Depression, alexithymia, and pain prone disorder: a Rorschach study

Links among emotional awareness, somatic awareness and autonomic homeostatic processing

Emotional awareness and somatic interoceptive awareness are essential processes for human psychosomatic health. A typical trait of lacking emotional awareness related to psychosomatic symptoms is alexithymia. In contrast, alexisomia refers to the trait of lacking somatic awareness. Links between emotional and somatic awareness and homeostatic processing are also significant for the psychosomatic health. The purpose of the present paper is to review the links among emotional awareness, somatic interoceptive awareness and autonomic homeostatic processing. On the basis of the collected evidence, the following arguments were presented¹: (1) The main subcortical neural substrates for these processes are limbic-related systems, which are also responsible for autonomic functions for optimization of homeostatic efficiency. (2) Considerable studies have shown that autonomic activity and/or reactivity to stress correlate with both emotional and interoceptive awareness. A hypothesis was advocated about the links between the two types of awareness and autonomic function: Autonomic dysfunction, especially high sympathetic tone at baseline and/or attenuated reactivity or variability to stress, appears to be involved in disturbance of emotional and interoceptive awareness. (3) Several studies suggest that a link or a cooperative relationship exists between emotional and somatic awareness, and that somatic awareness is the more fundamental of the two types of awareness. Emotional awareness, somatic awareness and autonomic homeostatic processing generally occur in parallel or concurrently. However, some complex features of pathologies include coexistence of reduced interoceptive awareness and somatosensory amplification. The autonomic homeostatic process is fundamentally involved in emotional and somatic awareness. Investigation of these types of awareness with both neuroimaging evaluations and estimation of peripheral autonomic function are required as next steps for exploration of the relationship between awareness and human somatic states including somatic symptoms as well as general psychosomatic health.

Psychological characteristics of Japanese patients with chronic pain assessed by the Rorschach test

BACKGROUND

The increasing number of patients with chronic pain in Japan has become a major issue in terms of the patient's quality of life, medical costs, and related social problems. Pain is a multi-dimensional experience with physiological, affective, cognitive, behavioral and social components, and recommended to be managed via a combination of bio-psycho-social aspects. However, a biomedical approach is still the dominant method of pain treatment in Japan. The current study aimed to evaluate comprehensive psychological functions and processes in Japanese chronic pain patients.

METHODS

The Rorschach Comprehensive System was administered to 49 in-patients with non-malignant chronic pain. Major variables and frequencies from the test were then compared to normative data from non-patient Japanese adults by way of the t-test and chi-square test.

RESULTS

Patients exhibited high levels of emotional distress with a sense of helplessness with regard to situational stress, confusion, and ambivalent feelings. These emotions were managed by the patients in an inappropriate manner. Cognitive functions resulted in moderate dysfunction in all stages. Information processing tended to focus upon minute features in an inflexible manner. Mediational dysfunction was likely to occur with unstable affective conditions. Ideation was marked by pessimistic and less effective thinking. Since patients exhibited negative self-perception, their interpersonal relationship skills tended to be ineffective. Originally, our patients displayed average psychological resources for control, stress tolerance, and social skills for interpersonal relationships. However, patient coping styles were either situation- or emotion-dependent, and patients were more likely to exhibit emotional instability influenced by external stimuli, resulting in increased vulnerability to pain.

CONCLUSIONS

Data gathered from the Rorschach test suggested psychological approaches to support chronic pain patients that are likely to be highly beneficial, and we thus recommend their incorporation into the course of current pain treatments.

The mangled butterfly: Rorschach results from 45 violent psychopaths

Participants were 45 violent California male prison inmates scoring 30 or more on the Psychopathy Checklist-Revised (PCL-R; Hare, 1991, 2003). Inmates were evaluated using Rorschach and neuropsychological test data. The participants' intellectual functioning was within the low-average range and displayed a lack of flexibility. Rorschach data were not suggestive of chronic narcissism and anger as in other psychopathic samples. This group resembled Exner's normative sample of high Lambda adults. Consistent with previous studies, psychopaths demonstrated poor emotional modulation, diminished reality testing, little interest in people, and virtually no attachment capacity. Most utilized a simplistic, avoidant, and concrete style. This appeared to be consistent with the concrete thinking and fragmentation attributed to the criminal personality. Concrete thinking is based upon literal interpretations of events. Fragmentation is associated with attitudes that are situation specific and self-serving.

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 and 7.5-year incidence of compensated low back pain in 1207 urban public transit operators

OBJECTIVE

Alexithymia, a lack of emotional awareness, was positively associated with self-reported low back pain (LBP) in cross-sectional studies. We assessed the association of alexithymia with 7.5-year incidence of LBP prospectively in a cohort study of 1207 San Francisco transit operators.

METHODS

Alexithymia was measured by the 20-item Toronto Alexithymia Scale (TAS-20). LBP was assessed by physician-confirmed diagnoses from administrative workers' compensation data. Cox proportional hazards analyses controlled for demographic, behavioral, and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all drivers, 27.7% (n=334) filed compensated claims for LBP injuries with workers' compensation insurance during the 7.5-year observation time. The hazard ratios from the fully adjusted model were 0.73 (0.56-0.96) for the TAS-20 scale and 0.82 (0.69-0.98) for the subscale "difficulty describing feelings." Alexithymia scores did not predict the duration of compensated work disability.

CONCLUSION

In contrast to previous cross-sectional positive associations between alexithymia and LBP, alexithymia is negatively associated with compensated LBP claims. We hypothesize that shame and reporting behavior may explain these inconsistent results.

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.

[A critique of the construct "alexithymia" and its measurement--the weakness of self-report and the opportunities of an objective assessment approach]

Approximately thirty years ago the term alexithymia was coined but it is still open which characteristics have to be considered core symptoms of alexithymia. A selective review of recent expert definitions reveals dynamism in defining the alexithymia construct. At present, the self-report Toronto-Alexithymia-Scales (TAS) are the most frequently used measures of alexithymia. Empirical findings regarding various aspects of validity (factorial, concurrent, and experimental construct validity data) question the validity of the Toronto-Alexithymia-Scales. Alexithymia as measured by the TAS appears not to be consistently related to physiological, affect decoding or affective vigilance characteristics. The heterogeneity of the results could be due to the fact that non-alexithymic persons such as depressed or socially anxious individuals yield high scores on the TAS; on the other hand self-report appears to be in principle a methodologically inadequate approach for the assessment of alexithymia. Objective or direct measures of alexithymic characteristics as the Levels of Emotional Awareness Scale or the prototypicity analysis of mood diaries based on adjective checklists seem to be promising assessment methods for future research.

Alexithymia and sociocultural factors in a Japanese sample: a study with the Rorschach

We reexamined the Japanese version of the 20-item Toronto Alexithymia Scale, a self-report sc ale for measuring alexithymic characteristics, by comparing the scores on three factors and the total scores with variables of the Rorschach in a sample of 40 (originally 48) Japanese college students. Based on prior studies, our aims were to further validate the 20-item Toronto Alexithymia Scale by comparing its scores with those on a projective technique. We also investigated whether sociocultural factors, such as repression of hostility. are associated with scores on the 20-item Toronto Alexithymia Scale (especially Factor 3). None of the seven Rorschach Alexithymia Variables were significantly related to the factors and total scores of the 20-item Toronto Alexithymia Scale. However, scores for Factor 1 (difficulty identifying feelings) of the 20-item Toronto Alexithymia Scale correlated positively with scores on Sum C' (reserved responses to emotional stimuli) and Adj es (stimulus demand), suggesting that individuals who score high for Factor 1 experience gloomy, depressive feelings but in constricted ways. Scores for Factor 3 (externally oriented thinking) correlated positively with the D scores (stress tolerance) and negatively with m (situational stress) responses, suggesting that Factor 3 may reflect a psychological defense that enhances stress tolerance. There was a nonsignificant negative correlation between Factor 1 and Factor 3 scores, but, unlike our hypothesis. Factor 3 was neither related to AG (aggression) nor S (space responses reflecting oppositional tendency), indices of aggression or hostility in the Rorschach Comprehensive System. It may be that the 20-item Toronto Alexithymia Scale and the Rorschach measure quite different aspects of personality, but further research is necessary.

Conversion disorder and multiple chemical sensitivity: a comparative study of psychological defense strategies

This study compared psychological defensive strategies in two groups of patients with multiple chemical sensitivity (n = 10) and conversion disorder (n = 10) by means of the projective perceptual Defense Mechanism Test. We attempted to create a model for personality assessment based on the test data of prior patients, in which new patients could successively be tested. The overall results indicated that it was possible to separate the clinical groups significantly from a control group and from each other. In comparison to the controls, the clinical groups were characterized by patterns that were more nonemotionally adapted as well by a lateness of perception, but the ways in which the clinical groups maintained this difference were not the same. The multiple chemical sensitivity group was characterized above all by blocking maneuvers, while the main defensive strategy of the conversion disorder group was distortion of content.

Impaired verbal and nonverbal emotion recognition in alexithymia

Although clinical observations suggest that alexithymic individuals have a deficit in their ability to recognize emotional stimuli and that this deficit is not simply due to a problem in verbal labeling, these two hypotheses have not been empirically confirmed. Three hundred eighty participants in a community survey without current or past histories of psychiatric disorder completed two independent measures of alexithymia [the Levels of Emotional Awareness Scale (LEAS) and the Toronto Alexithymia Scale (TAS-20)] and the Perception of Affect Task (PAT), a 140-item measure of the ability to match emotion stimuli. The PAT includes four subtasks that require the subject to match verbal or nonverbal emotion stimuli with verbal or nonverbal emotion responses. The subtasks include matching sentences and words (verbal-verbal), faces and words (nonverbal-verbal), sentences and faces (verbal-nonverbal), and faces and photographs of scenes (nonverbal-nonverbal). Across the entire sample, higher (alexithymic) TAS-20 and lower LEAS scores were both correlated with lower accuracy rates on each of the subtasks of the PAT (p < .001), accounting for 10.5% and 18.4% of the variance, respectively. Fifty-one subjects met TAS-20 criteria for alexithymia. Alexithymic individuals scored lower than other subjects on purely nonverbal matching, purely verbal matching, and mixed verbal-nonverbal matching (all p < .001). These results suggest that alexithymia is associated with impaired verbal and nonverbal recognition of emotion stimuli and that the hallmark of alexithymia, a difficulty in putting emotion into words, may be a marker of a more general impairment in the capacity for emotion information processing.

Alexithymia in a normal elderly population

The aim of the study was to determine the prevalence of alexithymia in an elderly Finnish population sample. Associations between alexithymia and sociodemographic factors were investigated, together with the relationship between alexithymia and perceived somatic health and self-reported psychic health. The study forms a part of the Turun Vanhustutkimus (TUR-VA) project, which is a longitudinal, prospective follow-up study dealing with psychosocial adaptation to retirement and to old age. The study group consisted of a population sample of 72-year-old people (N = 190). Alexithymia was measured with the 26-item version of the Toronto Alexithymia Scale (TAS-26). The prevalence of alexithymia was 34%. Alexithymia was associated with poor perceived somatic health. Alexithymia was associated with having a psychiatric disturbance (measured by the 36-item General Health Questionnaire [GHQ-36]), but this relationship disappeared when the influence of perceived somatic health was controlled for. Alexithymia was not associated with gender, marital status, social status, or residential area.

Somatoform pain disorder in a case of Klinefelter's syndrome with multiply operated lower back

We report a case of Klinefelter's syndrome with multiply operated low back (MOB). Psychological and/or psychosocial problems related to MOB have been of recent interest in the field of orthopedic surgery. Based on psychiatric interviews, this case was diagnosed as a somatoform pain disorder of the DSM-III-R somatoform disorders. In addition to psychological problems, the pain was partly explicable by severe osteoporosis, which was prematurely caused by endocrinological disturbances associated with Klinefelter's syndrome. Patients with this syndrome are more likely to develop severe osteoporosis. In the presenile period of Klinefelter's syndrome with severe osteoporosis, liaison psychiatrists may pay attention to somatoform disorders (e.g. somatoform pain disorder and conversion disorder) linked with the MO.

The relationship between somatosensory amplification, alexithymia, and neuroticism

Both amplification of normal visceral phenomena and the personality trait of alexithymia are factors in the process of somatization, whereby somatic symptoms become metaphors for emotional distress. The relationship between these two variables was investigated in 101 psychiatric out-patients. Each subject was administered the Somatosensory Amplification Scale (SSA); the Toronto Alexithymia Scale (TAS); the NEO-FFI, which measures five personality factors; and the health locus of control (HLC). In addition, anxiety and depression were quantitatively measured. SSA and TAS significantly correlated only in the female subjects. A regression model found neuroticism to contribute the most variance in predicting SSA while TAS did not fit into the model. Amplification is a perceptual element in potentiating somatization, whereas alexithymia contributes to the cognitive aspects of the process. The role of neuroticism is discussed as a mediating factor.

Depression and back pain

Depressive and anxiety neuroses are the most common psychiatric disorders associated with back pain. In assessing the connections between back pain and depression, the different forms of depression should be considered. There are some depressed back pain patients with the traditional depressed mood as the principal symptom of mood disorder. It seems, however, that the depression associated with back pain is usually atypical in nature and that signs of depression other than the depressed mood have to be taken into account. Alexithymic features associated with the pain can also mask the depression.

C' and depression

Research assessing the validity of the Rorschach hypothesis that achromatic responses (C') reflect depressiveness was reviewed. The conclusions drawn from these data are that the research does not support the hypothesis as stated and research is needed to clarify the relationship of depressiveness to the determinants or the psychological meaning of C'. Until such time as objective signs of depression and depressiveness can be discovered by research, clinicians should not interpret C' as signifying depressiveness. If the search is for assistance in discerning depressiveness from the analysis of Rorschach data, until a more objective and valid method of such assessment is developed, the presence of depressive content would appear to be a satisfactory method of assessing a person's depressiveness.

Is alexithymia distinct from health locus of control?

OBJECTIVE

Both locus of control and alexithymia have been considered personality factors fostering health concerns and behaviors. This study investigates the relationship between the health locus of control and alexithymia.

METHOD

Seventy-eight psychiatric outpatients were administered the Wallston Health Locus of Control Scale (HLC), the Toronto Alexithymia Scale (HLC), and the Five Factor Inventory, which measures neuroticism, extraversion, openness, agreeableness, and conscientiousness. Depressive and anxious affect was also measured. Regression models were developed to assess the influence of the above variables upon alexithymia.

RESULTS

Although there was a significant bivariant correlation between an external locus of control and increased alexithymia, regression models found that HLC did not significantly predict TAS. Neuroticism, however, provided the most significant contribution to predict increased alexithymia.

CONCLUSION

Neuroticism may link HLC and TAS due to the face validity of each construct. A sense of vulnerability is stated in each measure. This may foster somatic preoccupation. The data suggest HLC and TAS to be separate phenomena and further support the validity of alexithymia as a unique personality trait.

Personality in patients with long-term patellofemoral pain syndrome

Personality characteristics in patients with long-term patellofemoral pain were compared to those of matched controls and other groups both of non-patients and of psychiatric outpatients with character disorders. Personality was described using the self-administered dependency and alexithymia scales, the Karolinska Scales of Personality and the Rorschach inkblot method. The hypothesis was that the patellofemoral pain patients would have higher levels of anxiety, depression, helplessness, aggression and alexithymic characteristics than the matched controls. There were only a few significant differences between the knee patients and the matched controls. The Rorschach measures suggested significantly greater depression, hostility and passive attitude in the knee patients as compared to the reference data. There were no indications of the hypothesised alexithymic characteristics in the knee patients. If patellofemoral pain patients do not improve as expected, referral to a pain clinic with psychological expertise could be considered.

Psychoanalysis and psychosomatics: a new synthesis

The usefulness of psychoanalysis to psychosomatic medicine has been limited by the longstanding assumption that the psychological disorder in psychosomatic patients resembles the conflict-based psychopathology that Freud identified in psychoneurotic patients. Recent investigations of the alexithymia construct, and the discovery that social relationships can influence health over the entire life span, have challenged this assumption and created an opportunity for a new and active involvement of psychoanalysis with psychosomatic medicine. In this contribution, I offer a synthesis of contemporary psychoanalytic observations and theories with concepts and research findings from developmental psychology, developmental biology, and the biomedical sciences. The proposed synthesis is consistent with the view that living organisms are self-regulating cybernetic systems; it also extends an evolving new psychosomatic model that conceptualizes illnesses and diseases as disorders of psychobiological regulation. A modern psychoanalytic approach to physically ill and disease-prone individuals focuses less on the resolution of neurotic conflicts, and more on correcting deficits in these patients' self and object representations and capacity cognitively to process emotions.

Alexithymia and the five-factor model of personality

The relationship between alexithymia assessed by the Toronto Alexithymia Scale (TAS) and the five-factor model of personality measured by the NEO Five-Factor Inventory (FFI) was investigated in a group of psychiatric outpatients (n = 114) and normal volunteers (n = 71). When controlling for depression, the domains of neuroticism, introversion, and low openness predicted alexithymia. These three dimensions accounted for 57.1% of the explained variance in the patient cohort and 38.1% in the volunteer group. In the patient cohort, neuroticism contributed the majority of explained variance, which may reflect the state effect of distress that elevates neuroticism. Introversion was the most significant predictor in the volunteer group. These data suggest alexithymia is a unique personality trait that is not fully explained by the five-factor model of personality.

Alexithymia and depression: distinct or overlapping constructs?

Previous research showing moderate to high correlations between the Toronto Alexithymia Scale (TAS) and Beck Depression Inventory (BDI) has generated controversy as to whether alexithymia and depression are distinct or overlapping constructs. The present study addressed this controversy using the statistical method of factor analysis. In a sample of undergraduate university students, a correlation matrix comprising items from both the TAS and BDI yielded a four-factor solution with virtually no overlap of the significant factor loadings for the items from each scale, and with the factors corresponding closely with their respective construct. These results were replicated and cross-validated with a sample of psychiatric outpatients. The findings support the view that alexithymia is a construct that is distinct and separate from depression.

Problems with measuring alexithymia

Research evaluating the relationship of alexithymia to medical and psychiatric disorders has been compromised by the poor psychometric properties of the instruments that have been used to measure alexithymia. This study evaluated the psychometric properties of a recently introduced measure of alexithymia--the revised Schalling-Sifneos Personality Scale (SSPS-R). While the factor structure of the SSPS-R was found to be reasonably congruent with the theoretical domains of the alexithymia construct, the scale lacked homogeneity and internal reliability. These results are compared with the reliability and validity of other available measures of alexithymia. Recommendations are offered for the improved assessment of alexithymia in future research studies.

The alexithymia construct. A potential paradigm for psychosomatic medicine

During the past decade, the alexithymia construct has undergone theoretical refinement and empirical testing and has evolved into a potential new paradigm for understanding the influence of emotions and personality on physical illness and health. Like the traditional psychosomatic medicine paradigm, the alexithymia construct links susceptibility to disease with prolonged states of emotional arousal. But whereas the traditional paradigm emphasizes intrapsychic conflicts that are presumed to generate such emotional states, the alexithymia construct focuses attention on deficits in the cognitive processing of emotions, which remain undifferentiated and poorly regulated. This paper reviews the development and validation of the construct and discusses its clinical implications for psychosomatic medicine.

Reassessing the validity and reliability of the MMPI Alexithymia Scale

In the past decade, alexithymia has emerged as a heuristically useful personality construct used to explain the pathogenesis of a variety of physical illnesses, including classical psychosomatic diseases, somatization disorders, hypochondriasis, and somatoform pain disorders. Unfortunately, research evaluating the alexithymia construct has been conducted with little attention to assessing the psychometric properties of various scales used to measure it. In two separate studies, we examined various scale and item properties as well as the factor structure and validity of the Minnesota Multiphasic Personality Inventory Alexithymia Scale (MMPI-A), one of the most commonly used scales to assess alexithymia. In Study 1, the 22 items that comprise the MMPI-A were extracted from a computerized MMPI data bank which included separate samples of psychiatric inpatients and outpatients. Poor item-to-scale characteristics and only moderate levels of internal reliability were found for both samples. Factor analysis produced factors that were poorly related to the theoretical domains of the alexithymia construct. In Study 2, we found little support for validity of the scale as those patients identified as alexithymic and nonalexithymic by the MMPI-A did not differ on several theoretically relevant scales. These results question seriously the value of the MMPI-A in investigating the alexithymia construct.

Dimensions of alexithymia and their relationships to anxiety and depression

Investigators have suggested that alexithymia is a multidimensional construct and that it is responsive to situational stressors. We tested these hypotheses in a sample of 110 freshman medical students. We conducted factor analyses on the Toronto Alexithymia Scale (TAS), the Beck Depression Inventory (BDI), and the state portion of the State-Trait Anxiety Inventory (STAI) and then used LISREL to examine the relationships among the various factors. The results indicated that the TAS consists of several independent dimensions and that the dimensions associated with difficulties identifying and communicating feelings are positively related to depression and anxiety. Thus, the evidence now affirms that alexithymia (as measured by the TAS) is multidimensional and that certain dimensions are state dependent.

Alexithymia and stimulus augmenting/reducing

Alexithymia is thought to be a trait that predisposes individuals to psychosomatic and drug abuse disorders. It was hypothesized that alexithymic characteristics would lead an individual to augment stimuli in order to prevent ignoring stimuli that might be dangerous. Subjects (N = 175) were administered alexithymia and augmenting-reducing questionnaires. These concepts were related as expected for male, but not female, subjects. In addition, it was found that alexithymic characteristics in general, rather than a specific difficulty in discriminating physical and emotional stimuli, contributed to this relationship.

Validation of the alexithymia construct: a measurement-based approach

Alexithymia is a hypothetical personality construct that has been associated with a variety of medical and psychiatric disorders. This article reviews a program of research evaluating the validity of the construct using a measurement-based, construct validation approach. For this purpose the Toronto Alexithymia Scale (TAS) was developed. In a series of studies the TAS demonstrated internal consistency, good test-retest reliability, and a stable factor structure theoretically congruent with the alexithymia construct. In separate tests of construct validity, the TAS correlated in a theoretically meaningful fashion with measures of other constructs. Criterion validity was supported by a study in which the TAS was able to discriminate between behavioural medicine outpatients designated as alexithymic and those designated as nonalexithymic on the basis of objectively rated structured interviews. In a normal adult sample, TAS scores were not related to sociodemographic variables or intelligence. These results provide considerable empirical support for the validity of the alexithymia construct. In addition, the TAS appears to be a psychometrically sound measure of alexithymia that may prove useful in testing the construct with psychiatric and medical patient populations.