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Are treatment options related to alexithymia in eating disorders? Results from a three-year naturalistic longitudinal study
Biomedicine & Pharmacotherapy 65 (2011) 585–589
Original article
Are treatment options related to alexithymia in eating disorders? Results from a three-year naturalistic longitudinal study Mario Speranza a,*, Gwenole´ Loas b, Olivier Guilbaud c, Maurice Corcos c a b c
Inserm U669, Department of Child Psychiatry, universite´ Paris-Sud, universite´ Paris-V, centre hospitalier de Versailles, 177, rue de Versailles, 78157 Le Chesnay, France Department of psychiatry, centre hospitalier Amiens, Amiens, France Institut Mutualiste Montsouris, Paris, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 August 2009 Accepted 25 January 2010 Available online 25 February 2010
Objective. – Longitudinal studies have shown that alexithymic features can interfere with treatment response in eating disorders. However, an alternative hypothesis could be that clinicians faced with alexithymic patients chose different treatment options according to their perceptions of these patients. The aim of this investigation was to explore the relationships between alexithymic features and treatment options provided by professionals in a naturalistic prospective study of eating disorders. Methods. – We conducted a 3-year longitudinal study exploring a sample of 102 DSM-IV Eating Disorder patients with the Toronto Alexithymia Scale (TAS-20). All treatments received during follow-up were recorded and recoded dichotomously, and crossed with the variation of alexithymic categories (cutoff 56) between inclusion and follow-up. Results. – 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. Patients who became alexithymics during follow-up were more often rehospitalized and received fewer regular psychotherapies than the non-alexithymic patients. Conclusions. – Professionals should carefully monitor these personality features and be aware of the potential impact of alexithymic features on treatment compliance and on treatment choice for eating disordered patients. ß 2010 Elsevier Masson SAS. All rights reserved.
Keywords: Alexithymia Depression Eating disorders Longitudinal study Treatments
1. Introduction Alexithymia is a personality construct characterized by a difficulty in identifying and describing feelings, a diminution of fantasy and a concrete and externally-oriented thinking style [1]. Factor analyses and longitudinal studies have supported the idea that alexithymia is a stable personality trait rather than a statedependent phenomenon linked to depression or to clinical status [2,3]. Several studies have reported high levels of alexithymia in patients with eating disorders, especially in individuals with anorexia nervosa [4–7]. There are several reasons to believe that this construct can play a major role in the illness course in eating disorders: on one hand, the cognitive limitations in emotional regulation in alexithymic individuals may favour maladaptive behaviours such as starving, bingeing or drug misuse to selfregulate disruptive emotions [8]. On the other hand, the lack of insight and the externally-oriented thinking style of alexithymic
* Corresponding author. Tel.: +33 01 39 63 97 53; fax: +33 01 39 63 93 45. E-mail address: [email protected] (M. Speranza). 0753-3322/$ – see front matter ß 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.biopha.2010.01.009
subjects may interfere with patients’ ability to benefit from psychotherapeutic interventions [9]. However, in spite of the clinical relevance of this issue, few studies have specifically explored the impact of alexithymic features on treatment response in eating disorders. De Groot et al. [6] explored the outcome of a 10-week intensive group psychotherapy program in a sample of bulimic patients. At program completion they observed that in spite of the reduction of alexithymic intensity, patients showing the highest levels of alexithymia were the most symptomatic. Although these patients were also the most depressed, the authors suggested that alexithymic features could mark a vulnerability to relapse or favour a chronic outcome of the eating disorder. De Panfilis et al. [10] conducted a prospective study to detect pretreatment psychopathological predictors of compliance and outcome in a behavioural weight-loss program for obesity. They showed that in obese patients with a psychiatric disorder (mood or anxiety disorder and binge eating disorder), poor outcome at eight months was predicted by difficulty in describing feelings to others (the second factor of the alexithymia construct) and by disinterest or difficulty in engaging in social relationships. They suggested that a personality style of this sort may prevent these patients from
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building a collaborative relationship with the clinicians. Finally, we conducted a 3-years longitudinal study to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders. Logistic and hierarchical regression analyses showed that the difficulty in identifying feelings (the second factor of the alexithymia construct) emerged as a significant negative predictor of treatment outcome, independently from depressive symptoms and eating disorder severity [11]. The results of these studies suggest that the presence of alexithymic features could interfere with treatment response in eating disorders. However, an alternative hypothesis could be that clinicians faced with alexithymic patients chose different treatment options among their therapeutic armamentarium according to their negative perceptions of their suitability for these patients. A recent paper from Ogrodniczuk et al. [12] showed that the higher the level of alexithymia, the more negative were the therapist’s reactions to the patient. This suggests that clinician’s reactions to a patient represent a major mechanism through which alexithymia can exert its effect, for example by creating a bias in the selection of the treatment instated. The aim of this investigation was to explore the relationships between alexithymic features and treatment choices by professionals in a naturalistic prospective study of eating disorders. We hypothesized that alexithymic features modify the type of treatment provided by professionals independently from the severity of the eating disorder. 2. Materials and methods 2.1. Procedure The subjects of this study were derived from a multicentre research project investigating the psychopathological features of eating disorders (Inserm Network No. 494013). The overall design of the Network was a cross-sectional investigation, with only a subset of research centres involved in a prospective follow-up study. The recruitment centres were academic psychiatric hospitals specialized in adolescents and young adults (age range for reception: 15–30 years). For this study, only female participants who had requested care for an eating disorder were screened for inclusion. At the first assessment and 3 years later, patients included in the sample completed a research protocol which consisted of a clinical interview (for sociodemographic and diagnostic data) and a self-report questionnaire eliciting psychopathological features. Eating disorder diagnoses, whether of Anorexia Nervosa or Bulimia Nervosa, were made by a psychiatrist or a clinical psychologist specialized in the field of eating disorders using DSM-IV diagnostic criteria [13]. Diagnostic assessment was made using the Mini International Neuropsychiatric Interview (MINI) which is a structured, validated diagnostic instrument that explores each criterion necessary for the establishment of current and lifetime DSM-IV axis I main diagnoses (anxiety and depressive disorders, substance-related disorders)[14]. Patients were invited to participate in the follow-up study 3 years later. At 18 months, a reminder letter was sent to all participants. A second letter was sent just before contacting them by phone to plan the second assessment. Only patients with complete files at follow-up were included in the study. The protocol was approved by the local ethics committee (Paris-Cochin Hospital). After full information was provided, all subjects gave written consent for participation in the study. 2.2. Measures Alexithymia was rated using the French translation of the revised Toronto Alexithymia Scale (TAS-20)[15,16] a self-report
scale with 20 items rated on a five-point Lickert scale. The items in the TAS cluster into three factors: Difficulty Identifying Feelings (DIF); Difficulty Describing Feelings (DDF); and Externally Oriented Thinking (EOT)[17]. The categorical score was defined as 56 following Loas et al. [18]. Depression severity was measured with the French translation of the abridged version of the Beck Depression Inventory (BDI13)[19]. The BDI-13 was developed by Beck et al. as a specific tool for epidemiological studies by selecting among all the items those showing a high correlation (> .90) with the total score of the BDI21 [20]. The severity of the illness was assessed by the Severity of Illness item of the Clinical Global Impression (CGI). The CGI requires the clinician, on a seven-point scale (1 = normal to 7 = extremely ill), to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience and training with patients with the same diagnosis. The clinical outcome at 3 years was approached dimensionally according to the degree of clinical improvement between baseline and follow-up: (CGI at base-line – CGI at follow-up/CGI at baseline) 100 (between 100% and +100% of change [3]. Treatments received during follow-up were recorded (types of treatment, age at the beginning, duration), and recoded dichotomously (yes/no) according to Honkalampi et al. [21] as follows: (1) Pharmacotherapy: antidepressants: treatment was considered as correct if prescribed at least for 3 months at a usual dosage; anxiolytics: prescription was recorded positively independently from doses and duration. (2) Psychotherapy: any psychotherapy was recorded as positive, independently from the type, if duration was at least 6 months weekly. (3) Hospitalisation: (full or partial admission). (4) Combination of pharmacotherapy and psychotherapy. Finally, we explored the personality traits associated with a negative compliance to treatments with the Negative Treatment Indicators scale from the French adaptation of the revised version of the Minnesota Multiphasic Personality Inventory-2 [22]. The Negative Treatment Indicators scale is designed to evaluate the subject’s attitudes toward change and towards mental health treatments. 2.3. Statistical analysis Since this study was a naturalistic observation not designed as a formalized treatment study, it was not possible to assess directly the impact of alexithymic features on treatment choice and efficacy. Indeed, as changes in alexithymic scores were possible between the two assessments and treatments could be introduced at any time during the three years follow-up, it was not possible to directly study the relationships between alexithymic scores at inclusion and the treatments received. The strategy chosen to assess the relationships between treatments and alexithymia was to cross treatments with the variation of alexithymic categories (cut-off 56) between inclusion and follow-up. We chose to explore with a Chi-square test the association between changing alexithymic profiles and the treatments received at the two assessments. Four alexithymic profiles were defined according to the presence or absence of categorical alexithymia at inclusion and at follow-up: alexithymics at inclusion and at follow-up (TAS-II), alexithymics at inclusion but not at follow-up (TAS-I0), nonalexithymics at inclusion but alexithymics at follow-up (TAS-0I), non-alexithymics at inclusion and at follow-up (TAS-00). This procedure was possible because groups did not differ in clinical severity and depression at inclusion (see results). Secondarily, using variance analysis, the impact of treatments on changing scores of alexithymia, depression and clinical severity was studied. Finally, we calculated the correlations between alexithymic scores
M. Speranza et al. / Biomedicine & Pharmacotherapy 65 (2011) 585–589
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Table 1 Treatments received during follow-up according to the variation in alexitymic category.
Antidepressants Benzodiazepines Psychotherapy Hospitalisation Medication + psychotherapy At least 1 treatment BDI at inclusion CGI at inclusion D - CGI
TAS-II (N = 23)
TAS-I0 (N = 30)
TAS-0I (N = 8)
TAS-00 (N = 41)
Total
Test
12 (52%) a 9 (39%) 15 (65%) 13 (56%) 7 (30%) 21 (91%) 16.2 6.7 5.1 1.0 1.3 1.3
14 (47%) 11 (29%) 13 (43%) 13 (43%) 5 (17%) 22 (73%) 15.2 9.2 4.9 1.0 1.2 1.6
4 (50%) 1 (12%) 3 (37%) b 6 (75%) c 1 (12%) 7 (87%) 9.4 9.6 5.0 1.0 1.0 1.6
11 (27%) a 10 (24%) 27 (66%) b 10 (24%) c 7 (17%) 33 (80%) 10.4 7.0 4.6 1.0 1.1 1.7
41 (40%) 31 (30%) 58 (57%) 42 (41%) 20 (20%) 83 (81%) 13.4 8.4 4.8 1.0 1.1 1.5
F = 4.12, p < 0.05 Ns F = 5.30, p < 0.05 F = 7.80, p < 0.01 Ns Ns Ns Ns Ns
Ns: not significant (difference). Statistics: x2 or ANOVA. N = 102. One-way ANOVA with Bonferroni corrections. Significant differences between groups are indicated by similar letters. TAS: Toronto Alexithymia Scale; BDI: Beck Depression Inventory; CGI: Clinical Global Impression. TAS-II: TAS + at inclusion and at follow-up. TAS-I0: TAS + at inclusion and TAS at followup. TAS-0I: TAS at inclusion and TAS + at follow-up. TAS-00: TAS at inclusion and at follow-up.
Table 2 Changes in alexithymic scores according to treatments received. Antidepressants
D -TAS D - BDI D - CGI
Psychotherapy
Medication + Psychotherapy
No (n = 61)
Yes (n = 41)
F (p)
No (n = 44)
Yes (n = 58)
F (p)
No (n = 82)
Yes (n = 20)
F (p)
6.1 11.7 3.7 8.1 1.1 1.6
7.1 11.8 6.8 8.8 1.3 1.6
0.2 (Ns) 3.4 (0.05) 0.4 (Ns)
5.8 12.8 6.5 8.9 1.3 1.5
7.0 11.0 3.7 8.0 1.1 1.6
0.2 (Ns) 2.8 (Ns) 0.2 (Ns)
6.1 12.1 5.0 8.4 1.2 1.5
7.9 10.3 4.6 8.7 1.1 1.7
0.4 (Ns) 0.03 (Ns) 0.1 (Ns)
Statistics. ANOVA: F(dl 1, 100). TAS: Toronto Alexithymia Scale; BDI: Beck Depression Inventory; CGI: Clinical Global Impression.
and the MMPI Negative Treatment Indicators scale at inclusion to investigate the impact of this personality trait on the type of treatment chosen. Results are presented as mean standard deviation. Statistical analyses were performed with the 10.1 version of the Statistical Package for Social Sciences. 3. Results From the initial sample of the Inserm Network on eating disorders, 144 women were selected to be included in the followup study and retraced 3 years later. Among these subjects, 35 refused to participate or were unavailable. One hundred and nine subjects were directly interviewed. Seven subjects had to be excluded because they did not complete the questionnaire. Statistical analyses were performed on a final sample of 102 subjects (72.8%). Sixty-three had an initial diagnosis of anorexia nervosa, 39 of bulimia. No significant differences were found between the patients who did not participate in the follow-up and those who completed the study for sociodemographic variables, eating disorder subtypes, severity of the eating disorder (CGI), and levels of alexithymia (TAS-20) and depression (BDI-13) at baseline. The sample was composed exclusively of young women (mean age of 21.5 5), with a medium to high level of education, with a severe (CGI of 4.8 1.0) and chronic eating disorder (duration: 4.3 4.8 years).
subjects who had high and stable scores of alexithymia or who became alexithymic at follow-up, received treatments different from those of the other groups. Stable alexithymic subjects showed a tendency to receive overall a larger amount of treatment of every kind. They had significantly more antidepressants than nonalexithymic subjects. Patients who became alexithymic at follow up were more often hospitalized and they less frequently received regular psychotherapies than non-alexithymic subjects. Although this group had the same initial clinical severity, it is the group that show the least clinical improvement, approaching statistical significance (p < 0.06) (Table 1). Variations of alexithymic scores over time are not influenced by the use of antidepressants, by psychotherapy, or by the association of the two. Neither are changes in clinical severity influenced by these different treatments. However, the introduction of an adequate antidepressant is accompanied by significant changes in depression scores (F = 3.4, p < 0.05) (Table 2). 3.2. Alexithymia and MMPI Negative Treatment Indicators scale There is a strong association between the Negative Treatment Indicators scale and the total score on the Toronto Alexithymia Scale at inclusion (r = 0.64, p < 0.001). These variables are strongly correlated with depression. However, only depression predicts the prescription of an antidepressant during the follow-up (BDI: Exp(B) = 1.21, p < 0.05). None of these variables are associated with the prescription of a psychotherapy.
3.1. Treatments received and variations in alexithymic categories 4. Discussion and conclusions Dimensional results concerning alexithymic scores at inclusion and follow-up are presented elsewhere [11]. In brief, patients with eating disorders presented medium to high levels of alexithymia and depression with a global improvement of both dimensions during the follow-up, but to a lesser extent than the clinical improvement. Groups defined according to changing categories of alexithymia over time did not differ in clinical severity and depression at inclusion. However, there were differences in prescriptions according to the variations of alexithymic categories. Specifically,
The results of this longitudinal observational study show that patients with eating disorders received different treatments according to their alexithymic profile. This is true in terms both of number and of type of treatment received. Patients with high and stable levels of alexithymia received overall more treatments, and significantly more antidepressants, than non-alexithymic patients. Patients who became alexithymics during follow-up were more often rehospitalized and received less regular psychotherapies than the non-alexithymic patients. In spite of their similar
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clinical and depressive severity at inclusion, the clinical outcome of these patients was the least favourable. These results are in line with the experience of clinicians faced with eating disordered patients with marked alexithymic features, who are struck by the limited response of these patients to traditional approaches [9]. They also support the notion that professionals alter their therapeutic strategies according to patient functioning. There are several ways in which alexithymia can reduce the efficacy of therapeutic interventions: first, the lack of insight and the externally oriented thinking style may interfere with the patients’ ability to engage in psychotherapeutic interventions. McCallum et al. [23] found that, for both short-term group therapy and shortterm individual therapy, alexithymic features were associated with a worst treatment outcome. Second, alexithymia can limit the compliance with care through the negative reactions induced by the therapeutic setting. The gap existing between the physiological arousal induced by emotional demands elicited by psychotherapy and the deficit in the cognitive experience of these emotions can generate a feeling of discomfort which can lead to interruptions [24]. Our study points to a third mechanism through which alexithymia could exert its negative effect on therapeutic compliance: therapist reactions to an alexithymic patient can induce a selection among treatment options. In our study, alexithymic patients received significantly more antidepressants than non-alexithymic patients although they shared similar depressive scores at inclusion. This means that professionals can erroneously attribute higher levels of depression to alexithymic patients with eating disorders and prescribe more antidepressants than needed, with lesser efficacy. Indeed, Ozsahin et al. [25] have shown that alexithymic features have a negative effect on antidepressant treatment response in depression. If alexithymia and depression share similar features, they are independent dimensions that do not overlap [26]. Results from our follow-up study confirm this point, showing that only variations in depressive scores, but not in alexithymic scores, were influenced by the use of antidepressants. This result strengthens the trait notion in alexithymia [2]. The bias that alexithymia can induce on treatment indications in patients with eating disorders also appears in the fact that the nonalexithymic patients in our study received more regular psychotherapies than patients who became alexithymics during followup. Professionals may consider alexithymic patients as less suitable for psychotherapy. It has been shown by Ogrodniczuk et al. [27] that if alexithymic features were associated with a less favourable outcome in a randomized controlled trial on two forms of group therapy for complicated grief, this relationship was largely mediated by therapist reactions and perceptions of a patient’s positive qualities and personal compatibility. In another similar study, Rasting et al. [28] videotaped and evaluated the facial affects displayed in dyadic therapeutic interactions in a sample of psychosomatic patients. They observed that the predominant emotional reaction among therapists to negative affects expressed by alexithymic patients was contempt, thus producing a potential negative interaction in therapy. These results should urge professionals to be aware of the potential impact of alexithymic features on therapeutic relationships with patients, and to avoid misinterpreting their emotional expressions as a negative engagement in psychotherapy. In our study we explored the relationships between alexithymia and attitudes towards psychotherapy using the Treatment Indicators scale from the MMPI. This scale has been designed to evaluate the subject’s view of psychotherapy and the ability to accept help from mental health professionals to produce a positive change in life [29]. Although alexithymic features were strongly correlated at inclusion with the Negative Treatment Indicators scale, these variables did not predict the type of treatment chosen (whether antidepressant or psychotherapy).
There are several limitations to this study that must be acknowledged. Our sample was composed of young women with a severe; chronic eating disorder recruited from academic hospitals specialized in eating disorders. This may reduce the generalisability of the results to other less specialized settings. However, the naturalistic design of the study offered an unbiased picture of the current therapeutic options for eating disorders. There are probably other parameters that guide treatment choice in eating disorders besides alexithymia, such as comorbid disorders, cultural orientation or availability of specific treatments. These factors are usually taken into account by professionals in their decision strategies. A final limitation is the middling rate of follow-up. A certain number of refusals can be explained by the young age at inclusion and the long duration of the study. However, the bias of losing observations should not be overvalued because we did not find any differences in clinical and demographic variables between followed and lost patients. Aside from these limitations, the results of our study indicate that patients with eating disorders received different treatments according to their alexithymic profiles, both in terms of number and type of treatments received. Professionals should carefully monitor these personality features and be aware of the potential impact of alexithymic features on treatment compliance and on treatment choice for eating disordered patients. This should facilitate the matching of treatments to individuals on the basis of their clinical profile at presentation. Conflict of interest None. Acknowledgements This work was conducted within the clinical research project called ‘‘Dependence Network 1994–2000’’ which has received the support of the Institut national de la sante´ et de la recherche me´dicale (re´seau Inserm no 494013) and of the Fondation de France. The promoter of the project is the institut mutualiste Montsouris. References [1] Taylor G, Bagby M, Parker J. Psychological-mindedness and the alexithymia construct. Br J Psychiatry 1989;154:731–2. [2] Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression. Psychother Psychosom 2001;70:254–60. [3] Porcelli P, Bagby RM, Taylor GJ, De Carne M, Leandro G, Todarello O. Alexithymia as predictor of treatment outcome in patients with functional gastrointestinal disorders. Psychosom Med 2003;65:911–8. [4] Bourke MP, Taylor GJ, Parker JD, Bagby RM. Alexithymia in women with anorexia nervosa. A preliminary investigation. Br J Psychiatry 1992;161:240–3. [5] Corcos M, Guilbaud O, Speranza M, et al. Alexithymia and depression in eating disorders. Psychiatry Res 2000;93:263–6. [6] de Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995;36:53–60. [7] Taylor GJ, Parker JD, Bagby RM, Bourke MP. Relationships between alexithymia and psychological characteristics associated with eating disorders. J Psychosom Res 1996;41:561–8. [8] Goodsit A. Self-regulatory disturbances in eating disorders. Int J Eat Disord 1983;2:51–60. [9] Krystal H. Alexithymia and the effectiveness of psychoanalytic treatment. Int J Psychoanal Psychother 1982;9:353–78. [10] De Panfilis C, Cero S, Dall’Aglio E, Salvatore P, Torre M, Maggini C. Psychopathological predictors of compliance and outcome in weight-loss obesity treatment. Acta Biomed 2007;78:22–8. [11] Speranza M, Loas G, Wallier J, Corcos M. Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. J Psychosom Res 2007;63:365–71. [12] Ogrodniczuk JS, Piper WE, Joyce AS. Alexithymia and therapist reactions to the patient: Expression of positive emotion as a mediator. Psychiatry 2008;71: 257–65. [13] Association AP. Diagnostic and statistical manual of mental disorders. Washington: DC, 1994.
M. Speranza et al. / Biomedicine & Pharmacotherapy 65 (2011) 585–589 [14] Sheehan DV, Lecrubier Y, Sheehan KH, et al. The mini-international neuropsychiatric interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl. 20):22–33. quiz 34–57. [15] Bagby RM, Taylor GJ, Parker JD. The twenty-item Toronto alexithymia scale–ii. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33–40. [16] Loas G, Otmani O, Lecercle C, Jouvent R. Relationships between the emotional and cognitive components of alexithymia and dependency in alcoholics. Psychiatry Res 2000;96:63–74. [17] Loas G, Corcos M, Stephan P, et al. Factorial structure of the 20-item Toronto alexithymia scale: Confirmatory factorial analyses in nonclinical and clinical samples. J Psychosom Res 2001;50:255–61. [18] Loas G, Otmani O, Verrier A, Fremaux D, Marchand MP. Factor analysis of the French version of the 20-item Toronto alexithymia scale (tas-20). Psychopathology 1996;29:139–44. [19] Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71. [20] Beck AT, Beck RW. Screening depressed patients in family practice. Rapid Technic Postgrad Med 1972;52:81–5. [21] Honkalampi K, Hintikka J, Saarinen P, Lehtonen J, Viinamaki H. Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychother Psychosom 2000;69:303–8.
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[22] Butcher JN, Dahlstrom WG, Graham JR, Tellegen A, Kaemmer B. The minnesota multiphasic personality inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis (MN): University of Minnesota Press; 1989 . [23] McCallum M, Piper WE, Ogrodniczuk JS, Joyce AS. Relationships among psychological mindedness, alexithymia and outcome in four forms of shortterm psychotherapy. Psychol Psychother 2003;76:133–44. [24] Taylor GJ, Bagby RM. New trends in alexithymia research. Psychother Psychosom 2004;73:68–77. [25] Ozsahin A, Uzun O, Cansever A, Gulcat Z. The effect of alexithymic features on response to antidepressant medication in patients with major depression. Depress Anxiety 2003;18:62–6. [26] Hintikka J, Honkalampi K, Lehtonen J, Viinamaki H. Are alexithymia and depression distinct or overlapping constructs? A study in a general population. Compr Psychiatry 2001;42:234–9. [27] Ogrodniczuk JS, Piper WE, Joyce AS. The negative effect of alexithymia on the outcome of group therapy for complicated grief: What role might the therapist play? Compr Psychiatry 2005;46:206–13. [28] Rasting M, Brosig B, Beutel ME. Alexithymic characteristics and patienttherapist interaction: A video analysis of facial affect display. Psychopathology 2005;38:105–11. [29] Nichols D. Development and use of the mmpi-2: Content scales. J Pers Assess 1992;58:434–7.
Original article
Are treatment options related to alexithymia in eating disorders? Results from a three-year naturalistic longitudinal study Mario Speranza a,*, Gwenole´ Loas b, Olivier Guilbaud c, Maurice Corcos c a b c
Inserm U669, Department of Child Psychiatry, universite´ Paris-Sud, universite´ Paris-V, centre hospitalier de Versailles, 177, rue de Versailles, 78157 Le Chesnay, France Department of psychiatry, centre hospitalier Amiens, Amiens, France Institut Mutualiste Montsouris, Paris, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 August 2009 Accepted 25 January 2010 Available online 25 February 2010
Objective. – Longitudinal studies have shown that alexithymic features can interfere with treatment response in eating disorders. However, an alternative hypothesis could be that clinicians faced with alexithymic patients chose different treatment options according to their perceptions of these patients. The aim of this investigation was to explore the relationships between alexithymic features and treatment options provided by professionals in a naturalistic prospective study of eating disorders. Methods. – We conducted a 3-year longitudinal study exploring a sample of 102 DSM-IV Eating Disorder patients with the Toronto Alexithymia Scale (TAS-20). All treatments received during follow-up were recorded and recoded dichotomously, and crossed with the variation of alexithymic categories (cutoff 56) between inclusion and follow-up. Results. – 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. Patients who became alexithymics during follow-up were more often rehospitalized and received fewer regular psychotherapies than the non-alexithymic patients. Conclusions. – Professionals should carefully monitor these personality features and be aware of the potential impact of alexithymic features on treatment compliance and on treatment choice for eating disordered patients. ß 2010 Elsevier Masson SAS. All rights reserved.
Keywords: Alexithymia Depression Eating disorders Longitudinal study Treatments
1. Introduction Alexithymia is a personality construct characterized by a difficulty in identifying and describing feelings, a diminution of fantasy and a concrete and externally-oriented thinking style [1]. Factor analyses and longitudinal studies have supported the idea that alexithymia is a stable personality trait rather than a statedependent phenomenon linked to depression or to clinical status [2,3]. Several studies have reported high levels of alexithymia in patients with eating disorders, especially in individuals with anorexia nervosa [4–7]. There are several reasons to believe that this construct can play a major role in the illness course in eating disorders: on one hand, the cognitive limitations in emotional regulation in alexithymic individuals may favour maladaptive behaviours such as starving, bingeing or drug misuse to selfregulate disruptive emotions [8]. On the other hand, the lack of insight and the externally-oriented thinking style of alexithymic
* Corresponding author. Tel.: +33 01 39 63 97 53; fax: +33 01 39 63 93 45. E-mail address: [email protected] (M. Speranza). 0753-3322/$ – see front matter ß 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.biopha.2010.01.009
subjects may interfere with patients’ ability to benefit from psychotherapeutic interventions [9]. However, in spite of the clinical relevance of this issue, few studies have specifically explored the impact of alexithymic features on treatment response in eating disorders. De Groot et al. [6] explored the outcome of a 10-week intensive group psychotherapy program in a sample of bulimic patients. At program completion they observed that in spite of the reduction of alexithymic intensity, patients showing the highest levels of alexithymia were the most symptomatic. Although these patients were also the most depressed, the authors suggested that alexithymic features could mark a vulnerability to relapse or favour a chronic outcome of the eating disorder. De Panfilis et al. [10] conducted a prospective study to detect pretreatment psychopathological predictors of compliance and outcome in a behavioural weight-loss program for obesity. They showed that in obese patients with a psychiatric disorder (mood or anxiety disorder and binge eating disorder), poor outcome at eight months was predicted by difficulty in describing feelings to others (the second factor of the alexithymia construct) and by disinterest or difficulty in engaging in social relationships. They suggested that a personality style of this sort may prevent these patients from
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building a collaborative relationship with the clinicians. Finally, we conducted a 3-years longitudinal study to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders. Logistic and hierarchical regression analyses showed that the difficulty in identifying feelings (the second factor of the alexithymia construct) emerged as a significant negative predictor of treatment outcome, independently from depressive symptoms and eating disorder severity [11]. The results of these studies suggest that the presence of alexithymic features could interfere with treatment response in eating disorders. However, an alternative hypothesis could be that clinicians faced with alexithymic patients chose different treatment options among their therapeutic armamentarium according to their negative perceptions of their suitability for these patients. A recent paper from Ogrodniczuk et al. [12] showed that the higher the level of alexithymia, the more negative were the therapist’s reactions to the patient. This suggests that clinician’s reactions to a patient represent a major mechanism through which alexithymia can exert its effect, for example by creating a bias in the selection of the treatment instated. The aim of this investigation was to explore the relationships between alexithymic features and treatment choices by professionals in a naturalistic prospective study of eating disorders. We hypothesized that alexithymic features modify the type of treatment provided by professionals independently from the severity of the eating disorder. 2. Materials and methods 2.1. Procedure The subjects of this study were derived from a multicentre research project investigating the psychopathological features of eating disorders (Inserm Network No. 494013). The overall design of the Network was a cross-sectional investigation, with only a subset of research centres involved in a prospective follow-up study. The recruitment centres were academic psychiatric hospitals specialized in adolescents and young adults (age range for reception: 15–30 years). For this study, only female participants who had requested care for an eating disorder were screened for inclusion. At the first assessment and 3 years later, patients included in the sample completed a research protocol which consisted of a clinical interview (for sociodemographic and diagnostic data) and a self-report questionnaire eliciting psychopathological features. Eating disorder diagnoses, whether of Anorexia Nervosa or Bulimia Nervosa, were made by a psychiatrist or a clinical psychologist specialized in the field of eating disorders using DSM-IV diagnostic criteria [13]. Diagnostic assessment was made using the Mini International Neuropsychiatric Interview (MINI) which is a structured, validated diagnostic instrument that explores each criterion necessary for the establishment of current and lifetime DSM-IV axis I main diagnoses (anxiety and depressive disorders, substance-related disorders)[14]. Patients were invited to participate in the follow-up study 3 years later. At 18 months, a reminder letter was sent to all participants. A second letter was sent just before contacting them by phone to plan the second assessment. Only patients with complete files at follow-up were included in the study. The protocol was approved by the local ethics committee (Paris-Cochin Hospital). After full information was provided, all subjects gave written consent for participation in the study. 2.2. Measures Alexithymia was rated using the French translation of the revised Toronto Alexithymia Scale (TAS-20)[15,16] a self-report
scale with 20 items rated on a five-point Lickert scale. The items in the TAS cluster into three factors: Difficulty Identifying Feelings (DIF); Difficulty Describing Feelings (DDF); and Externally Oriented Thinking (EOT)[17]. The categorical score was defined as 56 following Loas et al. [18]. Depression severity was measured with the French translation of the abridged version of the Beck Depression Inventory (BDI13)[19]. The BDI-13 was developed by Beck et al. as a specific tool for epidemiological studies by selecting among all the items those showing a high correlation (> .90) with the total score of the BDI21 [20]. The severity of the illness was assessed by the Severity of Illness item of the Clinical Global Impression (CGI). The CGI requires the clinician, on a seven-point scale (1 = normal to 7 = extremely ill), to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience and training with patients with the same diagnosis. The clinical outcome at 3 years was approached dimensionally according to the degree of clinical improvement between baseline and follow-up: (CGI at base-line – CGI at follow-up/CGI at baseline) 100 (between 100% and +100% of change [3]. Treatments received during follow-up were recorded (types of treatment, age at the beginning, duration), and recoded dichotomously (yes/no) according to Honkalampi et al. [21] as follows: (1) Pharmacotherapy: antidepressants: treatment was considered as correct if prescribed at least for 3 months at a usual dosage; anxiolytics: prescription was recorded positively independently from doses and duration. (2) Psychotherapy: any psychotherapy was recorded as positive, independently from the type, if duration was at least 6 months weekly. (3) Hospitalisation: (full or partial admission). (4) Combination of pharmacotherapy and psychotherapy. Finally, we explored the personality traits associated with a negative compliance to treatments with the Negative Treatment Indicators scale from the French adaptation of the revised version of the Minnesota Multiphasic Personality Inventory-2 [22]. The Negative Treatment Indicators scale is designed to evaluate the subject’s attitudes toward change and towards mental health treatments. 2.3. Statistical analysis Since this study was a naturalistic observation not designed as a formalized treatment study, it was not possible to assess directly the impact of alexithymic features on treatment choice and efficacy. Indeed, as changes in alexithymic scores were possible between the two assessments and treatments could be introduced at any time during the three years follow-up, it was not possible to directly study the relationships between alexithymic scores at inclusion and the treatments received. The strategy chosen to assess the relationships between treatments and alexithymia was to cross treatments with the variation of alexithymic categories (cut-off 56) between inclusion and follow-up. We chose to explore with a Chi-square test the association between changing alexithymic profiles and the treatments received at the two assessments. Four alexithymic profiles were defined according to the presence or absence of categorical alexithymia at inclusion and at follow-up: alexithymics at inclusion and at follow-up (TAS-II), alexithymics at inclusion but not at follow-up (TAS-I0), nonalexithymics at inclusion but alexithymics at follow-up (TAS-0I), non-alexithymics at inclusion and at follow-up (TAS-00). This procedure was possible because groups did not differ in clinical severity and depression at inclusion (see results). Secondarily, using variance analysis, the impact of treatments on changing scores of alexithymia, depression and clinical severity was studied. Finally, we calculated the correlations between alexithymic scores
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Table 1 Treatments received during follow-up according to the variation in alexitymic category.
Antidepressants Benzodiazepines Psychotherapy Hospitalisation Medication + psychotherapy At least 1 treatment BDI at inclusion CGI at inclusion D - CGI
TAS-II (N = 23)
TAS-I0 (N = 30)
TAS-0I (N = 8)
TAS-00 (N = 41)
Total
Test
12 (52%) a 9 (39%) 15 (65%) 13 (56%) 7 (30%) 21 (91%) 16.2 6.7 5.1 1.0 1.3 1.3
14 (47%) 11 (29%) 13 (43%) 13 (43%) 5 (17%) 22 (73%) 15.2 9.2 4.9 1.0 1.2 1.6
4 (50%) 1 (12%) 3 (37%) b 6 (75%) c 1 (12%) 7 (87%) 9.4 9.6 5.0 1.0 1.0 1.6
11 (27%) a 10 (24%) 27 (66%) b 10 (24%) c 7 (17%) 33 (80%) 10.4 7.0 4.6 1.0 1.1 1.7
41 (40%) 31 (30%) 58 (57%) 42 (41%) 20 (20%) 83 (81%) 13.4 8.4 4.8 1.0 1.1 1.5
F = 4.12, p < 0.05 Ns F = 5.30, p < 0.05 F = 7.80, p < 0.01 Ns Ns Ns Ns Ns
Ns: not significant (difference). Statistics: x2 or ANOVA. N = 102. One-way ANOVA with Bonferroni corrections. Significant differences between groups are indicated by similar letters. TAS: Toronto Alexithymia Scale; BDI: Beck Depression Inventory; CGI: Clinical Global Impression. TAS-II: TAS + at inclusion and at follow-up. TAS-I0: TAS + at inclusion and TAS at followup. TAS-0I: TAS at inclusion and TAS + at follow-up. TAS-00: TAS at inclusion and at follow-up.
Table 2 Changes in alexithymic scores according to treatments received. Antidepressants
D -TAS D - BDI D - CGI
Psychotherapy
Medication + Psychotherapy
No (n = 61)
Yes (n = 41)
F (p)
No (n = 44)
Yes (n = 58)
F (p)
No (n = 82)
Yes (n = 20)
F (p)
6.1 11.7 3.7 8.1 1.1 1.6
7.1 11.8 6.8 8.8 1.3 1.6
0.2 (Ns) 3.4 (0.05) 0.4 (Ns)
5.8 12.8 6.5 8.9 1.3 1.5
7.0 11.0 3.7 8.0 1.1 1.6
0.2 (Ns) 2.8 (Ns) 0.2 (Ns)
6.1 12.1 5.0 8.4 1.2 1.5
7.9 10.3 4.6 8.7 1.1 1.7
0.4 (Ns) 0.03 (Ns) 0.1 (Ns)
Statistics. ANOVA: F(dl 1, 100). TAS: Toronto Alexithymia Scale; BDI: Beck Depression Inventory; CGI: Clinical Global Impression.
and the MMPI Negative Treatment Indicators scale at inclusion to investigate the impact of this personality trait on the type of treatment chosen. Results are presented as mean standard deviation. Statistical analyses were performed with the 10.1 version of the Statistical Package for Social Sciences. 3. Results From the initial sample of the Inserm Network on eating disorders, 144 women were selected to be included in the followup study and retraced 3 years later. Among these subjects, 35 refused to participate or were unavailable. One hundred and nine subjects were directly interviewed. Seven subjects had to be excluded because they did not complete the questionnaire. Statistical analyses were performed on a final sample of 102 subjects (72.8%). Sixty-three had an initial diagnosis of anorexia nervosa, 39 of bulimia. No significant differences were found between the patients who did not participate in the follow-up and those who completed the study for sociodemographic variables, eating disorder subtypes, severity of the eating disorder (CGI), and levels of alexithymia (TAS-20) and depression (BDI-13) at baseline. The sample was composed exclusively of young women (mean age of 21.5 5), with a medium to high level of education, with a severe (CGI of 4.8 1.0) and chronic eating disorder (duration: 4.3 4.8 years).
subjects who had high and stable scores of alexithymia or who became alexithymic at follow-up, received treatments different from those of the other groups. Stable alexithymic subjects showed a tendency to receive overall a larger amount of treatment of every kind. They had significantly more antidepressants than nonalexithymic subjects. Patients who became alexithymic at follow up were more often hospitalized and they less frequently received regular psychotherapies than non-alexithymic subjects. Although this group had the same initial clinical severity, it is the group that show the least clinical improvement, approaching statistical significance (p < 0.06) (Table 1). Variations of alexithymic scores over time are not influenced by the use of antidepressants, by psychotherapy, or by the association of the two. Neither are changes in clinical severity influenced by these different treatments. However, the introduction of an adequate antidepressant is accompanied by significant changes in depression scores (F = 3.4, p < 0.05) (Table 2). 3.2. Alexithymia and MMPI Negative Treatment Indicators scale There is a strong association between the Negative Treatment Indicators scale and the total score on the Toronto Alexithymia Scale at inclusion (r = 0.64, p < 0.001). These variables are strongly correlated with depression. However, only depression predicts the prescription of an antidepressant during the follow-up (BDI: Exp(B) = 1.21, p < 0.05). None of these variables are associated with the prescription of a psychotherapy.
3.1. Treatments received and variations in alexithymic categories 4. Discussion and conclusions Dimensional results concerning alexithymic scores at inclusion and follow-up are presented elsewhere [11]. In brief, patients with eating disorders presented medium to high levels of alexithymia and depression with a global improvement of both dimensions during the follow-up, but to a lesser extent than the clinical improvement. Groups defined according to changing categories of alexithymia over time did not differ in clinical severity and depression at inclusion. However, there were differences in prescriptions according to the variations of alexithymic categories. Specifically,
The results of this longitudinal observational study show that patients with eating disorders received different treatments according to their alexithymic profile. This is true in terms both of number and of type of treatment received. Patients with high and stable levels of alexithymia received overall more treatments, and significantly more antidepressants, than non-alexithymic patients. Patients who became alexithymics during follow-up were more often rehospitalized and received less regular psychotherapies than the non-alexithymic patients. In spite of their similar
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clinical and depressive severity at inclusion, the clinical outcome of these patients was the least favourable. These results are in line with the experience of clinicians faced with eating disordered patients with marked alexithymic features, who are struck by the limited response of these patients to traditional approaches [9]. They also support the notion that professionals alter their therapeutic strategies according to patient functioning. There are several ways in which alexithymia can reduce the efficacy of therapeutic interventions: first, the lack of insight and the externally oriented thinking style may interfere with the patients’ ability to engage in psychotherapeutic interventions. McCallum et al. [23] found that, for both short-term group therapy and shortterm individual therapy, alexithymic features were associated with a worst treatment outcome. Second, alexithymia can limit the compliance with care through the negative reactions induced by the therapeutic setting. The gap existing between the physiological arousal induced by emotional demands elicited by psychotherapy and the deficit in the cognitive experience of these emotions can generate a feeling of discomfort which can lead to interruptions [24]. Our study points to a third mechanism through which alexithymia could exert its negative effect on therapeutic compliance: therapist reactions to an alexithymic patient can induce a selection among treatment options. In our study, alexithymic patients received significantly more antidepressants than non-alexithymic patients although they shared similar depressive scores at inclusion. This means that professionals can erroneously attribute higher levels of depression to alexithymic patients with eating disorders and prescribe more antidepressants than needed, with lesser efficacy. Indeed, Ozsahin et al. [25] have shown that alexithymic features have a negative effect on antidepressant treatment response in depression. If alexithymia and depression share similar features, they are independent dimensions that do not overlap [26]. Results from our follow-up study confirm this point, showing that only variations in depressive scores, but not in alexithymic scores, were influenced by the use of antidepressants. This result strengthens the trait notion in alexithymia [2]. The bias that alexithymia can induce on treatment indications in patients with eating disorders also appears in the fact that the nonalexithymic patients in our study received more regular psychotherapies than patients who became alexithymics during followup. Professionals may consider alexithymic patients as less suitable for psychotherapy. It has been shown by Ogrodniczuk et al. [27] that if alexithymic features were associated with a less favourable outcome in a randomized controlled trial on two forms of group therapy for complicated grief, this relationship was largely mediated by therapist reactions and perceptions of a patient’s positive qualities and personal compatibility. In another similar study, Rasting et al. [28] videotaped and evaluated the facial affects displayed in dyadic therapeutic interactions in a sample of psychosomatic patients. They observed that the predominant emotional reaction among therapists to negative affects expressed by alexithymic patients was contempt, thus producing a potential negative interaction in therapy. These results should urge professionals to be aware of the potential impact of alexithymic features on therapeutic relationships with patients, and to avoid misinterpreting their emotional expressions as a negative engagement in psychotherapy. In our study we explored the relationships between alexithymia and attitudes towards psychotherapy using the Treatment Indicators scale from the MMPI. This scale has been designed to evaluate the subject’s view of psychotherapy and the ability to accept help from mental health professionals to produce a positive change in life [29]. Although alexithymic features were strongly correlated at inclusion with the Negative Treatment Indicators scale, these variables did not predict the type of treatment chosen (whether antidepressant or psychotherapy).
There are several limitations to this study that must be acknowledged. Our sample was composed of young women with a severe; chronic eating disorder recruited from academic hospitals specialized in eating disorders. This may reduce the generalisability of the results to other less specialized settings. However, the naturalistic design of the study offered an unbiased picture of the current therapeutic options for eating disorders. There are probably other parameters that guide treatment choice in eating disorders besides alexithymia, such as comorbid disorders, cultural orientation or availability of specific treatments. These factors are usually taken into account by professionals in their decision strategies. A final limitation is the middling rate of follow-up. A certain number of refusals can be explained by the young age at inclusion and the long duration of the study. However, the bias of losing observations should not be overvalued because we did not find any differences in clinical and demographic variables between followed and lost patients. Aside from these limitations, the results of our study indicate that patients with eating disorders received different treatments according to their alexithymic profiles, both in terms of number and type of treatments received. Professionals should carefully monitor these personality features and be aware of the potential impact of alexithymic features on treatment compliance and on treatment choice for eating disordered patients. This should facilitate the matching of treatments to individuals on the basis of their clinical profile at presentation. Conflict of interest None. Acknowledgements This work was conducted within the clinical research project called ‘‘Dependence Network 1994–2000’’ which has received the support of the Institut national de la sante´ et de la recherche me´dicale (re´seau Inserm no 494013) and of the Fondation de France. The promoter of the project is the institut mutualiste Montsouris. References [1] Taylor G, Bagby M, Parker J. Psychological-mindedness and the alexithymia construct. Br J Psychiatry 1989;154:731–2. [2] Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression. Psychother Psychosom 2001;70:254–60. [3] Porcelli P, Bagby RM, Taylor GJ, De Carne M, Leandro G, Todarello O. Alexithymia as predictor of treatment outcome in patients with functional gastrointestinal disorders. Psychosom Med 2003;65:911–8. [4] Bourke MP, Taylor GJ, Parker JD, Bagby RM. Alexithymia in women with anorexia nervosa. A preliminary investigation. Br J Psychiatry 1992;161:240–3. [5] Corcos M, Guilbaud O, Speranza M, et al. Alexithymia and depression in eating disorders. Psychiatry Res 2000;93:263–6. [6] de Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995;36:53–60. [7] Taylor GJ, Parker JD, Bagby RM, Bourke MP. Relationships between alexithymia and psychological characteristics associated with eating disorders. J Psychosom Res 1996;41:561–8. [8] Goodsit A. Self-regulatory disturbances in eating disorders. Int J Eat Disord 1983;2:51–60. [9] Krystal H. Alexithymia and the effectiveness of psychoanalytic treatment. Int J Psychoanal Psychother 1982;9:353–78. [10] De Panfilis C, Cero S, Dall’Aglio E, Salvatore P, Torre M, Maggini C. Psychopathological predictors of compliance and outcome in weight-loss obesity treatment. Acta Biomed 2007;78:22–8. [11] Speranza M, Loas G, Wallier J, Corcos M. Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. J Psychosom Res 2007;63:365–71. [12] Ogrodniczuk JS, Piper WE, Joyce AS. Alexithymia and therapist reactions to the patient: Expression of positive emotion as a mediator. Psychiatry 2008;71: 257–65. [13] Association AP. Diagnostic and statistical manual of mental disorders. Washington: DC, 1994.
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