Criterion-related validity of diagnostic criteria for alexithymia in a general hospital psychiatric setting

Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology, cardiology, oncology and dermatology

OBJECTIVE

To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and other DCPR criteria.

METHOD

Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of 188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to cluster analysis.

RESULTS

Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%).

CONCLUSIONS

The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety disorder in about one third of cases; it is related to various forms of somatization and abnormal illness behavior in another third and may occur without psychiatric comorbidity in another subgroup. Identification of alexithymic features may entail major prognostic and therapeutic differences among medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or medical diagnosis.

Diagnostic criteria for psychosomatic research and somatic symptom disorders

The Diagnostic Criteria for Psychosomatic Research (DCPR) were introduced in 1995 by an international group of investigators to expand the traditional domains of the disease model. The DCPR are a set of 12 'psychosomatic syndromes' which provide operational tools for psychosocial variables with prognostic and therapeutic implications in clinical settings. Eight syndromes concern the main manifestations of abnormal illness behaviour: somatization, hypochondriacal fears and beliefs, and illness denial. The other four syndromes (alexithymia, type A behaviour, demoralization and irritable mood) refer to the domain of psychological factors affecting medical conditions. This review describes the conceptual bases of the DCPR and the main findings concerning their application, with particular reference to the incremental information they added to the customary psychiatric classification. The DCPR were also compared with the provisional DSM-5 somatic symptom disorders. The DCPR were found to be more sensitive than DSM-IV in identifying subthreshold psychological distress and characterizing patients' psychological response to medical illness. DSM-5 somatic symptom disorders seem to neglect important clinical phenomena, such as illness denial, resulting in a narrow view of patients' functioning. The additional information provided by the DCPR may enhance the decision-making process.

Psychosomatic syndromes and anorexia nervosa

BACKGROUND

In spite of the role of some psychosomatic factors as alexithymia, mood intolerance, and somatization in both pathogenesis and maintenance of anorexia nervosa (AN), few studies have investigated the prevalence of psychosomatic syndromes in AN. The aim of this study was to use the Diagnostic Criteria for Psychosomatic Research (DCPR) to assess psychosomatic syndromes in AN and to evaluate if psychosomatic syndromes could identify subgroups of AN patients.

METHODS

108 AN inpatients (76 AN restricting subtype, AN-R, and 32 AN binge-purging subtype, AN-BP) were consecutively recruited and psychosomatic syndromes were diagnosed with the Structured Interview for DCPR. Participants were asked to complete psychometric tests: Body Shape Questionnaire, Beck Depression Inventory, Eating Disorder Inventory-2, and Temperament and Character Inventory. Data were submitted to cluster analysis.

RESULTS

Illness denial (63%) and alexithymia (54.6%) resulted to be the most common syndromes in our sample. Cluster analysis identified three groups: moderate psychosomatic group (49%), somatization group (26%), and severe psychosomatic group (25%). The first group was mainly represented by AN-R patients reporting often only illness denial and alexithymia as DCPR syndromes. The second group showed more severe eating and depressive symptomatology and frequently DCPR syndromes of the somatization cluster. Thanatophobia DCPR syndrome was also represented in this group. The third group reported longer duration of illness and DCPR syndromes were highly represented; in particular, all patients were found to show the alexithymia DCPR syndrome.

CONCLUSIONS

These results highlight the need of a deep assessment of psychosomatic syndromes in AN. Psychosomatic syndromes correlated differently with both severity of eating symptomatology and duration of illness: therefore, DCPR could be effective to achieve tailored treatments.

Kellner's emotional inhibition scale: a clinimetric approach to alexithymia research

BACKGROUND

Emotional inhibition has been an enduring concept in the psychosomatic literature explaining the onset and course of medical disorders. Currently the personality style of alexithymia is a focus of this dimension in psychosomatic theory, while actual conscious emotional inhibition, which may overlap with alexithymia, has received less attention. In the early 80s Robert Kellner developed the Emotional Inhibition Scale (EIS), a self-rating scale for emotional inhibition based on clinimetric principles. In this study we explored whether the EIS differentiated a sample of cardiac recipients from normal controls, as well as the associations between the EIS and 2 measures of alexithymia, i.e. the Toronto Alexithymia Scale-20 (TAS-20) and the Diagnostic Criteria for Psychosomatic Research (DCPR). We also examined whether the EIS and the TAS-20 were differently related to depressive symptoms measured by the Symptom Questionnaire (SQ).

METHODS

Ninety-five heart-transplanted patients and a sample of normal controls, matched for sociodemographic variables, were administered the EIS (total score and 4 subscales concerning 'verbal inhibition', 'timidity', 'disguise of feelings', and 'self-control'), the TAS-20, the SQ, and the Structured Interview according to the DCPR for alexithymia.

RESULTS

Cardiac recipients did not display significant differences compared to normal controls in observer (DCPR) and self-rated (TAS-20) measures of alexithymia. There were, however, significant differences in EIS with regard to 'disguise of feelings'. In both groups the EIS 'verbal inhibition' and 'timidity' subscales were positively associated with the TAS-20, while the EIS 'disguise of feelings' and 'self-control' subscales were independent of alexithymia. Depressive symptoms were more related to TAS-20 than EIS total scores.

CONCLUSIONS

Our results suggest that emotional inhibition and alexithymia are distinct phenomena even though they may share certain features. The EIS appears to be relatively independent of depressed mood and will be useful in assessing the individual's conscious management of affect in future psychosomatic research.

Criteria for psychosomatic research (DCPR) in the medical setting

The Diagnostic Criteria for Psychosomatic Research (DCPR) represent a diagnostic and conceptual framework that aims to translate psychosocial variables derived from psychosomatic research into operational tools whereby individual patients can be identified. A set of 12 syndromes was developed: disease phobia, thanatophobia, health anxiety, illness denial, persistent somatization, functional somatic symptoms secondary to a psychiatric disorder, conversion symptoms, anniversary reaction, irritable mood, type A behavior, demoralization, and alexithymia. The aim of this article is to survey the research evidence that has accumulated on the DCPR in several clinical settings (cardiology, oncology, gastroenterology, endocrinology, primary care, consultation psychiatry, nutrition, and community), to examine prevalence and specific diagnostic clusters of the more prevalent DCPR syndromes, and to review their clinical utility in terms of clinical decision, prediction of psychosocial functioning, and treatment outcomes. The implications for classification purposes (DSM-V) are also discussed.

Interrater Reliability, Prevalence, and Relation to ICD-10 Diagnoses of the Diagnostic Criteria for Psychosomatic Research in Consultation-Liaison Psychiatry Patients

The Diagnostic Criteria for Psychosomatic Research (DCPR) have been proposed by an international group of psychosomatic investigators as an operationalized tool for the assessment of psychological distress in medical patients. The aims of the present study were to evaluate interrater reliability, the distribution of DCPR syndromes, and their relationship with ICD-10 diagnostic categories. One hundred consecutive patients who were referred for psychiatric consultation in a university general hospital consented to assessment for DCPR syndromes as elicited in a joint interview conducted by two researchers. The results showed excellent interrater agreement, with kappa values for the 11 DCPR syndromes ranging from 0.69 to 0.97. More patients met criteria for one or more of the DCPR (87%) than for an ICD-10 diagnosis (75%). Four DCPR syndromes were particularly prevalent: demoralization, alexithymia, illness denial, and type A behavior. DCPR criteria appear to be a useful, reliable, and promising approach in the assessment and description of psychological distress in medical patients. They may serve as a focus of intervention studies in this population.

Alexithymia, depressive experiences, and dependency in addictive disorders

Alexithymia, depressive feelings, and dependency are interrelated dimensions that are considered potential "risk factors" for addictive disorders. The aim of this study was to investigate the relationships between these dimensions and to define a comprehensive model of addiction in a large sample of addicted subjects, whether affected by an eating disorder or presenting an alcohol- or a drug use-related disorder. The participants in this study were gathered from a multicenter collaborative study on addictive behaviors conducted in several psychiatric departments in France, Switzerland, and Belgium between January 1995 and March 1999. The clinical sample was composed of 564 patients (149 anorexics, 84 bulimics, 208 alcoholics, 123 drug addicts) of both genders with a mean age of 27.3 +/- 8 years. A path analysis was conducted on the 564 dependent patients and 518 matched controls using the scores of the Toronto Alexithymia Scale, the Depressive Experiences Questionnaire, and the Interpersonal Dependency Inventory. Statistical analyses showed good adjustment (Goodness of Fit Index = 0.977) between the observable data and the assumed model, thus supporting the hypothesis that a depressive dimension, whether anaclitic or self-critical, can facilitate the development of dependency in vulnerable alexithymic subjects. This result has interesting clinical implications because identifying specific patterns of relationships leading from alexithymia to dependency can provide clues to the development of targeted strategies for at-risk subjects.

Factorial structure of the 20-item Toronto Alexithymia Scale: confirmatory factorial analyses in nonclinical and clinical samples

OBJECTIVE

The 20-item Toronto Alexithymia Scale (TAS-20) measures three intercorrelated dimensions of alexithymia: (1) difficulties identifying feelings (DIF), (2) difficulties describing feelings (DDF), and (3) externally oriented thinking (EOT). The aim of the study was to test the three-factor model of the TAS-20 using confirmatory factorial analyses (CFA).

METHOD

769 healthy subjects and 659 patients meeting the DSM-IV criteria for substance use disorders or eating disorders completed the TAS-20. The correlation matrices for each of the samples were analyzed with LISREL 7.16.

RESULTS

In each sample, the three-factor model was found to be replicable.

CONCLUSION

The three TAS-20 subcales can be used to explore the distinct facets of the alexithymia construct.

Relationships between the emotional and cognitive components of alexithymia and dependency in alcoholics

Several authors have shown that alexithymia, emotional and perceptual dependency characterize patients suffering from substance abuse. The aim of the study is to test the hypothesis that the emotional and cognitive components of alexithymia are associated with dependency in alcoholics. Three groups were investigated: 60 inpatients meeting the DSM-IV criteria for alcohol dependence, 57 healthy subjects, 144 university students. All subjects completed the following rating scales: The 20-item Toronto Alexithymia Scale (TAS-20), the Interpersonal Dependency Inventory (IDI), the Beck Depression Inventory (BDI), and the Embedded Figures Test (EFT). Partial correlations, using the BDI score as constant, were calculated. In normal subjects, the 'Emotion' subscale of the TAS-20 correlated with the 'Lack of social self-confidence' subscale of the IDI and the 'Cognitive' subscale of the TAS-20 did not correlate with the EFT score. In alcoholics, the 'Cognitive' subscale of the TAS-20 correlated with the 'Lack of social self-confidence' subscale, with the EFT score and with the 'Affirmation of autonomy' subscale. A particular cognitive style characterized by externally oriented thinking, affirmation of autonomy as denial of emotional dependency and field dependence could characterize alcoholics.