Emotional awareness among eating-disordered patients: the role of narcissistic traits

European Eating Disorders Review
Eur. Eat. Disorders Rev. 16, 44–48 (2008)
Emotional Awareness AmongEating-Disordered Patients:The Role of Narcissistic Traits

*Correspondence to: Glenn Waller, CNWLTrust, Osbert Street, London SW1Pþ44-20-8237-2104. Fax: þ44-20-8237-2280.E-mail: [email protected]

Copyright # 2007 John Wiley & Sons, Ltd a

Published online 23 October 2007 in Wiley In

Rachel Lawson1,2, Glenn Waller1,3*,Jennie Sines4 and Caroline Meyer41Eating Disorders Section, Institute of Psychiatry, King’s College London, UK2South Island Eating Disorders Service, Canterbury District Health Board,New Zealand3Vincent Square Eating Disorders Service, London, UK4Department of Human Sciences, University of Loughborough, UK

The narcissistic defences and a lack of emotional awareness (alex-ithymia) are both salient features of eating disorder pathology, aswell as being linked to each other. As each of these characteristicsimpacts independently on treatment, it is important to understandhow they interact within an eating-disordered population. Thepresent study assessed the associations between the three coreelements of alexithymia and the core and defensive elements ofnarcissism in this clinical group. Seventy eating-disorderedpatients completed standardised measures of alexithymia andnarcissism, and multiple regression analyses were conducted inorder to examine the relationship between these variables. Corenarcissism (e.g. grandiosity, entitlement) was associated with dif-ficulties in describing feelings to others, whereas the narcissisticdefences were associated with difficulties in identifying feelingsand distinguishing them from somatic experiences. These patternsof association suggest that different aspects of alexithymia areassociated with different aspects of narcissism. Clinical sugges-tions are made for how these characteristics might require modi-fications of standard treatment approaches for the eating disorders.Copyright # 2007 John Wiley & Sons, Ltd and Eating DisordersAssociation.

Keywords: eating disorders; narcissism; alexithym
ia; emotion
INTRODUCTION

Alexithymia is a construct characterised by func-tional problems in emotional processing. Theseproblems include: difficulty in identifying anddescribing feelings; difficulty in distinguishing

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between feelings and the bodily sensations associ-ated with emotional arousal; a paucity of fantasiesand other imaginative activities and a preferencefor focusing on external events rather than innerexperiences (Hendryx, Haviland, & Shaw, 1991;Taylor, Parker, Bagby, & Bourke, 1996). There isevidence that women with eating disorders havesuch difficulties in identifying and expressingemotions (Bydlowski et al., 2005; Cochrane, Bre-werton, Wilson, & Hodges, 1993; Corcos et al., 2000;Taylor et al., 1996; Zonnevijlle-Bendek, van Goozen,

Association.

rscience.wiley.com) DOI: 10.1002/erv.838

Role of Narcissistic Traits in Eating Disordered Patients 45

Cohen-Kettenis, van Elburg, & van Engeland, 2002).However, such patients do not differ from non-clinical controls in levels of externally orientedthinking (Taylor et al., 1996; Troop, Schmidt, &Treasure, 1995). This pattern suggests that thereare specific deficits in the cognitive processing ofemotion in the eating disorders, rather than deficitsin operational cognitive style. Thus, the core issuefor understanding and treating emotional issues inthe eating disorders should be the affective deficitsof alexithymia, rather than the associated cognitivedisturbances (Laquatra & Clopton, 1994).While there is little evidence that levels of alexi-

thymia differ reliably across eating disorder diag-noses, there is a considerable degree of differencebetween individual patients. Personality and tem-perament issues seem to be critical determinantsof the level of emotional experience. While somepatients have relatively high levels of impulsivity intheir expression of emotion (e.g. those with border-line personality disorder features), others arerelatively averse to expressing their feelings (e.g.those with comorbid avoidant personality disorderfeatures). Among eating-disordered patients, Sex-ton, Sunday, Hurt and Halmi (1998) found that thepresence of either of these personality disordersis predictive of difficulty in expressing feelings toothers. Other Cluster B personality pathologies(American Psychiatric Association, 1994) might beexpected to be particularly related to emotionalregulation problems, given the dramatic, erraticnature of those personality styles. Of those person-ality characteristics, there is one that has particularlinks to the psychopathology of the eating dis-orders—narcissism. Patients with narcissistic fea-tures have difficulty with emotional states, particu-larly in identifying triggers for their emotions(Dimaggio, Nicolo, Popolo, Semerari, & Carcione,2006). High levels of narcissism are inversely relatedto empathy, particularly emotional responses to thefeelings of others (Watson, Grisham, Trotter, &Biderman, 1984).There is a literature that posits a link between

narcissism and emotional awareness. However, it ismostly psychoanalytic in nature (e.g. Davis &Marsh, 1986) being based on clinical opinion andexample case studies. Therefore, the empiricalsupport for this hypothesised link is weak. Inaddition, this literature has been largely concernedwith the core elements of narcissism (grandiosity,entitlement and self-importance). While core nar-cissism has been linked to the eating disorders (e.g.Lehoux, Steiger, & Jabalpurwala, 2000; McLaren,Gauvin, & Steiger, 2001), it is also important to

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

consider the role of the narcissistic defences inthis clinical population (e.g. Waller, Sines, Meyer,Foster, & Skelton, 2007). O’Brien (1987) hasidentified two narcissistic defensive styles thatcan accompany core narcissism—poisonous peda-gogy (others are seen as wrong, and are in need ofdirection), and narcissistically abused personality(others are seen as abusive, and the needs of othersare put first). Although alexithymia has been linkedto both the eating disorders and core narcissism, it isnot clear whether the narcissistic defences that arepertinent in the eating disorders are also linked toproblems in emotional awareness among thatclinical group.From a clinical perspective, understanding the

association between narcissistic personality featuresand alexithymia offers the prospect of being able towork more effectively with patients who presentwith the emotionally unstable features of narcis-sism. If such patients are unable to identify orexplain emotional states, treatments will be neededthat focus on this deficit, in order to help thosepatients to engage in therapy and to modify anybehavioural responses that can interfere withtreatment for the eating disorder itself. Therefore,the aim of this study was to determine theassociations between different facets of narcissismand alexithymia in an eating-disordered group.

METHOD

Participants

The participants were a clinical case series of 70 adulteating-disordered patients (69 women, 1 man) whowere referred to an eating disorders service fortreatment. All of the participants met DSM-IVdiagnostic criteria (American Psychiatric Association,1994) for an eating disorder. Among the participants,9 were cases of anorexia nervosa, 23 of bulimianervosa and 38 with an eating disorder not otherwisespecified (e.g. not meeting all criteria for anorexianervosa or bulimia nervosa). The mean age of thesample was 28.5 years (SD¼ 8.66, range¼ 18–59),while their mean body mass index (BMI¼weight[kg]/height [m]2) was 22.1 (SD¼ 6.51, range¼ 13.8–52.4).

Measures and Procedure

Ethical approval was granted by the local researchethic committee. The following two measures weregiven to the patients at assessment. Theywere asked

ssociation. Eur. Eat. Disorders Rev. 16, 44–48 (2008)

DOI: 10.1002/erv

46 R. Lawson et al.

to complete them and send them back in a pre-paidenvelope. Participants were weighed and theirheight taken during assessment.

Toronto alexithymia scale-20-item version (TAS-20))The TAS-20 (Bagby, Parker, & Taylor, 1994) is a

20-item measure of the three core elements ofalexithymia—difficulty identifying feelings anddistinguishing them from bodily sensations; diffi-culty describing feelings to others; and externallyoriented thinking. The TAS-20 has good reliabilityand validity (Bagby, Taylor, & Parker, 1994), and isthe most widely used instrument for measuring theconstruct of alexithymia (Taylor, 2000). Higherscores indicate higher levels of alexithymia.

O’Brien multiphasic narcissistic inventory (OMNI))The OMNI (O’Brien, 1987) is a 41-itemmeasure of

narcissistic features. It has three scales: narcissisticpersonality (core elements of narcissism, such asentitlement); the poisonous pedagogy defence (thebelief that one should control others, and the tend-ency to criticise others to govern their behaviour)and the narcissistically abused defence (placing theneeds of others before one’s own needs, but witha tendency to present oneself as ‘martyred’). TheOMNI has good reliability and validity (O’Brien,1987, 1988). Higher scores indicate greater levels ofnarcissism.

Data Analysis

As previous work has shown that levels of nar-cissism and alexithymia do not differ substantiallyacross eating disorder diagnoses (Corcos et al., 2000;Waller et al., 2007), the clinical group was notsubdivided by diagnosis for the analyses. Thisapproach is in keeping with moves towards‘transdiagnostic’ models of the eating disorders(Fairburn, Cooper, & Shafran, 2003; Wade, Bergin,Martin, Gillespie, & Fairburn, 2006; Waller, 1993).Multiple regression analyses (simultaneous entry

Table 1. Multiple regression analyses, showing the assoalexithymia (TAQ scores) among eating-disordered women

Dependent variable (TAS-20 scale) Overa

OverallF

p

Difficulty identifying feelings/distinguishingemotions from bodily sensations

17.3 0.00

Difficulty describing feelings to others 11.2 0.00Externally oriented thinking 1.49 NS


method) were conducted to assess the associationsbetween the three narcissism elements (OMNIscales) and the three dimensions of alexithymia(TAS-20 scales). The three facets of narcissism wereused to predict levels of each of the three elements ofalexithymia.

RESULTS

The patients’ mean narcissism scores on the OMNIwere: narcissistic personality scale¼ 6.61 (SD¼3.16); narcissistic abused personality scale¼ 5.46(SD¼ 2.21) and poisonous pedagogy scale¼ 6.11(SD¼ 2.91). Their mean alexithymia scores on theTAS-20 were: difficulties identifying feelingsscale¼ 21.5 (SD¼ 7.16); difficulty describing feel-ings scale¼ 15.5 (SD¼ 5.07) and externally orientedthinking scale¼ 21.1 (SD¼ 9.02). Kolmogorov–Smirnov tests showed that all the OMNI andTAS-20 scales met the criteria for normal distri-bution (p> .05), with the exception of the TAS-20externally oriented thinking scale (Z¼ 1.45, p< .04).Table 1 shows the associations (multiple regre-

ssion analyses) between narcissistic characteristics(OMNI scales) and each of the three individualelements of alexithymia (TAS scales). The patternsof association differed for each of the three elementsof alexithymia. The two narcissistic defences wereassociated with difficulties in identifying feelingsand distinguishing them from somatic experiences.In contrast, core narcissism was associated withdifficulties in describing feelings to others. Finally,no elements of narcissism were associated withexternally oriented thinking.

DISCUSSION

This study has assessed the association betweennarcissistic characteristics and alexithymia in aneating-disordered population, in order to determine

ciation of elements of narcissism (OMNI scores) with(N¼ 70)

ll effect Individual effects

% Varianceexplained

Significant independentvariables (OMNI scales)

t p b

1 45.7 Narcissistically abused 4.07 0.001 0.437Poisonous pedagogy 2.14 0.05 0.259

1 34.5 Narcissistic personality 3.60 0.001 0.4372.50 — — — —


DOI: 10.1002/erv

Role of Narcissistic Traits in Eating Disordered Patients 47

how these treatment-impacting variables interact.As hypothesised, both core narcissism and thenarcissistic defences were linked to emotionalawareness. However, the associations were rela-tively specific rather than generalised. While corenarcissism was linked with difficulty in describingfeelings to others, the narcissistic defences wereassociated with difficulties in identifying feelingsand distinguishing them from somatic experiences.No elements of narcissism were associated with theexternally oriented thinking element of alexithymia,but this element is of little relevance to eatingpathology (Taylor et al., 1996; Troop et al., 1995).The link between core narcissism and alexithymia

is consistent with the existing literature, whichposits a link between core narcissistic features andpoor emotional awareness (Davis & Marsh, 1986;Dimaggio et al., 2006). This study has elaborated thelinks with relation to one clinical group, show-ing that core narcissism is linked specifically todifficulties in describing feelings to others. Thispattern of association suggests an individual who isso self-oriented that she or he is unable to under-stand either that others’ emotions are different toone’s own, or that others might not be automaticallyaware of one’s emotions. This conclusion issupported by the relationship between core narcis-sism and lack of empathy (Watson et al., 1984). Incontrast, the narcissistic defences were specificallyassociatedwith difficulty in identifying feelings anddistinguishing them from somatic experiences. Thislink might arise because such defensive behaviours(e.g. criticism of others, seeing others as hostile) aredivorced from the individual’s true underlyingemotional state (e.g. ‘I feel lonely, but I behaveangry’).Further research is needed to substantiate these

hypotheses, and to discover if these associations arerelevant to other clinical groups outside of theeating disorders. However, these findings demon-strate that the way in which alexithymia manifestsin the eating disorders is influenced by thepersonality variables of narcissism. Both alexithy-mia and narcissism can interfere with the treatmentof the eating disorders. Alexithymia can make itdifficult to identify the emotional factors that triggereating behaviours (e.g. Meyer, Waller, & Waters,1998), while narcissism in the patient can make ithard to work collaboratively towards goals thatthe patient does not necessarily share initially (e.g.experimenting with eating in a structured way).These findings suggest that it might be necessaryto address both the alexithymic and narcissisticcharacteristics of the patient in a joint way, rather


than as separate phenomena, using approaches thataim to modify both emotional processing (e.g.Corstorphine, 2006) and schema level core beliefs(e.g. Beck, Freeman, Davis, & Associates, 2004;Young, Klosko, & Weishaar, 2003). This work maybe necessary before it is possible to address theeating behaviours and cognitions themselves, butthis remains to be determined.

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DOI: 10.1002/erv

Emotional awareness among eating-disordered patients: the role of narcissistic traits

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