Lexithymia in Ating Isorders: Rosa Behar and Marcelo Arancibia

Chapter
ALEXITHYMIA IN EATING DISORDERS
Rosa Behar and Marcelo Arancibia

Department of Psychiatry, University of Valparaiso, Chile
ABSTRACT
Introduction: There is a remarkable relationship between alexithymia and eating
disorders.
Objective: The aim of this chapter is to make an exhaustive review of the literature about
the construct of alexithymia within the context of eating disorders and its subtypes.
Method: Medline/Pubmed databases and specialized textbooks were used to look for the
evidence on alexithymia in eating disordered patients.
Discussion: The main findings show that eating disordered patients are considerably
more alexithymic than normal controls while eating disorder symptoms are more
common in alexithymic adolescents. Alexithymia is a predisposing factor for
perfectionism, which also may lead to the development of eating disorders and it may be
conceptualized as a maladaptive-reactive construct. Those with active eating disorders
achieve high scores for alexithymia mediating a relationship between family dynamic and
maltreatment. Parental alexithymia could be a trait of personality, but it could also be a
state due to distress. Depressive dimension can facilitate the development of interpersonal
deficits (e.g., dependence) in vulnerable alexithymic eating disordered subjects. The
perceived inability to experience emotional feelings is higher in anorectic patients who
show a more diminished fantasy life, are particularly prone to silencing negative affect
and avoid communication involving unpleasant affect, experience their emotions in a
confusing way and are often unable to describe them; nevertheless, it is uncertain whether
these deficits result from starvation. Bulimics are characterized by their inability to
describe feelings and differentiate between emotions and bodily sensations, and by their
tendency to be impatient, showing hostility and a hard-driving style; they usually respond
to stress by binging and vomiting, but find it difficult to make a link between their
behaviour and emotional triggers. Alexithymic binge eating disordered patients exhibited
more difficulty in identifying and describing feelings associated with an increased suicide
ideation. Alexithymia can act as a negative prognostic factor of the long-term outcome
worsening over the course of treatment. Traditional psychoanalysis has been found to be
rather ineffective, whereas an approach evoking encouragement of initiative and
autonomy during therapy interventions (cognitive-behavioural, psycho-educational and
2 Rosa Behar and Marcelo Arancibia
interpersonal), which promote the identification and expression of feelings, may be

particularly useful.
Conclusion: Alexithymic eating disordered patients process emotional information
differently than non-alexithymic subjects. The quality of research in the field of
alexithymia could be raised by including more interdisciplinary perspectives and
experimental methods. Furthermore, the need for early intervention to avoid a chronic
installation of these emotional deficits and a more global impairment on identity
construction is suggested.
PRELIMINARY CONSIDERATIONS
The processing, representation, and perception of bodily signals (interoception) plays an
important role for human behaviour. Theories of embodied cognition hold that higher
cognitive processes operate on perceptual symbols and that concept use involves reactivations
of the sensory-motor states that occur during experience with the world. Similarly, activation
of interoceptive representations and meta-representations of bodily signals supporting
interoceptive awareness are profoundly associated with emotional experience and cognitive
functions (Herbert & Pollatos, 2012).
Emotional awareness was defined by Lane & Schwartz in the late 1980s as the capacity
of an individual to describe one’s own feelings and another person’s emotional experience
(Lane & Schwartz, 1987). They conceptualized emotional awareness as a cognitive process
undergoing various structural transformations along a cognitive-developmental sequence.
Their model, which accounts for individual differences in emotional awareness, stems from
Piaget’s (1972, 1990, 1995) theory of cognitive development, and from the point of view of
Werner and Kaplan (1963) that symbolization is a structure-building, schematizing activity.
The structural organization of the cognitive processes, leading to accurate empathy,
undergoes five clearly differentiated levels of progressive differentiation and integration,
intimately linked to the developing structure of knowledge about the internal and external
world, of the ego and the ability to engage in interpersonal relationships identifying feelings
and distinguishing emotions from physical sensations, difficulties in communicating
emotional states to others, restricted daydreaming, and a concrete/externally oriented thinking
(Lane & Schwartz,1987), conceptualized as alexithymia.
Several studies suggest that alexithymia is a predominant factor in eating disorders
(Beales& Dolton, 2000; Bourke, Taylor, Parker, & Bagby, 1992; Guilbaud, Corcos,
Chambry, Paterniti, Loas, & Jeammet, 2000; Schmidt, Jiwany, & Treasure, 1993;Taylor,
Parker, Bagby, & Bourke, 1996;Zonnevijlle-Bender, Van Goozen, Cohen-Kettenis, & Van
Engeland, 2002; Bydlowski, Corcos, Jeammet, Paterniti, Berthoz, Laurier, & et al., 2005).
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. Gilboa-Schechtman, Avnon, Zubery, & Jeczmien, (1993) found that patients with
both bulimia nervosa and anorexia nervosa had significantly higher alexithymia scores than
controls (Schmidt et al., 1993). Both subtypes hold the same structure of maladaptive emotion
regulation, using or misusing eating or not eating to regulate their negative feelings. Both
fasting and binge-eating are highly effective strategies to suppress emotions and to divert
Alexithymia in Eating Disorders 3
attention from negative feelings by focusing on body weight and nutrition (Becker-Stoll, &
Gerlinghoff, 2004).
THE CONCEPT OF ALEXITHYMIA

The term alexithymia is derived from the Greek and means no words for feelings and is
used to describe a personality trait characterized by the inability to experience and express
emotion (Pinaquy, Chabrol, & Barbe, 2002).
Sifneos (1972) proposed the concept of alexithymia that literally means “lack of words
for emotion”. According to Sifneos’s definition, three features characterize the alexithymic
person: (i) a difficulty in recognizing, identifying, and describing emotions, and in
distinguishing between emotional states and bodily sensations; (ii) an impaired
symbolization, as evidenced by a paucity of fantasies and other imaginative activity; and (iii)
a preference for focusing on external events rather than inner experiences.
Initially, alexithymia was thought to be closely linked to psychosomatic disease, although
the specificity of this link was later questioned. Consequently, alexithymia was found to be
associated with non-psychosomatic pathologies such as substance abuse, post-traumatic stress
disorder, eating disorders, and somatisation disorders (Jimerson, Wolfe, Franko, Covino, &
Sifneos, 1994; Taylor, 1984; Taylor, Parker, & Bagby, 1990; Krystal, 1988). Nowadays,
alexithymia is more generally viewed as a cognitive style of language and of thoughts
characterized by a deficit in the processing of emotional information, or as a lack of affect
regulation (Taylor, Bagby, & Parker, 1997)and is now considered as a syndrome acting as a
continuum (Taylor et al., 1997).
The constriction of imaginative processes as assessed by the difficulty fantasizing factor
has been considered as a core feature of alexithymia since the initial definition of the
construct by Sifneos (1972). Additionally, this trait can provide a differential diagnostic
between alexithymia and personality disorders, such as schizophrenic or obsessive-
compulsive disorders (Sifneos, 1996). These disorders are also characterized by flattened
affects but, in contrast to alexithymia, they are generally associated with a rich fantasy life.
Furthermore, some traumatic situations can modify substantially the magnitude of
alexithymia for an extended period of time (Zech, Luminet, Rimeâ, & Wagner, 1999).
Originally, the conception of alexithymia emerged from clinical observations of
psychosomatic patients, predominantly described as unimaginative and as often manifesting
difficulties in verbal and symbolic expression of emotion (Ruesch, 1948). Psychoanalytic
treatment was impeded for them because of a lack of emotional awareness, paucity of inner
experiences, concreteness of thinking, and externalized style of living (Horney, 1952;
Kelman, 1952). Marty &de M'Uzan (1963) coined the term pensée opératoire (operatory
thinking) to indicate the trait characterizing psychosomatic patients according to which they
generally report on experienced events and on their own actions and behaviours without
affective or emotional connotations (Zech et al., 1999). Also, this notion includes difficulty
locating bodily sensations, infrequent dreaming and a tendency to use action rather than
words to cope with emotional situations (Nemiah, Freyberger, & Sifneos,1976). Alexithymia
is thus an ubiquitous characteristic that may be found in the healthy population and in patients
suffering from medical and psychiatric pictures (Blanchard, Arena, & Pallmeyer, 1981), as
eating disorders. People suffering from these pathologies show alexithymia as a prominent
feature. These patients have problems identifying sensations of hunger and satiety and are
unable to describe their emotions (Sureda, Valdes, & de Pablo, 1999).
Moreover, alexithymia was considered by Lane & Schwartz (1987) as corresponding to
the lower end of the emotional awareness continuum, that is, the preconceptual level of
emotion organization and regulation within their hierarchical model. Indeed, alexithymia can
be viewed as a deficit in the cognitive processes involved in the representation of emotional
internal and external experiences, characterized by the persistence of cognitive-affective
modalities of the first levels of development, below the concrete operational level where
emotions are experienced somatically (Corcos et al., 2005).
Alexithymia Assessment
According to Marjo, Zonnevylle-Bender van Goozen, Cohen-Kettenis, van Elburg,

Martin de Wildt, Stevelmans, & et al. (2004), the broad range of occurrence of alexithymia in
adult and adolescent anorectic might be explained partly by the heterogeneous methodologies
of the studies (e.g., different assessment instruments, inclusion and/or diagnostic criteria).
Alexithymia score can be measured mainly by questionnaires such as the Toronto
Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), the
Eating Disorders Inventory (EDI), the Levels of Emotional Awareness Scale (LEAS), the
Observer Alexithymia Scale (OAS) and the Modified Beth Israel Hospital Questionnaire
(BIQ).
Toronto Alexithymia Scale (TAS)

The Twenty-Item Toronto Alexithymia Scale (TAS-20) was developed by Bagby,
Parker,& Taylor (1994a) and is a self-report instrument intended to assess five traits derived
from a literature review about alexithymia (Taylor, 1984). It corresponds to a revised version
of the earlier 26-item Toronto Alexithymia Scale (TAS);(Taylor, Ryan, & Bagby, 1985). The
TAS-20 has demonstrated good internal consistency and test-retest reliability. The
validational study yielded a three factor structure congruent with the theoretical construct of
alexithymia: (F1) difficulty identifying feelings and distinguishing between feelings and the
bodily sensations of emotional arousal; (F2) difficulty describing feelings to others; (F3)
externally oriented thinking. Despite the absence of items on the TAS-20 directly assessing
daydreaming and other imaginative activity, which were included on the TAS-26, the third
factor, together with factor 2, seem to reflect the operatory thinking component of the
alexithymia construct, a cognitive style that shows a preference for the external details of
everyday life rather than thought content related to feelings, fantasies, and other aspects of a
person's inner experience (Marty & de M'Uzan, 1963; Nemiah et al., 1976; Taylor, Bagby, &
Luminet, 2000).
Nevertheless, alexithymic levels measured by the TAS-20 are modulated by the severity
of symptoms, suggesting that alexithymia can represent a state phenomenon in patients with
major depression, panic disorders, eating disorders and substance use disorders, since the
TAS-20 seems overly sensitive to a general distress syndrome, and it is more likely to
measure negative affects rather than alexithymia itself (Marchesi, Ossola, Tonna, & de
Panfilis, 2014).
Bermond-Vorst Alexithymia Questionnaire (BVAQ)

Another instrument is the Bermond-Vorst Alexithymia Questionnaire (BVAQ)(Vorst
&Bermond,2001), which evolved from the Amsterdam Alexithymia Scale (AAS) (Bermond,
Vorst, Vingerhoets, & Gerritsen, 1999), a 20-item questionnaire intending to assess five
elements of alexithymia. Bermond & Vorst extended the questionnaire with the purpose of
having two parallel versions, leading to the 40-item Bermond-Vorst Alexithymia
Questionnaire. The existence of five factors questionnaire emerging by a factor analyses were
designed as (i) verbalizing, or the degree to which someone is able or inclined to describe or
communicate about his or her emotional reactions; (ii) fantasizing, or the degree to which
someone is inclined to fantasize, imagine, daydream; (iii) identifying, or the degree to which
someone is able to define his or her arousal states; (iv) emotionalizing, or the degree to which
someone can be emotionally aroused by emotion-inducing events; and (v) analysing, or the
degree to which someone is looking for explanations of one's own emotional reactions.
Eating Disorders Inventory (EDI)

Eating Disorders Inventory (EDI) (Garner, Olmsted, & Polivy, 1983) scores, specifically
on the subscale interoceptive awareness reflects one’s lack of confidence in recognizing and
accurately identifying emotions and sensations of hunger and satiety. Bruch (1962, 1978) and
Selvini-Palazzoli (1978) have described this deficiency in interoceptive labelling as
fundamental to anorexia nervosa. This item has been related to the affective deficits of
alexithymia, but not to the cognitive disturbance associated with alexithymia (Laquatra &
Clopton, 1994).
Levels of Emotional Awareness Scale (LEAS)

The Levels of Emotional Awareness Scale (LEAS) is a performance measure that
assesses emotional awareness within a cognitive-developmental framework. Structurally
parallel to Piaget's (1972, 1990) stages of cognitive development, this model holds that
awareness of one's own and others' emotions progresses in a hierarchically ascending order of
1) physical sensations; 2) action tendencies; 3) single emotions; 4) blends of emotion; and 5)
blends of blends of emotion. The scale poses evocative interpersonal situations and elicits
descriptions of the emotional responses of self and others which are scored using specific
structural criteria (Lane, Quinlan, Schwartz, Walker, & Zeitlin, 1990).The Levels of
Emotional Awareness Scale (LEAS) was developed to measure individual differences in the
complexity of emotional awareness among adults (Lane et al., 1990).
Support for the levels of emotional awareness model has grown over the past decade.
Systematic differences in the emotional awareness of adults have been identified (Lane,
Sechrest, Riedel, Weldon, Kasniak, & Schwartz, 1996). Consistent gender differences have
also emerged, with females reporting higher levels of emotional awareness than males
(Barrett, Lane, Sechrest,& Schwartz, 2000). Emotional awareness has been found to correlate
with other areas of emotional functioning, such as the ability to recognize and categorize
emotional stimuli (Lane, 2000; Lane et al., 1996). It has also been found to correlate
negatively with mood congruent bias, that is, individuals high in emotional awareness are
more aware of their moods and are consequently more likely to prevent their mood from
biasing their judgment when compared with individuals low in emotional awareness
(Ciarrochi & Forgas, 2000).
On this instrument inpatients with eating disorders do not exhibited deficits in

differentiating their emotional states, moreover, there was not significant association between
the TAS-20 and the LEAS scores, maybe implying that the two measurements provide insight
into different aspects of emotional processing, although restrictive anorectic patients
experienced difficulties when differentiating the emotional states of others (Rommel,
Nandrino, Antoine, & Dodin, 2013). The LEAS has been shown to correlate positively with
the degree of right hemisphere dominance in the judgment of facial emotion (Lane, Kivley,
Du Bois, Shamasundara, & Schwartz, 1995), and with the ability to match verbal or non-
verbal emotional stimuli with verbal or non-verbal emotional responses (Lane, Sechrest, &
Riedel, 1998).
Patients suffering from eating disorders showed evidence of an emotion-processing
deficit independent of affective disorders, showed by their higher depression and anxiety
levels. Whereas the TAS might also measure depression-related features, it seems that the
LEAS captures a personality trait and not a secondary state generated by depression or
stressful life events. It has been suggested that emotional awareness and expressiveness are
important factors to consider in eating disorders. The LEAS seems to be a measure
complementary to the TAS, the former being unrelated to the subject’s depressive mood but
not the latter. Alexithymia and a low level of emotional awareness are factors that may
obstruct patients from seeking health care, interfere their compliance with treatment
recommendations, and facilitate both the chronic nature of the disorder as well as potential for
relapse or complications (De Groot, Rodin,& Olmsted, 1995; Schmidt, Jiwany,&
Treasure,1993;Bydlowskiet al., 2005).
In one research, individuals with an eating disorder were characterized by a global
emotion-processing deficit, with diminished ability to identify their own emotions, as well as
impairment in judging others’ emotional experience. Anorectic patients had a significantly
lower level of emotional awareness than bulimics, but the TAS score cannot differentiate
between them. In agreement with other studies, the emotional data (alexithymia, emotional
awareness) do not differentiate between restricting and purging anorectics (Cochrane,
Brewerton, Wilson, & Hodges, 1993; Schmidt et al., 1993). Conversely, purging anorectics
clearly were more depressed. Mastery and control, characteristics of restricting anorectics,
have currently been described as protective against the risk of depressive illness. According to
the authors, eating disordered patients have good verbal skills, but cannot use them
adequately to describe their emotional experience, indicating a pronounced incapacity for
emotional understanding. Some researches consider the deficits in the processing of the
subjective experience and the perception of oneself as the most essential difficulties of this
type of disorder (Corcos, 2000; De Groot & Rodin, 1994; Jeammet, 1997; Bydlowskiet al.,
2005).
Observer Alexithymia Scale (OAS)

The Observer Alexithymia Scale (OAS) (Haviland, Warren& Riggs, 2000) consists of 33
items and is rated on a four-point Likert scale. The total score ranges from 0 to 99 and higher
scores again indicate greater alexithymia. The authors developed a relatively brief observer
alexithymia measure that can be used by patients’ acquaintances and relatives, assessing
alexithymia of participants from the point of view of those who know them well. Moreover, it
has an interpretable five-factor structure (based on exploratory and confirmatory factor
analyses): (i) distant (indicating a lack of interpersonal skills of interest; e.g., “is a warm
person”), (ii) uninsightful (indicating a lack of self-understanding and stress tolerance; e.g.,
“falls apart when things are really tough”), (iii) somatizing (reflecting worries about health
and physical problems; e.g., “worries too much about his or her health”), (iv) humorless
(appearing colorless and uninteresting to others; e.g., “is unexciting, boring”), and (v) rigid
(indicating excessive self-control; e.g., “sees things as only black or white”). Each item is
rated on a scale of 0 (never, not at all like the person) to 3 (all of the time, completely like the
person). The OAS is a reliable instrument with a stable factor structure and good conceptual
coverage and thus, it appears to be a useful tool for collecting observer data on the clinically
relevant expressions of alexithymia that receive minimal attention. In a study carried out by
Thorberg, Young, Sullivan, Lyvers, Connor, & Feeney (2010), the TAS-20 was more
strongly associated with alcohol problems than the OAS.
Modified Beth Israel Hospital Questionnaire (BIQ)

This 12-item scale assesses alexithymia from the perspective of a clinician after
completion of a clinical interview. This questionnaire comprises six items pertaining to the
ability to identify and verbally communicate feelings (e.g., affect awareness), and six items
pertaining to imaginal activity and externally-oriented thinking (e.g., operatory thinking).It
provides a total alexithymia score as well as subscores for: (1) affect awareness (e.g., had
difficulty communicating feelings to the interviewer) and (2) operatory thinking (e.g., thought
content was associated more with external events rather than with fantasy or feelings). Each
item is rated on a scale of 1(not true) to 7 (very true). Higher total and subscale scores
indicate greater alexithymia (Bagby, Taylor & Parker, 1994b; Sriram, Pratap, &
Shanmugham, 1988).
ALEXITHYMIA AND ITS RELATION TO EATING DISORDERS

There is strong evidence that eating disorder patients perceive themselves as highly
controlled both by the family and the society. However, they do not show assertive
behaviours towards controllers and reports significantly more external control, more inwardly
directed hostility, less self-assertion and less family encouragement of independence than
dieters and non-dieting controls(Williams, Chamove, &Millar, 1990; Williams, Power,
Millar, Freeman, Yellowlees, Dowds, & et al., 1993).
Some studies have verified that people with eating disorders have alexithymia (Beales,
2000; Troop, Schmidt, & Treasure, 1995), likewise, eating disordered patients are
considerably more alexithymic than normal controls (Schmidt et al., 1993). Conversely,
eating disorder symptoms are more common in alexithymic adolescents (Karukivi, Hautala,
Korpelainen, Haapasalo-Pesu, Liuksila, Joukamaa, & et al., 2010).
Tapia & Ormstein (1997) detected that 50% of eating disordered female patients ranged
60 or more as a total score on TAS versus 0.007% in a control group without eating disorders.
There were no statistically significant differences between anorectic and bulimic patients
regarding the presence of alexithymia. Although Cochrane et al.(1993) found no significant
difference in alexithymia scores between female bulimics and anorectics, as well; Schmidt et
al. (1993) showed that among female patients with eating disorders, restrictive anorectics had
significantly higher scores than bulimics (Bydlowski et al., 2005).
Alexithymia in eating disorders is associated with interpersonal distrust and lack of
interoceptive awareness (Taylor, Parker, Bagby, & Bourke, 1996;Taylor et al., 1997;
Eyzaguirre, Saenz de Cabezon, de Alda, Olariaga, & Juaniz, 2004). Starvation, hyperactivity,
binging, and purging can be thought of as attempts to regulate undifferentiated emotional
states (Taylor et al., 1997; Eyzaguirre et al., 2004). Anorectic patients use cognitive and
behavioural strategies (rituals, purging, or exercises) in order to avoid or attenuate negative
affect. Another cognitive avoidance strategy could also consist in modifying access to
autobiographical emotional memories by retrieving memories less specifically (Raes,
Hermans, de Decker, Eelen, & Williams, 2003; de Decker, Hermans, Raes, & Eelen, 2003). A
hypothesis suggested by Williams (1996) and supported by empirical tests of Raes et
al.(2003) is that individuals who have experienced early negative events or trauma learn that,
by retrieving painful memories in a less specific way, they minimize associated negative
emotions (Nandrino, Doba, Lesnef, Christophe, &, Pezard, 2006).
Eleven meta-analyses showed evidence that people with eating disorders had attachment
insecurity, perceived low parental care, appraised high parental overprotection, impaired
facial emotion recognition, and facial communication, increased facial avoidance, reduced
agency, negative self-evaluation, alexithymia, poor understanding of mental states, and
sensitivity to social dominance. There is less evidence for problems with production and
reception of non-facial communication, animacy and action (Caglar-Nazali, Corfield, Cardi,
Ambwani, Leppanen, Olabintan, & et al., 2014).
Eating disordered patients seem to have a limited access to their emotional life and/or feel
easily dominated and overwhelmed by their emotions (Bruch, 1962). Thus, the ability to take
into account one’s own emotions is diminished in these individuals, probably because body
sensations cannot be related to affects, or because the perception of undifferentiated body
impulses prevents understanding of how affects are elaborated. Lacking knowledge of their
own emotions, these subjects are not able to represent another person’s emotional experience.
Because the capacity to differentiate one’s own and others’ emotions in a given context is
associated with the ability to tolerate and manage a large number of emotional states,
emotions that are not integrated remain global and undifferentiated, which leads to an
incapacity to use affects to guide the selection of an adapted behaviour (Krystal, 1974). These
emotion-processing deficits induce intense, often uncontrolled, affective reactions. The food
related behavioural problems of anorectic and bulimic patients have been conceptualized as a
consequence of the incapacity to control distressing emotions through psychic processes
(Taylor, 1997a). Projection and splitting, which are typical defense mechanisms observed in
these patients, may constitute an attempt to contain overwhelming states of negative affects.
Abnormal eating behaviours would thus represent a way of discharging negative affects, such
as anxiety and depression (van Vreckem & Vandereycken, 1995). Cook (1991) considers that
intense reactions, leading to addictive behaviours, are those distracting the subject from
his/her negative affects. Food ingestion or deprivation, as well as psychoactive substance
consumption, would constitute responses to experiencing such intense reactions. The
frequency of substance use disorders (e.g., alcohol, drugs, psychotropic medications)
associated with the increase in eating disorders supports the view that addiction is an
important parameter to consider in the process of understanding emotional functioning
abilities in eating disorders (Corcos, Nezelof, Speranza, Topa, Guilbaud, Girardon, & et al.,
2001). Eating disorders should, therefore, be regarded as addictive behaviours, whose purpose
is to control the subject’s affective inner turmoil (Jeammet,1997). The finding that neither
level of emotional awareness scores nor alexithymia scores were correlated with the duration
of illness suggests that emotional internal life impoverishment is not due to the severity of the
disorder. This hypothesis is in line with the point of view of some authors who consider
alexithymia to be a predisposing factor for addictive behaviours (Taylor, 1997a, 1997b;
Bydlowski et al., 2005).
Non-Clinical Samples
EDI
In a non-clinical sample of college women, EDI scores were related to the affective
deficits of alexithymia, but not to the cognitive disturbance associated with this condition
(Laquatra & Clopton, 1994). In another survey, relative to the low EDI scores in females with
non-clinical disordered eating in contrast to high EDI participants, the former exhibited a
general deficit in recognition of emotion, which was linked to their scores on the alexithymia
measure and the bulimia subscale of the EDI. They also displayed a specific lack in the
recognition of anger, which in turn was related to their scores on the body dissatisfaction
subscale of the EDI. In line with clinical eating disorders, non-clinical disordered eating is
associated with emotion recognition deficits. However, the nature of these deficits appears to
be dependent upon the type of eating psychopathology and the degree of co-morbid
alexithymia (Ridout, Thom, & Wallis, 2009).
Predictors and Predisposing Factors of Alexithymia
Some predictors and/or predisposing factors related to alexithymia among eating

disordered patients have been detected, such as perfectionism, low maternal care, some core
beliefs, shame, state of illness, premenstrual dysphoric disorder, body esteem, body image
disturbance, negative affects, depression and interpersonal relationships.
Perfectionism
Alexithymia is a predisposing factor for maladaptative perfectionism, which also may
lead to the development of eating disorders (Marsero, Ruggiero, Scarone, Bertelli, &
Sassaroli, 2011).
Maternal care
Female students with two alexithymic characteristics, difficulty identifying and
describing feelings, exhibited more abnormal eating attitudes (e.g., poor oral
control).Although these subjects were not patients with eating disorders the results suggest
that the two alexithymic characteristics studied were associated with lack of maternal care
and are a risk factor for eating disorders (Fukunishi, 1998). Similarly, as stated by de Panfilis,
Rabbaglio, Rossi, Zita, & Maggini (2003), TAS total score and difficulty in describing
feelings were predicted by low maternal care. Body image disturbance in eating disorders
may be conceptualized as a deficit in self-development, resulting from failures in parent-child
interactions which impaired the ability to distinguish bodily needs from emotional.
Core beliefs
Difficulties in identifying emotions has been associated with entitlement beliefs, while
difficulties in describing emotions were linked with both abandonment and emotional
inhibition beliefs, suggesting that it may be necessary to work with core beliefs in order to
reduce levels of alexithymia, prior to addressing the emotions that drive and maintain
pathological eating behaviours (Lawson, Emanuelli, Sines, & Waller, 2008).
Shame
Over a large clinical sample, the subjects showed higher scores on alexithymia, shame,
dissociation, and traumatic feelings scales than the non-clinical population. Partial
correlations highlighted that feelings of shame are related to body dissatisfaction, irrespective
of trauma or depressed mood. Multiple regression analysis demonstrates that shame
(anorectic patients) and perceived traumatic conditions (bulimic and eating disorder not
otherwise specified) are associated with adverse image disorders. Shame seems to hold a
central role in the perception of a negative self-image. Alexithymia may be interpreted as
being a consequence of previous unelaborated traumatic experiences and feelings of shame,
and it could therefore be conceptualized as a maladaptive-reactive construct (Franzoni,
Gualandi, Caretti, Schimmenti, di Pietro, Pellegrini, & et al., 2013).
State of illness
Beales & Dolton (2000) emphasize the difference between those with active eating
disorders who achieved high scores for privacy, introversion, and alexithymia, and those who
have recovered. These character traits give potential helpers an important indication of the
areas that can both block and facilitate recovery, and they act as a reminder that the
presenting symptoms in eating disorders and other psychosomatic conditions are the outward
presentation of internal conflict.
Body dissatisfaction
Difficulty in identifying and describing feelings subscales of TAS were predictors of
severity of premenstrual dysphoric disorder. Alexithymic women with more severe
premenstrual dysphoric disorder exhibited significantly poorer appearance evaluation and
body satisfaction than non-alexithymic women (de Berardis, Campanella, Gambi, Sepede,
Carano, Pelusi, & et al., 2005).On the other hand, patients with eating disorders tend to
experience low levels of body esteem. Keating, Tasca, & Hill (2013) 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, implying
that therapists may attend to attachment insecurity and affective regulation strategies when
addressing body image issues in patients with eating disorders.
De Berardis, Carano, Gambi, Campanella, Giannetti, Ceci, & et al. (2007) found that a
combination of alexithymia, low self-esteem, body checking behaviours and body
dissatisfaction may be a risk factor for symptoms of eating disorders at least in a non-clinical
sample of university women.
Family characteristics
Alexithymia has been found to mediate the relationship between family dynamic and
maltreatment variables and disordered eating among female undergraduates (Mazzeo &
Espelage, 2004). In addition, poor interoceptive awareness, or the inability to distinguish
between various internal physiological cues such as hunger, satiety, and emotional states, is
one of the strongest predictors of disordered eating in adolescent girls (Leon, Fulkerson,
Perry, & Early-Zald,, 1995). Given that the construct of interoceptive awareness includes
characteristics that overlap with features of disordered eating (e.g., confusion regarding
hunger or satiety), it is possible that the strong relationship found between these two
paradigms relates to the fact that they may be overlapping constructs. Although there is a
strong relationship between disordered eating and alexithymia (Cochrane et al., 1993;
Schmidt et al., 1993), as well as between disordered eating and interoceptive awareness (Leon
et al., 1995; Sim & Zeman, 2006).
Negatively expressive families significantly induced unhealthy eating and restraint but
only among young women susceptible to emotion contagion, which may be at increased risk
for eating disorders (Weisbuch, Ambady,Slepian, & Jimerson, 2010). Likewise, daughters
with eating disorders, and their parents, present greater scores in the TAS-20, proposing that
alexithymia could be a characteristic of families with an eating disorder; nonetheless, Espina,
Ortego, & Ochoa (2001) can not affirm that alexithymia is a trait or a state due to the eating
disorder. The same author in a more recent research, points out that parents of daughters with
eating disorders show higher scores in the TAS-20 than the controls, associated with
neuroticism, anxiety and depression and emphasizes that alexithymia in those parents could
be a trait of personality, but it could also be a state due to distress (Espina, 2003).
Negative affects
Even though anorectic and bulimic patients showed higher alexithymia scores compared
to controls, this result could be mainly related to negative affect, but taking these feelings into
account, anorectic and bulimic patients did not report higher TAS-20 and BVAQ scores
compared to controls. The only variable useful to discriminate among anorectics, bulimics
and controls was the perceived inability to experience emotional feelings, which was higher
in anorectic patients compared to the other two groups (Montebarocci, Codispoti, Surcinelli,
Franzoni, Baldaro, & Rossi, 2006).
Depression
Deborde, Berthoz, Godart, Perdereau, Corcos, & Jeammet (2006) observed that
alexithymia and anhedonia both refer to a deficit in emotion regulation. Although these two
concepts have been conceived to be closely linked, very few studies aimed at examining
carefully their interrelations. Eating disorder patients had higher alexithymia and anhedonia
scores than controls. Among alexithymic individuals, 8.9% were social anhedonics, and
31.1% had a physical anhedonia, while among the latest two third were alexithymics. The
same proportion of participants with a social anhedonia was alexithymic too (66.7%).
Sexton, Sunday, Hurt, & Halmi (1998) demonstrated that after controlling for depression,
only the TAS factor difficulty expressing feelings, remained significantly different between
groups, with the restrictive anorectic patients having significantly higher scores than controls
and bulimia nervosa patients. This factor appears to be a relatively stable personality
characteristic in restrictive anorexia. The level of depression and the presence of avoidant
personality disorder were the most predictable variables for the alexithymia total score
(Sexton et al., 1998).In line with this, Tapia & Ormstein (1997) stated that alexithymia was
positively related to depression; 15 out of 17 alexithymic patients had depressive
symptomatology versus5% of non-alexithymic patients. There were not a statistically
significant relationship between alexithymia and the Eating Attitude Test score, a global
screening of psychopathological and behavioural eating disorders features, neither the
evolution time of the illness nor nutritional state of patients.
On the other hand, comparisons of alexithymic traits between patients and controls after
adjustment for depression showed a significant difference between bulimic patients and
controls for the TAS difficulty identifying feelings factor, and between restricting anorectic
patients and controls for the TAS difficulty describing feelings factor. Concerning the
depressive personality styles, only scores on the self-critical dimension were significantly
higher in bulimic patients than in restricting anorectic patients and controls. In the whole
group of eating disorders, dependency was associated with the TAS difficulty identifying
feelings factor only in anorectic patients. Self-criticism, instead, was associated with the TAS
difficulty identifying feelings factor in all subtypes of eating disorders, although the
relationship was significantly stronger in restricting anorectic than in bulimic patients,
suggesting that both kind of patients show specific clinical profiles associating alexithymic
features and depressive dimensions (Speranza, Corcos, Loas, Stéphan, Guilbaud, Perez-Diaz,
& et al., 2005).However, along Corcos, Guilbaud, Speranza, Paterniti, Loas, Stephan, et
al.(2000), after taking depression into account as a confounding variable, rates of alexithymia
did not vary according to the type of eating disorder (anorexia or bulimia).As stated by
Speranza, http://www.ncbi.nlm.nih.gov/pubmed?term=Speranza%20M%5BAuthor%5D&
cauthor=true&cauthor_uid=12910037Stéphan, Corcos, Loas, Taieb, Guilbaud, & et al.(2003),
depressive dimension can facilitate the development of dependence in vulnerable alexithymic
subjects including eating disorder in which the term of addiction is currently applied to
describe a whole range of phenomena characterized by an irresistible urge to engage in a
series of behaviours carried out in a repetitive and persistent manner despite accruing adverse
somatic, psychological and social consequences for the individual. Moreover, depression has
been correlated to some somatic sensations as induced pain. Patients with bulimia exhibited
significantly higher thresholds to mechanically induced pain than healthy subjects.
Thresholds to thermally induced pain in patients with anorexia or bulimia were similar and
significantly higher than in the healthy subjects. Alexithymia and depression scores were
significantly higher in anorectic and bulimic patients than in the healthy subjects. Analyses of
covariance revealed that the degree of alexithymia did not influence thresholds to thermally
and mechanically induced pain, whereas the severity of depression affected to some extent the
threshold to thermally induced pain (de Zwaan, Biener, Bach, Wiesnagrotzki, & Stacher,
1996).
De Groot, Rodin, & Olmsted (1995) detected that disturbances in emotional awareness,
sometimes referred to as alexithymia, have been hypothesized to contribute to the
development of binge/purge symptoms among women with bulimia nervosa and/or are
considered secondary to the state of depression and/or disordered eating. Using the TAS,
significantly more bulimic women were alexithymic at pre-treatment (61.3%) and post-
treatment (32.3%) than in the comparison group (5.0%), even when depression was controlled
for. At discharge, abstinence from binge/purge episodes was associated with a significant
reduction in alexithymia, although there was a significant correlation between TAS scores,
depression, and vomit frequency. Alexithymia among bulimic women is not simply a
concomitant of disordered eating. Its partial reversibility following an intensive
psychotherapy program may be a direct effect of the treatment and/or may be secondary to a
reduction in depressive and/or binge/purge symptoms.
Interpersonal relationships
Relatively little is known about the underlying neurobiological relationships between
alexithymia, anorexia nervosa and interpersonal functioning. According to Miyake, Okamoto,
Onoda, Shirao, Okamoto, & Yamawaki (2012), these patients showed significant activation
of the orbitofrontal cortex, dorsolateral and medial prefrontal cortex while processing
negative words regarding interpersonal relationships, as compared to the processing of neutral
words. In fact, the subjective rating of unpleasantness with negative words and neural
activities in the amygdala, posterior cingulate cortex and anterior cingulate cortex negatively
correlated with the level of alexithymia in anorexia nervosa. The neuroimaging results
suggest that anorectic patients tend to cognitively process negative words about interpersonal
relationships, resulting in activation of the prefrontal cortex. Lower activation of these
structures in response to these words may contribute to the impairments of emotional
processing that are hallmarks of alexithymia. Functional abnormalities associated with
alexithymia may be involved in the emotional processing impairments in anorectic patients.
Girls with interpersonal deficits related to eating disorders had greater depressive
symptoms and alexithymia than those with role disputes. However, girls with role transitions
did not differ from the former or role disputes. Interpersonal problem area had an indirect
association with depression via alexithymia; interpersonal deficits related to eating disorders
showed greater alexithymia, which in turn, was associated to higher depressive symptoms.
Among girls at risk for excess weight gain and eating disorders, those with interpersonal
deficits related to eating disorders appear to have greater distress as compared to girls with
role disputes or role transitions (Berger, Elliott, Ranzenhofer, Shomaker, Hannallah, Field, &
et al.,2014).
ALEXITHYMIA IN EATING DISORDERS SUBTYPES
Anorexia Nervosa
Adolescent eating disorder patients, just like adult ones, are characterised by alexithymia
and show specific deficits in emotional functioning. Zonnevijlle-Bender, van Goozen, Cohen-
Kettenis, van Elburg&van Engeland (2002)declare that anorectics are more alexithymic than
control subjects, more alexithymic than their parents, and that alexithymia is inversely related
to the capacity for empathy (Guttman & Laporte, 2002).
High prevalence rates of alexithymia up to 77% have been reported for patients with
anorexia nervosa (Bourke,Taylor, Parker, & Bagby, 1992)(considerably higher than that
found in other groups of patients)corroborating that this population show disturbances in
recognizing internal visceral and affective states. As described by Bruch (1985), patients with
anorexia nervosa experience their emotions in a confusing way and are often unable to
describe them.
Compared with a prevalence of 6.7% in normal female subjects, alexithymia was
correlated negatively with education in the anorectic group, but was unrelated to duration of
illness, amount of weight loss, and levels of depression and of general psychoneurotic
pathology (Bourke et al., 1992). According to Råstam, Gillberg, Gillberg, & Johansson(1997)
alexithymia, as defined using the TAS-20, was found only in a subgroup of anorectics and
possibly more often in those who are also clinically diagnosed as suffering from empathy
disorder.
From a different point of view, Torres, Guerra, Lencastre, Roma-Torres, Brandão,
Queirós, & et al.(2010) state that despite presenting higher levels of alexithymia, anorectics
are able to imagine emotions in hypothetical situations and to identify and label them,
revealing that their feelings are more intense and show internally based negative emotions in
comparison with the controls, but this emotional pattern tends to occur in situations
associated with food and weight. Findings on meta-emotional abilities suggested no global
deficit in emotional processing, but rather, specific sensitivities pertaining to situations
relevant to anorexia nervosa, in view of that, women with this disorder have difficulties with
emotional recognition and regulation. It is uncertain whether these deficits result from
starvation and to what extent they might be reversed by weight gain alone, and may need to
be targeted in treatment (Harrison, Sullivan, Tchanturia, & Treasure, 2009).The specific
socio-cognitive style of anorectic patients has already been described in the 1960s: it involves
a concrete style with abstraction difficulties. It is the verbal description of feelings that seems
to be particularly impaired. It may explain underlying difficulties in empathy. Indeed, these
subjects have lower scores on emotional tests drawn from the theory of mind. As mentioned
by Troop et al. (1995), restrictive anorectic patients had a more diminished fantasy life than
bulimics and students without eating disorders. There was a trend towards significance on
non-communication of feelings, with patient groups expressing their feelings less than
comparison subjects.
In another survey, Abbate-Daga, Delsedime, Nicotra, Giovannone, Marzola, Amianto, &
et al.(2013) identified illness denial and alexithymia as the most common characteristics in an
anorexia nervosa sample. Cluster analysis classified three groups: moderate psychosomatic
group, somatization group and severe psychosomatic group. Restrictive anorectic patients
reporting often only illness denial and alexithymia mainly represented the first group. The
somatization group showed more severe eating and depressive symptomatology and
frequently syndromes of the somatization cluster. The severe psychosomatic group reported
longer duration of illness and all patients were found to show the alexithymia syndrome.
Their results highlight the need of a deep assessment of psychosomatic syndromes in anorexia
nervosa and could be effective to achieve tailored treatments.
As quoted by Bruch (1985), anorectic patients not only show impaired differentiation
between hunger and satiety, but they can hardly differentiate their physical sensations from
their intimate emotions, which they often cannot describe (Bydlowskiet al., 2005). Ohmannn,
Popow, Wurzer, Karwautz, Sackl-Pammer. & Schuch (2013) mentioned that anorectic girls
had multiple emotional deficits, low self-confidence, and exaggerated needs of control and of
being accepted. In these patients, emotional deficits were resistant to change, but hedonistic
activities, social skills, and recovery from depression were positive aspects, and comorbid
disorders and parental psychopathology were considered negative prognostic factors.
Rommel et al. (2013) showed that maternal care had a positive influence on emotional
awareness in restrictive anorectics. The authors also verified that inpatients with eating
disorders do not present deficits in personal emotional awareness despite their impaired self-
perception. Nonetheless, restrictive anorectic patients showed deficits in the emotional
awareness of others.
It has been found a deficit in the recognition of non-verbal emotional cues from faces,
voices and visual or prosody recognition tasks in anorexia nervosa (Wentz, Gillberg, Gillberg,
& Råstam, 2000; Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004; Zonnevijlle-
Bender, van Goozen, Cohen-Kettenis, van Elburg, & van Engeland, 2002, 2004; Kucharska-
Pietura, Nikolaou, Masiak, & Treasure, 2003). In particular, they poorly recognize negative
emotions in facial expression (Kucharska et al., 2003). Emotional troubles appear in
situations wherein adolescents are in conflict or try to avoid it (Lattimore, Wagner, &
Gowers, 2000; Latzer & Gaber, 1998). Moreover, these patients are particularly prone to
silencing negative affect and avoid communication involving unpleasant affect (Geller,
Cockell, & Goldner, 2000; Sohlberg & Striber, 1994; Strober, 1981). These emotional
dysregulations can be related to alexithymia (Bourke et al., 1992; Oneill & Bornstein 1996;
Råstam, Gillberg, Gillberg, & Johansson, 1997; Corcos et al., 2000; Eyzaguirre et al., 2004)
and is nowadays recognized as an impairment in cognitive components of emotional response
systems (subjective awareness and verbal reporting of feelings) and in interpersonal
regulation of emotions (Eyzaguirre et al., 2004; Nandrino et al., 2006). However, it is
uncertain whether this effect is intrinsically related to alexithymia, comorbidity, or starvation,
possibly contributing to the difficulties in social functioning that have been frequently
reported in these patients (Ratnasuriya et al., 1991).
Anorectic patients are prone to suppress or control not only a negative affect (Geller et
al., 2000) but also a positive one (Kucharska et al., 2003). According to the hypothesis of
affect regulation (Williams, Ellis, Tyers, Healy, Rose, & McLeod, 1996), general memories
allow patients to diminish the affective impact of a negative event (Raes et al., 2003). The
emotional deficit of anorectic patients is thus more global and affects the whole emotional
experience. This supports the hypothesis that eating disorders are emotional regulation
disorders (Taylor et al., 1996, Taylor et al., 1997). Furthermore, memory overgeneralization
deficits could stem from the repetition of negative experiences or from avoidance of
emotional contexts (Nandrino et al., 2006).
Bulimia Nervosa
In bulimia nervosa, alexithymia may be a trait, unaffected by clinical improvement unless

psychological treatment (Schmidt et al., 1993).Bulimic patients often respond to stress with
binging and purging behaviours, but they can hardly correlate their crisis with any emotional
stimulus because of their alexithymic condition (Davis & Marsh, 1986; Schmidt et al., 1993).
Jimerson et al. (1994) noticed that some alexithymia subscales scores were significantly
higher for patients with bulimia nervosa than for controls showing affect deficit states, but
normal scores for factors reflecting imagination, abstract thinking, fantasy or metaphorical
thought. Frequency of binge eating or purging behaviours was not correlated with alexithymia
ratings. Additionally, Feinstein & Sorosky (1988) observed that bulimic patients have
difficulty identifying, describing and controlling a wide range of emotional states. They
underline the high prevalence of alexithymia among bulimics, who are characterized by their
inability to describe feelings and differentiate between emotions and bodily sensations, and
by their tendency to be impatient and show hostility and a hard-driving style (Sureda et al.,
1999). Moreover, it has been shown in bulimic patients that emotional information processing
evolves with age: older women are characterized by negative bias toward negatively balanced
emotional material, while in younger women, more severe eating disorders are distinguished
by greater avoidance of both positive and negative emotion cues (Seddon & Walker, 2000;
Nandrino et al., 2006).
Binge Eating Disorder
Wheeler, Greiner & Boulton (2005) found that alexithymia was more highly correlated
with binge eating than with either anorexia or bulimia nervosa. In addition, a significant
history of trauma and health problems for those who reported as binge eaters was described.
Carano, de Berardis, Gambi, di Paolo, Campanella, Pelusi, & et al.(2006) demonstrated a
high prevalence of alexithymia in patients with binge eating disorders. At the same time,
individuals with alexithymia showed higher body dissatisfaction, lower self-esteem,
depressive symptoms, and the difficulty in identifying feelings/difficulty in describing
feelings subscales of the TAS-20 were predictors of the severity of binge eating disorder.
Zeeck, Stelzer, Linster, Joos, & Hartmann(2010) highlighted that subjects suffering from
binge eating disorder show a more negative pattern of everyday emotions, higher alexithymia
scores and the strongest desire to eat, especially if emotions are linked to interpersonal
aspects. The emotion most often reported preceding a binge was anger. Feelings of loneliness,
disgust, exhaustion or shame lead to binge eating behaviour with the highest probability.
Binge eating disordered patients with alexithymia had higher prevalence of suicide
ideation, and more previous suicide attempts than those without it, phenomenon associated
with higher scores on the difficulty in identifying and describing feelings dimensions of the
TAS-20 (Carano et al., 2012).
On the other hand, de Zwaan, Bach, Mitchell, Ackard, Specker, Pyle, & et al.(1995)
observed that the mean TAS scores did not differ between obese subjects with and without
binge eating disorder. However, a slightly higher prevalence of alexithymia in binge eating
disorder subjects was found, exhibiting a significant relationship between the TAS and
educational level and the Eating Disorder Inventory (EDI) subscales interpersonal distrust and
ineffectiveness.
THERAPEUTIC IMPLICATIONS
The Occurrence of Alexithymia within the Therapeutic Context
Alexithymia is supposed to limit therapeutic outcome (Taylor, 1997c; Bydlowski et al.,

2005). Longitudinal studies have shown that alexithymic features can interfere with treatment
response in eating disorders. Speranza, Loas, Guilbaud, & Corcos (2010) underline in their
research that patients received different treatments according to their alexithymic profile, in
terms both of number and type of treatment received. Patients with high, stable levels of
alexithymia received overall more treatments, and significantly more antidepressants, than
non-alexithymic patients. Those who became alexithymics during follow-up were more often
rehospitalized and controversely received fewer regular psychotherapies than the non-
alexithymic patients. The authors draw attention to professionals that should carefully
monitor these personality features and to be aware of the potential impact of alexithymic
features on treatment compliance and on management choice for eating disordered patients.
Therapeutic Approaches
Traditional psychoanalysis, with its emphasis on interpretation of unconscious processes,

has been found to be rather ineffective, whereas an approach evoking active participation on
the part of the patient led to better treatment results. The experience of being listened has
appeared to be of utmost importance. The distinctive deficits in self-concept and body
awareness could be related to paucity or an absence of confirming responses in the early
mother-child interactions. This concept reinforced the focus on encouragement of initiative
and autonomy during therapy (Bruch, 1982a,b). On the words of Bruch (1962), anorectic
patients do not suffer from loss of appetite but actively pursue self-starvation and are
frantically preoccupied with food, and even more with their size and shape. It is not an illness
of weight and nutrition but a desperate effort to establish a sense of control to counteract
deficits in the sense of effectiveness and the self-concept. After a childhood of over
conformity, these patients are ill prepared to meet the demands for independence and self-
assertion that growing up implies. Traditional treatment has emphasized the restitution of
weight, which, however, is insufficient for cure. For effective treatment, reparation of the
underlying personality deficits is essential. It is suggested that effective screening and needs
assessment will facilitate a more appropriate and prompt therapeutic response. This may be
provided in the primary care setting where appropriate training has occurred (Beales &
Dolton, 2000). Troop et al. (1995) suggest that approaches that promote the identification and
expression of feelings may be particularly useful in the treatment of eating disorders.
Furthermore, Gamber, Lane-Loney & Levine (2013) stress that eating disordered populations,
often alexithymic, may have difficulty engaging with the disclosure task and could potentially
benefit from guidance in processing traumatic events and their affective states. Though,
psychotherapies that focus on maternal bonding and emotional communication within the
family unit may enhance emotional awareness in patients with anorexia or subclinical eating
pathologies as an alternative as well (Rommel et al., 2013). Still, the use in bulimic patients
of
therapeutic strategies developed to modify impatience and hostility in type A subjects could
be useful to treat the bulimic eating patterns and to improve daily mood in bulimic patients
(Sureda et al., 1999).
Outcome
Difficulty in identifying feelings can act as a negative prognostic factor of the long-term
outcome of patients with eating disorders. Professionals should carefully monitor emotional
identification and expression in these patients and develop specific strategies to encourage
labelling and sharing of emotions (Speranza, Loas, Wallier, & Corcos, 2007).
Bourke, Taylor & Crisp (1985) assessed alexithymia prospectively in anorectic inpatients
and found that in a large proportion of cases alexithymia worsened over the course of
treatment, suggesting that this may be the result of increasing demands and life problems that
patients have to face after weight restoration. Thus the effect of psychological treatment on
alexithymia remains unclear. In the authors’ understanding, emotion dysregulation and
therefore alexithymia is not merely a personality feature but the result of the individual’s
history of learning how to cope with emotions, especially with negative and even
overwhelming states of emotional arousal.
Sexton et al., (1998) found significant decreases in the TAS total score and depression
scores over treatment. Nevertheless, after level of depression was controlled, no significant
changes in the alexithymia scores were evident over the course of treatment.
Following attachment theory, the regulation of emotions is learned in the context of the
individual’s history of interactions with attachment figures, which leads to systematic
differences in how the individual attends to and copes with distress related cues (Cole-Detke
& Kobak, 1996).Becker-Stoll & Gerlinghoff (2004) underline a significant decrease in
alexithymia during a 4-month-day-hospital treatment (cognitive-behavioural, psycho-
educational and interpersonal interventions), TAS scores were positively related to post-
treatment EDI scores and negatively interrelated to the prognosis score, showing that patients
with persisting alexithymia still report eating-disordered symptoms, and that these patients
have the least favourable prognosis for their further recovery.
Recommendations and Proposals
In line with the study of Helmes, McNeill, Holden& Jackson (2008), replication in
independent samples is recommended; researchers should also include clinical samples, or at
least a substantial number of subjects with elevated alexithymia scores in their studies; and
for the measurement of variables associated with emotional processing and regulation, they
should not rely on self-report measures alone. Taylor & Bagby (2004) emphasize that
including more interdisciplinary perspectives and experimental methods could raise the
quality of research in the field of alexithymia. In this context, a number of experimental
psychological studies have already shown that alexithymic subjects process emotional
information differently than non-alexithymic subjects (Luminet, Vermeulen, Demaret, Taylor,

& Bagby, 2006; Mueller, Alpers, & Reim, 2006; Vermeulen, Luminet, & Corneille,
2006).Furthermore, functional magnetic resonance imaging studies have detected patterns of
neural activation concomitant of alexithymia (Aleman, 2005; Frewen, Pain, Dozois, &
Lanius,2006; Moriguchi, Decety, Ohnishi, Maeda, Mori, Nemoto, et al., 2007); and
psychophysiological studies into the mental processing of arousal and into correlates of
alexithymia are gaining attention (Guilbaud, Corcos, Hjalmarsson, Loas, & Jeammet, 2003).
On the other hand, the chronic character of anorexia nervosa reinforces the avoidance of
emotional situations and could protect against depressive affect. In this sense, Nandrino et al.
(2006) highlight the importance of emotional process dysregulation in anorexia nervosa and,
particularly, the need for therapeutic intervention both to minimize negative situation
avoidance and to reinforce the hedonic features of emotional experiences. The need for early
intervention to avoid a chronic installation of these emotional deficits and a more global
impairment on identity construction is also suggested.
REFERENCES
[1] Abbate-Daga, G., Delsedime, N., Nicotra, B., Giovannone, C., Marzola, E., Amianto,
F., et al. (2013). Psychosomatic syndromes and anorexia nervosa. BMC Psychiatry, 9,
13, 14.
[2] Aleman, A. (2005). Feelings you can’t imagine: towards a cognitive neuroscience of
alexithymia. Trends in Cognitive Sciences, 9, 553-555.
[3] Bagby, R. M., Parker, J. D. A. & Taylor, G. J. (1994a). The Twenty-Item Toronto
Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal
of Psychosomatic Research, 38, 23-32.
[4] Bagby, R. M., Taylor, G. J. & Parker, J. D. A. (1994b). The Twenty-Item Toronto
Alexithymia Scale: II. Convergent, discriminant, and concurrent validity. Journal of
Psychosomatic Research, 38, 33-40.
[5] Barrett, L. F., Lane, R. D., Sechrest, L. & Schwartz, G. E. (2000). Sex differences in
emotional awareness. Personality and Social Psychology Bulletin, 26, 1027-1035.
[6] Beales, D. L. & Dolton, R. (2000). Eating disordered patients: personality, alexithymia,
and implications for primary care. British Journal of General Practice, 50, 21-6.
[7] Becker-Stoll, F. & Gerlinghoff, M. (2004). The impact of a four month day treatment
programme on alexithymia in eating disorders. European Eating Disorders Review, 12,
159-163.
[8] Berger, S. S., Elliott, C., Ranzenhofer, L. M., Shomaker, L. B., Hannallah, L., Field, S.
E., et al. (2014). Interpersonal problem areas and alexithymia in adolescent girls with
loss of control eating. Comprehensive Psychiatry, 55, 170-8.
[9] Bermond, B., Vorst, H. C., Vingerhoets, A. J. & Gerritsen, W. (1999). The Amsterdam
Alexithymia Scale: its psychometric values and correlations with other personality
traits. Psychotherapy and Psychosomatics, 68, 241-51.
[10] Blanchard, E. D., Arena, J. G. & Pallmeyer, T. P. (1981). Psychometric properties of a
scale to measure alexithymia. Psychotherapy and Psychosomatics, 35, 64-71.
[11] Bourke, M. P., Taylor, G. J. & Crisp, A. (1985). Symbolic functioning in anorexia
nervosa. Journal of Psychiatry Research, 19, 273-278.
[12] Bourke, M. P., Taylor, G. J., Parker, J. D. & Bagby, R. M. (1992). Alexithymia in
women with anorexia nervosa. A preliminary investigation. British Journal of
Psychiatry, 161, 240-3.
[13] Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia nervosa.
Psychosomatic Medicine, 24, 187-194.
[14] Bruch, H. (1978). The golden cage: the enigma of anorexia nervosa. Cambridge, MA:
Harvard University Press.
[15] Bruch, H. (1982a). Anorexia nervosa: therapy and theory. American Journal of
[16] Bruch, H. (1982b). Treatment in anorexia nervosa. International Journal of
Psychoanalysis and Psychotherpy, 9, 303-12.
[17] Bruch, H. (1985). Four decades of eating disorders. In Garner D. & Garfinkel P. (Eds.).
Handbook of psychotherapy for anorexia nervosa and bulimia, (7-18). New York:
Guilford.
[18] Bydlowski, S., Corcos, M., Jeammet, P., Paterniti, S., Berthoz, S., Laurier, C., et al.
(2005). Emotion-processing deficits in eating disorders. International Journal of Eating
Disorders, 37, 321-329.
[19] Caglar-Nazali, H. P., Corfield, F., Cardi, V., Ambwani, S., Leppanen, J., Olabintan, O.,
et al. (2014). A systematic review and meta-analysis of 'Systems for Social Processes'
in eating disorders. Neuroscience & Biobehavioral Reviews, 42, 55-92.
[20] Carano, A., De Berardis, D., Gambi, F., Di Paolo, C., Campanella, D., Pelusi, L., et al.
(2006). Alexithymia and body image in adult outpatients with binge eating disorder.
International Journal of Eating Disorders, 39, 332-40.
[21] Ciarrochi, J. & Forgas, J. P. (2000). The pleasure of possessions: Affective influences
and personality in the evaluation of consumer items. European Journal of Social
Psychology, 30, 631-649.
[22] Cochrane, C. E., Brewerton, T. D., Wilson, D. B. & Hodges, E. L. (1993). Alexithymia
in eating disorders. International Journal of Eating Disorders, 14, 219-222.
[23] Cole-Detke, H. & Kobak, R. (1996). Attachment processes in eating disorder and
depression. Journal of Consulting and Clinical Psychology, 64, 282-299.
[24] Cook, D. R. (1991). Shame, attachment, and addictions: implications for family
therapists. Contemporary Family Therapy, 13, 405-419.
[25] Corcos, M., Guilbaud, O., Speranza, M., Paterniti, S., Loas, G., Stephan, P., et al.
(2000). Alexithymia and depression in eating disorders. Psychiatry Research, 93,
263-6.
[26] Corcos, M. (2000). Le corps absent. Approche psychosomatique des troubles des
conduits alimentaires. [The missing body. Psychosomatic approach of eating
disorders]. Paris: Dunod.
[27] Corcos, M., Nezelof, S., Speranza, M., Topa, S., Guilbaud, O., Girardon, N., et al.
(2001). Psychoactive substance consumption in eating disorders. Eating Behaviors, 2,
27-38.
[28] Davis, M. S. & Marsh, L. (1986). Self-love, self-control, and alexithymia: narcissistic
features of two bulimic adolescents. American Journal of Psychotherapy, 40, 224-32.
[29] De Berardis, D., Campanella, D., Gambi, F., Sepede, G., Carano, A., Pelusi, L., et al.
(2005). Alexithymia and body image disturbances in women with premenstrual
dysphoric disorder.Journal of Psychosomatic Obstetrics & Gynaecology, 26, 257-64.
[30] De Berardis, D., Carano, A., Gambi, F., Campanella, D., Giannetti, P., Ceci, A.,
Mancini, E., et al. (2007). Alexithymia and its relationships with body checking and
body image in a non-clinical female sample. Eating Behavior, 8, 296-304.
[31] Deborde, A. S., Berthoz, S., Godart, N., Perdereau, F., Corcos, M. & Jeammet P.
(2006). Relations between alexithymia and anhedonia: a study in eating disordered and
control subjects. Encephale, 32, 83-91.
[32] De Decker, A., Hermans, D., Raes, F. & Eelen, P. (2003). Autobiographical memory
specificity and trauma in inpatient adolescents. Journal of Clinical Child &
Adolescence Psychology, 32, 22-31.
[33] De Groot, J. M. & Rodin, G. (1994). Eating disorders, female psychology, and the self.
Journal of the American Academy of Psychoanalysis, 22, 299-317.
[34] De Groot, J. M., Rodin, G. & Olmsted, M. P. (1995). Alexithymia, depression, and
treatment outcome in bulimia nervosa. Comprehensive Psychiatry, 36, 53-60.
[35] De Panfilis, C., Rabbaglio, P., Rossi, C., Zita, G. & Maggini, C. (2003). Body image
disturbance, parental bonding and alexithymia in patients with eating disorders.
Psychopathology, 36, 239-46.
[36] De Zwaan, M., Bach, M., Mitchell, J. E., Ackard, D., Specker, S. M., Pyle, R. L., et al.
(1995). Alexithymia, obesity, and binge eating disorder. International Journal of Eating
Disorders, 17, 135-40.
[37] De Zwaan, M., Biener, D., Bach, M., Wiesnagrotzki, S. & Stacher, G. (1996). Pain
sensitivity, alexithymia, and depression in patients with eating disorders: are they
related? Journal of Psychosomatic Research, 41, 65-70.
[38] Espina, A., Ortego, M. A., Ochoa, I. & Alemán, A. (2001). Alexitimia, familia y
trastornos alimentarios. Anales de Psicología, 17, 139-149.
[39] Espina, A. (2003). Alexithymia in parents of daughters with eating disorders. Its
relationships with psychopathological and personality variables. Journal of
Psychosomatic Research, 55, 553-60.
[40] Eyzaguirre, A., Saenz De Cabezon, A., De Alda, I., Olariaga, L., & Juaniz, M. (2004).
Alexithymia and its relationships with anxiety and depression in eating disorders.
Personality and Individual Differences, 36, 321–31.
[41] Feinstein, S. C. & Sorosky, A. D. (1988). Trastornos de la alimentación. Buenos Aires:
Nueva Visión.
[42] Franzoni, E., Gualandi, S., Caretti, V., Schimmenti, A., Di Pietro, E., Pellegrini, G., et
al. (2013). The relationship between alexithymia, shame, trauma, and body image
disorders: investigation over a large clinical sample. Journal of Neuropsychiatric
Disease and Treatment, 9, 185-93.
[43] Frewen, P. A., Pain, C., Dozois, D. J. A. & Lanius, R. A. (2006). Alexithymia in PTSD:
psychometric and FMRI studies. Annals of the New York Academy of Sciences, 1071,
397-400.
[44] Fukunishi, I. (1998). Eating attitudes in female college students with self-reported
alexithymic characteristics. Psychological Reports, 82, 35-41.
[45] Gamber, A. M., Lane-Loney, S. & Levine, M. P. (2013). Effects and linguistic analysis
of written traumatic emotional disclosure in an eating-disordered population.
Permanente Journal, 17, 16-20.
[46] Garner, D., Olmsted, M. & Polivy, J. (1983). Development and validation of a
multidimensional eating disorders inventory for anorexia nervosa and bulimia.
[47] Geller, J., Cockell, S. & Goldner, E. (2000). Inhibited expression of negative emotions
and interpersonal orientation in anorexia nervosa. International Journal of Eating
[48] Gilboa-Schechtman, E., Avnon, L., Zubery, E. & Jeczmien, P. (2006). Emotional
processing in eating disorders: specific impairment or general distress related
deficiency? Depression and Anxiety, 23, 331-9.
[49] Guilbaud, O., Corcos, M., Chambry, J., Paterniti, S., Loas, G. & Jeammet, P. (2000).
Alexithymie et depression dans les troubles des conduits alimentaires. [Alexithymia and
depression in eating disorders]. Encephale, 26, 1-6.
[50] Guilbaud, O., Corcos, M., Hjalmarsson, L., Loas, G. & Jeammet, P. (2003). Is there a
psychoneuroimmunological pathway between alexithymia and immunity? Immune and
physiological correlates of alexithymia. Biomedicine and Pharmacotherapy, 57,
292-295.
[51] Guttman, H. & Laporte, L. (2002). Alexithymia, empathy, and psychological symptoms
in a family context. Comprehensive Psychiatry, 43, 448-55.
[52] Harrison, A., Sullivan, S., Tchanturia, K. & Treasure, J. (2009). Emotion recognition
and regulation in anorexia nervosa. Clinical Psychology and Psychotherapy, 16,
348-56.
[53] Haviland, M. G., Warren, W. L. & Riggs, M. L. (2000). An observer scale to measure
alexithymia. Psychosomatics, 41, 385-92.
[54] Helmes, E., McNeill, P. D., Holden, R. R. & Jackson, C. (2008). The construct of
alexithymia: associations with defense mechanisms. Journal of Clinical Psychology,
64, 318-331.
[55] Herbert, B. M. & Pollatos, O. (2012). The body in the mind: on the relationship
between interoception and embodiment. Top Cognitive Science, 4, 692-704.
[56] Horney, K. (1952). The paucity of inner experiences. American Journal of
Psychoanalysis, 12, 3-9.
[57] Jeammet, P. (1997). Vers une clinique de la dépendance. Approche psychanalytique.
[Towards a clinical approach of the dependence. Psychoanalytical approach]. In Padieu,
R., F. Beauge, F., Choquet, R. Molimard, R., Parquet P., & Stinus L. (Eds.),
Dépendance et conduits de consummation, (33-56). Paris: Edition INSERM.
[58] Jimerson, D. C., Wolfe, B. E., Franko, D. L., Covino, N. A. & Sifneos, P. E. (1994).
Alexithymia ratings in bulimia nervosa: clinical correlates. Psychosomatic Medicine,
56, 90-93.
[59] Karukivi, M., Hautala, L., Korpelainen, J., Haapasalo-Pesu, K. M., Liuksila, P. R.,
Joukamaa, M., et al. (2010). Alexithymia and eating disorder symptoms in adolescents.
Eating Disorders, 18, 226-38.
[60] Keating, L., Tasca, G. A. & Hill, R. (2013). Structural relationships among attachment
insecurity, alexithymia, and body esteem in women with eating disorders. Eating
Behavior, 14, 366-73.
[61] Kelman, N. (1952). Clinical aspects of externalized living. American Journal of

[62] Krystal, H. (1974). The genetic development of affects and affect regression. Annual of
[63] Krystal, H., Giller, E. L. & Cicchetti, D. V. (1986). Assessment of alexithymia in
posttraumatic stress disorder and somatic illness: introduction to a reliable measure.
[64] Kucharska-Pietura, K., Nikolaou, V., Masiak, M. & Treasure, J. (2004). The
recognition of emotion in the faces and voice of anorexia nervosa. International
Journal of Eating Disorders, 35, 42-47.
[65] Lane, R. D. & Schwartz, G. E. (1987). Levels of emotional awareness: a cognitive-
developmental theory and its application to psychopathology. American Journal of
[66] Lane, R. D., Quinlan, D. M., Schwartz, G. E., Walker, P. A. & Zeitlin, S. B. (1990).
The levels of Emotional Awareness Scale: a cognitive-developmental measure of
emotion. Journal of Personality Assessment, 55, 124-134.
[67] Lane, R. D., Kivley, L. S., Du Bois, A. M., Shamasundara, P. & Schwartz, G. E.
(1995). Levels of emotional awareness and the degree of right hemispheric dominance
in the perception of facial emotion. Neuropsychologia, 33, 525-538.
[68] Lane, R. D., Sechrest, L., Riedel, R., Weldon, V., Kasniak, A. W. & Schwartz, G. E.
(1996). Impaired verbal and non-verbal emotion recognition in alexithymia.
[69] Lane, R. D., Sechrest, L. & Riedel, R. (1998). Sociodemographic correlates of
alexithymia. Comprehensive Psychiatry, 39, 377-385.
[70] Lane, R. D. (2000). Levels of emotional awareness: Neurobiological, psychological and
social perspectives. In Bar-On R., & Parker, J., (Eds.), Handbook of emotional
intelligence: theory, development, assessment and application at home, school, and in
the workplace, (171-191). San Francisco: Jossey-Bass.
[71] Laquatra, T. A. & Clopton, J. R. (1994). Characteristics of alexithymia and eating
disorders in college women. Addicted Behaviour, 19, 373-80.
[72] Lattimore, P., Wagner, H. & Gowers, S. (2000). Conflict avoidance in anorexia
nervosa: an observational study of mothers and daughters. European Eating Disorders
Review, 8, 355- 68.
[73] Latzer, Y. & Gaber, L. (1998). Pathological conflict avoidance in anorexia nervosa:
family perspectives. Contemporary Family Therapy, 20, 539-51.
[74] Lawson, R., Emanuelli, F., Sines, J. & Waller, G. (2008). Emotional awareness and
core beliefs among women with eating disorders. European Eating Disorders Review,
16, 155-9.
[75] Leon, G. L., Fulkerson, J. A., Perry, C. L. & Early-Zald, M. B. (1995).Prospective
analysis of personality and behavioural vulnerabilities and gender influences in the later
development of disordered eating. Journal of Abnormal. Psychology, 104, 140-149.
[76] Luminet, O., Vermeulenm, N., Demaret, C., Taylor, G. J. & Bagby, R. M. (2006).
Alexithymia and levels of processing: evidence for an overall deficit in remembering
emotion words. Journal of Research in Personality, 40, 713-733.
[77] Marchesi, C., Ossola, P., Tonna, M. & De Panfilis, C. (2014). The TAS-20 more likely
measures negative affects rather than alexithymia itself in patients with major
depression, panic disorder, eating disorders and substance use disorders.

Comprehensive Psychiatry, 55, 972-8.
[78] Marjo, J. S., Zonnevylle-Bender van Goozen, S., Cohen-Kettenis, P., van Elburg A.,
Martin de Wildt, R. N., Stevelmans, E., et al. (2004). Emotional functioning in anorexia
nervosa patients: adolescents compared to adults. Depression and Anxiety, 19, 35-42.
[79] Marsero, S., Ruggiero, G. M., Scarone, S., Bertelli, S. & Sassaroli, S. (2011). The
relationship between alexithymia and maladaptive perfectionism in eating disorders: a
mediation moderation analysis methodology. Eating and Weight Disorders, 16, 182-7.
[80] Marty, P. & de M'Uzan, M. (1963). La pensée opératoire [Operatory thinking]. Revue
Française de Psychanalyse, 27, 345-356.
[81] Mazzeo, S. E. & Espelage, D. L. (2004). Association between childhood physical and
emotional abuse and disordered eating behaviours in female undergraduates: an
investigation of the mediating role of alexithymia and depression. Journal of
Counselling Psychology, 49, 86-100.
[82] Miyake, Y., Okamoto, Y., Onoda, K., Shirao, N., Okamoto, Y. & Yamawaki, S. (2012).
Brain activation during the perception of stressful word stimuli concerning
interpersonal relationships in anorexia nervosa patients with high degrees of
alexithymia in an fMRI paradigm. Psychiatry Research, 201, 113-9.
[83] Montebarocci, O., Codispoti, M., Surcinelli, P., Franzoni, E., Baldaro, B. &, Rossi, N.
(2006). Alexithymia in female patients with eating disorders. Eating and Weight
[84] Moriguchi, Y., Decety, J., Ohnishi, T., Maeda, M., Mori, T., Nemoto, K., et al.
(2007).Empathy and judging other’s pain: an fMRI study of alexithymia. Cerebral
Cortex, 17, 2223-2234.
[85] Mueller, J., Alpers, G. W. & Reim, N. (2006). Dissociation of rated emotional valence
and Stroop interference in observer-rated alexithymia. Journal of Psychosomatic
Research, 61, 261-269.
[86] Nandrino, J. L., Doba, K., Lesnef, A., Christophe, V. & Pezard, L. (2006).
Autobiographical memory deficit in anorexia nervosa: emotion regulation and effect of
duration of illness. Journal of Psychosomatic Research, 61, 537-543.
[87] Nemiah, J. C., Freyberger, H. & Sifneos, P. E. (1976). Alexithymia: a view of the
psychosomatic process. In Hill, O. (Ed.), Modern trends in psychosomatic medicine,
(430-439). London: Butterworths.
[88] Ohmann, S., Popow, C., Wurzer, M., Karwautz, A., Sackl-Pammer, P. & Schuch, B.
(2013). Emotional aspects of anorexia nervosa: results of prospective naturalistic
cognitive behavioural group therapy. Neuropsychiatry, 27, 119-128.
[89] O’Neill, R. & Bornstein, R. (1996). Dependency and alexithymia in psychiatric
inpatients. Journal of Nervous and Mental Disease, 184, 302-6.
[90] Piaget, J. (1972). The psychology of the child. New York: Basic Books.
[91] Piaget, J. (1990). The child's conception of the world. New York: Littlefield Adams.
[92] Piaget, J., Gruber, H. & Voneche, J. J. (1995). The essential Piaget (100th Anniversary
Ed.). New York: Jason Aronson.
[93] Pinaquy, S., Chabrol, H. & Barbe, P. (2002). Factorial analysis and internal consistency
of the French version of the Toronto Alexithymia Scale (TAS 20), in obese women.
Encephale, 28, 277-82.
[94] Raes, F., Hermans, D., De Decker, A., Eelen, P. & Williams, J. (2003).
Autobiographical memory specificity and affect regulation: an experimental approach.
Emotion, 3, 201-6.
[95] Råstam, M., Gillberg, C., Gillberg, I. C. & Johansson, M. (1997). Alexithymia in
anorexia nervosa: a controlled study using the 20-item Toronto Alexithymia Scale. Acta
Psychiatrica Scandinavica, 95, 385-8.
[96] Ratnasuriya, R. H., Eisler, I., Szmukler, G. I. & Russell, G. F. (1991). Anorexia
nervosa: outcome and prognostic factors after 20 years. British Journal of Psychiatry,
158, 95-502.
[97] Ridout, N., Thom, C. & Wallis, D. J. (2009). Emotion recognition and alexithymia in
females with non-clinical disordered eating. Eating Behavior, 11, 1-5.
[98] Rommel, D., Nandrino, J. L., Antoine, P. & Dodin, V. (2013). Emotional differentiation
and parental bonding in inpatients suffering from eating disorders. British Journal of
Clinical Psychology, 52, 215-29.
[99] Ruesch, J. E. (1948). The infantile personality. Psychosomatic Medicine, 10, 134-144.
[100] Schmidt, U., Jiwany, A. & Treasure, J. (1993). A controlled study of alexithymia in
eating disorders. Comprehensive Psychiatry, 34, 54-8.
[101] Seddon, K. & Waller, G. (2000). Emotional processing and bulimic psychopathology:
age as a factor among non-clinical women. International Journal of Eating Disorders,
28, 364-9.
[102] Selvini-Palazzoli, M. (1978). Self-starvation ⎯ From individual to family therapy in
the treatment of anorexia nervosa. New York: Jason Aronson.
[103] Sifneos, P. E. (1972). Short-term psychotherapy and emotional crisis. Cambridge:
Harvard University Press.
[104] Sifneos, P. E. (1996). Alexithymia: past and present. American Journal of Psychiatry,
153, 137-142.
[105] Sim, L. & Zeman, J. (2006). The contribution of emotion regulation to body
dissatisfaction and disordered eating in early adolescent girls. Journal of Youth and
Adolescence, 35, 219-228.
[106] Sohlberg, S. & Strober, M. (1994). Personality in anorexia nervosa: an update and a
theoretical integration. Acta Psychiatrica Scandinavica, 89, 1-15.
[107] Sriram, T. G., Pratap. L. & Shanmugham, V. (1988). Towards enhancing the utility of
the Beth Israel Hospital Psychosomatic Questionnaire. Psychotherapy and
Psychosomatics, 49, 205-211.
[108] Speranza, M., Stéphan, P., Corcos, M., Loas, G., Taieb, O., Guilbaud, O., et al. (2003).
Relationships between alexithymia, depression and interpersonal dependency in
addictive subjects. Annales de Médecine Interne (Paris), 154, 65-75.
[109] Speranza, M., Corcos, M., Loas, G., Stéphan, P., Guilbaud, O., Perez-Diaz, F., et al.
(2005). Depressive personality dimensions and alexithymia in eating disorders.
Psychiatry Research, 15, 153-63.
[110] Speranza, M., Loas, G., Wallier, J. & Corcos, M. J. (2007). Predictive value of
alexithymia in patients with eating disorders: a 3-year prospective study. Psychosomatic
Research, 63, 365-71.
[111] Speranza, M., Loas, G., Guilbaud, O. & Corcos, M. (2010). Are treatment options
related to alexithymia in eating disorders? Results from a three-year naturalistic
longitudinal study. Biomedicine & Pharmacotherapy, 56, 105-110.
[112] Strober, M. (1981). The significance of bulimia in juvenile anorexia nervosa: an

exploration of possible etiologic factors. International Journal of Eating Disorders, 1,
28-34.
[113] Sureda, B., Valdes, M. I. & de Pablo, J. (1999). Alexithymia, type A behaviour and
bulimia nervosa. European Eating Disorders Review, 7, 286-292.
[114] Tapia, P. & Ornstein, C. (1997). Alexithymia in anorexia nervosa and bulimia nervosa.
Revista Chilena de Neuro-Psiquiatría, 35, 579-84.
[115] Taylor, G. J. (1984). Alexithymia: concept, measurement, and implications for
treatment. American Journal of Psychiatry, 141, 725-732.
[116] Taylor, G. J., Ryan, D. & Bagby, R. M. (1985). Toward the development of a new self-
report alexithymia scale. Psychotherapy and Psychosomatics, 44, 191-199.
[117] Taylor, G. J., Parker, J. D. A. & Bagby, R. M. (1990). A preliminary investigation of
alexithymia in men with psychoactive substance dependence. American Journal of
Psychiatry, 147, 1228-1230.
[118] Taylor, G. J., Parker, J. D. A., Bagby, R. M. & Bourke, M. P. (1996). Relationships
between alexithymia and psychological characteristics associated with eating disorders.
Journal of Psychosomatic Research, 41, 561-568.
[119] Taylor, G. J., Bagby, R. M. & Parker, J. D. (1997a). Eating disorders. In Taylor, G.J.,
Bagby, R.M., &Parker, J.D.A., (Eds.), Disorders of affect regulation: alexithymia in
medical and psychiatric illnesses, (190-215). Cambridge: Cambridge University Press.
[120] Taylor, G. J. (1997b). Substance use disorders. In Taylor, G.J., Bagby, R.M., & Parker,
J.D.A., (Eds.), Disorders of affect regulation: alexithymia in medical and psychiatric
illness, (166-189).Cambridge: Cambridge University Press.
[121] Taylor, G. J. (1997c). Treatment considerations. In Taylor, G.J., Bagby, R.M., &
Parker, J.D.A., (Eds.), Disorders of affect regulation: alexithymia in medical and
psychiatric illness (248-266).Cambridge: Cambridge University Press.
[122] Taylor, G. J., Bagby M. & Luminet, O. (2000). Assessment of alexithymia: self-report
and observer-rated measures. In Parker, J.D.A., & Bar-On, R., (Eds.). The handbook of
emotional intelligence, (301-319). San Francisco, CA: Jossey Bass.
[123] Taylor, G. J. & Bagby, R. M. (2004). New trends in alexithymia research.
Psychotherapy and Psychosomatics, 73, 68-77.
[124] Thorberg, F., Young, R., Sullivan, K., Lyvers, M., Connor, J. & Feeney, G. (2010). A
psychometric comparison of the Toronto Alexithymia Scale (TAS-20) and the Observer
Alexithymia Scale (OAS) in an alcohol-dependent sample. Personality and Individual
Differences, 49, 119-123.
[125] Torres, S., Guerra, M. P., Lencastre, L., Roma-Torres, A., Brandão, I., Queirós, C., et
al. (2011). Cognitive processing of emotions in anorexia nervosa. European Eating
Disorders Review, 19, 100-111.
[126] Troop, N. A., Schmidt, U. H. & Treasure, J. L. (1995). Feelings and fantasy in eating
disorders: a factor analysis of the Toronto Alexithymia Scale. International Journal of
Eating Disorders, 18, 151-157.
[127] Van Vreckem, E. & Vandereycken, W. (1995). Dépendance et nourriture. [Dependance
and food]. In Bailly, D., & Venisse, J.L., (Eds.), Dépendance et conduites de
dependence, (167-176).Paris: Masson.
[128] Vermeulen, N., Luminet, O. & Corneille, O. (2006). Alexithymia and the automatic
processing of affective information: evidence from the affective priming paradigm.
Cognition and Emotion, 20, 64-91.
[129] Vorst, H. C. M. & Bermond, B. (2001). Validity and reliability of the Bermond–Vorst
alexithymia questionnaire. Personality and Individual Differences, 30, 413-34.
[130] Weisbuch, M., Ambady, N., Slepian, M. L. & Jimerson, D. C. (2011). Emotion
contagion moderates the relationship between emotionally-negative families and
abnormal eating behavior. International Journal of Eating Disorders, 44, 716-720.
[131] Wentz, E., Gillberg, I. C., Gillberg, C. & Råstam, M. (2000). Ten-year follow-up of
adolescent-onset anorexia nervosa: physical health and neurodevelopment.
Developmental Medicine and Child Neurology, 42, 328-333.
[132] Wheeler, K., Greiner, P. & Boulton, M. (2005). Exploring alexithymia, depression, and
binge eating in self reported eating disorders in women. Perspectives in Psychiatric
Care, 41, 114-23.
[133] Werner, H. & Kaplan, B. (1963). Symbol formation: An organismic-developmental
approach to language and the expression thought. New York: Wiley.
[134] Williams, G. J., Chamove, A. S. & Millar, H. R. (1990). Eating disorders, perceived
control, assertiveness and hostility. British Journal of Clinical Psychology, 29, 327-35.
[135] Williams, G. J., Power, K. G., Millar, H. R., Freeman, C. P., Yellowlees, A., Dowds, T.,
et al. (1993). Comparison of eating disorders and other dietary/weight groups on
measures of perceived control, assertiveness, self-esteem, and self-directed hostility.
[136] Williams, J. (1996). Depression and the specificity of autobiographical memory. In
Rubin, D.C. & Press C.U., (Eds.), Remembering our past: studies in autobiographical
memory, (244-67). Cambridge: Cambridge University Press.
[137] Williams, J., Ellis, N., Tyers, C., Healy, H., Rose, G. & McLeod, A. (1996). The
specificity of autobiographical memory and imageability of the future. Memory &
Cognition, 24, 116-25.
[138] Zech, E., Luminet, O., Rimeâ, B. & Wagner, H. (1999). Alexithymia and its
measurement: confirmatory factor analyses of the 20-Item Toronto Alexithymia Scale
and the Bermond-Vorst Alexithymia Questionnaire. European Journal of Personality,
13, 511-532.
[139] Zeeck, A., Stelzer, N., Linster, H. W., Joos, A. & Hartmann, A. (2010). Emotion and
eating in binge eating disorder and obesity. European Eating Disorders Review, 19,
426-37.
[140] Zonnevijlle-Bender, M. J., van Goozen, S. H., Cohen-Kettenis, P. T., van Elburg, A. &
van Engeland, H. (2002). Do adolescent anorexia nervosa patients have deficits in
emotional functioning? European Child and Adolescent Psychiatry, 11, 38-42.
[141] Zonnevijlle-Bender, M., Van Goozen, S., Cohen-Kettenis, P., Van Elburg, A. & Van
Engeland, H. (2004). Emotional functioning in adolescent anorexia nervosa patients: a
controlled study. European Child & Adolescence Psychiatry, 13, 28-34.

Lexithymia in Ating Isorders: Rosa Behar and Marcelo Arancibia

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lexithymia in Ating Isorders: Rosa Behar and Marcelo Arancibia

Uploaded by

Copyright:

Available Formats

Chapter

ALEXITHYMIA IN EATING DISORDERS

Rosa Behar and Marcelo Arancibia

interpersonal), which promote the identification and expression of feelings, may be

THE CONCEPT OF ALEXITHYMIA

According to Marjo, Zonnevylle-Bender van Goozen, Cohen-Kettenis, van Elburg,

Toronto Alexithymia Scale (TAS)

Bermond-Vorst Alexithymia Questionnaire (BVAQ)

Eating Disorders Inventory (EDI)

Levels of Emotional Awareness Scale (LEAS)

On this instrument inpatients with eating disorders do not exhibited deficits in

Observer Alexithymia Scale (OAS)

Modified Beth Israel Hospital Questionnaire (BIQ)

ALEXITHYMIA AND ITS RELATION TO EATING DISORDERS

Predictors and Predisposing Factors of Alexithymia

Some predictors and/or predisposing factors related to alexithymia among eating

ALEXITHYMIA IN EATING DISORDERS SUBTYPES

In bulimia nervosa, alexithymia may be a trait, unaffected by clinical improvement unless

Binge Eating Disorder

Alexithymia is supposed to limit therapeutic outcome (Taylor, 1997c; Bydlowski et al.,

Traditional psychoanalysis, with its emphasis on interpretation of unconscious processes,

Recommendations and Proposals

information differently than non-alexithymic subjects (Luminet, Vermeulen, Demaret, Taylor,

[61] Kelman, N. (1952). Clinical aspects of externalized living. American Journal of

depression, panic disorder, eating disorders and substance use disorders.

[112] Strober, M. (1981). The significance of bulimia in juvenile anorexia nervosa: an

You might also like