The association between communication impairments and acquired alexithymia in chronic stroke patients

The prevalence and characteristics of alexithymia in stroke patients: a systematic review and meta-analysis

BACKGROUND

Previous studies have indicated the potential occurrence of alexithymia among stroke patients, yet the prevalence of alexithymia in this population remains disparate across different investigations without a synthesized overview.

AIM

To systematically evaluate the prevalence and characteristics of alexithymia in stroke patients.

METHODS

A systematic review and meta-analysis was conducted following the PRISMA guidelines. PubMed, Embase, Web of Science, The Cochrane Library, CINAHL, China Knowledge Resource Integrated Database (CNKI), Wanfang Database, Chinese Biomedical Database, and Weipu Database (VIP) were searched from inception to December 31,2022, two independent researchers extracted data and evaluated article quality.

RESULTS

Seventeen studies were included, reporting on the prevalence of alexithymia or Toronto Alexithymia Scale-20 (TAS-20) scores among stroke patients. The pooled prevalence was found to be 35.0% (95%CI= 23.0-47.0%; I2 =97.5%), and the total scores (TS) of TAS-20 was 59.90 (95% CI=56.34-63.47; I2 =100.0%). Subgroup analysis revealed significant variation in TAS-20 scores across different geographical regions. Specifically, the total TAS-20 score in Chinese stroke patients (62.95, 95%CI=58.75-67.14; I2=100%) was higher compared to non-Chinese stroke patients (52.58, 95%CI=49.12-56.04; I2 = 99.0%).

CONCLUSIONS

The prevalence of alexithymia is high among stroke patients, with TAS-20 scores surpassing those observed in patients with certain other medical conditions. This underscores the importance of addressing alexithymia in stroke patients promptly through assessment and intervention to mitigate negative emotional consequences and enhance overall quality of life. Future research could explore the influence of demographic factors such as age and sex on alexithymia in stroke patients, enabling a more comprehensive understanding of alexithymia.

Speech, language and communication needs and mental health: the experiences of speech and language therapists and mental health professionals

BACKGROUND

While the relationship between speech, language and communication needs (SLCN) and mental health difficulties has been recognized, speech and language therapists (SLTs), and mental health professionals face challenges in assessing and treating children with these co-occurring needs. There exists a gap in the evidence base for best practice for professionals working with children and young people (CYP) who experience difficulties in both areas.

AIMS

To explore the views of SLTs and mental health clinicians about their experiences of working with CYP exhibiting co-occurring SLCN and mental health difficulties.

METHODS & PROCEDURES

Semi-structured interviews were conducted with eight SLTs and six mental health professionals, including psychotherapists, clinical psychologists, play therapists and counsellors, with experience working with CYP with SLCN. Interviews were analysed using reflexive thematic analysis and themes were identified from the data.

OUTCOMES & RESULTS

Participants felt that SLCN and mental health difficulties frequently co-occur. Participants described how CYP with SLCN and mental health issues commonly experience difficulties across and between the domains of language and cognition, emotional well-being and challenging behaviour. Findings suggest that there are organizational limitations in the fields of SLT and mental health that have implications for the efficacy of assessment and treatment of CYP with SLCN and mental health difficulties. Traditional talking therapies were perceived to be inaccessible and ineffective for CYP with SLCN and mental health difficulties. Interventions blending behaviour and emotion programmes with language and communication interventions were considered potentially beneficial.

CONCLUSIONS & IMPLICATIONS

Future research should explore and evaluate current services and service set-up in SLT and mental health. The findings from this study have important implications for the efficacy of treatments provided to this population suggesting that more research needs to be done into effective diagnosis and interventions for this population.

WHAT THIS PAPER ADDS

What is already known on the subject Research suggests that CYP with SLCN, such as developmental language disorder (DLD), are likely to experience mental health difficulties including depression, anxiety and poor emotional well-being. CYP who experience difficulties with SLCN and poor mental health are not well understood and this area remains under-researched. This has implications for clinician knowledge and therefore the effective diagnosis and treatment of children and adolescents experiencing SLCN and mental health difficulties. In addition, little is known about the accessibility of talking therapies to CYP presenting with SLCN and mental health difficulties. What this paper adds to existing knowledge SLCN issues are understood by SLTs and mental health issues are understood by mental health professionals, but where these co-occur difficulties exist for the diagnostic process, with professionals perceiving that CYP in this category are often undiagnosed or misdiagnosed. Organizational boundaries between SLT and mental health were perceived to contribute to a lack of understanding of SLCN and mental health needs, which has implications for effective diagnosis and treatment. Traditional talking therapies were thought to be inaccessible for CYP with SLCN and mental health difficulties. Interventions used in both SLT and psychotherapy were perceived as clinically useful if combined. What are the potential or actual clinical implications of this work? This paper highlights implications for the accessibility and efficacy of the assessment and treatment provided to this population and to the organization of services currently treating this group of CYP. A direction for future research would be to undertake service evaluations and intervention-based studies.

Furthering the language hypothesis of alexithymia: An integrated review and meta-analysis

Alexithymia, including the inability to identify and express one's own feelings, is a subclinical condition responsible for some of the socioemotional symptoms seen across a range of psychiatric conditions. The language hypothesis of alexithymia posits a language-mediated disruption in the development of discrete emotion concepts from ambiguous affective states, exacerbating the risk of developing alexithymia in language-impaired individuals. To provide a critical evaluation, a systematic review and meta-analysis of 29 empirical studies of language functioning in alexithymia was performed. A modest association was found between alexithymia and multi-domain language deficits (r = -0.14), including structural language, pragmatics, and propensity to use emotional language. A more theoretically-relevant subsample analysis comparing alexithymia levels in language-impaired and typical individuals revealed larger effects, but a limited number of studies adopted this approach. A synthesis of 11 emotional granularity studies also found an association between alexithymia and reduced emotional granularity (r = -0.10). Language impairments seem to increase the risk of alexithymia. Heterogeneous samples and methods suggest the need for studies with improved alexithymia assessments.

Impaired emotion perception and categorization in semantic aphasia

According to a constructionist model of emotion, conceptual knowledge plays a foundational role in emotion perception; reduced availability of relevant conceptual knowledge should therefore impair emotion perception. Conceptual deficits can follow both degradation of semantic knowledge (e.g., semantic 'storage' deficits in semantic dementia) and deregulation of retrieval (e.g., semantic 'access' deficits in semantic aphasia). While emotion recognition deficits are known to accompany degraded conceptual knowledge, less is known about the impact of semantic access deficits. Here, we examined emotion perception and categorization tasks in patients with semantic aphasia, who have difficulty accessing semantic information in a flexible and controlled fashion following left hemisphere stroke. In Study 1, participants were asked to sort faces according to the emotion they portrayed - with numbers, written labels and picture examples each provided as category anchors across tasks. Semantic aphasia patients made more errors and showed a larger benefit from word anchors that reduced the need to internally constrain categorization than comparison participants. They successfully sorted portrayals that differed in valence (positive vs. negative) but had difficulty categorizing different negative emotions. They were unimpaired on a control task that involved sorting faces by identity. In Study 2, participants matched facial emotion portrayals to written labels following vocal emotion prosody cues, miscues, or no cues. Patients presented with overall poorer performance and benefited from cue trials relative to within-valence miscue trials. This same effect was seen in comparison participants, who also showed deleterious effects of within-valence miscue relative to no cue trials. Overall, we found that patients with deregulated semantic retrieval have deficits in emotional perception but that word anchors and cue conditions can facilitate emotion perception by increasing access to relevant emotion concepts and reducing reliance on semantic control. Semantic control may be of particular importance in emotion perception when it is necessary to interpret ambiguous inputs, or when there is interference between conceptually similar emotional states. These findings extend constructionist accounts of emotion to encompass difficulties in controlled semantic retrieval.

The Association between Parent and Child-Report Measures of Alexithymia in Children with and without Developmental Language Disorder

Accurate measures of alexithymia, an inability to recognise and describe one’s own emotions, that are suitable for children are crucial for research into alexithymia’s development. However, previous research suggests that parent versus child reports of alexithymia do not correlate. Potentially, children may report on the awareness of their emotions, whereas parent-report measures may reflect children’s verbal expression of emotion, which may be confounded by children’s communicative abilities, especially in conditions such as Developmental Language Disorder (DLD). Given theoretical arguments that alexithymia may develop due to language impairments, further research into alexithymia in DLD is also needed. This project examined parent and child report measures of alexithymia in children with DLD (n = 106) and without DLD (n = 183), and their association to children’s communication skills. Parent and child reports were not significantly correlated in either group, and children with DLD had higher alexithymia scores on the parent-report measure only. Thus, parent and child measures of alexithymia likely reflect different constructs. Pragmatic language problems related to more parent-reported alexithymia, over and above group membership. Structural language abilities were unrelated to alexithymia. We suggest decreased social learning opportunities, rather than a language measure artefact, underlie increased alexithymic difficulties in DLD.

The Prevalence and Characteristics of Alexithymia in Adults Following Brain Injury: A Meta-Analysis

Alexithymia is the inability to identify and describe one's own emotions. Some research suggests that organic alexithymia may occur after acquired brain injury (ABI). However, the results in the literature are inconsistent, when comparisons are made against healthy controls. Furthermore, a precise estimate of alexithymia prevalence in the ABI population has not yet been reported. Consequently, this meta-analysis aimed to estimate the prevalence and characteristics of alexithymia in ABI, as measured by the Toronto Alexithymia Scale-20 (TAS-20). Based on 22 unique ABI samples, a series of random-effects meta-analyses estimated moderate to large positive effect sizes (i.e., greater alexithymia in ABI samples) for the TAS-20 total scale (Hedges' g = 1.00, 95% CI [0.75, 1.35]), as well as the subscales: difficulty identifying feelings (Hedges' g = 0.92, 95% CI [0.66, 1.17]), difficulty describing feelings (Hedges' g = 0.69, 95% CI [0.50, 0.87]) and externally oriented thinking (Hedges' g = 0.75, 95% CI [0.64, 0.85]). Furthermore, a meta-regression identified a larger effect size (TAS-20 total scale score) for traumatic brain injury (TBI) samples, in comparison to non-TBI samples. Finally, the prevalence of clinically significant levels of alexithymia (TAS-20 total scale ≥ 68.4; i.e., two SDs above the general population mean) in ABI patients was estimated at 15.2%. We interpreted the results to suggest that ABI may have a substantial negative impact on affective processing abilities and, thus, comprehensive assessment of emotional functioning deficits following ABI should be considered by practitioners.