Implications of Alexithymia in Binge Eating Disorder
Amy H. Olson, LCSW
Binge Eating Disorder (BED) is characterized by multi-etiological risk factors including social,
familial, interpersonal, psychological (Waller, 2002) as well as genetic and neurochemical (de Zwann
et al., 1995). It has been suggested that early stages of BED are influenced by physiological states
such as hunger imposed by dietary restraint. Later stages are maintained by the role binge eating
plays in helping one to manage affective states (Waller, 2002). This paper is primarily concerned in
identifying how alexithymia, the difficulty identifying and expressing feelings, creates vulnerability for
the development of BED.
Binge Eating Disorder
BED is the most common eating disorder with a lifetime prevalence of 2-3 % of the adult population
and 8 % of obese individuals (Grillo, 2002). It is characterized by consuming large quantities of food in
short periods of time, accompanied by a sense of out-of-control, guilt and self-hatred. Those with BED
have similar levels of dysfunctional thinking about weight and shape as those with Bulimia Nervosa
(BN). When compared to obese individuals without BED, higher lifetime rates of psychiatric disorders,
personality disorders and alcohol use are evident (Grillo, 2002).
As in anorexia nervosa (AN) and BN, BED has been delineated into subtypes “…distinguishing
individuals whose binge eating precedes their dieting (binge-first [BF]) from those whose dieting
precedes their binge eating (diet-first [DF])” (Manwaring et al., 2006, p. 101). In a study Manwaring et
al., the BF group reported higher rates of substance abuse, psychiatric co morbidities and poorer
treatment outcomes. The BF group reported earlier onset of bingeing behavior, mean age of 19.7,
while DF group reported onset at a mean age of 24.5. No significant differences in risk factors were
been found between BF and DF groups, but the DF group reported higher rates of sexual abuse.
Alexithymia
Alexithymia is a term that was introduced in the 1970’s to describe the condition of those who have
“no words for feelings” (Sifneos, 1972). “The alexithymic individual struggles with identifying and
expressing emotions and misinterprets emotions as physical sensations. For example, the person may
interpret sadness or loneliness as hunger” (Wheeler, Greiner, & Boulton, 2005). Additional
conditions of alexithymia include externally oriented thinking, concrete and stereotyped speech, an
impoverished fantasy life and a diminution of daydreaming (de Zwann et al., 1995).
Alexithymia is not unique to BED or eating disorders in general, instead it is known to underpin
many psychological disorders. However, in Hilde Bruch’s seminal works on eating disorders she
suggested that, “…the difficulty to distinguish and describe feelings is the main deficit in eating
disorders, related to a sense of general inadequacy and lack of control over one’s life” (Carano et
al., 2006).
Alexithymia is more highly correlated with BED than with AN or BN (Wheeler, Greiner & Boulton, M.,
2005) and a higher prevalence is found in BED subjects vs. non-BED subjects (de Zwann et al.,
1995). Precursors to alexithymia occur in early childhood, including trauma, parental misattunement
and/or temperamental differences between child and caregiver. Such events and deficits prevent the
proper development of internal mechanisms of self-soothing needed to manage affective states.
Binge Eating as Affect Regulation
Binge eating serves as blocking agent to unpleasant or strong affective states. If an individual
experiences bankruptcy in other modes of internal soothing, food provides the nurturance and
calming necessary to regulate emotions. Unique circumstances lead the binge eater to prefer food
over other types of blocking agents such as drugs, alcohol, gambling or sex addiction, although such
behaviors may also be present to a degree. Food is a readily available substance, socially accepted
and affords the binge eater a certain degree of functionality to take care of responsibilities and
obligations.
The power of binge eating as a blocking agent presents a treatment challenge, as one often cannot
remember the situation or affective state that preceded the binge (Waller, 2002). This maintains the
alexithymic condition as the individual does not identify emotions or become practiced in the natural
course of emotions. After binge eating, the negative emotions experienced as a result of the binge
become prominent and drive compensatory behaviors to reduce anxiety about the food eaten.
Compensatory behaviors may include food restriction, strict dietary guidelines and/or critical self-
statements, driving the binge eater back into the disordered eating cycle and maintaining alexithymia.
Treatment Implications
If BED is recognized as a consequence of alexithymia, then the defining characteristics of
alexithymia must be considered in the treatment planning process. Primary goals must include
teaching individuals to identify and manage feelings in a more functional way. It can be hypothesized
that emotional development became arrested around the time that binge eating became a primary
mechanism of internal soothing. Behavioral skills such as relaxation, imagery and biofeedback may
enhance the treatment outcomes. Interpersonal skills may also be treatment targets as, “Alexithymics
have a restricted ability to keep close interpersonal relationships and to feel socially comfortable” (de
Zwann et al., 1995). Maintenance of the therapeutic bond also aids in correcting such deficits.
Treatment is effective as research supports, “…that abstinence of binge eating is associated with a
reduction in alexithymia and improvement of emotional awareness after treatment” (Wheeler, Greiner
& Boulton, M., 2005, p. 116).
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