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

Poor respiratory health outcomes associated with high illness worry and alexithymia: Eleven-year prospective cohort study among the working-age population

OBJECTIVE

Poor respiratory health outcomes have been associated with poorer physical health and higher psychological distress. The aim of this study was to investigate whether illness worry, alexithymia or low sense of coherence predict i) the onset of new respiratory disease, ii) respiratory symptoms or iii) lung function among the working-age population, independently of comorbidity mood-, anxiety, or alcohol abuse disorders.

METHODS

The study was conducted among a nationally representative sample of the Finnish population (BRIF8901) aged 30-54 years (N = 2310) in 2000-2001 and was followed up in 2011. Individuals with a diagnosed respiratory disease or a severe psychiatric disorder at baseline were excluded. Lung function was measured by a spirometry test and psychiatric disorders were diagnosed using a structured clinical interview. Structured questionnaires were used to measure self-reported respiratory symptoms and diseases, illness worry, alexithymia, and sense of coherence.

RESULTS

High illness worry predicted an 11-year incidence of asthma (OR 1.47, 95% CI 1.09-1.99, p = 0.01). Alexithymia predicted shortness of breath (OR 1.32, 95% CI 1.13-1.53, p < 0.01) and 11-year incidence of COPD (OR 2.84, 95% CI 1.37-5.88, p < 0.01), even after several adjustments for physical and mental health. Psychological dispositions did not associate with lung function in 2011.

CONCLUSIONS

In the general population, psychological factors that modify health behaviour predicted adverse respiratory health outcomes independently of lung function after 11 years of follow-up. This indicates that considering them part of personalized treatment planning is important for promoting health-related behaviour among the working-age population.

Alexithymia is associated with increased all-cause mortality risk in men, but not in women: A 10-year follow-up study

OBJECTIVE

Alexithymia is associated with various mental as well as physical disorders. Some evidence also suggested high alexithymia to increase mortality risk, but these results are few and based on specific sample compositions. We aimed to investigate the impact of alexithymia on mortality risk in a large population based cohort. In addition, we sought to elucidate the effects of the subfactors of alexithymia and sex differences.

METHODS

In a sample of N = 1380 individuals from the Study of Health in Pomerania (SHIP), we investigated the hazard-ratio (HR) of alexithymia as obtained by the Toronto Alexithymia Scale-20 (TAS-20) on all-cause mortality over an average observation time of 10 years. Sex-by-TAS-20-interactions as well as sex-stratified analyses were performed.

RESULTS

Alexithymia was significantly associated with enhanced mortality risk (HR = 1.033; 95%-CI = 1.008-1.058); p = 0.009). While sex-by-TAS-20 interactions remained insignificant, sex-stratified analyses showed that this effect was only significant in men (HR = 1.050; 95%-CI = 1.022-1.079; p ≤ 0.001), but not in women (HR: 1.008; 95%-CI = 0.960-1.057; p = 0.76). The effect was validated for the "difficulties identifying feelings" (DIF) and "difficulties describing feelings" (DDF) subfactors of the TAS-20.

CONCLUSION

Our study supports and extents previous findings by indicating that mortality risk enhancing effects of alexithymia are specific to male subjects and validated for the DIF and DDF facets. Socioeconomic, clinical and metabolic factors were associated with this relationship. Finding that the impact of alexithymia remains stable in the fully adjusted models suggests that yet unidentified additional factors must be considered.

Emotion and overeating behavior: effects of alexithymia and emotional regulation on overweight and obesity

PURPOSE

Obesity and overweight are significant risk factors for many serious diseases. Several studies have investigated the relationship between emotional regulation and overweight or obesity in people with eating disorders. Although a few studies have explored alexithymia in individuals with severe obesity without eating disorders, no attention has been paid to individuals with overweight and preclinical form of obesity. This study aims to assess whether overweight and obesity are related to emotional dysregulation and alexithymia.

METHODS

The study involved 111 undergraduate students who had not been diagnosed with an eating disorder. The sample was divided into two groups according to their body mass index (BMI): normal weight (N = 55) and overweight (N = 56). All of them completed the Toronto Alexithymia Scale (TAS-20), the Emotional Regulation Questionnaire (ERQ), and the Eating Disorder Inventory-2 (EDI-2).

RESULTS

Results showed higher levels of alexithymia, and specifically higher difficulty in identifying feelings and an externally oriented thought, in participants with overweight. Multiple correlation analysis highlighted the positive relations between some EDI-2 subscales and both alexithymia and emotional regulation scores. Linear regressions revealed a significant relationship between body BMI and both alexithymia and emotional regulation strategies.

CONCLUSIONS

The condition of overweight/obesity seems to be associated with higher emotional dysregulation compared to normal weight condition. It is essential to study this relationship because it could represent a risk factor for the worsening of problems related to overeating and excessive body weight. These findings suggest that an integrated approach aimed at considering the promotion of emotional regulation could contribute to the effectiveness of a program designed to reduce overweight and obesity.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Correlations between TSIA and TAS-20 and their relation to self-reported negative affect: A study using a multi-method approach in the assessment of alexithymia in a nonclinical sample from Italy

The 20 item Toronto Alexithymia Scale (TAS-20) has been set as the golden standard in assessing alexithymia despite its limitation due to its self-report structure. Overcoming this bound is the main reason that in 2006 brought Bagby, Taylor and Parker to develop the Toronto Structured Interview for Alexithymia (TSIA): a structured interview composed of 24 questions with the purpose of assessing four dimensions of alexithymia: Identifying emotional feelings (DIF), Describing emotional feelings (DDF), Imaginal processes (IMP), and Externally oriented thinking (EOT). The present study aimed to confirm the validity of the TSIA in the assessment of alexithymia, using internal consistency (alpha) and convergent validity (comparing TSIA and TAS-20). Since it has been demonstrated an association between alexithymia, measured with the TAS-20, and negative affect, an additional goal was to evaluate the correlation of TSIA with two measures of depression and anxiety (BDI-II and STAI-Y2). Our results showed a significant capability of the TSIA in assessing alexithymia while clearing the limitation of the TAS-20 in keeping aside partially overlapping construct such as depression and anxiety. The final suggestion is that a reliable assessment of alexithymia might come from the application of both a self-report and an observer-rated instrument.

Alexithymia according to Bucci's multiple code theory: A preliminary investigation with healthy and hypertensive individuals

OBJECTIVE

To evaluate the relation between alexithymia and Referential Activity (RA), a linguistic measure of the process by which non-verbal emotional experience is connected to language.

METHODS

The 20-Item Toronto Alexithymia Scale (TAS-20) and the Toronto Structured Interview for Alexithymia (TSIA) were administered to 20 postgraduate students and 15 outpatients with hypertension. The Weighted Referential Activity Dictionary (WRAD) and other linguistic measures (Reflection, Disfluency, and Somatic Sense) were applied to texts derived from the TSIA using the Discourse Attributes Analysis Program (DAAP).

RESULTS

Multiple linear regressions performed in the whole sample showed a relation between TSIA scores and Somatic Sense. Comparing the two groups, hypertensive subjects yielded higher scores on the TSIA than the young adult sample; no differences in DAAP measures emerged. A significant negative correlation was found between the TAS-20 Difficulty Describing Feelings score and the DAAP measure of references to body activations (Somatic Sense) both in the young adult sample and in hypertensives. In the young adult sample, negative relations emerged between different TSIA factors, WRAD score, and Somatic Sense; a positive relation with fragmented speech (Disfluency) and use of rationalization (Reflection) was also found. In hypertensive subjects, using the TSIA, a negative correlation between alexithymia and Somatic Sense and a positive correlation between alexithymia and the Mean High WRAD (a measure of intensity of engagement during the speech) were found.

CONCLUSION

The TSIA seems to be a more adequate instrument than the TAS-20 to explore relations between alexithymia and RA. Results appear to suggest a complex, nonlinear relation between alexithymia and RA, presumably influenced by subject-specific characteristics.

PRACTITIONER POINTS

A relation between alexithymia and RA has been proposed on theoretical grounds, but there has been minimal empirical investigation. This was the first study to employ both a self-report measure and a structured interview for measuring alexithymia in relation to RA. The results of this study suggest a complex, nonlinear relation between alexithymia and RA; this finding is essentially obtained with the structured interview measure of alexithymia. This relation is presumably influenced by subject-specific characteristics.

Alexithymia in Gastroenterology and Hepatology: A Systematic Review

Background: Alexithymia is a multifaceted personality construct that represents a deficit in the cognitive processing of emotions and is currently understood to be related to a variety of medical and psychiatric conditions. The present review aims to investigate the relationship of alexithymia with gastrointestinal (GI) disorders as functional gastrointestinal disorders (FGID, as irritable bowel syndrome (IBS) and functional dyspepsia) and inflammatory bowel disease (IBD) [ulcerative colitis (UC) and Crohn's disease (CD)] and liver diseases as chronic hepatitis C (CHC), cirrhosis, and liver transplantation. Methods: The articles were selected from the main electronic databases (PsycInfo, Medline, PubMed, Web of Science, Scopus, Cochrane, and ScienceDirect) using multiple combinations of relevant search terms (defined GI and liver diseases, articles in English, use of the Toronto scales [TAS] for alexithymia). The TAS was selected as inclusion criterion because it is the most widely used measure, thus allowing comparisons across studies. Results: Forty-eight studies met the inclusion criteria, of which 38 focused on GI disorders (27 on FGID and 11 on IBD) and 10 on liver diseases. Most studies (n = 30, 62%) were cross-sectional. The prevalence of alexithymia was higher in FGID (two third or more) than IBD and liver diseases (from one third to 50% of patients, consistent with other chronic non-GI diseases) than general population (10-15%). In functional disorders, alexithymia may be viewed as a primary driver for higher visceral perception, symptom reporting, health care use, symptom persistence, and negative treatment outcomes. Also, it has been found associated with psychological distress and specific GI-related forms of anxiety in predicting symptom severity as well as post-treatment outcomes and is associated with several psychological factors increasing the burden of disease and impairing levels of quality of life. A number of critical issues (small sample sizes, patients referred to secondary and tertiary care centers, cross-sectional study design, use of one single scale for alexithymia) constitutes a limitation to the generalization of findings. Conclusions: Alexithymia showed to play different roles in gastroenterology according to the clinical characteristics and the psychological burden of the various disorders, with main relevance in increasing subjective symptom perception and affecting negatively post-treatment outcomes.

Alexithymia and perception of illness in patients with cancer

This study aimed to determine how alexithymia affects the perception of illness in patients with cancer. This was a descriptive study conducted at the Atatürk University Health, Research and Practice Hospital and the Erzurum Regional Training and Research Hospital's Medical Oncology Clinic and Chemotherapy Unit. The study data were collected between July 2013 and January 2014. In total, data were collected from 283 patients with cancer. The data were collected using questionnaires enquiring about demographic and medical information: the IPQ and TAS-20. The study concluded that 50.5% of the participating patients had alexithymia. It was found that the alexithymic patients with cancer perceived the negative outcomes of their illness more strongly, and their negative feelings about the illness were more intense. This study suggests that further research should be carried out on alexithymia in patients with cancer and that their positive beliefs about the illness could be enhanced using psychosocial interventions.

Measuring Alexithymia via Trait Approach-I: A Alexithymia Scale Item Selection and Formation of Factor Structure

INTRODUCTION

It is not clear in the literature whether available instruments are sufficient to measure alexithymia because of its theoretical structure. Moreover, it has been reported that several measuring instruments are needed to measure this construct, and all the instruments have different error sources. The old and the new forms of Toronto Alexithymia Scale are the only instruments available in Turkish. Thus, the purpose of this study was to develop a new scale to measure alexithymia, selecting items and constructing the factor structure.

METHODS

A total of 1117 patients aged from 19 to 82 years (mean = 35.05 years) were included. A 100-item pool was prepared and applied to 628 women and 489 men. Data were analyzed using Explanatory Factor Analysis, Confirmatory Factor Analysis, and Item Response Theory and 28 items were selected. The new form of 28 items was applied to 415 university students, including 271 women and 144 men aged from 18 to 30 (mean=21.44).

RESULTS

The results of Explanatory Factor Analysis revealed a five-factor construct of "Solving and Expressing Affective Experiences," "External Locused Cognitive Style," "Tendency to Somatize Affections," "Imaginary Life and Visualization," and "Acting Impulsively," along with a two-factor construct representing the "Affective" and "Cognitive" components. All the components of the construct showed good model fit and high internal consistency. The new form was tested in terms of internal consistency, test-retest reliability, and concurrent validity using Toronto Alexithymia Scale as criteria and discriminative validity using Five-Factor Personality Inventory Short Form.

CONCLUSION

The results showed that the new scale met the basic psychometric requirements. Results have been discussed in line with related studies.

Moving on: the BodyMind ApproachTM for medically unexplained symptoms

Purpose

The purpose of this paper is to summarise practice-based evidence from an analysis of outcomes from a county-wide pilot study of a specialised primary care clinic employing an original approach for patients with medically unexplained symptoms (MUS). Conditions with persistent bodily symptoms for which tests and scans come back negative are termed MUS. Patients are generic, high health-utilising and for most there is no effective current treatment pathway. The solution is a proven service based on proof of concept, cost-effectiveness and market research studies together with practice-based evidence from early adopters. The research was transferred from a university into a real-world primary care clinical service which has been delivering in two clinical commissioning groups in a large county in England.

Design/methodology/approach

Clinical data calculated as reliable change from the various clinics were aggregated as practice-based evidence pre- and post-intervention via standardised measurements on anxiety, depression, symptom distress, functioning/activity, and wellbeing. It is not a research paper.

Findings

At post-course the following percentages of people report reliable improvement when compared to pre-course: reductions in symptom distress 63 per cent (39/62), anxiety 42 per cent (13/31) and depression 35 per cent (11/31); increases in activity levels 58 per cent (18/31) and wellbeing 55 per cent (17/31) and 70 per cent felt that they had enough help to go forward resulting in the self-management of their symptoms which decreases the need to visit the GP or hospital.

Research limitations/implications

Without a full clinical trial the outcomes must be interpreted with caution. There may be a possible Hawthorne or observer effect.

Practical implications

Despite the small numbers who received this intervention, preliminary observations suggest it might offer a feasible alternative for many patients with MUS who reject, or try and find unsatisfying, cognitive behaviour therapy.

Social implications

Many patients suffering MUS feel isolated and that they are the only one for whom their doctor cannot find an organic cause for their condition. The facilitated group has a beneficial effect on this problem, for example they feel a sense of belonging and sharing of their story.

Originality/value

The BodyMind Approach is an original intervention mirroring the new wave of research in neuroscience and philosophy which prides embodiment perspectives over solely cognitive ones preferred in the “talking” therapies. There is a sea change in thinking about processes and models for supporting people with mental ill-health where the need to include the lived body experience is paramount to transformation.

A comprehensive approach to understand somatic symptoms and their impact on emotional and psychosocial functioning in children

INTRODUCTION

Somatic symptoms are frequently reported by children with significant impairment in functioning. Despite studies on adult populations that suggest somatic symptoms often co-occur with difficulties in identifying and describing feelings, little research has been done in childhood. This study aimed to investigate the prevalence and frequency of somatic symptoms as well as to investigate the functional impairment in children with high number of self reported somatic symptoms versus those with fewer somatic symptoms. Additionally the parental perception of their children's somatic symptoms and functioning was explored. Finally, we explored the direct and indirect effects of difficulties in identifying feelings in predicting somatic symptoms and functional disability among school-aged children.

METHODS

356 Italian school-aged children and their mothers participated in this study. Children (mean age = 11.43; SD = 2.41) completed the Children's Somatization Inventory (CSI-24) to assess somatic symptoms, the Functional Disability Inventory (FDI) to assess physical and psychosocial functioning and the Alexithymia Questionnaire for Children (AQC) to evaluate alexithymic features. Mothers completed the parental forms of the CSI and the FDI.

RESULTS

Among children, 66.3% did not declare somatic symptoms and 33.7% reported one or more somatic symptoms in the last two weeks. A significant positive correlation emerged between children's and mothers' CSI total scores. Both children's and mothers' FDI total scores were significantly correlated with CSI scores. A significant correlation was observed between somatic symptoms and alexithymic features. Furthermore, the data showed that somatic symptoms mediated the relationship between difficulties in identifying feelings and functional impairment. Finally, it was showed that alexithymia facet of difficulty in identifying feelings contributed in large part to the prediction of the somatic symptomatology (b = 0.978, p < 0.001; R2 = 0.164, F(5, 350) = 10.32, p < 0.001).

CONCLUSIONS

Findings from this study provide evidence that a higher frequency of somatic symptoms is associated with functional disabilities and alexithymic facets in school-aged children.

Touching the Lived Body in Patients with Medically Unexplained Symptoms. How an Integration of Hands-on Bodywork and Body Awareness in Psychotherapy may Help People with Alexithymia

Medically unexplained symptoms (MUS) are a considerable presenting problem in general practice. Alexithymia and difficulties with mental elaboration of bodily arousal are hypothesized as a key mechanism in MUS. In turn, this inability influences the embodied being and participating of these patients in the world, which is coined as 'the lived body' and underlies what is mostly referred to as body awareness (BA). The present article explores a more innovative hypothesis how hands-on bodywork can influence BA and serve as a rationale for a body integrated psychotherapeutic approach of MUS. Research not only shows that BA is a bottom-up 'bodily' affair but is anchored in a interoceptive-insular pathway (IIP) which in turn is deeply connected with autonomic and emotional brain areas as well as verbal and non-verbal memory. Moreover, it is emphasized how skin and myofascial tissues should be seen as an interoceptive generator, if approached in the proper manual way. This article offers supportive evidence explaining why a 'haptic' touch activates this IIP, restores the myofascial armored body, helps patients rebalancing their window of tolerance and facilitates BA by contacting their bodily inner-world. From a trans-disciplinary angle this article reflects on how the integration of bodywork with non-directive verbal guidance can be deeply healing and resourcing for the lived body experience in MUS. In particular for alexithymic patients this approach can be of significance regarding their representational failure of bodily arousal.

It's in the mix: psychological distress differs between combinations of alexithymic facets

Alexithymia is a personality trait characterized by difficulties in identifying, describing, and communicating one's emotions. The aim of the present study is to examine the usefulness of a typological approach considering the interaction between distinct alexithymic features within a population of high-alexithymic German adults (N = 217). Latent profile analysis (LPA) was employed to test for possible underlying profiles. A 3-profile solution showed the best fit: The profiles can be described as (1) "low": lower load on all facets of alexithymia, (2) "mixed": specific problems on identifying emotions, and (3) "high": higher load on all facets of alexithymia. Moreover, this study tested how these profiles differed in psychological distress. "Mixed" profile, with specific problems on identifying emotions showed the highest levels of psychological distress. The present study suggests the importance of a specific combination of alexithymic features, rather than total alexithymia scores, as a risk factor for psychological distress.

Depression symptom clusters and their predictive value for treatment outcomes: results from an individual patient data meta-analysis of duloxetine trials

We evaluated individual patient data from phase II to IV clinical trials of duloxetine in major depressive disorder (MDD) (34 studies, 13,887 patients). Our goal was to identify clusters of patients with similar depressive symptom patterns at baseline, as measured by the 17-item Hamilton Depression Rating Scale (HAMD-17), and to investigate their respective predictive value of outcomes as measured by the HAMD-17 total score. Five clusters were identified at baseline: 1) "Lack of insight"; 2) "Sleep/sexual/somatic"; 3) "Typical MDD"; 4) "Gastrointestinal/weight loss"; and 5) "Mild MDD". However, it should be noted that cluster descriptors are not mutually exclusive. Analyses of the HAMD-17 total score results over time were performed using the 18 randomized placebo and/or actively controlled studies representing 6723 patients. At the end of acute treatment (ranging from 4 to 36 weeks), different levels of effect sizes for active therapy (64.5% duloxetine) vs. placebo were detected by cluster. In 3 out of 5 clusters (representing about 80% of the patients), the effect size was significantly different from 0, in favor of active therapy. The effect size was largest in those clusters with severe somatic symptoms ("Sleep/sexual/somatic" cluster [-0.4170], and "Gastrointestinal/weight loss" cluster [-0.338]). In conclusion, our cluster analysis identified 5 clinically relevant MDD patient clusters with specific mean treatment outcomes. Identification of MDD clusters may help to improve outcomes by adapting MDD treatment to particular clinical profiles.

Relationship between alexithymia and coping strategies in patients with somatoform disorder

PURPOSE

A multidimensional intervention integrating alexithymia, negative affect, and type of coping strategy is needed for the effective treatment of somatoform disorder; however, few studies have applied this approach to the three different dimensions of alexithymia in patients with somatoform disorder. The purpose of this study was to determine the relationship between type of coping strategy and three different dimensions of alexithymia expressed in patients.

PATIENTS AND METHODS

A total of 196 patients with somatoform disorder completed the 20-item Toronto Alexithymia Scale, the Zung Self-Rating Depression Scale, the Spielberger State-Trait Anxiety Inventory, the Somatosensory Amplification Scale, and the Lazarus Stress Coping Inventory. The relationships between alexithymia (Toronto Alexithymia Scale - 20 score and subscales), demographic variables, and psychological inventory scores were analyzed using Pearson's correlation coefficients and stepwise multiple regression analysis.

RESULTS

The mean Toronto Alexithymia Scale - 20 total score (56.1±10.57) was positively correlated with the number of physical symptoms as well as with psychopathology scores (Self-Rating Depression Scale, State-Trait Anxiety Inventory trait, state, and Somatosensory Amplification Scale), but negatively correlated with planful problem solving, confrontive coping, seeking social support, and positive reappraisal coping scores. With respect to coping strategy, multiple regression analyses revealed that "difficulty in identifying feelings" was positively associated with an escape-avoidance strategy, "difficulty in describing feelings" was negatively associated with a seeking social support strategy, and "externally oriented thinking" was negatively associated with a confrontive coping strategy.

CONCLUSION

Alexithymia was strongly associated with the number of somatic symptoms and negative affect. Patients with high "difficulty in describing feelings" tend to rely less on seeking social support, and patients with high "externally oriented thinking" tend to rely less on confrontive coping strategies. The coping skills intervention implemented should differ across individuals and should be based on the alexithymia dimension of each patient.

Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: a cross-sectional study on burden

Background

To determine whether healthcare resources are allocated fairly, it is helpful to have information on the quality of life (QoL) of patients with Unexplained Physical Symptoms (UPS) and on the costs associated with them, and on how these relate to corresponding data in other patient groups. As studies to date have been limited to specific patient populations with UPS, the objective of this study was to assess QoL and costs in a general sample of patients with UPS using generic measures.

Methods

In a cross-sectional study, 162 patients with UPS reported on their QoL, use of healthcare resources and lost productivity in paid and unpaid work. To assess QoL, the generic SF-36 questionnaire was used, from which multidimensional quality-of-life scores and a one-dimensional score (utility) using the SF-6D scorings algorithm were derived. To assess costs, the TiC-P questionnaire was used.

Results

Patients with UPS reported a poor QoL. Their QoL was mostly decreased by limitations in functioning due to physical health, and the least by limitations in functioning due to emotional problems. The median of utilities was 0.57, and the mean was 0.58 (SD = .09).

The cost for the use of healthcare services was estimated to be €3,123 (SD = €2,952) per patient per year. This cost was enlarged by work-related costs: absence from work (absenteeism), lower on-the-job productivity (presenteeism), and paid substitution of domestic tasks. The resulting mean total cost was estimated to be €6,815 per patient per year.

Conclusions

These findings suggest that patients with UPS have a high burden of disease and use a considerable amount of healthcare resources. In comparison with other patient groups, the QoL values of patients with UPS were among the poorest and their costs were among the highest of all patient groups. The burden for both patients and society helps to justify the allocation of sufficient resources to effective treatment for patients with UPS.

Trial registration

Nederlands Trial Register, NTR1609

Effective group training for patients with unexplained physical symptoms: a randomized controlled trial with a non-randomized one-year follow-up

BACKGROUND

Although cognitive-behavioral therapy for Unexplained Physical Symptoms (UPS) is effective in secondary care, studies done in primary care produced implementation problems and conflicting results. We evaluated the effectiveness of a cognitive-behavioral group training tailored to primary care patients and provided by a secondary community mental-health service reaching out into primary care.

METHODOLOGY/PRINCIPAL FINDINGS

The effectiveness of this training was explored in a randomized controlled trial. In this trial, 162 patients with UPS classified as undifferentiated somatoform disorder or as chronic pain disorder were randomized either to the training or a waiting list. Both lasted 13 weeks. The preservation of the training's effect was analyzed in non-randomized follow-ups, for which the waiting group started the training after the waiting period. All patients attended the training were followed-up after three months and again after one year. The primary outcomes were the physical and the mental summary scales of the SF-36. Secondary outcomes were the other SF-36-scales and the SCL-90-R. The courses of the training's effects in the randomized controlled trial and the follow-ups were analyzed with linear mixed modeling. In the randomized controlled trial, the training had a significantly positive effect on the quality of life in the physical domain (Cohen's d = 0.38;p = .002), but this overall effect was not found in the mental domain. Regarding the secondary outcomes, the training resulted in reporting an improved physical (Cohen's d = 0.43;p = 0.01), emotional (Cohen's d = 0.44;p = 0.01), and social (Cohen's d = 0.36;p = 0.01) functioning, less pain and better functioning despite pain (Cohen's d = 0.51;p = <0.001), less physical symptoms (Cohen's d = -.23;p = 0.05) and less sleep difficulties (Cohen's d = -0.25;p = 0.04) than time in the waiting group. During the non-randomized follow-ups, there were no relapses.

CONCLUSIONS/SIGNIFICANCE

The cognitive-behavioral group training tailored for UPS in primary care and provided by an outreaching secondary mental-health service appears to be effective and to broaden the accessibility of treatment for UPS.

TRIAL REGISTRATION

TrialRegister.nl NTR1609

Psychological and clinical correlates of functional somatic complaints in depression

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Altered brain activity during emotional empathy in somatoform disorder

Somatoform disorder patients suffer from impaired emotion recognition and other emotional deficits. Emotional empathy refers to the understanding and sharing of emotions of others in social contexts. It is likely that the emotional deficits of somatoform disorder patients are linked to disturbed empathic abilities; however, little is known so far about empathic deficits of somatoform patients and the underlying neural mechanisms. We used fMRI and an empathy paradigm to investigate 20 somatoform disorder patients and 20 healthy controls. The empathy paradigm contained facial pictures expressing anger, joy, disgust, and a neutral emotional state; a control condition contained unrecognizable stimuli. In addition, questionnaires testing for somatization, alexithymia, depression, empathy, and emotion recognition were applied. Behavioral results confirmed impaired emotion recognition in somatoform disorder and indicated a rather distinct pattern of empathic deficits of somatoform patients with specific difficulties in "empathic distress." In addition, somatoform patients revealed brain areas with diminished activity in the contrasts "all emotions"-"control," "anger"-"control," and "joy"-"control," whereas we did not find brain areas with altered activity in the contrasts "disgust"-"control" and "neutral"-"control." Significant clusters with less activity in somatoform patients included the bilateral parahippocampal gyrus, the left amygdala, the left postcentral gyrus, the left superior temporal gyrus, the left posterior insula, and the bilateral cerebellum. These findings indicate that disturbed emotional empathy of somatoform disorder patients is linked to impaired emotion recognition and abnormal activity of brain regions responsible for emotional evaluation, emotional memory, and emotion generation.

Multimodal psychodynamic psychotherapy induces normalization of reward related activity in somatoform disorder

OBJECTIVES

Somatoform disorder patients demonstrate a disturbance in the balance between internal and external information processing, with a decreased focus on external stimulus processing. We investigated brain activity of somatoform disorder patients, during the processing of rewarding external events, paying particular attention to the effects of inpatient multimodal psychodynamic psychotherapy.

METHODS

Using fMRI, we applied a reward task that required fast reactions to a target stimulus in order to obtain monetary rewards; a control condition contained responses without the opportunity to gain rewards. Twenty acute somatoform disorder patients were compared with twenty age-matched healthy controls. In addition, 15 patients underwent a second scanning session after participation in multimodal psychodynamic psychotherapy.

RESULTS

Acute patients showed diminished hemodynamic differentiation between rewarding and non rewarding events in four regions, including the left postcentral gyrus and the right ventroposterior thalamus. After multimodal psychodynamic psychotherapy, both regions showed a significant normalization of neuronal differentiation.

CONCLUSION

Our results suggest that diminished responsiveness of brain regions involved in the processing of external stimuli underlies the disturbed balance of internal and external processing of somatoform disorder patients. By providing new approaches to cope with distressing events, multimodal psychodynamic psychotherapy led to decreased symptoms and normalization of neuronal activity.

Differentiation in the momentary rating of somatic symptoms covaries with trait emotional awareness in patients at risk for sudden cardiac death

OBJECTIVES

Somatic symptom ratings covary with neuroticism. Yet, people vary from one another in their ability to report their own emotions and differentiate them from bodily sensations. We hypothesized that stressed individuals with greater emotional awareness would experience somatic symptoms in a more differentiated way independent of neuroticism.

METHODS

Over 3 days, ecological momentary assessments were completed in 161 patients (72.6% female; mean age, 35 years) with Long QT Syndrome, a genetic disorder associated with increased risk for sudden cardiac death. Patients were paged randomly ten times per day to report their momentary experience of nine somatic symptoms (e.g., headache, sore throat, tiredness) as well as other variables. We examined the intercorrelation between somatic symptom ratings, reasoning that greater intercorrelation among ratings indicated less differentiation. Subjects completed measures of neuroticism, depression, and the Levels of Emotional Awareness Scale, a trait measure of the tendency to experience emotions in a complex and differentiated way.

RESULTS

Higher Levels of Emotional Awareness Scale-Self scores were associated with greater differentiation in the momentary rating of somatic symptoms (p < .001) in men and women independently. This association did not change after removing variance due to neuroticism, depression, or symptom intensity.

CONCLUSIONS

Among individuals stressed by having a life-threatening condition, those who are more emotionally aware report somatic symptoms in a more differentiated way. These findings regarding symptoms largely unrelated to the disorder are consistent with other evidence that medically unexplained physical symptoms, which tend to be nonspecific, may be accompanied by relatively undifferentiated negative affect.

Type 1 diabetes is associated with alexithymia in nondepressed, non-mentally ill diabetic patients: a case-control study

OBJECTIVE

Alexithymia refers to difficulty in identifying and expressing emotions, and it is a characteristic common to several psychiatric and medical conditions, including autoimmune disorders. Type 1 diabetes (T1D) is an autoimmune disorder with increased psychiatric comorbidity. Previously reported associations between alexithymia and T1D may have been confounded by the presence of depression. The central aim of this study was to examine alexithymia levels in psychiatrically uncomplicated T1D outpatients with that of nondiabetic controls.

METHODS

Ninety-six T1D patients without any DSM-IV Axis I diagnoses and 105 age- and sex-matched healthy controls entered the study. Alexithymia and depressive symptoms were assessed with the Toronto Alexithymia Scale (TAS-20) and the Beck Depression Inventory (BDI-21), respectively. Multivariate regression models were used to evaluate the association of alexithymia with the presence of diabetes, duration of diabetes, diabetes control, parameters of treatment intensification, and diabetic complications.

RESULTS

T1D was positively associated with the TAS-20 "identifying feelings" (beta coefficient=2.64, P=.003) and "externally oriented thinking" (beta coefficient=1.73, P=.011) subscales. The prevalence of overall alexithymia (TAS-20 total score, > or =60) was 22.2% in T1D patients and 7.6% in the controls (OR, 4.6; 95% CI, 1.7-12.8). TAS-20 scores were positively associated with diabetes duration and negatively with treatment intensification parameters.

CONCLUSIONS

Alexithymia is higher in psychiatrically uncomplicated T1D patients than in healthy controls even after adjustment for confounding depressive symptoms; it is greater with longer diabetes duration and is associated with some reduced parameters of treatment intensification but not with worse outcome in terms of glycemic control or somatic complications.

Alexithymia and health-related quality of life in a general population

BACKGROUND

Alexithymia is thought to reflect a deficit in the cognitive processing of emotion, and, therefore, it may predispose individuals to both psychological and somatic symptoms.

OBJECTIVE

The authors investigated the relationship between alexithymia and health-related quality of life (HRQoL) in a nationally representative population sample of 5,418 subjects, age 30 to 97 years.

METHOD

Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and HRQoL measured with the 15D, a generic HRQoL measure.

RESULTS

Alexithymia was significantly associated with lower HRQoL independently of other variables. The TAS-20 subfactor Difficulties Identifying Feelings was the strongest common denominator between alexithymia and HRQoL.

CONCLUSION

Alexithymia may be a predisposing factor to poorer HRQoL.

Understanding the medically unexplained: emotional and familial influences on children's somatic functioning

BACKGROUND

Many youth experience impairing, unexplained somatic complaints. Psychosocial models of child somatization have primarily focused on parent somatic functioning. Although helpful in understanding child somatization, this narrow focus on parental factors leaves a large proportion of the variance unaccounted for when explaining children's general somatic functioning. The goal of this investigation is to extend current models of child somatization by collectively examining the influence of parent somatization and child emotional functioning.

METHODS

Forty-two children (50% male; M age = 9.11) reported on their somatic symptoms, emotion awareness skills, and negative affect. Parents reported on their own somatic symptoms and their child's somatic symptoms and emotion regulation skills.

RESULTS

Regression analyses indicated that poor awareness of emotional experiences and frequency of negative effect predicted child-reported somatic symptoms. Parental somatic symptoms and parent reports of children's emotion regulation difficulties predicted mother-reported child somatic symptoms. Only parental somatic symptoms significantly predicted father-reported child somatic symptoms.

CONCLUSIONS

These results suggest that models of child somatization should consider both family - (e.g. parent somatization) and child-level (e.g. emotional functioning) variables. The discrepancies between parent and child report of youth somatic symptoms underscore the importance of including multiple reporters on symptomatology in research and clinical settings. Suggestions for future research are provided.

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 in adolescents with chronic fatigue syndrome

BACKGROUND

Alexithymia is postulated as an important factor in the development of medically unexplained physical symptoms. Chronic fatigue syndrome (CFS) is presently medically unexplained. The aim of this study was to investigate whether the prevalence of alexithymia was higher in adolescents with CFS compared to healthy adolescents. Comorbidity such as anxiety and depression were analyzed as possible confounding factors. Secondly, alexithymia was investigated as a prognostic factor for the recovery of CFS.

METHODS

A cross-sectional study was performed among 40 adolescent outpatients diagnosed with CFS and 36 healthy controls. The 20-item Toronto Alexithymia Scale was used to assess all participants for alexithymia. Additionally, all participants completed a number of questionnaires regarding fatigue (Checklist Individual Strength), somatic complaints (Checklist Somatization Inventory), depression (Children's Depression Inventory), and trait anxiety (Spielberger State Trait Anxiety Questionnaire). A follow-up study was performed among the CFS adolescents 1 1/2 years after the initial assessment.

RESULTS

CFS adolescents scored higher only on the subscale identifying feelings of the TAS-20 [mean difference after adjustment for depression and anxiety 2.8 (95% CI: 0.6; 4.9]. Twelve CFS adolescents (30%) fulfilled criteria for alexithymia. This subgroup was characterized by higher scores for depression and anxiety and equal scores for fatigue and somatic complaints. At follow-up, no differences in recovery were established between the alexithymic and nonalexithymic CFS adolescents.

CONCLUSIONS

Alexithymia neither appears to be a unique correlate of CFS nor to be a prognostic factor for recovery of the CFS illness.

Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts

Medically unexplained symptoms (MUS) are frequently associated with a history of traumatization. The first purpose of the present review paper was to investigate systematically the evidence for such relation in a subset of clinical samples with MUS presenting with functional somatization: chronic pelvic pain, irritable bowel syndrome and conversion and somatization disorder. The second purpose was to critically review three dominant models explaining the relation between trauma and MUS (i.e. dissociation, conversion and hierarchical cognitive models). The latter model in particular adequately accounts for the non-volitional and non-intentional character of MUS and explains how traumata can affect the development of MUS without assuming that previous trauma is a necessary prerequisite of MUS. The cognitive model, however, lacks integration with current neurobiological findings, indicative of central stress-and central nervous system alterations in MUS. The final purpose of the present paper was, therefore, to review current neurobiological studies focused on trauma and MUS and to formulate a research agenda to integrate these neurobiological developments with cognitive models for MUS.

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.

Somatization and alexithymia in young adult Finnish population

BACKGROUND

We assessed alexithymia and alexithymic features among young adult subjects with and without somatization symptoms in an epidemiological setting with a sample of young adults.

METHODS

The sample consisted of urban 31-year-old subjects (N=1002). Data on somatization were gathered from a review of all public health outpatient records. Subjects with four or more somatization symptoms according to the DSM-III-R criteria were considered somatizers. The 20-item version of the Toronto Alexithymia Scale (TAS-20) was used to measure alexithymia. Subjects with a total TAS score over 60 were considered as being alexithymic, and those with a score under 52 were considered nonalexithymic. Subjects with a total TAS score from 52 to 60 were considered as having alexithymic features.

RESULTS

The prevalence of alexithymia was 6.0% among somatizers and 4.8% among subjects without somatization symptoms, and the prevalence of alexithymic features was 7.5% and 12.6%, respectively.

CONCLUSIONS

No association was found between alexithymia and somatization in young adult general population. The earlier theory of the association between alexithymia and somatization may be questionable.

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.

Alexithymia does not predict the persistence of medically unexplained physical symptoms

BACKGROUND

Alexithymia is thought to be associated with the development of medically unexplained physical symptoms (UPS). So far little research has been published on alexithymia as a risk factor for the persistence of UPS.

OBJECTIVE

To determine the clinical outcome in UPS patients and to study the relative importance of alexithymia in predicting that outcome.

METHODS

A follow-up study was conducted among general medical outpatients with UPS. Patients underwent extensive examinations at baseline and were reassessed after a mean 61-week interval. Outcome of the UPS and general health perception at follow-up were used as major outcome variables.

RESULTS

Outcome of the UPS and general health perception at follow-up were not strongly associated with each other. More than half (63%) of the patients reported improvement of their initial symptoms, but only 38% of the patients considered themselves at follow-up to be in good health. UPS outcome was predominantly predicted by the duration of the UPS and the number of additional physical symptoms at baseline. General health perception at follow-up was predominantly predicted by the general health perception at baseline and the number of additional physical symptoms and pain experience at baseline. The explained variance of the general health perception was three times as high as the explained variance for the UPS outcome. Alexithymia was not associated with any of the two outcome variables.

CONCLUSIONS

Outcome of the UPS and general health perception at follow-up are not strongly associated and are predicted by different variables. Alexithymia, however, is not an important predictor for the outcome in the majority of UPS patients.

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.