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British Journal of General Practice, January 2000 21
Original papers
DAVID L BEALES
ROS DOLTON
SUMMARY
Background. Eating disorders are becoming more appar-
ent in primary care.
1
Descriptions of character traits related
to people with eating disorders are rarely reported in the pri-
mary care literature and there is little awareness of the impli-
cations of alexithymia — a concept that defines the inability
to identify or express emotion. We hypothesised that many
individuals with active eating disorders have alexithymic
traits and a tendency to somatise their distress.
Aim. To analyse the character traits and degree of alex-
ithymia of a selected group of women with active eating dis-
orders and in recovery, and to recommend responses by
members of the primary care team that might meet the
needs of such individuals.
Method. Letters were sent to 200 female members of the
Eating Disorders Association who had agreed to participate
in research. Seventy-nine women volunteered to complete
four postal questionnaires. This gave a response rate of
38.5%. Responders were categorised into three groups —
anorexic, bulimic, and recovered — using the criteria of the
Eating Disorders Inventory (EDI-2). The results of the 16PF5
Personality Inventory (16PF5) and the Toronto Alexithymia
Scale (TAS-20) were analysed using one-way analysis of
variance (ANOVA) and correlated using Pearson’s correla-
tion. A biographical questionnaire was also completed.
Results. In all three subgroups, high scores were achieved
on the 16PF5 on ‘apprehension and social sensitivity’, while
there were significant differences in the scores for ‘private-
ness’: a scale that measures the ability to talk about feelings
and confide in others. On the TAS-20, 65% of the anorexic
and 83% of the bulimic group scored in the alexithymic
range compared with 33% of the recovered group. There
was a significant negative correlation between alexithymia
and social skills such as ‘social and emotional expressivity’
on the 16PF5.
Conclusion. The results of this study emphasise the differ-
ence between those with active eating disorders who
achieved high scores for privacy, introversion, and alex-
ithymia, and those who have recovered. These character
traits give potential helpers an important indication of the
areas that can both block and facilitate recovery, and they
act as a reminder that the presenting symptoms in eating
disorders and other psychosomatic conditions are the out-
ward presentation of internal conflict. It is suggested that
effective screening and needs assessment will facilitate a
more appropriate and prompt therapeutic response. This
may be provided in the primary care setting where appropri-
ate training has occurred.
Keywords: anorexia; bulimia; personality; alexithymia; pri-
mary care; therapy.
Introduction
S
OMATISATION — a tendency to experience and communi-
cate psychological distress in the form of somatic symptoms
and to seek medical help for them — accounts for 20% of all
new presentations in primary care.
2
Alexithymia is a syndrome that is defined by the inability to
identify and express feelings, and the inability to distinguish
between emotions and bodily sensations. It is common in
patients who somatise. Individuals with alexithymia ‘may not
distinguish anxiety from depression or excitement from fatigue,
or, indeed, anger from hunger’.
3
The inability to articulate feel-
ings prevents a healthy discharge of emotional stress. Instead,
stress is contained within the body and ultimately manifests itself
in physical ill-health.
4
Inner distress is then expressed through
physical pain and it may be the somatic symptoms that finally
persuade the individual to visit the doctor.
Alexithymia is common in many syndromes where the physical
symptoms are real and readily distinguished, but where the under-
lying causes are psychological and not organic. It is a common
feature in patients with psychoactive abuse disorders,
5,6
post-trau-
matic stress disorder,
7
and classic psychosomatic disorders such
as gastrointestinal complaints, migraine, dermatological symp-
toms, and irritable bowel syndrome.
8,9
It is also common in eating
disorders: various studies have used the Toronto Alexithymia
Scale
10
to measure the degree of alexithymia in patients with eat-
ing disorders. Results suggest that 40%
11
to 50%
12
of bulimic
patients meet the threshold for alexithymia, and 56%
12
to 69%
13
of restricting anorexic patients meet alexithymic criteria.
Recent studies suggest that the incidence of anorexia present-
ing to primary care has stabilised at a rate of 4.2 per 100 000,
with a ratio of women to men of 40:1.
1
A threefold increase in
the incidence of bulimia was recorded between 1988–1993, and
the current rate has been recorded as 12.2 per 100 000, with a sex
ratio of females to males of 47:1.
1
However, it is common for
many cases of eating disorder to go undetected by the general
practitioner, even when a patient has been consulting their doctor
for secondary complications of the disorder and sometimes for
many years.
14
The cost implications of anorexia, bulimia, and other somato-
form disorders are enormous. These illnesses run a protracted
course: those with anorexia have a mean duration of illness of six
years, and it is the third most chronic illness in teenage girls,
resulting in a standardised mortality rate between 12 to 15 times
that of the general population.
15
Within Europe, hospital admis-
sion rates are rising with approximately 80% of patients with
anorexia and 60% with bulimia referred to secondary care,
1
although it is debatable whether hospitalisation is an effective
form of treatment.
16
Of those who are admitted to hospital, less
than 50% will recover fully.
17,18
However, the prognosis does
improve where there is early intervention and remedial
action.
17,19
In this study, we assess the alexithymic characteristics that are
present in patients with eating disorders and consider the possi-
ble implications for primary care. Our hypothesis was that
patients with eating disorders demonstrate deficits in a wide
range of social skills. We wanted to know whether improved
understanding of the patients could be used to develop models of
care that might lead to improved outcomes.
Eating disordered patients: personality,
alexithymia, and implications for primary care
D L Beales, DCH, DRCOG, MRCP, MRCGP, general practitioner, Phoenix
Surgery, Cirencester, Gloucestershire. R Dolton, MA, research assistant,
University of Birmingham.
Submitted: 9 June 1998; final acceptance: 21 May 1999.
© British Journal of General Practice, 2000, 50, 21-26.
22 British Journal of General Practice, January 2000
D L Beales and R Dolton Original papers
Method
Design
All the responders were volunteers. Letters were sent to 200
female members of the Eating Disorders Association (EDA) who
had given their names as potential contacts for research. Ethical
approval was given by the EDA. Seventy-nine women completed
four questionnaires: a biographical questionnaire, the 16PF5,
20
the Eating Disorders Inventory (EDI-2),
21
and The Toronto
Alexithymic Scale (TAS-20).
10
Responders
The sample group provides illustrative cases from the eating dis-
order population with a variety of treatment experiences: the
responders came from 40 different health authorities in mainland
Britain; they ranged from 17 to 46 years of age, the mean age
being 27.9 years; the mean age of onset of the eating disorder
was 16.3 years (SD = 4). A total of 46% had been ill for three to
10 years, 35% had been ill for over 10 years, and 19% had been
ill for less than three years. The fact that 67% had been hospi-
talised suggests that the sample is biased towards severe and
chronic illness, and this may correlate with a high incidence of
alexithymia.
Three sub-groups were formed using the EDI-2. Thirty-three
per cent (n = 26) were shown to be still suffering from restricting
anorexia, 37% (n = 29) were suffering from bulimia, and 30% (n
= 24) were recovered. Two of the recovered group had devel-
oped bulimia after suffering from anorexia; 22 had suffered from
anorexia only.
Instruments
The biographical questionnaire asked about age of onset, details
about weight loss, experience of treatment, family background,
and precipitating factors.
The EDI-2
21
is a widely used self-report measure of symptoms
commonly associated with anorexia and bulimia. It provides
standardised sub-scale scores on 11 dimensions that are clinically
relevant to eating disorders (Table 1).
The TAS-20
10
is a 20-item self-report questionnaire measuring
alexithymia: a construct denoting an inability to identify or
express emotions, an inability to distinguish between different
emotional states and physical sensations, and a cognitive style
that shows a preference for concrete and external details, rather
than feelings, fantasies, and inner experience.
22
The TAS-20
takes about 30 minutes to complete, is user-friendly and easy to
interpret, enabling useful feedback to patients. It measures three
scales: difficulty identifying feelings, difficulty describing feel-
ings, and externally oriented (concrete) thinking.
The 16PF5
20
assesses the individual personality against 16 pri-
mary personality factor scales that reflect behaviour (Table 2).
The broad personality domains under which primary factors clus-
ter are also measured as ‘Global Factors’ (Table 3). The norms
used for comparative purposes are females, all ages: British
General Population (sample size 661). The 16PF5 uses ‘stan-
dardised ten’ (Sten) score scales, with a norm of 5.5 and a stan-
dard deviation of 2. Scores that fall farther from the norm are
considered more extreme. Theoretically, about 68% of the popu-
lation obtain a score within plus or minus one standard deviation
from the norm.
Procedure
The responses to the 16PF5 were analysed using one-way analy-
sis of variance (ANOVA) for unrelated designs, and, where the
results were found to be significant, the Scheffé Multiple Range
Test for use with one-way ANOVA was applied to determine the
degree of difference between each group. The results of both the
ED1-2 and the 16PF5 were correlated with the results of the
TAS-20, using Pearson’s correlation to clarify the relationship
between the personality traits and to increase understanding of
the alexithymia construct.
Results
Fifty-three (67%) responders had been hospitalised for eating
disorders and 33 had been re-admitted at least once. Twenty-six
found the treatment totally unsuccessful, while just six found it
beneficial. Only one of these six has now recovered. Of the 57
(72%) who received one-to-one therapy, 15 found it unhelpful,
while 30 found it very beneficial. The main reason given for the
success of therapy was rapport with the therapist, characterised
by features such as warmth, a non-judgemental attitude, and con-
tinuing contact.
The time lapse between onset of the illness and the provision
of treatment outside primary care varied for the three groups: the
average waiting time for the anorexic group was five years (SD =
6.3); for the bulimic group, 4.7 years (SD = 5); and for the recov-
ered group, 3.4 years (SD = 4.2).
The TAS-20
Sixty-five per cent (n = 17) of the anorexic group, 83% (n = 24)
of the bulimic group, and 33% (n = 8) of the recovered group
scored above the cut-off point for alexithymia. There was a sig-
nificant positive correlation between alexithymia and ‘interper-
sonal distrust’, ‘interoceptive awareness’, and ‘social insecurity’
(EDI-2).
The 16PF5
All three sub-groups had high mean scores on ‘abstract reason-
ing’, ‘apprehension’, and ‘social sensitivity’, but the recovered
group was closer to the norm on other factors. There was a sig-
nificant difference between the recovered and clinical groups on
‘emotional stability’ (P<0.001), ‘liveliness’ (P<0.01), ‘private-
ness’ (P<0.001), ‘self reliance’ (P<0.01), ‘extroversion’
(P<0.001), ‘anxiety’ (P<0.025), ‘emotional and social adjust-
ment’ (P<0.001), ‘emotional and social expressivity’ (P<0.001),
and ‘empathy’ (P<0.001). There was a significant negative corre-
lation in all three groups between alexithymia and ‘social bold-
ness’, ‘sensitivity’, ‘openness to change’, ‘extroversion’, ‘social
adjustment’, ‘emotional expressivity’, ‘emotional sensitivity’,
‘social expressivity’, ‘social control’, and ‘empathy’. There was
a significant positive correlation between alexithymia and ‘vigi-
lance’ and ‘privateness’.
Discussion
This study indicates that alexithymia is a very common feature of
both bulimia and anorexia in these patients, and more common
than previous research has suggested. However, the 79 respon-
ders represent only 40% of the sampled group and are not repre-
sentative of the whole eating disordered population. The scores
on the TAS-20 were high for the two clinical groups: 65% of the
anorexic group and 83% of the bulimic group scored within the
alexithymic range, while just 33% of the recovered group were
alexithymic. This suggests that a lower alexithymic score may be
a factor in recovery. This study does not demonstrate whether
fewer recovered individuals were alexithymic before their illness
or whether they changed as a result of treatment. More research
British Journal of General Practice, January 2000 23
D L Beales and R Dolton Original papers
is needed in this area.
It is important to note that, in many of these patients, the prob-
lem of alexithymia still exists after years with the disorder and of
treatment, suggesting that the therapy has often been ineffective.
This supports the hypothesis that the early administration of a
measure, such as the TAS-20, would enhance understanding of
the individual patient and facilitate an appropriate therapeutic
response. There is, as yet, little evidence-based research on alex-
ithymia and none that examines eating disorders and alex-
ithymia.
22
However, evidence-based strategies using self-com-
pletion questionnaires and brief interventions have resulted in
favourable outcomes for eating disorders within primary care set-
tings.
23-25
This study is not advocating a particular therapeutic
approach, but concentrating on the nature of the patient.
The high mean scores on ‘anxiety and social sensitivity’ sug-
gest that those who suffer from eating disorders may be astute
observers of others and inordinately sensitive to external cues.
However, the significant negative correlation between alex-
ithymia and the social skills traits on the 16PF5 reflects individu-
als who have severe problems with communicating feelings and
needs. Their verbal and non-verbal skills are equally restricted.
The significant positive correlation between alexithymia, ‘pri-
vateness’ (16PF5), ‘interpersonal distrust’, ‘interoceptive aware-
ness’, and ‘social insecurity’ (EDI-2) also portrays individuals
who are likely to be shy and withdrawn, personally guarded and
self-conscious. They will tend to be apprehensive and insecure in
social situations, including therapeutic relationships. This has
four specific implications for treatment by the primary care team:
• non-presentation,
• lack of trust,
• poor communication of needs, and
• inability to articulate the problem.
Implications for primary care
These personality characteristics suggest that such patients may
benefit from an early intervention in a familiar setting and by a
doctor whom they already know. Primary care teams that estab-
lish a protocol for responding to patients with eating disorders
and other psychosomatic problems where alexithymia might be
present, may thus be able to provide effective interventions.
Table 1. Correlation of theTAS-20 and EDI-2.
Drive Body Inter- Intero-
for dissatis- Ineffect- Perfect- personal ceptive Maturity Ascet- Impulse Social
EDI-2 thinness Bulimia faction iveness ionism distrust awareness fears icism regulation insecurity
Anorexic -0.12 0.12 0.06 0.37 0 0.53 0.79 0.01 0.14 0.38 0.46
Bulimic -0.32 0.14 0 0.33 0.1 0.44 0.44 0.14 0.1 0.18 0.32
Recovered 0.06 -0.01 0.02 0.13 0.24 0.73 0.7 0.34 0.36 0.19 0.47
Figures in bold are correlation significant at P<0.05.
Figure 2. 16PF5: global factors mean scores.
Extroversion
Anxiety
Tough-mindedness
Independence
Self-control
Self-esteem
Emotional adjustment
Social adjustment
Emotional expressivity
Emotional sensitivity
Emotional control
Social expressivity
Social sensitivity
Social control
Empathy
0123456789
Recovered
Bulimic
Anorexic
Figure 1. 16PF5: primary factors mean scores.
Warmth
Abstract reasoning
Emotional Stability
Dominance
Lively
Rule conscious
Socially bold
Sensitivity
Suspicious
Imaginative
Privacy
Apprehension
Open to change
Self reliance
Perfectionism
Tension
0123456789
Recovered
Bulimic
Anorexic
24 British Journal of General Practice, January 2000
D L Beales and R Dolton Original papers
Table 2. The results of the 16PF5: primary factors.
Anorexic Bulimic Recovered 16PF5 Scheffe Scheffe TAS correlation
16PF5 primary factors mean (n = 26) SD mean (n = 26) SD mean (n = 24) SD norm ANOVA AN/Rec BN/Rec AN BN Rec.
Warmth 4.5 1.6 4.3 1.9 5.7 1.5 5.5 P<0.05 - P<0.05 -0.6 -0.3 -0.3
Abstract reasoning 7.3 1.8 6.9 2.0 7.2 1.9 5.5 - - - -0.4 0.1 0.0
Emotional stability 1.6 0.8 1.3 0.7 2.9 1.5 5.5 P<0.001 P<0.01 P<0.001 -0.2 -0.2 -0.3
Dominance 2.7 1.6 3.3 2.2 4.7 2.5 5.5 P<0.01 P<0.01 - 0 -0.2 -0.2
Liveliness 3.6 1.5 3.3 2.0 5.2 2.0 5.5 P<0.01 P<0.025 P<0.025 -0.2 -0.1 -0.3
Rule consciousness 5.6 1.9 4.4 2.3 5.0 1.6 5.5 - - - 0.1 -0.3 0.1
Social boldness 3.8 1.9 4.0 1.3 4.9 1.5 5.5 P<0.025 P<0.025 - -0.5 -0.4 -0.4
Sensitivity 6.2 1.9 6.2 1.7 5.9 2.0 5.5 - - - -0.5 -0.4 -0.4
Vigilance 6.8 1.8 6.6 1.8 5.4 2.7 5.5 - - - 0.4 0.2 0.3
Abstractedness 7.0 1.7 7.8 1.5 6.6 1.6 5.5 - - - 0.1 -0.2 -0.1
Privateness 7.8 1.5 6.4 2.2 4.5 2.5 5.5 P<0.001 P<0.001 P<0.025 0.5 0.1 0.9
Apprehension 7.8 0.6 7.7 0.7 7.2 0.7 5.5 - - - 0.5 -0.3 0.2
Openness to change 5.6 0.7 6.0 2.0 6.3 2.1 5.5 - - - -0.4 -0.4 -0.5
Self-reliance 8.2 1.9 8.2 1.4 6.6 1.8 5.5 P<0.01 P<0.01 P<0.025 0.3 0.1 0.3
Perfectionism 7.2 1.4 6.1 1.6 5.8 1.9 5.5 P<0.01 P<0.025 - 0.1 0.0 -0.2
Tension 6.4 1.9 6.6 1.9 6.5 1.6 5.5 - - - 0.1 -0.1 -0.2
Figures in bold are correlation significant at P<0.05. AN = anorexia nervosa; BN = bulimia nervosa; rec. = recovered.
Table 3. Results of the 16PF5: global factors.
Anorexic Bulimic Recovered 16PF5 Scheffe Scheffe TAS correlation
Global factors mean (n = 26) SD mean (n = 26) SD mean (n = 24) SD norm ANOVA AN/Rec BN/Rec AN BN Rec.
Extroversion 2.8 1.4 3.1 1.9 5.3 1.8 5.5 P<0.001 P<0.001 P<0.01 -0.59 -0.24 -0.64
Anxiety 8.7 1.3 8.8 0.9 7.8 1.6 5.5 P<0.025 P<0.05 P<0.05 0.31 0.07 0.25
Tough-mindedness 5.0 1.6 4.5 2.0 4.5 1.8 5.5 - - - 0.50 0.42 0.56
Independence 3.6 1.5 4.2 1.6 5.1 1.9 5.5 P<0.025 P<0.025 - -0.19 -0.36 -0.39
Self-control 6.2 1.6 5.0 1.5 5.1 1.7 5.5 P<0.05 - - 0.10 0.06 0.23
Self-esteem 2.7 1.1 2.4 1.1 3.5 1.2 5.5 P<0.01 - P<0.01 -0.57 -0.19 -0.14
Emotional adjustment 2.2 0.7 2.1 0.5 3.2 1.0 5.5 P<0.001 P<0.001 P<0.001 -0.43 -0.07 -0.31
Social adjustment 2.7 1.2 3.1 1.6 4.5 1.7 5.5 P<0.001 P<0.001 P<0.05 -0.56 -0.35 -0.50
Emotional expressivity 2.0 1.5 3.9 2.6 5.6 2.7 5.5 P<0.001 P<0.01 P<0.05 -0.4 -0.23 -0.69
Emotional sensitivity 4.4 1.7 4.4 2.1 5.6 1.6 5.5 - - - -0.62 -0.37 -0.48
Emotional control 6.6 1.2 5.6 2.0 4.6 2.2 5.5 P<0.001 P<0.001 - 0.00 0.12 0.75
Social expressivity 2.6 1.3 3.1 1.9 5.1 1.9 5.5 P<0.001 P<0.001 P<0.01 -0.52 -0.22 -0.57
Social sensitivity 8.0 0.9 8.0 0.9 7.6 1.2 5.5 - - - 0.06 -0.10 0.25
Social control 2.9 1.3 3.2 1.6 4.5 1.8 5.5 P<0.01 P<0.01 - -0.61 -0.38 -0.51
Empathy 2.9 1.3 3.0 1.7 4.7 1.7 5.5 P<0.001 P<0.01 P<0.01 -0.60 -0.32 -0.50
Figures in bold are correlation significant at P<0.05. On all 16PF5 factors, the descriptive label reflects the right (high score) end of a bi-polar scale.
British Journal of General Practice, January 2000 25
D L Beales and R Dolton Original papers
Screening and assessment
The provision of effective treatment is dependent upon accurate
diagnosis and assessment,
26
but this can be impeded by the resis-
tance, ambivalence, impaired trust, and denial that is typical of
patients with eating disorders and alexithymia.
22,27
In this sample,
the variations in time lapse before treatment outside primary care
are not statistically significant, but the results do suggest a delay
before therapeutic help is provided and would seem to have impli-
cations for the task of the primary care team. We therefore recom-
mend that a diagnostic pathway is used by administering a com-
mon checklist
28
or a computer-aided diagnostic instrument such
as PRIME-MD.
29
Detection can be further enhanced by the rou-
tine inclusion in all consultations, for whatever cause, of ques-
tions that have a high sensitivity and specificity regarding weight
history, body image, dieting history, bingeing and purging activi-
ty, and exercise.
30
Identification and grading of the severity of the
alexithymia through a screening process can be aided by the rou-
tine use of assessment tools such as the TAS-20.
While we recognise the differences in expertise and training
between practices, we feel it is important that each primary care
team adopts certain strategies for responding to patients with
alexithymic traits. Because these patients experience confusion
in recognising and accurately responding to emotional states and
will not be able to interpret bodily sensations or to distinguish
these from emotions, the first task of the general practitioner may
be to give reassurance that there is no organic disease. This then
allows for a new focus on the intrinsic problem. However, fear
about the consequences of emaciation may cause a preoccupation
with the physical status of the patient, and the general practition-
er needs to recognise that focusing on the outward symptoms of
distress fails to deal with the underlying emotional disconnection
between the symptom and the meaning of that symptom.
Furthermore, an earlier response from the primary care team
could prevent progression to the severe, often unremitting,
course seen in hospital practice and experienced by many
patients in this sample.
It is helpful if more than one member of the team is involved:
the practice nurse or dietician may provide nutritional coun-
selling and a non-alarmist monitoring of weight, body mass
index, and medical symptoms to prevent deterioration of the dis-
order, while another member of the team provides support for a
guided self-help regime and counselling. What is important is
that the person who adopts the therapeutic role should be able to
provide continuity, have good inter-personal skills, and be empa-
thetic, sensitive to hidden messages, and able to interpret often
obscure and indirect behavioural clues. Where the appropriate
expertise is lacking, training should be given; the effectiveness of
the programme should be carefully monitored.
Therapy
From the results of this study and other research,
22,27
alexithymia
seems to be a key construct determining the therapeutic response
and outcome. We therefore suggest that the general philosophy
of the therapeutic contract should be open and collaborative, giv-
ing maximum autonomy and responsibility for eating and other
behaviours to the patient.
31
The aims of therapy
22,27
would be to:
• explain to the patient that they tend to experience their emo-
tions as physical reactions rather than as feelings,
• help them to understand their lack of empathy,
• help them overcome inhibitions in self-care,
• encourage them to identify, differentiate, and manage their
emotions,
• enable them to acquire the vocabulary to express feelings
accurately and appropriately,
• empower them to act effectively in social situations, and to
• build self-esteem.
Conclusion
It is shown, in this sample, that alexithymia is a common feature
of eating disorders and that it is allied to considerable social
skills deficits. The results also suggest that the symptoms in eat-
ing disorders, and other psychosomatic conditions, are the out-
ward presentation of internal conflict and the physical expression
of unidentified emotion. We postulate that a primary care team,
which is trained to recognise alexithymia and uses evidence-
based strategies, is more likely to manage these distressing and
potentially life-threatening disorders more effectively. Such
strategies may be an interim measure while the patient awaits
hospitalisation, but may prove sufficient to avert the need for
secondary care. This study provides recommendations based on
illustrative cases and further research is needed to evaluate the
benefits of the approach.
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Acknowledgements
We thank the following for their comments on this paper: Sam Clark-
Stone, SRN, clinical coordinator, eating disorders, Severn NHS Trust; Dr
Carolyn Hicks at the University of Birmingham; Barbara Smith; the part-
ners of the Phoenix Surgery; and Pat Turton, director of education, Bristol
Cancer Help Centre.
Address for Correspondence
Dr D L Beales, Phoenix Surgery, 9 Chesterton Lane, Cirencester,
Glousestershire GL7 1XG. E-mail: springbank@tunley95.freeserve.co.uk.
