Effects of childhood trauma on somatization in major depressive disorder: The role of alexithymia

Alexithymia in food-allergic versus healthy children and young adults

Alexithymia is a multifaceted personality construct associated with several medical illnesses. However, no studies have focused on food allergy. We investigated alexithymia among food-allergic youths, compared to a matched healthy sample. A total of 220 participants aged 9–25 years were assessed using the Toronto Alexithymia Scale and the Alexithymia Questionnaire for Children. Food-allergic patients reported higher levels of alexithymia compared to a matched healthy sample. Furthermore, an association between alexithymia and a clinical history of anaphylaxis was found among patients. Some possible hypotheses have been discussed considering physiological, psychological, developmental, and cognitive/behavioral factors.

Predictors for DSM-5 nonsuicidal self-injury in female adolescent inpatients: The role of childhood maltreatment, alexithymia, and dissociation

The purpose of this study was to examine the relationship between various adverse childhood experiences, alexithymia, and dissociation in predicting nonsuicidal self-injury (NSSI) in an inpatient sample of female adolescents. Seventy-two adolescents (aged 14-18 years) with NSSI disorder (n=46) or mental disorders without NSSI (n=26) completed diagnostic interviews and self-report measures to assess NSSI disorder according to the DSM-5 criteria, childhood maltreatment, alexithymia, and dissociation. Alexithymia and dissociation were highly prevalent in both study groups. Multivariate logistic regression analyses indicated that only alexithymia was a significant predictor for NSSI, whereas childhood maltreatment and dissociation had no predictive influence. The association between alexithymia and NSSI emphasizes the significance of emotion regulation training for female adolescents with NSSI. Efforts to reduce NSSI behavior should therefore foster skills to heighten the perception and recognition of one's own emotions.

Feasibility and Preliminary Efficacy of a Novel RDoC-Based Treatment Program for Adolescent Depression: "Training for Awareness Resilience and Action" (TARA)-A Pilot Study

BACKGROUND

The novel group treatment program Training for Awareness, Resilience, and Action (TARA) was developed to target specific mechanisms based on neuroscience findings in adolescent depression and framed within the National Institute of Mental Health Research Domain Criteria. TARA contains training of autonomic and emotional self-regulation, interoceptive awareness, relational skills, and value-based committed action.

METHODS

We performed a single-arm trial to test the feasibility and preliminary efficacy of TARA in reducing depression and anxiety levels and assessed whether the specific targeted domains of function reflected the hypothesized symptom change. Twenty-six adolescents (14-18 years old, 7 males and 19 females) participated in the 12-week group program. Assessment was performed before (T0), immediately after (T1), and 3 months after the end of TARA (T2).

RESULTS

Significant improvement was seen in depression symptoms (Reynolds Adolescent Depression Scale Second Edition) between T0-T1 (t-value = -3.56, p = 0.002, CI = -6.64, -1.77) and T0-T2 (t-value = -4.17, p < 0.001, CI = -11.20, -3.75) and anxiety symptoms (Multidimensional Anxiety Scale for Children) between T0-T1 (t-value = -2.26, p = 0.033, CI = -4.61, -0.21) and T0-T2 (t-value = -3.06, p = 0.006, 95% confidence interval = -9.02, -1.73). Significant improvements in psychological flexibility, sleep, and mindfulness skills were also found between T0 and T2.

LIMITATIONS

The sample size was small without a control condition. The pilot design did not allow for testing the hypothesized brain changes and effect of TARA on relevant systemic biomarkers.

CONCLUSION

TARA is feasible in a sample of clinically depressed and/or anxious adolescents and preliminary efficacy was demonstrated by reduced depression and anxiety symptoms. The specific symptom and behavioral outcomes corresponded well with the hypothesized mechanisms of change.

Trichotillomania and Trauma: Dissociation and Alexithymia in a Case of Pregnancy Denial

Pregnancy denial is rare yet reported and is often the result of complex psychosocial circumstances. We present an unusual case of pregnancy denial associated directly with both remote and ongoing trauma. A woman suddenly gave birth to a child in a hospital while visiting her other daughter, resulting in emergent labor and delivery as well as social work and psychiatric evaluation. Various atypical findings were noted, including pathological hair-pulling, alexithymia, indifference, and pregnancy denial. We offer a biopsychosocial conceptualization of the case, commenting on various possible processes including dissociation. The case also explores current states of knowledge regarding the interaction between impulse control disorders such as trichotillomania, dissociation, and trauma, with a call for future clinical and investigational attention to these interactions.

The Role of Alexithymia in the Incidence of Poststroke Depression

Poststroke depression (PSD) is the most frequent neuropsychiatric consequence of stroke, and alexithymia is a construct characterized by the inability to identify and describe emotions. Our study aimed to determine whether alexithymia is a risk factor for the development of PSD. Patients with ischemic stroke admitted to a general teaching hospital were enrolled in this 6-month study. The patients were evaluated with the Toronto Alexithymia Scale-20 (TAS-20), Beck Anxiety Inventory (BAI), National Institute of Health Stroke Scale (NIHHS), and Mini-Mental Status Examination at baseline and then followed up each month for detection of PSD using the Center for Epidemiologic Studies of Depression scale. In all, 285 patients with ischemic stroke were enrolled, and 93.3% completed the 6-month study. The overall incidence of PSD within 6 months was 16.5%. In multivariate regression analyses, the incidence of PSD was significantly associated with higher BAI, higher NIHSS, and higher TAS-20 scores. In conclusion, our study highlights the importance of alexithymic symptoms as a risk factor for PSD.

Dorsal Anterior Cingulate Thickness Is Related to Alexithymia in Childhood Trauma-Related PTSD

Alexithymia, or “no words for feelings”, is highly prevalent in samples with childhood maltreatment and posttraumatic stress disorder (PTSD). The dorsal anterior cingulate cortex (dACC) has been identified as a key region involved in alexithymia, early life trauma, and PTSD. Functional alterations in the dACC also have been associated with alexithymia in PTSD. This study examined whether dACC morphology is a neural correlate of alexithymia in child maltreatment-related PTSD. Sixteen adults with PTSD and a history of childhood sexual abuse, physical abuse, or exposure to domestic violence, and 24 healthy controls (HC) completed the Toronto Alexithymia Scale 20 (TAS–20) and underwent magnetic resonance imaging. Cortical thickness of the dACC was measured using FreeSurfer, and values were correlated with TAS–20 scores, controlling for sex and age, in both groups. Average TAS–20 score was significantly higher in the PTSD than the HC group. TAS–20 scores were significantly positively associated with dACC thickness only in the PTSD group. This association was strongest in the left hemisphere and for TAS–20 subscales that assess difficulty identifying and describing feelings. We found that increasing dACC gray matter thickness is a neural correlate of greater alexithymia in the context of PTSD with childhood maltreatment. While findings are correlational, they motivate further inquiry into the relationships between childhood adversity, emotional awareness and expression, and dACC morphologic development in trauma-related psychopathology.

The Relation of Alexithymic Traits to Affective Theory of Mind

Little research has focused on the contributors to adult theory of mind (ToM) even though there is reason to suspect individual differences in performance in neurotypical samples. Alexithymia, a term that references an impaired ability to attend to and verbally label emotions via ongoing introspection, is a useful construct through which to explore how socially relevant dimensions of emotion processing enable ToM. As 1 study has explored alexithymia vis-à-vis cognitive ToM, this study examined the relationships between facets of alexithymia and affective ToM while controlling for the potential confounds of empathy, verbal ability, and negative affect. A nonclinical sample of adults (N = 86) completed the Toronto Alexithymia Scale, the Reading the Mind in the Eyes Test, the Mehrabian and Epstein Scale of Emotional Empathy, the Profile of Mood States, and the Wechsler Abbreviated Scale of Intelligence. Hierarchical regression analysis showed that externally oriented thinking contributed unique variance to affective ToM, confirming an inverse relationship between alexithymia and affective ToM but highlighting the need to parse alexithymia into discrete facets when exploring its relevance to social cognition.

Traditional Chinese medicinal herbal tea consumption, self-reported somatization, and alexithymia

INTRODUCTION

Somatic presentations of distress are common cross-culturally, although perhaps more so in Asian cultures. Somatic presentations of distress may be associated with alexithymia, a difficulty in experiencing and expressing emotions. Although the constructs of somatization and alexithymia have been examined in depth both within and across cultures, there is minimal information on culture-specific behaviors utilized to cope with stress in individuals who tend to somaticize distress or are alexithymic. The current report investigates the association between somatization and alexithymia, and a culture-specific behavior of traditional Chinese medicinal herbal tea consumption, in a nonclinical, young adult sample.

METHODS

A sample of 222 undergraduate university students of Chinese ethnicity completed self-report measures of somatization and the related construct of somatosensory amplification, alexithymia, and attitude toward the consumption of herbal tea possessing traditional Chinese medicinal value.

RESULTS

After controlling for gender, alexithymia was significantly correlated with somatization (r[220] = 0.29, P < 0.05) and somatosensory amplification (r[220] = 0.19, P < 0.05). Attitudes toward herbal tea consumption were significantly correlated with somatosensory amplification (r[220] = 0.16, P < 0.05).

DISCUSSION

The connection between alexithymia and somatization was confirmed in the current report in a nonclinical sample. A culture-specific behavior (consumption of traditional Chinese medicinal herbal tea) was significantly associated with somatosensory amplification. Potential etiologies and implications of the current findings are discussed.

How do maternal PTSD and alexithymia interact to impact maternal behavior?

Maternal interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) is known to be associated with impairment of a mother's capacity to participate in mutual emotion regulation during her child's first years of life. This study tested the hypothesis that maternal difficulty in identifying feelings in self and other, as an important dimension of the construct of alexithymia, together with maternal IPV-PTSD, would be negatively associated with maternal sensitivity. Maternal sensitivity to child emotional communication is a marker of maternal capacity to engage in mutual regulation of emotion and arousal. Following diagnostic interviews and administration of the Toronto Alexithymia Scale, 56 mothers and their toddlers (ages 12-42 months) were filmed during free-play and separation/novelty-exposure. Observed maternal sensitivity was coded via the CARE-Index. Maternal IPV-PTSD severity, difficulty in identifying emotions, and lower socio-economic status were all associated with less maternal sensitivity, and also with more maternal controlling and unresponsive behavior on the CARE-Index.

The role of language in emotion: predictions from psychological constructionism

Common sense suggests that emotions are physical types that have little to do with the words we use to label them. Yet recent psychological constructionist accounts reveal that language is a fundamental element in emotion that is constitutive of both emotion experiences and perceptions. According to the psychological constructionist Conceptual Act Theory (CAT), an instance of emotion occurs when information from one's body or other people's bodies is made meaningful in light of the present situation using concept knowledge about emotion. The CAT suggests that language plays a role in emotion because language supports the conceptual knowledge used to make meaning of sensations from the body and world in a given context. In the present paper, we review evidence from developmental and cognitive science to reveal that language scaffolds concept knowledge in humans, helping humans to acquire abstract concepts such as emotion categories across the lifespan. Critically, language later helps individuals use concepts to make meaning of on-going sensory perceptions. Building on this evidence, we outline predictions from a psychological constructionist model of emotion in which language serves as the "glue" for emotion concept knowledge, binding concepts to embodied experiences and in turn shaping the ongoing processing of sensory information from the body and world to create emotional experiences and perceptions.

The Psychological Evaluation of Patients with Chronic Pain: a Review of BHI 2 Clinical and Forensic Interpretive Considerations

Pain is the most common reason why patients see a physician. Within the USA, it has been estimated that at least 116 million US adults suffer from chronic pain, with an estimated annual national economic cost of $560-635 billion. While pain is in part a sensory process, like sight, touch, or smell, pain is also in part an emotional experience, like depression, anxiety, or anger. Thus, chronic pain is arguably the quintessential biopsychosocial condition. Due to the overwhelming evidence of the biopsychosocial nature of pain and the value of psychological assessments, the majority of chronic pain guidelines recommend a psychological evaluation as an integral part of the diagnostic workup. One biopsychosocial inventory designed for the assessment of patients with chronic pain is the Battery for Health Improvement 2 (BHI 2). The BHI 2 is a standardized psychometric measure, with three validity measures, 16 clinical scales, and a multidimensional assessment of pain. This article will review how the BHI 2 was developed, BHI 2 concepts, validation research, and an overview of the description and interpretation of its scales. Like all measures, the BHI 2 has strengths and weaknesses of which the forensic psychologist should be aware, and particular purposes for which it is best suited. Guided by that knowledge, the BHI 2 can play a useful role in the forensic psychologist's toolbox.

The development of an RDoC-based treatment program for adolescent depression: "Training for Awareness, Resilience, and Action" (TARA)

Major depressive disorder (MDD) is one of the current leading causes of disability worldwide. Adolescence is a vulnerable period for the onset of depression, with MDD affecting 8–20% of all youth. Traditional treatment methods have not been sufficiently effective to slow the increasing prevalence of adolescent depression. We therefore propose a new model for the treatment of adolescent depression – Training for Awareness, Resilience, and Action (TARA) – that is based on current understanding of developmental and depression neurobiology. The TARA model is aligned with the Research Domain Criteria (RDoC) of the National Institute of Mental Health. In this article, we first address the relevance of RDoC to adolescent depression. Second, we identify the major RDoC domains of function involved in adolescent depression and organize them in a way that gives priority to domains thought to be driving the psychopathology. Third, we select therapeutic training strategies for TARA based on current scientific evidence of efficacy for the prioritized domains of function in a manner that maximizes time, resources, and feasibility. The TARA model takes into consideration the developmental limitation in top-down cognitive control in adolescence and promotes bottom-up strategies such as vagal afference to decrease limbic hyperactivation and its secondary effects. The program has been informed by mindfulness-based therapy and yoga, as well as modern psychotherapeutic techniques. The treatment program is semi-manualized, progressive, and applied in a module-based approach designed for a group setting that is to be conducted one session per week for 12 weeks. We hope that this work may form the basis for a novel and more effective treatment strategy for adolescent depression, as well as broaden the discussion on how to address this challenge.

Trichotillomania and emotion regulation: is symptom severity related to alexithymia?

Previous research on trichotillomania (TTM) has demonstrated an emotion regulation function of hair pulling behavior. One condition that can impede the regulation of emotions is alexithymia. The present study aimed to explore the relationship between the degree of alexithymia and the severity of hair pulling behavior in individuals with TTM. Multiple strategies were used to recruit a sample of 105 participants via the internet. All participants were diagnosed with TTM by an experienced clinician via a subsequent phone-interview. Multiple linear regression analysis was performed to test the potential predictive value of the different facets of alexithymia (20-item Toronto Alexithymia Scale) on the severity of TTM (Massachusetts General Hospital Hair-Pulling Scale). Both the difficulty in identifying feelings (DIF) facet of alexithymia (p=0.045) and depression (p=0.049) were significant predictors of the severity of TTM. In conclusion, alexithymia seems to play a role in hair pulling behavior in individuals with TTM. However, the significant association was small in terms of the overall variance explained, thus warranting further research. If replicated in prospective studies, then these results indicate that therapeutic approaches aimed at supporting patients in recognizing and differentiating feelings might be useful for the treatment of TTM.

Medically unexplained symptoms

In summary, caring for patients with MUS is challenging for health care providers. Even defining somatization syndromes is complex and controversial, reflecting the medical community’s limited understanding of the pathophysiology for this group of disorders. Although risk factors for MUS have been described and are well understood, little is known about how MUS can be prevented. Uncertainty in medicine, as in any human enterprise, is a given, but the difficulties in identification and treatment of patients with MUS highlight the limitations in understanding the intersection between physical and mental health. Patients come to their physician looking for clarity, understanding, and relief of debilitating symptoms. The understanding of MUS will evolve, and perhaps an organic cause not yet understood or described may emerge to lend clarity and therapeutic opportunities to some patients with somatic disorders. In the meantime, the most powerful tools available are the ability to communicate the limits of current understanding, acknowledge the difficulties faced by patients with this disorder, and reinforce the willingness and desire of clinicians to partner with patients as the focus shifts from diagnosis to symptom management. Thus, the physician-patient relationship, still in its rightful place at the heart of the practice of medicine, lies at the center of effective treatment of patients with MUS.

Dissociative depression among women with fibromyalgia or rheumatoid arthritis

The aim of this study was to inquire about the possible relations of childhood trauma, anger, and dissociation to depression among women with fibromyalgia or rheumatoid arthritis. Fifty female patients diagnosed as having fibromyalgia (n = 30) or rheumatoid arthritis (n = 20) participated in the study. The Childhood Trauma Questionnaire, Somatoform Dissociation Questionnaire (SDQ), Dissociation Questionnaire (DIS-Q), Beck Depression Inventory (BDI), Spielberger State-Trait Anger Expression Inventory, and Dissociative Disorders Interview Schedule were administered to all participants. Women with a lifetime diagnosis of depressive disorder had higher scores for somatoform and psychoform dissociation than the nondepressive patients. However, childhood trauma scores did not differ between the 2 groups. In regression analysis, current severity of depression (BDI) was predicted by psychoform dissociation (DIS-Q) and lower education, and lifetime diagnosis of major depression was predicted by somatoform dissociation (SDQ). Whereas childhood emotional neglect predicted somatoform dissociation, psychoform dissociation was predicted by childhood sexual abuse. Mental processing of anger seems to be 1 of the dimensions of psychodynamics in trauma-related depressive conditions. In the context of the perceived threat of loss of control due to expressed anger and mental disintegration, somatoform dissociation seems to contribute to overmodulation of emotions in dissociative depression. Among patients suffering from physical illness with possible psychosomatic dimensions, assessment of somatoform dissociation in addition to psychoform dissociation may be helpful to understand diverse psychopathological trajectories emerging in the aftermath of childhood adversities. The recently proposed category of "dissociative depression" (Sar, 2011) seems to be a promising concept for future research on psychosomatic aspects of traumatic stress.

Pros and cons of a wandering mind: a prospective study

Mind wandering (MW) has recently been associated with both adaptive (e.g., creativity enhancement) and maladaptive (e.g., mood worsening) consequences. This study aimed at investigating whether proneness to MW was prospectively associated with negative health outcomes. At time 0, 21 women, 19 men; mean age = 24.5 (4.9) underwent a 5-min baseline electrocardiogram (ECG), a 20-min laboratory tracking task with thought probes, and personality questionnaires. At time 1 (1 year follow-up), the same participants underwent a 24-h Ecological Momentary Assessment characterized by ambulatory ECG recording and electronic diaries. First, we examined if the likelihood of being a “mind wanderer” was associated with specific personality dispositions. Then, we tested if the occurrence of episodes of MW in the lab would be correlated with frequency of MW in daily life. Finally, multiple regression models were used to test if MW longitudinally acted as a risk factor for health, accounting for the effects of biobehavioral variables. Among dispositional traits, the frequency of MW episodes in daily life was inversely associated with the capacity of being mindful (i.e., aware of the present moment and non-judging). There was a positive correlation between frequency of MW in the lab and in daily life, suggesting that it is a stable disposition of the individual. When differentiated from perseverative cognition (i.e., rumination and worry), MW did not predict the presence of health risk factors 1 year later, however, a higher occurrence of episodes of MW was associated with short-term adverse consequences, such as increased 24-h heart rate (HR) on the same day and difficulty falling asleep the subsequent night. Present findings suggest that MW may be associated with short term “side effects” but argue against a long term dysfunctional view of this cognitive process.

Parents' physical victimization in childhood and current risk of child maltreatment: the mediator role of psychosomatic symptoms

OBJECTIVE

To test the potential mediation effect of psychosomatic symptoms on the relationship between parents' history of childhood physical victimization and current risk for child physical maltreatment.

METHODS

Data from the Portuguese National Representative Study of Psychosocial Context of Child Abuse and Neglect were used. Nine-hundred and twenty-four parents completed the Childhood History Questionnaire, the Psychosomatic Scale of the Brief Symptom Inventory, and the Child Abuse Potential Inventory.

RESULTS

Mediation analysis revealed that the total effect of the childhood physical victimization on child maltreatment risk was significant. The results showed that the direct effect from the parents' history of childhood physical victimization to their current maltreatment risk was still significant once parents' psychosomatic symptoms were added to the model, indicating that the increase in psychosomatic symptomatology mediated in part the increase of parents' current child maltreatment risk.

DISCUSSION

The mediation analysis showed parents' psychosomatic symptomatology as a causal pathway through which parents' childhood history of physical victimization exerts its effect on increased of child maltreatment risk. Somatization-related alterations in stress and emotional regulation are discussed as potential theoretical explanation of our findings. A cumulative risk perspective is also discussed in order to elucidate about the mechanisms that contribute for the intergenerational continuity of child physical maltreatment.