Alexithymia and its relationships with body checking and body image in a non-clinical female sample

Eating Behaviors 8 (2007) 296–304

Alexithymia and its relationships with body checking and bodyimage in a non-clinical female sample

Domenico De Berardis a, Alessandro Carano a, Francesco Gambi a, Daniela Campanella a,Paola Giannetti a, Anna Ceci a, Enrico Mancini b, Raffaella La Rovere a,

Alessandra Cicconetti a, Laura Penna a, Danilo Di Matteo a,Barbara Scorrano a, Carla Cotellessa a, Rosa Maria Salerno a,

Nicola Serroni c, Filippo Maria Ferro a,⁎

a Department of Oncology and Neurosciences, Institute of Psychiatry, University “G. d'Annunzio” of Chieti, Italyb Institute of Psychology, University “Carlo Bo” of Urbino, Italy

c Department of Mental Health, SPDC Teramo, Italy

Received 29 December 2005; received in revised form 29 July 2006; accepted 6 November 2006

Abstract

The aim of the present study was to evaluate in a non-clinical sample of undergraduate women, the relationships betweenalexithymia, body checking and body image, identifying predictive factors associated with the possible risk of developing anEating Disorder (ED). The Toronto Alexithymia Scale (TAS-20), Body Checking Questionnaire (BCQ), Eating Attitudes Test(EAT-26), Body Shape Questionnaire (BSQ), Interaction Anxiousness Scale (IAS), Rosenberg Self-Esteem Scale (RSES) and theBeck Depression Inventory (BDI) were completed by 254 undergraduate females. We found that alexithymics had more consistentbody checking behaviors and higher body dissatisfaction than nonalexithymics. In addition, alexithymics also reported a higherpotential risk for ED (higher scores on EAT-26) when compared to nonalexithymics. Difficulty in identifying and describingfeelings subscales of TAS-20, Overall appearance and Specific Body Parts subscales of BCQ as well as lower self-esteemwas associated with higher ED risk in a linear regression analysis. Thus, a combination of alexithymia, low self-esteem, bodychecking behaviors and body dissatisfaction may be a risk factor for symptoms of ED at least in a non-clinical sample of universitywomen.© 2006 Elsevier Ltd. All rights reserved.

Keywords: Alexithymia; Body checking; Body image; Eating disorders; Emotions

⁎ Corresponding author. Department of Oncology and Neurosciences, Institute of Psychiatry, University “G. D'Annunzio” of Chieti, Palazzina SE.BI. — Scuole di Specializzazione, via dei Vestini, 31-66013 Chieti, Italy. Tel.: +39 08713556750; fax: +39 08713556721.

E-mail address: [email protected] (D. De Berardis).

1471-0153/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.doi:10.1016/j.eatbeh.2006.11.005

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1. Introduction

It is widely recognized that the body dissatisfaction and an excessive concern about body weight and shape are corecharacteristic of Eating Disorders (ED) and are used to determine self-worth (Fairburn, Cooper, & Shafran, 2003;Garner, Olmstead, Polivy, & Garfinkel, 1984). Recently, there was an increased interest about the body image as amultidimensional issue that involves perceptual, attitudinal and behavioral characteristics (Cash & Henry, 1995;Ehrsson, Kito, Sadato, Passingham, & Naito, 2005; Williamson, 1990, 1996). Many researchers have focused theirattention mainly to the perceptual and attitudinal aspects of body image whereas only few studies have investigated thebehavioral consequences related to a negative body image (Reas, Whisenhunt, Netemeyer, & Williamson, 2002).Patients with or at risk of ED often have a negative perception of several body parts; in some cases, they avoid socialsituations that may point out their physical appearance and exert a ritualistic checking on their body weight and shape(Reas et al., 2002; Toro, Gila, Castro, Pombo, & Guete, 2005). The body checking could be considered somewhatsimilar to compulsive behaviors; through this checking patients are often able to avoid the anxiety that derives fromnegative concerns about their body weight and shape (Rosen, 1997; Williamson, 1990). Examples of body checkingare the repetitive measure of body weight, the frequent exposures at mirror in order to verify possible body shapechanges, the use of particular clothes that can “measure” the fatness or the thinness, the pinching of several body partsto verify their consistence, the comparison with other people about the own body weight and shape, the checking to seeif thighs rub together and many more (Fairburn et al., 2003; Reas et al., 2002).

On the other hand, in ED patients, paradoxically, the body checking may reinforce the body dissatisfaction focusingfurther attention on concerns related to a negative body image (Fairburn, 1997). Fairburn, Shafran, and Cooper (1999)have pointed out the rule of the “body control” in the clinical evolution of anorexia. The body control and checking areused to monitor the body weight and shape changes, but increase the perceived imperfections and may lead to a higherbody weight control. As consequence, a hypervigilant body control preserves the negative beliefs about presumedabnormal body shape. Moreover, they have hypothesized that the normal variations of body weight may be directlyrelated to mood swings in ED patients. Since the body control and checking may play a role in the development andmaintenance of an ED, the evaluation of the body checking behaviors may be useful in therapeutic programs aimed tohelp patients with ED (Bowers, 2000; Garner & Garfinkel, 1997). In fact, as clinical observations indicate that bodychecking increase both the patient's preoccupation with body shape and weight and the motivation to maintain dietaryrestraint, a therapeutic program aimed to reducing body checking may contribute to reduce body dissatisfaction and,consequently, ED symptoms (Shafran, Fairburn, Robinson, & Lask, 2004).

Furthermore, it is reasonable to think that individuals with anorexia nervosa and bulimia nervosa develop a highlyorganized cognitive schema concerning body- and weight-related information (Williamson, Muller, Reas, & Thaw,1999). Body checking behaviors, like social scanning, may be both positively and negatively reinforced and strengthenthe concerns about body size and shape as well as food and eating. Body checking rituals are used to regulate emotionsthrough confirmation or attenuation of fears (and are therefore negatively reinforced), whereas in many circumstancesthe checking behaviors reinforce disordered patterns of behavior when the ritual results in an unfavourable or negativeperception (Williamson, White, York-Crowe, & Stewart, 2004).

Coined by Sifneos (1973), the term “alexithymia” was introduced to designate a cluster of cognitive and affectivecharacteristics that were observed among patients with psychosomatic diseases. The alexithymia construct, formulatedfrom clinical investigations, is multifaceted and includes four distinct characteristics: (a) difficulty in identifying anddescribing feelings, (b) difficulty in distinguishing feelings from the bodily sensations, (c) diminution of fantasy, and(d) concrete and poorly introspective thinking (Taylor, Bagby, & Parker, 1991). Alexithymic individuals have affectivedysregulation, the inability to self soothe and manage emotions because of a lack of awareness of emotions (Taylor,Bagby, & Parker, 1997). Thus, the adaptive informational value of emotions that is important for emotion regulationoften eludes these individuals.

In non-clinical samples, the prevalence of alexithymia ranges from 0% to 28% (Guilbaud et al., 2002; Jimerson,Wolfe, Franko, Covino, & Sifneos, 1994). An increasing body of research indicates that alexithymia features exist notonly in classic psychosomatic disorders but also in other severe and chronic somatic diseases and psychiatric disorderssuch as Somatoform Disorders, Major Depression and other Axis I disorders (Bankier, Aigner, & Back, 2001; DeBerardis et al., 2005).

Concerning EDs, Bruch (1973) suggested that the difficulty to distinguish and describe feelings is one of the mainproblems in ED patients, related to a sense of general inadequacy and a lack of control over one's life. Moreover, Bruch

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(1962) proposed that in anorexia nervosa an approach that helps patients to become aware of and identify inner states,including emotions, would be useful. It is known that alexithymia may play an important role in EDs: specificallyalexithymics patients may show a higher psychological distress than nonalexithymics (Taylor, Parker, Bagby, &Bourke, 1996) and the presence of an alexithymic trait may be related to a higher severity of EDs themselves(Bydlowski et al., 2005; Carano et al., 2006).

Furthermore, there are evidences that ED patients are considerably more alexithymic than apparently healthycontrols (Cochrane, Brewerton, Wilson, & Hodges, 1993; Schmidt, Jiwany, & Treasure, 1993) and some studies havespecified that alexithymia is more related to the psychological characteristics of patients with EDs than to the eatingbehavior itself (Bydlowski et al., 2005; de Groot, Rodin, & Olmsted, 1995; Taylor et al., 1996). It is reported thatemotional expression may be inversely related to body dissatisfaction (Hayaki, Friedman, & Brownell, 2002).However, concerning non-clinical samples, in an interesting and well conducted study, Quinton and Wagner (2005)found that alexithymia did not predict neither total EAT-26 score, nor two EDI-2 subscales measuring aspects of eatingpsychopathology. They concluded that, although disturbed emotional functioning is a feature of eating disorders, it didnot relate directly to the core psychopathology.

Some core aspects of alexithymic construct, as a difficulty in distinguishing emotional states from bodily sensations,may be more characterized in patients with EDs and a possible explanation might be that ED patients may appeardramatically and deeply incapable of being in touch with their inner emotive world (Andersen, 1988). As consequence,these subjects may focus their attention on negative perceptual aspects of body bypassing emotional experiences(Montebarocci et al., 2006). Taken together, these findings may suggest that alexithymia, body checking and body-image disturbances may be strongly correlated in EDs. In our opinion, the body checking on an alexithymiabackground can create or exacerbate body-image problems. So, the aim of the present study was to evaluate in a non-clinical sample of female university students the relationships between alexithymia, body checking and body image,testing whether alexithymics present higher psychological distress and identifying possible predictive factorsassociated with the possible risk of developing an ED. This may have important clinical implications especiallyconcerning cognitive aspects related to EDs.

2. Method

2.1. Participants

Many eating-disordered behaviors, such as binge eating, self-induced vomiting, inappropriate dieting and bodydissatisfaction, exist in samples of non-clinical women (Kent & Clopton, 1992; Williamson et al., 1995). Therefore, aconvenience sample was selected and the participants in this study were 288 undergraduate women students from theUniversity of Chieti ranging in age from 18 to 30 years, drawn from university psychology classes. Approval for thestudy was granted by the university's Ethics Board. The sample was restricted to women because of the disproportionaterepresentation of women among all types of eating disorders (Murray, 2003). 271 women (94.1%) of those offered thechance to participate agreed. Of the participants who began the study, 17 returned incomplete tests and therefore wereexcluded from the study. The final sample was comprised of 254 women (93.7% retention rate), ranging in age from 18to 30 (M=22.5, S.D.=1.9). 34 (18.4%) women were married and 55 (21.6%) were working during study period.

Body mass index (BMI) was recorded for each participant. BMI was calculated by dividing weight in kilograms byheight in meters squared. A BMI below 18.5 indicates unusual thinness. A BMI between 18.6 and 24.9 is considerednormal. A BMI over 25 indicates overweight or obese status. BMI in our sample ranged from 17.3 to 31.1 (M=21.2, S.D.=2.6). Eighty-nine percent of the sample was classified as normal weight, 4.3% was classified as overweight orobese, and 6.7% were classified as underweight.

2.2. Procedure

Subjects were approached as a group at the end of a lecture, and the aim of the study was briefly outlined. Weassured students that their participation was voluntary and asked them to submit their responses anonymously.Participants were required to read and sign an informed consent letter prior to filling out the questionnaires. They didnot receive course credits for their participation. The survey required approximately 30–90 min to complete (M=34.6,S.D.=6.9).

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2.3. Measures

2.3.1. Body Checking Questionnaire (BCQ)The BCQ is a reliable and valid measure of body checking behaviors (Reas et al., 2002). It is a 23-item self-report

questionnaire with higher scores associated with more intense body dissatisfaction, body-image avoidant behaviors,and general eating disturbances. The BCQ measures a high-order factor (body checking) with three subfactors that arehighly correlated: overall appearance (OA), specific body parts (SBP) and idiosyncratic checking (IC). The Italianversion has been validated by Calugi, Dalle Grave, Ghisi, and Sanavio (2006) and confirmatory factor analysisconfirmed the same three-factor structure of the English version.

In our study, Cronbach's α was .93 for the BCQ total score and .86, .89, 77, respectively, for the OA, SBP and ICsubfactors.

2.3.2. Toronto Alexithymia Scale (TAS-20)Alexithymia was measured using the 20-item TAS-20, the most widely used measure of alexithymia (Bagby, Parker,

& Taylor, 1994). The TAS-20 has a three-factor structure (Haviland & Reise, 1996). Factor l assesses the capacity toidentify feelings and to distinguish between feelings and the bodily sensations of emotional arousal (Difficulty inIdentifying Feelings, DIF); Factor 2 reflects the inability to communicate feelings to other people (Difficulty inDescribing Feelings, DDF); Factor 3 assesses Externally Oriented Thinking (EOT). Cut-off scores for the TAS-20 areprovided by Bagby et al. (1994) and a score of 61 and above is considered to be within the alexithymic range. TheItalian version of the TAS-20 was used (Bressi et al., 1996).

In our study, Cronbach's α was .83.

2.3.3. Eating Attitude Test-26 (EAT-26)Disordered eating was assessed through the 26-item EAT-26 (Garner & Garfinkel, 1979; Garner, Olmstead, &

Polivy, 1983). We used EAT-26 total score as evaluation of possible risk for developing an ED; a cut-off score of ≥20on the total score indicates an individual is susceptible to developing an ED (Becker, Grinspoon, Klibanski, & Herzog,1999). The Italian version of the EAT-26 has demonstrated the same psychometric properties of the English version(Dotti & Lazzari, 1998).

In our study, Cronbach's α was .90.

2.3.4. Body Shape Questionnaire (BSQ)The BSQ is a 34-item self-rating scale that estimates the participants' disturbed perceptions of body size and body

shape (Cooper, Taylor, Cooper, & Fairburn, 1987). Higher scores reflect greater body-image concerns. The BSQ is awidely used instrument in studies of eating and weight disorders. The Italian version was used (Conti, 1999).

In our study, Cronbach's α was .93.

2.3.5. Interaction Anxiousness Scale (IAS)The IAS is a 15-item measure that assesses social anxiety in relation to, though not avoidance of, situations in which

the individual is directly interacting with others, as opposed to being observed by others (Leary, 1983). The Italianversion was used (Conti, 1999).

In our sample, Cronbach's α was .89.

2.3.6. Rosenberg Self-Esteem Scale (RSES)Self-esteem measurement was made using the 10-item RSES (Rosenberg, 1965). The scores range from 10 to 40,

with higher scores reflecting higher self-esteem. The Italian version of RSES has previously been validated (Prezza,Trombaccia, & Armento, 1997).

In our study, Cronbach's α was .87.

2.3.7. Beck Depression Inventory (BDI)Depressed mood was assessed with the Italian version of BDI (Scilligo, 1983), a 21-item self-report scale with

higher scores indicating more depressive symptoms.In our study, Cronbach's α was .86.

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3. Statistical analysis

Descriptive statistics (means and standard deviations as appropriate) and percentages were computed for the studysample on demographic variables and all psychometric scales. The differences between alexithymics andnonalexithymics were tested by using analyses of covariance (ANCOVA) with TAS-20 positivity/negativity as factorand age, BMI and BDI scores as covariates. Chi-square analyses (with the Yates' correction for 2×2 tables) and oddsratios were used for categorical variables. Cohen's index d-values were also calculated to obtain a better evaluation ofthe magnitude of group differences on continuous study measures. By convention, d≥ .80 denoted a large effect,d≥ .50 a medium effect and d≥ .20 a small effect. Partial correlations controlling for age, BMI and BDI were usedto examine the degree of association between the study variables; partial correlations were used to add control variablesand to see their affect on the relationships. Age, BMI and BDI scores were considered controlling variables in bothANCOVA and partial correlations in order to obtain a better estimation of differences between groups as these variablesmay interact with ED measures, alexithymia, anxiety and self-esteem, potentially confounding the results.

A blockwise linear regression analysis was performed in order to find which variables were associated with possiblerisk of ED (EAT-26 score as dependent variable). In the first block BMI, demographic variables and measures ofpsychological distress (BDI, IAS and RSES) were entered. In the second block body checking and dissatisfactionmeasures (BCQ subscales and BSQ) were added to the model. DIF, DDF and EOTsubscales of TAS-20 were entered inthe last block. The quality of the regression model was also tested using the Durbin–Watson statistic (a value between 0and 4 indicating the amount of autocorrelation within the model with an optimum of 2.0).

p values≤ .05 were considered to be statistically significant. All statistical testing was two-sided. Statistical analyseswere performed using SPSS for Windows release 10.0.0 (2000). All data are expressed, if otherwise specified, as mean(M )± standard deviation (S.D.).

4. Results

Twenty participants (7.9%) scored higher than the clinical cut-off (20) for the EAT-26. TAS-20 score was 43.6(S.D.=12.5). 10.2% (n=26) of 254 subjects scored 61 or more on TAS-20 total score and therefore were categorizedas alexithymics. BDI score was 9.0 (S.D.=8.4).

The overall results and the comparisons between alexithymics and nonalexithymics are reported in Table 1. Nodifferences between groups were found concerning age, marital status and occupation. The results of ANCOVAcontrolling for age, BMI and BDI scores showed that alexithymics had more consistent body checking behaviors(higher scores on BCQ and subscales OA, SBP, IC) and higher body dissatisfaction (higher scores on BSQ) thannonalexithymics. Alexithymics reported also a higher potential risk for ED (higher scores on EAT-26) when comparedto nonalexithymics. Finally, alexithymics showed higher IAS and lower RSES scores than nonalexithymics. Moreover,the number of subjects who scored higher than the clinical cutoff (20) for the EAT-26 was higher in the alexithymicgroup (n=8, 30.8%) and this difference was statistically significant ( pb .001, odds ratio=8.0). Effect size calculationshowed that the magnitude of group effect for all variables was large.

Table 1Overall results and comparison between alexithymics and nonalexithymics, controlling for age, BMI and depressive symptoms

Overall Alexithymics Nonalexithymics d

M S.D. M S.D. M S.D.

BCQTotal 47.8 16.9 63.9⁎ 24.3 46.0 14.8 .89OA 23.5 7.9 29.5⁎ 10.3 22.8 7.3 .85SBP 16.8 7.1 23.0⁎ 9.8 16.1 6.4 .83IC 7.5 3.3 11.5⁎ 6.1 7.1 2.5 .94

EAT-26 6.3 7.8 12.7⁎ 13.4 5.6 6.6 .81BSQ 75.7 35.5 102.5⁎ 49.1 72.7 32.3 .82IAS 44.6 12.2 59.6⁎ 10.9 42.8 11.2 .80RSES 20.8 5.2 14.4⁎ 3.1 21.5 4.9 1.73

(⁎) AlexithymicsNNonalexithymics, pb .001 (2-tailed).

Table 2Partial correlations between studied variables controlling for age, BMI and depressive symptoms

1 2 3 4 5 6 7 8 9 10 11 12

1. BCQ .93⁎⁎⁎ .93⁎⁎⁎ .83⁎⁎⁎ .40⁎⁎⁎ .42⁎⁎⁎ .29⁎⁎⁎ .08 .50⁎⁎⁎ .40⁎⁎⁎ .15⁎⁎ − .23⁎⁎⁎2. OA .76⁎⁎⁎ .68⁎⁎⁎ .36⁎⁎⁎ .39⁎⁎⁎ .25⁎⁎⁎ .05 .42⁎⁎⁎ .33⁎⁎⁎ .09 − .17⁎⁎3. SBP .75⁎⁎⁎ .34⁎⁎⁎ .36⁎⁎⁎ .26⁎⁎⁎ .11 .50⁎⁎⁎ .39⁎⁎⁎ .16⁎⁎ − .22⁎⁎⁎4. IC .42⁎⁎⁎ .44⁎⁎⁎ .32⁎⁎⁎ .06 .46⁎⁎⁎ .40⁎⁎⁎ .16⁎⁎ − .27⁎⁎⁎5. TAS-20 .88⁎⁎⁎ .87⁎⁎⁎ .64⁎⁎⁎ .31⁎⁎⁎ .20⁎⁎⁎ .21⁎⁎ − .39⁎⁎⁎6. DIF .64⁎⁎⁎ .33⁎⁎⁎ .32⁎⁎⁎ .20⁎⁎⁎ .23⁎⁎⁎ − .40⁎⁎⁎7. DDF .48⁎⁎⁎ .28⁎⁎⁎ .18⁎⁎ .19⁎⁎ − .36⁎⁎⁎8. EOT .09 .11 .10 − .14⁎9. EAT-26 .31⁎⁎⁎ .07 − .17⁎⁎10. BSQ .16⁎⁎ − .18⁎⁎11. IAS − .15⁎⁎12. RSES

N=254, ⁎pb .05, ⁎⁎pb .01, ⁎⁎⁎pb .001.

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The results of partial correlations controlling for age, BMI and BDI scores showed that BCQ and subscales werehighly intercorrelated as well as TAS-20 and subscales (Table 2). The total score of BCQ and their subscales showedpositive correlation with TAS-20 total score and DIF/DDF subscales, but not with EOT subscale of TAS-20. EAT-26significantly correlated with BCQ total scores and subscales, TAS-20 total score and DIF/DDF subscales, BSQ, IASand RSES but not with EOT subscale of TAS-20. Also BSQ significantly correlated with BCQ total scores andsubscales, TAS-20 total score, DIF/DDF subscales, IAS and RSES but not with EOT.

Finally, blockwise linear regression analysis with EAT-26 score as dependent variable and potential predictivefactors as independent variables was conducted in order to determine the contributions of the variables for predictingpossible risk for ED (EAT-26 score as dependent variable) in the whole study sample (Table 3). In the first block BMI,demographic variables and measures of psychological distress (BDI, IAS and RSES) were entered. In the second blockbody checking and dissatisfaction measures (BCQ subscales and BSQ) were added to the model. DIF, DDF and EOTsubscales of TAS-20 were entered in the last block. (F=10.47 df=12 pb .001). The results of linear regressionindicated that DIF and DDF subscales of TAS-20 were significantly associated with higher risk. The presence of alower self-esteem (lower scores on SES) was also significantly associated with higher risk as well as higher bodychecking and dissatisfaction (higher scores on OA and SBP subscales of BCQ). In this analysis, the R2 valuesdemonstrated good accuracy of the prediction with the model accounting for 71% of the variance in EAT-26. Inaddition, the Durbin–Watson coefficient was 1.680 (near to the optimum of 2.0) and the standardized residuals werenormally distributed.

5. Discussion

To our knowledge, this is the first study that evaluated interrelationships between alexithymia, body checking andbody image in a sample of non-clinical women. Consistent with our hypothesis, alexithymic subjects reported higherrisk of EDs (as resulted from higher scores on EAT-26), higher body checking behaviors and body dissatisfaction thannonalexithymics as well as higher social anxiety and lower self-esteem. Concerning alexithymia, in our sample, the

Table 3Blockwise linear regression analysis with EAT-26 score as dependent variable and potential predictive factors as independent variables

Variables Standardized β CI 95% (reference) t p

Constant 1.71/10.60 3.93 b .001RSES − .18 − .18/− .91 −2.92 .004OA .18 − .01/.85 1.95 .053SBP .34 .16/.59 3.43 .001DIF .33 .14/.58 3.22 .001DDF .17 .03/.47 2.25 .025

Only statistically significant variables are showed.

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difficulty in identifying and describing feelings and emotions seems to be a core feature without a prevalence of anexternally oriented thinking.

In our study, results of linear regression showed that difficulty in identifying and describing feelings wassignificantly associated with a higher risk for EDs as well as the presence of lower self-esteem and higher bodydissatisfaction. The relationships between negative feelings on own body, low self-esteem, depressed mood and eatingdisturbances have been widely investigated (Speranza et al., 2005; Wheeler, Greiner, & Boulton, 2005). Moreover,body checking behavior seems to be related as well to higher EAT-26 scores especially concerning dissatisfaction andchecking of whole body (OA subscale of BCQ) and specific body parts (SBP subscale of BCQ).

On the basis of our results, we hypothesize that the presence of alexithymia could play an indirect role inpathogenesis and maintenance of abnormal eating behaviors facilitating the presence of depressive symptoms andlower self-esteem. Depressive symptoms and lower self-esteem may directly exacerbate abnormal eating behaviors orhave repercussions on body checking and body dissatisfaction with a worsening of abnormal eating behaviorsthemselves. On its own, abnormal eating behaviors may worsen self-esteem and body dissatisfaction. In fact, it isreported that abnormal eating attitudes and lower self-esteem may be linked to higher body-image dissatisfaction(Gilbert & Meyer, 2005; Grilo & Masheb, 2005; Toro et al., 2005).

In addition, difficulty in identifying and describing feelings may let misinterpret perceptual and behavioral aspectsof body image. This may cause a higher body checking that, on its own, may lower self-esteem and increase negativebody-image perception. As consequence, it can be triggered a vicious circle that may conduct to a higher risk ofdeveloping and maintaining a possible ED. In accordance with Overton, Selway, Strongman, and Houston (2005), wemay suppose that women with EDs are proficient at using disordered eating behaviors to manipulate their experience ofboth positive and negative emotional states. This dynamic may be more pervasive especially in the presence ofalexithymia and should be recognized as an important maintenance factor. ED patients under- and/or over-regulateemotions due to an impaired ability to use blends of emotion to coping with emotional experience (Sifneos, 1973). Thishypothesis is consistent with de Groot and Rodin (1998) who suggested that individuals with ED may either have littleaccess to their emotional life or feel dominated and overwhelmed by it.

On the other hand, in contrast with other studies (Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000;Thomas, James, & Bachmann, 2002), there was no relationship between BMI and symptoms of EDs in our sample.These findings suggest that psychological variables that relate to alexithymia and body perception may be moreimportant risk factors of ED than actual body size, at least among a non-clinical sample of women.

One of the findings of the present study is important for the construct of alexithymia itself. In fact, factor 3 of TAS-20, i.e., externally oriented thinking, appears to be a quite independent variable from ED, body checking anddissatisfaction. Externally oriented thinking corresponds closely to “la pensee operatoire” a concept launched byFrench researchers Marty and de M'Uzan (1963). The main characteristics of “la pensee operatoire,” are a utilitarianstyle of thinking and a relative absence of fantasies. It seems that externally oriented thinking can be described as apersonality trait that does not readily change with mood. In contrast, the other two factors of the Toronto AlexithymiaScale, i.e., Difficulty in Identifying and Describing feelings, change with the degree of depression, and thus also reflectchanges in mood. Concerning EOT another consideration must be done: in the cross validation of factor structure ofItalian TAS-20, α coefficients and mean interitem correlation coefficients indicated optimal levels of item homogeneityfor DIF and DDF whereas EOT coefficients were considerably lower in magnitude (Bressi et al., 1996). Also in otherstudies, is reported that the α coefficients of EOT factor were lower than those of the DIF and DDF factors (Loas et al.,2001). So, interpretation of EOT results must be viewed with caution.

There are several limitations to this study. The first was the use of a convenience sample of undergraduate students.Although our university-based sample was comparable in size and composition to other research studies in this area,future research should consider the strength of using a larger, more generalized sample, such as a community-basedparticipant pool. Moreover, although identifying factors related to subclinical ED symptoms is arguably important, thenon-clinical population used makes it unclear how well these findings generalize to a clinical population and whetherthe model will explain additional variance among ED individuals. Future studies will want to consider to replicate thesefindings with the same methods and scales in clinical samples with ED to confirm or not an association betweenalexithymia and body checking and to develop a therapeutic strategy.

Another limitation is that the data gathered were all self-reports. It is well known the potential limitations inherent inself-report assessments even if self-report may facilitate disclosure of embarrassing or uncomfortable material asreported by Grilo, Masheb, and Wilson (2001). However, future studies could expand this research by including

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assessments of observer-rated measures of ED presence and body image. Furthermore, this study employed a cross-sectional design and thus limits statements regarding causality. Prospective longitudinal studies with repeated measuresare needed to definitely determine risk factors. Future work should also include different comparison groups (e.g.patient with an established DSM-IV diagnosis of Anorexia or Bulimia Nervosa).

Acknowledgements

The authors would like to extend their sincere gratitude to Drs. Vincenzo Matera, Gianna Sepede, Salvatore Spinellaand Mariella Castrovilli, Department of Oncology and Neurosciences, Institute of Psychiatry, University of Chieti, fortheir most helpful advice and review on this manuscript. The authors would also sincerely thank Prof. Donald A.Williamson, Ph.D., Pennington Biomedical Research Center, Baton Rouge, and His staff for permission to use theBCQ scale. This study was not funded by any research grants, and no pharmaceutical companies were informed of orinvolved in the investigation.

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