once a week over the past 3 months) with no appropriate compensatory behaviors to weight gain [1]. BED is a complicated and multifaceted eating disorder that requires a comprehensive treatment approach. Recovery from BED and weight loss should be the main goal in treating people with obesity [2]. Difficulty in Emotion Regulation (DER) is an important factor in the development and maintenance of BED. People with DER use binge eating as a coping strategy [3]. A study of 2436 hospitalized female patients with anorexia, bulimia, and BED showed that 97% had at least one other detectable psychiatric disorder regardless of the type of eating disorder; 94% showed one type of mood disorder (mostly unipolar depression), and 56% had anxiety disorder [4]. Therefore, emotions should be considered in treatment of people with BED.
Emotion-focused therapy) EFT (is a therapy that combines the hypotheses and therapeutic approaches of Gestalt therapy and other humanistic therapies [5, 6]. EFT helps patients reveal and modify their emotional experiences (emotional schemas), engaging them with a set of perceptions, emotions, cognition, physical experiences, and behavioral form of individual reactions [5]. In order to modify emotional schemas, EFT use various tasks including empathy-based relational, experiencing and reprocessing tasks and actions such as two-chair technique [5]. Considering the role of emotional dysregulation in BED and given that EFT has not been studied in Iran on BED patients, this study aims to examine the effectiveness of EFT on anxiety, depression, DER, and severity of binge eating in women with BED.

2. Method
This is a quasi-experimental with a pre-test/post-test design and two months follow-up period using a control group. Study population consists of all men referred to the obesity clinic of Sina Hospital in Tehran, Iran. Of these, 40 were selected using a convenience sampling method and divided randomly into two groups of intervention(n=20) and control (n=20). To diagnose their BED, a 45-min structural clinical interview was conducted with each subject and the inclusion and exclusion criteria were determined based on this interview. 
Pre-test and post-test assessments were carried out for both groups by using the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II), Difficulties in Emotion Regulation Scale (DERS), and Binge Eating Scale (BES). After the pre-test phase, group EFT was conducted in the intervention group for eight weeks at 10 sessions each for 90 minutes at the obesity clinic of Sina Hospital. The control group, in addition to nutritional counseling, received placebo during this period. Data were analyzed using descriptive (mean and standard deviation) and inferential statistics (Repeated measures ANOVA).

3. Results
The Mean±SD age of participants was 38.4±11.6 years in the intervention group and 39.56±7.58 years in the control group. The results of repeated measures ANOVA with 2 × 3 design showed that the effect of time on the variables of anxiety(P≤0.05, η2=0.35), depression (P≤0.05, η2=0.55), DER (P≤0.05, η2=0.30), and severity of binge eating (P≤0.05, η2=0.40) was significant (Table 1).




EFT affected 40% of BED severity, 55% of depression, 35% of anxiety and 30% of DER in women. According to the results in Table 2, significant differences were found between the two groups in terms of depression, anxiety, severity of binge eating, and DER, where the group factor could explain 40% of the changes in anxiety, 32% in depression, 42% in the severity of binge eating, and 29% in DER. This indicates the effectiveness of EFT in the intervention group.



4. Discussion and Conclusion
The purpose of the study was to examine the effect of EFT on anxiety, depression, DER and severity of binge eating in women with BED. The results showed a significant reduction in binge eating severity and DER of women in the intervention group which is consistent with the results of Ivanovo [7]. Wnuk et al. [41] also showed that EFT significantly improved the symptoms of mal-regulation, depression, and self-efficacy and reduced binge eating in women with bulimia nervosa. Compar et al. also showed that EFT alone and in combination with nutritional counseling improved the pathological symptoms of eating disorder and improved the quality of life in people with BED and obesity. Its effect lasted after 6 months of follow-up. Several studies have reported the relationship between negative emotions and eating disorders [52]. The most important goal of EFT is to help modify maladaptive emotions (such as shame, chronic fear, etc.). This modification is due to the patients’ access to adaptive emotions during treatment sessions [9]. Inappropriate eating habits are for releasing negative emotions [10] and binge eating is a way for escaping from self-awareness by focusing on excessive eating followed by purging [11]. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1397.78). Also, this article has been registered in the Clinical Trial Registration Center of Iran (Code: IRCT20200222046583N1). The participants were informed of the purpose of the research and its implementation stages. A written consent has been obtained from the subjects. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors contributions
Treatment protocol and its implementation and data collection: Yousef Asmari Bardezard; Data analysis: Sajjad Khanjani; Writing an introduction and theoretical basis, discussion and conclusion: Sajjad Khanjani and Ismail Mousavi; Supervision: Behrooz Dolatshahi.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
We want to thank the experts and people who worked with the research team at the weight loss and Obesity Treatment Clinic at Sina Hospital.

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