Treatment of eating disorders improves eating symptoms but not alexithymia and dissociation proneness
Introduction
The prevalence of eating disorders has been reported to increase in recent decades, especially among young girls [1]. Anorexia nervosa reaches a prevalence of 1%, whereas bulimia nervosa is estimated to affect 5% of the population. Strong cultural influences are possibly behind this epidemic, but although the cultural pressure among Western girls is ubiquitous, it is not clear why only certain individuals will develop an eating disorder [2]. Therefore, the search for specific psychological variables that may contribute to the pathophysiology of these disorders is of great importance. Two such relevant factors are alexithymia (AL) and dissociation proneness, both considered as strategies of dealing with negative emotions.
Alexithymia was originally characterized as an inability to find words to describe one's feelings but is also conceptualized as a dysfunction in identifying (or awareness to) one's feelings [3], [4], [5]. Alexithymia has been studied in psychosomatic diseases, functional somatic symptoms, and depressive and anxiety disorders [6], [7], [8], [9], and has also been associated with suicidality [7]. Patients with eating disorders have a significant difficulty at identifying their feelings and expressing them verbally (especially negative affects and anger) [10], [11], [12], [13], [14], [15], [16]. They may attempt to avoid feared sensations by attempting to constrict emotional experiences in general. Moreover, bulimic patients might deal with negative feelings by excluding the bad object or feelings through the vomiting symptom. Alexithymia may result in patients with eating disorders also from frequent traumatic experiences during childhood such as sexual abuse (secondary AL), and the symptom may be one way to regain control. If one function of AL is the avoidance of affect [8], then patients with eating disorders should be more alexithymic. Indeed, an association was reported between anorexia nervosa and AL [6], [9], [10], [11], [12], [13] and between bulimia and AL [14], [15], [16].
Dissociation results from a disintegration of consciousness, memory, identity, and perception and is considered a defense mechanism against intolerable trauma and/or memories [17], [18]. Dissociative disorders and experiences are related to childhood neglect and abuse history [19], [20], [21]. These features (abuse and neglect) are quite frequent among patients with eating disorders, particularly those involving bulimic features, and may therefore explain the high dissociation tendency in patients with eating disorders [22], [23], [24]. These patients are also characterized by emotional disavowal, a retreat to eating and fasting experiences, disturbed body image, and bodily sensations (such as increased pain tolerance) and identity problems. These features may link eating disorders with the process of dissociation [25], [26]. Dissociation could also be related to self-injurious behavior in patients with eating disorder [27], [28].
In this study, we examined the efficacy of our treatment program for eating disorders in a sample of young soldiers at a military clinic and to evaluate the rate of AL and dissociation proneness in the sample, both before and after treatment. This study reports on the results of 2 consecutive groups of patients with eating disorders treated in 2002 and 2003.
Section snippets
Sample
The sample included soldiers referred to the Eating Disorder Clinic at the Zeriffin Mental Health Clinic, Israel Defense Forces during the years 2001 to 2003. This military clinic is the only eating disorders clinic in the army, supplying tertiary services to soldiers from the whole army. Yearly, the clinic examines 200 soldiers, and only up to 5 of these are discharged from military service because of severe symptoms and significant decrease in functioning (Hartuv, personal communication). The
Results
Twenty-four subjects completed the treatment period, and 6 patients (all women) dropped out because of noncompliance and lack of motivation. The dropouts' diagnoses were anorexia nervosa [2], bulimia nervosa [3], and eating disorder NOS. [1]. Their initial scores on the various scales were similar to those of the completers. For the completers, the scores on the EDI-2, EAT-26, DES, and TAS-26 scales before and after treatment are displayed in Table 1.
Discussion
The main findings of this study are as follows: the intervention was associated with a significant improvement in eating symptoms (50% decrease in the EAT-26 and EDI-2 scores), but there was no significant decrease on the DES and TAS-26 scores. The decrease on the EDI-2 and EAT-26 was similar to the clinical impression of significant improvement. This specific psychometric change may be indicative of the lack of importance of changes in AL or dissociation proneness in the short-term improvement
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