Résumés
Résumé
Même si l’association entre l’alexithymie et les troubles de la conduite alimentaire (TCA) est établie, on comprend mal comment une personne en vient à développer des traits de personnalité alexithymiques qui, à leur tour, prédisent les TCA. En s’inspirant de modèles psychanalytiques, cette étude approfondit les connaissances actuelles en testant deux stratégies de régulation émotionnelle comme prédicteurs de cette relation: la suppression expressive et la réévaluation cognitive. Il était attendu que la suppression constante d’une émotion prédise positivement les traits alexithymiques (indicateur de dérégulation émotionnelle), qui à leur tour, prédiraient positivement les symptômes TCA. Inversement, il était suggéré que l’usage de la réévaluation cognitive prédise négativement les traits alexithymiques et donc les symptômes TCA. Les séquences hypothétiques ont été confirmées.
Mots-clés :
- trouble de la conduite alimentaire,
- alexithymie,
- suppression expressive,
- réévaluation cognitive,
- dérégulation émotionnelle
Abstract
The association between alexithymia and eating disorders is now well established. However, the precursors to such an association are not well known. Based on a series of psychoanalytic models, this study attempts to deepen current knowledge by testing the role of two emotion regulation strategies (expressive suppression and cognitive reappraisal) as predictors of this relationship. It is proposed that the constant suppression of emotions, will predict alexithymia personality traits, witch favours emotion dysregulation and thus eating disorder symptoms. Inversely, the use of cognitive reappraisal would negatively predict alexithymic personality traits, which would negatively predict ED symptoms. The hypothetical sequences were confirmed.
Keywords:
- eating disorder,
- alexithymia,
- expressive suppression,
- cognitive reappraisal,
- emotion dysregulation
Parties annexes
Bibliographie
- Ackard, D. M., Croll, J. K. et Kearney-Cooke, A. (2002). Dieting frequency among college females : Association with disordered eating, body image, and related psychological problems. Journal of Psychosomatic research, 52(3), 129-136.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders DSM-5 (5e éd.). Arlington, VA : American Psychiatric Publishing.
- American Psychiatric Association. (2014). Eating disorders. Repéré à http://www.psychiatry.org/eating-disorders
- Anorexie et boulimie Québec. (2013). Les troubles alimentaires. Repéré à http://www.psychiatry.org/eating-disorders
- Archinard, M., Rouget, P., Painot, D. et Liengme, C. (1994). Inventaire des troubles alimentaires 2. Dans M. Bouvard et J. Cottraux (dir.), Protocoles et échelles d’évaluation en psychiatrie et en psychologie (5e éd., p. 284-287). Paris, France : Masson
- Bagby, R. M., Parker, J. D. et Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38(1), 23-32.
- Bagby, R. M. et Taylor, G. J. (1997). Affect dysregulation and alexithymia. Dans G. J. Taylor, R. M. Bagby, J. D. A. Parker (dir.), Disorders of affect regulation: Alexithymia in medical and psychiatric illness (p. 26-45). Cambridge, Angleterre : University Press.
- Baron, R. M. et Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research : Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173-1182.
- Bateman, A. W. et Fonagy, P. (2004). Mentalization-based treatment of BPD. Journal of Personality Disorders, 18(1), 36-51.
- Bateman, A. et Fonagy, P. (2006). Mentalization-based treatment for borderline personality disorder: A practical guide. Oxford, Royaume-Uni : Oxford University Press
- Bateman, A. et Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9(1), 11-15.
- Baumeister, R. F., Bratslavsky, E., Muraven, M. et Tice, D. M. (1998). Ego depletion: is the active self a limited resource. Journal of Personality and Social Psychology, 74(5), 1252-1265.
- Bourke, M. P., Taylor, G. J., Parker, J. D. et Bagby, R. M. (1992). Alexithymia in women with anorexia nervosa : A preliminary investigation. The British Journal of Psychiatry, 161(2), 240-243.
- Brauer, M. (2000). L'identification des processus médiateurs dans a recherche en psychologie. L'Année psychologique, 100(4), 661-681.
- Brockmeyer, T., Bents, H., Holtforth, M. G., Pfeiffer, N., Herzog, W. et Friederich, H.-C. (2012). Specific emotion regulation impairments in major depression and anorexia nervosa. Psychiatry Research, 200(2), 550–553.
- Brockmeyer, T., Skunde, M., Wu, M., Bresslein, E., Rudofsky, G., Herzog, W. et Friederich, H.-C. (2014). Difficulties in emotion regulation across the spectrum of eating disorders. Comprehensive Psychiatry, 55(3), 1-7.
- Bruch, H. (1985). Four decades of eating disorders. Dans D. M. Garner et P. E. Garfinkel (dir.), Handbook of psychotherapy for anorexia nervosa and bulimia (p. 7-18). New-York, NY : The Guilford Press
- Bucci, W. (1997). Symptoms and symbols: A multiple code theory of somatization. Psychoanalytic Inquiry, 17(2), 151-172.
- Byrne N, Ditto B, Silverman C. (1999, juin). Alexithymia and autonomic reactivity to emotion- inducing films. Affiche présentée à the second international conference on the (non)expression of emotions in health and disease, Tilburg.
- Carter, J. C., Blackmore, E., Sutandar-Pinnock, K. et Woodside, D. B. (2004). Relapse in anorexia nervosa: a survival analysis. Psychological Medicine, 34(4), 671-679.
- Chavez, M. et Insel, T. R. (2007). Eating disorders: National Institute of Mental Health's perspective. American Psychologist, 62(3), 671-679.
- Christophe, V., Antoine, P., Leroy, T. et Delelis, G. (2009). Évaluation de deux stratégies de régulation émotionnelle : la suppression expressive et la réévaluation cognitive. Revue Européenne de Psychologie Appliquée/European Review of Applied Psychology, 59(1), 59-67.
- Cochrane, C. E., Brewerton, T. D., Wilson, D. B. et Elizabeth, L. H. (1993). Alexithymia in the Eating Disorders. International Journal of Eating Disorders, 14(2). 219-222
- Cohen, J. et Kingston, W. (1984). Repression theory: A new look at the cornerstone. International Journal of Psychoanalysis, 65, 411-422.
- Corcos, M., Guilbaud, O., Speranza, M., Paterniti, S., Loas, G., Philippe, S. et Jeammet, P. (2000). Alexithymia and depression in eating disorders. Psychiatry Research, 93(3), 263-266.
- Corcos, M., Pirlot, G. et Loas, G. (2011). Qu'est-ce que l'alexithymie? Paris, France : Dunod.
- Corcos, M. et Speranza M. (2003). Psychopathologie de l’alexithymie. Paris, France : Dunod.
- Crow, S. J., Stewart Agras, W., Halmi, K., Mitchell, J. E. et Kraemer, H. C. (2002). Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: A multicenter study. International Journal of Eating Disorders, 32(3), 309-318.
- Danner, U. N., Sternheim, L. et Evers, C. (2014). The importance of distinguishing between the different eating disorders (sub)types when assessing emotion regulation strategies. Psychiatry Research, 215(3) 1–6.
- de Groot, J. M., Rodin, G. et Olmsted, M. P. (1995). Alexithymia, depression, and treatment outcome in bulimia nervosa. Comprehensive Psychiatry, 36(1), 53–60.
- Dodge K. A., Garber J. (1991). Domains of emotion regulation. Dans J. Garber et K. A. Dodge (dir.), The development of emotion regulation and dysregulation (p. 3-11). Cambridge, Angleterre : Cambridge University Press.
- Dorpat, T. L. (1985). Denial and defense in the therapeutic situation. New-York, NY : Jason Aronson.
- Douglas Institut Universitaire en Santé Mentale. (2013). Troubles de l’alimentation : causes et symptômes. Repéré à http://www.douglas.qc.ca/info/troubles-alimentation
- El Akremi, A. et Roussel, P. (2003). Analyse des variables modératrices et médiatrices par les méthodes d’équations structurelles: applications en GRH. Dans Actes de la 10e conférence de l'Association française de gestion des ressources humaines (p. 1063-1096). Grenoble, France.
- Fairburn, C. G., Cooper, Z., Doll, H. A. et Davies, B. A. (2005). Identifying dieters who will develop an eating disorder: a prospective, population-based study. American Journal of Psychiatry, 162(12), 2249-2255.
- Fairburn, C. G. et Harrison, P. J. (2003). Eating disorders. The Lancet, 361(9355), 407-416.
- Garfinkel, P. E., Lin, E., Goering, P., Spegg, C., Goldbloom, D. S., Kennedy, S., ... et Woodside, D. B. (1995). Bulimia nervosa in a Canadian community sample: Prevalence and comparison of subgroups. American Journal of Psychiatry, 152(7), 1052-1058.
- Garner, D. M. (1991). Eating Disorder Inventory - 2 Professional Manual. Lutz, FL : Psychological Assessment Ressources, Inc.
- Grabe, H. J., Spitzer, C. et Freyberger, H. J. (2001). Alexithymia and the temperament and character model of personality. Psychotherapy and Psychosomatics, 70(5), 261-267.
- Greenberg, S. J. (1997). Alexithymia in an anorexic population: Prevalence and predictive variables. (Thèse de doctorat, Pace University, New York). Repéré à https://digitalcommons.pace.edu/dissertations/AAI9801921
- Gross, J. J. (1998). Antecedent-and response-focused emotion regulation : divergent consequences for experience, expression, and physiology. Journal of personality and social psychology, 74(1), 224-237.
- Gross, J. J. et John, O. P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348-362.
- Gutzwiller, J., Oliver, J. M. et Katz, B. M. (2003). Eating dysfunctions in college women: The roles of depression and attachment to fathers. Journal of American College Health, 52(1), 27-32.
- Harrison, A., Sullivan, S., Tchanturia, K. et Treasure, J. (2010). Emotional functioning in eating disorders: Attentional bias, emotion recognition and emotion regulation. Psychological Medicine, 40(11), 1887-1897.
- Hayes, S. C., Strosahl, K. D. et Wilson, K. G. (2002). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press.
- Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach (2e éd.). New York, NY: Guilford Press.
- Hayes, A. F., Preacher, K. J. et Myers, T. A. (2011). Mediation and the estimation of indirect effects in political communication research. Sourcebook for Political Communication Research: Methods, Measures, and Analytical Techniques, 23, 434-465.
- Haynos, A. F., Roberto, C. A., Martinez, M. A., Attia, E. et Fruzzetti, A. E. (2014). Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration. International Journal of Eating Disorders, 47(8), 888-891.
- Heatherton, T. F., Mahamedi, F., Striepe, M., Field, A. E. et Keel, P. (1997). A 10-year longitudinal study of body weight, dieting, and eating disorder symptoms. Journal of Abnormal Psychology, 106(1), 117-125.
- Herzog, D. B., Dorer, D. J., Keel, P. K., Selwyn, S. E., Ekeblad, E. R., Flores, A. T., … Keller, M.D. (1999). Recovery and relapse in anorexia and bulimia nervosa : A 7.5-Year Follow-up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 38(7), 829–837.
- Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C. et Agras, W. S. (2004). Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130(1), 19.
- Juarascio, A. S., Forman, E. M. et Herbert, J. D. (2010). Acceptance and commitment therapy versus cognitive therapy for the treatment of comorbid eating pathology. Behavior Modification, 34(2), 175-190.
- Keel, P. K., Haedt, A. et Edler, C. (2005). Purging disorder: An ominous variant of bulimia nervosa. International Journal of Eating Disorders, 38(3), 191-199.
- Kennedy, M. et Franklin, J. (2002). Skills-based treatment for alexithymia: An exploratory case series. Behaviour Change, 19(3), 158-171.
- Kenny, D. A., Kashy, D. A. et Bolger, N. (1998). Data analysis in social psychology. Dans D. Gilbert, S. Fiske et G. Lindzey (dir.), The handbook of social psychology (4e éd., vol. 1, p. 233-265). Boston, MA: McGraw-Hill.
- Kojima, M. (2012). Alexithymia as a prognostic risk factor for health problems: a brief review of epidemiological studies. BioPsychoSocial Medicine, 6(1), 21.
- Krystal, H. (1979). Alexithymia and psychotherapy. American Journal of Psychotherapy, 33(1), 17-31.
- Krystal, H. (1988). Integration and Self-healing : Affect, Trauma, and Alexithymia. New-York, NY : Routledge
- Krystal, H. (1997). Desomatization and the consequences of infantile psychic trauma. Psychoanalytic Inquiry, 17(2), 126-150.
- Lane, R. D. et Schwartz, G. E. (1987). Levels of emotional awareness: A cognitive-developmental theory and its application to psychopathology. The American Journal of Psychiatry, 144(2), 133-143.
- Lane, R. D. et Schwartz, G. E. (1992). Levels of emotional awareness: Implications for psychotherapeutic integration. Journal of Psychotherapy Integration, 2(1), 1.
- Langs, R. (1973). The technique of psychoanalytic psychotherapy, the initial contact, theoretical framework, understanding the patient’s communications, the therapist’s interventions (vol. 1). New York, NY: Jason Aronson.
- Leweke, F., Leichsenring, F., Kruse, J. et Hermes, S. (2012). Is alexithymia associated with specific mental disorders. Psychopathology, 45(1), 22-28.
- Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder (vol. 51). New York, NY: Guilford Press.
- Lissek, S., Rabin, S. J., McDowell, D. J., Dvir, S., Bradford, D. E., Geraci, M., ... et Grillon, C. (2009). Impaired discriminative fear-conditioning resulting from elevated fear responding to learned safety cues among individuals with panic disorder. Behaviour Research and Therapy, 47(2), 111-118.
- Loas, G., Fremaux, D. et Marchand, M. P. (1995). Factorial analysis and internal consistency of the french version of the 20-item Toronto Alexithymia Scale (TAS-20)- Study on 183 Healthy-Subjects. L’Encéphale: Revue de psychiatrie clinique biologique et thérapeutique, 21(2), 117-122.
- Luminet, O., Bagby, R. M., Wagner, H., Taylor, G. J. et Parker, J. D. (1999). Relation between alexithymia and the five-factor model of personality: a facet-level analysis. Journal of Personality Assessment, 73(3), 345-358.
- Luminet, O. et Rimé, B. (1998, août). Assessing the empirical validity of alexithymia: its predictive value for various levels of emotional responding when exposed to an eliciting situation and when reevoking it verbally. Affiche présentée à the 10th conference of the International Society for Research of Emotion, Wuerzburg, Germany.
- Marty, P. (1990). La psychosomatique de l’adulte. Paris, France : Presses Universitaires de France.
- Mash, E. J. et Wolfe, D. A. (2010). Abnormal Child Psychology (4e éd.). Belmont, CA : Wadsworth
- Mathieu, J. E. et Taylor, S. R. (2006). Clarifying conditions and decision points for mediational type inferences in organizational behavior. Journal of Organizational Behavior, 27(8), 1031-1056.
- Mazzeo, S. E. et Espelage, D. L. (2002). Association between childhood physical and emotional abuse and disordered eating behaviors in female undergraduates: An investigation of the mediating role of alexithymia and depression. Journal of Counseling Psychology, 49(1), 86.
- McDougall, J. (1978). Plaidoyer pour une certaine anormalité. Paris, France : Gallimard.
- Milos, G., Spindler, A., Schnyder, U. et Fairburn, C. G. (2005). Instability of eating disorder diagnoses: prospective study. The British Journal of Psychiatry, 187(6), 573-578.
- Mond, J., Hay, P., Rodgers, B., Owen, C., Crosby, R. et Mitchell, J. (2006). Use of extreme weight control behaviors with and without binge eating in a community sample: Implications for the classification of bulimic-type eating disorders. International Journal of Eating Disorders, 39(4), 294-302.
- Mowrer, O. H. (1947). On the dual nature of learning—a reinterpretation of "conditioning" and "problem-solving." Harvard Educational Review, 17, 102-148.
- Muraven, M., Tice, D. M. et Baumeister, R. F. (1998). Self-control as a limited resource : Regulatory depletion patterns. Journal of Personality and Social Psychology, 74(3), 774-789.
- Neumark-Sztainer, D. R., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E. et van den Berg, P. A. (2007). Shared risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventive Medicine, 33(5), 359-369.
- Nielsuchowski, P. K. (2003). An examination of the interrelationship among interoceptive awareness, internal state awareness, and alexithymia. Dissertation Abstract International, 63(11), 5561B.
- Nowakowski, M. E., McFarlane, T. et Cassin, S. (2013). Alexithymia and eating disorders: a critical review of the literature. Journal of Eating Disorders, 1(21), 1-14.
- Patton, G. C., Johnson-Sabine, E., Wood, K., Mann, A. H. et Wakeling, A. (1990). Abnormal eating attitudes in London schoolgirls - a prospective epidemiological study: outcome at twelve month follow-up. Psychological Medicine, 20(2), 383-394.
- Preacher, K. J. et Hayes, A. F. (2008). Contemporaty approaches to assessing mediation in communication research. Dans A. Hayes, M. Slater et L.B. Snyder (dir.), The Sage sourcebook of advanced data analysis methods for communication research (p. 13-54). Thousand Oaks, CA : Sage.
- Racine, S. E. et Wildes, J. E. (2013). Emotion dysregulation and symptoms of anorexia nervosa: The unique roles of lack of emotional awareness and impulse control difficulties when upset. International Journal of Eating Disorders, 46(7), 713-720.
- Rathus, J. H. et Miller, A. L. (2014). DBT skills manual for adolescents. New York, NY : Guilford Publications.
- Richards, J. M. et Gross, J. J. (2000). Emotion regulation and memory : the cognitive costs of keeping one's cool. Journal of Personality and Social Psychology, 79(3), 410-424.
- Rosen, D. S. (2003). Eating disorders in children and young adolescents : etiology, classification, clinical features, and treatment. Adolescent Medicine Clinics, 14(1), 49-59.
- Saarijärvi, S., Salminen, J. K. et Toikka, T. (2006). Temporal stability of alexithymia over a five-year period in outpatients with major depression. Psychotherapy and psychosomatics, 75(2), 107-112.
- Salovey, P., Hsee, C. K. et Mayer, J. D. (1993). Emotional intelligence and the self-regulation of affect. Dans D. M. Wegner et J. W. Pennebaker (dir.), Century psychology series. Handbook of mental control (p. 258-277). Englewood Cliffs, NJ: Prentice-Hall, Inc.
- Salbach-Andrae, H., Bohnekamp, I., Klinkowski, N., Pfeiffer, E. et Lehmkuhl, U. (2008). Dialectical behavior therapy versus cognitive behavior therapy in the treatment of Anorexia and Bulimia Nervosa in adolescents. International Journal of Psychology, 43(3), 434-435.
- Salbach, H., Klinkowski, N., Pfeiffer, E., Lehmkuhl, U. et Korte, A. (2007). Dialectical behavior therapy for adolescents with anorexia and bulimia nervosa (DBT-AN/BN)--a pilot study. Praxis der Kinderpsychologie und Kinderpsychiatrie, 56(2), 91-108.
- Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, 98-109.
- Smink, F. R., Van Hoeken, D. et Hoek, H. W. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406-414.
- Spence, S. et Courbasson, C. (2012). The role of emotional dysregulation in concurrent eating disorders and substance use disorders. Eating Behaviors, 13(4), 382-385.
- Speranza, M., Loas, G., Wallier, J. et Corcos, M. (2007). Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. Journal of Psychosomatic Research, 63(4), 365–371.
- Stephenson, M. G., Levy, A. S., Sass, N. L. et McGarvey, W. E. (1987). 1985 NHIS findings: nutrition knowledge and baseline data for the weight-loss objectives. Public Health Reports, 102(1), 61.
- Stern, D. B. (2010). Partners in thought: Working with unformulated experience, dissociation, and enactment. (vol.12). New York, NY : Routledge.
- Stice, E., Marti, C. N., Spoor, S., Presnell, K. et Shaw, H. (2008). Dissonance and healthy weight eating disorder prevention programs: long-term effects from a randomized efficacy trial. Journal of Consulting and Clinical Psychology, 76(2), 329.
- Striegel-Moore, R. H., Seeley, J. R. et Lewinsohn, P. M. (2003). Psychosocial adjustment in young adulthood of women who experienced an eating disorder during adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 42(5), 587-593.
- Summers, R. F. et Barber, J. P. (2009). Psychodynamic therapy: A guide to evidence-based practice. New York, NY: Guilford Press.
- Svaldi, J., Griepenstroh, J., Tuschen-Caffier, B. et Ehring, T. (2012). Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Research, 197(1-2), 103-111.
- Swart, M., Kortekaas, R. et Aleman, A. (2009). Dealing with feelings : characterization of trait alexithymia on emotion regulation strategies and cognitive-emotional processing. PLoS One, 4(6), e5751.
- Swiller, H. I. (1988). Alexithymia: Treatment utilizing combined individual and group psychotherapy. International Journal of Group Psychotherapy, 38(1), 47-61.
- Tabachnick, B. G. et Fidell, L. S. (2013). Using Multivariate Statistics (6e éd.). New-York, NY : Pearson Education.
- Taylor, G. J., Bagby, R. M. et Parker, J. D. A. (1997). The development and regulation of affects. Dans G. J. Taylor, R. M. Bagby et J. D. A. Parker (dir.), Disorders of affect regulation (p. 7-25). Cambridge, Angleterre: Cambridge University Press.
- Taylor, G. J., Bagby, R. M. et Parker, J. D. (2016). What’s in the name ‘alexithymia’? A commentary on “Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy”. Neuroscience & Biobehavioral Reviews, 68, 1006-1020.
- Taylor, G. J., Parker, J. D., Bagby, R. M. et Bourke, M. P. (1996). Relationships between alexithymia and psychological characteristics associated with eating disorders. Journal of Psychosomatic Research, 41(6), 561-568.
- Taylor, G. J., Ryan, D. et Bagby, M. (1985). Toward the development of a new self-report alexithymia scale. Psychotherapy and Psychosomatics, 44(4), 191-199.
- Telch, C. F., Agras, W. S. et Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061.
- Van't Wout, M., Aleman, A., Bermond, B. et Kahn, R. S. (2007). No words for feelings: alexithymia in schizophrenia patients and first-degree relatives. Comprehensive psychiatry, 48(1), 27-33.
- Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134(2), 163.
- Weiner, I. B. et Bornstein, R. F. (2009). Principles of psychotherapy: Promoting evidence-based psychodynamic practice (3e éd.). Hoboken, NJ : Wiley.
- Wegner, D. M., Broome, A. et Blumberg, S. J. (1997). Ironic effects of trying to relax under stress. Behaviour Research and Therapy, 35(1), 11-21.
- Wenzlaff, R. M. et Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51(1), 59-91.