Eating Disorders based on a Body “Feeling State” Confusion?

Here we look at emotion processing deficits in eating disorders and whether the extent of these difficulties can predict treatment outcome three years later.  This would demonstrate the ongoing role of emotion processing, as conceptualised as alexithymia, plays an ongoing role in the pathomechanism driving eating disorders.

This article also had a very good description of the somatic/emotional confusion which creates that unpleasant feeling state we have referred to before which appears to end in compulsive reactive behaviour rather than goal-directed, adaptive, evaluative, action-outcome thinking.

As we have shared before this is due to emotions not be labelled and used as guides to recruit goal directed parts of the brain but rather in their emotionally undifferentiated state they appear to compel us to react rather than consider our long term actions and their consequences.

“Several cross-sectional studies have reported high levels of alexithymia in populations with eating disorders.

However, only few studies, fraught with multiple methodological biases, have assessed the prognostic value of alexithymic features in these disorders. The aim of this study (1) was to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders.

The Difficulty  Identifying Feelings factor of the Toronto Alexithymia Scale (TAS-20), often used to assess levels of alexithymia, emerged as a significant
predictor of treatment outcome. In other words, the results  of this study indicated that difficulty in identifying feelings can act as a negative prognostic ( meaning predictive of something in the future)   factor of the long-term outcome of patients with eating disorders.

eating_disorder_by_ttonny-d2yezty (1)

 

The authors of this study also suggested that professionals should carefully monitor emotional identification and expression in patients with eating disorders and develop specific strategies to encourage labeling and sharing of emotions.

The identification of variables that predict treatment outcome in patients with eating disorders is critical if we are to increase the degree of sophistication with which we treat eating disorders…Among the several psychological features that have been proposed to predict treatment outcome in patients with eating disorders, alexithymia has attracted special interest.
Alexithymia is a personality construct characterized (partly) by a difficulty in identifying and describing feelings.

Several arguments, namely, factor analyses and longitudinal studies, have supported the view that alexithymia is a stable personality trait rather than a state-dependent phenomenon linked to depression or to clinical status [3,4].

Several studies have reported high levels of alexithymia in patients with eating disorders, especially in individuals with anorexia nervosa [5–8]. There are several reasons to believe that this construct could play a major role in the illness course of eating disorders: due to their cognitive limitations in emotion regulation, alexithymic individuals with eating disorders may resort to
maladaptive self-stimulatory behaviors such as starving, bingeing, or drug misuse to self-regulate disruptive emotions.

The results of our study indicate that one of the facets of the alexithymia construct, the difficulty in identifying feelings, is a negative prognostic factor for the long-term outcome of patients with eating disorders. Patients with the
greatest difficulties at identifying emotions at baseline are more often symptomatic at follow-up and show a less favorable clinical improvement.

There are several ways in which alexithymia can affect the clinical outcome of eating disorders: via the negative influence it exerts on the clinical expression of the disorders and on the response to therapeutic interventions.

First, the difficulty in identifying feelings may reduce the capacity of patients with eating disorders to adapt to stressful situations [28]. Such situations generate an emotional overflow that alexithymic subjects apprehend less by emotional and cognitive features than by their associated somatic indexes[29]. This uncertainty between feelings and bodily sensations reminds us of the interoceptive (a sensitivity to stimuli originating inside of the body) confusion proposed by Hilde Bruch [30,31].

Luminet et al. [32] have experimentally observed a dissociation of the components of the emotional response of alexithymic subjects (a physiological hyperreactivity to emotional stimuli associated to a deficit at the level of the cognitive experience), which illustrate the functioning of patients with eating disorders.

Faced with the physiological arousal induced by emotional demands, these patients may show poor adaptive strategies. They may resort to restricted patterns of repetitive and automated behaviors, such as the hyperactivity of anorexic individuals or the binges/purge cycles of bulimic  subjects, which temporarily relieve their feeling of discomfort and restore their inner equilibrium [33,34] but generate, in the long term, a positive reinforcement of the eating disorder. 

Second, alexithymia may be related to a chronic course of eating disorders by its relationship with other pathological behaviors, especially with addictive disorders. We have shown in previous studies that alexithymia is associated
with addictive behaviors in patients with bulimia [35].

Patients with eating disorders may resort to addictive behaviors to relieve the anxious and depressive feelings elicited by their negative perceptions of themselves [36].”

Thus to conclude, eating disorders appear to have the same emotion processing and regulation deficits as other addictive behaviours, particularly emotional differentiation, a difficulty in knowing exactly what one is feeling.

Interestingly eating disorders seem also to be driven by the same negative self perception we have seen in other addictive disorders.

References

1.  Speranza, M., Loas, G., Wallier, J., & Corcos, M. (2007). Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study.Journal of psychosomatic research, 63(4), 365-371.

 

Different addictive behaviours all centre on the same inherent difficulties.

by alcoholicsguide

 

Commonalities across all addictive disorders. 

There are those, and some in treatment centres, who maintain that addiction is addiction is addiction. I have not always been convinced by this, mainly because I see differences in temperament and personality among different types of addicts (i.e alcoholics often appear different to heroin addicts in my mind) but these supposed and perhaps superficial distinctions may be masking inherent similarities or commonalities in the aetiology of all addictive disorders. There seems to be commonalities in particular between alcoholics, sex addicts, gambling addicts and those with eating disorders.  This commonality may also help explain “cross addiction” – the tendency to become addicted to various things, whether substances or behaviours.
I personally have become” addicted” in very short periods of time to chocolate and many other substances and behaviours, such as constantly having to watch my workaholic behaviour. By addicted I mean I have quickly suffered addictive behaviour symptoms such as excessive consumption, pathological craving, physiological withdrawals from the substance or behaviour and the gamut of negative emotions surrounding my shame and despair  at these obsessive compulsive behaviours. I can’t take it or leave in relation to many things in my life. Period!
There seems to a “manic hamster on the treadmill” mechanism in me that gets ignited by my engaging in what appears to be the most innocuous behaviour. Suddenly, whatever it is, leads me to want more, more, MORE of it!
I have an addicted brain and a recovering mind. 
What is this intrinsic mechanism in my brain? What trips the switch towards addictive behaviour? This is the heart of the question.
How does the brain tumble towards unbridled wanting. What leads our brain to suddenly say I NEED THIS! rather than simply wanting it?
Why does the most simple behavioural decision suddenly seem life or death, urgent, most necessary? Why a such a sudden recruitment of this emergency state? For us it is due to the limbic and subcortical areas, the “fight or flight” areas of the brain being recruited to make the most simple decision urgent. Even the most simple decisions seem to involve feeling about our very survival. As we have blogged about before in “Why a “Spiritual Solution” to a Neurobiological Disease?” survival becomes the domain of these emergency parts of the brain so we do everything like there is no tomorrow, It is everything or nothing NOW. We need these things. Our survival regions have become extreme and constantly react, not act.
Our very survival has become habitually and compulsive governed as if our brains are constantly under siege.
These commonalities centre on the fundamental role we believe emotional processing and regulation deficits have in these various types of addictive disorder. It may be these deficits that are present in all addictive behaviours and  it may suggest that they are fundamental mechanisms in driving addictive behaviours forward.
In a previous blog we showed how these areas of emotional dysfunction may even be inherited in many, so it is tempting to conclude that the vulnerability, or some of the major vulnerabilities that addicts and those with addictive behaviours inherit are the impaired ability to process and regulate emotions which leads to fundamental decision making difficulties and distress-based impulslivity (as the lack of processing emotions represents as distress signals act to relief these states not guide reflective decision making) which combine to shape the rest of their lives.
The encouraging aspect is that at an affective-cognitive level it may be possible to target these deficits in children at risk via prevention programs.
It illustrates what addicts of various types have said about their illness, however, that they suffer from an emotional disease.
The solution may be prevention and/or intervention to shore up these difficulties which is primarily what various treatments do without explicitly saying so. We first need to state categorically this is what we think drives addictive behaviours and then use complementary therapeutic strategies to specifically address these vulnerabilities.
We have to relearn emotions, how to identity, label, verbalise, process and subsequently regulate our emotions so that we become less impulsively driven and ultimately make better decisions in our lives.

We have in previous blogs discussed how substance addiction seems to have emotional processing and regulation deficits at the heart of their manifestation and act as pathomechanisms in propelling these disorders to eventual  chronicity.

In the next series of blogs we will be discussing whether fundamental emotional processing and regulation deficits are common to (or intrinsic to the aetiology of) other addictive disorders too).

First up, we discuss emotional (or otherwise known in research as affective) dysregulation in those with Hypersexual Disorder or more commonly know to lay persons as sexual addiction.

Hypersexual Disorder – the proposed diagnostic criteria that were given consideration for the Diagnostic and Statistical Manual of Mental Disorder Fifth Edition (DSM-5) characterize hypersexual disorder (HD) (1) which is commonly known as sexual addiction.

This study (1) states that HD is a phenomenon involving repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning(Bancroft, 2008; Kafka, 2010; Kaplan & Krueger, 2010; Marshall & Briken, 2010; Reid, Garos, & Fong, 2012).

Patients seeking help for HD typically experience multiple unsuccessful attempts to control or diminish the amount of time spent engaging in sexual fantasies, urges, and behaviors in response to dysphoric mood states or stressful life events (Kafka, 2010).

Personality characteristics such as proneness to boredom (Chaney
& Blalock, 2006), impulsivity and shame (Reid, Garos, & Carpenter, 2011), interpersonal sensitivity, alexithymia, loneliness, and low self-esteem also have been observed in association with hypersexual behavior (Reid, Dhuffar, Parhami, & Fong, 2012; Reid, Stein, et al., 2011; Reid, Carpenter, Spackman, & Willes, 2008). Collectively, these  characteristics create significant challenges for hypersexual patients.

The importance of finding effective treatments for HD cannot be underestimated given the gravity of its consequences (Reid, Garos, et al., 2012): Hypersexual patients are at increased risk for loss of employment, legal problems, social isolation, higher rates of divorce (Reid & Woolley, 2006; Reid, Carpenter, Draper, & Manning, 2010; Zapf, Greiner, & Carroll, 2008), and sexually transmitted infections (Coleman et al., 2010; Dodge, Reece, Cole, & Sandfort, 2004; Rinehart & McCabe, 1997, 1998).

This study found (1) significant associations between unpleasant emotions, impulsivity, stress proneness, and hypersexuality replicating findings
noted in other studies (Reid et al., 2008; Reid, 2010). The findings in this study also offer some support for the DSM-5 proposed classification criteria for HD (Kafka, 2010). Specifically, stress and emotional dysregulation have been hypothesized as precipitating and perpetuating risk factors for hypersexuality, and, accordingly,  correlations to reflect this relationship, were consistent with findings of this study (1).

Another study (2) looked at  investigating alexithymia, emotional instability, and vulnerability to stress proneness among individual seeking help for hypersexual behavior. Findings (2) provide evidence for the hypothesis thatindividuals who manifest symptoms of hypersexual behavior are more likely to experience deficits in affect regulation and negative affect (including
alexithymia,  depression, and vulnerability to stress).

Sex-Addiction-Impulse-Treatment-Center

An increasing number of individuals are seeking help for hypersexual behavior related to a constellation of symptoms that reflect difficulties in regulating sexual thoughts, feelings, and behaviors.

This study’s (2) conceptualization of this phenomenon keys onbehavior dysregulation as manifest through exaggerated frequency and focus on sexual behavior (from sexual activity with partners, to use of pornography, sexual fantasy, or other erotic stimuli, to excessive masturbation).

Hypersexual behavior may include a sense of being out of control or a history of failed attempts at increased control, and it encompasses elements common to other psychiatric dysfunctions, such as impaired functioning in aspects of daily living, subjective distress, and deficits in coping strategies for addressing uncomfortable affective experiences (e.g., anxiety reduction), usually because of over reliance on sexual behavior as a means of affective regulation and relief. Many patients presenting with hypersexual behavior also report incongruence between their values and beliefs and their sexual behavior.

This study, used the definition of Reid and Woolley (2006) was used
to operationalize hypersexual behavior as: difficulty in regulating (e.g., diminishing or inhibiting) sexual thoughts, feelings, or behavior to the extent that negative consequences are experienced by self or others. The behavior causes significant levels of personal or interpersonal distress and may include activities that are incongruent with personal values, beliefs, or desired goals.The behavior may function as a maladaptive coping mechanism (e.g., used to avoid emotional pain or used as a tension-reduction activity)…. (p. 220)

“It may be that such persons possess deficits in affective regulation similar to those encompassed by the constructs of alexithymia and neuroticism. . It
is plausible that such deficits would influence exaggerated sexual behavior
in some persons (e.g., in the absence of other coping strategies for successful affective monitoring and regulation, the stress-reduction aspects of sexual behavior as a substitute may be powerfully reinforced).

Adams and Robinson (2001), as well as others (e.g., Schwartz & Masters,
1994; Wilson, 2000), have theoretically postulated thathypersexuality represents a compensatory behavior that attempts to alleviate symptom distress associated with problems of affect regulation. A similar theory among individuals with eating disorders was advanced by Heatherton and Baumeister (1991), who argued that motivation for binge eating emerged as an attempt to escape from negative appraisals associated with self-awareness and unpleasant mood states triggered by stressful events.
It can be reasonably argued that sexual activity provides a mood-altering experience enabling individuals to disassociate from uncomfortable, awkward, or unpleasant emotions (Quayle, Vaughan, & Taylor, 2006).

The power of sexual experience to shield one from negative emotions, then, probably arises from sexual arousal’s inherent ability to create intense focus on the competing state of pleasurable arousal, as well as the release of tension associated with orgasm. Furthermore, some individuals may find that fantasizing about sexual activity provides a greater distraction than partnered activity because it encourages—and maybe even requires— disconnect from relationships with their inherent problems, challenges, and complexities.

One plausible way to understand hypersexuality is seeing behaviors associated with reward, distraction, or soothing—such as overeating, exaggerated focus on somatic complaints, substance abuse, or hypersexuality—as being particularly likely in those for whom emotional distancing has high priority. This need for emotional distance can arise from increased stress proneness, negative affective states, emotional pain associated with unresolved trauma, or the inability to develop and form secure attachment bonds.

Our clinical impressions of patients displaying hypersexuality, as defined above, are consistent with those of other researchers who have suggested that alexithymic individuals seek tension reduction from uncomfortable or unpleasant emotions (Keltikangas-Jarvinen, 1982; Kroner & Forth,
1995; Zimmermann, Rossier, de Stadelhofen, & Gaillard, 2005), thereby contributing to their eating disorders (Corcos et al., 2000; Larsen, van Strien, & Eisinga, 2006), substance abuse (Haviland, Hendryx, Shaw, & Henry, 1994),
and the like. Our rationale for suggesting associations of stress vulnerability, emotional instability, and alexithymia with hypersexual behavior also stems, in part, from our own observations of poor affect regulation and deficits in stress management among these patients.

Research supports some associations between alexithymia and stress. For instance, high, as compared to low, alexithymic individuals show different cardiovascular response to stress (e.g., Linden, Lenz, & Stossel, 1996).

The findings  support our hypothesis that alexithymia, emotional instability,
and vulnerability to stress are associated with the severity of hypersexual
behavior. More specifically, it appears that patients who present with more
profound levels of hypersexual behavior are more depressed, alexithymic,
and prone to stress.

These findings are consistent with our theoretical conceptualization of
emotional instability among individuals with hypersexual behavior. Our clinical impressions suggest this population struggles with uncomfortable, awkward, or unpleasant affective states, and in fact, these data indicate that they also experience the prevalence of such emotions in greater proportions than those found in normal populations.

images (34)

Many of the subjects in the present study displayed emotional deficits and a paucity of emotional awareness. Queries about feelings in therapy would often elicit a response such as “I don’t know” or “I’m not feeling anything.” – otherwise know as emotional differentiation and discussed recently in another blog. 

Our clinical impressions of hypersexual patients suggest that many of
these individuals habitually entertain negative self-appraisals that are likely
influenced by attention bias which seeks evidence in daily experiences to
confirm irrational beliefs (I’m unlovable, worthless, etc.). Additionally, many
of these patients devote time to maintaining facades and implementing strategies of impression management that may further disconnect them from their authentic self, including their genuine emotions. Patients desperately desire external validation by others and privilege such adulation while marginalizing subjective positive perceptions about the self. Unable to control and predict the reactions of others, patients vacillate along a continuum of emotional instability. Negative appraisals by others become threats to their sense of self-worth, and such criticisms often result in disavowing aspects of the self. Specifically, the patients disconnect from undesirable emotional states.

The function of sexual activity in these instances is stress reduction and escape from or avoidance of uncomfortable and unpleasant affective experiences attributable to difficulties in their interpersonal relationships and other challenges in daily living.

 

References

1.  Reid, R. C., Bramen, J. E., Anderson, A., & Cohen, M. S. (2014). Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. Journal of clinical psychology, 70(4), 313-321.

2.  Reid, R. C., Carpenter, B. N., Spackman, M., & Willes, D. L. (2008). Alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior. Journal of Sex & Marital Therapy, 34(2), 133-149.