پیوند پتانسیلی بین علائم اختلال بدریخت انگاری و آلکسیتیمیا در یک نمونه از اختلال تعذیه ای در جستجوی درمان

This study aimed to explore the manifestation of body dysmorphic disorder symptoms in a sample of people with eating disorders and to investigate possible associations between body dysmorphia and alexithymia. Forty patients currently seeking treatment for an eating disorder completed a battery of six measures assessing alexithymia, mood, eating behaviours, weight-related body image, body dysmorphia and non-weight related body image. Significant moderate positive correlations (Pearson's r) between selected variables were found, suggesting that participants with high levels of dysmorphic concern (imagined ugliness) have more difficulty with the affective elements of alexithymia, that is, identifying and describing feelings. When depression, eating attitudes, and weight-related body image concerns were controlled for, significant moderate positive correlations between this alexithymia factor and dysmorphic concerns remained present. An independent-samples t-test between eating-disordered participants with and without symptoms of body dysmorphic disorder (BDD) revealed significant group differences in difficulties identifying feelings. This pattern of results was replicated when the groups were identified on the basis of dysmorphic concerns, as opposed to BDD symptoms. This study highlights the associations between alexithymia and body dysmorphia that have not previously been demonstrated.

Body dysmorphic disorder (BDD), previously known as dysmorphophobia, is an under-recognized psychiatric disorder (Phillips and Castle, 2001a, Phillips and Castle, 2001b and Phillips, 2004). It is classified as a somatoform disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) (DSM-IV) and is characterized by a distressing or impairing preoccupation with an imagined or slight defect in appearance. In spite of the classification of BDD under the somatoform umbrella, the DSM-IV also states that this grouping is based on the need to exclude medical causes for the bodily symptoms, rather than assumptions about shared etiology or mechanism. Indeed, BDD does not appear to fit well with the somatoform grouping. Thus, in an attempt to better understand the manner in which BDD develops, research has explored the relationship between BDD and psychological disorders with related symptomatology (Ruffolo et al., 2006). Connections have been made with disorders such as obsessive–compulsive disorder and depression (Allen and Hollander, 2004 and Phillips, 2005; see also Ruffolo et al., 2006). Additionally, some experts have proposed a shared etiology with eating disorders (Phillips et al., 1995a, Phillips et al., 1995b, Grant and Phillips, 2004 and Phillips, 2005). There is considerable overlap between eating disorders (EDs) and BDD, with major similarities including a high value being placed on appearance, body image disturbance, overlap in bodily areas of concern, obsessive thoughts, compulsive behaviours and avoidance, and similarities in onset and course (for example, see Allen and Hollander, 2004, Grant and Phillips, 2004, Phillips, 2005 and Hrabosky et al., 2009). It should be noted that research looking at the relationship between BDD and EDs has not been consistent in terms of whether the sample has included only people with anorexia nervosa, people with bulimia nervosa, or both. That said, there is currently a move towards a ‘transdiagnostic’ approach to the theory and treatment of eating disorders (Fairburn et al., 2008). This approach recognizes that although anorexia nervosa and bulimia nervosa are separate disorders in the DSM-IV, many people with serious eating disorders do not fit neatly into either category and may change between categories over time (Fairburn et al., 2008). Thus the transdiagnostic approach is applicable to all eating disorders and there is more focus on attitudes and beliefs regarding shape and weight, rather than so much emphasis on the behavioural components of EDs (Fairburn et al., 2008). Comorbidity of EDs and BDD is high. For example, Grant et al. (2002) assessed a sample of patients with anorexia and found that 39% could be diagnosed with comorbid body dysmorphic disorder unrelated to weight concerns. Conversely, Ruffolo et al. (2006) found that 32% of subjects with BDD had a comorbid lifetime eating disorder. Research suggests that body dysmorphic concerns are high amongst ED populations (Rosen et al., 1995, Gupta and Johnson, 2000, Grant et al., 2002 and Dyl et al., 2006) and conversely that disordered eating is common amongst patients with BDD (Phillips, 2005, Ruffolo et al., 2006 and Kittler et al., 2007). Indeed, although BDD is currently classified as a somatoform disorder, it has also been described as a body image disorder due to its parallels with EDs (Phillips et al., 1995b and Grant and Phillips, 2004). To the authors' knowledge, there have been no studies looking at BDD and alexithymia. Alexithymia is a multifaceted personality construct characterized by three main features, two of which are related to affective factors (i.e., difficulty identifying and describing feelings) whereas the last, which is related to cognitive features, manifests as concrete, Externally Oriented Thinking (Taylor et al., 1991 and Taylor et al., 1997; see also Zackheim, 2007). Given the well documented link between alexithymia and EDs (Bourke et al., 1992, Cochrane et al., 1993, deGroot et al., 1995, Taylor et al., 1996, Corcos et al., 2000, De Berardis et al., 2007, Speranza et al., 2007, Lawson et al., 2008a and Lawson et al., 2008b), the more specific link between alexithymia and weight-related body image (De Berardis et al., 2005, Carano et al., 2006, De Berardis et al., 2007 and De Berardis et al., 2009) and the vast research on alexithymia in somatoform conditions other than BDD (Sifneos, 1973, Warnes, 1985, Taylor et al., 1992, Bach and Bach, 1995, Taylor and Bagby, 2004 and Zackheim, 2007), an investigation of a potential relationship between BDD and alexithymia may prove informative. Whilst it is accepted that EDs and alexithymia are linked, and it is plausible that BDD and alexithymia are linked, it is important to consider the nature of these relationships. In the case of EDs and alexithymia, this relationship is not fully understood. Although findings from treatment evaluations (e.g., group therapy, individual therapy, and pharmacologic therapy) have varied, successfully treated ED patients may continue to score highly on alexithymia measures (Iancu et al., 2006; cf Becker-Stoll and Gerlinghoff, 2004). Further, the possibility that the relationship between EDs and alexithymia is mediated by a third ‘general distress’ factor has also been raised (Hund and Espelage, 2006). Such findings, together with research that suggests a strong association between EDs, alexithymia, and affective disorders (Sexton et al., 1998, Eizaguirre et al., 2004 and Speranza et al., 2005), has led to the suggestion that there may be various types of clinical profiles, with the different aspects of alexithymia being related to various aspects of eating pathology and depression or anxiety (Quinton and Wagner, 2005, Speranza et al., 2005, Kiyotaki and Yokoyama, 2006 and Speranza et al., 2007). A closer investigation of whether specific elements of alexithymia, namely affective components, are more strongly related to EDs than other components (e.g., cognitive elements), shows support for this contention (Speranza et al., 2007, Lawson et al., 2008a, Lawson et al., 2008b and De Berardis et al., 2009). Further, the cognitive component of alexithymia — Externally Oriented Thinking — does not appear to be related to EDs (Troop et al., 1995 and Taylor et al., 1996). As with EDs, there is also a selective association between the affective components of alexithymia and somatoform disorders (Bankier et al., 2001 and Waller and Scheidt, 2004). Thus, based on these findings (with EDs and somatoform conditions), one might expect that BDD and the affective components of alexithymia will be most strongly related. It could also be hypothesized that a global emotion-processing deficit (as reflected in the affective elements of alexithymia) could partially underlie a shared etiology between EDs and BDD. The aim of this study was to assess the relationship between alexithymia and body dysmorphic concerns in ED patients. It was hypothesized that there would be a difference between ED patients with and without significant body dysmorphic concerns in terms of alexithymia. Furthermore, it was expected that the relationship between BDD symptoms and alexithymia would be partially accounted for by levels of depression, but that alexithymia would still have an independent relationship with BDD. 2. Method 2.1. Participants The participants comprised 40 females seeking treatment for an ED. Participants were aged between 14 and 69 years old (M = 29 years; S.D. = 11.61). Participants' Body Mass Index (BMI) ranged from 11.53 to 36.24 (M = 18.43; S.D. = 4.34). Ninety percent of subjects were Caucasian Australians. Questionnaires were distributed by psychiatrists and psychologists at a private psychiatric clinic in Brisbane, as well as by local private practitioners and the Eating Disorders Association. Participation was voluntary and did not affect treatment in any way. It should be noted that the participants included both those with anorexia nervosa, bulimia nervosa and possibly some with Eating Disorder Not Otherwise Specified (EDNOS) diagnosed by a psychologist or psychiatrist using standard DSM-IV criteria. This approach was taken because the core body image disturbance is similar in these groups (Gupta and Johnson, 2000). The study sample was one of convenience, in that doctors and psychologists approached all patients who were in their care (at the private psychiatric clinic, through private practitioners in the community or through a community support group). Thus, the sample comprised both inpatients and outpatients. However, due to the data collection method used (anonymous drop-off boxes or reply paid envelopes) it was not possible to determine how many were inpatients versus outpatients. To be included in the study, participants had to be seeking treatment for a diagnosed eating disorder and provide a written informed consent. There were no exclusion criteria, other than if clinicians judged that patients were too critically unwell to participate or if questionnaires were returned with excessive missing data.