The Relationship between Alexithymia and Intolerance of Uncertainty in Anorexia Nervosa

Alexithymia, intolerance to uncertainty and mental health difficulties in adolescents with Type 1 diabetes mellitus

BACKGROUND

Type 1 Diabetes Mellitus (T1DM) represents a serious chronic condition affecting a wide number of people. Discussion of the physical issues associated with T1DM pervades the literature, however, there is less discussion of the psychological consequences. Mental health difficulties, alexithymia and uncertainty are present in this population, and known to be harmful for the onset, maintenance and worsening of T1DM. This study aimed to evaluate the presence of these phenomena in people with T1DM.

METHODS

105 participants aged between 11 and 17 years old (M: 13.88; SD: 2.16) affected by T1DM were included in the sample. To assess the presence of mental health difficulties, SAFA scales (Depression, Anxiety and Somatic symptoms) were included in the protocol together with TAS-20 and IUS-12, which evaluate the presence and role of alexithymia and intolerance to uncertainty in the sample, respectively.

RESULTS

A concerning presence of anxiety, depression and somatic symptoms was found in the sample. Mental health difficulties appeared to be consistently present in the sample, often overcoming pathological thesholds. Alexithymia and uncertainty were also common, highlighting their role in T1DM.

CONCLUSIONS

Active mental health difficulties together with high rates of alexithymia and intolerance to uncertainty were prevalent in the sample of adolescents with diabetes.

Interplay between uncertainty intolerance, emotion regulation, cognitive flexibility, and psychopathology during the COVID-19 pandemic: a multi-wave study

The COVID-19 pandemic has created a significant mental health burden on the global population. Studies during the pandemic have shown that risk factors such as intolerance of uncertainty and maladaptive emotion regulation are associated with increased psychopathology. Meanwhile, protective factors such as cognitive control and cognitive flexibility have been shown to protect mental health during the pandemic. However, the potential pathways through which these risk and protective factors function to impact mental health during the pandemic remain unclear. In the present multi-wave study, 304 individuals (18 years or older, 191 Males), residing in the USA during data collection, completed weekly online assessments of validated questionnaires across a period of five weeks (27th March 2020-1st May 2020). Mediation analyses revealed that longitudinal changes in emotion regulation difficulties mediated the effect of increases in intolerance of uncertainty on increases in stress, depression, and anxiety during the COVID-19 pandemic. Further, individual differences in cognitive control and flexibility moderated the relationship between intolerance of uncertainty and emotion regulation difficulties. While intolerance of uncertainty and emotion regulation difficulties emerged as risk factors for mental health, cognitive control and flexibility seems to protect against the negative effects of the pandemic and promote stress resilience. Interventions aimed at enhancing cognitive control and flexibility might promote the protection of mental health in similar global crises in the future.

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.

An updated transdiagnostic review of social cognition and eating disorder psychopathology

Existing data suggest that deficits in social cognitive functioning are transdiagnostic phenomena that are observed across various forms of psychopathology. The goal of the present review was to provide an updated systematic review of the literature on social cognitive functioning across eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Studies that assessed six areas of social cognition were included: theory of mind, social perception, social knowledge, attributional bias, emotion perception, and emotion processing. A systematic search identified 71 studies, the majority of which examined adult women with AN. Research typically focused on alexithymia, theory of mind, empathy, social processing, emotion recognition, or emotion processing. Results suggested some deficits in social cognition in EDs. AN had the most studies with some evidence for deficiencies in social cognition but a fair amount of variability. Research on BN and BED was limited and inconsistent, though there appear to be some deficits in social cognition. Together, the limited coverage across EDs and heterogeneous methodology preclude firm conclusions regarding general or ED-specific deficits, as well as understanding the role of social cognition in ED etiology and maintenance. Therefore, several key questions and future directions are outlined for research moving forward.

Feeling imperfect and imperfectly feeling: A network analysis on perfectionism, interoceptive sensibility, and eating symptomatology in anorexia nervosa

OBJECTIVE

In recent years, the network analysis (NA) methodology has been applied to identify the central features of the psychopathology of anorexia nervosa (AN) and specific connections to previously recognized vulnerabilities. However, an NA investigating both multidimensional perfectionism and interoceptive sensibility in connection to eating symptomatology is currently missing.

METHOD

A total of 260 individuals (139 patients with AN, 121 healthy control individuals) completed the Frost Multidimensional Perfectionism Scale, the Multidimensional Assessment of Interoceptive Awareness and the Eating Disorders Inventory-2. Using state-of-the-art techniques, we estimated a main network with data from all participants and then compared the two separated networks. We checked the variables for empirical overlap through goldbricker, combined as suggested and implemented the empirical measure of the bridge nodes.

RESULTS

Ineffectiveness and need for control over self and body (resulting from combining Asceticism and Drive for Thinness) were the most central nodes, whereas perfectionistic evaluative concerns (resulting from combining Doubts about Actions and Concern over Mistakes) and mistrust in body sensations were the bridge nodes. No significant differences between the patient and control networks emerged.

CONCLUSIONS

Perfectionistic evaluative concerns and mistrust in body sensations could be key components in the relationships among perfectionism, interoceptive sensibility and eating symptomatology.

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.

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

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

Intolerance of uncertainty and eating disorder behaviour: Piloting a consumption task in a non-clinical sample

BACKGROUND AND OBJECTIVES

Intolerance of uncertainty (IU) is a transdiagnostic process contributing to the maintenance of anxiety disorders, and is a potential target for treatment. Recent literature has investigated IU as a cognitive process underpinning pathological fear and anxiety in Anorexia Nervosa (AN). The current study was designed to examine trait and state IU, and their relationship to restrictive eating disorder symptoms, anxiety, worry, cognitive rigidity and eating behaviour.

METHODS

A sample of undergraduate women (N = 85) completed measures of eating disorder symptoms, IU, cognitive rigidity and worry. Participants were randomised to complete an eating task under one of two conditions: the "certain" condition received a high-calorie meal and nutritional information, while the "uncertain" condition received the meal alone. During the meal, state IU and state anxiety were examined at three time-points (baseline, pre-eating, post-eating).

RESULTS

Trait IU was correlated with cognitive rigidity, worry, global eating disorder symptoms, and, in particular, dietary restraint. No differences emerged between conditions with respect to eating-related anxiety, or amount of food eaten. Controlling for condition and eating disorder symptoms, state IU predicted pre-eating anxiety. Beyond the contribution of condition, BMI and eating disorder symptoms, state IU predicted consumption, specifically greater dietary restriction.

LIMITATIONS

The study employed a non-clinical sample.

CONCLUSIONS

IU may be implicated in a rigid cognitive style, the anxiety response to energy-dense food, and restrictive eating behaviour. Should these findings be replicated in a clinical sample, then IU might emerge as an adjunctive treatment target for AN.

Behavioral Responses to Uncertainty in Weight-Restored Anorexia Nervosa - Preliminary Results

Impaired decision-making under conditions of uncertainty seems to contribute to the expression and maintenance of anorexia nervosa (AN), but it is not clear whether this impairment is a disease state that would remit with treatment, or a persisting trait in patients with AN. To examine this question, a longitudinal study was conducted in 12 female inpatients with AN (age M = 22.2, SE = 1.36), before (Time-1) and after reaching a body mass index of >17.5 kg/m² (Time-2). Intolerance of uncertainty (IU) was assessed via a decision-making task, the wheel of fortune (WOF). Weight gain at Time-2 was accompanied with significant changes in uncertainty-related performance compared to Time-1 [(Time × Uncertainty), p < 0.05]. At Time-1, reaction times (RTs) varied in function of uncertainty, while at Time-2, uncertainty did not modulate RTs. These findings support a change in decision-making under uncertainty with successful weight-rehabilitation in AN. While IU was present in underweight patients, it became non-significant after weight restoration.

Development and validation of the Premorbid Childhood Traits Questionnaire (PCT-Q) in eating disorders

PURPOSE

Some features of eating disorders (EDs) are often present in childhood before the onset of the ED. We developed a novel questionnaire to retrospectively capture such childhood traits.

METHODS

Focus groups were conducted at the University of California-San Diego, USA, and at the University of Turin, Italy. Three focus groups were conducted at each site, interviewing patients and parents to identify those traits that most commonly characterize childhood of patients with EDs. A preliminary version of the Premorbid Childhood Traits Questionnaire (PCT-Q) derived from these focus groups was then administered to 94 consecutive inpatients with an ED and to 286 healthy controls (HCs) at the Turin site. Also, 208 participants' parents were enrolled as well; in fact, the PCT-Q was developed with both a proband and an informant version.

RESULTS

A 37-item final version of the PCT-Q was generated. Reliability analyses suggested acceptability for harm avoidance (HA), social phobia, alexithymia, interoceptive awareness (IA), and food obsessions. Inter-rater reliability ranged from fair to moderate. ED sufferers scored significantly higher than HCs on HA, social phobia, alexithymia, IA, and food obsessions.

CONCLUSIONS

These findings support the possibility that premorbid traits contribute to a risk to develop an ED in some individuals.

LEVEL OF EVIDENCE

III: case-control analytic study.

The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa

Recent research has demonstrated that certain components of body image (i.e., shape and weight over-evaluation, preoccupation, and dissatisfaction) in secondary school students shared a distinct clinical significance because of their differential relation to measures of psychopathology. The present study aimed to replicate and extend on these findings by examining the distinctiveness of these body image constructs, in addition to a fear of weight gain, in individuals with anorexia nervosa (AN)-a disorder this is facilitated and maintained by extreme body image concerns. Treatment-seeking females with AN (n = 124) completed a questionnaire battery that measured these constructs. Findings demonstrated that once any shared variance between body image components was removed in regression analyses, fear of weight gain was the only unique predictor of eating disorder psychopathology (e.g., dietary restraint and compulsive exercise), while over-evaluation and preoccupation were the only unique predictors of general psychopathology (e.g., depressive and anxiety symptoms). Overall, these findings demonstrate certain components of body image may operate differently in AN, and reinforce previous calls to consider and assess for distinct facets of body image in this population.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms

BACKGROUND

Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied.

METHODS

Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested.

RESULTS

Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group.

CONCLUSIONS

Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

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.

Intolerance of Uncertainty in eating disorders: An update on the field

Pathological fear and anxiety regarding food, eating, weight and body shape are at the core of eating disorder (ED) psychopathology. To manage anxiety, patients develop complicated repertoires of ritualistic and repetitive behaviours, which can lead to total functional impairment. Yet the cognitive processes underlying anxiety, fear, and anxiety-driven behaviours in EDs remain poorly understood. Intolerance of Uncertainty (IU) is defined as a tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events. There is substantial evidence that IU is a transdiagnostic process that contributes to the maintenance of anxiety disorders; however, IU may also be relevant to the understanding and treatment of EDs. The current review summarises the growing literature examining IU in relation to ED symptoms, including restriction, bingeing, purging, ritualised behaviours, reassurance-seeking and body checking. Extending from the obsessive-compulsive disorder (OCD) and anxiety disorder literature, we propose that IU provides a novel theoretical and clinical framework from which to understand the anxiety, fixation with rules and rituals, and the cognitively rigid profile that is characteristic of ED presentations. We conclude with suggestions for future research, and discuss IU as a potential treatment target for core features of EDs and comorbid symptoms.

A factor analysis of the meanings of anorexia nervosa: intrapsychic, relational, and avoidant dimensions and their clinical correlates

BACKGROUND

Anorexia nervosa (AN) is a difficult to treat disorder characterized by ambivalence towards recovery and high mortality. Eating symptomatology has a sort of adaptive function for those who suffer from AN but no studies have to date investigated the relationship between the reported meanings of AN and patients' clinical characteristics. Therefore, we aimed to perform a factor analysis of a new measure testing its psychometric properties in order to clarify whether subjective meanings of AN can be related to AN severity, to ascertain if some personality traits correlate with the meanings attributed to AN by patients, and finally to verify to what extent such meanings relate to patients' duration of both illness and treatment.

METHODS

Eighty-one inpatients affected by AN were recruited for this study and clinical data were recorded. Participants were asked to complete a novel instrument, the Meanings of Anorexia Nervosa Questionnaire (MANQ) focused on the measurement of values that patients attribute to AN and other measures as follows: Eating Disorders Inventory-2, Beck Depression Inventory, Temperament and Character Inventory, and Anorexia Nervosa Stages of Change Questionnaire.

RESULTS

As measured by the MANQ, body dissatisfaction, problems of adolescence, and distress at school or work mainly triggered the onset of AN. Balance and self-control were mostly reported as meanings of AN while the most frequent negative effects were: being controlled by the illness, obsessive thoughts about body shape, and feeling alone. Differences were found between diagnostic subtypes. When a factorial analysis was performed, three factors emerged: intrapsychic (e.g., balance/safety, self-control, control/power, way to be valued), relational (e.g., communication, way to be recognized), and avoidant (e.g., the avoidance of negative feelings, emotions, and experiences). These factors correlated with patients' personality and motivation to treatments but were unrelated to duration of both illness and treatments.

CONCLUSIONS

Given the ego-syntonic nature of AN, the understanding of patients' value of their disorder could be relevant in treatment; moreover, the positive value of AN resulted to be unrelated to the duration of both illness and treatments. Future research is warranted to replicate these findings and test their clinical implications.

A debate on working memory and cognitive control: can we learn about the treatment of substance use disorders from the neural correlates of anorexia nervosa?

BACKGROUND

Anorexia Nervosa (AN) is a debilitating, sometimes fatal eating disorder (ED) whereby restraint of appetite and emotion is concomitant with an inflexible, attention-to-detail perfectionist cognitive style and obsessive-compulsive behaviour. Intriguingly, people with AN are less likely to engage in substance use, whereas those who suffer from an ED with a bingeing component are more vulnerable to substance use disorder (SUD).

DISCUSSION

This insight into a beneficial consequence of appetite control in those with AN, which is shrouded by the many other unhealthy, excessive and deficit symptoms, may provide some clues as to how the brain could be trained to exert better, sustained control over appetitive and impulsive processes. Structural and functional brain imaging studies implicate the executive control network (ECN) and the salience network (SN) in the neuropathology of AN and SUD. Additionally, excessive employment of working memory (WM), alongside more prominent cognitive deficits may be utilised to cope with the experience of negative emotions and may account for aberrant brain function. WM enables mental rehearsal of cognitive strategies while regulating, restricting or avoiding neural responses associated with the SN. Therefore, high versus low WM capacity may be one of the factors that unites common cognitive and behavioural symptoms in those suffering from AN and SUD respectively. Furthermore, emerging evidence suggests that by evoking neural plasticity in the ECN and SN with WM training, improvements in neurocognitive function and cognitive control can be achieved. Thus, considering the neurocognitive processes of excessive appetite control and how it links to WM in AN may aid the application of adjunctive treatment for SUD.