Alexithymia and adult attachment representations: Associations with the five-factor model of personality and perceived relationship adjustment

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Alexithymia and adult attachment representations: Associations with the five-factor model of personality and perceived relationship adjustment Graeme J. Taylor a,⁎, R. Michael Bagby b , Shauna C. Kushner c , Diane Benoit d , Leslie Atkinson e a Department of Psychiatry, University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada Departments of Psychology and Psychiatry, University of Toronto, and Centre for Addiction and Mental Health, Toronto, Ontario, Canada c Department of Psychology, University of Toronto Scarborough, Ontario, Canada d Department of Psychiatry, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada e Department of Psychology, Ryerson University, Toronto, Ontario, Canada

b

Abstract Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition, measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security, assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship adjustment beyond the domains of the FFM. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Alexithymia is a multi-faceted personality trait characterized by difficulties in identifying and describing subjective feelings, a limited imaginal capacity, and an externally orientated cognitive style [1]. These cognitive and affective features are thought to reflect a deficit in the cognitive processing and regulation of emotions [2,3] and were described during the 1970s by Nemiah and Sifneos [4,5], who observed them initially among patients with classic psychosomatic diseases. During the past three decades the construct of alexithymia has generated a large body of empirical research, including an interest in identifying factors that might influence the cognitive ⁎ Corresponding author at: Department of Psychiatry, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada. Tel.: +1 416 9321796. E-mail addresses: [email protected] (G.J. Taylor), [email protected] (R.M. Bagby), [email protected] (S.C. Kushner), [email protected] (D. Benoit), [email protected] (L. Atkinson). http://dx.doi.org/10.1016/j.comppsych.2014.03.015 0010-440X/© 2014 Elsevier Inc. All rights reserved.

processing of emotions and individual differences in levels of emotional awareness. There is now substantial empirical support for the validity of the construct, as well as evidence that it is a dimensional personality trait, which overlaps conceptually with some facets of the openness to experience domain in the five-factor model (FFM) of personality, but does not correspond to any single higher-order personality trait domain or lower-order (facet) trait within this model [1,6]. There is empirical evidence also that alexithymia is associated with several common medical and psychiatric disorders including eating disorders, substance use disorders, post-traumatic stress disorders, panic disorder, and functional gastrointestinal disorders [1,3]. Other empirical research has implicated genetic and environmental/developmental factors in the etiology of alexithymia, in particular childhood trauma and insecure attachments [7–12]. The association between alexithymia and insecure attachment reflects the role the attachment system plays in affect development and affect regulation [13,14]. It is well established, for example, that attachment experiences in early childhood influence the development of emotion schemas,

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imagination, and other cognitive skills involved in the regulation of affective experiences [15,16]. A creative imagination and effective emotion-regulating skills and other mentalizing abilities are more likely to emerge in the context of secure attachment relationships [14,17]. In a longitudinal study across four time points between ages 17 and 36 months, insecurely attached and disorganized children showed a delay in developing a mentalizing language to express emotions and other inner states [18]. Insecurely attached children also display less positive affect and lower levels of symbolic play than securely attached children, and are less adaptable and competent in their subsequent relationships [19,20]. Bowlby [21] proposed that infants and children develop mental representations (“internal working models”) of their primary attachment relationships. These representations become progressively more elaborated and differentiated during childhood and adolescence, but remain relatively stable over time thereafter [22]. The attachment representations of adults may be assessed with the Adult Attachment Interview (AAI) [23], which addresses the individual’s reports and memories regarding early attachment experiences with parents. The AAI yields classifications based mainly on the structural properties of the individual’s narrative rather than the content, especially on the coherence of the narrative, and thus assesses “state of mind with respect to attachment” [24,25]. Another approach to assessing adult attachment relies on self-report questionnaires, which address the individual’s conscious attitudes and feelings and style of relating with their current romantic partner or other close personal relationship. The correlations between the AAI and the attachment style questionnaires are generally small, suggesting that they measure different aspects of attachment [26,27]. Whereas the AAI yields the primary attachment classifications of secure–autonomous, insecure–dismissing, insecure– preoccupied, and unresolved [23,28], the self-report attachment questionnaires either assign individuals to categories of attachment style or measure the degree to which dimensions of attachment style are present [29]. In a second-order factor analysis, Brennan, Clark and Shaver [30] demonstrated that the factors derived from all known self-report attachment questionnaires form two higher-order factors representing the two dimensions of attachment anxiety and attachment avoidance. In recent years several researchers have questioned whether categories are the best way to define individual differences in attachment, as there is accumulating evidence that the distinction between secure and insecure patterns of attachment is more reliable and predictive than distinctions between various types of insecurity [31]. Maunder and Hunter [31], for example, have proposed a “prototype-based model of attachment”, which reduces the boundaries between categories and places individuals along a dimension of severity of attachment insecurity that is determined by how strongly selfreport measures of attachment anxiety and attachment avoidance are associated. Although it is usual practice to code the AAI categorically, Kobak [32] developed the AAI Q-sort that yields continuous

measures of secure vs. anxious and deactivation vs. hyperactivation, as well as for dismissing and preoccupied attachment representations; however, the Q-sort does not identify the unresolved category among the Main and Goldwyn AAI classifications [28]. The hyperactivation and deactivation dimensions correspond conceptually to the attachment anxiety and avoidance dimensions assessed with attachment style questionnaires [33]. Some empirical support for coding AAI-related variation dimensionally was provided by a taxometric investigation of the latent structure of the AAI; the variation underlying secure vs. dismissing states of mind was more consistent with a dimensional than a taxonic model [34]. On the basis of this finding, Roisman, Fraley, and Belsky [34] recommend that researchers use either the AAI Q-sort in their empirical analyses or State of Mind scales, which are continuous rating scales used by AAI coders to sort participants into attachment categories. Waters, Treboux, Fyffe, and Crowell [35] similarly describe advantages of using the AAI State of Mind scales for research on attachment development and stability. 1.1. Previous research on alexithymia and attachment Most studies exploring associations between alexithymia and attachment have assessed attachment styles with selfreport questionnaires; self-report scales were used to measure alexithymia, usually the 20-item Toronto Alexithymia Scale (TAS-20), which has three factor scales that assess the facets of the alexithymia construct — difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally oriented thinking (EOT) [36,37]. The majority of the studies were conducted with university student samples, but samples of alcoholic inpatients, young men with mood symptoms, and male parolees have also been investigated. In sum, all of the studies found that alexithymia was associated with insecure attachment styles — dismissing/avoidant, and/or preoccupied, and/or fearful avoidant styles — although the various categorical and dimensional questionnaires may label these styles differently [38–45]. Moreover, in a student sample, attachment style dimensions significantly improved the prediction of the TAS-20 score beyond that afforded by anxiety, depression, the domains of the FFM of personality, and temperament and character dimensions [43]. To our knowledge, only two studies have used the AAI to explore relations between alexithymia and state of mind with respect to attachment. In one study, 40 patients with systemic lupus erythematosus were administered the AAI and classified as secure, insecure (dismissing or entangled/preoccupied), or unresolved; the secure patients had significantly lower TAS20 total scores and DDF factor scale scores than the insecure and unresolved groups, but there were no differences on the DIF and EOT factor scale scores [46]. The other study was conducted with a sample comprised of 40 subjects (including patients with idiopathic spasmodic torticollis and healthy individuals); the AAI was scored with the AAI Q-sort, resulting in dimensional scores for secure, dismissing, preoccupied, and

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deactivating participants [47]. The TAS-20 and its EOT factor scale correlated negatively and significantly with the secure dimension and positively and significantly with the dismissing and deactivating dimensions; the DIF and DDF factor scales did not correlate significantly with any of the attachment dimensions. 1.2. Influence of alexithymia and attachment on close relationships On theoretical grounds, both attachment and alexithymia are assumed to influence the quality of close relationships in adulthood. Findings from several empirical studies support this assumption, although the evidence linking attachment and relationship functioning is primarily from studies that assessed attachment styles rather than attachment states of mind. For example, in a study with married couples, relationship satisfaction was associated positively with a secure attachment style in both husbands and wives, negatively with an anxious style in wives, and negatively with an avoidant style in men [48]. And in a study with couples who had recently become parents for the first or second time, insecure attachment was associated significantly with marital dissatisfaction and was especially strong in second-time parents with dismissing–avoidant attachment styles [49]. In other research with a sample of students who were currently or recently in a romantic relationship, dimensional measures of attachment anxiety and attachment avoidance correlated negatively with a relationship quality index [50]. Interestingly, the attachment style dimensions predicted relationship quality better than the domains and facets of the FFM of personality [50]. Whereas the above studies demonstrate an association between self-reported attachment styles and the quality of adult intimate relationships, studies that assessed state of mind with respect to attachment found no association with self-reports of marital satisfaction and couple communication [51] or with self-reported perceptions of intimacy, love, and ambivalence in the marital relationship [52]. Observations of interactions between husbands and wives, however, revealed some significant findings; secure–autonomous husbands were in more harmonious and less conflictual marriages than insecure husbands [51], insecure–preoccupied wives expressed less positive affect than secure wives, and insecure–dismissing wives engaged in more withdrawal than secure wives [52]. In a more recent study with 50 engaged couples, security (measured with the AAI Q-sort) was associated with higher levels of observed collaboration between partners in negotiating mild conflict, but neither the security dimension, nor the deactivation dimension of the AAI Q-sort was associated with the self-reported emotional tone of their relationship [26]. Although the discrepancy between self-report and observational findings, and the lack of consistency with results obtained in studies that assessed attachment styles, may be attributed to different methods of measurement and to differences in the constructs being measured, they suggest

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that state of mind with respect to attachment may not be a strong predictor of marital quality. To investigate the influence of alexithymia on relationship satisfaction, Yelsma and Marrow [53] administered the TAS20 to 66 married couples and assessed their marital satisfaction with the Dyadic Adjustment Scale [54]. Wives’ difficulties with identifying feelings negatively influenced their own and their husbands’ marital satisfaction; husband’s difficulties describing their feelings negatively influenced their own and their wives’ marital satisfaction; and husbands with an externally oriented thinking style were less satisfied in their marriages. In a study with a sample of university students, all of whom were involved in a romantic relationship, the TAS-20 and its three factor scales all correlated negatively with measures of relational and sexual satisfaction [55]. Hesse and Floyd [56] also found alexithymia to be inversely related to the amount of affection one gave to their closest relationship and how close they were to that person in a student sample. 1.3. The current study Our first aim of the current study was to examine relations between alexithymia and state of mind with respect to attachment in a sample of healthy pregnant women. This was a subsample of women who participated in earlier longitudinal investigations of maternal and infant attachment [57,58]. Although pregnant women are a highly-select sample, we hypothesized that the level of alexithymia would be higher in women classified as insecure than those classified as secure, and that alexithymia would be related negatively to coherence of mind, assessed with the AAI Coherence of Mind scale, which is considered “the single best dimensional predictor of security vs insecurity” [26]. Our second aim was to examine relations among alexithymia, coherence of mind, perceived relationship adjustment, and the domains of the FFM of personality. We hypothesized that alexithymia would be a stronger predictor of coherence of mind than the domains of the FFM. We hypothesized also that alexithymia and the domains of the FFM would predict perceived relationship adjustment.

2. Method 2.1. Participants The participants were a subsample of a larger sample described elsewhere [57,58]. In the larger sample, expectant mothers were recruited during the second or third trimester of pregnancy from prenatal classes at hospitals in a large urban centre or provided by the public health department for a longitudinal study of the first two years of life. A research assistant visited each class and asked for volunteers to complete the Attachment Screening Questionnaire (ASQ) [59], the purpose of which was to increase the number of women in the insecure attachment categories. Of the 680 mothers attending classes, 357 (52%) completed the ASQ.

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Based on their scores, 233 women were contacted and 139 (60%) of them agreed to participate in the study; this was a large percentage given that the women were asked for a twoyear commitment for the longitudinal investigations, which included two prenatal visits and four postnatal visits to the lab [58]. As indicated in a report of an earlier investigation with this sample, some women withdrew during prenatal data collection and others before post-partum follow-up visits [58]. Some of the mothers who withdrew did not complete the AAI and the interviews of those who withdrew later were not transcribed and scored. The women gave written voluntary informed consent to their participation as approved by the institutional research ethics board. For the current investigation, we included only those 97 mothers with complete data on all relevant measures. Independent samples t-tests and χ 2 tests were conducted to compare the characteristics of participants included in the current sample vs. those who did not complete all measures. The results of these analyses showed that non-completers were more likely to be unmarried (χ 2 (1) = 10.59, p = .001) and to have parents who divorced (χ 2 (1) = 6.06, p = .014), relative to those in the current sample. No other differences were observed. The ethno-racial composition of the sample was: Caucasian (74.2%); Asians (5.2%), African–Canadians (2.1%), Hispanics (2.1%), First Nations Canadians (1%), and “other” (14.4%). The mean age of the sample was 31.77 years, (SD = 3.65, range 20–42 years); the mean years of education was 15.73 (SD = 3.04, range 5–23 years of school). The majority of the participants were married or in a common-law relationship (97%); most were employed (91.8%) and 79.4% reported an earned annual family income exceeding CDN$50,000. 2.2. Measures Alexithymia was assessed with the self-report 20-item Toronto Alexithymia Scale (TAS-20), which is the most widely and frequently-used measure of alexithymia; it is well-validated and shows internal and retest reliability [36,37]. Each item is rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores range from 20 to 100 with higher scores indicating higher levels of alexithymia. Empirically established cut-off scores may be used to identify high, moderate, and low levels of alexithymia. The TAS-20 has three factor scales that assess: (1) Difficulty identifying feelings and distinguishing them from the bodily sensations that accompany states of emotional arousal (DIF) (7 items); (2) Difficulty describing feelings to others (DDF) (5 items); and (3) Externally-oriented style of thinking (EOT) (8 items). There is evidence that the restricted imagination facet of the alexithymia construct is measured indirectly by the EOT factor [37,60]. The Attachment Screening Questionnaire (ASQ) is derived from the Adult Attachment Questionnaire and consists of 18 statements about the respondent’s parents, relationship with

each parent during childhood, and the impact of these relationships on the person’s development [59]. Each statement is rated on a Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). Aside from 2 filler items, the scores on 8 items are added to provide a “dismissing” score and the remaining 8 items provide a “preoccupied” score. The scores are used to identify potential dismissing and preoccupied participants. The Adult Attachment Interview (AAI) is a semistructured interview with open-ended questions that ask the respondent to recollect childhood relationships with attachment figures, describe attachment-relevant experiences from early childhood, and evaluate the impact of these experiences on their development, current functioning, and parenting [61]. The interview, which takes approximately one hour to complete, is tape-recorded, transcribed, and coded using guidelines described in a manual [28]. Focusing on the qualitative aspects of the narrative rather than factual information, each transcript is rated on a series of 9-point scales, which assess experiences with each attachment figure (Experience scales) and current state of mind with respect to those experiences (State of Mind scales). The principal scale to assess “overall state of mind … with respect to adult attachment” is the Coherence of Mind (CohM) scale, which is considered “to predict, better than any other single score, a subject’s overall functioning insofar as it is related to attachment” [28]. CohM scores range from 1 to 9 and refer to the degree to which respondents discussed and evaluated their attachment-related experiences, including loss and trauma, in a reasonably consistent manner, without gaps and defenses, and gave specific, appropriate, and believable examples to support their attachment experiences [27,62]. All transcripts used in the current study had been coded in a previous study by a trained coder (DB) who had passed the standard reliability test at top level and established reliability with other laboratories; the coder was “masked” to all other measures [58]. The women received classifications of secure–autonomous, insecure– dismissing, insecure–preoccupied, or unresolved with respect to loss or abuse. Following the method used by other researchers [63], for the purpose of this study unresolved women were classified as insecure, regardless of their secondary classification. To increase statistical power to the analyses, ratings on the CohM scale were used as a continuous variable. The Dyadic Adjustment Scale (DAS) is a 32-item scale for assessing relationship quality and satisfaction among married couples or similar dyads [54]. The scale has been used in previous investigations of the influence of alexithymia or attachment styles on perceived relationship adjustment [48,49,53] and can be administered in self-report or interview formats. The DAS has four subscales that measure the respondent’s perception of consensus, satisfaction, cohesion, and affectional expression in the relationship. As in the previous investigations, we computed the total score as an overall measure of relationship adjustment. Scores of the two partners can be compared or examined individually, with higher scores reflecting a higher level of

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adjustment. Internal consistency of the DAS has been demonstrated [64]. The Revised NEO Personality Inventory (NEO PI-R) is a widely-used instrument that was designed to assess the five higher-order domains of the FFM of personality and also six lower-order facets nested within each of these five domains [65]. It is composed of 240 items presented in a 5-point Likert format ranging from 1 (strongly agree) to 5 (strongly disagree). There are two forms – self-report and informant report – the self-report version was used in the current study. Scores are computed for each domain (Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness) and for the separate facets in each domain. Due to statistical power restriction we used only domain level scale scores. 2.3. Procedure The TAS-20, DAS, and NEO PI-R were administered at a prenatal visit. The AAI was administered at a second prenatal visit. 2.4. Statistical analyses TAS-20 scores were compared between participants classified as secure–autonomous on the AAI and those classified as insecure–dismissing, insecure–preoccupied, or insecure–unresolved. Relations between the TAS-20 and the DAS, NEO PI-R domains, and CohM scale were examined using Pearson product moment correlations. Regression analyses were conducted to compare the TAS-20 total score with the three TAS-20 factor scale scores in predicting CohM scores. In addition, regression analyses were conducted to determine how the TAS-20 and the NEO PI-R compare in predicting CohM scores and DAS scores.

3. Results Mean scores and standard deviations for the TAS-20, NEO PI-R, CohM scale, and DAS are displayed in Table 1. Of the total sample, 79 (81.4%) women scored in the low alexithymia range (b52) of the TAS-20, 12 women (12.4%) in the moderate range (52-60), and 6 women (6.2%) in the high range (N60). Based on coding of the AAI transcripts, 45 women were classified as secure–autonomous, 13 women as insecure–dismissing, 15 as insecure–preoccupied, and 24 as insecure–unresolved; the last three classifications were combined to form an insecure group. The range of scores and the mean score for the CohM scale indicate adequate variability for this variable. As shown in Table 2, the insecure group of women scored significantly higher than the secure group of women on the total TAS-20 and on its DIF factor scale. Table 3 displays the pattern of correlations among the TAS-20 and its three factor scales, the CohM scale, and the DAS. The TAS-20 and its three factor scales all correlated significantly and negatively

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Table 1 Mean raw scores, standard deviations, and range of scores for the TAS-20, NEO PI-R, AAI Coherence of Mind scale, and DAS. Scale

Range

M

SD

TAS-20 Total DIF factor scale DDF factor scale EOT factor scale NEO PI-R Neuroticism NEO PI-R Extraversion NEO PI-R Openness NEO PI-R Agreeableness NEO PI-R Conscientiousness AAI Coherence of Mind DAS

23–70 7–29 5–22 9–27 46–146 68–158 84–156 97–151 75–160 1.50–8.00 81–144

42.22 14.22 11.50 16.51 86.36 116.34 119.18 123.84 121.19 4.18 116.72

10.32 5.27 4.05 4.25 19.33 17.06 17.38 11.56 19.08 1.52 10.55

TAS-20 = 20-Item Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings; DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking; NEO PI-R = Revised NEO Personality Inventory; AAI = Adult Attachment Interview; DAS = Dyadic Adjustment Scale.

with the CohM scale. The TAS-20 and its DIF and DDF factor scales also correlated negatively with the DAS, but the EOT factor was unrelated to the DAS. The CohM scale did not correlate significantly with the DAS. In Table 4 the pattern of correlations among the TAS-20, the NEO PI-R domains, the CohM scale, and the DAS is displayed. The TAS-20 correlated positively with the Neuroticism domain and negatively with the Extraversion, Openness to Experience, and Conscientiousness domains of the NEO PI-R. Conversely, the DAS correlated negatively with the Neuroticism domain and positively with the Extraversion, Openness to Experience, and Conscientiousness domains of the NEO PI-R. The Agreeableness domain did not correlate significantly with the TAS-20 or the DAS. The CohM scale did not correlate significantly with any of the domains of the NEO PI-R. 3.1. Regression analyses The results of the regression analyses examining alexithymia as a predictor of coherence of mind are presented in Table 5. In the first analysis (Model 1) we entered the three TAS-20 factor scales as a block; in the second analysis (Model 2) we entered Table 2 Differences in mean TAS-20 total and factor scale scores between insecure (dismissing, preoccupied, and unresolved) and secure AAI categories of attachment. Insecure (n = 52)

TAS-20 Total TAS-20 DIF TAS-20 DDF TAS-20 EOT

Secure (n = 45)

M

SD

M

SD

44.79 15.56 11.98 17.25

11.00 5.53 4.10 4.36

39.24 12.67 10.93 15.64

8.67 4.54 3.97 4.00

t(95)

3.16⁎⁎ 3.32⁎⁎ 1.05 1.21

TAS-20 = Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings; DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking; AAI = Adult Attachment Interview. ⁎⁎ p b .01.

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Table 3 Inter-correlations among the TAS-20, DAS, and AAI Coherence of Mind scale.

1. 2. 3. 4. 5. 6.

TAS-20 Total TAS-20 DIF TAS-20 DDF TAS-20 EOT DAS AAI Coherence of Mind

1

2

3

.83*** .83*** .61*** −.27** −.32**

.62*** .17 −.27** −.28**

.29** −.23* −.21*

4

5

order, the Openness to Experience domain of the NEO PI-R was a positive predictor of DAS scores (β = .27; p = .008; R 2 = .23); the TAS-20 scores entered in Step 2 did not significantly increase the predictive power.

4. Discussion −.11 −.21*

.15

DAS = Dyadic Adjustment Scale; TAS-20 = Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings; DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking; AAI = Adult Attachment Interview. * p b .05, ** p b .01, *** p b .001.

the total TAS-20. The total TAS-20 was a significant negative predictor of CohM scores (β = −.32; p = .002; R 2 = .10). The individual factor scales of the TAS-20 on their own did not significantly predict CohM scores. To determine how the TAS-20 and the five domains of the NEO PI-R compare in predicting CohM scores, we subsequently performed two hierarchical regression analyses. In the first analysis (Model 1) we entered the TAS-20 in the first step, and block entered the domains of the NEO PI-R in the second step. In the second analysis (Model 2) we reversed the order of variable entry and entered the block of NEO PI-R domains first, and the TAS-20 second. As shown in Table 6, the TAS-20 significantly predicted CohM scores whether entered in Step 1 or Step 2; the domain scales of the NEO PI-R did not contribute to the prediction. A similar procedure was used to compare the TAS-20 and the five domains of the NEO PI-R in predicting total scores on the DAS. In the first analysis (Model 1) in which the TAS-20 was entered in Step 1, the alexithymia scores emerged as a significant negative predictor of DAS scores (β = −.27; p = .007); however, when the domain scales of the NEO PI-R were entered in the second step, there was an increase in predictive power (Δ R 2 = .15; Δ F = 3.54; p = .006), which was accounted for primarily by the Openness to Experience domain (β = .27; p = .020) (see Table 7). In the second analysis (Model 2) with the variables entered in the reverse

Using a sample of healthy pregnant women, this study extended previously published studies examining relations between alexithymia and attachment, as well as studies that have investigated the associations of one or other of these constructs with perceived relationship adjustment or the domains of the FFM of personality. Our finding that women classified as insecure on the AAI were more alexithymic than women classified as secure is consistent not only with findings from two previous studies that measured attachment with the AAI [46,47], but also with multiple studies that assessed attachment styles with self-report questionnaires [38–45]. In addition, our study is the first to examine relations between alexithymia and coherence of mind, which is rated as a continuous variable and is considered “theoretically and empirically the single best indicator of AAI security” [26]. In our sample of women, TAS-20 total scores correlated negatively with the CohM scale, and in the regression analyses also predicted coherence of mind scores, whereas the five domains of personality measured with the NEO PI-R did not correlate with coherence of mind or add significantly to the prediction. The absence of significant associations between coherence of mind and the domains of the FFM of personality is interesting as previous studies have reported modest or moderate relations between the “Big Five” personality domains and measures of attachment styles. For example, in an early study with a university student sample, students who were securely attached were found to be less neurotic and more extraverted than insecurely attached students, and also more agreeable and slightly more conscientious than insecure–avoidant students [66]. In a later study also conducted with a student sample, insecure attachment styles were related positively to neuroticism and negatively to extraversion

Table 4 Correlations of the NEO PI-R domains with the TAS-20, AAI Coherence of Mind scale, and Dyadic Adjustment Scale.

1. 2. 3. 4. 5. 6. 7. 8.

TAS-20 Total NEO PI-R Neuroticism NEO PI-R Extraversion NEO PI-R Openness NEO PI-R Agreeableness NEO PI-R Conscientiousness AAI Coherence of Mind DAS

1

2

3

4

5

6

7

.42*** −.25** −.38*** .03 −.28** −.32** −.27**

−.36*** −.06 −.10 .36*** −.11 −.32**

.37*** −.04 .11 .05 .30**

.12 −.10 .19 .32**

.02 .00 .13

.04 .21*

.15

TAS-20 = 20-item Toronto Alexithymia Scale; NEO PI-R = Revised NEO Personality Inventory; AAI = Adult Attachment Interview; DAS = Dyadic Adjustment Scale. * p b .05, ** p b .01, *** p b .001.

G.J. Taylor et al. / Comprehensive Psychiatry xx (2014) xxx–xxx Table 5 Multiple regression analyses predicting AAI Coherence of Mind scores with TAS-20 total scores and factor scale scores. Scale

B

Model 1 TAS-20 DIF TAS-20 DDF TAS-20 EOT Model 2 TAS-20 Total

SEB

β

R2

95% C.I.

−0.07 0.00 −0.06

0.04 0.05 0.04

−.25 −.01 −.17

[−0.14, 0.00] [−0.10, 0.09] [−0.13, 0.01]

−0.05

0.01

−.32**

[−0.08, −0.02]

F

.11

3.73*

.10

10.43**

TAS-20 = Toronto Alexithymia Scale; DIF = Difficulty Identifying Feelings; DDF = Difficulty Describing Feelings; EOT = Externally Oriented Thinking; AAI = Adult Attachment Interview. * p b .05. ** p b .01.

and conscientiousness, but were unrelated to agreeableness; students with an insecure–avoidant style were less open to experience than secure students [50]. Moreover, in regression analyses, neuroticism and conscientiousness added significantly to relationship status (being single or in a relationship) in predicting anxious attachment, and extraversion and conscientiousness added significantly to relationship status in predicting avoidant attachment. Noftle and Shaver [50] summarized many other studies that examined relations between attachment styles and the “Big Five” personality dimensions; in most studies, secure attachment was related negatively to neuroticism, and positively to extraversion, agreeableness, and conscientiousness, whereas insecure attachment was related positively to neuroticism, and negatively to extraversion and agreeableness. In a more recent study, both the AAI (scored with the Q-sort) and a self-report measure of attachment style were administered to a sample of undergraduate university students; in regression models, the strongest personality predictors of scores on the avoidance and anxiety dimensions of the attachment style

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questionnaire were extraversion and neuroticism, respectively; the deactivating dimension of the AAI Q-sort was associated negatively with neuroticism and to a lesser extent openness to experience, and marginally with extraversion, whereas the Q-sort security dimension was marginally associated with conscientiousness and extraversion [26]. In a separate sample of engaged couples, however, none of the five dimensions of personality were uniquely associated with the AAI Q-sort security or deactivating dimensions [26]; this finding is consistent with the absence of significant associations between the FFM personality domains and AAI coherence of mind in our sample of pregnant women. In contrast to the different findings obtained with self-report vs. state of mind measures of attachment, it is noteworthy that alexithymia, which correlates in predictable ways with the domains of the FFM of personality [6], is associated with insecure attachment measured by both the AAI and self-report adult attachment questionnaires. In the current study, as in several previous studies [6], alexithymia measured with the TAS-20 was associated positively with neuroticism, negatively with extraversion, openness to experience, and conscientiousness, and was unrelated to agreeableness. In addition, both alexithymia and neuroticism were associated negatively with relationship adjustment, whereas extraversion, openness to experience, and conscientiousness were associated positively with relationship adjustment. Coherence of mind, on the other hand, was unrelated to relationship adjustment. In regression analyses, the FFM of personality was stronger than alexithymia in predicting relationship adjustment with the openness to experience domain explaining 23% of the variance in DAS scores. That is, women who scored high in openness reported being better adjusted in their marital or other close relationship.

Table 6 Multiple regression analyses predicting coherence of mind with alexithymia and the domains of the FFM of personality. β

95% C.I.

.01

−.32**

[−0.08, −0.02]

0.00 −0.01 0.01 0.00 0.00

.01 .01 .01 .01 .01

−.02 −.06 .09 −.03 −.04

[−0.02, 0.02] [−0.03, 0.02] [−0.01, 0.03] [−0.03, 0.02] [−0.02, 0.01]

Neuroticism Extraversion Openness Agreeableness Conscientiousness

−0.01 −0.01 0.02 −0.01 0.00

0.01 0.01 0.01 0.01 0.01

−.12 −.07 .21 −.04 .02

[−0.03, 0.01] [−0.03, 0.02] [0.00, 0.04] [−0.03, 0.02] [−0.02, 0.02]

TAS-20 Total

−0.04

0.02

−.30*

[−0.08, −0.01]

Scale

B

TAS-20 Total

−0.05

Neuroticism Extraversion Openness Agreeableness Conscientiousness

SEB

Model 1 Step 1 Step 2

Model 2 Step 1

Step 2 TAS-20 = 20-Item Toronto Alexithymia Scale; FFM = five-factor model. * p b .05. ** p b .01.

R2

F

R2 Δ

FΔ

.10

10.43**

–

–

.11

1.82

.01

0.19

.05

0.96

–

–

.11

1.82

.06

5.91*

8

G.J. Taylor et al. / Comprehensive Psychiatry xx (2014) xxx–xxx

Table 7 Multiple regression analyses predicting relationship adjustment with alexithymia and the domains of the FFM of personality. Scale

B

SEB

β

95% C.I.

TAS-20

−0.28

.10

−.27**

[−0.48, −0.08]

Neuroticism Extraversion Openness Agreeableness Conscientiousness

−0.11 0.07 0.16 0.07 0.08

.06 .07 .07 .09 .06

−.19 .11 .27* .08 .15

[−0.23, 0.02] [−0.06, 0.20] [0.03, 0.30] [−0.10, 0.24] [−0.03, 0.20]

Neuroticism Extraversion Openness Agreeableness Conscientiousness

−0.11 0.07 0.17 0.07 0.08

.06 .07 .06 .09 .06

−.20 .11 .27** .08 .15

[−0.23, 0.01] [−0.06, 0.20] [0.04, 0.29] [−0.10, 0.24] [−0.03, 0.19]

TAS-20

−0.02

.12

−.02

[−0.25, 0.21]

Model 1 Step 1 Step 2

Model 2 Step 1

Step 2

R2

F

R2 Δ

FΔ

.08

7.66**

–

–

.23

4.40**

.15

3.54**

.23

5.33***

–

–

.23

4.40**

.00

0.03

TAS-20 = 20-Item Toronto Alexithymia Scale; FFM = five-factor model. * p b .05. ** p b .01.

These women may be considered low in alexithymia since, as noted earlier, there is some conceptual overlap of the alexithymia construct and the openness to experience domain [6]. Indeed, the facet scales of the openness domain measured by the NEO PI-R include openness to fantasy and receptivity to one’s own inner feelings [65], which have been shown to correlate negatively with the TAS-20 in Canadian university student and community samples [6,37]. Our results may be compared with findings from several other studies. For example, with a sample of French Canadian couples, Bouchard, Lussier, and Sabourin [67] conducted regression analyses with the DAS total score as the criterion variable and scores of the domains of the FFM of personality as predictors; neuroticism was the strongest predictor of women’s marital adjustment explaining 16% of variation, with agreeableness explaining another 1% of the overall variation. For the men, however, neuroticism explained only 6% of the variation in DAS scores; openness, agreeableness, and conscientiousness added another 5%. The absence of a significant relation between coherence of mind and relationship adjustment in our study is consistent with previous studies in which AAI categorical classifications were unrelated to self-report measures of marital quality [51,52]; however, such findings contrast with Noftle and Shaver’s [50] finding that dimensional measures of attachment anxiety and attachment avoidance predicted relationship quality, whereas none of the “Big Five” domains of personality made unique, significant contributions to account for variance. The different findings are most likely explained by the distinct nature of the constructs being measured. As noted earlier, the AAI assesses state of mind with respect to attachment, whereas self-report measures of attachment style assess an individual’s conscious attitudes

and feelings regarding closeness in their current adult attachment relationship. And while one would expect measures of attachment styles to predict some of the ways adults relate to each other in their intimate relationships, as Shaver, Belsky, and Brennan [27] point out, “the AAI was originally designed to predict a child’s quality of attachment to his or her parent based on the parent’s state of mind with respect to attachment” (p. 26). As noted by others, the quality of adult attachment relationships is not explained solely by the adult’s history of relationships with parents, but involves other qualities including commitment, communication, sexual attraction, conflict resolution strategies, loneliness, and patterns of self-disclosure [25,27]. 4.1. Limitations and future research The main limitations of the study pertain to the nature of the sample. Given that the participants were, overall, young, well-educated women at a special time in their lives as they anticipated giving birth to a baby, the findings may not generalize to older or less-educated women, to women who are not pregnant, or to men. Questions may also be raised about applying the findings to highly insecure women since the non-completers in the study were more likely to be unmarried and to have parents who were divorced, and therefore likely to be insecurely attached; yet 54% of the completers were classified as insecure on the AAI. Nonetheless, the findings need to be replicated with samples of men and non-pregnant women with a wide range of ages and attachment classifications. Despite the selective nature of the sample, pregnant women are of considerable interest to psychiatry given their risk for postpartum depression, and evidence from developmental research that expectant mothers’ attachment

G.J. Taylor et al. / Comprehensive Psychiatry xx (2014) xxx–xxx

representations and mentalizing ability influence the organization of infant–mother attachment at one year of age and the mothers’ ability to “read” the emotional states of their infants [68]. Depressed mothers and mothers with insecure attachment and alexithymia are liable to have difficulty attending to their infants’ attachment needs and responding in ways that foster the development of mentalizing and affectregulating capacities in their children [14,17,18]. Moreover, there is evidence that maternal depression during infancy contributes to the prediction of depressive symptoms in children and adolescents [69]. It has been argued that individuals with higher levels of alexithymia may be unable to accurately evaluate their ability to identify and describe subjective feelings. A potential limitation of our study, therefore, was the use of a self-report scale to assess alexithymia. The percentage of pregnant women who scored in the high range of the TAS-20 (6.2%), however, was quite small, although identical to the percentage reported for women in a recent study of married couples in the U.S. [70]. Moreover, at the time our data were collected a multi-method approach to measuring alexithymia was not possible as non-self-report measures of alexithymia were either not fully validated or not yet developed. Future studies might use the Toronto Structured Interview for Alexithymia [60,71] in combination with the TAS-20. Another limitation was our reliance on the self-report DAS to assess the pregnant women’s relationship satisfaction and other aspects of relational functioning with their spouse or intimate partner. Given that two earlier studies investigating associations between attachment states of mind and marital functioning reported some differences between findings based on selfreports and those based on observations of couple’s interactions [51,52], future studies exploring associations between coherence of mind and relationship adjustment should also employ multiple methods of assessment. An additional limitation of our study is that we did not have the women’s partner’s reports of the quality of their relationship. It would be preferable in future studies to assess both partners in the relationship as there is some evidence that gender may play a role in how alexithymia may adversely affect marital quality [70], and that an individual’s marital adjustment may be influenced by the attachment status of the spouse [51,52]. Another limitation is that we were not able to examine the facet scales of the NEO PI-R in predicting coherence of mind and relationship adjustment because of the relatively small sample size and lack of statistical power; this might be done in future studies with larger samples and more statistical power. 4.2. Conclusion As anticipated, alexithymia predicted state of mind with respect to attachment, whereas the domains of the FFM of personality did not add significantly to the prediction. This finding is not surprising since alexithymia is thought to reflect a deficit in the cognitive processing and regulation

9

of emotions, capacities that develop optimally only when children have secure attachment relationships with their parents [14]. In contrast, the FFM is a descriptive model of personality structure that emerged from a lexical tradition; major personality traits, like temperament, are presumed to be biologically-based [72]. Although previous studies have found consistent and meaningful associations between attachment style questionnaires and personality trait measures [50], attachment style questionnaires assess the level of security in an adult’s current intimate relationship rather than the coherence of discourse and “state of mind” regarding childhood attachment-related experiences [26]. Thus, although there is now evidence that alexithymia is associated with insecure attachment measured dimensionally by both the AAI and attachment style questionnaires, these associations cannot be assumed to have the same meaning. A difference in meaning is further suggested by the finding in the current study that perceived relationship adjustment was unrelated to attachment state of mind assessed with the CohM scale, whereas two previous studies [48,49] reported associations between marital satisfaction and attachment dimensions measured with attachment style questionnaires. Alexithymia may be rooted in early childhood experiences, but difficulties in identifying and communicating feelings undoubtedly affect the quality of adult relationships, particularly with a spouse, as implied by the negative correlations between the TAS-20 and its DIF and DDF factor scales and the DAS. As hypothesized, relationship adjustment was also influenced by personality traits, with the openness to experience domain of the FFM emerging as the strongest predictor for our sample. Acknowledgment This research was supported by funds from the Social Sciences and Humanities Research Council of Canada awarded to Leslie Atkinson, and funds from the Ontario Mental Health Foundation awarded to Susan Goldberg and Diane Benoit. We are indebted to Susan Goldberg, one of the major contributors to the original investigations, who passed away shortly after they were completed, but whose influence is present in subsequent papers. References [1] Taylor GJ, Bagby RM. The alexithymia personality dimension. In: & Widiger TA, editor. The Oxford handbook of personality disorders. New York: Oxford University Press; 2012. p. 648-73. [2] Sifneos PE. Affect deficit and alexithymia. New Trends Exp Clin Psychiatry 1994;10:193-5. [3] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge: Cambridge University Press; 1997. [4] Nemiah JC, Sifneos PE. Affect and fantasy in patients with psychosomatic disorders. In: & Hill OW, editor. Modern trends

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