Psychosomatics 42:229-234, June 2001
© 2001 The Academy of Psychosomatic Medicine
Alexithymia and Depression
A Prospective Study of Patients With Major Depressive Disorder
Kirsi Honkalampi, Lic. Psych.,
Jukka Hintikka, M.D., Ph.D.,
Eila Laukkanen, M.D., Ph.D.,
Johannes Lehtonen, and
Heimo Viinamäki
Received March 29, 2000; revised October 25, 2000; accepted December 8, 2000. From the Department of Psychiatry, Research and Development Unit, Kuopio University Hospital, Kuopio, Finland, and the Department of Psychology, University of Joensuu, Joensuu, Finland. Address reprint requests to Dr. Honkalampi, Department of Psychiatry 4975, Kuopio University Hospital, P.O. Box 1777, FIN-70211 Kuopio, Finland. E-mail: kirsi.honkalampi{at}kuh.fi
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ABSTRACT
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The authors conducted a 12-month follow-up study to determine the association between alexithymia and depression in 116 outpatients with major depressive disorder (MDD) and 540 control subjects from the general population. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20), and depression was assessed using the Beck Depression Inventory (BDI). The results show that the severity of depression was significantly associated with alexithymia. In addition, the BDI scores increased or decreased proportionately with the change in TAS-20 score in both groups. These results lend further support to the idea that alexithymia may be a state-dependent phenomenon.
Key Words: Depression • Alexithymia • Affective Disorder
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INTRODUCTION
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Major depressive disorder (MDD) is a common psychiatric illness, with an estimated 12-month prevalence ranging from 10% to 14%.1 Moreover, several findings2,3 support the longitudinal stability of depression. MDD has been found to be associated with anxiety disorders,1 somatic symptoms,4 and some personality characteristics, such as neuroticism,5 introversion5 and alexithymia.6–8 Alexithymia, the inability to recognize and verbalize emotions9,10 has been shown to be a stable personality trait,11,12 distinct from depression, although these constructs have been found to be correlated.13
However, as early as 1977, Freyberger14 proposed that alexithymia might also represent a secondary phenomenon. Spurred by this suggestion, a number of studies have attempted to find an association between depressive mood and alexithymia in psychiatric patients,15 somatic patients,16 alcoholic inpatients,17 patients with depressive disorders7,8 and chronic pain,18,19 and in the general population.20,21 Nevertheless, the design of these studies has usually been cross-sectional, and thus no causal relationship between depressive mood and alexithymia could be determined.
Since 1977, only two follow-up studies have focused on patients with major depressive disorders. In one, a 6-month follow-up study, the level of depression was found to be associated with alexithymia, together with a concomitant decrease in Toronto Alexithymia Scale (TAS) and Beck Depression Inventory (BDI) scores.22 In contrast, the second study, a 5-day test-retest study in patients with depressive disorders, revealed no clinically significant changes in TAS scores.6 Despite the growing interest in this area, no studies have yet assessed the comparability of the findings from depressed patients with those from the general population.
The aim of this study was to determine the relationship between depression and alexithymia among patients with MDD and general population control subjects. We were especially interested in the following questions: 1) Is alexithymia a stable feature in both patients with MDD and in general population control subjects? and 2) Is the stability of alexithymia related to the severity of depression in control subjects and in patients with MDD?
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SUBJECTS
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Patients With Major Depressive Disorder
The original patient sample included 137 outpatients (78 women, 59 men) undergoing psychiatric outpatient care at the Kuopio University Hospital, Finland. All participating patients were suffering from a current episode of MDD and provided written informed consent before entering the study. At baseline, the diagnosis of MDD was confirmed by means of the Structured Clinical Interview for DSM-III-R (SCID I)23 conducted by a trained interviewer. The interviewer had passed a 3-day clinical training course prior to this study, achieving a total kappa of 0.78 against an experienced trainer in SCID diagnoses. Approval for the study was obtained from the Ethics Committee of the Kuopio University Hospital and the University of Kuopio. All patients were examined at baseline (T1) (admittance) and at 12 months (T2).
At baseline, one patient was excluded because of a postencephalic state. Twelve months later, 19 patients declined to participate, and one patient had died. Thus, the final sample consisted of 116 patients (85% of the baseline sample). More men (67%) than women were found among the dropouts ( 2=6.0, df=1, P<0.05). However, no significant differences were found in age, educational level, or in TAS-20 [56.8±11.2 vs. 56.1plusmn;12.3] and BDI (22.1±8.1 vs. 23.5±12.1) baseline scores among the participants and the dropouts.
General Population Control Subjects
The control group consisted of 548 subjects from the general population who were randomly selected from a larger sample of the general population.21 The age and gender distributions of control subjects were similar to the patient group. All control subjects were selected from the National Population Register and were currently living in the Province of Kuopio. Because of incomplete questionnaires, 8 (1%) control subjects were excluded from the analysis. The final sample of control subjects (n=540) was made up of 233 (43%) men and 307 (57%) women. Information about the control subjects was collected at baseline (T1) and at the 12-month follow-up (T2).
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METHODS
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Patients and control subjects completed the same questionnaires at both study phases. Data collection differed between the two groups in only one respect: a research nurse individually met with the patients, whereas the control subjects received a mailed study questionnaire. The questionnaires for the control subjects were mailed for the first time in April-May 1998, and again a year later in May 1999. The questionnaire included questions relating to the subject's sociodemographic background and asked participants to evaluate their subjective general health, financial status, and work ability on a 4-point scale (1–2 good, 3–4 poor).
Alexithymia was assessed using the validated Finnish version24 of the 20-item Toronto Alexithymia Scale (TAS-20), which is a self-report questionnaire. The original English version of TAS-20 has been validated by Bagby and co-workers.25,26 Each TAS-20 item was rated on a 5-point (1–5) Likert scale, with total scores ranging from 20 to 100. The cut-off point for alexithymia was  61, which has been empirically established.27 In both study phases, the Cronbach's alphas were between 0.82 and 0.89, showing that TAS-20 has an acceptable internal consistency.
In addition, the 21-item Beck Depression Inventory (BDI) was used to assess the severity of depression.28 Scores were analyzed either as a continuous variable or divided into two groups: 0–18 representing normal mood to moderate depression, and 19–63 indicating a moderate to severe depression. In some analyses, the BDI score was also separated into two groups: a BDI score 9 was considered to represent recovery from depression or a normal mood, while a BDI score>9 was interpreted as indicating nonrecovery from depression or a depressed mood. The Cronbach's alpha ranged between 0.84 and 0.92 at every study phase.
The statistical methods used included the Pearson chi-square or Fisher's two-tailed exact test for categorical variables, and Mann-Whitney U-tests and Spearman's two-tailed correlation analyses for continuous variables. Logistic regression analyses were used to identify whether the severity of depression was associated with alexithymia. A P-value of <0.05 was considered to indicate statistical significance in all of the analyses. All data analyses were conducted with SPSS version 9.0; data are means±SD unless otherwise noted.
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RESULTS
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Baseline
Forty-five percent (n=52) of the patients with MDD had a TAS-20 score61. They were more often men, had less than 12 years of education, considered themselves unhealthy, and their subjective work ability was more frequently diminished compared to the other patients (Table 1). Neither age (45.0±9.3 vs. 44.0±11.5 years) nor any other background variables were associated with alexithymia.
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TABLE 1. Background characterictics of the patients with major depressive disorder in the baseline according to alexithymia status
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In the control group, the prevalence of alexithymia (TAS-20 score61) was significantly lower than in the patients with MDD (9% vs. 45%, 2=97.2, df=1, P<0.001). As in the patient sample, alexithymia was associated in the control subjects with male gender, a lower level of education, lower perceived level of health and diminished work ability (Table 1). Contrary to the patients, alexithymic control subjects (n=47) had a lower financial status, were more often blue-collar workers, and older (48.0±9.3 vs. 43.2±10 years, Z=-3.1, P<0.01) than the other subjects (n=493).
Follow-up
At follow-up (T2), 22% (n=26) of the patients with MDD were still alexithymic. From T1 to T2, the TAS-20 scores dropped below 61 in 58% (n=30/52) of the alexithymic patients. Among those patients who recovered from alexithymia, the average decrease in TAS-20 score between the period T1 and T2 was 17±9 points, with BDI scores decreasing by 14±8 points. The BDI scores of patients still found to be alexithymic after 1 year (n=22/52) decreased significantly less (6±11 points; Z=–2.8, P<0.01). In contrast, only four (6%) patients with a TAS-20 score<61 at baseline had a TAS-20 score61 on follow-up. These patients experienced an increase of 14±7 points in their TAS-20 score and a 7±6-point increase in the BDI score. In both phases the TAS-20 score correlated significantly with the BDI score (r=0.38, n=116, P<0.001 and r=0.68, n=116, P<0.001, at T1 and T2, respectively). A significant correlation was also found between the change in TAS and BDI scores from T1 to T2 (r=0.48, n=116, P<0.001).
The control subjects were significantly less often alexithymic than the patients with MDD at T2 (9% vs. 22%, 2=18.9, df=1, P<0.001). Although the prevalence rate of alexithymia among the control subjects was similar to that at baseline, the consistency of the alexithymic group had changed. From T1 to T2, the TAS-20 score decreased below 61 in 60% of the alexithymic control subjects. Among these control subjects, the TAS-20 score had decreased an average 11±8 points and the BDI score by 4±8 points. In the control group, the incidence of new cases of alexithymia during the 12 months was 6%. These new cases showed an average increase of 14±9 points on the TAS-20 score, while at the same time their BDI scores increased by 5±8 points. In both phases, the total score of TAS-20 correlated significantly with the BDI score (r=0.46, n=540, P<0.001 and r=0.50, n=540, P<0.001, at T1 and T2, respectively). A significant correlation was also found between the change in TAS-20 and BDI scores between T1 and T2 (r=0.33, n=540, P<0.001).
Is Alexithymia Associated With Level of Depression?
In both the patients with MDD and the control subjects, the prevalence of alexithymia was related to the level of depression at each study phase (Table 2). At T2, 92% of the nonrecovered patients (BDI score>9) were alexithymic, whereas only 4% (n=2) of the nondepressed patients were alexithymic (2=18.7, df=1, P<0.001). In the control group, the alexithymic control subjects more frequently had BDI scores over 9 compared to the others in both study phases (70% vs. 17%, 2=73.5, df=1, P<0.001 and 61% vs. 18%, 2=, df=1, P<0.001, at T1 and T2, respectively).
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TABLE 2. Mean and standard deviation of BDI and TAS-20 scores in the different study phases between patients and control subjects with alexithymia and other patients/subjects
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We used several multivariate logistic regression analyses to identify whether the severity of depression was independently associated with alexithymia among patients with MDD and control subjects. All independent variables were simultaneously in the model. The chosen social variables for all models were gender (0=female, 1=male), age, education (12 vs.<12 years), perceived health status (good/poor), and subjective work ability (good/poor). In addition, the BDI score (0–18 vs. 19–63) was included in the models for patients with MDD. The logistic analysis for the control group consisted of the same social variables, and the BDI score (0–9 vs. 10–63) was used because of the distribution of the BDI score in this group (Table 2).
At baseline, moderate to severe depression was associated with a significantly increased risk of alexithymia in patients with MDD (Table 3). This association remained at 1-year follow-up. In the control subjects, a BDI score of >9 was associated with alexithymia (OR=9.6, 95%CI=4.4–21.2 and OR=18.9, 95%CI=8.3–43.0, in T1 and T2, respectively).
Finally, the last logistic regression analysis was done by combining both study groups. All previously mentioned social variables and the BDI score (0–9 vs. 10–63) at T2 were included in the model. In addition, the diagnosis of MDD was added to the model (no=0, yes=1). In that analysis, only a BDI score >9 was found to be associated with alexithymia (OR=16.8, 95%CI=8.3–34.2).
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DISCUSSION
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This study provides evidence that the severity of depression among patients with MDD, and among subjects from the general population, increases the risk of being alexithymic at a 12-month follow-up. Moreover, our findings indicate that the prevalence of alexithymia is higher among patients with MDD compared to subjects from the general population. These results are in line with earlier studies showing that alexithymia is more common among psychiatric patients,15 especially among patients with MDD,8 compared to the general population.21,29 However, our logistic regression models indicated that only severity of depression was significantly associated with alexithymia in both groups, thus suggesting that level of depression may represent an important variable explaining the prevalence of alexithymia in both the patients with MDD and in the general population.
To our knowledge, this is the first follow-up study focusing on the association between alexithymia and depression in both the general population and in patients with MDD. Although all information from the control group were collected with a mailed study questionnaire, both the TAS-20 and the BDI were found to have good internal consistency for both study groups and at all phases. Nevertheless, because of the limited number of severely depressed subjects among the control group, it was not possible to conduct a similar cut-off point for BDI in the all logistic regression models for both groups.
Although the total prevalence of alexithymia decreased from 45% to 22% among patients with MDD during the 1-year period, a similar decrease was not found among the control subjects. However, over half of the alexithymic patients and control subjects were found to have recovered from alexithymia during the year. Moreover, the incidence of new cases of alexithymia among both the control subjects and patients with MDD was approximately 6%. Among these subjects, the BDI score had also increased. These findings suggest that a poor recovery from depression among patients with MDD and increasing symptoms of depression among subjects from the general population could, in some cases, result in the appearance of alexithymic features.
Could alexithymia be a permanent feature? Thus far, only a few follow-up studies have attempted to investigate this question among patients with various disorders. In those studies, the period followed has varied between 4 weeks30 and 1 year.11 Nevertheless, their findings are quite contradictory; in women with bulimia nervosa30 and in patients with panic disorder and social phobia,31 alexithymia scores have decreased significantly during the follow-up period, whereas in general hospital psychiatric outpatients11 and in patients with inflammatory bowel disease,12 the alexithymic features remained quite consistent. We found that the alexithymia score correlated strongly with depression (BDI) and also that the decrease in alexithymia scores was related to a corresponding decrease in BDI scores. However, it is possible that the stability of alexithymic features reported in previous follow-up studies may have been biased because these studies only examined the mean scores of TAS-20 at different study phases and did not focus on changes in alexithymia status occurring at an individual level. In addition, there could be other important confounding factors, similar to depression, which could cause the inability to recognize and alter negative affective states in that way could to be connected with alexithymia.
Our study shows that almost all the patients who had recovered from depression had also recovered from alexithymia. It has been noted earlier5 that self-reported personality traits do not change after an episode of MDD. It seems possible that upon recovery the nature of emotional experience and the ability to describe it may change. Furthermore, the self-critical aspects of depression, especially those pertaining to difficulty in identifying and describing feelings, may produce elevated TAS-20 scores. However, further long-term studies are needed to determine whether these findings can be supported by evidence from other samples.
Taken together, these results suggest that the severity of depression is strongly associated with alexithymic features. We found that MDD itself was not associated with alexithymia, but rather that recovery from alexithymia was related to a corresponding recovery from depression. These results lend further support to the idea that alexithymia may be a state-dependent feature among patients with major depression as well as in individuals in the general population.
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ACKNOWLEDGMENTS
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The authors thank statistician Pirjo Halonen for helping with the statistical methods and MHSc, RN Kaisa Haatainen for performing all the interviews.
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REFERENCES
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-
Kessler RC, DuPont RL, Berglund P, et al: Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. Am J Psychiatry 1999; 156:1915–1923
-
Thornicroft G, Sartorius N: The course and outcome of depression in different cultures:10-year follow-up of the WHO Collaborative Study on the Assessment of Depressive Disorders. Psychol Med 1993; 23:1023–1032
-
Lovibond PF: Long-term stability of depression, anxiety, and stress syndromes. J Abnorm Psychol 1998; 107:520–526[CrossRef][Medline]
-
Silverstein B: Gender difference in the prevalence of clinical depression: the role played by depression associated with somatic symptoms. Am J Psychiatry 1999; 156:480–482[Abstract/Free Full Text]
-
Shea MT, Leon AC, Mueller TI, et al: Does major depression result in lasting personality change? Am J Psychiatry 1996; 153:1404–1410
-
Wise TN, Mann LS, Randell P: The stability of alexithymia in depressed patients. Psychopathology 1995; 28:173–176[Medline]
-
Loas G, Dhee-Perot P, Chaperot C, et al: Anhedonia, alexithymia and locus of control in unipolar major depressive disorders. Psychopathology 1998; 31:206–212[CrossRef][Medline]
-
Honkalampi K, Saarinen P, Hintikka J, et al: Factors associated with alexithymia in patients suffering from depression. Psychother Psychosom 1999; 68:270–275[CrossRef][Medline]
-
Sifneos PE: The prevalence of "Alexithymic" characteristics in psychosomatic patients. Psychother Psychosom 1973; 22:255–262[Medline]
-
Sifneos PE: Affect, emotional conflict, and deficit: an overview. Psychother Psychosom 1990; 56:116–122
-
Salminen JK, Saarijärvi S, Äärelä E, et al: Alexithymia–State or trait? One-year follow-up study of general hospital psychiatric consultation outpatients. J Psychosom Res 1994; 38:681–685[CrossRef][Medline]
-
Porcelli P, Leoci C, Guerra V, et al: A longitudinal study of alexithymia and psychological distress in inflammatory bowel disease. J Psychosom Res 1996; 41:569–573[CrossRef][Medline]
-
Parker JDA, Bagby RM, Taylor GJ: Alexithymia and depression: Distinct or overlapping constructs? Compr Psychiatry 1991; 32:387–394
-
Freyberger H: Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychother Psychosom 1977; 28:337–342[Medline]
-
Wise TN, Mann LS, Hill B: Alexithymia and depressed mood in the psychiatric patient. Psychother Psychosom 1990; 54:26–31[Medline]
-
Wise TN, Jani NN, Kass E, et al: Alexithymia: relationship to severity of medical illness and depression. Psychother Psychosom 1988; 50:68–71[CrossRef][Medline]
-
Haviland MG, Shaw DG, MacMurray JP, et al: Validation of the Toronto Alexithymia Scale with substance abusers. Psychother Psychosom 1988; 50:81–87[Medline]
-
Kosturek A, Gregory RJ, Sousou AJ, et al: Alexithymia and somatic amplification in chronic pain. Psychosomatics 1998; 39:399–404[Abstract/Free Full Text]
-
Okasha A, Ismail MK, Khalil AH, et al: A psychiatric study of nonorganic chronic headache patients. Psychosomatics 1999; 40:233–238[Abstract/Free Full Text]
-
Haviland MG: The validity of the California Q-set Alexithymia Prototype. Psychosomatics 1998; 39:536–539[Abstract/Free Full Text]
-
Honkalampi K, Hintikka J, Tanskanen A, et al: Depression is strongly associated with alexithymia in the general population. J Psychosom Res 2000; 48:99–104[CrossRef][Medline]
-
Honkalampi K, Hintikka J, Saarinen P, et al: Is alexithymia a permanent feature in depressed patients? Results from 6-month follow-up study. Psychother Psychosom 2000; 69:303–308[CrossRef][Medline]
-
Spitzer RL, Williams JBW, Gibbon M, et al: The Structure Clinical Interview for DSM-III-R (SCID) I: History, rationale and description: Arch Gen Psychiatry 1992; 49:624–629
-
Joukamaa M, Miettunen M, Kokkonen P, et al: Psychometric properties of the Finnish 20-item Toronto Alexithymia Scale. Nord J Psychiatry, in press
-
Bagby RM, Parker JDA, Taylor GJ: The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994; 38:23–32[CrossRef][Medline]
-
Bagby RM, Taylor GJ, Parker JDA: The twenty-item Toronto alexithymia scale-II. Convergent, discriminant and concurrent validity. J Psychosom Res 1994; 38:33–40[CrossRef][Medline]
-
Taylor GJ, Bagby RM, Parker JDA: Disorders of Affect Regulation. Cambridge, Cambridge University Press 1997, pp 60–66
-
Beck AT, Steer RA, Garbin MG: Psychometric properties of the Beck Depression Inventory. Twenty-five years of evaluation. Clin Psychol Rev 1988; 8:77–100
-
Salminen JK, Saarijärvi S, Äärelä E, et al: Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. J Psychosom Res 1999;46:75–82
-
De Groot JM, Rodin G, Olmsted MP: Alexithymia, depression, and treatment outcome in bulimia nervosa. Compr Psychiatry 1995; 36:53–60[Medline]
-
Fukunishi I, Kikuchi M, Wogan J, et al: Secondary alexithymia as a state reaction in panic disorder and social phobia. Compr Psychiatry 1997; 38:166–170[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
