Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study

Journal of Psychosomatic Research 63 (2007) 365 – 371

Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study Mario Speranzaa,b,4, Gwenole´ Loasc, Jenny Wallierd, Maurice Corcosb,d a

Department of Child Psychiatry, Centre Hospitalier de Versailles, Versailles, France b INSERM U669, Paris, France c Department of Psychiatry, Hoˆpital Pinel, Amiens, France d Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France Received 3 January 2007; received in revised form 27 February 2007; accepted 6 March 2007

Abstract Objective: Several cross-sectional studies have reported high levels of alexithymia in populations with eating disorders. However, only few studies, fraught with multiple methodological biases, have assessed the prognostic value of alexithymic features in these disorders. The aim of the present study was to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders. Methods: Within the framework of a European research project on eating disorders (INSERM Network No. 494013), we conducted a 3-year longitudinal study exploring a sample of 102 DSM-IV eating disorder patients using the Toronto Alexithymia Scale (TAS-20) and the Beck Depression Inventory. Results: At the 3-year assessment, 74% (n=76) of the sample still presented a syndromal or subsyndromal eating

disorder (unfavorable outcome: score of z3 on the Psychiatric Status Rating Scale for anorexia nervosa or bulimia nervosa). In logistic and hierarchical regression analyses, the Difficulty Identifying Feelings factor of the TAS-20 emerged as a significant predictor of treatment outcome, independent of depressive symptoms and eating disorder severity. Conclusions: The results of this study indicate that 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 patients with eating disorders and develop specific strategies to encourage labeling and sharing of emotions. D 2007 Elsevier Inc. All rights reserved.

Keywords: Alexithymia; Depression; Eating disorders; Longitudinal study; Outcome predictors

Introduction The identification of variables that predict treatment outcome in patients with eating disorders is critical if we are to increase the degree of sophistication with which we treat these disorders. Understanding predictors of outcome could theoretically facilitate matching treatments to individuals based on their clinical profile at presentation. Dirks et al. [1] have coined the term bpsychic maintenanceQ to describe the chronic outcome of an illness due to psychological reasons. 4 Corresponding author. Centre Hospitalier de Versailles, Child Psychiatry, 78157 Le Chesnay, France. Fax: +33 1 39 63 94 25. E-mail address: [email protected] (M. Speranza). 0022-3999/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2007.03.008

Among the several psychological features that have been proposed to predict treatment outcome in patients with eating disorders, alexithymia has attracted special interest. 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 [2]. Several arguments, namely, factor analyses and longitudinal studies, have supported the view that alexithymia is a stable personality trait rather than a state-dependent phenomenon linked to depression or to clinical status [3,4]. Several studies have reported high levels of alexithymia in patients with eating disorders, especially in individuals with anorexia nervosa [5–8]. There are several reasons to believe that this construct could play a

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major role in the illness course of eating disorders: due to their cognitive limitations in emotion regulation, alexithymic individuals with eating disorders may resort to maladaptive self-stimulatory behaviors such as starving, bingeing, or drug misuse to self-regulate disruptive emotions [9]. The lack of insight and the externally oriented thinking style of alexithymic subjects may also interfere with their capacity to benefit from psychotherapeutic interventions. However, in spite of the clinical relevance of this issue, clear data on the prognostic value of alexithymic features in eating disorders are still lacking. Two studies conducted on individuals with bulimia have failed to demonstrate a specific impact of alexithymia on the outcome of these patients. However, these studies presented some methodological limitations: samples were relatively small; the longitudinal time period was too short (10 weeks); both studies used an earlier version of the Toronto scale to assess alexithymic features; and finally, the outcome measures did not account for the degree of clinical change between baseline and follow-up [6,10]. The aim of the present study was to investigate the longterm prognostic value of alexithymic features in a large sample of patients with eating disorders, taking into account the limitations of previous studies.

Method Participants and procedures The subjects of this study were derived from a multicenter 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 centers involved in a prospective follow-up study. The recruitment centers were academic psychiatric hospitals specialized in adolescents and young adults (age range of reception: 15–30 years). For this study, only female participants who had requested care for a disorder of eating behavior 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 (namely, alexithymia and depression). 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 [11]. Diagnostic assessment was made using the Mini International Neuropsychiatric Interview, 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) [12,13]. In relation to the main purpose of the study, which was to

investigate the predictive power of alexithymia in eating disorders, we excluded patients presenting a comorbid diagnosis of current major depressive episode (MDE) (n=11) and patients presenting a current alcohol or drug dependency (n=6). MDEs were excluded to raise the chance of detecting a significant relationship between alexithymia and outcome, which would have been reduced by an excessive overlap between alexithymic and depressive scores. Alcohol and drug dependencies were excluded because of very few cases, thus creating a more homogeneous sample of eating disorders. 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. The protocol was approved by the local ethics committee (Paris Cochin Hospital). After all the necessary information was provided, all subjects gave written consent for participation in the study. Measures Alexithymia was rated using the French translation of the revised Toronto Alexithymia Scale (TAS-20) [14–16], which is a self-report scale with 20 items rated on a fivepoint Likert scale. The items of the TAS are clustered into three factors: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT) [17]. Depression severity was measured with the French translation of the abridged version of the Beck Depression Inventory (BDI-13) [18]. The BDI-13 has been developed by Beck and Beck [19] as a specific tool for epidemiological studies by selecting within all the items showing a high correlation (N.90) with the total score of the BDI-21. The severity of the illness was assessed by the bseverity of illnessQ item of the Clinical Global Impression (CGI). The CGI requires the clinician to rate on a 7point scale (1=normal to 7=extremely ill) 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. Outcome criteria The clinical outcome at 3 years was approached by two complementary perspectives: categorically, according to the presence or absence of eating symptoms, and dimensionally, according to the degree of clinical improvement between baseline and follow-up. For the categorical approach, eating disorder symptoms were assessed by the Psychiatric Status Rating Scale (PSRS) for anorexia nervosa or bulimia nervosa [20,21]. The PSRS, which is part of the diagnostic assessment LIFE Eat II, is based on DSM-IV diagnostic criteria for eating disorders. It defines six levels of severity according to the presence and the degree of clinical

M. Speranza et al. / Journal of Psychosomatic Research 63 (2007) 365 – 371

symptoms. According to Fichter and Quadflieg [22], we have defined two categories: a favorable outcome (score of 1 or 2) with a complete disappearance of all eating symptoms and an intermediate/unfavorable outcome (score of 3 or more), characterized by the persistency of a subsyndromal pattern or a complete diagnosis of eating disorder. For the dimensional approach, following Porcelli et al. [4], the degree of clinical improvement, according to the initial clinical level, was calculated as follows: (CGI at baseline CGI at follow-up/CGI at baseline)100 (between 100% and +100% of change). Treatments received during follow-up were recorded (types of treatment, age at the beginning of treatment, duration). The types of treatment were recoded in dichotomous answers (yes/no) according to Honkalampi et al. [23]. Statistical analysis To compare the mean scores at baseline and follow-up, we used a t test for paired samples for the entire group and according to outcome. The relative stability of alexithymic features was assessed by test–retest correlations and by the comparison of the magnitude of changes of the scores of alexithymia, depression, and clinical severity (Cohen’s D for paired samples: g 2 paired=t 2/t 2+N 1 1). To evaluate the predictive power of alexithymic features, we performed a series of stepwise (logistic or hierarchical) regression analyses with the TAS factors of the baseline assessment. To assess the extent of the predictive power of alexithymia, over and above those of depression and/or clinical severity

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(incremental predictivity), we secondarily added to the regression analyses, with a forced-entry method, the CGI and the BDI-13 [3]. Differences in treatments delivered during the study period were taken into account by maintaining these variables in the models. Results are presented as meanFstandard deviation. Statistical analyses were performed with the 10.1 version of the Statistical Package for Social Sciences.

Results From the initial sample of the Inserm Network on eating disorders, 144 patients were selected to be included in the follow-up study and retraced 3 years later. Among these subjects, 35 refused to participate or were unavailable. One hundred nine subjects were directly interviewed, of whom seven had to be excluded because they did not completely answered the self-questionnaire. Statistical analyses were performed on a final sample of 102 subjects (72.8%). Sixtythree had an initial diagnosis of anorexia nervosa, while 39 had an initial diagnosis of bulimia. No significant differences were found between the patients who did not participate in the follow-up and those who completed the study with regard to 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 mostly of young women (meanFS.D. age: 21.5F5 years), with a medium to high level of education.

Table 1 Scores at baseline and follow-up T1 Variables

Mean

Entire sample (N=102) TAS-TOT 56.7 TAS-DIF 22.8 TAS-DDF 16.7 TAS-EOT 17.1 BDI 13.4 CGI 4.8 Unfavorable outcome (n=76) TAS-TOT 58.1 TAS-DIF 23.7 TAS-DDF 17.1 TAS-EOT 17.3 BDI 14.8 CGI 4.9 Favorable outcome (n=26) TAS-TOT 52.0 TAS-DIF 20.1 AS-DDF 15.5 TAS-EOT 16.4 BDI 9.23 CGI 4.6

T3

Statistics Cohen D

R

5.654 6.934 4.244 0.07 5.424 7.654

0.24 0.32 0.15 0.00 0.22 0.37

.534 .404 .494 .614 .424 .2044

12.4 6.2 5.2 4.7 7.6 1.0

4.684 5.514 3.594 0.03 4.964 4.294

0.23 0.29 0.15 0.00 0.25 0.20

.554 .374 .524 .614 .444 .294

11.7 5.1 4.7 4.9 7.8 0.8

3.134 4.284 2.1544 0.09 2.3144 12.64

0.28 0.42 0.16 0.00 0.18 0.86

.4044 .26 .3844 .594 .13 .18

S.D.

Mean

S.D.

11.5 5.8 4.5 4.7 8.4 1.0

50.0 18.3 14.6 17.2 8.7 3.6

12.7 6.3 5.1 4.7 7.9 1.4

11.5 5.5 4.6 4.8 8.3 1.0

52.0 19.5 15.1 17.3 10.0 4.2

10.4 5.9 4.1 4.3 7.4 0.9

44.3 14.5 13.3 16.5 4.7 1.8

TAS-TOT, TAS-20 total score. T 1, initial assessment. T 3, follow-up assessment at 3 years. 4 Pb.01. 44 Pb.05.

t

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M. Speranza et al. / Journal of Psychosomatic Research 63 (2007) 365 – 371

Outcome results On the basis of the outcome criteria, the sample showed an overall negative outcome: 47% (n=48) of the sample still had a moderate to severe diagnosis of eating disorder (a score of 5 or 6 on the PSRS). One third of patients (n=26; 28%) had an intermediate outcome (persistency of clear symptoms without filling the diagnostic criteria: a score of 3 or 4 on the PSRS). Only 25% (n=26) had a favorable outcome with a complete disappearance of any eating disorder symptoms (a score of 1 or 2 on the PSRS). Concerning the degree of clinical change, there was an overall improvement of the sample, as well as major interindividual differences (mean: 22%; from 67% to +83% improvement). The outcome was independent from the initial diagnosis of anorexia or bulimia. The majority of the patients had at least one form of therapeutic intervention between baseline and follow-up. Psychotherapy was the most common (57%), followed by antidepressants (40%). Since patients with anorexia and bulimia had similar clinical outcomes and did not show any differences in alexithymic scores at baseline, statistical analyses were performed on the entire sample. Table 1 displays the means and standard deviations of the entire sample, in accordance with the favorable or unfavorable outcome for the TAS-20, BDI-13, and CGI at baseline and follow-up. In the entire sample, there was a significant improvement between baseline and follow-up scores for alexithymia [TAS-TOT: t(100)= 5.65, Pb.01], paralleled by a similar improvement in clinical severity [CGI: t(100)= 5.42, Pb.01] and depression [BDI: t(100)= 7.65, Pb.01]. Improvement concerned all subjects independent of the clinical outcome of the eating disorder. The magnitude of change (calculated via Cohen’s D) for alexithymic scores was similar to BDI and smaller than CGI. Moreover, although data failed to show an absolute stability between baseline and follow-up for alexithymic scores, a relative stability was observed in the correlation coefficients between the two assessments, thus suggesting that alexithymia may serve as a predictor of treatment outcome. Correlations were moderate to strong for all alexithymic factors. The issue of the relative weight of trait and state effects on alexithymia scores (and the influence of depression and clinical severity) was further explored with a structural equation modeling procedure. The results (data not shown) highlight that a model combining a state and a trait effect has the best adjustment to the data (Speranza et al., in preparation). Predicting treatment outcome Regression analyses were performed on the entire sample of patients with eating disorders in the absence of differences in outcome between patients with anorexia and patients with bulimia. The subjects/variables ratio of 17 was large enough for statistical power. Outliers were

eliminated and non-multicollinearity was verified. For all the analyses, we used standardized scores [24]. Favorable versus unfavorable outcome Seventy-six patients (74%) were classified as having an unfavorable outcome. Logistic regression analysis showed that the best model contained the DIF factor of the TAS (TAS-DIF). TAS-DIF was a significant predictor of an unfavorable outcome of eating disorders [Exp(B)=1.76, P=.02]. This model correctly predicted belongingness to the clinical categories in 76.5% of the cases [ 2log L=103.3, Model F(1)=12.5, Pb.002] and explained 17% of the variance (Nagelkerke R 2=.17). A second model integrating the BDI and the CGI was still significant [ 2logL=103.3, Model F(3)=16.1, Pb.003]. It slightly improved the explained variance compared to the first model (Nagelkerke R 2 changes from 17 to 21; prediction from 76.5% to 77.5%). Although BDI and CGI reduced the predictive power of the TAS-DIF [Exp(B)=1.32, P=.04], they did not erase it completely. TAS-DIF continued to be significant predictive factors of outcome, whereas CGI [Exp(B)=1.05, P=ns] and BDI [Exp(B)=1.76, P=ns] were not. Degree of change in eating disorders The logistic regression according to the clinical outcome categorized the subjects independently of the initial clinical status. This procedure can artificially raise the relationships between the predicting variables and the subjects, presenting a more severe clinical presentation at baseline. To assure that the model predicted the real change of clinical severity between the assessments, we performed a hierarchical regression analysis using the degree of improvement on the CGI as the dependent variable. This variable integrated the level of initial severity. Since the CGI was one of the predicting variables, the baseline CGI was discarded from the predictors in the final model [4]. Results of hierarchical regression were close to those of the logistic regression. The TAS-DIF was significantly Table 2 Hierarchical regression predicting the clinical improvement of eating disorders Final model Steps/Variables

R2

F

df

1 TAS-DIF 2nd TAS-DIF BDI-13

.09

5.424

1, 99

.14

7.144

2, 98

b

B

S.E.

P

0.32

0.14

.02

.22

0.25 0.13

0.16 0.16

.05 .15

.17 .15

Dependent variable: improvement of the clinical severity (%). Predictors: Treatments (enter method); TAS-DIF, TAS-DDF, TAS-EOT (stepwise method); BDI (enter method). R 2=Nagelkerke R 2. Change was produced by adding the BDI: R 2chg=.04, F(1)=2.38, P=ns. 4 Pb.01.

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associated to the outcome of patients with eating disorders. It was negatively correlated to the clinical improvement (TAS-DIF: b= .22). The model explained a limited part of the variance of change of the clinical severity (9%). Adding BDI to the model slightly reduced the significance of the TAS-DIF, which remained a significant predictor of the clinical improvement at follow-up (see Table 2).

Discussion The results of our study indicate that one of the facets of the alexithymia construct, the difficulty in identifying feelings, is a negative prognostic factor for the long-term outcome of patients with eating disorders. Patients with the greatest difficulties at identifying emotions at baseline are more often symptomatic at follow-up and show a less favorable clinical improvement. The relative stability shown by alexithymia over time legitimates its use as a potential prognostic factor in eating disorders. Furthermore, this result highlights how a multidimensional approach can be more informative than a unidimensional one because it allows to explore the impact of each facet of the construct on other psychopathological variables [25]. It must be acknowledged that the predictive power of this factor is limited (it explains a small amount of the variance of the clinical outcome); however, it remains significant even after having taken into account the impact of received treatments and the influence of the initial clinical severity and depressive symptoms. This is especially notable because the long duration of the study (3 years) inevitably introduces an important number of noncontrollable factors. Among the many correlation studies exploring alexithymic features in eating disorders, not one has longitudinally investigated the predictive value of alexithymia on the longterm clinical outcome of these patients. Therefore, our results cannot be easily compared with those of the two earlier negative studies. These studies were limited by their small recruitment of patients with bulimia (31 and 41 subjects) over a short period (10 weeks maximum), by their analysis of only the total score of the TAS, and by their use of outcome measures that did not account for the initial clinical severity [6,10]. Our results are close to those carried out with patients presenting functional somatic symptoms [4,26], which share many features with eating disorders [4,27]. Bach and Bach [26] observed that alexithymia slightly predicted the persistency of functional somatizations 2 years later, independently of depressive symptoms. The limited predictive value of alexithymia in our study contrasts with the results of the study of Porcelli et al. [4] who found that alexithymia was a strong negative predictor of the evolution of gastrointestinal functional disorders. It must be noted that Porcelli et al. used the total score of the TAS-20. Three points can explain the different results: the duration of the

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studies (6 months vs. 3 years), the low levels of depression of patients with functional disorders, and finally, a largely favorable response of these disorders to any kind of therapeutic intervention compared to patients with eating disorders (Porcelli, personal communication, May, 2004). There are several ways in which alexithymia can affect the clinical outcome of eating disorders: via the negative influence it exerts on the clinical expression of the disorders and on the response to therapeutic interventions. First, the difficulty in identifying feelings may reduce the capacity of patients with eating disorders to adapt to stressful situations [28]. Such situations generate an emotional overflow that alexithymic subjects apprehend less by emotional and cognitive features than by their associated somatic indexes [29]. This uncertainty between feelings and bodily sensations reminds us of the interoceptive confusion proposed by Hilde Bruch [30,31], which continues to be pertinent from a clinical point of view. Luminet et al. [32] have experimentally observed a dissociation of the components of the emotional response of alexithymic subjects (a physiological hyperreactivity to emotional stimuli associated to a deficit at the level of the cognitive experience), which illustrate the functioning of patients with eating disorders. Faced with the physiological arousal induced by emotional demands, these patients may show poor adaptive strategies. They may resort to restricted patterns of repetitive and automated behaviors, such as the hyperactivity of anorexic individuals or the binges/purge cycles of bulimic subjects, which temporarily relieve their feeling of discomfort and restore their inner equilibrium [33,34] but generate, in the long term, a positive reinforcement of the eating disorder. Second, alexithymia may be related to a chronic course of eating disorders by its relationship with other pathological behaviors, especially with addictive disorders. We have shown in previous studies that alexithymia is associated with addictive behaviors in patients with bulimia [35]. Patients with eating disorders may resort to addictive behaviors to relieve the anxious and depressive feelings elicited by their negative perceptions of themselves [36]. Finally, alexithymia can worsen the outcome of eating disorders by limiting the compliance to care and the efficacy of therapeutic strategies. This hypothesis has been the object of many theoretical reflections [37–39] but of very few empirical studies. Recently, McCallum et al. [39] have found that, for both short-term group therapy and short-term individual therapy, alexithymic features were associated with the worst treatment outcome. There are several limitations to this study that reduce the generalizability of results. First, the sample was composed of young women with a medium to high level of education recruited from university hospitals specialized in adolescents and young adults. It is possible that the sample contained patients with specific clinical and sociodemographic profiles. However, the degree of clinical improvement was individually assessed, and being female and

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having a high level of education are known to be typical characteristics of patients with eating disorder. One must also be cautious in generalizing because we excluded from the sample patients presenting an MDE and/or an alcohol or drug dependency. However, the number of excluded cases was limited, and the sample seems to reflect a homogenous population of patients with eating disorders consulting in the centers participating in the study. It is also hard to compare our results with those of other studies because none of the previous studies on eating disorders and alexithymia accounted for comorbid addictive disorders. Future research on this topic should better describe the clinical profile and the comorbidity of the research samples. Second, the study had a naturalistic design, with therapeutic interventions freely chosen on the basis of usual practices. Differences in treatments received by patients may have influenced the evolution of alexithymia over time (although we controlled treatments in all statistical analyses). If this can be considered a limitation of the study, it also underscores the fact that clinicians choose therapeutic strategies on the basis of several factors, among which alexithymia might be an important one that needs to be better formalized. We project to further analyze the data of our naturalistic study concerning the treatments given to patients according to their alexithymia levels. Third, the rate of follow-up was not high, with a certain amount of refusals explained by the young age at inclusion and the long duration of the study. However, we made the choice of directly collecting the data and retaining only patients with complete files because the aim of this research was the study of psychopathological features associated with eating disorders; it did not aim to conduct an exhaustive epidemiological survey. The bias of losing observations must not be overvalued because we did not find any differences in clinical and demographic variables between followed-up and lost patients. Aside from these limitations, the results of our study indicate that 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 patients with eating disorder and develop specific strategies to encourage emotion labeling and sharing, such as group therapy that is focused on emotional communication [40] or writing disclosure techniques [41], which have already proven their efficacy in medical and surgical patients. Controlled studies on the impact of these techniques in eating disorders are of major interest.

Acknowledgments This work was conducted within the clinical research project called bDependence Network 1994–2000,Q 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. We would like to thank Olivier Luminet of the University of Louvain for his helpful advice on this research.

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