Autobiographical narratives in relation to affect regulation in an Italian sample of patients in an acute phase of Anorexia Nervosa

doi:10.21203/rs.3.rs-1621801/v1

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Autobiographical narratives in relation to affect regulation in an Italian sample of patients in an acute phase of Anorexia Nervosa

https://doi.org/10.21203/rs.3.rs-1621801/v1

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Purpose: This research aims to analyze the relationship between emotional regulation and the symbolic process in autobiographical narratives in a group of individuals diagnosed with restrictive Anorexia Nervosa (AN), compared to a non-clinical group. The study is framed within Multiple Code Theory MCT (Bucci, 1997; 2021) which considers mind-body integration. The purposes of this study are to investigate whether AN will show greater alexithymia and emotional dysregulation than the non-clinical group; and whether the specific linguistic and symbolic features, such as somatic-sensory words, affect words, and difficulty in symbolizing process will predict the AN group.

Methods: Twenty-nine female participants hospitalized with AN in an acute phase (mean age 19.8 ±4.1) and thirty-six non-clinical female participants (mean age 21 ±2.4) were selected through snow-ball sampling. The participants completed the Toronto Alexithymia Scale (TAS-20), the Profile of Mood of State (POMS), the Emotion Regulation Questionnaire (ERQ), and a Relationship Anecdotes Paradigm Interview (RAP). The Referential Process (RP) Linguistic Measures has been applied to transcribed interviews. A T-test for paired samples and logistic binary regression has been performed.

Results: AN presented a significantly higher emotional dysregulation through the ERQ, TAS20 and POMS measures. Specifically, AN showed higher ER expression/suppression strategies, fewer functional cognitive strategies, higher alexithymia, and higher mood dysregulation. Specific linguistic features such as sensory-somatic, affect word, and difficulty in RP symbolizing, predict the AN group (R2 = .349; χ2 = 27,929; df = 3; p = .001).

Conclusions: Emotional dysregulation is connected to AN symptoms and autobiographical narratives. The results can help a clinical assessment phase showing specific linguistic features in AN patients.

Eating Disorders

Emotional Regulation

Linguistic analysis

Alexithymia

Autobiographical Narratives

Anorexia nervosa (AN) is a psychiatric syndrome characterized by a progressive loss of appetite followed by a pathological decrease in body weight. The disorder is generally defined by a threefold pathological structure with a behavioral and psychopathological component, as well as organic symptomatology. Anorexia is a condition of self-induced food restriction to a significant degree (behavioral aspect), accompanied by a deep desire to be thin and/or fear of fatness (psychopathological aspect), which involves the appearance of symptoms and clinical signs related to the conspicuous weight loss (organic symptomatology). In addition, a certain degree of polarization on one's outward appearance may be added to the symptom spectrum and, therefore, considered as body image disturbance (BID). In such a case, the syndrome is characterized by an altered perception of the body and dissatisfaction with one's image. Patients with anorexia nervosa commonly perceive themselves to be normal or overweight even though they are in fact, underweight.

AN causes significant psychological and relational impairment in the person and is one of the main contributors to the reduction of the quality of life in the context of eating disorders. Affected patients show a lower Health-Related Quality of Life (HRQoL) than the healthy population [1]. In Western countries, including Italy, it is estimated that the prevalence of anorexia nervosa is around 0.2–0.8% and that the incidence is 4–8 new cases per year, per 100,000 individuals [2]. The average age of onset is between 14 and 18 years and the diagnosis is ten to twenty times more frequent in women than in men. The diagnosis of Anorexia Nervosa is predominantly clinical and is supported by the diagnostic criteria reported in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There are three prominent aspects to consider: the voluntary restriction of calorie intake in relation to needs; the intense fear of gaining weight; and the alteration in the way of perceiving one’s weight or the shape of one’s body. Symptoms must be present for no less than three consecutive months [3].

There are two different clinical manifestations of anorexia nervosa: the restrictive type and the one characterized by binges and eliminatory behaviors. In restrictive AN, or type I, weight loss is mainly achieved through a restrictive diet, fasting, and sometimes excessive physical activity, with no recurrent binge eating or purging behaviors (e.g., self-induced vomiting, use of inappropriate laxatives or diuretics), which are typical of type II or type binging/purging AN. Obsessive-compulsive symptoms related to food or other aspects of life often occur in the restricted type of anorexia nervosa [4]. The most common obsessions are: fear of weight gain and the intrusive thought of calorie restriction with diet [5] while restricting food intake; exhausting physical activity and the compulsive series of exercises carried out with a detailed schedule; and the continuous and ritualistic monitoring of body weight. Studies confirm that individuals diagnosed with the purely restrictive variant have lower chances of recovery than those with the variant consisting of binges and eliminatory behaviors, notwithstanding its association with a lower suicide rate [4]. The severity of the anorexic syndrome is considered by evaluating the entity of the body mass index (BMI) in the case of adult patients or through the percentile of the index itself for children and adolescents [3]. Mild severity is attributed for a BMI ≥ 17 kg/m2, moderate for a BMI between 16 and 16.99 kg/m2, and severe if the BMI is between 15 and 15.99 kg/m2. Despite the clear ease and convenience with which the BMI is used to define the severity of the anorexic syndrome, an exclusive reference to the numerical value seems simplistic. In addition to an evaluation of the entity of weight loss, it is necessary to reflect on the more general implications related to it, such as the influence that this has on body related attitudes (BodyRA) and especially on body dissatisfaction in adolescents [6]. The course of AN is variable. While spontaneous recovery without treatment is permissible, a fluctuating course is more likely the case in which the affected individual shows signs of improvement while remaining anchored to some of the preoccupations regarding food, weight, and bodily appearance. In some cases, however, the clinical history predicts a gradual decline and physical deterioration, leading to the deadly consequences of starvation. This would also seem to impact the scores of alexithymia, and in fact, in its acute phase, Anorexia Nervosa is associated with a greater reduction of facial expressions of emotions compared to that which occurs in recovered patients [7]. The advantage after hospitalization is undoubtedly in terms of weight, but it is less concrete in terms of socialization and mood; poor relations with peers remain, and sometimes severe depressions are highlighted [8]. Quantifying the mortality of anorexia nervosa is a complex matter. Some studies indicate mortality of approximately 5.25% and a Standardized Mortality Ratio (SMR) of 9.7 [9]. The SMR of anorexia nervosa is by far one of the highest in the context of psychiatric disorders.

The severity of the disorder and the implications related to high psychiatric mortality show the need to analyze assessment factors that can help better understand the psychological factors underlying the symptomatology of AN. In fact, numerous studies have emphasized the relationship between AN and the individual’s deficits in emotional awareness [10–11–12] or heightened alexithymia. Recent review findings even suggest that if overall empathy levels are intact in AN, however, greater emotion regulation difficulties, elevated alexithymia levels, and reduced emotional awareness are evident [13]. Various empirical studies reveal emotional regulation plays an important role in the development, maintenance, and psychopathology of AN [14–15–16–17]. Research that used the Emotional Regulation construct confirmed that AN is characterized by dysfunctional emotional regulation strategies oriented towards a purely suppressive pole rather than cognitive re-evaluation [18]. Individuals with AN also display alexithymia, closely related to the difficulties in identifying feelings about themselves [19–20]. Foye et al. [21] pointed out that AN represents an attempt to modulate current or persistent aversive emotional arousal, in a dysfunctional way. Avoiding emotions could be considered to be a coping strategy against feeling feelings, avoiding positive or negative emotions, showing poor interoceptive awareness, and displaying confusion of emotional states and difficulties with emotional language.

The lack of language that can express emotions is central to our study. Our study aims to frame the phenomenon of emotional dysregulation and alexithymia in relation to verbal symbolic production. Alexithymia can be defined as quite literally, ‘a lack of words to express emotion,’ [22] characterized by difficulties in identifying and expressing emotions, as well as employing fantasy to regulate painful feelings and finding creative solutions to problems, as well as in communicating needs to others in order to obtain support [23]. Taylor and Bagby [24] suggested that alexithymia may be more fully understood in light of Bucci’s [25] Multiple Code Theory (MCT). MCT is a general theory of emotional information processing, derived from current work in cognitive psychology, psychoanalysis, and affective neuroscience [26]. This model poses that information is processed in parallel [27] among three different systems, which organizes the experience in a global and raw way: 1) the subsymbolic coding system is characterized by experience gradients, (rather than discrete representations), and they manifest as sensations and feelings in all sensory modalities, as well as in physical and motoric experience; 2) the non-verbal symbolic coding system, which is delegated to representations, images, and metaphors; 3) and the symbolic verbal coding system, which concerns words, and is defined in general semiotic terms as discrete entities that represent other entities and that may be combined to generate new forms. Bucci [28] argues that a Referential Process (RP) connects these three types of processing systems and allows people to express their emotional experiences into words. In other words, Alexithymia can further be understood as an expression of the disconnection of RP [29]. The RP and emotional communication are connected to Damasio’s notion of dispositional representations [30] that provide a neurobiological basis for the concept of emotional schema. These innate dispositional representations can be associated to the arousal/emotional activation and to a non-conscious state of the self, where raw bodily aspects are totalizing. The dispositional representation is activated in autobiographical memories, which can activate emotional schemas [31]. A good RP allows for the representation of emotional schema memories in verbal forms, which follows the implications of MCT [32], concerning access to the experiential and preverbal code of the implicit self [33–34]. The food restriction and procedures that AN describes as connected to the autobiographical narratives of individual assumes the function of an organizational symbol within emotional schemes. Nandrino et al. [35] showed that AN is characterized by an excessive generalization of autobiographical memories that would lead individuals to manifest greater difficulties in making use of an affective narrative, capable of leading the other to "live" their own experience. Additionally, patients with AN tend to use specific cognitive and behavioral strategies in order to avoid or mitigate negative affect [36]. The verbalization process can represent a measure of the capacity to emotionally regulate, which is expressed through linguistic indicators. In Mariani et al. [37], what was found to emerge was a representative linguistic pattern of emotional regulation difficulties in narrative processes in psychopathology, such as sensory-somatic words and the presence of strong negative feelings.

The aim of this study, according to MCT, is to explore whether specific dysfunctional patterns in emotional regulation could also be found in AN psychopathology. More specifically, we hypothesize that a specific pattern of emotional regulation in AN patients will be seen, in emotional regulation strategies as well as in linguistic patterns in autobiographical narratives following these specific hypotheses:

a) Individuals diagnosed with AN will show greater alexithymia, emotional dysregulation, and affect dysregulation compared to non-clinical groups;

b) Specific linguistic features, that show difficulties in the symbolization process, such as higher sensory somatic words, higher negative affect words, and dysfunctional RP patterns will predict the clinical group.

2.1 Participants

A clinical sample of patients seeking hospitalization or visiting for an inpatient DH crisis was recruited for the study. The diagnosis of Restrictive Anorexia Nervosa was confirmed using the semi-structured interview, SCID-5-CV [38]. The constitution of the clinical group was made according to the following criteria: Inclusion: between 16 and 30 years of age, acute phase of AN, BMI ≥ 12.5 Kg / m2, Time from diagnosis ≥ 6 months; Exclusion: Chronic pathology (time from diagnosis ≥ 10 years), diagnosis of acute psychosis, mental retardation, cognitive impairment, ongoing alcohol or psychoactive substance abuse and/or other conditions that may affect the understanding of the questionnaires and the ability to provide informed consent. Simultaneously, a control group was recruited, which was similar to the clinical group in terms of age and educational attainment. The exclusion criteria for control group were the presence of DCA symptoms, which was evaluated using the Eating Attitudes Scale test (EAT-26) [39]. The sample numerosity has been estimated by G*Power 3.1.9.2 (Düsseldorf, Germany) for two group comparison on an effect size of f .25 (mean), power of 80%, assuming α .05.

Specifically, 29 female clinical participants and 36 non-clinical female participants have been included, with an average age and standard deviation of 19.8 years and 4.1 ds respectively for the first group, and 21 years and 2.4 ds for the second.

2.2 Procedure

Following the recruitment procedure, described above, participants completed the informed consent. Research involved the administration of standardized self-report tests through a special form and, subsequently, of an interview through online platforms, due to the global COVID-19 pandemic. The interview was carried out through an online meeting program and The Relational Anecdotical Protocol method of interviewing was used. This method of interviewing is similar to that of a psychotherapy session transcript analysis, which offers a broad scope of in the study of narratives [40-41]. The administration of the measures took place in similar settings for all groups- individually, with a qualified and experienced psychologist. The audio-recorded interviews were transcribed following specific procedures for the Italian version of the Discourse Attributes Analysis Program (DAAP) [42] for the computerized application of the RP linguistic measures. The protocol has been approved by the Department Ethics Committee, where the study was developed.

2.3 Measures

The research consisted of different questionnaires, including the following:

-Socio-demographic questionnaire: a demographic sheet that contains questions regarding gender, age, level of education, marital status, family of origin, current occupation, and whether the individual is currently in psychotherapy and/or receiving pharmacological treatment;

- Profile of Mood of State -POMS [43-44] is a self-report psychological measure of mood states consisting

of a 65-item mood adjective checklist in which each adjective is scored from 0 (absent) to 4 (very much), based on how well each item describes the respondent's mood during a specified time frame (during the past week, including today). Following the standard scoring method for the Italian population, six mood scales are derived: tension-anxiety, depression-dejection, anger-hostility, vigor activity, fatigue-inertia, and confusion-bewilderment. A higher score denotes a higher level of a certain emotion.

- Toronto Alexithymia Scale – TAS-20 [45] a questionnaire that evaluates the presence of clinical or non-clinical alexithymia, and therefore identifies the subjects most at risk of pathology. Three factors emerge from the factor analysis, which correspond closely to the construct: Difficulty in identifying feelings (DIS) and distinguishing between emotions and bodily sensations; and Difficulty in describing feelings (DDS);

- Emotion Regulation Questionnaire -ERQ [46-47]: a self-report questionnaire that includes 10 items and contains two scales corresponding to two different strategies of emotional regulation: cognitive restructuring and repression of the response;

- Linguistic measures of the Referential Process: (see Table 1)

Computerized language measures have been applied to the transcripts of the interviews of the referential process, according to the Multiple Code Theory to which we refer [25]. The following dimensions were used on the narratives and were later coded with support of the IDAAP software (Italian Discourse Attributes Analysis Program) [48], the Italian version of the DAAP [49]. IDAAP is a computerized software that compares any type of text with sets of words by assigning a specific weight, in order to indicate its frequency, compared with specific dictionaries. It allows for the measurement of the emotional intensity of the speech and how much the speaker is connected with the experience they are talking about. These measures are applied for each speaker and for each verbal shift.

The measures used are listed below:

- Italian Weighted Referential Activity Dictionary IWRAD [48] is a list of 9596 frequently used linguistic elements. In addition to ordinary words and contraction parts, the dictionary contains words with a high-frequency function, such as articles, pronouns, and prepositions that are aspects of the generative function of language, usually used without specific intent. IWRAD evaluates language style rather than content, represents unintended aspects of emotional expression, and provides microanalytic tracking of Symbolizing fluctuations within various forms of communicative speech. For a deeper discussion on the method of building a weighted dictionary like IWRAD, see [49].

- The Italian Mean High Weighted Referential Activity Dictionary (MH-IWRAD) is a variable that is calculated using IWRAD scores. It is defined as the Referential Activity Intensity Index, essentially a measure of high intensity of emotional engagement emerging from speech [48]. It indicates the amount by which the IWRAD exceeds the neutral value of 0.5. It is obtained by looking only at the words with IWRAD scores lying above the neutral value and then computing, for only those words, the average IWRAD scores. This is perhaps best understood as a measure of upward oscillations in RA scores.

- The Italian DisFluency Dictionary (IDFD) is a small set of words as well as repeated words, incomplete words, and filled pauses that people tend to use when struggling to communicate [50]. A score on this index corresponds to the proportion of IDFD words present in the speech. High scores typically characterize the arousal phase in which emotional schemas are activating.

- Italian Reflection Dictionary (IREF) [48], a dictionary that contains words about the way people think and communicate thoughts. It includes basic logical words and elements that refer to cognitive, logical, or impaired functions. These elements will probably dominate in the reorganization phase.

- The Italian Sensory Somatic Dictionary (ISensD) is a list of Italian words related to the body and bodily activities, and to sensory processes and/or descriptions of symptoms [29]. The number of ISensD words in a speech sample is a measure of the arousal of bodily, sub-symbolic aspects of emotion schemas.

- The Italian Sum Affect Dictionary (ISAffD) [48] contains Italian words concerning how people feel and communicate feelings directly. It includes emotion labels, functions associated with affective arousal, and words indicating an emotional response, either positive or negative. ISAffD consists of three sub-dictionaries related to domains of affect: positive affect (IPAffD), negative affect (INAffD), neutral affect without a specific valence (IZAffD)

- The Relationship Anecdotal Paradigm (RAP) [51] Interviewees are presented with the following prompt, “Please tell me some incidents or events about an interaction between yourself in relation to another person” (Luborsky, 1998, p. 110), specifying when it occurred, with whom it occurred, something about what the other person said or did, and what happened in the end. Interviewees are asked to tell between 6 to 10 relationship episodes and are free to describe any incidents about any person. Evidence for the validity of the RAP was provided by Barber, Luborsky, Crits-Christoph, & Diguer [52].

Statistical Analysis

All statistical analyses were performed using the Statistical Package for Social Science version 26 (SPSS version 25). Data is reported as means and standard deviations for continuous variables and as percentages for discrete variables. Student’s t- and Chi-square tests were performed in order to evaluate the homogeneity of the two groups respectively for continuous and discrete variables. The t-test for paired samples was applied to explore differences between two groups for all measures applied and a Cohen’s D effect size was performed. A logistic binary regression predicting clinical and non-clinical groups was performed, using specific linguistic variables as independent variables.

The comparison of the two groups highlighted the following results. With respect to socio-demographic characteristics, the two groups can be considered homogeneous; no significant differences in age and education emerge. In regards to the first hypothesis of the study, the findings which emerged (Table 2) showed that the results for ERQ, TAS-20 and POMS are significantly different. This result highlights that individuals with AN show greater emotional dysregulation, specifically higher emotional expression and suppression, and lower levels of functional cognitive strategies. Individuals with AN show higher levels of significant alexithymia than the control group, but also compared to the cut-off > 60, the AN alexithymia mean is higher than the cut-off. The sub-factor outward-oriented thinking is the only result that is not significant. The assessment of mood states measured by the POMS shows significant differences in all subfactors except for the fatigue factor. The second hypothesis of the study is also confirmed and the linguistic analysis shows a significantly greater use of sensory-somatic words in the AN group. Regarding the symbolic narrative properties of AN patients, there is a specific difference in the narrative characteristics. AN patients have a significantly higher use of words connoted with negative affect, and fewer words connoted with positive affect. They also show a significant dysregulation process showing higher RA intensity index (MH-IWRAD). To investigate possible predictors of an AN clinical group, a logistic binary regression was performed using the clinical group as a dependent variable, as well as linguistic measures, such as Sensory-Somatic, Negative Affects, and the RA Intensity Index. The model accounted for 35% (R2 = .349; χ2 = 27,929; df = 3; p = .001) of the criterion variable (clinical group). In particular, the model showed a significant predictive effect on the AN group of Sensory-Somatic (B = 85,099; df = 1; p = .039), Negative Affect (B=132,202; df=1; p=.011), and Intensity Index (MH-IWRAD; B= 322,410; df=1; p=.029).

Starting from the first hypothesis of this work, we found a significant presence of emotional dysregulation in the AN group, for all the factors explored utilizing cognitive emotional regulation strategies. Further confirmation of the use of dysfunctional strategies related to food control is provided by the presence of significant alexithymia in patients with AN. The presence of very high values in all the POMS scales also highlight the great presence of a difficult connotation of the affects and, consequently a greater emotional conflict than in the control group. Differences in the linguistic measures of the RP in autobiographical narratives were also significant. This element confirmed the Mariani et al. study [37] which highlights how language features can be a direct expression of psychopathology. Characteristics specific to acute AN emerged in this study. Three linguistic indices are more related to this disorder than others: the sensory-somatic words, the prevalence of negative affect descriptions and less positive words, and the RP dysregulation index indicated by the RA Intensity Index. All these results show a direct relationship between the difficulties in staying in contact with the emotional world, which involves the use of acted behaviors to express dysfunctional emotional schemas [28]. The AN patients, in an acute phase, express their dysfunctional emotional regulation rising symptoms. The linguistic analysis pointed out a good predisposition to narrate autobiographical experiences, however the narrative process showed an overwhelmed feelings process. That pattern should be taken into consideration to help patients with AN integrate memories and autobiographical experiences.

The second aim was to investigate if the linguistic factors had been hypothesized as predictive indicators of the clinical group. The results confirmed that the sensory-somatic and affect dictionaries, together with the RA Intensity Index, can predict the clinical group.

These results show coherent implication to MCT and specific theoretical implications which can be applied to eating disorder symptoms. AN could be seen in terms of attempting to organize emotional experiences. The food and body control could be a first process of symbolization, as a proto-symbol, of negative internal experience. In other words, the body is utilized as the only possible vehicle of expression and therefore, it becomes the first element of recognized emotional conflict. Therefore, dysregulated eating behaviors would represent significant modes of expression that would assume the role of transitional symbol: the somatization conditions that the patients experience constitute the first discrete entities available which are able to allow the entry of the schema, in the symbolic domain. Food rituals represent a means of self-care for the regulation of unpleasant emotional states and other aspects of oneself. Eating behaviors, with an illusion of necessity, contain the emotional experience, and reinforce the sense of inviolability and psychological integrity, to the point of becoming a compulsive defense mechanism aimed at regulating intolerable states of tension [53–56]. The latter, being expressed immediately through motor and somatic channels, would give rise to the maladaptive modalities of affective regulation

These findings suggest that the introduction of linguistic measures in the phases of assessment of patients in the acute phase for symptoms related to AN can facilitate the diagnosis and also, the processes of emotional and verbal connection. The results show that the symptom of food and body control is an attempt to regulate the difficult emotional process experienced by patients. The possibility of developing an autobiographical process of self-narration in the very early stages of treatment facilitates the understanding of the disorder itself. Narrative processes and symptoms are two sides of the same coin and can provide useful elements to enhance the healing process. To better show these findings, we show a clinical vignette from the autobiographical narratives:

Clinical example: High Somatic Sense, High Negative Affect, High RA index

At school the only thing that I will never forget [360,8,15,1], it happened that I had a pseudo panic attack [370,18,15,1], we were doing religion and at a certain [380,28,15,1] point I had kind of a detachment from my head [390,38,15,1], from- with the mind and body and practically I have [400,48,15, 1] started screaming in panic, I (I know) felt terrible [410,58,15,1] and I remember that then they called like the ambulance […] I began to stay bad from [450,98,15,1] we were all put in a circle around the desk [490,14,19,1], I don't remember what the teacher was talking about, of [500,24,19,1] which argument, I was listening, then at a certain point [510,34,19,1] I began to feel entire distant voices [520,44,19,1] of the speaker and I remember that I closed my eyes for a moment [530,54,19,1] and then when I opened them again, yes [540,64,19, 1] it was all upside down, that is, everything was spinning, as I no longer felt [550,74,19,1] my body, as if I were no longer inside [560,84,19,1] myself.

These findings are consistent with other studies (57) which suggest how to develop more effective physician–patient dialogues regarding eating behaviors, in general, which may be beneficial in treatment. Conversations should highlight the AN diagnostic criterion, assessment of patients’ emotions and sense of lack of control, and the relationship between body weight and AN.

Our work tries to explore innovative aspects in the treatment of Anorexia Nervosa, such as language in relation to emotional regulation. However, it is necessary to highlight the limitations of our study, such as the sample size which will be progressively increased to confirm the data obtained. Furthermore, it would be useful to be able to better differentiate the processes concerning restrictive AN with other eating disorders. In the future, we also intend to refine the diagnostic evaluation by relating it to other comorbid phenomena and personality disorders, because they, too, can have an impact in the management of acute conditions.

Author Contributions

“All authors contributed to the study conception and design. Material preparation, data collection was performed by Mariani Rachele, Marini Isabella, the dataset was performed by Catena Carlotta, Patino Francesca, Riccioni Raffaele and analysis were performed by Mariani Rachele and Di Trani Michela. The first draft of the manuscript was written by Mariani Rachele and Marini Isabella. All authors commented on previous versions of the manuscript, the supervision of all work was performed by Pasquini Massimo. All authors read and approved the final manuscript.”

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Sapienza of Rome prot.n. 1205 of 15/12/2020

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Table 1

Examples of words belonging to Italian linguistic measures of the Referential Process

IWRAD high weight: odore (smell = 0.981); maledetto (damned = 0.890); urla (scream = 0.835); stupore (astonishment = 0.786); baciare (to kiss = 0.747);

IWRAD medium weight: il (the = 0.058); capisci (you understand = 0.0314); io (I = 0.018); lei (she = 0.008), ciò (that = -0.011); tu (you = -0.042)

IWRAD low weight: superficiali (superficial = -0.870); parlavamo (we talked = -0.870); ansiosa (anxious = -0.867); capiscono (they understand = -0.654); carini (nice = -0.519)

IRefD: Attenzione (attention), capire (to understand), decisione (decision), dubbio (doubt), meditare (to meditate), ragione (reason), razionalità (rationality), ricordo (memory).

IDFD: Quindi (so), cioè (that is), comunque (however), allora (then), insomma (well), niente (nothing), magari (maybe), vabbè (don’t care), boh (don’t know), and ‘ehmm’ and ‘mm’ representing filled pauses with slightly different significance.

ISenSD: Ammalato (sick), digerire (digest), disorientamento (disorientation), dolore (pain), impotente (impotent), innervosito (unnerved), pesare (weigh), ridere (laugh), sintomi (symptoms), vomitare (throw up).

INAffD: Abbandonato (abandoned), depresso (depressed), impaurito (frightened), invidioso (envious), malinconia (gloom), odio (hate), sofferenza(suffering).

IPAffD: Abbracci (hugs), affidabile (reliable), baciare (to kiss), felice (happy), innamorato (in love), speranza (hope).

IZAffD: Attesa (expectation), bisogno (need), coinvolto (involved), eccitato (excited) intensità (intensity), motivazione (motivation), reagire (react), sensazione (feeling).

ISAffD: Sum of all Positive, Negative, Neutral Affect Dictionaries as global affect list

Note: IWRAD = Italian Weighted Referential Activity Dictionary; IRefD = Italian Reflection Dictionary; IDFD = Italian Disfluency Dictionary; ISenSD = Italian Sensory-Somatic Dictionary; ISAffD, IPAffD, INAffD, IZAffD = Italian Dictionary of respectively Sum, Positive, Negative, Neutral (Z) Affects.

Table 2

Two sample independent t-test on the Emotional Regulation (ERQ), Mood States (POMS), Alexithymia (TAS-20):

	AN Group (N. 29)		Control Group (N. 36)
	M	Sd	M	Sd	T(gf.63)		p	D-Cohen effect size
ERQ Cognitive	20.59	5.828	25.53	4.601	-3.821		0.000	-0.841
ERQ Expressive	18.55	5.262	12.56	5.485	4.461		0.000	0.956

POMS - Tension	20.69	7.947	13.89	9.029	3.182		0.002	0.722
POMS - Depression	30.83	13.957	14.42	13.793	4.743		0.000	0.956
POMS – Anger	19.17	11.311	12.78	11.931	2.198		0.032	0.523
POMS – Vigour	11.17	6.709	17.08	6.959	-3.459	0.001		-0.769
POMS - Fatigue	13.41	7.291	10.33	7.111	1.724	0.090		0.400
POMS - Confusion	16.07	6.771	10.25	5.331	3.878	0.000		0.846
POMS GLOBAL	89.00	46.297	44.58	41.910	4.054	0.000		0.886
TAS-20 DIF	25.38	6.264	15.89	5.908	6.267	0.000		1.233
TAS-20 DDF	19.55	4.641	14.06	5.297	4.391	0.000		0.954
TAS-20 EOT	17.10	3.416	15.72	4.314	1.405	0.165		0.337
TAS-20 TOT	62.03	11.372	45.67	11.556	5.717	0.000		1.158
Note: TAS-20 DIF: Difficulty identifying feelings; TAS-20 DDF: Difficulty describing feelings; TAS-20 EOT: Outward-oriented thinking

Table 3

Two sample independent t-test on RP the linguistic measures

	ED group N.29		Control Group N.36
	M	Sd	M	Sd	T (gf.63)	p	D-Cohen effect size

IDFD	0.1021	0.0311	0.0921	0.0229	1.484	0.143	0.367
INAffD	0.0156	0.0065	0.0111	0.0041	3.368	0.001	0.779
IPAffD	0.0163	0.0059	0.0131	0.0048	2.383	0.020	0.573
IZAffD	0.0044	0.0023	0.0045	0.0020	-0.329	0.743	-0.082
ISAffD	0.0364	0.0058	0.0289	0.0070	4.641	0.000	1.007
ISenSD	0.0443	0.0103	0.0354	0.0071	4.115	0.000	0.918
IRefD	0.0320	0.0087	0.0329	0.0095	-0.407	0.685	-0.102
IWRAD	0.5140	0.0033	0.5015	0.0026	1.897	0.042	0.463
MH-IWRAD	0.0103	0.0022	0.0083	0.0017	2.725	0.008	0.648

Note: IDFD = Italian Disfluency Dictionary; ISAffD, IPAffD, INAffD, IZAffD = Italian Dictionary of respectively Sum, Positive, Negative, neutral (Z) Affects; ISenSD = Italian Sensory-Somatic; IRefD = Italian Reflection Dictionary; Dictionary; IWRAD= Italian Weighted Referential Activity Dictionary; MH-IWRAD= Italian Referential Activity Intensity Index;

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Autobiographical narratives in relation to affect regulation in an Italian sample of patients in an acute phase of Anorexia Nervosa

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Conclusions

Clinical example: High Somatic Sense, High Negative Affect, High RA index

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