First, the descriptive statistic indexes were extrapolated (). On average, the subjects presented with moderate to severe symptoms relative to the variables considered in our study. In fact, participants appeared to be borderline with regard to alexithymia (TAS-20 = 56.3 ± 12), and they presented with a shame score (ESS = 67.4 ± 19) of greater than the 90th percentile when compared with the results from preliminary sample studies of Italian instrument validation. ESS average score in the Italian population is 45.72, SD 13.15
Moreover, even if the cut-off score for dissociative disorders in DES-II was 30, the dissociation scores appeared to increase (DES-II = 21.6 ± 15) if compared with the average range observed in the nonreferred population from the Italian sample (12.5 ± 8); the average values of the perceived traumatic conditions (weighted average TSI-A = 1.26 ± 0.5) in our sample are higher than those obtained from a nonclinical population.27
A total of 86 patients (60%) showed symptoms of depressed mood as detected by the TSI-A depression scale. Finally, with regard to the body image disorders, there was evidence that participants had such a disorder across both the psychological and behavioral subscales (BUT-GSI = 2.2 ± 1.2, average scores of normal population 0.45–0.75), and with respect to the level of dissatisfaction participants exhibited towards specific aspects of their bodies (BUT-PST = 20.2 ± 10). These results appear to be only marginally influenced by patients’ age ().
Average values (±SD) of the total sample and each diagnostic group
Correlations between subjective measures and patients’ age
We have compared the three different diagnostic groups in order to detect statistically significant differences in some of the investigated psychopathologic areas. The one-way ANOVA was performed when variables followed a normal distribution, while the Kruskal–Wallis test was used when a normal distribution was not obtained. The ANOVA results showed statistically significant differences between the groups for the following dependent variables: ESS, P < 0.05; TSI-A intrusive experiences, P < 0.05; TSI-A depression, P < 0.05; TSI-A dissociation, P < 0.005; BUT dissatisfaction concerning body and weight, P < 0.005; BUT avoidance and compulsive control behavior, P < 0.005; BUT depersonalization (feelings of detachment and estrangement from the body), P < 0.005; BUT-PST, P < 0.05; the Kruskal–Wallis test detected a statistical significance with regard to the DES-II value (P < 0.05). We used the post hoc Bonferroni test in order to verify where the discrepancies among the investigated psychopathologies could be found; we observed that regarding ESS, the subjects with AN exhibited less feelings of shame than subjects who had a diagnosis that overlapped with AN and BN (P < 0.05). With regard to the TSI-A, the BN group showed higher perceived intrusive experiences (P < 0.05) and higher dissociation (P < 0.01) than the AN group. Meanwhile, on the BUT-A scale, the BN group and EDNOS group showed higher values of altered body image (P < 0.05), avoidance and compulsive control (P < 0.05 and P < 0.01, respectively), and depersonalization (P < 0.05). The group with the overlapping diagnosis also showed higher values on the BUT-PST subscale (P = 0.05) when compared to the results from the AN group. The Kruskall–Wallis test detected that the BN and the EDNOS groups showed higher values of dissociation on the DES-II test (P < 0.05).
We have performed correlation studies in order to verify how the investigated variables are related. By performing Pearson’s and Spearman’s correlations, we found that TSI-A, TAS-20, DES-II, and ESS are linked together in a statistically significant manner. When considering the AN group, we noticed that TAS-20 scores correlate with ESS scores (r = 0.55, P < 0.0001), DES-II scores (r = 0.49, P < 0.0001), and TSI-A perceived traumatic conditions (r = 0.47, P < 0.0001). In addition, ESS scores correlate with DES-II scores (r = 0.51, P < 0.0001) and TSI-A scores (r = 0.71, P < 0.0001). Moreover, DES-II and TSI-A scores are also correlated (r = 0.62, P < 0.0001). In the BN group, TAS-20 correlates with ESS (r = 0.39, P < 0.01), DES-II (r = 0.46, P = 0.001), and TSI-A scores (r = 0.52, P < 0.001). ESS scores correlate with DES-II (r = 0.53, P < 0.0001) and TSI-A scores (r = 0.61, P < 0.0001); DES-II scores correlate with TSI-A scores (r = 0.66, P < 0.0001). In the EDNOS group, TAS-20, TSI-A, and DES-II scores correlate with each other (r = 0.53, P < 0.05 between TAS-20 and DES-II; r = 0.47, P = 0.05 between TAS-20 and TSI-A; and r = 0.55 and P < 0.05 between DES-II and TSI-A), while ESS scores correlate with some of the TSI-A subscales: anger/irritability (r = 0.45, P < 0.05), depression (r = 0.49; P < 0.05), and impaired self-reference (r = 0.61, P < 0.005) ().
Correlations among TAS-20, ESS, DES-II, and TSI-A
The relationship between shame and alexithymia was studied in-depth using Bonferroni’s test. As the total sample was subdivided on the basis of TAS-20 scores, ESS scores progressively increased. A P < 0.01 was detected between ESS scores in nonalexithymic (ESS = 55.8 ± 17) and borderline alexithymic subjects (ESS = 68.1 ± 14), while P, 0.0001 was detected between shame scores in nonalexithymic and pathologically alexithymic subjects (ESS = 74.8 ± 19). We then analyzed how these variables interact with results from the BUT scale (). In the AN group, we noticed that BUT-GSI scores correlate with each of the mentioned variables with a P-value <0.0001 (r = 0.48 with TAS-20; r = 0.71 with ESS; r = 0.44 with TSI-A and DES-II), while BUT-PST correlates with the first factor of TAS-20 (r = 0.58), ESS (r = 0.49), TSI-A (r = 0.49), and DES-II (r = 0.44) with a P-value < 0.0001. In the group composed of BN patients, we found that BUT-GSI also correlates with ESS (r = 0.67), DES-II (r = 0.66), the first factor of TAS-20 (r = 0.54), each with P < 0.0001 and TSI-A (r = 0.54 and P < 0.001, with a higher correlation noted with regard to depression and dissociation subscales). In addition, BUT-PST correlates with the TSI-depression subscale (r = 0.48, P < 0.0001), ESS (r = 0.38, P < 0.01), DES-II (r = 0.31), and the first factor of the TAS-20 (r = 0.35) with P < 0.05. Finally, BUT-GSI correlates with the first factor of the TAS-20 (r = 0.65), TSI-A (r = 0.53) with P < 0.001, DES-II (r = 0.55, P < 0.01), and ESS (r = 0.49, P < 0.05) in the EDNOS group. No correlation was found with regard to the BUT-PST subscale.
Correlations between BUT-GSI and BUT-PST and the other variables
In the total ED patients sample, post hoc correlations were used to explore how perceived traumatic conditions influence experiences of shame (as measured by ESS) and body dissatisfaction (as investigated by BUT-A and BUT-B). Bonferroni’s test revealed that ESS and BUT values increase in a statistically significant manner (P < 0.0001) when TSI-A scores are indicative of a pathology.
Finally, through stepwise linear regression analysis between the considered variables we have detected those that explain, in a statistically significant manner, the body image disorders observed in EDs. We found different results among the three diagnostic groups ().
When considering the AN group, with regard to BUT-GSI scores, the independent variable selected through the stepwise method included feelings of shame (ESS), which explain the 53% of the total variance in the BUT-GSI subscale (R2 = 0.53, P < 0.0001). With regard to the BUT-PST scores, the variable most predictive of body image disorders in ED is the first factor of the TAS-20 (difficulty in identifying feelings, R2 = 0.33, P < 0.0001), which explains 33% of the total variance. In the BN group, BUT-GSI scores are strongly predicted by feelings of shame (ESS, R2 = 0.58, P < 0.0001) and by the TSI-A dissociation subscale (R2 change = 0.08, P < 0.01). The TSI-A depression subscale appeared to be predictive of the level of body dissatisfaction measured by the BUT-PST subscale (R2 = 0.29, P < 0.0001), explaining 29% of its variance. Finally, in the EDNOS group, BUT-GSI scores were explained by perceived traumatic conditions (TSI-A, R2 = 0.69, P < 0.001).
The influence of depression on the aforementioned variables has also been investigated. In the total sample of ED patients, the TSI-A depression subscale values correlate with TAS-20 (r = 0.51), ESS (r = 0.68), BUT-A (r = 0.69), and BUT-PST scores (r = 0.48, as previously mentioned). These values reached a level of statistical significance of P < 0.0001. However, when partial correlation analysis filtered the effects determined by the ESS results, no statistically significant correlation was determined between the TSI-A depression subscale and the BUT-PST results (r = 0.13; P > 0.05), and the correlation between the TSI-A depression subscale and BUT-A scores appears to be moderate (r = 0.27, P = 0.01). Stepwise regression analysis instead showed that TSI-A depression values can be explained by BUT-A and ESS scores (R2 = 0.51, P < 0.001). Analogous data were obtained when partial correlation analysis filtered the effects of shame (ESS) on the relationship between results on the TSI-A and BUT scales. Instead, when the effects of perceived traumatic conditions are not considered by partial correlations, a strong correlation between ESS and BUT scores is maintained (r = 0.53 between ESS and BUT-A; r = 0.39 between ESS and BUT-PST; P < 0.0001).