The relationship between alexithymia, shame, trauma, and body image disorders

Neuropsychiatric Disease and Treatment
2013:9 185–193

Background: The connections between eating disorders (EDs) and alexithymia have not been fully clarified. This study aims to define alexithymia’s connections with shame, trauma, dissociation, and body image disorders.
Methods: We administered the Dissociative Experience Scale-II, Trauma Symptom Inventory, Experience of Shame Scale, Toronto Alexithymia Scale-20, and Body Uneasiness Test questionnaires to 143 ED subjects. Extensive statistical analyses were performed.
Results: The subjects showed higher scores on alexithymia, shame, dissociation, and traumatic feelings scales than the nonclinical population. These aspects are linked with each other in a statistically significant way. Partial correlations highlighted that feelings of shame are correlated to body dissatisfaction, irrespective of trauma or depressed mood. Multiple regression analysis demonstrates that shame (anorexic patients) and perceived traumatic conditions (bulimic and ED not otherwise specified) are associated with adverse image disorders.
Conclusion: Shame seems to hold a central role in the perception of an adverse self-image. Alexithymia may be interpreted as being a consequence of previous unelaborated traumatic experiences and feelings of shame, and it could therefore be conceptualized as a maladaptive–reactive construct.
Keywords: eating disorders, trauma, alexithymia, shame, body image



Alexithymia is a construct characterized by the difficulty in identifying and describing feelings (affective factors), and by concrete and externally oriented thinking (cognitive factors).1 Eating disorders (EDs) are recognized in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) as separate disorders: anorexia nervosa (AN), bulimia nervosa (BN), and ED not otherwise specified (EDNOS). However, many people with serious EDs do not fit neatly into these categories, or they may change between categories over time.2 The etiologic multifactorial model where biological, individual, and environmental aspects interact seems to be the one that best explains the onset of EDs.3

The association between EDs and alexithymia has been widely demonstrated. For instance, Corcos et al4identified that ED patients showed a statistically significant difference insofar as patients with ED were more likely to exhibit alexithymia when compared to a nonclinical population; these data were recently confirmed by Karukivi et al5 in a sample of older adolescents. Moreover, a prognostic study by Speranza et al6 investigating 102 ED patients demonstrated that difficulty in identifying feelings can act as a negative prognostic factor in the long-term outcomes of EDs. De Berardis et al7 studied the relationship between alexithymia, dissociative experiences, and low self-esteem in 546 undergraduate females, stating that a combination of these three constructs may represent risk factors for developing the symptoms of EDs. However, the relationship between EDs and alexithymia is not completely understood; ED patients that are being treated may continue to score high on measures of alexithymia, even when food-related abnormal behaviors have remitted.8 Moreover, the cognitive component of alexithymia does not appear to be related to EDs.9 Therefore, the relationship between EDs and alexithymia may be mediated by a third factor,10and these two conditions are also associated with affective disorders.11

When looking for factors that may act as a link between alexithymia and EDs, the literature states that higher levels of dissociation are associated with severe bulimia,12 and that anorexic patients appear to use dissociation in order to avoid processing anger;13 it should be underlined that alexithymia and dissociation are both related to the failure of an individual to integrate his or her perceptions and emotions into his or her conscious experience. Dissociative experiences and alexithymia may be considered to be a coping mechanism that is used to alleviate painful emotions.14 In fact, nonelaborated and painful emotions produce a sense of tension that is perceived as dangerous for the subject’s inner integrity, and, therefore, the dissociative mind states are possible defense mechanisms against anxiety.15

Among the various feelings experienced by ED patients, shame seems to play a central role. Shame can be regarded as the effect of dysregulated emotions experienced during childhood,16 which increase the possibility of dissociative mind states.17 Moreover, bodily shame has been found to predict an increase in anorexic symptoms.18 Thus, this study aims to investigate the presence of alexithymia in EDs.

With this research, we want to verify whether alexithymia could be associated with and have an influence on the structure of an adverse image disorder; however, the presence of other factors mediating the relationship between affective dysregulation and body image disorders has been postulated.10 Therefore, we investigated several variables that represent a core feature in the ED psychopathology – namely, dissociation, shame, affective disorders, and trauma – in order to determine which one may demonstrate a possible link between alexithymia and body image disorders in EDs.

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