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Alexithymia in Chinese chronic obstructive pulmonary disease (COPD) patients: The prevalence and related factors of alexithymia
Psychiatry Research 198 (2012) 274–278
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Alexithymia in Chinese chronic obstructive pulmonary disease (COPD) patients: The prevalence and related factors of alexithymia Dai Han a,⁎, Yuqin Zhang b, Bo Li c, Zhifang Lv c, Xia Huo d, Yan Li d, Ying Zhong e a
Psychiatry Department of Huashan Hospital, Fudan University, Shanghai, PR China, 200040 Department of Neurology, Anqing City Municipal Hospital, Anqing, Anhui, PR China, 246001 Department of Respiratory, Anqing City Municipal Hospital, Anqing, Anhui, PR China, 246001 d Analytical Cytology Laboratory and the Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, PR China, 515031 e Department of Medicine, Hu Zhou Third People Hospital, Huzhou, Zhejiang, PR China, 313000 b c
a r t i c l e
i n f o
Article history: Received 17 November 2010 Received in revised form 17 July 2011 Accepted 24 October 2011 Keywords: chronic obstructive pulmonary disease (COPD) forced expiratory volume in one second percentage of predicted (FEV1% predicted) socio-demographic factors 20-item Toronto Alexithymia Scale (TAS-20)
a b s t r a c t In this study, 53 Chinese COPD moderate outpatients and 50 health controls, matched for age, family income and education level, were recruited to assess the prevalence of Alexithymia and its relationship to sociodemographic factors and pulmonary function. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS–20). The patients’ socio-demographic variables and the forced expiratory volume in one second percentage of predicted (FEV1% predicted) were recorded. The results indicated that alexithymia was significantly more common in the Chinese COPD patients than in controls. Male patients presented higher TAS-20 total scores and externally oriented thinking (EOT) scores than the females. Elder age and higher family income were connected with the patients’ lower TAS-20 indexes (except for difficulty identify feeling [DIF]). All the TAS-20 indexes were negatively associated with FEV1% predicted. These findings suggested that, in the management of COPD, alexithymia feature should not be ignored and the appropriate psychotherapeutic treatment for Alexithymia should be applied. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Alexithymia is a personality trait characterized by poor ability to recognize and verbalize internal emotions and thoughts tend to be fixated on external environment. The term “alexithymia” was originally introduced by Sifneos in 1970s, when he described the emotional deficits among psychosomatic patients (Sifneos, 1973). Over the past three decades the personality variable of alexithymia has come to be defined by the following salient features: difficulties in identifying and describing feelings to other people and distinguishing between feelings and the bodily sensations accompanying emotional arousal; as well constricted imagine processes with paucity of fantasies; and a stimulus-bound, externally oriented cognitive style (Taylor et al., 1997). The prevalence of these cognitive and affective characteristics oscillates in a range of 8-19% in general population, but it can be higher in individuals with a number of medical conditions (Rybakowski et al., 1988; Bourke et al., 1992; Parker et al., 1993; Schmidt et al., 1993; de Groot et al., 1995; Porcelli et al., 1999; Mennin et al., 2005; Turk et al., 2005), especially in patients with chronic somatic diseases, including hypertension (Todarello et al., 1995; Jula et al., 1999), Type 1 diabetes (Leda et al., 2009) and
⁎ Corresponding author: Tel.: + 86 13681642796. E-mail addresses: [email protected], [email protected] (D. Han). 0165-1781/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.10.018
psoriasis (Richards et al., 2005). As for chronic respiratory disease, studies’ results showed a higher incidence of alexithymia among NFA patients than in general population (Dirks et al., 1981; Serrano et al., 2006). However, limited information is available in alexitymic patients with COPD. COPD is a major cause of morbidity and mortality worldwide. Evidence suggests that the mortality rate is increasing (Pauwels et al., 2001). The World Health Organization has estimated that by 2020, COPD would be the third-leading cause of death and the fifthleading cause of disability worldwide (Murray and Lopez, 1997). China is expected to bear the brunt of this disabling disease. Indeed, COPD is currently the fourth leading cause of death in China's cities and the first leading cause in rural areas (Ministry of Public Health of China, 1998). COPD is a chronic respiratory disease with multiple complications, characterized by chronic airflow limitation,a range of pathological changes in the lung, some significant extrapulmonary effects (especially cigarette smoking), and important comorbidities that may contribute to the severity of the disease in individual patients (Klaus. et al., 2007; Anthonisen et al., 2002). COPD is associated with elevated levels of psychological distress, with 6-80% of patients suffering from anxiety and depressive symptoms, and up to 55% suffering from actual psychiatric disorders (Yohannes et al., 2009). These psychological distresses may have been associated with the severity of COPD, such as increases in the frequency and duration of hospitalizations (Dahlen and Janson,
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2002; Ng et al., 2007). The association between the psychological symptoms and COPD need investigation. Currently most studies are focus on depression and anxiety. To date only one study has investigated alexithymia in COPD, which showed the prevalence of Alexithymia in Greek COPD outpatietns, contrary to what has been observed in patients with other chronic respiratory diseases seems to be lower (Tselebis et al., 2010). However, the lack of a control group may limit the generalisability of this study's results. The present study was designed to evaluate the prevalence of alexithymia in Chinese moderate COPD outpatients and clarify the relationships of overall alexithymia and its facets with patients’ socio-demographic variables and pulmonary function (as one indicator of disease severity), as well supply useful information to improve the management of COPD. 2. Method 2.1. Participants In the period of November in 2008 to May 2010, all outpatients with moderate COPD, attending the chest clinics at Anqing City Municipal Hospital (Anhui province, China) for regular follow-up examination were recruited. They all met the diagnostic criteria defined by Global Initiative for moderate COPD, which is worsening airflow limitation (FEV1/FVC b 0.70; 50% b FEV1 b 80% predicted), with shortness of breath typically developing on exertion and cough and sputum production sometimes also present (Klaus et al., 2007). In the mean time, from the list of a group of healthy volunteers, who visited Anqing City Municipal Hospital for physical examination in the same period and matched with the recruited COPD patients about age, gender, education status and family economic condition, subjects of the control group were randomly selected. All participants must have received at least 9-year education and can smoothly read, understand and complete the questionnaires personally. Each participant's written informed consent must be obtained after study procedures had been fully explained. Participants were excluded for any evidence of other major somatic and emotional illness (such as heart and cerebrovascular disease, cancer, schizophrenia and major depression) or consuming any psychotropic medications within the six months before the study. All protocols were approved by the Ethics Committee of Hu Zhou Municipality Science and Technology Bureau. 2.2. Measures 2.2.1. Socio-demographic assessment A socio-demographic questionnaire was designed to get the information about the subjects’ age, gender, family income and education level. COPD patients and healthy volunteers were asked to complete this demographic questionnaire firstly. 2.2.2. Psychological assessment Alexithymia was assessed with the Chinese version of TAS-20, which.was introduced by Bagby in, 1994, and is the most widely used and presumably the most carefully validated self-reported scale for measuring alexithymia (Bagby et al., 1994). This scale has been translated in Chinese language. The reliability and validity of the Chinese version of TAS-20 have been well demonstrated (YI et al., 2003). The items in this scale are rated on a 5-point scale ranging from “totally disagree” (scored 1) to “totally agree” (scored 5), with the total score ranging from 20 to 100. The higher score is associated with the worse condition of alexithymia. The scale has a three-factor structure: Factor l assesses the capacity to identify feelings and to distinguish between the feelings and the bodily sensations of emotional arousal (DIF); Factor 2 reflects the inability to communicate feelings to other people (DDF); Factor 3 assesses externallyoriented thinking (EOT) (Cinzia et al., 1996). According to the recommendation by the developers of this scale, the total score >60 are defined as alexithymic cases (Bagby and Taylor, 1997). 2.2.3. Physical measures For COPD patients, spirometric evaluation was performed by an experienced certified technician at the lung function laboratory of Anqing City Municipal Hospital. Each patient's FEV1% predicted were recorded. 2.3. Data analysis Descriptive statistics and percentages were computed for the study sample on socio-demographic variables, TAS-20 total score, and three factor score. Data normality was assessed by the Kolmogorov–Smirnov test. Data showing a normal distribution are summarized as means ± SD, and data showing a non-normal distribution are summarized as medians. Independent-samples t-tests were used to determine the differences of socio-demographic variables (except for gender) between the COPD group and the control group in order to ensure the demographic condition of the COPD group is same with the control. Chi-square test was used to determine the gender distribution of the two groups. Then on the base of equal variance, the differences of TAS-20 total score and three factor score between the COPD group and the control group were
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determined using independent-sample t-test. Finally, the relationship of TAS-20 indexes with the socio-demographic variables and FEV1% predicted were analyzed using bivariate correlation analysis. All the analyses were conducted with SPSS statistical software version 13.0 (SPSS, Inc., Chicago, IL, USA) and EXCEL. Differences were considered significant at 2-sided p-value of 0.05 or highly significant at p-values of 0.01.
3. Results At the end of the study, data of the 103 eligible samples (53 patients and 50 healthy controls) were analyzed. The demographic variables and the alexithymic prevalence in the whole eligible study subjects were summarized by the group in Table 1. The two groups did not differ in terms of age, gender, family income and education level. However, the proportion of patients with alexithymia was significantly higher in the COPD group (42%) than the control group (26%). The results of the comparison between the two groups’ TAS-20 indexes are presented in Table 2. Compared with the control group, the COPD group's mean TAS-20 total score and DDF score were significantly higher (p b 0.05). Mean DIF score was highly significantly higher in the COPD group than the control group (p b 0.01). However, the data can not support that there is a notable difference between the EOT score of two groups. Table 3 presents the summary of TAS-20 total and factor score by gender. The t-test analytic result showed that TAS-20 total score, DIF score, DDF score and EOT score were higher in male patients than in female patients. However, only the differences of TAS-20 total score and EOT score between female and male patients had statistical significance. As shown in Table 4, none significant association was found between patients’ TAS-20 measurements and education level. However, TAS-20 total score negatively associated with patients’ age and family income. For three factor scores, except for DIF score, lower DDF score and EOT score were significantly associated with older age and higher family income. In COPD group, a negative association was observed between patients’ FEV1% predicted and TAS-20 total score (pb0.05). Furthermore,.FEV1% predicted (67.58±7.27) are negatively correlated with three factor scores, especially for DDF and EOT score (pb0.01).
4. Discussion COPD is an important health problem that affects 80 million people worldwide (World Health Organization, 2010). The psychological morbidities have various impacts on the patients with COPD and are currently increasingly concerned. It would be theoretically and clinically important to assess if alexithymia plays a role in COPD. Thus alexithymia and related factors in COPD patients were explored in the present study. The result supported that the prevalence of alexithymia is higher in COPD patients, especially in male COPD patients, in comparation with the health control subjects. Moreover the notable association of alexithymia and its facets with age, gender, financial situation and lung function were observed in COPD patients in the present study. Table 1 Summary of Demographic variables and alexithymia prevalence by group.
Gender (M/F) Age (years) Family income (10,000 /year) Years of education (years) Alexithymic prevalence (%)
COPD group N = 53
Control group N = 50
P-value
33/20 61.36 ± 8.01 5.94 ± 2.70 13.72 ± 2.66 42
27/23 60.44 ± 7.52 5.45 ±2.40 13.52 ± 2.41 26
>0.05 > 0.05 > 0.05 > 0.05 b 0.05
⁎ Data are presented as percentage/ratio or mean ± SD.
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Table 2 Comparison of TAS-20 indexes between groups.
TAS-20 TAS-20 TAS-20 TAS-20
DIF score DDF score EOT score total score
Table 4 Correlations of TAS-20 indexes to age, income, years of education, FEV1% predicted.
COPD group
Control group
P-value
18.36 ± 4.36 14.17 ± 2.84 24.80 ± 3.65 57.18 ± 8.75
15.90 ± 4.33 13.10 ± 2.53 24.42 ± 3.67 53.42 ± 8.98.
b0.01 b0.05 >0.05 b0.05
⁎ Data are presented as mean ± SD.
Table 3 Summary of TAS-20 indexes by gender.
DIF score DDF score EOT score total score
Male
Female
P-value
17.86 ± 4.53 13.90 ± 2.89 25.23 ± 3.69 56.85 ± 9.31
16.20 ± 4.32 13.30 ± 2.49 23.76 ± 3.46 53.26 ± 8.24
>0.05 >0.05 b0.05 b0.05
⁎ Data are presented as mean ± SD.
Age
Family income
The current study indicated that the prevalence of alexithymia in Chinese COPD patients (42%) were significantly higher than the health subjects (26%). Interestingly the prevalence of alexithymia in the control subjects seems globally higher than those known from the surveys on general population in other countries, which were all measured by TAS-20 (Salminen et al., 1999; Franz et al., 2007). This could be explained by the ethnocultural differences. Kenneth (Dion, 1996) reported that native Chinese language speakers scored consistently higher than native English and European language speakers on the overall TAS-20 and three factors. He supposed that these ethno linguistic differences may reflect sociocultural influences making ethnic Chinese individuals likely to be less psychologically minded and more somatically oriented versus their emotions than those from Western ethnocultural traditions. In the present study, COPD patients’ TAS-20 factor scores (except for EOT) were consistently higher than the control subjects, especially in DIF, which suggested that COPD individuals tend to show a reduction in, or absence of, symbolic thought, a limited ability to fantasies and difficulty to express their feelings in words and identifying physical sensations, such as pain or dyspnoea. In various chronic somatic disorders, presence of alexithymia, including disturbance of interoceptive awareness may contribute to maladaptive behaviors (Nemiah and Sifneos, 1970; Bourke et al., 1992). Alexithymic characteristics could contribute to a 5-year delay between symptom onset and clinical consultation in bulimia nervosa patients (Johnson et al., 1984). In patients with asthma, alexithymic patients can not timely and clearly perceive dyspnoea and then underestimate the severity of an asthma exacerbation, and increase the risk of developing a fatal or near-fatal asthma attack. (Serrano et al., 2006) Alexithymic patients tend to report more symptomatology in absence of the illness, perhaps in lieu of emotional complaints (Paez et al., 1995). Significant positive correlations have been reported between alexithymia and measures of somatization and hypochondriasis (Bagby et al., 1986; Deary et al., 1997). Alexithymia has also been found to be positively associated with reports of experimental and clinical pain (Dalton et al., 1989; Nyklicek and Vingerhoets, 2000). Given these findings, it is reasonable to suppose that alexithymic COPD individuals could not clearly and timely perceive their real condition, and even underestimate the disease severity and then delay beginning recommended treatment. Even though they try to turn to doctors, their insufficiency in expressing their feelings in words may frequently cause the inaccurate diagnosis and result in unsuitable treatment. The study by Tselebis presented a strong association between alexithymia, depression and anxiety levels in COPD outpatients (Tselebis et al., 2010). The study in patients with severe asthma identified that alexithymia had a significant negative correlation with quality of life
TAS-20 TAS-20 TAS-20 TAS-20
TAS-20 TAS-20 TAS-20 DIF score DDF score EOT score
Years of education
FEV1% predicted
Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N
TAS-20 total score
− 0.097
− 0.276⁎⁎ − 0.276⁎⁎ − 0.233⁎
0.330 103 − 0.160
0.005 0.005 0.018 103 103 103 ⁎⁎ ⁎⁎ − 0.346 − 0.299 − 0.296⁎
0.106 103 0.133
0.000 103 0.123
0.180 103 − 0.298⁎
0.215 0.086 0.093 103 103 103 − 0.533⁎⁎ − 0.368⁎⁎ − 0.450⁎
0.030 53
0.000 53
0.002 103 0.170
0.007 53
0.002 103 0.166
0.001 53
⁎ Correlation is significant at the 0.05 level (2-tailed). ⁎⁎ Correlation is significant at the 0.01 level (2-tailed).
(Chugg et al., 2009). These findings supported the assumption that alexithymia should negatively affect the condition of COPD patients. Given the high rate of alexithymia in COPD patients, medical professional are obligated to pay more attention to alexithymic patients and adopt the appropriate treatment. Therefore, the characteristics of alexithymic COPD patients and its relationship with COPD symptoms should be addressed for utilizing various therapies appropriately. The present study showed that male COPD patients were significantly higher than female COPD patients on TAS-20 total score. This gender tendency has also been generally observed in alexithymia studies in past decades (Richard et al., 1998; Pirkko et al., 2001; Kirsi et al., 2006). As for TAS-20 factor scores, we found that only EOT score was significantly higher in male COPD patients than in female COPD patients, suggested that it was externally oriented thinking predisposing male patients to alexithymia. We also found that there was a negative association between alexithymia and age in COPD patients, similarly to the study by Moriguchi and coworkers’ research in Japan arriving to the negative relationship between alexithymia and age (Moriguchi et al., 2007). However a few studies positively related alexithymia to older age in general population (Pasini et al., 1992; Richard et al., 1998). As regards the rest socio-demographic variables, the present result of COPD patients were in agreement with previous findings in general population relating alexithymia to lower levels of household income (Franz et al., 2007; Pirkko et al., 2001), but in disagreement with the relevant studies in general population relating alexithymia to lower levels of education (Franz et al., 2007; Parker et al., 2003), no trend was found between severity of alexithymia and education level in COPD subjects of the current study. An alternative explanation for this disagreement is that most of these older Chinese patients have experienced a special historical era (China Cultural Revolution) in their school ages, when students no need study in the school or university before they graduated, thus it is very difficult to evaluate their real educational level. On the level of TAS-20 factor scores, lower DDF and EOT factor score were associated with older age, as well as ideal financial situation. However, DIF score showed relatively stable and did not relate with any social-demographic variable. The findings above-mentioned suggested that DDF and EOT factor possibly represented the special aspects of alexithymia influenced by current socialdemographic factors or primary medical illness. On the contrary, DIF factor might be a life-long personality feature of alexithymia determined by biological or genetic factor. Wise suggested in 1990 that it was possible to differentiate between “primary” and “secondary” alexithymia (Wise et al., 1990). Primary alexithymia was described as a life-long, dispositional factor that could lead to psychosomatic illness. Secondary alexithymia, however, was seen as a result from a primary medical
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illness or other stress. In one sense, our conclusion is consistent with the view of “primary” and “secondary” alexithymia. Another notable finding of this study was that we observed a strong negative correlation of FEV1% predicted with the total score and the three factor scores of TAS-20. On the base of the abovementioned two points, it can be concluded that FEV1% predicted represents pulmonary function level and is one indicator of disease severity, which confirm that alexithymia is associated with the process of COPD, which is coincided with previous findings that patients with higher TAS-20 scores had a significant correlation with poorer asthma symptom control (Chugg, et al., 2009). Therefore alexithymia's influence should be considered when the clinicians try to find the better management of COPD. A recent research by Vanheule and co-workers observed that classic psychotherapy approaches are not sufficient to treat alexithymia appropriately (Vanheule, et al., 2011). A study in coronary heart disease (CHD) patients indicated that group psychotherapy was able to decrease alexithymia and a reduction in the degree of alexithymia seemed to favorably influence the clinical course of CHD (Beresnevaite, 2000). Research has proved that psychodynamic group therapy significantly reduced psychopathological distress and alexithymic features in alexithymic patients with various physical diseases and psychological illnesses (Grabe et al., 2008). 5. Conclusion This study is limited by the absence of the subjects’ condition of smoking and other emotional features, including depression and anxiety, in the analysis of the relationship between alexithymia and various factors in patients with COPD. In conclusion, the present study confirmed that the prevalence of alexithymia is higher in Chinese outpatients with moderate COPD, who can not effectively communicate their feelings to other people and tend to externallyoriented think. In the management of COPD, alexithymia features of individual should not be ignored. To facilitate the remission, COPD patients require not only medical treatment but also appropriate psychotherapy for alexithymia. Acknowledgments This research was funded by Huzhou Municipal Science and Technology Project Foundation (2008YS36). We also thank the members of the respiratory department of Anqing City Municipal Hospital and the lung function laboratory of Anqing City Municipal Hospital for technical assistance, as well as Xia Huo PhD and Yan Li PhD for editing this manuscript. References Anthonisen, N.R., Connett, J.E., Murray, R.P., for the Lung Health Study Research Group, 2002. Smoking and lung function of Lung Health Study participants after 11 years. American Journal of Respiratory and Critical Care Medicine 166, 675–679. Bagby, M., Taylor, G., 1997. Construct validation. In: Taylor, G. (Ed.), Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. UK, Cambridge University Press, Cambridge, pp. 46–66. Bagby, R.M., Taylor, G.J., Ryan, D.P., 1986. Toronto Alexithymia Scale: relationship with personality and psychopathology measures. Psychotherapy and Psychosomatics 45, 207–215. Bagby, R.M., Parker, J.D.A., Taylor, G.J., 1994. The 20-item Toronto Alexithymia Scale, I: item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 23–32. Beresnevaite, M., 2000. Exploring the benefits of group psychotherapy in reducing alexithymia in coronary heart disease patients: a preliminary study. Psychotherapy and Psychosomatic 69, 117–122. Bourke, M.P., Taylor, G.J., Parker, J.D., Bagby, R.M., 1992. Alexithymia in women with anorexia nervosa: a preliminary investigation. The British Journal of Psychiatry 161, 240–243. Chugg, K., Barton, C., Antic, R., Crockett, A., 2009. The impact of alexithymia on asthma patient management and communication with health care providers: a pilot study. The Journal of Asthma 46, 126–129.
277
Cinzia, B., Graeme, T., James, P., Sergio, B., Virginia, B., Eugenio, A., Ida, A., Antonio, B., Franco, G., Maurizio, B., Orlando, T., Camilla, C., Simone, V., Constanzo, G., Giordano, I., 1996. Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study. Journal of Psychosomatic Research 41, 551–559. Dahlen, I., Janson, C., 2002. Anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease. Chest 122, 1633–1637. Dalton, J.A., Feuerstein, M., Fear, 1989. Alexithymia, and cancer pain. Pain 38, 159–170. de Groot, J.M., Rodin, G., Olmsted, M.P., 1995. Alexithymia, depression, and treatment outcome in bulimia nervosa. Comprehensive Psychiatry 36, 53–60. Deary, I.J., Scott, S., Wilson, J.A., 1997. Neuroticism, alexithymia and medically unexplained symptoms. Personality and Individual Differences 22, 551–564. Dion, Kenneth L., 1996. Ethnolinguistic correlates of alexithymia: Toward a cultural perspective. Journal of Psychosomatic Research 41, 531–539. Dirks, J.F., Robinson, S., Dirks, D.L., 1981. Alexithymia and the psychomaintenance of bronchial asthma. Psychotherapy and Psychosomatics 36, 63–71. Franz, M., Popp, K., Schaefer, R., Sitte, W., Schneider, C., Hardt, J., Decker, O., Braehler, E., 2007. Alexithymia in the German general population. Social Psychiatry and Psychiatric Epidemiology 43, 54–62. Grabe, H.J., Frommer, J., Ankerhold, A., Ulrich, C., Groger, R., Franke, G.H., Barnow, S., Freyberger, H.J., Spitzer, C., 2008. Alexithymia and outcome in psychotherapy. Psychotherapy and Psychosomatics 77, 189–194. Johnson, A.J., Nunn, A.J., Somner, A.R., Stableforth, D.E., Stewart, C.J., 1984. Circumstances of death from asthma. British Medical Journal 288, 1870–1872. Jula, A., Salminen, J.K., Saarija¨rvi, S., 1999. Alexithymia: a facet of essential hypertension. Hypertension 33, 1057–1061. Kirsi, H., Heli, K., Jukka, H., Risto, A., Kaisa, H., Antti, T., Heimo, V., 2006. Do stressful lifeevents or sociodemographic variables associate with depression and alexithymia among a general population-a 3-year follow-up study. Comprehensive Psychiatry 45, 254–260. Klaus, F.R., Suzanne, H., Antonio, A., Peter, J.B., Sonia, A.B., Peter, C., Yoshinosuke, F., Christine, J., Roberto, R., Chris, W., Jan, Z., 2007. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease - 2006 Update. The American Thoracic Society. Leda, C., Panos, B., Eleni, S., Irini, C., Evridiki, K., Maria, S., Manolis, K., Nikolaos, K., Angelos, P., 2009. Type 1 diabetes is associated with alexithymia in nondepressed, non-mentally ill diabetic patients: A case–control study. Journal of Psychosomatic Research 67, 307–313. Mennin, D.S., Heimberg, R.G., Turk, C.L., Fresco, D.M., 2005. Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder. Behaviour Research and Therapy 43, 1281–1310. Ministry of Public Health of China, 1998. Yearbook of China Healthcare. People's Health Publishing House, pp. 355–361. Moriguchi, Y., Maeda, M., Igarashi, T., Ishikawa, T., Shoji, M., Kubo, C., Komaki, G., 2007. Age and gender effect on alexithymia in large, Japanese community and clinical samples: a cross-validation study of the Toronto Alexithymia Scale (TAS-20). Biopsychosocial Medicine 1, 1–15. Murray, C.J., Lopez, A.D., 1997. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. The Lancet 349, 1498–1504. Nemiah, J.C., Sifneos, P.E., 1970. Affect and fantasy in patients with psychosomatic disorders. In: Hill, O.W. (Ed.), Modern Trends in Psychosomatic Medicine, 2. Butterworths, London, pp. 26–34. NG, T., Mathew, N., Wan-Cheng, T., CAO, Z.Y., ONG, K., Philip, N., 2007. Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life. Archives of Internal Medicine 167, 60–67. Nyklicek, I., Vingerhoets, A.D., 2000. Alexithymia is associated with low tolerance to experimental painful stimulation. Pain 85, 471–475. Paez, D., Basabe, N., Valdoseda, M., Velasco, C., Iraurgi, I., 1995. Confrontation: inhibition, alexithymia, and health. In: Pennebaker, J.W. (Ed.), Emotion, Disclosure & Health. American Psychological Association, Washington, DC, pp. 195–222. Parker, J.D., Taylor, G.J., Bagby, R.M., Acklin, M.W., 1993. Alexithymia in panic disorder and simple phobia: a comparative study. The American Journal of Psychiatry 150, 1105–1107. Parker, J.D., Taylor, G.J., Bagby, R.M., 2003. The 20-Item Toronto Alexithymia Scale: III. Reliability and factorial validity in a community population. Journal of Psychosomatic Research 55, 269–275. Pasini, A., Chiaie, R.D., Seripa, S., Ciani, N., 1992. Alexithymia as related to sex, age, and educational level: Results of the Toronto Alexithymia Scale in 417 normal subjects. Comprehensive Psychiatry 33, 42–46. Pauwels, R.A., Buist, A.S., Calverley, P.M., Jenkins, C.R., Hurd, S.S., on behalf of GOLD Scientific Committee, 2001. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. American Journal of Respiratory and Critical Care Medicine 163, 1256–1276. Pirkko, K., Juha, T.K., Juha, V., Kristian, L., Jari, J., Marjo-Riitta, J., Matti, J., 2001. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Comprehensive Psychiatry 42, 471–476. Porcelli, P., Taylor, G.J., Bagby, R.M., De Carne, M., 1999. Alexithymia and functional gastrointestinal disorders: a comparison with inflammatory bowel disease. Psychotherapy and Psychosomatics 68, 263–269. Richard, D., Lee, S., Robert, R., 1998. Sociodemographic correlates of alexithymia. Comprehensive Psychiatry 39, 377–385. Richards, H.L., Fortune, D.G., Griffiths, C., Main, C., 2005. Alexithymia in patients with psoriasis: Clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20. Journal of Psychosomatic Research 58, 89–96.
278
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Rybakowski, J., kowski, M.Z., Zasadzka, T., Ski, R.B., 1988. High prevalence of alexithymia in male patients with alcohol dependence. Drug and Alcohol Dependence 21, 133–136. Salminen, J.K., Saarijärvi, S., Äärelä, E., Toikka, T., Kauhanen, J., 1999. Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. Journal of Psychosomatic Research 46, 75–82. Schmidt, U., Jiwany, A., Treasure, J., 1993. A controlled study of alexithymia in eating disorders. Comprehensive Psychiatry 34, 54–58. Serrano, J., Plaza, V., Sureda, B., de Pablo, J., Picado, C., Bardagı, S., Lamela1, J., Sanchis, J., on behalf of the Spanish High Risk Asthma Research Group, 2006. Alexithymia: a relevant psychological variable in near-fatal asthma. The European Respiratory Journal 28, 296–302. Sifneos, P.E., 1973. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics 22, 255–262. Taylor, G.J., Bagby, R.M., Parker, J.D.A., 1997. Disorders of Affect Regulation. Cambridge University Press, Cambridge. Todarello, O., Taylor, G.J., Parker, J.D.A., Fanelli, M., 1995. Alexithymia in essential hypertension and psychiatric outpatients: a comparative study. Journal of Psychosomatic Research 39, 987–994.
Tselebis, A., Kosmas, E., Bratis, D., Moussas, G., Karkanias, A., Ilias, I., Siafakas, N., Vgontzas, A., Tzanakis, N., 2010. Prevalence of alexithymia and its association with anxiety and depression in a sample of Greek chronic obstructive pulmonary disease (COPD) outpatients. Annals of General Psychiatry 9, 16. Turk, C.L., Heimberg, R.G., Luterek, J.A., Mennin, D.S., Fresco, D.M., 2005. Emotion Dysregulation in Generalized Anxiety Disorder: A Comparison with Social Anxiety Disorder. Cognitive Therapy and Research 29, 89–106. Vanheule, S., Verhaeghe, P., Desmet, M., 2011. In search of a framework for the treatment of alexithymia. Psychology and Psychotherapy: Theory, Research and Practice 84, 84–97. Wise, T.N., Mann, L.S., Mitchell, J.D., Hryvniak, M., Hill, B., 1990. Secondary alexithymia: an empirical validation. Comprehensive Psychiatry 31, 284–288. World Health Organization, 2010. Chronic respiratory diseases burden. Available at: http://www.who.int/respiratory/copd/burden/en/index.html. Yi, J., Yao, S., Zhu, X., 2003. The Chinese version of the TAS- 20: reliability and validity. Chinese Mental Health Journal 17, 763–767. Yohannes, A.M., Willgoss, T.G., Baldwin, R.C., Connolly, M.J., 2009. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry 25, 1209–1221.
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Alexithymia in Chinese chronic obstructive pulmonary disease (COPD) patients: The prevalence and related factors of alexithymia Dai Han a,⁎, Yuqin Zhang b, Bo Li c, Zhifang Lv c, Xia Huo d, Yan Li d, Ying Zhong e a
Psychiatry Department of Huashan Hospital, Fudan University, Shanghai, PR China, 200040 Department of Neurology, Anqing City Municipal Hospital, Anqing, Anhui, PR China, 246001 Department of Respiratory, Anqing City Municipal Hospital, Anqing, Anhui, PR China, 246001 d Analytical Cytology Laboratory and the Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, PR China, 515031 e Department of Medicine, Hu Zhou Third People Hospital, Huzhou, Zhejiang, PR China, 313000 b c
a r t i c l e
i n f o
Article history: Received 17 November 2010 Received in revised form 17 July 2011 Accepted 24 October 2011 Keywords: chronic obstructive pulmonary disease (COPD) forced expiratory volume in one second percentage of predicted (FEV1% predicted) socio-demographic factors 20-item Toronto Alexithymia Scale (TAS-20)
a b s t r a c t In this study, 53 Chinese COPD moderate outpatients and 50 health controls, matched for age, family income and education level, were recruited to assess the prevalence of Alexithymia and its relationship to sociodemographic factors and pulmonary function. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS–20). The patients’ socio-demographic variables and the forced expiratory volume in one second percentage of predicted (FEV1% predicted) were recorded. The results indicated that alexithymia was significantly more common in the Chinese COPD patients than in controls. Male patients presented higher TAS-20 total scores and externally oriented thinking (EOT) scores than the females. Elder age and higher family income were connected with the patients’ lower TAS-20 indexes (except for difficulty identify feeling [DIF]). All the TAS-20 indexes were negatively associated with FEV1% predicted. These findings suggested that, in the management of COPD, alexithymia feature should not be ignored and the appropriate psychotherapeutic treatment for Alexithymia should be applied. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Alexithymia is a personality trait characterized by poor ability to recognize and verbalize internal emotions and thoughts tend to be fixated on external environment. The term “alexithymia” was originally introduced by Sifneos in 1970s, when he described the emotional deficits among psychosomatic patients (Sifneos, 1973). Over the past three decades the personality variable of alexithymia has come to be defined by the following salient features: difficulties in identifying and describing feelings to other people and distinguishing between feelings and the bodily sensations accompanying emotional arousal; as well constricted imagine processes with paucity of fantasies; and a stimulus-bound, externally oriented cognitive style (Taylor et al., 1997). The prevalence of these cognitive and affective characteristics oscillates in a range of 8-19% in general population, but it can be higher in individuals with a number of medical conditions (Rybakowski et al., 1988; Bourke et al., 1992; Parker et al., 1993; Schmidt et al., 1993; de Groot et al., 1995; Porcelli et al., 1999; Mennin et al., 2005; Turk et al., 2005), especially in patients with chronic somatic diseases, including hypertension (Todarello et al., 1995; Jula et al., 1999), Type 1 diabetes (Leda et al., 2009) and
⁎ Corresponding author: Tel.: + 86 13681642796. E-mail addresses: [email protected], [email protected] (D. Han). 0165-1781/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.10.018
psoriasis (Richards et al., 2005). As for chronic respiratory disease, studies’ results showed a higher incidence of alexithymia among NFA patients than in general population (Dirks et al., 1981; Serrano et al., 2006). However, limited information is available in alexitymic patients with COPD. COPD is a major cause of morbidity and mortality worldwide. Evidence suggests that the mortality rate is increasing (Pauwels et al., 2001). The World Health Organization has estimated that by 2020, COPD would be the third-leading cause of death and the fifthleading cause of disability worldwide (Murray and Lopez, 1997). China is expected to bear the brunt of this disabling disease. Indeed, COPD is currently the fourth leading cause of death in China's cities and the first leading cause in rural areas (Ministry of Public Health of China, 1998). COPD is a chronic respiratory disease with multiple complications, characterized by chronic airflow limitation,a range of pathological changes in the lung, some significant extrapulmonary effects (especially cigarette smoking), and important comorbidities that may contribute to the severity of the disease in individual patients (Klaus. et al., 2007; Anthonisen et al., 2002). COPD is associated with elevated levels of psychological distress, with 6-80% of patients suffering from anxiety and depressive symptoms, and up to 55% suffering from actual psychiatric disorders (Yohannes et al., 2009). These psychological distresses may have been associated with the severity of COPD, such as increases in the frequency and duration of hospitalizations (Dahlen and Janson,
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2002; Ng et al., 2007). The association between the psychological symptoms and COPD need investigation. Currently most studies are focus on depression and anxiety. To date only one study has investigated alexithymia in COPD, which showed the prevalence of Alexithymia in Greek COPD outpatietns, contrary to what has been observed in patients with other chronic respiratory diseases seems to be lower (Tselebis et al., 2010). However, the lack of a control group may limit the generalisability of this study's results. The present study was designed to evaluate the prevalence of alexithymia in Chinese moderate COPD outpatients and clarify the relationships of overall alexithymia and its facets with patients’ socio-demographic variables and pulmonary function (as one indicator of disease severity), as well supply useful information to improve the management of COPD. 2. Method 2.1. Participants In the period of November in 2008 to May 2010, all outpatients with moderate COPD, attending the chest clinics at Anqing City Municipal Hospital (Anhui province, China) for regular follow-up examination were recruited. They all met the diagnostic criteria defined by Global Initiative for moderate COPD, which is worsening airflow limitation (FEV1/FVC b 0.70; 50% b FEV1 b 80% predicted), with shortness of breath typically developing on exertion and cough and sputum production sometimes also present (Klaus et al., 2007). In the mean time, from the list of a group of healthy volunteers, who visited Anqing City Municipal Hospital for physical examination in the same period and matched with the recruited COPD patients about age, gender, education status and family economic condition, subjects of the control group were randomly selected. All participants must have received at least 9-year education and can smoothly read, understand and complete the questionnaires personally. Each participant's written informed consent must be obtained after study procedures had been fully explained. Participants were excluded for any evidence of other major somatic and emotional illness (such as heart and cerebrovascular disease, cancer, schizophrenia and major depression) or consuming any psychotropic medications within the six months before the study. All protocols were approved by the Ethics Committee of Hu Zhou Municipality Science and Technology Bureau. 2.2. Measures 2.2.1. Socio-demographic assessment A socio-demographic questionnaire was designed to get the information about the subjects’ age, gender, family income and education level. COPD patients and healthy volunteers were asked to complete this demographic questionnaire firstly. 2.2.2. Psychological assessment Alexithymia was assessed with the Chinese version of TAS-20, which.was introduced by Bagby in, 1994, and is the most widely used and presumably the most carefully validated self-reported scale for measuring alexithymia (Bagby et al., 1994). This scale has been translated in Chinese language. The reliability and validity of the Chinese version of TAS-20 have been well demonstrated (YI et al., 2003). The items in this scale are rated on a 5-point scale ranging from “totally disagree” (scored 1) to “totally agree” (scored 5), with the total score ranging from 20 to 100. The higher score is associated with the worse condition of alexithymia. The scale has a three-factor structure: Factor l assesses the capacity to identify feelings and to distinguish between the feelings and the bodily sensations of emotional arousal (DIF); Factor 2 reflects the inability to communicate feelings to other people (DDF); Factor 3 assesses externallyoriented thinking (EOT) (Cinzia et al., 1996). According to the recommendation by the developers of this scale, the total score >60 are defined as alexithymic cases (Bagby and Taylor, 1997). 2.2.3. Physical measures For COPD patients, spirometric evaluation was performed by an experienced certified technician at the lung function laboratory of Anqing City Municipal Hospital. Each patient's FEV1% predicted were recorded. 2.3. Data analysis Descriptive statistics and percentages were computed for the study sample on socio-demographic variables, TAS-20 total score, and three factor score. Data normality was assessed by the Kolmogorov–Smirnov test. Data showing a normal distribution are summarized as means ± SD, and data showing a non-normal distribution are summarized as medians. Independent-samples t-tests were used to determine the differences of socio-demographic variables (except for gender) between the COPD group and the control group in order to ensure the demographic condition of the COPD group is same with the control. Chi-square test was used to determine the gender distribution of the two groups. Then on the base of equal variance, the differences of TAS-20 total score and three factor score between the COPD group and the control group were
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determined using independent-sample t-test. Finally, the relationship of TAS-20 indexes with the socio-demographic variables and FEV1% predicted were analyzed using bivariate correlation analysis. All the analyses were conducted with SPSS statistical software version 13.0 (SPSS, Inc., Chicago, IL, USA) and EXCEL. Differences were considered significant at 2-sided p-value of 0.05 or highly significant at p-values of 0.01.
3. Results At the end of the study, data of the 103 eligible samples (53 patients and 50 healthy controls) were analyzed. The demographic variables and the alexithymic prevalence in the whole eligible study subjects were summarized by the group in Table 1. The two groups did not differ in terms of age, gender, family income and education level. However, the proportion of patients with alexithymia was significantly higher in the COPD group (42%) than the control group (26%). The results of the comparison between the two groups’ TAS-20 indexes are presented in Table 2. Compared with the control group, the COPD group's mean TAS-20 total score and DDF score were significantly higher (p b 0.05). Mean DIF score was highly significantly higher in the COPD group than the control group (p b 0.01). However, the data can not support that there is a notable difference between the EOT score of two groups. Table 3 presents the summary of TAS-20 total and factor score by gender. The t-test analytic result showed that TAS-20 total score, DIF score, DDF score and EOT score were higher in male patients than in female patients. However, only the differences of TAS-20 total score and EOT score between female and male patients had statistical significance. As shown in Table 4, none significant association was found between patients’ TAS-20 measurements and education level. However, TAS-20 total score negatively associated with patients’ age and family income. For three factor scores, except for DIF score, lower DDF score and EOT score were significantly associated with older age and higher family income. In COPD group, a negative association was observed between patients’ FEV1% predicted and TAS-20 total score (pb0.05). Furthermore,.FEV1% predicted (67.58±7.27) are negatively correlated with three factor scores, especially for DDF and EOT score (pb0.01).
4. Discussion COPD is an important health problem that affects 80 million people worldwide (World Health Organization, 2010). The psychological morbidities have various impacts on the patients with COPD and are currently increasingly concerned. It would be theoretically and clinically important to assess if alexithymia plays a role in COPD. Thus alexithymia and related factors in COPD patients were explored in the present study. The result supported that the prevalence of alexithymia is higher in COPD patients, especially in male COPD patients, in comparation with the health control subjects. Moreover the notable association of alexithymia and its facets with age, gender, financial situation and lung function were observed in COPD patients in the present study. Table 1 Summary of Demographic variables and alexithymia prevalence by group.
Gender (M/F) Age (years) Family income (10,000 /year) Years of education (years) Alexithymic prevalence (%)
COPD group N = 53
Control group N = 50
P-value
33/20 61.36 ± 8.01 5.94 ± 2.70 13.72 ± 2.66 42
27/23 60.44 ± 7.52 5.45 ±2.40 13.52 ± 2.41 26
>0.05 > 0.05 > 0.05 > 0.05 b 0.05
⁎ Data are presented as percentage/ratio or mean ± SD.
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Table 2 Comparison of TAS-20 indexes between groups.
TAS-20 TAS-20 TAS-20 TAS-20
DIF score DDF score EOT score total score
Table 4 Correlations of TAS-20 indexes to age, income, years of education, FEV1% predicted.
COPD group
Control group
P-value
18.36 ± 4.36 14.17 ± 2.84 24.80 ± 3.65 57.18 ± 8.75
15.90 ± 4.33 13.10 ± 2.53 24.42 ± 3.67 53.42 ± 8.98.
b0.01 b0.05 >0.05 b0.05
⁎ Data are presented as mean ± SD.
Table 3 Summary of TAS-20 indexes by gender.
DIF score DDF score EOT score total score
Male
Female
P-value
17.86 ± 4.53 13.90 ± 2.89 25.23 ± 3.69 56.85 ± 9.31
16.20 ± 4.32 13.30 ± 2.49 23.76 ± 3.46 53.26 ± 8.24
>0.05 >0.05 b0.05 b0.05
⁎ Data are presented as mean ± SD.
Age
Family income
The current study indicated that the prevalence of alexithymia in Chinese COPD patients (42%) were significantly higher than the health subjects (26%). Interestingly the prevalence of alexithymia in the control subjects seems globally higher than those known from the surveys on general population in other countries, which were all measured by TAS-20 (Salminen et al., 1999; Franz et al., 2007). This could be explained by the ethnocultural differences. Kenneth (Dion, 1996) reported that native Chinese language speakers scored consistently higher than native English and European language speakers on the overall TAS-20 and three factors. He supposed that these ethno linguistic differences may reflect sociocultural influences making ethnic Chinese individuals likely to be less psychologically minded and more somatically oriented versus their emotions than those from Western ethnocultural traditions. In the present study, COPD patients’ TAS-20 factor scores (except for EOT) were consistently higher than the control subjects, especially in DIF, which suggested that COPD individuals tend to show a reduction in, or absence of, symbolic thought, a limited ability to fantasies and difficulty to express their feelings in words and identifying physical sensations, such as pain or dyspnoea. In various chronic somatic disorders, presence of alexithymia, including disturbance of interoceptive awareness may contribute to maladaptive behaviors (Nemiah and Sifneos, 1970; Bourke et al., 1992). Alexithymic characteristics could contribute to a 5-year delay between symptom onset and clinical consultation in bulimia nervosa patients (Johnson et al., 1984). In patients with asthma, alexithymic patients can not timely and clearly perceive dyspnoea and then underestimate the severity of an asthma exacerbation, and increase the risk of developing a fatal or near-fatal asthma attack. (Serrano et al., 2006) Alexithymic patients tend to report more symptomatology in absence of the illness, perhaps in lieu of emotional complaints (Paez et al., 1995). Significant positive correlations have been reported between alexithymia and measures of somatization and hypochondriasis (Bagby et al., 1986; Deary et al., 1997). Alexithymia has also been found to be positively associated with reports of experimental and clinical pain (Dalton et al., 1989; Nyklicek and Vingerhoets, 2000). Given these findings, it is reasonable to suppose that alexithymic COPD individuals could not clearly and timely perceive their real condition, and even underestimate the disease severity and then delay beginning recommended treatment. Even though they try to turn to doctors, their insufficiency in expressing their feelings in words may frequently cause the inaccurate diagnosis and result in unsuitable treatment. The study by Tselebis presented a strong association between alexithymia, depression and anxiety levels in COPD outpatients (Tselebis et al., 2010). The study in patients with severe asthma identified that alexithymia had a significant negative correlation with quality of life
TAS-20 TAS-20 TAS-20 TAS-20
TAS-20 TAS-20 TAS-20 DIF score DDF score EOT score
Years of education
FEV1% predicted
Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N
TAS-20 total score
− 0.097
− 0.276⁎⁎ − 0.276⁎⁎ − 0.233⁎
0.330 103 − 0.160
0.005 0.005 0.018 103 103 103 ⁎⁎ ⁎⁎ − 0.346 − 0.299 − 0.296⁎
0.106 103 0.133
0.000 103 0.123
0.180 103 − 0.298⁎
0.215 0.086 0.093 103 103 103 − 0.533⁎⁎ − 0.368⁎⁎ − 0.450⁎
0.030 53
0.000 53
0.002 103 0.170
0.007 53
0.002 103 0.166
0.001 53
⁎ Correlation is significant at the 0.05 level (2-tailed). ⁎⁎ Correlation is significant at the 0.01 level (2-tailed).
(Chugg et al., 2009). These findings supported the assumption that alexithymia should negatively affect the condition of COPD patients. Given the high rate of alexithymia in COPD patients, medical professional are obligated to pay more attention to alexithymic patients and adopt the appropriate treatment. Therefore, the characteristics of alexithymic COPD patients and its relationship with COPD symptoms should be addressed for utilizing various therapies appropriately. The present study showed that male COPD patients were significantly higher than female COPD patients on TAS-20 total score. This gender tendency has also been generally observed in alexithymia studies in past decades (Richard et al., 1998; Pirkko et al., 2001; Kirsi et al., 2006). As for TAS-20 factor scores, we found that only EOT score was significantly higher in male COPD patients than in female COPD patients, suggested that it was externally oriented thinking predisposing male patients to alexithymia. We also found that there was a negative association between alexithymia and age in COPD patients, similarly to the study by Moriguchi and coworkers’ research in Japan arriving to the negative relationship between alexithymia and age (Moriguchi et al., 2007). However a few studies positively related alexithymia to older age in general population (Pasini et al., 1992; Richard et al., 1998). As regards the rest socio-demographic variables, the present result of COPD patients were in agreement with previous findings in general population relating alexithymia to lower levels of household income (Franz et al., 2007; Pirkko et al., 2001), but in disagreement with the relevant studies in general population relating alexithymia to lower levels of education (Franz et al., 2007; Parker et al., 2003), no trend was found between severity of alexithymia and education level in COPD subjects of the current study. An alternative explanation for this disagreement is that most of these older Chinese patients have experienced a special historical era (China Cultural Revolution) in their school ages, when students no need study in the school or university before they graduated, thus it is very difficult to evaluate their real educational level. On the level of TAS-20 factor scores, lower DDF and EOT factor score were associated with older age, as well as ideal financial situation. However, DIF score showed relatively stable and did not relate with any social-demographic variable. The findings above-mentioned suggested that DDF and EOT factor possibly represented the special aspects of alexithymia influenced by current socialdemographic factors or primary medical illness. On the contrary, DIF factor might be a life-long personality feature of alexithymia determined by biological or genetic factor. Wise suggested in 1990 that it was possible to differentiate between “primary” and “secondary” alexithymia (Wise et al., 1990). Primary alexithymia was described as a life-long, dispositional factor that could lead to psychosomatic illness. Secondary alexithymia, however, was seen as a result from a primary medical
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illness or other stress. In one sense, our conclusion is consistent with the view of “primary” and “secondary” alexithymia. Another notable finding of this study was that we observed a strong negative correlation of FEV1% predicted with the total score and the three factor scores of TAS-20. On the base of the abovementioned two points, it can be concluded that FEV1% predicted represents pulmonary function level and is one indicator of disease severity, which confirm that alexithymia is associated with the process of COPD, which is coincided with previous findings that patients with higher TAS-20 scores had a significant correlation with poorer asthma symptom control (Chugg, et al., 2009). Therefore alexithymia's influence should be considered when the clinicians try to find the better management of COPD. A recent research by Vanheule and co-workers observed that classic psychotherapy approaches are not sufficient to treat alexithymia appropriately (Vanheule, et al., 2011). A study in coronary heart disease (CHD) patients indicated that group psychotherapy was able to decrease alexithymia and a reduction in the degree of alexithymia seemed to favorably influence the clinical course of CHD (Beresnevaite, 2000). Research has proved that psychodynamic group therapy significantly reduced psychopathological distress and alexithymic features in alexithymic patients with various physical diseases and psychological illnesses (Grabe et al., 2008). 5. Conclusion This study is limited by the absence of the subjects’ condition of smoking and other emotional features, including depression and anxiety, in the analysis of the relationship between alexithymia and various factors in patients with COPD. In conclusion, the present study confirmed that the prevalence of alexithymia is higher in Chinese outpatients with moderate COPD, who can not effectively communicate their feelings to other people and tend to externallyoriented think. In the management of COPD, alexithymia features of individual should not be ignored. To facilitate the remission, COPD patients require not only medical treatment but also appropriate psychotherapy for alexithymia. Acknowledgments This research was funded by Huzhou Municipal Science and Technology Project Foundation (2008YS36). We also thank the members of the respiratory department of Anqing City Municipal Hospital and the lung function laboratory of Anqing City Municipal Hospital for technical assistance, as well as Xia Huo PhD and Yan Li PhD for editing this manuscript. References Anthonisen, N.R., Connett, J.E., Murray, R.P., for the Lung Health Study Research Group, 2002. Smoking and lung function of Lung Health Study participants after 11 years. American Journal of Respiratory and Critical Care Medicine 166, 675–679. Bagby, M., Taylor, G., 1997. Construct validation. In: Taylor, G. (Ed.), Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. UK, Cambridge University Press, Cambridge, pp. 46–66. Bagby, R.M., Taylor, G.J., Ryan, D.P., 1986. Toronto Alexithymia Scale: relationship with personality and psychopathology measures. Psychotherapy and Psychosomatics 45, 207–215. Bagby, R.M., Parker, J.D.A., Taylor, G.J., 1994. The 20-item Toronto Alexithymia Scale, I: item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 23–32. Beresnevaite, M., 2000. Exploring the benefits of group psychotherapy in reducing alexithymia in coronary heart disease patients: a preliminary study. Psychotherapy and Psychosomatic 69, 117–122. Bourke, M.P., Taylor, G.J., Parker, J.D., Bagby, R.M., 1992. Alexithymia in women with anorexia nervosa: a preliminary investigation. The British Journal of Psychiatry 161, 240–243. Chugg, K., Barton, C., Antic, R., Crockett, A., 2009. The impact of alexithymia on asthma patient management and communication with health care providers: a pilot study. The Journal of Asthma 46, 126–129.
277
Cinzia, B., Graeme, T., James, P., Sergio, B., Virginia, B., Eugenio, A., Ida, A., Antonio, B., Franco, G., Maurizio, B., Orlando, T., Camilla, C., Simone, V., Constanzo, G., Giordano, I., 1996. Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study. Journal of Psychosomatic Research 41, 551–559. Dahlen, I., Janson, C., 2002. Anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease. Chest 122, 1633–1637. Dalton, J.A., Feuerstein, M., Fear, 1989. Alexithymia, and cancer pain. Pain 38, 159–170. de Groot, J.M., Rodin, G., Olmsted, M.P., 1995. Alexithymia, depression, and treatment outcome in bulimia nervosa. Comprehensive Psychiatry 36, 53–60. Deary, I.J., Scott, S., Wilson, J.A., 1997. Neuroticism, alexithymia and medically unexplained symptoms. Personality and Individual Differences 22, 551–564. Dion, Kenneth L., 1996. Ethnolinguistic correlates of alexithymia: Toward a cultural perspective. Journal of Psychosomatic Research 41, 531–539. Dirks, J.F., Robinson, S., Dirks, D.L., 1981. Alexithymia and the psychomaintenance of bronchial asthma. Psychotherapy and Psychosomatics 36, 63–71. Franz, M., Popp, K., Schaefer, R., Sitte, W., Schneider, C., Hardt, J., Decker, O., Braehler, E., 2007. Alexithymia in the German general population. Social Psychiatry and Psychiatric Epidemiology 43, 54–62. Grabe, H.J., Frommer, J., Ankerhold, A., Ulrich, C., Groger, R., Franke, G.H., Barnow, S., Freyberger, H.J., Spitzer, C., 2008. Alexithymia and outcome in psychotherapy. Psychotherapy and Psychosomatics 77, 189–194. Johnson, A.J., Nunn, A.J., Somner, A.R., Stableforth, D.E., Stewart, C.J., 1984. Circumstances of death from asthma. British Medical Journal 288, 1870–1872. Jula, A., Salminen, J.K., Saarija¨rvi, S., 1999. Alexithymia: a facet of essential hypertension. Hypertension 33, 1057–1061. Kirsi, H., Heli, K., Jukka, H., Risto, A., Kaisa, H., Antti, T., Heimo, V., 2006. Do stressful lifeevents or sociodemographic variables associate with depression and alexithymia among a general population-a 3-year follow-up study. Comprehensive Psychiatry 45, 254–260. Klaus, F.R., Suzanne, H., Antonio, A., Peter, J.B., Sonia, A.B., Peter, C., Yoshinosuke, F., Christine, J., Roberto, R., Chris, W., Jan, Z., 2007. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease - 2006 Update. The American Thoracic Society. Leda, C., Panos, B., Eleni, S., Irini, C., Evridiki, K., Maria, S., Manolis, K., Nikolaos, K., Angelos, P., 2009. Type 1 diabetes is associated with alexithymia in nondepressed, non-mentally ill diabetic patients: A case–control study. Journal of Psychosomatic Research 67, 307–313. Mennin, D.S., Heimberg, R.G., Turk, C.L., Fresco, D.M., 2005. Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder. Behaviour Research and Therapy 43, 1281–1310. Ministry of Public Health of China, 1998. Yearbook of China Healthcare. People's Health Publishing House, pp. 355–361. Moriguchi, Y., Maeda, M., Igarashi, T., Ishikawa, T., Shoji, M., Kubo, C., Komaki, G., 2007. Age and gender effect on alexithymia in large, Japanese community and clinical samples: a cross-validation study of the Toronto Alexithymia Scale (TAS-20). Biopsychosocial Medicine 1, 1–15. Murray, C.J., Lopez, A.D., 1997. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. The Lancet 349, 1498–1504. Nemiah, J.C., Sifneos, P.E., 1970. Affect and fantasy in patients with psychosomatic disorders. In: Hill, O.W. (Ed.), Modern Trends in Psychosomatic Medicine, 2. Butterworths, London, pp. 26–34. NG, T., Mathew, N., Wan-Cheng, T., CAO, Z.Y., ONG, K., Philip, N., 2007. Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life. Archives of Internal Medicine 167, 60–67. Nyklicek, I., Vingerhoets, A.D., 2000. Alexithymia is associated with low tolerance to experimental painful stimulation. Pain 85, 471–475. Paez, D., Basabe, N., Valdoseda, M., Velasco, C., Iraurgi, I., 1995. Confrontation: inhibition, alexithymia, and health. In: Pennebaker, J.W. (Ed.), Emotion, Disclosure & Health. American Psychological Association, Washington, DC, pp. 195–222. Parker, J.D., Taylor, G.J., Bagby, R.M., Acklin, M.W., 1993. Alexithymia in panic disorder and simple phobia: a comparative study. The American Journal of Psychiatry 150, 1105–1107. Parker, J.D., Taylor, G.J., Bagby, R.M., 2003. The 20-Item Toronto Alexithymia Scale: III. Reliability and factorial validity in a community population. Journal of Psychosomatic Research 55, 269–275. Pasini, A., Chiaie, R.D., Seripa, S., Ciani, N., 1992. Alexithymia as related to sex, age, and educational level: Results of the Toronto Alexithymia Scale in 417 normal subjects. Comprehensive Psychiatry 33, 42–46. Pauwels, R.A., Buist, A.S., Calverley, P.M., Jenkins, C.R., Hurd, S.S., on behalf of GOLD Scientific Committee, 2001. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. American Journal of Respiratory and Critical Care Medicine 163, 1256–1276. Pirkko, K., Juha, T.K., Juha, V., Kristian, L., Jari, J., Marjo-Riitta, J., Matti, J., 2001. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Comprehensive Psychiatry 42, 471–476. Porcelli, P., Taylor, G.J., Bagby, R.M., De Carne, M., 1999. Alexithymia and functional gastrointestinal disorders: a comparison with inflammatory bowel disease. Psychotherapy and Psychosomatics 68, 263–269. Richard, D., Lee, S., Robert, R., 1998. Sociodemographic correlates of alexithymia. Comprehensive Psychiatry 39, 377–385. Richards, H.L., Fortune, D.G., Griffiths, C., Main, C., 2005. Alexithymia in patients with psoriasis: Clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20. Journal of Psychosomatic Research 58, 89–96.
278
D. Han et al. / Psychiatry Research 198 (2012) 274–278
Rybakowski, J., kowski, M.Z., Zasadzka, T., Ski, R.B., 1988. High prevalence of alexithymia in male patients with alcohol dependence. Drug and Alcohol Dependence 21, 133–136. Salminen, J.K., Saarijärvi, S., Äärelä, E., Toikka, T., Kauhanen, J., 1999. Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. Journal of Psychosomatic Research 46, 75–82. Schmidt, U., Jiwany, A., Treasure, J., 1993. A controlled study of alexithymia in eating disorders. Comprehensive Psychiatry 34, 54–58. Serrano, J., Plaza, V., Sureda, B., de Pablo, J., Picado, C., Bardagı, S., Lamela1, J., Sanchis, J., on behalf of the Spanish High Risk Asthma Research Group, 2006. Alexithymia: a relevant psychological variable in near-fatal asthma. The European Respiratory Journal 28, 296–302. Sifneos, P.E., 1973. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics 22, 255–262. Taylor, G.J., Bagby, R.M., Parker, J.D.A., 1997. Disorders of Affect Regulation. Cambridge University Press, Cambridge. Todarello, O., Taylor, G.J., Parker, J.D.A., Fanelli, M., 1995. Alexithymia in essential hypertension and psychiatric outpatients: a comparative study. Journal of Psychosomatic Research 39, 987–994.
Tselebis, A., Kosmas, E., Bratis, D., Moussas, G., Karkanias, A., Ilias, I., Siafakas, N., Vgontzas, A., Tzanakis, N., 2010. Prevalence of alexithymia and its association with anxiety and depression in a sample of Greek chronic obstructive pulmonary disease (COPD) outpatients. Annals of General Psychiatry 9, 16. Turk, C.L., Heimberg, R.G., Luterek, J.A., Mennin, D.S., Fresco, D.M., 2005. Emotion Dysregulation in Generalized Anxiety Disorder: A Comparison with Social Anxiety Disorder. Cognitive Therapy and Research 29, 89–106. Vanheule, S., Verhaeghe, P., Desmet, M., 2011. In search of a framework for the treatment of alexithymia. Psychology and Psychotherapy: Theory, Research and Practice 84, 84–97. Wise, T.N., Mann, L.S., Mitchell, J.D., Hryvniak, M., Hill, B., 1990. Secondary alexithymia: an empirical validation. Comprehensive Psychiatry 31, 284–288. World Health Organization, 2010. Chronic respiratory diseases burden. Available at: http://www.who.int/respiratory/copd/burden/en/index.html. Yi, J., Yao, S., Zhu, X., 2003. The Chinese version of the TAS- 20: reliability and validity. Chinese Mental Health Journal 17, 763–767. Yohannes, A.M., Willgoss, T.G., Baldwin, R.C., Connolly, M.J., 2009. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry 25, 1209–1221.