Problems with measuring alexithymia

Research evaluating the relationship of alexithymia to medical and psychiatric disorders has been compromised by the poor psychometric properties of the instruments that have been used to measure alexithymia. This study evaluated the psychometric properties of a recently introduced measure of alexithymia--the revised Schalling-Sifneos Personality Scale (SSPS-R). While the factor structure of the SSPS-R was found to be reasonably congruent with the theoretical domains of the alexithymia construct, the scale lacked homogeneity and internal reliability. These results are compared with the reliability and validity of other available measures of alexithymia. Recommendations are offered for the improved assessment of alexithymia in future research studies.

The alexithymia construct. A potential paradigm for psychosomatic medicine

During the past decade, the alexithymia construct has undergone theoretical refinement and empirical testing and has evolved into a potential new paradigm for understanding the influence of emotions and personality on physical illness and health. Like the traditional psychosomatic medicine paradigm, the alexithymia construct links susceptibility to disease with prolonged states of emotional arousal. But whereas the traditional paradigm emphasizes intrapsychic conflicts that are presumed to generate such emotional states, the alexithymia construct focuses attention on deficits in the cognitive processing of emotions, which remain undifferentiated and poorly regulated. This paper reviews the development and validation of the construct and discusses its clinical implications for psychosomatic medicine.

Reassessing the validity and reliability of the MMPI Alexithymia Scale

In the past decade, alexithymia has emerged as a heuristically useful personality construct used to explain the pathogenesis of a variety of physical illnesses, including classical psychosomatic diseases, somatization disorders, hypochondriasis, and somatoform pain disorders. Unfortunately, research evaluating the alexithymia construct has been conducted with little attention to assessing the psychometric properties of various scales used to measure it. In two separate studies, we examined various scale and item properties as well as the factor structure and validity of the Minnesota Multiphasic Personality Inventory Alexithymia Scale (MMPI-A), one of the most commonly used scales to assess alexithymia. In Study 1, the 22 items that comprise the MMPI-A were extracted from a computerized MMPI data bank which included separate samples of psychiatric inpatients and outpatients. Poor item-to-scale characteristics and only moderate levels of internal reliability were found for both samples. Factor analysis produced factors that were poorly related to the theoretical domains of the alexithymia construct. In Study 2, we found little support for validity of the scale as those patients identified as alexithymic and nonalexithymic by the MMPI-A did not differ on several theoretically relevant scales. These results question seriously the value of the MMPI-A in investigating the alexithymia construct.

The influence of aluminum on growth, carbohydrate, and organic acid content of an aluminum-tolerant and an aluminun-sensitive cultivar of wheat

An aluminum-sensitive cultivar (Katepwa) and an aluminum-tolerant experimental line (PT741) of Triticum aestivum were grown in nutrient solutions containing 0–400 μM aluminum at pH 4.5. After 18 days of growth, plant fresh weight was reduced in the Al-sensitive and Al-tolerant germ plasm by as little as 100 and 200 μM Al, respectively, and a number of changes in carbon allocation were observed. Shoot to root ratios increased with Al concentration in the Al-sensitive 'Katepwa' and remained constant in the Al-tolerant PT741.In both 'Katepwa' and PT741, shoot carbon was increasingly deposited into starch and fructan pools with increasing Al concentration. However, fructan deposition was more marked in the Al-sensitive 'Katepwa', possibly reflecting a failure to export carbon to the roots. Differences between Al-tolerant and Al-sensitive germ plasm were also observed in some organic acid levels. Contrary to several previous reports, higher concentrations of organic acids were found in the roots of Al-sensitive 'Katepwa'. In shoots, higher concentrations of organic acid were found in the Al-tolerant PT741. These results suggest that allocation of carbon to specific pools is affected by the concentration of Al. However, synthesis of organic acids and subsequent chelation of intracellular Al does not appear to represent a tolerance strategy in wheat. Observed changes in metabolic levels more likely represent a broad array of toxic lesions, with the magnitude of changes being greater in the Al-sensitive 'Katepwa' than in the Al-tolerant PT741. Key words: stress, aluminum tolerance, aluminum sensitivity, fructans.

Dimensional analysis of the MMPI Alexithymia scale

Recently, the alexithymia construct has emerged as a heuristically useful personality construct in the explanation of the pathogenesis of a variety of physical illnesses. Research that has evaluated the alexithymia construct, however, has been conducted with little attention to the psychometric properties of the various scales constructed to measure it. This study investigated the underlying dimensions and factor structure stability of the MMPI Alexithymia scale (MMPI-A). The MMPI-A was administered to 552 undergraduates, and the data then were split randomly into two samples. Factor analysis of both samples produced a three-factor solution with little theoretical relevancy to the alexithymia construct. Comparisons of the factor structures from the two samples revealed only moderate congruence, which indicates an unstable factor structure.

Kinetics of Aluminum Uptake in Triticum aestivum L: Identity of the Linear Phase of Aluminum Uptake by Excised Roots of Aluminum-Tolerant and Aluminum-Sensitive Cultivars

The identity of a linear phase of aluminum (Al) uptake in Triticum aestivum was investigated by analysis of the kinetics of Al uptake by excised roots and purified cell wall fractions. Classical interpretation of kinetic data suggests that a linear phase of uptake with time reflects uptake across the plasma membrane; however, in studies with Al the possibility that the linear phase of uptake includes accumulation of Al in both the symplasm and the apoplasm has not been discounted. In our experiments, we observed a linear phase of Al uptake at both ambient and low temperatures, although the rate of uptake at 0 degrees C was 53 to 72% less than at 23 degrees C, depending on cultivars. This nonsaturable phase of uptake at low temperature suggests that a portion of the linear phase of Al uptake is nonmetabolic. Furthermore, analysis of Al in cell wall fractions isolated from excised roots pretreated with Al suggests that the linear phase of uptake includes a cell wall component. When excised roots were pretreated with Al, accumulation of Al in purified cell wall material included a linear phase that could not be desorbed with a 30 minute wash in citrate. The rates of linear-phase accumulation of Al by cell wall material and cell contents were similar. In contrast, the linear phase of in vitro uptake of Al by purified cell wall material was completely desorbed by a 30 minute wash with citrate. These results suggest that the linear phase of Al uptake observed in excised roots of T. aestivum included metabolism-dependent binding of Al in apoplasm.

Perioperative wound infection in elective orthopaedic surgery

Between 1981 and 1987, 12,907 [corrected] consecutive open elective orthopaedic procedures were performed. The in-patient infection rate was 1.43%. There was a significantly greater risk of infection in revision total knee replacement (15.3%), ankle fusion (9.3%), subtalar fusion (5.8%), primary total knee replacement (5.7%), spinal fusion (5.7%) and revision total hip replacement (4.5%). Revision surgery carried approximately a threefold greater risk than primary procedures. Staphylococci were present in 83% of positive wound cultures. Infection rates varied among surgeons but when number and type of procedure were taken into account only two surgeons differed significantly from that expected. Patients undergoing spinal and hindfoot fusion suffered considerable morbidity as a consequence of wound infection. Antibiotic prophylaxis may be helpful in these procedures.

A preliminary investigation of alexithymia in men with psychoactive substance dependence

The prevalence of alexithymia in a group of newly abstinent male substance abusers (N = 44) was 50%. The alexithymic patients had significantly less ego strength and repressive defensive behavior and significantly higher levels of somatic complaints and general dysphoria.

Validation of the alexithymia construct: a measurement-based approach

Alexithymia is a hypothetical personality construct that has been associated with a variety of medical and psychiatric disorders. This article reviews a program of research evaluating the validity of the construct using a measurement-based, construct validation approach. For this purpose the Toronto Alexithymia Scale (TAS) was developed. In a series of studies the TAS demonstrated internal consistency, good test-retest reliability, and a stable factor structure theoretically congruent with the alexithymia construct. In separate tests of construct validity, the TAS correlated in a theoretically meaningful fashion with measures of other constructs. Criterion validity was supported by a study in which the TAS was able to discriminate between behavioural medicine outpatients designated as alexithymic and those designated as nonalexithymic on the basis of objectively rated structured interviews. In a normal adult sample, TAS scores were not related to sociodemographic variables or intelligence. These results provide considerable empirical support for the validity of the alexithymia construct. In addition, the TAS appears to be a psychometrically sound measure of alexithymia that may prove useful in testing the construct with psychiatric and medical patient populations.

Computerised arthrotomography of primary anterior dislocation of the shoulder

Computerised arthrotomography was performed on 33 patients four to six weeks after acute primary anterior dislocation of the shoulder. Seventeen patients were under, and 16 over 50 years of age. Damage to the anterior glenoidal labrum was seen in all the younger patients and in 75% of the older ones. A large redundant capsular pouch, seen in the older patients, was present in 35% of the younger ones, and a posterior humeral head defect was seen in 82% of the younger patients and only 50% of the older. Associated fractures were more common in the older patients, and a tear of the rotator cuff was demonstrated in 63% of the older patients and in none of the younger ones.

Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications

This is a prospective study of 500 consecutive patients having coronary artery bypass surgery; mean hospital charge from time of surgery to discharge was +11,900 +/- 12,700. Multiple regression analysis was performed using preoperative variables and postoperative complications. No preoperative clinical feature was a significant predictor of higher average charge. Sternal wound infection (p = 0.0001), respiratory failure (p = 0.0001) and left ventricular failure (p = 0.017) were associated with higher average hospital charge. The absence of any complication predicted a lower average charge, and postoperative death (4.4 +/- 4.5 days after surgery) was also associated with lower average charge. A cost equation was developed: hospital charge equalled $11,217 + $41,559 of sternal wound infection, + $28,756 for respiratory failure, + $5,186 for left ventricular failure, - $1,798 for no complication and - $6,019 for death. Recognition of the influence of complications on charges suggests that low average charges can only be achieved by surgical programs with a low complication rate.

The primary care physician and thrombolytic therapy for acute myocardial infarction: comparison of intravenous streptokinase in community hospitals and the tertiary referral center

From September 1982 through December 1987, 1012 patients were treated with intravenous streptokinase within 6 hours of acute myocardial infarction. Most of them (816/1012, 81 percent) were treated in community hospitals by primary care physicians. The remaining 196 (19 percent) were treated in the referral center, usually by a cardiologist. Cardiac catheterization within 2 days showed an open infarct artery in 87 percent of the community hospital and 83 percent of the referral center patients (P = NS). Predischarge ejection fraction was similar for community hospital and referral center patients (49 percent +/- 14 percent versus 51 percent +/- 14 percent, respectively), and there was a similar rate of bleeding complications (10 percent versus 13 percent, respectively). We conclude that primary physicians can use intravenous streptokinase effectively and safely in the treatment of patients in community hospitals.

Cross-validation of the factor structure of the Toronto Alexithymia Scale

The Toronto Alexithymia Scale (TAS) is a self-report measure of the alexithymia construct. In previous studies with college students, the TAS demonstrated excellent psychometric properties including a 4-factor structure theoretically congruent with the alexithymia construct. The present study attempted to cross-validate the factor structure of the TAS with samples of normal adults, psychiatric outpatients and college students. Congruence coefficients comparing the similarity of the factor structures for these three samples indicated good congruence for all four factors. The results provide further support for the validity of both the TAS and the alexithymia construct. In addition, the results provide evidence of the applicability of the scale to normal adult and clinical samples.

Kinetics of Aluminum Uptake by Excised Roots of Aluminum-Tolerant and Aluminum-Sensitive Cultivars of Triticum aestivum L

Uptake of aluminum (Al) by excised roots of two Al-tolerant cultivars and two Al-sensitive cultivars of Triticum aestivum L. (wheat) was biphasic, with a rapid phase of uptake in the first 30 minutes followed by a linear phase of uptake up to 180 minutes. At the end of the uptake period, higher concentrations of Al were found in roots of the Al-sensitive cultivars (Neepawa and Scout-66) than in the Al-tolerant cultivars (Atlas-66 and PT-741), but differences were small. Experiments testing the effectiveness of several desorption agents demonstrated that citric acid was most effective in desorption of loosely bound Al (the putative apoplasmic compartment) followed by others in the order tartaric acid > EDTA > CaSO(4) = ScCl(3). In all cultivars, 30 minutes of desorption with citric acid depleted the rapidly exchanging, putative apoplasmic compartment, although some tightly bound Al remained in that compartment. The relationship between Al remaining after desorption and time in the uptake medium was nearly linear and no distinction was observed between Al-tolerant and Al-sensitive cultivars. However, uptake of Al by the Al-tolerant cultivars was increased by treatment with the protonophore 2,4-dinitrophenol (DNP), while uptake of Al by Al-sensitive cultivars was relatively unaffected. Such results suggest the possible involvement of an active exclusion mechanism in Al-tolerant cultivars of T. aestivum.

The alexithymia construct: relationship with sociodemographic variables and intelligence

Conflicting results have been reported in studies examining the relationships between alexithymia and the variables of age, gender, social class, and intelligence. Moreover, these results are of dubious validity and generalizability because many of the studies used psychometrically poor scales to measure the alexithymia construct. The present study reexamined the relationships between alexithymia and sociodemographic variables and intelligence in a sample of normal adults using the Toronto Alexithymia Scale (TAS), a recently developed self-report measure with evidence of reliability and validity. The results indicate that alexithymia, as measured by the TAS, is not associated with age, gender, educational level, socioeconomic status, and intelligence.

Measurement of alexithymia. Recommendations for clinical practice and future research

The clinical assessment of alexithymia and research investigating its neurobiologic correlates require standardized assessment instruments. Observer-rated questionnaires, self-report scales, and projective techniques are currently available for measuring alexithymia, but most of these lack adequate reliability and validity. The Toronto Alexithymia Scale appears to have excellent psychometric properties, but a multimethod, multimeasure approach will enhance both measurement and further evaluation of the alexithymia construct.

Criterion validity of the Toronto Alexithymia Scale

The criterion validity of the Toronto Alexithymia Scale (TAS) was assessed by administering the scale to 46 patients referred to a behavioral medicine outpatient clinic. Clinical ratings derived from observed interviews served as the criterion. TAS scores were significantly higher for the group of patients identified by two out of three raters as "alexithymic" than for the group identified as "nonalexithymic." On the basis of these findings, preliminary TAS cutoff scores were suggested. The results from this study and from previous investigations assessing the reliability and construct validity of the TAS indicate that it is currently the psychometrically best-validated measure of alexithymia. Further refinement and cross-validation with other clinical samples are recommended.

Revascularization after thrombolytic therapy for acute myocardial infarction: an analysis of 573 patients

From October, 1981, to January, 1987, at our center, 891 patients received streptokinase within 6 hours of acute myocardial infarction. A total of 318 patients were treated medically, while 388 patients (43.5%) underwent coronary artery bypass grafting (CABG) alone and 185 (20.7%) were treated with percutaneous coronary angioplasty (PTCA). Subsequent CABG was performed in 37 of 185 PTCA patients after unsuccessful angioplasty. Group characteristics were similar. However, multiple-vessel coronary artery disease was present in 70.3% of CABG patients compared with 24.1% in the PTCA groups. Procedure mortality was 3.6% for CABG alone, 5.4% for PTCA alone, and 13.5% for the combined angioplasty and operation group (p less than 0.05 compared with CABG). All deaths in the PTCA group with subsequent CABG occurred in those patients taken emergently to CABG (5 of 20 patients). We conclude that with proper patient selection both forms of revascularization are safe and effective. However, emergency coronary bypass surgery in the event of failed angioplasty has a high risk.

Prognostic cardiac catheterization variables in survivors of acute myocardial infarction: a five year prospective study

The prognostic variables from predischarge coronary angiography and left ventriculography in survivors of acute myocardial infarction during the years 1974 to 1978 were evaluated in 143 patients (less than or equal to 66 years of age) with documented myocardial infarction who were then followed up prospectively for 5 years. One half of the study population had triple vessel coronary disease (greater than or equal to 50% stenosis). However, only 7% of patients had severely depressed left ventricular function with an ejection fraction less than or equal to 29%. Evaluation of the contribution of many clinical and angiographic variables to a first cardiac event (death, nonfatal reinfarction or coronary artery bypass surgery) was considered with Kaplan-Meier actuarial curves and multivariate Cox's hazard function analysis. A risk segment was defined as an area of contracting myocardium supplied by a coronary artery with a greater than 50% stenosis. Multivariate analysis demonstrated that right plus left anterior descending coronary artery stenoses (p less than 0.01), ejection fraction (p less than 0.01) and the presence of risk segments (p less than 0.05) were significant predictors of outcome. Furthermore, on separate multivariate analyses, the angiographic variables added significantly to the clinical variables to predict cardiac events over 5 years of follow-up. Therefore, in survivors of acute myocardial infarction who undergo cardiac catheterization, additive prognostic information is obtained that can be used to stratify risk over 5 years.

Construct validity of the Toronto Alexithymia Scale

Previous reports have documented the development of the Toronto Alexithymia Scale (TAS) in addition to evaluating its reliability and validity. The present paper describes two studies designed to further evaluate the construct validity of the TAS. In Study I 117 university students completed the TAS and the three subscales of the Short Imaginal Processes Inventory. In Study II 74 students completed the TAS and measures of ego strength, anger expression, and physical symptoms. In both studies the pattern of correlations between the TAS and the various psychological measures converged and diverged in a theoretically meaningful fashion, providing further evidence for the validity of the TAS and of the alexithymia construct.

Alexithymia: a comparative study of three self-report measures

This study evaluates and compares the psychometric properties of the three self-report measures of alexithymia - a hypothetical personality construct thought to be associated with hypochondriasis, somatization disorder and a variety of other medical and psychiatric disorders. Two hundred and nine college students were administered the Schalling-Sifneos Personality Scale (SSPS), MMPI alexithymia scale (MMPI-A), Toronto Alexithymia Scale (TAS), and two measures of functional somatic symptoms. Results indicated that the TAS is internally consistent and sensitive to reports of somatic symptoms. In contrast, the SSPS and MMPI-A were found to have response and/or gender biases, poor internal reliabilities, and no systematic relationship with somatic symptoms. In addition, factor analysis showed the TAS to have a stable, replicable factor structure, while the SSPS demonstrated little factor stability. These findings suggest that the TAS is the most psychometrically sound measure of the alexithymia construct.

Early and late results of operation after thrombolytic therapy for acute myocardial infarction

Recent reports have established the efficacy of thrombolytic therapy in limiting myocardial infarction. Between September 1981 and September 1984, 355 patients were treated with intracoronary (87) or intravenous (268) streptokinase within 6 hours of acute myocardial infarction. Thrombolysis was successful in 63% of patients receiving intracoronary streptokinase and 81% of those receiving intravenous streptokinase. Because residual critical stenosis is usually present and predisposes the patient to reinfarction, revascularization procedures were investigated as an extension of thrombolytic therapy. One hundred ninety-one patients aged 56 +/- 10 (25 to 77) years underwent early surgical revascularization 4.1 +/- 3.6 days after intracoronary or intravenous streptokinase for acute myocardial infarction. Results of this treatment were successful in 89% (170/191) of the patients. Thirteen patients (6.8%) underwent emergency coronary artery bypass grafting for failed percutaneous angioplasty. There were 3.2 +/- 1.4 grafts per patient and 3.8 +/- 2.9 units of blood were administered in the perioperative period. Operative mortality was 4.2% (8/191) with a 15.4% mortality (2/13) in the group in which angioplasty failed. Mean hospitalization time after operation was 10.9 +/- 6.8 days. Follow-up was 27 +/- 8 (12 to 48) months and was obtained on all patients. Late cardiac mortality was 1.0% (2/183). Ninety percent of the follow-up group was without angina and only 1.7% showed no improvement after operation. Reinfarction occurred in four patients (2.2%), with graft failure documented by coronary arteriography in two of these patients. This experience indicates that early revascularization after thrombolytic therapy may be performed with low operative mortality and morbidity and is associated with excellent late results.

Thrombolytic therapy followed by early revascularization for acute myocardial infarction

During a 24-month period, 192 patients with acute myocardial infarction were treated with intracoronary or intravenous streptokinase (SK). In 147 patients (77%) an open infarct artery was demonstrated by coronary angiography; 117 of these 147 patients were judged to have viable myocardium supplied by a critically narrowed coronary artery and underwent revascularization 3 +/- 2 days after SK therapy. In-hospital mortality was 6% (12 of 192). The mortality rate over the subsequent 20 +/- 7 months of follow-up was lower for those in whom SK therapy was successful (1 of 137, 0.7%) than in those in whom it was not (6 of 43, 14%) (p less than 0.001), and tended to be lower for those treated with intravenous (2 of 111, 2%) rather than intracoronary SK (5 of 69, 7%, p = 0.11). Reinfarction occurred in 3% of the 180 survivors of hospitalization, angina pectoris in 11% and congestive heart failure in 7%. Clinical outcome was similar for patients treated with intravenous and intracoronary SK and for patients treated in community hospitals and the referral center.

Prominence of the calcaneus: is operation justified?

Sixty-nine heels in 42 patients with prominence of the calcaneus sufficient to cause symptoms were operated upon after conservative treatment had failed. At review the overall results of operation were found to be poor.

Percutaneous transluminal coronary angioplasty as palliation for patients considered poor surgical candidates

Thirty-one patients with angina inadequately controlled by medical therapy, but who were poor surgical candidates because of advanced age and poor general condition, or because of depressed left ventricular function, had percutaneous transluminal coronary angioplasty (PTCA). These high-risk patients were identified prospectively, and coronary artery bypass surgery (CABS) was planned only in the event of arterial occlusion and chest pain. PTCA was successful in 11 of 17 (65%) high-risk geriatric patients, in 11 of 12 (92%) patients with left ventricular ejection fraction less than 40%, and in two additional patients having PTCA without surgical stand-by because of technically difficult vascular anatomy for CABS. There were no PTCA-related deaths; three of the 31 high-risk patients had emergency surgery because of arterial occlusion, and the remaining four patients with PTCA failure remain on medical therapy for angina. The clinical course of the 31 high-risk patients was similar to that of 155 patients having PTCA during the study period who were considered good candidates for either PTCA or CABS. PTCA may thus be considered an intermediate, palliative procedure for patients with inadequate control of ischemic symptoms who are poor surgical candidates.

Reliability of Q-wave formation and QRS score in predicting regional and global left ventricular performance in acute myocardial infarction with successful reperfusion

The frequency of electrocardiographic Q-wave formation and the relation of Q wave and QRS score to regional and global left ventricular (LV) performance were determined in 131 patients with acute myocardial infarction (AMI) receiving thrombolytic therapy. Thrombolytic therapy was successful in reperfusing the occluded infarct artery in 100 patients and was unsuccessful in 31. The number of patients who had 1 or more Q waves (88 vs 87%) and 2 or more Q waves (70 vs 74%) was similar. In contrast, normal wall motion was significantly more common in the infarct area in patients in whom reperfusion was successful (42 vs 15%, p less than 0.05). Total QRS scores were similar in patients in whom reperfusion was successful and in those in whom it was not (6.0 +/- 3.2 vs 6.4 +/- 4.2). Despite similar QRS scores, successfully treated patients had significantly higher LV ejection fraction (53 +/- 13% vs 46 +/- 15%, p less than 0.05). Thus, Q-wave formation after successful thrombolytic therapy for AMI is common but does not faithfully reflect regional or global LV performance. Electrocardiographic analysis alone is not a reliable method to assess efficacy of reperfusion therapy.

The role of the plaster bed after spinal fusion

Between 1974 and 1983, 40 patients underwent intertransverse lumbar fusion at the Royal Free Hospital, London. Nine of these were managed after operation on a plaster bed for 12 weeks and the rest were mobilized within 2 weeks. A satisfactory radiologic fusion rate of 75% was achieved in the first group and of 70% in the second group. There was no significant difference between these two groups, (chi 2 test). The results do not support the use of the plaster bed after lumbar fusion.

Toronto Alexithymia Scale: relationship with personality and psychopathology measures

The Toronto Alexithymia Scale (TAS) is a 26-item self-report measure of alexithymia with good internal consistency and test-retest reliability, and a factor structure congruent with the alexithymia construct. This study assesses the construct validity of the scale by examining its relationship with several personality and psychopathology measures. In a sample of 81 college students, the TAS correlated strongly and positively with a measure of hypochondriasis but negatively with measures of psychological mindedness and 'need for cognition'. There were low-magnitude correlations between the TAS and measures of self-depreciation, social introversion, persecutory ideation, and impulse expression, but no correlation with a measure of denial. These results indicate that the TAS is assessing adequately the theoretical domain relevant to its item and factor structure.

Ergonovine-induced coronary artery spasm and myocardial infarction after normal delivery

Reported is the first known case of postpartum myocardial infarction probably induced by ergonovine maleate, a drug known to provoke coronary artery spasm in susceptible patients.

Toward the development of a new self-report alexithymia scale

Addressing methodological problems in the development of existing scales for measuring alexithymia, this study reports the development of a new self-report scale. The Toronto Alexithymia Scale (TAS) was devised with concern for theoretical congruence with the alexithymia construct, independence of social desirability response bias, and internal consistency. Initially, 41 items were administered to 542 college students. Twenty-six items meeting preestablished psychometric guidelines were retained. Factor analysis yielded four interpretable factors, all consistent with the construct. The scale demonstrated adequate split-half and test-retest reliability, and scores were not significantly associated with age, education, and socioeconomic status. These preliminary results suggest that the TAS may be used as a clinical screening device with psychiatric and general medical patient populations.

Verbal measures of alexithymia: what do they measure

Previous studies have shown that measurement of verbal affective expression is influenced by the method used for obtaining speech samples, thereby supporting a situation-dependent, or state concept of alexithymia. In this study monadic speech samples obtained from 20 psychoneurotic and 20 psychosomatic patients, using selected thematic apperception test (TAT) cards, were examined using different methods of content analysis. Although no differences were found with the Gottschalk-Gleser anxiety, hostility outward and hope scales, the psychosomatic patients had a more limited emotional vocabulary than the psychoneurotic patients as measured by an 'affect vocabulary score' (AVS). In contrast to the Gottschalk-Gleser scores (GGS), the AVS correlated with measures of fantasizing ability and would appear to be a more valid method of measuring alexithymia. The findings also supported a trait concept rather than a state concept of alexithymia.

Early operative intervention after thrombolytic therapy for acute myocardial infarction

Thrombolytic therapy effectively interrupts acute myocardial infarction but does not correct the underlying plaque causing acute thrombosis. Early operation and treatment of the residual coronary artery disease has therefore been evaluated. Over 29 months, 184 patients with acute myocardial infarction of less than 6 hours duration were treated with intracoronary (IC) or intravenous (IV) streptokinase (SK). Angiography was performed early and thrombolysis found to be successful in 70% of the IC-SK group and 82% of the IV-SK group. One hundred six patients with successful thrombolysis had early revascularization surgery performed 3.3 +/- 2.1 days following SK treatment (range 0 to 11 days). These patients were compared with 110 consecutive patients who underwent coronary artery bypass grafting for standard indications. The SK group had an average of 3.0 +/- 1.4 grafts, 4.3 +/- 3.1 units of blood, and 10.8 +/- 5.3 days in the hospital postoperatively per patient and had an operative mortality rate of 2.7%. The control group averaged 3.6 +/- 1.3 grafts, 4.0 +/- 2.4 units of blood, and 9.6 +/- 3.5 days in the hospital postoperatively per patient with an operative mortality rate of 2.7%. This experience indicates that early operation following SK therapy can be performed with low operative risk and without prolonged hospitalization.

Comparative cost of myocardial revascularization: percutaneous transluminal angioplasty and coronary artery bypass surgery

A consecutive series of 78 patients having percutaneous transluminal coronary angioplasty for single vessel coronary artery disease and 85 patients having single vessel coronary artery bypass graft surgery were followed up prospectively for 1 year. Days in hospital and angiographic and revascularization procedures were counted in the two groups of patients and total cost of care for 12 months was calculated using current billing levels. Angioplasty was initially successful in 74% of patients; because of initial failure in 26% and late restenosis in 18%, bypass surgery was ultimately needed in 23 of 78 patients having coronary angioplasty. Nevertheless, total cost of care per patient was 43% lower for those having angioplasty as an initial procedure for single vessel coronary artery disease.

Intravenous versus intracoronary streptokinase therapy for acute myocardial infarction in community hospitals

A consecutive series of 184 patients with acute myocardial infarction (AMI) received thrombolytic therapy. The first 63 were treated in the catheterization laboratory with intracoronary streptokinase (IC-STK), and 44 (70%) had successful thrombolysis. One hundred twenty-one patients received intravenous (IV) STK immediately after diagnosis of AMI, and 99 (82%) were found to have an open infarct artery. Only 58% of patients (14 of 24) who required transfer from out-of-town hospitals for IC-STK treatment had successful thrombolysis; in contrast, IV-STK given in the local hospital resulted in an 85% (72 of 85) rate of thrombolysis (p = 0.005). IV-STK thus appears at least as effective as IC-STK for AMI and is more effective for patients treated in hospitals without catheterization facilities.

Alexithymia: concept, measurement, and implications for treatment

Alexithymia refers to a specific disturbance in psychic functioning characterized by difficulties in the capacity to verbalize affect and to elaborate fantasies. Although initially described in the context of psychosomatic illness, alexithymic characteristics may be observed in patients with a wide range of medical and psychiatric disorders. The author reviews the concept of alexithymia, including its historical background, clinical and demographic features, and possible etiology. He critically evaluates the different methods used to measure alexithymia and discusses the important implications it has for medical and psychiatric treatment.

Psychotherapy with the boring patient

Boredom is an unpleasant affective state which may be evoked by monotonous sensory input and reduction of an individual's internal instinctual and fantasy activity. Certain difficult patients have the capacity to evoke boredom in their psychotherapists and unless technical modifications are used, therapy quickly reaches an impasse and may be terminated on the grounds that the patient is 'not psychologically-minded.' Chronically boring patients have an impaired capacity for symbolization and can be identified by their non-symbolic communicative style. This reflects an inner struggle with primitive mental states due to fixation at, or regression to, the paranoid-schizoid developmental position. The patient may use projective identification to discharge unbearable psychic tension into the therapist whose boredom is partly a defense against this. Alternatively, the patient may create impenetrable barriers with language by making 'attacks on linking' which are tantamount to attacks on the therapist's peace of mind. The therapist should initially interpret the form and function of the patient's communications rather than the contents. In a manner comparable to a mother's interaction with her young child, the therapist can help the patient acquire a greater capacity for symbolization, including the ability to accurately label and verbalize different affective experiences. Careful analysis of the countertransference will identify the patient's projective identifications, provide valuable information about the patient's primitive mental life, and prevent anti-therapeutic projective counter-identifications. The patient will become less boring as he learns to use symbols and as his primitive anxieties are resolved.

Relation of therapeutic response to nifedipine to coronary anatomy and motion of S-T segment during unstable angina pectoris

Of 77 patients hospitalized for unstable angina pectoris and failure of oral, dermal, or intravenous nitrates and/or beta blockade, 81 percent with negligible or single-vessel disease and 55 percent with two- or three-vessel disease showed response (p less than 0.05) to nifedipine therapy. Patients with either S-T elevation or no change during pain responded better (31 of 45) than those with any S-T depression (16 of 32; p less than 0.05). Patients with negligible or single-vessel disease had a higher prevalence of S-T elevation (13 of 16) than patients with two- or three-vessel disease (15 of 31; p = 0.004). S-T motion did not predict response in patients with two- or three-vessel disease, but did predict response in patients with negligible or single-vessel disease. On follow-up study at 9 +/- 8 (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. Five who showed response had elective bypass surgery. The addition of nifedipine abolished or reduced pain episodes by more than 50 percent in 61 percent of patients with refractory unstable angina pectoris. Patients with negligible or single-vessel disease with S-T elevation benefit most. In patients with two- or three-vessel disease, the type of S-T motion did not predict response. Follow-up of all those with response indicated sustained amelioration by nifedipine therapy. Failure of nifedipine therapy should not be accepted until a dose of 120 mg per day has been achieved, or until intolerable side effects appear.

Prospective assessment of regional myocardial perfusion before and after coronary revascularization surgery by quantitative thallium-201 scintigraphy

Because thallium-201 uptake relates directly to the amount of viable myocardium and nutrient blood flow, the potential for exercise scintigraphy to predict response to coronary revascularization surgery was investigated in 47 consecutive patients. All patients underwent thallium-201 scintigraphy and coronary angiography at a mean (+/- standard deviation) of 4.3 +/- 3.1 weeks before and 7.5 +/- 1.6 weeks after surgery. Thallium uptake and washout were computer-quantified and each of six segments was defined as normal, showing total or partial redistribution or a persistent defect. Persistent defects were further classified according to the percent reduction in regional thallium activity; PD25-50 denoted a 25 to 50% constant reduction in relative thallium activity and PD greater than 50 denoted a greater than 50% reduction. Of 82 segments with total redistribution before surgery, 76 (93%) showed normal thallium uptake and washout postoperatively, versus only 16 (73%) of 22 with partial redistribution (probability [p] = 0.01). Preoperative ventriculography revealed that 95% of the segments with total redistribution had preserved wall motion, versus only 74% of those with partial redistribution (p = 0.01). Of 42 persistent defects thought to represent myocardial scar before surgery, 19 (45%) demonstrated normal perfusion postoperatively. Of the persistent defects that showed improved thallium perfusion postoperatively, 75% had normal or hypokinetic wall motion before surgery, versus only 14% of those without improvement (p less than 0.001). Whereas 57% of the persistent defects that showed a 25 to 50% decrease in myocardial activity demonstrated normal thallium uptake and washout postoperatively, only 21% of the persistent defects with a decrease in myocardial activity greater than 50% demonstrated improved perfusion after surgery (p = 0.02). Thus, preoperative quantitative thallium-201 scintigraphy appears useful in predicting response to revascularization surgery, and some persistent defects may revert to normal thallium uptake after surgery. Importantly, the preoperative distinction between viable and nonviable myocardium can be reasonably established by quantitating the amount of persistent reduction in thallium uptake and correlating this with preoperative wall motion.

Traumatic pericardiocentesis: two-dimensional echocardiographic visualization of an unfortunate event

Two-dimensional echocardiography was performed simultaneously with pericardiocentesis in an attempt to visualize the pericardiocentesis needle. Rapid penetration of the right ventricular myocardium by the pericardiocentesis needle occurred and was only appreciated in a slow-motion analysis of the two-dimensional echocardiogram videotape. Development of an intrapericardial thrombus was clearly detected by the two-dimensional echocardiogram videotape. Development of an intrapericardial thrombus was clearly detected by the two-dimensional echocardiogram within 24 hours following this traumatic pericardiocentesis. While two-dimensional echocardiography may offer the possibility for seeing the pericardiocentesis needle, technical considerations may limit the easy visualization of the pericardiocentesis needle and accurate localization of its tip. However, two-dimensional echocardiography may be useful in identifying consequences of suspected or proved traumatic pericardiocentesis procedures.

Precordial ST-segment depression during acute inferior myocardial infarction: clinical, scintigraphic and angiographic correlations

The cause and associated pathophysiology of precordial ST-segment depression (ST decreases) during acute inferior myocardial infarction (IMI) are controversial. To investigate this problem, electrocardiographic findings in 48 consecutive patients with acute IMI were prospectively compared with results of coronary angiography, submaximal exercise thallium-201 (201TI) scintigraphy and multigated blood pool imaging, all obtained 2 weeks after IMI, and with clinical follow-up at 3 months. Patients were classified according to the admission ECG obtained 3.3 +/- 3.1 hours after the onset of chest pain. Twenty-one patients (group A) had no or less than 1.0 mm ST decreases, and 27 (group B) had greater than or equal to 1.0 mm ST decreases in two or more precordial (V1-6) leads. Patients in group B had more prolonged chest pain after admission to the coronary care unit than those in group A (2.8 +/- 3.0 vs 1.2 +/- 1.1 hours, p less than 0.03), greater summed ST-segment elevation in leads II, III, aVF (6.7 +/- 4.7 vs 3.3 +/- 4.5 mm, p less than 0.02), higher plasma peak creatine kinase levels (1133 +/- 781 vs 653 +/- 482 IU/l, p less than 0.01), a higher prevalence of "true posterior" infarction by ECG criteria (26% vs 5%, p less than 0.05), a lower radionuclide ejection fraction (46 +/- 9% vs 54 +/- 6%, p less than 0.001), more extensive infarct-related asynergy (p less than 0.001) and 201TI perfusion abnormalities (p less than 0.01), more complications during hospitalization (p less than 0.03), and more cardiac events at 3 months (p less than 0.02). There were no significant differences between group A and group B in the extent of underlying coronary disease, prevalence of left anterior descending coronary artery disease, exercise-induced ST decreases or angina, and 201TI defects or wall motion abnormalities in anterior or septal segments. Thus, patients with acute IMI who have associated precordial ST decreases have greater global and regional left ventricular dysfunction due to more extensive inferior or inferoposterior wall infarction, rather than concomitant anteroseptal ischemic injury.