Abstract
Purpose
This research aims to analyze the relationship between emotional regulation and the symbolic process in autobiographical narratives of a group of individuals diagnosed with restrictive anorexia nervosa (AN), compared to a non-clinical group. The study is framed within multiple code theory (MCT) (Bucci, 1997; 2021), which considers mind–body integration. The purposes of this study are to investigate whether participants of the AN group will show greater alexithymia and emotional dysregulation than the non-clinical group; and whether the specific linguistic and symbolic features, such as somato-sensory words, affect words, and difficulty in the symbolizing process will predict the AN group.
Methods
Twenty-nine female participants hospitalized with AN during an acute phase (mean age 19.8 ± 4.1) and 36 non-clinical female participants (mean age 21 ± 2.4) were selected through snow-ball sampling. The participants completed the Toronto Alexithymia Scale (TAS-20), the Profile of Mood of State (POMS), the Emotion Regulation Questionnaire (ERQ), and the Relationship Anecdotes Paradigm Interview (RAP). The RAP interview was audio-recorded and transcribed to apply the Referential Process (RP) Linguistic Measures. A T test for paired samples and a logistic binary regression was performed.
Results
AN presented a significantly higher emotional dysregulation through the ERQ, TAS20 and POMS measures. Specifically, AN showed higher ER expression/suppression strategies, fewer functional cognitive strategies, higher alexithymia, and higher mood dysregulation. Specific linguistic features such as sensory-somatic, word affect, and difficulty in RP symbolizing predict the AN group (R2 = 0.349; χ2 = 27,929; df = 3; p = .001).
Conclusions
Emotional dysregulation is connected to AN symptoms and autobiographical narratives. The results can help a clinical assessment phase showing specific linguistic features in AN patients.
Level of evidence
Level II, controlled trial without randomization.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
Clinical symptom classification AN
Anorexia nervosa (AN) is a psychiatric syndrome characterized by a reduction in calorie intake, followed by a pathological decrease in body weight. Anorexia is a condition of self-induced food restriction, accompanied by a deep desire to be thin, and/or fear of fatness. which involves the appearance of symptoms and clinical signs related to the conspicuous weight loss.
AN is associated with significant psychological and relational impairment in the person and is one of the main contributors to the reduction of the quality of life in the context of eating disorders. Affected patients show a lower health-related quality of life (HRQoL) than the healthy population [1]. In Western countries, including Italy, it is estimated that the prevalence of anorexia nervosa is around 0.2–0.8% and that the incidence is 4–8 new cases per year, per 100,000 individuals [2]. The average age of onset is between 14 and 18 years and the diagnosis is ten to twenty times more frequent in women than in men.
There are two different clinical manifestations of anorexia nervosa: the restrictive type I, in which weight loss is mainly achieved through a restrictive diet, fasting, and sometimes excessive physical activity; and type II, with the accompaniment of binging/purging behaviors. The course of AN is variable, and while spontaneous recovery without treatment is possible, a fluctuating course is more likely the case in which the affected individual shows signs of improvement while remaining anchored to some of the preoccupations regarding food, weight, and bodily appearance. Related studies show conflicting evidence about the severity of the two different types. In fact, some research argues that type I is associated with lower chances of recovery, compared to those with the variant consisting of binges and eliminatory behaviors, notwithstanding its association with a lower suicide rate [3]. Other studies report that binge–purge presentations fare off worse [4]. Finally, the high crossover rate in the sample from type I to type II suggests that restrictive AN could be considered a phase in the course of AN rather than a distinct subtype [5]. The advantage after hospitalization is undoubtedly in terms of weight, but it is less concrete in terms of socialization and mood; poor relations with peers remain, and sometimes severe depressions are highlighted [6]. Quantifying the mortality rate of anorexia nervosa is a complex matter. Some studies indicate a mortality rate of approximately 5.25% and a Standardized Mortality Ratio (SMR) of 9.7 [7]. The SMR of anorexia nervosa is by far one of the highest in the context of psychiatric disorders.
The severity of the disorder and the implications related to high mortality show the need to analyze assessment factors that can help better understand the psychological factors underlying the symptomatology of AN. One aspect of AN symptom severity is body mass index (BMI) [8]. Mild severity is attributed for a BMI > 17 kg/m2, moderate for a BMI between 16 and 16.99 kg/m2, severe if the BMI is between 15 and 15.99 kg/m2, and extreme for a BMI < 15. Despite the clear ease and convenience with which the BMI is used to define the severity of the anorexic syndrome, an exclusive reference to the numerical value seems reductionistic and simplistic. The clinical history predicts a gradual decline and physical deterioration, leading to the deadly consequences of starvation. In addition to an evaluation of the entity of weight loss, it is necessary to reflect on the more general implications related to it, such as the influence that this has on body related attitudes (BodyRA) and especially, on body dissatisfaction in adolescents [9].
Emotional regulation and alexithymia in AN
Several studies have emphasized the relationship between AN and the individual’s deficits in emotional awareness [10,11,12], or heightened alexithymia. Alexithymia can be defined as quite literally, ‘a lack of words to express emotion,’ [13] characterized by difficulties in identifying and describing emotions, as well as employing fantasy to regulate painful feelings and finding creative solutions to problems, and communicating needs to others to obtain support [14]. The fight against the feeling of hunger and the long abstinence from it seems to lead to a greater reduction in feeling emotion and related facial expressions, and showing higher alexithymia in the acute phase, compared to that which occurs in recovered patients [15].
Individuals with AN also display alexithymia, closely related to the difficulties in identifying feelings about themselves [16, 17]. Foye et al. [18] pointed out that AN represents an attempt to modulate current or persistent aversive emotional arousal, in a dysfunctional way. Avoiding emotions could be considered to be a coping strategy against feeling affect, avoiding positive or negative emotions, showing poor interoceptive awareness, and displaying confusion of emotional states and difficulties with emotional language. Recent review findings even suggest that although overall empathy levels may be intact in AN, greater emotional regulation difficulties, elevated levels of alexithymia, and reduced emotional awareness can still be evident [19]. Various empirical studies reveal that emotional regulation plays an important role in the development, maintenance, and psychopathology of AN [20,21,22,23]. Research that used the Emotional Regulation construct confirmed that AN is characterized by dysfunctional emotional regulation strategies oriented towards a suppressive strategy rather than cognitive re-evaluation [24].
AN according to the multiple code theory
Multiple code theory (MCT) is a general theory of emotional information processing, derived from current work in cognitive psychology, psychoanalysis, and affective neuroscience [25]. Taylor and Bagby [26] suggested that alexithymia may be more fully understood in light of Bucci’s [27] multiple code theory (MCT).
This model poses that information is processed in parallel [28] among three different systems, the subsymbolic, non-verbal symbolic and verbal symbolic systems, which organize the experience in a global and integrated way. Bucci [29] argues that a Referential Process (RP) connects these three types of processing systems and allows people to express their emotional experiences into words. In other words, Alexithymia can be further understood as an expression of the disconnection of RP [30]. The RP and emotional communication are connected to Damasio’s notion of dispositional representations [31] that provide a neurobiological basis for the concept of emotional schema. These are complex units that combine emotion and cognition, necessarily founded and rooted in bodily interactions with others [32]. More specifically, they are made up of desires, expectations, and beliefs about other people that develop during interactions with the latter, from the beginning of life. Consequently, the individuals and situations in which these relationships took place constitute the specific contexts and contents of the emotion patterns [32]. The latter, therefore, includes patterns of visceral or somatic experience associated with the emotional experience, as well as images of the object of emotion or what we desire or hate and fear. These innate dispositional representations can be associated to the arousal/emotional activation and to a non-conscious state of the self, where sub-symbolic systems and bodily experiences are predominant. The dispositional representation is activated in autobiographical memories, which can activate emotional schemas [31]. A good RP allows for the representation of emotional schema memories in verbal forms, which follows the implications of MCT [32], concerning access to the experiential and preverbal code of the implicit self [33, 34]. The food restriction and procedures that AN describes as connected to the autobiographical narratives of individuals assumes the function of an organizational symbol within emotional schemes. Nandrino et al. [35] showed that AN is characterized by an excessive generalization of autobiographical memories that would lead individuals to manifest greater difficulties in making use of an affective narrative, capable of leading the other to "live" their own experience. In addition, patients with AN tend to use specific cognitive and behavioral strategies to avoid or mitigate negative affect [36]. The verbalization process can represent a measure of the capacity to emotionally regulate, which is expressed through linguistic indicators. In Mariani et al. [37], what was found to emerge was a representative linguistic pattern of emotional regulation difficulties in narrative processes in psychopathology, such as sensory-somatic words and the presence of strong negative feelings.
We hypothesize that according to MCT, a specific pattern of emotional regulation in AN patients will be seen in both, emotional regulation strategies, as well as in linguistic patterns in autobiographical narratives. More specifically:
-
(a)
Individuals diagnosed with AN will show greater levels of alexithymia, emotional dysregulation, and affect dysregulation compared to non-clinical groups;
-
(b)
Specific linguistic features, that show difficulties in the symbolization process, such as higher sensory-somatic words, higher negative affect words, and dysfunctional RP patterns will predict the clinical group.
Method
Participants
A clinical sample of patients seeking hospitalization or visiting an inpatient unit at a day hospital was recruited for the study. The diagnosis of restrictive anorexia nervosa was confirmed using the semi-structured interview, SCID-5-CV [38]. The constitution of the clinical group was made according to the following criteria: Inclusion: between 16 and 30 years of age, experiencing an acute phase of AN, BMI ≥ 12.5 kg/m2, Time from diagnosis ≥ 6 months; and Exclusion: Chronic pathology (time from diagnosis ≥ 10 years), diagnosis of acute psychosis, mental retardation, cognitive impairment, ongoing alcohol or psychoactive substance abuse and/or other conditions that may affect the understanding of the questionnaires and the ability to provide informed consent. 31 female clinical participants were recruited, of which 29 agreed to participate in the study. As a result, our clinical sample consists of 29 participants, mean age 19.8, sd. 4.1; year of education 12.2, s.d. 2.3; patients were classified according to the severity level of BMI at time of study (Table 1). Simultaneously, a control group was recruited, pairing for age and educational attainment. The exclusion criteria for the control group was the presence of major mental disorder and eating disorder symptoms, which was evaluated using the Eating Attitudes Scale test (EAT-26) [39]. 36 non-clinical female participants have been included, mean age 21, sd 2.4; year of education 12.6, s.d. 2.5. The non-clinical sample’s EAT-26 mean was 9.04, sd. 4.09; 11 participants have been excluded from the study due to the EAT-26 clinical cutoff (> 26). All non-clinical participants reported being in good health and had an average BMI (between 19 and 24). Other main characteristics are shown below (see Table 1).
The sample numerosity has been estimated by G*Power 3.1.9.2 (Düsseldorf, Germany) for the two groups comparison on an effect size of f 0.25 (mean), power of 80%, assuming α 0.05.
Procedure
Following the recruitment procedure, described above, participants completed the informed consent. Research involved the administration of standardized self-report tests through a special form and, subsequently, of an interview through online platforms, due to the COVID-19 pandemic. The interview was carried out through an online meeting program and The Relational Anecdotical Protocol method of interviewing was used. This method of interviewing is similar to that of a psychotherapy session transcript analysis, which offers a broad scope of studying the narratives [40, 41]. The administration of the measures took place in similar settings for all groups individually, with a qualified and experienced psychologist. The audio-recorded interviews were transcribed following specific procedures for the Italian version of the Discourse Attributes Analysis Program (DAAP) [42] for the computerized application of the RP linguistic measures. The protocol has been approved by the Department Ethics Committee, where the study was developed.
Measures
The research consisted of different questionnaires, including the following:
-
Socio-demographic questionnaire—a demographic sheet that contains questions regarding gender, age, level of education, marital status, family of origin, current occupation, and whether the individual is currently in psychotherapy and/or receiving pharmacological treatment;
-
Profile of Mood of State: POMS [43, 44]—a self-report psychological measure of mood states consisting of a 65-item mood adjective checklist in which each adjective is scored from 0 (absent) to 4 (very much), based on how well each item describes the respondent's mood during a specified time frame (during the past week, including today). Following the standard scoring method for the Italian population, six mood scales are derived: tension–anxiety, depression–dejection, anger–hostility, vigor activity, fatigue–inertia, and confusion–bewilderment. A higher score denotes a higher level of a certain emotion. In the current study, Cronbach's alpha was found to vary between 0.82 and 0.91.
-
Toronto Alexithymia Scale: TAS-20 [45]—a questionnaire that evaluates the presence of clinical or non-clinical alexithymia, and, therefore, identifies the subjects most at risk of pathology. Three factors emerge from the factor analysis, which correspond closely to the construct: Difficulty in identifying feelings (DIS) and distinguishing between emotions and bodily sensations; and Difficulty in describing feelings (DDS); The TAS-20 uses cutoff scoring: equal to or less than 51 = non-alexithymia, equal to or greater than 61 = alexithymia. Scores of 52 to 60 = possible alexithymia. In the current study, Cronbach’s alpha value was 0.81
-
Emotion Regulation Questionnaire: ERQ [46, 47]—a self-report questionnaire that includes 10 items and contains two scales corresponding to two different emotional regulation strategies: 1. Reappraisal (6 items): cognitive restructuring, a conscious mental process that allows to modify the interpretation associated with an emotional stimulus. Higher scores in this factor show a good strategy to reduce stressful effect (Gross, 2002); 2. Suppression (4 items): an attempt to suppress the expression of emotions through both verbal and body language, higher scoring in this factor shows emotional distress. For the present study, Cronbach’s alpha was found to vary between 0.76 and 0.85.
-
Linguistic measures of the Referential Process: (see Table 2)
-
Computerized language measures have been applied to the transcripts of the interviews of the referential process, according to the multiple code theory [25], using Italian Discourse Attributes Analysis Program (IDAAP) software [48; 49]. Listed below are the linguistic measures:
-
Italian Weighted Referential Activity Dictionary IWRAD [48]—a list of 9596 frequently used linguistic elements. The dictionary contains words with a high-frequency function, such as articles, pronouns, and prepositions that are aspects of the generative function of language. IWRAD evaluates language style rather than content, represents unintended aspects of emotional expression, and provides microanalytic tracking of the Symbolizing phase of RP. For a deeper discussion on the method of building a weighted dictionary, such as IWRAD, see [49].
-
The Italian Mean High Weighted Referential Activity Dictionary (MH-IWRAD)—a derivate variable of IWRAD, which is defined as the Referential Activity Intensity Index. This is essentially a measure of high intensity emotional engagement emerging from speech [48]. It is obtained by counting IWRAD scores lying above the neutral value. This is perhaps best understood as a measure pick of IWRAD.
-
The Italian DisFluency Dictionary (IDFD)—a small set of 11 words and repeated words, incomplete words, and filled pauses that people tend to use when struggling to communicate [50]. A score on this index corresponds to the proportion of IDFD words present in the speech. High scores typically characterize the arousal phase in which emotional schemas are activating.
-
Italian Reflection Dictionary (IREF) [48]—a dictionary that contains words about the way people think and communicate thoughts. It includes basic logical words and elements that refer to cognitive, logical, or impaired functions. These elements will probably dominate in the reorganization phase.
-
The Italian Sensory Somatic Dictionary (ISensD)—a list of Italian words related to the body and bodily activities, and to sensory processes and/or descriptions of symptoms [29]. The number of ISensD words in a speech sample is a measure of the arousal of bodily, sub-symbolic aspects of emotion schemas.
-
The Italian Sum Affect Dictionary (ISAffD) [48]—contains Italian words concerning how people feel and communicate feelings directly. It includes emotion labels and functions associated with affective arousal. ISAffD consists of three sub-dictionaries related to domains of affect: positive affect (IPAffD), negative affect (INAffD), neutral affect without a specific valence (IZAffD).
-
The relationship anecdotal paradigm: (RAP) [51] Interviewees are presented with the following prompt, “Please tell me some incidents or events about an interaction between yourself in relation to another person” (Luborsky, 1998, p. 110), specifying when it occurred, with whom it occurred, something about what the other person said or did, and what happened in the end. Interviewees are asked to tell between 6 to 10 relationship episodes and are free to describe any incidents involving any person. Evidence for the validity of the RAP was provided by Barber, Luborsky, Crits-Christoph, & Diguer [52].
Statistical analysis
All statistical analyses were performed using the Statistical Package for Social Science version 26 (SPSS version 25). Data is reported as means and standard deviations for continuous variables and as percentages for discrete variables. T tests and Chi-square tests were performed to evaluate the homogeneity of the two groups, respectively, for continuous and discrete variables. The t-test for paired samples was applied to explore differences between the two groups, using Bonferroni correction for multiple t-tests for all measures applied and a Cohen’s D effect size was also performed. A series of logistic binary regressions were performed, using specific linguistic variables as independent variables, which belonged to the clinical or the control group as dependent variables.
Results
The comparison of the two groups highlighted the following results. With respect to socio-demographic characteristics, the two groups can be considered homogeneous; no significant differences in age and education emerged. In regards to the first hypothesis of the study, the findings which emerged (Table 3) showed that the results for ERQ, TAS-20, and POMS are significantly different (using Bonferroni correction for multiple t-test p < 0.05).
Emotional regulation, alexithymia and mood states
This result highlights that participants with anorexia nervosa show greater emotional dysregulation, specifically higher in suppressive strategy, i.e., dysregulated expression of emotions, and lower levels of cognitive reappraisal functional strategies. The AN group displayed significantly higher levels of alexithymia than the control group; however, the mean total score of alexithymia for the AN group overcame the general cut-off > 60, showing a clinical value of alexithymia for the AN group. The sub-factor outward-oriented thinking is the only result that is not significant. The assessment of mood states measured by the POMS shows significant differences in all subfactors except for the fatigue and anger factors.
Referential process linguistic measures
The second hypothesis explores if specific linguistic features predict the belonging to a clinical or healthy group. The linguistic analysis shows a significantly greater use of sensory-somatic words in the AN group. Regarding the symbolic narrative properties of AN patients, there is a specific difference in the narrative characteristics. AN patients have a significantly higher use of words connoted with negative affect. They also show a significant dysregulation process, resulting in a higher RA intensity index (MH-IWRAD) (see Table 4).
To investigate possible predictors of an clinical group, a series of logistic binary regressions were performed using the belonging to the clinical or control group as a dependent variable and linguistic measures, such as Sensory-Somatic, Negative Affects, and the RA Intensity Index as independent variables. The model accounted for 35% (R2 = 0.349; χ2 = 27,929; df = 3; p = 0.001) of the criterion variable (belonging to the clinical group). In particular, the model showed a significant predictive effect on the AN group of Sensory-Somatic (β = 85,099; df = 1; p = 0.039); Negative Affect (β = 132,202; df = 1; p = 0.011); and Intensity Index (MH-IWRAD; β = 322,410; df = 1; p = 0.029).
To better explain these findings, we show a clinical vignette from the autobiographical narratives:
Clinical example: high somatic sense, high negative affect, high RA index
At school the only thing that I will never forget [360,8,15,1], it happened that I had a pseudo panic attack [370,18,15,1], we were doing religion and at a certain [380,28,15,1] point I had kind of a detachment from my head [390,38,15,1], from with the mind and body and practically I have [400,48,15, 1] started screaming in panic, I (I know) felt terrible [410,58,15,1] and I remember that then they called like the ambulance […] I began to stay bad from [450,98,15,1] we were all put in a circle around the desk [490,14,19,1], I don't remember what the teacher was talking about, of [500,24,19,1] which argument, I was listening, then at a certain point [510,34,19,1] I began to feel entire distant voices [520,44,19,1] of the speaker and I remember that I closed my eyes for a moment [530,54,19,1] and then when I opened them again, yes [540,64,19, 1] it was all upside down, that is, everything was spinning, as I no longer felt [550,74,19,1] my body, as if I were no longer inside [560,84,19,1] myself.
Discussion
The most relevant finding of the study is the association between AN and several features of emotional dysregulation. This aspect is found both in the greater use of suppression strategy, as well as in lower cognitive reappraisal capacity. Moreover, the presence of higher values in all the POMS scales, except for anger and fatigue, suggests greater emotional arousal in almost all of the scales. The elevated mood profile in the AN group highlights a relationship between altered mood states and AN, reinforcing the hypothesis that food control is a form of behavior related to emotional control. In fact, many studies reveal a relationship between AN and mood disorders [55].
Finally, the AN group showed higher levels of alexithymia than the control group, indicating difficulty in recognizing and describing emotions through words. As Taylor & Bagby [14] posed, alexithymia is an effect of a disrupted or failed RP process, i.e., the regulation of emotional arousal, and the construction of emotional meanings [31]. Moreover, activation of the subsymbolic system without symbolic connections may result in poorly regulated states of emotional arousal, which may contribute to the pathogenesis of different disorders, both somatically and psychiatrically [30].
In general, the presence of emotional dysregulation, alexithymia, and altered mood states in AN patients reinforce the centrality of the regulatory function that food assumes as an addiction [56] and also the centrality of an experience of being foreign to one's body [57].
In our study, emotion dysregulation was also indirectly found in the autobiographical narratives, since according to MCT [26], disruptive emotional process can involve the difficulty of symbolizing one's own affective experience. Results confirmed specific linguistic features of the RP in autobiographical narratives of AN patients. Specifically, three linguistic indices were found to be more related to this disorder than others: the sensory-somatic words, the prevalence of negative affect, and the RA Intensity Index (MH-IWRAD), which represents the RP disconnection. The presence of emotional disconnection detected in linguistic measures, together with high indices of sensory-somatic words is in line with the literature linking AN to the use of concrete thinking and metaphors, showing a reduction of symbolic capacity and impaired reflective function [58,59,60]. Mariani et al. [37] highlighted how language features can be related to a personal expression of psychopathology. The findings of our study demonstrated a relationship between AN and the difficulty of the symbolizing process. Linguistic analysis reveals the presence of concrete and body references that are coherently used to preview findings, suggesting that AN's severe metabolic impairment may have an effect for a peculiar pattern of linguistic difficulties in using the symbolizing process [58, 59].
The clinical vignettes showed specific linguistic features which connected bodily distress, AN symptoms, and personal emotional conflicts. Linguistic analysis emphasizes the relevance in understanding the relationship between words and emotional activation in psychopathology [30, 37, 60, 61].
In conclusion, all these results described a direct relationship between emotion regulation and language, following MCT [29], showing specific patterns of language in autobiographical narrative as an expression of emotional activation. This aspect can be related to possible clinical interventions aimed at narrating one's own experiences, such as the development of the ability to recognize one's affective states during clinical interviews to manage emotional dysregulation [54]. Furthermore, these results support the usefulness of setting up psychotherapeutic treatments aimed at increasing symbolic processes, managing to increase connections between the body, symptoms and mental states [61].
What is already known on this subject?
AN shows a relevant connection between food control symptoms and difficulty in managing emotions and one's affective states. Maladaptive aspects of emotional regulation and mood alterations were found in connection with anorexia nervosa.
What does this study add?
This study adds new evidence that AN disorder is closely related to maladaptive strategies utilized to regulate emotions, as well as difficulty in recognizing and symbolizing one's affective states. Furthermore, the analysis of autobiographical narratives strengthens the identification of specific linguistic characteristics of a concrete thought based on the perception of the body and symptoms, with a prevalence of negative affective states.
Conclusions
The main results of the present study show that the AN group displays higher levels of alexithymia, emotional dysregulation, and mood profile. These results are consistent with recent literature describing AN as a disorder related to emotional regulation and that food control is a possible regulator on which patients depend. This study highlights the importance of investigating the relationship between AN and emotional regulation, especially by trying to explore whether or not patients with AN are lacking an understanding of emotional states of other people, as well as their own [62]. This consideration is particularly important for designing specific treatment interventions.
A further novelty of the study is the exploration of the relationship between linguistic characteristics and AN. It is noted that in the autobiographical stories, AN patients express their illness showing a linguistic index of emotional dysregulation and greater sensory-somatic words and negative affect. This result highlights how language is closely related to the body and its psychic suffering.
Limitation
Our work explores innovative aspects in the treatment of anorexia nervosa, such as language in relation to emotional regulation. However, it is necessary to highlight the limitations of our study, such as the sample size, which will be progressively increased to confirm the data obtained. Furthermore, it would be useful to be able to better differentiate the processes concerning restrictive AN with other eating disorders. In the future, we also intend to refine the diagnostic evaluation by relating it to other comorbid phenomena and personality disorders, because they, too, can have an impact in the management of acute conditions.
Data availability
“The data sets generated and analyzed during the current study are available from the corresponding author upon reasonable request.”
Abbreviations
- ED:
-
Eating Disorders
- AN:
-
Anorexia Nervosa
- BMI:
-
Body Mass Index
- EAT-26:
-
Eating Attitudes Scale Test
- SCID-5-CV:
-
Structured Clinical Interview for Dsm-5 Disorders: Clinician Version
- MCT:
-
Multiple code theory
- TAS-20:
-
Toronto Alexithymia Scale
- ERQ:
-
Emotional Regulation Questionnaire
- POMS:
-
Profile of Mood of State
- RAP:
-
Relationship Anecdotal Paradigm
- ER:
-
Emotional Regulation; RP: Referential Process
- RA:
-
Referential Activity Intensity Index
- IDAAP:
-
Italian Discourse Attributes Analysis Program
- IWRAD:
-
Italian Weighted Referential Activity Dictionary
- MH-IWRAD:
-
Italian Mean High Weighted Referential Activity Dictionary
- IDFD:
-
Italian DisFluency Dictionary
- IREF:
-
Italian Reflection Dictionary
- ISensD:
-
Italian Sensory Somatic Dictionary
- ISAffD:
-
Italian Sum Affect Dictionary
- IPAffD:
-
Positive Affect
- INAffD:
-
Negative Affect
- IZAffD:
-
Neutral Affect
References
Ágh T, Kovacs G, Supina D, Pawaskar M, Herman BK, Vokó Z, Sheehan DV (2016) A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder. Eat Weight Disord 21(3):353–364. https://doi.org/10.1007/s40519-016-0264-x
Epidemiology and research over sanitary services - IFC - CNR, (2019).
Sadock BJ, Sadock VA, Ruiz P (2014) Kaplan & Sadock’S Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th edn. Wolters Kluwer, Alphen aan den Rijn
Peat C, Mitchell JE, Hoek HW, Wonderlich SA (2009) Validity and utility of subtyping anorexia nervosa. Int J Eat Disord 42(7):590–4. https://doi.org/10.1002/eat.20717
Eddy KT, Keel PK, Dorer DJ, Delinsky SS, Franko DL, Herzog DB (2002) Longitudinal comparison of anorexia nervosa subtypes. Int J Eat Disord 31(2):191–201. https://doi.org/10.1002/eat.10016
Giannini M, Pannocchia P, Dalle Grave R, Muratori F, Viglione V (2008) Eating disorder inventory-3. Firenze:
Signorini A, De Filippo E, Panico S, De Caprio C, Pasanisi F, Contaldo F (2007) Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature. Eur J Clin Nutr 61(1):119–122. https://doi.org/10.1038/sj.ejcn.1602491
American Psychiatric Association (2014) DSM-5 Diagnostic and statistical manual of mental disorders. American Psychiatric Association, Washington, DC
Achermann M, Günther J, Goth K, Schmeck K, Munsch S, Wöckel L (2022) Body-related attitudes, personality, and identity in female adolescents with anorexia nervosa or other mental disorders. Int J Environ Res Public Health 19(7):4316. https://doi.org/10.3390/ijerph19074316
Brockmeyer T, Holtforth MG, Bents H, Kämmerer A, Herzog W, Friederich HC (2012) Starvation and emotion regulation in anorexia nervosa. Compr Psychiatry 53(5):496–501. https://doi.org/10.1016/j.comppsych.2011.09.003
Gilboa-Schechtman E, Avnon L, Zubery E, Jeczmien P (2006) Emotional processing in eating disorders: specific impairment or general distress related deficiency? Depress Anxiety 23(6):331–339. https://doi.org/10.1002/da.20163
Bourke MP, Taylor GJ, Parker JD, Bagby RM (1992) Alexithymia in women with anorexia nervosa: a preliminary investigation. Br J Psychiatry 161(2):240–243. https://doi.org/10.1192/bjp.161.2.240
Nemiah JC, Freyberger H, Sifneos PE (1976) Alexithymia: a view of the psychosomatic process. In: Hill OW (ed) Modern trends in psychosomatic medicine, vol 3. Butterworths, London, pp 430–439
Taylor GJ, Bagby RM (2004) New trends in alexithymia research. Psychother Psychosom 73(2):68–77. https://doi.org/10.1159/000075537
Dapelo MM, Hart S, Hale C, Morris R, Tchanturia K (2016) Expression of positive emotions differs in illness and recovery in anorexia nervosa. Psychiatry Res 246:48–51. https://doi.org/10.1016/j.psychres.2016.09.014
Waller E, Scheidt CE (2006) Somatoform disorders as disorders of affect regulation: a development perspective. Int Rev Psychiatry 18(1):13–24. https://doi.org/10.1080/09540260500466774
Brown TA, Avery JC, Jones MD, Anderson LK, Wierenga CE, Kaye WH (2018) The impact of alexithymia on emotion dysregulation in anorexia nervosa and bulimia nervosa overtime. Eur Eat Disord Rev 26(2):150–155. https://doi.org/10.1002/erv.2574
Foye U, Hazlett DE, Irving P (2019) ‘The body is a battleground for unwanted and unexpressed emotions’: exploring eating disorders and the role of emotional intelligence. Eat Disord 27(3):321–342. https://doi.org/10.1080/10640266.2018.1517520
Tauro JL, Wearne TA, Belevski B, Filipčíková M, Francis HM (2022) Social cognition in female adults with anorexia nervosa: a systematic review. Neurosci Biobehav Rev 132:197–210. https://doi.org/10.1016/j.neubiorev.2021.11.035
Harrison A, Sullivan S, Tchanturia K, Treasure J (2010) Emotional functioning in eating disorders: attentional bias, emotion recognition and emotion regulation. Psychol Med 40(11):1887–1897. https://doi.org/10.1017/s0033291710000036
Haynos AF, Fruzzetti AE (2011) Anorexia nervosa as a disorder of emotion dysregulation: evidence and treatment implications. Clin Psychol Sci Pract 18(3):183. https://doi.org/10.1111/j.1468-2850.2011.01250.x
Wildes JE, Ringham RM, Marcus MD (2010) Emotion avoidance in patients with anorexia nervosa: initial test of a functional model. Int J Eat Disord 43(5):398–404. https://doi.org/10.1002/eat.20730
Wonderlich SA, Peterson CB, Crosby RD, Smith TL, Klein MH, Mitchell JE, Crow SJ (2014) A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychol Med 44(3):543–553. https://doi.org/10.1017/s0033291713001098
Lombardo C, David M, Moreschini A, Battagliese G, Maccioli L, Pierotti A, Stella A (2013) Risposte emozionali e regolazione delle emozioni nei Disturbi dell’Alimentazione. Psic Cogn e Comp 19:2
Bucci W (1997) Psychoanalysis and cognitive science: a multiple code theory. Guilford Press, New York
Taylor GJ, Bagby RM (2013) Psychoanalysis and empirical research: the example of alexithymia. J Am Psychoanal Assoc 61(1):99–133. https://doi.org/10.1177/0003065112474066
Bucci W, Maskit B (2007) Beneath the surface of the therapeutic interaction: the psychoanalytic method in modern dress. J Am Psychoanal Assoc 55(4):1355–1397. https://doi.org/10.1177/000306510705500412
McClelland DC, Koestner R, Weinberger J (1989) How do self-attributed and implicit motives differ? Psychol Rev 96(4):690. https://doi.org/10.1037/0033-295X.96.4.690
Bucci W (2021) Overview of the referential process: the operation of language within and between people. J Psycholinguist Res 50(1):3–15. https://doi.org/10.1007/s10936-021-09759-2
Di Trani M, Mariani R, Renzi A, Greenman PS, Solano L (2018) Alexithymia according to Bucci’s multiple code theory: a preliminary investigation with healthy and hypertensive individuals. Psychol Psychother Theory Res Pract 91(2):232–247. https://doi.org/10.1111/papt.12158
Damasio A (2010) Self Comes to Mind: Constructing the Conscious Brain. Pantheon Books, New York
Bucci W (2001) Pathways of emotional communication. Psychoanal Inq 20:40–70
Bucci W (2002) The referential process, consciousness, and the sense of self. Psychoanal Inq 22(5):766–793
Storch M, Keller F, Weber J, Spindler A, Milos G (2011) Psychoeducation in affect regulation for patients with eating disorders: a randomized controlled feasibility study. Am J Psychother 65(1):81–93. https://doi.org/10.1176/appi.psychotherapy.2011.65.1.81
Gamber AM, Lane-Loney S, Levine MP (2013) Effects and linguistic analysis of written traumatic emotional disclosure in an eating-disordered population. Perm J 17(1):16–20. https://doi.org/10.7812/TPP/12-056
Nandrino JL, Doba K, Lesne A, Christophe V, Pezard L (2006) Autobiographical memory deficit in anorexia nervosa: emotion regulation and effect of duration of illness. J Psychosom Res 61(4):537–543. https://doi.org/10.1016/j.jpsychores.2006.02.008
Ben-Meir M (2006) The nature of language in anorexia nervosa: a multiple code account. Adelphi University, The Institute of Advanced Psychological Studies, Garden City
Mariani R, Di Trani M, Negri A, Tambelli R (2020) Linguistic analysis of autobiographical narratives in unipolar and bipolar mood disorders in light of multiple code theory. J Affect Disord 273:24–31. https://doi.org/10.1016/j.jad.2020.03.170
First MB (2015) Structured clinical interview for the DSM (SCID). In: Cautin RL, Lilienfeld SO (eds) The encyclopedia of clinical psychology. Wiley, Hoboken
Garner DM, Olmsted MP, Bohr Y, Garfinkel PE (1982) The eating attitudes test: psychometric features and clinical correlates. Psychol Med 12(4):871–878. https://doi.org/10.1017/s0033291700049163
Wiseman H, Raz A, Sharabany R (2007) Depressive personality styles and interpersonal problems in young adults with difficulties in establishing long-term romantic relationships. Isr J Psychiatry Relat Sci 44(4):280
Wiseman H, Barber JP (2004) The core conflictual relationship theme approach to relational narratives: interpersonal themes in the context of intergenerational communication of trauma. American Psychological Association, Washington
Maskit B, Murphy S (2011) The discourse attributes analysis program. The Referential Process.
McNair DM, Lorr M, Droppleman LF (1992) EdITS Manual for the Profile of Mood States (POMS). Educational and industrial testing service.
Farnè M, Sebellico A, Gnugnoli D, Corallo A (1991) POMS. Profile of Mood States: Adattamento italiano. Organizzazioni Speciali, Firenze
Bagby RM, Taylor GJ, Parker JD (1994) The Twenty-item Toronto Alexithymia Scale—II Convergent, discriminant, and concurrent validity. J Psychosom Res. 38(1):33–40. https://doi.org/10.1016/0022-3999(94)90006-x
Gross JJ, John OP (2003) Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J Pers Soc Psychol 85:348–362
Balzarotti S, John OP, Gross JJ (2010) An Italian adaptation of the emotion regulation questionnaire. Eur J Psychol Assess 26(1):61–67. https://doi.org/10.1027/1015-5759/a000009
Mariani R, Maskit B, Bucci W, De Coro A (2013) Linguistic measures of the referential process in psychodynamic treatment: the English and Italian versions. Psychother Res 23(4):430–447. https://doi.org/10.1080/10503307.2013.794399
Bucci W, Maskit B, Hoffman L (2012) Objective measures of subjective experience: the use of therapist notes in process-outcome research. Psychodynamic psychiatry 40(2):303–340. https://doi.org/10.1521/pdps.2012.40.2.303
Bonfanti AA, Campanelli L, Ciliberti A, Golia G, Papini SP (2008) Speech Disfluency in spoken language: The Italian computerized dictionary (I-Df) and its application on a single case. In SPR International Meeting, Barcelona, Spain.
Luborsky L (1998) The Relationship Anecdotes Paradigm (RAP) interview as a versatile source of narratives. In: Luborsky L, Crits-Christoph P (eds) Understanding transference: the core conflictual relationship theme method. American Psychological Association, Washington, DC, pp 109–120
Barber JP, Luborsky L, Crits-Christoph P, Diguer L (1995) A comparison of core conflictual relationship themes before psychotherapy and during early sessions. J Consult Clin Psychol 63(1):145–148. https://doi.org/10.1037/0022-006X.63.1.145
Kornstein SG, Keck PE Jr, Herman BK, Puhl RM, Wilfley DE, DiMarco ID (2015) Communication between physicians and patients with suspected or diagnosed binge eating disorder. Postgrad Med 127(7):661–670. https://doi.org/10.1080/00325481.2015.1084866
Colli A, Gentile D, Tanzilli A, Speranza AM, Lingiardi V (2016) Therapeutic interventions in the treatment of eating disorders: a naturalistic study. Psychotherapy 53(2):152–162. https://doi.org/10.1037/pst0000063
Craba A, Mazza M, Marano G, Rinaldi L, Sani G, Janiri L (2021) Which comes first? New insights on comorbidity between eating disorders and bipolar disorders. Emerg Trends Drugs Addict Health. https://doi.org/10.1016/j.etdah.2021.100023
Mallorquí-Bagué N, Lozano-Madrid M, Testa G, Vintró-Alcaraz C, Sánchez I, Riesco N, César Perales J, Francisco Navas J, Martínez-Zalacaín I, Megías A, Granero R, De Las Veciana, Heras M, Chami R, Jiménez-Murcia S, Fernández-Formoso JA, Treasure J, Fernández-Aranda F (2020) Clinical and Neurophysiological Correlates of Emotion and Food Craving Regulation in Patients with Anorexia Nervosa. J Clin Med. 9(4):960. https://doi.org/10.3390/jcm9040960 (PMID: 32244331; PMCID: PMC7230937)
Stanghellini G, Trisolini F, Castellini G, Ambrosini A, Faravelli C, Ricca V (2015) Is feeling extraneous from one’s own body a core vulnerability feature in eating disorders? Psychopathology 48(1):18–24. https://doi.org/10.1159/000364882 (Epub 2014 Oct 22 PMID: 25341960)
Skårderud F (2007) Eating one’s words, part I: “Concretised metaphors” and reflective function in anorexia nervosa–an interview study. Eur Eat Disord Rev 15(3):163–174. https://doi.org/10.1002/erv.777 (PMID: 17676686)
Cuteri V, Minori G, Gagliardi G, Tamburini F, Malaspina E, Gualandi P, Rossi F, Moscano M, Francia V, Parmeggiani A (2022) Linguistic feature of anorexia nervosa: a prospective case-control pilot study. Eat Weight Disord. 27(4):1367–1375. https://doi.org/10.1007/s40519-021-01273-7. (Epub 2021 Jul 26. PMID: 34309776; PMCID: PMC8311399)
Skårderud F (2007) Eating one’s words, part II: the embodied mind and reflective function in anorexia nervosa–theory. Eur Eat Disord Rev 15(4):243–252. https://doi.org/10.1002/erv.778 (PMID: 17676695)
Skårderud F (2007) Eating one’s words: Part III. Mentalisation-based psychotherapy for anorexia nervosa–an outline for a treatment and training manual. Eur Eat Disord Rev. 15(5):323–39. https://doi.org/10.1002/erv.817 (PMID: 17701977)
Preti A, Siddi S, Marzola E et al (2022) Affective cognition in eating disorders: a systematic review and meta-analysis of the performance on the “reading the mind in the eyes” test. Eat Weight Disord. https://doi.org/10.1007/s40519-022-01393-8
Funding
Open access funding provided by Università degli Studi di Roma La Sapienza within the CRUI-CARE Agreement. The authors declare that no funds, grants, or other support was received during the preparation of this manuscript.
Author information
Authors and Affiliations
Contributions
“All authors contributed to the study conception and design. Material preparation, data collection was performed by Mariani Rachele, Marini Isabella, the data set was performed by Catena Carlotta, Patino Francesca, Riccioni Raffaele and analysis were performed by Mariani Rachele and Di Trani Michela. The first draft of the manuscript was written by Mariani Rachele and Marini Isabella. All authors commented on previous versions of the manuscript, the supervision of all work was performed by Pasquini Massimo. All authors read and approved the final manuscript.”
Corresponding author
Ethics declarations
Ethics approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Sapienza of Rome prot.n. 1205 of 15/12/2020.
Conflict of interests
The authors have no relevant financial or non-financial interests to disclose, nor competing interests to declare that are relevant to the content of this article.
Informed consent
All participants provided informed consent prior to their participation.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Mariani, R., Marini, I., Di Trani, M. et al. Emotional dysregulation and linguistic patterns as a defining feature of patients in the acute phase of anorexia nervosa. Eat Weight Disord 27, 3267–3277 (2022). https://doi.org/10.1007/s40519-022-01456-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40519-022-01456-w