Psychoanalysis and psychosomatics: a new synthesis

Impact of Attachment Style and Temperament Traits on the Quality of Life of Patients with Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory skin disease with manifestations that go beyond the visual manifestation, and include psychological aspects. Some mental disorders or personality traits in psoriasis patients have also been highlighted, such as a negative or problematic attitude towards life, impulsive or avoidant behavior, and lower satisfaction with life. The aim of our cross-sectional study was to explore the associations between adult attachment, temperament, and quality of life of patients with psoriasis.

METHODS

A sample of 75 patients with psoriasis was evaluated with the Attachment Style Questionnaire (ASQ) to study adult attachment, the Temperament Evaluation of Memphis, Pisa, and San Diego Auto-questionnaire (TEMPS-A) to study temperament traits, and the Dermatology Life Quality Index (DLQI) to study the impact of dermatological diseases on patients' lives.

RESULTS

Depressive, cyclothymic, and irritable temperaments were found to be significantly positively associated with a need for approval and preoccupation with relationships subscales of the ASQ. The severity of skin disease effect on the patient's life was higher in women than in men. Moreover, a statistically significant effect of the need for approval subscale of the ASQ was found. The positive correlation between the severity of skin disease effect on the patient's life with a need for approval was statistically significant and stronger in women than in men.

CONCLUSIONS

A better understanding of the impact of mental comorbidities on psoriasis and vice versa places an ever-greater responsibility on dermatologists involved in the management of psoriasis to recognize these problems and collaborate with psychologists and psychiatrists to help these patients.

Factorial validity of the 20‐item Toronto Alexithymia Scale

The 20‐item Toronto Alexithymia Scale (TAS‐20) was developed in previous research to measure a general dimension of alexithymia with three inter correlated factors. These three factors reflect distinct facets of the alexithymia construct: (1) difficulty identifying feelings and distinguishing them from the bodily sensations of emotion, (2) difficulty describing feelings to others, and (3) an externally orientated style of thinking. This study tested the three‐factor model for the TAS‐20, using confirmatory factor analysis, in separate samples of young adults from Germany, Canada, and the United States. The previously established three‐factor model was found to be replicable in all three samples. In addition, the full TAS‐20 and its three factors demonstrated adequate internal reliability in all three samples. Although evaluation of the convergent, discriminant, and criterion validity of the TAS‐20 is required in diverse cultural groups, the present results provide evidence for the factorial validity and internal reliability of the TAS‐20.

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

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

Family-of-origin expressiveness: measurement, meaning, and relationship to alexithymia

The need for research instruments to assess the impact of affective expressiveness within the family is evident, yet few appear to be adequately designed for this purpose. In this article, we present two studies addressing this need. In the first study, the original 40-item Family-of-Origin Scale was administered to 416 students to determine those items that constitute the factor structure. This instrument was designed to assess perceived levels of health in the family of origin but has unsubstantiated construct validity. Results from a confirmatory factor analysis indicated that the instrument has one major factor, and results from five other studies provide evidence supporting the construct validity. Face validity of this 22-item construct indicates that it assesses an individual's perceived level of global expressive atmosphere within his or her family of origin. In the second study, the new Family-of-Origin Expressive Atmosphere Scale and the 20-item Toronto Alexithymia Scale were administered to 295 students. Students' self-reported expressive atmospheres in their family-of-origin scores were significantly correlated with the total scores of alexithymia and each of the three factors: impaired ability to identify feelings, impaired ability to describe feelings, and externally oriented thinking processes. No significant gender differences were found.

The status of alexithymia as a risk factor in medically unexplained physical symptoms

Some decennia ago, the concept of alexithymia was developed from the clinical experience of psychosomaticians who at the time were largely working within a psychoanalytic frame of reference. Alexithymia can briefly be described as a cognitive-affective disturbance characterized by difficulties in differentiating one's feelings and expressing them in words. Clinicians who treat patients with medically unexplained physical symptoms may often recognize alexithymic features in their patients. It is supposed that alexithymia could be a predisposing factor for the development or persistence of medically unexplained physical symptoms. In this review, the concept of alexithymia as well as paradigmatic shifts in psychoanalysis and psychosomatics are discussed to place the concept of alexithymia in its epistemiological context. Furthermore, the empirical literature on the association between alexithymia and medically unexplained physical symptoms is reviewed. The main conclusions are that alexithymia appears to be a theoretically important and clinically appealing concept, but that so far the empirical evidence that alexithymia predisposes to the development or persistence of medically unexplained physical symptoms is imperfect. This is mainly because of the cross-sectional design of most studies and is due to other methodological shortcomings, such as the lack of allowance for depression and anxiety as possible confounding factors. Suggestions for future research are made.

A California Q-set alexithymia prototype and its relationship to ego-control and ego-resiliency

The primary purposes of the present study were to use the Q-sort method to develop a measure of alexithymia and to locate the construct within a two-dimensional (ego-control and ego-resiliency) model of personality. Thirteen professional judges described the characteristics of the alexithymic personality with the 100-item California Q-set. Scores from the sorts were aggregated to form the Alexithymia Prototype, which had a Spearman-Brown reliability of 0.99. Alexithymic people were described as having difficulties experiencing and expressing emotion, lacking imagination, and being literal, socially conforming, and utilitarian; they lack insight, are humorless, and experience meaninglessness; and anxiety and tension find outlet in bodily symptoms. This description is consistent, for the most part, with modern formulations of the alexithymia construct. In the language of the two-dimensional personality model, alexithymic individuals appear to be overcontrolling and lacking ego-resiliency (i.e., constricted, anxious, rigid, and withdrawn). We, therefore, compared the Alexithymia Prototype with two independently developed prototypes, Overcontrol and Ego-Resiliency. The Q-correlations between alexithymia and overcontrol and between alexithymia and ego-resiliency were 0.45 and -0.70, respectively. Although item analyses confirmed moderate overlap between alexithymia and overcontrol and considerable overlap between alexithymia and lacking ego-resiliency (ego-brittle), item differences suggest that alexithymia, indeed, is a unique personality construct.

Affective language between depressed mothers and their children: the potential impact of psychotherapy

OBJECTIVE

To determine whether depressed mothers who had had psychotherapy were more able to communicate accurately about emotions than depressed mothers who had not had treatment.

METHOD

Three groups of mother-child pairs were studied: mothers without psychiatric diagnosis or treatment (n = 31), depressed mothers without treatment (n = 10), and depressed mothers with psychotherapy (n = 43). Photographs of infants expressing emotions were viewed and discussed by the mother-child pair and were rated independently.

RESULTS

A comparison by analysis of variance and Duncan procedures revealed significant differences between groups in both mothers' and children's accuracy scores. Mothers who had had psychotherapy were more able to interpret emotional expression with accuracy (p < .05), particularly about negative emotions such as anger and sadness (p < .01), than were the mothers of the depressed no treatment group. Depressed mothers without treatment were more inaccurate (for example, sadness interpreted as anger).

CONCLUSIONS

Psychotherapy may contribute to the depressed mother's achievement of accuracy in speaking with her child about emotions. The depressed mother whose depressive illness goes untreated is more inclined to be inaccurate and may pass these inclinations on to her child. The generality of the psychotherapy variable makes these findings preliminary.

Family factors related to alexithymia characteristics

There is little empirical research on the familial and parental correlates of alexithymia. A two-part study explored how the affective and cognitive characteristics of alexithymia are related to family dysfunction and maternal alexithymia. In Part I, 127 young adults were evaluated for alexithymia with the Toronto Alexithymia Scale-20 (TAS-20), for impaired imagination with the Scored Archetypal Test with Nine Elements, and for family dysfunction with the McMaster Family Assessment Device. In Part II, 80 of their mothers completed the TAS-20 about themselves, and maternal alexithymia characteristics were correlated with those of their offspring. In Part I, general family pathology was associated with alexithymia. In particular, difficulty identifying feelings was related to dysfunctional family affective involvement, externally oriented thinking was related to deficient family behavior control, and impaired imagination was related to inadequate family problem solving; these relationships were independent of general family pathology and subjects' positive and negative affect. In Part II, maternal alexithymia characteristics were correlated significantly with the offsprings', controlling for both respondents' positive and negative affect. These findings implicate disturbed family functioning and maternal alexithymia in the development of alexithymia characteristics in children.

Alexithymia and health care utilization

Alexithymia's link with health care utilization is unclear. Alexithymia may be overrepresented among clinical samples because of a proclivity to seek care, or alexithymia may prompt delay or avoidance of care, perhaps exacerbating illness. In 911 young adults, this study examined relationships between alexithymia (Toronto Alexithymia Scale-20; total and three factor scores) and the use of six health services during the past year: outpatient medical treatment, emergency room, hospitalization, psychotherapy, routine dental care, and nonprescription analgesics. Three potential mediators (insurance status, depression, and somatic complaints) were controlled to determine alexithymia's unique relation to utilization. The alexithymic difficulty in identifying feelings was linked to increased use of outpatient treatment, after controlling for potential mediators. Difficulty identifying feelings also was related to the use of psychotherapy and analgesics, but these relationships were accounted for by increased depression and somatic complaints, respectively. The alexithymic preference for externally oriented thinking was independently linked with the decreased use of outpatient treatment, to not having psychotherapy, and to being more likely to obtain preventive dental care. Our results may explain contradictions in the literature; separate alexithymic characteristics have different relationships with different types of health care utilization.

A psychodynamic view of the chronic fatigue syndrome. The role of object relations in etiology and treatment

The chronic fatigue syndrome (CFS) is a constellation of physical and psychological symptoms including incapacitating fatigue associated with a marked reduction in activity. Although the etiology of CFS is unclear, reports in the literature suggest the presence of both physical and psychological dysfunction in this patient population. These findings have led to a debate between those who consider CFS to be primarily organic in origin and those who view CFS as a primary psychiatric disorder characterized by somatic preoccupations. This debate led the authors to develop a working model for CFS designed to integrate the psychological and physiological findings, based on the hypothesis that early object relations have an etiologic relationship to CFS. This hypothesis then formed the rationale for a psychoanalytic treatment approach which will be described. There are no published case reports describing psychoanalytic psychotherapy as a primary treatment modality for this patient population. The current paper attempts to fill a void. Two case reports of long-term (> 18 months), intensive (2-3 times per week) psychoanalytic psychotherapy with CFS patients referred by infectious disease specialists at a university teaching hospital will be presented. The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to disturbances in object relationships, particularly within the transference; (2) the improvement in symptoms when this relationship is seen and understood by the patient; (3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; (4) the challenges involved in treating CFS patients with psychotherapy.