Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology, cardiology, oncology and dermatology.
ABSTRACT OBJECTIVE: To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and other DCPR criteria. METHOD: Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of 188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to cluster analysis. RESULTS: Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%). CONCLUSIONS: The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety disorder in about one third of cases; it is related to various forms of somatization and abnormal illness behavior in another third and may occur without psychiatric comorbidity in another subgroup. Identification of alexithymic features may entail major prognostic and therapeutic differences among medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or medical diagnosis.
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ABSTRACT: Objective Gastrointestinal-specific anxiety (GSA) and alexithymia are two psychological constructs that may contribute to severity of irritable bowel syndrome (IBS). We aimed to investigate their independent contribution in predicting the level of severity in a group of patients with moderate to severe IBS. Method A sample of 177 consecutive IBS patients (49.2% with moderate and 50.8% with severe IBS), diagnosed with Rome III criteria, were evaluated for IBS symptoms, alexithymia, GSA, psychological distress, and psychosocial functioning with validated scales. Results IBS severity was highly associated to both alexithymia (r = 0.61) and GSA (r = 0.66), that were also associated to each other (r = 0.64). Severe IBS patients scored significantly different than moderate IBS patients to all scales in the expected direction. Multiple and hierarchical regression analyses showed that IBS severity was predicted at a similar degree by alexithymia and GSA, controlled for IBS symptoms, psychological distress, and psychosocial functioning. Effect sizes showed that the highest IBS severity scores were obtained by patients with high alexithymia alone (d = 1.16) or combined with higher GSA (d = 1.45). Conclusion Alexithymia and GSA were closely related to each other and associated to IBS severity, thus suggesting a common basis of emotional dysregulation. However, alexithymia (particularly the facets of difficulty identifying and describing feelings) resulted to be a stronger predictor of IBS severity than GSA, thus suggesting that impaired affective awareness may reflect on the clinical manifestations of IBS.Comprehensive Psychiatry 10/2014; · 2.26 Impact Factor
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ABSTRACT: Although the field of psychological reactions of patients in response to cancer and cancer treatment has been the object of intense psycho-oncology research, the DSM and ICD nosological systems fail to give proper space to this area. Both the ICD and DSM rubrics Psychological Factors affecting a Medical Condition fail to fully describe the several psychosocial implications of cancer. The development of Diagnostic Criteria for psychosomatic Research (DCPR) is in line with the psychosomatic and biopsychosocial tradition and has given a new impulse to this area by translating psychosocial variables into operational tools for psychosocial variables with prognostic and therapeutic implications in medically ill patients. The application of the DCPR has been shown to be useful in a more precise identification of several psychological conditions affecting cancer patients. The DCPR dimensions of health anxiety, demoralization and alexithymia have been recognized in oncology, with a low overlap with a formal DSM psychiatric diagnosis; the DCPR dimensions dealing with the patients’ ways of perceiving, experiencing, evaluating, and responding to their health status (abnormal illness behaviour) have also been demonstrated, while more data are needed with regard to the complex area of somatization and somatic symptom presentation of distress in cancer patients, for which the DCPR clusters of somatization (functional somatic symptoms secondary to psychiatric disorders, persistent somatization, conversion symptoms, and anniversary reaction) can be of help. More research and the possible refinement of DCPR clustering dimensions are needed in order to understand the several and multiform psychosocial responses of cancer patients across the trajectory of the disease.Psycho-Oncologie 11/2013; 7(4):235-242. · 0.08 Impact Factor
- Psychotherapy and Psychosomatics 08/2014; 83(5):310-311. · 9.37 Impact Factor
Alexithymia in the medically ill. Analysis of 1190 patients in gastroenterology,
cardiology, oncology and dermatology☆,☆☆
Piero Porcelli, Ph.D.a,⁎, Jenny Guidi, Ph.D.b, Laura Sirri, Ph.D.b, Silvana Grandi, M.D.b, Luigi Grassi, M.D.c,
Fedra Ottolini, Ph.D.d, Paolo Pasquini, M.D.e, Angelo Picardi, M.D.f, Chiara Rafanelli, M.D., Ph.D.b,
Marco Rigatelli, M.D.d, Nicoletta Sonino, M.D.g,h,i, Giovanni Andrea Fava, M.D.b,g
aPsychosomatic Unit, IRCCS De Bellis Hospital, Castellana Grotte, Italy
bLaboratory of Psychosomatics and Clinimetrics, Department of Psychology, University of Bologna, Bologna, Italy
cDepartment of Medical Sciences of Communication and Behavior, University of Ferrara, Ferrara, Italy
dDepartment of Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
eClinical Epidemiology, IDI-IRCCS, Rome, Italy
fMental Health Unit, National Center of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Roma, Italy
gDepartment of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
hDepartment of Statistical Sciences, University of Padova, Padova, Italy
iDepartment of Mental Health, Padova, Italy
a b s t r a c ta r t i c l ei n f o
Received 9 January 2013
Revised 4 April 2013
Accepted 8 April 2013
Diagnostic Criteria for Psychosomatic Research
Objective: To use the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing alexithymia in
a large and heterogeneous medical population, in conjunction with Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) and other DCPR criteria.
Method: Of 1305 patients recruited from 4 medical centers in the Italian Health System, 1190 agreed to
participate. They all underwent an assessment with DSM-IV and DCPR structured interviews. A total of
188 patients (15.8%) were defined as alexithymic by using the DCPR criteria. Data were submitted to
Results: Five clusters of patients with alexithymia were identified: (1) alexithymia with no psychiatric
comorbidity (29.3% of cases); (2) depressed somatization with alexithymic features (23.4%); (3) alexithymic
illness behavior (17.6%); (4) alexithymic somatization (17%) and (5) alexithymic anxiety (12.8%).
Conclusions: The results indicate that DCPR alexithymia is associated with a comorbid mood or anxiety
disorder in about one third of cases; it is related to various forms of somatization and abnormal illness
behavior in another third and may occur without psychiatric comorbidity in another subgroup.
Identification of alexithymic features may entail major prognostic and therapeutic differences among
medical patients who otherwise seem to be deceptively similar since they share the same psychiatric and/or
© 2013 Elsevier Inc. All rights reserved.
Alexithymia is a reduced ability to identify and describe subjective
feelings and to distinguish among different feelings, a paucity of
fantasy and a cognitive style that is utilitarian and externally oriented,
a definition that Nemiah et al.  derived from clinical observations of
medical patients. Alexithymia is one of the constructs that has
received higher attention in the psychosomatic literature [2,3].
Current evidence shows that the alexithymic deficit in processing
feelings is likely to affect health in affective states (e.g., alcohol and
drug abuse, disordered eating behaviors, smoking, sedentary life-
style); psychopathology directly related to emotional dysregulation
through somatosensory amplification leading to low tolerance to
painful stimuli (e.g., somatoform disorder, panic disorder, chronic
pain, increase of pain-related symptoms of diseases); posttraumatic
shutdown of emotions (e.g., posttraumatic stress disorder, acute
reactions to severe organic diseases); altered autonomic, endocrine
and immune activity leading to tissue damage (e.g., vulnerability to
inflammatory processes); somatosensory amplification and health
care-seeking behavior [4,5]. In sum, alexithymia appears to modulate
the onset, the course and the recovery of psychological and medical
General Hospital Psychiatry 35 (2013) 521–527
☆ This study was supported in part by a grant from Compagnia di San Paolo
Foundation, Torino, Italy, to Dr. Rafanelli. The Foundation has had no relationships with
the study design, the recruitment of patients, the analysis and the interpretation of data,
the writing of the report, and the decision to submit the paper for publication.
☆☆ No conflict of interest is declared by any of the authors.
⁎ Corresponding author. UO Psicologia Clinica, IRCCS Ospedale De Bellis, Via Turi 27,
70013 Castellana Grotte, Bari, Italy. Tel.: +39 080 4994685; fax: +39 080 4994340.
E-mail address: email@example.com (P. Porcelli).
0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
General Hospital Psychiatry
journal homepage: http://www.ghpjournal.com
syndromes, particularly when they occur jointly, even though its role
in illness configuration is still unclear.
Current psychiatric classification relies almost exclusively on the
assessment of a limited range of symptoms resulting in syndromes
identified by diagnostic criteria [6,7]. The customary psychiatric
taxonomy does not include psychological dimensions such as alexithy-
therapeutic differences among patients who otherwise seem to be
deceptively similar since they share the same diagnosis .
The Diagnostic Criteria for Psychosomatic Research (DCPR) were
developed by an international group of investigators to translate the
large body of evidence accumulated in psychosomatic medicine into
operational tools [9–13]. The DCPR allow to translate in clinical terms
abnormal illness behavior (a maladaptive way of experiencing,
perceiving, evaluating, and responding to one’s own health status)
; the various modalities of somatization and constructs such as
demoralization, irritable mood and alexithymia, assessed through a
structured interview . Whenever the DCPR have been used in
conjunction with the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), they have been found to carry
additional clinical information [12,13,15,16].
The aim of this investigation was to use the DCPR for assessing
alexithymia in a highly heterogeneous group of medical patients and
to explore its associations with DSM-IV disorders and other DCPR
syndromes by a cluster analysis technique.
2.1. Design, procedures and subjects
Patients were recruited from different medical settings in an
ongoing multicenter project concerned with the psychosocial di-
mensions of medical patients . In each medical setting, patients
were recruited consecutively, with the intent of being representative
of their respective patient populations. Patient samples from each
center had different sample size, socio-demographic characteristics
and clinical features that were obviously due to specific aspects of the
respective patient populations. Also, some different scales and
questionnaires were administered according to the specific aims of
each study. Nonetheless, all studies were involved in the same overall
DCPR research project of the assessment of psychosocial and
psychopathological characteristics of medical patients; they shared a
common methodology (use of the same structured interviews for
identifying DCPR and DSM-IV syndromes); and all studies were
coordinated by a pool of investigators involved in the development
and validation of DCPR criteria and the structured interview for DCPR.
Because of these methodological characteristics, the overall sample is
provided with homogeneity for analysis, even though differences
related to the specific medical settings were expected. The whole
sample is therefore composed of:
1. Consecutive outpatients with functional gastrointestinal disor-
ders (FGID) (N=190; 16% of the total sample) from the IRCCS
Gastroenterology Hospital at Castellana Grotte, Italy. Patients
with organic disease were excluded.
2. Consecutive outpatients with heart diseases (N=351; 29.5%)
from 3 different sources: (1) 198 patients who underwent heart
transplantation from the Heart Transplantation Unit of the
Institute of Cardiology at S. Orsola Hospital of Bologna, Italy; (2)
61 consecutive patients with a recent (within 1 month) first
myocardial infarction diagnosis from the Cardiac Rehabilitation
Program of the Bellaria Hospital in Bologna, Italy; and (3) 92
consecutive patients with a recent (within 1 month) first
myocardial infarctiondiagnosis,fromthe Institute of Cardiology
of University Hospital in Modena, Italy. There were no medical
3. Consecutive outpatients who had received a diagnosis of cancer
within the past 18 months (N=104; 8.7%) from the S. Anna
University Hospital in Ferrara, Italy. Exclusion criterion was the
presence of cognitive impairment.
4. Consecutive outpatients with skin diseases (N=545; 45.8%)
from the Dermopathic Institute of the Immaculate (IDI-IRCCS),
Rome, Italy. Dermatological diagnoses encompassed psoriasis,
urticaria, non-atopic dermatitis, connective tissue disease, skin
tumors, bullous disease, skin ulcers and atopic dermatitis.
The study was approved by institutional review boards and local
ethics committees, and written informed consent was obtained from
all patients. The patients who were approached were 1305; 115
(8.8%) declined to participate. The most common reason for refusal
was lack of time. The total sample included 1190 patients (591 men;
49.7%), with a mean age of 45.8 (SD=15.55) years, and a mean of 10.7
(SD=3.91) years of education. There were no significant differences
in terms of sociodemographic variables between the patients who
accepted and those who refused.
All patients underwent two detailed structured interviews by
clinical psychologists or psychiatrists with extensive experience,
including psychosomatic research. Psychiatric disorders were inves-
tigated with the Structured Clinical Interview for DSM-IV (SCID) .
Diagnoses were grouped according to diagnostic categories such as
mood disorders, anxiety disorders, somatoform disorders, adjustment
disorders, and other disorders (i.e., psychotic disorders, eating
disorders, sexual dysfunctions and substance use disorders). Psycho-
somatic syndromes were diagnosed with the Structured Interview for
DCPR . The DCPR encompass 5 diagnostic rubrics that include 12
distinct syndromes. Beyond alexithymia – that is the subject of the
present study, the DCPR system include diagnostic criteria for
irritability (type A behavior, irritable mood), demoralization, abnor-
mal illness behavior (health anxiety, disease phobia, thanatophobia,
illness denial), and somatization (persistent somatization, functional
somatic symptoms secondary to a psychiatric disorder, conversion
symptoms, anniversary reaction). The interview for the DCPR consists
of 59 items scored in a yes/no response format. The cluster for
abnormal illness behavior includes 13 items, somatization 21 items,
irritability 14 items, demoralization 5 items, and alexithymia 6 items.
The full description of item contents and scoring criteria of the
structured interview for DCPR syndromes have been described
elsewhere [8,10,12]. The interview has shown excellent inter-rater
reliability, construct validity, and predictive validity for psychosocial
functioning and treatment outcome [12,18]. In particular, inter-rater
agreement has been shown to be good to excellent with kappa
coefficients ranging from 0.69 to 0.92 .
The DCPR criteria for alexithymia include 6 items, at least 3 of
which are necessary for the diagnosis. Two questions concern the
subject’s ability to verbalize and to communicate emotional states,
two questions are related to cognitive features, namely reduced
ability to fantasizing and external-related thinking, one further
question concerns the manifestation of somatic problems subsequent
to the experience of strong emotions, and one last question concerns
emotional, non-mentalized outbursts  (Table 1).
The inter-rater reliability of the DCPR criteria for alexithymia was
excellent (k=0.89) , and the construct validity has been
confirmed in 4 independent studies [20–23].
2.3. Data analysis
Data were entered in SPSS (SPSS, Chicago, IL, USA), after which
descriptive statistics were calculated. Two-step cluster analysis was
performed to organize observations into two or more mutually
P. Porcelli et al. / General Hospital Psychiatry 35 (2013) 521–527
exclusive groups, where members of the groups shared properties in
common . The following variables were included in the analysis:
DSM-IV mood disorders, anxiety disorders, somatoform disorders,
adjustment disorders, other disorders, absence of any DSM-IV
disorder, DCPR abnormal illness behavior, somatization, irritability
The two-step cluster method is a scalable cluster analysis
algorithm designed to handle large data sets. It can handle both
continuous andcategorical variables. Thetwo stepsare (1) pre-cluster
the cases into many small sub-clusters and (2) cluster the sub-clusters
resulting from pre-cluster step into the desired number of clusters.
The log-likelihood distance measure was used, with subjects assigned
to the cluster leading to the largest likelihood. No prescribed number
of clusters was suggested. The Bayesian Information Criterion was
used to judge adequacy of the final solution. Differences in socio-
demographic characteristics were compared according to cluster
membership using univariate analyses of variance and chi squared
tests for continuous and categorical variables, respectively. χ2tests
and independent-sample t tests were also performed to compare
alexithymic and non-alexithymic patients according to categorical
and dimensional variables, respectively. For all tests performed, the
significance level was set at .05, two-tailed.
A total of 188 patients (15.8% of the total sample; 54.3% female)
received a DCPR diagnosis of alexithymia, with a mean age of 48.9
(S.D.=15.63) years,anda meanof 8.6(S.D.=3.78) yearsof education.
Of these, 118 (62.8%) had at least one comorbid Axis I disorder
(particularly mood, somatoform, and adjustment disorders), and 143
(76.1%) presented with at least one further DCPR syndrome (mainly
concerning somatization and abnormal illness behavior as well as
demoralization). The prevalence of alexithymia according to the DCPR
was more frequent among patients with FGID (N=90; 47.4%) and
cancer (N=33; 31.7%) than those recruited in cardiology (N=33;
9.4%) and dermatology (N=32; 5.9%). Frequencies for each of the
diagnostic categories of psychiatric disorders and psychosomatic
syndromes in alexithymic patients are shown in Table 2. Significantly
higher rates of DSM-IV adjustment disorders (χ2=15.44, Pb.001) and
DCPR abnormal illness behavior (χ2=22.22, Pb.001) were found
among alexithymic patients recruited in oncology, whereas signifi-
cantly higher rates of DSM-IV somatoform disorders (χ2=25.33,
Pb.001) and DCPR somatization (χ2=68.33, Pb.001) were found
among FGID patients.
Two-step cluster analysis yielded 5 clusters, with no exclusion of
cases. The composition of the clusters and the importance of variables
within a cluster were then examined (Table 3).
The first cluster included 29.3% of the total sample (N=55) and
contained primarily patients who did not fit with any DSM-IV
categories, even though they might report psychological distress
(i.e., a DCPR syndrome); this cluster was named alexithymia with no
The second cluster had 23.4% of the cases (N=44) and was
characterized by the presence of DSM-IV mood disorders, DCPR
demoralization and somatization syndromes (persistent somatiza-
tion, functional somatic symptoms secondary to a psychiatric
disorder, conversion symptoms, anniversary reactions); this cluster
was named depressed somatization with alexithymic features.
In the third cluster (N=33; 17.6%), DSM-IV adjustment and
somatoform disorders were predominant, as well as DCPR syndromes
concerning abnormal illness behavior; this cluster was named
alexithymic illness behavior.
The fourth cluster (N=32; 17%) contained primarily patients with
DCPR somatization syndromes and/or DSM-IV somatoform disorders;
this cluster was thus named alexithymic somatization.
The fifth cluster had 12.8% of the cases (N=24) and was
characterized by the presence of DSM-IV anxiety disorders; thus it
was named alexithymic anxiety.
The frequency and the importance of the remaining variables (e.g.,
other disorders listed in DSM-IV and the DCPR syndromes concerning
DCPR structured interview for alexithymia
1 When you experience something good or bad, are you able to describe your
emotions (delight, joy, worry, sadness, anger)?
When you experience either good or bad events, do you talk about what has
happened and what you feel inside of you?
Do you often day-dream and let your imagination run away?
Do your thoughts concern more often your internal emotions and feelings?
When you experience a strong emotion, do youalso feel physical reactions? (e.g.
sick to stomach etc.?)
Have you ever had occasional but violent outbursts of anger, crying, or joy, that
are inappropriate either in relationship with what was happening or your usual
The interviewer should assess the overall content of the interview and non verbal
behavior, in addition to the questions above:
NOTE: Keys for scoring alexithymia (at least 3 items): 1=no; 2=no; 3=no; 4=no; 5=
Characteristics of patients meeting DCPR criteria for alexithymia
AbB, AbC, BND
Abnormal illness behavior
Lower in B, higher in C ⁎
Higher in C ⁎
Higher in A ⁎
Lower in D, Higher in C ⁎
Higher in A ⁎
⁎ Standardized deviates.
P. Porcelli et al. / General Hospital Psychiatry 35 (2013) 521–527
irritability) were comparable among the groups, indicating that these
diagnostic categories did not make a substantial contribution to
When sociodemographic characteristics were examined, no
significant differences were found with regard to gender, age, and
years of education between the cluster groups. Most patients with
FGID were found in clusters 2 and 4 (N=24; 26.7% and N=28; 31.1%,
respectively); a substantial number of patients with heart diseases
was found in the first cluster (N=14; 42.4%), but they were also
present in the second (N=10; 30.3%); cancer patients were mainly
represented in thefirst cluster (N=14;42.4%), eventhoughthey were
also present in the third (N=11; 33.3%); more than half of patients
with skin diseases (N=17; 53.1%) were included in the first cluster.
A separate cluster analysis on all non-alexithymic patients (N=
1002) including the same variables was performed. Two clusters were
obtained. The first cluster (N=635; 63.4%) was characterized by the
absenceofanyDSM disorderwhile the second cluster (N=367;36.6%)
included DSM anxiety, mood, adjustment and somatoform disorders.
even though they were more frequent (somatization 66%, demorali-
zation 62%, abnormal illness behavior 53%) in the second cluster.
When patients diagnosed with alexithymia (N=188) were
compared to non-alexithymic patients (N=1002), no significant
difference was found with respect to gender and age, even though
alexithymic patients showed less education than non-alexithymic
participants [8.61±3.79 vs 11.13±3.78 years of education; t(921)=
7.62, Pb.001]. Moreover, compared to non-alexithymic patients, those
withalexithymiaweresignificantly morelikelyto comefromtheFGID
setting (χ2=213.37, Pb.001), where nearly half of the patients were
diagnosed with alexithymia (N=90; 47.4%). DSM-IV mood and
somatoform disorders were significantly more prevalent among
alexithymic patients (χ2=29.38, Pb.001 and χ2=23.32, Pb.001,
respectively), as well as DCPR somatization syndromes (χ2=44.47,
Pb.001). Conversely, the DCPR rubric concerning irritability (i.e.,
irritable mood and type A behavior) was significantly less represented
in the alexithymic subgroup (χ2=10.03, Pb.001).
This study has found that about 16% of patients in a wide range of
medical settings met the DCPR criteria for alexithymia, which was
particularly frequent in patients with FGID and cancer, with a
prevalence of about half and one third, respectively. Alexithymia
showed a much lower prevalence in cardiology and dermatology.
Alexithymic characteristics may interact with psychiatric and psy-
chological syndromes in a number of ways, as it was depicted by
cluster analysis. In interpreting the results, it should be noted that the
diagnostic criteria for alexithymia are not only related to the classic
alexithymic constructs but also to emotional inhibition . The
concept of emotional inhibition describes conscious inhibition of
emotional states. According to Kellner, emotional inhibition may
include not only trait (e.g., introversion) but also state (e.g., voluntary
disguise of certain feelings in social interactions) features, since it may
arise as a response to prolonged stressful situations, such as a medical
illness [23,25]. A recent study , found alexithymia as assessed by
the DCPR to be significantly associated with Kellner’s Emotional
Inhibition Scale scores pertaining to verbal inhibition and self-control.
The first cluster (alexithymia with no psychiatric comorbidity)
encompassed patients who did not present a specific psychiatric
disorder, even thoughthey often had at least one DCPRsyndrome,and
it included substantial percentages of the alexithymic patients
recruited in dermatology (N=17; 53.1%), oncology (N=14; 42.4%)
and cardiology (N=14; 42.4%).
Clusters 2 (depressed somatization with alexithymic features), 3
(alexithymic illness behavior) and 4 (alexithymic somatization)
encompassed 58% of cases and were mainly characterized by the
clinical phenomena related to somatization, conceived as the tendency
to experience and communicate psychological distress in the form of
The independent association between alexithymia and somatization
has been established in a Finnish large, nationally representative
nonclinical sample, over and above medical diagnoses, anxiety and
depression disorders, and sociodemographic factors .
One of the potential mechanisms linking alexithymia and
somatization is related to illness behavior. Some studies found a
significant relationship between alexithymia and increased health
care utilization [29–31]. However, it was suggested that distinct
features of alexithymia may yield different effects on illness behavior,
with difficulties in identifying feelings and externally-oriented
thinking being significantly associated with increased and decreased
use of outpatient medical treatments, respectively .
Furthermore, subjects with alexithymia may be prone to experi-
ence hypochondriacal fears and beliefs, which in turn may lead to
somatization. The difficulties in identifying feelings and in differen-
tiating them from bodily sensations may result in misinterpretation of
somatic changes which frequently accompany unpleasant feelings.
For instance, muscle tension or increased heart rate during anxious
states will be more likely to be interpreted as signs of something
wrong in one’s own body rather than to be attributed to anxiety.
Although little attention has been paid to the role of alexithymia in
hypochondriasis, alexithymia was found to be significantly associated
with both anxiety sensitivity  and somatosensory amplification
, which are related to the hypochondriacal spectrum [35,36].
Anxiety sensitivity describes the belief that one’s own anxiety
symptoms may have harmful consequences . Somatosensory
amplification, the tendency to experience somatic sensations as
Frequencies of DSM-IV psychiatric disorders and DCPR psychosomatic syndromes within each cluster and in the total sample of alexithymic patients
Diagnostic categoryCluster 1
Alexithymia with no
Depressed somatization with
DSM mood disorders
DSM anxiety disorders
DSM somatoform disorders
DSM adjustment disorders
Other DSM disorders
No DSM diagnoses
DCPR somatization syndromes
DCPR abnormal illness behavior syndromes
DCPR irritability syndromes
P. Porcelli et al. / General Hospital Psychiatry 35 (2013) 521–527
intense, noxious and disturbing because of hyper-vigilance, selective
attention and tendency to catastrophizing, deserves particular
attention . Alexithymic individuals may experience more severe
somatic symptoms as a consequence of sustained arousal of the
physiological component of emotion response systems. Alexithymia
was significantly associated with hypersensitivity to visceral stimuli,
blood levels of adrenaline and activity of the insula and the anterior
cingulate cortex , with anxiety sensitivity and increased chest
pain severity , pain perception in women with fibromyalgia 
and pain severity in cancer patients . In acute asthmatic patients,
alexithymia significantly predicted higher symptom amplification,
misinterpretation of emotions as asthma exacerbations, and more
frequent visits to emergency rooms after the index visit .
Cluster 2 (depressed somatization with alexithymic features) is of
difficult interpretation. Because of the cross-sectional nature of the
study, the associationmay simply reflect the emotional inhibition that
is associated with depressed mood, in what has been defined as
secondary alexithymia , that may subside upon treatment of
depression. It may also mean, however, that individuals with
alexithymic features may be likely to develop somatization when
they become depressed. Similar considerations apply to the fifth
cluster (alexithymic anxiety).
Clusters2and 4(alexithymicsomatization) included nearlya third
of the alexithymic patients with cardiovascular problems (N=10;
30.3%) and FGID (N=28; 31.1%), respectively. These findings are fully
consistent with several earlier studies. FGID symptoms result from
deregulated interaction among multiple factors including gastrointes-
tinal motility disturbances, altered thresholds of pain and other
sensory input from the gut, gastrointestinal inflammation and
infection, psychological distress and personality disturbances, medi-
ated by the bi-directional brain-gut axis . Previous studies showed
a strict link between alexithymia and FGID. Alexithymia was
associated with higher gastrointestinal symptoms regardless of the
presence of positive findings to endoscopy  or gallstone disease
; was about two-fold higher in FGID patients than in those with
chronic inflammatory bowel disease (66% versus 38%), even after
controlling for psychological distress ; was associated with gut
hyper-sensitivity, activation of specific brain areas, and changes in
blood neuroendocrine levels in the expected direction ; indepen-
dently predicted poor outcome after treatment, even after controlling
for depressive symptoms [48,49]; and largely overlapped with the
DCPR cluster of somatization (75%) and with the DSM-IV somatoform
disorders (48%) . Also the link between alexithymia and
cardiovascular activity has been repeatedly demonstrated. A number
of studies have found that alexithymia is related to higher levels of
resting sympathetic, heart rate, and blood pressure reactivity to
experimental stressors (reviewed in ). In line with these results,
alexithymia was significantly elevated in samples of newly diagnosed
yet untreated hypertensive subjects  and showed a prevalence of
up to 55% in patients with essential hypertension . Post-
myocardial infarction (MI) patients developed high levels of alex-
previous MI or established coronary heart disease were found
with a first MI, it might be speculated that the greater delay time may
be due to secondary alexithymia, resulting from previous cardiac
events, leading many of these patients to use emotion-focused coping
for dealing with the threat of renewed symptoms rather than taking
more immediate action to seek care . In a survey on general
population, alexithymia was independently predicted by higher levels
of C-reactive protein (CRP), even after controlling for age, sex, lifestyle
and use of anti-inflammatory medications . Consistently, in drug-
naïve depressed outpatients, higher levels of alexithymia were
significantly associated with altered serum lipid levels (particularly
total cholesterol and high-density lipoprotein) and higher CRP . In
a large survey of general population , alexithymia was associated
with hypertension and carotid atherosclerosis, independently of any
mediating variables. In particular, the risk of hypertension and
atherosclerosis started to increase already at moderate scores of the
Toronto Alexithymia Scale , thus leading to the hypothesis that
alexithymic traits are likely to represent a long-term risk for
cardiovascular disease independently from behavioral risk factors.
Cluster 3 (alexithymic illness behavior) indicates that the link
between alexithymia and somatization may be characterized by
manifestations of abnormal illness behavior and cluster 4 (alexithy-
mic somatization) thatit doesnotnecessarilyinvolvemoodor anxiety
Cluster 3 included one third of the alexithymic oncology patients
(N=11; 33.3%) and was characterized by alexithymia associated with
DCPR abnormal illness behavior and DSM-IV somatoform and
adjustment disorders. The link between alexithymia and cancer has
yielded controversial results , while more consistent results have
been found when specific dimensions of the cancer experience were
studied. For example, pain perception has been found closely related
to mental adjustment to cancer and abnormal illness behavior [60,61].
Consistently, pain experience was associated with alexithymic
characteristics, maladjustment to cancer and health concerns, in
addition to the biomedical aspects of tumor site and status , and
all these aspects, including alexithymia and pain, may be significantly
reduced by psychological intervention . Cancer pain is a common
final pathway resulting from the interrelationships of biological,
psychological, and sociocultural factors . Cancer patients with
excessive observing and thinking about physical symptoms, hope-
lessness, problematic adjustment to the disease, and alexithymic
difficulties in processing and identifying feelings may be more prone
The link between anxiety disorders and alexithymia (cluster 5) is
also supported by several findings in the literature. Previous in-
vestigations have found a significant association of alexithymia with
anxiety symptoms both in general  and in clinical  populations,
particularly obsessive-compulsive disorder [66–68] and panic disorder
mechanisms linkingalexithymia to theexperience ofanxiety, reflecting
the disintegration betweenemotionschemas and consciousness and, in
particular, the transformation of stress-induced arousal into a general-
ized autonomic discharge [3,71] and affect dysregulation .
It is to be noted that a separate cluster analysis on non-alexithymic
very different composition compared to those of alexithymic patients.
This further analysis corroborate our findings that alexithymia (as
defined by the DCPR) is associated with a comorbid mood or anxiety
disorder in about one third of cases, it is related to various forms of
somatization and abnormal illness behavior in another third and may
occur without psychiatric comorbidity in another subgroup.
This study has limitations due to its cross-sectional nature. We
have no way to know the longitudinal course of these clusters. This
would indeed be an important area to be explored by future research.
Further, our patient population was very heterogeneous both in terms
of setting (e.g., inpatient, outpatient) and type of disease. The fact,
however, that the same clusters occurred in very different settings
and types of morbidity, even though their distribution varied, may be
seen as a strength of the study. Another limitation is concerned with
the fact that symptoms of somatization related to a medical illness can
often be extremely difficult to tease apart from symptoms related to
the illness itself . Finally, another limitation is the fact that the
clusters we obtained need to be verified in independent studies using
other instruments to assess alexithymia, even though the construct
validity of the DCPR criteria for alexithymia has been confirmed in
some earlier studies [20–23].
Nonetheless, the results of this investigation have a number of
important clinical implications. They indicate that the categorical
P. Porcelli et al. / General Hospital Psychiatry 35 (2013) 521–527
definition of alexithymia/emotional inhibition entailed by use of the
DCPR is associated with a comorbid mood or anxiety disorder in about
one third of cases, it is related to various forms of somatization and
abnormal illness behavior in another third and may occur without
psychiatric comorbidity in another subgroup.
The clinical value of identifying alexithymic characteristics in
medical patients is given by the relationship between alexithymia and
health outcomes. Alexithymia is indeed associated with impaired
psychosocial functioning in patients with coronary artery disease,
brain injury, depressive disorders, inflammatory bowel disease, breast
cancer, end-stage renal disease , skin disorders  and general
population , beyond sociodemographic variables, psychopathol-
ogy, medical diagnoses and burden of somatic symptoms. In a large
cohort of general population followed-up for 20 years, after all
adjustments forcovariatesandknownriskfactors,theriskof deathfor
cardiovascular causes was increased by 1.2% for each one-point
increasein theTorontoAlexithymia Scale. Finally,amongpatients
in chronic hemodialysis followed-up for 5 years, alexithymic in-
dividuals had a double risk (3.62-fold) than depressed individuals
(1.70-fold) of all-cause mortality after adjustment for education and
clinical variables . One may therefore reasonably conclude that
alexithymic patients are at higher risk of poor health-related and
illness-related outcomes and a longitudinal study using the DCPR
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