Alexithymia, emotional empathy, and self-regulation in anorexia nervosa
Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
Una Mano per la Vita, Clinics and Association of Families and their Doctors, San Giovanni La Punta, Italy, Universidad Diego Portales, Santiago, Chile
Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, USALaurie M. McCormick, MD
Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
BACKGROUND: Individuals with anorexia nervosa (AN) who are starved have poor awareness (alexithymia), reduced understanding of others’ mental states (cognitive empathy), and difficulty regulating personal emotions (self-regulation). Despite its important role in social interaction, sympathy for others (emotional empathy) has not been measured in AN. Furthermore, it is unknown how restoring weight affects the relationship among alexithymia, empathy, and self-regulation in AN.
METHODS: Women with AN were tested longitudinally during their starvation period (N = 26) and after weight was restored (N = 20) and compared with 16 age-matched healthy women. Alexithymia, empathy, and self-regulation were assessed with the Toronto Alexithymia Scale, the Interpersonal Reactivity Index, and items measuring self-regulation from the Minnesota Multiphasic Personality Inventory–2, respectively.
RESULTS: Relative to comparison participants, individuals with AN during both starvation and weight restoration reported greater alexithymia and emotional empathy in one domain, personal distress (vicarious negative arousal to others’ suffering). Among AN participants, personal distress was positively correlated with alexithymia and negatively correlated with self-regulation, when accounting for depression.
CONCLUSIONS: High levels of alexithymia and personal distress may be persistent features of AN because they do not resolve upon weight restoration. Greater personal distress in AN may be a function of poor emotional awareness and regulation.
KEYWORDS: anorexia nervosa, social cognition, alexithymia, empathy, self-regulation, weight effects, starvation
ANNALS OF CLINICAL PSYCHIATRY 2013;25(2):107-120
Numerous studies have suggested that people who develop anorexia nervosa (AN) have poor awareness of their own emotions during the starvation period and after weight has been restored,1-4 a psychological process termed alexithymia,5,6 which may be a heritable vulnerability factor for AN.7 Furthermore, previous research suggests that individuals with AN have lower cognitive empathy than healthy adults, or the understanding of others’ mental states.8-11 However, the extent to which poor cognitive empathy persists upon weight restoration has not been well characterized longitudinally. Individuals with AN also have difficulties regulating their own emotions,12,13 which is thought to influence their emotional understanding of others.
Whereas the cognitive domain of empathy has been investigated in AN, the emotional domain of empathy (ie, vicariously experiencing the emotions of others or feeling sympathy) largely has been ignored despite its critical role in interpersonal relationships, which are widely known to be deficient in individuals with AN. Moreover, associations between empathy, alexithymia, and self-regulation have not been fully characterized in individuals with AN longitudinally from the point at which they are severely starved to when their weight has been restored due to clinical treatment. The present study addresses this gap in the literature by investigating alexithymia, empathy, and self-regulation longitudinally in the same individuals to examine effects of both starvation and weight restoration as well as relationships among these psychological processes in AN.
It is well established that alexithymia is greater in individuals with AN during the acute starvation/malnutrition phase than in healthy comparison (HC) individuals.1,2,4,14-16 There also is growing evidence that even when weight has been restored, individuals with AN continue to report higher alexithymia scores than HC individuals.3,4,17 Many individuals with AN also experience depression during the starvation period of AN and this may contribute to greater alexithymia during this phase.14,16,17 Studies of individuals with AN in the starvation phase have found mixed results regarding the effect of depression on alexithymia.14,16 For example, one study found that alexithymia in individuals with AN did not differ from HC individuals after accounting for depression,14 whereas another study demonstrated that individuals with AN had higher alexithymia on one of the 3 Toronto Alexithymia Scale (TAS-20) factors (Difficulty Describing Feelings [DDF]) when depression was considered.16 The first step in resolving this debate may be the study by Speranza et al17 that investigated alexithymia longitudinally over 3 years in individuals with AN and found that even after accounting for eating disorder symptom and depression severity, the Difficulty Identifying Feelings factor of the TAS-20 predicted treatment outcome. An additional issue may be the effects of antidepressant use on alexithymia scores, because it is has been reported that antidepressants may lead to emotional blunting,18,19 and some individuals with AN may be treated with antidepressants for their depression during the starvation phase.
A number of studies have found that individuals who are in the acute, starvation phase of AN have reduced capacity for cognitive empathy.8-11 Cognitive empathy refers to adopting others’ mental states, through imagination and perspective taking,20-23 in order to detect their thoughts, feelings, and motivations.24 Cognitive empathy studies have shown that during starvation, individuals with AN perform poorly on a variety of mental state detection tasks that use different types of stimuli, including emotional expressions in the eye region of the face and in the voice, as well as those depicted in films and written vignettes.8-11
There is mixed evidence for the degree to which difficulties in detecting mental states improve in individuals with AN upon weight restoration.9,10 A cross-sectional study comparing individuals with AN in the starvation phase with a group of individuals who previously had AN but had been weight restored for at least 1 year found that difficulties discerning others’ mental state through voices or films were greatest in the AN starvation group, but the restored AN group performed similarly to the HC group.10 In contrast, individuals who were fully recovered from AN and were 18 years post-AN diagnosis had poorer performance detecting others’ feelings from cartoons (Happé’s mental cartoons task) than did healthy matched comparison participants.9 Therefore, further research is needed to elucidate the degree to which cognitive empathy difficulties persist longitudinally in the same individuals with AN during starvation and upon weight restoration several months later.
Currently, it is unclear whether emotional empathy is abnormal or fluctuates with weight changes in individuals with AN. One’s capacity for emotional empathy plays an important role in social interaction because it has been consistently and directly linked to social bonding and empathetic behaviors in healthy adults, such as helping others in need20,25,26 and also is linked to greater relationship satisfaction.27 Emotional empathy is thought to comprise 2 components: 1) empathic concern, ie, experiencing compassion and sympathy for others in need, and 2) personal distress, ie, experiencing negative arousal involving feelings of unease and upset in response to seeing another person suffer.21,28 Previous research in healthy adults has shown that individuals with high levels of alexithymia (scores >60 on the TAS-20) typically have low empathic concern but high personal distress, as measured by the Interpersonal Reactivity Index (IRI).21,29 This suggests that high levels of alexithymia and emotional empathy may co-occur in the same individual. However, the direct association between these 2 types of emotional empathy and alexithymia has not been examined in individuals with AN. Although normal or high levels of empathic concern are important for relationship satisfaction,27 it is likely that personal distress may cause individuals to withdraw from relationships in order to reduce negative emotions they may feel as a consequence of viewing another person’s suffering. In healthy adults, self-regulation strategies can be used to reduce personal distress in order to allow for feelings of sympathy and helping others in need.30
Poor self-regulation is known to be pervasive in individuals with AN, and this may have potential effects on emotional empathy. Approximately 25% of individuals with AN meet criteria for an avoidant personality disorder,31-33 which includes avoidance or suppression of negative emotions. Self-regulation measures the degree to which an individual controls personal thoughts, behaviors, and feelings.34 Previous self-regulation studies have found that individuals with AN show poor reappraisal (ie, reframing thoughts and emotions in a more positive direction) and high suppression (ie, modifying one’s behavioral response to an event).12,13
Social and emotional impairments found in the starvation phase of AN may recover upon weight restoration.10,35 The first study to investigate the effect of starvation on social and emotional processing was reported by Keys et al in the 1950s.36 This study provided evidence that starvation (and low body mass index [BMI]) among men following a severely restricted diet of 6 months’ duration produced social withdrawal, which had not been observed prior to starvation. A more recent study of starved individuals with AN found that they too had poorer accuracy in determining the mental states of others from voices and films than a separate sample of participants with AN who had recovered their weight.10 However, there also is evidence that a subset of individuals with AN may demonstrate difficulties with social interaction similar to that of Asperger’s disorder and obsessive-compulsive disorder (OCD) that are still present at 10-year follow-up.37 Furthermore, many individuals who go on to develop AN have shown poor social functioning prior to illness onset; for example, the majority of individuals with AN in one study reported that before age 10 they had either no friendships or only superficial acquaintances.38 Thus, social and emotional impairment in AN may be a vulnerability factor that precedes illness onset and continues after recovery.37,38
In the present study, the effect of weight changes on self-reported alexithymia and emotional empathy were assessed among patients with AN who participated in a longitudinal study. Relationships among alexithymia, emotional empathy, and self-regulation were examined. Because individuals with AN during the starvation phase have low BMIs and high levels of depression relative to HC individuals, these variables were accounted for when investigating the effects of weight restoration on alexithymia and emotional empathy.
It was hypothesized that participants with AN would show: 1) greater alexithymia, lower emotional empathy, and lower self-regulation than HC participants during the starvation phase, and 2) lower alexithymia, higher emotional empathy, and higher self-regulation upon weight restoration than during the starvation phase (thus showing a tendency to return toward baseline), but they would still significantly differ from the HC group. If the predicted results were found, AN participants’ scores on alexithymia, emotional empathy, and self-regulation would reflect both a state effect (due to starvation in the acute phase of the illness) and a trait effect of AN (potentially a vulnerability to develop the illness). Furthermore, based on previous research in healthy adults, it was predicted that alexithymia would be negatively related to the empathic concern domain of emotional empathy and positively related to the personal distress domain in participants with AN.29 Lastly, based on a study in healthy adults,30 it was hypothesized that self-regulation would be positively associated with empathic concern and negatively associated with personal distress.
As part of a longitudinal study of women with AN approved by the institutional review board at the University of Iowa (Iowa City, IA, USA), participants were assessed with a comprehensive battery of clinical, cognitive, and personality measures during starvation shortly after being hospitalized for treatment. Participants completed the informed consent process prior to testing. Repeated testing was carried out after weight restoration during the hospitalization period or during care in a partial hospitalization program following hospitalization. The inpatient eating disorder program at the University of Iowa consists of daily cognitive-behavioral therapy (CBT) groups and individual therapy, supervised eating, occupational and recreational therapy, as well as physician supervision.
Study participants included 26 individuals with AN who were severely starved and were hospitalized with the main goal of weight restoration (Time 1). Of these AN participants, 20 were reassessed after weight restoration (Time 2) (TABLE). Testing of AN participants at Time 2 typically occurred after body weight was restored to a BMI of ≥18.5 kg/m2 (mean [M] = 20.28; standard deviation [SD] = 1.32). This testing took place approximately 1.35 days (SD = 10.22) after the patients’ last day of treatment in either the hospital or the partial hospitalization program (16 of the 20 patients available for testing at Time 2 had transitioned to the partial hospitalization program). AN participants had not been weight restored for an extended period of time before testing. These participants are part of a longitudinal study that also involves a 1-year follow-up visit. Testing for this third time point is ongoing and is not included in the present study.
AN participants were also characterized by subtype: either Restricting or Binge-Purge (TABLE). Concurrent major depressive and borderline personality disorder (BPD) diagnoses were recorded as well as antidepressant treatment. Participants were interviewed regarding antidepressant, antipsychotic, and anxiolytic use, and their responses were subsequently corroborated via chart review.
The participants with AN were compared with 16 sex- and age-matched HC women who were tested at the same time intervals as the patients with AN to control for differences that could be attributed to the length of time between sessions. Fifteen of the 16 HC participants returned for testing at Time 2.
Demographic, cognitive, and clinical assessments in participants with AN and HC participants
||HC participants (N = 16)a
|AN participants Time 1 (N = 26)a
|AN vs HC participants Time 1b (P)
||AN participants Time 2 (n = 20)c
|AN participants Time 1 vs Time 2d (P)
||R = 57.7%, BP = 42.3%
|Comorbid depressive disorder
|Comorbid borderline personality disorder
|Stroop Interference T-score
|CPT II Perseveration score
|WCST: CV4 perseverative errors
Clinical assessments. Eating disorder symptoms were assessed by the Eating Attitudes Test39,40 and the Eating Disorder Inventory–3,41 and obsessions and compulsions related to eating disorder symptoms were measured by the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS).42,43 Current levels of depression and anxiety were assessed by the Hamilton Depression Rating Scale (HDRS)44 and the Hamilton Anxiety Rating Scale (HARS),45 respectively. (At Time 1, one AN individual and one HC participant were not available to complete the YBC-EDS, and at Time 2, a second AN individual did not complete this scale. For the HDRS and HARS, at Time 1, one HC participant did not complete these questionnaires, and at Time 2, one AN individual did not complete these questionnaires.)
Cognitive assessments. The Wechsler Adult Intelligence Score–Fourth Edition (WAIS-IV) measured Full Scale IQ.46,47 Attentional ability (sustained attention) was tested by the Conners’ Continuous Performance Test II (CPT II).48 To assess cognitive flexibility, ie, the ability of individuals to disengage from one process or task and engage effectively in another task, the Stroop Color and Word Test49 and the Wisconsin Card Sorting Test–Computer Version 4 (WCST:CV4)50 were used. (For Time 1, one individual with AN was unable to complete the CPT II, and one HC participant was not available to complete the WAIS-IV, Stroop Color and Word Test, CPT II, and WCST:CV4. For Time 2, two individuals with AN were not able to complete the Stroop Color and Word Test, and 3 were not available to complete the WCST:CV4.)
Alexithymia, empathy, and self-regulation assessments. Alexithymia was measured by the TAS-20,51,52 a standard and reliable measure of an individual’s difficulties identifying and describing personal emotions. This scale51,52 includes 3 factors: 1) Difficulty Identifying Feelings (DIF), 2) DDF, and 3) Externally Oriented Thinking (EOT). Empathy was assessed through the Interpersonal Reactivity Index (IRI), a valid, multidimensional self-report measure.21 (For the Time 2 assessment, only a subsample of participants were able to complete the IRI, resulting in a sample size of N = 12 for the AN group, whereas for the TAS-20 all AN individuals who returned at Time 2 completed this measure. All HC individuals who returned at Time 2 completed the IRI and TAS-20.) This questionnaire assesses cognitive empathy through 2 subscales—Perspective Taking and Fantasy, measuring one’s ability to mentally adopt others’ thoughts and feelings, and in the case of the Fantasy subscale, that of fictional characters in books and movies.21 Emotional empathy is assessed in the IRI through the Empathic Concern subscale (IRI-EC), measuring the degree to which individuals feel sympathy and compassion for others in need, and the Personal Distress subscale (IRI-PD), which assesses vicarious negative emotions and arousal due to seeing others’ suffering.21 Self-regulation was assessed by 37 items from the Minnesota Multiphasic Personality Inventory–2 (MMPI-2)53 that measure the regulation of feelings, thoughts, and behavior.34 This subset of items from the MMPI-2 previously has been used to measure self-regulation in a longitudinal study of older adults.34 It has been shown that this self-regulation scale has good construct validity because the items are comparable to those of previously validated measures of self-regulation (eg, Values in Action Inventory of Strengths and Self-Control Scale) and has adequate internal consistency reliability (Cronbach α = 0.75).34
Differences in descriptive demographic, cognitive, clinical, and personality characteristics between participants with AN and HC participants at Time 1 were assessed using independent-samples t tests. Paired-samples t tests were used to investigate differences between the starvation and weight restoration phases within the AN group.
Primary hypotheses were examined using repeated-measures analysis of variance (ANOVA) on alexithymia, and emotional empathy scores using time of assessment (starvation phase, Time 1; and weight restoration phase, Time 2) as the within-subjects’ variable, and group membership (individuals with AN and HC participants) as the between-subjects’ independent variables. Significant results from the ANOVA analysis were followed up with Bonferroni-corrected t tests. Because previous literature has suggested a relationship between depression and alexithymia in AN, the repeated-measures ANOVA examining alexithymia over time was repeated with the inclusion of the covariate depression change score (Time 2 minus Time 1) measured by the HDRS. In addition, Pearson product-moment correlations were computed to examine relationships between alexithymia, emotional empathy, and self-regulation. Partial correlations were used to investigate relationships between these variables, controlling for depression and/or BMI when relevant.
Demographic, cognitive, and clinical characteristics of individuals with AN and HC participants
Demographic, cognitive, and clinical characteristics were compared between individuals with AN in the starvation period and HC participants at Time 1, and between the starvation phase and the weight restoration phase within the AN group (TABLE).
Alexithymia in AN during starvation and after weight restoration
The effect of weight restoration on alexithymia was assessed using an omnibus repeated-measures ANOVA comparing TAS-20 total scores as a function of time point (Time 1, starvation period; Time 2, weight restoration period) and group (AN, HC participants) (FIGURE 1). Participants with AN reported greater TAS-20 total scores than HC participants overall (F[1,33] = 30.21; P < .001; partial eta2 = .48; AN: M = 51.85; standard error [SE] = 1.90; comparison: M = 35.87; SE = 2.20). Overall, the sample had higher scores at Time 1 than at Time 2 (F[1,33] = 7.41; P < .05; partial eta2 = .18; Time 1: M = 46.28; SE = 1.72; Time 2: M = 41.43; SE = 1.69). However, this main effect was further clarified by a significant time point by group interaction (F[1,33] = 8.68; P < .01; partial eta2 = .21). This interaction addressed the primary research question, whether alexithymia differed in individuals with AN as a function of weight restoration. Bonferroni-corrected follow-up t tests indicated that participants with AN showed a significant decrease in alexithymia from the starvation period to the weight restoration period (P < .001), whereas the healthy volunteers showed no difference (P = .88). Participants with AN reported significantly greater alexithymia scores relative to HC participants at both Time 1 (P < .001) and Time 2 (P < .01).
FIGURE 1: Alexithymia in participants with AN during starvation and weight restoration relative to comparison participants
aP < .01
bP < .001
Alexithymia was measured by the TAS-20 at Time 1 (the starvation phase of AN) and Time 2 (the weight restoration phase of AN) in participants with AN and in healthy comparison participants.
Error bars reflect standard error.
AN: participants with anorexia nervosa; HC: healthy comparison participants; TAS-20: Toronto Alexithymia Scale.
Next, because the omnibus ANOVA revealed that weight restoration did have an effect on TAS-20 total scores in AN, the effect of weight restoration on each of the TAS-20 factors (DIF, DDF, and EOT) was examined through a series of planned comparisons that included repeated-measures ANOVA to investigate the effect of group and time point on each TAS-20 factor (FIGURE 2).
These analyses revealed that for the DIF factor, there were significant effects of time point (F[1,33] = 11.15; P < .01; partial eta2 = .25), group (F[1,33] = 29.32; P < .001; partial eta2 = .47), and a time point × group effect (F[1,33] = 8.82; P < .01; partial eta2 = .21). Follow-up Bonferroni-corrected t tests indicated that individuals with AN reported higher scores than HC participants at Time 1 (P < .001) (FIGURE 2) and Time 2 (P < .01). Within the AN group, participants reported higher scores at starvation than at weight restoration on the DIF factor (P < .001), but there was no effect of time point within the HC group (P = .81).
FIGURE 2: TAS-20 factor scores in participants with AN during starvation and weight restoration relative to comparison participants
aP < .05
bP < .01
cP < .001
Alexithymia in AN during starvation (Time 1) and weight restoration (Time 2) relative to healthy comparison participants was measured by 3 factors from the TAS-20, represented in the 3 panels: 2A: Factor 1 – DIF; 2B: Factor 2 – DDF; and 2C: Factor 3 – EOT.
Error bars reflect standard error.
AN: participants with anorexia nervosa; DDF: difficulty describing feelings; DIF: difficulty identifying feelings; EOT: externally oriented thinking; HC: healthy comparison participants; TAS-20: Toronto Alexithymia Scale.
For the DDF factor, there was no group by time point interaction (F[1,33] = 1.84; P = .18; partial eta2 = .05), but there were significant main effects of time point (F[1,33] = 5.76; P < .05; partial eta2 = .15) and group (F[1,33] = 18.88; P < .001; partial eta2 = .36). Follow-up tests indicated that participants with AN had higher scores on the DDF factor than HC participants overall (P < .001; AN: M = 14.25; SE = .73; comparison: M = 9.40; SE = .84), and the sample as a whole reported higher scores on this factor at Time 1 than Time 2 (P < .05; Time 1: M = 12.59; SE = .64; Time 2: M = 11.06; SE = .64).
For the EOT factor, there was also a significant interaction between time point and group (F[1,33] = 5.23; P < .05; partial eta2 = .14). In addition, there was a significant main effect of group (F[1,33] = 7.48; P < .05; partial eta2 = .19), but no main effect of time point (F[1,33] = .16; P = .69; partial eta2 = .01). Follow-up tests revealed that participants with AN had greater scores on the EOT factor than HC participants at Time 1 (P < .001), but not Time 2 (P = .63). Within the AN group, participants reported higher scores at starvation than weight restoration (P < .05).
In summary, in the starvation phase, individuals with AN had higher scores than HC participants on the first (DIF) and third (EOT) TAS-20 factors. On the DIF factor, individuals with AN also demonstrated higher scores than HC participants upon weight restoration. Within the AN group, there was a decrease in DIF factor scores upon weight restoration (relative to starvation). For the EOT factor, individuals with AN showed decreased scores upon weight restoration (compared with starvation) but did not differ from HC participants during the weight restoration phase. Finally, for the second TAS-20 factor, DDF, individuals with AN had higher scores than HC participants overall, but there was no difference between the starvation and weight restoration phases.
Relationships between alexithymia, depression, and treatment
The extent to which depression affected alexithymia in AN and HC participants was considered. At Time 1 among AN participants, there was a moderate, positive relationship between TAS-20 and HDRS depression scores (r = .57; P < .01). Thus, the covariate depression change score between Time 1 and Time 2 (HDRS score) was included in a repeated-measures ANOVA comparing individuals with AN with the HC participants on TAS-20 total scores at Times 1 and 2. The significant interaction between time of assessment and group reported in the preceding section was no longer significant (F[1,31] = 0; P = 1; partial eta2 = 0). However, participants with AN still showed greater TAS-20 total scores than healthy participants at the group level when depression was accounted for (F[1,31] = 11.60; P < .01; partial eta2 = .27; AN: M = 50.45 [SE = 2.27]; comparison: M = 37.10 [SE = 2.64]).
Next, effects of depression on TAS-20 factors in the AN and HC participant groups were considered. Similar to the finding for the TAS-20 total score, the inclusion of the depression change score as a covariate in the analysis of the DIF TAS-20 factor resulted in the time point by group interaction no longer reaching significance (F[1,31] = .11; P = .74; partial eta2 = .004). The main effect of group remained significant, with AN participants reporting higher scores on this factor than HC participants (F[1,31] = 9.98; P < .01; partial eta2 = .24; AN: M = 16.97; SE = 1.26; comparison: M = 10.07; SE = 1.47). For the EOT factor, including the depression change score also resulted in the time point × group interaction no longer being significant (F[1,31] = .28; P = .60; partial eta2 = .01). Similar to the DIF factor, AN participants showed greater scores on the EOT factor than HC participants overall (F[1,31] = 4.48; P < .05; partial eta2 = .13; AN: M = 19.76; SE = .66; comparison: M = 17.34; SE = .77). For the DDF factor, the main effect of group remained after considering depression change score as a covariate (F[1,31] = 7.56; P < .05; partial eta2 = .20; AN: M = 13.71; SE = .84; comparison: M = 9.70; SE = .98). Therefore, after accounting for the change in depression scores from the starvation to the weight restoration period, individuals with AN had higher scores than HC participants on all 3 TAS-20 factors, but there was no longer a significant effect of weight restoration.
There is a possibility that alexithymia scores of individuals with AN may have been affected by other relevant factors, such as taking antidepressants, which has been linked to reduced emotional awareness,18,19 or degree of cognitive therapy. In the present sample, there was variability in the number of hospitalizations each AN individual had undergone previously, and each of these instances included cognitive therapy. Therefore, exploratory analyses were conducted to assess the degree to which alexithymia (TAS-20 total score) was affected by antidepressant treatment and cognitive therapy (as a proxy, measured by the number of previous hospitalizations for AN). These preliminary results indicated that antidepressant use and hospitalization did not significantly affect alexithymia in the present sample. AN participants who were or were not taking antidepressants at the time of the study did not differ on their TAS-20 scores either during starvation or weight restoration (starvation: t = 1.41; P = .17; weight restoration: t = .71; P = .49). The effect of prior hospitalizations was not statistically significant both at Time 1 (t = .27; P = .80) and Time 2 (t = .61; P = .55). Because these variables did not significantly affect TAS-20 total score, follow-up analyses on the TAS-20 factors were not conducted.
Empathy in AN
A repeated measures ANOVA was computed using emotional empathy (average of responses to Empathic Concern and Personal Distress subscales on the IRI) as the dependent variable, and time point and group as independent variables. The main effect of group was found to be significant (F[1,25] = 16.88; P < .001; partial eta2 = .40), indicating that individuals with AN reported greater emotional empathy than comparison participants overall (FIGURE 3). There was no significant effect of assessment time point (F[1,25] = 1.83; P = .19; partial eta2 = .07) nor a significant time point by group interaction (F[1,25] = 2.74; P = .11; partial eta2 = .10).
FIGURE 3: Emotional empathy in AN during starvation and weight restoration relative to comparison participants
aP < .001
Emotional empathy was assessed by taking the average of the Empathic Concern and Personal Distress subscales for each participant on the IRI. This was measured at Time 1 (the starvation phase of AN) and Time 2 (the weight restoration phase of AN) in participants with AN and in healthy comparison participants.
Error bars reflect standard error.
AN: participants with anorexia nervosa; HC: healthy comparison participants; IRI: Interpersonal Reactivity Index.
To ascertain if specific aspects of emotional empathy were greater in AN relative to comparison participants, planned comparisons were used to investigate participants with AN and healthy participants on 2 aspects of emotional empathy: Empathic Concern (IRI-EC) and Personal Distress (IRI-PD). Because there were no significant effects of time point on emotional empathy, participants’ scores on the empathy measures were averaged across the 2 time points. Participants with AN showed greater Personal Distress than HC participants (t = 4.14; P < .001; AN: M = 14.33; SE = 1.54; comparison: M = 7.47; SE = .83). The effect of Empathic Concern for individuals with AN was marginally significant relative to HC participants (t = 2.02; P = .06; AN: M = 22.25; SE = .87; comparison: M = 19.33; SE = 1.09).
For completeness, cognitive empathy (measured by the average of the IRI-Fantasy and Perspective Taking subscales) also was examined. This analysis showed no significant main effects of time point (F[1,25] = 1.38; P = .25; partial eta2 = .05), group (F[1,25] = .004; P = .95; partial eta2 = .00), nor a time point by group interaction (F[1,25] = .44; P = .52; partial eta2 = .02).
Self-regulation in AN
Individuals with AN during the starvation phase reported lower self-regulation scores than healthy adults at this time point (t = 5.93; P < .001; AN: M = 22.92; SE = .98; comparison: M = 30.31; SE = .37). Time 2 data was available only for individuals with AN, and thus a paired t test was used to compare their self-regulation scores at starvation and upon weight restoration. This analysis revealed that individuals with AN did not significantly differ in their self-regulation scores at the starvation and weight restoration phases (t = 1.32; P = .21).
Relationships between alexithymia, emotional empathy, and self-regulation in AN
First, the relationship between the Personal Distress domain of emotional empathy (IRI-PD) and alexithymia (TAS-20 total score) during the starvation phase was investigated in AN participants while accounting for depression (HDRS score) and BMI. This analysis revealed a significant, positive relationship between TAS-20 total scores and IRI-PD (r = .46; P < .05). Due to a smaller sample size at the Time 2 weight restoration phase (N = 12), an exploratory analysis examined the relationship between IRI-PD and TAS-20 total score at this time point. Depression and BMI were no longer included as covariates at this time point because these scores had returned to levels similar to HC participants. During the weight restoration phase, participants with AN showed a direct, positive correlation between IRI-PD and TAS-20 total scores (r = .64; P < .05).
Next, relationships between self-regulation (MMPI 37-item subscale), Personal Distress (IRI-PD), and alexithymia (TAS-20 total score) in individuals with AN during the starvation phase were examined. Because depression (HDRS score) was higher and BMI was lower in the AN group during the starvation phase than the weight restoration phases, an assessment was made as to whether these variables were correlated with self-regulation to determine whether they should be used as covariates in the analysis considering the starvation phase. Pearson correlations indicated that in individuals with AN, self-regulation was significantly and negatively correlated with HDRS scores (r = –.65; P < .01), but not BMI (r = –.06; P = .78), and thus HDRS scores were used as covariates in 2 self-regulation analyses. The P values underwent Bonferroni correction to account for the 2 comparisons. The first analysis indicated that TAS-20 total score and self-regulation were not significantly associated (r = –.23; P = .58). However, in the second analysis, IRI-PD was significantly, negatively correlated with self-regulation (r = –.49; P < .05).
Summary of results
AN participants reported higher TAS-20 total alexithymia scores than HC participants at the starvation and weight restoration phases, even though there was a slight improvement after weight restoration. When the 3 TAS-20 factors were examined individually, it became evident that weight-related improvements in alexithymia are primarily related to changes in DIF and EOT and that DDF didn’t change with weight restoration. It is important to note that when depression scores (HDRS) were accounted for, AN participants reported higher total TAS-20 alexithymia scores than comparison participants overall, but the difference between the starvation and weight restoration phases was no longer significant. Furthermore, when accounting for depression in the analysis of the TAS-20 factors, this same pattern was upheld, whereby the AN group had higher scores than the healthy participants on all 3 factors overall, but there was no longer an effect of weight restoration. For emotional empathy, AN participants had higher ratings than comparison participants overall across the starvation and weight restoration phases, but there was no significant effect of weight restoration. Follow-up tests revealed that it was the Personal Distress domain of emotional empathy that was driving this effect. In addition, self-regulation in AN during the starvation phase was found to be lower than in HC participants and did not significantly change in individuals with AN as a function of weight restoration.
There was a significant, positive relationship between TAS-20 total score and IRI-PD during the starvation phase of AN (HDRS and BMI were covariates), and a positive association during the weight restoration phase. In contrast, self-regulation was negatively associated with the IRI-PD domain in individuals with AN during the starvation phase (HDRS scores were used as a covariate).
The present study provides a novel contribution to the literature on emotion and social cognition in AN because of its longitudinal design, allowing for examination of relationships among alexithymia, empathy, and self-regulation during the acutely ill phase of starvation and again after weight restoration. Furthermore, this is the first study to investigate the emotional component of empathy longitudinally in AN, as most previous studies have focused on the cognitive component.8-11 Whereas cognitive empathy has been examined primarily through either a cross-sectional analysis10 or by examining only individuals in the starvation phase8,11 or weight recovered phase,9 this study extends previous research by investigating empathy longitudinally in the same individuals with AN. Previous studies of individuals with AN often have considered the constructs of alexithymia, empathy, and self-regulation separately.1,9,11,13,54 However, this study is the first to directly investigate relationships between these variables within the AN population. This research aids in the understanding of how difficulties in various emotional and social abilities in AN may interact with each other throughout the course of the illness, and which psychological functions may be vulnerability factors or consequences of starvation. Before discussing the results of the present study in the context of the existing literature, some limitations need to be mentioned.
Using a longitudinal design and self-report questionnaires to measure empathy, the present study did not find a significant difference between individuals with AN and HC participants in reported cognitive empathy. Whereas previous studies have found differences between individuals with AN and HC participants in cognitive empathy, this research has primarily focused on the starvation phase of AN.8,11 Or in other cases, individuals with AN in the starvation phase have been compared with a separate group whose weight had been restored for at least 1 year,10 rather than using a longitudinal design. In addition, these studies often have used task-based assessment of cognitive empathy (eg, the Eyes Task)8-11 rather than a questionnaire, as used in the present study. When a questionnaire has been used to assess cognitive empathy (ie, the Empathy Quotient), no significant differences between individuals with AN and healthy women were found.54 Taken together, these findings suggest that the type of measure used (self-report vs task-based) and the design of the study (cross-sectional vs longitudinal) may yield differing results when assessing cognitive empathy among participants with AN.
Antidepressant medication use and number of hospitalizations for eating disorder treatment (as a proxy for length of cognitive therapy) did not significantly affect alexithymia and emotional empathy in the present study. However, these variables were dichotomized in the present study (ie, taking antidepressants vs not taking antidepressants and previous hospitalizations vs no previous hospitalizations), and thus different results may be found if these variables are considered in a continuous manner in future studies.
Alexithymia in AN
The present study found that participants with AN report higher levels of alexithymia than HC participants, whether alexithymia is measured during the starvation or weight restoration phase and even after controlling for depression. This is consistent with previous literature that has shown that AN participants report greater alexithymia than HC participants during the starvation phase1,2,15,16 and the weight restoration phase.3,4 Despite participants with AN in the present sample showing a slight reduction in alexithymia upon weight restoration, after controlling for depression, the effect of weight restoration on alexithymia was no longer significant.
Previous studies have shown that AN may contribute to certain factors of alexithymia over and above that contributed by depression, including the DDF factor16 and the DIF factor.17 Similar to these studies, the present study also found that individuals with AN had higher alexithymia scores on these 2 TAS-20 factors but also on the EOT factor. This difference from previous studies may be a function of variation in study design, whereby the Sexton et al16 study compared individuals with AN with HC participants only in the starvation phase, not the weight restoration phase, while Speranza et al17 used a longitudinal design to investigate individuals in the acute phase and 3 years later, at which time there was variability in the length of time individuals with AN had been recovered. Because there was no significant effect of weight restoration after controlling for depression, this suggests that alexithymia may be either a trait feature of AN or a “permanent” change that is a consequence of the illness and may not recover upon weight restoration.
Emotional empathy in AN
Emotional empathy did not differ as a function of weight restoration, and thus, increased emotional empathy may be a trait feature in AN. Specifically, it was found that the personal distress domain of emotional empathy was higher in individuals with AN than in HC participants. This is in contrast to typical findings involving cognitive empathy, which generally demonstrate reduced cognitive empathy in individuals with AN compared with healthy adults.8-11 In light of this literature, this finding was unexpected because studies of healthy adults suggest that cognitive and emotional empathy levels often show moderate, positive correlations.21 Thus, it was expected that AN participants would show lower emotional empathy in the empathic concern domain in particular than HC participants. However, this dissociation between emotional and cognitive empathy is, in general, not new.55 For instance, in psychopathy, individuals have intact cognitive empathy but show deficits in aspects of emotional empathy that may influence their moral responsiveness to others.55,56
Higher levels of personal distress found in individuals with AN may be partially explained by the greater levels of social anxiety and difficulty regulating emotions that individuals with AN experience. Individuals with AN also have been shown to be highly sensitive to facial expressions of social rejection and may demonstrate an attentional bias towards this type of stimuli.57 When negative emotion is induced through film clips, participants with AN draw their attention away from the stimuli more often than HC participants.58 Hence, AN participants’ heightened sensitivity to negative emotional expressions may potentially extend to the perception of the suffering of others.
Relationships between emotional empathy, alexithymia, and self-regulation in AN
Empathy is thought to require an understanding of one’s own emotions in order to comprehend the emotions of others. Thus, it was expected that high alexithymia, or poor personal self-awareness of emotions, would be associated with low levels of emotional empathy. Individuals with alexithymia typically show reduced emotional empathy in the domain of empathic concern and increased emotional empathy in the personal distress domain.29 Consistent with Moriguchi et al,29 the present study found that greater alexithymia scores were associated with greater personal distress among individuals with AN, but in contrast, no relationship was found between empathic concern and alexithymia. Furthermore, personal distress was negatively associated with self-regulation in the starvation phase (when accounting for depression), suggesting that high levels of personal distress may co-occur with poor self-regulation in AN.
Greater alexithymia may be related to greater personal distress because observing others’ negative emotions (and especially their suffering) may elicit high levels of negative arousal, and individuals with poor awareness of personal emotions may show reduced expression of negative emotions (eg, sadness) and experience them in the body, which in turn leads to poorer capacity for regulation. In fact, a study of healthy adults suggests that emotion regulation is a necessary component for individuals to experience healthy empathic concern. This is because it enables individuals to reduce the feelings of personal distress that they experience as a consequence of others’ suffering and reappraise their emotional response so that it becomes focused on the other person as compassion.30 This relationship may also extend to other psychiatric disorders, as seen in a study that included patients with BPD, AN, their families, and healthy adults, which reported high levels of personal distress among those individuals who reported high alexithymia.59,60 Again, this same pattern of association was shown in individuals with OCD.61
It is known that individuals with AN dislike experiencing strong emotions and often experience a lack of emotional self-control.62 Individuals with AN often use less psychologically healthy strategies such as thought suppression12,13,63 or engage in unhealthy behaviors (eg, restricting food or excessive exercising) to control their negative emotions.64-67 Thus, high levels of personal distress in individuals with AN may be related to a tendency to engage in poor self-regulation and poor emotional awareness (FIGURE 4).
FIGURE 4: Poor emotional awareness and regulation and increased emotional empathy in anorexia nervosa
IRI-PD: Interpersonal Reactivity Index, Personal Distress subscale; MMPI-2: Minnesota Multiphasic Personality Inventory 2; TAS-20: Toronto Alexithymia Scale.
The present study adds to the growing literature on emotion and social cognition in AN by examining relationships between alexithymia, emotional empathy, and self-regulation during the starvation phase and after weight has been restored. This study demonstrates that both alexithymia and the personal distress domain of emotional empathy may reflect trait features of AN because high levels of these features are found even upon weight restoration. Whereas the present study focuses on relationships between these psychological processes, future research may consider the degree to which poor self-regulation and emotional awareness play a causative role in high levels of personal distress. Furthermore, the present study has investigated individuals with AN immediately after weight has been recovered, but it is known that psychological effects due to starvation may not recover immediately upon weight restoration. Thus, future studies may elucidate the degree to which high alexithymia, personal distress, and poor self-regulation persist after weight has been recovered for a longer period. The design of our ongoing longitudinal study also will be able to speak to this question upon the completion of the 1-year follow-up assessments. Additional research is needed to investigate these psychological constructs through a more comprehensive battery of measures, including both self-report and performance-based measures. Potential therapeutic interventions aimed at reducing personal distress and increasing emotional awareness and regulation may help to facilitate higher quality social interactions in individuals with AN.
DISCLOSURES: Drs. Beadle and Paradiso and Ms. Salerno report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. McCormick received grant support from the National Institute of Mental Health: K23 MH083879-01.
ACKNOWLEDGMENTS: The authors thank Michael Brumm for all of his assistance involving participant testing and data entry as well as his help proofreading the final version of the manuscript.
- Corcos M, Guilbaud O, Speranza M, et al. Alexithymia and depression in eating disorders. Psychiatry Res. 2000;93:263–266.
- Kessler H, Schwarze M, Filipic S, et al. Alexithymia and facial emotion recognition in patients with eating disorders. Int J Eat Disord. 2006;39:245–251.
- Parling T, Mortazavi M, Ghaderi A. Alexithymia and emotional awareness in anorexia nervosa: time for a shift in the measurement of the concept? Eat Behav. 2010;11:205–210.
- Tchanturia K, Davies H, Harrison A, et al. Altered social hedonic processing in eating disorders. Int J Eat Disord. 2012;45:962–969.
- Marty P, De Muzan M. Functional aspects of the dream life. “Operative thinking” [in French]. Rev Fr Psychanal. 1963;27(suppl):345–356.
- Sifneos PE. The prevalence of ‘alexithymic’ characteristics in psychosomatic patients. Psychother Psychosom. 1973;22:255–262.
- Espina A. Alexithymia in parents of daughters with eating disorders: its relationships with psychopathological and personality variables. J Psychosom Res. 2003;55:553–560.
- Russell TA, Schmidt U, Doherty L, et al. Aspects of social cognition in anorexia nervosa: affective and cognitive theory of mind. Psychiatry Res. 2009;168:181–185.
- Gillberg IC, Billstedt E, Wentz E, et al. Attention, executive functions, and mentalizing in anorexia nervosa eighteen years after onset of eating disorder. J Clin Exp Neuropsychol. 2010;32:358–365.
- Oldershaw A, Hambrook D, Tchanturia K, et al. Emotional theory of mind and emotional awareness in recovered anorexia nervosa patients. Psychosom Med. 2010;72:73–79.
- Harrison A, Sullivan S, Tchanturia K, et al. Emotion recognition and regulation in anorexia nervosa. Clin Psychol Psychother. 2009;16:348–356.
- Davies H, Swan N, Schmidt U, et al. An experimental investigation of verbal expression of emotion in anorexia and bulimia nervosa. Eur Eat Disord Rev. 2012;20:476–483.
- Geller J, Cockell SJ, Hewitt PL, et al. Inhibited expression of negative emotions and interpersonal orientation in anorexia nervosa. Int J Eat Disord. 2000;28:8–19.
- Montebarocci O, Codispoti M, Surcinelli P, et al. Alexithymia in female patients with eating disorders. Eat Weight Disord. 2006;11:14–21.
- Taylor GJ, Parker JD, Bagby RM, et al. Relationships between alexithymia and psychological characteristics associated with eating disorders. J Psychosom Res. 1996;41:561–568.
- Sexton MC, Sunday SR, Hurt S, et al. The relationship between alexithymia, depression, and axis II psychopathology in eating disorder inpatients. Int J Eat Disord. 1998;23:277–286.
- Speranza M, Loas G, Wallier J, et al. Predictive value of alexithymia in patients with eating disorders: a 3-year prospective study. J Psychosom Res. 2007;63:365–371.
- McCabe C, Mishor Z, Cowen PJ, et al. Diminished neural processing of aversive and rewarding stimuli during selective serotonin reuptake inhibitor treatment. Biol Psychiatry. 2010;67:439–445.
- Sansone RA, Sansone LA. SSRI-induced indifference. Psychiatry (Edgmont). 2010;7:14–18.
- Coke JS, Batson CD, McDavis K. Empathic mediation of helping: a two-stage model. J Pers Soc Psychol. 1978;36:752–766.
- Davis MH. A multidimensional approach to individual differences in empathy [dissertation]. Austin TX: University of Texas at Austin; 1980.
- Krebs D. Empathy and altruism. J Pers Soc Psychol. 1975;32:1134–1146.
- Stotland E. Exploratory investigations of empathy. In: Berkowitz L ed. Advances in experimental social psychology. New York, NY: Academic Press; 1969.
- Frith U, Frith CD. Development and neurophysiology of mentalizing. Philos Trans R Soc Lond B Biol Sci. 2003;358:459–473.
- Batson CD, Duncan BD, Ackerman P, et al. Is empathic emotion a source of altruistic motivation? J Pers Soc Psychol. 1981;40:290–302.
- Batson CD. The altruism question: toward a social-psychological answer. Hillsdale NJ: Lawrence Erlbaum Associates, Inc; 1991.
- Davis MH, Oathout HA. Maintenance of satisfaction in romantic relationships: empathy and relational competence. J Pers Soc Psychol. 1987;53:397–410.
- Batson CD, O’Quin K, Fultz J, et al. Influence of self-reported distress and empathy on egoistic versus altruistic motivation to help. J Pers Soc Psychol. 1983;45:706–718.
- Moriguchi Y, Ohnishi T, Lane RD, et al. Impaired self-awareness and theory of mind: an fMRI study of mentalizing in alexithymia. Neuroimage. 2006;32:1472–1482.
- Eisenberg N, Fabes RA, Murphy B, et al. The relations of emotionality and regulation to dispositional and situational empathy-related responding. J Pers Soc Psychol. 1994;66:776–797.
- Schmidt U, Treasure J. Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol. 2006;45:343–366.
- Skodol AE, Oldham JM, Hyler SE, et al. Comorbidity of DSM-III-R eating disorders and personality disorders. Int J Eat Disord. 1993;14:403–416.
- Diaz-Marsá M, Carrasco JL, Sáiz J. A study of temperament and personality in anorexia and bulimia nervosa. J Pers Disord. 2000;14:352–359.
- Kubzansky LD, Park N, Peterson C, et al. Healthy psychological functioning and incident coronary heart disease: the importance of self-regulation. Arch Gen Psychiatry. 2011;68:400–408.
- Oldershaw A, Dejong H, Hambrook D, et al. Emotional processing following recovery from anorexia nervosa. Eur Eat Disord Rev. 2012;20:502–509.
- Keys A, Brožek J, Henschel A, et al. The biology of human starvation. Minneapolis, MN: University of Minnesota Press; 1950.
- Nilsson EW, Gillberg C, Gillberg IC, et al. Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders. J Am Acad Child Adolesc Psychiatry. 1999;38:1389–1395.
- Gillberg C, Råstam M. Do some cases of anorexia nervosa reflect underlying autistic-like conditions? Behavioural Neurology. 1992;5:27–32.
- Garner DM, Garfinkel PE. The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychol Med. 1979;9:273–279.
- Garner DM, Olmsted MP, Bohr Y, et al. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med. 1982;12:871–878.
- Garner DM. Eating Disorder Inventory-3: professional manual. Lutz FL: Psychological Assessment Resources, Inc.; 2004.
- Mazure CM, Halmi KA, Sunday SR, et al. The Yale-Brown-Cornell Eating Disorder Scale: development, use, reliability and validity. J Psychiatr Res. 1994;28:425–445.
- Sunday SR, Halmi KA, Einhorn A. The Yale-Brown-Cornell Eating Disorder Scale: a new scale to assess eating disorder symptomatology. Int J Eat Disord. 1995;18:237–245.
- Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62.
- Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32:50–55.
- Wechsler D. Wechsler Adult Intelligence Scale. 4th ed. San Antonio TX: Pearson Assessment; 2008.
- Wechsler D. Wechsler Adult Intelligence Scale. 4th ed. Technical and interpretive manual. San Antonio TX: Pearson Assessment; 2008.
- Conners CK. Conner’s Continuous Performance Test II. North Tonawanda NY: Multi-Health Systems Inc.; 2009.
- Golden CJ. Stroop Color and Word Test. Chicago IL: Stoelting; 1978.
- Heaton RK. Wisconsin Card Sorting Test: Computer version 4 research edition (WCST:CV4) [computer program]. Lutz, FL: PAR; 2003.
- Bagby RM, Taylor GJ, Parker JD. The Twenty-item Toronto Alexithymia Scale–II. Convergent discriminant, and concurrent validity. J Psychosom Res. 1994;38:33–40.
- Bagby RM, Parker JD, Taylor GJ. The Twenty-Item Toronto Alexithymia Scale–I. Item selection and cross-validation of the factor structure. J Psychosom Res. 1994;38:23–32.
- Ben-Porath YS, Tellegen A. MMPI-2-RF: manual for administration scoring, and interpretation. Minneapolis, MN: University of Minnesota Press; 2008.
- Hambrook D, Tchanturia K, Schmidt U, et al. Empathy, systemizing, and autistic traits in anorexia nervosa: a pilot study. Br J Clin Psychol. 2008;47:335–339.
- Blair RJ. Fine cuts of empathy and the amygdala: dissociable deficits in psychopathy and autism. Q J Exp Psychol (Hove). 2008;61:157–170.
- Blair RJ. A cognitive developmental approach to mortality: investigating the psychopath. Cognition. 1995;57:1–29.
- Cardi V, Matteo RD, Corfield F, et al. Social reward and rejection sensitivity in eating disorders: an investigation of attentional bias and early experiences [published online March 16, 2012]. World J Biol Psychiatry. doi:10.3109/15622975.2012.665479.
- Davies H, Schmidt U, Stahl D, et al. Evoked facial emotional expression and emotional experience in people with anorexia nervosa. Int J Eat Disord. 2011;44:531–539.
- Guttman HA, Laporte L. Empathy in families of women with borderline personality disorder anorexia nervosa, and a control group. Fam Process. 2000;39:345–358.
- Guttman HA, Laporte L. Alexithymia empathy, and psychological symptoms in a family context. Compr Psychiatry. 2002;43:448–455.
- Kang JI, Namkoong K, Yoo SW, et al. Abnormalities of emotional awareness and perception in patients with obsessive-compulsive disorder. J Affect Disord. 2012;141(2-3):286–293.
- Bruch H. Anorexia nervosa: therapy and theory. Am J Psychiatry. 1982;139:1531–1538.
- Hambrook D, Oldershaw A, Rimes K, et al. Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome. Br J Clin Psychol. 2011;50:310–325.
- Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther. 2003;41:509–528.
- Polivy J, Herman CP. Causes of eating disorders. Annu Rev Psychol. 2002;53:187–213.
- Peñas-Lliedó E, Vaz Leal FJ, Waller G. Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology. Int J Eat Disord. 2002;31:370–375.
- Fox JR, Smithson E, Baillie S, et al. Emotion coupling and regulation in anorexia nervosa [published online November 20, 2012]. Clin Psychol Psychother. doi:10.1002/cpp.1823.
CORRESPONDENCE: Janelle N. Beadle, PhD Department of Psychiatry University of Iowa Roy J. and Lucille A. Carver College of Medicine W-278 GH 200 Hawkins Drive Iowa City, IA 52242 USA E-MAIL: firstname.lastname@example.org
Annals of Clinical Psychiatry ©2013 Frontline Medical Communications Inc.