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This is to certify that the

dissertation entitled

ALEXITHYMIA AND SELF-REGULATION:
AFFECTIVE AND COGNITIVE FUNCTIONING IN
COMPULSIVE EATING

presented by

Regina C. O'Connell

has been accepted towards fulfillment
of the requirements for

Ph.D. degreein PSYCHOLOGY

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ALEXITHYMIA AND SELF-REGULATION:
AFFECTIVE AND COGNITIVE FUNCTIONING IN
COMPULSIVE EATING
By

Regina C. O’Connell

A DISSERTATION
Submitted to
Michigan State University

in partial fiilfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

2002

ABSTRACT

ALEXITHYMIA AND SELF -REGULATION: AF F ECTIVE AND
COGNITIVE FUNCTIONING IN COMPULSIVE EATING

By

Regina C. O‘Connell

Research suggests that individuals with eating disorders have higher rates of
alexithymia than the general population. The alexithymia construct consists of four
salient features: I) difficulty discriminating feelings from bodily sensations of emotional
arousal. 2) difficulty identifying and describing feelings, 3) reduced imaginative
capabilities. and 4) preoccupation with somatic and external events. The theory behind
these difficulties is that there is a deficit - a dysregulation of affect that leads to a more
diffuse. somatic and unverbalized processing of physiological and psychological affective
experience. Research suggests that these difficulties are common in psychosomatic and
addictive disorders and interfere with the ability to make use of psychotherapeutic
approaches that rely on verbalization to process affective and cognitive information.

The study tested the hypothesis that the relationship between obesity and
alexithymia is due to a mediating variable. a subgroup of the obese population that
engages in compulsive overeating or “bingeing”. The study investigated whether somatic
complaints. somatization and addictive behavioral patterns are more common in the
compulsive eating population. The Thematic Apperception Test (TAT) and Toronto
Alexithymia Scale-20 (TAS-ZO) were administered to obese women enrolled in Weight
Watchers programs and to a control group of women from the community. To assess the

potential influences of other variables. such as intellectual functioning and

L

psychiatric/mood symptoms on cognitive and affective processing. the WAlS-R
Vocabulary subtest and the Brief Symptom Inventory (881) were administered. Results
indicated that it is compulsive overeating. as opposed to obesity. that is associated with
alexithymic and somaticizing deficits. In particular. severe compulsive overeaters. as
compared to non-compulsive eaters and moderate compulsive eaters. produced
significantly different performances on both the TAS-ZO and the TAT. Severe
compulsive eaters were more likely to report multiple somatic problems for which they
had sought medical treatment. In this sample. severe compulsive eaters were also more
likely to be experiencing comorbid addictive problems. Severe compulsive eaters had
comorbid nicotine addiction and impulsive addiction to shopping.

Compulsive overeating serves a self-regulatory function in a quick and
temporarily reliable way for individuals with deficits in the cognitive processing and
regulation of affect. A concrete act (bingeing) is used to self-soothe and self-regulate
physiologic arousal tension states. For such individuals, affect remains at a sensory-
motoric level that stimulates and prompts action for self-regulation. Since affect does not
become processed at a cognitive level, verbalized and modulated. it remains diffuse and
chronically overwhelming. Given the difficulty in processing affect and using it as a
signal about internal affective and cognitive states. modifications need to be made in
psychotherapeutic technique. The goal is to assist the individual in tolerating affective
tension while learning to identify. discriminate. verbalize and ultimately regulate internal

affective experience.

ACKNOWLEDGMENTS

This project was completed over a period of four years and a distance of several
hundred miles. It probably would not have been completed without the guidance. support
and patience of the following people.

I am ever grateful to Bert Karon for chairing my dissertation committee and for
his guidance and encouragement throughout the project. His knowledge of
psychoanalytic concepts. particularly regarding affect theory. was integral to the
development of this study. His gifts of enthusiasm and availability were greatly
appreciated. His ideas on clinical work and life in general have greatly influenced me.
both as a person and as a psychologist.

I would not have been able to begin or complete my graduate training without
Norm Abeles. He has been my primary advisor. supporter and motivator during my
development as a psychologist. His clinical expertise. sound judgment. creativity and
kind mentoring have made him a role model for me. Thank you. Norm. for all the doors
you’ve opened for me!

I am indebted to Bob Caldwell for his knowledge and support as my guidance
committee chairperson. supervisor. and instructor during my graduate experience. His
easy-going style. paired with his directness and clarity. made it much easier to receive
constructive feedback as a psychologist-in-training and as a developing individual.

Sharon Hoerr came on board with the dissertation project at a very critical time in
the process and I am most grateful to her participation. Her expertise in the area of

nutrition and obesity research played a major role in the dissertation coming to its

iv

fruition. Furthermore. her questions. ideas and recommendations for organizing and
discussing the results were most helpful.

I’d like to thank my research assistants. Laurie. Danielle and Donna. whose
perseverance and flexibility on this project were admirable. I appreciated their
willingness to ‘ruminate’ about scoring details so that the results would be reliable.
Their enthusiasm for learning about emotion in relation to eating was noteworthy. and I
was impressed with their desire to do investigation on their own during the project.
Thanks for the “thousandth” time!

Last but not least. I am blessed to have colleagues. friends and loved ones in my
life who have made many concessions to help me through my graduate. and particularly.
my dissertation experience. Heartfelt thanks go out to Susan and Audrey for lovingly
blurring the lines between sister. friend. and mentor. Many thanks go to Webb and Scott
for “existential” discussions that kept me plodding on with the dissertation. Thank you.
David. for your poetry and your love. Humble gratitude goes out to Ruth and Carolyn for

embarking on the critical journey and clearing the way for me to grow as an individual.

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................... ix
RESEARCH RATIONALE AND RESEARCH QUESTIONS ........................................ 5
REVIEW OF THE LITERATURE ........................................................................ 6
Obesity and Compulsive Eating ................................................................... 7
Classification and Physiological Components ......................................... 7
Psychodynamics: Clinical Observations .............................................. 10

Psychodynamic & Personality Characteristics: Empirical Findings .............. 21

Affect Development and Regulation ............................................................ 20

Affect Theory ............................................................................ 20

Affect Development ..................................................................... 25

Affect Regulation & Dysregulation ................................................... 27

Affect Regulation: Origins in Attachment ........................................... 28

Affect Regulation: Symbolic Representation ......................................... 30

Affect Regulation: Neurobiologic Findings .......................................... 32

Alexithymia: “Words Without Emotion” ....................................................... 33
Alexithymia Construct ................................................................... 33

Alexithymia: Affective Component .................................................... 34

Alexithymia: Cognitive Component ................................................... 36

Alexithymia and Compulsive / Addictive Behavior ................................ 38

Depression and Alexithymia ........................................................... 40

Measurement of Alexithymia: Empirical Data ...................................... 4l

Alexithymic Disturbances in Eating Disorders ................................................ 43
Alexithymia & Disordered Eating ...................................................... 43

Toronto Alexithymia Scale ............................................................. 44

vi

Thematic Apperception Test ........................................................... 52

Archetypal Test with 9 Elements ...................................................... 54
Rorschach Inkblot Test ................................................................. 55
Purpose of Study .................................................................................. 58
Hypotheses ......................................................................................... 59
Hypothesis One .......................................................................... 59
Hypothesis Two .......................................................................... 60
Hypothesis Three ......................................................................... 60
Hypothesis Four .......................................................................... 60
Hypothesis Five ........................................................................... 60
Hypothesis Six ........................................................................... 60
Hypothesis Seven ........................................................................ 60
Hypothesis Eight ......................................................................... 6]
METHOD .................................................................................................... 62
Population .......................................................................................... 62
Procedure ........................................................................................... 62
Measures ............................................................................................ 63
Structured Clinical Questionnaire (SCI) .............................................. 63
Binge Eating Scale (BES; Gonnally, Black, Daston, Rardin, 1982) .............. 64
Wechsler Adult Intelligence Inventory-Revised, Vocabulary subtest
(Wechsler, 1981) ............................................................... 65
Brief Symptom Inventory (BSI; Derogatis, I993) ................................... 65
Toronto Alexithymia Scale-20 (TAS-20; Bagby, Parker, & Taylor, 1994) ...... 66
Thematic Apperception Test (TAT; Murray and Morgan, 1932) .................. 67
RESULTS ..................................................................................................... 70
Demographic Data ................................................................................. 7O

vii

Results of Hypotheses ............................................................................. 75

Hypothesis One ........................................................................... 75
Hypothesis Two ........................................................................... 77
Hypothesis Three ......................................................................... 77
Hypothesis Four .......................................................................... 77
Hypothesis Five .......................................................................... 78
Hypothesis Six ........................................................................... 80
Hypothesis Seven ........................................................................ 80
Hypothesis Eight ......................................................................... 81
Compulsive Eating and Psychiatric Symptoms ................................................ 81
Verbal Intelligence and Alexithymia ............................................................ 82
DISCUSSION ................................................................................................ 83
Descriptive Information ........................................................................... 83
Demographics ............................................................................ 83
Compulsive Eating ................................................................................ 84
Obesity and Alexithymia ............................................................... 84
Somatization .............................................................................. 85
Addictive Behavior ...................................................................... 87
Alexithymia and Psychiatric Distress ................................................. 87
Alexithymia and Affect Regulation ................................................... 88
CONCLUSIONS ............................................................................................. 9O
Strengths and Limitations ........................................................................ 91
Strengths .................................................................................. 91
Limitations ................................................................................ 92
Future Directions .................................................................................. 93

viii

Assessment Measures ................................................................... 93

Psychotherapeutic Interventions ....................................................... 93
APPENDIX A: Binge Eating Scale (BES) ............................................................... 95
APPENDIX E: Toronto Alexithymia Scale-20 (TAS-20) ........................................... 102
APPENDIX C: Thematic Apperception Test (TAT) ................................................. 105
APPENDIX D: Structured Clinical Inventory (SCI) ................................................. 107
APPENDIX E: Consent to Participate in Research ................................................... 1 13
LIST OF REFERENCES ................................................................................. I 16

ix

LIST OF TABLES

Table 1: Body Mass Index classification system for weight recommended by the World Health

Organization (WHO; 2001) ............................................................. 8
Table 2: Affects and their physiological and behavioral expressions (Kauffrnan, 1992) .......... 22
Table 3: Body Mass Index (BMI) and Binge Eating Scale (BES) summary scores ................ 74

Table 4: Number of participants by levels of compulsive eating and degree of overweight/
obesity by BMI (body mass index) .................................................... 74

Table 5: Intercorrelations among BMI, BES, TAS-20, TAT total score, TAT total word
score, TAT total affect score, and TAT total vague affect score .................. 76

Table 6: Mean T- scores (standard deviations) for BSI subscale and index scores ................. 79

RESEARCH RATIONALE AND RESEARCH QUESTIONS

Clinicians and researchers have long sought to understand the emotional and
cognitive variables in the pathogenesis of eating disorders. and to develop therapeutic
modes to address and treat these disorders. Bruch’s (1962. 1973. 1982. 1985) work was
seminal to current understanding of the psychological deficits underlying eating disorders.
She emphasized a deficit model in which the core issue for the eating disordered
individual is a chronic struggle with a deficient sense of self and a profound sense of
ineffectiveness. She noted the cognitive and affective deficits that compromised their
ability to attend to. accurately perceive. effectively interpret and use what was ‘going on”
in their bodies. Bruch’s use of the term ‘interoceptive confusion’ highlighted a
disconnect in awareness of the interaction among physiological sensations. affective
experiences. and cognitive appraisals.

Bruch’s observations of the psychological deficits of the eating disordered
population are similar to the deficits underlying the construct of alexithymia. The core
aspects of alexithymia are: l) difficulty discriminating between feelings and the
physiological sensations of affective arousal; 2) difficulty identifying and describing
feelings; 3) limited imagination and fantasy life; and 4) a concrete. extemally-oriented
thinking style (Taylor. Bagby, Ryan & Parker. 1990; Taylor, Bagby, & Parker. 1991).

The alexithymic individual has difficulty cognitively processing emotions so they
can be regulated. As a result. there tends to be a focus on. and an amplification of. the
bodily sensations that accompany emotional arousal (Krystal. 1979. 1982. 1988). This

tendency leaves the alexithymic individual vulnerable to increasing tension resulting from

undifferentiated states of unpleasant emotional arousal. The arousal and tension is
understood in terms of concrete somatic states. rather than cognitively processed.
verbalized. and ultimately modulated. Since cognitive processing of affect is deficient.
the alexithymic individual is prone to regulate tension through physical action as an
immediate response to unpleasant physiological arousal. Concrete actions. such as
compulsive eating and substance abuse. are temporary strategies for reducing somatic
tension. However. this leaves the individual dependent on repetitive concrete acts. rather
than internal cognitive processing and regulation of affect. to reduce tension (McDougall.
1974. 1982a. 1982b). Emotional arousal cannot be used to signal what an individual is
experiencing internally. rather. it is considered as an unpleasant physiologic state to be
quickly eliminated (Krystal. 1975. 1988. 1997; Taylor. Bagby & Parker. 1991).

Disturbance of self-regulation involves impairment in the capacity to cognitively
process and regulate emotions to achieve a state of homeostasis (Grotstein. 1986). To
compensate for the underlying affect dysregulation. individuals may develop a variety of
impulsive and addictive behavioral patterns as defensive reparative strategies to regulate
tension states and undifferentiated dysphoric moods. Unable to insulate against
overstimulation. and without the ability to self-soothe and self-regulate through cognitive
processes. concrete substances and actions are employed to regulate the physiological
affective states.

Clinical observation and research has lead to the assertion that alexithymic
deficits and self-regulation impairments are common in eating disordered populations
(Bruch. 1973. 1982. I985; Selvini Palazzoli. 1971. 1974; Stunkard. 1975; Waysfield.

LeBarzic. Guy-Grand. 1977; Casper. I983: Goodsitt. 1983. 1985; Swift & Letvin. 1984;

Abraham & Beaumont. 1982; Kaye. Gwirtsman. George. Weiss & J immerson. 1986;
Schupak-Neubergh & Nemeroff. 1993; Henderson & Huon. 2002). Most of the empirical
research that supports these observations is based on anorexic and bulimic and. more
recently. binge eating populations (Bourke, Taylor & Crisp. 1985; Bourke. Taylor. Parker
& Bagby. 1992; Schmidt. Jiwany. Treasure. 1993; Cochrane, Brewerton, Wilson &
Hodges. 1993; Laquatra & Clopton. 1994; de Zwaan. Bach. Mitchell. Ackard. Specker.
Pyle & Pakesch. 1995; de Groot. Rodin. Olmstead. 1995; Morosin & Riva. 1997).
Empirical research on alexithymic deficits in the obese population has been equivocal
(Logorreta. Bull. and Kiely. I988; Laquatra & Clopton. 1994).

The current research project sought to examine whether such alexithymic deficits
are present in a non-clinical female population that is overweight and/or obese. Given
that the obese population does not present specific psychopathological difficulties due to
its heterogeneous nature (Morosin & Riva. 1997). it was hypothesized that a subgroup of
the obese - those that engage in compulsive overeating - would have alexithymic deficits
similar to those of anorexic and bulimic populations. Compulsive overeating or “binge
eating" is characterized by repeated episodes of the consumption of a large amount of
food in a relatively short period of time. As described in the Diagnostic and Statistical
Manual of Mental Disorders. Fourth Edition (DSM-IV), these episodes involve both
subjective and behavioral aspects of difficulty controlling. and distress about. the binge
eating. In contrast to the eating disorders anorexia nervosa and bulimia nervosa. there is
no consistent use of inappropriate compensatory behaviors (e.g.. self-induced vomiting.

laxative abuse. excessive exercise. starvation. etc...) to try to prevent weight gain.

Compulsive eating is understood as an addictive process in which a concrete act is
carried out repetitiously providing. in part. a temporary self-regulatory function to cope
with affective arousal that is experienced primarily at a somatic level. The affect is not
free to serve a signaling function for the individual because deficits in discriminating
emotional arousal from physiological arousal preclude the identification and verbalization
of the feelings (Krystal. 1975. 1988. 1997). Since verbalization is preempted by
somatization. the aim is to reduce the tension as quickly as possible. Repetitious acts
provide temporary relief of emotional arousal.

Investigating whether alexithymic traits are characteristic of individuals who
compulsive overeat. rather than the obese population in general. may explain the marginal
effectiveness of insight-oriented psychotherapies for the obese. Furthermore.
modifications in psychotherapeutic treatment to accommodate such deficits may be
warranted. as some analysts have recommended (Krystal. 1979. 1982. 1988: Bruch. 1973.
1982. McDougall. l982a. l982b).

This research investigation sought to answer several research questions. First. is
the reported relationship between alexithymia and obesity due to the moderator variable.
specifically compulsive overeating? Second, does the severity of compulsive overeating
coincide with the severity of alexithymia? Third. do compulsive eaters tend to somaticize
and/or have more somatic problems than non-compulsive eaters? Fourth. are compulsive

eaters more likely to have comorbid addiction problems than non-compulsive eaters?

REVIEW OF THE LITERATURE

Obesity is a problem for health professionals. in that. although many theories exist
about the nature. etiology. and course of obesity. there has been a paucity of lasting
treatments (Wadden & Osei. 2002; Peri & Corsica. 2002; Fairbum & Brownell. 2002).
This is especially problematic. as obesity tends to have widespread detrimental
consequences in psychological (Yuker. Allison. Faith. 1995; Wadden & Stunkard. 1985:
Istvan. Zavela. & Weidner. 1992). physical (Manson. Colditz. Stampfer. Willet. Rosner.
Monson. Speizer. & Hennekens, 1990; Sjostrom. 1992; Field. Bamoya & Colditz. 2002).
interpersonal (Shapiro. Baumeister.& Kessler. 1991; Wadden. Womble. Stunkard. &
Anderson. 2002). and economic (F reize. Olson & Good. 1990; Klesges. I990; Crandall.
1991; Field. Bamoya & Colditz. 2002 ) realms. Furthermore. treatment is negatively
affected by the attitudes and countertransference of health professionals (Adams. Smith.
Wilbur & Grady. 1993; Harvey & Hill. 2001; Heble & Xu. 2001).

Treatments for obesity have been weak in tackling its chronicity. as evidenced by
substantial post-treatment regaining of weight (Perri & Corsica. 2002). Several
approaches are currently used to treat obesity. including pharmacological (Atkinson.
1994; Bray. 2002). surgical (Latifi. Kellum. de Maria. Sugerrnan. 2002). cognitive-
behavioral (Cooper & Fairbum. 2002; Wilfiey & Cohen. 1997). behavioral treatments
(Fairbum. 1991. 1993; Wing. 2002). and various self-help and commercialized programs
(Womble. Wang. Wadden. 2002) for the obese. There is a limited literature base of
empirical data supporting the benefits of insight-oriented treatments. such as traditional

psychoanalytic (Rand and Stunkard. 1977. 1978. 1983; Wadden & Stunkard. 2000) and

modified psychodynamic-interpersonal therapies (Bruch. I973, I985; Wilfley. 1993) for
eating disordered populations. There is minimal support for the benefit of insight-
oriented therapy with the obese when reduction in weight is the criterion for effectiveness
(Brownell & Wadden. 1993 ); however. the orientation of such therapies attends more to
general personality characteristics and interpersonal dynamics rather than just symptom
remediation.

The finding that obese individuals tend not to experience weight reduction as a
function of involvement in insight-oriented psychotherapies may be related to
observations of an increased frequency of psychosomatic traits in this population (Bruch
1957. 1966. 1973; Rand & Stunkard. 1983. 1977; Waysfeld et al. 1977; Taylor, Bagby &
Parker. 1991). Such traits reflect the process of isolating affect from other aspects of
mental life. interfering with the process of reviewing and verbalizing one’s inner
experience (i.e.. fantasies. wishes. feelings. attitudes. etc..) which is common to
psychotherapy . Gaddini (1976) indicated that the psychosomatic symptom evolves from
disturbances in the interaction between mother and infant. at a time when the infant has
not developed the psychic structures necessary to use a particular object as symbolizing
the mother. Gaddini indicated that the child’s energy is self-focused rather than focused
on the mutuality of the relationship with the mother. This disturbance in mutuality leaves
the child invested mainly in his physical experience. Symptoms become displayed
through somatization when tensions and emotions are not differentiated. identified and
verbalized. The body and its functions become the medium through which distress may
be communicated (Sifneos. 1970. 1976. 1994). Notably. clinical observations with the

obese reveal deficits in differentiating among bodily sensations and emotions and feelings

of frustration and helplessness. Overeating temporarily regulates tension. but at the
expense of achieving resolution of internal distress (Bruch. 1972. 1973; Glucksman.
Rand. Stunkard. 1978). Waysfield. LeBarzic. Aimez. & Guy-Grand (1977) worked with
the obese and noted a cognitive style restricted to a concrete focus on somatic symptoms
and external details that seemed to preclude the verbalization of feelings and wishes.
Prior to discussing the affective and cognitive disturbances in obesity and
compulsive eating. a brief look at the physiological components and an extensive review
of clinical and empirical literature on the psychodynamics associated with obesity and

other eating disturbances may be helpful.

Obesity and Compulsive Overeating

 

Classifications and Physiological Components

Overweight is a general term that refers to an excess of body weight that includes
fat, muscle. bone and water. while the term obesity refers specifically to excess body fat
(Bray. Bouchard. & James. 1998). One can be overweight without being obese. although
excess body fat is the main variable in being overweight.

There are several ways to assess obesity using body fat and weight. The method
most commonly used by researchers and health professionals is the Body Mass Index
(BMI) (NIH. 1998). BMI is determined by the formula kg/ m2. which represents an
individual‘s weight in kilograms (kg) divided by height in meters squared (m2). Although
BMI is not exact in terms of a specific healthy or unhealthy weight. it is useful in that it
can be used to predict the development of health-related problems. Table 1 lists the

current BMI classification system used by the World Health Organization (WHO).

Although body fat is essential for stored energy. shock absorption. heat insulation.
excess body fat is associated with a variety of health conditions. Approximately 55% of
the current U.S. population is overweight (Fairbum & Brownell. 2002). Being obese is

associated with increased risk of compromised quality of life and mortality.

Table 1: Body Mass Index (BMI) classification system for weight recommended by the

World Health Organization (WHO; 2001 ).

 

 

 

 

 

 

 

Weight Classification BMI range
Underweight Less than 18.5
Normal Weight 18.5 to 24.9
Overweight 25 to 29.9
Obese 30 and higher
Moderately Obese 30 to 34.9
Severely Obese 35 to 40

 

 

 

 

The most common health-related problems associated with obesity include hypertension.
type II diabetes. lipid disorders. coronary heart disease. stroke. gallbladder disease. sleep
apnea and respiratory problems. kidney disease. osteoarthritis and bone disease.

There does not appear to be one specific physiological cause for obesity. as
several factors seem to be related to weight gain. Obesity tends to run in families. with
family and twin studies producing increasing evidence of a genetic link for obesity (Price.
2002). Research suggests that neural. endocrine. and metabolic mechanisms play a role
in regulation of appetite. satiety and body weight. Lifestyle factors such as diet/eating
choices (amount and types of food) and level of physical activity are also clearly linked to
obesity. In particular. consumption of high fat. sugar. and processed food diet along with
a sedentary lifestyle is associated with obesity (Foster & McGuckin. 2002). While many
physiological variables associated with obesity cannot easily be altered. lifestyle changes
can be modified to affect physiological systems which lead to weight loss and
maintenance.

Compulsive or “binge“ eating often leads to being overweight. since binges
involve consuming a large number of calories in a short amount of time. The foods
commonly selected for a binge are often considered to be “comfort” foods that tend to be
processed foods that are high fat and high starch (Stunkard. 2002). Approximately 25%
of obese individuals engage in frequent episodes of binge eating. with the percentage
increasing to nearly 40% in the severely obese (Fairbum. 1998). Since compulsive eaters
do not engage in the purging behavior characteristic of bulimia. they are more likely to be

overweight than are bulimics.

n .- ~.:+ii.ng

Although compulsive eaters do not typically have the chronic health
complications that bulimics experience due to purging behavior. they do experience
physiological consequences of their eating style (Fairbum & Brownell. 2002).
Compulsive eaters may not obtain the necessary vitamins and minerals due to binging on
high fat and high sugar foods. Regular consumption of these processed foods increases
the risk for Type II diabetes. hypertension. high blood cholesterol. digestive problems.
and gallbladder disease (Berkow & Fletcher. 1987).

PsvchodLnamics: Clinical Observations

According to D. Brenner (1981. 1983). eating disorders serve a self-regulatory
function. Overeating and compulsive eating may serve to regulate self functions that are
unable to be achieved in more adaptive and effective ways. Eating disordered symptoms
communicate particular self-representations. object-representations. and self-object

interactions. Brenner suggests that the ego state sought by obese individuals relates to

aspects of “early object relations which have contributed to or impeded ego development.

and which have influenced the internalized self- and object- representational world”.
Segal. (1956. 1978). Rosalato (1978). Meissner & VanDamm (1977) discussed
the theoretical foundations for how the infant becomes less reliant and dependent on
literal objects (mother) in the environment. by explaining the process of language
acquisition and symbol formation in normal development. Both Geist (1989) and
Brenner (1983) applied this to eating disorders by linking disturbances in empathic
connectedness between mother and child to the development of eating disorders. In
particular. Brenner stated that the network of individual representations, based on the

child’s ability to call up the mental image of the mother or of the functions provided by

the mother. such as self-soothing or other self-regulations. should provide the normal
child with the internal capacities to deal with frustration and excitement through symbolic
mediation. McDougall (1974. 1982a. l982b) has stated that when these intemalizations
are compromised. the person remains addictively stuck on external objects or actions to
complete the missing symbolic representation. She added that. such repetitions will fall
short. Without internalization of the object’s function within the self, a deficit remains
that can only partly and temporarily filled by endless repetition and addictive attachment
to external objects (McDougall. 1980. 1982b).

Goodsitt (1983) stated that eating disorders represent deficits in self-organization
and self-regulation. with the overeating process. especially bingeing. symbolizing a
desperate attempt to subdue states of tension and internal distress. In particular. he noted
that such stimulatory behavior reduces feelings of deadness. emptiness and their related
tensions.

Both Goodsitt (1983) and Bruch (1961, 1970) noted that internal psychic
mechanisms of the self-regulation of self-esteem. moods. and tensions are not dependable
for the eating disordered individual. Most markedly with compulsive eating or bingeing.
the seeking of extreme sensations of fullness relates to the intensity of stimulation as a
goal. Goodsitt stated that it is often the individual‘s lack of awareness of her internal
states and ability to identify only vague and uneasy discomfort. where the eating is
experienced rather than the underlying tension-state. Krystal (1979) noted a parallel
phenomenon with drug-abusing individuals. when the “high” is experienced rather than
the underlying physiological and psychological state. Thus. the eating—disordered

individual is similar to the substance-abusing individual. in that. there is a preoccupation

with internal physical stimuli. with the ingestion of a substance as an escape from the
difficulty of relating to themselves and others.

Charone (1982) and C astelnuovo-Tedesco (I986) postulated that the nature and
symptoms of overeating or bingeing occur as a developmental failure. utilizing the early
feeding relationship as a paradigm of the mother-child relationship. In doing so. several
levels of disturbance in the mutuality of the mother-child relationship were reviewed.
Kohut’s (1971) descriptions of failures in empathic mirroring. idealizing. and the
appropriate transitional experiences during childhood that lead to internalization of self-
regulating abilities leave individuals seeking pathological substitutes that are reliable in
their ability to provide immediate self-soothing functions. Kohut stressed the relational
aspect of the actual action of eating. He noted that when the need for a nurturing self-
object relationship remains unfulfilled. depressive eating may occur to replicate an aspect
or part of the larger ‘mother-infant unit’. Schick (1947) noted imagery reminiscent of
striving for merger with mother. with the process of overeating recapitulating both the
feeder and the one being fed as an interacting unit. White (1981) indicated that
overeating serves a range of self-object functions directed toward restoring self-cohesion.
Castelnuovo-Tedesco (1986) reported that overeating and bingeing. similar to other
addictions. were pathological substitutes that provide temporary restitution and self-
regulation. Unlike transitional objects. he noted that they do not lead to the ability to
relate well to objects or even to “psychic restructuralization” by internalization of
symbolic representations of self-soothing and self-regulating behaviors.

The literature on the psychodynamics of compulsive eating symptomatology

highlighted the centrality of feelings of emptiness. loneliness. and neediness in the

gggfi'

dynamics of individuals who use food in an addictive fashion (de Groot et al. 1994.
Bemporad. Beresin. Ratey. O’Driscoll, Lindem. & Hertzog. 1992a.1992b; Castelnuovo-
Tedesco. 1996). Furthermore. Chessick (1985) pointed out the particular focus on
separation-individuation conflicts by writers in the eating disorder field.

Giovacchini (1972) speculated. similar to McDougall (1980. 1982a.]982b). that in
syndromes such as addiction to alcohol and food. the original mother-infant symbiosis
was not adequate to allow the child to assimilate the mother’s capacities for self-care and
regulation of internal states. and for reassurance of object permanence. Thus. the infant
was inadequately prepared to separate and develop further individuation. He noted that
experiences of separating were anxiety-provoking. and at times of particular stress the
child might attempt to simulate symbiotic connectedness with the mother by eating to
deal with the anxiety.

Blackwell (1968) stressed that the impulse to binge represents the desire to fill up
the feeling of emptiness. The overeater seems to be trying to fill a depleted or lonely self.
via taking in food. Bliss and Branch (1960) commented on food as a means of security
and protection. a means of achieving temporary contentment when experiencing
interpersonal rejection. and for one patient. a way to recreate earlier periods of familial
harmony. Bemporad et al (1992a) investigated the function of eating disorders as trying
to maintain the fragility of the family unit by presenting an image of robustness and unity.

Wurmser (1977) described addicts as being caught between the a fearfulness
about merging and a simultaneous desire for that feared merger. which is more
characteristic of the ambivalence experienced by those that binge eat as compared to

overeating. In contrast. the obese individual appears to long for and seek out the

I A -JA-Ifi' “At" “m.

experience of symbiosis with an “all good” mother representation. which is recreated in
the process of overeating (Bruch. 1973). Sugarrnan and Quinlan (1981) suggested that
such individuals experience developmental arrests that leave him fixated at the level of
sensorimotor self- and object- representations. where the object can be internalized only
as part of repetitive action. Eating assumes the status of a need-gratifying activity that
restores a sensorimotor representation of the mother.

D. Brenner‘s dissertation work (1980) involved assessment of early interpersonal
family interactions. current interpersonal patterns. and the internalized object-relational
world in the obese compulsive eaters. Obese subjects indicated a preference for
companionship and a fear of being alone. For obese subjects. the more overweight they
were. the greater their dependency needs and the more they tended to seek out and trust
others. The families of overeaters were characterized by closeness. sometimes to an
unhealthy degree. and familial problems focused on conflicts surrounding dependency
and overprotectiveness.

Bruch (1973) observed that in such families. certain needs seem to be met but, at
times. in such excess as to be developmentally inappropriate and actually thwarted the
child’s need for emotional support to grow up, separate. and become autonomous.
Bemporad et al (1992a.b). collecting collaborative data from analysts who typically
worked with eating disordered patients. found impaired familial relationships. with the
mother typically being both overinvolved and distant and the mother-child relationship
being recalled as lacking in mutuality and closeness. Relationships with fathers were also
less than mutual. and often with fathers presenting narcissistic traits and using the child to

meet their own needs. Many authors noted that the experience sought out and

recapitulated by those that overeat and binge was characterized by qualities of the mother-
child relationship (Bemporad et al. 1992a.b; Bruch. 1963, 1973; Goodsitt. 1985; Brenner.
1980. 1983). Overeaters tended to indulge in too much of the “wrong” thing (i.e. food).
rather than emotional support for becoming more functional or for working through
difficult experiences. Brenner (1983) stated that overeating recreates a particular self-
object state. Clinical data also suggested that overeaters reported feeling lonely. alone.
rejected and resorted to food as comforting. “love-object substitute”. and as a way to
avoid experiencing feelings and maintain self-control (Glucksman. 1989; Bemporad. et
al. 1992a; Brenner. 1983).

To understand the psychodynamics of obesity and compulsive overeating. it is
important to note that one of the central psychoanalytic ideas of psychosocial
development is that overgratification or frustration during the oral stage is likely to result
in a dependent personality style and in preoccupation with food and eating as a self-
regulating method to obtain nurturance and security (Borenstein, 1991). Brenner noted
the importance of a focus on the different self-regulating functions served by the action
patterns of each symptom. Obese. compulsive eaters are conflicted by issues of loss and
separation anxiety. and turn to binge-eating as a symbolic act of merger. She issued that
the therapeutic task for the overeater is to internalize more self-object functions. toward
the goal of becoming more autonomous and independent. This is consistent with
Krystal’s (1978b) work with substance-dependent individuals. where it was observed that
they did not appear to have internalized self-regulating and basic self-care functions. In
fact. he suggested that such individuals see that task as reserved for the omnipotent self-

object. and recapitulate that process by using substances for self—regulation. McDougall

(I974, l982b) added to this by suggesting that because they have been unable to
internalize such functions and create a mental representation of the self-object function.
they are prone to repeat the experience of pseudo self-care by addiction to substances.

Slochower (1983. 1987) reviewed a number of empirical studies exploring the
relationship between excessive eating and the impact of emotions and the environment.
She found that the obese tend to have difficulty in spontaneously identifying and
describing their emotional reactions to emotion-arousing cues. as well as their tendency to
overeat in response to a variety of emotional states which are perceived as overwhelming
and uncontrollable. Slochower also found that obese individuals report significant affect
reduction following eating.

Psychodynamic & Personality Charflefistics: Empirical Findings

 

Houston (1995) compared the personality functioning of morbidly obese females
seeking gastric surgery to normal weight females using the Sixteen Personality Factor
Inventory (16-PF; Catell. 1963). He found no significant differences in personality traits
between obese and normal weight females. Most of the empirical research suggests that.
while the obese as a group report dysphoric affect. low self-esteem. and interpersonal
sensitivity. their overall psychiatric status does not appear to be significantly different
from normal weight groups (Kayloe. 1993; Williams. Power. Millar, & Freeman. 1993).

Auerbach-Barber (1998) examined the interpersonal and personality
characteristics that distinguish obese binge eaters (n = 30) from obese nonbinge eaters (n
= 78) seeking weight-loss treatment at a university center. Participants completed self-
report inventories assessing personality characteristics. interpersonal patterns. and

depression. Binge eaters reported experiencing significantly more interpersonal

problems. depressive symptoms and neurotic personality traits than non-binge eaters.
Binge eaters scored higher than non-binge eaters on subscales indicating non-
assertiveness. vindictiveness. social avoidance. exploitability and intrusiveness. Binge
eaters also scored lower on extroversion compared to non-binge eaters. Auerbach-Barber
(1998) suggested that obesity treatment might be enhanced by addressing the nterpersonal
styles of obese binge eaters. since they differed from obese non-binge eaters.

Several studies examined compared the personality characteristics and general
distress of bulimic. obese binge eaters. obese nonbinge eaters. and normal weight using
the Minnesota Multiphasic Personality Inventory (MMPI) and/or other measures of
psychological distress. Kolotkin. Revis. Kirkley. and Janick (1987) administered the
MMPI and the Binge Eating Scale (BES; Gormally et al. 1982) to obese binge eaters and
obese nonbingers. BES scores varied from nonbinging to very severe bingeing and were
consistently and linearly related with all of the standard MMPI scales except Hypomania.
Hysteria. and Masculinity-Femininity. Psychasthenia (measuring tension. anxiety.
rumination. insecurity) accounted for 23% of the variance in binge scores. Results
indicate that binge severity varies within obese population and that binge eating is
associated with psychological disturbance. particularly difficulties with
anxiety/insecurity.

Kirkley. Kolotkin. Hernandez. and Gallagher (1992) compared MMPI
distributions obtained from binge-purgers. obese binge eaters. and obese nonbingers and
found significant differences on all scales except Masculinity-Femininity and Hypomania.
Binge-purgers exhibited the most psychological distress and obese nonbingers exhibited

the least distress. Obese binge eaters differed significantly from binge-purgers on fewer of

17

the scales than they did from obese nonbingers. These results suggest that binge eaters
are a subgroup of the obese population that may benefit from treatment used for bulimia.

Prather and Williamson (1988) compared binge-purgers. binge eaters. and obese
nonbinge eaters who were seeking obesity treatment. obese non-patients. and normal
weight/eating controls on the MMPI. Symptom Checklist-90--Revised (SCL-90-R;
Derogatis. Lipman & Covi. 1973). and the Beck Depression Inventory (BDI. Beck &
Steer. I983). The binge-purge group presented the highest levels of psychopathology
compared to other groups. Obese binge eaters and obese nonbinge patients presented
significantly more distress than the obese non-patient and normal weight/eating group.
These findings highlight the importance of the discriminating between obese individuals
who are. or are not. in treatment when conducting research.

.Iackson (1997) explored the effects of eating style (binge or nonbinge eater) and
weight (overweight and normal weight) on subscale scores of the Eating Disorders
Inventory-2 (EDI-2. Garner. 1991). which reflects psychological traits. attitudes and
behaviors relevant to eating disorders. She found that overweight. binge eaters scored
significantly higher on Impulse Regulation and Bulimia subscales than overweight.
nonbinge eaters. Binge eaters scored higher than nonbinge eaters on Drive for Thinness.
Bulimia. Body Dissatisfaction. Ineffectiveness. Perfectionism. Interpersonal Distruct.
lnteroceptive Awareness. Ascesticism. and Social Insecurity subscales. Overweight
women scored higher than normal weight women on Drive for Thinness. Bulimia. Body
Dissatisfaction. lnteroceptive Awareness. and Ascesticism subscales.

Berman. Berman. Hcymsfield. and Fauci (1992) used structured clinical

diagnostic interviews and found that about half of a group of severely obese individuals

seeking dietary treatment had a DSM-IV Axis I psychiatric disorder (particularly affective
disorders). They also found that most of the individuals had some mild to moderate
personality deficits that resulted in isolation. interpersonal sensitivity. and interpersonal
difficulties. Black. Goldstein. & Mason (1992) used systematic. structured interviews to
assess personality functioning in morbidly obese seeking gastric surgery and a
psychiatrically normal comparison group. They found that morbidly obese subjects were
more likely than the comparison group to have a lifetime history of mood disorders.
bulimia. and nicotine dependence. and were more likely to meet diagnostic criteria for a
personality disorder.

Yanovski (1993) found that among obese individuals not in weight loss treatment.
those that were binge eaters were significantly more likely than non-binge caters to have a
lifetime prevalence of DSM-III-R psychiatric (especially major depression. panic
disorder. bulimia) and personality disorder diagnoses (especially borderline and avoidant
personality disorders). to have participated in psychotherapy. and to have a family history
of substance abuse. Specker. de Zwaan. Raymond. and Mitchell (1994) found that three
times as many obese binge eaters. as compared to obese nonbinge eaters. met criteria for
an DSM-IV personality disorder. They stated that obese binge eaters should be
considered as a qualitatively different group than obese non-binge eaters when addressing
treatment issues.

Daniels (1996) administered the Questionnaire on Eating and Weight Patterns
(QEWP. Spitzer. 1992). EDI-2. BDI. and Borderline Symptom Index (BSI; Conte.
Plutchik. Karasu. & .lerrett. 1980) to individuals participating in an eating disorders

program. Individuals were separated into bulimic. obese binge eating. and obese non-

binge eating groups. and all three groups differed significantly on psychopathology.
weight attitudes. and eating behavior. The bulimic group exhibited the highest depression
scores. the strongest borderline personality patterns. the most generalized distress. and the
most dietary/weight attitude disturbance compared to the other groups. Obese binge
eaters displayed mild to moderate levels of these psychological and behavioral

disturbances. but of more severity than obese non—binge eaters.

Affect Development and Regulation

Affect Theory

Some theorists discriminate between affect. emotion and feelings. but many use
them interchangeably. There is general agreement among theorists that the human
experience and expression of affect involves three interacting processes (Watson & Clark.
1994; Dodge & Garber. I991; Izard & Kobak. 1991; Frijda. 1986). The biological or
physiological system underlying affect involves the autonomic nervous system and
neuroendocrine activation. The behavioral/expressive system relates to affect being
evidenced in facial expression. speech quality. and body gesture. The
cognitive/experiential system involves the reflective awareness and verbal expression of
feeling states. Affect and emotion are often used interchangeably to reference
physiological states and behavioral expression (Watson & Clark. 1994). while feelings
are usually limited to labeling the subjective experience of emotion (Schwartz. 1987).
Sifneos (1988) stated that affects are complex states consisting of interacting

physiological. expressive and experiential systems. He also described affects as being

_. 56.5.,

___“ . ‘

mental representations of feeling states linked with recollections of experiences that result
in personalized meanings attributed to current feeling states.

Silvan Tomkins (1962. 1963. 1984) considered affects to be innate biological
motivating processes and theorized that human motivation was based upon innate affects.
He labeled specific innate affects in pairs that reflect the affective intensity range and
their associated behavioral expression. Tomkins classified affects in terms of neutral.

positive. and negative affects. with their expressive indicators. as follows in Table 2

1.0 oeuvres-a"

(Kaufman. 1992).
Eckman (I993) emphasized that behavioral expressions of affects serve as i

feedback to us. and as critical information communicated to others so they have hints as

to what we are feeling. Even when we are unaware or have not reflected upon our

emotions. others notice changes in our behavior and provide feedback about their

observations and ideas about what we may be feeling (Greenberg & Safran. 1989).
Tomkins believed that affects were primary motivators. He stated that affects

serve as amplifiers for instinctual drives. such that drives obtain their power from

affective influence. Although he believed that affect functioning was a system separate

from cognition. he noted that affective and cognitive processes influence one another and

work in relation to one another. Tomkins developed the concept of idea-affective

organizations. in which the unique union and interrelation of particular affects and

cognitions become important personality traits. influencing thinking processes. affect

regulation systems and behavioral displays.

21

Table 2: Affects and their physiological and behavioral expressions (Kauffman.

1992x
affect tone affect rang e
neutral surprise-startle
positive interest-excitement
em’oymenljoy
negative distress-anguish

fear-terror

anger-rage

shame-humiliation
contempt-dissmell

disgust-repulsion

22

behavioral expression

 

eyebrows uplifted.
eyes blinked

eyebrows down. eyes
tracking. listening

lips widening. smiling

arched eyebrows. lip comers
down, rhythmic crying

eyes wide open. face
trembling. skin pale and cool.

skin hair erect

red face. frowning.
jaw clenched

eyes and head cast downward
nose and upper lip raised

lower lip lowered/protruding

Izard (1971. 1977; Izard & Buechler. 1980) proposed an affect theory called
differential emotions theory. He agreed with Tomkins” idea that there was a fundamental
set of affects. with each affect having a specific innate neurological substrate. a unique
behavioral expression. and a particular subjective feeling. He changed Tomkins’ distress-
unguish classification to sadness and added guilt to the basic set of affects. Izard‘s theory

suggests that particular primary affects instigate and organize behavior. rather than simply

- “#11

being responses that result from cognitive evaluation processes (Izard & Buechler. 1980).
Izard identified a set of six subsystems that can function alone or together- homeostatic.
drive. emotion. perceptual, cognitive and motor systems - to form personality. He said
that the most critical connections are the combinations of affective-cognitive structures
that produce certain individual differences in personality traits and one's ability to relate
to others. Izard believed that the fundamental affect. interest, had the most dramatic
influence on personality structure. since it is an important motivation for the development
of competencies. creativity. and relationship with others. Interest underlies the
personality trait of openness to experience (McCrae and Costa. 1985). which consists of
curiosity about internal and external experiences. as well as openness to new ideas and
experiences. The ability to tolerate and reflect upon such experiences is a necessary
component for affect-regulation and self-regulation.

Freud conceptualized affects as derivatives of instinctual drives rather than as
primary motivating factors (Sulloway. 1979). Secondary to drives. affects were
considered to be discharge processes occurring only when the drive was not completely

gratified. Jones (1995) noted that Freud later began to separate affects from drives and

23

stated that anxiety could be a signal affect in response to perceived environmental
dangers or drive-related impulses that were threatening. Freud never developed a system
to describe affects as separate from the drive theory framework. Prompted by Tomkins'
affect theory and developmental psychology’s infant research. a number of theorists have
revised the psychoanalytic theory of affects to view affects. rather than drives. as the
primary motivators in human life. In particular, Jones (1995) developed a psychoanalytic
theory of affect and stated that affects are the “experiential representation of a non-
symbolic information-processing system that can serve as the central control mechanism
for all aspects of behavior” (p. xxi). He conceptualized affects as nonsymbolic signals
that relay information. even without the influence of cognition or conscious reflection.

There are affect theorists that assert that cognitive and/or perceptual processing
precedes emotional processing (Lazarus. I991. Plutchik. 1980). Much of this work has its
roots in the work of Schachter (Schachter and Singer. 1962). who stated that
environmental stimuli can create a state of autonomic arousal that develops into unique
emotional experiences by the meanings that the individual assigns to the stimuli. He
suggested that there was no emotion without autonomic arousal. He also stated that there
was no emotional experience when the arousal state is attributed to non-emotional
sources. Furthermore. Schachter & Singer (1962) were able to conduct empirical
research that produced findings suggesting that emotional experiences may be determined
by the manner in which individuals interpret the arousal state.

Lazarus (1991) proposed a cognitive theory of emotion in which the cognitive
appraisal of the significance of the relationship between the individual and the

environment is both sufficient and necessary for emotional experience. Emotional

24

experiences are essentially initiated by the unique appraisal and. without this assignment
of meaning. there will be no emotional experience. Plutchik’s (1980) theory asserts that
cognitive appraisal precedes all emotion. but his definition of appraisal is based on using
perceptual information rather than formal cognitive processing. To clarify this issue.

Davidson & Ekman (1994) state that emotional experience does not depend on formal

cognitive operations. rather. most emotional experience is preceded by some sensory I“

information. .
It appears that emotion and cognition are unique processes that are fundamentally :

indivisible. yet are separated for ease of conception and discussion. Zajonc (1984) stated if

that affect development does precede cognitive development. but that both emotion and
cognition can be primary at any given time. He noted that cognition becomes inseparably
connected with emotions early in development and that cognition can activate emotional
processes. Izard (1994) stated that cognitive processes assume a critical role in affect
regulation. regardless of whether they active or are activated by emotional experience.
Affect Development

Basic innate emotions are present in infancy and are primarily experienced and
expressed physiologically and behaviorally (Tomkins. 1984; Schore. 1994). Krystal
(1988) explained that the expressive aspects of affect become the principal mode of
communication for the infant. with the experiential aspects of affect manifesting as
undifferentiated precursor states of contentment and distress. As the infant matures into
childhood. cognitive processes and social contact have progressive influence on the
experiential aspects of affect. The developing complexity and range of emotion involves

desomatization and differentiation of the affect precursor states. With the development of

cognition and ultimately language. emotions become represented symbolically and can be
communicated through verbal exchange (Krystal. 1974. 1988; 1997). Lane. Quinlan.
Schwartz. Walker. & Zeitlin (1990) stated that emotion is transformed and proceeds
though developmental steps of desomatization. differentiation, and integration.

Lane & Schwartz (1987) developed a theory of affect development based upon
Piaget’s theory of cognitive development and infant/child observation research. They
suggested that affect development involves cognitive structural transformations that
determine the way we experience ourselves and the world around us. The levels of affect
development are as follows: l)sensorimotor reflexive stage- affect is experienced only
through somatic sensations; 2) sensorimotor enactive stage - awareness of body
sensations and the body in action is based upon global and consuming states of
contentment or distress; 3) preoperational stage - individual emotions are experienced
somatically and psychologically. but descriptions of the emotion tend to be simplistic and
one-dimensional; 4) concrete operational stage - differentiated and complex blends of
emotion are aspects of one‘s subjective experience; 5) formal operational stage. Full
awareness of a range of complex blends of emotion coupled with ability to distinguish
subtle nuances of emotion and understand the full range of emotional experiences of
others.

Lane & Schwartz‘s (1987) model of affect development helps to promote better
understanding of the information processing of the cognitive aspects of affects. Their
model also provides a framework to discuss variability in how affects are individually
experienced. expressed. regulated. as well as how this information can be used in social

exchanges. Krystal (1987. 1988) stated that this scheme associates developmental stages

26

with l ) differentiation of affect; 2) one‘s ability to identify and express emotions; 3) level
of complexity of the mental representation of self and objects; 4) the use of emotion as
data on internal and external experiences; 5) degrees of differentiation between self-
reprcsentation and object-representation; and 6) the capacity for empathy. He noted that
their system provides a structure upon which clinical observations may be discussed in
cognitive-affective terms.

Frosch (1995) presented a similar but less complex framework for discussing
affect development. His preconceptual stage includes affects experienced as bodily
sensations. perceptual stimuli. and impulses to engage in action. without access to affect
in symbolic representation. Frosch stated that typical affect development enables a move
from the sensorimotor level to a more abstract logical stage in which the individual
experiences affect in a differentiated and symbolic manner that can be considered and
expressed verbally. These two stages represent qualitatively different ways of regulating
affect. namely sensation/action versus abstraction/verbalization.

Affect Regulation & Dysregulation

The word “emotion” is derived from the Latin verb emovere. which means to
“move out‘. Similarly. Tomkins (1984) stated that affects are primary factors in
motivation. amplifying drives. needs. thoughts and behavior. A major task for
individuals is the management and regulation of these “moving” affects. Affect
regulation is defined as what we do to influence the emotions we have and how these
emotions are experienced and expressed (Kopp. 1987; Krystal. 1988; Schore. 1994; Gross
& Munoz. 1995). It is a process that involves reciprocal interactions between

physiological. behavioral-expressive. and cognitive-experiential realms of affect response

27

processes. Affect regulation is an integral aspect of self-regulation - the ability to
organize and manage aspects of one‘s own physiological and psychological processes to
promote independent functioning within personal and social realms.

When the degree of affect becomes excessive and unregulated. it can adversely
influence mental and physical health and function. Dysregulated emotions become out of
sync from one‘s self-organizing reciprocal feedback loop and may alter biopsychosocial
systems at random. This concept involves an almost indivisible connection between
affects and their contribution to the cognitive processing of them as the valid data of
one‘s personal experience
Affective Regulation: Origins in Attachment

Developmental research findings indicate that the early relationship between
infant and caregiver plays an integral role in the development of cognitive abilities for
affect- and self— regulation (Stern. 1984. 1985; Emde. 1988a. 1988b; Edgcumbe. 1984;
Beebe & Lachmann. I988; Furman. I992; Osofsky. 1992; Goldberg. MacKay-Soroka. &
Rochester. 1994). It is the synchrony and attunement to an infant’s emotional expression
that guides the caregiver to respond with facial/gestural expressions that help organize
and regulate the emotional life of the infant (Stern. 1984; Emde. 1988a. 1988b). Early
on. the parent reads and regulates the infant’s emotional cues by providing an external
“container” in service of the infant. The parent cognitively holds. processes and
transforms the infant’s undifferentiated sensations and affects into meaningful. reassuring
affective experiences that can be given back to the infant. This function is the beginning

of the teaching of affect tolerance (Krystal. 1988).

28

The development of language skills significantly impacts the child’s developing
emotional awareness and capacity for affect regulation. since they can begin to be taught
names and meanings for their somatic affective sensations and experiences (Edgcumbe.
1984). Stern (1985) stated that language. along with the process of labeling and
validating. permits the verbalization of affect and the growing awareness of the
complexities of emotions. Furman (1992) added that when children and parents discuss
feelings. they experience the beginnings of empathy. and it encourages them to seek
assistance in soothing their distress. Kopp (1989) noted that children can state their
feelings to others. get information about the appropriateness of their emotional displays.
and develop coping skills to regulate emotional expression.

The developmental research of Kopp (1989). Stern (1985). and Bretherton. Fritz.
Zahn-Waxler. and Ridgeway. (1986) supports the idea that the ability to form verbal
representations helps the child organize and integrate affective experiences. reflect on his
feelings. and plan affect-regulating strategies. Labeling emotions provides a sense of
control in handling emotions. rather than feeling overwhelmed and reliant on others to
help contain and process the emotions. Krystal (1988) added that, in developing affect
tolerance. the child learns to identify emotions as signals that can be evaluated and used
to act in a way to eliminate or change stressful situations. He suggested that developing
the capacity to represent the idea of an affect and other subjective experiences. as well as
developing an awareness of how one feels and others feel. suggests that the child has
acquired an understanding of the concept of mind.

Goldberg. MacKay-Soroka. & Rochester’s ( l 994) research on attachment and

affect has supported that the sensitivity and responsiveness of the parent to a child‘s

29

emotional experience is a critical influence on the way a child learns to regulate
distressing emotions and to form relationships with others. They found that children who
form secure attachments have learned that regulated emotional expression leads to
positive results. These children. as compared to insecurely attached children. tended to
maintain higher levels of symbolic play. exhibited more positive affect. and showed
greater competence in their relationships with others. Research by Main (1991) revealed
that deficient responsiveness may result in insecure attachment behavior. compromised
affect regulation skills. and poor behavioral control.
Affective Regulation: Symbolic Representjaflon

Most infants will attempt to engage in some independent self-soothing behavior.
These behaviors typically take the form of thumb/finger sucking. body rocking. playing
with caregiver’s clothing etc... or rhythmic sounds. These behaviors also may serve as a
precursor for development of transitional objects and phenomena (Winnicott. 195 3;
Gaddini. 1978; Tustin. 1981). Winnicott (1953) described transitional object as the
infant’s first creation - an attempt to independently self-soothe. The object. often a soft
toy or blanket. is sought out in times of distress and/or separation from the mother. The
behavior. typically surfacing around 4-6 months of age. functions as a means of affect
regulation and a way to preserve union with the soothing qualities of the mother. Over
time. the object takes on these characteristics. becomes a symbol of the mother and
bridges the space and tension created by her periodic absences. Similarly. transitional
phenomenon include babbling. engaging in ‘sing-song’ talk. and later developing

imaginary friends. are also used to reduce tension and regulate distress.

30

Mayes & Cohen (1992) stated that the connection between the child and an
attuned. empathic caretaker is necessary for the development of imagination and
creativity. This symbolic play activity helps the child form a mental picture of the
caretaker in her absence. which takes on the some of the affect regulating and cognitive
processing skills of the mother. The development of imagination. usually through play. is
a resource that aids the child in organizing complex experiences into manageable forms.
Play also wards off overwhelming emotions and promotes opportunities for positive
emotions. Izard & Kobak (1991) see play as essential developmental work whereby
feeling. thinking and acting can be organized

Dreams. imagination and creative stories also serve as a vehicle for regulation of
affect. as well as opportunities for displacement and storage of affect-laden events into
long-term memory (Taylor. 1987). Typically. transitional objects and phenomena are
replaced by progressively more symbolic representations and activities as means of
tension reduction and self-regulation. Although the development of interest sometimes
reflect innate skill and predisposition. the activities secondarily serve affect-regulating
functions for which the primary caregiver was once solely responsible. Development of
imagination and activities which stimulate positive affects such as interest and joy tend to
lead to broadening of experiences and strengthening of relationships. which further
influence affect regulating functions (Izard & Kobak. 1991). Individuals with narrow
imagination. limited play. few interests. and superficial relationships may rely on less

effective means for temporary regulation of affect. such as excessive eating.

31

Affect Regulation: Neurobiological Findings

The empirical research findings on the neurobiologic processing of emotion highlight the
interdependence of brain function systems. Affect processing and regulation depends on
the interrelation of subcortical and cortical systems. the interdependence of both the left
and right cerebral hemispheres. and the converging actions of different neurotransmitters
(Derryberry & Tucker. 1992; Ciompi. 1991; Schwartz. 1987; Cicchetti & Tucker. 1994).

MacLean (1949) wrote of the ‘triune brain’, involving the interactive functions of

n I .‘A. M u.‘-_.'
> ' n

the brainstem and hypothalamus (regulates autonomic and endocrine bases of emotional

processes). the limbic system or ‘visceral brain’ (interprets experience in terms of I
emotional states and visceral manifestations). and the neocortex or ‘word brain’

(cognitive processing/symbolic representation of emotion into feeling states that can be

reflected upon. expressed and modulated).

Findings from empirical research on the neurobiology of alexithymia has
supported the idea that alexithymia is associated with some kind of variability in brain
organization. Researchers have found that alexithymia is associated with right
hemisphere dysfunction (Parker, Taylor. & Bagby. 1992; Weintraub & Mesulam. 1983):
over—activation of the left hemisphere and inhibition of the right hemisphere (Berenbaum
& Prince. 1994). and interhemispheric transfer deficits (Hoppe. 1977; Zeitlin.
Lane,O’Leary. & Schrift. 1989). It is clear that both the left and right hemispheres play
their own unique and complementary roles in the processing of emotion. cognition. and
symbolic representation of emotion. However. results from these studies have been
equivocal and the exact nature of the neurobiologic function and/or dysfunction

underlying alexithymia is not yet clear.

32

Aleximymia: "Without Words for Emotion"

Alexithymig Construct

Krystal (1988) stated that “the assumption that other people’s emotional responses
are similar to ours is the basis of empathy and is basic to human interaction.”
Nevertheless. he stated that the uncritical acceptance of this assumption has led to the
“false belief that all patients have available to them the affective functions necessary for
the utilization of psychotherapy.” Psychotherapists and psychoanalysts reported that
particular patients. especially those with psychosomatic presentations. were difficult to
treat with insight-oriented psychotherapy (Sifneos & Nemiah. 1970; Bruch, 1961 .
Waysfield et al. 1977; Taylor. 1995). Many observed that the patients experienced
difficulty identifying and communicating feelings. presented a paucity of imagination and
fantasy. report few dreams. and displayed an extemally-oriented style of thinking
(Homey. 1952. Bruch. 1962). Such characteristics have also been observed with patients
presenting a variety of psychiatric disorders. notably post-traumatic stress and substance
abuse disorders (Krystal 1962. 1968. 1971; Krystal & Raskin. 1970). eating disorders
(Bruch. 1982. 1983), and somatization disorders (Nemiah. 1984).

Focusing on the cognitive disturbances of such patients. such as the reduced
fantasy life. externally oriented style. and operational thinking of these patients. the term
“pensee operatoire” was offered by Marty & de M’Uzan (1963). The term “pensee
operatoire”. emerging from work with psychosomatic individuals. described a similar
concrete style of restricted. stereotyped relating. and operational thinking which reflected
deficits in symbolic function as well as fantasy production. Sifneos (1973) coined the

term “alexithymia”. which derived from the Greek roots a = lack. lexis = word. thymos =

33

emotion. with particular focus on the impairments in identifying and verbalizing feelings.
Krystal (1988) noted the importance of related problems of impairment in the capacity for
self-care and anhedonia. The cluster of the cognitive and affective characteristics
described by Sifneos and Marty & de M’Uzan were more precisely defined and integrated
into the personality construct of “alexithymia” as we know it today. It is of note that.
alexithymia is not a disorder, per se. but characterizes a personality style that overlaps
various diagnostic categories.

Alexithymia Affective Components

Krystal (1988) provided a focus on the disturbances in affect as they related to the
alexithymia construct. He stated that such individuals’ impaired ability to “utilize
emotions as signals to themselves is based in the form that their emotional responses
take.” Their responses emerge from the physiological. “expressive”. aspects of affect and
are basically somatic in nature with limited verbalization. Their emotions tend to be
undifferentiated. vague. and nonspecific. “as if they represented an undifferentiated form
of common affect precursors.” Thus. differentiation among the physiological and
psychological aspects. as well as separation of feelings per se. does not appear.

The undifferentiated affective experience and minimization of affective
verbalization leaves such individuals experiencing somaticized and distressing reactions
rather than more “complete” experience and expression of emotions. He noted that only
when one can experience the cognitive aspects of emotions (i.e.. its meaning and source).
and can concurrently have both the expressive reaction and an adequate capacity for
introspection. is one free to experience and identify a “feeling”. Alexithymics have

difficulty differentiating between physiological and psychological experiences. and

34

although they are aware of generalized distress and may comment on vague physiological
aspects of affective experience. they do not recognize or identify particular emotions or
states. The inability for reflective self-awareness. which allows one to identify feelings as
being an appropriate response to self-evaluation. is typical of alexithymia. What can
emerge. through observation of others or what they think they should experience. is use of
common expressions denoting affect but absent of a concomitant introspection and self-
awareness with conviction and life that enhances their view of themselves.

Flannery (1978) noted that some individuals seem to experience distressing
affects in somatic manner. often as illness. He noted the problems in diagnostics and
treatment of such persons in medical settings. Similarly. he discussed that those with
chronic pain syndromes often display alexithymic characteristics. With such individuals.
and other psychosomatic illnesses, there is a common theme of presenting with emotions
that are undifferentiated and nonverbalized. When such individuals are invited to explore
feelings and when they do produce “affect” words (e.g. sad). they tend to have a loss of
appropriate language to convey the experience further. Thus. emotions are not
experiences as distinct. separate. identifiable responses. but rather generalized states of
tension and discomfort (Nemiah. Freyberger. & Sifneos, 1976). They also tend to be
unable to identify common autonomic somatic sensations that accompany the experience
of particular feelings. and if able to identify as somatic component it is identical with
symptoms of their presenting illness.

McDougall (1974. 1982) discussed that many patients displaying psychosomatic
illnesses tend to exhibit deficits in proprioception. and seem faithful to their tendency to

ignore physiological and psychological distress signals from the body. She also

35

 

described the concomitant rigidity in facial expression and body posture. Taylor (1991.
1995) stated that the alexithymic. prone to addictive behavior (e. g. substances. food). may
show heightened focus on affective sensations that are distressing and present a driven
need to block them. McDougall related this to the overabundance of sensory perceptions
in place of introspection and self-awareness. Wurmser (1978) commented on the
importance of such substitution of sensory preoccupation as being related to the
insistence on the concrete and tendencies toward extemalization. which is common in
addictive personalities.

Given the lack of self-reflective behavior and absence of identification of specific
feelings. alexithymic persons may be subject to a building up of affective components to
an intolerable intensity. where sudden outbursts of affect can occur. Nemiah et a1 (1976)
noted that such outbursts do not appear to aid in the awareness of the feeling. and
individuals may see it as attributable to distressing somatic symptoms or external
intrusions upon the body.

Alexithymia: Cognitive Component

The countertransference of many psychotherapists to alexithymic clients is one of
feeling bored and drained. which reflects that such individuals present a style that tends to
be dull and utilitarian with an emphasis on extemally-oriented concrete details and facts
(de M’Uzan, I974; Nemiah. 1970; Taylor. 1984. 1995). Marty and de M’Uzan’s (1963)
classic study on “pensee operatoire” noted that diminished symbolizing capacity is
associated with unimaginative. factual expressions. They also remarked on an affective
flatness that characterized speech. Nemiah & Sifneos (1970) described the alexithymic’s

relating of mundane facts in the place of wish-fulfillment fantasy. Krystal (1979) added

36

that. although dull and monotonous communication is common. he also found hysterical
and verbose expressions that were similarly vague about the individual’s wishes and
needs. He noted that a severe impoverishment of imagination and difficulty using dreams
were characteristic of both presentations. Several clinicians have commented on the lack
of introspection and awareness. precluding revelation of inner attitudes. feelings. or
wishes that usually animates speech (Nemiah & Sifneos. 1970; de M’Uzan. 1974. Taylor
et al. 1984. 1992. 1995; Krystal. 1988).

Nemiah (1975) noted the tendency toward a utilitarian way of relating to others.
McDougall (1974. 1982 a.b) stated that “their love objects are interchangeable, the central
demand being that someone must be there”. De M’Uzan (1974) spoke to the
alexithymic’s perception of herself and others as being stripped of personal. human
qualities. which leads to the operative and concrete thinking. Taylor (1984. 1992, 1995)
indicated that their communication style is marked by a reduced ability to form symbolic
representations. so that inner attitudes. feelings. wishes. and drives are not revealed.

Krystal (1979. 1982. 1988) remarked on the impairment in the capacity for fantasy
and association. with few dreams and difficulty utilizing dreams. He noted the need for
fantasy and symbolization to permit creativity and neurotic formulations. This absence of
symbolic formation regarding conflicts makes it difficult to deal with the cognitive
aspects of affects. thus permitting verbalization and communication. Such individuals are
left with only awareness of generalized physiological states. and are prone to
communication through psychosomatic syndromes. The discomfort and tensions can be
overwhelming. and the need to block physiological, affective tension is seen in the

compulsive use of substances such as alcohol. drugs. food due to impairments in

37

C L". hm;

symbolization and internalization of self-regulating functions which were limited to the
external and omnipotent object representation. McDougall (1982) noted that an
alexithymic style is characterized by “elimination of mental representations of their own
parts and parts of their object representations.” The outcome is a stereotyped existence
with an over-adaptation to reality. and imagination, fantasy. and feeling has been
eliminated. McDougall (1974) saw the cognitive deficits as the failure to form essential
self- and object-representations and functions. with a lack of symbolic structures with
which representation of feelings and fantasy is possible.

Segal (1957) stated that the early symbols for objects are not experienced as

“Hf : .n‘utn

symbolic or representative. but stand for the object itself. and she termed this “symbolic
equations”. She stated that the symbolic equation between the original object and the
symbol in the external and internal world is the basis of concrete thinking where
substitutes for original objects can be used freely and are not experienced as significantly
different from the object itself. The symbol and the object are treated as though they are
identical and possess similar functions. Thus. the differentiation between the self and the
object are obscured. She noted that when advanced symbolic capacities are absent.
symbolic equivalents that involve use of the symbol as the actual object itself. renders the
individual dependent on external objects. This is observed in addictive behaviors.
AlexithymiL and C ompulsive/Addictive thgvior

Krystal (1988) explained that the dynamic process underlying addiction is an
inability to assume responsibility for soothing oneself. Relief for the alexithymic often
comes from the use of some external agent and/or repetitive act. The objective of

blocking distress reactions can be accomplished temporarily by the use of substances such

38

as drugs. food. and compulsive behaviors. When in distress. alexithymics feel
overwhelmed. tense and helpless because they are not “free” to relieve their own distress.
Alexithymics live as though some “external agent” must provide the “mothering” task of
reducing distress. This process parallels that of a mother who must “read” the
communications of her infant and take the appropriate actions to relieve the infant’s
distress. Krystal (1988) stated that their self-presentation tends to seem immature and
that the assumption of responsibility for self-soothing functions appears “dangerous” to

them. He stated that. with such a presentation. distress can only be signaled - verbalizing. I

 

 

considering. and resolving the needs are reserved for the mother (Krystal. 1988).

The verbalization of affect allows one to communicate distress on one’s own.
Krystal (1988) stated that alexithymics are unable to consciously assume responsibility
for organizing and composing their thoughts. and depend on a chronological or thing-
oriented scheme for their thoughts. He noted. “inhibition of self-caring tasks interferes
with the adult potential to use and organize images. memories. and ideas and express
them in adult language” (Krystal. 1988). Krystal (1979:1988) noted that if alexithymics
make an effort to verbalize and clarify feelings. they may make sense of the dull.
mundane “ babbling”. Krystal understands their monotonous. fact-based speech as their
way of pretending that time itself will organize their thoughts for them if they continue
the act of talking. He noted that any therapist must maintain a balance between
verbalizing feelings and ideas in a way that is meaningful and erring in the way of
informing the person about what they should think or feel (Krystal. 1988).

McDougall (1978) stated that their speech represents is an “act” rather than a

symbolic means of communication of ideas or affect. The act is an effort to induce

39

feeling in the analysts so that the analyst will “act” in their behalf. McDougall (1982)
stated that the objective is to make sure the analyst understands and relieves the distress
that they signal. She described this process as primitive communication. suggestive of
early psychic trauma that requires special intervention. She stated that alexithymic
patients have difficulty observing and verbalizing their own mental processes. Such
communications. permeated with messages not yet verbalized. are made known through
countertransference affect. On a similar note. Taylor (1984) highlighted the alexithymic’s
use of projective identification that. like the barrier that prevents the alexithymia from
introspection. “serves to create massive barriers between their own inner world and the
therapist-listener”(Taylor. 1984).
Dgnessiogafll Alexithymia
Some clinicians and researchers have suggested alexithymia and depression may not be
distinct. independent constructs. This criticism largely comes from empirical research
finding moderate correlations between measures of alexithymia and the Beck Depression
Inventory (BDI; Beck & Steer. 1983). a structured. self-report measure of depression
(Haviland. Shaw. Mac Murray. & Cummings. 1988; Hendryx, Haviland. & Shaw. 1991).
In an effort to empirically examine the relationship between alexithymia and
depression. Parker, Bagby. & Taylor (1991) conducted factor analyses using the items
from the TAS and the BDI. In both undergraduate and psychiatric outpatient samples. a
four factor solution was produced. with no overlap between BDI items (Factor I) and
TAS items (Factors 2. 3. 4). The factors corresponded closely with each particular
construct. Factor 1 was comprised of BDl items suggesting depression; Factor 2.

represented by TAS items assessing difficulty discriminating feelings from bodily

40

sensation and ability to communicate feeling states; Factor 3. was made up of TAS items
suggesting imagination capabilities; and Factor 4 was comprised of TAS items assessing
an extemally-oriented thinking style. There was a weak but significant correlation ([ =
.22. p < 0 .01) between the BDI and TAS Factor 2 (discriminating and communicating
feelings) for both the undergraduate and psychiatric samples. There was also a weak
negative correlation between the BDI and Factor 3 (imaginal capacities) correlation ([ = -
.10, p < 0.05). Thus. while there seems to be a relationship between depression and
alexithymia, they appear to be distinct constructs that can be measured independently.

Longitudinal studies with substance abusers (Keller, Carroll, Nich. & Rounsaville.
I995; Pinard. Negrete. Annable. & Audet. 1996), psychiatric outpatients (Salminen.
Saarijarvi. Aairela. & Tarnminen (1994) and inflammatory bowel patients (Porcelli,
Leoci. Guerra. Taylor. & Bagby, 1996) revealed that alexithymia scores remain stable
after depression and general distress has diminished.
Measurement of Alexithymia: Empirical Data

The failure to develop reliable and valid measures has been a fundamental
obstacle to the development and elaboration of the alexithymia construct. Confusion
tends to lie in the broad definitions of deficits in affective and cognitive function. Several
authors have described various problems with the measurement of alexithymia (J.
Krystal. 1988; Taylor et al, 1984. 1986, 1993,1996).

A variety of measures have been developed over the years and can be divided into
three main categories: interviewer-based, projective, and self-report. Each presents some
problematic issues for consideration (Borenstein & O’Neill, 1993; J. Krystal. I988.

Interviewer-based measures, the most well-known being the Beth Israel Psychosomatic

4r

Questionnaire (BIPQ; Sifneos, 1973; Apfel & Sifneos, 1979), have presented
methodological problems such as difficulty with the administration and scoring
procedure. susceptibility to interviewer bias, variable effects of the interview setting and
experimenter skill. and unacceptable inter-rater reliability (Sneider. 1977; Taylor, 1981).
Projective measures used have been based on existing projective tests (Rorschach and
TAT ) as well as those constructed for the purpose of assessing alexithymia (SAT-9;
Cohen & Demers-Desroisiers, 1984). Most obvious concerns stem from the required
prior training in the projective theory. administration and scoring (J. Krystal, 1988;
Cohen, 1992). Although particular projective measures have been noted by several
authors as promising (Taylor, 1993), reliability and validity information for use in
different populations is needed. Self-report methods. such as the Toronto Alexithymia
Scale (TAS; Taylor. Ryan. & Bagby. 1985), tend to address the problems with
interviewer-based and projective methods. They are easy to administer and score, and
relatively free of examiner bias effects. Nevertheless, construct validity issues have been
noted. and research on reliability and validity is warranted.

An important issue that has been problematic in the assessment of alexithymia is
that several measures have only successfully measured particular aspects of the
alexithymia construct. For example, the TAS has been most useful in assessing self-
report of the ability to identify and express emotion, whereas the AT-9 has been quite
promising as a tool with particular focus on assessing symbolic functioning. To date, the
Rorschach indices advanced by Acklin et al (1988) appear to be the most promising efl’ort

at the global assessment of the alexithymia construct (Taylor, 1996). Nevertheless.

42

assessment of alexithymia in various populations and utilization of control groups is
needed (J. Krystal, 1986. 1988. Taylor. 1994).
In his review on the assessment of alexithymia, J. Krystal (1988) noted several
important issues that should be considered when conducting further research on the
assessment of alexithymia. One of the overriding concerns is that the objective
assessment of alexithymia is in its youth. However, he stated that the construct “rings 5.-

true” to many clinicians, and may help to clarify the obstacles to effective intervention for

.n.-.. -.._.. ._ -__
.~ ..
In...

several populations. historically those with psychosomatic traits. He stated that, while

much of the literature has treated alexithymia as a dichotomous variable. the research

if.‘ “. .A.‘
2

actually provides more support for its consideration as a continuous variable (Kleiger &
Kinsman, 1980; Martin, et al. 1984; Taylor, 1992). Thus, he noted that documenting the
percentage of alexithymic patients is not useful. and that using means and standard
deviations to reflect base comparisons on the actual data is more appropriate. He also
indicated that dichotomizing patients as alexithymic or non-alexithymic should be
considered arbitrary, and that it may be sufficient to identify those that are at risk so that

attention may be drawn to the potential need to modify psychotherapeutic interventions.

Alexithymic Disturbances in Eating Disorders
Alexitlymija& Disordered Eating
There have been a number of studies assessing alexithymia in eating disordered
populations, with more investigations with anorexic and bulimic populations than with
the obese or compulsive eaters. Based on clinical work, Bruch (1962, 1973) and

Stunkard (1975) observed that women with eating disorders had difficulty discriminating

43

between bodily sensations and the inner qualities of emotions. a capacity Bruch labeled as
“interoceptive awareness”. Both authors noted that obese individuals experienced their
emotional state in a relatively undifferentiated way that subsequently led to overeating to
relieve unpleasant and generalized emotional tension or anxiety. Additionally, Wolff
(1977) and Goodsitt (1983) observed that anorexics and bulimics both tend to display
high rates of alexithymic characteristics. with a specific inability to differentiate among
specific emotional states. Results of formal testing tended to relate to the particular
aspects of the alexithymia construct that were assessed and the various measures that
were employed.

Toronto Alexithymia Scale (TAS)

The vast majority of studies assessing alexithymia with eating disordered
populations have utilized the Toronto Alexithymia Scale (TAS). The original TAS
(Bagby, Ryan, & Taylor, 1985) attempted to assess all four aspects of the alexithymia
construct: 1) identification of feelings, 2) verbalization/description of feelings, 3) fantasy
life, and 4) extemally-oriented thinking. The TAS has had two subsequent major
revisions. which resulted in the TAS-R (Taylor, Bagby, and Parker, 1992), TAS-26 and
the TAS-20 (Bagby, Taylor, and Parker, 1994). It is notable that on the most recent
version. the TAS-20, the two factors regarding emotion have been shown to be most
stable (Haviland & Reese, 1996). The factor assessing fantasy, included on the TAS and
used in many of the studies, has been dropped from the TAS-20 due to lack of correlation
with the global TAS score and high correlation with measures of social desirability.
Thus, it does not appear that alexithymia, as defined by impairment in fantasy and

symbolic representation. has been adequately assessed by the TAS in these studies.

44

F urthemtore. assessment of extemalized-thinking may not be as stable as those for
emotional awareness, as reflected by the factor breaking into two separate. unrelated
factors for a drug-dependent sample (Haviland & Reise, 1996).

Other studies using the TAS found higher TAS alexithymia scores for eating
disordered groups than non-eating disordered controls (Bourke Taylor. Parker & Bagby
1992, Walton et al. 1992, Schmidt et al 1993, Cochrane et al 1993). There has been no
relationship found between global TAS scores and binge eating frequency, duration of
illness. amount of weight loss. and BMI (Bourke et al. 1992; Garrow & Webster, 1985;
Schmidt et al. 1993; Cochrane et al, 1993; Jimmerson et al , 1994). Regarding level of
depression. Schmidt et al (1992) found no relationship with TAS scores, but Cochrane et
al (1993) found a positive relationship between those variables. Taylor et al (1985) stated
that while depression and alexithymia were related, they were clearly different constructs.

Schmidt, Jiwany and Treasure (1993) conducted a controlled study of alexithymia
in female patients referred to a hospital-based eating disorders clinic (n-l73) who met
DSM-IIl-R criteria for bulimia nervosa (BN) (n = 93), anorexia nervosa/ restrictor type
(AN/R) (n = 55), and anorexia nervosa/ bulimic type (AN/BN) (n = 25). In the first part
of the study, the mean TAS scores of the three eating disordered groups were compared to
one another. as well as to those of a control group (n = 95) of undergraduate students
(females = 48, males = 47). The AN/R group (M = 76.5; SD = 12.8) produced a
significantly higher mean TAS score than the BN (M = 72.4; SD = 10.9) and AN/BN (M
= 74.2: SD = 13.1) groups. All three eating disordered groups produced significantly
higher alexithymia scores than the female (M = 66.8. SD = 9.3) and male (M = 63.6, SD

= 11.2) control groups. For 56% of the AN/R group. 48% of the AN/BN group. and 50%

45

of the BN group, alexithymia was identified using the recommended pre-established TAS
cut-off point (_>_ 74) (Taylor et al. 1990; Bagby et al. 1990) for alexithymia. compared to
27% of the female controls and 9% of the male controls. TAS scores were not correlated
with Body Mass Index (BMI) for eating disordered groups.

In the second part of the study, Schmidt et al (1993) investigated whether
alexithymia is a personality trait common in bulimia or if it is a state-dependent effect of
bulimia. The study also investigated whether alexithymia predicts short-term outcome in
bulimia. Bulimic patients (n = 41) were administered the TAS, Hamilton Depression
Scale (HAM-D; Hamilton, 1967). and measures assessing bulimic symptoms, body shape
concerns, and symptom frequency before and after 10-week treatment with antidepressant
therapy (2 week single- blind placebo trial followed by an 8 week double-blind placebo-
controlled fluvoxamine trial). Researchers found significant improvement in eating
pathology (binge / purge frequency), but no significant change in mean TAS or HAM-D
scores from baseline to week 10. This finding suggests that alexithymia does not vary
with clinical improvement. However. for those who had not fully recovered by the end of
treatment, it could be stated that alexithymia may be associated with persistent symptoms.
At treatment end, 73% of patients who scored as alexithymic at baseline (TAS 3 74) were
still alexithymic at week 10, and 87.5% of the patients who were not alexithymic at the
outset remained in this category at week 10.

Schmidt et al (1993) did find a highly significant positive correlation between
TAS scores at week 1 and 10. although baseline TAS scores did not correlate with any
other variables. Assessed eating pathology at week 10 was positively correlated with

HAM-D depression scores. and the TAS score at week 10 was positively correlated with

46

binge frequency at week 10. Contrary to previous suggestion/report ofan association
between alexithymia and depression, TAS scores did not correlate with HAM-D scores at
the beginning nor the end of treatment. Interestingly. the researchers noted that
alexithymic prevalence in their eating disorders sample was comparable, if not higher,
than that reportedly found in other psychiatric samples. such as substance abusers
(Taylor. Parker, & Bagby, 1990), psychiatric patients (Bagby. Taylor, Parker. & Loiselle.

1990; Parker. Bagby & Taylor, 1991), and psychosomatic patients (Rubino, 1991).

Cochrane, Brewerton, Wilson. and Hodges (1993) interviewed and administered
the TAS and the self-report measure Diagnostic Survey for Eating Disorders (DSED;
Johnson, 1985) to patients being evaluated for a university-based eating disorders
program. Patients met DSM-lll-R criteria for anorexia (n = 19), bulimia (n = 52), mixed
anorexia and bulimia (n = 18). and eating disorder NOS (obese and/or non-purging binge
eaters) (n = 25). They compared the performances from these four eating disordered
groups to published norms for female college students (n = 370) (Taylor, Ryan & Bagby,

1985).

C ochrane et al (1993) found no significant differences in mean TAS scores were
found among the eating disordered groups. but the scores of the total group of eating
disordered patients (M = 74.8, SD = 10.8) were significantly higher than that of the
comparison control group (M = 61.1, SD = 11.3). The majority of eating disordered
patients scored in the alexithymic range. with 63% of anorexics (M = 72.4, SD = 12.2).
56% of bulimics (M = 74.9, SD = 11.2), 61% of mixed anorexics-bulimics (M = 78.5; SD

= l 1.1). and 64% of the eating disorders NOS patients (M = 74.1, SD = 8.4) producing a

47

TAS score 3 74 (TAS cut-off score). Mean TAS scores were not significantly correlated
with age. body weight, or binge or purge frequency. Mean TAS scores were significantly
related to the DSED total score and DSED ratings of depression (rho = .50. p = < 0.01 ).
anxiety (rho = .29. p_ < 0.01), crying (rho = .38, p < 0.01), irritability (rho = .29, p < 0.01),
sleep difficulty (rho = .24. p < 0.05).

J immerson, Wolfe. Franko, Covino, and Sifneos (1994) administered the TAS,
and two other measures of alexithymia - the Beth Israel Hospital Psychosomatic
Questionnaire (BIQ; Sifneos. 1973) and the Revised Schalling Sifneos Scale (SSPS-R;
Apfel & Sifneos, 1979) to non-medicated female outpatients who met DSM-III-R criteria
for bulimia nervosa (n = 20) and to healthy females controls (n = 20). The bulimic group
produced a mean TAS score that was significantly higher than that of the control group,
with 40% of the bulimic sample scoring higher than the TAS cut-off score (_>_ 74). None
of the control group produced TAS scores above the cut-off score. Additionally, the
bulimic group produced higher mean scores than controls on both the BIQ and SSPS-R.
Although none of the participants met criteria for a major depressive disorder. the bulimic
group produced higher depression scores on the Beck Depression Inventory (BDI) and
Hamilton Rating Scale for Depression (HAM-D).

Laquatra and C lopton (1994) examined the relationship between alexithymia and
characteristics associated with disordered eating (anorexia, bulimia, and obesity) in a non-
clinical female undergraduate sample (n = 308). They administered the TAS and the
Eating Disorders Inventory (EDI; Garner, Olmstead, Polivy, 1982). Overall, TAS scores
and weight were not significantly correlated. A plot of the relationship between global

TAS and the weight index suggested that the relationship differed for those subjects who

48

were more than 10% overweight and more than 10% underweight. For those more than
10% overweight, the TAS subscale scores for difficulty identifying emotion was
positively correlated with weight (r = 28. p < 0.05). EDI subscale scores (except
Perfectionism) were all significantly correlated with TAS subscales for difficulty
identifying and difficulty expressing feelings (affective deficits), but not to TAS subscales
for lack of fantasy life and extemally-oriented thinking (cognitive deficits). They also
found that suicidal ideation frequency was positively correlated with TAS subscales for
difficulty identifying (r = 0.32, p < 0.01) and difficulty communicating emotions (_r =
0.29. p < 0.01), and negatively correlated with extemally- oriented thinking (I = -0.17, p <
0.01). Suicidal ideation frequency was also significantly correlated with EDI subscales
for Ineffectiveness. lnteroceptive Awareness and Interpersonal Distrust (r = 0.52. 0.38.
and 0.34. p < 0.01, respectively).

Laquatra and Clopton (1994) highlighted the finding that this sample had
difficulty identifying feelings, adding to past findings that eating disordered individuals
have difficulty expressing emotions (Kent & Klopton, 1990; Rybicki, Leppkowsky &
Amdt. 1989). They attempted to explain the finding that disordered eating was related to
the affective deficits, as opposed to the cognitive deficits, of alexithymia. Similar to
implications made Morrison and Pihl (1989). these researchers suggested that the
affective deficits are the primary feature of alexithymia and that individuals develop other
difficulties (e.g.. extemally-oriented thinking) as they attempt to cope with their affective
deficits. Making analogy to the qualitative differences associated with severity levels in
depression. Laquatra and Clopton (1994) suggested that milder forms of alexithymia

(nonclinical samples) may reveal only affective deficits. but more severe forms may

49

include both affective and cognitive deficits. The nonclinical college sample used may
not have included the severity of alexithymia or disordered eating necessary to produce a
significant relationship between disordered eating and cognitive deficits of alexithymia.
The researchers did note that even women with subclinical eating and affective
difficulties may be at some risk for distress and suicidal ideation.

de Groot, Rodin. and Olmstead (1995) conducted a longitudinal study to evaluate
the relationship among alexithymia, depression. and somatic symptoms in a bulimic
sample (n = 31) and a comparison control group (n = 20) following treatment at a
hospital-based eating disorder unit. The researchers wanted to investigate whether
intensive group psychotherapy contributes to a decrease in alexithymia. The bulimia
group was significantly more depressed and more alexithymic (69% has TAS scores 3 74
cut-off) than the control group (5% had scores 3 74).

de Zwaan, Bach, Mitchell, Ackard. Specker. Pyle and Pakesch (1995) investigated
whether obese patients with binge eating disorder have higher rates of alexithymia than
obese patients who do not binge eat. The sample consisted of obese females (11 = 182)
who were entering a treatment study at a university based eating disorders program that
involved a 26-week supplemented diet plus group psychotherapy. Participants had no
significant health problems, no history of substance abuse, no history of schizophrenia or
bipolar disorder. and were not taking psychotropic medication at the time of the study.
Participants were categorized as having Binge Eating Disorder (BED) (n = 83) or non-
BED ( n = 99) according to DSM—IV criteria.

de Zwaan et al (1995) administered to participants the Hamilton Depression and

Anxiety Scales (HAM-D, HAM—A; Hamilton, 1959, 1960), and the Beck Depression

50

Inventory (BDI; Beck. Ward. Mendelson. Mock, & Erbaugh, 1961) to assess mood
symptoms. Mean scores on HAM-D and HAM-A did not differ between the BED and
non-BED groups and generally fell within normal limits. The BED group did have a
significantly higher mean BDI score than the non-BED group, but the mean score for the
BED group reflected only mild depression. Participants were administered the Binge
Eating Scale (BES: Gormally et al 1982) which assesses binge eating severity specifically
designed for use with obese subjects. the Eating Disorder Inventory (EDI; Gamer.
Olmstead, Polivy, 1982) which measures eating-related and general psychological
characteristics judged to be of significance with eating disordered populations, the Three
Factor Eating Questionnaire (TFEQ; Stunkard & Messik, 1985) which assesses cognitive
restraint. eating disinhibition, and hunger susceptibility, and the Control/Impulsivity
subscale of the Multidimentional Personality Questionnaire (MPQ, Tellegen, 1982). The
BED group produced significantly higher mean scores than the non-BED group on the
BES, EDI, TFEQ. and Control/lmpulsivity scale. Mean scores were not significantly
different on EDI Maturity Fears and Interpersonal Distrust scales or the TFEQ Cognitive
Restraint scale.

de Zwaan et al (1995) administered the 26-item Toronto Alexithymia Scale (TAS-
26. Taylor, Ryan & Bagby, 1985) to participants. Considering alexithymia as a
categorical personality variable, 17% of subjects had TAS scores of 74 or higher, which is
comparable to rates found in nonpatient control groups (Parker, Taylor & Bagby, 1989)
but significantly lower than other eating disordered groups studied (Bourke et al. 1992;
Cochrane et al. 1993; Schmidt et al. 1993). They did find a higher prevalence of

alexithymia in the BED group (24%) compared to the non-BED(11%) group. but the

51

difference was not significant after correcting for multiple comparisons. No significant
difference was found between mean TAS scores for BED (M = 63.8, SD = l 1.5) and non-
BED ( M = 61.9. SD = 8.9) groups. They did find that high scores on EDI subscales of
Interpersonal Distrust and Ineffectiveness. and low educational level, were independent
predictors of global TAS scores and together explained 27% of the variance. The BMI,
depression. and eating pathology were not significant predictors of TAS scores.

de Zwaan et al (1995) qualified the low level of alexithymia found in their total
sample. compared with normal sample, by stating that the pre-selection included women
paying for treatment which involved group psychotherapy. They suggested that the
sample may have been a more psychologically-minded group than other obese and/or
binge eating individuals in the general population. Furthermore, they added that their
sample was highly educated. with more than half possessing a college degree.

Morosin and Riva (1997) investigated the presence of alexithymia in an obese,
non-bingeing eating sample (n = 165) from an inpatient eating disorders clinic compared
with a normal-weight female control sample (n = 135). Participants were administered
the TAS-20. Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Anxiety Scale
Questionnaire. and the Eating Attitudes Test (EAT). Alexithymia was not characteristic
of the obese sample, as they had mean TAS-20 global and subscale scores below the
established cut-off (3 61) and did not differ significantly from the control group. Only a
subgroup of the obese sample presenting psychopathological traits displayed significantly
higher rates of alexithymia, with a mean TAS-20 score (M = 63.4, SD 13.6) above the
cut-off.

Thematic Apperception Test (TAT)

52

Taylor and Doody (1985) obtained monadic speech samples from neurotic and
psychosomatic patients using responses to selected TAT cards. They found the latter
group to be less verbally productive (total words) and produced a more limited emotional
vocabulary ([unambiguous] affect vocabulary score: AVS) than the former group. The
investigators suggested that the AVS correlated with total word count and number of
human movement responses (M) on the Rorschach, which they stated reflected
fantasizing ability. Given that the samples were collected from a monadic situation, the
investigators reported more support for a trait, rather than state concept of alexithymia, as
past studies found differences between the same groups only when an interactional or
dyadic situation was used (Lolas & von Rad. 1981). Taylor, Doody. and Newman (1981)
found that in using the TAT, inflammatory bowl patients uttered less affect words and
less total words than a neurotic sample. Defoumay, Hubin, Luminet (1977) also
investigated alexithymia by examining total word production to TAT cards and found
diminished production in a coronary-prone Type A sample group. There were no
investigations available that examined the relationship between obesity and affect word
production using the TAT.

Gray (2001) further examined the presence of affective and cognitive deficits
using the TAT (with a battery of other measures) in an sample (n = 61) of outpatients and
inpatients classified into eating disorder (ED). borderline personality disorder (BPD). and
mixed ED / BPD groups and a sample of non-patients controls (n = 10). To assess
alexithymic characteristics. TAT narratives were coded for amount and quality of verbal
expression across the four dimensions of the alexithymia construct. She found that eating

disordered patients were less likely than non-patients to refer to their own affective

53

experiences on the TAT. but did not present narratives that reflected reduced
fantasy/imagination or a concrete/extemalized style.
Archetypal Test with Nine Elements (AT-9 and SAT-9)

The AT-9 is a grapho-projective test used to measure symbolic function. a central
aspect of the alexithymia construct. was created by Durand (1967) and introduced into the
alexithymia literature by Demers-Desroisiers (1982). Cohen, Demers-Desroisiers. and
C atchlove (1983) developed a quantitative scoring system (SAT-9) which resulted in
highly acceptable inter-rater reliability. On the SAT-9, the participant is presented with 9
items and asked to integrate them into a drawing and provide a written explanation for the
drawing. Two of the nine items (fall. devouring monster) elicit anxiety, three items
resolve anxiety (sword, refuge. something cylindrical which turns/ progresses), one item
is the resolving agent (character), and three accessory items which reinforce the
constructed myth (water, fire. animal). The items become symbols when integrated into a
myth through a drawing, to which meaning is given with a written explanation. The
objective is the acknowledgment and resolution of the anxiety elicited by some of the
items using other items for that purpose. Prerequisite to adequate performance is the
ability to use symbolic representation and imaginative processes. Those with inhibited
symbolic function are unable to integrate the items into a drawing/story and are unable to
acknowledge or resolve the anxiety.

The AT-9 and SAT-9 have most often been used to assess symbol functioning of
psychosomatic individuals, including chronic pain patients and various types of
psychosomatic patients (Cohen et al. 1983; Catchlove et al. 1985) patients with various

somatic symptoms and psychiatric outpatients (Cohen et a1 1994). Regarding eating

54

disorders, only two studies could be found. Bourke et al (1985) found that anorexic
inpatients assessed with the SAT-9 manifested impaired symbolic function. The authors
stated that they found a lack of correlation between symbolic function and performance
on a scale of interoceptive awareness; it was suggested that this finding supported the
trait-cluster concept of alexithymia.

Legorreta et al (1988) investigated symbolic functioning aspects of alexithymia in
moderately and morbidly obese women and found that both groups presented a higher
degree of impaired symbolic function inhibition than normal-weight controls. The
authors suggested that the type of measure revealed inconsistent results. Self-report
measures of alexithymia suggested that moderately obese individuals perform more like
nomral weight controls than the morbidly obese; however, it is notable that the measure
used has questionable reliability and validity. Conversely, interviewer-based measures
suggested that the two obese groups were more similar in alexithymic symptoms. This
finding highlighted the idea that different scale formats for measuring alexithymia can
blur results. The authors also stated that, given clear alexithymic impairments in the
morbidly obese, surgical intervention was the treatment of choice. However. they noted
surgery was more concrete and parallel to obese individuals’ style of cognition, but their
assumption that physical capacity and overeating response would be diminished neglected
to consider how the underlying conflict might then be resolved.

Rorschach Inkblot Test

Multiple studies using the Rorschach have identified alexithymic characteristics in

various types and severity levels of psychosomatic pathologies (Waysfield et al. 1977;

Acklin & Alexander. 1988; Faleide et a1 1988). Results of these investigations revealed

55

limited productivity. inhibited affective expression and poorly modulated affect, reduced
fantasy. and cognitive constriction. Earlier studies of alexithymia in psychosomatic
individuals (Leavitt & Garron, 1982; Vogt et al, 1977; Safar et al. 1978; Taylor et al.
1981) were fraught with methodological difficulties, as different methods of test
administration. scoring. and interpretation precluded reliable comparison of findings from
different studies (Bash, 1986). These factors included lack of control for response
productivity. inter-rater reliability checks, and normative reference data (Acklin &
Alexander, 1988). More recent studies have utilized the Rorschach Comprehensive
Scoring System (Exner, 1985) to facilitate comparisons among results from various
studies.

Acklin and Alexander (1988) assessed four groups of psychosomatic patients and
found that, not only were psychosomatic patients significantly more alexithymic than
nonpatients, but that there exist a number of differences in the personality processes
among different patient groups. They suggested that research assessing alexithymia using
heterogeneous groupings of psychosomatic patients is of questionable validity and
reliability. Psychosomatic patients produced significantly more impaired performances on
the seven variables assessing the four characteristics of the alexithymia construct. The
variables reflected functioning in the areas of fantasy (low R, low M), affect (low wtd
SumC, low F C), cognition-perception (low blends, high lambda), and available adaptive
resources (low EA).

Acklin and Bemat (1987) used the same Rorschach variables to investigate the
relationship among alexithymia, depression, and chronic low back pain symptoms. These

patients were distinguishable from inpatient depressives, in their exhibition of

56

alexithymic symptoms. and were more similar to a comparable personality disorders
group. The back pain patients were impaired on all seven alexithymic variables, and were
most impoverished in capability for fantasy (low M), affective responsiveness (low
Suan). and adaptively integrated affect (low FC). Compared to the other groups, back
pain patients exhibited the greatest degree of cognitive constriction (low blends) and
perceptual stereotype (high lambda). The latter finding is notable, as the authors
indicated that response productivity was controlled by eliminating protocols with R < 13.
Although not included as a variable representing aspects of the alexithymia construct,
most of the low back pain patients displayed an ambitent style (EB) suggesting
vulnerability to poor coping under stress.

Clerici et a1 (1988) explored alexithymic characteristics in a morbidly obese
sample preparing for surgical treatment, a group the investigators considered to be
representative of psychosomatic patients. With this study. they utilized the same
Rorschach variables to reflect alexithymic characteristics, except for concrete cognition
reflected in low blends. To examine whether the obese group was significantly more
alexithymic than normal weight controls, the authors used the Exner general population
reference group norms. lmpoverished fantasy and poor perceptual interpretation were
noted. The controlled affective experience and expression were related to the Exner’s
comment on the rigidity frequently exhibited by children and adolescents reflecting
incapability to show emotions and conflicts without fearing retaliation. The reduced
adaptive available resources were related to diminished use of emotional and self-

reflective resources. The investigators also noted reduced ability to express and elaborate

57

aggression (low S) and social conformity (high H, high A). These results confirmed

earlier findings of alexithymic style in psychosomatic symptomatology.

 

Purpose of the Stud;

The intent of this study was to assess alexithymia in an obese female population
displaying a wide range of levels of overweight. It was hypothesized that a mediating
variable. compulsive eating. may be the significant factor in the relationship between
alexithymia and obesity. Although there have been a number of investigations assessing
alexithymia in various populations, questions about measurement abound the literature.
Assessment of alexithymia in eating disorders, specifically obese populations, has tended
to focus on particular aspects of the alexithymia construct. Therefore. it is unclear
whether alexithymia is 1) characteristic of the obese in general. 2) characteristic of
compulsive overeaters. or perhaps 3) unrelated to obesity and/or compulsive overeaters.

This investigation examined the utility of two kinds of measures of alexithymia
within this population. A projective measure. the TAT, was administered to assess
affective verbalization (total affect words) and fantasy production (total word score and
story development). The TAS-20 was administered to assess identification of emotion.
verbalization of feelings (attitude and behavior), and an extemalized cognitive style. To
understand the role of alexithymic characteristics in those with overeating disturbances,
these characteristics are discussed within a theoretical framework highlighting the
overeating process as serving a self-regulatory function.

In documenting alexithymia in the obese and/or in compulsive eaters. it is hoped

that a better understanding of possible impediments to effective insight-oriented therapy

58

for overweight individuals will be revealed. It was hypothesized that an alexithymic style
is more common with the obese population as compared to a non-eating disordered
population. but may be especially characteristic of a subset of the population whose
compulsive eating or bingeing symptoms are notoriously difficult to treat. The literature
has implicated alexithymic impairments in the problem of obesity, which involve
difficulty identifying and expressing feelings, reduced fantasy and impaired symbolic
functioning. and an extemally-oriented cognitive style. These characteristics are believed
to play an integral role in the meaning inherent in the process of eating and the food itself
to the obese individual.

In uncovering alexithymia as a characteristic of compulsive overeaters, we may
better understand the difficulties in treating such individuals in psychotherapy. Finally.
we can develop better methods for assessing which individuals will be better suited for
various methods of psychotherapeutic interventions. Understanding the nature of the
symptomatic process may lead to ideas toward resolving the conflicts underlying the
symptom, especially as the symptom leads to a condition having detrimental physical,

psychological. and social effects.

Hyp_otheses

Hypothesis One

There is a positive correlation between weight (BMI) and alexithymia.
a) As BMI increases. TAS-20 total score will increase
b) As BMI increases, TAT total word score will decrease

c) As BMI increases. TAT total affect word score will decrease

59

(I) As BMI increases. TAT total vague affect word score will increase
Hypothesis Two
The relationship between weight and alexithymia is mediated by compulsive eating.

Hypothesis Three

 

Non-compulsive eaters (NC E) have lower alexithymia scores, as measured by the TAS-
20. than moderate compulsive eaters (MCE) or severe compulsive eaters (SCE).
Hypothesis Four
Non-compulsive eaters (NC E) are more likely to have lower alexithymia scores. as
measured by the TAT scores (TAT total word, total affect words, total vague affect
words), than moderate compulsive eaters (MCE) or severe compulsive eaters (SC E).
Hypothesis Five
Compulsive eaters have higher somatization scores than non-compulsive eaters
Hypothesis Six
Non-compulsive eaters (BES cutoff < 15) will have less self-reported somatic complaints
for which they have sought medical services than either moderate (BES 15-24) or severe
(BES _>_ 25) compulsive eaters.
Hypothesis Seven
There is a significant positive relationship between somatization and alexithymia.

a) As BSI somatization increases, TAS-20 total score increases

b) As BSI somatization increases. TAT total word score decreases

c) As BSI somatization increases, TAT—20 total affect score decreases

(I) As BSI somatization increases. TAT-20 vague affect score increases.

60

Hypothesis Eight
Moderate and severe compulsive eaters are significantly more likely than non-compulsive

caters to have other self-reported addiction problems.

61

METHOD

Population

This study involved an experimental group (N = 97) consisting of female
participants. ranging from mildly to morbidly obese, who are enrolled in local Weight
Watchers programs. Participants at least age 18. Age, educational level, and occupation
will vary significantly. The control group (N = 80) will consist of individuals from the
community with a variety of weight levels and eating patterns. This group was obtained
by sampling 1) university non-professional staff . 2) clerical staff at a local community

mental health center. 3) individuals from the community at large.

Procedure

During a formal meeting, individuals enrolled in a Weight Watchers program
were presented with an detailed overview of the study. The disclosure allowed enough
information so that they could decide if they would like to volunteer. but they were kept
blind to purpose and hypotheses of the actual study. They were informed that the
investigation is part of a dissertation project that focuses on learning more about
individuals participating in a weight reduction programs with the goal of improving
current services aimed at enhancing weight loss and improving health. The general
nature of the tests and time commitment involved were disclosed. Potential participants
were informed of the importance of their anonymity during and after the assessment, and
that only assigned numbers will be paired with demographic information and responses.

lnforrnation regarding their rights in psychological investigations will be provided

verbally and in writing. with particular emphasis on the right to withdraw from
participation at any time. Participants were told that they will be paid $5.00, not for their
time but. rather, in appreciation of their involvement.

Individuals that agreed to participate signed-up and were contacted by this
investigator to schedule a testing appointment. Participants were informed that testing
would last approximately 90-minutes and that rest breaks would be included. Testing
was conducted on an individual basis at the Weight Watchers facility and at a nearby
community center. Participants completed consent forms that provided information about

participant rights and the investigator’s phone number for any questions or comments.

Measures
Structured Clinical Questionnaire (SCD

A questionnaire was administered to obtain demographic information, past and
present weight-loss strategies and goals. and past and present medical and psychological
services used. A copy of the questionnaire is provided in Appendix A. The questionnaire
was self-administered and required approximately 15 -20 minutes.

Determinations regarding weight status, such as overweight and obese. were
established by use of the Quetelet’s Body Mass Index (BMI), a method of standardizing
body weight across height, was calculated for all subjects’ reported weight as kg/m(m).
To compute one’s BMI, weight is measured in kilograms (pounds x 0.45). and that
product is divided by the square of height in meters (inches x 0.0254). BMIs between 19
and 25 are considered within normal limits. However, Manson (1995) conducted a study

of over 100.000 nurses and found that women weighing at least 15 percent less than

63

average were the least likely to die prematurely and that death rates rose steadily with
increasing weight - even in women that were not considered obese. Findings from that
study suggested that a BMI of less than 20 is optimal.

For the proposed study. BMI was used as a continuous variable and was converted
into categories indicating average weight (BMI < 25). moderately overweight (BMI = 25-
29). and severely overweight/obese (BMI 2 30). The categories are made in accordance
with the World Health Organization’s recommendations and accepted medical standard
for obesity being at 20% over expected/ideal weight and 40% over expected weight being
severely overweight. It should be noted that the BMI. as with most other weight
measures, has its limitations.

Binge Eating Scale (BES; Gormally. Black, Daston, & Rardin, I982).

The BES is a self-report assessing binge eating in obese individuals. It has been
applied in clinical research studies with a variety of samples to categorize individuals
according to severity of binge eating. This tool assesses behavioral aspects of binge
eating episodes. in addition to the feelings and thoughts associated with bingeing. It
yields one total score providing a general measure of severity, but precludes measurement
of binge frequency or establishment of a specific diagnosis. The BES is free of clinical
jargon and is written with “I” statements in which the participant is asked to choose the
statement in each item with which she most identifies. Scoring involves an uneven
distribution of weights for each item.

Norms are available for two obese samples, with cutoffs established by comparing
interview data for severity of binge eating with the BES scores. Gormally et al (1982)

demonstrated satisfactory internal consistency by comparing overall total BES scores

with scores on individual items. Concurrent validity was demonstrated by comparing
scores on the BES with binge eating severity ratings made by trained interviewers. BES
scores were significantly different across rated severity levels in two different obese
samples. There have be no known studies assessing test-retest reliability, or discriminant
and predictive validity for the BES. Completion of this scale required approximately 10
minutes.

Wechsler Adult Intelligence Sufi-Revised. Vocabulary subtest (Wechsler. 1981).

There are conflicting findings regarding the correlation between intelligence
alexithymia. Although some studies did not show any significant relationship (Parker et
al 1989; Taylor, Parker. Bagby & Acklin, 1992), others studies reported that lower
educational level or intelligence was associated with higher rates of alexithymia (Bagby
et al 1986; Bourke et al 1992; Pasini et al 1992). Thus, the vocabulary subtest of the
WAIS-R will be administered to provide a brief screening of intelligence. The
Vocabulary subtest has a correlation with Full Scale IQ score of 0.86, and is considered
adequately reliable with a test-retest reliability coefficient of 0.92 and split-half
coefficient of 0.96 (Kaufman. 1990). Administration time was approximately 10
minutes. Individuals trained to administer the subtests were kept blind to the purpose and
hypotheses of the study. Scoring was completed by the principal investigator.

Brief Symptom Inventory (BSI; Derogatis, 1993)

This 53-item Likert self-report scale provides a brief, standardized measure of the
presence and severity of psychiatric symptoms experienced by the subject over the past
week. It includes subscales for somatization (SOM), obsessive-compulsive (O-C),

interpersonal sensitivity (I-S). depression (DEP). anxiety (ANX), hostility (HOS). phobia

65

(PHB), paranoia (PAR), and psychoticism (PSY). It also provides for a global symptom
severity index (GSI). positive symptom total index (PST), and a positive symptom
distress index (PSDI).

The reliability and validity of the BSI has been demonstrated with both clinical
and non-clinical populations. The BSI has also been used with eating disordered and
alexithymic populations (Taylor. 1994). The measure has good concurrent validity. The
administration took approximately 10 minutes and served as a good screen for psychiatric
symptoms and mood problems that might have impacted performance on the other
measures.

Toronto Alexithymia Scale-20 (TAS-20; Bagby. Parker, & Bylorgl 994).

This twenty item self-report scale consists of a three-factor structure theoretically
congruent with the alexithymia construct. This version is the result of the second major
revision of the original TAS. which purported to measure the four aspects of the
alexithymia construct. On the TAS-20, those items originally included to assess
daydreaming and fantasy activity were dropped due to low item-total scale correlations (r
< 0.20) and high correlation with a measure of social desirability (r < 0.20). The stability
and replicability of this three-factor structure has been demonstrated with both clinical
and non-clinical populations by the use of confirmatory factor analysis. This revision
documented good internal consistency, test-rest reliability, as well as good convergent,
discriminant. and concurrent validity. Factor 1 consists of seven items that collectively
represent difficulty identifying feelings; Factor 2 consists of five items which represent
difficulty describing feelings; Factor 3 consists of eight items which reflect extemally-

oriented thinking.

66

The TAS-20 demonstrated good internal consistency (Chronbach’s alpha = .81 ).
as did each of the three factors (Fl = 0.78, F2 = 0.75, F3 = 0.66). Test-retest reliability
over a 3-week period was also demonstrated (r = 0.77; p < 0.01). Convergent validity was
adequate, as revealed by the negative relationship with the NEO-Pl domain scales of
Openness to Experience (r = -0.49, p < 0.01), and the subscales of feelings (r = -0.55. p <
0.01). and fantasy (r < -0.30, p < 0.01). The TAS-20 was also negatively correlated with a
measure of psychological mindedness (r = -0.68. p < 0.01). Discriminant validity was
demonstrated by non-significant relationships between the TAS-20 and traits of
agreeableness (r = -0.09. p < 0.05) conscientiousness (r = -0.21, p < 0.05) and
excitement—seeking (r = 0.07, p < 0.05). Concurrent validity was demonstrated by a
significant positive relationship between the TAS-20 (r = 0.53, p < 0.01) and all three
factors (r = 0.36, 0.57. 0.30. p < 0.05) with the Beth Israel Psychosomatic Questionnaire
(BIPQ).

Haviland and Reise (1996) evaluated the factor structure utilizing a sample of
medical students and corroborated the three factors. However, they found that use of the
scale with a psychoactive substance-dependent inpatient sample resulted in the first two
factors actually formed one factor. and the third factor split into two unrelated factors.
Thus. they recommended checking the factor structure when practicable. For this study,
the scale provided information regarding the participant’s self-reported ability to identify
and express feelings and acknowledgment of a cognitive style relying on external stimuli.
Administration time for the measure was approximately 10-15 minutes. Scoring was

conducted by the principal investigator.

67

Thematic Apperception Test (TAT; Murray and Morgan, 1932).

TAT Cards 1, 2. 38M and 4, which consist of characters in various situations, and
Card 20, a blank card. will be administered to assess expression of affect and fantasizing
ability. The TAT is expected to reveal the overt expression of affect that is an essential
feature of the alexithymia construct; that is. the actual identification and communication
of feelings. rather than the self-report of such behavior. There is evidence to suggest that.
compared with controls. psychosomatic populations use fewer affective words and fewer
total words on the TAT (Taylor & Doody. 1985; Taylor, et al 1981). To this
investigator’s knowledge, The TAT has not been used in this manner to assess
alexithymia with an eating disordered population. The goal was to obtain objective
ratings on frequency of word type, rather than scoring it for content/theme, related to
assessing alexithymic characteristics of affective expression (affect /vague affect words)
and imagination/fantasy production (total word production).

In this study. the TAT total affect score was obtained by tabulating the total
number of words that are reflect unambiguous affect or its derivatives (e.g.. “sad”,
“angry”. etc.). A vague affect score was obtained by tabulating all words/short phrases
that suggest affect but are ambiguous. These words either leave the reader guessing the
nature of the emotion (e.g.. “feels bad”) or reflect physiological states of experience (e.g..
“wom out" or “tired”). The scores of three independent raters were recruited to identify
and score “affect” and “vague affect” words. The TAT total word count is the sum of the
total word production across cards. Administration was verbal and in written format and
lasted approximately 20 minutes. Assistants administering the TAT were trained to use

an administration technique that included both spoken and written instructions. Subjects

68

were informed that they had 5 minutes to write a story for each TAT card. (see Appendix
D). The examiner left the room during the writing of each story. This process was

intended to create a monadic (one-person) situation that is associated with a trait concept
of alexithymia. rather than a dyadic situation (two-person) that is associated with a state-

dependent concept of alexithymia.

69

RESULTS

Demogramric Data

 

One hundred seventy-seven females participated in the study. Participants ranged
in age from 23-70 years (mean = 39.05, SD = l 1.14). The sample was 70.1 percent
Caucasian (n = 124). 13 percent African-American (n = 23), 5.1 percent Latin American
(n = 9). 5.1 percent Native American (n = 9), 3.4 percent Asian American (n = 6). 1.1
percent East Indian (n = 2). and 2.3 percent West Indian (n = 4).

Forty percent of participants were married (n = 72), 16.4 percent were divorced (n
= 29). 9.6 percent were separated (n = 17). 2.3 percent were widowed (n=4), 6.8 percent
were living with a significant other (n = 12). and 24.3 percent identified themselves as
never married (n = 43).

Thirty-three (18.6 percent) of the participants identified themselves as
unemployed and/or homemakers. Twenty (l 1.3 percent) were employed in unskilled
labor positions. 27 (15.3 percent) held clerical positions, 29 (16.4 percent) held
skilled/trade positions. 52 (29.4 percent) held semi-professional positions. and 16 (9
percent) held professional positions.

Three participants (1.7 percent) had obtained some high school education. 35
(19.8 percent) were high school graduates. 40 (22.6 percent) had some college education,
19 (10.7 percent) had two-year/associate degrees. 51 (28.8 percent) had graduated from

college. 8 (4.5 percent) had some graduate/pre-master’s degree education, 13 (7.3

70

percent) had master’s degrees. 1 (0.6 percent) had some doctoral level training. and 7 (4
percent) had their doctoral/law degrees.

Approximately 28 percent (n = 51) of participants were in individual counseling
or psychotherapy at the time of testing or within the past six months of testing. Seventy-
eight of the participants (47 percent) had been in some kind of individual psychotherapy
or counseling during their life. Thirty of these individuals (45 percent) reported seeking
psychotherapy primarily for assistance with depression. twenty-nine (27 percent) for
anxiety, nineteen (17 percent) for mixed depression and/or anxiety. seven (5 percent) for
obsessive-compulsive disorder, seven (5 percent) for bipolar disorder, two (0.5 percent)
for psychosis. Two individuals (0.5 percent) had been in psychotherapy for disordered
eating Forty-one individuals (28 percent) had been in marital therapy. Twenty-two
percent (n = 39) of the participants were taking psychotropic medication. Of the
individuals taking psychotropic medication, 13.6 percent (n = 24) of participants received
prescriptions from a psychiatrist and 9 percent (n = 16) from their primary care or other
physician.

Nine (5.1 percent) of the participants were receiving counseling for addiction to
drugs/alcohol and/or gambling. Eighteen (10.2 percent) were attending 12-step (AA, NA.
OA) meetings at least monthly. Six (3.4 percent) of participants reported being addicted
to illegal drugs. 13 (7.3 percent) to alcohol, 1 (0.6 percent) to prescription medication. 5
(2.8) to gambling. and 1 1 (6.2 percent) to shopping. Thirty-one (17.5 percent)
participants reported that they were addicted to food. Eighty-seven (49.2 percent)
reported an addiction to nicotine and 45 of these individuals reported that they continue to

smoke cigarettes daily.

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Participants reported their medical conditions and/or physical complaints. Some
of these difficulties included whether they were experiencing symptoms of a potential
psychosomatic illness. Somatic complaints not associated with specific disease etiology.
such as migraine headaches. chronic headaches, essential hypertension. stomach
discomfort/gastritis. irritable bowel syndrome, chronic pain, dermatitis and chronic
fatigue were classified as psychosomatic symptoms. in concert with past research on
classic psychosomatic illness. Forty-six (26 percent) participants reported seeking
medical treatment for these somatic complaints within the past 6 months. Twelve (6.8
percent) individuals reported seeking medical treatment for more than one somatic
complaint within the past 6 months. Seven (4 percent) participants reported seeking
medical treatment for nonspecific somatic conditions in the past. At the time of testing,
26 (14.7 percent) participants were taking prescription medication for somatic symptoms,
and 5 (2.8 percent) were taking medication for multiple somatic symptoms.

Sixty-nine of the participants (43 percent) had used psychotropic medication.
Forty-three of these individuals were taking psychotropic medication at the time of the
study and 26 individuals had taken psychotropic medication in the past. Twenty-nine
individuals (21 percent) received psychotropic medication from their primary care
physician (PCP). 16(11 percent) from a psychiatrist, 7 (3 percent) from another specialty
physician, and l7 (12 percent) from multiple physicians (e.g.. PCP, psychiatrist).

Mean and standard deviation scores of BES scores for participants are reported in
Table 3. Quetelet’s Body Mass Index (BMI), a method of standardizing body weight

across height. was calculated for all subjects’ reported weight as kg/m(m).

Crosstabulations for level of compulsive eating (BES level) and level of overweight (BMI
level) are summarized in Table 3.

To ensure that the TAS-20 did indeed assess the three components of the
alexithymia construct with this population, a confirmatory factor analysis was conducted.
Three factors emerged: l) difficulty distinguishing between feelings and bodily
sensations, 2) difficulty communicating feelings to others, and 3) a focus on concrete
stimuli and orientation toward action. These factors mirror those factors that have

emerged in empirical studies using the TAS-20. A chi square goodness of fit was

significant or 2 (2. 174): 76.4, p < 0.01).

73

Table 3: Body Mass Index (BMI) and Binge Eating Scale (BES) summary scores

Variable Mean S_D Minimum Maximum N
BMI 32.59 6.42 20.00 51.00 177
BES 16.65 9.26 0 46.00 177

Table 4: Number of participants by levels of compulsive eating and degree of

overweight/obesity by BMI (body mass index):

Normal BMI Moderate BMI Severe BMI Totals

ELIE

Non-

compulsive 17 24 25 66
eaters

MC E
Moderate
compulsive l6 17 28 61

eaters

SEE

Severe

compulsive 10 14 26 50
eaters

Totals 43 55 79 N=l 77

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On the TAT. three independent raters scored the cards for individual card and
total word count. affect word count, and vague affect count. Each record was scored by
two independent raters. Initial inter-rater reliability for scoring the first 10 TAT
administrations was r = 0.90. Additional review and training on the scoring procedure
and discussion among raters on how to score difficult items (e.g.. “not good”, “tired”)
resulted in inter-rater reliability increasing to r = 0.97. Inter-rater reliability checks were

conducted on five records after every 20 administrations.

Results of Hypotheses

Hypothesis One
There is a positive correlation between weight (BMI) and alexithymia.

a) As BMI increases. TAS-20 total score will increase

b) As BMI increases. TAT total word score will decrease

c) As BMI increases. TAT total affect word score will decrease

d) As BMI increases, TAT total vague affect word score will increase
A Pearson-product moment correlation revealed that the relationship between BMI and
alexithymia TAS-20 total score was significant (1 = 0.25, p < 0.01). The relationship
between BMI and TAT total word score was not significant (1; = 0.03, p > 0.05). BMI
was significantly correlated with both the TAT total affect word score ( g = -0.33, p <
0.05) and TAT total vague affect score (g = 0.28, p < 0.05). Intercorrelations between

variables are presented in Table 5.

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Table 5: Interrelations among BMI, BES, TAS-20 total score, TAT total word score,

TAT total affect score, and TAT total vague affect score

- - Correlation Coefficients - -

BMI BES TAS-20 TATword TATaffect TATvague

BMI .641 1 .2518 .0279 -.3306 .2829
p< .01 p< .05 p< .05 p< .05 p< .01

BES .4126 .1144 -.5334 .4373
p< .01 p> .05 p< .01 p< .01

TAS-20 .2322 -.3104 .4142
p> .05 p< .0] p< .01

TATword .141 l .0516

p> .05 p> .05

TATaffect -.341 5
p< .05

Note: BMI = Body Mass Index; BES = Binge Eating Scale; TAS-20 = Toronto
Alexithymia Scale; TAT = Thematic Apperception Test ; TATword = TAT word
summary score; TAT affect = TAT affect summary score; TAT vague = TAT vague

affect summary score.

76

Hypothesis Two
The relationship between weight and alexithymia is mediated by compulsive eating.

A partial correlation revealed that, when compulsive eating (BES) was controlled
for, the significance of the relationship between BMI and TAS-20 was eliminated (r = -
0.18. p_ > 0.05). The significance of the relationships between BMI and TAT total affect
score (5 = -0.09, p > 0.05) and BMI and TAT total vague affect score (r = 0.1 l, p > 0.05)
were also eliminated.

Hypothesis Three
Non-compulsive eaters (NCE) have lower alexithymia scores, as measured by the TAS-
20. than moderate compulsive eaters (MCE) or severe compulsive eaters (SC E).

Hypotheses related to participants’ scores on the TAS-20 were tested using a one-
way analysis of variance. The difference between TAS-20 scores for the NCE, MCE and
SCE groups was significant (F (2, 175) = 24.15, p < 0.01). A planned comparison of
TAS-20 scores across groups revealed that the NCE group’s mean TAS-20 was
significantly lower than that of the MC E or SCE group (T (47.5) = 6.329. p < 0.05). This
post hoc comparison also revealed that the SCE group’s mean TAS-20 score was
significantly higher than that of the MCE group (T (55.2) = 5.139, p < 0.05).

Hypothesis Four

Non-compulsive eaters (NCE) are more likely to have lower alexithymia scores, as
measured by the TAT summary scores (TAT total word. total affect words. total vague
affect words), than moderate compulsive eaters (MC E) or severe compulsive eaters

(SCE).

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Hypotheses related to participants’ summary scores on the TAT were tested using
a one-way analysis of variance. The difference between TAT total word (TATW) scores
for the NCE. MCE and SCE groups was not significant (F (2, 174) = 3.15, p > 0.05).
The difference between TAT total affect (TATA) scores for the NCE. MC E and SCE
groups was significant (F (2, 174) = 21.09, p < 0.05). A planned comparison of TATA
scores across groups revealed that the SCE group’s mean TATA score was significantly
lower than that of the NCE or MC E group (T (40.4) = 1.917. p < 0.05). There was no
significant difference between The NCE and MCE groups on the TATA mean scores.

The difference between TAT total vague affect (TATVA) scores for the NC E,
MCE and SCE groups was significant (F (2. 174) = 23.53, p < 0.01). A planned
comparison of TATVA scores across groups revealed that the SCE group’s mean
TATVA score was significantly higher than that of the NCE or MCE group (T (34.2) =
1.347. p < 0.01). There was no significant difference between The NCE and MCE groups
on the TATVA mean scores.
Hypothesis Five
Compulsive eaters have higher levels of somatization than non-compulsive eaters

a) Non-compulsive eaters (BES cut-off score < 15) will have significantly lower
scores on the BSI somatization scale than moderate compulsive

eaters (BES 15-24) and severe compulsive eaters.

b) Severe compulsive eaters (BES > 25) will have higher levels of

somatization than moderate compulsive eaters (BES 15 - 24).

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Hypotheses related to participants’ scores on the BSI somatization subscale were
explored using a one-way analysis of variance. Means and standard deviations of each

group’s BSI somatization scores are presented in Table 6.

Table 6: Means T-scores (standard deviations) for BSI subscale and index scores:

NCE MCE SCE
SOM 48.3 (4.9) 50.1 (5.1) 56.7 (7.2)
O-C 43.5 (6.1) 46.2 (7.8) 43.9 (6.3)
rs 53.1 (8.1) 57.1 (8.9) 57.7 (8.8)
DEP 57.7 (7.7) 59.7 (8.9) 62.1 (7.1)
ANX 49.9 (9.4) 53.8 (9.1) 54.0 (7.5)
HOS 48.6 (5.1) 48.8 (4.7) 54.3 (7.3)
PHOB 48.6 (5.9) 50.3 (6.5) 48.1 (5.3)
PAR 45.1 (5.3) 47.3 (7.5) 46.8 (5.2)
PSY 44.4 (4.7) 46.3 (6.4) 47.1 (5.5)
GSl 48.4 (6.9) 49.8 (7.4) . 49.9 (5.0)
PSDI 52.6 (8.7) 54.5 (8.5) 56.6 (7.6)
PST 47.9 (6.3) 45.8 (6.0) 46.1 (5.4)

Note: SOM = Somatization; O-C = Obesessive Compulsive; IS = Interpersonal
Sensitivity; DEP = Depression; ANX = Anxiety; HOS = Hostility; PHOB = Phobia; PAR
== Paranoia; PSY = Psychoticism; GSI = General Symptom Index; PSDI = Positive

Symptom Distress Index; PST = Positive Symptom Total

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The mean differences across NCE. MCE, and SCE groups on the BSI
somatization scale were significant (F (2, 175) = 4.35, p > .05). A Bonferroni planned
comparison of BSI somatization scores across groups revealed that the
SC E group’s mean somatization score was significantly higher than that of the NC E or
MCE group (T (32.2) = 4.1 l l, p < 0.01). There was no significant difference between
NC E and MCE groups on the BSI somatization mean scores.

Hypothesis Six

Non -compulsive eaters (BES cutoff < 15) will have less self-reported somatic complaints
for which they have sought medical services than either moderate (BES 15-24) or severe
(BES Z 25) compulsive eaters.

A Chi square test of significance indicated significant difference between groups

(Chi square x2 (4, N = 177) = 7.85. p< 0.05). The difference between the expected and

observed frequency of somatic complaints was only significant between the MCE and
SC E groups.
Hypothesis Seven
There is a significant positive relationship between somatization and alexithymia.

a) As BSI somatization increases. TAS-20 total score increases

b) As BSI somatization increases, TAT total word score decreases

c) As BSI somatization increases. TAT-20 total affect score decreases

(I) As BSI somatization increases, TAT-20 vague affect score increases.
The Pearson product moment correlation between the BSI somatization score and the
TAS-20 total was significant (r = 0.42. p < 0.01). There were significant negative

correlations between the BSI somatization score and TAT total word score (r = —0. 16. p <

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0.05) and TAT total affect score (r = -0.36, p < 0.01). There was a significant positive
correlation between the BSI somatization score and the TAT vague affect score (r = 0.37.
p < 0.01).
Hypothesis Eight
Moderate and severe compulsive eaters are significantly more likely than non-compulsive
caters to have other self-reported addiction problems.

Chi square tests of significance were conducted to assess the relationship between
compulsive eating and addictive behavior with nicotine, alcohol, narcotics, and shopping.

A chi-square test of significance with the variables of compulsive eating and nicotine use

indicated significant difference between groups (Chi square X2 (2. N = 175) = 6.79. p =

0.03). The difference between the expected and observed presence of nicotine use was
only significant for the SC E group. A chi-square test of significance with the variables of

compulsive eating and excessive shopping indicated significant difference between

groups (Chi square X2 (2, N = 175) = 1 1.28, p < 0.01). The difference between the

expected and observed presence of excessive shopping was significant for the SCE group.

Compulsive eating and psychiatric sgmptoms
Brief Symptom Inventory (BSI) scale and index means and standard deviations for
NC E. MCE and SCE groups are presented in Table 2. In addition to being correlated
with the BSI somatization score, compulsive eating was also significantly correlated with
BSI hostility scores (r = .15, p < .05). A one-way analysis of variance was conducted to

examine this relationship. The mean differences across NCE, MCE, and SCE groups on

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the BSI hostility scale were significant (F (2, 174) = 13.46, p > .01). A Scheffe post hoc
comparison across groups (alpha = .05) revealed that the SCE group’s mean hostility
score was significantly higher than that of the NCE or MCE group. There was no

significant difference between NCE and MCE groups.

Verbal Intelligence and Alexithymia

Intellectual functioning was obtained using WAlS-R Vocabulary subtest scaled
scores. IQ scaled scores had a normal distribution. with a mean of 12.49, median of 12,
standard deviation of 1.99. and range of 8 - 17.

One measure of alexithymia was related to verbal intelligence. There was a
significant positive correlation between IQ and the TAT total word score. Total scores
from the TAS—20 (r = -0.10, p > 0.05), TAT affect word score (r = -0.06. p > 0.05), and
TAT vague affect word score (r = 0.10. p > 0.05) were not significantly related to the

WAlS-R Vocabulary subtest score.

DISCUSSION

Descriptive Information
This investigation provides support for the assertion that it is compulsive eating.
rather than obesity, that is associated with the affective and cognitive deficits of
alexithymia. Overall, results suggest that more severe levels of compulsive eating are
associated with alexithymia and somatization. Results do not consistently support the
assertion that milder levels of compulsive eating are associated with significant
differences from non-compulsive eaters.

Demographics

 

Overall, a diverse population was obtained for this project. The participants were
diverse in age. education and occupation, although less so for ethnicity/race (70%
Caucasian sample). A normal distribution of IQ scores suggested representation of
individuals at various levels of intellectual functioning women. The sample appeared to
be psychiatrically stable, in that BSI score means generally fell within one standard
deviation of the normative mean (50th percentile). Participants were recruited from
Weight Watchers in an effort to obtain a non-clinical sample that is representative of
relatively healthy women from the general population that have concerns about eating
patterns and weight management. None of the participants were recruited from medical
or psychiatric clinic settings. All participants were employed and/or homemakers. Those
participants that were not recruited from Weight Watchers came were recruited from

community. business. and educational university settings.

83

Compulsive Eating

 

Obesity and Alexithymia

 

As indicated by prior research (Brownell. 1995; Fairbum & Brownell. 2002),
obese individuals appear to be a heterogeneous group. Hypotheses one and two were
supported and indicated that it is a subgroup of the obese. compulsive overeaters. and not
the obese generally, that are more likely to demonstrate alexithymic deficits. Most
research has not shown a significant relationship between BMI and alexithymia scores
(Schmidt et al. 1993; Cochrane et a1, 1993; J immerson et al. 1993; Laquatra & Clopton.
1994)

Past research finding a significant relationship between obesity and alexithymia
did not account for the role of compulsive eating within the population (Legorreta et a1.
1988; Clerici.et al, 1992; Fukunihi & Kaji, 1997). Morosin & Riva (1997) found
alexithymic only in a subgroup of the obese that exhibited psychopathologic traits. de
Zwaan et a1 (1995), investigating differences between obese binge and non-binge eaters.
found no difference in alexithymia levels. They qualified these results with the finding
that their sample of obese women were selected from a group seeking psychotherapy
treatment and may have been more psychologically-minded than obese women in general.

It should be noted that. even within the population of compulsive overeaters. those
with severe compulsive eating demonstrate more severe alexithymic difficulties. In this
investigation, severe compulsive eaters were more likely than moderate compulsive or
non-compulsive eaters to show alexithymic deficits (Hypotheses three andfour). The
severe compulsive eaters were significantly more alexithymic than moderate compulsive

eaters and non-compulsive eaters on both the self-report measure (TAS-20) and verbal

84

production samples (TAT) assessing alexithymia. These results support the notion that
individuals with severe compulsive overeating patterns have difficulty processing and
regulating emotions

As discussed by the authors of the BES (Gormally et al, 1983) and others
conducting research with eating disordered populations (Cochrane, 1995; de Groot.
1995). the deficits that moderate and severe compulsive eaters display seem to be
significantly different. Gormally et al (1982) found that the major difference between
moderate compulsive and severe compulsive eaters was their sense of self-control over
binge urges. Severe compulsive eaters report that they experience a complete lack of
control that leads to an unrelenting struggle to avoid a binge and react to their loss of
control with marked guilt and self-loathing. Moderate compulsive eaters report more
episodic loss of control, often feel able to restrain themselves from giving in to eating
urges. and are more forgiving of their lapses. Non-compulsive obese eaters, report
minimal emotional response to overeating and indicate that they overeat because they
enjoy eating rather than eating because they have lost control.

The results of this study suggest that the assessment of the presence and severity
of compulsive eating is integral to planning treatment. Furthermore, research findings
suggest that therapeutic treatment efforts should address impulse control and self-esteem
issues in the management of eating and weight.

Somatization

 

Somaticizing deficits were observed in the performances of severe compulsive
overeaters in this study (hypothesis seven). Severe compulsive overeaters produced

significantly higher somatization scores (SOM) on the BSI. They were also significantly

85

more likely than moderate compulsive and non-compulsive eaters to report multiple
somatic problems for which they sought medical treatment (hypotheses five and six).

The clinical explanations of alexithymia (Mc Dougall, 1989, Krystal 1988, 1992,
Taylor et al. 1992. 1995, 1997) suggest that limited subjective awareness and cognitive
processing of emotions may lead to a focus on, amplification and misinterpretation of the
somatic sensations that accompany emotional arousal. Barsky and Klerrnan (1983)
suggested that it is a normal experience for individuals to notice but understand that the
perceptions of somatic sensations are usual accompaniments to states of emotional
arousal. If this acknowledgement does not occur. the individual experiences an ongoing
tension state. The alexithymic individual may become preoccupied with the sensations as
a result of failing. and/or being unable, to recognize and use the internal (e.g.. sadness.
anger) provoking stimulus to understand what he is experiencing. If the sensations are
not identified, explored, verbalized, understood. and regulated via affective and cognitive
processing. autonomic system responses may be exacerbated and become conducive to
the development of somatic discomfort and disease (Kellner, I990).

The deficits in alexithymia and somatization go hand in hand. The difficulty with
the cognitive processing of affect renders affect to a somatic-motoric-sensory level.
Somatization has generally and erroneously been labeled as physical symptoms and
disease that have underlying psychiatric sources which are misdiagnosed or
misrepresented. Affect and its derivatives are primarily biological processes that involve
all systems and functions of the body. Using the affect dysregulation model, affective
experience remains diffuse. somatized, unverbalized and does not move to the operational

level of cognitive awareness. labeling and processing. The affective experience is

86

experienced primarily at a sensorimotor level. The chronic overwhelming tension that
results prompts the individual into action (eating, drinking, smoking etc..). a concrete
sensorimotor response to manage the physiological tension that is rising from within.

Addictive Behavior

 

The results of the study (hypothesis eight) supported the idea that severe
compulsive eating is associated with self-reported addictive behavioral patterns.
Severe compulsive eaters reported significantly higher levels of nicotine use (cigarette
smoking) and excessive shopping than moderate compulsive or non-compulsive eaters.

Difficulty modulating emotional arousal through affective and cognitive
processing might explain the tendency of individuals with alexithymic deficits to
discharge tension arising from unpleasant emotional states through impulsive and
compulsive behavior, such as binge eating, excessive shopping, and cigarette smoking.
This finding is consistent with past research (Peveler & Fairbum. 1990) revealing that
one-third of women seeking alcohol abuse treatment reported binge eating symptoms.
Research has found high prevalence of addictive problems in eating disorders groups.
although subjects involved were bulimic (prevalence 3% to 55%) or anorexic (prevalence
6% to 13%). Although the research did not specifically include compulsive eaters. the
high prevalence in a bulimic group who engage in binge eating is notable.
Alexithymia and Psychiatric Distress

In additon to scoring significantly higher on the BSI index of somatization. severe
compulsive eaters scored significantly higher than moderate compulsive or non-
compulsive eaters on the BSI index of hostility. This finding is consistent Auerbaek-

Barber’s (1998) research finding obese binge eaters having significantly more reported

87

interpersonal problems and higher scores on measures of passivity, social avoidance.
vindictiveness, exploitability and intrusiveness. Specker et a1 (1994) found that obese
binge eaters were three times as likely to meet criteria for a personality disorder.

Notably, there were no significant differences among the groups on BSI indexes
of depression, anxiety, or general distress. However, the non-compulsive eaters had
lower mean scores on these indexes than moderate compulsive eaters, and moderate
compulsive eaters had lower mean scores than severe compulsive eaters. This finding
may be related to the fact that the study used a generally non-clinical. community-based
sample of women enrolled in a Weight Watchers program. Clinically and empirically.
alexithymia and somatization have been linked with personality deficits rather than
neurotic conflict/defenses. Bruch (1982, 1983) understands eating pathology as emerging
out of an ineffective, deficient sense of self, accompanied by deficits in conceptual
development and interoceptive confusion regarding bodily sensation of all kinds.

Interestingly. alexithymia and somatization were not significantly associated with
mood symptoms such as depression and anxiety. In fact. the mean scores all remained
within normal limits in terms of clinical symptomatology. The finding that severe
compulsive eaters are more likely than moderate compulsive and non-compulsive caters
to experience multiple somatic symptoms also supports a trait over state
conceptualization of these deficits. The deficits did not appear to be related to mood
related changes.
Alexitlymia and Affect Regulation

Grotstein (1986. 1987) suggested that compulsive eating. and other kinds of

disordered eating patterns. are attempts to reestablish a concrete but temporary self-

88

regulation ofchronic unpleasant emotional states and unpleasant aspects of the self.
Goodsitt (1983) indicated that severe deficits in affective and self-regulation leave a
person vulnerable to profound states of overstimulation and tension. In this way.
compulsive eaters engage in frantic self-stimulatory activities to drown out anguished
feelings and diffuse physiological sensations that cannot be discriminated. identified.
processed and regulated in an organized manner. Casper (1983) suggested “food and
physiological processes become perversely employed to regulate emotions”.

Lane and Schwartz (1987) stated that the “experience of emotion is hypothesized
to undergo structural transformation in a hierarchical developmental sequence of
progressive differentiation and integration” (p.125). Their five cognitive-developmental
levels of emotional organization help explain individual differences in the experience,
expression, and regulation of affects. An individual moves progressively from affect
being experienced at a purely somatic-motoric level, to being gradually integrated with
developing cognitive processing to help differentiate and understand emotions and
express a variety of feeling states. If there is some interruption in this process, via
neurological or interpersonal insult, an individual may not be able to develop affective
functioning in a full way. When affect becomes “stuck” at more somatic levels, the
individual experiences chronic states of tension that may be temporarily subdued through

repetitive motoric acts (e.g.. substance abuse).

89

CONCLUSIONS

Clinicians and researchers agree that alexithymia and somatization may have their
genesis in several sources. Neurobiological impairments (right hemisphere or
intrahemispheric transfer deficits) may be associated with constitutional deficits (Banich.
1995). They may also result from early developmental parent-child attachment
disruptions (inadequate, unreliable attunement) that influence neurological and
psychological development (McDougall, 1982; Schore. 1994). Additionally,
overwhelming psychological/physical trauma Wazi concentration camps) is associated
with profound alexithymia and somatization deficits. particularly when anhedonia is part
of the picture (Krystal, I988).

The results of this study add further support to the significant relationship among
alexithymia. somatization, addictive behavior and severe compulsive eating.
Nevertheless. treatment issues remain a big concern. Due to the cognitive and affective
deficits and the somatization of affect. using the medium of psychotherapy seems
daunting. Krystal (1988) recommends using psychotherapy to assist the individual in
acknowledging that he or she processes emotion differently and has not learned to tolerate
and use affect as signals to know what is going on internally. He describes the therapy
process as focused on this releaming aspect - sitting with somatic sensations and affects
and slowly learning to make use of their signaling function. Bruch (1982) suggests that
an orientation toward exploration and interpretation around conflicts is inappropriate for
most eating disordered individuals. She suggests that treatment focus at the level of

disruption. a disconnect between physiological and subjective feeling components of

90

emotion. She adds that the approach should be aimed at increasing eating disordered
individuals awareness that there are feelings and impulses that originate in themselves
and that they can learn to recognize. While pharrnacotherapy may assist in helping to
regulate tension. it also interferes with assisting the individual in the process of tolerating

and using the changes to identify what is being experienced.

 

Strepgths and Limitations

Strengths

A strength of this study is in the empirical examination of the relationship among
alexithymia, somatization, and obese compulsive and non-compulsive eaters. Past
research in this area has focused primarily on eating disordered groups such as anorexics
and bulimics. Furthermore, the sample is a non-clinical one, compared to past research
using samples about to begin or involved in formal treatment. This study enables us to
obtain information about women in the general community and how their eating and
weight issues are related to affective and cognitive processing abilities.

Another strength of the study lay in the use of multiple measures of alexithymia to
assess both the affective and cognitive aspects of the alexithymia construct. It also
involved both self-report and projective measures to assess whether individuals’ reported
and actual ability to discriminate, identify and verbalize affect would differ. Additionally.
the use of the TAT permitted the assessment of ambiguous or vague affect words (e. g..
not good, bad) versus unambiguous affect words (e.g.. sad. angry). The study was able to
reveal that those individuals who are alexithymic tend to use vague affect references that

are either ambiguous or describe somatic sensations and physiological states.

91

Past research has suggested a relationship between alexithymia and intelligence.
Use of a screening instrument, such as the WAIS-R vocabulary subtest, allowed for the
clarification of the relationship between intelligence and alexithymia. The results
revealed that only total word score produced on the TAT was correlated with IQ subtest
scores. while the other measures of alexithymia did not correlate with IQ scores.

The use of the BSI provided examination of the relationship between psychiatric
distress and/or symptomatology and alexithymia. Previous research findings were
equivocal regarding the relationship of depression and anxiety to alexithymia. This study
did not find a significant relationship between these mood difficulties and alexithymia.
However. the BSI did reveal a relationship between severe compulsive eating and
hostility, which is consistent with the some clinical and empirical research findings.
Limitations

A potential limitation of the study was that the sample did not include a large
percentage of severely obese women. Most of the women in the sample were not
involved in formal medically supervised treatment for weight management, as might be
the case for those with severe to morbid obesity that poses significant medical problems.
Nevertheless. the findings may have been stronger with a broader range of
overweight/obese. Additionally, the study only involved as sample of women, which
precludes the generalization of the findings to men.

Another potential limitation of the study was posed by the method involved with
administering the TAT. The test administrator was not present during the writing of the
TAT stories. nor did she review them at the time of administration. The literature on

alexithymia suggests that, although alexithymic individuals may be able to state “feelings

“ words such as “sad” or “depressed”, they are rarely able to engage in reflective self-
awareness. verbally elaborate on emotional states. or provide associations that link
emotion with meaningful, internal experiences (Krystal, 1988; McDougall, 1983). If the
administrator prompted the participant to elaborate on affect words produced. a richer

assessment of cognitive processing of emotional experience would have been available.

Future Directions

Assessment Measures

New assessment measures have been developed to assess emotional intelligence.
psychological-mindedness, empathy. and other constructs that are intertwined with the
construct of alexithymia. Future research will benefit from extending experimental
approaches to construct validation. Research is developing in the areas of physiological
assessment measures that provide feedback about physiological arousal and affective
states. This research will allow for better understanding of the specific somatic
experiences that accompany affective and cognitive processing of emotion. Furthermore.
neurobiological research on alexithymia is burgeoning and. as it progresses, we will learn
more about the particular mechanisms and systems involved in processing and translating
emotional stimuli.
Psychotherapeutic Interventions

In terms of therapeutic intervention, empirical studies need to be conducted to
investigate and validate the effectiveness of modified psychotherapies for alexithymic
individuals. Further research investigating the relationship among somatization. affect

dysregulation. and the development of chronic disease processes is warranted.

93

APPENDIX A

94

APPENDIX A

BES - Eating Habits Checklist Sub. #

Instructions: Below are groups of statements about eating. Read all of the statements in
each numbered group. Circle the letter next to the statement in each group which best
describes the way you feel about your eating.

#1

#2

 

I don’t feel self-conscious about my weight or body size when I’m with others.

I feel concerned about how I look to others. but it normally does not make me feel
disappointed with myself.

I do get self-conscious about my appearance and weight which makes me feel
disappointed with myself.

I feel very self-conscious about my weight and frequently, I feel intense shame

and disgust for myself. I try to avoid social contacts because of my self-
consciousness.

I don’t have any difficulty eating slowly in the proper manner.

Although I seem to “gobble down” foods, I don’t end up feeling stuffed because
of eating too much.

At times, I tend to eat quickly and then, I feel uncomfortably full afterward.

I have the habit of bolting down my food. without really chewing it. When this
happens I usually feel uncomfortably stuffed because I’ve eaten too much.

I feel capable to control my eating urges when I want to.
I feel like I have failed to control my eating more than the average person.
I feel utterly helpless when it comes to feeling in control of my eating urges.

Because I feel so helpless about controlling my eating, I have become very
desperate about trying to get in control.

95

BES - Eating Habits Checklist

#4

(“a

#5

#6

I don’t have the habit of eating when I am bored.

I sometimes eat when I’m bored. but I’m often able to “get busy” to get my mind
off of food.

I have a regular habit of eating foods when I’m bored. but occasionally, I can use
some other activity to get my mind off of eating.

I have strong habit of eating when I’m bored. Nothing seems to help me break
this habit.

I’m usually physically hungry when I eat something.
Occasionally. I eat something on impulse even though I’m not really hungry.

I have the regular habit of eating foods, that I really may not enjoy. to satisfy a
hungry feeling even though physically, I don’t need the food.

Even though I’m not physically hungry. I get a hungry feeling in my mouth that
only seems to be satisfied when I eat food, like a sandwich, that fills my mouth.

Sometimes, when I eat food to satisfy my mouth hunger, I spit the food out so I
won’t gain weight.

I don’t feel any guilt or self-hate after I overeat.
After I overeat. occasionally I feel guilt or self-hate.

Almost all the time I experience strong guilt or self-hate after I overeat.

96

BES - Eating Habits Checklist

#7

#8

#9

1 don’t lose total control of my eating when dieting even after periods when l
overeat.

Sometimes when I eat a “forbidden food” while on a diet, I feel like I “blew it”
and eat even more.

Frequently, I have the habit of saying to myself, “I’ve blown it now, why not go
all the way” when I overeat on a diet. When that happens I eat even more.

I have the regular habit of starting strict diets for myself. but I break the diets by
going on an eating binge. My life seems to be feast or famine.

I rarely eat so much that I feel uncomfortably stuffed afterward.

Usually about once a month. I eat such a quantity of food that I end up feeling
very stuffed.

I have regular periods during the month when I eat large amounts of food, either at
mealtime or at snacks.

I eat so much that I regularly feel quite uncomfortable after eating and sometimes
a bit nauseous.

My level of calorie intake does not go up very high or go down very low on a
regular basis.

Sometimes after I overeat. 1 will try to reduce my caloric intake to almost nothing
to make up for the excess calories I’ve eaten.

I have a regular habit of overeating during the night. It seems my routine is not to
be hungry in the morning but overeat in the evening.

In my adult years, I have had week-long periods in which I practically starved
myself. This follows periods when I overeat. Seems I live a life of feast or famine

97

BES - Eating Habits Checkli—st

#10

#11

#12

I am usually able to stop eating when I want to. I know when “enough is
enough”.

Every so often. I experience a compulsion to eat which I can’t seem to control.

Frequently. I experience strong urges to eat which I seem unable to control, but at
other times 1 can control my eating urges.

I feel incapable of controlling urges to eat. I have a fear of not being able to stop
eating voluntarily.

1 don’t usually have any problem stopping eating when I feel full.

I usually can stop eating when I feel full but occasionally I overeat, leaving me
feeling uncomfortably stuffed.

I have a problem stopping eating once I start and usually I feel uncomfortably
stuffed after I eat a meal.

Because I have a problem not being able to stop eating when I want, I sometimes
have to make myself vomit to relieve my stuffed feeling.

I seem to eat just as much when I’m with others (family, social gatherings) as
when I’m by myself.

Sometimes. when I’m with other people, I don’t eat as much as I want to eat
because I’m self-conscious about my eating.

F requently, I eat only a small amount of food when others are present. because
I’m very embarrassed about my eating.

I feel so ashamed about overeating that I pick times to overeat when I know no
one will see me. I feel like a “closet eater.”

98

BES - Eating Habits Checklist

#13

#14

#15

I eat three meals a day with an occasional between meal snack.
I eat three meals a day, but I also normally snack between meals.
When I am snacking heavily, I get in the habit of skipping regular meals.

There are regular periods when I seem to be continually eating. with no planned
meals.

I don’t think much about trying to control unwanted eating urges.

At some times. I feel my thoughts are preoccupied with trying to control my
eating urges.

Frequently I spend much time thinking how much I ate or about trying not to eat
more

It seems to me that most of my waking hours are preoccupied by thoughts about
eating or not eating. I feel like I’m constantly struggling not to eat.

I don’t think about food a great deal.
I have strong cravings for food but they only last for brief periods of time.
1 have days when I can’t seem to think about anything else but food.

Most of my days seem to be preoccupied with thoughts about food. I feel like 1
live to eat.

99

BES - Eating Habits Checklist

#16

a. I usually know whether or not I’m physically hungry. I take the right amount of
food to satisfy me.

b. Occasionally. I feel uncertain about knowing whether or not I’m physically
hungry. At these times, it’s hard to know how much food I should take to satisfy
me.

e. Even though I might know how many calories 1 should eat. I don’t have any idea

what is a “normal” amount of food for me.

100

APPENDIX B

101

APPENDIX B

TAS-20

Please indicate the extent to which you agree or disagree with each statement. Use the
following scale to indicate your answers: strongly disagree = 1; moderately disagree =
2; neither agree or disagree = 3; moderately agree = 4; strongly disagree = 5.

1. Iam often confused about what emotion I am feeling. 1 2 3 4 5
2. It is difficult for me to find the right words for my feelings. I 2 3 4 5
3. I have physical sensations that even doctors don’t understand. 1 2 3 4 5
4. I am able to describe my feelings easily. 1 2 3 4 5
5. I prefer to analyze problems rather than just describe them. 1 2 3 4 5
6. When I am upset, I don’t know if I am sad, frightened, or angry. I 2 3 4 5
7. I am often puzzled by sensations in my body. 1 2 3 4 5

8. I prefer to just let things happen rather than to understand

why they turned out that way. 1 2 3 4 5
9.1have feelings thatlcan’tquite identify. 1 2 3 4 5
10. Being in touch with emotions is essential. l 2 3 4 5

102

TAS-20

Please indicate the extent to which you agree or disagree with each statement. Use the
following scale to indicate your answers: strongly disagree = l; moderately disagree =
2; neither agree or disagree = 3; moderately agree = 4; strongly disagree = 5.

1 l. I find it hard to describe how I feel to people. 1 2 3 4 5
12. People tell me to describe my feelings more. 1 2 3 4 5
13. I don't know what’s going on inside of me. 1 2 3 4 5
14. I often don’t know why I am angry. I 2 3 4 5

15. I prefer to talk to people about their daily activities
rather than their feelings. I 2 3 4 5

16. I prefer to watch “light” entertainment shows rather
than psychological dramas. 1 2 3 4 5

17. It is difficult for me to reveal my innermost feelings,

even to close friends. 1 2 3 4 5
18. 1 can feel someone, even in moments of silence. I 2 3 4 5
19. 1 find examination of my feelings useful in l 2 3 4 5

solving personal problems.

20. Looking for hidden meanings in movies or plays
distracts from their enjoyment. I 2 3 4 5

103

APPENDIX C

104

APPENDIX C

TAT Sub. 4

Instructions:

On the next task, you will be using your imagination . You will be given six cards, one at
a time. The first five cards will provide a picture and the last card will be blank. Your
task will be to make up as dramatic a story as you can for each separate picture. For the
blank card. you will have to imagine a picture so that you can make up a story about that
p1cture.

You may make up each story any way you please. However, you should make sure to
describe what has led up to the event shown in the picture, what is happening at the
moment, what the characters in the picture are thinking and feeling, and an outcome or
ending for each story.

You will be given only one ( 1) card at a time and you may use up to five (5) minutes to
write a story about that picture. After five minutes, you will be given the next card. This
procedure will be followed for each of the six cards. Once you are finished with a card.
you will not be able to review it later.

Please do not write your name on the paper. It is important that only a subject number be
assigned to all data so that all participants may remain anonymous.

105

APPENDIX D

106

P T '7. “Quinn. 4'

APPENDIX D

SCI Sub. #
Please do not include your name or other identifying information.
Please answer the following questions to the best oLyour ability.

1.Age

2. Ethnic/Racial Background (check answer that best applies to you). If the categories do
not adequately apply to you. please check “other” and describe your ethnicity/race.

__ African-American/Black Asian-American East Indian
__ Anglo-Saxon/Caucasian American Indian West Indian
..__... Pacific Islander Latino/Hispanic other

3. Highest grade of school completed (please check the answer that best applies to you):

__ No school _ Two-Year/Associate Degree (e.g. AA)
__ Kindergarten - 5th grade __ Undergraduate degree (e.g. BA. BS)
__ 6th - 8th grade _ Some graduate school (pre-master’s)
__ 9th - 12th grade (no diploma) __ Master’s degree (e.g. MA, MBA)

__ High school diploma or GED. _ Some doctoral training (post-master’s)
__ Some college _ Doctoral degree (e.g. PhD, MD. DO)

4. Current Occupation (specify position):

 

5. Marital Status:

single. never married divorced
married widow
separated live with significant other

6. List any current prescription medication (if possible, include dosage/duration of use):

 

 

107

 

pg Sub. #

7. List any current over-the-counter medication (include dosage/duration of use)

 

 

 

8. List all current medical/physical problems for which you obtained medical
advise/treatment. (Indicate how long you’ve experienced the problem(s)).

 

 

9. Please check whether you have been diagnosed with any of the following conditions:
Past Present

chronic headaches / migraines

irritable bowel syndrome

ulcers/ ulcerative colitis

gastritis

asthma

rheumatoid arthritis

hypertension (high blood pressure)

dermatitis/ psoriasis / eczema

chronic fatigue syndrome

back pain

10. Is there any history of problems with your mood (e.g. anxiety. depression. etc...)
and/or other psychological problems (e.g. phobic. obsessive-compulsive disorders).
Please list below and describe as needed:

 

 

1 1. Have you ever been prescribed medications for treatment of problems listed in
question # 10? If yes. list problem. medication, duration of use. and treatment provider
source (e.g.. family physician, psychiatrist, etc..).

 

 

108

SQ Sub. #

13. Have you ever been involved in psychotherapy/counseling for problems listed in
questions # 8. #9, or #10?

I£y_e_§. list problem, treatment provider source (e.g., psychologist, psychiatrist. counselor
etc..) and approximate length of treatment (e.g.. duration and/or number of sessions).

 

 

14. Do you believe that you abuse and/or have problems with any of the following:
(check all that apply):

 

‘1
__ alcohol __ prescription medication fi
__ over the counter medication other substances/drugs

__ gambling (lottery, slots, etc.) shopping

__ nicotine/cigarettes food/eating

15. If yes to any item in #14, indicate whether you received treatment for these problems
and indicate type of provider (e.g., psychologist, psychiatrist, counselor, etc..)

 

 

16. Have you ever attended any self-help/ 12-step groups for yourself (e.g., Overeaters
Anonymous, Gamblers Anonymous, etc.)‘? Indicate duration and/or # of groups attended.

 

 

17. Indicate your height ft. in. Indicate current weight lbs.

18. C heck the answer that YOU believe describes your weight compared to your height:
underweight average weight mildly overweight

moderately overweight severely overweight

109

S 1 Sub. #

19. When using the term “diet”, what is YOUR intention/ end-point /goal of dieting:
C 'heck all that apply, but circle your primary goal:

__ to lose pounds __ better fit in clothes

____ to reduce fat __ fit into smaller size clothing
__ to tone /shape my body _ build muscle

__ cardiovascular fitness __ general fitness

specify other:

 

20. If you are dieting currently, what methods are being used? Check all that apply:

__ reduce intake of amount of food _ increase cardiovascular exercise
__ reduce intake of total calories __ weight training /resistance training
__ reduce intake of fat calories _ water pills/diuretics

__ diet pills __ laxatives

_ vomiting _ diet supplements (e.g., Herbalife)

1 am not dieting at the present time specify other:

 

21. In the past. what dieting methods have you used? Check a_ll that apply:

__ reduce intake of amount of food __ increase cardiovascular exercise
__ reduce intake of total calories _ weight training /resistance training
____ reduce intake of fat calories __ water pills/diuretics

__ diet pills _ laxatives

______ vomiting _ diet supplements (e.g., Herbalife)
__ I have never dieted in the past specify other:

 

22. Have you ever been prescribed medication for any eating problems? Indicate type
of professional (e. g.. psychiatrist. primary care physician) and medications prescribed:

 

 

23. Have you ever had surgery to reduce body size/weight (e.g. stomach stapled.
liposuction)? Please describe as needed:

 

110

S_Q Sub. #

24. Have you ever had an inpatient hospitalization stay related to eating problems?
If yes, please describe and indicate year / duration of hospital stay.

 

25. Have you ever sought psychotherapy / counseling for eating problems? Please
indicate type of professional (e.g. psychologist, psychiatrist, counselor) and describe
treatment process (e.g.. talking therapy. homework assignments, weight/exercise charts)

 

 

26. Have you ever been enrolled in a formal weight-loss program (e.g., Weight Watchers.
Jenny Craig etc..). List type and past or current use of program.

 

 

27. Were you ever overweight as a(n) 28. Were you ever underweight as a(n)
I have never been overweight I have never been underweight
. child (1 1 yrs. old or younger) child (11 yrs. old or younger)
adolescent (12 -17 yrs. old) adolescent (12 -17 yrs. old)

adult (18 yrs. old or older) adult (18 yrs. old or older)

APPENDIX E

112

APPENDIX E

CONSENT TO PARTICIPATE IN RESEARCH

 

This research project will require approximately 60 to 90-minutes of your time for
which you will be paid $5.00 immediately following your participation. The study
involves questionnaire and assessment measures to clarify characteristics of individuals
seeking support/assistance with eating and weight concerns. Your participation in this
study will help the investigators better understand the needs of individuals seeking weight
loss services so that future services may be improved. Some of the measures used in the
study require that participants report past and present health information.

Participants must be over 18 years of age to participate. Individuals who
participate in this study do so on a free and voluntary basis. This means that individuals
may refuse to participate at all, refuse to complete certain measures, or may discontinue
participation in the study at any time without penalty. The study does not involve
experimental procedures or treatment of any kind. There are no significant risks
associated with participation in this study. Your signature below will indicate that 1) you
are voluntarily participating in this study, 2) any risks and benefits have been explained to
you. 3) you understand those risks and benefits, and 4) you will receive a copy of this
statement.

Total anonymity and confidentiality will be maintained. Subject numbers will be
assigned to all data/responses and no names will be recorded or associated with specific
responses or findings. Your signed consent form will be kept separate from your
responses.

If you have questions about this study. contact:

Regina O’Connell, MA. (856-251-1459)
Bert Karon, Ph.D. (517-355-2154)
Department of Psychology

129 Psychology Research Building
Michigan State University

East Lansing. MI 48824-11 l7

 

 

Witness Signature

 

Date

113

CONSENT TO PARTICIPATE IN RESEARCH

 

This research project will require approximately 60 - 90 minutes of your time.
The study involves questionnaire and assessment measures to clarify characteristics of
individuals seeking support/assistance with eating and weight concerns. Your
participation in this study will help the investigators better understand the needs of
individuals seeking weight loss services so that future services may be improved. Some
of the measures used in the study require that participants report past and present health
information.

Participants must be over 18 years of age to participate. Individuals who
participate in this study do so on a free and voluntary basis. This means that individuals
may refuse to participate at all, refuse to complete certain measures. or may discontinue
participation in the study at any time without penalty. The study does not involve
experimental procedures or treatment of any kind. There are no significant risks
associated with participation in this study. Your signature below will indicate that 1) you
are voluntarily participating in this study. 2) any risks and benefits have been explained to
you. 3) you understand those risks and benefits, and 4) you will receive a copy of this
statement.

Total anonymity and confidentiality will be maintained. Subject numbers will be
assigned to all data/responses and no names will be recorded or associated with specific
responses or findings. Your signed consent form will be kept separate from your
responses.

If you have questions about this study. contact:

Regina O’Connell, MA. (856—251-1459)
Bert Karon, Ph.D. (517-355-2154)
Department of Psychology

129 Psychology Research Building
Michigan State University

East Lansing, MI 48824-1117

 

 

Witness Signature

 

Date

114

LIST OF REFERENCES

115

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