Independency of alexithymia and somatization. A factor analytic study

The conceptualization of emotions across cultures: a model based on interoceptive neuroscience

Mental processes are recognized to be embodied, hence dependent upon functions of the body. Interoception (i.e., the sense of the internal bodily physiology) underpinning motivational states and emotional feelings, however, are mostly ignored within present sensory-motor accounts of embodiment. The inclusion of interoception within models of embodiment is important both for health psychology and for theories of cognition. Here, we deduce that reference to visceral organs, in language describing emotion concepts, should be viewed as metonymy (i.e., the mental mapping wherein a component is used to describe the whole), rather than metaphor (i.e., one familiar and concrete concept used to describe another unfamiliar and/or abstract concept that shares some similarities). This view contrasts with a dominant assumption within cognitive linguistics. We further argue that conceptual differences in the assumption about the body-mind-emotion relationship or emotional somatization, evident when comparing Chinese to standard English, is culturally and cognitively determined (e.g., by divergent Western and Chinese philosophical, medical traditions and meaning systems). We propose a new model in which two contending variables, bodily transparency and cognitive granularity, define cultural differences in emotion conceptualization, capturing the dynamic multidimensional interaction between body, mind, brain, language, and society.

Factorial structure of the 20-item Toronto Alexithymia Scale in a large sample of somatoform patients

Although a strong association between alexithymia and somatization has been postulated in numerous studies, no systematic study has investigated the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) in a sample of patients with somatoform disorder yet. The purpose of this study was to ensure a valid assessment by the German version of the TAS-20 in somatoform samples. We investigated whether the original three-factor model proposed by Bagby et al. (1994a), which is widely used in clinical research and practice, is replicable in a large sample of somatoform patients (n=806). Using confirmatory factor analysis (CFA) the goodness-of-fit of the originally proposed factor structure was compared to three factor models generated with exploratory factor analysis (EFA) and other factorial solutions derived from the literature. Our results demonstrate that the original three-factor model is not replicable in somatoform patients. Instead, the four-factor model by Franz et al. (2001b) described the data best. However, none of the models met all criteria of confirmatory factor analysis. Our results indicate that the three-factor model is not robust in the German version of the TAS-20. At this state of research we recommend to use the TAS-20 sum-score as a measure of alexithymia in somatoform patients in clinical practice.

Assessing embodied interpersonal emotion regulation in somatic symptom disorders: a case study

The aim of the present study was to examine the intra- and interpersonal emotion regulation of patients with somatic symptom disorders (SSDs) during interactions with significant others (i.e., romantic partners). We presented two case couples for analysis. The first couple consisted of a patient with SSD and his healthy partner, whereas the second couple consisted of two healthy partners. The couples underwent an interpersonal experiment that involved baseline, anger and relaxation tasks. During each task, partners' cutaneous facial temperature, heart rate and skin conductance levels were measured simultaneously. Participants' trait-emotion regulation, state-affect reports for self and other, and attachment styles were also examined. The experimental phases were successful in creating variations in physiological processes and affective experience. As expected, emotion regulation difficulties predicted higher increase in the course of temperature at each phase. Besides, the patient showed restricted awareness and reflection to emotions despite his higher autonomic activity compared to healthy controls. Both partners of the first couple revealed limited ability in understanding the other's emotions, whereas the second couple performed relatively better in that domain. The temperature variations between the patient and his partner were significantly correlated while the correlations of temperature changes between the second couple were negligible except anger task. The study supported the merits of an embodied interpersonal approach in clinical studies. The tentative results of the cases were discussed in the light of findings in emotion regulation and attachment research.

Comparison of health-related quality-of-life measurement instruments in diabetic patients

The objective of the study was to compare three different questionnaires (Short Form (SF)-6D, EuroQuol (EQ)-5D and WHO-5) to establish which one is more sensitive and which one gives an adequate assessment of the quality of life in patients with diabetes.

In an observational and transversal study with duration of 4 months, in 5 Bulgarian cities, 146 patients were randomly selected. The following quality-of-life measuring instruments were applied: 146 questionnaires SF-6D, 146 questionnaires EQ-5D and 103 questionnaires of WHO-5. Descriptive statistics, chi-Square and correlation coefficients were used for data analysis. The study assessed the quality of life of patients suffering from diabetes mellitus with a mean age of 57.39 years (standard deviation (SD) 17.087); 95% confidence interval (CI) 54.60–60.19; 76% of the patients had diabetes type 2. The patients received a mean SF-6D score of 0.6290, an EQ-5D score of 0.6272, a visual analogue scale score of 0.7158 and a WHO-5 score of 0.4635. Preferences measured by the SF-6D and by the EQ-5D showed significant correlations with one another, and the Pearson coefficient was r = 0.906 (p < 0.01). The most current version of SF-6D, based on the 2002 model, was found to be valid and reliable when compared to the EQ-5D and is a questionnaire alternative to assess preferences in economic analysis carried out in health care.

Adolescents' emotional competence is associated with parents' neural sensitivity to emotions

An essential component of youths’ successful development is learning to appropriately respond to emotions, including the ability to recognize, identify, and describe one’s feelings. Such emotional competence is thought to arise through the parent–child relationship. Yet, the mechanisms by which parents transmit emotional competence to their children are difficult to measure because they are often implicit, idiosyncratic, and not easily articulated by parents or children. In the current study, we used a multifaceted approach that went beyond self-report measures and examined whether parental neural sensitivity to emotions predicted their child’s emotional competence. Twenty-two adolescent–parent dyads completed an fMRI scan during which they labeled the emotional expressions of negatively valenced faces. Results indicate that parents who recruited the amygdala, VLPFC, and brain regions involved in mentalizing (i.e., inferring others’ emotional states) had adolescent children with greater emotional competence. These results held after controlling for parents’ self-reports of emotional expressivity and adolescents’ self-reports of the warmth and support of their parent relationships. In addition, adolescents recruited neural regions involved in mentalizing during affect labeling, which significantly mediated the associated between parental neural sensitivity and adolescents’ emotional competence, suggesting that youth are modeling or referencing their parents’ emotional profiles, thereby contributing to better emotional competence.

Beyond the unexplainable pain: relational world of patients with somatization syndromes

Somatization syndromes are highly prevalent disorders with unknown etiology and are challenging to treat. Integrating previous findings on alexithymia, attachment, and trauma, we hypothesized that somatization syndromes are associated with a specific internal representation of relationships-the unmet need for closeness with others (desire for interpersonal closeness combined with the fear of being rejected, hurt, or abandoned). Twenty patients with DSM-IV somatization syndromes and 20 well-matched healthy controls completed the Relationship Anecdotes Paradigm/Core Conflictual Relationship Themes interview and measures of interpersonal relatedness, alexithymia, and history of trauma. The results showed that the unmet need for closeness with others was the main internal representation of relationships in 90% of the patients and in only 10% of controls; it was also the strongest predictor of somatization syndrome diagnosis. This suggests that somatization syndromes are strongly associated with the interpersonal representation of the unmet need for closeness with others, which has direct implications for their treatment and future research on their etiology.

Psychological and clinical correlates of functional somatic complaints in depression

BACKGROUND

Studies have shown that functional somatic symptoms are common in patients of depression. However, very few studies have assessed the socio-demographic, psychological and clinical correlates of functional somatic complaints in depression.

METHOD

Fifty (50) patients of first-episode unipolar depression (except for severe depression with psychotic symptoms), aged 18 to 50 years, with duration of depression of more than one month, with no comorbid psychiatric disorders and comorbid medical illnesses, and with at least one symptom on Bradford Somatic Inventory were assessed on the Beck's Depression Inventory, the Comprehensive Psychopathological Rating Scale - Anxiety Index, the Toronto Alexithymia Scale (Hindi version), the Somato-sensory Amplification Scale and the Whiteley Index.

RESULTS

The most commonly reported functional somatic complaints were a lack of energy much of the time (98%) and feeling tired when not working (82%). A significant positive correlation (Pearson's product moment value = 0.362, p < 0.01) was found between severity of depression and number of functional somatic complaints. Significant negative Spearman's rank correlation (-0.346, p < 0.05) was found between Bradford Somatic Inventory total score and Toronto Alexithymia Scale severity grade. A significant positive correlation between Bradford Somatic Inventory total score and somato-sensory amplification emerged only when common items were taken care of. No correlation was found between Bradford Somatic Inventory total score and any of the socio-demographic variables, age at onset of illness, total duration of illness, melancholic symptoms, suicidality, level of anxiety and hypochondriacal worry. Beck's Depression Inventory total score alone accounted for 11.3% of the variance in the Bradford Somatic Inventory total score.

CONCLUSION

Functional somatic complaints are more prevalent in patients with higher severity of depression, high somato-sensory amplification and less alexithymia. There is no correlation of functional somatic complaints with level of anxiety and hypochondriacal worry.

The impact of alexithymia on somatization after traumatic brain injury

INTRODUCTION

High rates of alexithymia have been reported following traumatic brain injury (TBI). Difficulty modulating emotional states has been shown to increase the risk of affective distress and the tendency to express this distress in the form of physical symptoms. The current study therefore examined relationships between alexithymia, affective distress and somatization in a TBI sample.

METHOD

Eighty-three patients with TBI completed the Toronto Alexithymia Scale (TAS-20) and the Symptom Checklist (SCL-90-R).

RESULTS

Alexithymic individuals reported higher ratings of anxiety, low mood and somatic symptoms. Alexithymia accounted for a significant amount of variance in anxiety, depression and somatization ratings. Scores on sub-scale 1 of the TAS-20 (difficulty identifying feelings) made a significant unique contribution to explaining somatization ratings after controlling for the influence of anxiety and depression ratings.

CONCLUSION

Alexithymia after TBI increases the risk of affective disturbance and somatization. It needs to be identified at an early stage to direct rehabilitation interventions and improve prospects for psychosocial outcome.

Alexithymia as a predictor of outcome of psychodynamically oriented inpatient treatment

This naturalistic study aimed to determine whether the initial degree of alexithymia can predict treatment outcome of psychodynamically oriented multimodal therapy. The Toronto Alexithymia Scale-26, the Global Severity Index (GSI), and the Depression subscale of the Symptom Checklist-90-Revised were administered at hospital admission and at discharge to 480 inpatients with various psychological disorders. GSI and depressive symptoms decreased significantly during treatment. High initial alexithymia total scores significantly predicted treatment outcome, especially in patients with somatoform disorders. Difficulties in verbalizing feelings had the strongest association with less favourable symptom improvement. Although significant, the predictive values were relatively small, and patients with alexithymia indeed benefited from therapy. Implications of these results are discussed for the specificity of disorders and therapeutic approach.

Alexithymia and somatization in general population

OBJECTIVE

Even though the association between alexithymia and somatization seems plausible according to several studies with selected populations, it has not been verified in carefully controlled and nationally representative population studies. We conducted such a study to find out whether alexithymia is associated with somatization at population level.

METHODS

This study was a part of the Finnish Health 2000 Study. The nationally representative sample comprised 5129 subjects aged 30 to 97 years. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and somatic symptom reporting with the 12-item somatization scale derived from the Hopkins Symptom Checklist. Sociodemographic and health-related variables, including depressive and anxiety disorders, and physician verified somatic diagnoses, were treated as confounders in multivariate analyses.

RESULTS

Alexithymia was associated with somatization independently of somatic diseases, depression and anxiety and confounding sociodemographic variables. The TAS-20 factor scale "Difficulties Identifying Feelings" was the strongest common denominator between alexithymia and somatization.

CONCLUSIONS

This was the first time the independent association between alexithymia and somatization was established in a large, nationally representative nonclinical sample of both young and old adults with and without mental disorders and somatic diseases.

Alexithymia and 7.5-year incidence of compensated low back pain in 1207 urban public transit operators

OBJECTIVE

Alexithymia, a lack of emotional awareness, was positively associated with self-reported low back pain (LBP) in cross-sectional studies. We assessed the association of alexithymia with 7.5-year incidence of LBP prospectively in a cohort study of 1207 San Francisco transit operators.

METHODS

Alexithymia was measured by the 20-item Toronto Alexithymia Scale (TAS-20). LBP was assessed by physician-confirmed diagnoses from administrative workers' compensation data. Cox proportional hazards analyses controlled for demographic, behavioral, and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all drivers, 27.7% (n=334) filed compensated claims for LBP injuries with workers' compensation insurance during the 7.5-year observation time. The hazard ratios from the fully adjusted model were 0.73 (0.56-0.96) for the TAS-20 scale and 0.82 (0.69-0.98) for the subscale "difficulty describing feelings." Alexithymia scores did not predict the duration of compensated work disability.

CONCLUSION

In contrast to previous cross-sectional positive associations between alexithymia and LBP, alexithymia is negatively associated with compensated LBP claims. We hypothesize that shame and reporting behavior may explain these inconsistent results.

Alexithymia and anxiety sensitivity in Turkish depressive, anxiety and somatoform disorder outpatients *

Objective. To assess the relations between anxiety sensitivity, and dimensions of alexithymia in somatoform, anxiety and depressive disorder patients. Methods. The sample consisted of 124 patients with the diagnosis of depressive, anxiety, or somatoform spectrum disorders (DSM-IV). Toronto Alexithymia Scale (TAS-20), 16-item Anxiety Sensitivity Index (ASI), Hamilton Depression (HDRS), and Anxiety (HAS) scales were used. Results. The total sample (n=124) was divided into three diagnostic categories. There was one Depression Group (n=69). Due to small sample sizes, diagnoses in anxiety and somatoform spectrum disorders were combined in two relatively larger Anxiety (n=42) and Somatoform Groups (n=13) for statistical purposes. No statistically significant difference was found in the TAS-20 total or subscale scores between the three diagnostic groups. In all three diagnostic groups, there was a strong and significant positive correlation between ASI and TAS-20 total scores. In all three groups, there was a significant positive correlation between TAS-20 Factor 1 and ASI. In the Depression and Somatoform Groups, ASI scores were found to be significantly positively correlated with scores on TAS-20 Factor 2. Conclusion. This study reveals that alexithymia does not differentiate depressive, anxiety, or somatoform disorders, yet suggests a functional relation with anxiety sensitivity on a subscale basis.

Alexithymia and anxiety in female chronic pain patients

OBJECTIVES

Alexithymia is highly prevalent among chronic pain patients. Pain is a remarkable cause for high levels of chronic anxiety. The purpose of this study was to investigate the prevalence of alexithymia and to determine anxiety levels among DSM-IV somatoform pain disorder (chronic pain) female patients and to examine the relationship between alexithymia and the self-reporting of pain.

METHODS

Thirty adult females (mean age: 34.63 +/- 10.62 years), who applied to the outpatient psychiatry clinic at a public hospital with the diagnosis of chronic pain disorder (DSM-IV), were included in the study. Thirty seven healthy females (mean age: 34.46 +/- 7.43 years), who matched for sociodemographic features with the patient group, consisted the control group. A sociodemographic data form, 26-item Toronto Alexithymia Scale (TAS-26), Spielberger Trait Anxiety Inventory (STAI) were administered to each subject and information was obtained on several aspects of the patients' pain, including intensity (measured by VAS), and duration.

RESULTS

Chronic pain patients were found significantly more alexithymic than controls. There was a positive correlation between TAS-26 scores and the duration of pain. The alexithymic and nonalexithymic group did not differ in their perception of pain. Neither positive correlation nor significant difference was found between alexithymia and trait anxiety in pain patients.

DISCUSSION

Alexithymia may be important in addressing the diversity of subjective factors involved in pain. The conceptualization of alexithymia as a personality trait as well as a secondary state reaction is underlined by our data.

The 20-item Toronto Alexithymia Scale: validation of factor solutions using confirmatory factor analysis on physiotherapy out-patients

OBJECTIVE

Whilst the 20-item Toronto Alexithymia Scale (TAS-20) was developed to measure three intercorrelated dimensions, there is some debate as to whether the scale is best served by a two- or three-factor construct. In particular, there is some doubt as to whether clinical data exhibit the third factor. This study uses data from a sample of physiotherapy (physical therapy) out-patients in the UK to validate the factorial structure of a set of models postulated in the literature, including the three-factor model hypothesized by Bagby et al. (1994).

METHOD

Data were collected from a sample of physiotherapy out-patients (N=242). Specialist factor analysis software (LISREL 8.54) was used to perform confirmatory factor analyses on a range of models proposed in the literature.

RESULTS

The analysis supports the three-factor model assumed by Bagby et al. (1994), as well as most of the two-factor models suggested in the literature.

CONCLUSIONS

This new set of clinical data supports most of the two- and three-factor models postulated in the recent literature, including the three-factor model advocated by Bagby et al. (1994).

Alexithymia and somatosensory amplification in functional dyspepsia

Somatosensory amplification is the tendency to report somatic sensations as intense and disturbing. Alexithymia is a personality construct characterized by difficulty recognizing emotions and a tendency to focus on external events and bodily sensations. The association of somatosensory amplification and alexithymia with functional symptoms was assessed in 111 patients with functional dyspepsia and 53 healthy comparison subjects. The subjects completed several assessment instruments, including the Somatosensory Amplification Scale and the 20-Item Toronto Alexithymia Scale. The patients with dyspepsia had modestly higher scores on measures of alexithymia (especially difficulty identifying feelings) and somatosensory amplification. Alexithymia and somatosensory amplification may play important roles in symptom generation and perception in a subset of patients with functional dyspepsia, but the importance of these constructs in this patient population appears less than previously reported.

Are difficulties perceiving and expressing emotions associated with low-back pain? The relationship between lack of emotional awareness (alexithymia) and 12-month prevalence of low-back pain in 1180 urban public transit operators

OBJECTIVE

To assess the association of alexithymia (deficit in emotional awareness) with 12-month prevalence of low back pain (LBP) cross-sectionally in a cohort study of 1180 San Francisco transit operators.

METHODS

Alexithymia was measured by the Toronto Alexithymia Scale (TAS-20). LBP was assessed in medical histories during drivers relicensing exams. Multivariate logistic regression analyses controlled for demographic, behavioral (smoking, alcohol, coping style), and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all the drivers, 31.4% suffered from LBP. Scoring in the upper quartile of alexithymia summary scores was associated with twofold higher odds of LBP (adjusted odds ratio=2.00, 95% confidence interval: 1.31-3.00). The association was stronger in women (adj. OR=4.35) than in men (adj. OR=1.83). The factor "difficulty identifying feelings" showed the strongest association with LBP (adj. OR=2.23).

CONCLUSION

The results support an association between alexithymia and LBP.

Exploring the relations between depression, somatization, dissociation and alexithymia--overlapping or independent constructs?

BACKGROUND

The aim of this study was to extend our knowledge of associations among the constructs of alexithymia, depression, somatization and dissociation.

SAMPLING AND METHODS

924 nonclinical subjects answered questions about depression (21-item Beck Depression Inventory), somatization (13-item somatization part of Symptom Check List-90), dissociation (28-item Dissociative Experiences Scale) and alexithymia (20-item Toronto Alexithymia Scale). In addition, a 12-item General Health Questionnaire (GHQ-12) was administered to detect psychiatric distress among subjects.

RESULTS

The results suggested that there was a significant clinical correlation between somatization, dissociation, depression and alexithymia (rho varied from 0.31 to 0.56). The principal component analysis revealed the presence of four components: depression, somatization, dissociation and alexithymia. The use of factor scores diminished the covariance between measures (rho varied from -0.10 to 0.01 between the factor scores). There was almost no correlation between the dissociation factor (rho = 0.06) and alexithymia factor (rho = 0.09) scores and general distress (GHQ-12).

CONCLUSIONS

This study suggests that while somatization, dissociation, depression and alexithymia are distinct constructs, they correlate to a considerable extent. The use of factor analysis and factor scores should be considered to diminish covariance between the above constructs. Comparing results between factored and unfactored results may prove illuminating. As a case in point, the results suggest that the part of dissociation that coincides with other constructs (overlaps) is associated with distress, whereas the distinct part of dissociation (no shared covariance) is not associated with distress. The same applies to the alexithymia construct. Longitudinal studies are needed to show whether there is a trait such as a relatively stable dissociation component and also whether a separate state-dependent dissociation component exists that is associated with coincident distress, somatization and depression.

Theoretical and empirical exploration of the similarities between emotional numbing in posttraumatic stress disorder and alexithymia

This study rationally and scientifically examines the similarities between the emotional numbing symptoms of posttraumatic stress disorder (PTSD) and alexithymia. A clinical database from the Iowa City Department of Veterans Affairs Medical Center consisting of data from 274 combat veterans was used. Significant positive correlations were found between measures of PTSD, alexithymia, and combat exposure. Principal components analysis supported a lack of independence between PTSD subscales and alexithymia, as all variables loaded on one factor best labeled PTSD. This article presents both theoretical and empirical evidence suggesting that in traumatized persons, alexithymia may be better conceptualized as the emotional numbing aspect of PTSD rather than as a distinct construct.

The 20-Item Toronto Alexithymia Scale. III. Reliability and factorial validity in a community population

OBJECTIVE

Some researchers have questioned the stability of the three-factor structure of the 20-Item Toronto Alexithymia Scale (TAS-20) or the reliability of one or more factors of the scale. The aim of this study was to assess the replicability of the factor structure of the TAS-20 in a large community sample and to determine also whether the same three-factor structure can be recovered in men and women. The study also assessed the reliability of the scale and the influence of gender, age, and education on TAS-20 scores.

METHOD

The TAS-20 was administered to 1933 adults (880 men and 1053 women) residing in several small cities and towns in Ontario, Canada. The factor structure of the scale was assessed using confirmatory factor analysis (CFA).

RESULTS

The three-factor structure of the TAS-20 was replicable in the entire community sample and also separately in men and women. The TAS-20 and its three factors demonstrated internal reliability, and the variables of gender, age, and education accounted for relatively small or modest amounts of variability in total TAS-20 and factor scale scores.

CONCLUSION

The results provide strong support for the reliability and factorial validity of the TAS-20 and indicate the importance of using CFA when assessing the replicability and theoretical integrity of the factor structure of the scale.

Alexithymia and somatisation: quantitative review of the literature

OBJECTIVE

To present a quantitative review of the empirical literature on somatisation and alexithymia.

METHODS

Medline and PsycLIT searches for relevant studies were conducted. Meta-analytical techniques were applied to quantify the strength of the associations that were found.

RESULTS

A small to moderate relationship was found between general alexithymia and somatic symptom reporting. The alexithymia dimension measuring difficulty in identifying feelings showed the strongest association with symptom reports. The alexithymia dimension measuring externally oriented thinking was virtually unrelated to somatic symptom reports. Compared to healthy control populations, subjects suffering from a somatoform condition were significantly more alexithymic, with effect sizes ranging from moderate to large. The studies comparing somatoform to medical or psychiatric conditions yielded inconclusive results.

CONCLUSIONS

By means of quantitative procedures, an association between general alexithymia and somatic symptom reporting was established. Due to the use of questionnaires that can only check for symptoms, not whether these symptoms are medically explained or not, it is however not possible to draw conclusions on somatisation properly defined. The inconsistent results found when comparing somatoform conditions to medical and psychiatric controls may be attributed to confounding variables. In future studies, these variables should be statistically controlled to establish a more consistent pattern of associations between somatoform conditions and alexithymia. It is, however, equally feasible that this inconsistency reflects the nonspecific character of the association between alexithymia and somatisation. The presence of only one prospective study does not allow to draw conclusions on alexithymia as a predisposing factor for somatisation.

The assessment of alexithymia: a critical review of the literature and a psychometric study of the Toronto Alexithymia Scale-20

OBJECTIVE

The objectives were to give an overview of studies on the validity of the Toronto Alexithymia Scale (TAS-20) and to present data regarding the validity of the TAS-20.

METHODS

The literature on the psychometric properties of the TAS-20 was reviewed and a study was conducted of its psychometric properties in a sample of students and a sample of psychiatric outpatients using a statistical method allowing identification of a stable factor structure.

RESULTS

The review revealed that the majority of studies on the TAS-20 were conducted with nonpatient samples. The factorial validity and reliability of the dimensions 'identifying feelings' (DIF) and 'describing feelings' (DDF) could be replicated in many of these studies. However, in practically all studies the dimension 'externally oriented thinking' (EOT) appears to be unreliable. In addition, the presupposed fantasy aspect of the alexithymia construct is not included in the TAS-20. Although many studies were conducted on the construct validity of the TAS-20, no studies have been published on its criterion validity. Some studies show a different factor structure to exist in patient samples. This was confirmed in our own study in which the dimensions 'identifying feelings' and 'describing feelings' collapsed into one single subscale. As in other studies, the reliability of the dimension 'EOT' was low.

CONCLUSION

The TAS-20 has some important shortcomings with respect to validity and reliability. For the assessment of alexithymia in empirical research, it is recommended to use the TAS-20 in combination with other instruments. We do not recommend the TAS-20 to be used in clinical practice.

Alexithymia in DSM-IV Disorder: Comparative Evaluation of Somatoform Disorder, Panic Disorder, Obsessive-Compulsive Disorder, and Depression

The purpose of this study was a direct comparative evaluation of alexithymia in patients with somatoform disorder, panic disorder, obsessive-compulsive disorder, and depression, taking into account the multidimensionality of the alexithymia construct. The authors administered the Structured Clinical Interview for DSM-IV (SCID) and the Toronto Alexithymia Scale (TAS-20) to a sample of 234 subjects. Panic disorder, but no other diagnosis, was significantly related to lower TAS-20 total scores (P=0.000). Regarding TAS-20 subfactors, Factor 1 was significantly associated with somatoform disorder (P=0.006) and depression (P=0.002), Factor 2 was significantly associated with depression (P=0.025), and Factor 3 was significantly associated with obsessive-compulsive disorder (P=0.001), whereas panic disorder showed a significant negative correlation with Factor 3 (P=0.001). The relationships of the three subfactors with various DSM-IV diagnoses and sociodemographic variables emphasize the multidimensionality of alexithymia.

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.

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.

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.

Depressive disorders among somatizing patients in primary health care

Unrecognized, untreated and undertreated depressive disorders incur inordinate human and economic costs, despite the availability of an exclusive array of clinical interventions. The aim of this study was to identify cases of masked depression in primary health care, employing a two-stage design. In the first stage, involving a study of 442 patients, the prevalence of recognized depression was 1.8%. In the second step, 62 patients from stage 1 were investigated further because of their high score on somatization tendency. In total, 41 of the 62 patients were found to have a mood disorder according to DSM-III-R, i.e. a major depressive disorder or dysthymia. Two patients were found to have already had a diagnosis of major depression assigned to them in stage 1, but they were joined by 13 more patients. A further 26 patients were found to be suffering from dysthymia, nine had adjustment disorders with depressed mood, and 12 patients showed no signs of depressed mood. For the group suffering from a current episode of major depression or dysthymia, the prevalence rate increased to 11.7% in the initial total population after stage 2. The diagnostic category with the highest rate of depressed patients was 'musculoskeletal diseases'. Patients with masked depression had higher scores for alexithymia and psychasthenia than depressed patients who were directly diagnosed.

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.