Table 2.

Studies investigating the effects of treatment on alexithymia levels in subjects with ED

Study	Aims of the study	Sample and methods	Alexithymia assessment	Treatment	Results
Schmidt et al, 199310	1. To establish whether alexithymia is present in patients with BN 2. To compare BN with AN-R, AN-B/P, and HC with regard to alexithymia 3. To determine whether alexithymia is a state or a trait (Study 2) 4. To see whether alexithymia predicts short-term treatment outcome in BN	Study 1: F, outpatients, BN (93), AN-R (55), AN-B/P (25) (DSM-III-R), HC (48 F, 47 M) TAS-26, BITE, BSQ Study 2: F, outpatients, BN (41) TAS-26, BITE, BSQ, HAM-D	TAS-26 Study 2: TAS total score Baseline (t0) Post-treatment (t1)	Study 2: 10-week drug treatment	No significant changes in mean TAS Total after 10 weeks (while patients’ eating pathology improved significantly) At week 10, 73% of patients who had been alexithymic at t0 were still alexithymic, 87.5% who at t0 were nonalexithymic remained in this category
de Groot et al, 199511	1. To assess alexithymia among women with BN 2. To evaluate the interrelationship between alexithymia, depression, and somatic symptoms 3. To determine whether an intensive group psychotherapy program contributes to a reduction in the degree of alexithymia	F, day hospital, BN (31) (DSM-III-R), HC (F nurses; 20) TAS-26, EDE, EDI, BDI 2 groups: abstinent (0 binge/purge episodes) or symptomatic (>1 binge/purge episode) based on EDE	TAS-26 Baseline (t0) post-treatment (t1)	9.6 weeks (average) day hospital program, intensive group psychotherapy (focus on nutrition, body image, symptom management, relationships, family interactions)	Partial reversibility of alexithymia following treatment: alexithymia improved (significantly in the abstinent group), but remained disturbed in comparison to HC At t1 32.3% of patients scored in the alexithymic range vs 61.3% at t0
Ciano et al, 200221	To analyze the efficacy of two group therapies for B ED patients	F, BED (11) TAS-20, EDI-2, 16PF, HADS	TAS-20 TAS total score, DIF, DDF, EOT Baseline, post-treatment, 6 month – follow up, 1 year – follow up	1. Psychoanalytic group therapy: 28 weeks, 14 sessions, 6 patients; to enhance discovery and restructuring of self-esteem, thus producing an improvement in control of eating compulsivity 2 Psychoeducation group therapy: 10 weeks, 10 sessions, 5 patients; focused on nutritional information, communication ability and assertiveness and on nutritional rehabilitation	Psychoeducation group patients improved in DDF and in DIF at every follow-up assessment, with significant decrease on DDF at 6 month – follow up No changes in TAS scores in Psychoanalysis group patients
Becker-Stoll and Gerlinghoff, 200413	1. To investigate whether a 4-month day hospital treatment leads to a decrease in alexithymia in eating disorder patients 2. To see whether alexithymia predicts short-term outcome in this population	47 F, AN (18), BN (25), EDNOS (4) (DSM-IV criteria) TAS-20, EDI 2 groups: AN (20), BN (27) (EDNOS added to the anorexic/bulimic group, according to restrictive/binge eating behavior)	TAS-20 TAS total score, DIF, DDF, EOT Pretreatment (t0) Post-treatment (t1)	A three-phase treatment program, group settings: a 4 week outpatient motivation phase, a 4-month day hospital phase, a 4-month outpatient follow-up treatment phase A multimodal treatment program: CBT, PET, and IPT Understanding and expression of emotions is encouraged, different forms of art therapy are given to improve expression of emotions	A significant decrease in TAS total and DIF at t1 (marginal decrease in EOT, significant in BN), although patients still show a tendency to alexithymia
Clyne et al,200422	To investigate the utility of incorporating training in emotion recognition and regulation within a general cognitive-behavioral, psychoeducational group treatment for BED	11 F, BED TAS-20, BES, QEWP, DASS, PSS. COPE, EIS	TAS-20 TAS total score Baseline, post-treatment, 2 or 3 month follow-up	11 sessions (2 hours per week) Group psychoeducational program that focused on emotion discrimination and regulation in the context of eating: the program provided basic nutrition information and taught self-monitoring skills and recognition of binge episodes; behavioral management strategies were emphasized; emotion recognition was taught by teaching participants to attend to physiological changes, behavioral responses, psychological aspects, and facial expressions	Mean alexithymia scores decreased significantly from baseline to postintervention, and again at follow-up, showing a large effect size from pre- to post-treatment
Shiina et al, 200514	1. To examine the therapeutic efficacy of CGCBT 2. To explore the characteristics of patients who failed to complete it	25 outpatients, 24 F, 1 M BN, AN-B/P or EDNOS with binge eating (DSM-IV criteria) TAS-20, EDI-2, BITE, RSES, HAM-D, GAF, CGI-S, CGI-C 2 groups: completers (16), drop-outs (9)	TAS-20 TAS total score Pretreatment (t0) Post-treatment (t1)	10 week of CGCBT Two sessions, using role playing, in which patients were expected to recognize their own emotions and try to express them to the other participants by their attitude and speech	TAS-20 total showed a tendency toward improvement (P=0.06) at t1 in completers
Iancu et al,200623	To evaluate the efficacy of a combined intervention (group therapy, individual therapy, and pharmacologic therapy) in a group of soldiers with ED in the Israel Defense Forces	Soldiers with ED (30): AN (10), BN (15), EDNOS (5) (DSM-IV criteria); 3 M, 27 F TAS-26, EDI, EAT, DES, SCID-II 6 drop-outs	TAS-26 TAS total score Baseline, post-treatment	6 months of combined interventions: group therapy and, if necessary, additional individual insight-oriented psychotherapy and pharmacologic therapy Dietary counseling was strongly encouraged Group therapy included a CBT approach combined with a dynamic approach	TAS scores did not change significantly throughout the study period; 20 of 24 had alexithymia before the intervention, and 16 of 24 were still positive for alexithymia after intervention
Storch et al,201124	To assess the effect of a psychoeducational training program in affect regulation with an inpatient group with ED when compared to a group of inpatients who did not receive the training intervention	19 F, AN (15), BN (4) (DSM-IV criteria), inpatients TAS-26, ACS-90, EDE-Q	TAS-26 2 TAS subscales (DIF and DDF) Baseline, 3 and 12-month follow up	1. Control group (n=11), which received inpatient treatment as usual 2. Treatment group (n=8), which received training in addition to usual inpatient treatment (inpatient psychoeducation group therapy with training to recognize bodily sensations related to emotion and to improve affect-regulation skills); 3 weekly training sessions + booster session 8 weeks post-treatment	Scores on DIF were reduced in both groups, but no significant difference was observed in alexithymia
Balestrieri et al, 201318	1. To assess the efficacy of short-term (10 weeks) psychoeducation group treatment in patients with BED and EDNOS 2. To analyze determinants of the success of PET on single outcome measures 3. To investigate whether a PET protracted along 1 year warranted better results	98 outpatients, 91% F; BED (54), EDNOS (44) (DSM-IV criteria. TAS-20, EDI-2, EDI-SC, HADS	TAS-20 TAS total score Baseline (t0), after 10 weeks (t1)	10 weekly group sessions of PET Each session included nutritional intervention, analysis of ED-related thoughts and behaviors, and assertiveness training At t1, patients who maintained an ED were asked to take part in an extension protocol, which included two fortnightly sessions followed by further monthly sessions for a period of 8 months	Alexithymia was considered significantly improved at t1 (P=0.035)
Ohmann et al, 201319	1. To assess whether group CBT is effective for treating girls with AN 2. I f there are common emotional risk factors in anorexic girls complicating the course of their disorder	29 adolescent girls (13–17 years), outpatients; AN-R (22), AN-B/P (7) (ICD-10 criteria) TAS-26, BDI, YSR, JTCI, MUM, EV-A, EV-H, SPS, SIAS, MR-SOC 3 outcome groups: good, poor, drop-out	TAS-26 TAS total score pretreatment, 3,6,9 and 12 months after the group CBT, and 1 year after the end of group CBT	A maximum of 40 weekly sessions, family sessions once monthly A multimodal group CBT program with nine modules: therapeutic motivation, psychoeducation, individual problem analysis, problem solving strategies, soft and communication skills, hedonistic training, elements of awareness, body and schema psychotherapy	Alexithymia tended to improve in successfully treated patients, but did not change significantly in any group Alexithymia is resistant to change, especially in patients with poor outcome

Abbreviations: 16PF, 16 Personality Factors; AN-B/P, anorexia nervosa – bingeing/purging type; AN-R, anorexia nervosa – restricting type; BDI, Beck Depression Inventory; BED, binge eating disorder; BITE, Bulimic Investigatory Test Edinburgh; BN, bulimia nervosa; BSQ, Body Shape Questionnaire; CBT, cognitive behavioral therapy; CGCBT, combined group CBT; CGI-C, Clinical Global Impression Change; CGI-S, Clinical Global Impression of Disease Severity; DASS, Depression, Anxiety, and Stress Scale; DDF, Toronto Alexithymia Scale Difficulties Describing Feelings factor; DES, Dissociative Experiences Scale; DIF, Toronto Alexithymia Scale Difficulties Identifying Feelings factor; DSM-III-R, Diagnostic Statistical Manual of Mental Disorders, 3rd Edition Revised; DSM-IV, Diagnostic Statistical Manual of Mental Disorders, 4th Edition; EAT, Eating Attitudes Test; ED, eating disorders; EDE, Eating Disorder Examination; EDE-Q, Eating Disorder Examination Questionnaire; EDI, Eating Disorder Inventory; EDI-SC, Eating Disorder Inventory-Symptom Checklist; EDNOS, Eating Disorder Not Otherwise Specified; EOT, Toronto Alexithymia Scale Externally Orienting Thinking factor; EV-A, Euthymic Activities, General; EV-H, Euthymic Activities, Frequency; F, female; GAF, Global Assessment of Functioning; HADS, Hospital Anxiety and Depression Scale; HAM-D, Hamilton Depression; HC, healthy control; IPT, interpersonal therapy; JTCI, Junior Temperament and Character Inventory; M, male; MR-SOC, Marburg SOC Scale; MUM, Marburg Diagnostic Inventory; PET, psychoeducational therapy; RSES, Rosemberg Self-Esteem Scale; SCID-II, Structured Clinical Interview for DSM - II; SIAS, Social Interaction Anxiety Scale; SPS, Social Phobia Scale; TAS Total, Toronto Alexithymia Scale Total Score; TAS-20, Toronto Alexithymia Scale 20-item Version; TAS-26, Toronto Alexithymia Scale 26-item Version; YSR, Youth Self Report; EDI-2, Eating Disorder Inventory -2; ICD-10, International Classification of Diseases, tenth revision.