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Alexithymia—state or trait? One-year follow- up study of general hospital psychiatric consultation out-patients
Journal oJP3Tchosomatic Research, gol. 38. No. 7, pp. 681 685, 1994 Copyright © 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0022 3999/94 $7.00 + .00
Pergamon 0022-3999(94)00033--6
A L E X I T H Y M I A - - S T A T E O R TRAIT? O N E - Y E A R FOLLOWU P S T U D Y OF G E N E R A L HOSPITAL P S Y C H I A T R I C C O N S U L T A T I O N OUT-PATIENTS J O U K O K. S A L M I N E N , * S I M O S A A R I J A R V I , t TUULA TAMMINEN*
E R K K I filAIRELfit and
(Received for publication 6 May 1994)
Abstract We carried out a 1-year follow-up study on 54 out of 80 general hospital psychiatric consultation out-patients. Alexithymic features were measured by the Toronto Alexithymia Scale (TAS), and selfreported psychological distress with the Brief Symptom Inventory (BSI). Men were more alexithymic and distressed than women both at the baseline and at the follow-up evaluations. The degree of alexithymia in both genders remained consistent, whereas psychological distress decreased significantly in both genders during the follow-up period. Therefore we conclude that alexithymia presents a constant trait in psychiatric consultation out-patients. INTRODUCTION The term and concept of alexithymia originally referred to a personality trait of p s y c h o s o m a t i c patients [1]. It was thought that the poorer the capacity of a person to experience feelings and to express them verbally, the m o r e the individual is liable to develop somatic s y m p t o m s in an emotionally stressful situation. However, empirical research has shown that alexithymia is not specific for p s y c h o s o m a t i c patients [2]. M o r e recently, it has been p r o p o s e d that alexithymia is even m o r e prevalent in psychiatric than in p s y c h o s o m a t i c patients [3]. F u r t h e r m o r e , there is some evidence that alexithymic features m a y decrease in some patients diagnosed as medically ill as their condition improves, i.e. alexithymia could be a state dependent secondary p h e n o m e n o n [4, 5]. Wise and co-workers studied this p h e n o m e n o n and they found that the medically ill patients were m o r e alexithymic than the healthy population. Alexithymia was best predicted by b o t h depressed m o o d and lowered quality of life, rather than by the categorical ranking o f the severity o f the medical illness [6]. T h e consistency o f alexithymia has rarely been studied in clinical populations. The purpose of the present study was to investigate whether alexithymia in general hospital psychiatric out-patients is a constant feature, i.e. a trait, or whether it is a circumstantially dependent one and which changes time, i.e. rather a state. In our earlier study we found that psychological distress was strongly associated with alexithymia in psychiatric consultation-liaison patients [7]. Therefore it seemed
* The Rehabilitation Research Centre of the Social Insurance Institution, Turku, Finland. t Department of Psychiatry, University of Turku, Turku, Finland. 681
682
J. K. SALMINEN ET AL.
i m p o r t a n t t o f o l l o w t h e changes in state of distress of the patients as well as alexithymia.
METHOD
Subjects The subjects of the present study included 80 consecutive patients (31 men, 49 women) who were referred by non-psychiatric colleagues for consultation at the psychiatric out-patient clinic of the Turku University Hospital. The inclusion criteria of the study were informed consent and an age of 18 64 yr. The exclusion criteria were psychotic disorders, organic brain diseases, mental retardation, and clinically important sensory defects. Also all emergency patients were excluded, because they present primarily psychiatric problems such as suicide attempts and/or alcohol related problems. Assessments and measures at the baseline At the baseline evaluation each patient was interviewed by a psychiatrist and a diagnostic assessment was made according to axis 1 of the DSM-III-R criteria. After the interview the patients independently completed the 26-item Toronto Alexithymia Scale (TAS), a valid and reliable self-report measure of alexithymia [8]. The Finnish version of the TAS has been validated in a Finnish population study [9]. We used the mean of total score of the TAS as an indicator of alexithymia. The patients also completed the 37-item version of Brief Symptom Inventory (BSI-37) derived from the original 53-item BSI by omitting the psychotic and paranoid symptom dimensions that are quite rare in a sample such as ours [10]. The mean of total score of the BSI-37 was used as an indicator of psychological distress. The BSI-37 measure has also been validated in a Finnish population study [11]. Socioeconomic status was determined according to Handbook of the Central Statistical Office of Finland, which takes education into account [12]. In the final analysis we dichotomized socioeconomic status to a higher and a lower group. Physical diseases diagnosed by other physicians were recorded from patient data. The one-year Jollow-up Fifty-four patients (19 men, 35 women) of the total of 80 (67.5%) participated in the follow-up study. It consisted of an interview by a psychiatric nurse dealing with current perceived psychic health, and with the use of psychiatric and other health services during the preceding year. After the interview the patients completed the TAS and the BSI questionnaires again. Data analysis The data were analyzed using the SAS R, Version 6, Program Package [13]. Comparisons of continuous variables between two groups were analyzed by Student's t-test and respectively categorical variables by the Pearson chi-square test. Changes in continuous variables within a group were tested by the paired ttest.
RESULTS
Description o f subjects T h e s t u d y g r o u p ( S - g r o u p ) a n d t h e d r o p - o u t g r o u p ( D - g r o u p ) d i d n o t differ s i g n i f i c a n t l y in t h e i r m e a n a g e s o r m e a n T A S s c o r e s , o r i n t h e m e a n B S I s c o r e s f o r e i t h e r g e n d e r . N i n e t y p e r c e n t o f m e n , a n d 6 6 % o f w o m e n in t h e S - g r o u p w e r e m a r r i e d , c o m p a r e d t o 1 0 0 % o f m e n a n d 7 1 % o f w o m e n in t h e D - g r o u p . S i x t y - e i g h t percent of men and 86% of women belonged to lower socioeconomic groups (groups 4 - 7 ) i n t h e S - g r o u p , c o m p a r e d t o 6 7 % o f m e n a n d 7 9 % o f w o m e n in t h e D - g r o u p . At least one somatic disease was diagnosed in 58% of men and 37% of women in the S-group, and in 75% of men and 29% of women in the D-group. The most c o m m o n p s y c h i a t r i c d i s o r d e r s w e r e a n x i e t y d i s o r d e r s ( 4 7 % in m e n a n d 4 6 % in
Alexithymia--state or trait?
683
Table I.--Description of the Study G r o u p and the Drop-out G r o u p by Genders. Study group n Mean MEN Age TAS score BSI score WOMEN Age TAS score BSI score
[SD]
19
[SD]
p
44.5 74.7 58.8
(9.8) (9.8) (30.2)
NS NS NS
43.0 65.1 48.4
(10.6) (10.9) (19.9)
NS NS NS
I2 41.0 71.9 59.8
(11.3) (10.7) (27.5)
41.9 63.8 46.7
(11.4) (13.7) (20.0)
35
Table II.
Drop-out group n Mean
14
TAS and BSI Scores at the Baseline and at the Follow-up and the Significance of the Changes in Both Genders.
M E N ( n = 19) TAS score BSI score
Baseline Mean
[SD]
Follow-up Mean [SD]
p
71.9 59.8
(10.7) (27.5)
74.7 51.3
(13.1) (25.8)
NS 0.01
63.8 46.7
(13.7) (20.0)
62.5 36.7
(11.2) (21.8)
NS 0.007
W O M E N (n =
35) TAS score BSI score
women in the S-group, compared to 50% in men and 50% in women in the Dgroup), and affective disorders (32% in men and 11% in women in the S-group, compared to 17% in men and 7% in women in the D-group). N o statistically significant difference in the above-mentioned sociodemographic or clinical variables between the groups were noted (Table I).
Psychiatric treatment during the follow-up At the follow-up study the patients were asked about their psychiatric treatment during the preceding year. Nineteen patients (35% of total; 7 men and 12 women) had not undergone any kind of psychiatric treatment, whereas 35 patients (65% of total; 12 men and 23 women) had received some kind of active psychiatric treatment, mostly combined pharmacotherapy and supportive psychotherapy. There was one patient who had been treated only with pharmacotherapy.
The changes in TAS and BSI scores during the follow-up Men had higher TAS scores than women both at the baseline (p = 0.03) and at the follow-up (p = 0.0007) evaluations. The changes in TAS scores between the two assessments were not statistically significant either in men or in women (see Table II). Men also had higher BSI scores than women both at the baseline (p = 0.05) and at the follow-up (p = 0.03) evaluations. At the follow-up the BSI scores were,
684
J. K. SALMINEN E T AL.
however, significantly lower in both genders than at the baseline evaluation, i.e. the distress of the patients had clearly been alleviated during the year (see Table II) In alleviation of the distress during the follow-up, those patients, who received psychiatric treatment, did not differ significantly in the BSI scores from the patients who did not receive treatment. DISCUSSION
In this study we have shown that alexithymic characteristics remain constant in general hospital psychiatric consultation out-patients over 1-year follow-up, i.e. alexithymia seems to be a stable personality trait rather than a fluctuating state. This is true for both genders, although men were found to be more alexithymic and distressed than women in both evaluations. The finding of the constancy of alexithymic features in this clinical sample is in accordance with the results of a population study of Finnish middle-aged men, where a fairly high test-retest reliability score (0.78) for the TAS was obtained over a period of 8 months [9]. The results do not support the findings of a study suggesting that alexithymia in somatically ill patients is a state dependent phenomenon [5]. Psychological distress in the patients of both genders decreased significantly during the follow-up period. Interestingly, distress also decreased in those patients who had undergone psychiatric treatment. The explanation for this may be that consultation alone has effects which alleviate the distress of the patient. Another explanation is that the state of the patients improved spontaneously in due course. In conclusion, our study suggests that alexithymia in general hospital psychiatric consultation out-patients is a constant trait rather than a state. It was not found to change during a 1-year follow-up period either spontaneously or with psychiatric treatment. This is all the more remarkable because the psychological distress of the patients was alleviated significantly during the same period. This suggests that alexithymia and psychological distress are independent features of the psychological state of the patients. Acknowledgements--This paper was supported in part by Grant from the Signe and Ane Gyllenberg Foundation, Helsinki, Finland.
REFERENCES 1. SIFNEOS PE. The prevalence of alexithymic characteristics in psychosomatic patients. Psychother Psychosom 1973; 22: 255-262. 2. SMITH GR. A•exithymia in medica• patients referred t• a ••nsu•tati•n/•iais•n service. Am J Psychiatry 1983; 140: 9%101. 3. RUB1NO IA, GRASSO S, SONNINO A, PEZZAROSSA B. Is alexithymia a non-neurotic personality dimension? Br J Med Psychol 1991; 64:385 391. 4. FREYBERGER H. Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychoter Psychosom 1977; 28:337 342. 5. KELTIKANGAS-J~_RVINEN L. Concept of alexithymia II. The consistency of alexithymia. Psychother Psychosom 1987; 47:113-120. 6. WISE TN, MANN LS, MITCHELL JD, HRYVNIAK M, HILL B. Secondary alexithymia: An empirical validation. Compr Psychiatry 1990; 31" 284-288. 7. SAARIJ,~RVI S, SALMINEN JK, TAMMINEN T, AARELA. E. Alexithymia in psychiatric consultation-liaison patients. Gen Hosp Psychiatry 1993; 15:330 333.
Alexithymia
state or trait?
685
8. TAYLOR G J, BAGBY RM, RYAN DR P A R K E R JDA, DOODY K, K E E F E R Criterion validity of the Toronto Alexithymia Scale. Psychosom Med 1988; 50:500 509. 9. K A U H A N E N J, J U L K U N E N J, S A L O N E N JT. Validity and reliability of the Toronto Alexithymia Scale (TAS) in a population study. J Psychosom Res 1992; 36:687 694. 10. DEROGATIS LR, MELISARATOS N. The brief symptom inventory: An introductory report. Psychol Med 1983; 13:595 605. 11. K R O N H O L M E. Sleep and daytime vigilance. A Psychophysiological Community Study. Turku: Publications of the Social Insurance institution, Finland, ML:I21, 1993. In Finnish, with an English summary. 12. The Classification of Socio-economic Groups. Handbook of the Central Statistical Office of Finland, Helsinki 1989. In Finnish with an English summary. 13. SAS Institute Inc. SAS/STAT User's+Guide, Version 6, Fourth Edition, Volume 1 and 2, Gary, NC: SAS Institute Inc., 1990.
Pergamon 0022-3999(94)00033--6
A L E X I T H Y M I A - - S T A T E O R TRAIT? O N E - Y E A R FOLLOWU P S T U D Y OF G E N E R A L HOSPITAL P S Y C H I A T R I C C O N S U L T A T I O N OUT-PATIENTS J O U K O K. S A L M I N E N , * S I M O S A A R I J A R V I , t TUULA TAMMINEN*
E R K K I filAIRELfit and
(Received for publication 6 May 1994)
Abstract We carried out a 1-year follow-up study on 54 out of 80 general hospital psychiatric consultation out-patients. Alexithymic features were measured by the Toronto Alexithymia Scale (TAS), and selfreported psychological distress with the Brief Symptom Inventory (BSI). Men were more alexithymic and distressed than women both at the baseline and at the follow-up evaluations. The degree of alexithymia in both genders remained consistent, whereas psychological distress decreased significantly in both genders during the follow-up period. Therefore we conclude that alexithymia presents a constant trait in psychiatric consultation out-patients. INTRODUCTION The term and concept of alexithymia originally referred to a personality trait of p s y c h o s o m a t i c patients [1]. It was thought that the poorer the capacity of a person to experience feelings and to express them verbally, the m o r e the individual is liable to develop somatic s y m p t o m s in an emotionally stressful situation. However, empirical research has shown that alexithymia is not specific for p s y c h o s o m a t i c patients [2]. M o r e recently, it has been p r o p o s e d that alexithymia is even m o r e prevalent in psychiatric than in p s y c h o s o m a t i c patients [3]. F u r t h e r m o r e , there is some evidence that alexithymic features m a y decrease in some patients diagnosed as medically ill as their condition improves, i.e. alexithymia could be a state dependent secondary p h e n o m e n o n [4, 5]. Wise and co-workers studied this p h e n o m e n o n and they found that the medically ill patients were m o r e alexithymic than the healthy population. Alexithymia was best predicted by b o t h depressed m o o d and lowered quality of life, rather than by the categorical ranking o f the severity o f the medical illness [6]. T h e consistency o f alexithymia has rarely been studied in clinical populations. The purpose of the present study was to investigate whether alexithymia in general hospital psychiatric out-patients is a constant feature, i.e. a trait, or whether it is a circumstantially dependent one and which changes time, i.e. rather a state. In our earlier study we found that psychological distress was strongly associated with alexithymia in psychiatric consultation-liaison patients [7]. Therefore it seemed
* The Rehabilitation Research Centre of the Social Insurance Institution, Turku, Finland. t Department of Psychiatry, University of Turku, Turku, Finland. 681
682
J. K. SALMINEN ET AL.
i m p o r t a n t t o f o l l o w t h e changes in state of distress of the patients as well as alexithymia.
METHOD
Subjects The subjects of the present study included 80 consecutive patients (31 men, 49 women) who were referred by non-psychiatric colleagues for consultation at the psychiatric out-patient clinic of the Turku University Hospital. The inclusion criteria of the study were informed consent and an age of 18 64 yr. The exclusion criteria were psychotic disorders, organic brain diseases, mental retardation, and clinically important sensory defects. Also all emergency patients were excluded, because they present primarily psychiatric problems such as suicide attempts and/or alcohol related problems. Assessments and measures at the baseline At the baseline evaluation each patient was interviewed by a psychiatrist and a diagnostic assessment was made according to axis 1 of the DSM-III-R criteria. After the interview the patients independently completed the 26-item Toronto Alexithymia Scale (TAS), a valid and reliable self-report measure of alexithymia [8]. The Finnish version of the TAS has been validated in a Finnish population study [9]. We used the mean of total score of the TAS as an indicator of alexithymia. The patients also completed the 37-item version of Brief Symptom Inventory (BSI-37) derived from the original 53-item BSI by omitting the psychotic and paranoid symptom dimensions that are quite rare in a sample such as ours [10]. The mean of total score of the BSI-37 was used as an indicator of psychological distress. The BSI-37 measure has also been validated in a Finnish population study [11]. Socioeconomic status was determined according to Handbook of the Central Statistical Office of Finland, which takes education into account [12]. In the final analysis we dichotomized socioeconomic status to a higher and a lower group. Physical diseases diagnosed by other physicians were recorded from patient data. The one-year Jollow-up Fifty-four patients (19 men, 35 women) of the total of 80 (67.5%) participated in the follow-up study. It consisted of an interview by a psychiatric nurse dealing with current perceived psychic health, and with the use of psychiatric and other health services during the preceding year. After the interview the patients completed the TAS and the BSI questionnaires again. Data analysis The data were analyzed using the SAS R, Version 6, Program Package [13]. Comparisons of continuous variables between two groups were analyzed by Student's t-test and respectively categorical variables by the Pearson chi-square test. Changes in continuous variables within a group were tested by the paired ttest.
RESULTS
Description o f subjects T h e s t u d y g r o u p ( S - g r o u p ) a n d t h e d r o p - o u t g r o u p ( D - g r o u p ) d i d n o t differ s i g n i f i c a n t l y in t h e i r m e a n a g e s o r m e a n T A S s c o r e s , o r i n t h e m e a n B S I s c o r e s f o r e i t h e r g e n d e r . N i n e t y p e r c e n t o f m e n , a n d 6 6 % o f w o m e n in t h e S - g r o u p w e r e m a r r i e d , c o m p a r e d t o 1 0 0 % o f m e n a n d 7 1 % o f w o m e n in t h e D - g r o u p . S i x t y - e i g h t percent of men and 86% of women belonged to lower socioeconomic groups (groups 4 - 7 ) i n t h e S - g r o u p , c o m p a r e d t o 6 7 % o f m e n a n d 7 9 % o f w o m e n in t h e D - g r o u p . At least one somatic disease was diagnosed in 58% of men and 37% of women in the S-group, and in 75% of men and 29% of women in the D-group. The most c o m m o n p s y c h i a t r i c d i s o r d e r s w e r e a n x i e t y d i s o r d e r s ( 4 7 % in m e n a n d 4 6 % in
Alexithymia--state or trait?
683
Table I.--Description of the Study G r o u p and the Drop-out G r o u p by Genders. Study group n Mean MEN Age TAS score BSI score WOMEN Age TAS score BSI score
[SD]
19
[SD]
p
44.5 74.7 58.8
(9.8) (9.8) (30.2)
NS NS NS
43.0 65.1 48.4
(10.6) (10.9) (19.9)
NS NS NS
I2 41.0 71.9 59.8
(11.3) (10.7) (27.5)
41.9 63.8 46.7
(11.4) (13.7) (20.0)
35
Table II.
Drop-out group n Mean
14
TAS and BSI Scores at the Baseline and at the Follow-up and the Significance of the Changes in Both Genders.
M E N ( n = 19) TAS score BSI score
Baseline Mean
[SD]
Follow-up Mean [SD]
p
71.9 59.8
(10.7) (27.5)
74.7 51.3
(13.1) (25.8)
NS 0.01
63.8 46.7
(13.7) (20.0)
62.5 36.7
(11.2) (21.8)
NS 0.007
W O M E N (n =
35) TAS score BSI score
women in the S-group, compared to 50% in men and 50% in women in the Dgroup), and affective disorders (32% in men and 11% in women in the S-group, compared to 17% in men and 7% in women in the D-group). N o statistically significant difference in the above-mentioned sociodemographic or clinical variables between the groups were noted (Table I).
Psychiatric treatment during the follow-up At the follow-up study the patients were asked about their psychiatric treatment during the preceding year. Nineteen patients (35% of total; 7 men and 12 women) had not undergone any kind of psychiatric treatment, whereas 35 patients (65% of total; 12 men and 23 women) had received some kind of active psychiatric treatment, mostly combined pharmacotherapy and supportive psychotherapy. There was one patient who had been treated only with pharmacotherapy.
The changes in TAS and BSI scores during the follow-up Men had higher TAS scores than women both at the baseline (p = 0.03) and at the follow-up (p = 0.0007) evaluations. The changes in TAS scores between the two assessments were not statistically significant either in men or in women (see Table II). Men also had higher BSI scores than women both at the baseline (p = 0.05) and at the follow-up (p = 0.03) evaluations. At the follow-up the BSI scores were,
684
J. K. SALMINEN E T AL.
however, significantly lower in both genders than at the baseline evaluation, i.e. the distress of the patients had clearly been alleviated during the year (see Table II) In alleviation of the distress during the follow-up, those patients, who received psychiatric treatment, did not differ significantly in the BSI scores from the patients who did not receive treatment. DISCUSSION
In this study we have shown that alexithymic characteristics remain constant in general hospital psychiatric consultation out-patients over 1-year follow-up, i.e. alexithymia seems to be a stable personality trait rather than a fluctuating state. This is true for both genders, although men were found to be more alexithymic and distressed than women in both evaluations. The finding of the constancy of alexithymic features in this clinical sample is in accordance with the results of a population study of Finnish middle-aged men, where a fairly high test-retest reliability score (0.78) for the TAS was obtained over a period of 8 months [9]. The results do not support the findings of a study suggesting that alexithymia in somatically ill patients is a state dependent phenomenon [5]. Psychological distress in the patients of both genders decreased significantly during the follow-up period. Interestingly, distress also decreased in those patients who had undergone psychiatric treatment. The explanation for this may be that consultation alone has effects which alleviate the distress of the patient. Another explanation is that the state of the patients improved spontaneously in due course. In conclusion, our study suggests that alexithymia in general hospital psychiatric consultation out-patients is a constant trait rather than a state. It was not found to change during a 1-year follow-up period either spontaneously or with psychiatric treatment. This is all the more remarkable because the psychological distress of the patients was alleviated significantly during the same period. This suggests that alexithymia and psychological distress are independent features of the psychological state of the patients. Acknowledgements--This paper was supported in part by Grant from the Signe and Ane Gyllenberg Foundation, Helsinki, Finland.
REFERENCES 1. SIFNEOS PE. The prevalence of alexithymic characteristics in psychosomatic patients. Psychother Psychosom 1973; 22: 255-262. 2. SMITH GR. A•exithymia in medica• patients referred t• a ••nsu•tati•n/•iais•n service. Am J Psychiatry 1983; 140: 9%101. 3. RUB1NO IA, GRASSO S, SONNINO A, PEZZAROSSA B. Is alexithymia a non-neurotic personality dimension? Br J Med Psychol 1991; 64:385 391. 4. FREYBERGER H. Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychoter Psychosom 1977; 28:337 342. 5. KELTIKANGAS-J~_RVINEN L. Concept of alexithymia II. The consistency of alexithymia. Psychother Psychosom 1987; 47:113-120. 6. WISE TN, MANN LS, MITCHELL JD, HRYVNIAK M, HILL B. Secondary alexithymia: An empirical validation. Compr Psychiatry 1990; 31" 284-288. 7. SAARIJ,~RVI S, SALMINEN JK, TAMMINEN T, AARELA. E. Alexithymia in psychiatric consultation-liaison patients. Gen Hosp Psychiatry 1993; 15:330 333.
Alexithymia
state or trait?
685
8. TAYLOR G J, BAGBY RM, RYAN DR P A R K E R JDA, DOODY K, K E E F E R Criterion validity of the Toronto Alexithymia Scale. Psychosom Med 1988; 50:500 509. 9. K A U H A N E N J, J U L K U N E N J, S A L O N E N JT. Validity and reliability of the Toronto Alexithymia Scale (TAS) in a population study. J Psychosom Res 1992; 36:687 694. 10. DEROGATIS LR, MELISARATOS N. The brief symptom inventory: An introductory report. Psychol Med 1983; 13:595 605. 11. K R O N H O L M E. Sleep and daytime vigilance. A Psychophysiological Community Study. Turku: Publications of the Social Insurance institution, Finland, ML:I21, 1993. In Finnish, with an English summary. 12. The Classification of Socio-economic Groups. Handbook of the Central Statistical Office of Finland, Helsinki 1989. In Finnish with an English summary. 13. SAS Institute Inc. SAS/STAT User's+Guide, Version 6, Fourth Edition, Volume 1 and 2, Gary, NC: SAS Institute Inc., 1990.