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Alexithymia in women and men hospitalized for psychoactive substance dependence
Alexithymia
in Women and Men Hospitalized Substance Dependence
Mark G. Haviland,
Michael
S. Hendryx,
Self-report alexithymia, depression, and anxiety inventories were completed by 204 (84 women and 120 men) psychoactive substance-dependent patients during their first week of hospitalization. Eighty-five of the 204 patients (41.7%) scored in the alexithymic range on the revised Toronto Alexithymia Scale (TAS-20). Women’s average alexithymia, depression (Beck Depression Inventory [BDI]), and anxiety (State-Trait Anxiety Inventory-State [STAI-S]) scores were higher than men’s average scores. Ethnic (Hispanic whites Y non-Hispanic whites) and diagnostic (alcohol v drug v
A
LEXITHYMIA has long been associated with the etiology and treatment of alcohol and drug dependence. In fact, at roughly the same time that Nemiah and Sifneosl were describing in psychosomatic patients what now are regarded to be the core features of alexithymia, Krystal and Raskin’ were describing similar characteristics in drug-dependent patients. The alexithymia construct was formulated to include the following four features that were common to both patient groups: (1) difficulty identifying and describing feelings, (2) difficulty distinguishing feelings from bodily sensations, (3) diminution of fantasy/reduction or absence of symbolic thinking, and (4) an external, operative cognitive style.3-5 Alexithymia generally is thought to be a stable personality trait and a predisposing risk factor for a variety of medical and psychiatric illnesses$ however, there is accumulating evidence that alexithyrnia can be a state reaction to acutely stressful situations.6-9 Moreover, investigators10-12have demonstrated that at intake or shortly thereafter, roughly 50% of newly absti-
From the Department of Psychiatry, Loma Linda University School of Medicine, Loma Linda, CA; the Graduate Program in Hospital and Health Administration, Center for Health Services Research, University of Iowa College of Medicine, Iowa City, IA; and the Division of Research, Evaluation, and Development, Universi~ of Northern Colorado, Greeley CO. Supported in part by the Loma Linda University Behavioral Medicine Center. Address reprint requests to Mark G. Haviland, Ph.D., Department of Psychiatry, Loma Linda lJniversi& School of Medicine, Loma Linda, CA 92350. Copyright 0 I994 by U?B. Saunders Company 0010-440X/9413502-0009$03.0010 124
for Psychoactive
Dale G. Shaw, and James P. Henry mixed-substance dependence) group differences were not significant. To examine the interrelationships among alexithymia, depression, and anxiety, a causal model confirmed in medical students was tested. The model was reconfirmed; state anxiety predicted depression and alexithymia, and depression predicted alexithymia. These findings are consistent with previous research and compatible with the view that a state of alexithymia can result from severe anxiety and depression. Copyright 0 1994 by W.B. Ssunders Compeny
nent alcoholic-, drug-, and mixed-substancedependent/abusing patients score in the alexithyrnic range on the Toronto Alexithymia Scale (TAS);l”J4 yet, when the TAS is administered at the end of the third or fourth week of inpatient treatment, only approximately one third score in the alexithymic range.i5J6 Why the discrepancy? Haviland et al. 8~15have suggested that at intake and shortly thereafter, the alexithymia of many substance abusers (as measured by the TAS) is a state reaction; that is, they have become alexithymic or more severely alexithymic as a consequence of being depressed and anxious. As the dysphoria clears, patients become less (and in some instances, no longer) alexithymic. Hendryx et al9 retested and extended the causal model of Haviland et al.* and demonstrated in freshman medical students that depression and state anxiety predicted alexithymia. However, in both models, depression and anxiety predicted only the emotional awareness deficits components of alexithymia. The TAS is the most psychometrically sound self-report alexithymia scale;” however, it is not without fault. For example, Haviland et a1.,8 Hendryx et a1.,9J1 and Kirmayer and Robbins18J9 have long argued that the theoretical alexithymia construct is multidimensional and thus not well represented by a global TAS score. In fact, the application of item-response theory to alexithymia assessment among alcoholics confirmed that “TAS alexithymia” is multidimensionalii Moreover, in studies of alcoholics and freshman medical students,8~9~1honly the two emotional awareness deficits dimensions were related as expected to each other, to depression and anxiety, and to various biochemical mark-
Comprehensive Psychiatry, Vol. 35, No. 2 (March/April),
1994:
pp 724-128
ALEXITHYMIA
AND SUBSTANCE
125
DEPENDENCE
ers; the diminution of fantasy and external cognitive style components were not. It seems reasonable to conclude from these studies that the distinct dimensions of alexithymia ought to be studied separately. The TAS has undergone major revisions;‘O.” most notably, items failing to tap alexithymia’s diminution of fantasy/reduction or absence of symbolic thinking component were eliminated, and several items purporting to measure alexithymia’s external cognitive style component were added. In light of these substantial changes and the potential explanatory power of the causal model of Hendryx et a1.,9 it is necessary to use the most recent version of the TAS (TAS-20)” to validate and, if possible, extend previous findings in psychoactive substancedependent samples. Such samples, unlike the medical student sample, have good ranges of alexithymia and depression severity* and, likely, anxiety severity. Our specific aims were (1) to make alexithymia prevalence estimates among substancedependent inpatients; (2) to compare inpatient women’s and men’s alexithymia scores with published normative data, and their alexithymia, depression, and anxiety scores with each other; (3) to examine patients’ test score differences by raceiethnicity and by diagnosis; and (4) to test the causal model9 of the interrelationships among the dimensions of alexithymia, depression, and anxiety. METHOD
Subjects Subjects were a consecutive series of 204 consenting patients, 84 women and 120 men, admitted to a university medical center’s inpatient chemical dependency treatment program. (Roughly 40% of all admitted patients over a 14.month period agreed to participate.) Their ages ranged from 15 to 69 years, with a mean ? SD of 37 2 11 years. Six (2.9%,) were African-American. and 198 (97.1%) were white (28 were of Hispanic descent, and 170 were not). Seventy-two (35.3%) were being treated for alcohol dependence, 79 (38.7%) for dependence on a drug or drugs other than alcohol, and 53 (26.0%) for mixed-substance dependence (dependence on two or more psychoactive substances. one of which was alcohol). These clinical diagnoses were made by admitting physicians using DSM-III-R criteria.
Instruments To measure alexithymia, we used the most recent TAS (TAS-Xl).” Respondents rate the 20 self-descriptive state-
ments on a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Mean (*SD) TAS-20 scores for normal adult women and female psychiatric outpatients are 46.1 ? 9.8 and 54.5 2 13.5. respectively: for normal adult men and male psychiatric outpatients, the respective mean scores are 47.2 2 10.6 and 55.3 + 12.2.” Persons scoring 61 and above are considered alexithymic: those scoring 51 and below are considered nonalexithymic (Graeme J. Taylor, M.D., personal communication, April 1. 1993). The scale is reliable (coefficient (Y= 0.81) and has a three-factor structure (subscale abbreviations and coefficient alphas are shown in parentheses), i.e.. difftculty identifying feelings and distinguishing them from the bodily sensations that accompany emotions (TAS-20-IF, 0.78), difficulty describing feelings to others (TAS-20-CF. 0.75). and externally oriented thinking (TAS-20-ET, 0.66). To measure depression, we used the revised. 21.item Beck Depression Inventory (BDI).” Items are rated on a four-point Likert scale ranging from absent (0) to severe (3). The sum of the first 13 items represents cognitive/ affective symptoms (BDI-C/A), and the sum of the last eight items represents somatic/performance complaints (BDI-S/P). Ranges of depression severity are as follows: 0 to 9. normal or asymptomatic: IO to 18, mild to moderate: 19 to 29. moderate to severe; and 30 to 63, extremely severe. The mean (?-SD) BDI score for the alcoholic normative sample is 13.9 i lO.6.?? The BDI is reliable and valid” and thought to be a good measure of depression severity in psychoactive substance-dependent/abusing samples.‘“-?’ To measure anxiety, we used the 20-item state portion of the State-Trait Anxiety Inventory (STAI-S). a reliable and valid self-evaluation.?h To rate the items, respondents use a four-point Likert scale ranging from not at all (1) to very much so (4). The scale consists of 10 state “anxiety present” absent” and 10 state “anxiety items. Respective mean (+-SD) STAIN scores for working women and men are 35.2 + 10.6 and 35.7 t 10.4.“h
Procedure All subjects completed the three questionnaires in an individual setting at their convenience (typically within 3 days of admission; no later than within 7 days of admission).
Prevalence Estimates Based on their TAS-20 total scores. subjects were classified into the following two groups: 61 and above = alexithymic, 60 and below = neither alexithymic nor nonalexithymic and nonalexithymic. To compare women’s and men’s alexithymia rates, we used a 2 x 2 chi-square test ((Y = 0.05).
Means Comparisons To compare our subjects’ mean TAS-20 scores with normative data?’ and to evaluate total test score and subscale score differences of women and men and of Hispanic and non-Hispanic whites (there were too few African-Americans [n = h] to include in the raceiethnicity analyses). we used two-tailed t tests for independent samples. To evaluate test score differences by diagnosis (alcohol 1’ drug 1’ mixed-substance dependence). we used a one-way
126
HAVILAND ET AL
analysis of variance and the Neuman-Keuls multiple comparison procedure. For all of these tests, cxwas set at 0.05.
Table 1. Women’s and Men’s TAS-20, BDI, and STAI-S Total and Subscale Scores MlXl
Path Analyses
(n = 84)
Based on the structure of the three instruments described above, we defined three alexithymia factors (TAS-20-IF, TAS-20-CF, and TAS-20-ET), two depression factors (BDIC/A and BDI-S/P), and one anxiety factor (STAI-S). To arrive at factor scores, we simply summed subjects’ item scores within each factor. To study the directional relationships among the six alexithymia, depression, and anxiety factors and the bidirectional relationships among each instrument’s factors, we used LISREL VI’s*’ path analysis. The confirmatory model we tested was patterned after previously well-supported models; that is, the alexithymia factors were hypothesized to be affected by the depression and the anxiety factors and the depression factors by the anxiety factors.8,9 The model results indicate size and direction of path coefficients and which associations are significant at P less than .05; moreover, an overall model R* is given. RESULTS
Prevalence Estimates
Eighty-five of the 204 patients (41.7%) scored the alexithymic range on the TAS-20, 42 of the 84 women (50.0%) and 43 of the 120 men (35.8%). The difference between women and men was statistically significant (x2 = 4.08, in
df = 1, P < .05). Means Comparisons
Average TAS-20 scores for women (mean & SD = 59.5 + 11.1) were significantly higher than average TAS-20 scores for women in the two normative samples, normal adult women(46.1 + 9.8, t = 8.29,df = 166,P < .OOl) and female psychiatric outpatients (54.5 & 13.5, t = 2.81, df = 206, P < .Ol). Men’s mean TAS-20 scores (56.0 & 11.9) were significantly higher than those in one of the two normative groups, normal adult men (47.2 + 10.6, t = 4.70, df= 173, P < .OOl); however, they were not higher than those of male psychiatric outpatients (55.3 + 12.2). The comparisons of women’s and men’s alexithymia, depression, and anxiety assessments are summarized in Table 1. Women’s mean TAS20, BDI, and STAI-S scores were significantly higher than men’s mean scores. Moreover, women’s subscale scores were higher on the TAS-20-IF subscale and the BDI-S/P subscale. Ethnic differences (Hispanic v non-Hispanic whites) in age and in total and subscale scores were not significant. Diagnostic group differ-
(n = 120)
Mean
SD
Mean
SD
f.df,
SCOE
59.5
11.1
56.0
11.9
2.12,202,
<.05
TAS-20-IF
22.3
6.3
19.7
6.7
2.81,202,
< .Ol
TAS-20-CF
16.8
4.4
15.8
5.0
TAS-20-ET
20.4
4.5
20.4
4.1
21.6
11.0
17.5
10.4
BDI-C/A
13.3
7.4
11.5
7.1
BDI-S/P
a.3
4.7
6.1
4.4
3.52,202,
< .Ol
55.0
12.8
50.0
11.8
2.87,202,
< .Ol
TAS-20
P
total
BDI total
score
NS NS 2.69,202,
< .Ol
NS
STAI-S total score
ences in these mean scores were not significant, with one exception, i.e., on average, alcoholdependent patients were significantly older (42 + 12) than drug-dependent (34 + 9) and mixed-substance-dependent patients (34 + 10; P < .05, Neuman-Keuls post-hoc test). Path Analyses
The model for all subjects is displayed in Fig 1; only significant (P < .05) paths are shown. State anxiety predicted both depression factors and all three alexithymia factors; the depr:ssion factors predicted alexithymia’s difficulty ldentifying feelings factor. The two depression factors were correlated. Difficulty identifying feelings and difficulty communicating feelings were correlated, as were difficulty communicating feelings and external thinking. The coefficient of determination (R*) for the model was .393. The model for women differed in two minor ways from the total model; there was a significant negative link between somatic/performance and difficulty communicating feelings and no significant correlation between difficulty communicating feelings and external thinking. The coefficient of determination was .472. The model for men also differed slightly from the one for all subjects; here the link between anxiety and external thinking was not significant, and the coefficient of determination was .336. DISCUSSION
Before commenting on the results, we must note several limitations of the present study. First, the sample size is relatively small, particularly for the women’s and men’s path analyses.
ALEXITHYMIA
127
AND SUBSTANCE DEPENDENCE
DEPRESSION (=‘I)
ANXIETY (STAG)
ALEXITHYMIA (TAS-20)
------I Fig 1. Interrelationships among the dimensions of anxiety, depression, and alexithymia (LISREL model) for all subjects (N = 204).
Second, we used only single, self-report indicators of alexithymia, depression, and anxiety, and we have no estimate of neuropsychiatric impairment at the time of testing. Finally, drawing causal inferences from correlational data has many pitfalls. Despite these limitations, we believe that our findings are both interesting and potentially useful. Our 35.8% alexithymia prevalence estimate for men is less than the 50% prevalence estimates in three samples of psychoactive substance-dependent/abusing men in which the original TAS was used. lo-l2The rate for women (50.0%) in the present sample was significantly higher than the rate for men. The differences between women’s and men’s average TAS-20, BDI, and STAI-S scores were substantial and statistically significant. This finding is consistent with research showing that many alcohol- and drug-dependent women seek help for depression and anxiety, not for substance dependence per se,28.29and enter treatment programs when their depression and anxiety are severe.28.30 In the path analyses, state anxiety predicted the two depression factors and the three alexithymia factors. This is the first causal model in which all dimensions of alexithymia were related as hypothesized to anxiety. This suggests that alexithymia per se, not only its emotional awareness deficits, is responsive to situational stress. Moreover, TAS-20-CF and TAS-20-ET
were positively correlated. In no previous models was alexithymia’s externally oriented thinking component related to depression or anxiety or to alexithymia’s emotional awareness deficits components. Our long-held view is that state and trait alexithymia can result from deficits induced by severe and persistent stress+‘*J5 and that they have neurophysiologic underpinnings.‘6J’.3z In stressful circumstances, one is protected (i.e., defended) against the pain of full affect (see also Zeitlin et a1.3”and Zeitlin and McNally”4). An alexithymic individual may experience fear, anger, and sadness, as Taylor et al.” note, but these emotions have lost some of their persuasive quality.35 These subtle but serious losses can exact a price in vulnerability to addictive disorders and losses of critical social skills. We believe that the reasonableness of the hypothesized link between alexithymia and stress provides sufficient justification for setting up the path analyses and testing the models as we have. Our findings continue to support such a connection; however, we recognize that more study is needed to firmly establish this link.
ACKNOWLEDGMENT The authors thank the staff of the Recovery Services unit. Loma Linda University Behavioral Medicine Center. for their assistance with the study.
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ET AL
REFERENCES 1. Nemiah JC, Sifneos PE. Affect and fantasy in patients with psychosomatic disorders. In: Hill OW (ed): Modern Trends in Psychosomatic Medicine. Vol 2. London, England: Butterworths, 1970:26-34. 2. Krystal H, Raskin H. Drug Dependence: Aspects of Ego Functions. Detroit, MI: Wayne State University Press, 1970. 3. Nemiah JC. Freyberger H, Sifneos PE. Alexithymia: a view of the psychosomatic process. In: Hill OW (ed): Modern Trends in Psychosomatic Medicine. Vol3. London, England: Butterworths, 1976:430-439. 4. Taylor GJ. Alexithymia: concept, measurement, and implications for treatment. Am J Psychiatry 1984;141:725732. 5. Taylor GJ, Bagby RM, Parker JDA. The alexithymia construct: a potential paradigm for psychosomatic medicine. Psychosomatics 1991;32:153-164. 6. Wise TN, Mann LS, Mitchell JD, Hryvniak M, Hill B. Secondary alexithymia: an empirical validation. Compr Psychiatry 1990;31:284-288. 7. Fukunishi I, Saito S, Ozaki S. The influence of defense mechanisms on secondary alexithymia in hemodialysis patients. Psychother Psychosom 1992;57:50-56. 8. Haviland MG, Hendryx MS, Cummings MA, Shaw DG, MacMurray JP. Multidimensionality and state dependency of alexithymia in recently sober alcoholics. J Netv Ment Dis 1991;179:284-290. 9. Hendryx MS, Haviland MG, Shaw DG. Dimensions of alexithymia and their relationships to anxiety and depression. J Pers Assess 1991;56:227-237. 10. Haviland MG, Shaw DG, MacMurray JP, Cummings MA. Validation of the Toronto Alexithymia Scale with substance abusers. Psychother Psychosom 1988;50:81-87. 11. Hendryx MS, Haviland MG, Gibbons RD, Clark DC. An application of item response theory to alexithymia assessment among ,abstinent alcoholics. J Pers Assess 1992; 58506-515. 12. Taylor GJ, Parker JDA, Bagby RM. A preliminary investigation of alexithymia in men with psychoactive substance dependence. Am J Psychiatry 1990;147:1228-1230. 13. Taylor GJ, Ryan D, Bagby RM. Toward the development of a new self-report alexithymia scale. Psychother Psychosom 1985;44:191-199. 14. Taylor GJ, Bagby RM, Ryan DP, Parker JDA, Doody KF, Keefe P. Criterion validity of the Toronto Alexithymia Scale. Psychosom Med 1988;50:500-509. 15. Haviland MG, Shaw DG, Cummings MA, MacMurray JP. Alexithymia: subscales and relationship to depression. Psychother Psychosom 1988;50:164-170. 16. Henry JP, Haviland MG, Cummings MA, Anderson DL, Nelson JC, MacMurray JP, et al. Shared neuroendocrine patterns of post-traumatic stress disorder and alexithymia. Psychosom Med 1992;54:407-415. 17. Taylor GJ, Bagby RM, Ryan DP, Parker JDA.
Validation of the alexithymia construct: a measurementbased approach. Can J Psychiatry 1990;35:290-297. 18. Kirmayer LJ, Robbins JM. What does the Toronto Alexithymia Scale measure? [abstract]. Psychosom Med 1991;53:222. 19. Kirmayer LJ, Robbins JM. Cognitive and social correlates of the Toronto Alexithymia Scale. Psychosomatits 1993;34:41-52. 20. Taylor GJ, Bagby RM, Parker JDA. The revised Toronto Alexithymia Scale: some reliability, validity, and normative data. Psychother Psychosom 1992;57:34-41. 21. Bagby RM, Taylor GJ, Parker JDA. Reliability and validity of the 20-item revised Toronto Alexithymia Scale. Presented at the 50th Anniversary International Meeting of the American Psychosomatic Society; 1992 March 31-April 4; New York, NY. 22. Beck AT, Steer RA. Beck Depression Inventory Manual. San Antonio, TX: The Psychological Corp., 1987. 23. Clark DC, Gibbons RD, Fawcett J, Aagesen CA, Sellers D. Unbiased criteria for severity of depression in alcoholic inpatients. J Nerv Ment Dis 1985;173:482-487. 24. Clark DC, Gibbons RD, Haviland MG, Hendryx MS. Assessing the severity of depressive states in recently detoxified alcoholics. J Stud Alcohol 1993;54:107-114. 25. Weiss RD, Grillin ML, Mirin SM. Diagnosing major depression in cocaine abusers: the use of depression rating scales. Psychiatry Res 1989;28:335-343. 26. Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, 1983. 27. Joreskog KG, Sorbom D. LISREL VI: Analysis of Linear Structural Relationships by the Method of Maximum Likelihood. Mooresville, IN: Scientific Software, 1986. 28. Blume SB. Women and alcohol: a review. JAMA 1986;256:1467-1470. 29. Thorn B. Sex differences in help-seeking for alcohol problems. I. The barriers to help-seeking. Br J Addict 1986;81:777-788. 30. Weisner C, Schmidt L. Gender disparities in treatment for alcohol problems, JAMA 1992;268:1872-1876. 31. Henry JP. Biological basis of the stress response. Integr Physiol Behav Sci 1992;27:66-83. 32. Henry JP. Biological basis of the stress response. News Physiol Sci 1993;8:69-73. 33. Zeitlin SB. McNally RJ, Cassiday KL. Alexithymia in victims of sexual assault: an effect of repeated traumatization? Am J Psychiatry 1993;150:661-663. 34. Zeitlin SB, McNally RJ. Alexithymia and anxiety sensitivity in panic disorder and obsessive-compulsive disorder. Am J Psychiatry 1993;150:658-660. 35. Henry JP, Haviland MG. Alexithymia as a stress response. Presented at the 5th International Montreux Congress on Stress (The American Institute of Stress); I993 Feb 14-19; Montreux, Switzerland.
in Women and Men Hospitalized Substance Dependence
Mark G. Haviland,
Michael
S. Hendryx,
Self-report alexithymia, depression, and anxiety inventories were completed by 204 (84 women and 120 men) psychoactive substance-dependent patients during their first week of hospitalization. Eighty-five of the 204 patients (41.7%) scored in the alexithymic range on the revised Toronto Alexithymia Scale (TAS-20). Women’s average alexithymia, depression (Beck Depression Inventory [BDI]), and anxiety (State-Trait Anxiety Inventory-State [STAI-S]) scores were higher than men’s average scores. Ethnic (Hispanic whites Y non-Hispanic whites) and diagnostic (alcohol v drug v
A
LEXITHYMIA has long been associated with the etiology and treatment of alcohol and drug dependence. In fact, at roughly the same time that Nemiah and Sifneosl were describing in psychosomatic patients what now are regarded to be the core features of alexithymia, Krystal and Raskin’ were describing similar characteristics in drug-dependent patients. The alexithymia construct was formulated to include the following four features that were common to both patient groups: (1) difficulty identifying and describing feelings, (2) difficulty distinguishing feelings from bodily sensations, (3) diminution of fantasy/reduction or absence of symbolic thinking, and (4) an external, operative cognitive style.3-5 Alexithymia generally is thought to be a stable personality trait and a predisposing risk factor for a variety of medical and psychiatric illnesses$ however, there is accumulating evidence that alexithyrnia can be a state reaction to acutely stressful situations.6-9 Moreover, investigators10-12have demonstrated that at intake or shortly thereafter, roughly 50% of newly absti-
From the Department of Psychiatry, Loma Linda University School of Medicine, Loma Linda, CA; the Graduate Program in Hospital and Health Administration, Center for Health Services Research, University of Iowa College of Medicine, Iowa City, IA; and the Division of Research, Evaluation, and Development, Universi~ of Northern Colorado, Greeley CO. Supported in part by the Loma Linda University Behavioral Medicine Center. Address reprint requests to Mark G. Haviland, Ph.D., Department of Psychiatry, Loma Linda lJniversi& School of Medicine, Loma Linda, CA 92350. Copyright 0 I994 by U?B. Saunders Company 0010-440X/9413502-0009$03.0010 124
for Psychoactive
Dale G. Shaw, and James P. Henry mixed-substance dependence) group differences were not significant. To examine the interrelationships among alexithymia, depression, and anxiety, a causal model confirmed in medical students was tested. The model was reconfirmed; state anxiety predicted depression and alexithymia, and depression predicted alexithymia. These findings are consistent with previous research and compatible with the view that a state of alexithymia can result from severe anxiety and depression. Copyright 0 1994 by W.B. Ssunders Compeny
nent alcoholic-, drug-, and mixed-substancedependent/abusing patients score in the alexithyrnic range on the Toronto Alexithymia Scale (TAS);l”J4 yet, when the TAS is administered at the end of the third or fourth week of inpatient treatment, only approximately one third score in the alexithymic range.i5J6 Why the discrepancy? Haviland et al. 8~15have suggested that at intake and shortly thereafter, the alexithymia of many substance abusers (as measured by the TAS) is a state reaction; that is, they have become alexithymic or more severely alexithymic as a consequence of being depressed and anxious. As the dysphoria clears, patients become less (and in some instances, no longer) alexithymic. Hendryx et al9 retested and extended the causal model of Haviland et al.* and demonstrated in freshman medical students that depression and state anxiety predicted alexithymia. However, in both models, depression and anxiety predicted only the emotional awareness deficits components of alexithymia. The TAS is the most psychometrically sound self-report alexithymia scale;” however, it is not without fault. For example, Haviland et a1.,8 Hendryx et a1.,9J1 and Kirmayer and Robbins18J9 have long argued that the theoretical alexithymia construct is multidimensional and thus not well represented by a global TAS score. In fact, the application of item-response theory to alexithymia assessment among alcoholics confirmed that “TAS alexithymia” is multidimensionalii Moreover, in studies of alcoholics and freshman medical students,8~9~1honly the two emotional awareness deficits dimensions were related as expected to each other, to depression and anxiety, and to various biochemical mark-
Comprehensive Psychiatry, Vol. 35, No. 2 (March/April),
1994:
pp 724-128
ALEXITHYMIA
AND SUBSTANCE
125
DEPENDENCE
ers; the diminution of fantasy and external cognitive style components were not. It seems reasonable to conclude from these studies that the distinct dimensions of alexithymia ought to be studied separately. The TAS has undergone major revisions;‘O.” most notably, items failing to tap alexithymia’s diminution of fantasy/reduction or absence of symbolic thinking component were eliminated, and several items purporting to measure alexithymia’s external cognitive style component were added. In light of these substantial changes and the potential explanatory power of the causal model of Hendryx et a1.,9 it is necessary to use the most recent version of the TAS (TAS-20)” to validate and, if possible, extend previous findings in psychoactive substancedependent samples. Such samples, unlike the medical student sample, have good ranges of alexithymia and depression severity* and, likely, anxiety severity. Our specific aims were (1) to make alexithymia prevalence estimates among substancedependent inpatients; (2) to compare inpatient women’s and men’s alexithymia scores with published normative data, and their alexithymia, depression, and anxiety scores with each other; (3) to examine patients’ test score differences by raceiethnicity and by diagnosis; and (4) to test the causal model9 of the interrelationships among the dimensions of alexithymia, depression, and anxiety. METHOD
Subjects Subjects were a consecutive series of 204 consenting patients, 84 women and 120 men, admitted to a university medical center’s inpatient chemical dependency treatment program. (Roughly 40% of all admitted patients over a 14.month period agreed to participate.) Their ages ranged from 15 to 69 years, with a mean ? SD of 37 2 11 years. Six (2.9%,) were African-American. and 198 (97.1%) were white (28 were of Hispanic descent, and 170 were not). Seventy-two (35.3%) were being treated for alcohol dependence, 79 (38.7%) for dependence on a drug or drugs other than alcohol, and 53 (26.0%) for mixed-substance dependence (dependence on two or more psychoactive substances. one of which was alcohol). These clinical diagnoses were made by admitting physicians using DSM-III-R criteria.
Instruments To measure alexithymia, we used the most recent TAS (TAS-Xl).” Respondents rate the 20 self-descriptive state-
ments on a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Mean (*SD) TAS-20 scores for normal adult women and female psychiatric outpatients are 46.1 ? 9.8 and 54.5 2 13.5. respectively: for normal adult men and male psychiatric outpatients, the respective mean scores are 47.2 2 10.6 and 55.3 + 12.2.” Persons scoring 61 and above are considered alexithymic: those scoring 51 and below are considered nonalexithymic (Graeme J. Taylor, M.D., personal communication, April 1. 1993). The scale is reliable (coefficient (Y= 0.81) and has a three-factor structure (subscale abbreviations and coefficient alphas are shown in parentheses), i.e.. difftculty identifying feelings and distinguishing them from the bodily sensations that accompany emotions (TAS-20-IF, 0.78), difficulty describing feelings to others (TAS-20-CF. 0.75). and externally oriented thinking (TAS-20-ET, 0.66). To measure depression, we used the revised. 21.item Beck Depression Inventory (BDI).” Items are rated on a four-point Likert scale ranging from absent (0) to severe (3). The sum of the first 13 items represents cognitive/ affective symptoms (BDI-C/A), and the sum of the last eight items represents somatic/performance complaints (BDI-S/P). Ranges of depression severity are as follows: 0 to 9. normal or asymptomatic: IO to 18, mild to moderate: 19 to 29. moderate to severe; and 30 to 63, extremely severe. The mean (?-SD) BDI score for the alcoholic normative sample is 13.9 i lO.6.?? The BDI is reliable and valid” and thought to be a good measure of depression severity in psychoactive substance-dependent/abusing samples.‘“-?’ To measure anxiety, we used the 20-item state portion of the State-Trait Anxiety Inventory (STAI-S). a reliable and valid self-evaluation.?h To rate the items, respondents use a four-point Likert scale ranging from not at all (1) to very much so (4). The scale consists of 10 state “anxiety present” absent” and 10 state “anxiety items. Respective mean (+-SD) STAIN scores for working women and men are 35.2 + 10.6 and 35.7 t 10.4.“h
Procedure All subjects completed the three questionnaires in an individual setting at their convenience (typically within 3 days of admission; no later than within 7 days of admission).
Prevalence Estimates Based on their TAS-20 total scores. subjects were classified into the following two groups: 61 and above = alexithymic, 60 and below = neither alexithymic nor nonalexithymic and nonalexithymic. To compare women’s and men’s alexithymia rates, we used a 2 x 2 chi-square test ((Y = 0.05).
Means Comparisons To compare our subjects’ mean TAS-20 scores with normative data?’ and to evaluate total test score and subscale score differences of women and men and of Hispanic and non-Hispanic whites (there were too few African-Americans [n = h] to include in the raceiethnicity analyses). we used two-tailed t tests for independent samples. To evaluate test score differences by diagnosis (alcohol 1’ drug 1’ mixed-substance dependence). we used a one-way
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analysis of variance and the Neuman-Keuls multiple comparison procedure. For all of these tests, cxwas set at 0.05.
Table 1. Women’s and Men’s TAS-20, BDI, and STAI-S Total and Subscale Scores MlXl
Path Analyses
(n = 84)
Based on the structure of the three instruments described above, we defined three alexithymia factors (TAS-20-IF, TAS-20-CF, and TAS-20-ET), two depression factors (BDIC/A and BDI-S/P), and one anxiety factor (STAI-S). To arrive at factor scores, we simply summed subjects’ item scores within each factor. To study the directional relationships among the six alexithymia, depression, and anxiety factors and the bidirectional relationships among each instrument’s factors, we used LISREL VI’s*’ path analysis. The confirmatory model we tested was patterned after previously well-supported models; that is, the alexithymia factors were hypothesized to be affected by the depression and the anxiety factors and the depression factors by the anxiety factors.8,9 The model results indicate size and direction of path coefficients and which associations are significant at P less than .05; moreover, an overall model R* is given. RESULTS
Prevalence Estimates
Eighty-five of the 204 patients (41.7%) scored the alexithymic range on the TAS-20, 42 of the 84 women (50.0%) and 43 of the 120 men (35.8%). The difference between women and men was statistically significant (x2 = 4.08, in
df = 1, P < .05). Means Comparisons
Average TAS-20 scores for women (mean & SD = 59.5 + 11.1) were significantly higher than average TAS-20 scores for women in the two normative samples, normal adult women(46.1 + 9.8, t = 8.29,df = 166,P < .OOl) and female psychiatric outpatients (54.5 & 13.5, t = 2.81, df = 206, P < .Ol). Men’s mean TAS-20 scores (56.0 & 11.9) were significantly higher than those in one of the two normative groups, normal adult men (47.2 + 10.6, t = 4.70, df= 173, P < .OOl); however, they were not higher than those of male psychiatric outpatients (55.3 + 12.2). The comparisons of women’s and men’s alexithymia, depression, and anxiety assessments are summarized in Table 1. Women’s mean TAS20, BDI, and STAI-S scores were significantly higher than men’s mean scores. Moreover, women’s subscale scores were higher on the TAS-20-IF subscale and the BDI-S/P subscale. Ethnic differences (Hispanic v non-Hispanic whites) in age and in total and subscale scores were not significant. Diagnostic group differ-
(n = 120)
Mean
SD
Mean
SD
f.df,
SCOE
59.5
11.1
56.0
11.9
2.12,202,
<.05
TAS-20-IF
22.3
6.3
19.7
6.7
2.81,202,
< .Ol
TAS-20-CF
16.8
4.4
15.8
5.0
TAS-20-ET
20.4
4.5
20.4
4.1
21.6
11.0
17.5
10.4
BDI-C/A
13.3
7.4
11.5
7.1
BDI-S/P
a.3
4.7
6.1
4.4
3.52,202,
< .Ol
55.0
12.8
50.0
11.8
2.87,202,
< .Ol
TAS-20
P
total
BDI total
score
NS NS 2.69,202,
< .Ol
NS
STAI-S total score
ences in these mean scores were not significant, with one exception, i.e., on average, alcoholdependent patients were significantly older (42 + 12) than drug-dependent (34 + 9) and mixed-substance-dependent patients (34 + 10; P < .05, Neuman-Keuls post-hoc test). Path Analyses
The model for all subjects is displayed in Fig 1; only significant (P < .05) paths are shown. State anxiety predicted both depression factors and all three alexithymia factors; the depr:ssion factors predicted alexithymia’s difficulty ldentifying feelings factor. The two depression factors were correlated. Difficulty identifying feelings and difficulty communicating feelings were correlated, as were difficulty communicating feelings and external thinking. The coefficient of determination (R*) for the model was .393. The model for women differed in two minor ways from the total model; there was a significant negative link between somatic/performance and difficulty communicating feelings and no significant correlation between difficulty communicating feelings and external thinking. The coefficient of determination was .472. The model for men also differed slightly from the one for all subjects; here the link between anxiety and external thinking was not significant, and the coefficient of determination was .336. DISCUSSION
Before commenting on the results, we must note several limitations of the present study. First, the sample size is relatively small, particularly for the women’s and men’s path analyses.
ALEXITHYMIA
127
AND SUBSTANCE DEPENDENCE
DEPRESSION (=‘I)
ANXIETY (STAG)
ALEXITHYMIA (TAS-20)
------I Fig 1. Interrelationships among the dimensions of anxiety, depression, and alexithymia (LISREL model) for all subjects (N = 204).
Second, we used only single, self-report indicators of alexithymia, depression, and anxiety, and we have no estimate of neuropsychiatric impairment at the time of testing. Finally, drawing causal inferences from correlational data has many pitfalls. Despite these limitations, we believe that our findings are both interesting and potentially useful. Our 35.8% alexithymia prevalence estimate for men is less than the 50% prevalence estimates in three samples of psychoactive substance-dependent/abusing men in which the original TAS was used. lo-l2The rate for women (50.0%) in the present sample was significantly higher than the rate for men. The differences between women’s and men’s average TAS-20, BDI, and STAI-S scores were substantial and statistically significant. This finding is consistent with research showing that many alcohol- and drug-dependent women seek help for depression and anxiety, not for substance dependence per se,28.29and enter treatment programs when their depression and anxiety are severe.28.30 In the path analyses, state anxiety predicted the two depression factors and the three alexithymia factors. This is the first causal model in which all dimensions of alexithymia were related as hypothesized to anxiety. This suggests that alexithymia per se, not only its emotional awareness deficits, is responsive to situational stress. Moreover, TAS-20-CF and TAS-20-ET
were positively correlated. In no previous models was alexithymia’s externally oriented thinking component related to depression or anxiety or to alexithymia’s emotional awareness deficits components. Our long-held view is that state and trait alexithymia can result from deficits induced by severe and persistent stress+‘*J5 and that they have neurophysiologic underpinnings.‘6J’.3z In stressful circumstances, one is protected (i.e., defended) against the pain of full affect (see also Zeitlin et a1.3”and Zeitlin and McNally”4). An alexithymic individual may experience fear, anger, and sadness, as Taylor et al.” note, but these emotions have lost some of their persuasive quality.35 These subtle but serious losses can exact a price in vulnerability to addictive disorders and losses of critical social skills. We believe that the reasonableness of the hypothesized link between alexithymia and stress provides sufficient justification for setting up the path analyses and testing the models as we have. Our findings continue to support such a connection; however, we recognize that more study is needed to firmly establish this link.
ACKNOWLEDGMENT The authors thank the staff of the Recovery Services unit. Loma Linda University Behavioral Medicine Center. for their assistance with the study.
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ET AL
REFERENCES 1. Nemiah JC, Sifneos PE. Affect and fantasy in patients with psychosomatic disorders. In: Hill OW (ed): Modern Trends in Psychosomatic Medicine. Vol 2. London, England: Butterworths, 1970:26-34. 2. Krystal H, Raskin H. Drug Dependence: Aspects of Ego Functions. Detroit, MI: Wayne State University Press, 1970. 3. Nemiah JC. Freyberger H, Sifneos PE. Alexithymia: a view of the psychosomatic process. In: Hill OW (ed): Modern Trends in Psychosomatic Medicine. Vol3. London, England: Butterworths, 1976:430-439. 4. Taylor GJ. Alexithymia: concept, measurement, and implications for treatment. Am J Psychiatry 1984;141:725732. 5. Taylor GJ, Bagby RM, Parker JDA. The alexithymia construct: a potential paradigm for psychosomatic medicine. Psychosomatics 1991;32:153-164. 6. Wise TN, Mann LS, Mitchell JD, Hryvniak M, Hill B. Secondary alexithymia: an empirical validation. Compr Psychiatry 1990;31:284-288. 7. Fukunishi I, Saito S, Ozaki S. The influence of defense mechanisms on secondary alexithymia in hemodialysis patients. Psychother Psychosom 1992;57:50-56. 8. Haviland MG, Hendryx MS, Cummings MA, Shaw DG, MacMurray JP. Multidimensionality and state dependency of alexithymia in recently sober alcoholics. J Netv Ment Dis 1991;179:284-290. 9. Hendryx MS, Haviland MG, Shaw DG. Dimensions of alexithymia and their relationships to anxiety and depression. J Pers Assess 1991;56:227-237. 10. Haviland MG, Shaw DG, MacMurray JP, Cummings MA. Validation of the Toronto Alexithymia Scale with substance abusers. Psychother Psychosom 1988;50:81-87. 11. Hendryx MS, Haviland MG, Gibbons RD, Clark DC. An application of item response theory to alexithymia assessment among ,abstinent alcoholics. J Pers Assess 1992; 58506-515. 12. Taylor GJ, Parker JDA, Bagby RM. A preliminary investigation of alexithymia in men with psychoactive substance dependence. Am J Psychiatry 1990;147:1228-1230. 13. Taylor GJ, Ryan D, Bagby RM. Toward the development of a new self-report alexithymia scale. Psychother Psychosom 1985;44:191-199. 14. Taylor GJ, Bagby RM, Ryan DP, Parker JDA, Doody KF, Keefe P. Criterion validity of the Toronto Alexithymia Scale. Psychosom Med 1988;50:500-509. 15. Haviland MG, Shaw DG, Cummings MA, MacMurray JP. Alexithymia: subscales and relationship to depression. Psychother Psychosom 1988;50:164-170. 16. Henry JP, Haviland MG, Cummings MA, Anderson DL, Nelson JC, MacMurray JP, et al. Shared neuroendocrine patterns of post-traumatic stress disorder and alexithymia. Psychosom Med 1992;54:407-415. 17. Taylor GJ, Bagby RM, Ryan DP, Parker JDA.
Validation of the alexithymia construct: a measurementbased approach. Can J Psychiatry 1990;35:290-297. 18. Kirmayer LJ, Robbins JM. What does the Toronto Alexithymia Scale measure? [abstract]. Psychosom Med 1991;53:222. 19. Kirmayer LJ, Robbins JM. Cognitive and social correlates of the Toronto Alexithymia Scale. Psychosomatits 1993;34:41-52. 20. Taylor GJ, Bagby RM, Parker JDA. The revised Toronto Alexithymia Scale: some reliability, validity, and normative data. Psychother Psychosom 1992;57:34-41. 21. Bagby RM, Taylor GJ, Parker JDA. Reliability and validity of the 20-item revised Toronto Alexithymia Scale. Presented at the 50th Anniversary International Meeting of the American Psychosomatic Society; 1992 March 31-April 4; New York, NY. 22. Beck AT, Steer RA. Beck Depression Inventory Manual. San Antonio, TX: The Psychological Corp., 1987. 23. Clark DC, Gibbons RD, Fawcett J, Aagesen CA, Sellers D. Unbiased criteria for severity of depression in alcoholic inpatients. J Nerv Ment Dis 1985;173:482-487. 24. Clark DC, Gibbons RD, Haviland MG, Hendryx MS. Assessing the severity of depressive states in recently detoxified alcoholics. J Stud Alcohol 1993;54:107-114. 25. Weiss RD, Grillin ML, Mirin SM. Diagnosing major depression in cocaine abusers: the use of depression rating scales. Psychiatry Res 1989;28:335-343. 26. Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, 1983. 27. Joreskog KG, Sorbom D. LISREL VI: Analysis of Linear Structural Relationships by the Method of Maximum Likelihood. Mooresville, IN: Scientific Software, 1986. 28. Blume SB. Women and alcohol: a review. JAMA 1986;256:1467-1470. 29. Thorn B. Sex differences in help-seeking for alcohol problems. I. The barriers to help-seeking. Br J Addict 1986;81:777-788. 30. Weisner C, Schmidt L. Gender disparities in treatment for alcohol problems, JAMA 1992;268:1872-1876. 31. Henry JP. Biological basis of the stress response. Integr Physiol Behav Sci 1992;27:66-83. 32. Henry JP. Biological basis of the stress response. News Physiol Sci 1993;8:69-73. 33. Zeitlin SB. McNally RJ, Cassiday KL. Alexithymia in victims of sexual assault: an effect of repeated traumatization? Am J Psychiatry 1993;150:661-663. 34. Zeitlin SB, McNally RJ. Alexithymia and anxiety sensitivity in panic disorder and obsessive-compulsive disorder. Am J Psychiatry 1993;150:658-660. 35. Henry JP, Haviland MG. Alexithymia as a stress response. Presented at the 5th International Montreux Congress on Stress (The American Institute of Stress); I993 Feb 14-19; Montreux, Switzerland.