The Twenty-item Toronto Alexithymia Scale--II. Convergent, discriminant, and concurrent validity

Is alexithymia a risk factor for unexplained physical symptoms in general medical outpatients?

OBJECTIVE

Alexithymia is presumed to play an important predisposing role in the pathogenesis of medically unexplained physical symptoms. However, no research on alexithymia has been done among general medical outpatients who present with medically unexplained physical symptoms as their main problem and in which anxiety and depression have been considered as possible confounding factors. This study investigated whether patients with medically unexplained physical symptoms are more alexithymic than those with explained symptoms and whether, in patients with unexplained symptoms, alexithymia is associated with subjective health experience and use of medical services.

METHODS

We conducted a cross-sectional study among patients attending an internal medicine outpatient clinic. All patients were given a standardized interview and completed a number of questionnaires.

RESULTS

After complete physical examinations, 169 of 321 patients had unexplained physical symptoms according to two independent raters. Patients with medically unexplained symptoms more often had a mental disorder, but overall they were not more alexithymic. In patients with unexplained physical symptoms, alexithymia was not associated with subjective health experience or use of medical services. However, patients with both unexplained symptoms and a mental disorder who also denied any possible connection between emotional problems and their physical symptoms did have more alexithymic traits.

CONCLUSIONS

In the majority of patients with medically unexplained physical symptoms, alexithymia does not play a role of clinical significance. Patients with unexplained physical symptoms are heterogeneous with respect to psychiatric syndrome pathology and probably also with respect to personality pathology.

Perceived parental attitude, alexithymia and defense style in psychiatric outpatients

BACKGROUND

Although it is the clinical impression that alexithymia may be due to disturbances in the early parent-child relationship and that it is associated with primitive defense mechanisms, a possible association with neurotic defense mechanisms, such as repression and reaction formation, has also been mentioned. However, empirical studies on these and related issues are scarce. The aim of this study was to determine the association between perceived parental attitude, defense mechanisms and alexithymia.

METHODS

In a cross-sectional study we obtained data from 78 psychiatric outpatients. Alexithymia, defense mechanisms and perceived parental attitude were measured with the Toronto Alexithymia Scale, the Defense Style Questionnaire and the Parental Bonding Instrument.

RESULTS

We found only weak associations between perceived parental attitude and alexithymic features. Primitive and adaptive defenses were associated with alexithymic features in a clinically sensible way. The strongest association was found between primitive defense mechanisms and alexithymic features. There was hardly any association between neurotic defense mechanisms and alexithymic features.

CONCLUSIONS

The results of our study support the hypothesis that alexithymia is associated with a primitive defense style, whereas a relation to disturbances in early parent-child relationship could not be confirmed. It is argued that possibly more severe traumatic experiences, such as physical and sexual abuse, than merely a negatively perceived parental attitude, are necessary to develop alexithymic features.

Relationships between alexithymia, emotional control, and quality of life in patients with inflammatory bowel disease

BACKGROUND

Although the constructs of alexithymia and emotional control have been associated with physical health, the relationship between these constructs is unclear and their influence on health-related quality of life has not been investigated previously. This study examined the relationships between alexithymia, emotional control, and quality of life in 74 patients with inflammatory bowel disease (IBD).

METHODS

The subjects completed the 20-item Toronto Alexithymia Scale (TAS-20), the Emotional Expression and Control Scale (EEC), and the Inflammatory Bowel Disease Questionnaire (IBDQ) for assessing quality of life.

RESULTS

The TAS-20 correlated negatively and significantly with the IBDQ global score and with subscales assessing bowel symptoms, systemic symptoms, and emotional functioning; the emotional control subscale of the EEC correlated positively and significantly with these measures. Although the TAS-20 correlated significantly and negatively with the emotional control subscale, alexithymia and quality of life scores were unrelated to subscales of the EEC assessing tendencies to either hold back or express emotions. A hierarchical stepwise multiple regression analysis revealed that alexithymia and, to a lesser extent, emotional control play a role in predicting quality of life in patients with IBD.

CONCLUSIONS

Alexithymia and emotional control are negatively related constructs and each construct has an independent influence on the subjective health status of patients with IBD.

Cognitive behavioural therapy for patients with electric sensitivity - a multidisciplinary approach in a controlled study

BACKGROUND

Electric sensitivity is a syndrome that still lacks diagnostic criteria and proven aetiology. The suffering of afflicted persons motivates development and evaluation of effective handling and treatments. The aim of the study was to evaluate the effect of cognitive behavioural therapy in patients with electric sensitivity.

METHODS

Cognitive behavioural treatment, as part of a multidisciplinary treatment package for patients with electric sensitivity, was evaluated in a controlled trial. Ten patients who received treatment were compared to 12 controls. Outcome measures included different dimensions such as symptoms, beliefs, behaviour, and biochemical measurements of stress-related variables. All outcome measures were collected prior to the study, post-treatment, and after an additional 6-month follow-up.

RESULTS

The therapy group rated their electric sensitivity as significantly lower than did the control group at the 6-month follow-up, and reduction of self-rated discomforts from triggering factors was significant in the therapy group. There were no systematic changes in the biochemical variables. The symptom indices were significantly reduced over time, and ability to work continued to be good in both groups.

CONCLUSION

The prognosis for this syndrome is good with early intervention and cognitive therapy may further reduce the perceived hypersensitivity. This may have important implications on handling of patients with electric sensitivity.

Comparison of 26-item and 20-item versions of the Toronto Alexithymia Scale for psychiatric outpatients

This study compared the 20-item revised Toronto Alexithymia Scale with the 26-item version for 257 psychiatric outpatients. Scores on the 20-item version significantly correlated with those on the 26-item inventory even when controlled for depressed mood. Furthermore, the 20-item scale showed greater internal consistency. Factor analysis for both versions indicated three subfactors but the factors in the TAS-20 accounted for greater common variance (92%) than for the factors in the TAS-26 (78%). The total variance accounted for by these factors on the TAS-20 (45%) was also greater than for the TAS-26 (38%).

Concepts and methodology of psychosomatic research: facing the complexity

This review describes and discusses firstly the main characteristics and problems of psychosomatic research. One of the main problems is the validity of laboratory stressors in real-life situations. Secondly, it outlines the main philosophy and current concepts of psychosomatic medicine. The basic idea of a new integrative psychosomatic model is given. Thirdly, it presents some new methods that can be of use in psychosomatic research as well as research findings of special interest to cardiology. Especially the relationship between depression and coronary heart disease is discussed. The conclusion is that new methods and technical possibilities have great potential in enhancing psychosomatic research.

Pervasive emotion recognition deficit common to alexithymia and the repressive coping style

OBJECTIVE

Previous research has demonstrated a deficit in the ability to recognize emotions in alexithymic individuals. The repressive coping style is thought to preferentially impair the detection of unpleasant compared with pleasant emotions, and the degree of deficit is typically thought to be less severe than in alexithymia. We compared emotion recognition ability in both individuals with alexithymia and those with the repressive coping style.

METHODS

Three hundred seventy-nine subjects completed the 20-item Toronto Alexithymia Scale, the Levels of Emotional Awareness Scale, the Marlowe-Crowne Scale (a measure of repressive defensiveness), the Bendig Short Form of the Taylor Manifest Anxiety Scale, and the Perception of Affect Task. The Perception of Affect Task consists of four 35-item emotion recognition subtasks: matching sentences and words, faces and words, sentences and faces, and faces and photographs of scenes. The stimuli in each subtask consist of seven emotions (happiness, sadness, anger, fear, disgust, surprise, and neutral) depicted five times each. Recognition accuracy results were collapsed across subtasks within each emotion category.

RESULTS

Highly alexithymic subjects (for all, p<.01) and those with low emotional awareness (for all, p<.001) were consistently less accurate in emotion recognition in all seven categories. Highly defensive subjects (including repressors) were less accurate in the detection of anger, sadness, fear, and happiness (for all, p<.05). Furthermore, scores on the Levels of Emotional Awareness Scale accounted for significantly more variance in performance on the Perception of Affect Task than scores on the Marlowe-Crowne Scale (p<.01).

CONCLUSIONS

The results indicate that alexithymia and the repressive coping style are each associated with impairments in the recognition of both pleasant and unpleasant emotions and that the two styles of emotional self-regulation differ more in the magnitude than in the quality of these impairments.

Alexithymia and impoverished dream content: evidence from rapid eye movement sleep awakenings

OBJECTIVE

Despite the repeated suggestion in the literature of an association between impoverished dream processes and alexithymia, little systematic research has been conducted.

METHODS

Eight nonclinical adults scoring in the alexithymia range and eight nonclinical adults scoring in the nonalexithymia range on a measure of alexithymia were awakened for dream reports during their second, third, and fourth rapid eye movement periods on the second of two consecutive polygraphically monitored nights in a sleep laboratory.

RESULTS

The alexithymic and nonalexithymic groups did not differ in the number of dreams reported or the number of words used in the description of their dreams. The two groups also did not differ in their self-reports of the emotional valence associated with their dream experiences. In contrast, the dream reports of the alexithymic group were rated as less fantastic than the dream reports of the nonalexithymic group.

CONCLUSIONS

These findings provide additional evidence that alexithymia involves restricted imaginative processes.

Alexithymia and childhood family environment

Little research has been conducted on the contribution of environmental factors to the development of alexithymic tendencies. Ninety-two university students were surveyed to determine if features of the childhood family environment could predict the level of alexithymic tendencies. The 20-item Toronto Alexithymia Scale was used to measure alexithymic tendencies. Also surveyed retrospectively were dimensions of the childhood family environment such as the family's level of cohesion, expressiveness, conflict, disengagement, sociability, enmeshment, organization, and parenting style. Multiple-regression analysis showed that the set of family-environment variables did predict alexithymia scores. The sole family variable independently predictive of global alexithymic tendencies was expressiveness, although other family variables were predictive of individual components of alexithymia. The findings are consistent with the view that the childhood family environment has a bearing on the development of alexithymic tendencies, although other explanations by no means are excluded.

The relationship of alexithymia characteristics to dreaming

OBJECTIVE

In two studies, we tested two hypotheses about the relationship of alexithymia to dreaming; that dreams of alexithymic people are barren and rarely recalled, and that the dreams are unregulated and nightmarish.

METHODS

Study 1 was a retrospective survey of dreaming among several hundred young adults, and Study 2 was a 1-week, prospective diary study of 153 young adults in which recall, content, and length of dreams were assessed.

RESULTS

Across both studies, the externally oriented thinking (EOT) facet of the Toronto Alexithymia Scale (TAS)-20 correlated with different dream characteristics than the difficulty identifying feelings (DIF) and difficulty describing feelings (DDF) facets, even after statistically controlling for the other facets. Greater EOT was related to an increased frequency of nights without dream recall, having shorter dreams, having dreams rated as boring and lacking vividness, and not believing in the importance of dreams. In contrast, greater DIF or DDF was related to an increased frequency of nights with disturbing dreams, and having dreams rated as bizarre and aggressive.

CONCLUSION

We find support for both hypotheses, but different facets of the multidimensional alexithymia construct account for the two types of dream reports.

Pain location and psychological characteristics of patients with chronic pain

The authors assessed psychological characteristics of 140 medical outpatients with chronic non-malignant pain referred for psychiatric consultation. Subjects completed the Toronto Alexithymia Scale, Somatosensory Amplification Scale (SSAS), and Counter-dependency Scale (CDS). The only psychological measure able to differentiate the chronic pain group from the control subjects was the CDS. However, SSAS scores were significantly higher in subjects having pain involving the head, chest, abdomen, or pelvis than in subjects having pain only in their backs or extremities. The latter subgroup had significantly higher CDS scores. The findings suggest that there are discrete subgroups within the chronic pain population defined by pain location and specific psychological characteristics.

Attachment representation and cortisol response to the adult attachment interview in idiopathic spasmodic torticollis

OBJECTIVE

The study investigates individual differences in the mental representation of attachment and their impact on the cortisol response to psychosocial stress in idiopathic spasmodic torticollis (IST). It was hypothesized (a) that in IST insecure attachment is more prevalent than in a non-clinical control group and (b) that subjects with dismissing attachment respond with higher physiological arousal to a specific stimulus activating the attachment behavioural system than subjects with secure attachment.

METHOD

20 patients with IST and 20 healthy controls matched for age and sex underwent the Adult Attachment Interview, an hour-long, semiclinical interview on attachment experiences. During the interview salivary cortisol levels were monitored. The subjects' mental state with regard to attachment was classified using the attachment Q-sort method. Anxiety and depression were measured as potential covariates of the adrenocortical stress response.

RESULTS

Compared to the non-clinical group, dismissing attachment was strongly overrepresented in IST. In IST, but not in the healthy control group, dismissing attachment correlated with an elevated cortisol response to the interview.

CONCLUSION

In clinical, but not in non-clinical samples dismissing attachment may be associated with increased vulnerability to psychosocial stress. The factors contributing to this interaction are not yet fully elucidated.

A latent variable analysis of coexisting emotional deficits in substance abusers: alexithymia, hostility, and PTSD

The emotional disturbance of substance abusers is often described as an inability to identify and express feelings coupled with an excess vulnerability to experience negative affect. However, there is only limited empirical support for this perspective. To validate this description, we first defined components of alexithymia, hostility, and posttraumatic stress disorder (PTSD) derived from established measures of each by conducting confirmatory factor analyses based on a self-report data set from a clinical sample of 253 alcoholics and drug addicts. We then fashioned and tested overarching latent variables representing the three aspects of emotional dysfunction (i.e., alexithymia, hostility, and PTSD) and finally tested the correlations among these overarching variables. We found a strong association between a factor labeled Bottled-Up Emotions and another labeled Neurotic Hostility (r = .62) as well as an association between PTSD and Bottled-Up Emotions (r = .66). The structure, magnitude, and intercorrelation of the latent variables did not depend on the type of psychoactive substance abused. These results support the view that features of alexithymia and hostility coexist in substance abusers and that this joint deficit is part of a broad disturbance across multiple psychological domains including pathological response to traumatic stress.

Alexithymia and depression in eating disorders

We compared alexithymia and depression ratings for non-hospitalized women meeting DSM-IV criteria for anorexia nervosa (n=32) and bulimia nervosa (n=32) to ratings for healthy women (n=74). Alexithymia was evaluated by the Toronto Alexithymia Scale (TAS-20) and depression by the Hospital Anxiety and Depression Scale (HAD). TAS and HAD scores were significantly higher in anorexic compared to bulimic patients, although these two scales were significantly and positively correlated (r=0.53, P=0.001). After taking depression into account as a confounding variable, rates of alexithymia did not vary according to the type of eating disorder (anorexia or bulimia).

Alexithymia is associated with low tolerance to experimental painful stimulation

Alexithymics are known to report more somatic complaints than individuals scoring low on alexithymia. It was examined whether alexithymia would also be associated with enhanced sensitivity to an externally administered unpleasant physical stimulus. Forty-one healthy male and female subjects with a mean age of 33.9 years completed the 20-item version of the Toronto Alexithymia Scale and participated in a laboratory protocol consisting of exposure to painful electric stimulation. Multiple stepwise regression analyses revealed that after controlling for sensory threshold, duration of stimulation, and self-reported caffeine consumption, alexithymia predicted significantly pain tolerance level (beta=-0.33, P=0.01). Externally oriented thinking and difficulty identifying feelings, but not difficulty communicating feelings, were responsible for this association. Previous findings and the present results together indicate that alexithymia may be associated with an enhanced sensitivity to both internal (somatic) unpleasant sensations and externally induced pain, suggesting a potential general hypersensitivity to unpleasant stimuli in individuals scoring high on this trait.

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.

Zur Konstruktvalidität einer deutschen Fassung der Toronto Alexithymia Scale

Zusammenfassung: Eine deutsche Übersetzung der Toronto Alexithymie Skala (TAS) wurde an einer Studentenstichprobe (N = 228) auf ihre Faktorenstruktur und ihre psychometrischen Kennwerte hin überprüft. Anhand einer zweiten Stichprobe (N = 170) wurden die Zusammenhänge der Unterskalen der TAS mit Absorption untersucht, sowie mit Fragebogenskalen zu Beschwerdenäußerung, habitueller Gestimmtheit, Kontrollüberzeugung zu Krankheit und Gesundheit, Ärgerausdruck und defensiver Bewältigung. Die konfirmatorischen Faktorenanalysen (FA) sprachen für eine Mehrdimensionalität der TAS, mit einem Faktor zum Identifizieren, Differenzieren und Beschreiben von Gefühlen (TAS-ID), sowie zwei Faktoren des external orientierten Denkens. Die korrelierten TAS-Unterskalen zum external orientierten Denken, «Mangelnde Wichtigkeit von Emotionen» (TAS-WI) und «pragmatische Haltung» (TAS-PR), zeigten deutlich geringere Konsistenz als die von beiden relativ unabhängige Unterskala zu TAS-ID. Eine hierarchisch-oblique FA ergab keinen Sekundärfaktor im Sinne eines übergreifenden Alexithymiekonstrukts. Es ergaben sich widersprüchliche Zusammenhänge der TAS-Unterskalen mit der Absorption-Skala und weiteren Fragebogeninstrumenten. Es wird geschlossen, daß die TAS-Unterskalen kein einheitliches Alexithymiekonstrukt abbilden und daß weitere Untersuchungen zu Alexithymie auf Untermerkmale konzentriert werden sollten.

Depression is strongly associated with alexithymia in the general population

OBJECTIVE

This study examines how alexithymia and depression are related to each other in men and women in a sample of Finnish general population (n = 2018).

METHODS

Alexithymia was screened using the 20-item version of the Toronto Alexithymia Scale. Level of depression was assessed using the 21-item Beck Depression Inventory (BDI). Life satisfaction was estimated with a structured scale.

RESULTS

The prevalence of alexithymia was 12.8% in men and 8.2% in women. However, the prevalence of alexithymia was 32.1% among those having BDI scores of > or = 9, but only 4.3% among the nondepressed subjects (p < 0.001). The BDI scores explained 29.2% of the variation in TAS-20 scores. Alexithymia was associated with several sociodemographic factors if depression was not taken into account. However, after including depression in the logistic regression models, only depression and low life satisfaction were associated with alexithymia, both in men and women.

CONCLUSION

These results suggest that alexithymia has a close relationship to depression in the general population. The impact of social factors on alexithymia may be primarily explained by depression. Depression must be taken into account as a confounding factor when studying alexithymia in general populations due to the strong association between alexithymia and depression.

Alexithymic characteristics of HIV-positive patients

Despite extensive psychiatric research on HIV-positive patients, there are no published studies on alexithymia. Alexithymic characteristics and related factors were examined in a sample of 81 HIV-positive patients using the modified Beth Israel Psychosomatic Questionnaire and the Social Support of Stress and Coping Inventory. The severity of alexithymia was significantly higher in HIV patients than healthy controls, suggesting the presence of secondary alexithymia. Scores on two alexithymic characteristics, affect awareness and operational thinking, significantly correlated with ratings of poor utilization and perception of social support. As the severity of HIV infection progressed, affect awareness was higher, controlling for poor utilization and perception of social support. These results suggest that secondary alexithymia, associated with poor utilization and perception of social support, may be manifest as a state reaction to approaching death.

Alexithymia and health behaviors in healthy male volunteers

The association between alexithymia and maladaptive health behaviors was evaluated in 118 young, healthy men, aged 18-45 years. Subjects completed the Toronto Alexithymia Scale (TAS-26), and a health behaviors questionnaire, measuring alcohol and drug use, sedentary lifestyle, poor nutritional consumption, and risky sexual practices. In forced hierarchical regression analyses, the association between alexithymia and health behaviors was evaluated after adjusting for age, body mass index, social support, ambivalence over expression of emotion, and the expression of emotion. Results indicated that: (1) the TAS-26 and difficulty identifying feelings was associated with poor nutritional consumption; (2) difficulty identifying feelings was associated with greater alcohol and drug use; and (3) difficulty communicating feelings was associated with a more sedentary lifestyle. There was no association between risky sexual practices and alexithymia. These results suggest that, in young men, difficulties with identifying emotions and communicating emotions are associated with maladaptive nutritional habits, a sedentary lifestyle, and substance abuse, even after adjusting for other psychosocial and demographic variables. Such maladaptive health behaviors may help explain the association between alexithymia and premature mortality.

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.

Personality and social attitudes in chronic fatigue syndrome

One hundred one chronic fatigue syndrome (CFS) patients attending a specialist CFS clinic were compared with 45 rheumatoid arthritis (RA) patients on a range of standardized questionnaire measures, to investigate whether CFS patients are characterized by particular personality traits or social attitudes. No differences were found between CFS and RA patients in measures of perfectionism, attitudes toward mental illness, defensiveness, social desirability, or sensitivity to punishment (a concept related to neuroticism), on either crude or adjusted analyses. Alexithymia scores were greater in the RA patient group (p<0.05). Social adjustment, based on subjective assessment of overall restriction in activities and relationship difficulties, was substantially poorer in the CFS group (p<0.001). This was highly associated with depressive symptoms, but remained significant even after adjusting for depressive symptomatology. There was no evidence from this study of major differences between the personalities of CFS patients and RA patients. The stereotype of CFS sufferers as perfectionists with negative attitudes toward psychiatry was not supported.

The Amsterdam Alexithymia Scale: its psychometric values and correlations with other personality traits

BACKGROUND

This article describes the construction and validation of the Amsterdam Alexithymia Scale (AAS) and explores some of the nomological net of alexithymia.

METHODS

Four correlational studies are presented. The internal structure of the AAS is explored by factor analyses on items. Correlations of the AAS with sex and (Guilford) intellectual abilities are established. Mean scores of three different professional groups are compared. Correlations between the AAS and several clinical and personality scales are determined. Students served as subjects in all studies (347<n<559).

RESULTS

The 20-item AAS has a stable 5-factor structure, covering 5 defining features of alexithymia: difficulties in, respectively, experiencing emotions, fantasizing, analyzing emotions, differentiating between emotions and verbalizing emotions. The AAS showed to be reliable. The AAS scores were independent of verbal and nonverbal IQ. As expected, the AAS scores turned out to be significantly lower in a group of dramatic art students and significantly higher in a group of math and artificial intelligence students, when compared to psychology students. The AAS scores correlated negatively with extroversion, positively with social inadequacy and not with neuroticism. Finally, correlations between the AAS and the Adjective Check List scores indicated that alexithymia is associated with, respectively, a neglect of own needs and impulses, a reduced capability to understand social situations and a tendency to stick to rules rigidly, to flee into social isolation, to be submissive, to avoid commitment and to experiences of lack of personal meaning in life.

CONCLUSION

The AAS is the first instrument measuring the 5 defining features of alexithymia reliably and validly.

Alexithymia and functional gastrointestinal disorders. A comparison with inflammatory bowel disease

BACKGROUND

Although the alexithymia construct was derived from observations of patients with classical psychosomatic diseases, empirical studies have found only a moderate association between alexithymia and inflammatory bowel disease (IBD). Indeed, there is some evidence that alexithymia may be associated more strongly with functional somatic symptoms than with the psychosomatic diseases. The present study examined the relationship between alexithymia and functional gastrointestinal disorders (FGIDs) in a group of 121 FGID patients, and compared the results with findings from a group of 116 IBD patients and a group of 112 healthy subjects.

METHOD

The subjects completed the 20-item Toronto Alexithymia Scale and the Hospital Anxiety and Depression Scale.

RESULTS

The FGID group was significantly more alexithymic than the IBD group, and the two gastrointestinal groups were more alexithymic than the normal healthy group. These differences remained even after controlling for the influence of education, gender, anxiety, depression and gastrointestinal symptoms.

CONCLUSIONS

The finding of a high rate of alexithymia (66%) in the group of FGID patients is consistent with the propensity of these patients to somatization and to high levels of poorly differentiated psychological distress.

Relations between anxiety sensitivity and dimensions of alexithymia in a young adult sample

This study was conducted to assess the relations between anxiety sensitivity (AS) and dimensions of alexithymia in a nonclinical sample. We also sought to determine whether these relations persist after controlling for trait anxiety levels and panic attack history, and after controlling for item redundancy between the Anxiety Sensitivity Index (ASI) and the 20-item Toronto Alexithymia Scale (TAS-20). A sample of 238 undergraduate students completed the ASI, the TAS-20, and measures of trait anxiety and panic. A group of high AS participants (n=36) was found to have a significantly higher TAS-20 total score than a group of low AS participants (n=41), both before and after conceptually redundant TAS-20 items were removed. ASI scores were found to be significantly positively correlated with scores on the two TAS-20 subscales suspected of sharing a functional relation with AS (i.e., difficulty identifying emotions; difficulty describing emotions), whereas ASI scores were not significantly correlated with scores on the TAS-20 subscale believed to be functionally unrelated to AS (i.e., external-oriented thinking). This pattern of correlations between ASI scores and alexithymia dimensions persisted following the removal of conceptually redundant TAS-20 items, suggesting that the relation between AS and alexithymia is not merely an artifact of item redundancy. ASI scores remained significantly correlated with scores on the TAS-20's difficulty identifying emotions subscale, and marginally correlated with scores on the TAS-20's difficulty describing emotions subscale, after accounting for the influences of trait anxiety and panic history. The results also revealed that individuals who both experience frequent anxiety and who greatly fear their anxiety symptoms report the greatest difficulties identifying and describing emotional states. Implications for understanding the alexithymia construct, as well as potential clinical implications of the findings, are discussed.

Alexithymic traits as predictors of difficulties with adjustment in an outpatient cohort of expatriates in Tokyo

The purpose of this study was to examine whether alexithymic characteristics, which are thought to be related to poor coping with stress, would be associated with variables thought to reflect adjustment to life abroad. The subjects were 56 expatriates living in Tokyo, Japan. The Expatriate Adaptation Inventory, the Toronto Alexithymia Scale, and the Social Support Questionnaire of the Stress and Coping Inventory were given to the subjects. Scores on alexithymia were significantly associated with dissatisfaction with life abroad, higher satisfaction with life in one's home country prior to departure, and higher ratings on the perception of poor social support. An alexithymia variable, difficulty identifying feelings, was a significant predictor of dissatisfaction with life abroad and satisfaction with life in the home country. The results suggest that, because alexithymia was associated with lower satisfaction with life abroad and higher satisfaction in the home country prior to departure, it may be a predictor of adjustment difficulties when individuals live abroad. Empirical confirmation is needed.

Interhemispheric transfer deficit in alexithymia: an experimental study

OBJECTIVE

Previous research has demonstrated an association between alexithymia and a deficit in interhemispheric communication in Vietnam combat veterans with posttraumatic stress disorder. The purpose of this study was to evaluate this association in a nonclinical sample.

METHODS

The efficiency of interhemispheric transfer was assessed in 14 alexithymic and 15 nonalexithymic right-handed, male, undergraduate university students using a tactile finger localization task.

RESULTS

The nonalexithymic subjects were significantly more efficient at transferring information between the cerebral hemispheres than the alexithymic subjects.

CONCLUSIONS

This finding provides further evidence of an interhemispheric transfer deficit in alexithymia and suggests that an alexithymic cognitive style reflects poor integration of the information processing of the two cerebral hemispheres.

Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care

Frequent use of health services has been associated with such concepts as alexithymia, hypochondriasis, and psychological distress. The aim of this case-control study was firstly to assess whether alexithymia, hypochondriasis, and psychological distress are associated with frequent attendance and secondly to assess the gender differences of these associations in a primary health care setting. A sample of 304 frequent attenders (eight or more visits during 1 year), including all of the frequent attenders during 1994, and 304 randomly selected age- and sex-matched controls were selected. Half of the sample (every second individual selected in date-of-birth order) was invited for an interview, 113 frequent attenders and 107 controls completed a questionnaire during the interview. Alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20), hypochondriasis was screened with the Whiteley Index (WI), and Symptom Checklist-36 (SCL-36) was used to determine psychological distress. We found a distinct gender difference in the associations of these characteristics with frequent attending. Significant associations of alexithymia, hypochondriasis, and psychological distress with frequent attending were found among men, but not among women. Alexithymia, hypochondriasis, and psychological distress should be considered when treating frequent attenders, especially males.

Measuring counterdependency in patients with chronic pain

OBJECTIVE

Some reports have characterized patients with chronic pain as counterdependent, that is, having emotional suppression, idealization of relationships, strong work ethic, a caregiver role-identity, and self-reliance. However, research has been hampered because formal measures of these traits have been lacking. In this article, we describe a five-item self-report questionnaire, the Counterdependency Scale (CDS), designed to elicit each of these traits on a Likert scale.

METHODS

The CDS was administered to 150 consecutive patients evaluated in an outpatient psychiatry consultation program.

RESULTS

CDS scores were normally distributed and had significant interitem correlations and test-retest reliability (r = 0.68). As expected, subjects with chronic pain (N = 100) had higher mean CDS scores than those without chronic pain (t = 5.6, p = .000). CDS scores were independent of demographic variables and measures of anxiety, depression, alexithymia, and somatic amplification.

CONCLUSIONS

These results suggest that counterdependency can be described by a distinct and measurable cluster of traits associated with chronic pain.

Construct validity of the Sivik Psychosomaticism Test and test of operational style: correlations with four Minnesota Multiphasic Personality Inventory (MMPI) subscales

To evaluate the construct validity (convergent and divergent) of the Sivik Psycho Somaticism test (SPS) and test of Operationality (OPER), Pearson correlation coefficients between SPS scales and subscales, OPER and Minnesota Multiphasic Personality Inventory (MMPI) subscales Hypochondria (Hs), Depression (D), Hysteria (Hy) and Alexithymia (Al) were calculated. Eighty-eight healthy individuals and 285 psychosomatic patients completed the SPS and OPER tests and MMPI; Hs, D, Hy and Al. The results show that most of the SPS subscales and OPER are significantly correlated to several MMPI subscales in both a normal and a psychosomatic population. The results are in concordance with the theoretical hypotheses and confirm the validity of the SPS and OPER constructs.

Defense mechanisms in alexithymia

The Polish version of the Toronto Alexithymia Scale-20 and Defense Mechanisms Questionnaire were completed by 387 university students. Scores on alexithymia correlate significantly with scores on the whole group of 12 immature defenses (Pearson r = .39, p < .001) and with scores on such individual immature defense mechanisms as Autistic Fantasy (r = .39), Somatization (r = .37), Projection (r = .32), and Displacement (r = .32). These results support other findings indicating that alexithymia is significantly associated with immature ego defenses.

Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland

The prevalence of alexithymia and its association with sociodemographic variables were studied in a sample of 1285 subjects representing the general population of Finland. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20). Alexithymia was normally distributed in the population in both genders, confirming that it is a personality dimension. The prevalence of alexithymia was 13%. Men were alexithymic almost twice (17%) as often as women (10%). Multivariate analysis showed that alexithymia was associated with male gender, advanced age, low educational level, and low socioeconomic status. As to the three factors of the TAS-20, men scored higher in factors 2 (difficulty in describing feelings) and 3 (externally oriented thinking). but there was no gender difference in factor 1 (difficulty in identifying feelings). Comparative population studies in other countries are needed to find out whether there are any differences in the prevalence of alexithymia between cultures.

Alexithymia and attachment representation in idiopathic spasmodic torticollis

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

The validity of the California Q-set Alexithymia Prototype

The author examined the validity of the California Q-set Alexithymia Prototype (CAQ-AP), an observer- and self-report measure of the alexithymia construct. Alexithymia similarity scores (based on observer reports) were correlated with scores on several relevant self-report scales in a sample of 155 undergraduate college students. Alexithymia was positively correlated with neuroticism, depression, and anxiety; and negatively with extraversion, openness, and emotional expression. These correlations were statistically significant (P < 0.05) and in the expected direction. The CAQ-AP has passed its second validity check and, again, can be recommended as an observer measure of the alexithymia construct.

Sociodemographic correlates of alexithymia

The association between alexithymia and sociodemographic variables is not well understood. Previous studies using the current 20-item and previous 26-item versions of the Toronto Alexithymia Scale (TAS) have shown inconsistent associations with age, sex, socioeconomic status, and years of education. We tested 380 subjects from the community stratified equally across sex, five age groups, and three socioeconomic classes. In addition to the TAS-20, we also administered the Levels of Emotional Awareness Scale (LEAS), a behavioral measure of the ability to be aware of and represent emotions in words, a core component of alexithymia. The TAS-20 and LEAS were each correlated with age, sex, socioeconomic status (SES), and years of education (P < .01) in the same direction and to approximately the same degree. Alexithymia (or low emotional awareness) is associated with older age, male sex, lower SES, and fewer years of education. The TAS-20 and LEAS are only slightly correlated (r = -.19, n = 380, P < .001), but their correlation is largely accounted for by their shared variance with these demographic variables. The convergence of findings with these two quite different measures and the nature of their overlap support the validity of these associations between alexithymia and sociodemographic variables.