Alexithymia, depression, and treatment outcome in bulimia nervosa

Direct and indirect effects of adverse and protective childhood experiences on symptom improvement in psychotherapy

To investigate the effects of adverse and protective childhood experiences on symptom improvement in outpatient psychotherapy.

We evaluated n = 648 completed outpatient psychodynamic psychotherapies. First, we estimated the rate of symptom improvement for each patient using a two-stage hierarchical linear model. We then calculated the direct and indirect influences of childhood experiences on the improvement rate using a structural equation model. Personality functioning, according to the Operationalized Psychodynamic Diagnosis system, was examined as being a possible mediating factor.

The presence of adverse childhood experiences was directly associated with a slower improvement rate in psychotherapy. Moreover, a higher number of adverse childhood experiences was associated with greater impairments in the ability to communicate as one dimension of personality functioning, which in turn was associated with a slower improvement of symptoms. Protective childhood experiences were associated with fewer impairments in specific dimensions of personality functioning, but had no direct effect on the improvement rate.

Adverse childhood experiences can directly influence the course of psychotherapy. In addition, the communication dimension of personality functioning appears to be a central mediator on which adverse and protective childhood experiences act antagonistically and can thus indirectly affect the improvement rate in psychotherapy.

Effects of DBT-based interventions on alexithymia: a systematic review

While dialectical behavior therapy (DBT) appears effective for some psychiatric conditions commonly associated with alexithymia, it is unclear whether DBT improves difficulties experienced by alexithymic individuals. This review investigated the current evidence on the effectiveness of DBT-based interventions in improving alexithymia. A qualitative synthesis of studies that investigated the efficacy of DBT on self-reported alexithymia was performed, identifying eligible studies using EBSCO/Essentials, Google Scholar, PubMed, Web of Science, and PsychINFO databases. Eight studies were identified. Overall, the results were inconclusive due to the heterogeneity of the studies but suggest that DBT-based interventions may be associated with self-reported decreases in alexithymia and increases in the ability to identify emotional states. The literature is limited by significant methodological problems, such as the low number of controlled trials, small samples, and high variability between DBT programs, which increases the risk of bias across study outcomes. More research is needed to reach conclusions regarding the effectiveness of DBT in improving alexithymia. Future studies should conduct randomized controlled trial designs (primarily with active treatment control conditions), greater standardization of DBT-based interventions, and a more in-depth examination of the level of participant involvement in long-term DBT-based interventions may help to understand whether DBT improves alexithymia difficulties.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

How Does Psychological Distress Due to the COVID-19 Pandemic Impact on Internet Addiction and Instagram Addiction in Emerging Adults?

International research has underlined a worrying increase in Internet and Instagram addiction among emerging adults during the COVID-19 pandemic. Although the role played by alexithymia and psychological distress due to COVID-19 has been evidenced, no study has explored their complex relationship in predicting emerging adults' Internet and Instagram addiction. The present study aimed to verify whether peritraumatic distress due to the COVID-19 pandemic mediated the relationship between emerging adults' alexithymia and their Internet/Instagram addiction, in a sample composed of n = 400 Italian emerging adults. Results showed that females had higher peritraumatic distress due to COVID-19 than males, whereas males had higher externally oriented thinking and higher levels of Internet addiction than females. Emerging adults' psychological distress due to COVID-19 significantly mediated the effect of alexithymia on Internet and Instagram addiction. Our findings supported the presence of a dynamic relationship between individual vulnerabilities and the co-occurrence of other psychological difficulties in predicting emerging adults' Internet and Instagram addiction during the pandemic, with important clinical implications.

Alexithymia and Somatization in Agenesis of the Corpus Callosum

Deficient communication between the cerebral hemispheres is one of several prevailing neurobiological explanations for alexithymia and has been strongly supported by research on patients with commissurotomy. We examined self-reported symptoms of alexithymia in adults with agenesis of the corpus callosum (AgCC), a condition characterized by more subtle reductions in interhemispheric transfer than in commissurotomy. 16 adults with AgCC and FSIQ > 80 were compared with 15 age- and IQ-matched neurotypical controls. The AgCC group endorsed greater difficulty identifying and describing feelings and more vague physical symptoms than controls, but similar levels of emotional experience and emotional coping. This finding of impaired emotional interpretation with intact emotional experience is consistent with findings in callosotomy patients, implicating the critical role of the corpus callosum in cognitive dimensions of emotion processing. Further study of alexithymia in AgCC using task-based measures may help clarify the nature of this relationship.

[Alexithymia and its relation with eating disorders and obesity]

This manuscript provides a review of current literature on the relationship between overweight and alexithymia as a psychological factor associated with obesity, as well as the role of alexithymia in the development of various abnormalities and eating disorders (ED). Obesity is a multifactorial disease, and lifestyle characteristics are the most important pathogenetic links on its development, as well as a complex of genetic, epigenetic, biological and psychological factors that cause accumulation of excessive fat and prevent effective reduction and retention of body weight. One possible reason for the increased prevalence of obesity in adults is poor emotional management, which can affect healthy eating behavior and lifestyle. It was found that overweight and obese people have a high prevalence of alexithymia, and also the study shows its prognostic role in the development of ED. Alexithymia is a factor that not only predisposes to weight gain, but is also a significant predictor of inefficiency and premature termination of programs for the treatment of obesity and ED. Timely diagnosis and correction of alexithymic syndrome can help in developing the effective treatment strategies for obese patients.

The Impact of Alexithymia on Treatment Response in Psychiatric Disorders: A Systematic Review

Treatment of psychiatric disorders relies heavily on a trial and error approach, often prolonging the time required to obtain symptomatic improvements. The identification of reliable predictors of treatment response is instrumental to enact an individualized approach. Alexithymia represents a personality trait reflecting an intrinsic difficulty in recognizing the emotional components of subjective experiences. Thus, its modulating role on treatment outcome has gathered substantial attention during the past years. In the present paper, we aimed at exploring the available evidence for Alexithymia role in influencing the treatment outcome on a wide range of psychiatric conditions by means of a systematic review.

DATA SOURCE

We performed a systematic review in Medline and Scopus, augmented by tracking the reference list of the pertinent articles.

INCLUSION CRITERIA

To be included in this review, research studies had to assess alexithymia impact on a treatment intervention delivered to manage a primary psychiatric disorder.

STUDY EVALUATION AND DATA SYNTHESIS

After removing duplicates, titles were screened first, then abstracts, and last full texts were read, eventually leading to the inclusion or exclusion of the papers according to the criteria established before the online search. Then results of the search were downloaded in.xml format and uploaded in Rayyan, a free web software, that helps expedite the initial screening of abstracts and titles using a process of semi-automation while incorporating a high level of usability. After uploading, screening of the literature was performed in blind by two investigators. Disagreement between reviewers was resolved by joint discussion with a third senior investigator. The quality of evidence was assessed using the Newcastle Ottawa Scale. Thereafter, the data considered relevant was extracted and synthetized in this paper.

RESULTS

Our search yielded a total of 30 articles dealing with a wide range of psychiatric conditions and exploring both pharmacological and psychotherapeutic interventions. Several lines of evidence suggest a complex role for alexithymia in influencing the psychiatric treatment outcome, further underscoring the need for additional research in this area to better address the existing knowledge gaps.

The association between alexithymia and eating behavior in children and adolescents

OBJECTIVE

Alexithymia, or the difficulty identifying or describing one's own emotions, may be a risk factor for dysregulated eating and excess weight gain. However, the relationships between alexithymia and eating behaviors in community samples of non-clinical youth have not been well-characterized. We hypothesized that alexithymia would be positively associated with disordered and disinhibited eating in a community-based sample of boys and girls without an eating disorder.

METHOD

Two hundred children (8-17 years old) across the weight spectrum completed an interview to assess loss of control (LOC) eating and eating-related psychopathology, a laboratory test meal designed to induce disinhibited eating, and questionnaires to assess alexithymia, eating in the absence of hunger, and emotional eating. Linear and logistic regressions were conducted to examine the relationship between alexithymia and eating variables, with age, sex, race, and fat mass as covariates. Test meal analyses also adjusted for lean mass. Given the overlap between alexithymia and depression, all models were repeated with depressive symptoms as an additional covariate.

RESULTS

Alexithymia was associated with an increased likelihood of reporting LOC eating (p < .05). Moreover, alexithymia was positively associated with disordered eating attitudes, emotional eating, and eating in the absence of hunger (ps < .05). Greater alexithymia was associated with more carbohydrate and less fat intake at the test meal (ps < .05). After adjusting for depressive symptoms, alexithymia remained associated with eating in the absence of hunger and carbohydrate and fat intake (ps < .05).

DISCUSSION

In healthy children, alexithymia is associated with some facets of eating behavior and food intake. If supported prospectively, these preliminary findings suggest alexithymia may be a modifiable risk factor to reduce disordered eating and excess weight gain in youth.

Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study

BACKGROUND

Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in some mental disorders such as Borderline Personality Disorder (BPD). Some studies have suggested that Eating Disorders (EDs) may also be associated with impairments in mentalizing, but studies have not always yielded consistent results. This is the first study to systematically investigate mentalizing impairments in patients with Bulimia Nervosa (BN) compared with controls. In addition, we investigated whether impairments in mentalizing were related to BPD features, rather than BN per se, given the high comorbidity between BPD and BN.

METHODS

Patients with BN (n = 53) and healthy controls (HCs; n = 87) completed a battery of measures assessing mentalizing including the Reflective Function Questionnaires (RFQ), the Object Relations Inventory (ORI; Differentiation-Relatedness Scales) and the Reading The Mind in The Eyes Test (RMET).

RESULTS

Patients with BN scored significantly lower than HCs on all tests of mentalizing, with moderate to large between-group effect sizes. These differences were partially accounted for by BPD features as assessed with the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and partially by bulimic symptoms measured with the Eating Disorder Examination Questionnaire (EDE-Q).

CONCLUSIONS

Patients with BN have significantly lower levels of mentalizing as assessed with a broad range of tests compared to HCs. These differences were related to both bulimic symptoms and BPD features. Although further research in larger samples is needed, if replicated, these findings suggest that poor mentalizing may be a significant factor in BN patients and should be addressed in treatment, regardless of the presence of BPD features.

Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature

Depression affects around 4-10% of the general population in England. Depression can often lead to behaviors and thoughts related to suicide and aggression, which have a social and economic burden to the United Kingdom. One construct that has been theorized as having an association with these behaviors is alexithymia. People with alexithymia have difficulties identifying and describing their emotional experiences. To date, there is no consensus on types or causes of alexithymia. Whilst the literature evidences a strong relationship between alexithymia and suicidality and aggression, little is known about the nature of this relationship. The present article will attempt to describe the extant literature on this relationship, drawing out some of the contentions and unanswered questions.

Association of Internet addiction and alexithymia - A scoping review

It has been hypothesized that individuals with alexithymia who have difficulty in identifying, expressing, and communicating emotions may overuse Internet as a tool of social interaction to better regulate their emotions and to fulfill their unmet social needs. Similarly, an increasing body of evidence suggests that alexithymia may also play an essential role in the etiopathogenesis of addictive disorders. We conducted a scoping review of questionnaire-based studies of problematic Internet use/Internet addiction and alexithymia. From initial 51 studies, all of the final 12 included studies demonstrated a significant positive association between scores of alexithymia and severity of Internet addiction. However, the causal direction of the association is not clear because the interplay of numerous other variables that could affect the relation has not been studied. There are limitations in the methodology of the studies conducted. Hence, we emphasise the need for longitudinal studies with stronger methodologies.

Emotion differentiation mediates the association between emotion regulation difficulties and caloric intake

Emotion differentiation is the ability to identify and label emotional experiences into discrete categories. The present study examined the influence of emotion regulation difficulties, emotion differentiation, and emotional state-specifically sad versus positive mood-on caloric intake in a laboratory setting. Undergraduate participants completed a series of questionnaires, including measures of emotion regulation difficulties and emotion differentiation, and then underwent a randomly assigned sad or positive mood induction. Afterwards, they participated in a taste test. Food was counted before and after the taste test to determine total caloric intake. Results showed that negative emotion differentiation was significantly inversely associated with overall caloric intake, such that low negative emotion differentiators ate more regardless of mood induction group. Positive emotion differentiation was not associated with caloric intake. Additional analysis found that negative emotion differentiation mediated the relation between emotion regulation difficulties and caloric intake. An alternative model found that emotion regulation difficulties did not mediate the relation between negative emotion differentiation and caloric intake. Our results suggest that reducing caloric intake among individuals with emotion regulation difficulties may involve incorporating strategies to specifically target the ability to differentiate between emotions.

Short-Term Psychodynamic Psychotherapy with Mentalization-Based Techniques in Major Depressive Disorder patients: Relationship among alexithymia, reflective functioning, and outcome variables - A Pilot study

OBJECTIVES

In depressed patients, recent advances have highlighted impairment in mentalizing: identifying and interpreting one's own or other's mental states. Short-Term Psychodynamic Psychotherapy (STPP) has proven to be effective in reducing symptoms and improving relational/functional abilities in these subjects. Therefore, the first aim of our study was to evaluate effectiveness of STPP with Mentalization-Based Techniques (STMBP) on their clinical outcomes and the second, to investigate Reflective Functioning and alexithymia concerning treatment outcomes in depressed subjects.

DESIGN

A baseline evaluation of reflective functioning, alexithymia and depression was conducted before an STMBP treatment. Patients were re-tested successively after 40 weeks (T1) and in a follow-up after 1 year at the end of the treatment (T2).

METHODS

A total of 24 patients principally diagnosed with Major Depressive Disorder (MDD) underwent a STMBP conducted by two expert therapists. Global Assessment Functioning (GAF), Toronto Alexithymia Scale-20 (TAS-20) and Hamilton Depression Rating Scale (HAM-D) data were collected at the baseline (T0) by two clinical therapists, along with RF scores rated by two trained raters. HAM-D, TAS-20 and GAF follow-ups were conducted at the end of the treatment after 40 weeks (T1) and after 1-year follow-up (T2).

RESULTS

Results highlighted an improvement of both HAM-D and TAS-20 scores in our sample. Moreover, a negative correlation between RF and TAS-20 was found. Both HAM-D and RF at T0 influenced depressive outcomes at the end of the treatment.

CONCLUSIONS

Results confirmed the effectiveness of STMBP in MDD, suggesting also an inverse association between RF and alexithymia.

PRACTITIONER POINTS

Our study demonstrates how STMBP could be effective in MDD even after 40 sessions, maintaining its effect in a 1-year follow-up. STMBP improves subjective capability of reflecting on the mental states of oneself and others. Our intervention allows patients to orientate thoughts from inside to outside, reducing negative beliefs also in absence of a pharmacological therapy (during the follow-up).

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.

Brain correlates of alexithymia in eating disorders: A voxel-based morphometry study

AIMS

Alexithymia is a personality trait that consists of difficulty in identifying and acknowledging one's own and others' feelings. Recent studies reported that alexithymia is present in both anorexia (AN) and bulimia nervosa (BN). Brain morphological studies on healthy subjects showed that alexithymia correlates with several brain regions involved in emotions processing. The aim of this study was to investigate the anatomical correlates of alexithymia in AN and BN.

METHODS

We performed a voxel-based morphometry study on 21 patients with AN and 18 with BN. Seventeen healthy subjects were used as a control group. Alexithymia, depression and anxiety were assessed with self-administered questionnaires and correlated to gray matter (GM) density in each group.

RESULTS

In BN, alexithymia was correlated with the GM of the parietal lobe, in particular of the right angular gyrus. The correlation was predominantly linked with Difficulty Describing Feelings. In AN, we did not find correlations between GM and alexithymia.

CONCLUSIONS

In BN, our results support the hypothesis that this trait may represent a relevant pathogenic or maintenance factor that contributes to relational difficulties, present in this pathology. In AN, the lack of correlation between GM volume and alexithymia may be influenced by atrophy in several brain regions that in turn can be, as previously reported, a consequence of caloric restriction. Also, the nature of alexithymia may be different from that of BN and controls and this trait could be secondary to a psychopathologic process specific to AN.

Psychodynamic profile and reflective functioning in patients with bulimia nervosa

OBJECTIVE

The aim of this study was to examine the general psychological functioning of patients suffering from bulimia nervosa (BN) using the Karolinska Psychodynamic Profile (KAPP). Furthermore, KAPP data and data from the Reflective Functioning scale (RF), measuring the ability to mentalize, were combined in order to examine differences in alexithymia, impulse control and affect regulation in patients with high or low RF.

METHOD

Seventy patients with BN were interviewed with both the KAPP and the Adult Attachment Interview (AAI) from which RF is coded. Differences in KAPP scores of patients with high or low RF were analyzed.

RESULTS

Most of the patients with BN were found to have a personality structure within the normal or neurotic range (n=50 of 70). BN patients with a high RF had significantly lower scores on KAPP's alexithymia scale than patients with a low RF score, demonstrating that poor mentalizing is related to alexithymia. Concurrently, patients with high RF showed problems with impulse control and coping with aggressive affects according to KAPP scores.

CONCLUSION

Although BN patients with high RF showed good capacities for describing their mental states, they still had difficulties regulating the emotions and impulses related to these states.

SIGNIFICANT OUTCOME

Among patients suffering from BN, patients with high RF were significantly less alexithymic than low RF patients.

LIMITATIONS

The findings of this study are limited by the relatively small numbers of participants especially in the RF subgroups, posing a danger of not finding as significant existing differences in character pathology between high and low RF groups.

A longitudinal study on emotional dysregulation and obesity risk: From pregnancy to 3 years of age of the baby

Some recent findings indicate that maternal sensitivity and emotional regulation may play a key role in predicting the risk for obesity of the child in early ages. The current article describes a longitudinal study encompassing more than 50 women, across a time-span that currently goes from pregnancy (n = 65) to three years of age of the baby (n = 53). In a previous report on our ongoing research project, we showed that emotional regulation during pregnancy and pre-pregnancy BMI significantly predicted the quality of the early, dyadic feeding interactions, at 7 months of age of the baby. The current study confirmed and extended those findings, by showing that maternal emotional dysregulation (r = .355, p = .009) and pre-pregnancy BMI (r = .389, p = .004) predicted the BMI of the child at three years of age too, with a medium to large effect size. However, neither maternal emotional regulation nor pre-pregnancy BMI significantly predicted infant attachment at one year of age.

Electrophysiological evidence for an attentional bias in processing body stimuli in bulimia nervosa

Empirical evidence suggests abnormalities in the processing of body stimuli in bulimia nervosa (BN). This study investigated central markers of processing body stimuli by means of event-related potentials in BN. EEG was recorded from 20 women with BN and 20 matched healthy controls while watching and evaluating underweight, normal and overweight female body pictures. Bulimics evaluated underweight bodies as less unpleasant and overweight bodies as bigger and more arousing. A higher P2 to overweight stimuli occurred in BN only. In contrast to controls, no N2 increase to underweight bodies was observed in BN. P3 was modulated by stimulus category only in healthy controls; late slow waves to underweight bodies were more pronounced in both groups. P2 amplitudes to overweight stimuli were correlated with drive for thinness and body dissatisfaction. We present novel support for altered perceptual and cognitive-affective processing of body images in BN on the subjective and electrophysiological level.

Alexithymia in eating disorders: therapeutic implications

A high percentage of individuals affected by eating disorders (ED) achieve incomplete recovery following treatment. In an attempt to improve treatment outcome, it is crucial that predictors of outcome are identified, and personalized care approaches established in line with new treatment targets, thus facilitating patient access to evidence-based treatments. Among the psychological factors proposed as predictors of outcome in ED, alexithymia is of outstanding interest. The objective of this paper is to undertake a systematic review of the literature relating to alexithymia, specifically in terms of the implications for treatment of ED. In particular, issues concerning the role of alexithymia as a predictor of outcome and as a factor to be taken into account in the choice of treatment will be addressed. The effect of treatments on alexithymia will also be considered. A search of all relevant literature published in English using PubMed, PsycINFO, and Scopus databases was carried out on the basis of the following keywords: alexithymia, anorexia nervosa, bulimia nervosa, eating disorders, and treatment; no time limits were imposed. Despite the clinical relevance of alexithymia, the number of studies published on the above cited aspects is somewhat limited, and these studies are largely heterogeneous and feature significant methodological weaknesses. Overall, data currently available mostly correlate higher levels of alexithymia with a less favorable outcome in ED. Accordingly, alexithymia is seen as a relevant treatment target with the aim of achieving recovery of these patients. Treatments focusing on improving alexithymic traits, and specifically those targeting emotions, seem to show greater efficacy, although alexithymia levels often remain high even after specific treatment. Further investigations are needed to overcome the methodological limitations of previous studies, to understand the actual impact of alexithymia on ED outcome, and to allow more precise implications for treatment to be drawn. Additional research should also be undertaken to specify which of the alexithymic dimensions are specifically relevant to the course and outcome of ED, and to identify treatment protocols producing a significantly greater efficacy in ED patients with relevant alexithymic traits.

Alexithymia components in excessive internet users: a multi-factorial analysis

The increasing use of computers and the internet - especially among young people - apart from its positive effects, sometimes leads to excessive and pathological use. The present study examined the relationship among the excessive use of the internet by university students, the alexithymia components and sociodemographic factors associated with internet users and their online activities. 515 university students from the University of Thessaly participated in the study. Participants anonymously completed: a) the Internet Addiction Test (IAT), b) the Toronto Alexithymia Test (TAS 20) and c) a questionnaire covering various aspects of internet use and demographic characteristics of internet users. Excessive use of the internet among Greek university students was studied within a multi-factorial context and was associated with the alexithymia and demographic factors in nonlinear correlations, forming thus a personalized emotional and demographic profile of the excessive internet users.

The impact of maternal overweight and emotion regulation on early eating behaviors

Empirical data indicate that the risk for childhood obesity and overweight increases when one or both parents are overweight or obese. Such an association, however, cannot be entirely explained only by biological factors. Based on available literature, we hypothesized that maternal emotion regulation might play a role in explaining the intergenerational transfer of overweight and obesity. We conducted a quasi-experimental, longitudinal study: (step I) during the third trimester of pregnancy of 65 Italian women (33 overweight and 32 non-overweight), the Difficulties in Emotion Regulation Scale were administered to assess the quality of their emotion regulation strategies; and (step II) seven months after the delivery, the feeding interactions between the participants and their babies were evaluated in a 20-minute video-recording, by using the Italian version of the Observational Scale for Mother-Infant Interaction during Feeding. When compared to the non-overweight group, the overweight group had more difficulties in emotion regulation, was more psychologically distressed, and had poorer feeding interactions with their babies. Perhaps more importantly, the extent to which the participants were suffering difficulties in emotion regulation during pregnancy predicted, significantly, and beyond the effects of pre-pregnancy maternal weight, the quality of the mother-child feeding interactions 7months after the delivery.

Nothing Tastes as Good as Thin Feels: Low Positive Emotion Differentiation and Weight Loss Activities in Anorexia Nervosa

Positive emotion (PE) has not been well studied in anorexia nervosa. Low positive emotion differentiation (PED), which involves a diminished ability to distinguish between discrete positive emotions, may contribute to positive emotion dysregulation in anorexia. Specifically, low PED may interact with elevated PE intensity to both motivate and reinforce weight loss and evaluation behaviors. Using ecological momentary assessment, we examined PE and weight loss behaviors reported over two weeks. As hypothesized, low PED predicted more vomiting, laxative-use, exercising, weighing, checking for fat, and restricting. Furthermore, those with low PED who experienced elevated average PE intensity reported even more frequent behaviors. Within-person analyses indicated that, for those with low PED, more weight loss behaviors at one recording predicted elevated PE at the subsequent recording. Similarly, for those with low PED higher momentary PE predicted more subsequent weight loss behaviors. Thus, low PED in anorexia may reinforce and motivate weight loss behavior.

Toronto alexithymia scale for patients with eating disorder: [corrected] performance using the non-parametric item response theory

BACKGROUND

The aim of this study was to investigate the performance of the Toronto Alexithymia Scale (TAS-20) in patients with eating disorders. As a secondary objective, we analyzed a subset of items in order to determine whether the total score is a good tool for classifying these patients and whether the items are ordered according to the difficulty of choosing a particular answer depending on the severity of the patient's condition.

SUBJECTS AND METHODS

We administered the TAS-20 to 103 consecutive patients who met DSM-IV-R criteria for anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified. Mokken scale analysis, nonparametric item response theory (NIRT), and confirmatory factor analysis (CFA) were used to test the psychometric properties of the scale. To improve our understanding of the structure underlying the TAS-20, we used an automated item selection procedure based on the Mokken scale.

RESULTS

We identified a subset of 13 independent and clinically interpretable items that are potentially sufficient to rate patients with alexithymia. This subset was considered a unidimensional reduction of the TAS-20. However, the scale composed of this subset needs to be validated. Thirteen of the 20 items were maximally related to alexithymia because they have a one-dimensional structure. The NIRT and CFA enabled us to identify a maximal subset of items that conform to the requirements for good measurement of alexithymia in patients with eating disorders.

Changes in alexithymia following psychological intervention: a review

Alexithymia, a deficit characterized by difficulties identifying, differentiating, and articulating emotions, is associated with significant physical and mental health impairment. It is generally accepted that alexithymia has a negative impact on a variety of physical and mental health treatments. Less clear is the extent to which alexithymia itself can be modified. In this article we review studies that have examined the effects of psychological interventions on alexithymia. Taken together, findings from investigations included in this review suggest that alexithymia is partly modifiable with therapeutic interventions. Studies that directly targeted alexithymic symptoms tended to report significant reductions in alexithymia scores following treatment, whereas studies that measured changes in alexithymia but did not employ any psychological interventions specifically intended to treat alexithymia had more inconsistent results. We close by considering the practical implications of the findings, and by offering suggestions for future research.

Alexithymia and gambling: a risk factor for all gamblers?

The purpose of this study was to investigate alexithymia (in relation with depression) in three groups of French gamblers (n = 186) recruited in their gambling location: at the racetracks (n = 80 males; mean age 28.1 years), in the slot machine rooms (n = 65; 29 males, 36 females; mean age 34.6 years), and in the traditional gaming rooms (n = 41 males; mean age 36 years). Gambling behavior was measured by the South Oaks Gambling Screen and DSM-IV criteria for pathological gambling, Alexithymia by the Toronto Alexithymia Scale (TAS-20) and depression with the Beck Depression Inventory (BDI-13). For racetracks and slot machine gambling, pathological gamblers differed from non-pathological gamblers, regarding their alexithymia scores. These results remained stable after controlling for depression scores among the racetracks gamblers only. The relationship between alexithymia and depression depends on the type of pathological gambler. These findings are consistent with the idea of identifying clinically distinct subgroups of gamblers.

The role of depression and impulsivity in the psychopathology of bulimia nervosa

INTRODUCTION

The study aimed to analyze the role of depression and impulsivity in the psychopathology of bulimia nervosa (BN).

MATERIALS AND METHODS

Seventy female patients with DSM-IV BN, purging subtype, were assessed for eating-related symptoms, body dissatisfaction, affective symptoms, impulsivity, and personality traits. Factor analysis and structural equation modeling methods were used for statistical analysis.

RESULTS

BN appeared as a condition which incorporated 5 general dimensions: a) binge eating and compensatory behaviours; b) restrictive eating; c) body dissatisfaction; d) dissocial personality traits; and e) a cluster of features which was called «emotional instability» The 5 obtained dimensions can be grouped into 2 basic factors: body dissatisfaction/eating behaviour and personality traits/psychopathology. The first one contains the clinical items used for the definition of BN as a clinical condition in the DSM-V and the International Classification of Diseases 10, and reflects the morphology and the severity of the eating-related symptoms. The second dimension includes a cluster of symptoms (depressive symptoms, impulsivity, and borderline, self-defeating and dissocial personality traits) which could be regarded as the «psychopathological core» of BN and may be able to condition the course and the prognosis of BN.

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.

Alexithymia in Chinese chronic obstructive pulmonary disease (COPD) patients: the prevalence and related factors of alexithymia

In this study, 53 Chinese COPD moderate outpatients and 50 health controls, matched for age, family income and education level, were recruited to assess the prevalence of Alexithymia and its relationship to socio-demographic factors and pulmonary function. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS-20). The patients' socio-demographic variables and the forced expiratory volume in one second percentage of predicted (FEV(1)% predicted) were recorded. The results indicated that alexithymia was significantly more common in the Chinese COPD patients than in controls. Male patients presented higher TAS-20 total scores and externally oriented thinking (EOT) scores than the females. Elder age and higher family income were connected with the patients' lower TAS-20 indexes (except for difficulty identify feeling [DIF]). All the TAS-20 indexes were negatively associated with FEV(1)% predicted. These findings suggested that, in the management of COPD, alexithymia feature should not be ignored and the appropriate psychotherapeutic treatment for Alexithymia should be applied.

Cultural adaptation of the difficulties in emotion regulation scale: reliability and validity of an Italian version

OBJECTIVE

The aim of this study was to evaluate the reliability and validity of an Italian version of the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004).

METHOD

Three studies were completed. First, factorial structure, internal consistency, and concurrent validity of our Italian version of the DERS were examined with a sample of 323 students (77% female; mean age 25.6). Second, test-retest analyses were completed using a different sample of 61 students (80% female; mean age 24.7). Third, the scores produced by a small clinical sample of participants (N = 38; mean age = 24.2) affected by anorexia, binge eating disorder, or bulimia were compared to those of an age-matched, nonclinical female sample (N = 38; mean age = 24.7).

RESULTS

The factorial structure replicated quite well the six-factor structure proposed by Gratz and Roemer. The internal consistency and test-retest reliability were adequate and comparable to previous findings. The validity was good, as indicated by both the concurrent validity analysis and the clinical-nonclinical sample comparison.

CONCLUSIONS

These studies provide further support for the multidimensional model of emotion regulation postulated by Gratz and Roemer and strengthen the rationale for cross-cultural utilization of the DERS.

The neurocognition of alexithymia: evidence from neuropsychological and neuroimaging studies

OBJECTIVE

Alexithymia refers to an ineffective regulation and expression of emotions. It constitutes a major risk factor for a range of medical and psychiatric problems, including chronic pain, somatisation, anxiety and depression. Alexithymia is a multi-faceted concept, described in terms of cognitive and affective aspects. From a neuropsychological perspective, alexithymia can be defined as a disturbance in affective information processing and social cognition. As the growing literature on brain structures involved in alexithymia is fragmented and sometimes even contradictory, the aim of this article was to review findings on neural substrates with regard to their convergence.

METHODS

A narrative review was performed, including both early neuropsychological and more recent imaging studies, in order to achieve a better understanding of the aetiology of alexithymia.

RESULTS

Corpus callosum, cingulate cortex and insula are clearly involved in alexithymia. The amygdala and the orbitofrontal part of the cortex appear to be implicated as mediators, because of their broader involvement in emotional processing and executive control.

CONCLUSION

Notwithstanding the diffuse neural representation, the alexithymia construct can be usefully applied in the clinical and empirical studies of social cognition, particularly when adopting a dimensional neuropsychological approach.

Brain activation during the perception of stressful word stimuli concerning interpersonal relationships in anorexia nervosa patients with high degrees of alexithymia in an fMRI paradigm

Several studies have reported that anorexia nervosa (AN) patients have high levels of alexithymia. However, relatively little is known about the underlying neurobiological relationships between alexithymia and AN. We used functional magnetic resonance imaging to examine the brain responses in 30 AN patients and 20 healthy women during the processing of negative words concerning interpersonal relationships. We investigated the relationship between alexithymia levels and brain activation in AN. AN patients showed significant activation of the orbitofrontal cortex, dorsolateral prefrontal cortex and medial prefrontal cortex while processing negative words concerning interpersonal relationships, as compared to the processing of neutral words. Moreover, the subjective rating of unpleasantness with negative words and neural activities in the amygdala, posterior cingulate cortex (PCC) and anterior cingulate cortex (ACC) negatively correlated with the level of alexithymia in AN. Our neuroimaging results suggest that AN patients tend to cognitively process negative words concerning interpersonal relationships, resulting in activation of the prefrontal cortex. Lower activation of the amygdala, PCC and ACC in response to these words may contribute to the impairments of emotional processing that are hallmarks of alexithymia. Functional abnormalities associated with alexithymia may be involved in the emotional processing impairments in AN patients.

Reflective functioning in 70 patients suffering from bulimia nervosa

OBJECTIVE

This study is the first to evaluate the reflective functioning abilities of patients suffering from bulimia nervosa (BN).

METHOD

Seventy patients fulfilling Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BN were interviewed with the Adult Attachment Interview, which was subsequently coded for reflective functioning (RF).

RESULTS

On average, the sample of patients suffering from BN had close to normal mentalizing abilities. However, the distribution of RF scores was significantly different from the distribution of RF in a non-clinical control group, showing a more polarized pattern with more low and high RF scores.

CONCLUSION

The study indicates that the theory of mentalization may contribute to understanding BN. However, bulimic pathology may develop and be maintained despite good mentalizing abilities.

Perception of emotion and bilateral advantage in women with eating disorders, their healthy sisters, and nonrelated healthy controls

BACKGROUND

Eating disorders (EDs) are characterized not only by disordered eating, but also by other psychopathology. In this exploratory study, we examined the ability of women with different diagnoses of EDs, their unaffected sisters, and healthy unrelated controls to recognize their own and other's emotions. We also looked at interhemispheric integration of emotion recognition and its relationship with depression.

METHOD

Five groups of women participated: 1. anorexia nervosa restricting (AN-R) and 2. (AN-B/B) binge/purge, 3. bulimia nervosa binge/purge, (BN-B/P), 4. healthy sisters of women with ED, and 5. unrelated healthy controls. We used two questionnaires measuring alexithymia and depression, and two lateralized experimental tasks requiring recognition of facial emotion. Unilateral versus bilateral presentation allow the indexing of interhemispheric integration.

RESULTS

Alexithymia: All the ED groups were found to be more alexithymic and depressed on the self report scales compared to the two healthy groups. Depression completely mediated alexithymia in the AN-R group but not in the AN-B/P and BN-B/P patients. Sisters of ED women were more alexithymic than unrelated controls. Lateralized facial emotion recognition: ED women showed no deficits in recognizing basic emotions. However, the clinical groups did not show a bilateral advantage whereas the two healthy groups did so.

CONCLUSIONS

We present three conclusions: we show, for the first time, evidence for a deficit in hemispheric integration in EDs. This implies that EDs may be a disconnection syndrome; alexithymia characterizes women with EDs and members of their family; depression is manifested differently in AN-R, than in women who binge/purge.

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.

The relationship between alexithymia and maladaptive perfectionism in eating disorders: a mediation moderation analysis methodology

OBJECTIVE

This work aimed to explore the relationship between alexithymia and maladaptive perfectionism in the psychological process leading to eating disorders (ED).

METHOD

Forty-nine individuals with ED and 49 controls completed the Concern over Mistakes subscale of the Frost Multidimensional Perfectionism Scale, the Perfectionism subscale of the Eating Disorders Inventory, the total score of the Toronto Alexithymia Scale, and the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorders Inventory. We tested a model in which alexythimia is the independent variable and perfectionism is the possible mediator or moderator.

RESULTS

Analyses confirmed the assumed model. In addition, it emerged that perfectionism played a mediating or moderating role when measured by different instruments. This result suggested that different instruments measured subtly different aspects of the same construct.

DISCUSSION

Results could suggest that alexithymia is a predisposing factor for perfectionism, which in turn may lead to the development of eating disorders.

A resource of validated affective and neutral sentences to assess identification of emotion in spoken language after a brain injury

PRIMARY OBJECTIVE

The ability to identify emotions in spoken language is an essential component of communication and could be disrupted in persons with brain injury. Current tools to assess this function show important shortcomings. The aim is to present a set of validated and linguistically equated lexical sentences that can be used to separate the impact of lexical content and prosody on the processing of emotion in speech in persons with brain injury.

METHODS AND PROCEDURES

Using six-point Likert scales, a set of 125 sentences, carefully matched for linguistic variables, were rated by a group of young adults (n = 48) on their suitability to represent a particular emotion (anger, fear, happiness and sadness) in their lexical content.

MAIN OUTCOMES AND RESULTS

The findings identified a set of 50 sentences that were reliably associated with one particular emotion only or no emotion at all (neutral). Using less stringent criteria, 94 sentences were also found to be good representatives for these affective categories.

CONCLUSIONS

The findings generated a robust set of validated lexical stimuli necessary to reliably identify the specific contributions of verbal and prosodic information on difficulties in identifying emotions in speech with persons with brain injury.

Emotional awareness in substance-dependent patients

We explored emotional awareness in substance-dependent patients and its relationships to self-reported alexithymia. Sixty-four outpatients with drug dependence or alcohol dependence were evaluated before the beginning of treatment with the Hamilton Depressive Scale and the Covi Anxiety Scale, and they completed the Toronto Alexithymia Scale (TAS-20) and the Levels of Emotional Awareness Scale (LEAS). Subjects exhibited low levels of emotional awareness and TAS-20 scores were high. Both measures were not related to depressive and anxious symptomatology. This research is the first to provide LEAS results with substance-dependent patients and highlights their deficits in emotions' differentiation and complexity. The lack of a relationship between LEAS and TAS-20 is discussed from the methodological and theoretical points of view.

Psychological mindedness and symptom reduction after psychotherapy in a heterogeneous psychiatric sample

BACKGROUND

Psychological mindedness (PM) has been claimed to be beneficial for outcome of various forms of psychotherapy. The purpose of this study was to investigate the influence of PM on the therapy results of a psychiatric patient sample with heterogeneous psychological symptoms.

METHODS

Participants were 110 patients with different diagnoses who were hospitalized at the Center for Psychological Recovery (Rosmalen, Netherlands). Before and after treatment, they were asked to complete the Balanced Index of Psychological Mindedness and the Symptom Checklist-90.

RESULTS

Baseline PM was not associated with a decrease in symptom scores (F(8,73) < 1.0; P > .20; partial eta(2) < 0.10). However, PM increased over the course of the intervention (F(2,84) = 43.54; P < .001; eta(2) = 0.51) and larger increases in the insight component of PM were associated with larger decreases on 6 of 8 symptom scores (F(8,70) = 3.55; P < .005; partial eta(2) = 0.29).

CONCLUSIONS

These results suggest that although a high PM is not a prerequisite for successful cognitive behavioral therapy, an increase in insight is associated with better outcome.

Alexithymia and eating disorder symptoms in adolescents

An increasing amount of evidence indicates an association between alexithymia and eating disorder symptoms. This possible association was evaluated in a non-clinical sample of late adolescents. Seven hundred and twenty nine adolescents completed the questionnaire and formed the final sample. Alexithymia was measured using the 20-item Toronto Alexithymia Scale and eating disorder symptoms were assessed using the SCOFF questionnaire. The rate of alexithymia was 8.2%, without any gender difference. The mean SCOFF scores differed significantly between alexithymic and non-alexithymic subjects, and the share of SCOFF positive subjects was significantly higher among alexithymics. The results suggest that eating disorder symptoms are more common in alexithymic adolescents.

Are treatment options related to alexithymia in eating disorders? Results from a three-year naturalistic longitudinal study

OBJECTIVE

Longitudinal studies have shown that alexithymic features can interfere with treatment response in eating disorders. However, an alternative hypothesis could be that clinicians faced with alexithymic patients chose different treatment options according to their perceptions of these patients. The aim of this investigation was to explore the relationships between alexithymic features and treatment options provided by professionals in a naturalistic prospective study of eating disorders.

METHODS

We conducted a 3-year longitudinal study exploring a sample of 102 DSM-IV Eating Disorder patients with the Toronto Alexithymia Scale (TAS-20). All treatments received during follow-up were recorded and recoded dichotomously, and crossed with the variation of alexithymic categories (cut-off≥56) between inclusion and follow-up.

RESULTS

Patients received different treatments according to their alexithymic profile, in terms both of number and type of treatment received. Patients with high, stable levels of alexithymia received overall more treatments, and significantly more antidepressants, than non-alexithymic patients. Patients who became alexithymics during follow-up were more often rehospitalized and received fewer regular psychotherapies than the non-alexithymic patients.

CONCLUSIONS

Professionals should carefully monitor these personality features and be aware of the potential impact of alexithymic features on treatment compliance and on treatment choice for eating disordered patients.

Alexithymia and health-related quality of life in a general population

BACKGROUND

Alexithymia is thought to reflect a deficit in the cognitive processing of emotion, and, therefore, it may predispose individuals to both psychological and somatic symptoms.

OBJECTIVE

The authors investigated the relationship between alexithymia and health-related quality of life (HRQoL) in a nationally representative population sample of 5,418 subjects, age 30 to 97 years.

METHOD

Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and HRQoL measured with the 15D, a generic HRQoL measure.

RESULTS

Alexithymia was significantly associated with lower HRQoL independently of other variables. The TAS-20 subfactor Difficulties Identifying Feelings was the strongest common denominator between alexithymia and HRQoL.

CONCLUSION

Alexithymia may be a predisposing factor to poorer HRQoL.