alexithymia is very important for assessment of anorexia nervosa , emotion regulation has to be assessed in eating disorders

1. Alethixymia and Eating Disorders : Clinical
and Treatment Implication
By Heba Essawy MD., CEDS.,
Prof of Psychiatry
International Chapter chair –Egypt Iaedps
Head of Eating Disorders Clinics
Okasha Institute -Medical school
Ain Shams University . Egypt

2. Introduction
 The prevelance of Eating Disorders has been reported to increase in recent decades .
 One of specific psychological variables that may contribute to the etiology of Eds as
emotion regulation ability
 One situation that impede the regulation of emotion is Alexithymia
 Alexithymia as an important risk factor for psychopathology symptoms due to its
impairing effect on emotion regulation ability.
 So examining the role of emotion regulation difficulties on the relationship between
alexithymia and Eds is of great importance
Available from:
https://www.researchgate.net/publication/374086977_Alexithymia_and_eating_disorder_sy
mptoms_the_mediating_role_of_emotion_regulation [accessed Oct 06 2023].

3. Roadmap
 Understanding the influence of alexithymia on the development of
eating disorders
 Examines alexithymia levels and its correlation’s to Eating Disorders
 Highlighting alexithymia as a predictor of outcome in ED treatment
and influencing choice of treatments
 Clarifying the effect of treatments of alexithymia in ED patients.

5. Alexithymia : Definition
 Alexithymia is not a new concept. Sifneos (1973) explain a group of cognitive and affective
characteristics typical of many clients with somatic disorders.
 Taylor 1983, proposed 3 fundamental elements that defined alexithymia: difficulty identifying
feelings (DIF) , difficulty describing feelings( DDF) , and externally oriented thinking (EOT) .

6. Cognitive factors of Alexithymia Affective factors of Alexithymia
Deficits in the regulation of thoughts,
emotions and bodily processes
•Difficulty with interoception
Inhibition and impulsivity issues Blunted or limited personal experience of
emotions
•Limited imagination and fantasy life
Difficulty identifying and describing emotions
Constricted patterns of thought Emotion dysregulation
Reliance on concrete thinking almost to the
exclusion of symbolic thinking
Failure to identify the causes of personal
feelings
Lack of empathy
Limited use and understanding of verbal and

7. Physiological factors with alexithymia Social factors with alexithymia
Physical sensitivity to the experience of
different sensations
•Nonassertiveness
Tendency to mistake affective responses
as physiological experiences or
dysfunctions
Verbal and nonverbal communication
deficits
Loneliness
Weak social attachments

8. Alexithymia and Eating Disorders
 Individuals with eating disorders have elevated levels of alexithymia
 Alexithymia underlie emotional difficulties in individuals with
eating disorders , Particularly difficulties identifying and describing
their feelings.
 Alexithymia implicated in both the development and maintenance
of EDs
 Alexithymia is of great interest as an outcome predictor of recovery
from anorexia nervosa

9. Alexithymia and Eating Disorders
 Alexithymia interfere with both treatment compliance and patients’ ability to
benefit from the known interventions.
 For this reason, in the last years new treatment approaches targeting emotion
identification, expression, and regulation have been applied and tested.
 It is also related to poorer treatment outcome, making it a relevant treatment target
 Alexithymia was found be to be more prevalent in females than in males. Alexithymia
is also associated with higher levels of sub-clinical disordered eating in
undergraduate females .
Heather Westwood et., al.,2017

10.  Emotion regulation difficulties, such as a lack of problem-solving and
reappraisal strategies, have been recognized as a transdiagnostic feature across
eating disorder subtypes ( Oldershaw et al.2019)
 Eating disorder behaviours (e.g., purging, binge eating, restricted food intake,
excessive exercise) are known as maladaptive regulatory techniques that are
employed to manage unpleasant emotional states (Fairburn et al.,2003.
 Other theories suggest that individuals with eating disorders hold beliefs that
emotions are unacceptable, leading to secondary emotions of guilt or shame
which consequently manifest as eating disorder symptoms (Corstorphine, 2006
Goss & Allan, 2009)
Alexithymia , Eating Disorders and Emotion
Regulation

11. Alexithymia , Eating disorders and
Emotion Regulation
 Sfärlea et al. 2009 found that within an adolescent sample of Eds girls , alexithymia
levels predicted the use of more maladaptive emotion regulation strategies and less
frequent use of adaptive emotion regulation strategies.
 Furthermore, Brown et al. 2018 documented that anorexic patients, alexithymia
predicted levels of emotion regulation difficulties at discharge, suggesting that
alexithymia may interfere with the efficacy of treatment programs.
 Within non-clinical populations, similar findings have been established (essawy H., Al
awady S., et.,al., 2020)
 The findings of these studies conceptually align with the attention-appraisal model,
where by alexithymia disrupt the ability to regulate emotions, which may then put
people at risk of clinical symptoms characterized by affective disturbance

12. Alexithymia and Eating Disorder
symptoms: the mediating role of
emotion regulation
 1- The attention –appraisal model
 2-The Interoceptive sensation defecit
 3-Emotion recognition deficits
 4-Empathy deficit

13. 1-Alexithymia and Eating Disorders symptoms
: The attention –appraisal model
 The attention-appraisal model denotes that the impairing effect of alexithymia distort the
emotion regulation ability
 Emotion regulation occur via a series of dynamic and interacting systems that is
subdivided into four stages: situation, attention, appraisal, and response.
 Emotions are regulated when an emotion is present (situation stage), one then focuses
attention on the emotion (attention stage), appraises what the emotion is and what it
means for their goals (appraisal stage), and based on that appraisal, one might activate a
goal to try to regulate the unfolding emotion (response stage; i.e., emotion regulation)
 More specifically, externally orientated thinking affects a person’s ability to focus
attention on their emotional states (attention stage), and difficulties identifying and
describing emotions affect a person’s ability to accurately appraise their emotions
(appraisal stage) (Preece, Becerra, Allan, Robinson & Dandy Citation2017).

14. 1-Attention-appraisal model of alexithymia.
Components of alexithymia: EOT (externally orientated thinking), DIF (difficulty identifying feelings), and
DDF (difficulty describing feelings) mapped onto the attention and appraisal stages of Gross’s process
model of emotion regulation (Quoted)

15. 2- Alexithymia and Interoception
Alexithymia, traditionally defined in terms of difficulties
identifying and describing one's own emotions , has
focused relatively little on the ability to perceive non-
emotional states from the body (termed ‘interoception’).
- Interoception refers to the perception of a wide range
of physical states beyond emotions, including heart rate,
respiratory effort, temperature, fatigue, hunger, thirst,
satiety, muscle ache, pain and itch

16. 2-Alexithymia and Eating Disorders :
Deficit of interoception
Interoception is the sense through which we monitor the inner state of our
bodies, helping us to regulate emotion and understand whether we're hungry,
thirsty, in pain, too hot, or too cold.
 The ability to interocept has three-dimensional model :
1- Interoceptive sensitivity refers to the objective accuracy of one's
interoception (e.g. ability to perceive accurately one's heart rate).
2- Interoceptive sensibility, assesses one's subjectively perceived sensitivity
(the extent to which one believes at perceiving bodily states)
3-Interoceptive awareness is responsible for keeping our body in
homeostasis, telling us to get a snack when we're hungry or go to the bathroom
when our bladder is full. It balances the need for change with the need to stay the
same.
lack of interoceptive awareness can contribute to the onset and continuation of the
Eds specially Anorexia nervosa

17. 3-Alexithymia and eating disorder: Emotion
Recognition Deficits
 Emotion recognition deficits exhibited by patients with EDs are due to alexithymia, which
will impacts on social functioning and behavior .
 Ability to recognize facial emotion was investigated in a sample of individuals with EDs and
alexithymia, and an alexithymia-matched control group. Alexithymia but not ED
symptomology, was predictive of individuals' emotion recognition ability
 This relationship was specific to emotion recognition, as neither alexithymia nor ED
symptomology was associated with ability to recognize facial identity. These findings
suggest that emotion recognition difficulties exhibited by patients with ED are attributable
to alexithymia, and may not be a feature of EDs per se
Rebeccaa eit., al.,2015

18. 4-Alexithymia and Eating Disorders:
Empathy
 Researches suggest alexithymia explains increased empathic personal
distress in ED populations.
 Influence of lowered cognitive empathy and intact affective empathy
profile found in AN is similar to that found in other psychiatric disorders
 Atypical empathy may therefore not be a core feature of EDs, and
interventions aimed at improving empathy-related social functioning is
important
 These findings add to the literature characterizing the socio-emotional
phenotype for EDs.

19. Assessment tools
 Toronto Alexithymia Scale (TAS-20)
 The Emotion Regulation Questionnaire (ERQ) measures the use of two emotional
regulation strategies, cognitive reappraisal, and expressive suppression
 The Self-Awareness Questionnaire

20. Alexithymia and Eating Disorders :
Treatment Impact
 For better enhancing quality of life and improving long-term outcomes in the ED
population :
1- Screening for Alexithymia
2- Leveling of Alexithymia
3- Identifying interventions that improve outcomes for individuals with
alexithymia
4- Exploring new treatment approaches targeting emotion identification,
expression and regulation
NB: In Eds patients, alexithymia levels remain elevated even after treatment. Whether
alexithymia should be considered a state-dependent variable or a trait remains open
to debate.

21. Alexithymia and Eating Disorders :
Intervention and Treatment considerations
 Individuals with alexithymia typically have worse mental health treatment outcomes
than those without alexithymia.
 .The symptoms of alexithymia undermine the development of :
1- Therapeutic alliances with mental health professionals.
2- Poor treatment engagement.
3- Interpersonal closeness deficit with others.
due difficulties with recognizing and describing affective experiences .
4- poor treatment attendance and adherence, so failure to complete
treatment programs and relapses

22. Alexithymia intervention table by Jerrod Brown
Intervention category Potential intervention for Alexithymia
Specfic Alexithymia reduction treatment
Broad Family education, group therapy,mindfulness , music
therapy , psychoeducation , DBT,
Affective Emotional awareness, intelligence,recognition and
regulation Intervention
Stress/ Coping Stress management , burnout prevention, and resilience-
building interventions
Trauma Trauma-informed care

23. Alexithymia and eating disorders : Take
home message
 Alexithymia and emotion regulation difficulties have been shown to have an impact
on the course and maintenance of Eds and specialy anorexia and on treatment
outcome and recovery .
 The lack of insight and the externally-oriented thinking style typical of alexithymia
may interfere with treatment compliance and with Eds patients’ ability to benefit
from interventions, especially psychotherapy ones
.
 Evidence supports the importance to screen for alexithymia in the everyday
clinical practice with psychiatric patients, including those suffering from EDs

24. Heba Essawy MD.,CEDS.,
essawi_h@yahoo.com
www.heba Essawy.com