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Does perceived social support and parental attitude relate to alexithymia? A study in Finnish late adolescents
Psychiatry Research 187 (2011) 254–260
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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s
Does perceived social support and parental attitude relate to alexithymia? A study in Finnish late adolescents Max Karukivi a,b,⁎, Matti Joukamaa c,d, Lea Hautala a,e, Olli Kaleva e,f, Kirsi-Maria Haapasalo-Pesu b, Pirjo-Riitta Liuksila e, Simo Saarijärvi a,g a
Unit of Adolescent Psychiatry, University of Turku, Finland Unit of Adolescent Psychiatry, Satakunta Hospital District, Pori, Finland Social Psychiatry Unit, Tampere School of Public Health, University of Tampere, Finland d Department of Psychiatry, Tampere University Hospital, Finland e Turku Municipal Health Care and Social Services, Turku, Finland f Department of Public Health, University of Turku, Finland g Unit of Adolescent Psychiatry, Turku University Hospital, Finland b c
a r t i c l e
i n f o
Article history: Received 27 May 2010 Received in revised form 18 October 2010 Accepted 27 November 2010 Keywords: Adolescents Alexithymia Parental attitude Social support
a b s t r a c t The aim of the present study was to explore the associations of perceived social support and parental attitude with alexithymia in a Finnish adolescent population sample. Of the initial sample of 935 adolescents, 729 (78%) answered the questionnaire and formed the final sample. The mean age of the subjects was 19 years (range 17–21 years). The 20-item Toronto Alexithymia Scale (TAS-20) was used for assessment of alexithymia. Perceived social support from family, friends, and significant other people was measured using the Multidimensional Scale of Perceived Social Support (MSPSS). Perceived parental care and overprotection were assessed using the Parental Bonding Instrument (PBI), and separately for mother and father. After controlling for the sociodemographic factors, alexithymia was significantly associated with a lower degree of experienced social support and higher parental overprotection both in females and males. Maternal overprotection was associated (p b 0.04) with TAS-20 total score as well as the Difficulty Identifying Feelings (DIF) and Difficulty Describing Feelings (DDF) subscales. The lack of social support from friends appeared to predict alexithymia more strongly than lack of support from family and significant other people. Against our hypothesis, maternal and paternal care was not directly associated with alexithymic features. This study highlights the significance of intrusive and overprotective parental attitudes as a possible risk factor for development of alexithymia. However, to assess causality, we need longitudinal studies. The results also emphasize the need for further studies to establish the significance of peer relationships in the development of alexithymia. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Adverse parenting, manifested as, for example, lack of maternal and paternal care or intrusive and excessive control, has been suggested to be associated with several psychiatric conditions and illnesses (Parker, 1983; Torresani et al., 2000; Russ et al., 2003). One possible mediating factor in this regard may be alexithymia. Alexithymia is a personality construct that signifies reduced ability to identify and describe feelings, a limited imagination, and a preoccupation with externally oriented thinking. It was initially depicted in the mid-1970s in psychosomatic patients (Sifneos, 1973), but since then, a vast amount of studies have been published associating alexithymia with a broad range of mental disorders and ⁎ Corresponding author. Unit of Adolescent Psychiatry, Hansakatu 5, FI-28100 Pori, Finland. Tel.: + 358 2 627 47 60; fax: + 358 2 627 47 85. E-mail address: max.karukivi@utu.fi (M. Karukivi). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.11.028
somatic illnesses (Mattila, 2009). Accumulating evidence suggests that alexithymia is also associated with mental disorders such as depression and eating disorders in adolescents (Cochrane et al., 1993; Ciarrochi et al., 2008). On the basis of population studies, alexithymia appears to be rather a common personality construct. The prevalence of alexithymia in general adult population has shown to be approximately 10 %, and it appears more commonly in males than in females (Salminen et al., 1999; Honkalampi et al., 2000; Kokkonen et al., 2001; Mattila et al., 2006; Franz et al., 2008). In adolescents, the prevalence of alexithymia appears to be at the same level as a whole, but no gender difference has been shown (Joukamaa et al., 2001; Säkkinen et al., 2007; Honkalampi et al., 2009). Previous studies have suggested that the development of affect regulation in childhood can be impaired if caregivers are emotionally unavailable or if they expose the child to inconsistent affective responses (Lumley et al., 1996; Taylor et al., 1997; De Panfilis et al.,
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2008). Thus, there appears to be an association between alexithymia and childhood adversities (Honkalampi et al., 2004; Picardi et al., 2005). Furthermore, alexithymia has been associated with lower maternal care (Fukunishi et al., 1997; Mason et al., 2005) and low social support in general (Fukunishi and Rahe, 1995). However, the causation is still quite unclear. On one hand, alexithymic features may reduce social support directly by hindering the building of relationships through lack of emotional recognition and expression. On the other hand, alexithymic individuals may not be able to utilize social support adequately because they neither recognize others' emotions nor respond to them appropriately (Kojima et al., 2003). Interestingly, according to our knowledge, there are no previous studies investigating the association of perceived parental attitude and alexithymia, and taking into consideration also experienced social support, although both of these factors have been studied separately in association with alexithymia. Correspondingly, while both parental bonding and social support have been studied in alexithymic individuals, there are only few studies exploring these associations in younger populations. The aim of the present study was to explore this association in a Finnish adolescent population sample, taking into account both the experienced maternal and paternal care and social support. We hypothesized that adolescents with alexithymic characteristics may have experienced less maternal care when growing up and would assess their social support as having been weaker. We also hypothesized that the association would be stronger in males and likely attributed to the DIF and DDF subscales. 2. Methods 2.1. Materials The subjects were recruited from a sample of students who had earlier participated in a research investigating eating disorder (ED) symptoms among adolescents (14–16 years old) who were studying in secondary schools in the City of Turku, Finland, during the school years 2003–2005. The results of the previous studies are reported elsewhere (Hautala et al., 2006, 2008, 2009). Altogether 935 individuals were eligible for the present study, and of them, 729 (78%) participated. The mean age in the sample was 19 years (range 17–21 years), and 74% of the subjects were female and 26% were male. The participation rate was higher among female (p b 0.001) and younger subjects (p = 0.04). All subjects gave their written informed consent to participate in the study. The study protocol was approved by the Ethical Committee of the Turku University Hospital. 2.2. Measures Alexithymia was measured using the 20-item Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994a,b), which is the most widely used method for assessing alexithymia. It consists of three subscales: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). The validity of the scale has been shown to be good for the TAS-20 scale as a whole and for the DIF and DDF subscales, whereas the validity of the EOT subscale is only moderate (Bagby et al., 1994a,b; Parker et al., 2003; Taylor et al., 2003). The psychometric properties of the Finnish version have been proven satisfactory (Joukamaa et al., 2001), and the scale has been validated in Finnish adolescents in two different population samples (Joukamaa et al., 2007; Säkkinen et al., 2007). As recommended by the developers of the scale (Bagby and Taylor, 1997), we used a cut-off score of 61 points or more for identifying a subject as alexithymic. For the purposes of statistical analyses, the TAS-20 score was also treated as a continuous variable. The Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988) is a 12-item self-report measure for subjective assessment of experienced social support from three sources: Family, Friends, and Significant Other. Each item is rated on a 7-point Likert-type scale ranging from “strongly disagree” to “strongly agree”. The total score ranges from 12 to 84 for the whole 12-item questionnaire and from 4 to 28 for each of the three subscales. The scale as a whole and each of its subscales have shown good internal reliability and validity (Zimet et al., 1988, 1990), and there is evidence supporting it as a psychometrically sound instrument to be used with adolescents as well (Canty-Mitchell and Zimet, 2000; Bruwer et al., 2008). Parental Bonding Instrument (PBI) (Parker et al., 1979) is a self-report scale consisting of 25 items, which are divided in two subscales, one measuring experienced care (12 items) and the other, overprotection (13 items). The subject is asked to score each parent as remembered during his or her first 16 years of life. Both the care and overprotection subscales have bipolar dimensions. For care, the positive (high) pole represents affection, emotional warmth, and closeness, while the negative (low) pole consists of, e.g., emotional coldness and rejection, and correspondingly, for overprotection, the positive (low) pole represents promotion of autonomy, while the negative (high) pole is characterized by
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intrusion, infantilization, and excessive contact. Each item is rated on a 4-point Likert-type scale and scored on a scale from 0 to 3. Thus, the sum score for the care subscale ranges from 0 to 36 and for the overprotection subscale, from 0 to 39. The psychometric properties of the instrument have been shown to be good (Parker et al., 1979; Parker, 1989). We also examined the answers separately for the two subscales and excluded those subjects who did not answer to at least 80% of the questions in both the care (10/12) and overprotection subscales (10/13). Subjects who had answered to at least 80% of the questions in each subscale were included in the final sample. The missing values were estimated, using the mean value of the questions answered, and the scores thus calculated were rounded to the nearest integer. 2.3. Statistical methods Basic summary statistics were used in the characterization of the data. The subjects were recruited by first selecting the schools and then inviting students from each school to participate. Due to this study design, certain level of intra-class correlation in observations from the same school was expected. If the intra-class correlation is not taken into account, it can be expected to lead to too small estimates of standard errors and to too small p-values in tests. Mixed models offer a comprehensive tool for analysis of this kind of data. That is why we used linear mixed models (glimmix) where the explanatory variables of main interest were included as fixed effect(s) in the models with the school as a random effect. The distribution of the response variable in these models is assumed to be the normal distribution. The normal distribution assumption of the TAS-20 total scores and its subscale scores were confirmed to be adequate. The analyses of the associations of the explanatory variables and alexithymia scales were first done separately for each explanatory variable. Finally the significant explanatory variables were included into the multivariate analysis. With all multivariate models, the variables of interest were forced (without any stepwise technique) into the model. A confirmatory factorial analysis was carried out, and the psychometric properties of both the TAS-20 and MSPSS scales were shown to be satisfactory. For the TAS-20 scale, the goodness-of-fit index (GFI) was 0.93, a score ≥0.85 being acceptable, and the adjusted goodness-of-fit index (AGFI) was 0.89, a score ≥ 0.80 being acceptable. Also the root–mean–square residual (SRMR) was satisfactory at 0.04 (a score ≤ 0.10 being acceptable), and the Steiger's root–mean–square error of approximation RMSEA was 0.07 (a score ≤0.08 being acceptable). As regards the MSPSS scale, GFI was 0.93, AGFI was 0.90, SRMR was 0.03, and RMSEA was 0.08. The Cronbach coefficient alpha scores for the PBI care and overprotection subscales showed good internal consistency, both for the maternal and paternal scales. The values were as follows: PBI care (mother), 0.92; PBI overprotection (mother), 0.85; PBI care (father), 0.93; and PBI overprotection (father), 0.85. The data were analyzed using the SAS software, version 9.2. The mixed models analyses were carried out using the glimmix procedure of the SAS software. The significance level was set at p b 0.05 in all tests.
3. Results Due to missing data, the actual number of subjects varied between 679 and 729 for different variables. Table 1 presents the mean scores for the TAS-20, PBI, and MSPSS scales and their subscales by gender. The prevalence of alexithymia was 8.2% for females and 8.5% for males, and no statistically significant gender difference was observed. In pair-wise analyses, there was a significant difference between alexithymic and non-alexithymic subjects in the MSPSS and PBI scores, with alexithymic subjects having lower scores in all of the scales, except for the maternal and paternal PBI overprotection subscales, both of which showed significantly higher scores (Table 2). Gender interacted with some of the variables (MSPSS total score, and the Friends and Significant Other subscales), and consequently, the analyses were carried out separately for females and males. In both females and males, the MSPSS total score and also the Family, Friends, and Significant Other subscale scores were significantly associated with the TAS-20 total score and the DIF and DDF subscale scores in pair-wise analyses, with a higher level of social support being associated with fewer alexithymic features (Table 3). However, the EOT subscale score was associated with lower MSPSS scores only in females. In pair-wise analyses, the maternal and paternal PBI care and overprotection scores were associated with the TAS-20 total score and the DIF and DDF scores in females. In males, the association between maternal PBI care and overprotection scores and the alexithymic feature scores was almost as strong as in females. The paternal PBI care and overprotection scores were also partly related to TAS-20 total
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Table 1 Mean scores for the Toronto Alexithymia Scale (TAS-20), Multidimensional Scale of Perceived Social Support (MSPSS), Parental Bonding Instrument (PBI), and their subscales by gender. Males
TAS-20 total DIF DDF EOT MSPSS total MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Females
N
Mean score
SE
N
Mean score
SE
d.f.
F
pa
188 186 187 187 189 189 187 188 179 179 188 188
46.11 13.25 11.28 21.67 68.38 23.09 22.38 23.04 28.03 6.95 31.12 10.75
0.79 0.39 0.34 0.34 0.86 0.39 0.34 0.33 0.56 0.45 0.44 0.46
535 523 527 525 537 535 536 537 503 503 534 534
44.68 15.29 11.16 18.23 71.74 22.70 24.07 24.97 26.10 8.61 30.05 10.13
0.54 0.23 0.25 0.23 0.51 0.26 0.21 0.19 0.33 0.29 0.26 0.27
(1,706) (1,692) (1,697) (1,695) (1,709) (1,707) (1,706) (1,708) (1,665) (1,665) (1,705) (1,705)
2.74 19.73 0.11 92.73 11.33 0.84 17.94 25.56 8.70 10.32 4.36 1.35
NS b0.001 NS b0.001 b0.001 NS b0.001 b0.001 0.003 0.001 0.04 NS
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analyses. Due to the modelling, the statistical comparisons between genders were done using F-test. NS = non-significant. a p-Value for pair-wise analyses.
after controlling for sociodemographic factors. Surprisingly, alexithymic features were not associated with subjectively experienced maternal and paternal care. As far as we know, this was the first time the associations of both parental bonding and social support with alexithymia were assessed in this age group. Alexithymic individuals assessed their social support having been weaker compared to their non-alexithymic peers. The difference in the MSPSS total scores was significant between the groups, and in the multivariate analyses, the MSPSS Family and Friends scores were associated with the TAS-20 total score. The association was attributed to the DIF and DDF subscales and was stronger for the MSPSS Friends subscale. The MSPSS Significant Other score was not associated with alexithymic features, although in females, it was associated with the EOT subscale score. However, the associations of the EOT subscale were generally more obscure, which may be related to the fact that the validity of the EOT subscale has been shown to be weaker, both as compared to the DIF and DDF subscales and to the TAS-20 scale as a whole (Taylor et al., 2003). The weak association of the MSPSS Significant Other score with alexithymia is quite understandable, because youth in this age group may not yet have formed deep relationships outside their family and friends. In previous studies, alexithymia has been associated with low social support (Fukunishi and Rahe, 1995; Posse et al., 2002). Posse et al. (2002) estimated the level of perceived social support using an assessment method other than MSPSS, but they observed a clear difference between alexithymic and non-alexithymic subjects using the TAS-20 scale. Having a low level of social support was 3.5 times
score and the DIF and DDF subscale scores. Higher PBI care scores were associated with fewer alexithymic features, while higher PBI overprotection scores were positively related with the TAS-20 total and subscale scores. Of the sociodemographic factors, neither the number of siblings nor the separation or deaths of parents were significantly associated with the TAS-20 total score or the alexithymia subscales in pair-wise analyses. However, dwelling, parents' divorce, smoking, occupation, and perceived health were associated with the TAS-20 total score or at least with one of the alexithymia subscales and thus were included to the multivariate analyses. Multivariate analyses were carried out taking into account those sociodemographic variables that had shown an association with alexithymic features in the pair-wise analyses. The results are presented in Table 4. High maternal – and for the most part, also paternal – overprotection predicted most significantly high scores in the alexithymia scales. The correlations between parental overprotection and alexithymic features were most notable in the TAS-20 total score and DIF in both genders. Additionally, a higher MSPSS Friends score was statistically significantly associated with a lower score in the TAS-20 and its subscales particularly in females, although the regression coefficients were clearly negative also in males. 4. Discussion The main finding in the present study among adolescents was that alexithymia is associated with a lower level of social support and higher parental overprotection. The results remained significant even
Table 2 Mean scores for the Multidimensional Scale of Perceived Social Support (MSPSS), and Parental Bonding Instrument (PBI) and their subscales in alexithymic and non-alexithymic subjects. Alexithymic
MSPSS total MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Non-alexithymic
N
Mean score
SE
N
Mean score
SE
d.f.
F
pa
60 58 59 60 54 54 59 59
59.78 19.36 19.31 20.93 23.64 8.80 26.49 14.14
1.50 0.67 0.60 0.58 1.03 0.81 0.77 0.81
664 664 662 663 625 625 661 661
71.84 23.13 23.99 24.78 26.89 8.04 30.70 9.95
0.50 0.24 0.20 0.19 0.31 0.24 0.23 0.24
(1,705) (1,703) (1,702) (1,704) (1,661) (1,661) (1,701) (1,701)
61.01 30.41 57.02 40.68 9.20 0.80 27.34 24.64
b0.001 b0.001 b0.001 b0.001 0.003 NS b0.001 b0.001
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analyses. Due to the modelling, the statistical comparisons between the alexithymic and non-alexithymic groups were done using F-test. NS = non-significant. a p-Value for pair-wise analyses.
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Table 3 Associations of the Toronto Alexithymia Scale (TAS-20) and its subscales with the Multidimensional Scale of Perceived Social Support (MSPSS), and Parental Bonding Instrument (PBI) and their subscales by gender. Males
TAS MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother DIF MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother DDF MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother EOT MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Females d.f.
F
pa
Regression coefficient
95% CI
−0.17 −0.27 −0.35 −0.29 0.09 0.58 −0.11 0.70
(1,171) (1,171) (1,169) (1,170) (1,161) (1,161) (1,170) (1,170)
29.91 16.65 22.70 18.60 1.47 5.74 8.20 26.02
b0.001 b0.001 b0.001 b0.001 NS 0.02 0.005 b0.001
−0.42 −0.76 −0.99 −0.92 −0.35 0.38 −0.48 0.45
−0.49 −0.92 −1.17 −1.11 −0.45 0.23 −0.62 0.31
to to to to to to to to
−0.08 −0.18 −0.14 −0.09 −0.05 0.46 −0.16 0.42
(1,169) (1,169) (1,167) (1,168) (1,159) (1,159) (1,168) (1,168)
24.82 23.06 15.91 10.93 8.15 17.10 18.06 33.13
b0.001 b0.001 b0.001 0.001 0.005 b0.001 b0.001 b0.001
−0.21 −0.42 −0.46 −0.38 −0.24 0.25 −0.31 0.26
−0.24 −0.50 −0.56 −0.49 −0.30 0.17 −0.38 0.19
−0.16 −0.29 −0.40 −0.34 −0.15 −0.06 −0.25 0.09
to to to to to to to to
−0.08 −0.08 −0.19 −0.14 0.04 0.16 −0.04 0.26
(1,170) (1,170) (1,168) (1,169) (1,160) (1,160) (1,169) (1,169)
33.36 12.55 32.58 21.37 1.42 0.78 7.27 16.89
b0.001 b0.001 b0.001 b0.001 NS NS 0.008 b0.001
−0.16 −0.28 −0.40 −0.35 −0.13 0.11 −0.18 0.15
−0.05 −0.10 −0.13 −0.17 −0.06 −0.13 −0.08 −0.06
to to to to to to to to
0.05 0.16 0.14 0.09 0.16 0.14 0.19 0.15
(1,170) (1,170) (1,169) (1,170) (1,160) (1,160) (1,169) (1,169)
0.00 0.26 0.01 0.34 0.79 0.00 0.68 0.70
NS NS NS NS NS NS NS NS
−0.06 −0.07 −0.15 −0.20 0.01 0.02 −0.03 0.04
Regression coefficient
95% CI
−0.27 −0.52 −0.60 −0.54 −0.14 0.32 −0.37 0.51
−0.37 −0.77 −0.85 −0.79 −0.36 0.06 −0.62 0.31
to to to to to to to to
−0.14 −0.34 −0.29 −0.24 −0.17 0.31 −0.30 0.32
−0.20 −0.47 −0.43 −0.38 −0.30 0.16 −0.44 0.21
−0.12 −0.19 −0.29 −0.24 −0.05 0.05 −0.14 0.17 −0.002 0.03 0.005 −0.04 0.05 0.002 0.05 0.04
d.f.
F
pa
to −0.36 to −0.59 to −0.81 to −0.73 to −0.24 to 0.52 to −0.35 to 0.58
(1,518) (1,516) (1,517) (1,518) (1,484) (1,484) (1,515) (1,515)
151.83 84.88 122.46 88.93 39.41 26.95 51.19 42.84
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
to to to to to to to to
−0.17 −0.33 −0.37 −0.27 −0.18 0.32 −0.24 0.34
(1,506) (1,505) (1,506) (1,506) (1,474) (1,474) (1,503) (1,503)
115.63 87.79 87.21 48.22 69.09 41.75 71.30 52.04
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
−0.19 −0.35 −0.47 −0.43 −0.18 0.06 −0.23 0.09
to to to to to to to to
−0.13 −0.22 −0.32 −0.27 −0.09 0.17 −0.12 0.20
(1,510) (1,508) (1,509) (1,510) (1,477) (1,477) (1,507) (1,507)
134.97 73.05 117.57 77.61 36.21 15.31 40.09 28.59
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
−0.09 −0.14 −0.22 −0.28 −0.03 −0.04 −0.09 −0.01
to to to to to to to to
−0.03 −0.003 −0.07 −0.12 0.05 0.08 0.02 0.10
(1,508) (1,506) (1,507) (1,508) (1,475) (1,475) (1,505) (1,505)
17.33 4.17 14.56 23.59 0.17 0.41 1.19 2.53
b0.001 0.04 b0.001 b0.001 NS NS NS NS
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analysis. Due to the modelling, the statistical tests were done using F-test. All explanatory variables were continuous variables. The regression coefficient estimates the change in the mean value of the response variable corresponding to the unit change in the explanatory variable. NS = non-significant. a p-Value for pair-wise analyses.
more common in alexithymic than in non-alexithymic individuals. However, no firm conclusions about causality can be made, on one hand, because of the lack of longitudinal studies and, on the other hand, because alexithymic individuals presumably have difficulties utilizing social support due to their inherently low emotional and social skills and inability to form close relationship (Kojima et al., 2003). Irrespective of the reported level of social support, Posse et al. (2002) found a significant difference in the lack of well-being between the alexithymic and non-alexithymic subjects, with alexithymic individuals being clearly worse off. In the present study, perceived health was also significantly associated with alexithymic features in two of the TAS-20 subscales for females. A similar observation regarding the association between perceived health and alexithymia has been made in a study among Finnish general population (Mattila et al., 2006). Also, in a study by Honkalampi et al. (2009), alexithymic adolescents aged 13 to 18 assessed their health relatively good less commonly than their non-alexithymic peers did. The mother–child relationship has been of particular interest as regards the development of alexithymia, and alexithymic features have been suggested to be associated with early neglect and lack of maternal support in several cultures (Fukunishi et al., 1997; Mason et al., 2005). However, it has also been questioned if individuals who indeed are victims of parental neglect may resort to primitive defence
mechanisms, such as splitting and idealizing and, thus, are not really suitable persons to be studied with self-report instruments (Kooiman et al., 1998). In the present study, the strongest association was observed between maternal overprotection and alexithymia; the association was clear both in males and females and was attributed to the DIF and DDF subscales. Paternal overprotection was also, to some extent, associated with alexithymic features, mainly in females. De Panfilis et al. (2008) studied the mediating role of alexithymia between parental bonding and personality disorder. They found that the DDF subscale was associated with maternal overprotection in particular, and they suggested that maternal behavioral restrictiveness and intrusiveness could be associated with later difficulties in sharing and describing emotions. In another study with nonclinical subjects, the DDF scores were related with certain personality traits such as difficulty to be warm, sensitive, cooperative, and sociable (Picardi et al., 2005). Thus, it is plausible that maternal overprotection, manifested as denial of psychological autonomy and obtrusiveness, may lead to impairment in communicating emotions, which portrays the alexithymic feature of difficulty describing feelings. Alexithymic individuals reported having experienced significantly less care from both parents when growing up in comparison to their non-alexithymic peers. However, this association did not survive multivariate analyses. This was slightly surprising, because, in previous studies, alexithymia has been associated with lower maternal care.
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Table 4 Multivariate analysis of associations of the Toronto Alexithymia Scale (TAS-20) and its subscales with the Multidimensional Scale of Perceived Social Support (MSPSS) and Parental Bonding Instrument (PBI) and their subscales, and sociodemographic factors by gender. Males
TAS MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) DIF MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) DDF MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) EOT MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No)
good)
good)
good)
good)
Females d.f.
F
pa
Regression coefficient
95% CI
d.f.
−0.14 0.01 0.57 0.49 0.49 0.77 0.64 2.23 3.66 3.77 5.36 4.59
(1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143)
7.07 3.75 0.10 3.44 1.04 1.41 8.87 0.59 0.13 0.06 0.54 1.38
0.009 NS NS NS NS NS 0.003 NS NS NS NS NS
−0.28 −0.67 −0.08 −0.05 0.15 −0.04 0.22 0.61 −1.37 2.92 1.96 1.70
−0.52 to −0.05 −1.04 to −0.29 −0.46 to 0.30 −0.17 to 0.07 0.002 to 0.30 −0.23 to 0.14 0.06 to 0.37 −1.15 to 2.36 −3.04 to 0.29 0.66 to 5.18 −0.29 to 4.22 −0.01 to 3.42
(1,460) 5.92 (1,460) 12.33 (1,460) 0.17 (1,460) 0.66 (1,460) 4.00 (1,460) 0.22 (1,460) 7.75 (1,460) 0.46 (1,460) 2.62 (1,460) 6.47 (1,460) 2.92 (1,460) 3.82
0.015 b0.001 NS NS 0.046 NS 0.006 NS NS 0.011 NS NS
to to to to to to to to to to to to
0.01 0.02 0.37 0.18 0.36 0.32 0.32 1.11 1.78 1.89 3.86 3.29
(1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142)
3.55 3.41 0.64 0.38 4.21 0.19 6.67 0.73 0.02 0.01 2.75 4.98
NS NS NS NS 0.042 NS 0.011 NS NS NS NS 0.027
−0.11 −0.37 −0.11 −0.08 0.10 −0.06 0.09 −0.37 −0.59 0.55 2.55 0.53
−0.23 to −0.56 to −0.08 to −0.14 to 0.02 to −0.16 to 0.01 to −1.28 to −1.46 to −0.64 to 1.37 to −0.36 to
0.01 −0.17 −0.31 −0.01 0.18 0.03 0.17 0.55 0.27 1.73 3.73 1.42
(1,452) 3.50 (1,452) 13.99 (1,452) 1.24 (1,452) 5.59 (1,452) 6.52 (1,452) 1.55 (1,452) 5.44 (1,452) 0.61 (1,452) 1.81 (1,452) 0.82 (1,452) 18.11 (1,452) 1.35
NS b0.001 NS 0.019 0.011 NS 0.020 NS NS NS b0.001 NS
−0.33 −0.48 −0.14 −0.05 −0.19 −0.10 0.05 −2.40 −0.96 −1.12 −0.94 −1.00
to to to to to to to to to to to to
0.01 −0.07 0.26 0.16 0.08 0.29 0.26 0.61 1.62 1.64 2.34 1.39
(1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142)
3.25 6.93 0.35 1.21 0.60 0.88 8.38 1.37 0.25 0.14 0.71 0.10
NS 0.009 NS NS NS NS 0.004 NS NS NS NS NS
−0.10 −0.32 0.02 −0.04 0.02 −0.01 0.07 0.40 −0.57 0.87 1.01 0.08
−0.19 to 0.001 −0.47 to −0.16 −0.13 to 0.18 −0.09 to 0.01 −0.04 to 0.08 −0.09 to 0.07 0.002 to 0.13 −0.33 to 1.13 −1.26 to 0.13 −0.07 to 1.81 0.07 to 1.96 −0.63 to 0.80
(1,453) 3.79 (1,453) 16.30 (1,453) 0.08 (1,453) 2.25 (1,453) 0.56 (1,453) 0.05 (1,453) 4.10 (1,453) 1.17 (1,453) 2.57 (1,453) 3.27 (1,453) 4.44 (1,453) 0.05
NS b0.001 NS NS NS NS 0.040 NS NS NS 0.036 NS
−0.34 −0.23 −0.36 −0.07 −0.19 −0.16 −0.05 −1.60 −1.16 −2.03 −3.20 −1.18
to to to to to to to to to to to to
0.14 0.35 0.20 0.22 0.18 0.39 0.24 2.59 2.41 1.81 1.29 1.13
(1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143)
0.63 0.17 0.35 1.05 0.01 0.65 1.54 0.22 0.47 0.01 0.70 0.40
NS NS NS NS NS NS NS NS NS NS NS NS
−0.05 0.01 −0.22 0.06 0.02 0.01 0.05 0.66 −0.34 1.76 −1.52 1.08
−0.16 to 0.05 −0.15 to 0.18 −0.39 to −0.05 0.002 to 0.11 −0.04 to 0.09 −0.07 to 0.09 −0.01 to 0.12 −0.13 to 1.45 −1.08 to 0.41 0.74 to 2.78 −2.53 to −0.51 0.30 to 1.85
(1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452)
NS NS 0.011 0.041 NS NS NS NS NS b0.001 0.003 0.007
Regression coefficient
95% CI
−0.57 −0.49 0.08 0.24 0.17 0.29 0.39 −1.41 0.56 0.43 1.46 1.71
−0.99 −0.99 −0.41 −0.01 −0.16 −0.19 0.13 −5.05 −2.54 −2.91 −2.45 −1.17
to to to to to to to to to to to to
−0.22 −0.25 0.11 0.04 0.18 0.06 0.18 −0.84 0.12 0.10 1.76 1.75
−0.45 −0.52 −0.16 −0.09 0.01 −0.20 0.04 −2.79 −1.55 −1.69 −0.34 0.20
−0.16 −0.27 0.06 0.06 −0.05 0.09 0.15 −0.89 0.33 0.26 0.70 0.19 −0.10 0.06 −0.08 0.07 −0.01 0.11 0.09 0.49 0.62 −0.11 −0.95 −0.53
F
1.10 0.03 6.49 4.21 0.41 0.07 2.34 2.68 0.78 11.58 8.71 7.46
pa
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analysis. Due to the modelling, the statistical tests were done using F-test. Regarding the continuous variables, the regression coefficient estimates the change in the mean value of the response variable corresponding to the unit change in the explanatory variable. All explanatory variables are included into the multivariate models. *Explanatory variables were dichotomic variables. With each explanatory variable, the regression coefficient is the same as the difference in the mean values between the groups corresponding to the classification of the explanatory variables. a p-Value for pair-wise analyses. b The alternative that was used for the regression coefficient.
Mason et al. (2005) found a negative correlation between the PBI care scores and the TAS-20 total score and the DIF and DDF scores. Similar to our study, EOT was not associated with experienced care. However, the results are based mainly on correlations and the study design did not allow the assessment of the possible impact of, for example, sociodemographic factors on this relation (Mason et al., 2005). Fukunishi et al. (1997) suggested low maternal care to be associated with alexithymia, and this association was attributed mainly to the DDF subscale. Our results are partly supported by a study by Kooiman et al.
(1998), who found practically no association between perceived parental care and alexithymia. Associations were established between paternal overprotection and TAS-20 total and DIF scores, but being somewhat weak, these associations between parental attitudes and alexithymic features led the authors to question the feasibility of the PBI scale in measuring the parental attitudes, especially regarding the subjects' early years. In this regard, however, it can be argued that, due to their relatively young age, the subjects in the present study were possibly able to recall their childhood experiences more accurately.
M. Karukivi et al. / Psychiatry Research 187 (2011) 254–260
The present study assessed perceived social support and parental attitude, which both are suggested to be associated with alexithymia. As suspected, in pair-wise analyses, all of the factors were significantly associated with alexithymia, but the strongest associations existed between maternal (and, to some extent, paternal) overprotection and the social support from family and friends—especially from friends. On the basis of previous studies, we expected the import of parents to be more significant, regarding both the care and support they have provided. However, neither the parents' divorce nor a parent's death was associated with alexithymia. On the basis of this finding, we can ask if the presence of an overprotective, intrusive mother in some way alters the progress of autonomy and thereby hinders the development of close and supportive relationships with peers, which will further result in difficulties in sharing emotions. In this regard, we also wish to emphasize that the influence of peer relationships on the development of alexithymia should be studied further. There are some limitations in the present study to be considered. The cross-sectional design used in this study has the same limitations as in previous studies on the same topic: the format precludes the possibility of drawing any conclusions about causality. At the same time, reliable methods for measurement of alexithymia have existed only about 15 years, which in turn explains the lack of longitudinal studies so far. Causation is difficult to establish also because there are several possibilities as to which ways familial factors are affiliated to alexithymia. For instance, twin studies have suggested a genetic influence on alexithymic features (Heiberg and Heiberg, 1977; Jørgensen et al., 2007). Lumley et al. (1996) proposed that, in late adolescents, alexithymia could be an adult defence mechanism to cope with unresolved family conflict rather than a primary deficit due to early experiences, or that mother–child alexithymia association may reflect both parties' experience of contemporary home environment rather than a developmental influence of the mother's alexithymia on the child. Regarding the TAS-20 scale, it should be kept in mind that the cut-off score of 61 points or more was suggested by the developers of the scale according to a relatively small sample of students (Bagby and Taylor, 1997). Although the validity of the cut-off score has been questioned (Loas et al., 1996), it has been used in numerous studies using the TAS-20 scale in different languages. Therefore, we used the original cut-off score to enable prevalence comparisons with other studies. To our best knowledge, there are no other fully comparable studies to date. One methodological problem in comparing the results of the present study and those of the previous studies is that some of the previous studies evaluating these associations were carried out in clinical patient groups. Kooiman et al. (1998) suggested that parental attitude may not be a sufficient factor for the development of alexithymia, when compared to a severe trauma, such as sexual abuse. The subjects in several patient groups are often more traumatized, and it can be argued that, in these cases, the significance of perceived parental attitude in the development of alexithymic features is weaker and thus, these associations are more prominent in nonclinical subjects. It is also possible that certain traumatic experiences may induce overprotective behavior in parents. Lumley et al. (1996) found that distinct family dysfunction, such as emotional under or over involvement, was associated with the DIF subscale scores, and lack of family rules or guidelines was associated with the EOT subscale scores; however, the dimensions of experienced parental attitude as measured in their study were different from those used in our study. The measures applied set their limitations since, as pointed out in several previous studies, the validity of the EOT subscale is only satisfactory. In our study, its association with the other scales was vague as compared to the DIF and DDF subscales. Although the participation rate was lower among males and older subjects, the overall participation rate was quite high (78%), given the study design, and presumably without a deteriorating impact on generalization of the results.
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To conclude, even if there is a clear need for longitudinal studies in order to shed more light on the causal relationships, the present study adds to the findings of previous studies by showing that experienced social support and parental attitude are associated with alexithymic characteristics. Our results highlight the significance of intrusive and overprotective parental attitudes as a possible risk factor for development of alexithymia, and we wish to emphasize the need for further studies to evaluate the role of peer relationships in the development of alexithymia.
Acknowledgment This study was made possible by funding provided by the Margaretha Foundation.
References Bagby, M., Taylor, G., 1997. Construct validation. In: Taylor, G.J., Bagby, R.M., Parker, J.D.A. (Eds.), Disorders of Affect Regulation. Alexithymia in Medical and Psychiatric Illness. Cambridge University Press, Cambridge, pp. 46–66. Bagby, R., Parker, J., Taylor, G., 1994a. The 20-item Toronto Alexithymia Scale, I: item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 23–32. Bagby, R., Taylor, G., Parker, J., 1994b. The 20-item Toronto Alexithymia Scale, II: convergent, discriminant and concurrent validity. Journal of Psychosomatic Research 38, 33–40. Bruwer, B., Emsley, R., Kidd, M., Lochner, C., Seedat, S., 2008. Psychometric properties of the Multidimensional Scale of Perceived Social Support in youth. Comprehensive Psychiatry 49, 195–201. Canty-Mitchell, J., Zimet, G.D., 2000. Psychometric properties of the Multidimensional Scale of Perceived Social Support in urban adolescents. American Journal of Community Psychology 28, 391–400. Ciarrochi, J., Heaven, P.C., Supavadeeprasit, S., 2008. The link between emotion identification skills and socio-emotional functioning in early adolescence: a 1-year longitudinal study. Journal of Adolescence 31, 565–582. Cochrane, C.E., Brewerton, T.D., Wilson, D.B., Hodges, E.L., 1993. Alexithymia in the eating disorders. The International Journal of Eating Disorders 14, 219–222. De Panfilis, C., Salvatore, P., Marchesi, C., Cazzolla, R., Tonna, M., Maggini, C., 2008. Parental bonding and personality disorder: the mediating role of alexithymia. Journal of Personality Disorders 22, 496–508. Franz, M., Popp, K., Schaefer, R., Sitte, W., Schneider, C., Hardt, J., Decker, O., Braehler, E., 2008. Alexithymia in the general German population. Social Psychiatry and Psychiatric Epidemiology 43, 54–62. Fukunishi, I., Rahe, R.H., 1995. Alexithymia and coping with stress in healthy persons: alexithymia as a personality trait is associated with low support and poor responses to stress. Psychological Reports 76, 1299–1304. Fukunishi, I., Kawamura, N., Ishikawa, T., Ago, Y., Sei, H., Morita, Y., Rahe, R.H., 1997. Mothers' low care in the development of alexithymia: a preliminary study in Japanese college students. Psychological Reports 80, 143–146. Hautala, L., Alin, J., Liuksila, P.-R., Räihä, H., Saarijärvi, S., 2006. SCOFF syömishäiriöseulan reliabiliteetti ja rakennevaliditeetti murrosikäisten koululaisten seulonnassa (The reliability and construct validity of the SCOFF questionnaire in a schoolbased sample of adolescents). Duodecim 122, 2137–2144. Hautala, L., Junnila, J., Helenius, H., Väänänen, A.M., Liuksila, P.-R., Räihä, H., Välimäki, M., Saarijärvi, S., 2008. Towards understanding gender differences in disordered eating among adolescents. Journal of Clinical Nursing 17, 1803–1813. Hautala, L., Junnila, J., Alin, J., Grönroos, M., Maunula, A.M., Karukivi, M., Liuksila, P.-R., Räihä, H., Välimäki, M., Saarijärvi, S., 2009. Uncovering hidden eating disorders using the SCOFF questionnaire: cross-sectional survey of adolescents and comparison with nurse assessments. International Journal of Nursing Studies 46, 1439–1447. Heiberg, A., Heiberg, A., 1977. Alexithymia—an inherited trait? A study of twins. Psychotherapy and Psychosomatics 50, 81–87. Honkalampi, K., Hintikka, J., Tanskanen, A., Lehtonen, J., Viinamäki, H., 2000. Depression is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research 48, 99–104. Honkalampi, K., Koivumaa-Honkanen, H., Antikainen, R., Haatainen, K., Hintikka, J., Viinamäki, H., 2004. Relationships among alexithymia, adverse childhood experiences, sociodemographic variables, and actual mood disorder: a 2-year clinical follow-up study of patients with major depressive disorder. Psychosomatics 45, 197–204. Honkalampi, K., Tolmunen, T., Hintikka, J., Rissanen, M.L., Kylmä, J., Laukkanen, E., 2009. The prevalence of alexithymia and its relationship with Youth Self-Report problem scales among Finnish adolescents. Comprehensive Psychiatry 50, 263–268. Jørgensen, M.M., Zachariae, R.R., Skytthe, A., Kyvik, K., 2007. Genetic and environmental factors in alexithymia: a populationbased study of 8,785 Danish twin pairs. Psychotherapy and Psychosomatics 76, 369–375. Joukamaa, M., Miettunen, J., Kokkonen, P., Koskinen, M., Julkunen, J., Kauhanen, J., Jokelainen, J., Veijola, J., Läksy, K., Järvelin, M.R., 2001. Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nordic Journal of Psychiatry 55, 123–127.
260
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Joukamaa, M., Taanila, A., Miettunen, J., Karvonen, J.T., Koskinen, M., Veijola, J., 2007. Epidemiology of alexithymia among adolescents. Journal of Psychosomatic Research 63, 373–376. Kojima, M., Senda, Y., Nagaya, T., Tokudome, S., Furukawa, T.A., 2003. Alexithymia, depression and social support among Japanese workers. Psychotherapy and Psychosomatics 72, 307–314. Kokkonen, P., Karvonen, J.T., Veijola, J., Läksy, K., Jokelainen, J., Järvelin, M.R., Joukamaa, M., 2001. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Comprehensive Psychiatry 42, 471–476. Kooiman, C.G., Spinhoven, P., Trijsburg, R.W., Rooijmans, H.G., 1998. Perceived parental attitude, alexithymia and defense style in psychiatric outpatients. Psychotherapy and Psychosomatics 67, 81–87. Loas, G., Otmani, O., Fremaux, D., Lecercle, C., Duflot, M., Delahousse, J., 1996. External validity, reliability and basic score determination of the Toronto Alexithymia Scales (TAS and TAS-20) in a group of alcoholic patients. L'Encéphale 22, 35–40. Lumley, M.A., Mader, C., Gramzow, J., Papineau, K., 1996. Family factors related to alexithymia characteristics. Psychosomatic Medicine 58, 211–216. Mason, O., Tyson, M., Jones, C., Potts, S., 2005. Alexithymia: its prevalence and correlates in a British undergraduate sample. Psychology and Psychotherapy 78, 113–125. Mattila, A., 2009. Alexithymia in Finnish General Population. Acta Universitatis Tamperensis, 1377. Tampere University Press, pp. 40–46. Available at: http://acta. uta.fi/pdf/978-951-44-7563-4.pdf. Accessed January 10, 2010. Mattila, A.K., Salminen, J.K., Nummi, T., Joukamaa, M., 2006. Age is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research 61, 629–635. Parker, G., 1983. Parental Overprotection: A Risk Factor in Psychosocial Development. Grune & Stratton, New York. Parker, G., 1989. The parental bonding instrument. Psychometric properties reviewed. Psychiatric Developments 7, 317–335. Parker, G., Tupling, H., Brown, L.B., 1979. A parental bonding instrument. The British Journal of Medical Psychology 52, 1–10.
Parker, J., Taylor, G., Bagby, R., 2003. The 20-item Toronto Alexithymia Scale, III: reliability and factorial validity in a community population. Journal of Psychosomatic Research 55, 269–275. Picardi, A., Toni, A., Caroppo, E., 2005. Stability of alexithymia and its relationships with the ‘big five’ factors, temperament, character, and attachment style. Psychotherapy and Psychosomatics 74, 371–378. Posse, M., Hällström, T., Backenroth-Ohsako, G., 2002. Alexithymia, social support, psycho-social stress and mental health in a female population. Nordic Journal of Psychiatry 56, 329–334. Russ, E., Heim, A., Westen, D., 2003. Parental bonding and personality pathology assessed by clinician report. Journal of Personality Disorders 17, 522–536. Säkkinen, P., Kaltiala-Heino, R., Ranta, K., Haataja, R., Joukamaa, M., 2007. Psychometric properties of the 20-item Toronto Alexithymia Scale and prevalence of alexithymia in a Finnish adolescent population. Psychosomatics 48, 154–161. 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. Sifneos, P., 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. Alexithymia in Medical and Psychiatric Illness. Cambridge University Press, Cambridge. Taylor, G., Bagby, R., Parker, J., 2003. The 20-item Toronto Alexithymia Scale, IV: reliability and factorial validity in different languages and cultures. Journal of Psychosomatic Research 55, 277–283. Torresani, S., Favaretto, E., Zimmermann, C., 2000. Parental representations in drug-dependent patients and their parents. Comprehensive Psychiatry 41, 123–129. Zimet, G.D., Dahlem, N.W., Zimet, S.G., Farley, G.K., 1988. The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment 52, 30–41. Zimet, G.D., Powell, S.S., Farley, G.K., Werkman, S., Berkoff, K.A., 1990. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment 55, 610–617.
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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s
Does perceived social support and parental attitude relate to alexithymia? A study in Finnish late adolescents Max Karukivi a,b,⁎, Matti Joukamaa c,d, Lea Hautala a,e, Olli Kaleva e,f, Kirsi-Maria Haapasalo-Pesu b, Pirjo-Riitta Liuksila e, Simo Saarijärvi a,g a
Unit of Adolescent Psychiatry, University of Turku, Finland Unit of Adolescent Psychiatry, Satakunta Hospital District, Pori, Finland Social Psychiatry Unit, Tampere School of Public Health, University of Tampere, Finland d Department of Psychiatry, Tampere University Hospital, Finland e Turku Municipal Health Care and Social Services, Turku, Finland f Department of Public Health, University of Turku, Finland g Unit of Adolescent Psychiatry, Turku University Hospital, Finland b c
a r t i c l e
i n f o
Article history: Received 27 May 2010 Received in revised form 18 October 2010 Accepted 27 November 2010 Keywords: Adolescents Alexithymia Parental attitude Social support
a b s t r a c t The aim of the present study was to explore the associations of perceived social support and parental attitude with alexithymia in a Finnish adolescent population sample. Of the initial sample of 935 adolescents, 729 (78%) answered the questionnaire and formed the final sample. The mean age of the subjects was 19 years (range 17–21 years). The 20-item Toronto Alexithymia Scale (TAS-20) was used for assessment of alexithymia. Perceived social support from family, friends, and significant other people was measured using the Multidimensional Scale of Perceived Social Support (MSPSS). Perceived parental care and overprotection were assessed using the Parental Bonding Instrument (PBI), and separately for mother and father. After controlling for the sociodemographic factors, alexithymia was significantly associated with a lower degree of experienced social support and higher parental overprotection both in females and males. Maternal overprotection was associated (p b 0.04) with TAS-20 total score as well as the Difficulty Identifying Feelings (DIF) and Difficulty Describing Feelings (DDF) subscales. The lack of social support from friends appeared to predict alexithymia more strongly than lack of support from family and significant other people. Against our hypothesis, maternal and paternal care was not directly associated with alexithymic features. This study highlights the significance of intrusive and overprotective parental attitudes as a possible risk factor for development of alexithymia. However, to assess causality, we need longitudinal studies. The results also emphasize the need for further studies to establish the significance of peer relationships in the development of alexithymia. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Adverse parenting, manifested as, for example, lack of maternal and paternal care or intrusive and excessive control, has been suggested to be associated with several psychiatric conditions and illnesses (Parker, 1983; Torresani et al., 2000; Russ et al., 2003). One possible mediating factor in this regard may be alexithymia. Alexithymia is a personality construct that signifies reduced ability to identify and describe feelings, a limited imagination, and a preoccupation with externally oriented thinking. It was initially depicted in the mid-1970s in psychosomatic patients (Sifneos, 1973), but since then, a vast amount of studies have been published associating alexithymia with a broad range of mental disorders and ⁎ Corresponding author. Unit of Adolescent Psychiatry, Hansakatu 5, FI-28100 Pori, Finland. Tel.: + 358 2 627 47 60; fax: + 358 2 627 47 85. E-mail address: max.karukivi@utu.fi (M. Karukivi). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.11.028
somatic illnesses (Mattila, 2009). Accumulating evidence suggests that alexithymia is also associated with mental disorders such as depression and eating disorders in adolescents (Cochrane et al., 1993; Ciarrochi et al., 2008). On the basis of population studies, alexithymia appears to be rather a common personality construct. The prevalence of alexithymia in general adult population has shown to be approximately 10 %, and it appears more commonly in males than in females (Salminen et al., 1999; Honkalampi et al., 2000; Kokkonen et al., 2001; Mattila et al., 2006; Franz et al., 2008). In adolescents, the prevalence of alexithymia appears to be at the same level as a whole, but no gender difference has been shown (Joukamaa et al., 2001; Säkkinen et al., 2007; Honkalampi et al., 2009). Previous studies have suggested that the development of affect regulation in childhood can be impaired if caregivers are emotionally unavailable or if they expose the child to inconsistent affective responses (Lumley et al., 1996; Taylor et al., 1997; De Panfilis et al.,
M. Karukivi et al. / Psychiatry Research 187 (2011) 254–260
2008). Thus, there appears to be an association between alexithymia and childhood adversities (Honkalampi et al., 2004; Picardi et al., 2005). Furthermore, alexithymia has been associated with lower maternal care (Fukunishi et al., 1997; Mason et al., 2005) and low social support in general (Fukunishi and Rahe, 1995). However, the causation is still quite unclear. On one hand, alexithymic features may reduce social support directly by hindering the building of relationships through lack of emotional recognition and expression. On the other hand, alexithymic individuals may not be able to utilize social support adequately because they neither recognize others' emotions nor respond to them appropriately (Kojima et al., 2003). Interestingly, according to our knowledge, there are no previous studies investigating the association of perceived parental attitude and alexithymia, and taking into consideration also experienced social support, although both of these factors have been studied separately in association with alexithymia. Correspondingly, while both parental bonding and social support have been studied in alexithymic individuals, there are only few studies exploring these associations in younger populations. The aim of the present study was to explore this association in a Finnish adolescent population sample, taking into account both the experienced maternal and paternal care and social support. We hypothesized that adolescents with alexithymic characteristics may have experienced less maternal care when growing up and would assess their social support as having been weaker. We also hypothesized that the association would be stronger in males and likely attributed to the DIF and DDF subscales. 2. Methods 2.1. Materials The subjects were recruited from a sample of students who had earlier participated in a research investigating eating disorder (ED) symptoms among adolescents (14–16 years old) who were studying in secondary schools in the City of Turku, Finland, during the school years 2003–2005. The results of the previous studies are reported elsewhere (Hautala et al., 2006, 2008, 2009). Altogether 935 individuals were eligible for the present study, and of them, 729 (78%) participated. The mean age in the sample was 19 years (range 17–21 years), and 74% of the subjects were female and 26% were male. The participation rate was higher among female (p b 0.001) and younger subjects (p = 0.04). All subjects gave their written informed consent to participate in the study. The study protocol was approved by the Ethical Committee of the Turku University Hospital. 2.2. Measures Alexithymia was measured using the 20-item Toronto Alexithymia Scale (TAS-20) (Bagby et al., 1994a,b), which is the most widely used method for assessing alexithymia. It consists of three subscales: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). The validity of the scale has been shown to be good for the TAS-20 scale as a whole and for the DIF and DDF subscales, whereas the validity of the EOT subscale is only moderate (Bagby et al., 1994a,b; Parker et al., 2003; Taylor et al., 2003). The psychometric properties of the Finnish version have been proven satisfactory (Joukamaa et al., 2001), and the scale has been validated in Finnish adolescents in two different population samples (Joukamaa et al., 2007; Säkkinen et al., 2007). As recommended by the developers of the scale (Bagby and Taylor, 1997), we used a cut-off score of 61 points or more for identifying a subject as alexithymic. For the purposes of statistical analyses, the TAS-20 score was also treated as a continuous variable. The Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988) is a 12-item self-report measure for subjective assessment of experienced social support from three sources: Family, Friends, and Significant Other. Each item is rated on a 7-point Likert-type scale ranging from “strongly disagree” to “strongly agree”. The total score ranges from 12 to 84 for the whole 12-item questionnaire and from 4 to 28 for each of the three subscales. The scale as a whole and each of its subscales have shown good internal reliability and validity (Zimet et al., 1988, 1990), and there is evidence supporting it as a psychometrically sound instrument to be used with adolescents as well (Canty-Mitchell and Zimet, 2000; Bruwer et al., 2008). Parental Bonding Instrument (PBI) (Parker et al., 1979) is a self-report scale consisting of 25 items, which are divided in two subscales, one measuring experienced care (12 items) and the other, overprotection (13 items). The subject is asked to score each parent as remembered during his or her first 16 years of life. Both the care and overprotection subscales have bipolar dimensions. For care, the positive (high) pole represents affection, emotional warmth, and closeness, while the negative (low) pole consists of, e.g., emotional coldness and rejection, and correspondingly, for overprotection, the positive (low) pole represents promotion of autonomy, while the negative (high) pole is characterized by
255
intrusion, infantilization, and excessive contact. Each item is rated on a 4-point Likert-type scale and scored on a scale from 0 to 3. Thus, the sum score for the care subscale ranges from 0 to 36 and for the overprotection subscale, from 0 to 39. The psychometric properties of the instrument have been shown to be good (Parker et al., 1979; Parker, 1989). We also examined the answers separately for the two subscales and excluded those subjects who did not answer to at least 80% of the questions in both the care (10/12) and overprotection subscales (10/13). Subjects who had answered to at least 80% of the questions in each subscale were included in the final sample. The missing values were estimated, using the mean value of the questions answered, and the scores thus calculated were rounded to the nearest integer. 2.3. Statistical methods Basic summary statistics were used in the characterization of the data. The subjects were recruited by first selecting the schools and then inviting students from each school to participate. Due to this study design, certain level of intra-class correlation in observations from the same school was expected. If the intra-class correlation is not taken into account, it can be expected to lead to too small estimates of standard errors and to too small p-values in tests. Mixed models offer a comprehensive tool for analysis of this kind of data. That is why we used linear mixed models (glimmix) where the explanatory variables of main interest were included as fixed effect(s) in the models with the school as a random effect. The distribution of the response variable in these models is assumed to be the normal distribution. The normal distribution assumption of the TAS-20 total scores and its subscale scores were confirmed to be adequate. The analyses of the associations of the explanatory variables and alexithymia scales were first done separately for each explanatory variable. Finally the significant explanatory variables were included into the multivariate analysis. With all multivariate models, the variables of interest were forced (without any stepwise technique) into the model. A confirmatory factorial analysis was carried out, and the psychometric properties of both the TAS-20 and MSPSS scales were shown to be satisfactory. For the TAS-20 scale, the goodness-of-fit index (GFI) was 0.93, a score ≥0.85 being acceptable, and the adjusted goodness-of-fit index (AGFI) was 0.89, a score ≥ 0.80 being acceptable. Also the root–mean–square residual (SRMR) was satisfactory at 0.04 (a score ≤ 0.10 being acceptable), and the Steiger's root–mean–square error of approximation RMSEA was 0.07 (a score ≤0.08 being acceptable). As regards the MSPSS scale, GFI was 0.93, AGFI was 0.90, SRMR was 0.03, and RMSEA was 0.08. The Cronbach coefficient alpha scores for the PBI care and overprotection subscales showed good internal consistency, both for the maternal and paternal scales. The values were as follows: PBI care (mother), 0.92; PBI overprotection (mother), 0.85; PBI care (father), 0.93; and PBI overprotection (father), 0.85. The data were analyzed using the SAS software, version 9.2. The mixed models analyses were carried out using the glimmix procedure of the SAS software. The significance level was set at p b 0.05 in all tests.
3. Results Due to missing data, the actual number of subjects varied between 679 and 729 for different variables. Table 1 presents the mean scores for the TAS-20, PBI, and MSPSS scales and their subscales by gender. The prevalence of alexithymia was 8.2% for females and 8.5% for males, and no statistically significant gender difference was observed. In pair-wise analyses, there was a significant difference between alexithymic and non-alexithymic subjects in the MSPSS and PBI scores, with alexithymic subjects having lower scores in all of the scales, except for the maternal and paternal PBI overprotection subscales, both of which showed significantly higher scores (Table 2). Gender interacted with some of the variables (MSPSS total score, and the Friends and Significant Other subscales), and consequently, the analyses were carried out separately for females and males. In both females and males, the MSPSS total score and also the Family, Friends, and Significant Other subscale scores were significantly associated with the TAS-20 total score and the DIF and DDF subscale scores in pair-wise analyses, with a higher level of social support being associated with fewer alexithymic features (Table 3). However, the EOT subscale score was associated with lower MSPSS scores only in females. In pair-wise analyses, the maternal and paternal PBI care and overprotection scores were associated with the TAS-20 total score and the DIF and DDF scores in females. In males, the association between maternal PBI care and overprotection scores and the alexithymic feature scores was almost as strong as in females. The paternal PBI care and overprotection scores were also partly related to TAS-20 total
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Table 1 Mean scores for the Toronto Alexithymia Scale (TAS-20), Multidimensional Scale of Perceived Social Support (MSPSS), Parental Bonding Instrument (PBI), and their subscales by gender. Males
TAS-20 total DIF DDF EOT MSPSS total MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Females
N
Mean score
SE
N
Mean score
SE
d.f.
F
pa
188 186 187 187 189 189 187 188 179 179 188 188
46.11 13.25 11.28 21.67 68.38 23.09 22.38 23.04 28.03 6.95 31.12 10.75
0.79 0.39 0.34 0.34 0.86 0.39 0.34 0.33 0.56 0.45 0.44 0.46
535 523 527 525 537 535 536 537 503 503 534 534
44.68 15.29 11.16 18.23 71.74 22.70 24.07 24.97 26.10 8.61 30.05 10.13
0.54 0.23 0.25 0.23 0.51 0.26 0.21 0.19 0.33 0.29 0.26 0.27
(1,706) (1,692) (1,697) (1,695) (1,709) (1,707) (1,706) (1,708) (1,665) (1,665) (1,705) (1,705)
2.74 19.73 0.11 92.73 11.33 0.84 17.94 25.56 8.70 10.32 4.36 1.35
NS b0.001 NS b0.001 b0.001 NS b0.001 b0.001 0.003 0.001 0.04 NS
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analyses. Due to the modelling, the statistical comparisons between genders were done using F-test. NS = non-significant. a p-Value for pair-wise analyses.
after controlling for sociodemographic factors. Surprisingly, alexithymic features were not associated with subjectively experienced maternal and paternal care. As far as we know, this was the first time the associations of both parental bonding and social support with alexithymia were assessed in this age group. Alexithymic individuals assessed their social support having been weaker compared to their non-alexithymic peers. The difference in the MSPSS total scores was significant between the groups, and in the multivariate analyses, the MSPSS Family and Friends scores were associated with the TAS-20 total score. The association was attributed to the DIF and DDF subscales and was stronger for the MSPSS Friends subscale. The MSPSS Significant Other score was not associated with alexithymic features, although in females, it was associated with the EOT subscale score. However, the associations of the EOT subscale were generally more obscure, which may be related to the fact that the validity of the EOT subscale has been shown to be weaker, both as compared to the DIF and DDF subscales and to the TAS-20 scale as a whole (Taylor et al., 2003). The weak association of the MSPSS Significant Other score with alexithymia is quite understandable, because youth in this age group may not yet have formed deep relationships outside their family and friends. In previous studies, alexithymia has been associated with low social support (Fukunishi and Rahe, 1995; Posse et al., 2002). Posse et al. (2002) estimated the level of perceived social support using an assessment method other than MSPSS, but they observed a clear difference between alexithymic and non-alexithymic subjects using the TAS-20 scale. Having a low level of social support was 3.5 times
score and the DIF and DDF subscale scores. Higher PBI care scores were associated with fewer alexithymic features, while higher PBI overprotection scores were positively related with the TAS-20 total and subscale scores. Of the sociodemographic factors, neither the number of siblings nor the separation or deaths of parents were significantly associated with the TAS-20 total score or the alexithymia subscales in pair-wise analyses. However, dwelling, parents' divorce, smoking, occupation, and perceived health were associated with the TAS-20 total score or at least with one of the alexithymia subscales and thus were included to the multivariate analyses. Multivariate analyses were carried out taking into account those sociodemographic variables that had shown an association with alexithymic features in the pair-wise analyses. The results are presented in Table 4. High maternal – and for the most part, also paternal – overprotection predicted most significantly high scores in the alexithymia scales. The correlations between parental overprotection and alexithymic features were most notable in the TAS-20 total score and DIF in both genders. Additionally, a higher MSPSS Friends score was statistically significantly associated with a lower score in the TAS-20 and its subscales particularly in females, although the regression coefficients were clearly negative also in males. 4. Discussion The main finding in the present study among adolescents was that alexithymia is associated with a lower level of social support and higher parental overprotection. The results remained significant even
Table 2 Mean scores for the Multidimensional Scale of Perceived Social Support (MSPSS), and Parental Bonding Instrument (PBI) and their subscales in alexithymic and non-alexithymic subjects. Alexithymic
MSPSS total MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Non-alexithymic
N
Mean score
SE
N
Mean score
SE
d.f.
F
pa
60 58 59 60 54 54 59 59
59.78 19.36 19.31 20.93 23.64 8.80 26.49 14.14
1.50 0.67 0.60 0.58 1.03 0.81 0.77 0.81
664 664 662 663 625 625 661 661
71.84 23.13 23.99 24.78 26.89 8.04 30.70 9.95
0.50 0.24 0.20 0.19 0.31 0.24 0.23 0.24
(1,705) (1,703) (1,702) (1,704) (1,661) (1,661) (1,701) (1,701)
61.01 30.41 57.02 40.68 9.20 0.80 27.34 24.64
b0.001 b0.001 b0.001 b0.001 0.003 NS b0.001 b0.001
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analyses. Due to the modelling, the statistical comparisons between the alexithymic and non-alexithymic groups were done using F-test. NS = non-significant. a p-Value for pair-wise analyses.
M. Karukivi et al. / Psychiatry Research 187 (2011) 254–260
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Table 3 Associations of the Toronto Alexithymia Scale (TAS-20) and its subscales with the Multidimensional Scale of Perceived Social Support (MSPSS), and Parental Bonding Instrument (PBI) and their subscales by gender. Males
TAS MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother DIF MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother DDF MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother EOT MSPSS total score MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother
Females d.f.
F
pa
Regression coefficient
95% CI
−0.17 −0.27 −0.35 −0.29 0.09 0.58 −0.11 0.70
(1,171) (1,171) (1,169) (1,170) (1,161) (1,161) (1,170) (1,170)
29.91 16.65 22.70 18.60 1.47 5.74 8.20 26.02
b0.001 b0.001 b0.001 b0.001 NS 0.02 0.005 b0.001
−0.42 −0.76 −0.99 −0.92 −0.35 0.38 −0.48 0.45
−0.49 −0.92 −1.17 −1.11 −0.45 0.23 −0.62 0.31
to to to to to to to to
−0.08 −0.18 −0.14 −0.09 −0.05 0.46 −0.16 0.42
(1,169) (1,169) (1,167) (1,168) (1,159) (1,159) (1,168) (1,168)
24.82 23.06 15.91 10.93 8.15 17.10 18.06 33.13
b0.001 b0.001 b0.001 0.001 0.005 b0.001 b0.001 b0.001
−0.21 −0.42 −0.46 −0.38 −0.24 0.25 −0.31 0.26
−0.24 −0.50 −0.56 −0.49 −0.30 0.17 −0.38 0.19
−0.16 −0.29 −0.40 −0.34 −0.15 −0.06 −0.25 0.09
to to to to to to to to
−0.08 −0.08 −0.19 −0.14 0.04 0.16 −0.04 0.26
(1,170) (1,170) (1,168) (1,169) (1,160) (1,160) (1,169) (1,169)
33.36 12.55 32.58 21.37 1.42 0.78 7.27 16.89
b0.001 b0.001 b0.001 b0.001 NS NS 0.008 b0.001
−0.16 −0.28 −0.40 −0.35 −0.13 0.11 −0.18 0.15
−0.05 −0.10 −0.13 −0.17 −0.06 −0.13 −0.08 −0.06
to to to to to to to to
0.05 0.16 0.14 0.09 0.16 0.14 0.19 0.15
(1,170) (1,170) (1,169) (1,170) (1,160) (1,160) (1,169) (1,169)
0.00 0.26 0.01 0.34 0.79 0.00 0.68 0.70
NS NS NS NS NS NS NS NS
−0.06 −0.07 −0.15 −0.20 0.01 0.02 −0.03 0.04
Regression coefficient
95% CI
−0.27 −0.52 −0.60 −0.54 −0.14 0.32 −0.37 0.51
−0.37 −0.77 −0.85 −0.79 −0.36 0.06 −0.62 0.31
to to to to to to to to
−0.14 −0.34 −0.29 −0.24 −0.17 0.31 −0.30 0.32
−0.20 −0.47 −0.43 −0.38 −0.30 0.16 −0.44 0.21
−0.12 −0.19 −0.29 −0.24 −0.05 0.05 −0.14 0.17 −0.002 0.03 0.005 −0.04 0.05 0.002 0.05 0.04
d.f.
F
pa
to −0.36 to −0.59 to −0.81 to −0.73 to −0.24 to 0.52 to −0.35 to 0.58
(1,518) (1,516) (1,517) (1,518) (1,484) (1,484) (1,515) (1,515)
151.83 84.88 122.46 88.93 39.41 26.95 51.19 42.84
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
to to to to to to to to
−0.17 −0.33 −0.37 −0.27 −0.18 0.32 −0.24 0.34
(1,506) (1,505) (1,506) (1,506) (1,474) (1,474) (1,503) (1,503)
115.63 87.79 87.21 48.22 69.09 41.75 71.30 52.04
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
−0.19 −0.35 −0.47 −0.43 −0.18 0.06 −0.23 0.09
to to to to to to to to
−0.13 −0.22 −0.32 −0.27 −0.09 0.17 −0.12 0.20
(1,510) (1,508) (1,509) (1,510) (1,477) (1,477) (1,507) (1,507)
134.97 73.05 117.57 77.61 36.21 15.31 40.09 28.59
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001
−0.09 −0.14 −0.22 −0.28 −0.03 −0.04 −0.09 −0.01
to to to to to to to to
−0.03 −0.003 −0.07 −0.12 0.05 0.08 0.02 0.10
(1,508) (1,506) (1,507) (1,508) (1,475) (1,475) (1,505) (1,505)
17.33 4.17 14.56 23.59 0.17 0.41 1.19 2.53
b0.001 0.04 b0.001 b0.001 NS NS NS NS
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analysis. Due to the modelling, the statistical tests were done using F-test. All explanatory variables were continuous variables. The regression coefficient estimates the change in the mean value of the response variable corresponding to the unit change in the explanatory variable. NS = non-significant. a p-Value for pair-wise analyses.
more common in alexithymic than in non-alexithymic individuals. However, no firm conclusions about causality can be made, on one hand, because of the lack of longitudinal studies and, on the other hand, because alexithymic individuals presumably have difficulties utilizing social support due to their inherently low emotional and social skills and inability to form close relationship (Kojima et al., 2003). Irrespective of the reported level of social support, Posse et al. (2002) found a significant difference in the lack of well-being between the alexithymic and non-alexithymic subjects, with alexithymic individuals being clearly worse off. In the present study, perceived health was also significantly associated with alexithymic features in two of the TAS-20 subscales for females. A similar observation regarding the association between perceived health and alexithymia has been made in a study among Finnish general population (Mattila et al., 2006). Also, in a study by Honkalampi et al. (2009), alexithymic adolescents aged 13 to 18 assessed their health relatively good less commonly than their non-alexithymic peers did. The mother–child relationship has been of particular interest as regards the development of alexithymia, and alexithymic features have been suggested to be associated with early neglect and lack of maternal support in several cultures (Fukunishi et al., 1997; Mason et al., 2005). However, it has also been questioned if individuals who indeed are victims of parental neglect may resort to primitive defence
mechanisms, such as splitting and idealizing and, thus, are not really suitable persons to be studied with self-report instruments (Kooiman et al., 1998). In the present study, the strongest association was observed between maternal overprotection and alexithymia; the association was clear both in males and females and was attributed to the DIF and DDF subscales. Paternal overprotection was also, to some extent, associated with alexithymic features, mainly in females. De Panfilis et al. (2008) studied the mediating role of alexithymia between parental bonding and personality disorder. They found that the DDF subscale was associated with maternal overprotection in particular, and they suggested that maternal behavioral restrictiveness and intrusiveness could be associated with later difficulties in sharing and describing emotions. In another study with nonclinical subjects, the DDF scores were related with certain personality traits such as difficulty to be warm, sensitive, cooperative, and sociable (Picardi et al., 2005). Thus, it is plausible that maternal overprotection, manifested as denial of psychological autonomy and obtrusiveness, may lead to impairment in communicating emotions, which portrays the alexithymic feature of difficulty describing feelings. Alexithymic individuals reported having experienced significantly less care from both parents when growing up in comparison to their non-alexithymic peers. However, this association did not survive multivariate analyses. This was slightly surprising, because, in previous studies, alexithymia has been associated with lower maternal care.
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Table 4 Multivariate analysis of associations of the Toronto Alexithymia Scale (TAS-20) and its subscales with the Multidimensional Scale of Perceived Social Support (MSPSS) and Parental Bonding Instrument (PBI) and their subscales, and sociodemographic factors by gender. Males
TAS MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) DIF MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) DDF MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No) EOT MSPSS Family MSPSS Friends MSPSS Significant Other PBI care, father PBI overprotection, father PBI care, mother PBI overprotection, mother *Dwelling (With parent(s)b/Other) *Parents divorced (Yesb/No) *Main occupation (Studentb/Other) *Perceived health (At most moderateb/At least fairly *Smoking (Yesb/No)
good)
good)
good)
good)
Females d.f.
F
pa
Regression coefficient
95% CI
d.f.
−0.14 0.01 0.57 0.49 0.49 0.77 0.64 2.23 3.66 3.77 5.36 4.59
(1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143)
7.07 3.75 0.10 3.44 1.04 1.41 8.87 0.59 0.13 0.06 0.54 1.38
0.009 NS NS NS NS NS 0.003 NS NS NS NS NS
−0.28 −0.67 −0.08 −0.05 0.15 −0.04 0.22 0.61 −1.37 2.92 1.96 1.70
−0.52 to −0.05 −1.04 to −0.29 −0.46 to 0.30 −0.17 to 0.07 0.002 to 0.30 −0.23 to 0.14 0.06 to 0.37 −1.15 to 2.36 −3.04 to 0.29 0.66 to 5.18 −0.29 to 4.22 −0.01 to 3.42
(1,460) 5.92 (1,460) 12.33 (1,460) 0.17 (1,460) 0.66 (1,460) 4.00 (1,460) 0.22 (1,460) 7.75 (1,460) 0.46 (1,460) 2.62 (1,460) 6.47 (1,460) 2.92 (1,460) 3.82
0.015 b0.001 NS NS 0.046 NS 0.006 NS NS 0.011 NS NS
to to to to to to to to to to to to
0.01 0.02 0.37 0.18 0.36 0.32 0.32 1.11 1.78 1.89 3.86 3.29
(1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142)
3.55 3.41 0.64 0.38 4.21 0.19 6.67 0.73 0.02 0.01 2.75 4.98
NS NS NS NS 0.042 NS 0.011 NS NS NS NS 0.027
−0.11 −0.37 −0.11 −0.08 0.10 −0.06 0.09 −0.37 −0.59 0.55 2.55 0.53
−0.23 to −0.56 to −0.08 to −0.14 to 0.02 to −0.16 to 0.01 to −1.28 to −1.46 to −0.64 to 1.37 to −0.36 to
0.01 −0.17 −0.31 −0.01 0.18 0.03 0.17 0.55 0.27 1.73 3.73 1.42
(1,452) 3.50 (1,452) 13.99 (1,452) 1.24 (1,452) 5.59 (1,452) 6.52 (1,452) 1.55 (1,452) 5.44 (1,452) 0.61 (1,452) 1.81 (1,452) 0.82 (1,452) 18.11 (1,452) 1.35
NS b0.001 NS 0.019 0.011 NS 0.020 NS NS NS b0.001 NS
−0.33 −0.48 −0.14 −0.05 −0.19 −0.10 0.05 −2.40 −0.96 −1.12 −0.94 −1.00
to to to to to to to to to to to to
0.01 −0.07 0.26 0.16 0.08 0.29 0.26 0.61 1.62 1.64 2.34 1.39
(1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142) (1,142)
3.25 6.93 0.35 1.21 0.60 0.88 8.38 1.37 0.25 0.14 0.71 0.10
NS 0.009 NS NS NS NS 0.004 NS NS NS NS NS
−0.10 −0.32 0.02 −0.04 0.02 −0.01 0.07 0.40 −0.57 0.87 1.01 0.08
−0.19 to 0.001 −0.47 to −0.16 −0.13 to 0.18 −0.09 to 0.01 −0.04 to 0.08 −0.09 to 0.07 0.002 to 0.13 −0.33 to 1.13 −1.26 to 0.13 −0.07 to 1.81 0.07 to 1.96 −0.63 to 0.80
(1,453) 3.79 (1,453) 16.30 (1,453) 0.08 (1,453) 2.25 (1,453) 0.56 (1,453) 0.05 (1,453) 4.10 (1,453) 1.17 (1,453) 2.57 (1,453) 3.27 (1,453) 4.44 (1,453) 0.05
NS b0.001 NS NS NS NS 0.040 NS NS NS 0.036 NS
−0.34 −0.23 −0.36 −0.07 −0.19 −0.16 −0.05 −1.60 −1.16 −2.03 −3.20 −1.18
to to to to to to to to to to to to
0.14 0.35 0.20 0.22 0.18 0.39 0.24 2.59 2.41 1.81 1.29 1.13
(1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143) (1,143)
0.63 0.17 0.35 1.05 0.01 0.65 1.54 0.22 0.47 0.01 0.70 0.40
NS NS NS NS NS NS NS NS NS NS NS NS
−0.05 0.01 −0.22 0.06 0.02 0.01 0.05 0.66 −0.34 1.76 −1.52 1.08
−0.16 to 0.05 −0.15 to 0.18 −0.39 to −0.05 0.002 to 0.11 −0.04 to 0.09 −0.07 to 0.09 −0.01 to 0.12 −0.13 to 1.45 −1.08 to 0.41 0.74 to 2.78 −2.53 to −0.51 0.30 to 1.85
(1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452) (1,452)
NS NS 0.011 0.041 NS NS NS NS NS b0.001 0.003 0.007
Regression coefficient
95% CI
−0.57 −0.49 0.08 0.24 0.17 0.29 0.39 −1.41 0.56 0.43 1.46 1.71
−0.99 −0.99 −0.41 −0.01 −0.16 −0.19 0.13 −5.05 −2.54 −2.91 −2.45 −1.17
to to to to to to to to to to to to
−0.22 −0.25 0.11 0.04 0.18 0.06 0.18 −0.84 0.12 0.10 1.76 1.75
−0.45 −0.52 −0.16 −0.09 0.01 −0.20 0.04 −2.79 −1.55 −1.69 −0.34 0.20
−0.16 −0.27 0.06 0.06 −0.05 0.09 0.15 −0.89 0.33 0.26 0.70 0.19 −0.10 0.06 −0.08 0.07 −0.01 0.11 0.09 0.49 0.62 −0.11 −0.95 −0.53
F
1.10 0.03 6.49 4.21 0.41 0.07 2.34 2.68 0.78 11.58 8.71 7.46
pa
The possible intra-class correlation due to the school factor was taken into account by using linear mixed models in the analysis. Due to the modelling, the statistical tests were done using F-test. Regarding the continuous variables, the regression coefficient estimates the change in the mean value of the response variable corresponding to the unit change in the explanatory variable. All explanatory variables are included into the multivariate models. *Explanatory variables were dichotomic variables. With each explanatory variable, the regression coefficient is the same as the difference in the mean values between the groups corresponding to the classification of the explanatory variables. a p-Value for pair-wise analyses. b The alternative that was used for the regression coefficient.
Mason et al. (2005) found a negative correlation between the PBI care scores and the TAS-20 total score and the DIF and DDF scores. Similar to our study, EOT was not associated with experienced care. However, the results are based mainly on correlations and the study design did not allow the assessment of the possible impact of, for example, sociodemographic factors on this relation (Mason et al., 2005). Fukunishi et al. (1997) suggested low maternal care to be associated with alexithymia, and this association was attributed mainly to the DDF subscale. Our results are partly supported by a study by Kooiman et al.
(1998), who found practically no association between perceived parental care and alexithymia. Associations were established between paternal overprotection and TAS-20 total and DIF scores, but being somewhat weak, these associations between parental attitudes and alexithymic features led the authors to question the feasibility of the PBI scale in measuring the parental attitudes, especially regarding the subjects' early years. In this regard, however, it can be argued that, due to their relatively young age, the subjects in the present study were possibly able to recall their childhood experiences more accurately.
M. Karukivi et al. / Psychiatry Research 187 (2011) 254–260
The present study assessed perceived social support and parental attitude, which both are suggested to be associated with alexithymia. As suspected, in pair-wise analyses, all of the factors were significantly associated with alexithymia, but the strongest associations existed between maternal (and, to some extent, paternal) overprotection and the social support from family and friends—especially from friends. On the basis of previous studies, we expected the import of parents to be more significant, regarding both the care and support they have provided. However, neither the parents' divorce nor a parent's death was associated with alexithymia. On the basis of this finding, we can ask if the presence of an overprotective, intrusive mother in some way alters the progress of autonomy and thereby hinders the development of close and supportive relationships with peers, which will further result in difficulties in sharing emotions. In this regard, we also wish to emphasize that the influence of peer relationships on the development of alexithymia should be studied further. There are some limitations in the present study to be considered. The cross-sectional design used in this study has the same limitations as in previous studies on the same topic: the format precludes the possibility of drawing any conclusions about causality. At the same time, reliable methods for measurement of alexithymia have existed only about 15 years, which in turn explains the lack of longitudinal studies so far. Causation is difficult to establish also because there are several possibilities as to which ways familial factors are affiliated to alexithymia. For instance, twin studies have suggested a genetic influence on alexithymic features (Heiberg and Heiberg, 1977; Jørgensen et al., 2007). Lumley et al. (1996) proposed that, in late adolescents, alexithymia could be an adult defence mechanism to cope with unresolved family conflict rather than a primary deficit due to early experiences, or that mother–child alexithymia association may reflect both parties' experience of contemporary home environment rather than a developmental influence of the mother's alexithymia on the child. Regarding the TAS-20 scale, it should be kept in mind that the cut-off score of 61 points or more was suggested by the developers of the scale according to a relatively small sample of students (Bagby and Taylor, 1997). Although the validity of the cut-off score has been questioned (Loas et al., 1996), it has been used in numerous studies using the TAS-20 scale in different languages. Therefore, we used the original cut-off score to enable prevalence comparisons with other studies. To our best knowledge, there are no other fully comparable studies to date. One methodological problem in comparing the results of the present study and those of the previous studies is that some of the previous studies evaluating these associations were carried out in clinical patient groups. Kooiman et al. (1998) suggested that parental attitude may not be a sufficient factor for the development of alexithymia, when compared to a severe trauma, such as sexual abuse. The subjects in several patient groups are often more traumatized, and it can be argued that, in these cases, the significance of perceived parental attitude in the development of alexithymic features is weaker and thus, these associations are more prominent in nonclinical subjects. It is also possible that certain traumatic experiences may induce overprotective behavior in parents. Lumley et al. (1996) found that distinct family dysfunction, such as emotional under or over involvement, was associated with the DIF subscale scores, and lack of family rules or guidelines was associated with the EOT subscale scores; however, the dimensions of experienced parental attitude as measured in their study were different from those used in our study. The measures applied set their limitations since, as pointed out in several previous studies, the validity of the EOT subscale is only satisfactory. In our study, its association with the other scales was vague as compared to the DIF and DDF subscales. Although the participation rate was lower among males and older subjects, the overall participation rate was quite high (78%), given the study design, and presumably without a deteriorating impact on generalization of the results.
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To conclude, even if there is a clear need for longitudinal studies in order to shed more light on the causal relationships, the present study adds to the findings of previous studies by showing that experienced social support and parental attitude are associated with alexithymic characteristics. Our results highlight the significance of intrusive and overprotective parental attitudes as a possible risk factor for development of alexithymia, and we wish to emphasize the need for further studies to evaluate the role of peer relationships in the development of alexithymia.
Acknowledgment This study was made possible by funding provided by the Margaretha Foundation.
References Bagby, M., Taylor, G., 1997. Construct validation. In: Taylor, G.J., Bagby, R.M., Parker, J.D.A. (Eds.), Disorders of Affect Regulation. Alexithymia in Medical and Psychiatric Illness. Cambridge University Press, Cambridge, pp. 46–66. Bagby, R., Parker, J., Taylor, G., 1994a. The 20-item Toronto Alexithymia Scale, I: item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 38, 23–32. Bagby, R., Taylor, G., Parker, J., 1994b. The 20-item Toronto Alexithymia Scale, II: convergent, discriminant and concurrent validity. Journal of Psychosomatic Research 38, 33–40. Bruwer, B., Emsley, R., Kidd, M., Lochner, C., Seedat, S., 2008. Psychometric properties of the Multidimensional Scale of Perceived Social Support in youth. Comprehensive Psychiatry 49, 195–201. Canty-Mitchell, J., Zimet, G.D., 2000. Psychometric properties of the Multidimensional Scale of Perceived Social Support in urban adolescents. American Journal of Community Psychology 28, 391–400. Ciarrochi, J., Heaven, P.C., Supavadeeprasit, S., 2008. The link between emotion identification skills and socio-emotional functioning in early adolescence: a 1-year longitudinal study. Journal of Adolescence 31, 565–582. Cochrane, C.E., Brewerton, T.D., Wilson, D.B., Hodges, E.L., 1993. Alexithymia in the eating disorders. The International Journal of Eating Disorders 14, 219–222. De Panfilis, C., Salvatore, P., Marchesi, C., Cazzolla, R., Tonna, M., Maggini, C., 2008. Parental bonding and personality disorder: the mediating role of alexithymia. Journal of Personality Disorders 22, 496–508. Franz, M., Popp, K., Schaefer, R., Sitte, W., Schneider, C., Hardt, J., Decker, O., Braehler, E., 2008. Alexithymia in the general German population. Social Psychiatry and Psychiatric Epidemiology 43, 54–62. Fukunishi, I., Rahe, R.H., 1995. Alexithymia and coping with stress in healthy persons: alexithymia as a personality trait is associated with low support and poor responses to stress. Psychological Reports 76, 1299–1304. Fukunishi, I., Kawamura, N., Ishikawa, T., Ago, Y., Sei, H., Morita, Y., Rahe, R.H., 1997. Mothers' low care in the development of alexithymia: a preliminary study in Japanese college students. Psychological Reports 80, 143–146. Hautala, L., Alin, J., Liuksila, P.-R., Räihä, H., Saarijärvi, S., 2006. SCOFF syömishäiriöseulan reliabiliteetti ja rakennevaliditeetti murrosikäisten koululaisten seulonnassa (The reliability and construct validity of the SCOFF questionnaire in a schoolbased sample of adolescents). Duodecim 122, 2137–2144. Hautala, L., Junnila, J., Helenius, H., Väänänen, A.M., Liuksila, P.-R., Räihä, H., Välimäki, M., Saarijärvi, S., 2008. Towards understanding gender differences in disordered eating among adolescents. Journal of Clinical Nursing 17, 1803–1813. Hautala, L., Junnila, J., Alin, J., Grönroos, M., Maunula, A.M., Karukivi, M., Liuksila, P.-R., Räihä, H., Välimäki, M., Saarijärvi, S., 2009. Uncovering hidden eating disorders using the SCOFF questionnaire: cross-sectional survey of adolescents and comparison with nurse assessments. International Journal of Nursing Studies 46, 1439–1447. Heiberg, A., Heiberg, A., 1977. Alexithymia—an inherited trait? A study of twins. Psychotherapy and Psychosomatics 50, 81–87. Honkalampi, K., Hintikka, J., Tanskanen, A., Lehtonen, J., Viinamäki, H., 2000. Depression is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research 48, 99–104. Honkalampi, K., Koivumaa-Honkanen, H., Antikainen, R., Haatainen, K., Hintikka, J., Viinamäki, H., 2004. Relationships among alexithymia, adverse childhood experiences, sociodemographic variables, and actual mood disorder: a 2-year clinical follow-up study of patients with major depressive disorder. Psychosomatics 45, 197–204. Honkalampi, K., Tolmunen, T., Hintikka, J., Rissanen, M.L., Kylmä, J., Laukkanen, E., 2009. The prevalence of alexithymia and its relationship with Youth Self-Report problem scales among Finnish adolescents. Comprehensive Psychiatry 50, 263–268. Jørgensen, M.M., Zachariae, R.R., Skytthe, A., Kyvik, K., 2007. Genetic and environmental factors in alexithymia: a populationbased study of 8,785 Danish twin pairs. Psychotherapy and Psychosomatics 76, 369–375. Joukamaa, M., Miettunen, J., Kokkonen, P., Koskinen, M., Julkunen, J., Kauhanen, J., Jokelainen, J., Veijola, J., Läksy, K., Järvelin, M.R., 2001. Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nordic Journal of Psychiatry 55, 123–127.
260
M. Karukivi et al. / Psychiatry Research 187 (2011) 254–260
Joukamaa, M., Taanila, A., Miettunen, J., Karvonen, J.T., Koskinen, M., Veijola, J., 2007. Epidemiology of alexithymia among adolescents. Journal of Psychosomatic Research 63, 373–376. Kojima, M., Senda, Y., Nagaya, T., Tokudome, S., Furukawa, T.A., 2003. Alexithymia, depression and social support among Japanese workers. Psychotherapy and Psychosomatics 72, 307–314. Kokkonen, P., Karvonen, J.T., Veijola, J., Läksy, K., Jokelainen, J., Järvelin, M.R., Joukamaa, M., 2001. Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Comprehensive Psychiatry 42, 471–476. Kooiman, C.G., Spinhoven, P., Trijsburg, R.W., Rooijmans, H.G., 1998. Perceived parental attitude, alexithymia and defense style in psychiatric outpatients. Psychotherapy and Psychosomatics 67, 81–87. Loas, G., Otmani, O., Fremaux, D., Lecercle, C., Duflot, M., Delahousse, J., 1996. External validity, reliability and basic score determination of the Toronto Alexithymia Scales (TAS and TAS-20) in a group of alcoholic patients. L'Encéphale 22, 35–40. Lumley, M.A., Mader, C., Gramzow, J., Papineau, K., 1996. Family factors related to alexithymia characteristics. Psychosomatic Medicine 58, 211–216. Mason, O., Tyson, M., Jones, C., Potts, S., 2005. Alexithymia: its prevalence and correlates in a British undergraduate sample. Psychology and Psychotherapy 78, 113–125. Mattila, A., 2009. Alexithymia in Finnish General Population. Acta Universitatis Tamperensis, 1377. Tampere University Press, pp. 40–46. Available at: http://acta. uta.fi/pdf/978-951-44-7563-4.pdf. Accessed January 10, 2010. Mattila, A.K., Salminen, J.K., Nummi, T., Joukamaa, M., 2006. Age is strongly associated with alexithymia in the general population. Journal of Psychosomatic Research 61, 629–635. Parker, G., 1983. Parental Overprotection: A Risk Factor in Psychosocial Development. Grune & Stratton, New York. Parker, G., 1989. The parental bonding instrument. Psychometric properties reviewed. Psychiatric Developments 7, 317–335. Parker, G., Tupling, H., Brown, L.B., 1979. A parental bonding instrument. The British Journal of Medical Psychology 52, 1–10.
Parker, J., Taylor, G., Bagby, R., 2003. The 20-item Toronto Alexithymia Scale, III: reliability and factorial validity in a community population. Journal of Psychosomatic Research 55, 269–275. Picardi, A., Toni, A., Caroppo, E., 2005. Stability of alexithymia and its relationships with the ‘big five’ factors, temperament, character, and attachment style. Psychotherapy and Psychosomatics 74, 371–378. Posse, M., Hällström, T., Backenroth-Ohsako, G., 2002. Alexithymia, social support, psycho-social stress and mental health in a female population. Nordic Journal of Psychiatry 56, 329–334. Russ, E., Heim, A., Westen, D., 2003. Parental bonding and personality pathology assessed by clinician report. Journal of Personality Disorders 17, 522–536. Säkkinen, P., Kaltiala-Heino, R., Ranta, K., Haataja, R., Joukamaa, M., 2007. Psychometric properties of the 20-item Toronto Alexithymia Scale and prevalence of alexithymia in a Finnish adolescent population. Psychosomatics 48, 154–161. 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. Sifneos, P., 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. Alexithymia in Medical and Psychiatric Illness. Cambridge University Press, Cambridge. Taylor, G., Bagby, R., Parker, J., 2003. The 20-item Toronto Alexithymia Scale, IV: reliability and factorial validity in different languages and cultures. Journal of Psychosomatic Research 55, 277–283. Torresani, S., Favaretto, E., Zimmermann, C., 2000. Parental representations in drug-dependent patients and their parents. Comprehensive Psychiatry 41, 123–129. Zimet, G.D., Dahlem, N.W., Zimet, S.G., Farley, G.K., 1988. The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment 52, 30–41. Zimet, G.D., Powell, S.S., Farley, G.K., Werkman, S., Berkoff, K.A., 1990. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment 55, 610–617.