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Alexithymia and Outcome in Psychotherapy



About 25% of all patients seeking psychotherapeutic treatment are considered to be alexithymic. Alexithymia has been assumed to be negatively associated with therapeutic outcome. On the other hand, it is unclear to which extent alexithymia itself may be modified by psychotherapeutic interventions. From 414 consecutively admitted inpatients, 297 were followed up after 4 weeks (t1) and after 8-12 weeks (t2) upon discharge. Patients were treated with psychodynamic group therapy in a naturalistic setting. The Toronto Alexithymia Scale (TAS-20) and the Symptom Checklist-90 were administered. Twenty-seven percent of the patients were alexithymic (TAS-20 >/=61) at baseline. Multivariate models with repeated measurements indicated significant changes in Global Severity Index of the Symptom Checklist-90 in both alexithymic and nonalexithymic subjects. However, alexithymic subjects had significantly higher Global Severity Index scores than nonalexithymic subjects at t0, t1 and t2 (p < 0.001). The TAS-20 scores demonstrated a high relative stability in the total sample. However, in the alexithymic group, the TAS-20 scores changed considerably from baseline to discharge [66.3 (SD = 4.7) to 55.9 (SD = 9.9); t = 8.69; d.f. = 79; p < 0.001]. The inpatient treatment program including psychodynamic group therapy significantly reduced psychopathological distress and alexithymic features in alexithymic patients. Still, these patients suffered from higher psychopathological distress at discharge than nonalexithymics. Therefore, alexithymic features may negatively affect the long-term outcome.
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Regular Article
Psychother Psychosom 2008;77:189–194
DOI: 10.1159/000119739
Alexithymia and Outcome in
Hans Joergen Grabe
Jörg Frommer
Annegret Ankerhold
Cornelia Ulrich
Ralf Gröger
Gabriele Helga Franke
Sven Barnow
Harald J. Freyberger
Carsten Spitzer
Department of Psychiatry and Psychotherapy, University of Greifswald, Stralsund ,
Department of
Psychosomatic Medicine and Psychotherapy, University of Magdeburg, Magdeburg ,
Department of
Psychotherapeutic Medicine and Addiction, Uchtspringe ,
Department of Psychiatry and Psychotherapy, Bernburg ,
Psychology of Rehabilitation, University of Applied Sciences Magdeburg-Stendal, Stendal , Germany
changed considerably from baseline to discharge [66.3
(SD = 4.7) to 55.9 (SD = 9.9); t = 8.69; d.f. = 79; p ! 0.001]. Con-
clusion: The inpatient treatment program including psycho-
dynamic group therapy significantly reduced psychopatho-
logical distress and alexithymic features in alexithymic
patients. Still, these patients suffered from higher psycho-
pathological distress at discharge than nonalexithymics.
Therefore, alexithymic features may negatively affect the
long-term outcome.
Copyright © 2008 S. Karger AG, Basel
Personality is assumed to play an important role in
modulating ones capacity to cope with stressful life
events, interpersonal conflicts but also to influence one’s
ability to respond to psychotherapeutic treatment
[1, 2] .
The construct of alexithymia focuses on difficulties in
describing and expressing feelings, on the paucity of fan-
tasies. Recent studies have associated alexithymia with
[3] , depression [46] , anxiety disorders [7, 8] ,
pathological gambling
[9] and a broad range of psycho-
pathologic features
[10] . Given the relative temporal sta-
[11–16] , the pattern of correlations with traits of
personality models like the NEO-FFI and the tempera-
Key Words
Alexithymia Psychodynamic therapy Group therapy
Relative stability Absolute stability
Background: About 25% of all patients seeking psychother-
apeutic treatment are considered to be alexithymic. Alexi-
thymia has been assumed to be negatively associated with
therapeutic outcome. On the other hand, it is unclear to
which extent alexithymia itself may be modified by psycho-
therapeutic interventions. Methods: From 414 consecutively
admitted inpatients, 297 were followed up after 4 weeks (t1)
and after 812 weeks (t2) upon discharge. Patients were
treated with psychodynamic group therapy in a naturalistic
setting. The Toronto Alexithymia Scale (TAS-20) and the
Symptom Checklist-90 were administered. Results: Twenty-
seven percent of the patients were alexithymic (TAS-20 6 61)
at baseline. Multivariate models with repeated measure-
ments indicated significant changes in Global Severity Index
of the Symptom Checklist-90 in both alexithymic and non-
alexithymic subjects. However, alexithymic subjects had sig-
nificantly higher Global Severity Index scores than nonalex-
ithymic subjects at t0, t1 and t2 (p ! 0.001). The TAS-20 scores
demonstrated a high relative stability in the total sample.
However, in the alexithymic group, the TAS-20 scores
Published online: March 10, 2008
Hans Joergen Grabe, MD
Department of Psychiatry, Ernst-Moritz-Arndt University of Greifswald
HANSE-Klinikum Stralsund, Rostocker Chaussee 70
DE–18437 Stralsund (Germany)
Tel. +49 3831 45 2106, Fax +49 3831 45 2105, E-Mail
© 2008 S. Karger AG, Basel
Accessible online at:
Grabe et al.
Psychother Psychosom 2008;77:189–194
ment and character model [1719] , alexithymia is consid-
ered to be a unique and distinct personality construct.
However, there is an ongoing debate on the changeability
of alexithymic traits by psychotherapy in the light of lack-
ing absolute stability
[6, 14, 20, 21] .
The impact of alexithymia itself on outcome in psy-
chotherapy is less clear. First, subjects with alexithymia
are often socially avoidant, cold, less emotionally at-
tached to others. This could lead to a reduced adherence
to psychotherapy despite of severe mental distress
. Second, the lack of imagination, psychological mind-
edness and awareness to emotional cues may significant-
ly reduce the ability to be successfully engaged in psycho-
[5] . Third, early observations of Sifneos [23] and
others described alexithymic patients to respond poorly
to dynamic psychotherapy.
However, there has been little empirical research to
investigate whether alexithymia predicts psychotherapy
[24] . Some treatment studies found alexithymia
to be associated with persistent somatization in somato-
form disorders
[25] and with a negative outcome in med-
ical treatment of functional gastrointestinal disorders
[26] . In short-term group therapy for outpatients with
complicated grief and in short-term individual therapy
for outpatients with mixed diagnoses, alexithymia pre-
dicted a negative outcome
[27] as well as in a naturalistic
follow-up of outpatients with major depression
[28] .
However, alexithymia did not interfere with the response
to multimodal cognitive behavioral therapy in patients
with obsessive-compulsive disorder
[29] .
We evaluated a large sample of inpatients undergoing
intensive psychotherapeutic treatment to investigate the
following hypotheses: (1) Assuming higher levels of in-
terpersonal stress and social avoidance behavior, alex-
ithymics more often stop their inpatient treatment in the
early phase of therapy. (2) At baseline, alexithymic pa-
tients show higher levels of psychopathological distress
compared to nonalexithymics. (3) The symptom reduc-
tion in alexithymics is lower and the psychopathological
distress at the end of the intervention is still significantly
higher than in nonalexithymics. (4) There are no or only
little changes in Toronto Alexithymia Scale (TAS-20)
scores in both groups over the course of the treatment.
M e t h o d s
All participants gave their written informed consent prior to
inclusion into the study. The analyzed questionnaires were hand-
ed out from April 2005 to July 2006 to all consecutively admitted
patients for psychotherapeutic treatment at the hospitals for men-
tal health at Uchtspringe and Bernburg, Germany. Their thera-
pists added all professional information required. Patients with
depressive disorders, anxiety and adjustment disorders, somato-
form disorders, eating disorders and comorbid alcohol-related
disorders and personality disorders were admitted for psycho-
therapy. Patients with additional alcohol dependence or abuse
were withdrawn from alcohol prior to the psychotherapeutic
At baseline (t0), 414 questionnaires were returned. Fifty-one
patients were discharged prior to the 4-week follow-up (t1). Due
to missing data at t1 and/or t2, 66 patients were excluded from the
final analyses. 297 patients fully completed the questionnaires at
baseline, at the 4-week follow-up and at discharge (t2). Data col-
lection was performed by professional full-time documentary as-
sistants, one in each hospital, who also managed and supervised
data entry and quality procedures. Descriptive data of the sample
are given in table 1 and 2 .
Treatment Program
The duration of the inpatient treatment ranged regularly be-
tween 8 and 12 weeks depending on the individual response. Each
patient received 3 times per week psychodynamic short-term
group psychotherapy (1.5 h per session) with an insight-orien-
tated approach. Special focus was given to the verbalization of
individual emotional and interpersonal problems. The therapists
took a relatively active part in encouraging the patients to engage
themselves in the group process. Once a week, a group session
within a larger setting took place for role plays including psycho-
drama. Each patient received 1 h of individual psychotherapy per
week. Psychotropic medication (antidepressants, sedatives) was
offered when clinically indicated. Additionally, art therapy, sport
therapy, relaxation therapy, body and movement therapy were of-
fered on a daily basis.
Instruments and Diagnostic Procedure
Alexithymic traits were assessed with the German version of
the TAS-20
[3032] . This self-report scale comprises three factors:
(1) difficulty in identifying feelings; (2) difficulty in describing
feelings; (3) externally orientated thinking.
The revised version of the Symptom Checklist-90 (SCL-90-R)
is a 90-item, widely used self-report measure of current psycho-
[33] . In addition to nine syndrome scales, a global rat-
ing (Global Severity Index, GSI) reflects the general psychological
distress. The reliability and validity of the German version of the
SCL-90-R are similar to the original one
[34] . Both the SCL-90-R
and in particular the GSI are frequently used in psychotherapy
research, especially when assessing psychotherapeutic change
[35, 36] . For the purpose of this study, we chose the GSI as the
main outcome variable. Response was defined as a 50% reduction
of the baseline score.
The clinical diagnoses were assessed by standard clinical in-
terview according to the ICD-10 criteria. For the purpose of this
paper, only the main categories were analyzed.
Statistical Analysis
Descriptive statistics were performed with t tests or
(two tailed) or t tests for paired samples when appropriate. ANO-
VA was used to compare the GSI scores at t0, t1 and t2 between
both groups. The treatment response was analyzed with a MANO-
Alexithymia and Outcome in
Psychother Psychosom 2008;77:189–194
Table 1. Comparison between the patients (n = 51) with early discharge (<28 days) and the patients who completed treatment until t2
(n = 297)
Patients with
early discharge
(n = 51)
Patients completing
(n = 297)
Age, mean
8 SD, years 37.8811.7 37.8811.9
t = –0.009; d.f. = 346; p = 1.0
29 (56.9%) 158 (53.2%)
= 0.2; d.f. = 1; p = 0.6
22 (43.1%) 139 (46.8%)
Prior inpatient treatments
13 (29.5%) 85 (29.3%)
= 0.001; d.f. = 1; p = 1.0
TAS-20 ≥61
12 (23.5%) 80 (26.9%)
= 0.3; d.f. = 1; p = 0.6
Mean TAS-20 score 52.7 (10.9) 53.8 (10.2) t = –0.65; d.f. = 346; p = 0.5
Global Severity Index (SCL-90-R) 1.10 (0.8) 1.06 (0.7) t = 0.31; d.f. = 346; p = 0.7
High school education
7 (13.7%) 63 (21.2%)
= 1.5; d.f. = 1; p = 0.2
Marital status
11 (22.0%) 79 (26.6%)
= 0.5; d.f. = 1; p = 0.5
4 (8.0%) 19 (6.4%)
= 0.2; d.f. = 1; p = 0.7
5 (10.0%) 59 (19.9%)
= 2.8; d.f. = 1; p = 0.1
Number of ICD-10 diagnoses, mean
8 SD 1.980.9 2.580.8
t = –4.56; d.f. = 346; p < 0.001
Alcohol dependence or abuse
19 (37.3%) 149 (50.2%)
= 2.9; d.f. = 1; p = 0.09
Depressive disorders
14 (27.5%) 159 (53.2%)
= 11.5; d.f.=1; p= 0.001
Anxiety and/or adjustment disorder
23 (45.1%) 112 (37.7%)
= 1.0; d.f. = 1; p = 0.3
Dissociative and/or somatoform disorders
6 (11.8%) 34 (11.4%)
= 0.004; d.f. = 1; p = 0.9
Eating disorders
3 (5.9%) 38 (12.8%)
= 2.0; d.f. = 1; p = 0.2
Personality disorders
34 (67.6%) 247 (83.2%)
= 7.6; d.f. = 1; p = 0.006
Table 2. Comparison between the patients without and with alexithymia at baseline who completed the treatment
Patients without
(n = 217)
Patients with
(n = 80)
Age, mean
8 SD, years 38.5812.1 35.8811.4
t = 1.74; d.f. = 295; p = 0.08
126 (58.1%) 32 (40%)
= 7.7; d.f. = 1; p = 0.006
91 (41.9%) 48 (60%)
Prior inpatient treatments
60 (28.0%) 25 (32.9%)
= 0.6; d.f. = 1; p = 0.4
Admitted with psychopharmacological treatment
84 (38.7%) 36 (45%)
= 1.0; d.f. = 1; p = 0.3
Mean TAS-20 score 49.2 (7.5) 66.3 (4.7) t = –19.09; d.f. = 295; p < 0.001
Global Severity Index (SCL-90-R)
0.9 (0.6) 1.5 (0.8)
t = –6.94; d.f. = 295; p < 0.001
High school education
49 (22.6%) 14 (17.5%)
= 0.9; d.f. = 1; p = 0.34
Marital status
54 (29.9%) 25 (31.3%)
= 1.2; d.f. = 1; p = 0.3
14 (6.5%) 5 (6.3%)
= 0.005; d.f. = 1; p = 0.9
47 (21.7%) 12 (15.0%)
= 1.6; d.f. = 1; p = 0.2
Duration of treatment, mean
8 SD, days 68.5822.0 75.4829.0
t = –2.21; d.f. = 283; p = 0.03
Number of ICD-10 diagnoses, mean
8 SD 2.480.8 2.780.8
t = –3.40; d.f. = 295; p = 0.001
Alcohol dependence or abuse
116 (53.5%) 33 (41.3%)
= 3.5; d.f. = 1; p = 0.06
Depressive disorders
109 (52.2%) 49 (61.3%)
= 2.9; d.f. = 1; p = 0.09
Anxiety and/or adjustment disorder
76 (35.0%) 36 (45.0%)
= 2.5; d.f. = 1; p = 0.12
Dissociative and/or somatoform disorders
20 (9.2%) 14 (17.5%)
= 4.0; d.f. = 1; p = 0.047
Eating disorders
20 (9.2%) 18 (22.5%)
= 9.2; d.f. = 1; p = 0.002
Personality disorders
69 (86.3%) 178 (82%)
= 0.7; d.f. = 1; p = 0.4
Grabe et al.
Psychother Psychosom 2008;77:189–194
VA for repeated measures. The GSI scores of t0, t1 and t2 were the
dependent variables, alexithymia (TAS-20 score 6 61) at baseline
(t0) was entered as fixed factor. Age and sex were covariates. In a
second analysis, the diagnoses as categories according to ICD-10
were additionally entered as covariates into the equation.
The test-retest reliabilities were determined for the alexi-
thymia scores comparing the baseline rating with the ratings at
t2. Further, hierarchical regression analyses were performed in
order to test the extent to which the baseline TAS-20 scores pre-
dict the TAS-20 scores at t2 while controlling for individual dif-
ferences in the severity of the GSI score. In the first model, the
TAS-20 scores at t2 served as criterion variable, GSI at baseline
and GSI at t2 were the predictor variables. In the second model,
the baseline TAS-20 scores were added to the model as additional
predictor variable
[20, 26] . Additionally, linear regression analy-
ses were performed using the changes in the TAS-20 as criterion
variable and the changes of GSI scores as predictor variable in or-
der to determine the contribution of changes in the GSI to chang-
es in the TAS-20 scores from baseline to t2.
R e s u l t s
Fifty-one (12.6%) patients left the treatment program
before the 4-week follow-up and were compared with the
297 treatment completers ( table 1 ). These 51 patients were
characterized by a lower rate of depressive and personal-
ity disorders. However, no differences emerged with re-
gard to alexithymia or general psychopathological dis-
tress (GSI) at baseline compared to the completers. With-
in the sample of treatment completers (n = 297), 80
patients (26.9%) were considered as alexithymic at base-
line and 217 (73.1%) as nonalexithymic. Alexithymic pa-
tients were more likely to be female and to suffer from a
higher rate of comorbid dissociative, somatoform and
eating disorders. General psychopathological distress
(GSI) was significantly associated with alexithymia ( ta-
ble 2 ).
Alexithymic subjects had significantly higher mean
GSI scores than nonalexithymic subjects at t0 (ANOVA:
F = 48.2; d.f. = 1, 296; p ! 0.001), t1 (F = 43.8; d.f. = 1, 296;
p ! 0.001) and t2 (F = 22.7; d.f. = 1, 296; p ! 0.001). The
mean GSI score in the alexithymic group dropped from
1.51 (SD = 0.77) at t0 to 0.82 (SD = 0.65) at t2 and in the
nonalexithymic group from 0.90 (SD = 0.63) to 0.51
(SD = 0.43) at t2. The overall effect of change in GSI scores
in the first multivariate model with repeated measure-
ments (adjusting for age and gender) was highly signifi-
cant (Pillai-Spur = 0.14; F = 23.4; d.f. = 2, 292; p ! 0.001)
with significant effects of the interaction between GSI
scores and alexithymia (Pillai-Spur = 0.05; F = 7.4; d.f. =
2, 292; p = 0.001).
The overall effect of change in GSI scores in the second
multivariate model with repeated measurements (adjust-
ing additionally for the presence of depressive disorders,
anxiety or adjustment disorders, dissociative or somato-
form disorders, eating disorders, alcohol dependence,
personality disorders) was still significant (Pillai-Spur =
0.08; F = 12.3; d.f. = 2, 285; p ! 0.001) with significant ef-
fects of the interaction between GSI scores and alexi-
thymia (Pillai-Spur = 0.047; F = 7.1; d.f. = 2, 286; p =
One hundred and eleven (51.2%) of the baseline non-
alexithymics and 43 (53.8%) of the baseline alexithymics
had at least a 50% reduction in GSI scores from t0 to t2
= 0.16; d.f. = 1; p = 0.7). Upon discharge, 38.9% of
the baseline nonalexithymics and 42.5% of the baseline
alexithymics received psychopharmacological treatment
= 0.3; d.f. = 1; p = 0.6).
TAS-20 scores changed over the course of treatment.
The TAS-20 scores were 53.77 (SD = 10.25) at baseline
and 49.12 (SD = 10.78) at t2 for the whole completer sam-
ple (t = 7.76; d.f. = 296; p ! 0.001). In the nonalexithymic
group, the scores remained stable from t0 to t1 [49.16
(SD = 7.50) to 49.75 (SD = 9.62); t = –1.08; d.f. = 216; p =
0.3] but changed from t0 to t2 [49.16 (SD = 7.50) to 46.63
(SD = 10.0); t = 3.99 d.f. = 216; p ! 0.001]. From t0 to t2,
scores of factor 1 and 3 dropped significantly (p ! 0.001)
but not of factor 2. In the alexithymic group, the scores
changed from t0 to t1 [66.28 (SD = 4.74) to 62.50 (SD =
8.19); t = 4.37; d.f. = 79; p ! 0.001] and from t0 to t2 [66.28
(SD = 4.74) to 55.87 (SD = 9.91); t = 8.69; d.f. = 79; p !
0.001]. From t0 to t2, scores of all three factors decreased
significantly (p ! 0.001). Likewise, the rate of alexithymic
subjects (TAS-20 1 61) within the baseline-alexithymia
group dropped to 55 (68.8%) at t1 and to 29 (36.6%)
at t2.
In test-retest analyses (baseline-t2) the TAS-20 score
and the three factors showed r 6 0.5 (p ! 0.001; Pearson,
bivariate). The results of the hierarchical regression anal-
yses indicated a significant prediction of the TAS-20
score at t2 by the TAS-20 score at baseline (standardized
beta = 0.45; t = 9.03; p ! 0.001) while adjusting for the ef-
fects of GSI at baseline and at t2 for the total sample.
When performing the hierarchical regression analyses
for the alexithymic patients at baseline (n = 80) separate-
ly, the TAS-20 score (baseline) did not predict the TAS-20
score at t2 in model 2 (standardized beta = –0.07; t =
0.69; p = 0.50). GSI at t2 emerged as the only predictor
for TAS-20 scores at t2 (standardized beta = 0.69; t = 6.43;
p ! 0.001). Analyzing the impact of GSI changes from
baseline to t2 on changes of TAS-20 scores from baseline
Alexithymia and Outcome in
Psychother Psychosom 2008;77:189–194
to t2 by regression analyses the following results emerged.
The GSI changes explained 16% of the variance of TAS-
20 changes in the total sample (R
= 0.16; standardized
beta = 0.40; t = 7.57; p ! 0.001), 13% in the nonalexithymic
sample (n = 217; R
= 0.13; standardized beta = 0.36; t =
5.57; p ! 0.001) and also 13% in the alexithymic sample
(n = 80; R
= 0.13; standardized beta = 0.36; t = 3.36; p =
The first hypothesis was not confirmed by our data.
Patients who stopped treatment within the first 4 weeks
were not more alexithymic than patients who continued
the treatment program. Although unexpected, this find-
ing is in line with one study that found alexithymia not
to interfere with the compliance to psychotherapy in pa-
tients referred to a psychiatric consultation-liaison ser-
[37] . Additionally, one experimental study provided
evidence that verbalized empathic response from the
physician may be especially crucial for the alexithymic
patients’ postconsultation satisfaction and may thereby
become the basis for a solid treatment alliance
[38] . The
second hypothesis was fully confirmed by significantly
higher levels of psychopathological distress in alexithy-
mic patients at the beginning of the therapy
[10] . In con-
trast to our third hypothesis, the psychotherapeutic
high-care’ inpatient setting yielded a significant symp-
tom reduction in alexithymics which was comparable to
the relative symptom reduction in the nonalexithymic
group. Still, the alexithymics had mean GSI scores at the
end of the treatment that were almost identical to GSI
scores of the nonalexithymic group in the beginning of
the therapy. This corresponds to the finding of residual
symptoms in depressed alexithymic patients after short-
term psychotherapy
[39] .
There were modest reductions of TAS-20 scores in the
nonalexithymic group. Unexpectedly large reductions of
TAS-20 scores were found in the baseline-alexithymic
group, indicating a lack of absolute stability of alexi-
thymia during treatment. In contrast to Rufer et al.
[29] ,
all three TAS factors decreased significantly during the
treatment. However, we found evidence for a high degree
of relative stability of TAS-20 scores between t0 and t2 in
the total sample which is in line with a large body of evi-
[11–16] . Only 13–16% of the variance in the chang-
es of TAS-20 scores was explained by the changes in GSI
scores from baseline to t2. Therefore, besides the changes
in psychopathological distress, other unmeasured or un-
known factors contributed to the majority of changes in
the TAS-20 scores.
Acknowledging the significant decrease in TAS-20
scores and the robust symptom reduction of psycho-
pathological distress (GSI) at the end of the treatment in
the alexithymic group, we assume that the ‘high-care’ in-
patient setting was very effective in improving the iden-
tification, the differentiation and the verbalization of
emotions and feelings. Future studies should investigate
the efficacy of different treatments in alleviating alexi-
thymia and should use a recently developed interview for
the assessment of alexithymia
[40] . Prospective follow-up
studies are required to evaluate the impact of persistent
alexithymia and residual psychopathological symptoms
at discharge on long-term outcome.
This research work was funded by the SALUS Institute for
Trend-Research and Therapy Evaluation in Mental Health, Mag-
deburg, Germany. We would like to thank Mrs. Heike Zager-
mann, Mrs. Andrea Schütt and Mr. Oliver Büchner for coordinat-
ing the study, for data collection and data management. We would
like to thank Prof. Dr. Christfried Tögel for the management of
the Institute and his tremendous support on this project.
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... Additionally, higher ASD symptomatology scores were also related to elevated scores that were at or above clinical threshold (≥61) for alexithymia. These findings are important because the presence of co-occurring ASD symptomatology and alexithymia increases the chances of mood disorders and other psychiatric conditions that impinge upon both socio-emotional and general functioning (Grabe et al., 2008;Kinnaird et al., 2019). ...
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It has been asserted that the socio-emotional challenges associated with autism spectrum disorder (ASD) may be explained, in part, by the higher rates of alexithymia in individuals with autism. Alexithymia refers to difficulties in identifying one’s own emotional states and describing those states to others. Thus, one goal of the present study was to examine levels of alexithymia in relation to ASD symptomatology and trait emotion intelligence (EI). Trait EI is a multifaceted concept that captures emotional competencies and behavioral dispositions A second goal was to assess whether alexithymia, ASD symptomatology and trait EI served as significant predictors of adjustment to college, including academic, social, and personal-emotional adjustment. In addition to keeping with the spectrum nature of autism, our research strategy allowed us to capture those students who may not have received a formal diagnosis of ASD but report symptoms that can be indicative of ASD. This includes women, who are less likely to receive a diagnosis of ASD even when ASD symptomatology is present. The results of the study showed that students reporting higher levels of ASD symptomatology also reported significantly higher levels of alexithymia and lower trait emotional intelligence (trait EI) than those with less or no symptomatology. Alexithymia was also negatively related to trait EI, and both alexithymia and ASD symptomatology were found to be significant predictors of trait EI. However, only trait EI was a significant predictor of adjustment to college and only for social adjustment. These findings suggest that support programs that develop trait EI skills may improve the college experience for students with ASD, regardless of alexithymia or ASD symptomatology.
... Finally, findings suggest a limited response to psychotherapeutic treatment from persons with alexithymia traits (Ogrodniczuk et al., 2005). Alexithymia was a significant predictor for the persistence of residual symptom-load and higher psychological distress after psychotherapy (Grabe et al., 2008;Ogrodniczuk et al., 2004). Nevertheless, alexithymia as an individual predisposition of an impaired perception and processing of emotional information can be empirically distinguished from mental disorders like depression, anxiety (Marchesi et al., 2000), or autism (Cook et al., 2013). ...
Alexithymia is characterized by a reduced ability to identify and differentiate emotional aspects of social interaction. In this study we investigated, for the first time, whether alexithymia impairs facial mimicry in response to dynamic naturalistic facial affect expressions. Potential volunteers were recruited by means of an online survey (N = 3503). Based on their Toronto Alexithymia Scale-20 sum-score (TAS-20) probands were assigned to an alexithymic group (AG; M = 58.11, SD = 4.58) or a nonalexithymic healthy control group (HC; M = 32.05, SD = 5.56). Both groups were matched by age, gender, and education. All probands were shown digitally generated naturalistic video sequences of faces displaying the basic affects of fear, sadness, disgust, anger, and joy. During the presentation, the participants' facial mimicry responses were recorded by registering the electromyographic (EMG) activity of the corrugator supercilii and zygomaticus major muscles. Overall, the alexithymic probands showed a significantly lower facial EMG activity in response to the affective faces compared to HC. The results thus suggest that alexithymia is associated with a reduced facial mimicry. We discuss the implications of these findings from the perspective of alexithymic impairments within social interaction and the consideration for psychotherapeutic treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Grabe et al. [40] studied an inpatient treatment program including psychodynamic group therapy and found a significant reduction in psychopathology and alexithymia. The duration of the inpatient treatment was between 8 and 12 weeks. ...
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Despite being a longstanding and well-established concept, alexithymia is unfamiliar for many clinicians. This paper aims to address the alexithymia concept from a clinical perspective based on a review of the research on alexithymia intervention. Several strategies are proposed to help clinicians better work with alexithymic clients in psychotherapy. Alexithymia assessment, its impact on the therapeutic alliance, and the difficulties in emotional tasks are highlighted points. Considering alexithymia will inform clinicians’ current diagnosis and conceptualization and provide specific targets and venues for intervention, increasing the effectiveness of psychotherapy.
Alexithymia is the inability of an individual to adequately recognise and describe their emotions, which directly affects mental health by precipitating psychological disorders or by causing a disturbance to interpersonal functioning, coping responses, and quality of life. The purpose of this research was to test the efficacy of alexithymia reduction treatment (ART), a pilot online group intervention specifically designed to ameliorate alexithymia in men. As this was a pilot study, a small sample consisting entirely of male university students (n = 20) was selected. The participants were screened on the standardised measures at pre‐treatment and post‐treatment and were assigned to a treatment group (n = 10) or wait‐list control group (n = 10). The study utilised a quasi‐experimental design as the participants were assigned to the treatment and wait‐list control group based on their availability to attend the therapeutic sessions. The treatment group then received ART while the wait‐list control received no treatment at that time. The statistical analysis showed a significant reduction in the participants' alexithymia, as well as depression and anxiety, in the treatment group but not in the wait‐list control group. ART proves to be efficacious in reducing alexithymia. In addition, the treatment modality proved to be useful in improving the participants' general psychological distress (anxiety, depressive symptoms).
Background: Alexithymia is a psychological construct that describes one's difficulty in understanding and describing their own emotions as well as differentiating feelings from bodily signals of arousal. In the general population, alexithymia's prevalence is approximately 10%. Alexithymia may act as a triggering factor for many medical and psychiatric disorders. In patients with physical disease, alexithymia's prevalence reaches up to 63%. Additionally, alexithymia is associated with worse outcomes and heightened psychosocial comorbidities. Objective: This review continues where an earlier review (Willemsen, 2008) left off to (1) clarify alexithymia's prevalence in dermatology patients and (2) further investigate alexithymia's impact on disease burden, psychosocial comorbidities, and treatment. Methods: Systematic searches on alexithymia and dermatologic conditions were conducted using PubMed, Embase, PsycInfo, and Web of Science databases from March 8, 2021, to March 12, 2021. Data from eligible publications, which were full-text, clinical studies published after September 1, 2008, and available in English, were extracted by two medical students and summarized. Results: Despite a small number of publications (n = 37), data showed a markedly greater prevalence and severity of alexithymia in patients with alopecia, vitiligo, psoriasis, hidradenitis suppurativa, atopic dermatitis, chronic idiopathic urticaria, and primary focal hyperhidrosis compared to healthy controls. Further, data consistently demonstrate a complex interplay between alexithymia, disease burden, and psychosocial comorbidity. Conclusions: Identifying and addressing alexithymia in dermatology patients may improve treatment outcomes, associated comorbidities, and health-related quality of life.
Objective: The literature on alexithymia has multiplied in recent decades as the construct has important implications for mental health. The so far used inventories are of limited use in epidemiological research, primary care, and other clinical settings where time and effort are important factors in assessment. Based on items of the authorized German version of the Toronto Alexithymia Scale, the aim of this study was to develop an ultra-short questionnaire for a condensed and unidimensional assessment of alexithymia. Methods: Criteria for the abbreviated scale were: (a) one-dimensionality (necessary to calculate a global score), (b) one item from each of the originally postulated dimensions, and (c) no reverse-coded items (to avoid method artifacts). Data were drawn from two nationwide representative population surveys in Germany: a survey conducted in 1996 to develop the SAS-3 (N=2.047); and a survey conducted in 2013 (N=2.508) for the evaluation and calculation of SAS-3 percentiles. Results: Reasonable correlations between the SAS-3 and the PHQ-2, the GAD-2, and the GBB-8 were observed. Based on a confirmatory factor analysis, the one-dimensionality of the SAS-3 could be confirmed, achieving very good fit indices. An additional invariance analysis regarding gender and different age groups resulted in (partial) strict invariance for the different multi-group analyses. Percentile ranks for SAS-3 sum score are reported stratified by gender and by age groups. Conclusions: The SAS-3 appears to be suitable in epidemiological research and other instances requiring an economical assessment of alexithymia.
Objective: The current meta-analysis investigates the efficacy of psychotherapy during psychiatric hospitalization and examines the moderating role of diagnosis and therapeutic approach. Methods: We conducted systematic searches in literature databases, including PubMed, PsycInfo, and Google Scholar. In total, 37 samples were included for the meta-analysis with a total of 4,443 patients. The primary outcome was the standardized mean differences in clinical status measured by symptomatic and functional measures. Results: The meta-analysis of 22 samples without a control group resulted in the upper end of the medium effect size for the overall effect of treatment during psychiatric hospitalization that included psychotherapy (k = 22, Cohen's d = 0.70, and 95% Cl 0.36 to 1.04). The meta-analysis of 15 samples with a control group resulted in the upper end of the low effect size for the contribution of psychotherapy to the improvement of patients' clinical status measured by symptomatic and functional measures (k = 15, Cohen's d = 0.43, and 95% CI 0.06 to 0.81). No significant effects were uncovered for psychotherapy orientation. Diagnosis was found to moderate the contribution of psychotherapy in an inpatient setting to the improvement of patients' clinical condition. Conclusion: Psychotherapy during psychiatric hospitalization may be an effective treatment. Across the various samples, psychotherapy has a moderate effect on the reduction of psychiatric symptoms beyond the overall effect of ward treatment.
Migraine, which is a highly prevalent headache, is often comorbid with alexithymia. Parental styles contribute to the development of alexithymia. The core psychological mechanisms that connect parenting to alexithymia and can be targeted in psychotherapy are not yet studied. The objective of this study was to explore the role of emotional schemas as a possible mediator between perceived parental styles and alexithymia in migraine patients. Study participants consisted of 208 (67 males and 141 females) Iranians who completed the Farsi version of Toronto Alexithymia Scale (FTAS-20), Leahy Emotional Schema Scale (LESS II), and Measure of Parental Styles (MOPS) online. For mediation analysis, structural equation modeling was used based on Baron and Kenny's mediation model. The results demonstrated that mother overprotection and mother indifference were significantly related to alexithymia in migraine patients. Emotional schemas and alexithymia were also positively and significantly related. Additionally, mother overprotection and father indifference showed positive and significant covariation with emotional schemas. Data analysis with structural equation modeling revealed that emotional schemas partially mediate the relationship between parental styles and alexithymia in migraine patients. The current study expands our knowledge of possible mechanisms that relate childhood experiences of being parented and alexithymia in migraine patients. Findings of this research imply psychological treatments can benefit from targeting emotional schemas in migraine patients with alexithymia.
Emotional regulation is important for mental health and behavioral regulation. A relevant precursor to emotional regulation may involve identification of one's emotions. Here, we propose a model of seven components that may provide a foundation for emotion identification. These factors include baseline mood, monitoring, physiological responses, interoception, past personal experiences regarding emotions/metacognition, context, and labeling. We additionally examine how deficits in different components may contribute to the concept of alexithymia, which is defined by difficulty identifying and describing one's own emotions. Ultimately, we explore how the model may support a relationship between specific psychiatric disorders and alexithymia. The proposed model may help explain emotional identification impairment in multiple psychiatric disorders and guide future research and treatment development efforts.
The possible correlation between nausea and vomiting during pregnancy (NVP) with obsessive-compulsive disorder (OCD) and alexithymia were examined in this cross-sectional study. A cohort of pregnant women at the first trimester of pregnancy experiencing NVP were divided into three groups, according to severity (mild, moderate and severe) with the Pregnancy Unique Quantification of Emesis and Nausea (PUQE) test. The Maudsley Obsessive Compulsive Disorder Scale (MOCQ) and the Toronto Alexithymia Scale (TAS-20) were applied. Scores of scales were compared in all three groups, and the relationship between NVP severity and OCD and alexithymia was evaluated. On the 110 enrolled pregnant women, 42 had mild, 36 had moderate and 32 had severe NVP. Pregnant women with mild NVP had lower MOCQ scores than those with severe NVP (p = .010). Total scores of TAS-20 were higher among subjects with greater NVP severity (p < .001). PUQE scores were demonstrated significant correlations with MOCQ and total and subsection scores of the TAS-20, regardless of NVP groups. Study results showed that women with more pronounced OCD and/or alexithymia can experience somatic complaints, such as NVP, particularly intense in their first trimester of pregnancies. For this reason, psychotherapy in addition to medical treatments could be recommended to pregnant women with severe NVP. • Impact statement • What is already known on this subject? NVP is a condition experienced by most women, particularly in the first trimester of pregnancy, which can be affected by the psychosomatic condition of the pregnant woman. • What do the results of this study add? The severity of nausea and vomiting according to PUQE test were significantly associated with OCD and alexithymia presence in pregnant women during their first trimester period. • What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate the symptoms of NVP are correlated to OCD, as well as alexithymia. Longitudinal studies are required to demonstrate the clear causal relationship between NVP and psychiatric symptoms as in OCD and in alexithymia.
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The authors investigated patient characteristics predictive of treatment response in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program. Two hundred thirty-nine outpatients with major depressive disorder according to the Research Diagnostic Criteria entered a 16-week multicenter clinical trial and were randomly assigned to interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Pretreatment sociodemographic features, diagnosis, course of illness, function, personality, and symptoms were studied to identify patient predictors of depression severity (measured with the Hamilton Rating Scale for Depression) and complete response (measured with the Hamilton scale and the Beck Depression Inventory). One hundred sixty-two patients completed the entire 16-week trial. Six patient characteristics, in addition to depression severity previously reported, predicted outcome across all treatments: social dysfunction, cognitive dysfunction, expectation of improvement, endogenous depression, double depression, and duration of current episode. Significant patient predictors of differential treatment outcome were identified. 1) Low social dysfunction predicted superior response to interpersonal psychotherapy. 2) Low cognitive dysfunction predicted superior response to cognitive-behavior therapy and to imipramine. 3) High work dysfunction predicted superior response to imipramine. 4) High depression severity and impairment of function predicted superior response to imipramine and to interpersonal psychotherapy. The results demonstrate the relevance of patient characteristics, including social, cognitive, and work function, for prediction of the outcome of major depressive disorder. They provide indirect evidence of treatment specificity by identifying characteristics responsive to different modalities, which may be of value in the selection of patients for alternative treatments.
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A previous paper described the development of the twenty-item Toronto Alexithymia Scale (TAS-20) and reported preliminary evidence of reliability and factorial validity of the scale. This paper describes a study that further evaluated the construct validity of the TAS-20 by examining its relationship with measures of personality traits theoretically related or unrelated to the alexithymia construct, as well as its relationship with an observer-rated measure of alexithymia. Evidence of convergent and discriminant validity of the TAS-20 was demonstrated in samples of university students by a pattern of correlations with the scales of the NEO Personality Inventory and separate measures of psychological mindedness and need-for-cognition that was consistent with theoretical predictions. The concurrent validity of the scale was demonstrated by positive correlations with observer-ratings of alexithymia in a sample of behavioural medicine out-patients.
Foreword James S. Grotstein Acknowledgements Introduction Graeme Taylor 1. The development and regulation of affects Graeme Taylor, Michael Bagby and James Parker 2. Affect dysregulation and alexithymia Michael Bagby and Graeme Taylor 3. Measurement and validation of the alexithymia construct Michael Bagby and Graeme Taylor 4. Relations between alexithymia, personality, and affects James Parker and Graeme Taylor 5. The neurobiology of emotion, affect regulation and alexithymia James Parker and Graeme Taylor 6. Somatoform disorders Graeme Taylor 7. Anxiety and depressive disorders and a note on personality disorders Michael Bagby and Graeme Taylor 8. Substance use disorders Graeme Taylor 9. Eating disorders Graeme Taylor 10. Affects and alexithymia in medical illness and disease Graeme Taylor 11. Treatment considerations Graeme Taylor 12. Future directions James Parker, Michael Bagby and Graeme Taylor References Index.
Objective: To examine the changes in alexithymic features and depressive and other psychological distress symptoms during a 1-year follow-up among patients with major depression. Methods: The study population comprised 120 outpatients suffering from major depression. Diagnosis was made with Structured Clinical Interview (SCID-I) for DSM-III-R. The severity of depression was evaluated with the 17-item Hamilton Rating Scale for Depression (HAM-D), and self-reported depression with the Beck Depression Inventory (BDI-21). Alexithymic features were assessed with the Twenty-Item Toronto Alexithymia Scale (TAS-20). Self-reported psychological distress symptoms were evaluated with the Brief Symptom Inventory (BSI). Results: Measures of depression and distress were significantly lower at the follow-up than at the baseline, while the total TAS-20 scores did not change significantly during the follow-up. A closer examination revealed that various TAS-20 factors behaved differently. Changes in Factors 1 and 2 were associated with changes in mood, whereas those in Factor 3 were not. Additionally, recovery from depression was associated with decrease in alexithymic features. Conclusion: Difficulties in identifying and in describing feelings are associated with changes in mood, while externally oriented thinking is not.
The relationship between alexithymia assessed by the Toronto Alexithymia Scale (TAS) and the five-factor model of personality measured by the NEO Five-Factor Inventory (FFI) was investigated in a group of psychiatric outpatients (n = 114) and normal volunteers (n = 71). When controlling for depression, the domains of neuroticism, introversion, and low openness predicted alexithymia. These three dimensions accounted for 57.1% of the explained variance in the patient cohort and 38.1% in the volunteer group. In the patient cohort, neuroticism contributed the majority of explained variance, which may reflect the state effect of distress that elevates neuroticism. Introversion was the most significant predictor in the volunteer group. These data suggest alexithymia is a unique personality trait that is not fully explained by the five-factor model of personality.
In a follow-up study of 150 women who had undergone treatment on an outpatient basis for acute depression, it was found that the most important predictor of their long-term clinical outcome (8, 20, and 48 months after the acute episode) was personality as measured by the Neuroticism Scale of the Maudsley Personality Inventory (MPI-N). Age, race, social class, marital status, religion, number of previous depressions or suicide attempts, diagnosis, history of early deaths of or separations from significant others, history of neurotic traits as a child, amount and type of stress in the 6 months before onset, and severity and pattern of pretreatment symptoms were not predictive of outcome.
The principles which govern the kind of psychotherapy best suited for patients with physical disease who may or may not have alexithymic characteristics are based on the careful psychiatric evaluation of the patient's psychological difficulties, and on the early cooperation between the psychiatrist and his medical colleagues. The nature of the alexithymic phenomena is discussed and the words 'affect', 'emotion' and 'feeling' are defined. Supportive psychotherapeutic measures are indicated for patients with alexithymic characteristics. These can be offered by the medical personnel in consultation with a psychiatrist. Psychodynamic psychotherapy, on the other hand, offered by a well-qualified psychiatrist is the treatment of choice for neurotic problems which complicate the patient's physical illness.
In the present study, the potential role of alexithymia in predicting the long-term treatment outcome was investigated prospectively in 30 patients with DSM-III-R somatoform disorders and anxiety disorders. Using SCID interviews, diagnoses were assessed before inpatient treatment and 2 years after discharge. Patients who met criteria for DSM-III-R undifferentiated somatoform disorder at follow-up exhibited higher pretreatment alexithymia scores (as measured by the TAS) as compared with patients who showed remission of their somatoform disorder or patients who never had met criteria for a somatoform disorder. As a result stepwise logistic regression analyses, high alexithymia scores emerged as a significant predictor of persistent somatization, independent of other measures of psychopathology, sociodemographic variables, and measures of illness severity.
The stability of alexithymia as measured by the Toronto Alexithymia Scale (TAS) and its relationship to depression were investigated in 50 depressed inpatients. The test-retest coefficient for TAS over a 5-day period was 0.57 (p < 0.001). A reliable change index for depressed mood indicated that mood covaried with the TAS, but changes in TAS were not clinically significant. The data support alexithymia as a stable personality construct.