Secondary
Alexithymia:
An Empirical Validation
Thomas N. Wise, Lee S. Mann, J. David Mitchell, Michael Hryvniak, and Bethanne Hill Alexithymia is described as both a primary personality trait and a secondary state reaction to medical illness. To empirically study secondary alexithymia, a series of medically ill patients seen in psychiatric consultation were compared with a healthy control population. Measured by the Toronto Alexithymia Scale (TAS), the medically ill were more alexithymic than the healthy population. Alexithymia was best predicted by both depressed mood and lowered quality of life, rather than by the categorical ranking of the severity of the medical illness. Alexithymia did appear to be separate from self-reported mood. These data support the concept of secondary alexithymia. 0 1990 by W. B. Saunders Company.
A
LEXITHYMIA is a personality trait in which an individual has difficulty identifying emotional state, possesses minimal fantasy life, and focuses on external and somatic concerns, rather than on inner emotional states.’ Freyberger suggests there can also be a reactive alexithymia that functions as a “state reaction” to mitigate painful affects in the seriously i11.2This phenomenon has been called “secondary alexithymia.” Using a quantitative rank-ordered hierarchy for categorizing the severity of physical illness, a recent study found that alexithymic characteristics did not correlate with the categorical severity of illness in hospitalized medical patients, but that the patient’s level of depression was related to alexithymia.3 This report expands on that investigation by examining the relationship of alexithymia with functional aspects of a physical illness that modify quality of life and the ability to perform activities of daily living in a series of patients seen in psychiatric consultation. The study attempts to empirically validate Freyberger’s concept of secondary alexithymia. METHODS The subjects studied in this report are 53 medical inpatients evaluated on a psychiatric consultation service in a teaching hospital described previously.4 Delirious or demented patients were excluded from the sample. Each patient was diagnosed by a psychiatric consultation fellow, as well as by a faculty member using axis I of DSM-III-R (DSM-III-R, 1987).5 Axis II data are not reported due to low reliability of such categorical personality disorders.6 A comparison group was sampled from healthy volunteers in a hospital auxiliary service (n = 55). Alexithymia was measured dimensionally using the Toronto Alexithymia Scale (TAS).’ The TAS is a 26-item self-report instrument that has been demonstrated to have internal consistency, good reliability, as well as construct and criterion validity to measure alexithymic characteristics.* Other measurements included the QL Index a six-item observer-rated inventory that assesses the functional effect of the patient’s illness on physical activity, daily living, sense of perceived good health, social support, and actual mobility.” The Karnofsky Performance Status Scale measures the ability to physically function and care for oneself in an autonomous fashion on a scale of 0 to 100.” To insure reliability of such observer-rated scales, the initial 10 patients were blindly judged by two of the authors and interrater reliabilities were later compared.
From the Departments of Psychiatry, Fairfax Hospital, Falls Church, VA; and Georgetown University School of Medicine, Washington, DC. Address reprint requests to Thomas N. Wise, M.D., 3300 Gallows Rd. Falls Church, VA 22046. 0 1990 by W.B. Saunders Company. 0010-440X/90/3104-0008$03.00/0
284
Comprehensive
Psychiatry, Vol. 3 1, No. 4 (July/August),
1990: pp 284-288
SECONDARY ALEXITHYMIA
285
The seriousness of each patient’s illness was quantitatively ranked using the Revised Seriousness of Illness Rating Scale, according to a validated hierarchy.” (For example, a value of 1 is assigned to dandruff, and 137, the highest value, is assigned to acquired immunodeficiency syndrome.) Personality style was profiled using the Hysteroid-Obsessoid Scale, a 4%item questionnaire that views personality as a dimensional construct with hysteroid characteristics at one pole and obsessional, intellectualized, isolated characteristics at the other.12 Using these two styles as end points, it characterizes people on a dimension from emotional and dramatic to intellectualized and isolated of affect.‘j Last, mood was assessed using a lOO-mm visual analog scale. In addition, the comparison group completed the General Health Questionnaire (GHQ), a 30-item screening inventory to detect psychiatric illness in a normative population. ” Those control subjects found to have a GHQ of 5 or more, i.e., suggestive of psychiatric distress, were omitted from the study (n = 5).
RESULTS
The demographic characteristics of both the medically ill consult and control subjects are outlined in Table 1. Psychiatric diagnoses of consult patients are delineated in Table 2. The mean seriousness of illness for the hospitalized patients was 115.8 (SD = 22.4) (116 = congestive heart failure). Since the control group had significantly more females than the consultation group (x2 = 27.4, 1 df, P < .OOl), two-way analyses of variance were performed using sex and group as the dependent variables. Age and education were found not to be significantly different between groups. The consultation patients had significantly higher TAS scores than the normals (f = 9.2, 1 dJ P .c.Ol); and females had marginally higher (62.1) scores compared with males (60.5) (f = 4.8, 1 dJ P -=z .05). There were no significant differences between the consultation and control groups on the HOQ. However, the depression analog scale showed two main effects. The consultation group was more depressed than the control cohort (f= 38.2, 1 dJ; P -c.001) and males were mildly more depressed than females (40.9 v 38.1) (f = 8.9, 1 df, P -c.Ol). However, there was no significant interaction effects. Examining the consultation group alone, Pearson correlations showed that TAS significantly correlates with less education, less ability to perform activities of daily living, a lower quality of life index, a more obsessoid personality style, and more depression (Table 3). To examine the collective influence of both demographic and clinical variables on the TAS score, a stepwise regression analysis for both consult and control groups was conducted. In the regression for the consult group, the quality of life score was entered initially and its coefficient accounted for 23.1% of the variation for predicting alexithymia (P < .OOOl). Mood, i.e., level of depression, was the next variable entered and added an additional 9.1% of the variance (P < .Ol). Finally, after controlling for the quality of life and mood coefficients, education contributed Table 1. Demographic
and Clinical Variables Deprer-
N CO”S”h
53
service Namsl
55
“Ol”“few* .P< tP
Alexithymia:
An Empirical Validation
Thomas N. Wise, Lee S. Mann, J. David Mitchell, Michael Hryvniak, and Bethanne Hill Alexithymia is described as both a primary personality trait and a secondary state reaction to medical illness. To empirically study secondary alexithymia, a series of medically ill patients seen in psychiatric consultation were compared with a healthy control population. Measured by the Toronto Alexithymia Scale (TAS), the medically ill were more alexithymic than the healthy population. Alexithymia was best predicted by both depressed mood and lowered quality of life, rather than by the categorical ranking of the severity of the medical illness. Alexithymia did appear to be separate from self-reported mood. These data support the concept of secondary alexithymia. 0 1990 by W. B. Saunders Company.
A
LEXITHYMIA is a personality trait in which an individual has difficulty identifying emotional state, possesses minimal fantasy life, and focuses on external and somatic concerns, rather than on inner emotional states.’ Freyberger suggests there can also be a reactive alexithymia that functions as a “state reaction” to mitigate painful affects in the seriously i11.2This phenomenon has been called “secondary alexithymia.” Using a quantitative rank-ordered hierarchy for categorizing the severity of physical illness, a recent study found that alexithymic characteristics did not correlate with the categorical severity of illness in hospitalized medical patients, but that the patient’s level of depression was related to alexithymia.3 This report expands on that investigation by examining the relationship of alexithymia with functional aspects of a physical illness that modify quality of life and the ability to perform activities of daily living in a series of patients seen in psychiatric consultation. The study attempts to empirically validate Freyberger’s concept of secondary alexithymia. METHODS The subjects studied in this report are 53 medical inpatients evaluated on a psychiatric consultation service in a teaching hospital described previously.4 Delirious or demented patients were excluded from the sample. Each patient was diagnosed by a psychiatric consultation fellow, as well as by a faculty member using axis I of DSM-III-R (DSM-III-R, 1987).5 Axis II data are not reported due to low reliability of such categorical personality disorders.6 A comparison group was sampled from healthy volunteers in a hospital auxiliary service (n = 55). Alexithymia was measured dimensionally using the Toronto Alexithymia Scale (TAS).’ The TAS is a 26-item self-report instrument that has been demonstrated to have internal consistency, good reliability, as well as construct and criterion validity to measure alexithymic characteristics.* Other measurements included the QL Index a six-item observer-rated inventory that assesses the functional effect of the patient’s illness on physical activity, daily living, sense of perceived good health, social support, and actual mobility.” The Karnofsky Performance Status Scale measures the ability to physically function and care for oneself in an autonomous fashion on a scale of 0 to 100.” To insure reliability of such observer-rated scales, the initial 10 patients were blindly judged by two of the authors and interrater reliabilities were later compared.
From the Departments of Psychiatry, Fairfax Hospital, Falls Church, VA; and Georgetown University School of Medicine, Washington, DC. Address reprint requests to Thomas N. Wise, M.D., 3300 Gallows Rd. Falls Church, VA 22046. 0 1990 by W.B. Saunders Company. 0010-440X/90/3104-0008$03.00/0
284
Comprehensive
Psychiatry, Vol. 3 1, No. 4 (July/August),
1990: pp 284-288
SECONDARY ALEXITHYMIA
285
The seriousness of each patient’s illness was quantitatively ranked using the Revised Seriousness of Illness Rating Scale, according to a validated hierarchy.” (For example, a value of 1 is assigned to dandruff, and 137, the highest value, is assigned to acquired immunodeficiency syndrome.) Personality style was profiled using the Hysteroid-Obsessoid Scale, a 4%item questionnaire that views personality as a dimensional construct with hysteroid characteristics at one pole and obsessional, intellectualized, isolated characteristics at the other.12 Using these two styles as end points, it characterizes people on a dimension from emotional and dramatic to intellectualized and isolated of affect.‘j Last, mood was assessed using a lOO-mm visual analog scale. In addition, the comparison group completed the General Health Questionnaire (GHQ), a 30-item screening inventory to detect psychiatric illness in a normative population. ” Those control subjects found to have a GHQ of 5 or more, i.e., suggestive of psychiatric distress, were omitted from the study (n = 5).
RESULTS
The demographic characteristics of both the medically ill consult and control subjects are outlined in Table 1. Psychiatric diagnoses of consult patients are delineated in Table 2. The mean seriousness of illness for the hospitalized patients was 115.8 (SD = 22.4) (116 = congestive heart failure). Since the control group had significantly more females than the consultation group (x2 = 27.4, 1 df, P < .OOl), two-way analyses of variance were performed using sex and group as the dependent variables. Age and education were found not to be significantly different between groups. The consultation patients had significantly higher TAS scores than the normals (f = 9.2, 1 dJ P .c.Ol); and females had marginally higher (62.1) scores compared with males (60.5) (f = 4.8, 1 dJ P -=z .05). There were no significant differences between the consultation and control groups on the HOQ. However, the depression analog scale showed two main effects. The consultation group was more depressed than the control cohort (f= 38.2, 1 dJ; P -c.001) and males were mildly more depressed than females (40.9 v 38.1) (f = 8.9, 1 df, P -c.Ol). However, there was no significant interaction effects. Examining the consultation group alone, Pearson correlations showed that TAS significantly correlates with less education, less ability to perform activities of daily living, a lower quality of life index, a more obsessoid personality style, and more depression (Table 3). To examine the collective influence of both demographic and clinical variables on the TAS score, a stepwise regression analysis for both consult and control groups was conducted. In the regression for the consult group, the quality of life score was entered initially and its coefficient accounted for 23.1% of the variation for predicting alexithymia (P < .OOOl). Mood, i.e., level of depression, was the next variable entered and added an additional 9.1% of the variance (P < .Ol). Finally, after controlling for the quality of life and mood coefficients, education contributed Table 1. Demographic
and Clinical Variables Deprer-
N CO”S”h
53
service Namsl
55
“Ol”“few* .P< tP
