Open Access

Alexithymia as a prognostic risk factor for health problems: a brief review of epidemiological studies

BioPsychoSocial MedicineThe official journal of the Japanese Society of Psychosomatic Medicine20126:21

DOI: 10.1186/1751-0759-6-21

Received: 5 March 2012

Accepted: 13 December 2012

Published: 17 December 2012

Abstract

The number of articles on alexithymia has been steadily increasing since the word “alexithymia” was coined in the 1970s to denote a common characteristic that is observed among classic psychosomatic patients in whom therapy was unsuccessful. Alexithymia, a disorder of affect regulation, has been suggested to be broadly associated with various mental and physical health problems. However, most available evidence is based on anecdotal reports or cross-sectional observations. To clarify the predictive value of alexithymia for health problems, a systematic review of prospective studies was conducted. A search of the PubMed database identified 1,507 articles on “alexithymia” that were published by July 31, 2011. Among them, only 7 studies examined the developmental risks of alexithymia for health problems among nonclinical populations and 38 studies examined the prognostic value of alexithymia among clinical populations. Approximately half of the studies reported statistically significant adverse effects, while 5 studies demonstrated favorable effects of alexithymia on health outcomes; four of them were associated with surgical interventions and two involved cancer patients. The studies that showed insignificant results tended to have a small sample size. In conclusion, epidemiological evidence regarding alexithymia as a prognostic risk factor for health problems remains un-established. Even though alexithymia is considered to be an unfavorable characteristic for disease control and health promotion overall, some beneficial aspects are suggested. More prospective studies with sufficient sample sizes and follow-up period, especially those involving life course analyses, are needed to confirm the contribution of alexithymia to health problems.

Keywords

Systematic review Prospective study Epidemiology

Introduction

Alexithymia, a personality construct that reflects difficulties in affective self-regulation [1], was originally noted by psychotherapists as a common characteristic observed among classic psychosomatic patients in whom therapy was unsuccessful [2]. To date, researchers have revealed that alexithymia is broadly associated with various mental and physical health problems. It is now regarded as a key factor affecting treatment responses across the field of medical practice [3].

How is alexithymia associated with the development of health problems and their prognoses? Some of the possible underlying mechanisms have been well documented in previous review articles [1, 4, 5]. First, alexithymic individuals have impaired emotion-processing and regulating capacities which might induce disruption of homeostasis through alterations of autonomic, endocrine, and immune activities [1]. Second, alexithymic patients have a limited ability to cope adaptively with stressful situations and tend to have unhealthy behaviors, such as poor nutrition, alcohol and drug use, and a sedentary lifestyle [4, 5]. Third, alexithymic patients have difficulties in recognizing their own physical and emotional symptoms, which may be linked to a delay or excessive use of medical support, resulting in a poor prognosis. Finally, because of their difficulties communicating their own inner feelings and a poor understanding of other people’s emotions, alexithymic patients find it difficult to build and maintain close relationships with others and to appropriately utilize social supports in order to protect themselves from the potentially pathological influences of stressful events [6].

Thus, theoretically, there is no doubt that alexithymia plays a key role in disease control and health promotion.

Review of prospective cohort studies on alexithymia

Prospective cohort studies are the best type of observational design applied to examine the etiology and prognosis of health problems [7]. Since Sifneos introduced the concept of alexithymia in 1973 [2], the number of articles regarding alexithymia has been increasing year by year. According to the review by Taylor and Bagby published in 2004 [8], a search of the PsycINFO database revealed more than 1,000 journal articles on alexithymia, while approximately 120 publications on alexithymia had appeared by the mid-80s. However, most of them were anecdotal or cross-sectional data reports. To update the evidence and clarify the predictive value of alexithymia as a health determinant, a brief systematic review of the epidemiological literature was conducted.

Method of systematic review

The minimum criteria for studies to be included in the current review were as follows: (1) a prospective design with a clinical or nonclinical population sample, (2) evaluating the effects of baseline alexithymia on health-related outcomes, (3) using validated methods to assess alexithymia, and (4) written in English. To capture the broad linkage between alexithymia and health outcomes, the types of treatments and outcomes were not specified in the process of data collection. P ≤ 0.05 was considered statistically significant.

A systematic search was conducted using the PubMed database limiting the period from January 1, 1975 to July 31, 2011. A total of 1,507 documents were identified using [“alexithymia” or “alexithymic”] as search terms. By further adding [“prospective” or “prognostic” or “cohort” or “follow”] to the search terms, the search yielded 193 titles. After excluding 19 articles that were written in non-English languages and 8 articles that were published as a review, the remaining 166 articles were inspected manually. Among them, only 7 articles were identified as those reporting the developmental risks of alexithymia for health problems among nonclinical populations, and 38 articles were identified as those reporting the influences of alexithymia on prognosis or results of interventions among hospital-based populations. The reason for exclusion of most studies was the cross-sectional design of data collection (n = 106). Fifteen studies were excluded even though they were prospectively designed because they treated alexithymia as an outcome. Three articles were excluded because they were editorials or commentaries.

Almost all studies included in the current review used the Toronto Alexithymia Scale (TAS) or TAS-20 [9, 10] as a tool for evaluating alexithymia. Only two studies used other tools; one study used the Beth Israel Questionnaire and Schalling-Sifneos Personality Scale [11], and the other study used projective personality tests [12, 13]; they were included in the current review.

Major findings from nonclinical population studies

Table 1 shows the summary of studies examining the effects of alexithymia on health outcomes with a prospective design in a nonclinical population. Seven studies prospectively examined the developmental risks of alexithymia for health problems among nonclinical populations [1420]. Among them, 3 studies demonstrated the statistically significant adverse risk of baseline alexithymia for subsequent health problems [1416], 3 studies reported no association [1820], and one reported the beneficial effect of alexithymia on health [17].
Table 1

Studies examining the effects of alexithymia on health outcomes with a prospective cohort design in nonclinical population

Effects of alexithymia

N

Population

Follow up period

Outcomes

Country

Published year

Reference no

Adverse

2321

General population

20 years

Cardiac death

Finland

2010

14

Adverse

2297

General population

5.5 years

All cause morality

Finland

1996

15

Adverse

54

Police officer

2 years

PTSD

USA

2006

16

Beneficial

1207

Urban public transit Operators

7.5 years

Low back pain

USA

2007

17

No association

333

Subsample selected from general population cohort study sample

7 years

Depression

Finland

2010

18

No association

154

General population

30-22 years

Neck-shoulder and low-back pain

Finland

1991

19

No association

43

Fire fighter

2 years

PTSD

Switzerland

2005

20

Two studies were based on the same large cohort data derived from the Finnish general male population and demonstrated the statistically significant adverse effects of alexithymia on total mortality and/or cardiac death [14, 15]. A recently conducted cross-sectional study has reported results which may support the findings of these studies. Grabe et al examined 1,168 subjects who were randomly selected from the general population and found a significant association of alexithymia with hypertension and atherosclerotic plaques [21]. The authors pointed out that alexithymia may serve as a long-standing risk factor as well as a familial and genetic factor that deregulates the autonomic nervous system [21]. Autonomic nervous deregulation may positively influence the developmental risk for cardiac death and total mortality.

The most recently published Finnish report failed to show a significant association between baseline alexithymia and subsequent psychiatric diagnoses, such as major depression, personality disorder, and alcohol use disorders, which were confirmed by a structured clinical interview [18]. However, the report is based on the subsample data (n = 290) selected from a general population cohort (n = 2,050) by the presence or absence of chronic high mental symptoms. The study subjects were limited to those who completed the successive 3-year follow-up surveys (1998, 1999, and 2001) and a 7-year follow-up survey including a structured interview (2005). It cannot be denied that a considerable number of alexithymic participants might have developed mental disorders before 2005 and quit the study, which may have caused underestimation of the impact of alexithymia. In addition, the authors included previous depressive symptoms (BDI sum score) in logistic regression analysis to estimate the developmental risk of depression and that might have caused over adjustment [22]. In fact, the results of simple Chi square tests suggested significantly higher prevalence of such psychiatric diagnoses among those who had a TAS-20 sum score above the median [18].

Two studies examined the predictive value of alexithymia on the development of low-back pain (LBP) [17, 19]. One study found no association between baseline alexithymia that was evaluated by projective personality tests and the reported severity of neck–shoulder pain and/or LBP among 154 subjects, randomly selected from the general population [19]. The other study examined 1,207 municipal bus drivers and found a favorable association between alexithymia and the 7.5-year incidence of compensated LBP [17]. Inversely, the same research group reported an adverse association between alexithymia and LBP claims from cross-sectional data derived from the same population [23]. The authors speculated that the prevalence of self-reported LBP symptoms and the incidence of compensated LBP claims are not comparable even within the same population, and it might be difficult for alexithymic patients to complete the bureaucratic process to receive compensation, resulting in the low prevalence of compensated LBP [17].

Two studies examined the developmental risks of alexithymia for post-traumatic stress disorder (PTSD) and the results were inconsistent [16, 20]. One study examined 43 male firefighters for 2 years and found no significant risk of alexithymia [20]. The other study examined 54 police officers and reported that their TAS-20 scores significantly predicted PTSD symptoms for 2 years [16]. Both studies have too small sample size to estimate the developmental risk of PTSD associated with alexithymia. Further studies with sufficient sample size and follow-up period are necessary to confirm the vulnerability of alexithymic individuals to PTSD.

Major findings from clinical population studies

A summary of studies examining the effect of alexithymia on health outcomes with a prospective design in a clinical population is shown in Table 2. In total, 38 articles were identified that reported the clinical impacts of alexithymia on prognosis [2461]. Major types of participants were patients with psychiatric or psychosomatic illness recruited consecutively and the main outcome was the treatment response. Most of them were preliminary, naturalistic studies without control groups. Some studies assigned subjects to a specific treatment or other intervention, but none reported the blinding procedure. Overall, information to evaluate the risk of bias of each study is very limited; therefore, the presence of serious risk of bias should be considered to interpret the results.
Table 2

Studies examining the effects of alexithymia on health outcomes with a prospective cohort design in clinicalpopulation

Type of participants

Follow up period

Type of treatment

Type of main outcome

N

Country

Ref. no.

Adverse effect

      

Psychiatric inPT

4, 8-12W

Multimodal psychotherapy

Global severity Index and depression severity

480

Germany

24

Substance users

10+15W

Motivational intervention

Response to treatment

260

USA

25

Psychiatric outPT

12-21 W

Short-term psychotherapy

Psychiatric symptomatology

251

Canada

26

Hemodialysis outPT

5Y

Hemodialysis therapy

All cause mortality

230

Japan

27

Hemodialysis outPT

6M

Hemodialysis therapy

Depression deterioration

230

Japan

28

OutPT with possible

6Y

Pyschotherapy

Recovery from depression

121

Finland

29

Veterans with military sexual trauma.

7W

Specialized residential treatment

Symptom persistence

175

USA

30

Women taking elective surgical abortion

2M

Surgical abortion

Re-experience and avoidance

140

Netherlands

31

OutPT with functional gastrointestinal disorders

6M

Unspecified treatment

Response to treatment

112

Italy

32

PT taking implantable cardioverter defibrillator

2-5.5 Y

ICD placement

Posttraumatic stress

107

Switzerland

33

Eating disorder PT

3Y

Drug treatment and psychotherapy

PT’ compliance and types of treatments

102

France

34

Eating disorder PT

3Y

Unspecified treatment

Response to treatment

102

France

35

OutPT with major depression

1Y

Unspecified treatment

Response to treatment

86

Finland

36

PT with asthma

2Y

Unspecified treatment

Emargency room visits and QOL (SF-36)

76

Spain

37

OutPT with major depression

10W

Antidepressant

Reduction of depression severity

65

Turkey

38

PT with type 1 Diabetes

8W

Inpatient treatment

Decrease in HbA1c

64

Belgium

39

Alcohol abuser

15W

Inpatient treatment

Maintaining abstinent

46

France

40

PT with somatoform and anxiety disorder

2Y

Inpatient treatment

Symptom persistence

30

Austria

41

Beneficial effect

      

Cancer PT

6M

Multicomponent psychological intervention

Pain

104

Italy

42

PT taking in vitro fertilization

6M

In vitro fertilization

Delivery of a living infant

81

Greece

43

Colorectal cancer PT

3Y

Surgery

QOL (SF-36)

60

Italy

44

Ulcerative colotis PT

17M

Pelvic pouch surgery

Psychosocial adjustment

53

Sweden

45

Gynecologic PT

1M

Laparoscopy or laparotomy

QOL (SF-36)

40

Italy

46

No association

Psychiatric inPT

4, 8-12W

Psychodynamic group therapy

Global severity Index and depression severity

297

Germany

47

OutPT with unexplained physical symptom

6W

Unspecified treatment

Symptom persistence

127

Netherland

48

Pregnant women

1M

Unspecified

Depression development

149

Italy

49

PT with psoriasis

6M

Cognitive behavioral therapy

Response to treatment

80

UK

50

Obese outPT

8M

Behavioral program

Compliance and weight loss

68

Italy

51

InPT taking respiratory rehabilitation

4W

Respiratory rehabilitation

Functional recovery

60

Italy

52

Panic disorder PT

6M

CBT

Response to treatment

55

Switzerland

53

Psychiatric consultation outPT

1Y

Psychotherapy

PT’s compliance

54

Finland

54

OCD inPT

31-139 D

Multimodal CBT

Response to treatment

42

Germany

55

Bulmia nervosa PT

10W

Drug treatment

Symptom improvements

41

England

56

CFS outPT

18M

Unspecified treatment

Symptom improvements

40

Netherland

57

OutPT with psoriasis

3M

Delmatological treatment

Response to treatment

40

France

58

OCD inPT

6Y

Inpatient treatment

OCD deteriotion

34

Switzerland

59

Schizophrenia outPT

1Y

Appropriate treatment

Symptom improvements

29

Italy

60

Eating disorder inPT

1Y

Psychoeducation

Dietary restraint

19

Switzerland

61

PT=patient, OCD=obsessive-compulsive disorders, CFS=chronic fatigue syndrome, CBT=cognitive behavioral therapy, W=week, M=month, Y=year.

The number of studies reporting the adverse effects of alexithymia was 18 [2441], which was approximately 50% of the total studies. Five studies demonstrated the beneficial effects of alexithymia on clinical outcomes [4246]. One-third of the identified clinical studies (n = 15) reported no statistically significant associations between baseline alexithymia and treatment outcomes [4761]. The studies that failed to find significant associations between alexithymia and clinical outcomes tended to have small sample sizes (median = 54, min = 19, max = 297) [4761] compared with those that demonstrated significant results (median = 103, min = 30, max = 480) [2446].

The influence of alexithymia on the treatment process and outcomes has been discussed intensively by Lumley et al [4, 5]. They speculated that alexithymic patients might respond poorly to psychological treatments, although perhaps not to cognitive behavioral techniques because the compulsive nature and external focus of people with alexithymia may prompt greater adherence to structured exercises and behavioral recommendations [4]. The current review does not identify clear differences by the types of therapy in the influences of alexithymia on the outcomes. However, relatively consistent beneficial effects of alexithymia were observed in studies with surgical interventions [4347].

To date, the association between surgical treatments and alexithymia has rarely been discussed. Kakatsaki et al examined 81 women undergoing an in vitro fertilization program during a 6 month period and found that alexithymia predicted better outcome; delivery of a living infant [43]. Ripetti et al examined a series of 60 colorectal cancer patients with a three-month follow-up and found that a high-level alexithymia group (TAS-20 ≥51) showed more improvement in QOL measured by SF-36 test after surgery than did the low-level alexithymia group [44]. Weinryb et al examined 53 consecutive patients undergoing pelvic pouch surgery and followed them for 16 to 41 months [45]. They found that the level of alexithymia measured by the Beth Israel Questionnaire was inversely correlated with worse psychological distress and adjustment in relationships at home after surgery. Battista et al examined 40 consecutive patients with benign gynecologic pathology who underwent laparoscopy or laparotomy and found that patients with low-level of alexithymia (TAS-20≤ 59) showed a worsening of QOL score measured by SF-36 after a surgical procedure [46]. In general, surgical treatment procedures are highly structured and active so that the externally oriented thinking style of alexithymic patients may suit them well. Ripetti et al speculated that patients with alexithymia might perceive invasive surgery to be effective because surgical treatment leaves a visible body sign [44]. Weinryb et al suggested that patients with alexithymia may tend to have avoidant coping strategies to the negative aspects of surgery such that they may have better recovery during the postoperative period [45]. On the contrary, a study investigating short term re-experiencing and avoidance after surgical abortion conducted by van Emmerik et al demonstrated a significant adverse effect of alexithymia on the outcomes [31]. Because of the variety of the study backgrounds and the types of treatments and outcomes, we cannot draw definite conclusions from the available data. Further research will be necessary to fully disclose the favorable aspects of alexithymia on treatment outcomes.

One prospective study involving cancer patients conducted by Tulipani showed a significant beneficial effect of alexithymia on reduction in pain perception by psychological intervention to cancer patients [42]. They recruited study participants consecutively, and randomly allocated them to an intervention group or a control group. A total of 52 cancer patients were provided the 6-month psychological intervention with a variety of therapeutic approaches according to guidelines issued in the literature on alexithymia and cancer pain and compared to 52 controls. Psychological intervention significantly reduced alexithymia as well as pain. Multiple regression analysis showed that baseline alexithymia and psychological intervention were both independently associated with a reduction in pain perception. The role of alexithymia in cancer patients is still under study [62]. The effectiveness of intervention focusing on the reduction of alexithymia to improve QOL should be examined among cancer patients and other populations in future research.

Most studies examined the associations between baseline alexithymia and treatment outcomes, whereas only one study reported the 5-year total mortality risk of alexithymia [27]. Interestingly, the increased risk of total mortality associated with alexithymia in hemodialysis patients (multivariate adjusted hazard ratio = 3.62; 95% CI: 1.32–9.93) was higher than that observed among Finnish middle-aged men (1.96; 1.31–2.94) [15]. Whether or not the impact of alexithymia on total mortality may differ by populations should be further investigated.

Issues for future epidemiological research on alexithymia

Although alexithymia has been considered an unfavorable personality dimension for health promotion and disease prevention, the results of epidemiological studies were inconsistent. Most of them are preliminary and have many methodological problems. Apparently, we need more systematic, prospective studies with sound design to verify each pathway explaining the relationship between alexithymia and health problems that have been theoretically suggested [5]. There are some important points to be followed when conducting an epidemiological study to clarify the influence of alexithymia on health. First, alexithymia is considered a relatively stable characteristic, but it is actually dependent on psychological and/or physical conditions. Therefore, alexithymia should be chronologically measured repeatedly in the same individuals. Second, alexithymia and negative affect are closely associated. Also, interactions with social support cannot be dismissed when examining the influence of alexithymia on health problems. Thus, social support as well as negative affect must be assessed simultaneously when evaluating alexithymia to exclude potential confounding in statistical analysis. Third, if the pre-test score is extremely high, it is likely to show a drop in the post-test score; “regression to the mean [63].” People with alexithymia tend to have higher scores of distress than people without alexithymia. Therefore, simple subtraction of the post-treatment score from the pre-treatment score may cause overestimation of the treatment effect. Using the residual gain score, which is the difference between the actual post-test score and the score that was predicted from a regression equation is one method to adjust the phenomenon, and the use of the analyses of covariance method is also recommended [63]. Finally, as suggested by Grabe et al, alexithymia is considered to be a long-standing risk factor as well as a familial and genetic factor of health [21]. To detect the association between alexithymia and the developmental risk of specific health problems, a long observational period is required. Especially, the association between alexithymia and the onset of depression may occur at a relatively early stage of life. If so, prospective study of the middle-aged population may omit persons who have already developed depression due to alexithymia and overlook the association between them.

Alexithymia might explain social health inequality

Marmot, who directed the Whitehall Study, a longitudinal epidemiological study of British civil servants, pointed out from his 30 years of research that there are great health inequalities throughout the world that are related to social hierarchy [6466]. According to Marmot’s speculations, what profoundly affects our health and longevity is not income or lifestyle but autonomy and the opportunities for complete social participation; these follow social gradients and result in health inequalities [66]. Externally oriented thinking styles may inhibit alexithymic patients from feeling like they are in control, and their difficulty in “identifying and describing ones’ own inner feelings” may make them reluctant to participate in social activities. To date, there are two published studies reporting the association between alexithymia and long-term total mortality [15, 27], and both of them supported the above hypothesis. Considering its construct, alexithymia might be a key health determinant, as Marmot suggested [65]. In order to resolve social inequalities and improve our health, we should approach the structure of the whole society to reduce alexithymia urgently. Recently, several researchers reported successful interventions to reduce the level of alexithymia [42, 51, 67, 68]. We need more evidence to establish the treatment strategy for alexithymia.

How to approach alexithymia

The etiology of alexithymia has not been completely determined. Recent studies revealed the contribution of genetic factors to alexithymia development [6974]. Several studies suggested that the social environment of early life and cultural factors influence alexithymia development [7577]. Alexithymia is also known to develop secondarily as a reaction to stressful situations [78]. Moreover, some constructs may overlap with alexithymia [4, 79], such as emotional intelligence, emotional awareness, empathy deficits [80, 81], and autism spectrum disorders [82, 83]. How a person develops alexithymic characteristics and how it affects his or her health throughout the life course need to be clarified. We also need to know how to approach alexithymic patients when their developmental backgrounds are varied.

Current review has revealed some favorable influences of alexithymia on surgical treatment outcomes [4246]. A positive influence of alexithymia on behavioral treatments and adherence to treatment recommendations has been observed in several previous studies [4]. Lumley et al speculated that the compulsive nature and external focus of alexithymic patients prompt greater adherence to structured exercises and behavioral recommendations [4]. If clinicians and family members understand the characteristics of alexithymic patients and provide them with appropriate support, they might exhibit good compliance and thereby achieve good health outcomes. This point should be further explored in future studies.

Study limitation

To conduct the current systematic review, only the PubMed database for a limited period was used for the article search. The results of unpublished studies or articles not registered for PubMed were not included. Therefore, this systematic review did not cover all existing studies regarding alexithymia and the data need to be updated.

Almost all epidemiological studies reviewed in this article used the TAS or its short version, the TAS-20, to evaluate alexithymia. Both of them are self-measure questionnaires and have been used widely because of their good reliability and feasibility [84]. However, it has been argued that people with severe alexithymia may not evaluate their symptoms correctly because of having difficulty perceiving their inner feelings [85]. Moreover, a significant positive correlation of the TAS or the TAS-20 score and negative affect has been reported consistently [84]. The original authors of the TAS have recommended the measurement of alexithymia with several tools using different methods [8]. Whether or not we should use multiple measures of alexithymia has been very well discussed in the review article by Lumley et al [4]. Even though the application of interview-based assessment to epidemiological studies with large samples is difficult, the differences in measuring tools, especially those that include objective measures, should be verified in the future.

Conclusions

The epidemiological evidence regarding alexithymia as a prognostic risk factor for health problems is insufficient. Prospective studies with sufficient sample sizes will be necessary in order to confirm the contribution of alexithymia to health problems.

Declarations

Acknowledgements

This study was supported by a Grant-in Aid for JSPS KAKENHI 21590708.

Authors’ Affiliations

(1)
Department of Public Health, Nagoya City University Graduate School of Medical Sciences

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