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Psychosomatics 45:197-204, June 2004
© 2004 The Academy of Psychosomatic Medicine

Relationships Among Alexithymia, Adverse Childhood Experiences, Sociodemographic Variables, and Actual Mood Disorder: A 2-Year Clinical Follow-Up Study of Patients With Major Depressive Disorder

Kirsi Honkalampi, Ph.D., Heli Koivumaa-Honkanen, M.D., Ph.D., Risto Antikainen, Ph.D., Kaisa Haatainen, M.H.Sc., Jukka Hintikka, M.D., Ph.D., and Heimo Viinamäki

Received Nov. 12, 2002; revision received June 10, 2003; accepted July 21, 2003. From the Department of Psychiatry, Research and Development Unit, Kuopio University Hospital. Address reprint requests to Dr. Honkalampi, Department of Psychiatry/4975, Kuopio University Hospital, P.O. Box 1777, FIN-70211 Kuopio, Finland; kirsi.honkalampi{at}kuh.fi (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
This 2-year follow-up study examined relationships among alexithymia, adverse childhood experiences, sociodemographic variables, and actual mood disorder among patients with major depressive disorder (N=106). Alexithymia was assessed with the Toronto Alexithymia Scale (TAS-20), depression with the Beck Depression Inventory, and actual mood disorder with the Structured Clinical Interview for DSM-III-R. A questionnaire that assessed sociodemographic characteristics and adverse childhood experiences was also used. Long-lasting alexithymic features were associated with blue-collar work, harsh discipline, unhappiness of the childhood home, depression at 12 months, and major depressive disorder diagnosis at 24 months. Furthermore, the results showed that alexithymic features could also be situational reactions to depression.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
During the last three decades, alexithymic features, such as the inability to recognize and verbalize emotions,1 have been found to be surprisingly common, even among the general population. The prevalence of alexithymia has been found to be higher (from 10% up to 13% among general population samples)2,3 than that of major depressive disorder (from 6.4% to 8.6%).4,5 Moreover, in various clinical samples alexithymia has been associated with numerous psychiatric and somatic diseases6,7 and even with organic deficiencies.8,9

Alexithymia seems to be often but not unambiguously connected with several sociodemographic factors.10 The most common finding from general population studies is an association between alexithymia and male gender.2,3 In addition, alexithymia has been associated with older age,10,11 a low level of education,2,3 and a low socioeconomic status.2 Furthermore, living alone without social relationships6 has been associated with alexithymia among the general population. Similar findings have been reported from various samples of clinical patients.7,12

However, the most interesting debate concerns the developmental background of alexithymia. It has been argued that severe traumatic experiences, such as physical or sexual abuse, could lead to the development of alexithymic features.13 Lumley and co-workers14 suggested that the development of alexithymia could be connected with disturbances in the emotional atmosphere of the family during childhood. In addition, Fukunishi and co-workers15 have linked the development of alexithymia with maternal attachment in infancy or childhood. Alexithymia has been found to be associated with insecure attachment,16 with childhood abuse,17 and with low levels of family communication.18 However, the design of these studies has been cross-sectional, and thus no causal relationship between adverse childhood experiences and alexithymia could be determined.

A further question concerning the stability of alexithymic features is partly connected to hypotheses for the developmental background of alexithymia. To date, few studies have focused on changes in alexithymic status at the individual level. Follow-up studies on alexithymia and depressive mood have demonstrated that recovery from depression in patients with depressive disorders is associated with a decrease in alexithymic features.19–21 In a study by Beresnevaite,22 a proportion of patients with coronary heart disease showed a reduced level of alexithymia at a 2-year follow-up evaluation, and in this group there were fewer cardiac events than among patients whose alexithymia level did not change. However, none of the above studies examined at the same time whether other background factors could also be connected with changes in alexithymic status.

To date, it is not known whether specific factors are associated with changes in alexithymic status in depressed patients. Furthermore, the factors associated with the stability of the alexithymic status are completely unknown. The present 2-year clinical follow-up study aimed to identify the factors that explain the stability of alexithymia and changes in alexithymic status in patients with major depressive disorder.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
The original patient group included 137 outpatients (78 women, 59 men) undergoing psychiatric outpatient care at Kuopio University Hospital in Finland. All participating patients were suffering from a current episode of a major depressive disorder and provided written informed consent before entering the study. Approval for the study was obtained from the Ethics Committee of the Kuopio University Hospital and the University of Kuopio. At baseline and at a follow-up evaluation 2 years later, the diagnosis of a major depressive disorder was confirmed by means of the Structured Clinical Interview for DSM-III-R (SCID),23 conducted by a trained interviewer. All patients were examined clinically at baseline (admittance) and at follow-up evaluations after 6 months, 12 months, and 24 months.

The dropout from the baseline to the 1-year follow-up evaluation has been discussed in detail in our earlier report.20 Between the 12-month and the 2-year follow-up evaluations, five patients declined to participate, and three patients died. Because of incompletely filled questionnaires, two patients were rejected from the analysis, and the final sample thus consisted of 106 patients (77% of the baseline sample).

Procedure
The data were collected by questionnaire and interview. At the baseline evaluation, patients completed a questionnaire relating to their sociodemographic background. A separate question was used to assess each of the following factors: the patients' own evaluation of the social support they had received (1=adequate, 2=fairly adequate, 3=fairly inadequate, 4=inadequate), the patients' subjective evaluation of their health (1=good, 2=fairly good, 3=fairly poor, 4=poor), their financial situation (1=good, 2=fairly good, 3=fairly poor, 4=poor), and their ability to work (1=good, 2=reduced, 3=unable to work).

The questions also included subjective assessments of the following childhood experiences: the relationship between the parents (1 or 2=good, 3–5=don't know or poor); the happiness of the childhood home (1=happy, 2=unhappy); discipline (1 or 2=gentle, 3 or 4=harsh); physical punishment such as hair pulling, spanking, beating (1=no, 2–5=yes); domestic violence with or without sexual abuse directed at the child (1=no, 2–4=yes); and alcohol abuse in the primary family (1=no, 2=yes).24

Alexithymia was assessed with the 20-item version of the Toronto Alexithymia Scale (TAS-20).25 Each TAS-20 item was rated on a 5-point Likert scale, with total scores ranging from 20 to 100. The cutoff point used for alexithymia was >=61.26 The study by Joukamaa and co-workers27 reports in detail how the TAS-20 was translated into Finnish. Using confirmatory factor analysis, Joukamaa and co-workers27 showed that the three-factor structure of the original scale is consistent with the Finnish version of the scale.

The level of depression was assessed with the 21-item Beck Depression Inventory. The Beck Depression Inventory was originally derived from clinical observations concerning the attitudes and symptoms frequently displayed by depressed psychiatric patients and infrequently by nondepressed psychiatric patients.28 In this study the sum of total scores was treated as a continuous variable or divided into two groups: those who had a Beck Depression Inventory score <=9 at any follow-up evaluation were considered to have recovered from depression while those who had a Beck Depression Inventory score >9 were classified as nonrecovered. The patients completed TAS-20 and Beck Depression Inventory scales in each study phase.

Follow-Up Treatment
Data concerning treatment during the follow-up period were collected from patient case records and interviews with the patients. The antidepressant medication used was considered to have been adequate if the daily dose was within the range deemed efficient29 and if the length of drug treatment from baseline to the 6-month evaluation or from the 6-month to the 12-month evaluation exceeded 3 months or if the length of drug treatment from the 12-month to the 24-month evaluation exceeded 6 months. The quality of treatment visits was not assessed in the study. Only the total number of all treatment visits was calculated in all study phases.

Statistical Analysis
Patients were divided into three groups according to the change in or stability of their TAS-20 score at baseline and after 6 and 12 months. The "stable alexithymia" group consisted of those patients who were alexithymic (TAS-20 scores >=61) in each study phase from baseline to the 12-month evaluation (N=20, 19%), the "nonalexithymic" patients were not alexithymic (TAS-20 scores <61) at any evaluation (N=43, 40.5%), and the patients with "secondary alexithymia" were alexithymic at baseline but had TAS-20 scores under 61 at the 12-month evaluation (N=43, 40.5%).

The statistical methods included the Pearson chi-square test, Fisher's two-tailed exact test, and univariate logistic regression for categorical variables and independent-sample t tests for continuous variables. Repeated measures analysis of variance was used for repeated variables such as TAS-20 and Beck Depression Inventory. The normal distribution of variables and residuals (standardized and unstandardized) was verified in each analysis of variance. Clustering of K-means was carried out with a selected group of variables.30 The data were analyzed by using the statistical software package SPSS 10.0. A p value of <0.05 was considered statistically significant in all analyses.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Background Factors
The sociodemographic background of the studied groups was quite similar (Table 1). However, the proportion of male subjects and blue-collar workers was significantly higher in the stable alexithymia group than in the nonalexithymic group. There were two significant differences between the groups in adverse childhood experiences (Table 2). Patients in the stable alexithymia group reported harsh discipline and unhappiness of the childhood home significantly more frequently than did the nonalexithymic group.


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TABLE 1. Sociodemographic Characteristics of 106 Patients With Major Depressive Disorder by Alexithymia Ratingsa




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TABLE 2. Adverse Childhood Experiences in 106 Patients With Major Depressive Disorder by Alexithymia Ratingsa



>Alexithymia and Depression Ratings Over the Course of the Study
The mean TAS-20 and Beck Depression Inventory scores decreased during the successive follow-up phases (Table 3). Repeated-measures analysis of variance showed a significant linear decrease in TAS-20 mean scores (F=109.6, df=2.6, 276.9, p<0.001) and Beck Depression Inventory mean scores (F=62.3, df=2.6, 282.5, p<0.001) during the four study phases. There was a similar significant decrease in TAS-20 and Beck Depression Inventory scores when examined separately for each studied group (Table 3). At the 2-year follow-up evaluation, 29% (N=31) of all patients were diagnosed to have major depressive disorder.


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TABLE 3. Alexithymia and Depression Ratings Over the Course of the Study for 106 Patients With Major Depressive Disorder



The prevalence of alexithymia decreased in successive study phases (58% at baseline, 37% at 6 months, 20.4% at 12 months, and 17.6% at 2 years). Follow-up analysis showed that 84% of those patients who were in the secondary alexithymia group remained nonalexithymic at the 2-year follow-up evaluation. Moreover, of those patients with stable alexithymia, half (N=10) were not alexithymic and they were not diagnosed with major depressive disorder after 2 years. Among the recovered patients in the stable alexithymia group, the average decreases in TAS-20 and Beck Depression Inventory scores from the 12-month to the 2-year evaluation were 11.3 (SD 4) and 8.1 (SD 6.7), respectively, whereas they were only 1.9 (SD 8.5) and 0.6 (SD 7.8), in the total study population. There were no statistically significant differences in psychiatric treatment factors between the groups in any study phase (Table 4).


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TABLE 4. Treatment Received During a 2-Year Follow-Up Period by 106 Patients With Major Depressive Disorder by Alexithymia Ratingsa



>Which Variables Explain the Long-Lasting Alexithymic Features in Depressed Patients?
K-means clustering was performed in order to determine whether a selected group of variables could distinguish the stable alexithymia group from other groups. The variables for clustering were selected on the basis of statistical differences between groups. Male gender (0=no, 1=yes), blue-collar work (0=no, 1=yes), harsh discipline (0=no, 1=yes), and unhappiness of the childhood home (0=no, 1=yes) were included in the clustering analysis. Because of the strong correlation between the Beck Depression Inventory scores in different study phases (r=0.40–0.70), only Beck Depression Inventory scores over 9 at 12 months (0=no, 1=yes) and a diagnosis of major depressive disorder at 24 months (0=no, 1=yes) were included in the model.

The two-cluster solution (Table 5) classified the majority of the patients from the stable alexithymia group (95%, N=19) into cluster 1. Cluster 1 included also 18 patients from the nonalexithymic group and 19 patients from the secondary alexithymia group. Cluster 2 mainly included patients from the nonalexithymic group (N=22) and the secondary alexithymia group (N=23), and only one patient from the stable alexithymia group. The variables differing significantly between clusters were blue-collar work (41% vs. 15% in cluster 1 and cluster 2, respectively), a Beck Depression Inventory score over 9 at 12 months (89% vs. 11%), major depressive disorder diagnosis at 24 months (46% vs. 9%), harsh discipline (84% vs. 39%), and unhappiness of the childhood home (54% vs. 17%). Gender was not a significant variable in this model (males: 45% vs. 33% in cluster 1 and cluster 2, respectively).


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TABLE 5. Clustering Analysis of Variables Distinguishing Patients With STABLE Alexithymia Among 106 Patients With Major Depressive Disorder




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this 2-year follow-up study suggest that certain adverse childhood experiences, such as harsh discipline and unhappiness of the childhood home, are associated with long-lasting alexithymic features but not with secondary alexithymia in patients with major depressive disorder. Earlier studies among students32 and psychiatric outpatients33 have shown that the childhood family environment can have a bearing on alexithymic features in adulthood. It has been suggested that traumatic experiences, such as physical or sexual abuse, could in some cases lead to inhibition of affect in childhood and alexithymic features in adulthood.13 However, there is also evidence that adverse childhood experiences could associate with depression in adulthood,34,35 thus the association between alexithymia and adverse childhood experiences is not unambiguous at least in patients with major depressive disorder.

The proportion of male subjects was higher in the secondary alexithymia and stable alexithymia groups than among nonalexithymic patients. Several general population studies have reported alexithymia to be more common in men than in women,2,11 even when depression is taken into account.3 However, from the sociodemographic variables in the present study, blue-collar work, but not male gender, was associated with stable alexithymia in the cluster analysis. Of interest is that it has been suggested that alexithymia might have a negative influence on an individual's social success, which could result in a lower socioeconomic status in later life.2 However, even though some sociodemographic factors could play a role in the development of alexithymic features, this issue requires further research.

In general, the prevalence of alexithymia as well as the mean TAS-20 and Beck Depression Inventory scores decreased in successive study phases. Cluster analysis also showed that long-lasting alexithymic features are connected with both the severity and the stability of depression, a finding that is in line with an earlier study on depressed patients.21 Of interest is that the patients in the secondary alexithymia group seemed to recover from major depression nearly as well as the nonalexithymic patients. Thus, alexithymic features in these patients could mainly be interpreted as secondary reactions to the depressive mood.

The stable alexithymia group comprised those patients who were alexithymic in the first three successive clinical study phases. In addition, the study group was clinically quite homogenous because all patients suffered from major depression at baseline. Both of these facts add to the reliability of these results. However, adverse childhood experiences were measured by single questions, and there is a possibility of retrospective recall bias.36 In addition, because of the intimate nature of the questions concerning adverse childhood events, these responses should be interpreted with caution, which is a limitation of this study.

It is interesting that half of the patients with stable alexithymia had recovered from depression and their TAS-20 scores simultaneously decreased to under 61 points after 2 years. It seems to be possible that depressed individuals exhibit alexithymia because of their negative self-concept, low level of energy, self-perceived cognitive deficits, or the presence of the negative affect itself,33 which is always one limitation in drawing conclusions when evaluating patients with major depression at least in the acute phase.

Nemiah37 proposed that it is possible to recover from alexithymia following psychotherapy. In this study we found no differences in treatment factors between the studied groups, and few studies to date have recorded a decrease in alexithymic features following psychiatric treatment.19,22 In a study by Beresnevaite,22 20 post-myocardial infarction patients were in a treatment group that received weekly group psychotherapy for 4 months. The control group included 17 post-myocardial infarction patients who received two educational lessons over a period of 1 month. The results showed that there was a significant reduction in the mean TAS-20 score only in the psychotherapy treatment group, which was maintained over the 2-year follow-up period. The aim of the present study was not to examine different treatment methods. This may be considered a limitation of this study, but our results reflected the outcome of ordinary clinical practice.

Both of the scales used in the study, the Beck Depression Inventory and TAS-20, are self-report methods. There are certain limitations to these methods, especially to the TAS-20. These mostly concern the ability of individuals to evaluate themselves, for example, when feeling low,33 which we tried to take into account by including two depression variables in the cluster analysis. Roberts and DelVecchio38 incorporated a large number of personality trait measurements and found the results from self-report methods to be the most consistent (the mean of all test-retest correlations=0.52), followed by the observer method (0.48) and projective tests (0.43). Their results showed that self-report methods could be used in the assessment of personality characteristics.

Taken together, our results indicate that the long-lasting alexithymic features in patients with major depression were associated with several factors, including aspects from childhood, adulthood, and the actual mood disorder. Furthermore, the results from the secondary alexithymia group showed that alexithymia could also be a secondary phenomenon and that these temporary features of alexithymia may be situational reactions to depression.


  ACKNOWLEDGMENTS

 
The authors thank Veikko Jokela for assistance with the statistics.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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