Alexithymia and the five-factor model of personality

Comprehensive Psychiatry (Official Journal of the American Psychopathological Association)

VOL.33, NO. 3

MAY/JUNE 1992

Alexithymia

and the Five-Factor Thomas

Model

of Personality

N. Wise, Lee S. Mann, and Laurel Shay

The relationship between alexithymia assessed by the Toronto Alexithymia Scale (TAS) and the five-factor model of personality measured by the NE0 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. Copyright 0 7992 by W. B. Saunders Company

T

Measures

HE PERSONALITY TRAIT of alexithymia is receiving renewed interest due to its role in substance abuse, posttraumatic stress, and reactions to medical illness.1-4 Alexithymia denotes the inability to identify and report dysphoric affects, an externally oriented concrete mode of thinking, a diminution of daydreaming, and a tendency to somatize.’ There has been surprisingly Iittle research investigating the relationship of alexithymia to other models of personality dimensions. The development of a reliable and valid psychometric measure of alexithymia, the Toronto Alexithymia Scale (TAS), allows for the systematic study of this subject.h This report investigates the relationship of alexithymia to the five-factor model of personality, a comprehensive dimensional lexical trait taxonomy.7

Alexithymia was measured dimensionally using the TAS. The TAS is a 26-item self-report instrument demonstrated to have internal consistency, good reliability and construct, and criterion validity that measures alexithymic characteristics. A global score based on the method reported by Bagby and Taylor was used. ‘I In addition, subscales from a three-factor varimax solution similar to Haviland et al. allowed alexithymia to be partitioned into three subscales*: (a) the inability to identify and report feelings; (b) minimal daydreaming and fantasy, and (c) an externally oriented analytic mode of thinking.” Reliability coefficients for each subscale were as follows: feelings, (Y= .8542, no daydreaming, cx= .6562, and analytic cognition, (Y= .4908. Alexithymia was analyzed dimensionally both as a continuous variable and using median splits. Personality was assessed using the NE0 Five-Factor inventory (FFI), a ho-item self-report questionnaire that measures five domains of personality based on a trait model of personality.‘“,‘4 The five measures are neuroticism, which denotes a propensity to experience dysphoric affects, as well as the sense of vulnerability to cope with stress (high N); extroversion, which designates an emotionallyspirited, outgo-

METHOD

Subjects The subjects for this study were psychiatric outpatients (n = 114) evaluated in consultation by the senior author (T.N.W.). For each of these individuals, a full psychiatric evaluation generated a DSM-III-R diagnosis, if presenLx Axis II categorization was not used due to low reliability of such categories,” A comparison group consisted of hospital volunteers (n = 71), who were screened for psychiatric distress, with the 30-item General Health Questionnaire (GHQ).“’ Any potential subject in the comparison group who scored 5 or more on the GHQ, i.e., suggestive of a psychiatric disorder, was omitted from this cohort. ComprehensivePsychiatry,

Vol. 33,

No. 3

(May/June),

“TAS items for the subscales are: (a) (lack of feelings) items 4. 8, 10, 14, 17, 20, 22, 25, 26; (b) (no daydreaming) items5. 15. 16, 16. 18; (c) (analyticcognition) items7. 11. 13. 24. From the Department of Pwchiatry, Fairfax Hospital. Falls Church, VA; and the Georgetown Universil) School qf Medicine, Washington, DC. Address reprint requests to Thomas N. Wise, M.D.. 3300 Gallows Rd. Falls Church, VA 22046. Copyright 0 I992 by W B. Saunders Cornpan! 0010-440X/9213303-0007$03.0010

1992: pp 147-151

147

WISE, MANN, AND SHAY

148

ing, impulsive individual (high E); openness, which refers to whether individuals value intellectual matters, are rebellious, open to new or unusual ideas and are introspective (high 0), rather than moralistic and conventionally conservative (low 0). Agreeablenessis the fourth factor that refers to a sympathetic considerate and warm style (high A). The final domain isconscientiousness, which refers to dependability, responsibility, and high aspiration levels (high C). Low conscientiousness is defined as someone who is not very reliable, and is indecisive, disorganized, and not achievement-oriented. The neuroticism and extraversion dimensions of the FFI are similar to the N and E scales of the Eysenck Personality Questionnaire (EPQ).t4 To allow gender comparisons, raw scores of the NEO-FFI were converted to T scores using normative data.15 Depressed and anxious affect were each assessed using a lOO-mm Visual Analog Scale, with greater values indicating more dysphoric affects. I6 These scales have been demonstrated to provide a valid and reliable assessment of global affect.” Statistical analyses were performed using the SPSS Statistical package.t8 Demographic and inferential statistics were used, as well as multivariate analysis by multivariant analyses of variance (MANOVA). Stepwise multiple regressions examined the collective influence of both individual personality dimensions and clinical variables on TAS score globally and the three factors of the TAS.

RESULTS

The demographic and clinical characteristics of subjects in each cohort are reported in Tables 1 to 4. The diagnostic distribution from the outpatient sample included 64 patients with affective disorders: 15 with anxiety disorders, 14 with an assortment of motivated behaviors such as sexual dysfunctions, eating disorders, and sleep disorders, one with a somatoform disorder, and 1.5 without any DSM-III-R axis I diagnosis. Since the samples were not matched for sex, three-way analyses of covariance were performed using sex, group, and alexithymia as the factors, with the effects of depression or anxiety covaried.

Table 1. Subject Characteristics

Subjects

Age

Sew* Education

Depression Anxiety (Median) (Median)

Outpatients (n = 114)

41.8 -+ 12.9 57 M 15.5 + 2.7

52.5

60.0

18.0

30.0

57 F Normal volunteers (n = 71)

y

44.7 2 17.6 22 M 14.9 k 2.4 49 F

= 5.7, P < .05.

A three-way MANOVA (group x gender x TAS) was run on the dependent personality variables (N, E, 0, A, C) covarying for the effect of depression. The interaction of group by gender by TAS was not significant, nor were the interactions of group by TAS, nor gender by TAS. The main effects of TAS, gender, and group were all significant. The main effect of the TAS score (high v low) was significant (Hotellings T2 = .3984, P < .OOOl) with univariate F tests showing significant differences on the following variables: N (F = 4.4, P < .OOOl), E (F = 28.66, P < .OOOl), 0 (F = 15.82, P < .OOOl), A (F = 5.30, P < ,023) C (F = 20.33, P < .OOOl). The main effect of group was also significant (Hotellings T2 = .0738, P < .031), with significant univariant tests for the following dimensions: N (F = 8.02, P < .005), E (F = 7.367, P < .007). The main effect of gender was significant (Hotellings T2 = .1562, P < .OOOl), with the following dimensions significantly different on univariant tests: N (F = 5.17, P < .024), A (F = 9.33, P < .003), C (F = 4.46, P < ,036). The significantly higher scores by women on the FFI dimensions of neuroticism, agreeableness, and conscientiousness are consistent with normative data differences in both the NEOFFI and other inventories.13Jg Thus the subjects were retained in an outpatient group and comparison group for separate regression analysis. Partial correlation coefficients controlling for depression between TAS and its subfactors and the NEO-FFI dimensions are shown in Table 4. Finally, a series of stepwise multiple regression analyses were run attempting to predict global TAS score and its three constituent factors based on the independent variables of gender, N, E, 0, A, C, and depressed mood (Table 5). The results for the volunteer group were as follows: the FFI dimensions of N, E, and 0 explained 38.1% of the variance in predicting the global TAS scores by contributing 3.6%, 26.4%, and 8.3%, respectively. For the feelings subfactor, N predicted 27.5% of the variance. Low openness predicted 22.2% of the analytic subfactor. In predicting the daydreaming factor for the volunteer subgroup, N (5.8%) 0 (14.4%) and depression (5.3%) explained a total of 25.5% of the variance. For the outpatient cohort, the models were as

ALEXITHYMIA

AND FIVE-FACTOR MODEL

149

Table 2. NEO-FFI Profiles PsychiatricOutpatients NEO-FFI Variable N

Normal Controls

HighTAS Male

Female

48.6 5 13.5

Female

61.5 + 11.8

67.5 + 10.2

40.8 t 6.3

Male 47.7 t 11.5

HighTAS

Low TAS Male

LowTAS Female

43.4 r 10.1

Male

Female

46.5 f 8.6

56.1 f 10.4 45.7 -t 12.0

E

50.3 + 9.5

53.3 c 11.3

40.9 + 11.2

39.9 + 12.9

56.5 -’ 9.6

58.3 k 8.1

50.7 f 7.1

0

58.4 + 8.9

57.6 + 10.3

48.4 -’ 10.4

50.4 t 10.1

52.1 + 12.4

55.4 + 11.1

45.1 t 11.4

51.9 r 11.7

A

45.0 k 10.6

54.6 ? 11.09

39.4 f 14.4

44.4 + 14.9

47.1 c 10.3

52.5 k 12.5

45.1 2 4.2

48.4 + 9.3

C

46.0 f 13.4

54.3 f. 10.8

38.5 + 13.5

41.8 k 13.2

50.9 2 7.9

54.0 -+ 8.0

44.4 ? 9.8

45.7 + 11.1

N = 34

N = 33

N=9

N = 19

N = 23

N = 24

N = 13

N = 30

NOTE. Values are T scores based on 1991 normative population.

follows: 57.1% of the global TAS was explained by N (35.1%) E (5.7%) and 0 (16.3%). N (40.3%) and 0 (4.6%) predicted 44.6% of the variance for the feeling subfactor, while 0 predicted 16.5% of the variance for the analytic subfactor. For the daydreaming factor, 0 (4.4%) and A (2.7%) combined to account for 7.1% of the explained variance. DISCUSSION

Both alexithymia and the five-factor model of personality have been used in psychosomatic research. Individuals high in neuroticism report more physical symptoms and seek medical care to a greater extent than those with lower neuroticism.*OLikewise, alexithymic characteristics are believed to be found in more somatically focused individuals.” It is thus tempting to consider alexithymia as an overlapping construct with neuroticism. Our data suggest that the variance explained by the NEO-FFI for global TAS scores is primarily from the domains of neuroticism, extroversion, and openness. The magnitude of the explained variance from each dimension differed between the two study groups. In the patient cohort, neuroticism accounted for most of the variance, whereas extroversion was most significant in the regression model for the normative group. The ele-

Subjects

GlobalTAS”

Factor 1t

Factor2$

Factor34

Outpatients

67.8 + 12.1

20.0 + 6.4

10.1 + 2.7

11.0 + 3.2

Normal

Depressed Mood N

volunteers

60.8 + 10.5

25.0 t 7.4

9.9 t 2.5

*Covaried for depression (F = 40.7. P < ,001).

11.2 5 3.4

Main effect:

group (NS). for depression (F = 49.1, P < .OOl).

group (F = 4.6, P i

E

0

A

C

TAS

.3578t

-.4789$

-.3802*

-.0805

-.3089t

Feelings

,475lt

-.2480*

-.0330

-.1901

-.3162t

Analytic Daydream

NOTE. Values are mean *SD.

Kovaried

Table 4. Partial Correlation Coefficients, Covarying for

Controls (n = 71)

Table 3. TAS and Factor Scores

tcovaried

vated neuroticism of the patient group when compared with the volunteers could be a state effect, as these were patients experiencing sufficient emotional distress to seek psychiatric consultation. In the volunteer cohort, negative extroversion, ie, introversion, explained the greatest amount of variance in predicting global TAS. These findings support previous studies. Using the EPQ in a group of college students, Parker et al. found that alexithymia was strongly correlated with introversion, but more modestly with neuroticism.27 In a sample of chronic pain patients, Mendelson also found introversion to significantly predict alexithymia, as measured by a Minnesota Multiphasic Personality Inventory (MMPI) subscale. 23In general, extroversion has been the dimension that best discriminates between patient and control subjects.z4,‘5 The predictive significance of low openness in alexithymia supports the convergent validity of the two constructs, since low openness is denoted by the rejection of daydreaming and an inactive fantasy life.z6 The regression models using the TAS subfactors further support the above find-

Main effect:

.05).

for depression (NS). Main effect: group (NS).

ICovaried for depression (NS). Main effect: group (NS).

.1212 -.3556t

-.2729*

- .4734$

.1278

.0829

-.0911

-.3971*

.I608

.0881

Outpatients (n = 114) TAS

.4938*

-.5412$

-.5113$

-.1854*

-.4014*

Feelings

.5441*

-.4534*

-.32357$

-.1940*

-.4123*

.03977

-.04988

-.3928$

-.04721

-.0911

-.0949

-.2133*

.1523

Analytic Daydream *P < .05. tP < .Ol. SP

< ,001.

-.1147

.1201

150

WISE,

Table 5. Predictors of TAS and Subscales; Stepwise Multiple Regression Independent Variable

Global TAS p

Feelings P

Analytic P

Daydream P

Comparison group (n = 71) N

.2383t

E

- .3584*

0

-.3220t

.3124* -.7227 .9999

.9999 .9841 - .4722*

-.2618* .7061 -.3941t

A

.6737

.8961

C

.6698

.9022x

Gender

.6793

.9513

.9640

.9158

Depression

.5960

.7117

.9999

.7117

.5933*

.9591

.89681

.6567

,959

.9128

Outpatient

cohort

N

.9887 1.000

.8844 .9021

(n = 114) .3520*

E

-.2964*

0

-.3902*

-.2290t

-.4154x

A

.6542

.8968

.9589

.9128 -.1940*

C

.6175

.7468

.9802

.8533

Gender

.6539

.9348

.9989

.9070

Depression

.4824

.6788

.9789

.9419

*P < .a001 tP < ,001. SP

< .Ol.

ings. Although Parker et al. reported that alexithymia differs from the cognitive distortions of depression as measured by the Beck Depression Inventory, other data suggest that depressed mood can potentiate alexithymia.27 In the present study, correlations between FFI dimensions and TAS were maintained when covarying for depressed mood. That depression significantly predicted the TAS subfactor of inability to daydream suggests this element of alexithymia is sensitive to dysphoric state effects. Anxiety has also been suggested as an affect that can modify alexithymia, but the robust correlations between anxiety and depression in our population do not allow partitioning between these specific affective states.12 Alexithymia is the inability to report and identify dysphoric feelings despite the fact that the person is distressed. However, neuroticism denotes the disposition for an individual to be quickly aroused and readily able to identify anxiety, depression, and hostility. Thus the significant correlations between TAS and N could be due to the subjective sense of vulnerability and distress. The alexithymic subject reports but cannot specifically identify these feelings. The mechanisms for such differences are not clear, but there may be different psychotherapeutic strategies for those high in neuroticism in contrast to the highly alexithymic. The clinician evaluating individuals high in N

MANN,

AND

SHAY

can directly identify and empathize with the specific affect and treat the depression or anxiety. However, distressed alexithymic individuals possess abnormal illness beliefs by endorsing a greater disease conviction that their somatic complaints are based on organic pathology, rather than on emotional distress.28 Thus the alexithymic individual will not be able to recognize such specific affects and, instead, ruminate about somatic complaints. Insight-oriented strategies seem ineffective in working with these individuals.29 The alexithymic patient may require a cognitive-behavioral paradigm such as suggested by Barsky et al. for hypochondriasis.30 The data also suggest that alexithymic individuals are more introverted and less socially comfortable. Such introverted individuals have difficulty communicating their feelings, which may interpersonally isolate them.14 Their inability to use social supports may be a further factor in propelling these individuals to medical systems. This also explains the report by Horton et al. that alexithymic individuals are unable to find solace from social support when distressed. Introversion in the FFI further denotes an emotional blandness that correlates with the alexithymic characteristic of inability to identify and describe feelings.31 Hence, any dyadic psychotherapy may become more difficult as a result of the reported interpersonal limitations.29 The significant correlation between alexithymia and low conscientiousness appears not to be a function of mood, since the partial correlational coefficients remained significant after covarying for mood.32 It does reaffirm Acklin’s data that alexithymic subjects were vacillating and ineffective in making decisions.33 The present data support the validity of alexithymia as a unique personality construct. Although alexithymia overlaps with various dimensions of the five-factor model of personality, as well as affective states, these variables explain only a portion of the variance. Critics of alexithymia suggest it to be another label for the obsessional personality style. Our previous work has supported Nemiah’s contention that alexithymia is not an obsessional defense, but is a trait that differs from the obsessional style.34 A previous report also found alexithymia not to be related to the psychometric assessment of denia1.27

ALEXITHYMIA

AND FIVE-FACTOR MODEL

151

This report extends previous studies by further discriminant validation of alexithymia as a unique personality trait that parsimoniously describes individuals who cannot report and identify emotions, and who are socially introverted, less organized, and less motivated. Alexithymia is not a synonym for the neurotic introvert. Furthermore, alexithymia may be augmented by anxiety and depression. Future re-

search must be directed toward identifying therapeutic approaches for such individuals, since traditional insight-oriented psychotherapeutic strategies may not be effective. ACKNOWLEDGMENT The authors gratefully acknowledge the advice and encouragement of Drs. Graham .I. Taylor, R. Michael Bagby, Paul T. Costa, and Robert McCrae.

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