Alexithymia in eating disorders: therapeutic implications

Introducing a Smart Toy in Eating Disorder Treatment: A Pilot Study

Individuals with eating disorders (EDs) often encounter challenges related to body image, emotional, and sensory difficulties during nutritional rehabilitation. To address these challenges, a novel technology-enabled smart toy, Purrble, designed for immediate assistance in emotion regulation, is being explored. A mixed-method approach involving workshops, diaries, and focus groups was employed to examine the feasibility of Purrble as a therapeutic tool and its impact on participants' daily routines, sensory experiences, and emotional states. The study results demonstrate the engagement and acceptability of this device. Qualitative analysis revealed that participants independently used and integrated Purrble into their emotional and sensory regulation practices. These pilot results support the potential for a shift in the delivery of adjunct therapeutic tools through technology, particularly for ED patients with complex presentations. Future research is necessary to further explore the psychological benefits of this intervention.

Early evaluation of a DBT-informed online intervention for people with eating disorders

OBJECTIVES

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours.

METHOD

We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention.

RESULTS

We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours.

DISCUSSION

Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

Associations among alexithymia, disordered eating, and depressive symptoms in treatment-seeking adolescent military dependents at risk for adult binge-eating disorder and obesity

PURPOSE

Evidence suggests that difficulties identifying and describing one's feelings, core components of alexithymia, are associated with attitudinal and behavioral symptoms of disordered eating; depressive symptoms also may underlie these associations. Specifically, research indicates that alexithymia is positively related to depressive symptoms, which in turn may promote both disordered-eating attitudes and certain disinhibited-eating behaviors (e.g., emotional eating). Findings also suggest that military-dependent youth with high weight may exhibit elevated depressive symptoms and disordered eating. As such, understanding associations among alexithymia, depressive symptoms, and disordered eating is particularly relevant for this vulnerable population.

METHODS

We examined 149 adolescent military dependents (14.4 ± 1.6y; 55.0% female; 20.0% non-Hispanic Black; BMIz: 1.9 ± 0.4) at high risk for binge-eating disorder and obesity in adulthood. Participants completed questionnaires assessing two components of alexithymia (difficulty identifying feelings [DIF] and difficulty describing feelings [DDF]), depressive symptoms, emotional eating, and trait anxiety; disordered-eating attitudes were assessed via semi-structured interview.

RESULTS

A series of regression-based models examined indirect relationships of DIF and DDF with disordered-eating attitudes and emotional eating through depressive symptoms. Bootstrapped 95% confidence intervals revealed a significant indirect path from each of the alexithymia components to disordered-eating attitudes via depressive symptoms; indirect paths to emotional eating were non-significant.

CONCLUSION

Results support the salience of depressive symptoms in the relationship between alexithymia and disordered-eating attitudes. Future research should utilize prospective designs and explore direct and indirect associations of alexithymia with other disordered-eating behaviors.

LEVEL OF EVIDENCE

Level III, evidence obtained from a well-designed cohort study.

Family, friends, and feelings: the role of relationships to parents and peers and alexithymia in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with impairments in socio-emotional functioning, including difficulties in interpersonal relationships as well as alexithymia (difficulties identifying and describing one's emotions). Although the onset of the disorder is mostly in adolescence, a developmental period in which interpersonal relationships to parents as well as peers undergo major changes, only few studies have investigated the quality of interpersonal relationships in adolescent AN patients. Furthermore, the mechanisms linking poor relationship quality to eating disorder psychopathology are not yet clarified, albeit some research suggests that alexithymia might play a pivotal role. The aims of the present study were investigating the quality of interpersonal relationships to parents and peers in adolescents with AN compared to healthy adolescents as well as exploring the mediating role of alexithymia in the association between relationship quality and eating disorder symptoms.

METHODS

Self-report questionnaires were used to assess relationship quality (Inventory of Parent and Peer Attachment) and alexithymia (Toronto Alexithymia Scale) in 12-18 year old female adolescents with AN (n = 35) in comparison to healthy adolescents (n = 40).

RESULTS

Adolescents with AN reported lower relationship quality to both of their parents and to peers compared to healthy controls. Relationship quality scores were negatively correlated to alexithymia as well as eating disorder symptoms. Alexithymia fully meditated the association between eating disorder symptoms and relationship quality to parents and partially mediated the association between eating disorder symptoms and relationship quality to peers.

CONCLUSION

The results indicate difficulties in interpersonal relationships among adolescents with AN and emphasize the role of peer relationships for adolescents' eating disorder psychopathology. Alexithymia seems to play an important role in explaining the link between quality of relationships and eating disorder psychopathology. Results suggest that treatment should not only focus on family relationships but also address relationships to peers as well as adolescents' competence in identifying and dealing with their emotions.

Family Dysfunctional Interactive Patterns and Alexithymia in Adolescent Patients with Restrictive Eating Disorders

Adolescents diagnosed with Restrictive Eating Disorders (REDs) are at risk for alexithymia. REDs patients’ families show dysfunctional interactive patterns, and childhood family environment influences alexithymia development. We aimed to assess the relationship between family dysfunctional interactive patterns and patients’ alexithymia in a sample of adolescents diagnosed with REDs. Forty-five patients and their parents were enrolled. They participated in the clinical version of the Lausanne Triadic Play (LTPc), a standardized observational procedure to assess family functioning. We used the self-report questionnaire Toronto Alexithymia Scale (TAS-20) to assess patients’ alexithymia. The TAS-20 provides a multi-factorial measure of patients’ alexithymia: Difficulty in Identifying Feelings, DIF; Difficulty in Describing Feelings, DDF; Externally-oriented Thinking, EOT) and a total (TOT) score. DDF and EOT scores were significantly higher than DIF score. Patients’ families showed dysfunctional interactive patterns, with a predominance of collusive alliance. Patients from families characterized by collusive alliance had higher TOT scores compared to counterparts from families exhibiting a different interactive dysfunctional pattern. In families characterized by a collusive triadic alliance, the dysfunctional interactive pattern was linked with the risk of alexithymia in patients with REDs. Assessment of family relationships should be included in the routine consultation with adolescent patients affected by REDs.

Systematic Review of Alexithymia in the Population of Hemodialysis Patients

Alexithymia is a construct defined as the inability to differentiate between emotional experiences and bodily sensations. According to existing knowledge, alexithymia may have a major effect on the process of treatment and the outcome of the hemodialysis disease. The objective of this literature review was to determine the significance that alexithymia has for compliance and variables of clinical and mental health in the population of hemodialysis patients. For the above purpose, bibliographic databases “MEDLINE” and “Web of Science” were searched. The matrix method was used in analysis of articles. Searching both databases resulted in 248 articles. After applying exclusion and inclusion criteria, we included results of 13 articles in the literature review. The results of the search are findings regarding the prevalence and correlation of alexithymia with variables of clinical and mental health in hemodialysis patients. Alexithymia is significantly more common in the population of hemodialysis patients, and it has a negative effect on their mental and somatic health. Alexithymia levels in hemodialysis patients are more pronounced in cases where there is a greater number of comorbidities. Alexithymia is the predictor of high mortality rate in the population of hemodialysis patients, independent of other comorbidities.

Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology

BACKGROUND

Autistic people are disproportionately vulnerable to anorexia nervosa and other eating disorders (ED), and within the general population, autistic traits correlate with ED psychopathology. A putative mechanism which may underpin this heightened risk is alexithymia, a difficulty identifying and describing emotional states which is observed in both autism and ED. In two experiments with independent non-clinical samples, we explored whether alexithymia might mediate the heightened risk of eating psychopathology in individuals high in autistic traits.

METHODS

Our first experiment used the PROCESS macro for SPSS to examine relationships between alexithymia (measured by the Toronto Alexithymia Scale (TAS-20)), autistic traits (autism quotient (AQ)), and eating psychopathology (Eating Attitudes Test (EAT-26)) in 121 participants. Our second experiment (n = 300) replicated and furthered this analysis by examining moderating effects of sex and controlling for anxiety and depression as covariates. We also included an additional performance-based measure of alexithymia, the Levels of Emotional Awareness Scale (LEAS).

RESULTS

Study 1 suggested that TAS-20 scores mediated the relationship between heightened autistic traits and eating psychopathology. Replication and further scrutiny of this finding, in study 2, revealed that this mediation effect was partial and specific to the female participants in this sample. The mediation effect appeared to be carried by the difficulty identifying feelings subscale of the TAS-20, even when depression and anxiety were controlled for. LEAS scores, however, were not significantly related to autistic traits or eating psychopathology.

LIMITATIONS

Cross-sectional data prevents any conclusions around the direction and causality of relationships between alexithymia, autistic traits, and eating psychopathology (alongside depression and anxiety), necessitating longitudinal research. Our non-clinical sample was predominantly Caucasian undergraduate students, so it remains to be seen if these results would extrapolate to clinical and/or autistic samples. Divergence between the TAS-20 and LEAS raises crucial questions regarding the construct validity of these measures.

CONCLUSIONS

Our findings with respect to autistic traits suggest that alexithymia could partially explain the prevalence of ED in autistic people and may as such be an important consideration in the pathogenesis and treatment of ED in autistic and non-autistic people alike. Further research with clinical samples is critical to explore these ideas. Differences between men and women, furthermore, emphasize the importance of looking for sex-specific as well as generic risk factors in autistic and non-autistic men and women.

Re-inhabiting one's body: A pilot study on the effects of dance movement therapy on body image and alexithymia in eating disorders

BACKGROUND

Body image disturbance and alexithymia are two core aspects of Eating Disorders (EDs). However, standard treatments for EDs do not include specific techniques to approach these issues on a bodily level. This pilot study evaluated the effects of a Dance Movement Therapy (DMT) intervention on body image and alexithymia in patients with EDs, and also explored their experience of the therapeutic process.

METHOD

14 patients with EDs were recruited from a private clinic. Seven were assigned via quasi-randomization to the DMT group and the others (n = 5) continued their treatment as usual. The length of the intervention was 14 weeks. All participants completed the Multidimensional Body Self Relations Questionnaire (MBSRQ) and the Toronto Alexithymia Scale (TAS-20) at the beginning and at the end of the intervention. Additionally, the DMT group wrote reflective diaries about their experience at the end of each session, which were analyzed using qualitative methods.

RESULTS

Between the pre- and post-intervention, the participants of the DMT group significantly improved in Body Areas Satisfaction (effect size: 0.95) and Appearance Evaluation (effect size: 1.10), and they decreased significantly in Appearance Orientation (effect size: 1.30). A decrease in Overweight Preoccupation was observed (effect size: 0.75), however this was not statistically significant. The control group did not show significant changes in any of the MBSRQ subscales. Neither the DMT group nor the control group improved significantly in the alexithymia scores. The qualitative analysis revealed valuable insights into the participants' processes throughout the sessions. In general, participants received the DMT intervention positively. They reported improvements in their mood states and an increase in their self-awareness. They also appreciated the relationship with the group and the therapist.

CONCLUSION

These results indicate that DMT might be a complementary treatment option for EDs, as it may be able to address body image issues more effectively than verbal therapies. More studies with larger samples are needed to confirm these promising preliminary results.

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

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

DATA SOURCE

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

INCLUSION CRITERIA

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

STUDY EVALUATION AND DATA SYNTHESIS

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

RESULTS

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

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

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

Is it the Taste or the Buzz? Alexithymia, Caffeine, and Emotional Eating

BACKGROUND

Alexithymia, a relatively stable personality trait characterized by difficulties identifying and describing feelings and externally oriented thinking, has been linked to both substance use disorders and eating disorders. In nonclinical samples, alexithymia is associated with heavier consumption of alcohol and caffeine. Both are psychoactive drugs, but unlike most drugs they are typically consumed in the context of palatable and calorie-rich products.

OBJECTIVES

Given the association of alexithymia with disordered eating, the present study evaluated the hypothesis that heavier consumption of caffeine by those with high levels of alexithymia may be motivated by the palatable and caloric aspects of common caffeine products rather than by drug-seeking.

METHODS

There were 224 participants aged 17-63 years who completed instruments assessing demographics, alexithymia, emotional eating, caffeine consumption, alcohol consumption, negative moods, and reward sensitivity.

RESULTS

As predicted, alexithymia was positively related to emotional eating as well as consumption of caffeine and alcohol, and alexithymia was a significant predictor of caffeine intake in regression models. However, there was no indication of mediation by emotional eating.

CONCLUSIONS

Alexithymia is characterized by deficient emotion regulation and negative moods, hence use of drugs and/or foods to regulate emotions, combined with poor interoceptive awareness, may account for excessive consumption of drugs or foods as alternative emotion regulation strategies in those with high levels of this trait.

Alexithymia Predicts Attrition and Outcome in Weight-Loss Obesity Treatment

Obesity is a psychosomatic condition characterized by a complex interaction of biological and psychological factors and a large body of research has aimed to identify variables limiting efficacy and determining high attrition rates in weight loss programs. In this study, we used the Diagnostic Criteria for Psychosomatic Research (DCPR), designed to broaden the clinician's perspective on patients' problems by providing additional clinical information not found in the more traditional psychiatric classification, to predict psychosomatic variables that may limit efficacy and determine attrition in clinical interventions with people with obesity. We evaluated 82 consecutive participants with obesity at baseline for psychopathology, psychosomatic correlates, psychological distress, and eating-related symptoms before entering a weight loss program. Regression models were used to assess attrition and outcome at a 6-month follow-up and per-protocol and intention-to-treat analyses were performed. DPCR alexithymia significantly predicted attrition (OR = 6.9), and unsuccessful weight-loss (OR = 11.3). These findings suggest that the identification of psychosomatic factors, in addition to psychological and psychopathological factors, may predict adherence to weight-loss programs.

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.

The PED-t trial protocol: The effect of physical exercise -and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder

BACKGROUND

Sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t). The therapeutic underpinnings of these separate treatment components are well-known, but their combination to treat BN and BED have never been previously tested. The purpose of this paper is to provide the rationale for this new treatment approach and to outline the specific methods and procedures.

METHODS

The PED-t trial uses a prospective randomized controlled design. It allocates women between 18 and 40 years (BMI range 17.5-35.0) to groups consisting of 5-8 members who receive either CBT or PED-t for 16 weeks. Excess participants are allocated to a waiting list control group condition. All participants are assessed at baseline, post-treatment, 6, 12 and 24 months' post-follow-up, respectively, and monitored for changes in biological, psychological and therapy process variables. The primary outcome relates to the ED symptom severity, while secondary outcomes relates to treatment effects on physical health, treatment satisfaction, therapeutic alliance, and cost-effectiveness. We aim to disseminate the results in high-impact journals, preferable open access, and at international conferences.

DISCUSSION

We expect that the new treatment will perform equal to CBT in terms of behavioral and psychological symptoms, but better in terms of reducing somatic symptoms and complications. We also expect that the new treatment will improve physical fitness and thereby, quality of life. Hence, the new treatment will add to the portfolio of evidence-based therapies and thereby provide a good treatment alternative for females with BN and BED.

TRIAL REGISTRATION

Prospectively registered in REC the 16th of December 2013 with the identifier number 2013/1871 , and in Clinical Trials the 17th of February 2014 with the identifier number NCT02079935 .

Clinical evaluation of autistic symptoms in women with anorexia nervosa

BACKGROUND

Despite a suggested link between anorexia nervosa (AN) and autism spectrum disorder (ASD), previous studies have used self-report or diagnostic criteria to assess for ASD in AN populations, rather than direct observation of symptom characteristic of ASD. The aim of this study was to use a standardised, clinical assessment of ASD, the Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2), to investigate the presence of autistic symptoms in a cross-sectional sample of women with AN.

METHODS

Sixty women were recruited from inpatient or day-patient specialist eating disorder services. Each participant underwent the ADOS-2 assessment and completed a set of self-report questionnaires assessing eating disorder pathology and other psychiatric symptoms. IQ was also assessed.

RESULTS

Fourteen women (23.3%) scored above clinical cutoff for ASD on the ADOS-2. Only eight of these women displayed repetitive or restrictive behaviours, while all 14 had difficulties with social affect. Elevated ASD symptoms were associated with increased alexithymia and obsessive-compulsive symptoms, but not specific eating disorder pathology.

CONCLUSIONS

ASD symptoms are over-represented in women with severe AN and appear to be associated with other psychiatric symptoms, which warrant further investigation and consideration in treatment.

Alexithymia: Should This Personality Disorder Be Considered During Treatment of Patients With Mental Illness?

Alexithymia is characterized by impairment of an individual's ability to experience, identify, and express emotions, and is associated with impaired emotional intelligence and an externally oriented cognitive style. There has been increasing interest in the phenomenon, with numerous peer-reviewed articles published recently. Alexithymia may occur in patients with many psychiatric disorders, and more severe alexithymia is related to worse outcome. However, many clinicians remain unaware of the issue. The current article discusses alexithymia and its importance in the field of mental health.

Predictors of Dropout by Female Obese Patients Treated with a Group Cognitive Behavioral Therapy to Promote Weight Loss

OBJECTIVE

To investigate predictors of dropout from a group cognitive behavioral therapy (CBT) intervention for overweight or obese women.

METHODS

119 overweight and obese Japanese women aged 25-65 years who attended an outpatient weight loss intervention were followed throughout the 7-month weight loss phase. Somatic characteristics, socioeconomic status, obesity-related diseases, diet and exercise habits, and psychological variables (depression, anxiety, self-esteem, alexithymia, parenting style, perfectionism, and eating attitude) were assessed at baseline. Significant variables, extracted by univariate statistical analysis, were then used as independent variables in a stepwise multiple logistic regression analysis with dropout as the dependent variable.

RESULTS

90 participants completed the weight loss phase, giving a dropout rate of 24.4%. The multiple logistic regression analysis demonstrated that compared to completers the dropouts had significantly stronger body shape concern, tended to not have jobs, perceived their mothers to be less caring, and were more disorganized in temperament. Of all these factors, the best predictor of dropout was shape concern.

CONCLUSION

Shape concern, job condition, parenting care, and organization predicted dropout from the group CBT weight loss intervention for overweight or obese Japanese women.