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 Alexithymia, which literally means “no words for feelings” (1), is suggested by Taylor “to be a heuristically useful construct for exploring the role of personality and emotions in the pathogenesis of certain somatic illnesses and diseases” (2, p 134) Similarly, Mai’s review highlights the relevance of alexithymia in the etiology of somatoform disorders, which are characterized by a relative absence of physical cause and a presumed psychological cause (3). Further studies show a strong association between somatic complaints and manifestations of psychological distress, such as depression and anxiety (4,5). Alexithymia may reflect deficits in emotional regulation and cognitive processing (6). These deficits are attributed to an arrest in affect development during early childhood (7). Because no previous studies explore the rates of alexithymia, depression, and anxiety in an adolescent population experiencing somatic symptoms, our study provides a unique insight into the early relations between these factors. MethodsParticipants The sample group comprised adolescents aged 12 to 17 years with ICD-10 persistent somatoform pain disorder (8) (defined by the DSM-IV as a pain disorder associated with psychological factors) (9). These adolescents were hospitalized in Kaunas Medical University Hospital, Lithuania (n = 120), between 1999 and 2002. Pathology was excluded by physical examination and investigation. The control group (n = 60) comprised healthy adolescents aged 12 to 17 years who were randomly selected from 6 secondary schools in Kaunas. Informed consent was obtained from all subjects and their families, and the study was approved by the University Research Ethics Board. Instruments and Procedure Alexithymia was measured with a Lithuanian translation of the TAS-20 (10). The TAS-20 is reliable and valid (11,12). An empirically derived cutoff of ≥ 61 distinguishes individuals with alexithymia from those without alexithymia (13). Caseness was indicated by a self-reported score of ≥ 11 on either the anxiety or depression subscale of the HADS (14). Validation studies of English and foreign language translations show the HADS performs well in assessing caseness in hospital, community, and primary care settings (15–17). The HADS has been validated for use in adolescents (18). Statistics We calculated Fisher’s exact test P values to compare the differences in levels of alexithymia, depression, and anxiety between the sample and control groups. ResultsThe sample group contained 36 male subjects (30%) and 84 female subjects (70%) while the control group consisted of 42 male subjects (70%) and 18 female subjects (30%) (Table 1).
The rate of alexithymia in adolescents with somatoform disorder was 59%, which was significantly higher than that of the healthy control group (1%, P < 0.001). Similarly, the rate of anxiety was significantly higher among individuals in the sample group (62%), compared with control subjects (15%, P < 0.001). The rate of depression was low in both groups and did not differ significantly. DiscussionAlthough empirical evidence demonstrates a relation between alexithymia and somatoform disorders, the direction of causality cannot be established, given the lack of prospective studies. Our study did not control for several potential and important confounding variables such as sex. There were disproportionately more female adolescents in the sample group (70%), compared with the control group (30%). However, previous studies have shown a weak association between alexithymia and male sex (11,12,19), and so the higher rate of alexithymia in the sample group is unlikely owing to the sex distribution. To correctly assess somatization, it is important to rule out physical causes, which was done in our study through standard physical examination, investigations, and medical chart review rather than by questionnaires (20). The 59% rate of alexithymia found in our sample of adolescents with somatoform disorder was similar to the rate of 53% found in a study of DSM-III-R somatoform pain disorder (21). The prevalence of 59% among adolescents is substantially higher than the prevalence among general psychiatric outpatient and various normal adult samples (11,12). A recent review found that, compared with healthy control populations, individuals suffering from somatoform conditions were significantly more alexithymic, with effect sizes ranging from moderate to large (20). Significant positive correlations between both depression and anxiety and alexithymia have been reported (22–25). In one study by Berthoz and others, however, the alexithymia and depression scores did not remain correlated after controlling for anxiety, whereas the correlation between alexithymia and anxiety remained significant after controlling for depression (22). The authors suggested that anxiety directly influences alexithymia , whereas depression does not. Thus it is possible that depression is not present in our sample of adolescents with somatoform disorder because it is a late-occurring epiphenomenon. Rather than depression influencing somatization, somatization leads to depression. Depression may occur years later as a consequence of chronic somatic symptoms, poor functioning, and limited attainment of life goals. An association between alexithymia as a psychological correlate of somatization and depression may thus appear in the adult population, whereas no relation is found in the adolescent population. Funding and SupportThis study received no funding and no support. AcknowledgementsWe thank Dr Kevalas for his assistance. References1. Sifneos P. The prevalence of alexithymia in psychosomatic patients. Psychother Psychosom 1973;22:255–62. 2. Taylor GJ. Recent developments in alexithymia theory and research. Can J Psychiatry 2000;45:134–42. 3. Mai F. Somatization disorder: a practical review. Can J Psychiatry 2004;49:652–62. 4. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341:1329–36. 5. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734–41. 6. Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge (UK): Cambridge University Press; 1997. 7. Lane RD, Schwartz GE. Levels of emotional awareness: a cognitive developmental theory and its application to psychopathology. Am J Psychiatry 1987;144:133–43. 8. WHO. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research, vol II. Geneva (CH): WHO; 1993. 9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 10. Beresnevaitic M, Taylor GJ, Parker JDA, Andziulis A. Cross validation of the factor structure of a Lithuanian translation of the 20-item Toronto alexithymia Scale. Acta Medica Lituanica 1998;5:146–9. 11. Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto alexithymia scale—I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23–32. 12. Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto alexithymia scale—II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33–40. 13. Parker JDA, Taylor GJ, Bagby RM. Alexithymia and the processing of emotional stimuli: an experimental study. New Trends Exper Clin Psychiatry 1993;9:9–14. 14. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70. 15. Snaith RP. The hospital anxiety and depression scale: commentary. Health Qual Life Outcomes 2003;1:29. 16. Hermann C. International experience with the hospital anxiety and depression scale: a review of validation data and clinical results. J Psychosom Res 1997;42:17–41. 17. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale; an updated review. J Pscyhosom Res 2002;52:69–77. 18. White D, Leach C, Sims R, Cottrell D. Validation of the HADS in adolescents. Brit J Psychiatr 1999;175:452–4. 19. Lane RD, Sechrest L, Riedel R. Sociodemographic correlates of alexithymia. Compr Psychiatry 1998;39:377–85. 20. De Gucht V, Heiser W. Alexithymia and somatisation: a quantitative review of the literature. J Psychosom Res 2003;54:425–34. 21. Cox BJ, Kuch K, Parker JDA, Shulman ID, Evans RJ. Alexithymia in somatoform disorder patients with chronic pain. J Psychosom Res 1994;38:523–7. 22. Berthoz S, Consoli S, Perez-Diaz F, Jouvent R. Alexithymia and anxiety: compounded relationships? A psychometric study. Eur Psychiatry 1999;14:372–8. 23. Hendryx MS, Haviland MG, Shaw DG. Dimensions of alexithymia and their relationships to anxiety and depression. J Pers Assess 1991;56:227–37. 24. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinamaki H. Depression is strongly associated with alexithymia in the general population. J Psychosom Res 2000;48:99–104. 25. Parker JDA, Bagby RM, Taylor GJ. Alexithymia and depression: distinct or overlapping constructs? Compr Psychiatry 1991;32:387–94. AuthorsManuscript received July 2005, revised, and accepted March 2006. 1. Professor and Head, Department of Psychiatry, Kaunas Medical University Hospital, Kaunas, Lithuania. 2. Clinical Lecturer, Department of Psychiatry, University of Alberta, Edmonton, Alberta. 3. Clinical Lecturer, Department of Psychiatry, Kaunas Medical University Hospital, Kaunas, Lithuania. 4. Assistant Psychiatrist, Department of Psychiatry, Kaunas Medical University Hospital, Kaunas, Lithuania. 5. Associate Professor, Department of Psychiatry, University of Alberta, Edmonton, Alberta. Address for correspondence: Dr P Chue, 3rd Floor, 9942-108 Street, Edmonton, Alberta T5K 2J5 e-mail: pchue@ualberta.ca
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