Alexithymia in personality disorders: Correlations with symptoms and interpersonal functioning
Introduction
Understanding what one is feeling, putting that into words and communicating it to an addressee is necessary for health and adaptation. Emotions are an evolutionary selected basic aspect of human functioning. Accurate knowledge about internal experiences allows for many operations which are necessary for living a satisfying social life and coping with stressors. If I understand my heart is pounding because I have met a potential romantic partner, I can start to try to court him or her. If I recognize I am feeling guilty because my baby is crying and I am not available, I may take this as a cue to engage in more appropriate caretaking. In parallel, telling another person what one is feeling can help facilitate basic social exchanges. If the other person knows what one is feeling, he or she can be ready to give appropriate answers.
Poor emotional awareness has been studied for some decades and given the label of alexithymia (Nemiah and Sifneos, 1970). Alexithymia is a construct which includes different facets, namely difficulties identifying feelings and distinguishing them from somatic sensations; difficulties describing feelings to others; constricted imaginal processes; and a concrete, externally oriented style of thinking. The construct of alexithymia has been operationalized (Taylor et al., 1997) and linked to heightened levels of psychiatric symptoms (Parker et al., 2008) among persons with conditions such as eating disorder symptoms (Harrison et al., 2009), substance and alcohol abuse (Taylor et al., 1997, De Rick et al., 2009), depression (Luminet et al., 2001) and in particular a treatment-resistant subtype (Ogrodniczuk et al., 2004, Vanheule et al., 2007a), somatic complains and somatoform disorders (Pedrosa Gil et al., 2008), pathological dissociation and suicidality (Maaranen et al., 2005).
Alexithymia has also been linked with impaired social functioning and distortions of relationships. Alexithymia appears to be correlated with relational tendencies such as avoiding conflict, approaching others in a detached way (Taylor et al., 1997) and with less engagement in the psychotherapeutic process (Ogrodniczuk et al., 2005). These patients avoid close social relations, and when they do relate to others, they tend to form superficial bonds. Vanheule et al. (2007b) found that alexithymia is related to a kind of double interpersonal indifference: little is expected from others and there is limited interest in fulfilling the expectations of others. In another study Vanheule et al. (2007c) found that alexithymia was correlated with cold/distant and non-assertive personality styles. Poor emotional regulation appears to be associated to alexithymia. For example, poor impulse control has been found to be positively correlated with alexithymia in a sample of impulsive–aggressive veterans (Teten et al., 2008). Fossati et al. (2009) noted how difficulty identifying feelings and a low propensity to think about emotions were core components of impulsive aggression. Also in eating disorders studies provide consistent data that poor emotional awareness is linked with poor emotional regulation (Harrison et al., 2009).
Summarizing, alexithymia is related to a toxic combination of interpersonal dysfunctions, a wide array of symptoms and poor regulation of impulses, all problems which are hallmarks of personality disorder (PD). It is, therefore, reasonable to hypothesize that alexithymia is a typical feature of many PD sufferers (Grabe et al., 2004), an idea supported by findings that alexithymia is likely not a reaction to stressors but a stable personality trait (Luminet et al., 2001). Grabe et al. (2001) explored the associations between alexithymia and temperament — i.e. the biologically based underpinning of personality — and character. They found that some dimensions of Cloninger's psychobiological model of personality like low self-directedness, low reward dependence and to a minor degree harm avoidance were significantly correlated with the presence of alexithymia.
Many with PD have been suggested to experience core deficits in mentalizing (Bateman and Fonagy, 2004) or meta-cognition (Semerari et al., 2007), two processes closely related to being able to recognize and think about one's own internal states. Difficulties in translating bodily states into words have been hypothesized to be a core feature of borderline PD (Fonagy, 1991, Bouchard et al., 2008, Choi-Kain and Gunderson, 2008). Different PDs such as avoidant, obsessive–compulsive or narcissistic have been described in terms of poor emotional awareness and the idea has been put forward that some with PD may have greater difficulties using language to communicate emotion to while others (e.g.. dependent PD) may have less difficulties in expressing emotions verbally (Semerari et al., 2003, Dimaggio et al., 2007a, Colle et al., 2010). In single case studies, patients with avoidant and narcissistic PD have been found to have a limited ability to understand the causes of their own emotions (Dimaggio et al., 2007b).
In spite of the plausibility of the link between alexithymia and PD, few studies have explored this and almost none have focused on specifically on PD. In a ground-breaking study, Bach et al. (1994) found that on the Toronto Alexithymia Scale (TAS), 17% of the patients had alexithymic features. Schizotypal, dependent, and avoidant personality dimensions, as well as lack of histrionic features, emerged as significant predictors of alexithymia. Honkalampi et al. (2001) analyzed a sample of patients with major depression and found that alexithymia was more pronounced in patients with cluster C PD. They also found that alexithymia persisted after recovery from depression, thus reinforcing the idea it is a stable personality trait. Viinamäki et al. (2002) found that both alexithymia and personality disorder were the main factors predicting poor short-term response in treatment of major depression.
A few research examples focused on patients with personality disorder also support the idea that adult personality difficulties can be the result of poor emotional awareness. De Panfilis et al. (2008) found that in a sample of PD patients poor ability to describe feelings to others as measured with the Toronto Alexithymia Scale-20 fully mediated the relationship between excessive maternal protection and risk of having a PD. Lawson et al. (2008) noted that in a sample of women with eating disorder elements of narcissistic PD, such as grandiosity and entitlement, were associated with difficulties in describing feelings and that personality related coping styles, such as tendency to control and criticize others, or to present oneself as a martyr, were associated with difficulties in identifying feelings and distinguishing emotions from somatic experiences. Bouchard et al. (2008) examined the adult attachment interviews of 73 participants, both with and without psychiatric disorders. They found that many aspects of the ability to think about thinking, including the ability to describe somatic states in terms of feelings, were linked with the presence of a greater number of PD diagnoses. Spitzer et al. (2005) found that the interpersonal style of alexithymic individuals was characterized by cold and socially avoidant behaviour, corresponding to the predominantly insecure attachment pattern. They also noted how alexithymia involved a reduction in the capacity to use social interactions for affect regulation.
In short, while there is reason to presume a possible relationship between alexithymia and different aspects of PD, much remains to be formally investigated. Knowing more precisely whether alexithymia contributes to PD and symptom dysfunctions may have a range of important therapeutic implications. For one, alexithymia has been found to be a barrier to the creation of a therapeutic alliance leading to poorer outcome (Ogrodniczuk et al., 2004, Ogrodniczuk et al., 2005). More in-depth knowledge of the relations between poor emotional awareness and PD may lead to modifications in PD treatment, including refinements in existing therapies already focused on promoting better understanding of mental states (Levy et al., 2006, Dimaggio et al., 2007a, Allen et al., 2008).
In response this study seeks to test two primary hypotheses: 1) there would be increasingly greater social difficulties, greater levels of global psychopathology and more criteria met for clusters A, B and C personality disorders among patients who do not meet the criteria for alexithymia, who have borderline levels of alexithymia (indeterminate alexithymia) and patients who report clinically significant levels of alexithymia; 2) differences in dysfunctional representations of interactions among these three groups would persist when global psychopathology was controlled for statistically. In two sets of exploratory analysis we also sought to explore whether different components of alexithymia were more closely linked with select social problems and PT traits and whether different forms of PD should feature different patterns of associations with alexithymia, including depressive and passive–aggressive PD, both forms of PD identified by DSM-IV as objects of future study.
Section snippets
Participants
Participants were 388 consecutive adult and adolescent patients requiring treatment or consultation in an Italian outpatient clinic, Third Centre of Cognitive Psychotherapy, from 2006 to 2009. The mean age was 34.57 (S.D. = 10.54), with a minimum age of 16 years and a maximum of 69 years. One hundred and eighty-three (47%) were male and 208 (53%) were female. The mean GAF score was 61.39 (S.D. = 10.25). Referrals were made from colleagues mostly aware that this was a centre specialized for treating
Results
Mean scores on the IIP, TAS, SCL-90 and SCID-II clusters A, B and C traits and the general distribution of persons meeting SCID-II criteria for each individual PD in DSM-IV are presented in Table 1. Classification of participants on the basis of the TAS resulted in 95 (24%) participants being placed in the alexithymia group, 81 (21%) in the indeterminate alexithymia group and 215 (55%) in the no alexithymia group. Comparisons of groups on age revealed a significant group effect (F(2,385) = 4.92; p
Discussion
In this study we sought to examine whether participants classified as having alexithymia would have greater levels of social problems, general psychopathology and more PD traits than participants classified with as having either borderline levels of alexithymia (indeterminate levels) or no difficulties with alexithymia. In general this prediction was only partially confirmed. Participants classified as having alexithymia reported greater levels of psychopathology, social problems and clusters A
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