Alexithymia, ambivalence over emotional expression, and eating attitudes

Abstract

To clarify the relationships amongst alexithymia, emotional expression, and characteristics associated with eating psychopathology, 162 female undergraduate students completed questionnaire measures of alexithymia, emotional expressiveness, ambivalence over expression, eating psychopathology, and characteristics related to eating disorders. Despite the high frequency of alexithymia in eating disorders, when other variables were controlled alexithymia was not related to total EAT-26 (the measure of pathology), nor to two of the core aspects of eating pathology measured by EDI-2: body dissatisfaction and drive for thinness. Bulimia was directly predicted by difficulty identifying feelings, and negatively by difficulty describing feelings, both measured by TAS-20. The same bidirectional relations were observed for three characteristics of eating disorders: asceticism, impulse regulation, and perfectionism. Direct relationships with difficulty identifying feelings were found for ineffectiveness and interoceptive awareness. Ambivalence over emotional expression predicted ineffectiveness, interoceptive awareness, impulse regulation, maturity fears and perfectionism, but was not related to any of the measures of pathology. However, ambivalence over expressing anger predicted restrictive psychopathology. The results are discussed in relation to the origins and maintenance of eating-disordered attitudes and behaviours.

Introduction

The importance of emotion in the eating disorders has been recognised at least since Bruch’s work. Bruch (1962) advocated an approach to anorexia nervosa that helped patients become aware of and identify inner states, including emotions. Sifneos (1973) identified a pattern of emotional deficits common in psychosomatic patients, and which is consistent with Bruch’s view. This trait of alexithymia is characterised by difficulties in understanding, differentiating, describing, and expressing emotions, together with a paucity of dreams and fantasy, and a preoccupation with concrete details.

Alexithymia is identified as a continuum within the population, but we can describe people as alexithymic if, on measures of alexithymia, they score above empirically determined cut-off points which give a high probability of ill-health. In nonclinical groups, the incidence of alexithymia varies from 0% (Jimerson, Wolfe, Franko, Covino, & Sifneos, 1994) to 28% (Guilbaud et al., 2002). Higher levels are found in many physical conditions, for example hypertension (55%; Todarello, Taylor, Parker, & Fanelli, 1995), in alcohol and drug dependence (58% and 43%; Guilbaud et al., 2002), and in mixed psychiatric outpatients (e.g., 33%, Todarello et al., 1995). A number of studies have shown an even higher incidence of alexithymia in eating disorders (see Eizaguirre, de Cabezón, de Alda, Olariaga, & Juaniz, 2004). In anorexia nervosa, estimates range from 23% to 77%, and in bulimia nervosa from 51% to 83%. Eizaguirre et al. (2004) showed that the difference in levels of alexithymia between eating disorder and control groups disappeared when anxiety and depression were controlled for. Some of these studies reported results separately for different facets of alexithymia. When this is done, it is found that difficulties identifying and describing feelings are high in eating disorder patients, not concrete thinking or lack of fantasy life. Sexton, Sunday, Hurt, and Halmi (1998) showed that, after controlling for depression, only the alexithymia subscale measuring difficulty describing feelings significantly differentiated eating disorder groups from controls.

Aside from alexithymia, difficulty expressing emotion has been related to many illnesses, including eating disorders (e.g., Garfinkel et al., 1983; Rybicki, Lepkowsky, & Arndt, 1989), although the relationship has not been consistently found. King and Emmons (1990) argued that one reason for this is that it is not inexpressiveness as such that is important, but conflict or ambivalence over expressing emotion. This ambivalence often appears as lack of expression, and results from underlying goal conflict; it is this conflict that is pathogenic. They constructed two self-report questionnaires, one measuring emotional expressiveness (the EEQ) and the other ambivalence over emotional expression (the AEQ). In two studies (King and Emmons, 1990, King and Emmons, 1991) the AEQ, but not the EEQ, correlated with measures of well-being, and of physical symptoms. Ambivalence over emotional expression is also related to depression (Katz & Campbell, 1994; Mongrain & Zuroff, 1994).

Krause, Robins, and Lynch (2000) found that AEQ scores correlated .43 with total Eating Attitudes Test scores in a female student sample (EAT, Garner & Garfinkel, 1979, is a widely used indicator of eating pathology). Further, ambivalence mediated the relationship between sociotropy (concern over interpersonal relations) and EAT scores, and correlated with EAT even when depression was controlled for. Many authors (e.g., Casper, 1990; Geller, Williams, & Srikameswaran, 2001; Killick & Allen, 1997) have pointed out that eating disorder sufferers are often ambivalent about being treated for their symptoms. This could represent a conflict between wanting to retain symptoms and yet be rid of them, and could be the type of conflict that King and Emmons (1990) suggested underlies ambivalence over emotional expression. Ambivalence over expressing emotions and difficulty describing feelings seem to have much in common.

Eating disorders are complex, and such emotional difficulties might not relate to eating pathology as such, but to characteristics associated with eating disorders. This is suggested by the effect of controlling for depression and anxiety noted above. Many of these characteristics are assessed by the Eating Disorder Inventory-2 (EDI-2; Garner, 1991). We might expect a priori that some characteristics will be related to emotionality as reflected in emotion variables. Most obviously, Interoceptive Awareness, which measures “confusion and apprehension in recognizing and accurately responding to emotional states … [and] uncertainty in the identification of certain visceral sensations” (p. 6) ought to correlate with the alexithymia dimension of difficulty identifying feelings. Interpersonal Distrust (“an individual’s feeling of alienation and reluctance to form close relationships … reluctance to express thoughts or feelings to others”; p. 6) ought to be related to difficulty describing feelings. It also should be related to ambivalence over emotional expression, for much the same reason. Persons high in Interpersonal Distrust should also be less expressive of emotions, especially intimate and positive emotions. Similar considerations suggest that Social Insecurity (“the belief that social relationships are tense, insecure, disappointing, unrewarding, and generally of poor quality”; p. 6) should be related to the affective dimensions of alexithymia and to ambivalence over emotional expression, and inversely to expressions of emotion. Less clearly, Ineffectiveness (“feelings of general inadequacy, insecurity, worthlessness, emptiness, and lack of control over one’s life”; p. 5) should be associated with emotional uncertainty, and hence related to ambivalence. It might also reflect difficulty identifying feelings. The features of Asceticism (“the tendency to seek virtue through the pursuit of spiritual ideals such as self-discipline, self-denial, self-restraint, self-sacrifice, and control of bodily urges”; p. 6) suggest close monitoring of internal states, which may suggest an inverse relation with difficulty identifying feelings. However, as eating disorders often involve blocking of feelings (e.g., Lacey, 1986), denial, and failure to recognize emotional states (e.g., Bruch, 1962), Asceticism may be associated with difficulty identifying feelings. We might also expect ambivalence over expressiveness to be associated with high Asceticism, due to conflict over expressing feelings which are generally highly controlled and primarily for self-monitoring. Impulse Regulation (“the tendency toward impulsivity, substance abuse, recklessness, hostility, destructiveness in relationships, and self-destructiveness”; p. 6) involves poor control of emotional expression. We expect this to be related to emotional expressiveness (especially of negative emotions), and perhaps also to ambivalence.

We do not expect any relationship between alexithymia and ambivalence, and the remaining EDI-2 scales (Drive for Thinness, Bulimia, Body Dissatisfaction, Perfectionism, and Maturity Fears).

Taylor, Parker, Bagby, and Bourke (1996) examined the relationships between the eight scales on the original EDI (Eating Disorder Inventory; Garner, Olmsted, & Polivy, 1983) and the Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994a) in anorexia nervosa patients and student controls. In partial agreement with our predictions, they found high correlations (from .47 to .52) between overall alexithymia and Interpersonal Distrust in all groups; quite large ones with Interoceptive Awareness for patients (.42) and male students (.33); and with Ineffectiveness for patients (.33), male students (.28) and female students (.19). Contrary to our prediction, they also found quite high correlations for Maturity Fears for patients (.36) and male students (.29). The version of the EDI that they used did not include Asceticism, Impulse Regulation or Social Insecurity. Taylor et al. (1996) concluded that, while alexithymia is related to several characteristics of eating disorders, it is not related to attitudes and behaviours relating to abnormal eating attitudes and body weight and shape.

Laquatra and Clopton (1994) applied the same original version of EDI and an earlier version of TAS to 308 female college students. They reported significant correlations between overall TAS, and the two affective subscales, and all of the EDI scales apart from Perfectionism. These include correlations that we have not predicted, between overall TAS and Body Dissatisfaction (.16), and Drive for Thinness (.19). They also reported correlations between overall TAS and Bulimia (.26), and Maturity Fears (.34). The highest correlations were with Interpersonal Distrust (.48), Ineffectiveness (.47), and Interoceptive Awareness (.44). However, they applied no correction for multiple significance testing, and their large sample size resulted in what might be trivial correlations being described as significant.

In summary, this study examines the relationships within a nonclinical female sample between trait measures of expressiveness, ambivalence over expression, and alexithymia on the one hand, and measures of eating attitudes and of characteristics associated with eating disorders on the other. The aim is to clarify which traits are predictive of disordered eating attitudes and characteristics associated with eating disorders.