How am I feeling? Alexithymia and eating disorders

My treatment team always used to get so mad at me because I’d always answer the question “How are you doing?” with “I’m fine.” No, no, they said, tell me how you’re really feeling. Although I had times where I did know what I was feeling and either didn’t feel like sharing or didn’t feel I could or should share, most of the time, I really had no idea.

Decoding your own emotions is no easy task. I mean, how are you feeling? Right now, I’m tired. It’s after 10pm and now that I’m an old fart, that’s getting late for me. But as for emotions? Hell if I know.

Researchers call it alexithymia, which literally means “pushing away your emotions.” The understanding of alexithymia as a subclinical condition in and of itself, as well as a predictor or risk factor for other mental illness, means that this translation isn’t the actual definition of alexithymia. In the research literature, alexithymia is characterized by the following:

  1. difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal
  2. difficulty describing feelings to other people
  3. constricted imaginal processes, as evidenced by a scarcity of fantasies
  4. a stimulus-bound, externally oriented cognitive style (translation=focusing on the details of the events around you)

It has been associated with a variety of psychiatric conditions, including EDs. In a recent article in the Journal of Eating Disorders, a group of researchers from Canada reviewed the evidence for alexithymia in EDs (Nowakowski, McFarlane, & Cassin, 2013).

EDs and emotional difficulties

The researchers identified 24 studies that had been published on alexithymia and eating disorders since 1988, when the first clinical measure for alexithymia was published (the 20-question Toronto Alexithymia Scale, TAS-20). The papers they reviewed found higher levels of alexithymia in all of the eating disorders, although it appears that people with the restricting type of anorexia had higher alexithymia scores than the other EDs, meaning they had more difficulties describing their emotions than other subtypes. Whether this was a problem describing their emotions to another person or just describing their emotions is unclear. For someone with social anxiety (or who has the inability to shake the feeling that they are being judged all the damn time), it could be hard to describe your feelings to an outsider for reasons that have nothing to do with alexithymia and everything to do with interacting with another human being.

Specifically, people with EDs have trouble with two particular sets of behaviors: distinguishing emotions from physical sensation and describing feelings to others. Hence my “I’m fine” routine.

However, measuring alexithymia in people with active EDs can be difficult. Are the emotion recognition problems related to the malnutrition caused by the ED? By the increase in depression, anxiety, and general distress? Or are they stable? As with so many things, the answers are mixed. Some studies have found that alexithymia remains higher than expected in ED populations even when researchers factor in general distress and depression. This would indicate that, even if the distress of having an ED increases alexithymia symptoms, it was there beforehand.

Still, exactly what is causing this difficulty in interpreting and describing emotions may be different depending on diagnosis. Write the authors:

Specifically, while depression may directly contribute to difficulties with identifying and expressing emotions in patients who restrict, it may be the increased impulsivity and affective instability that underlies the affective difficulties of patients with bingeing and purging behaviors.

So does alexithymia go away with treatment and recovery? Well, maybe. Several studies have found that ED treatment can decrease alexithymia levels. Although they found a significant difference between pre- and post-treatment, they didn’t actually compare these levels to population norms, so there’s no way to say whether the alexithymia levels returned to normal or if they remained elevated. It’s also unclear whether the improvement was due to targeted emotional therapies or a decrease in general ED symptoms. Again, no one has really compared the two. It’s relatively straightforward to do, but like so many psychology studies, the lack of a control group really interferes with our ability to interpret the results.

Lastly, there’s the question of whether alexithymia is the result of an ED or helps to cause the ED. Most of the studies that have been done on alexithymia being a causative factor in mental disorders has been done in people who were mistreated as children. While this could very well big a significant contributing factor to many types of mental distress and psychiatric illness later in life, it doesn’t tell us much specifically about EDs and in people who had relatively normal childhoods.

Rethinking alexithymia

Perhaps the most interesting part of the paper is near the end when they raised the question of whether alexithymia was the best term to use to describe these difficulties.

It is important to consider whether applying the term alexithymic to patients with eating disorders is accurate based on the research to date, or whether it would be more accurate to highlight specific deficits in identifying and describing emotions.

Alexithymia appears closely linked to problems with interoceptive awareness. There are differences between the two, to be sure, but they both require an ability to understand and interpret internal states. Such as emotions. Perhaps individuals with EDs aren’t so much alexithymic as much as the appear to be so as a result of problems with interoception. A separate study also found that alexithymia is linked to perfectionism, and from there to EDs (Marsero et al., 2011).

Regardless of whether you call it alexithymia or interoceptive difficulties, it appears that difficulties with identifying, expressing, and regulating emotions are a key feature in eating disorders. For me, anyway, addressing these difficulties has been key to ongoing recovery so I don’t get so dysregulated that I return to ED behaviors either as the only way I can calm myself down or I get into that “Screw it, I don’t care” state. Neither of which are very useful.

And, for the record, I still mostly say that I’m fine, my day was fine. Sometimes it’s a matter of I just can’t be arsed to put my finger on exactly what I’m feeling. Other times, it’s more of an I-just-don’t-want-to-get-into-it kind of a thing. But I mostly just don’t stop and think and ask myself how I’m feeling.


Marsero S, Ruggiero GM, Scarone S, Bertelli S, Sassaroli S. (2011). The relationship between alexithymia and maladaptive perfectionism in eating disorders: a mediation moderation analysis methodology. Eating and Weight Disorders. DOI: 10.1007/BF03325130

Nowakowski ME, McFarlane T, & Cassin S. (2013) Alexithymia and eating disorders: a critical review of the literature. Journal of Eating Disordersdoi:10.1186/2050-2974-1-21

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10 Responses to “How am I feeling? Alexithymia and eating disorders”

  1. I kept thinking, I’m reading about Asperger’s. Anorexia is linked to autistic traits- of course it would also then be linked to things like alexithymia and poor interoception.

    I get confused when people ask me how I’m doing. I am never sure what exactly they’re asking. I’m not dying, I can function, so I am ok. I’m always ok. Is that what they’re asking? Unless there is an emotion that has just been thrown strongly into the forefront, I won’t be able to identify what I’m feeling- for example, if someone calls me on the phone and says really mean things to me right before I walk into my therapist’s office, then when she says, “How are you today?” I would probably answer “I don’t know” rather than “I’m ok,” but then upon further questioning and thought, I might answer, “Shocked” or “Confused.”

    If somebody was really, super mean though, all I’d feel is blank. Blank is definitely an affective state for me, and if I experience any emotion too strongly, my whole body reverts to blank. And then, once again, I am ok.

    Anyway, in case anyone’s interested, I found this site with a test for alexithymia:

    It was interesting. I thought many of my answers were very anti-alexithymic as I was entering them, but turns out I scored highly alexithymic in all categories.

    • Just as a reference point for my “baseline” comment below: I just did the test, and I was trying to “normalise” my answers as much as possible and filled it in as me having a “good” day… Yeah, still scored as high in almost every category

  2. I think it’s really important to remember how much an ED can flatten one’s affect all by itself. Being malnourished definitely has a numbing effect; there just isn’t enough energy available to fuel much beyond the basic survival instincts,which as we know often manifest themselves as bizarre ED compulsions. Additionally, at least in my experience, it’s hard to access – much less articulate – a wide range of emotional experiences when your baseline is already low. So if someone is suffering from the effects of malnutrition (and there is a good chance he/she is also suffering from some form of depression or anxiety), then it can become hard to accurately assess that skewed emotional landscape in ways that mentally healthy people would understand.

    • Absolutely. And the research seems to indicate that the ED increases alexithymia (in that most types of ED treatment decrease it). Still, it may be there beforehand and be a risk factor. If nothing else, it does seem to explain how those with EDs relate to the world during active illness.

  3. If I’ve made it out of bed, and I’ve turned up at my appointment, then I’m functioning and still in one piece, so of course I’m fine. It’s taken me years to realise that for some people, those people who don’t have ED or depression or anything else anymore, the baseline is soooo different. So it’s not just that I can’t connect to what I’m feeling (I mean, if I could do that, I really would be fine, or at least a bit better!), it’s also that my baseline standard of what is acceptable has become so distorted.
    And, if I’m being honest, feeling “fine” & functioning is a lot safer than accepting how rubbish I’m feeling and all that means

  4. Another way that I have heard alexithymia talked about in regard to eds (maybe in one of Liu’s books?) is that people with eating disorders can sometimes describe intellectually how they are feeling – or how they feel that they should be feeling – but that actually feeling the state emotion doesn’t happen. That was very true for me. With my first long-term therapist, I learned a vocabulary for emotions, so I could give an answer when asked how I felt – often based on how I thought I should feel or extrapolating off of mild emotion. However, it took A LOT of work with my second therapist to actually start deeply FEELING how I feel.

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