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

Enhancing emotional abilities in anorexia nervosa treatment: A rolling-group cognitive remediation and emotional skills training protocol

INTRODUCTION

Anorexia nervosa (AN) is characterised by limited remission rates and emotional dimensions are often neglected. Cognitive remediation and emotional skills training (CREST) protocol aims to address cognitive and emotional factors. This study evaluates the feasibility and effectiveness of a modified rolling-group CREST protocol in an inpatient setting.

METHODS

Quasi-experimental design evaluated CREST protocol in a rehabilitation programme. A total of 116 females diagnosed with AN were included, of whom 63 were included in the CREST protocol and 53 in the standard rehabilitation treatment. Various standardized measures were employed to assess psychopathology. Data collection occurred longitudinally, before and after CREST implementation.

RESULTS

No significant differences emerged between groups regarding changes in specific eating psychopathology. CREST group exhibited significant improvements in emotion regulation (p = 0.002) and social skills (p = 0.014), besides a reduction in alexithymia (p < 0.001) and cognitive rigidity (p = 0.013). Empathic features remained stable. Participants reported positive perceptions of the CREST intervention.

DISCUSSION

The study highlights the potential benefits of integrating emotional training within multidisciplinary intensive treatment for AN. Results emphasise the importance of treatment protocol with more affective and hot-cognition-related interventions, beyond weight-related psychopathology. Implementing a rolling-group CREST protocol in an inpatient setting showed promise in enhancing the emotional abilities of AN patients.

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.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Alexithymia Is Associated With Deficits in Visual Search for Emotional Faces in Clinical Depression

Background: The concept of alexithymia is characterized by difficulties identifying and describing one's emotions. Alexithymic individuals are impaired in the recognition of others' emotional facial expressions. Alexithymia is quite common in patients suffering from major depressive disorder. The face-in-the-crowd task is a visual search paradigm that assesses processing of multiple facial emotions. In the present eye-tracking study, the relationship between alexithymia and visual processing of facial emotions was examined in clinical depression. Materials and Methods: Gaze behavior and manual response times of 20 alexithymic and 19 non-alexithymic depressed patients were compared in a face-in-the-crowd task. Alexithymia was empirically measured via the 20-item Toronto Alexithymia-Scale. Angry, happy, and neutral facial expressions of different individuals were shown as target and distractor stimuli. Our analyses of gaze behavior focused on latency to the target face, number of distractor faces fixated before fixating the target, number of target fixations, and number of distractor faces fixated after fixating the target. Results: Alexithymic patients exhibited in general slower decision latencies compared to non-alexithymic patients in the face-in-the-crowd task. Patient groups did not differ in latency to target, number of target fixations, and number of distractors fixated prior to target fixation. However, after having looked at the target, alexithymic patients fixated more distractors than non-alexithymic patients, regardless of expression condition. Discussion: According to our results, alexithymia goes along with impairments in visual processing of multiple facial emotions in clinical depression. Alexithymia appears to be associated with delayed manual reaction times and prolonged scanning after the first target fixation in depression, but it might have no impact on the early search phase. The observed deficits could indicate difficulties in target identification and/or decision-making when processing multiple emotional facial expressions. Impairments of alexithymic depressed patients in processing emotions in crowds of faces seem not limited to a specific affective valence. In group situations, alexithymic depressed patients might be slowed in processing interindividual differences in emotional expressions compared with non-alexithymic depressed patients. This could represent a disadvantage in understanding non-verbal communication in groups.

Physiological, emotional and neural responses to visual stimuli in eating disorders: a review

BACKGROUND

Overconcern with food and shape/weight stimuli are central to eating disorder maintenance with attentional biases seen towards these images not present in healthy controls. These stimuli trigger changes in the physiological, emotional, and neural responses in people with eating disorders, and are regularly used in research and clinical practice. However, selection of stimuli for these treatments is frequently based on self-reported emotional ratings alone, and whether self-reports reflect objective responses is unknown.

MAIN BODY

This review assessed the associations across emotional self-report, physiological, and neural responses to both food and body-shape/weight stimuli in people with anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). For food stimuli, either an aversive or lack of physiological effect was generated in people with AN, together with a negative emotional response on neuroimaging, and high subjective anxiety ratings. People with BN showed a positive self-rating, an aversive physiological reaction, and a motivational neural response. In BED, an aversive physiological reaction was found in contrast to motivational/appetitive neural responses, with food images rated as pleasant. The results for shape/weight stimuli showed aversive responses in some physiological modalities, which was reflected in both the emotional and neural responses, but this aversive response was not consistent across physiological studies.

CONCLUSIONS

Shape/weight stimuli are more reliable for use in therapy or research than food stimuli as the impact of these images is more consistent across subjective and objective responses. Care should be taken when using food stimuli due to the disconnect reported in this review.

Explicit and Implicit Responses of Seeing Own vs. Others' Emotions: An Electromyographic Study on the Neurophysiological and Cognitive Basis of the Self-Mirroring Technique

Facial mimicry is described by embodied cognition theories as a human mirror system-based neural mechanism underpinning emotion recognition. This could play a critical role in the Self-Mirroring Technique (SMT), a method used in psychotherapy to foster patients’ emotion recognition by showing them a video of their own face recorded during an emotionally salient moment. However, dissociation in facial mimicry during the perception of own and others’ emotions has not been investigated so far. In the present study, we measured electromyographic (EMG) activity from three facial muscles, namely, the zygomaticus major (ZM), the corrugator supercilii (CS), and the levator labii superioris (LLS) while participants were presented with video clips depicting their own face or other unknown faces expressing anger, happiness, sadness, disgust, fear, or a neutral emotion. The results showed that processing self vs. other expressions differently modulated emotion perception at the explicit and implicit muscular levels. Participants were significantly less accurate in recognizing their own vs. others’ neutral expressions and rated fearful, disgusted, and neutral expressions as more arousing in the self condition than in the other condition. Even facial EMG evidenced different activations for self vs. other facial expressions. Increased activation of the ZM muscle was found in the self condition compared to the other condition for anger and disgust. Activation of the CS muscle was lower for self than for others’ expressions during processing a happy, sad, fearful, or neutral emotion. Finally, the LLS muscle showed increased activation in the self condition compared to the other condition for sad and fearful expressions but increased activation in the other condition compared to the self condition for happy and neutral expressions. Taken together, our complex pattern of results suggests a dissociation at both the explicit and implicit levels in emotional processing of self vs. other emotions that, in the light of the Emotion in Context view, suggests that STM effectiveness is primarily due to a contextual–interpretative process that occurs before that facial mimicry takes place.

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.

Alexithymia and Treatment Outcome in Anorexia Nervosa: A Scoping Review of the Literature

Alexithymia is of great interest as an outcome predictor of recovery from anorexia nervosa, since it may interfere with both treatment compliance and patients' ability to benefit from the adopted interventions. For this reason, in the last years new treatment approaches targeting emotion identification, expression, and regulation have been applied and tested. Using the PRISMA methodology, we performed a scoping review of the literature about treatment outcome in anorexia nervosa, in terms of changes in alexithymia as assessed by its most commonly used self-report measure, the Toronto Alexithymia Scale (TAS). The Medline and Scopus databases were searched, and articles were included if matching the following criteria: dealing with patients affected by anorexia nervosa, without limits of age; involving the application of any kind of targeted therapy or treatment; assessing alexithymia and the effect of a treatment intervention on alexithymia, using the TAS. Ten studies were eventually included; overall, according to the selected studies, alexithymia levels often remain high even after specific treatment. Further research aimed at a deeper understanding of the actual impact of alexithymia on the outcome of anorexia, as well as exploring alternative treatment strategies for alexithymia in eating disorders (EDs), are warranted.

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.

Parents' personality clusters and eating disordered daughters' personality and psychopathology

The present study explores how parents' personality clusters relate to their eating disordered daughters' personality and psychopathology. Mothers and fathers were tested with the Temperament Character Inventory. Their daughters were assessed with the following: Temperament and Character Inventory, Eating Disorder Inventory-2, Symptom Checklist-90, Parental Bonding Instrument, Attachment Style Questionnaire, and Family Assessment Device. Daughters' personality traits and psychopathology scores were compared between clusters. Daughters' features were related to those of their parents. Explosive/adventurous mothers were found to relate to their daughters' borderline personality profile and more severe interoceptive awareness. Mothers' immaturity was correlated to their daughters' higher character immaturity, inadequacy, and depressive feelings. Fathers who were explosive/methodic correlated with their daughters' character immaturity, severe eating, and general psychopathology. Fathers' character immaturity only marginally related to their daughters' specific features. Both parents' temperament clusters and mothers' character clusters related to patients' personality and eating psychopathology. The cluster approach to personality-related dynamics of families with an individual affected by an eating disorder expands the knowledge on the relationship between parents' characteristics and daughters' illness, suggesting complex and unique relationships correlating parents' personality traits to their daughters' disorder.

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.

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.

Borderline personality disorder and mental healthcare service use among adolescents

Borderline personality disorder (BPD) is believed to be frequent among adolescents. While several prospective studies have assessed the use of mental health services among adults who suffer from BPD, few studies have provided adolescent data. This paper presents findings from the first assessment point of the European Research Network on Borderline Personality Disorder (EURNET BPD) study. In this study, we describe lifetime treatment utilization for 85 adolescents with BPD (Mean age: 16.3 years old). In line with adult findings, adolescents with BPD reported greater mental healthcare service use (outpatient: 98%; inpatient: 79%) compared to controls. Phenothiazine, a sedative neuroleptic, was the most frequently prescribed treatment. 47% of patients had received psychotherapy; in one our of three cases this was psychodynamic therapy. Patients who had received psychotherapy did not differ on any psychopathological variables from those who did not receive psychotherapy; however, psychotherapy was more frequent among females.

Psychosomatic syndromes and anorexia nervosa

BACKGROUND

In spite of the role of some psychosomatic factors as alexithymia, mood intolerance, and somatization in both pathogenesis and maintenance of anorexia nervosa (AN), few studies have investigated the prevalence of psychosomatic syndromes in AN. The aim of this study was to use the Diagnostic Criteria for Psychosomatic Research (DCPR) to assess psychosomatic syndromes in AN and to evaluate if psychosomatic syndromes could identify subgroups of AN patients.

METHODS

108 AN inpatients (76 AN restricting subtype, AN-R, and 32 AN binge-purging subtype, AN-BP) were consecutively recruited and psychosomatic syndromes were diagnosed with the Structured Interview for DCPR. Participants were asked to complete psychometric tests: Body Shape Questionnaire, Beck Depression Inventory, Eating Disorder Inventory-2, and Temperament and Character Inventory. Data were submitted to cluster analysis.

RESULTS

Illness denial (63%) and alexithymia (54.6%) resulted to be the most common syndromes in our sample. Cluster analysis identified three groups: moderate psychosomatic group (49%), somatization group (26%), and severe psychosomatic group (25%). The first group was mainly represented by AN-R patients reporting often only illness denial and alexithymia as DCPR syndromes. The second group showed more severe eating and depressive symptomatology and frequently DCPR syndromes of the somatization cluster. Thanatophobia DCPR syndrome was also represented in this group. The third group reported longer duration of illness and DCPR syndromes were highly represented; in particular, all patients were found to show the alexithymia DCPR syndrome.

CONCLUSIONS

These results highlight the need of a deep assessment of psychosomatic syndromes in AN. Psychosomatic syndromes correlated differently with both severity of eating symptomatology and duration of illness: therefore, DCPR could be effective to achieve tailored treatments.

Alexithymia as a prognostic risk factor for health problems: a brief review of epidemiological studies

The number of articles on alexithymia has been steadily increasing since the word “alexithymia” was coined in the 1970s to denote a common characteristic that is observed among classic psychosomatic patients in whom therapy was unsuccessful. Alexithymia, a disorder of affect regulation, has been suggested to be broadly associated with various mental and physical health problems. However, most available evidence is based on anecdotal reports or cross-sectional observations. To clarify the predictive value of alexithymia for health problems, a systematic review of prospective studies was conducted. A search of the PubMed database identified 1,507 articles on “alexithymia” that were published by July 31, 2011. Among them, only 7 studies examined the developmental risks of alexithymia for health problems among nonclinical populations and 38 studies examined the prognostic value of alexithymia among clinical populations. Approximately half of the studies reported statistically significant adverse effects, while 5 studies demonstrated favorable effects of alexithymia on health outcomes; four of them were associated with surgical interventions and two involved cancer patients. The studies that showed insignificant results tended to have a small sample size. In conclusion, epidemiological evidence regarding alexithymia as a prognostic risk factor for health problems remains un-established. Even though alexithymia is considered to be an unfavorable characteristic for disease control and health promotion overall, some beneficial aspects are suggested. More prospective studies with sufficient sample sizes and follow-up period, especially those involving life course analyses, are needed to confirm the contribution of alexithymia to health problems.

Alexithymia and suicide ideation in a sample of patients with binge eating disorder

OBJECTIVE

The goal of this cross-sectional study was to evaluate the relationships between alexithymia and suicide ideation in 80 adult outpatients with a DSM-IV diagnosis of binge eating disorder (BED).

METHODS

Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20); suicide ideation was assessed with the Scale of Suicide Ideation (SSI); severity of BED was assessed with the Binge Eating Scale (BES); and depressive and anxiety symptoms were evaluated, respectively, with the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (Ham-A).

RESULTS

Prevalence of current suicide ideation was 27.5% (n = 22) in this sample and 10 subjects (12.5%) had attempted suicide at some time in their lives. Subjects with alexithymia had more significant suicide ideation, a higher prevalence of current suicide ideation, and more previous suicide attempts than those without alexithymia. In a linear regression model, higher MADRS scores and higher scores on the Difficulty in Identifying Feelings/Difficulty in Describing Feelings dimensions of the TAS-20 were associated with increased suicide ideation.

DISCUSSION

Suicidal behavior is no less common in BED than in other eating disorders. Individuals with BED may show increased suicide ideation, especially in the presence of alexithymia and depressive symptoms, even if these symptoms are subclinical. The authors also discuss limitations of this study and future research needs.