1 PhD in Psychology, Young Researchers and Elite Club, Mashhad Branch, Islamic Azad University, Mashhad, Iran.

2 PhD in Psychology, Young Researchers and Elite Club, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran.


There is a long-term interest in the effects of undesirable emotions to eating behaviors, due to the strain that it places on a person which can lead to loses his/her health. The present study examined the degree of disordered eating behaviors related to anxiety and alexithymia among high schools girls.
Materials and Methods:
This cross-sectional study on 344 girl students of Tehran’s high schools, who were selected by multiple cluster sampling, was conducted. Participants responded to the questionnaires of anxiety of Costello and Comrey (1967), Twenty-item Toronto alexithymia and disordered eating behaviors of Garner and colleagues (1982). The data were analyzed by regression and correlation techniques.
Results showed that there was significant positive correlation among anxiety, alexithymia and disordered eating behaviors (p



Eating disorders, as a life threatening condition, are serious disturbances in eating and body image. Eating disorders are very common among women (1). Eating disorders are as Heterogeneous multidimensional syndrome and as a result of neurobiology, psychological, social and cultural function (2). For example, eating disorders among women is due to the cultural focus on female thinness (3). From a developmental perspective, researchers have suggested various factors must be considered as integrated and eating disorders should be conceptualized as developmental disorders in the process of self-regulation with deficits in processing capacity and emotional regulation as the initial disturbance (4). In the recent years, eating disorders and problematic eating behaviors and beliefs are increasingly common (5). Anorexia nervosa and bulimia nervosa affect about 0.3% to 1% of women and is more common among aged 15 to 24 years old women (6). Maladaptive eating attitudes are a common problem among teenagers and can be a prelude for eating disorders (5). Research shows that people with emotional disorders such as depression, anxiety, obsessive-compulsive disorder, interpersonal sensitivity and social phobia have a greater risk of developing eating disorders (7-9). Recent researches have focused their attention on role of personality and their structures in creating the eating disorder (10). Conceptual relationship between personality and eating disorders are very complicated .Also people with eating disorders routinely have diagnostic criteria for personality disorders (11). From the perspective of treatment in eating disorders, comorbidity of eating disorders with personality disorders can interfere with the healing process (12). High schools girls are important target to encourage a healthy lifestyle in adolescence population (13). Researches show that the population in this age group has the greatest risk for beginning of eating disorders (14). Psychiatric comorbidity is very common in people with eating disorders. clinical and society studies show between 55% to 98% of individuals with anorexia nervosa and 88% to 97% of people with bulimia nervosa have axis I disorders (15).Studies show that the rate of anxiety disorders in women with anorexia nervosa is higher in compared with control group and beginning of the anxiety disorders is the prelude of anorexia nervosa. Women with bulimia nervosa in clinical and community samples, report one or more of an anxiety disorder (16, 17). One of the issues studied in this research was to investigation of relationship between anxiety variable and disordered eating behaviors.

In addition, the previous research showed alexithymia is related with disordered eating behaviors in non clinical population (18). A few researches is done in relationship between alexithymia and disordered eating behaviors in non-clinical samples and this type of research is undoubtedly important; Especially in non-clinical samples which  are combination of girls students that disordered eating behaviors are more common among them. Sifneos (19) defines alexithymic as persons with physical, mental symptoms which are unable to identify and express emotions. Alexithymic has three main features: difficulties identifying feelings, difficulties describing feelings, externally-oriented thinking (19, 20). Difficulty in identifying feelings occurs when a person is in distress with distinction between feelings. Difficulty in describing feelings is when a person can’t express what feels emotionally. External orientation thinking occurs when a person tends to think about the external affairs and in contrast to internal thinking orientation (21). Alexithymic will link as emotional adjustment disorder with primary defenses, non-adaptive coping styles, vulnerability against physical stress and psycho-physical symptoms (22). Individuals with alexithymic show lower levels of empathy (4). Recent research indicates that alexithymic have negative effects on psycho-emotional well-being and it is a risk factor in suffering individuals from emotional distress, psychological problems and lack of mental health (23). Alexithymia is related to pain (24), rheumatoid arthritis (25), obesity (26), irritable bowel syndrome (27), depression (28), self-injured behaviors (29), anorexia nervosa (30), overeating (31) and job burnout (23). One of the issues studied in this research is to investigate the relationship between alexithymia and disordered eating behaviors.

In attention to above materials, the aim of current research was to investigate the role of anxiety and alexithymia in predicting disordered eating behaviors among high school girls.

 Materials and Methods

In the current research is used of a cross-sectional design. This research was administrated on 344 girl students of Tehran-Iran high schools in 2013 year. The sample size was calculated using a multi-stage cluster sampling method and Morgan table among girls aged 13-16 years. The used questionnaires in this research were as

1)   Toronto Alexithymia Scale (32): Alexithymia was measured using the 20-item Toronto Alexithymia Scale which consists of three subscales “difficulty identifying feelings”, “difficulty describing feelings”, and an “externally oriented (or concrete) thinking style”. The statements are rank ordered to reflect agreements’ severity from strongly disagree (1) to strongly agree (5).  A total score is calculated by summing the three subscales scores for the total alexitymia. Besharat (33) prepare the Persian version of the Toronto alexithymia scale and Cronbach’s alpha coefficient for total alexithymia and its’ three subscales obtained, respectively, 0.85, 0.82, 0.75 and 0.72 that indicate the internal consistency of scale is good. The test-retest reliability of this scale was confirmed in a sample with 67 participants on two occasions with a internal of 4 weeks of 0.80 to 0.87 for total alexithymia and its’ subscales (34).  This scale is the most widely used tool to measure alexithymia (35).  In the present study, the reliability coefficient is obtained equal to 0.79 by Cronbach’s alpha.

2)   Anxiety Scale: This was measured with the Costello-Comrey Anxiety Scale (36). The CCAS is a nine-item scale developed to measure anxious affective states. Participants responded to this scale in a five-grade Likert style of 1 (mostly disagree) to 5(mostly agree). A sample of the questions of this scale: “when forced to wait, I’m nervous”. Validity and reliability of the scale have investigated in the research of Ghorbani and et al. (37). In this research, Cronbach’s alpha coefficient was reported 0.73 and also, has high validity. In the present study, the reliability coefficient is obtained equal to 0.78 by Cronbach’s alpha.

3)   Eating Attitudes Test-26 (EAT-26):the 26-items of Garner and et al. (38), is a screening tool that is used to help whether eating behavior and attitudes of respondents require further assessment. The questionnaire does not provide a diagnosis, but rather, it identifies symptoms that are consistent with any of the eating disorders. Two examples of this scale questions “I am constantly preoccupied with food’ and “when I eat, I feel I’m not able to stop her”. This scale is based on Likert style from 1 (always) to 6 (never). Rivas and et al. (39) showed that this scale have a high internal consistency. Also, the researchers found that the scale has the ability to distinguish between participants with eating disorders (ED), symptomatic and asymptomatic, using of the results of eating disorder diagnosis questionnaire (40) as the criterion. This study could identify subjects with ED and without ED. In the present study, the reliability coefficient is obtained equal to 0.83 by Cronbach’s alpha.

In the current study, was used of descriptive statistics and the regression analysis for analyzing data.  Data were analyzed using SPSS 15 software and p value less than 0.05 was statistically considered significant.


Mean, standard deviation and internal correlations of variables under study are presented in table 1.


Table 1: Mean, Error Standard and internal collections of variables
























3.Disordered eating behaviors







 As can be seen, there were significant relationships among anxiety, alexithymia and disordered eating behaviors (p<0.01).

To assess the predictive power of disordered eating behaviors by anxiety and alexithymia variables were used of the stepwise regression analysis. The results of model summary are

presented in Table 2.

Table 2: Summary of regression analysis model








Step 1:anxiety






Step 2: anxiety and alexithymia







 The results of regression model for explaining disordered eating behaviors based on anxiety and alexitymia indicated that F-statistic for both models is significant in p

Table 3: Summary of stepwise regression analysis to predict disordered eating behaviors

 based on anxiety and alexithymia






















As can be seen, anxiety variable with β=0.58 can significantly predict almost %35 of the variance of disordered eating behaviors.  Also, alexitymia variable with β=0.42 can significantly predict almost %22 of the variance of disordered eating behaviors.


The results of this study showed that anxiety variable can significantly predict disordered eating behaviors. These results are consistent with pervious finding (17, 38, 41 & 42). These findings can be interpreted in terms of the following possibilities: 

Eating disorders have high rates of comorbidity with other mental disorders, especially anxiety disorders .There is a diagnostic overlap between eating disorders with anxiety disorders (17). For example, the common symptoms of bulimia and anorexia nervosa may include severe anxiety about food and eating, fear of gaining weight and anxiety about social evaluation (43). For example, the effects of starving and other applied ways for losing weight may be observed in obsessive compulsive behaviors related to food, eating and body checking as an anxiety disorder (44). The researches show people with eating disorders who has anxiety disorders, are more likely to be resistant against symptoms of eating disorders, have lower health, and show a higher rate of mortality in comparison with people without comorbidity disorder in 14–years period follow up (45). For example, it can be said that the social anxiety by inhibiting commitment in people with eating disorders to the treatment process, due to fear of negative evaluation and avoiding from interaction with others may express a part of comorbid unfavorable variance of anxiety disorders with eating disorder in field of treatment (46). The comorbidity of anxiety disorders shows higher severity of disorder and complexity in appearing the eating disorders which may predict independently the poor consequences (47). In the research was done about the relation of eating with emotion over 22 high weight individuals, the results showed that unfavorable emotion have a specific relation with eating disorder and the anxiety was expressed the most reason for disordered eating behavior (48). When the anxiety is applied in experimental situations, it is more likely that the subjects suffer from disordered eating behavior even if the food isn't delicious (41). Although, the special nature of relations between eating disorders and anxiety is not clear, the researchers say that anxiety may be a dangerous factor in making eating disorders, anxiety may be secondary to eating disorders and or both disorders may share some common vulnerable factors (49). For example, recent theories say that the negative initial experiences are the dangerous factor in growing both disorders. In this model, the basic deleterious cognitions lead to deleterious avoided cognitions, these results from application of safe behaviors that includes both disorders (50). Of this view, the child's anxiety may have an etiology role in making eating disorders which their origin is from ultra fear about situations and certain events which finally leads to extra fear about eating, appearance and weight and at last, leads to disordered eating behavior (51).

Also, the results of this study showed alexithymia can significantly predict disordered eating behaviors. These results are consistent with the findings of previous research (52-55). These findings can be interpreted according to following possibilities. Alexithymia have dimensions of emotional disability in describing and identifying emotions and cognitive aspects of thinking has objective and external oriented (56). Research has shown inability to express emotional experiences as a result of non-discrimination and unregulated emotions have related with disordered eating behaviors by the distortion of body image (57). Cognitive constraints on emotion regulation in people with alexithymia are associated with maladaptive behavior such as starvation or substance abuse because of self-regulatory behaviors. Lack of insight and thinking styles (external oriented) of persons with alexithymia interfere with ability of these individuals to benefit of psychotherapeutic interventions. Females with disordered eating behaviors have higher level of alexithymia than women in the control group and may be their emotions transfer to physical feelings and physical appearance (58). Disability in identifying of emotions has related with body dissatisfaction in people with disordered eating behaviors (57). Researches show that the rate of alexithymia in people with eating disorders in a higher level than people who have been improved their eating disorders and symptoms of eating disorders represent internal conflicts and unclear feelings (59). Individuals with high levels of alexithymia have difficulties in identifying and describing their feelings. They are disorganized due to their limitations in adjusting these emotions by uncontrollable feelings; finally they try to adjust themselves by self-incitement maladaptive behaviors like being on a diet. These strategies are as non-conducive efforts which they are applied to organize internal emotions and feelings and integrate the self-defense sense. It is vital to identify alexithymia in persons with eating disorders symptoms as a negative prognostic factor for treatment strategies (55).


In summary, the present findings suggest that alexithymia and anxiety can significantly predict disordered eating behaviors among high school girls. The findings of this study will expand previous research on the relationship between anxiety and alexithymia with eating disorders in non-clinical sample of females.  A group of girl’s students are at risk for developing eating disorders and primary and secondary prevention programs are required in order to cope with the situation between them.  Using the strategy to provide information to young girls is important as prevention programs. These programs prevent the occurrence of new cases and persons who have this disorder are encouraged to look for the relevant professionals. This study is required replication and experimental confirmations because of its novelty in the Iranian cases. Until then, the findings should be interpreted with caution. Similarly, sample (group of students) and research (correlation) are discussed the limitations of findings generalizability, interpretation and causal attribution and should be considered. Furthermore, the limitations of self-report measures in this study should not be ignored.


The authors would like to acknowledge the generosity of girls students of Tehran-Iran high schools who agreed to participate in this research.



1. Agras WS. The Oxford handbook of eating disorders: Oxford University Press; 2010.
2.  Garner DM, Myerholtz, L.E. Eating disorders. In: Bellack AS, Hersen, M. , editor. Comprehensive Clinical Psychology: Elsevier Science; 2000.
3.  Wiseman CV, Gray JJ, Mosimann JE, Ahrens AH. Cultural expectations of thinness in women: An update. International Journal of Eating Disorders. 1992;11(1):85-9.
4.  Taylor GJ, Bagby RM, Parker JD. Disorders of affect regulation: Alexithymia in medical and psychiatric illness: Cambridge University Press; 1999.
5.  Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. Psychiatric comorbidity in treatment-seeking anorexics and bulimics. Journal of the American Academy of Child & Adolescent Psychiatry. 1992;31(5):810-8.
6.  Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current opinion in psychiatry. 2006;19(4):389-94.
7.  Wade TD, Bergin JL, Martin NG, Gillespie NA, Fairburn CG. A transdiagnostic approach to understanding eating disorders. The Journal of nervous and mental disease. 2006;194(7):510-7.
8.  Murphy R, Nutzinger D, Paul T, Leplow B. Conditional-associative learning in eating disorders: a comparison with OCD. Journal of Clinical and Experimental Neuropsychology. 2004;26(2):190-9.
9.  Hart TA, Flora DB, Palyo SA, Fresco DM, Holle C, Heimberg RG. Development and examination of the social appearance anxiety scale. Assessment. 2008;15(1):48-59.
10.       Wonderlich SA. Personality and eating disorders. In: Brownell CGFKD, editor. Eating disorders and obesity: A comprehensive handbook New York: Press; 2002.
11.       Sansone RA, Levitt JL, Sansone LA. The prevalence of personality disorders among those with eating disorders. Eating Disorders. 2004;13(1):7-21.
12.       Dennis AB, Sansone RA. Treatment of patients with personality disorders. 1997.
13.       Levine MP, Smolak L, Hayden H. The relation of sociocultural factors to eating attitudes and behaviors among middle school girls. The Journal of Early Adolescence. 1994;14(4):471-90.
14.       Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101 (Supplement 2):539-49.
15.       Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry. 2011;68(7):714-23.
16.       Rowe R, Pickles A, Simonoff E, Bulik CM, Silberg JL. Bulimic symptoms in the Virginia Twin Study of Adolescent Behavioral Development: correlates, comorbidity, and genetics. Biological psychiatry. 2002;51(2):172-82.
17.       Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K, Group PFC. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry. 2004;161(12):2215-21.
18.       Berthoz S, Perdereau F, Godart N, Corcos M, Haviland MG. Observer-and self-rated alexithymia in eating disorder patients: Levels and correspondence among three measures. Journal of psychosomatic research. 2007;62(3):341-7.
19.       Sifneos PE. Short-term psychotherapy and emotional crisis: Harvard University Press; 1972.
20.       Bankier B, Aigner M, Bach M. Alexithymia in DSM-IV Disorder: Comparative Evaluation of Somatoform Disorder, Panic Disorder, Obsessive-Compulsive Disorder, and Depression. Psychosomatics. 2001;42(3):235-40.
21.       Lundh L-G, Johnsson A, Sundqvist K, Olsson H. Alexithymia, memory of emotion, emotional awareness, and perfectionism. Emotion. 2002;2(4):361.
22.       Picardi A, Toni A, Caroppo E. Stability of alexithymia and its relationships with the ‘big five’factors, temperament, character, and attachment style. Psychotherapy and psychosomatics. 2005;74(6):371-8.
23.       Mattila AK, Ahola K, Honkonen T, Salminen JK, Huhtala H, Joukamaa M. Alexithymia and occupational burnout are strongly associated in working population. Journal of psychosomatic research. 2007;62(6):657-65.
24.       Sriram T, Chaturvedi S, Gopinath P, Shanmugam V. Controlled study of alexithymic characteristics in patients with psychogenic pain disorder. Psychotherapy and psychosomatics. 1987;47(1):11-7.
25.       Fernandez A, Sriram T, Rajkumar S, Chandrasekar A. Alexithymic characteristics in rheumatoid arthritis: a controlled study. Psychotherapy and psychosomatics. 1989;51(1):45-50.
26.       Legorreta G, Bull R, Kiely M. Alexithymia and symbolic function in the obese. Psychotherapy and psychosomatics. 1988;50(2):88-94.
27.       Porcelli P, Leoci C, Guerra V, Taylor GJ, Bagby RM. A longitudinal study of alexithymia and psychological distress in inflammatory bowel disease. Journal of psychosomatic research. 1996;41(6):569-73.
28.       Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinamäki H. Depression is strongly associated with alexithymia in the general population. Journal of psychosomatic research. 2000;48(1):99-104.
29.       Zlotnick C, Shea MT, Pearlstein T, Simpson E, Costello E, Begin A. The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive psychiatry. 1996;37(1):12-6.
30.       Carano A, De Berardis D, Gambi F, Di Paolo C, Campanella D, Pelusi L, et al. Alexithymia and body image in adult outpatients with binge eating disorder. International Journal of Eating Disorders. 2006;39(4):332-40.
31.       Quinton S, Wagner HL. Alexithymia, ambivalence over emotional expression, and eating attitudes. Personality and individual differences. 2005;38(5):1163-73.
32.       Bagby RM, Parker JD, Taylor GJ. The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. Journal of psychosomatic research. 1994;38(1):23-32.
33.       Besharat MA. The relations between personality dimensions and alexithymia. Contemporary Psychology. 2007;2:50-8.
34.       Kooranian F, Khosravi A, Esmaeeli H. The relationship between hardiness/locus of control and burnout in nurses. The Horizon of Medical Sciences. 2008;14(1):58-66.
35.       Grynberg D, Luminet O, Corneille O, Grèzes J, Berthoz S. Alexithymia in the interpersonal domain: A general deficit of empathy? Personality and individual differences. 2010;49(8):845-50.
36.       Costello C, Comrey AL. Scales for measuring depression and anxiety. The Journal of Psychology. 1967;66(2):303-13.
37.       Ghorbani N, Framarz AG, Watson P. Philosophy, self-knowledge, and personality in Iranian teachers and students of philosophy. The Journal of Psychology. 2005;139(1):81-95.
38.       Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: psychometric features and clinical correlates. Psychological medicine. 1982;12(04):871-8.
39.       Rivas T, Bersabé R, Jiménez M, Berrocal C. The eating attitudes test (EAT-26): reliability and validity in Spanish female samples. The Spanish journal of psychology. 2010;13(02):1044-56.
40.       Mintz LB, O'Halloran MS, Mulholland AM, Schneider PA. Questionnaire for Eating Disorder Diagnoses: Reliability and validity of operationalizing DSM—IV criteria into a self-report format. Journal of Counseling Psychology. 1997;44(1):63.
41.       Polivy J, Herman CP, McFarlane T. Effects of anxiety on eating: Does palatability moderate distress-induced overeating in dieters? Journal of Abnormal Psychology. 1994;103(3):505.
42.       Wall AD, Cumella EJ. Anxiety and Eating Disorders. Anxiety. 2005;4(4).
43.       Association AP. Diagnostic And Statistical Manual Of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision) Author: American Psychiatr. 2000.
44.       Mazure CM, Halmi KA, Sunday SR, Romano SJ, Einhorn AM. The Yale-Brown-Cornell eating disorder scale: development, use, reliability and validity. Journal of Psychiatric Research. 1994;28(5):425-45.
45.       Button EJ, Chadalavada B, Palmer RL. Mortality and predictors of death in a cohort of patients presenting to an eating disorders service. International Journal of Eating Disorders. 2010;43(5):387-92.
46.       Goodwin RD, Fitzgibbon ML. Social anxiety as a barrier to treatment for eating disorders. International Journal of Eating Disorders. 2002;32(1):103-6.
47.       Le Grange D, Lock J, Agras WS, Moye A, Bryson SW, Jo B, et al. Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa. Behaviour research and therapy. 2012;50(2):85-92.
48.       Masheb RM, Grilo CM. Emotional overeating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder. International Journal of Eating Disorders. 2006;39(2):141-6.
49.       Godart NT, Flament MF, Curt F, Perdereau F, Lang F, Venisse JL, et al. Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study. Psychiatry Research. 2003;117(3):245-58.
50.       Pallister E, Waller G. Anxiety in the eating disorders: Understanding the overlap. Clinical Psychology Review. 2008;28(3):366-86.
51.       Jacobi C, Hayward C, de Zwaan M, Kraemer HC, Agras WS. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychological bulletin. 2004;130(1):19.
52.       De Berardis D, Carano A, Gambi F, Campanella D, Giannetti P, Ceci A, et al. Alexithymia and its relationships with body checking and body image in a non-clinical female sample. Eating behaviors. 2007;8(3):296-304.
53.       Lawson R, Emanuelli F, Sines J, Waller G. Emotional awareness and core beliefs among women with eating disorders. European Eating Disorders Review. 2008;16(2):155-9.
54.       Lawson R, Waller G, Sines J, Meyer C. Emotional awareness among eating‐disordered patients: the role of narcissistic traits. European Eating Disorders Review. 2008;16(1):44-8.
55.       Speranza M, Loas G, Wallier J, Corcos M. Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. Journal of psychosomatic research. 2007;63(4):365-71.
56.       Zackheim L. Alexithymia: The expanding realm of research. Journal of psychosomatic research. 2007;63(4):345-7.
57.       Fenwick AS, Sullivan KA. Potential link between body dysmorphic disorder symptoms and alexithymia in an eating-disordered treatment-seeking sample. Psychiatry Research. 2011;189(2):299-304.
58.       Kessler H, Schwarze M, Filipic S, Traue HC, von Wietersheim J. Alexithymia and facial emotion recognition in patients with eating disorders. International Journal of Eating Disorders. 2006;39(3):245-51.
59.       Parling T, Mortazavi M, Ghaderi A. Alexithymia and emotional awareness in anorexia nervosa: time for a shift in the measurement of the concept? Eating behaviors. 2010;11(4):205-10.