Alexithymia ratings in bulimia nervosa: clinical correlates

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.

Alexithymia, Stress and Depression in Infertile Women: a Case Control Study

Background:

Alexithymia and stress are two main psychological factors which affect not only fertility, but also the outcome of assisted reproductive technology treatment.

Objective:

The primary aim of this study was to compare the levels of alexithymia and stress between infertile women undergoing assisted reproductive treatment and women with no fertility issues. The present study aims to: (i) explore the relation between alexithymia and infertility, (ii) investigate whether women with infertility problems show elevated levels of alexithymia compared to women with no fertility problems, and (iii) compare stress levels between women undergoing assisted reproductive technology treatment and women with no fertility problems.

Methods:

A case control trial was conducted. In total, data from 177 women were collected. The control group consisted of 102 women with no fertility problems, whilst the study group included 75 women undergoing assisted reproductive program. In order to measure the levels of alexithymia and the fertility-related stress among women in both groups and compare the results, validated questionnaires were distributed to every participant. Self-report instruments were used to measure alexithymia (TAS-20), fertility-related stress (FPI), depressive symptomatology (CES-D) and anxiety (STAI). Univariate and bivariate statistical analyses were used.

Results:

The mean values of alexithymia, anxiety and depressive symptomatology were higher in women with lower educational background and not within a marriage than in women with higher education and within marriage. Additionally, infertile women had similar levels of alexithymia, anxiety and depressive symptomatology compared to women with no fertility problems.

Conclusion:

Results from the present study suggest that infertile women show similar levels of alexithymia and stress in comparison to women who have not been confronted with fertility problems. Our study findings are in accordance with many previous published studies that have concluded that alexithymia rates are similar between group of patients and group of healthy individuals. However, future studies should aim to investigate the prevalence of alexithymia in infertile women with idiopathic and non-idiopathic infertility as well as to assess the levels of alexithymia in infertile women that are not in a fertility treatment.

Emotion and overeating behavior: effects of alexithymia and emotional regulation on overweight and obesity

PURPOSE

Obesity and overweight are significant risk factors for many serious diseases. Several studies have investigated the relationship between emotional regulation and overweight or obesity in people with eating disorders. Although a few studies have explored alexithymia in individuals with severe obesity without eating disorders, no attention has been paid to individuals with overweight and preclinical form of obesity. This study aims to assess whether overweight and obesity are related to emotional dysregulation and alexithymia.

METHODS

The study involved 111 undergraduate students who had not been diagnosed with an eating disorder. The sample was divided into two groups according to their body mass index (BMI): normal weight (N = 55) and overweight (N = 56). All of them completed the Toronto Alexithymia Scale (TAS-20), the Emotional Regulation Questionnaire (ERQ), and the Eating Disorder Inventory-2 (EDI-2).

RESULTS

Results showed higher levels of alexithymia, and specifically higher difficulty in identifying feelings and an externally oriented thought, in participants with overweight. Multiple correlation analysis highlighted the positive relations between some EDI-2 subscales and both alexithymia and emotional regulation scores. Linear regressions revealed a significant relationship between body BMI and both alexithymia and emotional regulation strategies.

CONCLUSIONS

The condition of overweight/obesity seems to be associated with higher emotional dysregulation compared to normal weight condition. It is essential to study this relationship because it could represent a risk factor for the worsening of problems related to overeating and excessive body weight. These findings suggest that an integrated approach aimed at considering the promotion of emotional regulation could contribute to the effectiveness of a program designed to reduce overweight and obesity.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Influence of alexithymia on the management of Latin American patients with asthma: A cross-sectional study

Objectives:

In asthmatic patients, studies suggest that alexithymia leads to negative consequences and emotions that can affect physical, psychological, and social aspects of life. We designed this study to determine the frequency of alexithymia in Latin American patients with asthma, as well as to understand how this personality trait and each of its components interact with asthma severity and demographic variables, and their implications on treatment adherence and disease control under such setting.

Methods:

We conducted a cross-sectional study, involving 265 Latin American patients with asthma. Patient demographics and clinical characteristics were reported. The presence of alexithymia, asthma severity, and control, as well as treatment adherence, was analyzed. To assess the presence of alexithymia, the 20-item Toronto Alexithymia Scale was used. For the statistical analyses, we performed Kendall’s tau-b correlation coefficient, chi-square tests for association, and one-way analysis of variance.

Results:

A total of 265 patients participated in the study with a gender distribution of 69.4% female and an average age of 54.7 years. In total, 30.2% of individuals presented alexithymia. There was a statistically significant correlation between educational level and 20-item Toronto Alexithymia Scale categories (p < .001), as well as a higher proportion of severe (35.1%, p = .001) and uncontrolled (50.0%, p = .185) asthma in patients with alexithymia. A higher proportion of patients with some level of non-adherence was seen on those with uncontrolled asthma (68.5%, p = .008).

Conclusion:

Our results suggest that in our sample, 3 in 10 Latin American asthma patients have alexithymia, and such mental condition is more common in those individuals with lower educational levels. Individuals with alexithymia present with severe asthma more frequently than do patients with possible or no alexithymia and are also more likely to have their disease uncontrolled.

Posttraumatic Stress and Interpersonal Sensitivity: Alexithymia as Mediator and Emotional Expressivity as Moderator

This study examined 1) the link between PTSD from past trauma, interpersonal sensitivity and psychiatric co-morbidity, 2) mediational effects of alexithymia on 1), and 3) moderated mediational effects with emotional expressivity as the moderator. Five hundred and fifteen Kazakh students completed the Posttraumatic Stress Diagnostic Scale, General Health Questionnaire-28, Toronto Alexithymia Scale-20, Berkeley Expressivity Questionnaire and Interpersonal Sensitivity Measure. The results showed that 28% met the criteria for full-PTSD. Controlling for academic year, age and university major, PTSD from past trauma was significantly correlated with interpersonal sensitivity and psychiatric co-morbidity. Alexithymia mediated the impact of PTSD on interpersonal sensitivity and psychiatric co-morbidity. Alexithymia, however, did not interact with type of emotional expressivity to influence outcomes. Moderated mediational effects were not found. To conclude, following trauma, Kazakh students can experience heightened levels of interpersonal sensitivity and psychological symptoms. These problems are particularly severe for those who have difficulty getting in touch with their emotions.

Alexithymia explains increased empathic personal distress in individuals with and without eating disorders

It is often assumed that empathy impairments are common in individuals with eating disorders (EDs), but empirical work has been limited and produced mixed results, making the clinical features and treatment needs of this population difficult to determine. Alexithymia, characterised by difficulties identifying and describing one’s own emotions, frequently co-occurs with EDs and is associated with atypical recognition of, and empathy for, others’ emotions. This study used an existing empathy for pain paradigm to determine whether atypical empathy in EDs stems from co-occurring alexithymia, rather than EDs per se. Empathy (specifically personal distress in response to others’ pain) was assessed in individuals with EDs ( N = 21) and an alexithymia-matched control group ( N = 22). Participants were simultaneously members of a high alexithymia ( N = 16) or low alexithymia ( N = 27) group, allowing the independent contributions of alexithymia and EDs to be determined. Participants judged the laterality of hands and feet in painful and non-painful situations, and the degree of empathic interference on response times was measured. Results indicated that observation of painful stimuli affected task performance in those with high levels of alexithymia more than those with low levels, but no effect of ED diagnosis was observed. These findings suggest that co-occurring alexithymia explains increased empathic personal distress in ED populations. Atypical empathy may therefore not be a core feature of EDs, and interventions aimed at improving empathy-related social functioning may only be necessary for patients who also have alexithymia. These findings emphasise the importance of determining the influence of co-occurring alexithymia when assessing empathy in clinical populations.

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.

Now or not-now? The influence of alexithymia on intertemporal decision-making

Optimal intertemporal decisions arise from the balance between an emotional-visceral component, signaling the need for immediate gratification, and a rational, long-term oriented component. Alexithymia, a personality construct characterized by amplified sensitivity to internal bodily signals of arousal, may result in enhanced activation of the emotional-visceral component over the cognitive-rational one. To test this hypothesis, participants with high- and low-alexithymia level were compared at an intertemporal decision-making task, and their choice behavior correlated with their interoceptive sensitivity. We show that high-alexithymic tend to behave more impatiently than low-alexithymic in intertemporal decisions, particularly when the sooner reward is immediately available. Moreover, the greater their sensitivity to their own visceral sensations, the greater the impatience. Together, these results suggest a disproportionate valuation of reward available immediately in high alexithymia, possibly reflecting heightened perception of bodily physiological signals, which ultimately would bias their intertemporal decision-making.

When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders

INTRODUCTION

In recent years alexithymia and attachment theory have been recognized as two parallel research lines trying to improve the information on the development and maintenance of eating disorders (EDs). However, no research has analyzed these constructs among patients' families. In this study we compared alexithymia and attachment in mothers of patients with EDs and a control group. Further, we hypothesized that mothers of daughters with EDs with insecure and unresolved states of mind will reported high levels of alexithymia. Lastly, we explored the daughters' evaluations of maternal alexithymia.

METHODS

45 mothers of ED women and 48 mothers of healthy controls (N = 93) matched for age and socio-demographic variables were administered by the Toronto Alexithymia Scale-20 (TAS-20) (S), while two sub-groups of "ED" mothers (n = 20) and "non-ED" ones (n = 22) were assessed by the Adult Attachment Interview (AAI). Moreover, the Observer Alexithymia Scale (OAS) was administered to the daughters for evaluating maternal alexithymia.

RESULTS

Regarding alexithymia, no differences were found between ED and non-ED mothers according to the TAS-20, while ED mothers showed more unresolved AAI classifications than non-ED mothers. No correlations were found between the TAS-20 and the AAI. Lastly, ED mothers were evaluated more alexithymic by their daughters with the OAS than those in the control group, and their alexithymic traits were significantly correlated with dismissing states of mind (idealization and lack of memory) in the AAIs.

DISCUSSION

Our results highlighted an interesting discrepancy among mothers with ED daughters between the low level of alexithymia provided by their self-reports and the high level of alexithymia observed by their daughters, although the OAS showed severe methodological limitations. Maternal attachment states of mind characterized by the lack of resolution of past losses could be connected to a confusing and incoherent quality of parenting.

Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature

Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer's (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.

Disordered eating attitudes, alexithymia and suicide probability among Turkish high school girls

We aimed to examine association between disordered eating attitudes (DEAs), alexithymia and suicide probability among adolescent females and to explore potential link between alexithymia and suicide probability in subjects with DEAs. 381 female students completed Eating Attitude Test (EAT-26), Toronto Alexithymia Scale (TAS-20) and Suicide Probability Scale (SPS). It was found that 13.2% (n=52) of the subjects have DEAs. Results indicated that total TAS-20 score and scores of Difficulty in Identifying Feelings (DIF) and Difficulty in Describing Feelings (DDF) subscales were significantly higher in DEAs group than in those non DEAs group (p<0.05). Additionally, total SPS score (p<0.001), Hopelessness (p=0.001), Suicide Ideation (p<0.001) and Hostility (p=0.003) subscales scores of SPS were significantly higher in the alexithymic DEAs than the non-alexithymic DEAs group. In order to control potential effect of depression, SPS subscales were used as covariate factors in ANCOVA. Negative Self-Evaluation subscale yielded a statistically significant difference between groups, other subscales did not. Results point out these; DEAs are relatively frequent phenomenon among female students in Turkey and presence of alexithymia was associated with an increased suicide probability in adolescents with DEAs. The results should be evaluated taking into account that depressive symptomatology was not assessed using a depression scale.

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.

The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study

BACKGROUND

Alopecia areata (AA) is a skin disease characterized by the sudden appearance of areas of hair loss on the scalp and other hair-bearing areas, but its aesthetic repercussions can lead to profound changes in patient's psychological status and relationships.

AIM

The goal was to investigate a possible relationship between AA and alexithymia as well as two other emotional dimensions, anxiety and depression.

MATERIALS AND METHODS

Fifty patients with AA seen in the Department of Dermatology of Hedi Chaker University Hospital, Sfax were included in this study. Anxiety and depression were evaluated by Hospital Anxiety and Depression scale questionnaire, alexithymia was assessed by Toronto Alexithymia scale 20, and severity of AA was measured by Severity of Alopecia Tool.

RESULTS

Patient's mean age was 32.92 years. 52% of patients were females. Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). Forty-two percent of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

CONCLUSIONS

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.

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.

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.

Structural relationships among attachment insecurity, alexithymia, and body esteem in women with eating disorders

Patients with eating disorders tend to experience low levels of body esteem. To assess the psychosocial processes that may predict low body esteem in these individuals, we assessed the structural interrelations among attachment anxiety, attachment avoidance, alexithymia, and body esteem in a cross-sectional sample of patients with eating disorders. We tested a model in which alexithymia mediates the relationship between attachment insecurity and body esteem. Participants were 300 women with anorexia nervosa (n = 109), bulimia nervosa (n = 130), and eating disorders not otherwise specified (n = 61) who completed pretreatment self-report questionnaires at intake for a day hospital treatment program. We found a direct and negative relationship between attachment anxiety and body esteem. Additionally, attachment avoidance had an indirect negative relationship to body esteem through alexithymia. These results indicate that therapists may attend to attachment insecurity and affective regulation strategies when addressing body image issues in patients with eating disorders.

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 cancer patients: review of the literature

OBJECTIVE

To summarize the literature on alexithymia in cancer patients.

METHODS

The empirical literature published between 1972 and January 2010 was searched through MEDLINE, PSYINFO, EMBASE and the Cochrane Library. Key words were: alexithymia, affective symptoms, cancer, neoplasms.

RESULTS

The search identified 16 relevant studies which are methodologically problematic and show conflicting results. However, several interesting hypotheses emerge such as a possible link between alexithymia and the immune system, between alexithymia and quality of life, or between alexithymia, anxiety and depression. The question to what degree alexithymia in cancer patients is a trait or a state cannot be answered by these studies.

CONCLUSIONS

A lack of methodologically sound studies and the large variations of results among studies suggest that the role of alexithymia in patients with cancer deserves more systematic research. Consequently, studies are needed which investigate the nature (state or trait) of alexithymia, its impact on cancer development and progression, as well as its influence on compliance and on the underestimation of psychological distress and psychiatric outcome in cancer patients.

Obesity, alexithymia and psychopathology: a case-control study

OBJECTIVE

The relationship between psychopathology and alexithymia in obese patients is uncertain. The present study was performed to evaluate this relationship in a clinical sample of patients attending a centre for the diagnosis and treatment of obesity compared to a matched sample of non-obese subjects.

METHODS

293 consecutive obese patients (48 males, 245 females, mean age 45, 41±13.55 yrs; mean BMI 35.60±6.20) were compared with a control group made of 293 non-obese subjects (48 males, 245 females, mean age 45, 66±13.86 yrs; mean BMI 21.8±2.06); all subjects were interviewed by means of SCID I and SCID II together with several self-evaluation instruments including the TAS-20 (Toronto Alexithymia Scale) and SCL-90 (Symptom Check List, Revised).

RESULTS

Alexithymia was significantly more frequent among obese patients compared to "normal" controls (12.9% vs 6.9%, p=0.010); moreover obese patients achieved significantly higher mean scores on subscales 1 and 2 and on overall scale of the Toronto Alexithymia Scale; comorbidity with axis I/II disorders, in particular Binge Eating Disorder, was associated with a significantly higher frequency of alexithymic traits and higher scores at TAS.

CONCLUSIONS

Alexithymia and psychopathology are strongly correlated among obese patients seeking treatment. Routine evaluation of personality traits and comorbid psychopathology may be relevant in treatment of obesity.

Appetite awareness as a mediator in an eating disorders prevention program

Difficulties identifying appetite signals and emotions have been implicated in the development and maintenance of disordered eating. The current study evaluated the mediating roles of appetite awareness and emotional awareness in a brief eating disorders prevention program designed to help participants identify and respond to internal appetite signals. A series of regression analyses was carried out to test the mediator effects of appetite and emotional awareness. Appetite awareness, but not emotional awareness, mediated improvements in binge eating symptoms as well as eating- and weight-control self-efficacy. Appetite awareness appears to be an effective target for eating disorders prevention programs.

Psychologic correlates of eating attitudes in Turkish female college students

OBJECTIVE

The purpose of this study is to determine the frequency and correlates of disordered eating attitudes in a university-sample Turkish female population and to evaluate the contribution of maternal psychopathologic symptoms and family functioning.

METHOD

Female students (n = 267; mean age, 21.21 +/- 1.88 years) completed the Eating Attitude Test, Beck Depression Inventory, 20-item Toronto Alexithymia Scale, Symptom Check List 90-R, and Family Assessment Device. Mothers (n = 96; mean age = 46.41 +/- 5.31 years) completed the Beck Depression Inventory, 20-item Toronto Alexithymia Scale, and Symptom Check List 90-R.

RESULTS

Twelve percent of the female college students had abnormal eating attitudes. Disordered eating attitudes were positively correlated with depression, obsessive-compulsive symptoms, and phobic anxiety. Eating attitude of the student sample was positively correlated with the mothers' obsessive-compulsive symptoms, phobic anxiety, and general psychopathology and "affective involvement" in family functioning.

CONCLUSIONS

It is necessary to pay attention to the levels of depression, alexithymia, anxiety, and obsession-compulsions, as well as family functioning and maternal psychopathology.

Alexithymia and its relationships with body checking and body image in a non-clinical female sample

The aim of the present study was to evaluate in a non-clinical sample of undergraduate women, the relationships between alexithymia, body checking and body image, identifying predictive factors associated with the possible risk of developing an Eating Disorder (ED). The Toronto Alexithymia Scale (TAS-20), Body Checking Questionnaire (BCQ), Eating Attitudes Test (EAT-26), Body Shape Questionnaire (BSQ), Interaction Anxiousness Scale (IAS), Rosenberg Self-Esteem Scale (RSES) and the Beck Depression Inventory (BDI) were completed by 254 undergraduate females. We found that alexithymics had more consistent body checking behaviors and higher body dissatisfaction than nonalexithymics. In addition, alexithymics also reported a higher potential risk for ED (higher scores on EAT-26) when compared to nonalexithymics. Difficulty in identifying and describing feelings subscales of TAS-20, Overall appearance and Specific Body Parts subscales of BCQ as well as lower self-esteem was associated with higher ED risk in a linear regression analysis. Thus, a combination of alexithymia, low self-esteem, body checking behaviors and body dissatisfaction may be a risk factor for symptoms of ED at least in a non-clinical sample of university women.

An evaluation of the absolute and relative stability of alexithymia in women with breast cancer

OBJECTIVES

In the controversy for alexithymia as a state or a trait dimension, recent studies showed that, whereas absolute changes (i.e., extent of alexithymia scores change over time) were observed, alexithymia was relatively stable (i.e., extent to which relative differences among individuals remain the same over time). The present study extended this question by investigating a disease with highly threatening outcomes (breast cancer), by looking at changes in depression and anxiety, and by examining stability for total and factor alexithymia scores.

METHODS

One hundred twenty-two women in treatment for a first instance of breast cancer were assessed for alexithymia (TAS-20), depression, and anxiety (HADS) the day before surgery (T1) and six months later (T2).

RESULTS

Alexithymia scores changed from baseline to follow-up (lack of absolute stability). Strong evidence of relative stability was also demonstrated, as alexithymia scores at baseline correlated significantly with alexithymia scores at follow-up and were also a significant predictor of follow-up alexithymia scores, after partialling the effects of depression and anxiety severity. Changes in alexithymia were explained only to a small extent by changes in depression and anxiety from T1 to T2. Results at the factor level revealed that "difficulty identifying feelings" follow-up and change score accounted for the highest variations in depression and anxiety, and "externally oriented thinking" for the lowest ones.

CONCLUSIONS

The finding of relative stability of alexithymia supports the view that this construct is a stable personality trait rather than a state-dependent phenomenon, even in a context of high threat for physical and psychological integrity.

Emotional processing in eating disorders: specific impairment or general distress related deficiency?

The literature on eating disorders emphasizes the relationship between alexithymia and anorexia nervosa on the one hand, and between bulimia nervosa and affect dysregulation on the other. In our study, two questions are addressed: (1) Are there different patterns of emotional processing deficiencies in anorexia and bulimia? and (2) Is there a unique contribution of eating disorders to emotional processing deficiencies? Participants were women with anorexia nervosa (ANs, n=20), bulimia nervosa (BNs, n=20), and normal controls (NCs, n=20). Three hypotheses were examined: (1) Women with eating disorders will exhibit lower emotional awareness and more deficient emotional regulation than will NCs (emotional deficiency); (2) ANs will be less emotionally aware than BNs, whereas BNs will be less capable of effective emotional regulation than ANs (disorder specificity); and (3) emotional distress will mediate the relationships between emotional processing and eating disorders (emotional distress mediation). Results supported the emotional deficiency and distress mediation hypotheses, and partially supported the disorder specificity hypothesis. The need to move beyond alexithymia in understanding the pattern of emotional processing deficiencies in eating disorders is discussed.

Body of evidence: tattoos, body piercing, and eating disorder symptoms among adolescents

OBJECTIVE

Tattoos and body piercing have been linked to risk-taking behaviors, including disordered eating, but the findings have come from selected samples that were at greater risk for bias due to comorbidity. This study set out to explore concurrently the prevalence of tattoos and body piercing, and eating disorder symptoms in a representative adolescent sample of a community in Sardinia, a major island in Italy.

METHODS

A community sample of 828 students (female, 535; male, 282; mean age=17.5+/-1.4 years) among those attending high school in the district of Cagliari, Italy, were invited to take the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, and the Body Attitudes Test, alongside a short questionnaire aimed at evaluating their resorting to body modification practices, including tattooing and body piercing.

RESULTS

Females scored higher than males at all eating disorder inventories. More males than females admitted the use of tattoos (14.5% vs. 5.4%), whereas the reverse was found for body piercing (18.4% vs. 21.3%). Tattoos among females and body piercing in both genders were statistically associated with eating disorder measures related to bulimia symptoms. On the whole, the degree of association was modest.

CONCLUSIONS

Tattoos and body piecing should be seen as desires to show a subject's identity rather than as a marker of psychopathology. Greater health education, however, is needed in the wake of the growing popularity of these body modification practices.

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

BACKGROUND

Eating disorders have been reported to increase in frequency, but it is yet unclear what psychological characteristics increase the proneness toward the development of eating disorders. Alexithymia (AL; a difficulty in awareness to one's emotions) and dissociation proneness are 2 such plausible features.

METHOD

In this study, we evaluated the efficacy of a combined intervention (group therapy, individual therapy, and pharmacologic therapy) in a group of soldiers with eating disorders (n = 30) in the Israel Defense Forces. Moreover, we examined whether AL and dissociation proneness were frequent in this group and whether clinical improvement was associated with an improvement in these factors as well.

RESULTS

High scores on the AL and dissociation measures were noted. The intervention was associated with a 50% decrease in the Eating Attitudes Test and Eating Disorders Inventory scores, consistent with our clinical impression of improvement in the eating symptoms. However, the decrease observed on the Dissociative Experiences Scale and Toronto Alexithymia Scale scores was minimal.

CONCLUSIONS

The combined intervention was efficient in our sample of patients with eating disorder despite the small sample size. The aforementioned specific psychometric change may be indicative of the lack of importance of changes in AL or dissociation proneness in the short-term improvement in patients with eating disorder.

Alexithymia in female patients with eating disorders

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

An open trial of outpatient group therapy for bulimic disorders: combination program of cognitive behavioral therapy with assertive training and self-esteem enhancement

The purposes of this study were to examine the therapeutic efficacy of combined group cognitive behavioral therapy (CGCBT) and to explore the characteristics of the patients who failed to complete it. Our group cognitive behavioral therapy combined with assertiveness training for alexithymia and self-esteem enhancement therapy were attended over a 10-week period. Twenty-five participants were enrolled in the study. The clinical symptoms were assessed before and after treatment, using rating scales including the Eating Disorder Inventory-2, the Bulimic Investigatory Test, Edinburgh, the Toronto Alexithymia Scale, the Rosenberg Self-Esteem Scale, and Global Assessment of Functioning. Sixteen participants (64%) completed the CGCBT program. Completion of the CGCBT resulted in significant improvements in reducing binge-eating behavior and improving social functioning. Eight patients (32%) significantly improved using the Clinical Global Impression Change (CGI-C). Stepwise logistic regression analysis of the results indicated that a lower age (P=0.04) and psychiatric comorbidity (P=0.06) were predictors of dropout from the CGCBT program. Our CGCBT program is a promising first-line treatment for bulimic outpatients. Lower age and the presence of comorbidity had effects on dropout rates.

Emotion Awareness and Identification Skills in Adolescent Girls With Bulimia Nervosa

This study examined emotion-identification skills in 19 adolescent girls (M age=16 years, 8 months) diagnosed with a Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) diagnosis of bulimia nervosa or eating disorder not otherwise specified in the bulimic spectrum, 19 age-matched girls with a DSM-IV diagnosis of unipolar depression, and 19 age-matched girls without a mental health history. Findings revealed that girls with bulimia nervosa compared to girls in the depressed and community control groups endorsed significantly greater reluctance to express emotions and inferior interoceptive awareness. Moreover, they exhibited significantly longer latencies to retrieve information regarding their emotional state in self-generated situations. When provided with a list of emotion labels, girls with bulimia endorsed significantly more labels to describe their responses to typical adolescent situations than girls in the control groups.

[Alexithymia, depression and drug addiction]

Alexithymia is a multidimensional concept associating an emotional component focused on the difficulty in identifying and describing feelings and a cognitive one centred on the use of a concrete and poorly introspective way of thinking. Alexithymia can be assessed by self-assessment instruments and in particular by the 20 items version of the Toronto Alexithymia Scale (TAS-20). Depressive disorders have complex relationships with the construct of alexithymia and there exist few experimental works on the subject. Epidemiological studies frequently raise an overlap between alexithymia and depression, in particular in the context of addiction. The main aim of this study was to confirm the high prevalence of alexithymia among drug addicted patients taking into account socio-demographic variables (sex, age, social and economic categories). The second aim of the study was to investigate the relationships between alexithymia and depression among drug addicted patients. A sample of 128 drug addicted patients answering DSM IV criteria of dependence to a psycho-active substance (alcohol excluded) was paired according to socio-demographic variables to a control sample of 128 normal subjects. Diagnostic assessment was made using the Mini International Neuropsychiatric Interview (MINI). Alexithymia and depression were assessed with the TAS-20 and with the short version of the Beck Depression Inventory (BDI-13). The results confirm the high prevalence of alexithymia among drug addicted patients (43.5%) compared to controls (24.6%). This difference is based namely on the emotional component of alexithymia, the cognitive component failing to show any difference between the two samples. Moreover, alexithymia appears to be independent from socio-demographic variables in our sample of drug addicted patients; 66.4% of drug addicted patients presents a depressive symptomatology (which is significantly more important in female patients), compared to 26% of the controls. Studies using the TAS and the BDI with 21 items have shown that from 10 to 20% of the variance of alexithymia is explained by depression. Our own results show a shared variance of 20% between the TAS-20 and the BDI, going in the direction of a moderated correlation between alexithymia and depressive symptomatology. Moreover, when we retain only subjects without depressive symptomatology at BDI, drug addicted (n=42) are not any more alexithymic than controls (n=114). Our results plead for a positive association between depression and alexithymia in drug addicted, depressed or healthy subjects. Alexithymia and depression would be two associated dimensions, the emotional component explaining alone this association. The emotional component of the alexithymia would be thymo-dependent, whereas the cognitive component (externally oriented thought) would be independent and constitute a stable clinical feature. These results are concordant with other studies in the literature suggesting that alexithymia in its emotional component is supported by depression. Alexithymia thus did not appear as an autonomous dimension which would discriminate between drug addicted and controls, independently of the absence of a depressive state. The Authors discuss the complexity of the relationships between alexithymia and depression and the correlations between TAS and BDI scales especially for the factor Difficulty Identifying Feelings. These results deserve further studies. The cross-sectional nature of this study do not allow to establish if alexithymia is a subjacent and preexistent in the form of a psychopathological dimension in addictive behaviours, so supporting its emergence, and/or if it develops once the dependence is installed and chronicized. Longitudinal studies remain to be realised.

Alexithymia in parents of daughters with eating disorders: its relationships with psychopathological and personality variables

OBJECTIVES

The purpose of this research was to investigate alexithymia among parents of a daughter with eating disorders (EDs) and to relate alexithymia to personality and psychopathology characteristics.

METHODS

Parents of 73 women with ED (20 with anorexia nervosa, restrictive subtype (ANR), 23 with anorexia nervosa, bulimic subtype (ANB) and 30 with bulimia nervosa (BN)) and parents of 72 normal women were evaluated with the Toronto Alexithymia Scale (TAS-20), the Eysenck Personality Questionnaire, the Beck Depression Inventory and the Self-Rating Anxiety Scale.

RESULTS

The parents of daughters with ED show higher scores in the TAS-20 and its factors than the controls. TAS-20 scores of parents are associated with neuroticism, anxiety and depression.

CONCLUSIONS

Alexithymia in parents of daughters with an ED could be a trait of personality, but it could also be a state due to distress. Alexithymia should be taken into account in order to help these parents express emotions.

[A critique of the construct "alexithymia" and its measurement--the weakness of self-report and the opportunities of an objective assessment approach]

Approximately thirty years ago the term alexithymia was coined but it is still open which characteristics have to be considered core symptoms of alexithymia. A selective review of recent expert definitions reveals dynamism in defining the alexithymia construct. At present, the self-report Toronto-Alexithymia-Scales (TAS) are the most frequently used measures of alexithymia. Empirical findings regarding various aspects of validity (factorial, concurrent, and experimental construct validity data) question the validity of the Toronto-Alexithymia-Scales. Alexithymia as measured by the TAS appears not to be consistently related to physiological, affect decoding or affective vigilance characteristics. The heterogeneity of the results could be due to the fact that non-alexithymic persons such as depressed or socially anxious individuals yield high scores on the TAS; on the other hand self-report appears to be in principle a methodologically inadequate approach for the assessment of alexithymia. Objective or direct measures of alexithymic characteristics as the Levels of Emotional Awareness Scale or the prototypicity analysis of mood diaries based on adjective checklists seem to be promising assessment methods for future research.

Cognitive and emotional characteristics of alexithymia: a review of neurobiological studies

OBJECTIVE

To review neurobiological studies of alexithymia in order to achieve a better understanding of the relationship between alexithymia and psychosomatic diseases and psychiatric illnesses.

METHODS

Neurobiological studies of alexithymia were reviewed with a special focus on how emotional and cognitive elements of alexithymia are reflected in earlier research.

RESULTS

Studies that have correlated alexithymia to corpus callosum dysfunctioning have mainly found impairments in cognitive characteristics of alexithymia, whereas from studies of right hemisphere and frontal lobe deficits, it may be concluded that both cognitive and emotional characteristics of alexithymia are impaired.

CONCLUSION

The fact that there is no general agreement on how to define alexithymia seems to have hampered theoretical and empirical progress on the neurobiology of alexithymia and related psychosomatic diseases and psychiatric illnesses. Alexithymia should no longer be approached as one distinct categorical phenomenon and follow-up studies should monitor subjects according to both the cognitive and emotional characteristics of alexithymia.

Alexithymia and body weight in obese patients

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

Alexithymia and sociocultural factors in a Japanese sample: a study with the Rorschach

We reexamined the Japanese version of the 20-item Toronto Alexithymia Scale, a self-report sc ale for measuring alexithymic characteristics, by comparing the scores on three factors and the total scores with variables of the Rorschach in a sample of 40 (originally 48) Japanese college students. Based on prior studies, our aims were to further validate the 20-item Toronto Alexithymia Scale by comparing its scores with those on a projective technique. We also investigated whether sociocultural factors, such as repression of hostility. are associated with scores on the 20-item Toronto Alexithymia Scale (especially Factor 3). None of the seven Rorschach Alexithymia Variables were significantly related to the factors and total scores of the 20-item Toronto Alexithymia Scale. However, scores for Factor 1 (difficulty identifying feelings) of the 20-item Toronto Alexithymia Scale correlated positively with scores on Sum C' (reserved responses to emotional stimuli) and Adj es (stimulus demand), suggesting that individuals who score high for Factor 1 experience gloomy, depressive feelings but in constricted ways. Scores for Factor 3 (externally oriented thinking) correlated positively with the D scores (stress tolerance) and negatively with m (situational stress) responses, suggesting that Factor 3 may reflect a psychological defense that enhances stress tolerance. There was a nonsignificant negative correlation between Factor 1 and Factor 3 scores, but, unlike our hypothesis. Factor 3 was neither related to AG (aggression) nor S (space responses reflecting oppositional tendency), indices of aggression or hostility in the Rorschach Comprehensive System. It may be that the 20-item Toronto Alexithymia Scale and the Rorschach measure quite different aspects of personality, but further research is necessary.

PERSONALITY AND SELF-CONCEPT IN SUBGROUPS OF PATIENTS WITH ANOREXIA NERVOSA AND BULIMIA NERVOSA

The question of subgroups in eating disorders was addressed in this study. According to the Diagnostic and Statistical Manual of Mental Disorders, IV, the two subtypes for anorexia nervosa are restricting and binge-eating/purging. For bulimia nervosa, the subtypes are purging and nonpurging. An attempt was made here to examine alternative ways to create meaningful subgroups in the eating-disordered patient group. A cluster analysis was performed in a group of 52 female patients (AN=21, BN=31). Fifty-five undergraduate students served as a control group. Three self-report instruments were used: the Eating Disorder Inventory-2, Karolinska Scales of Personality, and Tennessee Self-Concept Scale. The results reveal three different groups of patients. Factors like poor interoceptive ability and high degree of somatization differentiate between the groups, and contribute to severity of pathology, as well as to lower levels of self-concept.The results reveal three different groups of patients. Factors like poor interoceptive ability and high degree of somatization differentiate between the groups, and contribute to severity of pathology, as well as to lower levels of self-concept.

Association of emotional intelligence with alexithymic characteristics

We examined the association of emotional intelligence and alexithymic characteristics as the personality trait in cohorts of 267 college students and 398 psychiatric outpatients. Score on the Toronto Alexithymia Scale were significantly correlated with those on the Emotional Intelligence Scale, suggesting that alexithymic characteristics are related to lower emotional intelligence. In conclusion, these data suggest that emotional intelligence overlaps with alexithymia.

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

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

Recent developments in alexithymia theory and research

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Zur Konstruktvalidität einer deutschen Fassung der Toronto Alexithymia Scale

Zusammenfassung: Eine deutsche Übersetzung der Toronto Alexithymie Skala (TAS) wurde an einer Studentenstichprobe (N = 228) auf ihre Faktorenstruktur und ihre psychometrischen Kennwerte hin überprüft. Anhand einer zweiten Stichprobe (N = 170) wurden die Zusammenhänge der Unterskalen der TAS mit Absorption untersucht, sowie mit Fragebogenskalen zu Beschwerdenäußerung, habitueller Gestimmtheit, Kontrollüberzeugung zu Krankheit und Gesundheit, Ärgerausdruck und defensiver Bewältigung. Die konfirmatorischen Faktorenanalysen (FA) sprachen für eine Mehrdimensionalität der TAS, mit einem Faktor zum Identifizieren, Differenzieren und Beschreiben von Gefühlen (TAS-ID), sowie zwei Faktoren des external orientierten Denkens. Die korrelierten TAS-Unterskalen zum external orientierten Denken, «Mangelnde Wichtigkeit von Emotionen» (TAS-WI) und «pragmatische Haltung» (TAS-PR), zeigten deutlich geringere Konsistenz als die von beiden relativ unabhängige Unterskala zu TAS-ID. Eine hierarchisch-oblique FA ergab keinen Sekundärfaktor im Sinne eines übergreifenden Alexithymiekonstrukts. Es ergaben sich widersprüchliche Zusammenhänge der TAS-Unterskalen mit der Absorption-Skala und weiteren Fragebogeninstrumenten. Es wird geschlossen, daß die TAS-Unterskalen kein einheitliches Alexithymiekonstrukt abbilden und daß weitere Untersuchungen zu Alexithymie auf Untermerkmale konzentriert werden sollten.