Treatment of eating disorders improves eating symptoms but not alexithymia and dissociation proneness

Direct and indirect effects of alexithymia on disordered eating in a non-clinical female sample: Determining the role of negative affect

BACKGROUND

Alexithymia is an independent predictor of symptoms of eating disorders, but also influences disordered eating in clinical samples indirectly via negative affect (depression and anxiety). The aim of the current work was to establish if alexithymia predicts disordered eating in a non-clinical sample directly and indirectly (via negative affect).

METHODS

A sample of healthy females (n = 248) completed measures of depression, anxiety, alexithymia, and disordered eating (drive for thinness, bulimia, and body dissatisfaction). Bias-corrected bootstrapping was used to conduct parallel mediation analyses to determine if negative affect (depression and anxiety) mediated the influence of alexithymia on disordered eating.

RESULTS

The relationship between alexithymia (difficulty identifying feelings) and drive for thinness was mediated by depression but not anxiety. The link between difficulty identifying feelings and bulimia was mediated by anxiety but not depression. The correlation between alexithymia (difficulty describing feelings) and body dissatisfaction was mediated by both depression and anxiety. However, after controlling for negative affect, difficulty identifying feelings remained an independent predictor of drive for thinness, and difficulty describing feelings remained an independent predictor of body dissatisfaction.

CONCLUSION

Facets of alexithymia (DIF and DDF) directly predict disordered eating in healthy participants as well as indirectly via depression and anxiety. These findings suggest that targeted interventions to improve the ability of individuals to identify and describe their feelings could be beneficial in reducing disordered eating, particularly in those "at risk" of developing eating disorders.

Emotional eating during COVID-19 in the United Kingdom: Exploring the roles of alexithymia and emotion dysregulation

Emotional eating, generally defined as (over)-eating in response to negative emotions, has been associated with poor physical and psychological outcomes. During a time of heightened negative affect, it is important to understand the impact of the COVID-19 pandemic and associated lockdown measures on eating behaviours, and further elucidate the ways in which emotional eating is related to emotion dysregulation and impaired abilities to identify emotions (i.e. alexithymia). The aims of this study were to explore perceived changes in eating behaviours in relation to self-reported negative affect during the pandemic and to examine direct and indirect effects of alexithymia on emotional eating. An online questionnaire measured these constructs in the general population of the United Kingdom (n = 136). Findings demonstrated that those who reported changes to their eating behaviours during the pandemic also reported greater levels of depression during the same time frame. Mediation analyses revealed that difficulties identifying and describing feelings both predicted emotional eating indirectly via emotion dysregulation. Findings contribute to the understanding of the mechanisms underpinning the relationship between alexithymia and emotional eating and describe changes to eating behaviours during COVID-19. We discuss how these findings should be applied, and recommendations for future research.

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One quarter of participants reported eating more than usual during COVID-19.

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One third of participants reported eating less healthfully than usual.

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Difficulty identifying feelings influences emotional eating via emotion dysregulation.

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Difficulty describing feelings influences emotional eating via emotion dysregulation.

Psychoform and somatoform dissociation in anorexia nervosa: A systematic review

Dissociation is a debilitating condition often present as comorbidity in patients with eating disorders, but to date only sparse findings are available on this topic. Additionally, very little data exist on the classification of dissociation, namely, psychoform and somatoform, in anorexia nervosa (AN). This review aimed to provide an updated view on the literature about dissociation in AN, with a focus on AN subtypes (i.e., restricter and binge-purging) as well as dissociation type (i.e., psychoform and somatoform), when available. We screened 304 studies, and after title and abstract selection and full-text reading, 29 of them were included in this review. Most of the studies investigated psychoform dissociation, whereas just four publications considered somatoform dissociation. Dissociation resulted to be present in AN more than in healthy controls and in individuals with other psychiatric disorders, and it was related mostly to the binge-purging subtype of AN. Moreover, dissociation was linked to traumatic events, self-harm and negative treatment outcomes, especially in patients affected by the binge-purging subtype of AN. However, results on these matters are scarce and partially discordant. The methodological assessment we performed revealed an overall fair quality of the included studies, although several flaws emerged as well. The present review reported on one hand the relevance of dissociation in AN, but on the other hand the need to stimulate the scientific debate on (a) a deeper investigation of somatoform dissociation in AN and (b) the relationship between dissociation and both clinical severity and treatment response/resistance in AN.

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.

Group cognitive behavioral treatment in female soldiers diagnosed with binge/purge eating disorders

Cognitive behavioral treatment (CBT) is the recommended intervention in bulimia nervosa (BN) and eating disorders not otherwise specified with binge/purge (EDNOS-B/P) symptoms. There are fewer data on its application in a group format. We sought to investigate the effect of group CBT in female soldiers with B/P symptomatology in an open trial design. For this purpose we assessed 64 female soldiers serving in the Israeli Defense Force diagnosed with BN and EDNOS-B/P who participated in a group CBT format of 16 weekly sessions and one follow-up session. In this study, 42 participants (65.6%) completed treatment and 22 participants (34.4%) did not. A total of 39 treatment completers (92.8% of treatment completers) and 19 non-completers (86.4% of treatment non-completers) were assessed around 12 months after treatment. Participants completed at baseline and following treatment questionnaires assessing eating-related symptoms, depression, anxiety, and overall functioning. At follow-up they were assessed for eating-related symptoms. Our findings show only minimal baseline differences between treatment completers and non-completers. Significant improvement from baseline to post-treatment was shown for B/P and restrictive symptoms, depression, anxiety, and overall functioning. At that time, more than a third of treatment completers were abstinent from binging and more than a half from vomiting. The improvement in B/P and restricting symptoms was maintained at 1 year follow-up for treatment completers. At that time around 60% were abstinent from binging and more than 70% from vomiting. Participants not completing treatment were also improved at follow-up but to a lesser extent. The findings of the present study suggest that group CBT may be effective for the treatment of female soldiers with BN and EDNOS-B/P.

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.

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.

Thinking about internal states, a qualitative investigation into metacognitions in women with eating disorders

BACKGROUND

There is a need for qualitative research to help develop case conceptualisations to guide the development of Metacognitive Therapy interventions for Eating Disorders.

METHOD

A qualitative study informed by grounded theory methodology was conducted involving open-ended interviews with 27 women aged 18-55 years, who were seeking or receiving treatment for a diagnosed ED.

RESULTS

The categories identified in this study appeared to be consistent with a metacognitive model including constructs of a Cognitive Attentional Syndrome and metacognitive beliefs. These categories appear to be transdiagnostic, and the interaction between the categories is proposed to explain the maintenance of EDs.

CONCLUSIONS

The transdiagnostic model proposed may be useful to guide the development of future metacognitive therapy interventions for EDs with the hope that this will lead to improved outcomes for individuals with EDs.

The relationship between alexithymia, shame, trauma, and body image disorders: investigation over a large clinical sample

BACKGROUND

The connections between eating disorders (EDs) and alexithymia have not been fully clarified. This study aims to define alexithymia's connections with shame, trauma, dissociation, and body image disorders.

METHODS

We administered the Dissociative Experience Scale-II, Trauma Symptom Inventory, Experience of Shame Scale, Toronto Alexithymia Scale-20, and Body Uneasiness Test questionnaires to 143 ED subjects. Extensive statistical analyses were performed.

RESULTS

The subjects showed higher scores on alexithymia, shame, dissociation, and traumatic feelings scales than the nonclinical population. These aspects are linked with each other in a statistically significant way. Partial correlations highlighted that feelings of shame are correlated to body dissatisfaction, irrespective of trauma or depressed mood. Multiple regression analysis demonstrates that shame (anorexic patients) and perceived traumatic conditions (bulimic and ED not otherwise specified) are associated with adverse image disorders.

CONCLUSION

Shame seems to hold a central role in the perception of an adverse self-image. Alexithymia may be interpreted as being a consequence of previous unelaborated traumatic experiences and feelings of shame, and it could therefore be conceptualized as a maladaptive-reactive construct.

Alexithymia is not a stable personality trait in patients with substance use disorders

The construct of alexithymia as a vulnerability factor for substance use disorders (SUD) is under debate, because of conflicting research results regarding alexithymia as a state or trait phenomenon. The absolute and relative stability of alexithymia were evaluated in a pre-post design as part of a randomised controlled trial, controlling for several co-variates. Assessments were done with the Toronto Alexithymia Scale (TAS-20) and the Addiction Severity Index (EuropASI) at baseline and follow-up of a 3-month trial of inpatient Cognitive Behavioural Therapy (CBT) with or without a Shared Decision Making intervention for 187 SUD patients. Paired sample t-tests and analyses of variance were performed to assess absolute stability, intraclass correlation coefficients were calculated for relative stability and multivariate linear regression models were used to evaluate the relation between co-variates and change in alexithymia. Mean level reduction of total TAS-20 and two subfactors demonstrated no absolute stability, but change in alexithymia differed for patients with low, moderate and high alexithymia scores. Relative stability of alexithymia was moderate to high for the total population, but differed according to low, moderate and high alexithymia scores. The EuropASI "psychiatry" domain, covering anxiety and depression, was related to alexithymia, but CBT-related variables were not. In conclusion, alexithymia is partly a state-dependent phenomenon, but not a stable personality trait in this SUD population.

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.

Facial affect recognition in anorexia nervosa: is obsessionality a missing piece of the puzzle?

OBJECTIVE

Socio-emotional difficulties are thought to be important maintaining factors of eating disorders. Several studies point to deficits in facial affect recognition in anorexia nervosa (AN). However, the majority of these studies fail to control for comorbidity and its effect on emotional processing. This study aims to explore how patients with AN recognize happiness and sadness in human faces, controlling for different comorbidities, namely anxiety, depression, and obsessive-compulsive symptoms.

METHODS

Thirty patients with AN, and 40 healthy participants completed a facial emotion recognition task. This task measured discrimination accuracy, response bias and response time towards sad and happy faces presented at different durations (500 ms, 2000 ms). The associations between facial affect recognition and clinical symptoms and intelligence quotient were explored.

RESULTS

Regression analysis showed that discrimination accuracy of sad faces presented for 500 ms was significantly associated with AN diagnosis, body mass index, and Obsessive-compulsive symptoms. However, the level of Obsessive-compulsive symptoms was the strongest predictor of a poor discrimination of briefly presented sad faces.

CONCLUSIONS

Our results support previous studies that report emotional processing deficits in AN with obsessionality playing a pivotal role in this deficit.

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.

Transient psychosis in anorexia nervosa: review and case report

Psychotic symptoms are a key feature in eating disorders. Restrictive-type anorectics are more prone to suffer them, coherent with recent neurocognitive findings reporting attentional and processing deficits in restrictive anorexia partially common to schizophrenia. Psychotic crises urge psychiatrists to make an accurate differential diagnosis with endogenous psychoses and carefully judge treatment options. If attentively attended, such crises can give us clues to understand the patient s functioning and consider new strategies. We report two transient psychotic episodes in restrictive-type anorectic female patients, one with a previous experience. Onset of psychotic symptoms was related to severe malnutrition only in one of them (body mass index <15). We discuss risk factors, clinical presentation and treatment, focusing on the emotional disturbances maintained after recovery. Causes for psychotic features in these patients are reviewed and treatment individually tailored. An integrative understanding of eating disorders as a unique meeting point between psychosis and neurosis is encouraged.

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.