Validation of the alexithymia construct: a measurement-based approach

Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile dysfunction (ED)

Alexithymia is a multidimensional construct that describes a constellation of personality features characterised by difficulties in differentiating, identifying and communicating emotions. The purpose of the present study was to investigate prevalence of alexithymia in outpatients with erectile dysfunction (ED), both in the psychogenic lifelong type (PLED) and in the acquired one (PAED). ED severity was evaluated with the International Index of Erectile Function (IIEF) and alexithymia was measured using the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20). The results suggest a high incidence of alexithymic characteristics in patients with psychogenic ED, a positive correlation between the alexithymia level and ED severity in patients with PAED and statistically significant differences in the alexithymia level between the two subgroups PLED and PAED. We assumed that alexithymia contributes to the origin of the PLED, and to a more severe manifestation of ED, once it appears in the acquired form.

Adolescents’ self-mutilation - Relationship with dependent behaviour

The aim of this study, which was carried out in the French-speacking part of Switzerland, was to examine the relationship between suicide attempts and self-mutilation by adolescents and young adults. The population, aged 14-25 years (N = 308), included a clinical sample of dependent subjects (drug abuse and eating disorders) compared to a control sample. On the basis of the Mini Neuropsychiatric Interview ( Sheehan et al., 1998 ), DSM-IV criteria were used for the inclusion of the clinical population. The results concerning the occurrence of suicide attempts as well as on self-mutilation confirm most of the hypotheses postulated: suicidal attempts and self-mutilation were more common in the clinical group compared to the control group, and there was a correlation between suicide attempts and self-mutilation. However, there was only a partial overlap, attesting that suicide and self-harm might correspond to two different types of behaviour.

Salivary gland scintigraphy in Sjögren's syndrome and patients with sicca symptoms but without Sjögren's syndrome: the psychological profiles and predictors for salivary gland dysfunction

OBJECTIVE

To characterise the psychological profiles of Sjögren's syndrome (SS) and patients with sicca symptoms but without SS; to find predictors for salivary gland function; to evaluate salivary scintigraphy as a method to differentiate between SS and patients with sicca symptoms but without SS.

PATIENTS AND METHODS

Psychological tests (Medical Outcomes Study Short Form General Health Survey (SF-36), Jenkins Activity Survey, Toronto Alexithymia Scale, and Maastricht Questionnaire for vital exhaustion) were performed and assessment of the function of the salivary glands made in 26 patients with primary SS, 8 with secondary SS, and 9 with sicca symptoms but without SS. Data were analysed with BMDP new system version 1.0 statistical program.

RESULTS

Psychological profiles were similar in all groups. Hb, RF, ANA, and SSA differentiated between the groups. Results of salivary scintigraphy were predicted to 51% by ANA, SSA, SSB, IgG, IgA, diagnosis, vitality, and role limitations due to emotional problems. No predictors were found for the resting salivary flow. Salivary scintigraphy was pathological in 21/26 (81%) and in 8/8 (100%) patients with secondary SS, but only in 2/9 (22%) patients with sicca symptoms without SS (p=0.002) (sensitivity 85.3%, specificity 77.8%).

CONCLUSIONS

Patients with sicca symptoms but without SS have sickness behaviour similar to that of patients with SS. The results of salivary scintigraphy can be predicted by diagnosis and autoimmune findings; psychological characteristics added 20% to this predictive value. Distinction between SS and patients with sicca symptoms but without SS is difficult, but in addition to autoantibodies, salivary scintigraphy can be used for this purpose.

Spatial, object, and affective working memory in social anhedonia: an exploratory study

The domain-specificity of working memory was examined in psychosis-prone individuals with elevated social anhedonia scores. A group of individuals with deviant scores on the revised Social Anhedonia Scale (n=43) were compared with a normal control group (n=39) on delayed match-to-sample tasks involving spatial, identity, and affective information. The social anhedonia group performed less well on the spatial and emotion delayed match-to-sample tasks relative to the normally hedonic group. The two groups did not differ in terms of their performance on the identity delayed match-to-sample task. Although the social anhedonia group reported less positive affect, greater negative affect, and more alexithymic tendencies relative to the control group, there were no significant associations between these personality traits and working memory performance. In summary, the findings suggest that poorer working memory performance is not domain-specific in socially anhedonic individuals. The authors conclude that the socially anhedonic group's relatively poor performance on the emotion delayed match-to-sample task reflects difficulty and/or inefficiency in handling cognitively taxing tasks.

Adolescent's suicide attempts: populations at risk, vulnerability, and substance use

Adolescence corresponds to a transition period that requires adaptation and change capacities and skills. Most young people succeed with this challenge, whereas a minority fail. In order to identify with the teenage culture, become autonomous, and differentiate from their parents, some adolescents choose to use drugs, beginning with the use of cigarettes, alcohol, cannabis, followed by other illicit drugs such as opiates and stimulants. A high proportion of these adolescents attempt suicide, which is the primary cause of death during adolescence in many European countries. Who are the "vulnerable" adolescents? What are the mechanisms that can explain the varieties of drug-use initiation or suicide attempts? Can "protective factors" be identified? What kind of strategies might be developed at a social and political level in order to prevent or to minimize drug abuse and suicide attempts, among other harmful behaviors? These issues will be discussed on the basis of the recent literature and in the light of a recent study carried out in the French-speaking part of Switzerland on large cohorts of adolescent drug users. Unresolved critical issues are noted and future needed research is suggested.

Alexithymie: Kompetenzdefizit oder (motivierte) Hemmung?

Zusammenfassung. Theoretischer Hintergrund: Alexithymie bezeichnet eine eingeschränkte Fähigkeit, Affekte zu identifizieren und zu beschreiben. Auf konstruktheoretischer Ebene ist ungeklärt, ob alexithyme Phänomene auf einer defizitären oder auf einer gehemmten Affektregulation beruhen. Fragestellung: Um eine Entscheidung zu ermöglichen, wurden aus jeder der beiden theoretischen Perspektiven Hypothesen formuliert und überprüft. (1) Alexithyme Patienten verfügen über einen weniger differenzierten semantischen Raum für die Unterscheidung von Emotionen. (2) Alexithyme Patienten akzeptieren ihre eigene Emotionalität in geringerem Maße als nichtalexithyme Patienten und/oder erwarten in stärkerem Ausmaß, daß ihre Emotionalität von anderen abgelehnt wird. Methode: Bei 39 Patienten mit DSM-III-R Angststörungen wurde der Differenzierungsgrad der Emotionswahrnehmung individuell für jeden Patienten mit einer Variante der Repertory-Grid-Technik, dem “Emotions-Grid“, bestimmt. Die Emotionsakzeptanz wurde mittels Ratings für diverse Grundemotionen bestimmt. Mit der Toronto Alexithymia Scale (TAS-20) wurden alexithyme Merkmale psychometrisch erfasst. Ergebnisse: Eine emotionale Differenzierungsschwäche alexithymer Patienten kann belegt werden. Schlussfolgerungen: Die Befunde stützen ein “Defizitkonzept“ der Alexithymie.

[Testing and validation of the 26-Item Toronto Alexithymia Scale in a representative population sample]

This paper presents the authorized German version of the 26-item Toronto alexithymia scale (TAS-26). Due to the fact, that the revised version of this questionnaire (TAS-20) displays low reliability concerning the scale "external oriented thinking" in the German version, we decided to reinvestigate all TAS-26 items. In a representative sample of the German population (N=2047), the four factor structure of the original version could be reproduced and reliabilities for the four scales as well as for a pooled 5th scale (scales 1 to 3) varied satisfyingly between r=.67 to r=.84. TAS-scale no. 4 "reduced daydreaming" correlated negatively with other TAS scales in this German version also, so we can not recommend to use this construct for the study of alexithymia. Scale values proved to be independent from age and sex, whereas a clear relation with education could be detected: persons with low education scored high on alexithymia scales. To validate the German version of the TAS-26, a mood questionnaire and a body experience questionnaire were used. It could be shown that high alexithymia scores were associated with negative body image and undesirable emotions. It is discussed whether the latter correlation is due to a methodological artefact, since persons with high alexithymia scores tend to prefer middle categories of the mood questionnaire.

Relationship of numbing to alexithymia, apathy, and depression

The present study assessed the relationship between numbing and three associated conditions of alexithymia, apathy, and depression, utilizing data collected on 353 Vietnam combat veterans diagnosed with Posttraumatic Stress Disorder from in- and out-patient settings and an outreach center at various Department of Veterans Affairs Medical centers. All subjects completed four self-report measures: the Glover Numbing Scale, the Beck Depression Inventory, the Apathy Evaluation Scale, and the Toronto Alexithymia Scale-20. The correlation matrix indicated that scores on the four measures were moderately to highly correlated. Principal components analysis with a varimax rotation indicated a five-factor solution that provided evidence for the factorial validity of each of the constructs assessed. Results of the factor analysis of items from the four measures were consistent with numbing being a separate and distinct construct from alexithymia, apathy, and depression. In general, results indicated that all constructs measured were separate and distinct from one another.

Childhood sexual abuse, dissociation, and adult self-destructive behavior

Female college students reporting a history of childhood sexual abuse (N=175) and not reporting a history of childhood sexual abuse (N=260) were compared on indices of six self-destructive behaviors, including drug use, alcohol abuse, binge eating, self-mutilation, risky sex, and suicidality. The samples were also compared on two measures of dissociation, the Trauma Symptom Checklist dissociation subscale and the Dissociative Experiences Scale. The CSA group had significantly higher mean scores on all the indices of self-destructive behavior except self-mutilation (where the mean difference approached significance), and on both measures of dissociation. One or both dissociation measures were related significantly to each index of self-destructive behavior except binge eating. Multiple regression mediation analyses provided support for the hypothesis that dissociation mediates the relationships between CSA and both drug use and alcohol abuse. Dissociation also explained significant variability when added to the regressions of risky sex and suicidality on CSA.

Family-of-origin expressiveness: measurement, meaning, and relationship to alexithymia

The need for research instruments to assess the impact of affective expressiveness within the family is evident, yet few appear to be adequately designed for this purpose. In this article, we present two studies addressing this need. In the first study, the original 40-item Family-of-Origin Scale was administered to 416 students to determine those items that constitute the factor structure. This instrument was designed to assess perceived levels of health in the family of origin but has unsubstantiated construct validity. Results from a confirmatory factor analysis indicated that the instrument has one major factor, and results from five other studies provide evidence supporting the construct validity. Face validity of this 22-item construct indicates that it assesses an individual's perceived level of global expressive atmosphere within his or her family of origin. In the second study, the new Family-of-Origin Expressive Atmosphere Scale and the 20-item Toronto Alexithymia Scale were administered to 295 students. Students' self-reported expressive atmospheres in their family-of-origin scores were significantly correlated with the total scores of alexithymia and each of the three factors: impaired ability to identify feelings, impaired ability to describe feelings, and externally oriented thinking processes. No significant gender differences were found.

Recent developments in alexithymia theory and research

OBJECTIVE

To review recent developments in alexithymia theory and research that are relevant to the field of psychosomatic medicine.

METHOD

Articles were selected from the alexithymia literature published over the past decade that describe advances in the theoretical understanding of alexithymia or report empirical investigations of the relationships of the construct with emotion regulation and with somatic illness and disease. Empirical investigations of the neural correlates of alexithymia were reviewed also, as were studies that explore therapeutic attempts to modify alexithymic characteristics.

RESULTS

The salient features of the alexithymia construct are now thought to reflect deficits in the cognitive processing and regulation of emotions. This is supported by studies showing that alexithymia is associated with maladaptive styles of emotion regulation, low emotional intelligence, a bidirectional interhemispheric transfer deficit, and reduced rapid eye movement (REM) density (number of eye movements divided by number of REM periods). Although empirical evidence demonstrates that alexithymia is associated with several somatic disorders, more prospective studies are required to establish the direction of causality. Preliminary data suggest that psychotherapies involving specific techniques to enhance emotional awareness and integrate symbolic and subsymbolic elements of emotion schemas may be effective in reducing alexithymic characteristics.

CONCLUSION

Alexithymia is proving to be a heuristically useful construct for exploring the role of personality and emotions in the pathogenesis of certain somatic illnesses and diseases.

Relation between alexithymia and the five-factor model of personality: a facet-level analysis

The relation between alexithymia and both the domain and the facet level of the five-factor model (FFM) of personality was examined in a sample of 101 university students by using the Twenty-Item Toronto Alexithymia Scale (TAS-20; Bagby, Taylor, & Parker, 1994) and the Revised NEO Personality Inventory (Costa & McCrae, 1992c). Consistent with the alexithymia construct, the TAS-20 was positively correlated with Neuroticism (N) and negatively correlated with Extraversion (E) and Openness (O), whereas no significant relations were found with Agreeableness (A) and Conscientiousness (C). Analysis of the lower order traits (i.e., facets) of the FFM revealed that depression for N; positive emotions and assertiveness for E; feelings and actions for O; altruism, tender-mindedness, and modesty for A; and competence for C predicted alexithymia. These results support the uniqueness of the alexithymia construct, which is represented by a cluster of traits across the dimensions and facets of the FFM.

The Relationship Between Child Sexual Abuse and Alexithymic Symptoms in a Population of Recovering Adult Substance Abusers

Recovering substance abusers with a history of childhood sexual abuse (n = 69) or no history of childhood sexual abuse (n = 68) completed the Toronto Alexithymia Scale (TAS) and a background survey assessing demographic data and (In the case of sexually abused respondents) parameters of the childhood abuse experienced. The sexually abused group scored significantly higher than the non-abused group on the TAS. Within the abused group, measured alexithymic symptomatology was found to be related positively to the duration of the abuse. Alexithymia was significantly higher when the sexual abuse first occurred after the victim had reached the age of 12, when a perpetrator of the sexual abuse was a father or stepfather, and when the abuse involved oral, vaginal, and/or anal penetration. Results were interpreted as indicating that the development of alexithymic symptoms may represent another defense victims may employ to insulate themselves from painful affect, along with dissociative symptoms and substance abuse, which have been shown previously to characterize adult survivors of child sexual abuse.

Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women

OBJECTIVE

This study was conducted to determine whether large family responsibilities and their combination with high job strain were associated with an increase in ambulatory blood pressure (BP) among white-collar women.

METHODS

A cross-sectional study was conducted in a stratified random sample of 199 white-collar women with or without children who were employed full time in jobs involving high or low strain. These women were selected from a population of 3183 women of all ages, employed in eight organizations in Quebec City, Canada. Subjects wore an ambulatory BP monitor for 24 hours during a working day. Mean BPs were calculated. Different measures of family responsibilities were used, based on the number of children and their ages, and domestic work. Job strain was measured using the Job Content Questionnaire recommended by Karasek.

RESULTS

Family responsibility measures were significantly related to diurnal BP among women holding a university degree (N=69). Indeed, women having large family responsibilities had increases in systolic and diastolic BPs of 2.7 to 5.7/1.8 to 4.0 mm Hg (p< or =.05). Among women holding a university degree, increases in diurnal systolic and diastolic BPs reached 8.1 to 10.9/5.5 to 7.1 mm Hg (p< or =.01) among women having both large family responsibilities and high job strain. These results were independent of confounders. There was no significant association among women without a university degree (N=130).

CONCLUSIONS

Large family responsibilities were associated with significant increases in diurnal systolic and diastolic BPs among white-collar women holding a university degree. In these women, the combined exposure of large family responsibilities and high job strain tended to have a greater effect on BP than the exposure to only one of these factors.

The status of alexithymia as a risk factor in medically unexplained physical symptoms

Some decennia ago, the concept of alexithymia was developed from the clinical experience of psychosomaticians who at the time were largely working within a psychoanalytic frame of reference. Alexithymia can briefly be described as a cognitive-affective disturbance characterized by difficulties in differentiating one's feelings and expressing them in words. Clinicians who treat patients with medically unexplained physical symptoms may often recognize alexithymic features in their patients. It is supposed that alexithymia could be a predisposing factor for the development or persistence of medically unexplained physical symptoms. In this review, the concept of alexithymia as well as paradigmatic shifts in psychoanalysis and psychosomatics are discussed to place the concept of alexithymia in its epistemiological context. Furthermore, the empirical literature on the association between alexithymia and medically unexplained physical symptoms is reviewed. The main conclusions are that alexithymia appears to be a theoretically important and clinically appealing concept, but that so far the empirical evidence that alexithymia predisposes to the development or persistence of medically unexplained physical symptoms is imperfect. This is mainly because of the cross-sectional design of most studies and is due to other methodological shortcomings, such as the lack of allowance for depression and anxiety as possible confounding factors. Suggestions for future research are made.

Alexithymia: relationship with ego defense and coping styles

There is controversy in the literature as to whether alexithymia reflects a deficit in the cognitive processing of emotions or a defensive coping style. Previous studies with clinical populations reported a strong association between alexithymia and a maladaptive (immature) ego defense style. The present study was designed to examine this relationship in nonclinical populations, and also to explore the relationships between alexithymia and three general styles for coping with stressful situations. Sample 1, 287 nonclinical adults, completed the Twenty-Item Toronto Alexithymia Scale (TAS-20) and the Defense Style Questionnaire (DSQ). Sample 2, 83 undergraduate students who had been categorized previously into alexithymic and nonalexithymic subgroups, completed the DSQ and the Coping Inventory for Stressful Situations (CISS). In sample 1, the TAS-20 and its three factors were associated most strongly with an immature defense style, weakly with a neurotic defense style, and negatively with a mature defense style. In sample 2, alexithymic students scored significantly higher than nonalexithymic students on the immature and neurotic defense factors of the DSQ and significantly lower on the mature defense factor. Alexithymic students also scored significantly higher on the emotion-oriented coping scale and the distraction component of the avoidance-oriented coping scale of the CISS and significantly lower on the task-oriented coping scale. The results fail to support the view that alexithymia is an adaptive defense or coping style.

Alexithymia in chronic pain patients

Prior studies of alexithymia in chronic pain patients have used unvalidated alexithymia measures or have not controlled for treatment-seeking status. In this study, we compared 30 patients with chronic pain and patients seeking treatment for two other problems: nicotine dependence (n = 32) or moderate obesity (n = 25). Alexithymia was assessed with the well-validated Toronto Alexithymia Scale (TAS) and also with the Alexithymia Provoked Response Questionnaire (APRQ). On both alexithymia measures, chronic pain patients were more alexithymic than nicotine-dependent and obese patients; the latter two groups did not differ. Chronic pain patients had greater psychopathology on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and both alexithymia measures correlated positively with certain types of psychopathology. We conclude that alexithymia is increased among patients with chronic pain, that this relationship is not confounded by a treatment-seeking bias, and that alexithymia may contribute to both chronic pain and psychopathology.

Testing the alexithymia hypothesis: physiological and subjective responses during relaxation and stress

Alexithymia has been linked to various disorders, including compulsive behaviors, anxiety disorders, and physical conditions with or without symptoms. It has been hypothesized that these disorders result from the alexithymic inability to differentiate and elaborate affect, which gives rise to physiological arousal and a negative subjective state, which are not regulated by psychological strategies. We tested these hypothesized mechanisms by comparing 42 alexithymic subjects with 42 sex- and race-matched non-alexithymic subjects on physiological and subjective responses to an autogenic relaxation exercise and three different laboratory stressors. Alexithymic subjects had tonically greater electrodermal activity and reported more arousal and displeasure in general than nonalexithymic subjects. Groups did not differ in the degree to which they relaxed, but alexithymic subjects reported less enjoyment of, less involvement in, and poorer imagery during relaxation. All three stressors evoked reactivity, and alexithymic women had less heart rate change when viewing disgusting scenes than did nonalexithymic women; in general, however, groups did not differ in reactivity or recovery to the stressors. We find some support for the hypothesized mechanisms of alexithymia, and we suggest specific links between alexithymia and clinical disorders.

Alexithymia in a clinical sample of obese women

The purpose was to examine the rate of alexithymia as measured by the Toronto Alexithymia Scale in a clinical sample of obese women without Binge Eating Disorder. Subjects included 165 inpatients in an eating disorder unit and 135 normal-weight individuals (comparison group). The obese subjects also completed a series of tests including the Minnesota Multiphasic Personality Inventory, the Anxiety Scale Questionnaire, and the Eating Attitude Test. Analysis showed that the subgroups of obese persons differ in important ways and cannot necessarily be treated, studied, or understood through a single paradigm. Alexithymic behaviour, too, was not characteristic of obesity, but it was present only in the subgroup of subjects with psychopathological characteristics.

Alexithymia, social support and health problems

This article presents three studies examining whether alexithymia is associated with less perceived and network social support, whether such relationships are accounted for by reduced social skills associated with alexithymia, and whether limited social support links alexithymia to health problems. The relationships between alexithymia (Toronto Alexithymia Scale), social variables, and physical health and depression were examined in both healthy young adults and patients. Alexithymia (especially deficits in identifying and communicating feelings) was related to less perceived support, fewer close relationships, and less social skill: the social skills deficit accounted fully for the association between alexithymia and a smaller social network. Additionally, alexithymia was related to both somatic complaints and depression, but social support generally was not. It is concluded that alexithymia is associated with reduced perceived and network social support, that these associations are likely due to alexithymia-related deficiencies in social skills but that reduced social support does not account for the relationship between alexithymia and health problems.

A California Q-set alexithymia prototype and its relationship to ego-control and ego-resiliency

The primary purposes of the present study were to use the Q-sort method to develop a measure of alexithymia and to locate the construct within a two-dimensional (ego-control and ego-resiliency) model of personality. Thirteen professional judges described the characteristics of the alexithymic personality with the 100-item California Q-set. Scores from the sorts were aggregated to form the Alexithymia Prototype, which had a Spearman-Brown reliability of 0.99. Alexithymic people were described as having difficulties experiencing and expressing emotion, lacking imagination, and being literal, socially conforming, and utilitarian; they lack insight, are humorless, and experience meaninglessness; and anxiety and tension find outlet in bodily symptoms. This description is consistent, for the most part, with modern formulations of the alexithymia construct. In the language of the two-dimensional personality model, alexithymic individuals appear to be overcontrolling and lacking ego-resiliency (i.e., constricted, anxious, rigid, and withdrawn). We, therefore, compared the Alexithymia Prototype with two independently developed prototypes, Overcontrol and Ego-Resiliency. The Q-correlations between alexithymia and overcontrol and between alexithymia and ego-resiliency were 0.45 and -0.70, respectively. Although item analyses confirmed moderate overlap between alexithymia and overcontrol and considerable overlap between alexithymia and lacking ego-resiliency (ego-brittle), item differences suggest that alexithymia, indeed, is a unique personality construct.

Independency of alexithymia and somatization. A factor analytic study

In discussions on the several methodological limitations in the assessment of alexithymia, uncertainty still remains about whether alexithymia and somatization are distinct constructs or whether they share overlapping symptomatology and constructs, as suggested by previous studies. In this study, 379 normal adults completed the newly developed 20-item Toronto Alexithymia Scale (TAS-20) and a screening list for DSM-III-R somatization disorder. Items from both the TAS-20 and the somatization checklist were subjected to factor analysis, resulting in separate factor loadings according to these two scales. These results were replicated and cross-validated in a sample of 125 psychosomatic inpatients, supporting the view of an independency between alexithymia and somatization.

Family factors related to alexithymia characteristics

There is little empirical research on the familial and parental correlates of alexithymia. A two-part study explored how the affective and cognitive characteristics of alexithymia are related to family dysfunction and maternal alexithymia. In Part I, 127 young adults were evaluated for alexithymia with the Toronto Alexithymia Scale-20 (TAS-20), for impaired imagination with the Scored Archetypal Test with Nine Elements, and for family dysfunction with the McMaster Family Assessment Device. In Part II, 80 of their mothers completed the TAS-20 about themselves, and maternal alexithymia characteristics were correlated with those of their offspring. In Part I, general family pathology was associated with alexithymia. In particular, difficulty identifying feelings was related to dysfunctional family affective involvement, externally oriented thinking was related to deficient family behavior control, and impaired imagination was related to inadequate family problem solving; these relationships were independent of general family pathology and subjects' positive and negative affect. In Part II, maternal alexithymia characteristics were correlated significantly with the offsprings', controlling for both respondents' positive and negative affect. These findings implicate disturbed family functioning and maternal alexithymia in the development of alexithymia characteristics in children.

Alexithymia and health care utilization

Alexithymia's link with health care utilization is unclear. Alexithymia may be overrepresented among clinical samples because of a proclivity to seek care, or alexithymia may prompt delay or avoidance of care, perhaps exacerbating illness. In 911 young adults, this study examined relationships between alexithymia (Toronto Alexithymia Scale-20; total and three factor scores) and the use of six health services during the past year: outpatient medical treatment, emergency room, hospitalization, psychotherapy, routine dental care, and nonprescription analgesics. Three potential mediators (insurance status, depression, and somatic complaints) were controlled to determine alexithymia's unique relation to utilization. The alexithymic difficulty in identifying feelings was linked to increased use of outpatient treatment, after controlling for potential mediators. Difficulty identifying feelings also was related to the use of psychotherapy and analgesics, but these relationships were accounted for by increased depression and somatic complaints, respectively. The alexithymic preference for externally oriented thinking was independently linked with the decreased use of outpatient treatment, to not having psychotherapy, and to being more likely to obtain preventive dental care. Our results may explain contradictions in the literature; separate alexithymic characteristics have different relationships with different types of health care utilization.

Somatisation in children

This review summarises recent work on somatisation in childhood. Minor physiological dysfunction may play a part in a number of cases and associated psychiatric disorders are commonly though not universally found. Contributory family factors include high rates of health problems and of parental psychological distress and there is some evidence for the role of family modelling and reinforcement of illness behaviour. There is suggestive evidence linking somatisation to emotional closeness in families, to family togetherness around health matters and to anomalies in children's social relationships. Somatisation in children can respond to treatments involving cognitive-behavioural and family techniques as well as to sensitive, psychologically sound advice from paediatricians.

Alexithymia in primary health care patients

Although many studies have been published about the relationship between alexithymia and different somatic diseases, little is known about the occurrence of alexithymia in primary health care patients. The aim of the present study was to shed light on this problem. The study forms part of a larger project dealing with psychiatric morbidity in primary health care patients. The original material consisted of 1,000 randomly selected adult patients in Turku in 1989-90. As part of a follow-up study (N = 748) three years later, alexithymia was measured using the Toronto Alexithymia Scale (TAS). Primary care patients seemed to have commonly alexithymic features: The mean of the TAS-score was 64.41 +/- 11.71 for male and 63.51 +/- 11.86 for female patients. The results indicated that alexithymia was associated with psychological distress, age, educational level, and socioeconomic status. The nature of alexithymia is discussed.

Feelings and fantasy in eating disorders: a factor analysis of the Toronto Alexithymia Scale

The aim of the study was to examine the factor structure of alexithymia in patients with eating disorders and to compare scores on these factors with a non-eating disordered population. The Toronto Alexithymia Scale (TAS) was given to patients with restricting anorexia nervosa (AN/R, n = 29), bulimia nervosa (BN, n = 83), anorexia with a subtype bulimia (AN/BN, n = 15), and 79 female students. Factors were extracted using a principal-components factor analysis. Four factors were found--inability to Identify Feelings, Paucity of Fantasy, Noncommunication of Feelings, and Concrete Thinking. All three eating disorder groups were less able to identify their feelings than the comparison group and AN/R patients had a more diminished fantasy life than BN patients and students. Groups did not differ significantly on concrete thinking but there was a trend towards significance on noncommunication of feelings, with patient groups expressing their feelings less than comparison subjects. Differences between patient groups on factors of the TAS suggest that scores are not simply a result of psychopathology in general. Approaches which promote the identification and expression of feelings may be particularly useful in the treatment of eating disorders.

Alexithymia, affect recognition, and five factors of personality in substance abusers

A total of 80 adults (40 normal volunteers, 40 substance abusers) participated in a study about alexithymia and five factors of personality, measured on the Toronto Alexithymia Scale and the NEO Five Factor Inventory, respectively, and their relationship to recognition of affect. The substance abusers scored the same as the age- and sex-matched normal volunteers on recognizing posed facial expressions, but higher on the alexithymia scale, while on Neuroticism and Extraversion they had lower scores on Agreeableness.

A 20-h recovery sleep after prolonged sleep restriction: some effects of competing in a world record-setting cinemarathon

The recovery sleep of a 21-year-old normal woman was assessed after she had endured 11(1/2) days of sleep restriction in a world record-setting film-viewing marathon. An exceptional sleep debt was observed as indicated by an instanteous sleep onset, a high sleep efficiency, and a total sleep duration of over 20 hours. Other striking features of this recovery sleep were very short latencies to stages 3 and 4 sleep, return of Stage 4 sleep after 14.5 h, REM and SWS sleep rebound, and a linear increase in REM sleep efficiency across 14 consecutive REM-NREM episodes. Seven of nine home dreams reported after this recording contained competition themes, but none relating to the marathon films. Comparisons of the present results with those from subjects in previous record-setting events suggest possible explanations for the extremely long recovery sleep. Results also suggest that analyses of multiple consecutive sleep cycles may provide novel ways of assessing hypotheses about regulation of the REM-NREM cycle.

Alexithymia, obesity, and binge eating disorder

Eighty-three obese subjects with binge eating disorder (BED) were compared with 99 obese subjects not meeting criteria for BED on the Toronto Alexithymia Scale (TAS). Overall, the subjects in our sample were not significantly alexithymic, the mean global TAS score being 62.8 (SD = 10.2) which is comparable with the values found in non-patient control samples. Furthermore, the mean TAS scores did not differ between obese subjects with and without BED. However, we found a slightly higher prevalence of alexithymia (TAS total score 74 and above) in BED subjects compared with non-BED subjects (24.1% and 11.1%, respectively). A series of stepwise multiple regression analyses were run, exhibiting a significant relationship between the TAS and educational level and the Eating Disorder Inventory (EDI) subscales Interpersonal Distrust and Ineffectiveness. Age, body mass index, measures of depression, and eating pathology did not predict TAS scores.

The relationship between mood, somatization, and alexithymia in premenstrual syndrome

To examine the relationship between mood, somatization, and alexithymia in premenstrual syndrome (PMS), 66 women with a prospectively confirmed diagnosis of PMS were compared with a group of 49 non-PMS control women on a battery of self-administered tests measuring depression, anxiety, somatization, and alexithymia. Based on their scores on the Beck Depression Inventory, the PMS patients were subdivided into a high-depression and low-depression group and compared with the non-PMS control group on all test measures. Significantly greater somatization and alexithymia were reported in the high-depression PMS group, and no differences were found on any of the test measures between the low-depression PMS and non-PMS control groups.

Alexithymia, depression, and treatment outcome in bulimia nervosa

Disturbances in emotional awareness, sometimes referred to as alexithymia, have been hypothesized to contribute to the development of binge/purge symptoms among women with bulimia nervosa (BN) and/or are considered secondary to the state of depression and/or disordered eating. The present study was designed to assess alexithymia among women with BN, to evaluate the interrelationship between alexithymia, depression, and somatic symptoms, and to determine whether an intensive group psychotherapy program contributes to a reduction in the degree of alexithymia. Thirty-one of 50 BN women (62%) who completed The Toronto Hospital Day Hospital Program for Eating Disorders (DHP) were administered pretreatment and posttreatment questionnaires. Findings from this clinical sample were compared with those from 20 non-eating-disordered women who completed the same battery. Using the Toronto Alexithymia Scale (TAS), significantly more BN women were alexithymic at pretreatment (61.3%) and post-treatment (32.3%) than in the comparison group (5.0%), even when depression was controlled for. At discharge, abstinence from binge/purge episodes was associated with a significant reduction in alexithymia, although there was a significant correlation between TAS scores, depression, and vomit frequency. Alexithymia among BN women is not simply a concomitant of disordered eating. Its partial reversibility following an intensive psychotherapy program may be a direct effect of the treatment and/or may be secondary to a reduction in depressive and/or binge/purge symptoms.

Alexithymia and somatization: relationship to DSM-III-R diagnoses

In previous studies, results from psychometric measures suggested an association between alexithymia and somatization. However, alexithymia has not been examined in relation to somatoform disorders and other standard psychiatric diagnoses. In the present study, the prevalence of DSM-III-R diagnoses was determined by SCID interviews among 45 psychiatric inpatients with functional somatic syndromes. In addition, the Toronto Alexithymia Scale (TAS) and the SCL-90-R were administered. Of the sample, 42.2% scored in the alexithymic range of the TAS. The alexithymic patients presented significantly more psychological turmoil and overall psychopathology on the SCL-90-R, as well as a significantly higher number of current DSM-III-R diagnoses. However, alexithymia was unrelated to DSM-III-R somatoform disorders and other DSM-III-R diagnoses, as well as the course of illness. These results suggest that assessing clinical features in addition to psychometric measures seems to be necessary for further validating the potential role of the alexithymia construct in somatic symptom formation.

Characteristics of alexithymia and eating disorders in college women

This study examined the relationship between characteristics of alexithymia and eating disorders (anorexia nervosa, bulimia nervosa, and obesity) in a nonclinical sample of 308 college women. Scores on the Toronto Alexithymia Scale were mostly unrelated to a weight index, which assessed subjects' deviation from their expected weight, but were correlated with subjects' scores on the Eating Disorders Inventory (EDI). EDI scores were related to the affective deficits of alexithymia (difficulty identifying and communicating feelings), but not to the cognitive disturbance associated with alexithymia.

Alexithymia: relationship to personality disorders

Previous studies suggested an association of alexithymia with other personality models, as well as with various psychiatric syndromes. However, with regard to current diagnostic systems, the clinical validity of alexithymia remains to be established. In a sample of 182 psychiatric outpatients, the lifetime prevalence of DSM-III-R axis I disorders was determined by Structured Clinical Interview for DSM-III-R (SCID) interviews. In addition, DSM-III-R personality disorders were assessed using the Personality Diagnostic Questionnaire-Revised (PDQ-R). On the Toronto Alexithymia Scale (TAS), 17% of the sample scored in the alexithymic range. A series of stepwise multiple regression analyses were performed, exhibiting no relationship between alexithymia and any of the DSM-III-R axis I lifetime diagnoses. In contrast, schizotypal, dependent, and avoidant personality dimensions, as well as a lack of histrionic features, emerged as significant predictors of alexithymia, which further supports the conceptualization of alexithymia as a personality dimension.

Alexithymia, affect recognition, and the five-factor model of personality in normal subjects

A total of 62 staff members from a general hospital participated in a study about alexithymia and the five-factor model of personality, measured by the Toronto Alexithymia Scale and the NEO Five Factor Inventory, respectively, and their relationship to recognition affect. Subjects with alexithymic characteristics were less able to recognize affective states in posed facial expressions and so may have modified their empathic capacity.

Alexithymia in women and men hospitalized for psychoactive substance dependence

Self-report alexithymia, depression, and anxiety inventories were completed by 204 (84 women and 120 men) psychoactive substance-dependent patients during their first week of hospitalization. Eighty-five of the 204 patients (41.7%) scored in the alexithymic range on the revised Toronto Alexithymia Scale (TAS-20). Women's average alexithymia, depression (Beck Depression Inventory [BDI]), and anxiety (State-Trait Anxiety Inventory-State [STAI-S]) scores were higher than men's average scores. Ethnic (Hispanic whites v non-Hispanic whites) and diagnostic (alcohol v drug v mixed-substance dependence) group differences were not significant. To examine the interrelationships among alexithymia, depression, and anxiety, a causal model confirmed in medical students was tested. The model was reconfirmed; state anxiety predicted depression and alexithymia, and depression predicted alexithymia. These findings are consistent with previous research and compatible with the view that a state of alexithymia can result from severe anxiety and depression.

A controlled study of alexithymia in eating disorders

The aims of the study were (1) to establish whether alexithymia is present in patients with bulimia nervosa (BN), (2) to compare bulimic patients with restricting anorexics (AN/R), bulimic anorexics (AN/BN), and normal controls with regard to alexithymia, (3) to determine whether in BN patients alexithymia is a state or a trait, and (4) to see whether alexithymia predicts short-term treatment outcome in BN. Study 1 included 173 eating disorder patients (BN: n = 93, AN/R: n = 55, AN/BN: n = 25) who were compared with 95 controls on the Toronto Alexithymia Scale (TAS). Study 2 included 41 BN patients who were assessed prospectively with the TAS before and after a 10-week drug treatment. AN/R patients in study 1 had significantly higher alexithymia scores than BN patients. All three eating disorder groups had significantly higher alexithymia scores than controls. For BN patients in study 2, TAS scores before and after drug treatment were stable, despite significant symptomatic improvement. We conclude the following: (1) eating disorder patients are considerably more alexithymic than normal controls; and (2) in BN, alexithymia may be a trait, unaffected by clinical improvement unless psychological treatment, encouraging the expression of emotions is offered.

Cognitive and social correlates of the Toronto Alexithymia Scale

The authors examine the relationship of the Toronto Alexithymia Scale (TAS) to sociodemographic characteristics, medical history, symptomatology, and illness cognition in a sample of 244 family medicine patients. The TAS had moderate internal reliability. In multiple regression analysis, the TAS was related to age, education, depressive symptoms, emotion suppression, self-consciousness, illness worry, and tendency to attribute somatic symptoms to psychological causes. Factor analysis of the TAS yielded four factors: Factor 1 (difficulty identifying feelings and bodily sensations) was related to education, social desirability, depressive symptoms, and private body-consciousness. Factor 2 (externally oriented thinking) was related to emotion suppression and self-consciousness. Factor 3 (difficulty expressing feelings to others) was related to age, social desirability, severity of past medical illness, depressive and somatic symptoms, and emotion suppression. Factor 4 (reduced daydreaming) was related to age and self-consciousness. The TAS measures conceptually distinct dimensions that are best studied as separate factors in psychosomatic models.

Alexithymia in women with anorexia nervosa. A preliminary investigation

The prevalence of alexithymia in 48 female anorexia nervosa patients was 77.1% compared with a prevalence of 6.7% in 30 normal female subjects, matched by age and education. Alexithymia correlated negatively with education in the anorexic patient group, but was unrelated to duration of illness, amount of weight loss, and levels of depression and of general psychoneurotic pathology.

Alexithymia and somatic complaints in psychiatric out-patients

This study investigated the prevalence of alexithymia and its relationship with somatic complaints in a sample of 118 general psychiatric out-patients. Of the sample 39.8% scored in the alexithymic range of the Toronto Alexithymia Scale. Compared with the non-alexithymic patients, the alexithymic patients scored significantly higher on several Minnesota Multiphasic Personality Inventory (MMPI) scales that collectively measure a diverse and extensive range of somatic symptoms and bodily concerns. In addition, the alexithymic patients had significantly higher levels of anxiety, depression, and general psychological turmoil. Although the alexithymic and non-alexithymic patients did not differ on the MMPI Repression and overall Hysteria Scales, which reflect the defenses of denial and repression, the alexithymic patients had significantly less ego strength and were significantly more dependent and more likely to engage in impulsive and acting out behaviours. The overall pattern of results is consistent with the view that alexithymic individuals are prone to both 'functional' somatic symptoms and symptoms of emotional turmoil because they are not well equipped psychologically.

Psychoanalysis and psychosomatics: a new synthesis

The usefulness of psychoanalysis to psychosomatic medicine has been limited by the longstanding assumption that the psychological disorder in psychosomatic patients resembles the conflict-based psychopathology that Freud identified in psychoneurotic patients. Recent investigations of the alexithymia construct, and the discovery that social relationships can influence health over the entire life span, have challenged this assumption and created an opportunity for a new and active involvement of psychoanalysis with psychosomatic medicine. In this contribution, I offer a synthesis of contemporary psychoanalytic observations and theories with concepts and research findings from developmental psychology, developmental biology, and the biomedical sciences. The proposed synthesis is consistent with the view that living organisms are self-regulating cybernetic systems; it also extends an evolving new psychosomatic model that conceptualizes illnesses and diseases as disorders of psychobiological regulation. A modern psychoanalytic approach to physically ill and disease-prone individuals focuses less on the resolution of neurotic conflicts, and more on correcting deficits in these patients' self and object representations and capacity cognitively to process emotions.