Two decades of alexithymia

Inconspicuous Anomalies: Alexithymia and Ethical Relations to the Self

This article uses the analysis and discussion of the ‘alexithymia construct’ to approach the question of how we might think about the relationship between ethics and illness. After a brief introduction to the construct, its paradigmatic potential within the broader context of psychosomatic medicine is discussed. The article then elaborates on the sociocultural specificity of alexithymia, both as a construct and as a mode of being, to argue that central to this construct is the cultural value ascribed to the notion of an ‘authentic self’. The implications of the alexithymia construct are then examined in the vocabulary of narrative approaches to self and illness. The construct may be regarded as an expert meta-narrative on the relative value of different self-narratives in relation to the possibility of disease. As a result, the ethical responsibilities associated both with narrative and with illness become expanded and transformed.

Self-Objectification and Its Psychological Outcomes for College Women

The objectification of women by our society can become internalized by women, resulting in negative psychological outcomes. Using Fredrickson and Roberts' (1997) objectification theory, we tested a model of the relationships between self-objectification and disordered eating and depressive symptoms in a sample of undergraduate women ( n = 384). One postulate of self-objectification theory is that self-objectification can lead to a lack of internal awareness, which may mediate the relationship between self-objectification and restrictive eating, bulimic, and depressive symptoms. Results of structural equation modeling suggest that self-objectification has a direct relationship to restrictive eating, bulimic, and depressive symptoms. The mediational role of internal awareness was relevant for depressive symptoms but not for restrictive eating or bulimic symptoms. Depressive symptoms did, however, mediate the relationship between self-objectification and bulimic symptoms. The relevance of our findings to the understanding of objectification theory are discussed and future areas of research recommended.

Peculiar alexithymic traits in burning mouth syndrome: case-control study

OBJECTIVES

The present case-control study aims to assess the occurrence of alexithymic traits in burning mouth syndrome (BMS) subjects and to correlate alexithymic traits to anxious and depressive traits in BMS subjects.

MATERIALS AND METHODS

Prospectively enrolled BMS and control subjects were administered the 20-item Toronto Alexithymia Scale (TAS-20). Anxiety and depressive traits were assessed using the Hamilton Anxiety Rating Scale and the Montgomery and Asberg Depression Rating Scale. Occurrence of alexithymic traits was compared between BMS and control subjects. Correlation tests were used to measure the importance of alexithymic traits related to demographic characteristics, pain intensity (VAS score), and to the other psychometric scores.

RESULTS

Fifty-eight BMS subjects (46 females and 12 males) had a mean TAS-20 score significantly higher when compared to controls (p < 0.001; r = 0.72), corresponding to an occurrence rate of alexithymic traits of 79.3 versus 6.9%. Alexithymic traits in BMS subjects were just related to depressive traits (p = 0.02; ρ = 0.31).

CONCLUSIONS

The high occurrence of alexithymia in BMS is an adjunctive issue in favor of its multifactorial pathogenesis, with a not negligible role for somatization.

CLINICAL RELEVANCE

Clinicians should be aware of the high occurrence of alexithymic traits among BMS subjects as such traits may affect the doctor-patient relationship.

Alexithymia and posttraumatic stress disorder following asthma attack

This study examined the levels of posttraumatic stress disorder (PTSD) following asthma attack (post-asthma attack PTSD) and psychiatric co-morbidity among college students. It also investigated the association between these variables and alexithymia. One hundred and six college students participated in the study and completed an on-line survey comprising the Asthma Symptom Checklist, PTSD Checklist, General Health Questionnaire-28 and Toronto Alexithymia Scale. Ninety-one students without asthma and major illness formed the control group. 2 % met the diagnostic criteria for full-PTSD, while 42 and 56 % met the partial and no-PTSD criteria respectively. Compared with the control, the asthma group reported significantly more somatic problems, social dysfunction and depression and was five times more likely to have an elevated risk of developing a general psychiatric disorder. After adjusting age, marital status, asthma experience and symptoms, alexithymia did not predict PTSD, while difficulty identifying feelings predicted psychiatric co-morbidity. Mediational analyses showed that asthma symptoms partially mediated the link between difficulty identifying feelings and psychiatric co-morbidity. People can develop PTSD symptoms and other psychological difficulties following asthma attack. Alexithymia influenced general psychological difficulties independently of PTSD symptoms.

Posttraumatic stress disorder following asthma attack (post-asthma attack PTSD) and psychiatric co-morbidity: the impact of alexithymia and coping

This study investigated the prevalence of post-asthma attack posttraumatic stress disorder (PTSD) and the severity of psychiatric co-morbidity among a group of college students and whether alexithymia and coping strategies would relate to health outcomes. This is a cross-sectional study in which 156 college students who had previously experienced asthma attack were recruited. They completed a demographic page, Asthma Symptom Checklist, PTSD Checklist, General Health Questionnaire-28, Toronto Alexithymia Scale and the COPE. They were also matched with 141 students without asthma. The results showed that 3% met the criteria for full-PTSD, 44% for partial and 53% for no-PTSD. There were no significant differences between the asthma and control groups in severity of psychiatric co-morbid symptoms. Path analyses showed that asthma severity was significantly correlated with PTSD and psychiatric co-morbidity. It was also correlated with alexithymia which was in turn associated with psychiatric co-morbidity but not PTSD. Coping strategies were not correlated with health outcomes. To conclude, people can develop PTSD symptoms and degrees of psychiatric co-morbid symptoms after suffering asthma attack. The severity of these symptoms relates to people's perceptions of asthma severity and alexithymia.

The neurocognition of alexithymia: evidence from neuropsychological and neuroimaging studies

OBJECTIVE

Alexithymia refers to an ineffective regulation and expression of emotions. It constitutes a major risk factor for a range of medical and psychiatric problems, including chronic pain, somatisation, anxiety and depression. Alexithymia is a multi-faceted concept, described in terms of cognitive and affective aspects. From a neuropsychological perspective, alexithymia can be defined as a disturbance in affective information processing and social cognition. As the growing literature on brain structures involved in alexithymia is fragmented and sometimes even contradictory, the aim of this article was to review findings on neural substrates with regard to their convergence.

METHODS

A narrative review was performed, including both early neuropsychological and more recent imaging studies, in order to achieve a better understanding of the aetiology of alexithymia.

RESULTS

Corpus callosum, cingulate cortex and insula are clearly involved in alexithymia. The amygdala and the orbitofrontal part of the cortex appear to be implicated as mediators, because of their broader involvement in emotional processing and executive control.

CONCLUSION

Notwithstanding the diffuse neural representation, the alexithymia construct can be usefully applied in the clinical and empirical studies of social cognition, particularly when adopting a dimensional neuropsychological approach.

Schizotypy, alexithymia, and socioemotional outcomes

Studies have found higher levels of alexithymia in schizophrenic subjects relative to controls, with an overall higher level of emotional arousal and social withdrawal. The present study is an extension of this research to the assessment of schizotypy in a nonclinical sample. Seventy-two undergraduate students (40 female; 21.6 ± 6.38 years) were recruited to participate in this study. Consistent with earlier research, our results show that both schizotypy and alexithymia are associated with relatively poor socioemotional functioning across the variables of depression, anxiety, social functioning, and overall quality of life. Further, our results show that the significant associations found between alexithymia and these 4 outcome variables was predicated on shared variance with schizotypy. When both alexithymia and schizotypy were regressed onto these variables as independent predictors, the contribution of alexithymia was consistently nonsignificant. The implications of these findings are discussed in terms of hypothesized substrates of alexithymia.

Alexithymia and fear of pain independently predict heat pain intensity ratings among undergraduate university students

BACKGROUND

Alexithymia is a disturbance in awareness and cognitive processing of affect that is associated with over-reporting of physical symptoms, including pain. The relationship between alexithymia and other psychological constructs that are often associated with pain has yet to be evaluated.

OBJECTIVES

The present study examined the importance of alexithymia in the pain experience in relation to other integral psychological components of Turk's diathesis-stress model of chronic pain and disability, including fear of pain, anxiety sensitivity, pain avoidance and pain catastrophizing.

METHODS

Heat pain stimuli, using a magnitude estimation procedure, and five questionnaires (Anxiety Sensitivity Index, Fear of Pain Questionnaire III, Pain Catastrophizing Scale, avoidance subscale of the Pain Anxiety Symptoms Scale-20 and Toronto Alexithymia Scale-20) were administered to 67 undergraduate students (44 women) with a mean (+/- SD) age of 20.39+/-3.77 years.

RESULTS

Multiple linear regression analysis revealed that sex, fear of pain and alexithymia were the only significant predictors of average heat pain intensity (F[6, 60]=5.43; R2=0.35; P=0.008), accounting for 6.8%, 20.0% and 9.6% of unique variance, respectively. Moreover, the difficulty identifying feelings and difficulty describing feelings subscales, but not the externally oriented thinking subscale of the Toronto Alexithymia Scale-20 significantly predicted average heat pain intensity.

CONCLUSIONS

Individuals with higher levels of alexithymia or increased fear of pain reported higher average pain intensity ratings. The relationship between alexithymia and pain intensity was unrelated to other psychological constructs usually associated with pain. These findings suggest that difficulties with emotion regulation, either through reduced emotional awareness via alexithymia or heightened emotional awareness via fear of pain, may negatively impact the pain experience.

Does alexithymia differentiate between patients with nonepileptic seizures, patients with epilepsy, and nonpatient controls?

Considering the evidence of an association between alexithymia and somatization, this study aimed to discover whether alexithymia could distinguish patients with psychogenic nonepileptic seizures (NES) from those with epilepsy (ES) and nonpatient controls (C). Toronto Alexithymia Scale (TAS-20) scores were obtained from 21 matched participants from each of these groups, together with measures of anxiety and depression. Overall TAS-20 scores did not differentiate the three groups after controlling for anxiety and depression, but scores on certain subscales of the TAS-20 differed significantly between the patient groups and the controls. Although alexithymia could not discriminate individuals with NES from those with organic manifestations, whether the etiology of alexithymia may differ according to patient group was discussed. Given that 90.5% of NES patients were identified as alexithymic, treatment approaches used for individuals with alexithymia may be usefully applied to those with NES.

Are difficulties perceiving and expressing emotions associated with low-back pain? The relationship between lack of emotional awareness (alexithymia) and 12-month prevalence of low-back pain in 1180 urban public transit operators

OBJECTIVE

To assess the association of alexithymia (deficit in emotional awareness) with 12-month prevalence of low back pain (LBP) cross-sectionally in a cohort study of 1180 San Francisco transit operators.

METHODS

Alexithymia was measured by the Toronto Alexithymia Scale (TAS-20). LBP was assessed in medical histories during drivers relicensing exams. Multivariate logistic regression analyses controlled for demographic, behavioral (smoking, alcohol, coping style), and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all the drivers, 31.4% suffered from LBP. Scoring in the upper quartile of alexithymia summary scores was associated with twofold higher odds of LBP (adjusted odds ratio=2.00, 95% confidence interval: 1.31-3.00). The association was stronger in women (adj. OR=4.35) than in men (adj. OR=1.83). The factor "difficulty identifying feelings" showed the strongest association with LBP (adj. OR=2.23).

CONCLUSION

The results support an association between alexithymia and LBP.

Deficit in the discrimination of nonverbal emotions in children with obesity and their mothers

OBJECTIVE

Referring to the alexithymia construct and Bruch's clinical observations, this study investigated the ability to decode nonverbal signs of emotion in obese boys and girls, and their mothers.

METHOD

A group of 10 boys and 11 girls with obesity and their mothers, and a control group were tested. Both mothers and children were asked to recognize a set of 32 brief film sequences interpreted by four actors expressing four emotions (anger, sadness, fear, happiness) with two intensity levels. Each sequence was presented first without sound, second without video, and finally with video and sound.

RESULTS

As expected, boys and girls suffering from obesity and their mothers showed a reduced ability to decode visual and verbal signs of emotion compared to the control group.

DISCUSSION

This result may be interpreted in accordance with the alexithymia construct, and suggests the importance of developing therapeutic strategies to face alexithymic characteristics in obese children and their mothers.

Sobre o transtorno de pânico e a hipocondria: uma revisão

Introdução/Objetivos: A hipocondria é associada a diversos transtornos de ansiedade, sobretudo ao transtorno de pânico (TP). Estima-se que 50% a 70% dos pacientes com TP tenham sintomas hipocondríacos, e que 13% a 17 % dos hipocondríacos tenham TP associado. O presente estudo teve como objetivo revisar a literatura sobre as relações clínicas, fenomenológicas, cognitivas e psicodinâmicas entre o TP e a hipocondria, além de discutir aspectos conceituais e critérios diagnósticos. Métodos: A busca de artigos foi feita pelo sistema Medline entre 1990 e 2001, utilizando-se, como palavras-chave, transtorno de pânico, agorafobia, hipocondria e preocupações hipocondríacas. Resultados: Considera-se que há comorbidade com hipocondria no TP quando as preocupações com saúde não se restringem a sintomas das crises de pânico. Apesar de geralmente consideradas secundárias, vários pacientes com TP apresentam, antes da primeira crise, manifestações hipocondríacas que podem ser consideradas prodrômicas. A ansiedade pode gerar, num círculo vicioso, preocupações excessivas com saúde, auto-observação seletiva e antecipação do pior. Apesar do viés catastrófico comum, no TP sintomas autonômicos aumentam rapidamente até culminar num ataque, a catástrofe temida é iminente, com comportamentos de esquiva e busca imediata de socorro. Na hipocondria, temem-se doenças mais insidiosas, predominam comportamentos de hipervigilância e busca de reafirmação, as crenças são mais disfuncionais, é pior a relação médico-paciente e maior o foco de sensações erroneamente interpretadas catastroficamente. O medo patológico da morte e a alexitimia estariam presentes nos dois quadros. Conclusão: A sobreposição clínica entre TP/agorafobia e hipocondria é relevante, mas não completa. A relação entre os dois quadros é complexa e possivelmente bidirecional, um aumentando a vulnerabilidade ao outro. Há diferenças fenomenológicas identificáveis e relevantes, com implicações diagnósticas e terapêuticas.

Alexithymia and body weight in obese patients

The authors evaluated severely obese patients to determine whether being far different in body shape from the accepted standard may cause obese people to develop alexithymic personality traits. They evaluated the food- and weight-related attitudes in obesity surgery patients and in long-term follow-up of those who had previously had biliopancreatic diversion (BPD) for obesity. One quarter of the obese patients had alexithymic characteristics without any modification following stable weight loss, a rate of alexithymia similar to that observed in the nonclinical population. Furthermore, the frequency of alexithymia and the patients' scores on the Toronto Alexithymia Scale were similar in obese and post-BPD individuals. The authors concluded that being obese by itself does not influence the presence of alexithymic personality traits. However, they suggest that the improvement in food-related and weight-related attitudes following stable weight loss may be different in alexithymic and in nonalexithymic obese patients.

Concepts and methodology of psychosomatic research: facing the complexity

This review describes and discusses firstly the main characteristics and problems of psychosomatic research. One of the main problems is the validity of laboratory stressors in real-life situations. Secondly, it outlines the main philosophy and current concepts of psychosomatic medicine. The basic idea of a new integrative psychosomatic model is given. Thirdly, it presents some new methods that can be of use in psychosomatic research as well as research findings of special interest to cardiology. Especially the relationship between depression and coronary heart disease is discussed. The conclusion is that new methods and technical possibilities have great potential in enhancing psychosomatic research.

Zur Konstruktvalidität einer deutschen Fassung der Toronto Alexithymia Scale

Zusammenfassung: Eine deutsche Übersetzung der Toronto Alexithymie Skala (TAS) wurde an einer Studentenstichprobe (N = 228) auf ihre Faktorenstruktur und ihre psychometrischen Kennwerte hin überprüft. Anhand einer zweiten Stichprobe (N = 170) wurden die Zusammenhänge der Unterskalen der TAS mit Absorption untersucht, sowie mit Fragebogenskalen zu Beschwerdenäußerung, habitueller Gestimmtheit, Kontrollüberzeugung zu Krankheit und Gesundheit, Ärgerausdruck und defensiver Bewältigung. Die konfirmatorischen Faktorenanalysen (FA) sprachen für eine Mehrdimensionalität der TAS, mit einem Faktor zum Identifizieren, Differenzieren und Beschreiben von Gefühlen (TAS-ID), sowie zwei Faktoren des external orientierten Denkens. Die korrelierten TAS-Unterskalen zum external orientierten Denken, «Mangelnde Wichtigkeit von Emotionen» (TAS-WI) und «pragmatische Haltung» (TAS-PR), zeigten deutlich geringere Konsistenz als die von beiden relativ unabhängige Unterskala zu TAS-ID. Eine hierarchisch-oblique FA ergab keinen Sekundärfaktor im Sinne eines übergreifenden Alexithymiekonstrukts. Es ergaben sich widersprüchliche Zusammenhänge der TAS-Unterskalen mit der Absorption-Skala und weiteren Fragebogeninstrumenten. Es wird geschlossen, daß die TAS-Unterskalen kein einheitliches Alexithymiekonstrukt abbilden und daß weitere Untersuchungen zu Alexithymie auf Untermerkmale konzentriert werden sollten.

The influence of alexithymic characteristics on the self-perception and facial expression of a physiological stress state

BACKGROUND

In spite of the connection of alexithymic characteristics to many stress-related disorders, little is known about the effects of these characteristics on the self-perception of stress, which may have functional value in the regulation of daily behavior. The present study assessed the influence of alexithymic characteristics on the self-perception of stress in relation to the corresponding physiological/expressive responses during and while recovering from a phasic stressor.

METHODS

A median split of the scores on the Toronto Alexithymia Scale was used to divide 32 healthy middle-aged men into two groups, a high alexithymia (HA) and a low alexithymia (LA) group. Both groups participated in a 3-min hand-grip task, followed by a 3-min recovery period. During these periods, subjects' heart rate (HR) and facial electromyographical (EMG) activity on the corrugator supercilii and frontalis lateralis areas were measured and perceptions of exertion, unpleasantness and tension were self-rated. The perceptual style was assessed with the discrepancy scores: standardized scores of the physiological measures were subtracted from the corresponding standardized scores of the perceptions. Thus, positive scores indicated that self-reported perceptions exceeded the corresponding physiological or expressive activity (overestimation) and negative scores indicated the opposite (underestimation).

RESULTS

The HA group decreasingly underestimated exertion in relation to HR during the task and increasingly overestimated it during the recovery period. The HA group also overestimated unpleasantness in relation to the corrugator EMG response during the recovery period.

CONCLUSIONS

High alexithymic characteristics seem to predispose to the delayed self-perception of physiological stress state so that the beginning of this state may remain subjectively unnoticed and the subjective recovery from it prolonged relative to the physical recovery. During this prolonged subjective recovery the feelings of unpleasantness are not facially expressed. The consequences of this style for health-related behavior are discussed.

Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland

The prevalence of alexithymia and its association with sociodemographic variables were studied in a sample of 1285 subjects representing the general population of Finland. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20). Alexithymia was normally distributed in the population in both genders, confirming that it is a personality dimension. The prevalence of alexithymia was 13%. Men were alexithymic almost twice (17%) as often as women (10%). Multivariate analysis showed that alexithymia was associated with male gender, advanced age, low educational level, and low socioeconomic status. As to the three factors of the TAS-20, men scored higher in factors 2 (difficulty in describing feelings) and 3 (externally oriented thinking). but there was no gender difference in factor 1 (difficulty in identifying feelings). Comparative population studies in other countries are needed to find out whether there are any differences in the prevalence of alexithymia between cultures.

Alexithymic features do not predict compliance with psychotherapy in consultation-liaison patients

A 1-year follow-up study on 54 general hospital psychiatric consultation outpatients was carried out in order to determine whether alexithymic features, measured by the Toronto Alexithymia Scale (TAS) are predictive of psychotherapy recommendations and whether alexithymia is associated with patients' compliance with these recommendations. Contrary to what we expected, the presence of alexithymic features predicted neither treatment recommendations nor compliance. Psychological distress as measured by the Brief Symptom Inventory (BSI) proved to be a better predictor.

Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study

The 20-item Toronto Alexithymia Scale (TAS-20) has been shown in previous research to measure a general dimension of alexithymia with three intercorrelated factors. This study evaluated the reliability and factorial validity of an Italian translation of the TAS-20 in a group of normal adults (N = 206) and in a mixed group of medical and psychiatric outpatients (N = 642). Using confirmatory factor analyses, the previously established three-factor model of the TAS-20 was found to be replicable in both groups. In addition, the Italian TAS-20 demonstrated adequate estimates of internal reliability and test-retest reliability. Although evaluation of the convergent, discriminant, and concurrent validity of the TAS-20 is required in Italian populations, the present results support the use of the Italian translation of the scale for clinical and research purposes.