Alexithymia and attachment representation in idiopathic spasmodic torticollis

Attachment style and parental bonding: Relationships with fibromyalgia and alexithymia

Objectives

Fibromyalgia (FM) is a chronic pain syndrome, and alexithymia, which is a condition that is characterised by deficits in emotional self-awareness, is highly prevalent among individuals with FM. Insecure attachment styles and inadequate parental care appear to play an important role in the onset and maintenance of both alexithymia and chronic pain. Therefore, the present study aimed to examine the associations between attachment styles, parental bonding, and alexithymia among patients with FM and healthy controls (HC).

Methods

All participants completed a battery of tests that assessed alexithymia, attachment styles, and parental bonding. Two logistic regression models were tested to examine whether these variables predict (a) group membership (i.e. patients with FM vs. HC) and (b) the likelihood of having alexithymia (i.e. among patients with FM and HC).

Results

Alexithymia (i.e. difficulty identifying and describing feelings subscales of the 20-item Toronto Alexithymia Scale) significantly predicted group membership (i.e. the likelihood of having FM). On the other hand, educational level and dismissive attachment (i.e. the discomfort with closeness and relationships as secondary subscales of the Attachment Style Questionnaire) were the only significant predictors of the likelihood of having alexithymia.

Conclusions

These findings highlight both the relevance of alexithymic traits to the definition of FM and centrality of an insecure attachment style to the manifestation of alexithymia.

When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders

INTRODUCTION

In recent years alexithymia and attachment theory have been recognized as two parallel research lines trying to improve the information on the development and maintenance of eating disorders (EDs). However, no research has analyzed these constructs among patients' families. In this study we compared alexithymia and attachment in mothers of patients with EDs and a control group. Further, we hypothesized that mothers of daughters with EDs with insecure and unresolved states of mind will reported high levels of alexithymia. Lastly, we explored the daughters' evaluations of maternal alexithymia.

METHODS

45 mothers of ED women and 48 mothers of healthy controls (N = 93) matched for age and socio-demographic variables were administered by the Toronto Alexithymia Scale-20 (TAS-20) (S), while two sub-groups of "ED" mothers (n = 20) and "non-ED" ones (n = 22) were assessed by the Adult Attachment Interview (AAI). Moreover, the Observer Alexithymia Scale (OAS) was administered to the daughters for evaluating maternal alexithymia.

RESULTS

Regarding alexithymia, no differences were found between ED and non-ED mothers according to the TAS-20, while ED mothers showed more unresolved AAI classifications than non-ED mothers. No correlations were found between the TAS-20 and the AAI. Lastly, ED mothers were evaluated more alexithymic by their daughters with the OAS than those in the control group, and their alexithymic traits were significantly correlated with dismissing states of mind (idealization and lack of memory) in the AAIs.

DISCUSSION

Our results highlighted an interesting discrepancy among mothers with ED daughters between the low level of alexithymia provided by their self-reports and the high level of alexithymia observed by their daughters, although the OAS showed severe methodological limitations. Maternal attachment states of mind characterized by the lack of resolution of past losses could be connected to a confusing and incoherent quality of parenting.

Alexithymia and adult attachment representations: associations with the five-factor model of personality and perceived relationship adjustment

Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition, measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security, assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship adjustment beyond the domains of the FFM.

SGCE mutations cause psychiatric disorders: clinical and genetic characterization

Myoclonus dystonia syndrome is a childhood onset hyperkinetic movement disorder characterized by predominant alcohol responsive upper body myoclonus and dystonia. A proportion of cases are due to mutations in the maternally imprinted SGCE gene. Previous studies have suggested that patients with SGCE mutations may have an increased rate of psychiatric disorders. We established a cohort of patients with myoclonus dystonia syndrome and SGCE mutations to determine the extent to which psychiatric disorders form part of the disease phenotype. In all, 89 patients with clinically suspected myoclonus dystonia syndrome were recruited from the UK and Ireland. SGCE was analysed using direct sequencing and for copy number variants. In those patients where no mutation was found TOR1A (GAG deletion), GCH1, THAP1 and NKX2-1 were also sequenced. SGCE mutation positive cases were systematically assessed using standardized psychiatric interviews and questionnaires and compared with a disability-matched control group of patients with alcohol responsive tremor. Nineteen (21%) probands had a SGCE mutation, five of which were novel. Recruitment of family members increased the affected SGCE mutation positive group to 27 of whom 21 (77%) had psychiatric symptoms. Obsessive-compulsive disorder was eight times more likely (P < 0.001) in mutation positive cases, compulsivity being the predominant feature (P < 0.001). Generalized anxiety disorder (P = 0.003) and alcohol dependence (P = 0.02) were five times more likely in mutation positive cases than tremor controls. SGCE mutations are associated with a specific psychiatric phenotype consisting of compulsivity, anxiety and alcoholism in addition to the characteristic motor phenotype. SGCE mutations are likely to have a pleiotropic effect in causing both motor and specific psychiatric symptoms.

Emotion regulation and mental representation of attachment in patients with systemic lupus erythematosus: a study using the Adult Attachment Interview

Mental representations of attachment and emotion regulation influence individual patterns of stress response and vulnerability to illness. The present study investigates the adult attachment states of mind of 40 women with systemic lupus erythematosus (SLE) using the Adult Attachment Interview. We also assessed alexithymia using the Toronto Alexithymia Scale and dissociation using the Dissociative Experiences Scale. The results showed a high prevalence of the unresolved state of mind (13 patients, 32.5%) and the entangled state of mind (10 patients, 25%). The alexithymia score also varied significantly as a function of the mental representation of attachment and was modulated by amnestic dissociation. These findings suggest that adult attachment in patients with SLE influences the presence of alexithymic features. Moreover, these also indicate that dissociative states mediate the perception of painful memories and feelings, thus contributing to the partial avoidance of emotions and the failure to fully experience and recognize them. The clinical implications of these findings are also discussed.

Alexithymia and low cooperativeness are associated with suicide attempts in male military personnel with adjustment disorder: a case-control study

Subpopulations of patients with adjustment disorder are at increased risk for suicide. The current study investigated whether personality traits, including alexithymia, temperament, and character, are associated with an increased risk of suicide in individuals with adjustment disorder. Age- and sex-matched patients meeting the diagnostic and statistical manual of mental disorders (DSM-IV) criteria for adjustment disorder with (n=92) and without (n=92) a history of suicide attempts were recruited for the present study. Ninety-two healthy individuals who did not meet diagnostic criteria for Axis I or II diagnoses were used as controls. The Toronto alexithymia scale-20 (TAS-20) and the temperament and character inventory (TCI) were used to assess personality traits. Significantly higher total and subscale scores on the TAS-20, including on the difficulty-identifying-feelings (DIF) and difficulty-describing-feelings (DDF) subscales, and lower scores on the TCI cooperativeness subscale were noted in adjustment-disorder patients with previous suicide attempts. In the multivariate regression analysis, high DDF and DIF and low cooperativeness increased the risk of suicide attempts in adjustment-disorder patients. A subsequent path analysis revealed that high DDF had a direct effect on suicide attempts, whereas high DIF had an indirect effect on suicide attempts via low cooperativeness.

Psychoanalysis and empirical research: the example of alexithymia

An extensive body of research on the alexithymia construct is reviewed to show how various empirical methodologies can be used to evaluate the validity and increase our understanding of theoretical and clinically derived psychoanalytic concepts. The historical background of alexithymia and the theoretical framework in which the construct was formulated are presented, after which measurement- and experiment-based approaches to construct validation are described. This is followed by a review of empirical investigations that have yielded evidence that alexithymia is a dimensional personality trait associated with several illnesses of interest to psychoanalysts. Empirical research also supports clinical observations and impressions that individuals with high degrees of alexithymia principally employ primitive defenses, have a limited capacity for empathy, exhibit deficits in mentalization, and do not respond well to traditional interpretive psychotherapies. Also reviewed is empirical research that implicates genetic and environmental/developmental factors in the etiology of alexithymia, in particular childhood trauma and insecure attachments, factors generally associated with deficits in affect development and affect regulation. The clinical relevance of the empirical research findings is discussed in the final section.

Temperament and character of young male conscripts with adjustment disorder: a case-control study

Personality is an important clinical factor for successful adjustment in stressful situations. The aim of this study was to examine possible differences in temperament and character dimensions between patients with adjustment disorder with depressed mood and healthy controls. Among the young male conscripts, 86 subjects with adjustment disorder with depressed mood and 86 healthy controls were included. The mean scores in the 7 dimensions and 25 subscales of the Temperament and Character Inventory were compared between the patients with adjustment disorder with depressed mood and the control group by an independent t-test. The patients with adjustment disorder with depressed mood had significantly higher scores on harm-avoidance and lower scores on self-directedness, cooperativeness, and self-transcendence than did the controls. There were no differences in novelty seeking, reward dependence, and persistence in temperament between the two groups. The results of this study suggest that the personality traits of the subjects with adjustment disorder with depressed mood would make them vulnerable to stressful situations and less skilled in coping with conscription.

A naturalistic study of alexithymia among psychiatric outpatients treated in an integrated group therapy program

OBJECTIVES

Alexithymia is common among psychiatric outpatients and can complicate treatment. There has been little research into whether alexithymia can be modified by psychological intervention, and whether change in alexithymia is related to other areas of improvement. The purpose of the present study was to examine whether participation in an integrated group therapy program could effect change in alexithymia, and whether such change is related to improvement in interpersonal functioning.

DESIGN AND METHODS

Sixty-eight consecutively admitted psychiatric outpatients to a comprehensive group therapy program were evaluated at baseline, post-therapy, and 3-month follow-up using the Toronto Alexithymia Scale 20, the Beck Depression Inventory, and the Inventory of Interpersonal Problems-28. Associations among variables were evaluated with correlations and among group comparisons with t test, ANOVA, chi-square tests, and logistic regression. Change in alexithymia was examined using repeated measures ANOVA, controlling for change in depressive symptoms.

RESULTS

Alexithymia, particularly difficulty identifying feelings, decreased significantly during the treatment period. Post-therapy levels of alexithymia were maintained during the 3 months following treatment completion. Changes in alexithymia were significantly associated with changes in interpersonal problems, both during therapy and during the follow-up period.

CONCLUSIONS

The results of our study suggest that a comprehensive, integrated group therapy program can affect change in alexithymia, and that such change can be maintained once therapy is completed. Also, modifying alexithymia may contribute to improvement in interpersonal functioning.

Childhood trauma in obsessive compulsive disorder: the roles of alexithymia and attachment

OBJECTIVE

The aim of this study was to investigate the interrelationships between childhood trauma, attachment, alexithymia, and the severity of obsessive compulsive disorder (OCD) in a cohort of participants with OCD.

RATIONALE

There is a growing body of research linking traumatic experiences in childhood with the development of OCD. The mechanisms involved in this association are not yet clear.

METHODS

The sample was comprised of 82 people with OCD and 92 comparison participants. A cross-sectional design was used, utilizing internet-mediated administration of the Childhood Trauma Questionnaire - revised (CTQ-R); the Yale-Brown Obsessive Compulsive Scale - Self-Report (Y-BOCS-SR); the Experiences in Close Relationships Scale (ECR); and Toronto Alexithymia Scale (TAS-20). Partial least squares (PLS) analysis was used to determine significant paths between the constructs.

RESULTS

Results of PLS analysis supported all of the hypotheses made: there was a significant positive correlation between childhood trauma and attachment avoidance, which in turn was significantly positively associated with alexithymia. Alexithymia was significantly associated with the severity of OCD symptoms and the number of OCD symptoms. Mediational analysis showed that alexithymia significantly carried an influence from attachment avoidance to the severity of obsessions and the number of obsession symptoms.

CONCLUSIONS

There is a relationship between childhood trauma and OCD, however this relationship is not direct in nature but is influenced by peoples' past experiences with significant others and associated difficulties in emotional processing.

Metacognition, affect regulation and symptom expression: a transdiagnostic perspective

The editors of this special section commissioned this commentary to bring together some of the conceptual, empirical and measurement issues arising from this series of articles. This commentary explores metacognition in relation to its neurobiology, and diverse syndromes and clinical phenotypes, including schizophrenia, alexithymia, and personality disorders, as well as its relation to assessment and prospects for the further delineation of mechanisms of change in psychological therapy.

Does the 20-item Toronto Alexithymia Scale measure alexithymia? A study of natural language use

Construct validity of the 20-item Toronto Alexithymia Scale (TAS-20) was investigated by analyzing natural language use. It was hypothesized that the TAS-20 should be related to a lower use of emotion words and fewer references to social processes. 32 clinical interviews with mental health outpatients were analyzed with four categories of the computerized Linguistic Inquiry and Word Count dictionary: positive emotions, negative emotions, references to others, and communication words. The Difficulty Identifying Feelings subscale was positively related to negative emotion words, the Difficulty Describing Feelings subscale showed no relevant associations, and the Externally Oriented Thinking subscale was related to reduced use of positive emotion words and social process words. It is concluded that in this sample, the Externally Oriented Thinking subscale provides the best operationalization of the alexithymia construct.

Relationship between attachment style, parental bonding and alexithymia in adults with somatoform disorders

BACKGROUND

This study examines the relationship between parental bonding, adult attachment, and alexithymia in patients with Somatoform Disorders (SFD). There are few empirical studies to support the clinical hypothesis that alexithymia may be due to disturbances in the early parent-child relationship.

SAMPLING AND METHODS

In a cross-sectional study, data from 76 patients with SFD were obtained, consisting of questionnaire measures of alexithymia (TAS scale), attachment style (BFKE), and also the German version of the MOPS (Measure of Parental Style), the FDEB scale for measuring perceived parental attitude.

RESULTS

A higher than average prevalence of insecure attachment (n = 67, 88.2%) was found in our sample with SFD and a T-value of 54.3 (9.5) in the TAS total score, 22% reaching clinically significant alexithymia. Regression analyses demonstrated the relationship between the "ambivalent clinging" and "ambivalent withdrawing" attachment style and more marked alexithymia features. Furthermore, alexithymia was positively predicted by "indifference" in the relationship to the father, BDI, and Global severity index (SCL-90-R).

CONCLUSION

The results of this study support the hypothesis that alexithymia is associated with perceived parental bonding and attachment style.

Gastroesophageal reflux disease: alexithymia and attachment style

Alexithymia and its relation with attachment style were evaluated in a group of 69 patients (men, M age = 46.4 yr., SD = 12.6; women, M age = 44.2 yr., SD = 14.4) affected by Gastroesophageal Reflux Disease. Two self-evaluation questionnaires were used for psychological evaluation, the 20 item Toronto Alexithymia Scale (TAS-20) and the Attachment Style Questionnaire (ASQ). The TAS-20 analysis showed that the clinical sample taken as a whole did not score in the alexithymic range. The inverse correlations between the Confidence ASQ subscale and the Difficulty Communicating Feelings TAS-20 subscale showed that communication of emotions could develop more easily within the framework of a relational context characterized by safety and confidence. In this group of patients this was represented by the referent caregiver.

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.

The Role of Adult Attachment Styles in Psychopathology and Psychotherapy Outcomes

Attachment theory provides a model for understanding how the attachment styles formed in infancy systematically affect subsequent psychological functioning across the life span. Attachment styles provide the cognitive schemas, or working models, through which individuals perceive and relate to their worlds. In turn, these schemas predispose the development of psychopathologies and influence outcomes when people undergo psychotherapy. After reviewing recent empirical findings, the authors conclude that an understanding of attachment theory facilitates the conceptualization of clients' problems and the selection of appropriate interventions. Accordingly, attachment styles should be assessed as a standard part of treatment planning. Furthermore, the authors propose that attachment styles should be assessed as individual difference variables in psychotherapy outcome research because adult attachment styles dictate how people perceive and respond to their environments and, therefore, how clients respond differentially to various treatments.

Somatoform disorders as disorders of affect regulation: a development perspective

This paper considers the role of disturbances in affect regulation in the development and course of somatoform disorders. We first give an overview of contemporary theories in the field of psychosomatic medicine that links deficits in emotion regulation to the process of somatization, and then review recent empirical research that focuses on the association between affect regulation and somatoform disorders, with an emphasis on studies investigating the alexithymia construct. Overall, the findings suggest that somatoform disorders are linked to a diminished capacity to consciously experience and differentiate affects and express them in an adequate or healthy way. It must be noted, however, that this result has not been obtained exclusively for somatoform disorders. A promising approach to further our understanding of the developmental roots of impaired affect regulation in somatoform disorders is attachment research. The attachment research reviewed in this paper indicates that a dismissing status of attachment is linked to defensive forms of processing and expressing emotions. We present some new data that not only provide empirical support of a high proportion of dismissing attachment in somatoform disorders but also suggest that the degree to which somatoform disorder patients employ dismissing attachment strategies is strongly related to affect dysregulation. Finally, some implications for psychotherapeutic interventions in patients with somatoform disorders are considered.

Stability of alexithymia and its relationships with the 'big five' factors, temperament, character, and attachment style

BACKGROUND

Controversy still exists concerning the stability of the alexithymia construct. Also, although alexithymia has been found to be related in a theoretically meaningful way to other personality constructs such as the 'Big Five' factors, few studies have investigated its relationship with influential constructs such as temperament and character, and attachment security.

METHODS

Two hundred twenty-one undergraduate and graduate students were administered the Toronto Alexithymia Scale (TAS-20), the State-Trait Anxiety Inventory (STAI), the Zung Depression Scale (ZDS), the Temperament and Character Inventory (TCI-125), the Big Five Questionnaire (BFQ), and the Experiences in Close Relationships (ECR) questionnaire. After 1 month, 115 participants completed again the TAS-20, STAI, and ZDS.

RESULTS

Alexithymia was only moderately correlated with depression and anxiety. Both the absolute and relative stability of TAS-20 total and subscale scores was high, and a negligible portion of their change over time was accounted for by changes in depression or anxiety. In separate multiple regression models including also gender, age, depression and anxiety, TAS-20 total and subscale scores were correlated with low energy/extraversion, low emotional stability, openness, low friendliness/agreeableness; harm avoidance, low self-directedness, low cooperativeness, low reward dependence; attachment-related avoidance and anxiety.

CONCLUSIONS

Our findings lend support for both absolute and relative stability of alexithymia, corroborate an association between alexithymia and insecure attachment, and contribute to a coherent placing of alexithymia in the broader theoretical network of personality constructs.

Alexithymia: its prevalence and correlates in a British undergraduate sample

INTRODUCTION

Alexithymia is characterized by a difficulty identifying and describing emotional states, as well as an externally oriented thinking style. This study investigated the prevalence of alexithymia in a British undergraduate sample and assesses its relationship to both parental bonding and dissociation.

METHOD

The Toronto alexithymia scale (TAS-20), the Parental Bonding Instrument (PBI), and the Dissociative Experience Scale (DES) were administered to a sample of 181 male and 190 female undergraduate students from both arts and science subjects.

RESULTS

Rates of alexithymia were comparable with those observed in some other countries. Contrary to predictions, females were found to have higher rates than males, and the highest presence of alexithymia was in female science students. As in previous studies, alexithymia was linked to both dissociation and perceptions of a lack of maternal care, though the degree of association to the latter was small. Dissociative experiences were predicted by both maternal overprotection and difficulties identifying feelings.

DISCUSSION

Some qualified support was found for the relevance of early maternal bonding to later difficulties processing emotions. The presence of greater alexithymia in females, and female science students in particular, was discussed in reference to similar observations elsewhere. There was also an understandable relationship between 'difficulty identifying feelings' (TAS) and both depersonalization/derealization and absorption (DES).

Somatoform disorders as disorders of affect regulation: a study comparing the TAS-20 with non-self-report measures of alexithymia

OBJECTIVE

To determine the role of undifferentiated and dysregulated affects in somatoform disorders by using a multimethod assessment approach of alexithymia.

METHODS

Forty patients with ICD-10 somatoform disorders (SoD) and 20 healthy controls, matched for age, education and sex, were included in the study. Alexithymia was assessed using the Toronto Alexithymia Scale (TAS-20), the Affect Consciousness Interview (ACI), and the Levels of Emotional Awareness Scale (LEAS). All classifications were made blinded with regard to clinical status.

RESULTS

Scores of the ACI and the TAS-20 showed that alexithymia is higher in SoD than in healthy controls. No differences were found on the LEAS. In terms of the multidimensionality of the alexithymia construct, our results indicate a specific positive association between SoD and a proneness to experience undifferentiated affects. The three subfactors of the TAS-20 were differentially related to non-self-report measures of alexithymia and to negative affectivity (NA). Only the cognitive facet of the TAS-20 (externally oriented thinking [EOT]) was related to the LEAS and the ACI. In contrast, the affective facets of the TAS-20-difficulties identifying feelings (DIF) and difficulties describing feelings (DDF)-were substantially related to NA.

CONCLUSION

The findings highlight the important role of impaired affect regulation and NA in the process of somatization.

New trends in alexithymia research

Research investigating the alexithymia construct is advancing rapidly and has broadened considerably in recent years as a result of interdisciplinary efforts, new methodologies, and experimental techniques. New developments in the field include a shift from measurement-based validational studies to experimental investigations, which explore the relation between alexithymia and various aspects of emotional processing; the use of functional brain imaging techniques to explore neural activity associated with alexithymia; and experimental studies that measure multiple indices of physiological response to standardized emotion-inducing stimuli. Developmental research and attachment studies are providing ways for investigating potential etiological sources of the construct; and experimental approaches are being used to explore relations between alexithymia and other health-related personality constructs. In addition, longitudinal and treatment studies are clarifying the relation between alexithymia and psychopathology and the extent to which alexithymia predicts treatment outcome. Investigators need to embrace the new methods and techniques for the field of research to further increase understanding of the alexithymia construct and its association with physical and mental illness.

Communicating with alexithymic and non-alexithymic patients: an experimental study of the effect of psychosocial communication and empathy on patient satisfaction

BACKGROUND

Previous studies have shown that alexithymia is associated with a wide range of somatic and psychiatric conditions. The aim of this study was to investigate experimentally how psychosocial communication and empathic response from the physician affects satisfaction in alexithymic and non-alexithymic patients.

METHOD

Seven physicians and 65 female patients from a fibromyalgia patient association participated in the study. The Toronto Alexithymia Scale (TAS-20) was used to categorise patients as alexithymic or non-alexithymic. Patients also completed questionnaires regarding trait anxiety and satisfaction with their consultation. Physicians were instructed to differentiate their communication in terms of both psychosocial matters and empathic response. The content of the consultation was analysed using the Roter Interactional Analysis System.

RESULTS

Regression analyses revealed that alexithymic patients were significantly more satisfied when they received a greater empathic response from the physician. Non-alexithymic patients, however, were more satisfied when the consultation was of longer duration. Psychosocial communication did not have any statistically significant effect on satisfaction in either of the two subgroups.

CONCLUSIONS

Verbalised empathic response from the physician may be crucial for the alexithymic patient's post-consultation satisfaction and may thereby become the basis for a solid treatment alliance. The validity of this hypothesis should be tested in different clinical settings and with different patient populations. Future research on alexithymic patients' response to psychosocial communication may benefit from determining to what extent this communication is concerned with general distress or more complex emotional phenomena.

Attachment representation and illness behavior in somatoform disorders

Somatoform disorders are characterized by high health care utilization and conflictual interactions with health care providers. The aim of the present study was to explore whether patterns of insecure attachment are a prominent feature of somatoform disorder. In addition, the links between insecure attachment and health care utilization were evaluated. Thirty-seven patients with an International Classification of Diseases, 10th Revision diagnosis of somatoform disorders and 20 healthy control subjects matched for age, sex, and education were administered the Adult Attachment Interview. Psychological symptoms and health care utilization were assessed using various self-report measures. There was a clearly higher incidence of insecure attachment in the somatoform group compared with the nonclinical control subjects. In the somatoform group, dismissing attachment occurred approximately twice as frequently as the preoccupied pattern of attachment. The results provide evidence for an association between health care utilization and insecure attachment. Insecure attachment in somatoform disorder may underlie problems in interpersonal functioning and in health care behavior.

Psychosomatic factors in first-onset alopecia areata

Although the onset of alopecia areata has often been anecdotally linked with emotional stress, findings from the few controlled studies have not been univocal. The authors compared outpatients experiencing a recent onset of alopecia areata (N=21) with outpatients affected by skin conditions commonly believed as having a low psychosomatic component (N=102). Participants were administered Paykel's Interview for Recent Life Events, the Experiences in Close Relationships scale, the 20-item Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support. Multiple logistic regression was used to control for age and gender. The total number of recent life events (last 12 months) was not different between the alopecia patients and the comparison subjects. Also, the alopecia patients and the comparison subjects did not differ in terms of the number of undesirable or major events. The comparison subjects even experienced a greater number of uncontrollable events. Alopecia areata tended to be associated with high avoidance in attachment relationships, high alexithymic characteristics, and poor social support. The results suggest that personality characteristics might modulate individual susceptibility to alopecia areata.

High psychiatric comorbidity in spasmodic torticollis: a controlled study

Disturbed body image and negative self-referent cognitions caused by the postural disfigurement of the head are regarded as the main reason for elevated depression scores in spasmodic torticollis (ST), but this factor was never controlled for. We therefore compared 48 patients with ST and 48 patients with alopecia areata (AA) who were matched for age, sex, and body image dissatisfaction. Psychiatric diagnoses were based on a structured psychiatric interview (SCID-I). Results of patients with ST and AA were compared with a matched sample of the representative German population. Odds ratios to develop psychiatric comorbidity for patients with ST compared with patients with AA were significantly increased throughout nearly all assessed DSM-IV categories. Logistic regression analysis showed that (1) depressive coping and (2) belonging to the group of patients with ST correlated with a significantly higher rate of current psychiatric diagnosis. We conclude that high psychiatric comorbidity in ST is unlikely to be a mere consequence of chronic disease and disfigurement.

Stressful life events, social support, attachment security and alexithymia in vitiligo. A case-control study

BACKGROUND

It has often been suggested that stress might trigger vitiligo. However, only one study supported this hypothesis, and no study explored the role of other personality or social factors.

METHODS

Out-patients experiencing a recent onset or exacerbation of vitiligo (n = 31) were compared with out-patients with skin conditions in which psychosomatic factors are commonly were regarded as negligible (n = 116). Stressful events during the last 12 months were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia and social support were assessed with the 'Experiences in Close Relationships' questionnaire, the Toronto Alexithymia Scale (TAS-20), and the Multidimensional Scale of Perceived Social Support, respectively.

RESULTS

Cases and controls did not differ regarding the total number of events and the number of undesirable, uncontrollable or major events. Three or more uncontrollable events had occurred more frequently among cases than controls. Perceived social support was lower in cases than in controls. Cases scored higher than controls on anxious attachment, tended towards higher scores on avoidant attachment and were classified more often as insecure. Cases scored higher than controls on the TAS-20 and were classified more often as alexithymic or borderline alexithymic. The occurrence of many uncontrollable events, alexithymia and anxious attachment were associated with vitiligo also in multiple logistic regression analysis.

CONCLUSIONS

These findings suggest that vulnerability to vitiligo is not increased by stressful events, except for many uncontrollable events. Alexithymia, insecure attachment and poor social support appear to increase susceptibility to vitiligo, possibly through deficits in emotion regulation or reduced ability to cope effectively with stress.

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.

Attachment and coping with chronic disease

BACKGROUND

In this clinical study, attachment theory was applied to research in the field of coping with chronic disease. The approach was to integrate concepts of coping within a framework of attachment theory. It was hypothesised that attachment concepts have an influence on coping strategies, and that they may predict the subjective emotional and physical health status during the course of medical treatment.

METHOD

One hundred fifty patients were investigated with an adult attachment interview (AAPR coding system) and a coping interview (Bernese Coping Modes). Self-reported coping modes, social support, the subjective health status and quality of life were also assessed by self-report measures at two or more sampling points of measurement. Three subsamples of patients, suffering from (a) breast cancer, (b) chronic leg ulcers and (c) alopecia, were studied in order to include a broad range of subjective impairment caused by a disease.

RESULTS

Findings indicate a moderate statistical effect of attachment patterns on coping strategies when controlling the influence of confounding variables. Insecure attachment was related to less flexible coping. Coping strategies also differed between the different types of insecure attachment; however, there were differences depending on the perspective of the coping behaviour (self- vs. observer ratings) as well. From the observer perspective, ambivalently attached individuals showed more negative emotional coping while avoidantly attached individuals showed more diverting strategies. In the self-report, ambivalently attached patients revealed hyperactivating tendencies in their coping behaviour while avoidantly attached individuals revealed deactivating tendencies.

CONCLUSION

As a conclusion, two levels of coping should be differentiated. One level strongly corresponds with affect regulation, in particular the regulation of attachment-related emotions and concerns, while the other level shows a stronger tendency to outwardly oriented coping. A more secure attachment might be considered to be an important inner resource in the emotional adaptation to chronic diseases.

Insecure attachment and alexithymia in young men with mood symptoms

According to attachment theorists, affect regulation and quality of attachment are closely linked. As a personality trait associated with deficits in the cognitive processing and regulation of affects, alexithymia has been hypothesized to correlate with insecure attachment. To test this hypothesis, we studied the relationships between alexithymia, adult attachment style, and retrospective memories of separation anxiety symptoms during childhood in 100 young men with clinically significant mood symptoms. The most common DSM-IV diagnosis (N = 72) was adjustment disorder with depressed mood, with anxiety, or with mixed anxiety and depressed mood. Each participant completed the Twenty-Item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI), the state form of the State-Trait Anxiety Index (STAI), the Attachment Style Questionnaire (ASQ), the Relationship Questionnaire (RQ), and the Separation Anxiety Symptom Inventory (SASI). Alexithymic traits were more pronounced in those participants who had patterns of insecure attachment and who reported more severe symptoms of separation anxiety during childhood, independently of the severity of their current anxiety and depressive symptoms. Among the subgroup of participants with insecure attachment styles, those with preoccupied or fearful patterns had a higher prevalence of alexithymia (65% and 73%, respectively) than those with a dismissing pattern (36%). These data suggest a role for early developmental factors in the etiology of alexithymia

Intact physiological response to arousal with impaired emotional recognition in alexithymia

BACKGROUND

The purpose of the present study was to clarify the relationship between the recognition of emotion and physiological response to emotion (i.e. arousal) in alexithymia.

METHODS

This study investigated differences in physiological arousal state, as measured by continuous heart rate, electrodermal activity (EDA) and self-reported emotional intensity before and after exposure to an emotionally arousing or neutral videotape among 41 high- or low-alexithymic young adult participants.

RESULTS

Across subjects, emotionally negative stimuli produced increased physiological arousal. However, high-alexithymic participants exposed to the arousing videotape did not report increased subjective emotional intensity, as did low-alexithymic participants. In addition, the baseline EDA of high-alexithymic participants was significantly higher than that of the low-alexithymic participants.

CONCLUSIONS

Results support the prediction that alexithymia leads to a decoupling between subjective and physiological arousal when exposed to emotionally negative stimuli. This decoupling may increase alexithymic individuals' risks for stress-related illness.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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Theoretical issues and research emphasis within the field of attachment theory have shifted from attachment behavior "to the level of representation" (Bretherton, 1985) since the middle of the 80ies. The paper presents an overview on basic assumptions, research methodology and empirical findings in the field of attachment research. Four issues are addressed, which are relevant for psychosomatic research. These concern: (1) The prevalence of insecure attachment representation in psychosomatic disorders; (2) the association between insecure attachment representation and an increased psychophysiological reactivity; (3) the potential link between attachment and affect regulation and (4) the question, whether the classification of attachment representations may increase our understanding of specific aspects of illness behavior in psychosomatic conditions such as somatoform disorders.