Relationships between alexithymia and psychological characteristics associated with eating disorders

Emotional eating, alexithymia, and binge-eating disorder in obese women

OBJECTIVE

To investigate the relationships between alexithymia and emotional eating in obese women with or without Binge Eating Disorder (BED).

RESEARCH METHODS AND PROCEDURES

One hundred sixty-nine obese women completed self-report questionnaires, including the Beck Depression Inventory, the State Trait Anxiety Inventory, the Stress Perceived Scale, the Dutch Eating Behaviour Questionnaire, and the Toronto Alexithymia Scale. The presence of BED, screened using the Questionnaire of Eating and Weight Patterns, was confirmed by interview.

RESULTS

Forty obese women were identified as having BED. BED subjects and non-BED subjects were comparable in age, body mass index, educational level, and socioeconomic class. According to the Dutch Eating Behaviour Questionnaire, BED subjects exhibited higher depression, anxiety, perceived stress, alexithymia scores, and emotional and external eating scores than non-BED subjects. Emotional eating and perceived stress emerged as significant predictors of BED. The relationships between alexithymia and emotional eating in obese subjects differed between the two groups according to the presence of BED. Alexithymia was the predictor of emotional eating in BED subjects, whereas perceived stress and depression were the predictors in non-BED subjects.

DISCUSSION

This study pointed out different relationships among mood, alexithymia, and emotional eating in obese subjects with or without BED. Alexithymia was linked to emotional eating in BED. These data suggest the involvement of alexithymia in eating disorders among obese women.

Alexithymia, memory of emotion, emotional awareness, and perfectionism

The Toronto Alexithymia Scale (TAS-20; R. M. Bagby, J. D. A. Parker, & G. J. Taylor, 1994) is a self-assessment instrument designed to measure deficits in meta-emotional functioning (e.g., difficulties in identifying and describing emotions). Four studies were carried out to examine the association between the TAS-20 and (a) performance measures of meta-emotional functioning (memory of emotion and emotional awareness; Studies 1-2) and (b) measures of perfectionistic standards that may possibly be involved in the self-assessment of abilities-difficulties (Studies 3-4). The TAS-20 failed to correlate in the predicted direction with the performance measures but showed sizable correlations with measures of perfectionism. Moreover, perfectionism was found to predict TAS-20 scores independent of depression, anxiety, and somatic complaints. The results are discussed in terms of the TAS-20 measuring primarily certain aspects of meta-emotional self-efficacy.

Alexithymia, empathy, and psychological symptoms in a family context

Levels of alexithymia were measured with the Toronto Alexithymia Scale (TAS-20) in families of women with borderline personality disorder (BPD), restricting anorexia nervosa (AN) and a nonclinical (NC) group. Measures were correlated with sociodemographic information, empathy (as measured by the Interpersonal Reactivity Index [IRI]), emotional distress (using the Symptom Checklist-90-R [SCL-90-R]), and experiences of abuse. We have found that male gender, age, and low socioeconomic status are correlated with factor 3 of the TAS-20; that women with BPD and AN are more alexithymic than control subjects; that women with AN are more alexithymic than their parents; and that alexithymia is inversely related to the capacity for empathy. Family members of women with BPD have the highest levels of alexithymia and in these families there seems to be a complementary association between alexithymia in one parent and low levels of empathy in the other. There may be an association between the general emotional distress, history of abuse, and high levels of alexithymia that occur in women with BPD.

Alexithymia and body weight in obese patients

The authors evaluated severely obese patients to determine whether being far different in body shape from the accepted standard may cause obese people to develop alexithymic personality traits. They evaluated the food- and weight-related attitudes in obesity surgery patients and in long-term follow-up of those who had previously had biliopancreatic diversion (BPD) for obesity. One quarter of the obese patients had alexithymic characteristics without any modification following stable weight loss, a rate of alexithymia similar to that observed in the nonclinical population. Furthermore, the frequency of alexithymia and the patients' scores on the Toronto Alexithymia Scale were similar in obese and post-BPD individuals. The authors concluded that being obese by itself does not influence the presence of alexithymic personality traits. However, they suggest that the improvement in food-related and weight-related attitudes following stable weight loss may be different in alexithymic and in nonalexithymic obese patients.

Alexithymia: a challenge for mental health nursing practice

Alexithymia, under-recognized and under-diagnosed, presents a significant challenge to mental health nurses. This article explores the alexithymia construct, and presents the view that better recognition of this trait will allow nursing intervention to be more specific and effective. The mental health nurses' role is potentially the cornerstone of successful intervention with this group of complex patients, who do poorly when offered conventional, insight-orientated interventions. Standard psychotherapeutic treatments need to be modified in order to focus on increasing the ability to self-regulate affect, otherwise treatment may be both counterproductive and potentially damaging.

Relations of alexithymic characteristics with eating attitudes and hostility in female college students

We examined the correlations of alexithymic characteristics with the expression of unfavorable feelings such as anger and hostility and abnormal eating attitudes and behaviors in a sample of 278 Japanese female college students. Mean scores on the Eating Attitude Inventory, MMPI Hostility, and State-Trait Anger Expression Inventory were significantly higher for female college stUdents with alexithymic characteristics than for those with nonalexithymic characteristics. Multivariate analysis of covariance indicated that the significant relationships between alexithymic characteristics and oral control of the eating attitudes were controlled by scores on anger-in and anger control, suggesting that anger-in and anger control may mediate the relationship between alexithymic characteristics and abnormal eating attitudes.

Validating the Eating Disorder Inventory-2 (EDI-2) in Sweden

OBJECTIVE

To validate the Eating Disorder Inventory-2 (EDI-2) on a Swedish population by investigating differences between 1) young women with eating disorder symptoms (patients and non-patients), and normal controls and 2) patients with different eating disorder diagnoses, regarding symptom load and psychological characteristics. Another objective was to update EDI as a screening instrument

METHOD

Patients (n=194) with DSM-IV confirmed eating disorder diagnoses (anorexia nervosa AN; bulimia nervosa BN; eating disorder not otherwise specified, EDNOS) were compared vvith each other and with randomly selected and matched controls consisting of young women with self-reported eating disorder symptoms (n=51) and women without such symptoms (n=188).

RESULTS

In general, women vvith eating disorderproblems, whether or not they were patients, scored significantly higher on both symptoms and personality characteristics compared to normal controls. Patients with DSM verified eating disorders did not differ from women with self-reported eating disorders symptoms on body dissatisfaction, perfectionism and impulsiveness. Women with self-reported symptoms did not differ from women without symptoms on interpersonal distrust and maturity fears. Amongst the patient groups, BN patients scored highest, and AN patients lowest, on self-reported pathology. Most of the EDI-2 scales and all the three indexes had acceptable specificity and sensitivity.

CONCLUSION

EDI-2 discriminates well between women with eating disorder symptoms and normal controls, but responses from patients with AN should be interpreted with care. The EDI-2 indexes are especially recommended for screening purposes.

ALEXITHYMIA AND PSYCHIATRIC SYMPTOMS IN A POPULATION OF NURSERY WORKERS: A STUDY USING THE 20-ITEM TORONTO ALEXITHYMIA SCALE

This study investigated alexithymia in a sample of professional nursery workers in Huddinge community, Sweden. In a previous study in general practice it was found that alexithymia, in a mixed population seeking medical advice, was associated with higher age, male gender, low education and the personality traits suspicion and distance as well as undetected depression. The choice of a professional female population allowed alexithymia to be studied in a refined way without the impact of some of the confounding elements of previous studies. The six variables investigated apart from alexithymia were feelings of well-being, symptoms of somatic and psychic anxiety, depressive symptoms, gastro-intestinal symptoms, and level of social dysfunction. The prevalence of alexithymia was 7.9%. Fifty percent of the items assessing somatic anxiety and 28.5% of those assessing depressive symptoms were related to high TAS- 20 scores in this healthy all-female population. The feeling factors of TAS-20, difficulty in identifying and expressing feelings, accounted in this study for the majority of relations to the other variables whilst the third factor, externally oriented thinking, remained independent and mainly nonrelated to the other measured variables. It had been hypothesised that a deficit in the cognitive processing and modulation of emotions may leave alexithymic individuals prone to states of heightened sympathetic arousal. Confirmation of these theories was found in this study where subjects expressing high levels of vegetative and visceral symptoms of anxiety also scored high for alexithymia and depressive symptoms.

Ice-cream consumption, tendency toward overeating, and personality

OBJECTIVE

The exploration of the mechanisms underlying the tendency toward overeating by investigating the Dutch Eating Behavior Questionnaire (DEBQ)/Revised Eating Disorders Inventory (EDI-R) disinhibition, in sequence to the milkshake-ice cream study (van Strien, Cleven, and Schippers, in press).

METHOD

In hierarchical multiple regression analyses, the relative predictive power for ice-cream consumption was assessed, that is, emotional versus external versus bulimic eating using scales of the DEBQ and the EDI-R. In nonplanned stepwise multiple regression analyses, the association was assessed between these three types of eating behaviors and non-eating-related EDI-R scales.

RESULTS

Emotional eating was the most important variable for ice-cream consumption. External eating was borderline significant and bulimic eating nonsignificant when emotional and external eating had been partialled out. Emotional eating was best predicted by the EDI-R scales Asceticism, Interoceptive Awareness, and Social Insecurity.

DISCUSSION

Results are consistent with psychosomatic theory, which focuses on emotional eating as the result of confusion and apprehension in recognizing and accurately responding to emotional and visceral states related to hunger and satiety.

Alexithymia and depression in eating disorders

We compared alexithymia and depression ratings for non-hospitalized women meeting DSM-IV criteria for anorexia nervosa (n=32) and bulimia nervosa (n=32) to ratings for healthy women (n=74). Alexithymia was evaluated by the Toronto Alexithymia Scale (TAS-20) and depression by the Hospital Anxiety and Depression Scale (HAD). TAS and HAD scores were significantly higher in anorexic compared to bulimic patients, although these two scales were significantly and positively correlated (r=0.53, P=0.001). After taking depression into account as a confounding variable, rates of alexithymia did not vary according to the type of eating disorder (anorexia or bulimia).

Recent developments in alexithymia theory and research

OBJECTIVE

To review recent developments in alexithymia theory and research that are relevant to the field of psychosomatic medicine.

METHOD

Articles were selected from the alexithymia literature published over the past decade that describe advances in the theoretical understanding of alexithymia or report empirical investigations of the relationships of the construct with emotion regulation and with somatic illness and disease. Empirical investigations of the neural correlates of alexithymia were reviewed also, as were studies that explore therapeutic attempts to modify alexithymic characteristics.

RESULTS

The salient features of the alexithymia construct are now thought to reflect deficits in the cognitive processing and regulation of emotions. This is supported by studies showing that alexithymia is associated with maladaptive styles of emotion regulation, low emotional intelligence, a bidirectional interhemispheric transfer deficit, and reduced rapid eye movement (REM) density (number of eye movements divided by number of REM periods). Although empirical evidence demonstrates that alexithymia is associated with several somatic disorders, more prospective studies are required to establish the direction of causality. Preliminary data suggest that psychotherapies involving specific techniques to enhance emotional awareness and integrate symbolic and subsymbolic elements of emotion schemas may be effective in reducing alexithymic characteristics.

CONCLUSION

Alexithymia is proving to be a heuristically useful construct for exploring the role of personality and emotions in the pathogenesis of certain somatic illnesses and diseases.

Relation between alexithymia and the five-factor model of personality: a facet-level analysis

The relation between alexithymia and both the domain and the facet level of the five-factor model (FFM) of personality was examined in a sample of 101 university students by using the Twenty-Item Toronto Alexithymia Scale (TAS-20; Bagby, Taylor, & Parker, 1994) and the Revised NEO Personality Inventory (Costa & McCrae, 1992c). Consistent with the alexithymia construct, the TAS-20 was positively correlated with Neuroticism (N) and negatively correlated with Extraversion (E) and Openness (O), whereas no significant relations were found with Agreeableness (A) and Conscientiousness (C). Analysis of the lower order traits (i.e., facets) of the FFM revealed that depression for N; positive emotions and assertiveness for E; feelings and actions for O; altruism, tender-mindedness, and modesty for A; and competence for C predicted alexithymia. These results support the uniqueness of the alexithymia construct, which is represented by a cluster of traits across the dimensions and facets of the FFM.

Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders

OBJECTIVE

To study the development of personality disorders, especially those involving obsessions, compulsions, and social interaction problems, in a representative group of anorexia nervosa (AN) cases.

METHOD

The prevalence of personality disorders, obsessive-compulsive disorder, and autism spectrum disorders at mean age 24 years (10 years after reported onset) was examined in 51 adolescent-onset AN cases recruited after community screening and 51 comparison cases matched for age, sex, and school. All 102 cases had originally been examined at age 16 years and followed up at 21 years. At 24 years, structured and validated psychiatric diagnostic interviews were performed by a psychiatrist who was blind to original diagnosis. The majority of AN cases (94%) were weight-restored.

RESULTS

Personality disorders, particularly cluster C, and autism spectrum disorders were overrepresented in the AN group. Obsessive-compulsive personality disorder and/or autism spectrum disorder was diagnosed in a subgroup of AN cases in all 3 studies. This subgroup had a very poor psychosocial outcome.

CONCLUSIONS

Persistent problems with obsessions, compulsions, and social interaction characterized a substantial minority of weight-restored AN cases at 10-year follow-up. These problems appear to be constitutional rather than a result of AN, and they may warrant a different treatment approach.

Alexithymia and attachment representation in idiopathic spasmodic torticollis

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

Sociodemographic correlates of alexithymia

The association between alexithymia and sociodemographic variables is not well understood. Previous studies using the current 20-item and previous 26-item versions of the Toronto Alexithymia Scale (TAS) have shown inconsistent associations with age, sex, socioeconomic status, and years of education. We tested 380 subjects from the community stratified equally across sex, five age groups, and three socioeconomic classes. In addition to the TAS-20, we also administered the Levels of Emotional Awareness Scale (LEAS), a behavioral measure of the ability to be aware of and represent emotions in words, a core component of alexithymia. The TAS-20 and LEAS were each correlated with age, sex, socioeconomic status (SES), and years of education (P < .01) in the same direction and to approximately the same degree. Alexithymia (or low emotional awareness) is associated with older age, male sex, lower SES, and fewer years of education. The TAS-20 and LEAS are only slightly correlated (r = -.19, n = 380, P < .001), but their correlation is largely accounted for by their shared variance with these demographic variables. The convergence of findings with these two quite different measures and the nature of their overlap support the validity of these associations between alexithymia and sociodemographic variables.

Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study

The 20-item Toronto Alexithymia Scale (TAS-20) has been shown in previous research to measure a general dimension of alexithymia with three intercorrelated factors. This study evaluated the reliability and factorial validity of an Italian translation of the TAS-20 in a group of normal adults (N = 206) and in a mixed group of medical and psychiatric outpatients (N = 642). Using confirmatory factor analyses, the previously established three-factor model of the TAS-20 was found to be replicable in both groups. In addition, the Italian TAS-20 demonstrated adequate estimates of internal reliability and test-retest reliability. Although evaluation of the convergent, discriminant, and concurrent validity of the TAS-20 is required in Italian populations, the present results support the use of the Italian translation of the scale for clinical and research purposes.