آلکسیتیمیا و ارتباط آن با اضطراب و افسردگی در اختلالات تغذیه ای

The objective was to study alexithymia and its relationship with anxiety and depression in eating disorders (ED) in a Spanish sample. One hundred and fifty-one females with an eating disorder: 25 with anorexia nervosa, restricting subtype (ANR), 44 with anorexia nervosa, bulimic subtype (ANB), and 82 with bulimia nervosa (BN) [according to criteria from DSM-IV (American Psychiatric Association, 1994)], and a control group of 43 females, were assessed with the Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI) and the Self-Rating Anxiety Scale (SAS). Patients with ED present higher rates of alexithymia than controls, but after controlling for anxiety and depression the differences among groups disappear. Depression and anxiety predicted and correlated positively with alexithymia. Our findings are consistent with previous studies, and suggest that alexithymia is closely related to anxiety and depression, and could be a trait or a state in patients with ED.

Nemiah, Freiberger, and Sifneos (1977) defined the construct alexithymia as follows: (1) difficulty identifying and describing subjective feelings; (2) difficulty distinguishing between feelings and the bodily sensations of emotional arousal; (3) lack of fantasy; and (4) an externally oriented cognitive style. Nowadays, alexithymia is conceptualised as a deficit in the cognitive-experiential component of emotions response systems (subjective awareness and verbal reporting of feelings), and in the interpersonal regulation of emotions. Several authors have attributed alexithymia to the slowing of the affect development during early childhood (Taylor, 2000). Alexithymia has been found in many different pathologies such as somatoform disorders, alcoholism, drug addiction, posttraumatic stress, asthma, depression, eating disorders, but, as Taylor (2000) suggested, more prospective studies are required to establish a causality direction. Bruch, 1962, Bruch, 1973 and Bruch, 1982 suggested that the difficulty to distinguish and describe feelings is the main deficit in eating disorders (ED), related to a sense of general inadequacy and a lack of control over one's life. Following Bruch's suggestions, Taylor, Bagby, and Parker (1997) conceptualised ED as affect regulation disorders. Using the Toronto Alexithymia Scale (TAS) (Bagby, Parker, & Taylor, 1994) in its different versions, empirical studies reported alexithymia rates ranging from 22.9 to 77.1% for patients with anorexia nervosa and from 32.3 to 56% for patients with bulimia nervosa (Bourke et al., 1992, Cochrane et al., 1993, Corcos et al., 2000, De Groot et al., 1995, Jimerson et al., 1994, Rastam et al., 1997, Schmidt et al., 1993 and Taylor et al., 1996). The percentages found in patients and controls (range 3.3–27) are not reliable due to the different TAS versions and cut-off scores used. Taylor et al. (1996) stated that in eating disorders a deficit on the cognitive processing of emotions appears, but not on the operational cognitive style, suggesting that the lack of close relationships of anorexic patients could be due to alexithymia. Alexithymia is associated with interpersonal distrust, ineffectiveness, and lack of interoceptive awareness in ED, but it is not related to drive for thinness and body dissatisfaction. On the other hand, starvation, hyperactivity, bingeing and vomiting, could be attempts to regulate distressing and undifferentiated emotional states in these patients (Taylor et al., 1997). Numerous reports reveal the existence of a relationship between alexithymia, depression and anxiety. Hendryx, Haviland, and Shaw (1991) suggested that alexithymia is a multidimensional feature. They also reported that some dimensions correspond to a state, specially the difficulty to identify and to describe feelings, because they are related to a generalized anxiety response or stress in which depression would be a manifestation. These authors proposed that alexithymia could be an attempt to blockade negative emotions associated with stress. Pandey and Mandal (1996) suggested that the association between alexithymia and overestimated perceived arousal might be due to the association between alexithymia and anxiety. Jacob and Hautekeete (1999) found that alexithymia was related to low affective intensity, and suggested that it was an effect of lesser interest in emotions. However, if depression and anxiety were controlled, the relation between alexithymia and enhanced affective intensity disappeared. Honkalampi, Hintikka, Saarinen, Lehtonen, and Viinamaki (2000) and Honkalampi, Koivumaa-Honkanen, Tankanen, Hintikka, Lehtonen, and Viinamäki (2001) found that alexithymia, in depressed patients, was a state that was dependent on and strongly related to depression. Several authors note that alexithymia is a personality trait that could favour anxiety and depression (Martinez-Sanchez et al., 1998, Parker et al., 1991, Taylor, 2000 and Wise et al., 1992). Other authors argue that alexithymia could be considered as a state due to distress and depressive mood (Corcos et al., 2000). Finally, other authors outline that alexithymia can be either a state or a trait (Cochrane et al., 1993, Jimerson et al., 1994 and Sexton et al., 1998). Nevertheless, it is not clear which of these three hypotheses is closer to the truth: (1) alexithymia as a state could be caused by depression and anxiety as an answer to stress, (2) alexithymia as a trait could favour anxiety and depression development due to the difficulty of managing emotions, and (3) depending on the patients, alexithymia could also be conceptualised as a trait or as a state. It would be necessary to study alexithymia controlling anxiety and depression in order to find an answer to the unsolved question of alexithymia as a state or a trait in ED. There are few studies about this question: De Groot et al. (1995) controlling for depression, found differences in total TAS (26-item version) and in the factor Difficulty in Identifying Feelings, when comparing bulimic patients and controls. Sexton et al. (1998) also controlled for depression and used the TAS-26, and they found that the factor Difficulty in Identifying Feelings was more associated with the clinical state of depression in ED, as already suggested by Parker et al., 1991 and De Groot et al., 1995. The factor Difficulty in Expressing Feelings did not change when there was a decrease of depression in restrictive anorexics, and it was also associated with personality disorders. They concluded that difficulty in describing feelings was a trait in these patients, and that difficulty in identifying feelings was a state. Corcos et al. (2000) confirmed that alexithymia had an increased prevalence in eating disorders, but its occurrence could not be interpreted without taking depression into account. They also reported that increased rates of alexithymia in anorexic patients, compared to bulimic patients, seemed to be more closely related to depression than to an increased alexithymic way of functioning itself. Jimerson et al. (1994), using the TAS-26, and controlling anxiety and depression, compared controls and bulimics free of major depression and they found differences between both groups in their difficulty to identify feelings. They suggested that alexithymia, as it is associated with low self-esteem and insecurity, could be enhancing anxiety and depression in bulimic patients, and that it might be secondary to concurrent depression in certain patients. Studies that use the TAS-20 and control anxiety and depression in all the three cited subtypes of ED are non-existent, so there is no evidence that shows that alexithymia in ED is a personality trait which occurs independently of these symptoms. The aim of this study was to examine the prevalence of alexithymia and its relationship with anxiety and depression in three eating disorder subtypes and a control group.