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Two decades of alexithymia
Journal of Psychosomatic Research, Vol. 39, No. 7, pp. 803-807, 1995
Copyright© 1995ElsevierScience Inc. Printed in Great Britain. All rights reserved. 0022-3999/95 $29.00 + 0.00
Pergamon 0022-3999(95)00153-A
EDITORIAL
TWO DECADES OF ALEXITHYMIA JOUKO K. SALMINEN,* SIMO SAARIJARVIt and ERKKI A,~REL,~$
Twenty years ago Sifneos [1] reported that patients with 'classical' psychosomatic illnesses, such as ulcerative colitis, peptic ulcer, asthma etc., often had typical psychological characteristics, which differed markedly from traits which were typical of neurotic patients. The most central of these characteristics were a marked constriction in emotional functioning, poverty of fantasy life and inability to find appropriate words to describe emotions. "For lack of a better term" he called these characteristics 'alexithymic', meaning literally 'no words for feelings'. Since then the term and concept of alexithymia have been widely used in psychosomatic research. According to a Medline search more than 300 articles have been published on this topic in the years 1973-1993. The most recent research has stressed the point that in alexithymia there is not only a difficulty in expressing emotions verbally but a deficit in their cognitive processing. This causes emotions to remain undifferentiated and poorly regulated [2]. The alexithymia construct deals with a very central area of psychosomatic research--the influence of emotions on somatic symptom formation and on general health. In our opinion there have been two additional reasons for the widespread interest in this issue. Firstly, the concept of alexithymia lucidly expressed the findings of the studies by Nemiah and Sifneos [3] and some earlier observations on psychological characteristics thought to be common among patients with classical psychosomatic illnesses. As early as 1948 Ruesch proposed that the core problem of psychosomatic medicine is infantile personality [4] and in the beginning of the 1960s the French psychoanalysts Marty and de M'Uzan suggested that typical traits for patients with psychosomatic illnesses are that they lack fantasy, and are heavily prone to practical and action-oriented thinking, "la pensee operatoire" [5]. Secondly, the alexithymia construct seemed to be a way out of the theoretical impasse of the earlier prevailing psychodynamic hypothesis that the central factors in the aetiology of the classical psychosomatic diseases were unconscious drive conflicts specific to the disease, e.g. in asthma an unresolved dependency need and in rheumatoid arthritis long standing suppressed aggressive impulses [6]. The
* Research and Development Centre of the Social Insurance Institution, Turku, Finland. t Department of Psychiatry, University of Turku, Turku, Finland. :~ Clinic of Psychiatry, Turku University Central Hospital, Turku, Finland.
803
804
Editorial
alexithymia theory suggests that the central characteristic of the psychopatholegy of psychosomatic patients is not a specific unconscious drive conflict as proposed by Alexander, but a primary deficit in affective functioning. This manifests itself as an absence of drive-directed fantasy and as a general and deep-rooted inability to describe and express feelings verbally. It was argued that alexithymic individuals had never learned to express emotions verbally, because of a severe disturbance in their early psychosocial development or even because of some pathology in brain functioning, perhaps a defect in the interhemispheric communication [3, 7]. These characteristics were not neurotic phenomena or the result of regression but a primary deficiency of personality common for all patients with psychosomatic diseases. In consequence, it was suggested that these patients should not be treated with dynamic psychotherapy, but with supportive or behaviour therapy, case work etc to help them identify, process and express feelings more adequately. Now after two decades it is time to review the results of alexithymia research. Several questions are relevant. Is there empirical evidence that alexithymic characteristics are specific for patients with classical psychosomatic illnesses or for patients with functional somatization symptoms? Do patients with physical illness and secondary psychological difficulties display these traits as well? What is the theoretical position of alexithymia? Is it a primary non-neurotic personality trait, a personality defect, or a secondary phenomenon, a defensive psychic operation in a traumatic situation or a consequence of regression? Is alexithymia a psychological characteristic, or does it merely reflect sociocultural differences among people? Finally and most importantly, what should be the proper treatment for patients who express alexithymic traits? Alexithymia or alexithymic features seem not to be specific for patients with classical psychosomatic illnesses. Research has shown that chronically ill somatic patients and psychiatric patients as well are often alexithymic [8-10]. Alexithymic traits have been found to be common also in patients suffering from anorexia nervosa, bulimia, obesity, substance abuse, depression, panic disorder, post-traumatic stress disorder, and hypochondriasis among others. In psychiatric consultation outpatients the prevalence of alexithymic features exceeding the cutoff point has been between 30 and 40% [8, 10]. Even the non-ill can be alexithymic [11]. It also seems to be true that alexithymia can be a secondary phenomenon resulting from massive psychologic trauma during the critical period of infant development or from a major environmental catastrophe in adult life [12]. For example, studies of concentration camp survivors have given support to this view [13]. People suffering from severe illness can also manifest this kind of secondary alexithymia [14]. In these cases alexithymia can be best understood as a way of coping with a life-threatening stress rather than as a genuine personality trait. Epidemiological studies in non-clinical populations have so far mostly dealt with limited and selected samples. The measurement of alexithymia has been problematic although the concept was operationalized already 20 yr ago (the Beth Israel Hospital Questionnaire, B1Q [1]). The BIQ is an observer-rated instrument, but the problem in using it is, that it is not easy to assess the lack of appropriate affect especially in non-clinical situations. Several other measures, questionnaires and projective tests, to assess alexithymic features have been developed, but there have been problems in their validity. It was not until the development of a well validated self-rating
Editorial
805
instrument, the Toronto Alexithymia Scale [15] in 1985, that substantial epidemiological studies became possible. The largest one so far is that undertaken in Finland by Kauhanen et al. [16]. They studied four cohorts of 2682 middle-aged men drawn from the general population. The results showed that education, income and occupational status were inversely related to the degree of alexithymia measured by the TAS. In addition, men with high scores on the TAS were more often unmarried and had low levels of social contacts and acquaintances. Also an Italian study of 417 normal subjects by Pasini and co-workers showed that high scores of TAS were associated with low levels of education and high age [11]. No gender difference was found. Thus, it seems that alexithymia is not exclusively a psychological phenomenon but has important sociocultural implications as well. Another Finnish study comprising 266 subjects from a Finnish population and using the BIQ showed that the prevalence of alexithymia proper was rather low, 4.1'V,,, but that 21.8% of the subjects had mild alexithymic features [17]. There was also a distinct gender difference, in contrast to the lack of difference in Pasini study, men being more often alexithymic than women. Alexithymic features thus seem to be very common in the general population. Consequently, alexithymia is best considered as a personality dimension, rather than as a category. The original description of an alexithymic person by Sifneos was narrowly defined, and the BIQ therefore produces low prevalences of alexithymia. On the contrary the TAS, currently the most widely used instrument, seems to be over-inclusive and identifies a diluted and heterogenous group of alexithymics. The different factors of the TAS have had conflicting associations with various characteristics of the study populations [9, 18]. This raises the question whether alexithymia is a real clinical entity or would it be wiser to consider the different factors of alexithymia separately in connection with mood or social deprivation. The revised and shortened version of the TAS published in 1994 [19, 20] may be an improved instrument to the alexithymia research. The theories of the possible biological aetiology of alexithymia seem to be highly speculative. There is only one twin study dealing with alexithymia [21]. Although this showed that there is a hederitary component in alexithymia, the results should be interpreted with caution because of the small sample size, only 66 persons. In another study, commissurotomy patients were found to be more alexithymic than normal controls [22]. These studies enable no clear conclusions about association of alexithymia and psychosomatic illness. From the clinical point of view it is important to know whether measurements of alexithymia are of any help in the treatment of patients. Sifneos' original opinion was, that alexithymic patients are poor candidates for dynamic psychotherapy and that kind of therapy may even worsen the condition of the patient [23]. He therefore recommended supportive psychotherapy and pharmacotherapy. Later, however, he claimed that patients suffering from secondary alexithymia could possibly be treated with dynamic psychotherapy [12]. McDougall [24] has reported case studies where seemingly alexithymic patients have been successfully treated by psychoanalysis or analytic psychotherapy. She concludes that deeming patients as unsuitable for dynamic psychotherapy may be an example of countertransference. Our recent follow-up study of general hospital psychiatric out-patients showed that the TASscore predicted neither treatment recommendations nor acceptance of psychotherapy
806
Editorial
[25]. The level of subjective distress was the most important incentive for patients to seek professional help, regardless of the patients' insight into the causes of the distress. It seems likely that the attitude of the doctor is equally important here: he or she should be willing to see insight and motivation for therapy not as a prerequisite, but as one of the issues to be negotiated in the initial examination. It has also been stressed that during therapy the therapeutic relationship can markedly change its quality so that an initially alexithymic and unmotivated psychosomatic patient gradually becomes a good candidate for insight-oriented psychotherapy [26]. Measuring alexithymia can never replace a more comprehensive assessment of the patients' personality, but it can give useful additional information especially in planning of the treatment for patients complaining of unexplained somatic symptoms. In conclusion: it is evident that at present there are many questions and few answers concerning alexithymia. Following the introduction of clinically usable instruments for the measurement of alexithymia there has been a steady output of papers on the prevalence and associations of alexithymia in various patient groups. Here lies a danger of reification, i.e. what started out as a hypothetical construct derived from the psychodynamic tradition and to be further clarified by research may have begun to live a life of its own. It is surprising that after 20 yr of research a proper and large epidemiological study of alexithymia is still lacking. A comprehensive epidemiological study comparing the prevalence of of alexithymia in different cultures would also be very welcome to increase the understanding the nature of this phenomenon. We also need long-term follow-up studies to assess if alexithymia really is a risk factor for general health. To our knowledge no such studies exist. We also need more empirical research on the processing of affects in stressful situations to elucidate the mechanisms by which emotional stimuli can elicit somatic responses. Finally and most importantly, more clinical studies of the results of the treatment of alexithymic patients are needed.
REFERENCES 1. SIFNEOS PE. The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychother Psychosom 1973; 22: 255-262. 2. TAYLOR GJ, BAGBY RM, PARKER JDA. The alexithymia construct. A potential paradigm for psychosomatic medicine. Psychosomatics 1991; 32:153-164. 3. NEMIAH JC, SIFNEOS PE. Affect and fantasy in patients with psychosomatic disorders. In Modern Trends in Psychosomatic Medicine Vol. 2, (Edited by Hill OW), pp.26-34. London: Butterworths, 1970 4. RUESCH J. 'The infantile personality: the core problem of psychosomatic medicine'. Psychosom Med 1948; 10: 134-144. 5. MARTY P, DE M ' U Z A N M. La "pensee operatoire". Rev Franc Psychoanal 1963; 27(suppl): 1345-1356. 6. ALEXANDER F. Psychosomatic Medicine. New York: Norton, 1950. 7. SIFNEOS PE. Affect, emotional conflict, and deficit: An overview. Psychother Psychosom 1991; 56: 111-122. 8. SMITH GR Jr. Alexithymia in medical patients referred to a consultation/liaison service. Am J Psychiatry 1983; 140: 99-101. 9. RUB1NO IA, GRASSO S, SONNINO A, PEZZAROSSA B. Is alexithymia a non-neurotic personality dimension? Br J Med Psychol 1991; 64: 385-391. 10. SAARIJA.RVI S, SALMINEN JK, TAMMINEN T, A.A,RELA. E. Alexithymia in psychiatric consultation-liaison patients. Gen Hosp Psychiatry 1993; 15: 330-333.
Editorial
807
I 1. PASINI A, CHIAIE RD, SERIPA S, CIANI N. Alexithymia as related to sex, age, and educational level: Results of the Toronto Alexithymia Scale in 417 normal subjects. Compr Psychiatry 1992; 33: 4246. 12. SIFNEOS PE. Alexithymia and its relationship to hemispheric specialization, affect and creativity. Psychiat Clin N Am 1988; 11: 287-292. 13. KRYSTAL H. Integration and Self Healing: Affect, Trauma, Alexithymia. Hillsdale: Analytic Press, 1988. 14. FREYBERGER H. Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychother Psychosom 1977; 28: 337-342. 15. TAYLOR G J, RYAN DB, BAGBY RM. Toward the development of a new self-report alexithymia scale. Psychother Psychosom 1985; 44: 191-199. 16. KAUHANEN J, KAPLAN GA, JULKUNEN J, WILSON TW, SALONEN JT. Social factors in alexithymia. Compr Psychiatry 1993; 34: 330-335. 17. LINDHOLM T, LEHTINEN V, HYYPP,~. MT, PUUKKA P. Alexithymic features in relation to the dexamethasone suppression test in a Finnish population sample. Am J Psychiatry 1990; 147: 1216-1219. 18. KIRMAYER LJ, ROBBINS JM. Cognitive and social correlates of the Toronto Alexithymia Scale. Psychosomatics 1993; 34: 41-52. 19. BAGBY RM, PARKER JDA, TAYLOR GJ. The twenty-item Toronto Alexithymia Scale-- I. Item selection and cross validation of the factor structure. J Psychosom Res 1994; 38: 23-32. 20. BAGBY RM, TAYLOR GJ, PARKER JDA. The twenty-item Toronto Alexithymia Scale--lI. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38: 33~,0. 21. HEIBERG A, HEIBERG A. Alexithymia-- an inherited trait? A study of twins. Psychother Psychosom 1977; 28: 221-225. 22. TENHOUTEN WD, HOPPE KD, BOGEN JE, WALTER DO. Alexithymia and the split brain I1. Sentential-level content analysis. Psychother Psychosom 1985; 44: 1-5. 23. SIFNEOS PE. Problems of psychotherapy of patients with alexithymic characteristics and physical disease. Psychother Psychosom 1975; 26: 65-70. 24. MCDOUGALL J. Theatres of the Body.: London: Free Association Books, 1989. 25. SALMINEN JK, SAARIJ,~RVI S, AAREL~, E, TAMMINEN T. Alexithymia--state or trait? J Psychosom Res 1994; 38: 681-685. 26. KARASU TB. Psychotherapy of the psychosomatic patient. Am J Psychother 1979; 33: 354-364.
Copyright© 1995ElsevierScience Inc. Printed in Great Britain. All rights reserved. 0022-3999/95 $29.00 + 0.00
Pergamon 0022-3999(95)00153-A
EDITORIAL
TWO DECADES OF ALEXITHYMIA JOUKO K. SALMINEN,* SIMO SAARIJARVIt and ERKKI A,~REL,~$
Twenty years ago Sifneos [1] reported that patients with 'classical' psychosomatic illnesses, such as ulcerative colitis, peptic ulcer, asthma etc., often had typical psychological characteristics, which differed markedly from traits which were typical of neurotic patients. The most central of these characteristics were a marked constriction in emotional functioning, poverty of fantasy life and inability to find appropriate words to describe emotions. "For lack of a better term" he called these characteristics 'alexithymic', meaning literally 'no words for feelings'. Since then the term and concept of alexithymia have been widely used in psychosomatic research. According to a Medline search more than 300 articles have been published on this topic in the years 1973-1993. The most recent research has stressed the point that in alexithymia there is not only a difficulty in expressing emotions verbally but a deficit in their cognitive processing. This causes emotions to remain undifferentiated and poorly regulated [2]. The alexithymia construct deals with a very central area of psychosomatic research--the influence of emotions on somatic symptom formation and on general health. In our opinion there have been two additional reasons for the widespread interest in this issue. Firstly, the concept of alexithymia lucidly expressed the findings of the studies by Nemiah and Sifneos [3] and some earlier observations on psychological characteristics thought to be common among patients with classical psychosomatic illnesses. As early as 1948 Ruesch proposed that the core problem of psychosomatic medicine is infantile personality [4] and in the beginning of the 1960s the French psychoanalysts Marty and de M'Uzan suggested that typical traits for patients with psychosomatic illnesses are that they lack fantasy, and are heavily prone to practical and action-oriented thinking, "la pensee operatoire" [5]. Secondly, the alexithymia construct seemed to be a way out of the theoretical impasse of the earlier prevailing psychodynamic hypothesis that the central factors in the aetiology of the classical psychosomatic diseases were unconscious drive conflicts specific to the disease, e.g. in asthma an unresolved dependency need and in rheumatoid arthritis long standing suppressed aggressive impulses [6]. The
* Research and Development Centre of the Social Insurance Institution, Turku, Finland. t Department of Psychiatry, University of Turku, Turku, Finland. :~ Clinic of Psychiatry, Turku University Central Hospital, Turku, Finland.
803
804
Editorial
alexithymia theory suggests that the central characteristic of the psychopatholegy of psychosomatic patients is not a specific unconscious drive conflict as proposed by Alexander, but a primary deficit in affective functioning. This manifests itself as an absence of drive-directed fantasy and as a general and deep-rooted inability to describe and express feelings verbally. It was argued that alexithymic individuals had never learned to express emotions verbally, because of a severe disturbance in their early psychosocial development or even because of some pathology in brain functioning, perhaps a defect in the interhemispheric communication [3, 7]. These characteristics were not neurotic phenomena or the result of regression but a primary deficiency of personality common for all patients with psychosomatic diseases. In consequence, it was suggested that these patients should not be treated with dynamic psychotherapy, but with supportive or behaviour therapy, case work etc to help them identify, process and express feelings more adequately. Now after two decades it is time to review the results of alexithymia research. Several questions are relevant. Is there empirical evidence that alexithymic characteristics are specific for patients with classical psychosomatic illnesses or for patients with functional somatization symptoms? Do patients with physical illness and secondary psychological difficulties display these traits as well? What is the theoretical position of alexithymia? Is it a primary non-neurotic personality trait, a personality defect, or a secondary phenomenon, a defensive psychic operation in a traumatic situation or a consequence of regression? Is alexithymia a psychological characteristic, or does it merely reflect sociocultural differences among people? Finally and most importantly, what should be the proper treatment for patients who express alexithymic traits? Alexithymia or alexithymic features seem not to be specific for patients with classical psychosomatic illnesses. Research has shown that chronically ill somatic patients and psychiatric patients as well are often alexithymic [8-10]. Alexithymic traits have been found to be common also in patients suffering from anorexia nervosa, bulimia, obesity, substance abuse, depression, panic disorder, post-traumatic stress disorder, and hypochondriasis among others. In psychiatric consultation outpatients the prevalence of alexithymic features exceeding the cutoff point has been between 30 and 40% [8, 10]. Even the non-ill can be alexithymic [11]. It also seems to be true that alexithymia can be a secondary phenomenon resulting from massive psychologic trauma during the critical period of infant development or from a major environmental catastrophe in adult life [12]. For example, studies of concentration camp survivors have given support to this view [13]. People suffering from severe illness can also manifest this kind of secondary alexithymia [14]. In these cases alexithymia can be best understood as a way of coping with a life-threatening stress rather than as a genuine personality trait. Epidemiological studies in non-clinical populations have so far mostly dealt with limited and selected samples. The measurement of alexithymia has been problematic although the concept was operationalized already 20 yr ago (the Beth Israel Hospital Questionnaire, B1Q [1]). The BIQ is an observer-rated instrument, but the problem in using it is, that it is not easy to assess the lack of appropriate affect especially in non-clinical situations. Several other measures, questionnaires and projective tests, to assess alexithymic features have been developed, but there have been problems in their validity. It was not until the development of a well validated self-rating
Editorial
805
instrument, the Toronto Alexithymia Scale [15] in 1985, that substantial epidemiological studies became possible. The largest one so far is that undertaken in Finland by Kauhanen et al. [16]. They studied four cohorts of 2682 middle-aged men drawn from the general population. The results showed that education, income and occupational status were inversely related to the degree of alexithymia measured by the TAS. In addition, men with high scores on the TAS were more often unmarried and had low levels of social contacts and acquaintances. Also an Italian study of 417 normal subjects by Pasini and co-workers showed that high scores of TAS were associated with low levels of education and high age [11]. No gender difference was found. Thus, it seems that alexithymia is not exclusively a psychological phenomenon but has important sociocultural implications as well. Another Finnish study comprising 266 subjects from a Finnish population and using the BIQ showed that the prevalence of alexithymia proper was rather low, 4.1'V,,, but that 21.8% of the subjects had mild alexithymic features [17]. There was also a distinct gender difference, in contrast to the lack of difference in Pasini study, men being more often alexithymic than women. Alexithymic features thus seem to be very common in the general population. Consequently, alexithymia is best considered as a personality dimension, rather than as a category. The original description of an alexithymic person by Sifneos was narrowly defined, and the BIQ therefore produces low prevalences of alexithymia. On the contrary the TAS, currently the most widely used instrument, seems to be over-inclusive and identifies a diluted and heterogenous group of alexithymics. The different factors of the TAS have had conflicting associations with various characteristics of the study populations [9, 18]. This raises the question whether alexithymia is a real clinical entity or would it be wiser to consider the different factors of alexithymia separately in connection with mood or social deprivation. The revised and shortened version of the TAS published in 1994 [19, 20] may be an improved instrument to the alexithymia research. The theories of the possible biological aetiology of alexithymia seem to be highly speculative. There is only one twin study dealing with alexithymia [21]. Although this showed that there is a hederitary component in alexithymia, the results should be interpreted with caution because of the small sample size, only 66 persons. In another study, commissurotomy patients were found to be more alexithymic than normal controls [22]. These studies enable no clear conclusions about association of alexithymia and psychosomatic illness. From the clinical point of view it is important to know whether measurements of alexithymia are of any help in the treatment of patients. Sifneos' original opinion was, that alexithymic patients are poor candidates for dynamic psychotherapy and that kind of therapy may even worsen the condition of the patient [23]. He therefore recommended supportive psychotherapy and pharmacotherapy. Later, however, he claimed that patients suffering from secondary alexithymia could possibly be treated with dynamic psychotherapy [12]. McDougall [24] has reported case studies where seemingly alexithymic patients have been successfully treated by psychoanalysis or analytic psychotherapy. She concludes that deeming patients as unsuitable for dynamic psychotherapy may be an example of countertransference. Our recent follow-up study of general hospital psychiatric out-patients showed that the TASscore predicted neither treatment recommendations nor acceptance of psychotherapy
806
Editorial
[25]. The level of subjective distress was the most important incentive for patients to seek professional help, regardless of the patients' insight into the causes of the distress. It seems likely that the attitude of the doctor is equally important here: he or she should be willing to see insight and motivation for therapy not as a prerequisite, but as one of the issues to be negotiated in the initial examination. It has also been stressed that during therapy the therapeutic relationship can markedly change its quality so that an initially alexithymic and unmotivated psychosomatic patient gradually becomes a good candidate for insight-oriented psychotherapy [26]. Measuring alexithymia can never replace a more comprehensive assessment of the patients' personality, but it can give useful additional information especially in planning of the treatment for patients complaining of unexplained somatic symptoms. In conclusion: it is evident that at present there are many questions and few answers concerning alexithymia. Following the introduction of clinically usable instruments for the measurement of alexithymia there has been a steady output of papers on the prevalence and associations of alexithymia in various patient groups. Here lies a danger of reification, i.e. what started out as a hypothetical construct derived from the psychodynamic tradition and to be further clarified by research may have begun to live a life of its own. It is surprising that after 20 yr of research a proper and large epidemiological study of alexithymia is still lacking. A comprehensive epidemiological study comparing the prevalence of of alexithymia in different cultures would also be very welcome to increase the understanding the nature of this phenomenon. We also need long-term follow-up studies to assess if alexithymia really is a risk factor for general health. To our knowledge no such studies exist. We also need more empirical research on the processing of affects in stressful situations to elucidate the mechanisms by which emotional stimuli can elicit somatic responses. Finally and most importantly, more clinical studies of the results of the treatment of alexithymic patients are needed.
REFERENCES 1. SIFNEOS PE. The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychother Psychosom 1973; 22: 255-262. 2. TAYLOR GJ, BAGBY RM, PARKER JDA. The alexithymia construct. A potential paradigm for psychosomatic medicine. Psychosomatics 1991; 32:153-164. 3. NEMIAH JC, SIFNEOS PE. Affect and fantasy in patients with psychosomatic disorders. In Modern Trends in Psychosomatic Medicine Vol. 2, (Edited by Hill OW), pp.26-34. London: Butterworths, 1970 4. RUESCH J. 'The infantile personality: the core problem of psychosomatic medicine'. Psychosom Med 1948; 10: 134-144. 5. MARTY P, DE M ' U Z A N M. La "pensee operatoire". Rev Franc Psychoanal 1963; 27(suppl): 1345-1356. 6. ALEXANDER F. Psychosomatic Medicine. New York: Norton, 1950. 7. SIFNEOS PE. Affect, emotional conflict, and deficit: An overview. Psychother Psychosom 1991; 56: 111-122. 8. SMITH GR Jr. Alexithymia in medical patients referred to a consultation/liaison service. Am J Psychiatry 1983; 140: 99-101. 9. RUB1NO IA, GRASSO S, SONNINO A, PEZZAROSSA B. Is alexithymia a non-neurotic personality dimension? Br J Med Psychol 1991; 64: 385-391. 10. SAARIJA.RVI S, SALMINEN JK, TAMMINEN T, A.A,RELA. E. Alexithymia in psychiatric consultation-liaison patients. Gen Hosp Psychiatry 1993; 15: 330-333.
Editorial
807
I 1. PASINI A, CHIAIE RD, SERIPA S, CIANI N. Alexithymia as related to sex, age, and educational level: Results of the Toronto Alexithymia Scale in 417 normal subjects. Compr Psychiatry 1992; 33: 4246. 12. SIFNEOS PE. Alexithymia and its relationship to hemispheric specialization, affect and creativity. Psychiat Clin N Am 1988; 11: 287-292. 13. KRYSTAL H. Integration and Self Healing: Affect, Trauma, Alexithymia. Hillsdale: Analytic Press, 1988. 14. FREYBERGER H. Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychother Psychosom 1977; 28: 337-342. 15. TAYLOR G J, RYAN DB, BAGBY RM. Toward the development of a new self-report alexithymia scale. Psychother Psychosom 1985; 44: 191-199. 16. KAUHANEN J, KAPLAN GA, JULKUNEN J, WILSON TW, SALONEN JT. Social factors in alexithymia. Compr Psychiatry 1993; 34: 330-335. 17. LINDHOLM T, LEHTINEN V, HYYPP,~. MT, PUUKKA P. Alexithymic features in relation to the dexamethasone suppression test in a Finnish population sample. Am J Psychiatry 1990; 147: 1216-1219. 18. KIRMAYER LJ, ROBBINS JM. Cognitive and social correlates of the Toronto Alexithymia Scale. Psychosomatics 1993; 34: 41-52. 19. BAGBY RM, PARKER JDA, TAYLOR GJ. The twenty-item Toronto Alexithymia Scale-- I. Item selection and cross validation of the factor structure. J Psychosom Res 1994; 38: 23-32. 20. BAGBY RM, TAYLOR GJ, PARKER JDA. The twenty-item Toronto Alexithymia Scale--lI. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38: 33~,0. 21. HEIBERG A, HEIBERG A. Alexithymia-- an inherited trait? A study of twins. Psychother Psychosom 1977; 28: 221-225. 22. TENHOUTEN WD, HOPPE KD, BOGEN JE, WALTER DO. Alexithymia and the split brain I1. Sentential-level content analysis. Psychother Psychosom 1985; 44: 1-5. 23. SIFNEOS PE. Problems of psychotherapy of patients with alexithymic characteristics and physical disease. Psychother Psychosom 1975; 26: 65-70. 24. MCDOUGALL J. Theatres of the Body.: London: Free Association Books, 1989. 25. SALMINEN JK, SAARIJ,~RVI S, AAREL~, E, TAMMINEN T. Alexithymia--state or trait? J Psychosom Res 1994; 38: 681-685. 26. KARASU TB. Psychotherapy of the psychosomatic patient. Am J Psychother 1979; 33: 354-364.