Feelings and fantasy in eating disorders: a factor analysis of the Toronto Alexithymia Scale

Neural Response to Low Energy and High Energy Foods in Bulimia Nervosa and Binge Eating Disorder: A Functional MRI Study

Objective

Bulimia nervosa (BN) and binge eating disorder (BED) are eating disorders (EDs) characterized by recurrent binge eating (BE) episodes. Overlap exists between ED diagnostic groups, with BE episodes presenting one clinical feature that occurs transdiagnostically. Neuroimaging of the responses of those with BN and BED to disorder-specific stimuli, such as food, is not extensively investigated. Furthermore, to our knowledge, there have been no previous published studies examining the neural response of individuals currently experiencing binge eating, to low energy foods. Our objective was to examine the neural responses to both low energy and high energy food images in three emotive categories (disgust; fear; and happy) in BN and BED participants.

Methods

Nineteen females with BN (n = 14) or BED (n = 5), comprising the binge eating group (BEG; N = 19), and 19 age-matched healthy control (HC)’s completed thorough clinical assessment prior to functional MRI (fMRI). Neural response to low energy and high energy foods and non-food images was compared between groups using whole-brain exploratory analyses, from which six regions of interest (ROI) were then selected: frontal, occipital, temporal, and parietal lobes; insula and cingulate.

Results

In response to low energy food images, the BEG demonstrated differential neural responses to all three low energy foods categories (disgust; fear; and happy) compared to HCs. Correlational analyses found a significant association between frequency of binge episodes and diminished temporal lobe and greater occipital lobe response. In response to high energy food images, compared to HC’s, the BEG demonstrated significantly decreased neural activity in response to all high energy food images. The HC’s had significantly greater neural activity in the limbic system, occipital lobe, temporal lobe, frontal lobe, and limbic system in response to high energy food images.

Conclusion

Results in the low energy food condition indicate that binge frequency may be related to increased aberrant neural responding. Furthermore, differences were found between groups in all ROI’s except the insula. The neural response seen in the BEG to disgust food images may indicate disengagement with this particular stimuli. In the high energy food condition, results demonstrate that neural activity in BN and BED patients may decrease in response to high energy foods, suggesting disengagement with foods that may be more consistent with those consumed during a binge eating episode.

The mentalization profile in patients with eating disorders: a systematic review and meta-analysis

Context: Patients with eating disorders (EDs) may have a lower mentalization ability. To the best of our knowledge, no meta-analysis has so far addressed the multidimensional mentalization profile within these patients.Objective: To summarize the existing evidence of the mentalization profile and its association with EDs.Data sources: We searched for articles in PsychINFO, Embase and PubMed using the search terms mentalization, reflective function, adult attachment interview, alexithymia, Toronto Alexithymia Scale, eye test, Reading the Mind in the Eyes Test, Theory of Mind, mind-mindedness, mind-blindness, facial expression recognition, metacognition, ED, anorexia nervosa (AN) and bulimia nervosa (BN).Studies included: Quantitative studies including diagnosed patients with an ED, healthy controls (HCs) and relevant test methods.Data synthesis: Forty-four studies were included. Nine studies were eligible for the meta-analysis. Significantly lower mentalization ability about oneself was found in patients with an ED when compared to HCs. Groups were more comparable when dealing with mentalization ability of others. Non-significant but clinically relevant results include a tendency for a lower mentalization ability in patients with AN compared to patients with BN.Conclusion: The mentalization profile is complex and varies across dimensions of mentalization in patients with an ED. Different degrees of mentalization between various EDs were found, implying the necessity for further research on mentalization profiles in different ED diagnoses. The sparse existing literature was a limitation for this meta-analysis, emphasizing that further research on the mentalization profile in patients with EDs is needed.

Eating disorders among patients with borderline personality disorder: understanding the prevalence and psychopathology

BACKGROUND

Treatment protocols can be bolstered and etiological and maintenance factors can be recognized more easily by a superior understanding of emotions and emotion regulation in the comorbidity of borderline personality disorder (BPD) and feeding and eating disorders (FEDs). Therefore, the present study aimed at investigating the prevalence and psychopathology of FEDs in patients with BPD.

METHODS

In this cross-sectional study, 220 participants were examined in three groups, namely BPD (n = 38), BPD + FEDs (n = 72), and healthy controls (n = 110), from August 2018 to November 2019. The participants were selected by systematic random sampling among the patients who referred to Baharan psychiatric hospital in Zahedan, Iran, with the sampling interval of 3. The subjects were evaluated by 28-item General Health Questionnaire (GHQ-28), Borderline Personality Inventory (BPI), Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD), Structured Clinical Interviews for DSM-5: Research Version (SCID-5-RV), the 26-item Eating Attitudes Test (EAT-26), 20-item Toronto Alexithymia Scale (TAS-20), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II).

RESULTS

The results showed a 65.4% (n = 72) prevalence of FEDs in patients with BPD. Also, the highest and lowest prevalence rates were reported for other specified feeding and eating disorders (51.3%) and bulimia nervosa (6.9%), respectively. Although the highest mean score of TAS-20 was related to anorexia nervosa, there was no significant difference between the scores of various types of FEDs. The mediation analysis showed that anxiety and depression would play a mediating role in the relationship between alexithymia and eating-disordered behaviors.

CONCLUSIONS

The results have suggested that alexithymia, anxiety, and depression should receive clinical attention as potential therapeutic targets in the comorbidity of BPD and FEDs. The clinical implications of the research have been conducted to date, and directions for future research have been discussed.

Alexithymia in eating disorders: Systematic review and meta-analyses of studies using the Toronto Alexithymia Scale

OBJECTIVE

The aim of this review was to synthesise the literature on the use of the Toronto Alexithymia Scale (TAS) in eating disorder populations and Healthy Controls (HCs) and to compare TAS scores in these groups.

METHOD

Electronic databases were searched systematically for studies using the TAS and meta-analyses were performed to statistically compare scores on the TAS between individuals with eating disorders and HCs.

RESULTS

Forty-eight studies using the TAS with both a clinical eating disorder group and HCs were identified. Of these, 44 were included in the meta-analyses, separated into: Anorexia Nervosa; Anorexia Nervosa, Restricting subtype; Anorexia Nervosa, Binge-Purge subtype, Bulimia Nervosa and Binge Eating Disorder. For all groups, there were significant differences with medium or large effect sizes between the clinical group and HCs, with the clinical group scoring significantly higher on the TAS, indicating greater difficulty with identifying and labelling emotions.

CONCLUSION

Across the spectrum of eating disorders, individuals report having difficulties recognising or describing their emotions. Given the self-report design of the TAS, research to develop and evaluate treatments and clinician-administered assessments of alexithymia is warranted.

Alexithymia, empathy, emotion identification and social inference in anorexia nervosa: A case-control study

Alexithymia, difficulties in facial emotion recognition, poor socio-relational skills are typical of anorexia nervosa (AN). We assessed patients with AN and healthy controls (HCs) with mixed stimuli: questionnaires (Toronto Alexithymia Scale-TAS, Interpersonal Reactivity Index-IRI), photographs (Facial Emotion Identification Test-FEIT) and dynamic images (The Awareness of Social Inference Test-TASIT). TAS and IRI Personal Distress (PD) were higher in AN than HCs. Few or no differences emerged at the FEIT and TASIT, respectively. Larger effect sizes were found for the TAS results. Despite higher levels of alexithymia, patients with AN seem to properly acknowledge others' emotions while being inhibited in the expression of their own.

Self perception and facial emotion perception of others in anorexia nervosa

Background: Whether individuals with anorexia nervosa (AN) are able to accurately perceive emotions from faces of others is unclear. Furthermore, whether individuals with AN process images of their own face differently to healthy individuals has thus far not been investigated. Therefore, the aim of this study was to investigate facial affect processing and the processing of one’s own face through measures of emotion identification, functional magnetic resonance imaging (fMRI) and eyetracking.

Methods: Twenty-four females with AN and 25 matched healthy control participants were presented with an implicit emotion processing task during fMRI and eyetracking, followed by an explicit emotion identification task.

Results: The AN group were found to ‘hyperscan’ stimuli and avoided visually attending to salient features of their own face images. Results of the fMRI revealed increased activity to own face stimuli in AN in the right inferior and middle temporal gyri, and right lingual gyrus. AN participants were not found to display emotion identification deficits to the standard emotional face stimuli.

Discussion: The findings are discussed in terms of increased anxiety to disorder-relevant stimuli in AN. Potential clinical implications are discussed in relation to the use of eyetracking techniques to improve the perception of self in AN.

Dreams of the Rarebit Fiend: food and diet as instigators of bizarre and disturbing dreams

In the early 1900s, the Dream of the Rarebit Fiend comic strip conveyed how the spicy cheese dish Welsh rarebit leads to bizarre and disturbing dreams. Today, the perception that foods disturb dreaming persists. But apart from case studies, some exploratory surveys, and a few lab studies on how hunger affects dreaming, there is little empirical evidence addressing this topic. The present study examines three aspects of the food/dreaming relationship; it attempts to: (1) assess the prevalence of the perception of food-dependent dreaming and the types of foods most commonly blamed; (2) determine if perceived food-dependent dreaming is associated with dietary, sleep or motivational factors; and (3) explore whether these factors, independent of food/dreaming perceptions, are associated with reports of vivid and disturbing dreams. Three hundred and ninety six students completed questionnaires evaluating sleep, dreams, and dietary habits and motivations. Items queried whether they had noticed if foods produced bizarre or disturbing dreams and if eating late at night influenced their dreams. The perception of food-dependent dreaming had a prevalence of 17.8%; with dairy products being the most frequently blamed food category (39-44%). Those who perceived food-dependent dreaming differed from others by reporting more frequent and disturbing dreams, poorer sleep, higher coffee intake, and lower Intuitive Eating Scale scores. Reports of disturbing dreams were associated with a pathological constellation of measures that includes poorer sleep, binge-eating, and eating for emotional reasons. Reports of vivid dreams were associated with measures indicative of wellness: better sleep, a healthier diet, and longer times between meals (fasting). Results clarify the relationship between food and dreaming and suggest four explanations for the perception of food-dependent dreaming: (1) food specific effects; (2) food-induced distress; (3) folklore influences, and (4) causal misattributions. Research and clinical implications are discussed.

Alexithymia and eating disorders: a critical review of the literature

Alexithymia is characterized by difficulties identifying feelings and differentiating between feelings and bodily sensations, difficulties communicating feelings, and a concrete cognitive style focused on the external environment. Individuals with eating disorders have elevated levels of alexithymia, particularly difficulties identifying and describing their feelings. A number of theoretical models have suggested that individuals with eating disorders may find emotions unacceptable and/or frightening and may use their eating disorder symptoms (i.e., restricting food intake, bingeing, and/or purging) as a way to avoid or cope with their feelings. The current critical review synthesizes the literature on alexithymia and eating disorders and examines alexithymia levels across eating disorders (i.e., anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified), the role of alexithymia in binge eating disorder, and the influence of alexithymia on the development of eating disorders as well as treatment outcome. The clinical implications of the research conducted to date and directions for future research are discussed.

The role of emotional dysregulation in concurrent eating disorders and substance use disorders

This study explored the role of emotional dysregulation in 178 participants with concurrent EDs and SUDs. We ran two path analyses: Model 1 predicted negative mood regulation from alexithymia, and Model 2 predicted emotional eating from negative mood regulation. For Model 1, difficulty identifying and describing feelings was related to poor coping expectancies, while externally-oriented thinking was related to greater coping expectancies. For Model 2, poor coping expectancies in general were related to emotional eating, while greater coping expectancies in relation to behavior (i.e., the belief that some behavior or action can alleviate one's negative affect) also resulted in increased emotional eating. This finding suggests that there may be differences in the purpose of emotional eating; some people may believe that emotional eating can be used as an effective coping strategy to deal with negative affect.

Potential link between body dysmorphic disorder symptoms and alexithymia in an eating-disordered treatment-seeking sample

This study aimed to explore the manifestation of body dysmorphic disorder symptoms in a sample of people with eating disorders and to investigate possible associations between body dysmorphia and alexithymia. Forty patients currently seeking treatment for an eating disorder completed a battery of six measures assessing alexithymia, mood, eating behaviours, weight-related body image, body dysmorphia and non-weight related body image. Significant moderate positive correlations (Pearson's r) between selected variables were found, suggesting that participants with high levels of dysmorphic concern (imagined ugliness) have more difficulty with the affective elements of alexithymia, that is, identifying and describing feelings. When depression, eating attitudes, and weight-related body image concerns were controlled for, significant moderate positive correlations between this alexithymia factor and dysmorphic concerns remained present. An independent-samples t-test between eating-disordered participants with and without symptoms of body dysmorphic disorder (BDD) revealed significant group differences in difficulties identifying feelings. This pattern of results was replicated when the groups were identified on the basis of dysmorphic concerns, as opposed to BDD symptoms. This study highlights the associations between alexithymia and body dysmorphia that have not previously been demonstrated.

Brain dysfunction in anorexia nervosa: cause or consequence of under-nutrition?

PURPOSE OF REVIEW

Imaging studies that demonstrate loss of brain substance help explain why people with anorexia nervosa have cognitive deficits and may help to elucidate the cognitive style found in many patients. It is not known whether a neurobiological vulnerability predisposes to anorexia nervosa or if this is associated with maintenance of symptoms once the illness develops.

RECENT FINDINGS

Evidence emerging from functional neuro-imaging studies raise the possibility of a biological abnormality that may predispose to anorexia nervosa. Studies have found abnormal functioning in the frontal, limbic, occipital, striatal and cerebellar regions that may persist after recovery. However, most recent cross-sectional and prospective studies indicate improved cerebral activity and mixed findings in regards to neurocognitve function with recovery from anorexia nervosa.

SUMMARY

The elucidation of the neurobiology of anorexia nervosa has benefited from recent advances in neuro-imaging and cognitive neuroscience. Further research is needed to examine the degree to which abnormalities are a consequence of starvation or are caused by a putative anorexia nervosa endophenotype.

Eating Disorders – A Current Concern

Epidemiological data shows that Eating Disorders (ED) have been increasing over the past decades and have become one of the most common categories seen in outpatient settings. The EDNOS category – Eating Disorder Not Otherwise Specified – was included in DSM-IV, joining the traditional Anorexia and Bulimia categories. However, some controversy still exists about whether this inclusion is justified. For this reason we decided to examine the differences between ED groups and a population sample, and to compare the three subgroups using data from the Rorschach Comprehensive System. We compared 106 patients suffering from Eating Disorders with a population of 60 nonpatient subjects from a similar demographic subjects background. The ED group consists of 25 Anorexia, 27 Bulimia, and 54 EDNOS cases. We found that the three groups differ significantly from the nonpatient sample, and while they share some features, Anorexia differs from Bulimia and EDNOS. This last group presents differences in regard to introspective capacities. These differences may have an impact on therapy planning.

Anorexia nervosa: Valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice

Anorexia nervosa (AN) is highly valued by people with the disorder. It is also a highly visible disorder, evoking intense emotional responses from others, particularly those closest to the person. A maintenance model of restricting anorexia nervosa, combining intra- and interpersonal factors is proposed. Four main maintaining factors (perfectionism/cognitive rigidity, experiential avoidance, pro-anorectic beliefs, response of close others) are suggested and the evidence supporting these is examined. These factors need to be integrated with what is known about starvation-related maintenance factors. This model departs from other models of AN in that it does not emphasize the role of weight and shape-related factors in the maintenance of AN; that is, it is culture-free. Implications for clinical practice and research are discussed.

Eating disorders and multi-level models of emotion: an integrated model

This paper examines the relationship between emotions, depression and eating disorders. Initially, a review is undertaken of the current state of the research and clinical literature with regard to emotional factors in eating disorders. This literature is then integrated within a version of the multi-level model of emotion proposed by Power and Dalgleish. The aim of this paper is to incorporate a basic emotions, multi-modal perspective into developing a new emotions-based model that offers a theoretical understanding of psychological mechanisms in eating disorders. Within the new Schematic Propositional Analogical Associative Representation System model applied to eating disorders, it is argued that the emotions of anger and disgust are of importance in eating disorders and that the eating disorder itself operates as an inhibitor of emotions within the self. It is hoped that the development of a multi-levelled model of eating disorders will allow for the construction of number of specific testable hypotheses that are relevant to future research into the psychological treatment and understanding of eating disorders.

Emotional processing in women with anorexia nervosa and in healthy volunteers

Emotional processing was investigated in patients with anorexia nervosa (AN) and in healthy volunteers (HVs) using self report questionnaires and information processing tasks. Compared to the HVs, patients with AN had lower levels of self reported emotional awareness and expression. They also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words. There were no key differences between the two groups on non-emotional control tasks, suggesting that their deficits are specific to emotional information and not a general feature of the illness. Analysis indicated that some, but not all, of the differences found remained when depressive symptoms were taken into account. Exploratory analysis of sub-groups (medicated vs. unmedicated patients) indicated that those who were on medication may perform very differently from those who were not on medication, including when level of depression is controlled, although it is important to emphasise that these findings are preliminary. The implications of a deficit in emotional processing in those with AN, including discussion of the specific differences found between medicated and unmedicated, are discussed in relation to previous findings in the area. A number of implications for future research, theory and therapy with those with AN are discussed.

Emotional awareness and core beliefs among women with eating disorders

Patients with eating disorders have been shown to experience the emotional components of alexithymia-difficulties in identifying and describing emotions. In keeping with cognitive theories, which stress the role of schema-level beliefs in understanding emotions, this study examined the core beliefs that are associated with this difficulty in women with eating disorders. Seventy eating-disordered women completed standardised measures of core beliefs and alexithymia. There were no differences in alexithymia between diagnostic groups, so the women were treated as a single, transdiagnostic group. Multiple regression analyses showed specific patterns of association between the core beliefs and the emotional elements of alexithymia. Difficulties in identifying emotions were associated with entitlement beliefs, while difficulties in describing emotions were associated with both abandonment and emotional inhibition beliefs. These findings suggest that it may be necessary to work with core beliefs in order to reduce levels of alexithymia, prior to addressing the emotions that drive and maintain pathological eating behaviours.

Emotional responses to food, body dissatisfaction and other eating disorder features in children, adolescents and young adults

We aimed to assess and compare emotional responses to different foods in relationship to eating disorder and associated features, across gender and age groups. We hypothesized that negative emotional responses to images of foods would be higher in (i) those with higher body dissatisfaction and (ii) older females. Five hundred and thirty-six (18% Grade 5, 39% Grade 8 or 9, and 43% Grade 11 or 12) school, and 93 university students participated. Emotive responses to images of foods were assessed with a PowerPoint presentation of 16 differing food and four 'neutral' images shown over 30s intervals. Responses were rated on three 10-cm visual analog scales measuring levels of happiness, fear and disgust. Body image concern was assessed with the nine-item body dissatisfaction subscale of the EDI and eating disorder symptoms with the Eating Disorder Examination Questionnaire. With increasing age all three emotional responses towards food fell and body dissatisfaction increased. Compared to females, males showed significantly higher levels of a 'happy' response to food, and in adult females a fear emotive response correlated positively with eating concern and body dissatisfaction. In men, positive emotive responses to food may be indicative of broader factors that reduce their vulnerability to eating disorders.

Effects of distress, alexithymia and impulsivity on eating

OBJECTIVE

To improve our understanding of possible mechanisms underlying emotional overeating this study examined the effects of a distress manipulation on food intake in relation to alexithymia and impulsivity.

METHOD

Participants were 86 females who were subjected to a distress manipulation (the anticipation of a public speaking task) prior to an ad lib taste task and filled out questionnaires on impulsivity and the alexithymia constructs difficulty identifying and describing feelings.

RESULTS

Alexithymia significantly (p<.05) moderated the relationship between food consumption and distress. Instead of eating less in the distress condition, alexithymic females ate the same or even more, this showing a 'biological unnatural' and 'inapt' response.

CONCLUSION

Findings suggest that for the 'natural' distress response (reduction of food intake) good ability to identify and describe feelings to others is required, and that the presence or absence of these abilities may predict which people respond to distress by undereating or by overeating. The results provide empirical support for Bruch's conceptualisation of poor interoceptive awareness as possible predictive factor for emotional overeating.

Alexithymia and facial emotion recognition in patients with eating disorders

OBJECTIVE

Patients with anorexia or bulimia nervosa are reported to show high levels of alexithymia and to have difficulties recognizing facially displayed emotions. The current study tested whether it could be that facial emotion recognition is a basic skill that is independent from alexithymia.

METHOD

We assessed emotion recognition skills and alexithymia in a group of 79 female inpatients with eating disorders and compared them with a group of 78 healthy female controls. Instruments used were the Toronto Alexithymia Scale, the Facially Expressed Emotion Labeling (FEEL) test, and the revised Symptom Check List (SCL-90-R).

RESULTS

There were no significant differences between patients and controls in their emotion recognition scores, but patients with eating disorders displayed significantly more alexithymia and psychopathology. Emotion recognition in patients was not related to alexithymia, psychopathology, or clinical symptoms.

CONCLUSION

We suggest that the reported alexithymia of patients with eating disorders is complex and independent from basic facial emotion recognition.

Alexithymia in female patients with eating disorders

Previous studies indicate that patients with eating disorders have alexithymic characteristics, as revealed by the Toronto Alexithymia Scale (TAS). The aim of the present study was to investigate the role of negative affect (anxiety and depression) in the relationship between eating disorders and alexithymia. In addition, we have evaluated whether the relationship between negative affect and alexithymia varies according to the type of eating disorder (anorexia and bulimia). Eighteen female patients and 16 female patients who met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) diagnostic criteria for restrictive anorexia nervosa and bulimia nervosa, respectively, and 18 healthy female controls matched by age and education were submitted to Beck Depression Inventory and Spielberger State-Trait Anxiety Inventory to assess depression and anxiety and the Toronto Alexithymia Scale (TAS-20) and the Bermond Vorst Alexithymia Questionnaire (BVAQ) to evaluate alexithymic characteristics. The findings indicated that, although anorexic and bulimic patients showed higher alexithymia scores compared to controls, this result could be mainly related to negative affect. In fact, taking negative affect into account, anorexic and bulimic patients did not show higher TAS-20 and BVAQ scores compared to controls. The only variable useful to discriminate among anorexics, bulimics and controls is the perceived inability to experience emotional feelings, which is higher in anorexic patients compared to the other two groups.

Where do eating disorders lie on the diagnostic spectrum and what does it mean?

The aim of this paper is to review the concept of comorbidity as it pertains to eating disorders. The historical framing of eating disorders within medicine and psychiatry is described and then we move to what is understood by comorbidity in the current context of diagnostic compendiums. The issue of comorbidity highlights the unsatisfactory nature of the current description of illness phenotypes. There is a move to look for broader and more specific concepts such as that of endophenotypes, for example, in relationship to neuropsychology, and the response to reward and emotion. Finally, we consider how this approach may map onto treatment. For example, it may be necessary to have specific modules tailored to the relevant moderating and mediating factors.

Depressive personality dimensions and alexithymia in eating disorders

An association has been reported between high levels of alexithymia and depression in patients with eating disorders. This study has examined alexithymic features and depressive experiences in patients with DSM-IV eating disorder (restricting anorexia, n=105; purging anorexia, n=49; bulimia, n=98) and matched controls (n=279). The subjects were assessed with the Toronto Alexithymia Scale (TAS-20); the Beck Depression Inventory; and the Depressive Experiences Questionnaire, which defines two types of depressive personality style (dependent and self-critical). The patients had high levels of alexithymic features and depressive symptoms. Comparisons of alexithymic features between patients and controls after adjustment for depression showed a significant difference between bulimic patients and controls for the TAS Difficulty Identifying Feelings factor, and between restricting anorexic patients and controls for the TAS Difficulty Describing Feelings factor. With regard to depressive personality styles, only scores on the self-critical dimension were significantly higher in bulimic patients than in restricting anorexic patients and controls. In the entire group of eating disorders, dependency was associated with the TAS Difficulty Identifying Feelings factor only in anorexic patients. Self-criticism, on the other hand, was associated with the TAS Difficulty Identifying Feelings factor in all subtypes of eating disorders, although the relationship was significantly stronger in restricting anorexic than in bulimic patients. The results of this study suggest that people with restricting anorexia and bulimia show specific clinical profiles associating alexithymic features and depressive dimensions.

A neurodevelopmental model for anorexia nervosa

This paper integrates genetic and biological data on aetiological risk for anorexia nervosa (AN) with cognitive and psychosocial explanatory models. We have reviewed clinical and basic science data from each of these domains and then used a developmental perspective to formulate a multifactorial threshold model. By positioning interpersonal stress as a central component of this model, psychological, social and biological conceptualisations of AN can be used to generate a data driven, neurodevelopmental hypothesis for the aetiology of this complex disorder.

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.

Relationship between self-soothing, aloneness, and evocative memory in bulimia nervosa

OBJECTIVE

The relationship between characteristics of self-soothing ability, the capacity for evocative memory, and aloneness was investigated in a clinical sample of 50 bulimia nervosa (BN) patients.

METHOD

Individuals meeting DSM-III-R criteria for BN who participated in a randomized trial of guided imagery completed measures of Soothing Receptivity and a modified version of the UCLA-Loneliness scale, resulting in the Aloneness/Evocative Memory Scale.

RESULTS

A lower level of soothing receptivity (indicating a decreased capacity for self-soothing) was correlated with a decreased capacity for evocative memory. A lower level of soothing receptivity and decreased capacity for evocative memory were associated with a greater experience of aloneness.

DISCUSSION

Results suggest the need for a more comprehensive understanding of the role of affect regulation and the experience of aloneness in BN and the need to develop treatments to specifically address these features of the illness.

The development and clinical testing of an outpatient program for women with bulimia nervosa

This article describes the development of a cost-effective treatment program for women with Bulimia Nervosa (BN). A comprehensive review of the literature was undertaken to determine the most effective programs. The Time Limited Cognitive Behavioral Program (TLCBP) was developed and clinically tested on two groups of women to determine its cost-effectiveness. The program consisted of a 12-week intervention phase followed by a 14-week support/reinforcement phase. The clinical findings were that 9 of the 10 clients were abstinent following the 12-week intervention. Other symptoms improved following the 14-week phase of support/reinforcement. Utilizing an Advanced Practice Psychiatric-Mental Health Registered Nurse (APRN) significantly reduced the cost of the treatment, as did the use of a group model approach. APRN's have bio-behavioral knowledge as well as research skills. They are in a unique position to conduct outcome research with women with BN, as well as with clients who have other disorders with both biological and behavioral symptoms.

A comparison of inpatient and outpatient women with eating disorders

The purpose of this study was to compare two groups of women with eating disorders, one inpatient and one outpatient, on selected variables. The study was undertaken to clarify differences in the two samples about (1) current standards/criteria for hospitalization of individuals with eating disorders, (2) the criteria for inpatient/outpatient treatment selection, and (3) definition of severity of illness. Six hypotheses were developed and tested by using t-test, chi(2), and discriminant function analysis. The findings supported the current standards for practice. Compared with the outpatient group the inpatient group had significantly more reported physical signs and symptoms, were more anxious and depressed, had more somatization, and had more prior hospitalizations. Prior hospitalization and physical signs, along with the eating disorder dimension, ineffectiveness, were the best predictors of hospitalization. Implications for practice that focus on more comprehensive assessments and early detection of eating disorders are presented.

Eating attitudes in female college students with self-reported alexithymic characteristics

Several studies have indicated that there is a close relationship between eating attitudes and alexithymic characteristics. In this study, the influence of parental bonding on the association of alexithymic characteristics and eating attitudes was examined in a sample of 580 college students. Multivariate analyses of variance indicated that female students with two alexithymic characteristics, difficulty identifying feelings and difficulty describing feelings, exhibited more abnormal eating attitudes (poor oral control). Multivariate analysis of covariance gave significant associations with maternal care. Although these subjects were not patients with eating disorders the results suggest that the two alexithymic characteristics studied were associated with lack of maternal care and are a risk factor for eating disorders.

Alexithymic characteristics of bulimia nervosa in diabetes mellitus with end-stage renal disease

This study examined the clinical characteristics including stress-related factors of eating disorders in a sample of 312 diabetic patients with end-stage renal failure. The prevalence rate of bulimia nervosa was 5.1% (16 of 312 patients). The 16 patients with bulimia nervosa were 8 men and 8 women over 58 years old. Looking at the subjects by cause of end-stage renal failure, those with diabetes mellitus exhibited significantly higher prevalence rate of bulimia nervosa than two nondiabetic groups (diabetes 10%; nephritis 1.6%; others 1.9%). As for the association of bulimia nervosa and stress-related factors, end-stage renal failure patients with diabetes who exhibited bulimia nervosa showed significantly higher scores on a measure of alexithymia. These results suggest that, when liaison psychiatrists see diabetic patients with end-stage renal failure who exhibit bulimia nervosa, they should pay close attention to stress-related symptoms including alexithymia.

How are alexithymia and physical illness linked? A review and critique of pathways

We review the empirical literature and critique four possible pathways linking alexithymia and physical illness; (a) alexithymia leads to organic disease through physiological or behavioral mechanisms: (b) alexithymia leads to illness behavior (physical symptoms, disability, excessive health care use) through cognitive or social mechanisms: (c) physical illness leads to alexithymia; and (d) both alexithymia and physical illness result from sociocultural or biological factors. Our review suggests that alexithymia is associated with tonic physiological hyperarousal, certain types of unhealthy behavior, and a biased perception and reporting of somatic sensations and symptoms. Alexithymia also appears to influence health care use, but in a complex fashion. Although trauma may give rise to alexithymia, whether physical illness such as chronic pain does so is not known, and there is little evidence that sociocultural or biological factors lead to both alexithymia and physical illness. We conclude that alexithymia probably influences illness behavior, but there is little support for the hypothesis that alexithymia leads to chronic organic disease, especially when one distinguishes organic disease from illness behavior.

Relationships between alexithymia and psychological characteristics associated with eating disorders

This study examines the relationships between alexithymia and psychological characteristics and behaviors that are commonly associated with eating disorders. The 20-item Toronto Alexithymia Scale (TAS-20) and the Eating Disorder Inventory (EDI) were administered to a group of 48 female patients with anorexia nervosa, a matched comparison group of 30 normal women, and an unmatched comparison group of 116 male and 118 female university students. In the anorexic and male student groups, the TAS-20 correlated significantly and positively with the EDI subscales, Ineffectiveness, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. The TAS-20 correlated significantly only with Interpersonal Distrust in the matched comparison group, and only with Ineffectiveness and Interpersonal Distrust in the female student group. The results suggest that alexithymia is related to several psychological traits that are characteristic of patients with eating disorders and thought to play a role in the development of the disorders but is unrelated to attitudes and behaviors concerning abnormal eating and body weight and shape.