The relationship of alexithymia to subjective and biomedical measures of disease

Alexithymia in Patients with Somatization Difficulties and Tinnitus-Related Distress: A Systematic Review

Chronic tinnitus, the perception of sound without an external source, can significantly affect individuals' well-being. As an often medically unexplained symptom, chronic tinnitus can present as a "somatoform" or "functional" difficulty. Some evidence has pointed to alexithymia as a transdiagnostically relevant risk factor for both symptom clusters. Using a two-part rapid review-searching within EBSCO, Embase by Ovid, PubMed, Web of Science-we summarize psychological studies regarding alexithymia, i.e., difficulties in recognizing and expressing emotions and (1) somatoform conditions and (2) chronic tinnitus. For the former (inclusion criteria: (1) adult human beings with different kinds of somatization, (2) longitudinal study designs, (3) publication between 2001 and 2021, (4) full-text in English or German) we identified eight studies that revealed significant links between alexithymia and somatoform conditions. Psychotherapy improved alexithymia in most studies. Additionally, alexithymia was associated with broader treatment outcomes such as improvements in pain intensity, gastrointestinal symptoms, and patient-therapist alliance. The 'Risk Of Bias In Non-randomized Studies-of Interventions' tool (ROBINS-I) and 'Revised Cochrane risk-of-bias tool for randomized trials' (RoB 2) were used for risk of bias assessment. Summarizing all available studies on alexithymia and chronic tinnitus, we identified three studies. Inclusion criteria were: (1) adult human beings with chronic tinnitus, (2) publication between 2001 and 2021, (3) full-text in English or German. Risk of bias was assessed by the 'JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies'. The available studies suggested a high rate of alexithymia (65.7%) in patients with chronic tinnitus. Tinnitus-related distress was significantly associated with alexithymia in two studies, one of which, however, found no differences in alexithymia between patients with bothersome versus non-bothersome tinnitus. Conversely, one study reported high levels of alexithymia in patients with low levels of tinnitus-related distress. Overall, alexithymia may be a transdiagnostic psychological indicator of somatization phenomena, which might include some chronic tinnitus presentations. Psychotherapy likely improves alexithymia as well as somatoform symptom presentations.

Alexithymia Among People Living with HIV: A Scoping Review

The present scoping review aimed to identify studies that investigated alexithymia, defined as a difficulty in identifying and describing one's own emotions, in people living with HIV (PLWH).A literature search, in line with the guidelines of PRISMA-ScR, was conducted in the following bibliographic databases: PubMed, PsycINFO, and Web of Science. The databases were queried using the following strings (using Boolean operators): ("alexithymia" OR "alexithymic") AND ("HIV" OR "Human Immunodeficiency Virus"). In line with the eligibility criteria, fourteen articles were found.Ten studies showed the involvement of alexithymia in disease severity (e.g., viral load levels), and adherence to antiretroviral therapy. Three studies revealed an association between alexithymia and cardiovascular disease, and three studies highlighted the implication of alexithymia in cognitive impairment.This review revealed the complex role of alexithymia in HIV disease. A careful clinical assessment of the emotional regulation process of PLWH can provide useful prognostic information.

Application of a worry reduction intervention in a medically unexplained symptoms-analogue student-sample

OBJECTIVE

Worry is an important perpetuating factor of Medically Unexplained Symptoms (MUS). Former research has shown that a worry postponement instruction is effective in reducing Subjective Health Complaints (SHC) in non-clinical samples. This study aimed to (1) replicate these findings in a MUS-analogue student-sample and (2) assess alexithymia as a moderator.

DESIGN

The current study had an experimental design with two waves of data collection: pre- and post-intervention.

MAIN OUTCOME MEASURES

A MUS-analogue student-sample consisting of 114 undergraduate students with high self-reported health worry and a minimum of two doctor visits in the previous year with no current diagnosis for a (chronic or acute) disease were instructed to register their worry frequency and duration eight times per day via an experience sampling-application on their smartphones. The intervention group additionally postponed their worries to a 30-minute period in the evening. SHC were assessed pre- and post-intervention.

RESULTS

The intervention did not have an effect on worry or SHC. Alexithymia did not moderate this effect (p's > .05).

CONCLUSION

Our study did not find evidence for the effectiveness of the worry reduction intervention on SHC in a MUS-analogue student-sample. This finding contributes to several previous studies that have found mixed evidence for the effectiveness of the worry reduction intervention on SHC and suggests that the worry intervention may not be effective in all cases.

Emotional Regulation in Women with Chronic Fatigue Syndrome and Depression: Internal Representations and Adaptive Defenses

Chronic fatigue syndrome (CFS) presents challenges in differential diagnosis and treatment. Complicating diagnosis is that its symptoms overlap with those of depression. This study applies psychoanalytic concepts to understand emotional regulation (ER) in women with CFS and/or depression. One hundred eighty-six women were assigned to four groups and compared: (a) CFS plus high er depression (CFS-HD); (b) CFS plus lower depression (CFS-LD); (c) depressive disorder (DD); and (d) healthy controls (HC). ER was operationalized by measures of capacity to form internal representations and adaptive defenses. The study's premise was that difficulties metabolizing emotions psychologically would be associated with their greater somatic expression. Some support was found for the hypothesis that CFS participants would exhibit more impairment in representing emotions and in adaptive defenses compared to the DD and HC groups, but this held only for the CFS-HD group. Although CFS-LD participants were expected to be more purely somatizing than the CFS-HD group, they instead showed more sophisticated capacities for ER than that group and recalled less distressing early relationships, revealing more resilience. Still, however, we found support for somatization in some CFS sufferers: Within both the CFS-HD and the CFS-LD groups, weaknesses in representing emotions and in defensive functioning were associated with more severe physical symptoms. Clinically, the heterogeneity of CFS and those who suffer from it indicates the need for individual assessment and depression treatment.

[Personality and somatic disorders]

In the title of this text, by somatic disorders we mean those physical illnesses clearly related to a non-psychiatric medical field, frequently termed psychosomatic illnesses and somatoform disorders. For forty years, a trend of thought has focused with pertinence on the psychological peculiarities in patients with severe somatic diseases. Moreover, causality was often supposed in the regularly mentioned association between personality features and somatoform disorders. However, the revival of the study of the earlier field of relationships between mind and body by Briquet, Charcot, Janet and Freud in his first period has led to the reassessment of the meaning of these observations. This reexamination is marked out by several assertions. Two of them work as preliminaries to argumentation: 1. existential wounds may produce long-lasting personality alterations; 2. existential wounds may produce somatoform disorders. These phenomena have been rediscovered over the last few years among assaulted subjects as well as war veterans in whom a frequent occurrence of somatizations has been, in addition, closely linked to the incidence of behavior or personality disorders. Two theses then emerge: 1. somatic diseases may produce long-lasting personality alterations; 2. until now no premorbid personality univocally predisposing to somatic diseases could be found. Indeed, during the 1980s a growing body of negative results coming from retrospective and prospective studies as well as anatomical comparisons have accumulated upon the potential role of certain personality factors in the incidence of somatic illnesses. This dialectic leads to the connection of two corollary assertions: 1. "pensée opératoire" and "alexithymia" in patients with somatic diseases may represent only an effect of the announcement or chronicity of the organic disease; 2. the old "dissociative hysteria" with somatic manifestations finds its substratum in existential wounds and not in pre-trauma personality. Indeed, on the one hand, recent publications do not allow the assertion to be confirmed that alexithymia and "pensée opératoire" predispose to somatizations. On the other hand, personality disorders in subjects with "dissociative hysteria" as well as their somatoform symptoms appear mainly as an effect of an existential wound and express in fact the Janetian concept of "a drop in Psychological Tension". Then, in spite of their differences, conversion and psychosomatic symptoms share the property of being a primitive response to existential wounds in which the subject cannot produce any appropriate psychic or behavioral response to his distress. Light is shed on these phenomena when put alongside the field of "fixed ideas" thought of by Pierre Janet as the recourse to archaic automatisms. Indeed, the experience which contradicts the vision of existence provokes an "unspeakable terror". It is mentally unrepresented or represented in too slight a way. In such cases, no previous personality prevails, but the resulting personality often appears modified, including when the breakdown of vision of the existence results from the diagnosis of an illness or its protracted course.

Type D Personality and Alexithymia: Common Characteristics of Two Different Constructs. Implications for Research and Clinical Practice

In the last few decades, particular attention has been paid to the role of personality specific traits that can affect the loss of health, i.e., Type D personality and Alexithymia. They have been conceptualized in a different period, this means that they are different both for their theoretical positions and their empirical studies. Some authors have speculated that there is a potential conceptual overlap between Type D personality and alexithymia constructs but there is a shortcoming in the literature. The aim of the study was to examine the potential overlap between the constructs of type D personality and alexithymia, replicating previous two studies, to extend these findings to Italian population. The participants were 247 Italian adults (males = 43%), recruited in primary health care practices of Palermo. All participants did not have chronic diseases during tests administration. They ranged in age from 35 to 69 years old (M = 52.34 years, SD = 9.76). Participants were administered Type D Personality Scale (DS-14) and Toronto Alexithymia Scale (TAS-20). A series of confirmatory factor analyses was performed to evaluate the factorial structure underlying the TAS-20 and DS-14 items. Globally results showed that alexithymia and type D personality are distinct constructs, but they are also strictly positively related with each other. Negative affectivity (NA) was highly correlated with Difficulties in identifying feelings and Difficulties in describing feelings, while Social inhibition (SI) was highly correlated with Difficulties in describing feelings. These results are consistent with those of other studies conducted in this area. Future research should consider evaluating the relationship between a deficit of affect regulation and type D personality to improve the effectiveness of interventions of health cure.

Psychological Distress Mediates the Effect of Alexithymia on 2-Year Change in HIV Viral Load

PURPOSE

Individuals with trait alexithymia (AL) display poor cognitive assimilation of thoughts, feelings, and emotions. This may result in the persistence of stress, anxiety, and depressive disorders. The cumulative effect of this psychological distress is also linked clinical markers of human immunodeficiency virus (HIV) disease progression. This study examines the indirect effect of AL on HIV viral load as a function of baseline levels and change in psychological distress.

METHODS

N = 123 HIV positive adults aged 37.9 ± 9.2 years provided blood samples for HIV-1 viral RNA and CD4 T lymphocytes along with self-reported stress, anxiety, and depression every 6 months for 2 years. A second-order conditional latent growth model was used to represent baseline and 2-year change in cumulative levels of psychological distress and to test the indirect effect of baseline levels of trait AL on change in HIV-1 viral load through this latent measure.

RESULTS

AL was associated with baseline and latent change in psychological distress. Furthermore, baseline psychological distress predicted 2-year change in HIV-1 viral RNA after controlling for viral load at baseline. Altogether, trait AL had a significant indirect effect on change in viral load (β = 0.16, p = 0.03) as a function of baseline levels of distress.

CONCLUSION

Identification and communication of thoughts, feelings, and emotions are important for long-term psychological adaptation in HIV. Greater psychological distress, in turn, allows for persistence of peripheral viral replication.

Inconspicuous Anomalies: Alexithymia and Ethical Relations to the Self

This article uses the analysis and discussion of the ‘alexithymia construct’ to approach the question of how we might think about the relationship between ethics and illness. After a brief introduction to the construct, its paradigmatic potential within the broader context of psychosomatic medicine is discussed. The article then elaborates on the sociocultural specificity of alexithymia, both as a construct and as a mode of being, to argue that central to this construct is the cultural value ascribed to the notion of an ‘authentic self’. The implications of the alexithymia construct are then examined in the vocabulary of narrative approaches to self and illness. The construct may be regarded as an expert meta-narrative on the relative value of different self-narratives in relation to the possibility of disease. As a result, the ethical responsibilities associated both with narrative and with illness become expanded and transformed.

Alexithymia, Assertiveness and Psychosocial Functioning in HIV: Implications for Medication Adherence and Disease Severity

Psychosocial function and adherence to antiretroviral regimen are key factors in human immunodeficiency virus (HIV) disease management. Alexithymia (AL) is a trait deficit in the ability to identify and describe feelings, emotions and bodily sensations. A structural equation model was used to test whether high levels of AL indirectly relate to greater non-adherent behavior and HIV disease severity via psychosocial dysfunction. Blood draws for HIV-1 viral load and CD4 T-lymphocyte, along with psychosocial surveys were collected from 439 HIV positive adults aged 18-73 years. The structural model supports significant paths from: (1) AL to non-active patient involvement, psychological distress, and lower social support, (2) psychological distress and non-active involvement to non-adherent behavior, and (3) non-adherence to greater HIV disease severity (CFI = .97, RMSEA = .04, SRMR = .05). A second model confirmed the intermediary effect of greater patient assertiveness on the path from AL to social support and non-active patient involvement (CFI = .94, RMSEA = .04, SRMR = .05). Altogether, AL is indirectly linked with HIV disease management through it's association with poor psychosocial function, however greater patient assertiveness buffers the negative impact of AL on relationship quality with healthcare providers and members of one's social support network.

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

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

Complex regional pain syndrome, alexithymia, and psychological distress

OBJECTIVE

This study aims to elucidate the relationships between alexithymia, psychological distress, and pain in persons with complex regional pain syndrome (CRPS).

METHODS

Participants were 60 Israeli adults ages 19-65. This is a cross sectional study with a comparison group. Alexithymia, psychological distress, and pain were assessed in 30 individuals with CRPS in comparison to 30 gender- and age-matched persons with lower back pain (LBP). Assessments included the Toronto Alexithymia Scale, Hospital Anxiety and Depression Scale, and two subscales of the McGill Pain Questionnaire.

RESULTS

Persons with CRPS had significantly higher ratings of psychological distress and of alexithymia when compared to LBP controls. Pain severity was significantly associated with higher levels of alexithymia and psychological distress among persons with CRPS, but not among controls. Alexithymia and pain severity correlations were significantly different between the two groups. In persons with CRPS, the relationships between alexithymia and pain severity and between difficulty identifying feelings and pain were not confounded by psychological distress.

CONCLUSIONS

To our knowledge, this is the first cross sectional study providing empirical evidence on the relationship between alexithymia and CRPS. From the perspective of conceptualizing alexithymia as an outcome of CRPS, findings highlight the importance of early CRPS diagnosis and support the provision of care that addresses pain-related psychological distress and alexithymia among CRPS patients. Also, findings underscore the need to generate alternative, non-physical avenues, such as learning to identify feelings for processing pain, in order to reduce pain among persons with CRPS.

A longitudinal study of alexithymia in relation to physical activity in adolescent females with scoliosis subjected to cheneau brace treatment: preliminary report

STUDY DESIGN

A longitudinal pilot study of changes in levels of alexithymia among females with adolescent idiopathic scoliosis (AIS) under brace treatment.

OBJECTIVE

To investigate the prevalence of alexithymia and to evaluate changes in alexithymia levels among female patients with AIS treated with a Cheneau brace, in comparison with healthy female adolescents.

SUMMARY OF BACKGROUND DATA

Alexithymia is a personality trait incorporating the following core characteristics: difficulty in identifying and describing feelings, difficulty in distinguishing between feelings and the physical sensation of emotional arousal, limited imaginal processes, and an externally oriented cognitive style. Alexithymia can be common among adolescents and young adults with severe idiopathic scoliosis.

METHODS

Thirty-six female patients with AIS, aged 13.4 years (standard deviation [SD], 1.7) at the beginning of the study, completed the Polish version of the Toronto Alexithymia Scale-26 (TAS-26). The second and third evaluations took place at 6 and 12 months, respectively, after the beginning of the study. Thirty-six healthy female controls were also included.

RESULTS

The mean TAS-26 total score was 63.4 (SD, 9.3), 59.5 (SD, 12.1), and 59.6 (SD, 12.5) during the first, second, and last patient evaluation, whereas in healthy females 60.0 (SD, 10.9). With regard to the TAS-26 total score, results differed significantly between the first and the second (P = 0.007) and between the first and the third patient evaluation (P = 0.007). Regression analysis revealed that during the second and third patient evaluation, duration of recreational sports activity had a statistically significant (P = 0.029 and P = 0.005, respectively) influence on the probability of females reporting no alexithymia.

CONCLUSION

The prevalence of alexithymia in healthy female controls is the same as in patients with scoliosis subjected to underarm brace treatment. Statistically significant changes with regard to TAS-26 total score and externally oriented thinking domain were found in patient sample. Physical activity in females with AIS treated nonoperatively coexists with lower scores in the TAS-26.

LEVEL OF EVIDENCE

2.

Alexithymia is associated with greater risk of chronic pain and negative affect and with lower life satisfaction in a general population: the Hisayama Study

INTRODUCTION

Chronic pain is a significant health problem worldwide, with a prevalence in the general population of approximately 40%. Alexithymia -- the personality trait of having difficulties with emotional awareness and self-regulation -- has been reported to contribute to an increased risk of several chronic diseases and health conditions, and limited research indicates a potential role for alexithymia in the development and maintenance of chronic pain. However, no study has yet examined the associations between alexithymia and chronic pain in the general population.

METHODS

We administered measures assessing alexithymia, pain, disability, anxiety, depression, and life satisfaction to 927 adults in Hisayama, Japan. We classified the participants into four groups (low-normal alexithymia, middle-normal alexithymia, high-normal alexithymia, and alexithymic) based on their responses to the alexithymia measure. We calculated the risk estimates for the criterion measures by a logistic regression analysis.

RESULTS

Controlling for demographic variables, the odds ratio (OR) for having chronic pain was significantly higher in the high-normal (OR: 1.49, 95% CI: 1.07-2.09) and alexithymic groups (OR: 2.56, 95% CI: 1.47-4.45) compared to the low-normal group. Approximately 40% of the participants belonged to these two high-risk groups. In the subanalyses of the 439 participants with chronic pain, the levels of pain intensity, disability, depression, and anxiety were significantly increased and the degree of life satisfaction was decreased with elevating alexithymia categories.

CONCLUSIONS

The findings demonstrate that, in the general population, higher levels of alexithymia are associated with a higher risk of having chronic pain. The early identification and treatment of alexithymia and negative affect may be beneficial in preventing chronic pain and reducing the clinical and economic burdens of chronic pain. Further research is needed to determine if this association is due to a causal effect of alexithymia on the prevalence and severity of chronic pain.

Absence of somatization in non-coeliac gluten sensitivity

OBJECTIVE

In contrast to coeliac disease (CD), the mechanism behind non-coeliac gluten sensitivity (NCGS) is unclear. The aims of the study were to measure the presence of somatization, personality traits, anxiety, depression, and health-related quality of life in NCGS individuals compared with CD patients and healthy controls, and to compare the response to gluten challenge between NCGS and CD patients.

MATERIAL AND METHODS

We examined 22 CD patients and 31 HLA-DQ2+ NCGS patients without CD, all on a gluten-free diet. All but five CD patients were challenged orally for 3 days with gluten; symptom registration was performed during challenge. A comparison group of 40 healthy controls was included. Patients and healthy controls completed questionnaires regarding anxiety, depression, neuroticism and lie, hostility and aggression, alexithymia and health locus of control, physical complaints, and health-related quality of life.

RESULTS

The NCGS patients reported more abdominal (p = 0.01) and non-abdominal (p < 0.01) symptoms after gluten challenge than CD patients. There were no significant differences between CD and NCGS patients regarding personality traits, level of somatization, quality of life, anxiety, and depressive symptoms. The somatization level was low in CD and NCGS groups. Symptom increase after gluten challenge was not related to personality in NCGS patients.

CONCLUSIONS

NCGS patients did not exhibit a tendency for general somatization. Personality and quality of life did not differ between NCGS and CD patients, and were mostly at the same level as in healthy controls. NCGS patients reported more symptoms than CD patients after gluten challenge.

Skills-based Treatment for Alexithymia: An Exploratory Case Series

This paper describes a skills-based intervention for the treatment of alexithymia. The intervention incorporates components to address the following three areas: the relationship between alexithymia and early life experiences, identifying feelings and expressing feelings. The efficacy of the intervention was explored using three individual case studies extending over 16–24 weekly 1-hour sessions. A number of questionnaires were administered at five time intervals. The results suggest that the treatment was effective in reducing alexithymia within the three individuals and in helping them to clarify, identify and describe their feelings. Following treatment the participants were less ambivalent about expressing their feelings and more attentive to their emotional states. The results were generally maintained at a 1-year follow-up for two of the three cases.

Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain

The aim of this study was to examine independent and combined influences of alexithymia and anxiety sensitivity on chest pain and life interference in patients with non-cardiac chest pain (NCCP). Theories of NCCP posit a central role for emotion in the experience of chest pain, however, studies have not examined how alexithymia characterized by a difficulty identifying or verbalizing emotions, may influence this relationship. This study examined 231 patients (56% females, M age=50 years) with chest pain seeking cardiac evaluation, who showed no abnormalities during exercise tolerance testing. Forty percent (40%) scored at or above the moderate range of alexithymia. Whereas health care utilization was associated with elevated alexithymia among men, health care utilization was associated with elevated anxiety sensitivity among women. Hierarchical regression analyses revealed that alexithymia and anxiety sensitivity were both uniquely and independently associated with pain severity and life interference due to pain. Alexithymia-pain links were stronger for men compared to women. Secondary analyses conducted with a subsample suggest that alexithymia may be increasingly stable over time (i.e., 18-month follow-up). Findings are largely congruent with theoretical models of NCCP showing that personality and emotional factors are important in this medically unexplained syndrome.

Causal attributions and alexithymia in female patients with fibromyalgia or chronic low back pain

AIMS

Our general objective was to assess the psychological symptoms and the types of causal attributions linked to the symptoms among women chronic pain.

METHODS

70 fibromyalgia (FM) patients, 56 chronic low back pain (CLBP) patients and 72 healthy controls were assessed within a general hospital setting, using the Toronto Alexithymia Scale, Brief Symptom Inventory and Symptom Interpretation Questionnaire. Three-way analysis of variance and chi-square tests were used for inter-group comparisons, followed by multivariate correlation, covariate analysis and linear regression.

RESULTS

Alexithymia, somatization, depression, anxiety and hostility scores were significantly higher in FM patients relative to CLBP patients and healthy controls (P < 0.05). Alexithymia was linked to psychological attributions in FM patients and to somatic attributions in CLBP patients. Psychological attributions, the number of symptoms and difficulty in describing emotions were related to increased anxiety in FM patients. Depression, anxiety and somatization were significantly increased in subjects with high alexithymia scores in the FM group. There was no difference between groups regarding causal attributions.

CONCLUSIONS

Causal attributions do not seem to have distinctive features between functional somatic syndromes like FM and CLBP, though differences might exist between groups as to the effects of coexisting psychological distress symptoms like anxiety and depression.

Psychosocial modulators of angina response to myocardial ischemia

BACKGROUND

Although angina is often caused by atherosclerotic obstruction of the coronary arteries, patients with similar amounts of myocardial ischemia may vary widely in their symptoms. We sought to compare clinical and psychosocial characteristics associated with more frequent angina after adjusting for the amount of inducible ischemia.

METHODS AND RESULTS

From 2004 to 2006, 788 consecutive patients undergoing single-photon emission computed tomography stress perfusion imaging at 2 Seattle hospitals were assessed for their frequency of angina over the previous 4 weeks with the Seattle Angina Questionnaire and for a broad range of psychosocial characteristics. Among patients with demonstrable ischemia on single-photon emission computed tomography (summed difference score >or=2; n=191), angina frequency was categorized as none (Seattle Angina Questionnaire score=100; n=68), monthly (score=61 to 99; n=66), and weekly or daily (score=0 to 60; n=57). Using multivariable ordinal logistic regression, increasing angina was significantly associated with a history of coronary revascularization (odds ratio 2.24, 95% confidence interval 1.19 to 4.19), anxiety (odds ratio 4.72, 95% confidence interval 1.91 to 11.66), and depression (odds ratio 3.12, 95% confidence interval 1.45 to 6.69) after adjustment for the amount of inducible ischemia.

CONCLUSIONS

Among patients with a similar burden of inducible ischemia, a history of coronary revascularization and current anxiety and depressive symptoms were associated with more frequent angina. These results support the study of angina treatment strategies that aim to reduce psychosocial distress in conjunction with efforts to lessen myocardial ischemia.

Alexithymia in fibromyalgia syndrome: associations with ongoing pain, experimental pain sensitivity and illness behavior

OBJECTIVE

Alexithymia, a lack of emotional awareness, is common in chronic pain patients. The aim of the study was to investigate the relationship of alexithymia to ongoing pain, experimental pain sensitivity, and illness behavior in patients with chronic musculoskeletal pain.

METHODS

Sixty-eight women with fibromyalgia (age: average, 43.4 years; range, 19-72 years) completed self-report measures on alexithymia (20-Item Toronto Alexithymia Scale), ongoing pain [Visual Analogue Scale, Questionario Italiano del Dolore (QUID), Margolis], psychological distress (Center for Epidemiology Studies-Depression Scale, State-Trait Anxiety Inventory Form Y), and illness behavior (Illness Behavior Questionnaire). Psychophysical tests were performed to assess experimental pain sensitivity, including pain thresholds for mechanical (von Frey, tender point count) and thermal (heat, cold) stimuli, and cold pressor pain threshold and tolerance.

RESULTS

Alexithymia "difficulty identifying feelings" (DIF) was related to higher ratings of the affective-but not the sensory-dimensions of ongoing pain (QUID) and to a lower cold pressor pain tolerance, while alexithymia scores were independent of all pain thresholds. Multiple regression demonstrated that alexithymia DIF ceased to uniquely predict affective ongoing pain when psychological distress or illness behavior was separately controlled for. Higher alexithymia DIF scores were predictive of hypochondriacal illness behavior, over and above what was explained by psychological distress and affective pain.

CONCLUSION

Alexithymia is associated with increased affective pain and hypochondriacal illness behavior. The former relationship is better explained, and possibly mediated, by psychological distress and illness behavior. The hypothesis of a generally increased sensitivity to unpleasant stimuli in alexithymic chronic pain patients is not supported by the data.

The INSPIRE study: do personality traits predict general quality of life (Short form-36) in distressed patients with ulcerative colitis and Crohn's disease?

OBJECTIVE

To assess the role of personality as a predictor of Short form-36 (SF-36) in distressed patients (perceived stress questionnaire, PSQ) with ulcerative colitis (UC) and Crohn's disease (CD).

MATERIAL AND METHODS

Fifty-four patients with CD and 55 with UC (age 18-60 years) who had relapsed in the previous 18 months, i.e. with an activity index (AI) for UC or CD> or =4, PSQ> or =60, and without severe mental or other major medical conditions, completed the Buss-Perry Aggression Questionnaire (BPA), the Neuroticism and Lie scales of the Eysenck Personality Questionnaire (EPQ-N and -L), the Multidimensional Health Locus of Control Scale (LOC) (Internal (I), Powerful Other (PO), Chance (C)), the Toronto Alexithymia Scale (TAS) and the SF-36.

RESULTS

Multiple linear regression analyses controlling for gender, age and clinical disease activity (AI) in separate analyses for UC and CD showed that the mental and vitality subscales were predicted by neuroticism in both UC and CD. The highest explained variance was 43.8% on the "mental" subscale in UC. The social function subscale was related to alexithymia only in UC, while the role limitation and pain subscales were related to personality in CD only. The physical function subscale related differently to personality in UC and CD.

CONCLUSIONS

While mental and vitality subscales were predicted by neuroticism in both UC and CD, other subscales had different relationships to personality, suggesting different psychobiological interactions in UC and CD.

Angina pectoris during daily activities and exercise stress testing: The role of inducible myocardial ischemia and psychological distress

Physicians often consider angina pectoris to be synonymous with myocardial ischemia. However, the relationship between angina and myocardial ischemia is highly variable and we have little insight into the sources of this variability. We investigated the relationship of inducible myocardial ischemia on SPECT stress perfusion imaging to angina reported with routine daily activities during the previous four weeks (N=788) and to angina reported during an exercise stress test (N=371) in individuals with confirmed or suspected coronary disease referred for clinical testing. We found that angina experienced during daily life is more strongly and consistently associated with psychological distress and the personal threat associated with angina than with inducible myocardial ischemia. In multivariable models, the presence of any angina during routine activities over the prior month was significantly associated with age, perceived risk of myocardial infarction, and anxiety when compared to those with no reported angina in the past month. Angina during daily life was not significantly associated with inducible myocardial ischemia on stress perfusion imaging in bivariate or multivariable models. In contrast, angina experienced during exercise stress testing was significantly related to image and ECG ischemia, though it was also significantly associated with anxiety. These results suggest that angina frequency over the previous four weeks is more strongly associated with personal threat and psychosocial distress than with inducible myocardial ischemia. These results lend support to angina treatment strategies that aim to reduce threat and distress as well as to reduce myocardial ischemia.

Type C coping, alexithymia, and heart rate reactivity are associated independently and differentially with specific immune mechanisms linked to HIV progression

The maladaptive Type C coping style has been linked to disease progression in HIV and other immunologically mediated disorders. We hypothesized that strong Type C coping, higher levels of alexithymia, and greater cardiovascular (particularly heart rate) responses to, and prolonged recovery from stress would be associated with poorer functioning of immune parameters previously linked to HIV pathogenesis and progression: (1) antigen-stimulated production of the beta (beta)-chemokines MIP-1 alpha and MIP-1 beta, which bind to the HIV co-receptor CCR5 and block HIV entry into CD4(+) lymphocytes; and (2) antigen-stimulated production of the proinflammatory cytokine interleukin-6 (IL-6), which synergizes immune activation associated with HIV replication. We examined relations among psychological, cardiovascular, and immune variables in a baseline sample of 200 HIV-infected, predominantly African American outpatients attending an HIV primary care clinic in inner-city Baltimore. In regression analyses adjusted for CD4(+) count and age, strong Type C coping was associated with significantly higher IL-6 production, as predicted. The theoretically related construct of alexithymia was correlated with significantly lower stimulated production of HIV-inhibiting MIP-1 alpha. Independent of alexithymia, greater heart rate reactivity, and poorer heart rate recovery in response to experimental stressors were also significantly associated with lower production of MIP-1 alpha, adjusted for cardiovascular medications, methadone use, CD4(+) count, and age. These findings support our primary set of hypotheses that maladaptive Type C coping, alexithymia, and heart rate reactivity/recovery are associated with disturbances in two key immune parameters implicated in HIV pathogenesis. Our secondary hypothesis, that dysregulated heart rate reactivity may mediate the connections between Type C coping and/or alexithymia and IL-6/ MIP-1 alpha was not confirmed. The finding that Type C coping, alexithymia, and heart rate reactivity/recovery are associated independently and differentially with specific aspects of relevant immune functioning may reflect distinct biobehavioral pathways that contribute to HIV progression.

The assessment of alexithymia in medical settings: implications for understanding and treating health problems

The construct of alexithymia encompasses the characteristics of difficulty identifying feelings, difficulty describing feelings, externally oriented thinking, and a limited imaginal capacity. These characteristics are thought to reflect deficits in the cognitive processing and regulation of emotions and to contribute to the onset or maintenance of several medical and psychiatric disorders. In this article, we review recent methods for assessing alexithymia and examine how assessing alexithymia can inform clinical practice. Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviors. Alexithymic patients may respond poorly to psychological treatments, although perhaps not to cognitive-behavioral techniques, and it is unclear whether alexithymia can be improved through treatment. Interpretive problems regarding alexithymia include its overlap with other traits, whether it is secondary to illness or trauma, the possibility of subtypes, and low correlations among multiple measures. Nonetheless, we encourage the assessment of alexithymia in applied settings.

Alexithymia and global psychosocial functioning: a study on patients with skin disease

OBJECTIVE

The relationship between alexithymia and psychosocial functioning has been investigated in a few studies using indirect measures of adaptation. We aimed at directly evaluating the relationship between alexithymia and global psychosocial functioning, as measured by a standardised scale.

METHODS

A large, consecutive sample of dermatological inpatients (N=545) completed the 20-item Toronto Alexithymia Scale and the Skindex-29 and were administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders and the Global Assessment of Functioning (GAF) scale.

RESULTS

Multiple regression analysis was used to control for likely determinants of psychosocial functioning such as age, sex, education, burden of skin symptoms, and psychiatric morbidity. The GAF score was associated with psychiatric morbidity (beta=-.63, P<.001), alexithymia (in particular, the difficulty identifying feelings subscale) (beta=-.19, P<.001), and burden of skin symptoms (beta=-.07, P<.05).

CONCLUSION

Given the well-known association between poor psychosocial functioning and several behavioural risk factors for health, our study may provide a further reason for clinicians to pay attention to alexithymic features among their patients.

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, coping, and illness behavior correlates of pain experience in cancer patients

This paper aimed to investigate the role played by key psychological factors in the experience of pain in cancer. One hundred and eight consecutive cancer patients were administered validated scales for pain, alexithymia, coping with cancer, and illness behavior. Two groups of patients with (n=45, 42%) and without (n=63, 58%) current pain were compared. Pain was associated to tumor sites and status, poor adjustment to cancer, and higher disease conviction and perception, but not to global alexithymia. However, the component of difficulty identifying feelings (DIF) of the alexithymia construct was significantly higher in pain patients compared to pain-free patients (t=2.88, p<0.01), constituted one of the independent predictors of pain (r=0.37; beta=0.27, p<0.01), and correlated with quality descriptors of pain (r=0.33, p<0.05). The present findings showed for the first time that although alexithymia was not globally related to cancer pain, the DIF component was however associated to pain dimensions, thus suggesting it might be involved in the way patients describe their pain experience, together with maladaptive coping and abnormal illness behavior. Cancer patients experiencing pain should be helped to adopt a more adaptive coping with the disease by identifying more accurately the source of their feelings.

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.

Low Levels of Emotional Awareness Predict a Better Response to Dermatological Treatment in Patients with Psoriasis

BACKGROUND

Personality and emotional factors are thought to influence the onset of psoriasis, the occurrence of relapses, and the sensitivity of this condition to dermatological treatments.

OBJECTIVE

To explore the relationships between emotional disorders and emotional information processing in the one hand, and psoriasis severity and response to treatment on the other.

METHODS

We recruited 93 patients through an article in the local press. These patients attended three consultations. We evaluated psoriasis severity by Psoriasis Area and Severity Index (PASI) score and response to treatment by change in PASI score from baseline to the 3-month visit. We screened for comorbid mental disorders, using the Mini International Neuropsychiatric Interview. We used the Hospital Anxiety and Depression Scale to assess anxiety and depressive symptoms. Alexithymia (difficulty in identifying and expressing emotions) was evaluated with the 26-item version of the Toronto Alexithymia Scale (TAS-26) and the ability to integrate and differentiate emotions (emotional awareness) was assessed with the Lane and Schwartz Levels of Emotional Awareness Scale (LEAS).

RESULTS

Forty patients presented at least one psychiatric diagnosis and 33 were considered alexithymic (TAS > or =73). No psychological score was associated with baseline PASI score, which was higher in men and positively correlated with disease duration. Patients who considered their disease to be stress-reactive tended to have lower LEAS scores (p = 0.052). At the 3-month visit, PASI scores had significantly improved in the subset of patients (n = 67) presenting severe psoriasis at inclusion (PASI >2); emotional awareness and anxiety scores had also improved in these patients (p < 0.001), but dermatological and psychological changes were not statistically related. Dermatological improvement at 3 months with respect to baseline PASI was predicted by longer disease duration (>20 years) and lower baseline LEAS score (p = 0.044 and p = 0.021, respectively).

CONCLUSION

This study demonstrates the value of assessing the ability of patients with psoriasis to process emotional information, as defined by emotional awareness. Patients with low LEAS scores appear to be more reactive to stress, but also to be more responsive to treatment, suggesting the activation of a particular stress physiology by negative affective states that are not experienced.

Alexithymia and pain in temporomandibular disorder

OBJECTIVE

To clarify the relationship of global alexithymia and its facets with pain, assessed prospectively using experience sampling methods (ESMs), in temporomandibular disorder (TMD).

METHODS

People with painful TMD (n=49), pain-free somatic controls (24 people with disk displacement), and healthy controls (n = 28) completed measures of alexithymia (Toronto Alexithymia Scale-20 [TAS-20]) and depressed mood. Patients with painful TMD used ESM to record jaw pain multiple times daily for a week.

RESULTS

The somatic and the healthy controls were equivalent on alexithymia and were combined. The painful TMD group had higher difficulty in identifying feelings but lower externally oriented thinking (EOT); only the latter effect remained after covarying depressed mood. Among patients with painful TMD, the TAS-20 total and EOT correlated positively with pain severity after controlling for depressed mood.

CONCLUSION

Findings highlight the complex relationships of alexithymia and its facets to TMD pain. Research should examine alexithymia facets separately and distinguish between methods that compare groups on alexithymia (e.g., pain patients versus controls) and those that correlate alexithymia with pain severity within a group.

Psychological factors, pain attribution and medical morbidity in chest-pain patients with and without coronary artery disease

This cross-sectional psychiatric and cardiological study compared patients with and without coronary artery disease (CAD) with respect to psychiatric morbidity, psychological factors, pain characteristics, medical morbidity and the prevalence of coronary risk factors. The 199 participants had been referred to cardiological outpatient clinics for the investigation of chest pain and had no history of heart disease. Current panic disorder occurred significantly more often in non-CAD patients (41% vs. 22%). No significant differences were found for other psychiatric disorders and psychological variables. Non-CAD patients reported significantly longer histories of pain and a higher prevalence of atypical chest pain. In other respects, there were surprisingly few differences between the groups. High morbidity of both psychiatric disease (pain disorder, 19%; any current psychiatric disorder, 72%) and somatic conditions (musculoskeletal disease, 33%; dyspepsia, 23%) was found with no significant differences between the groups. In these patients, multifactorial complaints may explain chest pain in both patient groups. The physicians should attend to psychiatric disorders in non-CAD as well as in CAD patients.

Alexithymia--state or trait?

Alexithymia refers to a specific disturbance in emotional processing that is manifested by difficulties in identifying and verbalizing feelings and a tendency to focus on and amplify the somatic sensations that accompany emotional arousal. Alexithymia is conceptualized both as an affect-deficit disorder and a continuous personality variable. The main purpose of the present study was to investigate the stability levels of alexithymia with regard to changes in emotional distress levels caused by university exams. We tested 20 university students at four different times, before and after the exams. Alexithymic features and self-reported emotional distress (trait anxiety and physical symptoms) were measured. Whereas emotional distress measures changed significantly during the diverse phases, the level of alexithymia remained unchanged. We therefore conclude that alexithymia represents a constant trait.

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.

Association of symptoms of TMD and orofacial pain with alexithymia: an epidemiological study of the Northern Finland 1966 Birth Cohort

Alexithymia is a term denoting a deficit in the ability to differentiate emotional from physical states and to identify and describe one's feelings, as well as a preference for external oriented thinking. Alexithymia has been linked with various somatic and psychosomatic diseases, especially with chronic pain. The aim of this study was to evaluate the association between alexithymia and symptoms of temporomandibular disorders (TMD) as well as oro-lingual and dental pain, in a large representative population sample of young adults. The study was a part of the 31-year follow-up study of the Northern Finland Birth Cohort originally consisting of 12058 live births in the year 1966. In 1997, 4893 subjects living in northern Finland or in the capital area, who participated in a field study of the project and later returned a postal questionnaire, made up the sample of this study. Information concerning symptoms of TMD and oro-lingual and dental pain was collected from the subjects. To assess alexithymia, the Toronto Alexithymia Scale-20 (TAS-20) was used. In addition, information about depression, marital status and self-rated health was collected. The proportion of alexithymics (TAS score over 60) was higher in subjects with the most orofacial symptoms than in asymptomatic subjects. In men, alexithymia associated significantly with facial pain, difficulties in mouth opening, oro-lingual pain and dental pain, and in women with pain on jaw movement and dental pain. After adjusting for depression, marital status, and self-rated health, a significant association remained between alexithymia and the symptoms mentioned, except for facial pain in men. It can be concluded that alexithymia is connected with orofacial symptoms. Clinicians treating these symptoms should be familiar with the concept of alexithymia.

Preliminary data of a prospective study on neuropsychiatric side effects after initiation of efavirenz

OBJECTIVE

To assess baseline variables able to predict neuropsychiatric side effects (NPSEs) associated with the initiation of an efavirenz (EFV)-containing regimen in HIV-1-infected patients.

DESIGN

Open-label, prospective, observational study.

METHODS

Consecutive HIV-1-infected outpatients in whom EFV was prescribed underwent a psychiatric interview. At baseline and at 2, 4, and 12 weeks, patients completed the Symptoms Check List-90-Revised (SCL-90-R), the Medical Outcome Study for HIV-positive patients (MOS-HIV), and a standardized questionnaire concerning potential NPSEs.

RESULTS

Preliminary data showed that discontinuation of EFV because of NPSEs occurred in 4 of 31 patients (13%). Patients who completed the follow-up showed a decrease in SCL-90-R total score (p =.004) and in several subscales such as Interpersonal Sensitivity (p =.009), Depression (p =.001), and Anxiety (p =.040), whereas no changes in MOS-HIV were observed. Having fewer years of education (p =.006), having fewer baseline central nervous symptoms (p =.000), reporting better baseline physical status (p =.013), and having higher baseline scores in the Heath Transition subscale of the MOS-HIV (p =.000) and in the Somatization subscale of the SCL-90-R (p =.002) were associated with more NPSEs.

CONCLUSION

Patients maintained on EFV showed a decrease in psychologic distress related to self-image, depression, and anxiety, without any effect on quality of life. Patients with a lower level of education, those who feel physically and psychologically better at baseline than in the past, and those who suffer from more distress as a result of physical complaints may be at greater risk of reporting more NPSEs after EFV initiation.

Alexithymia in patients with coronary heart disease

OBJECTIVE

The aim of this study was to investigate factors associated with alexithymia in patients (n=153) with coronary heart disease (CHD) verified by coronary angiography.

METHOD

Self-rated depression was assessed using 21-item Beck Depression Inventory (BDI) and other psychiatric symptoms with Symptom Check List-90 (SCL-90). Life satisfaction was assessed using a separate scale. The Structured Clinical Interview (SCID I and II) for DSM-III-R was used to identify mental disorders. Assessments took place 1 day before angiography.

RESULTS

Twenty-one percent of CHD patients (n=32) were assessed as being alexithymic according to the Toronto Alexithymia Scale (TAS-20). Alexithymics were more often blue-collar workers, incapable of working, dissatisfied with life, and depressed than the other CHD patients. Occurrences of mental disorders were not associated with alexithymia. Logistic regression analysis revealed that factors independently associated with alexithymia were currently or previously being a blue-collar worker (adjusted odds ratio, AOR: 4.8), self-rated depression (AOR: 3.2), and dissatisfaction with life (AOR: 2.9).

CONCLUSION

In CHD patients alexithymia was unrelated to cardiovascular risk factors or exercise capacity but was related to self-rated depression and decreased life satisfaction. Alexithymia is associated with the enhanced psychosocial burden of suffering CHD. This patient group may need more individual support and attention than other CHD patients.

Alexithymia and polysomnographic measures of sleep in healthy adults

OBJECTIVE

This study examined associations between alexithymia and objective characteristics of sleep (latencies, stages, and amount and patterning of REM sleep) that may contribute to subjective reports of poor sleep quality and impaired dream recall among alexithymic people.

METHODS

Fifty healthy, normally sleeping adults from the community completed the 20-item Toronto Alexithymia Scale and slept uninterrupted for one night in the laboratory while polysomnography was conducted. Various measures of sleep latency, sleep stages, and REM sleep-related variables were obtained, and analyses correlated these sleep measures with alexithymia, controlling for age, sex, and level of depressed affect.

RESULTS

Higher alexithymia scores were significantly related to increased stage 1 (light) sleep and decreased stage 3/4 (deep) sleep. Alexithymia was unrelated to overall sleep efficiency or percentage of stage 2 sleep. Alexithymia was related to more frequent REM episodes and more stage 1 sleep during and immediately after REM episodes but was unrelated to the absolute amount of REM sleep. Alexithymia was also related to an earlier onset of the first REM episode.

CONCLUSIONS

Alexithymia is associated with more light sleep and less deep sleep, which may contribute to subjective reports of poor sleep and increased sleepiness, fatigue, and somatic symptoms. Although alexithymia is not associated with an overall reduction of REM sleep, the increased frequency of episodes of REM that are interrupted and followed by light sleep rather than complete awakenings may contribute to limited dream recall.

Type D personality. A potential risk factor refined

OBJECTIVE

Acute and chronic psychological distress have been associated with coronary heart disease (CHD) but little is known about the determinants of distress as a coronary risk factor. Broad and stable personality traits may have much explanatory power; this article selectively focuses on negative affectivity (NA; tendency to experience negative emotions) and social inhibition (SI; tendency to inhibit self-expression in social interaction) in the context of CHD.

METHODS

The first part of this article reviews research on NA and SI in patients with CHD. The second part presents new findings on NA and SI in 734 patients with hypertension.

RESULTS

Accumulating evidence suggests that the combination of high NA and high SI designates a personality subtype ("distressed" type or type D) of coronary patients who are at risk for clustering of psychosocial risk factors and incidence of long-term cardiac events. Type D and its contributing low-order traits (dysphoria/tension and reticence/withdrawal) could also be reliably assessed in a community-based sample of patients with hypertension. This finding was replicated in men and women, and in Dutch- and French-speaking subjects. Type D hypertensives reported more depressive affect than their non type D counterparts.

CONCLUSIONS

There is an urgent need to adopt a personality approach in the identification of patients at risk for cardiac events. NA and SI are broad and stable personality traits that may be of special interest not only in CHD, but in other chronic medical conditions as well.

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.

Decreased health care use among patients with silent myocardial ischemia: support for a generalized rather than cardiac-specific silence

OBJECTIVE

The absence of angina among patients with silent myocardial ischemia (SMI) may be a cardiac phenomenon or may reflect a generalized lack of bodily awareness and symptom reporting. We tested the hypothesis that the silence is generalized, and, therefore, that patients with SMI would make fewer health care visits for noncardiac/chest-pain problems than patients with symptomatic ischemia.

METHODS

We counted all out-patient visits to our medical system for the prior 18 months for 95 patients who demonstrated ischemia during treadmill exercise testing and subsequent nuclear scanning: 62 of the patients had SMI during exercise, and 33 of the patients had symptomatic ischemia.

RESULTS

Patients with SMI made were significantly less likely to have sought emergency care or primary care and had significantly fewer primary care visits than patients with symptomatic ischemia. Group differences remained after controlling for demographics and health status variables. The two groups did not differ on utilization of specialty care.

CONCLUSION

The reduced use of emergency and primary care among patients with SMI suggests that they have a generalized rather than cardiac-specific reduction in somatic awareness and/or symptom reporting.

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.