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Psychosomatics 48:489-495, November-December 2007
doi: 10.1176/appi.psy.48.6.489
© 2007 Academy of Psychosomatic Medicine
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Alexithymia and Emotional Distress in Patients With Central Serous Chorioretinopathy

Rupert Conrad, M.D., Nina Friederike Weber, M.D., Matthias Lehnert, M.D., Frank Gerhard Holz, M.D., Reinhard Liedtke, M.D., and Nicole Eter, M.D.

Received July 26, 2005; revised December 5, 2005; accepted June 6, 2006. From the Dept. of Psychosomatic Medicine and Psychotherapy and the Dept. of Ophthalmology, Univ. of Bonn, Germany. Send correspondence and reprint requests to Rupert Conrad, M.D., Dept. of Psychosomatic Medicine and Psychotherapy, University of Bonn, Sigmund Freud Str. 25, 53105 Bonn, Germany. e-mail: Rupert.Conrad{at}ukb.uni-bonn.de
© 2007 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors studied 31 consecutive patients newly diagnosed with central serous chorioretinopathy (CSC) as compared with 31 age- and gender-matched control subjects, assessing emotional distress (ED), nine psychopathological symptoms, critical life events, and alexithymia. Results showed no difference in the number of critical life events; however CSC patients showed elevated ED and elevated scores on seven psychopathological symptoms, including hostility. Controlling for ED, CSC patients showed elevated alexithymia sum scores. Alexithymia was correlated with hostility. Our findings point to personality-based difficulties in emotional regulation associated with hostility in CSC.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Psychological stress associated with sympathetic arousal has long been discussed as an important risk factor contributing to the development of the rare eye condition known as central serous chorioretinopathy (CSC).1,2 As stress theory emphasizes, negative stress (or distress) derives from a negative relationship between environment and personality.3 However, the relevance of specific environmental factors, such as critical life events, and personality-based factors, such as specific traits for the development of distress in CSC remains unclear.

Personality predispositions represent cognitive, affective, or behavioral tendencies on the part of a person that are relatively stable across time and context. Regarding CSC, we were particularly interested in personality traits that might predispose patients to be stressed. Previous studies have found traits such as a neuroticism,4 emotional instability and introversion,5,6 as well as Type A behavior7 in CSC patients. All these personality traits point to severe difficulties in emotional regulation. However, up to the present day, alexithymic personality features, which are thought to be of special importance in patients with psychosomatic diseases,8 have not been investigated in patients with CSC. Alexithymia, which means, literally, "no words for feelings," is characterized by an inability to identify and describe feelings, the absence of fantasies, and the utilization of an analytic cognitive style. There is broad evidence that alexithymia is closely related to personality traits such as neuroticism, emotional instability, and introversion,9 as well as to psychological states such as emotional distress, somatization,9,10 depression,9 anxiety,9 and hostility,11 because a limited capacity for adequate affective regulation is associated with emotional instability.12 As male gender is associated with an increased risk of developing CSC13 as well as an increased risk of being alexithymic,9 we would expect a certain overlap between both populations.

In this cross-sectional study, we aimed at investigating the following hypotheses, comparing CSC patients with an age- and gender-matched healthy-control group: Hypothesis 1 (H-1): The study group will show a significantly higher degree of emotional distress, as measured by the Symptom Checklist–90-R. H-2: In the course of 1 year preceding the onset of symptoms of CSC, the study group will show significantly more critical life events (CLE), as measured by the Munich, Germany, Event List. H-3: The study group will show a significantly higher degree of alexithymia, as measured by the TAS–20 sum score. H-4: In the study group, alexithymia, as measured by the TAS–20 sum score will be significantly related to general emotional distress, as well as to somatization (H-5), depression (H-6), anxiety (H-7), and hostility (H-8), as measured by the SCL-90–R.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Patients and Control Subjects
Between October 2003 and April 2006, we consecutively enrolled all patients presenting with the diagnosis of CSC at the department of ophthalmology, Bonn, Germany, University Hospital. All patients underwent a complete ophthalmological examination. CSC was defined as a localized neurosensory retinal detachment associated with a focal leak or leaks at the level of the retinal pigment epithelium confirmed by fluorescent angiography. The patients were asked to complete questionnaires within 6 weeks after the initial onset of symptoms. All participants gave their informed consent.

In all, 57 of 78 patients (73.1%) answered the questionnaires. There were no significant age (46.8 years versus 44.1 years; t=1.42; p=0.161) or gender (78.9% versus 91.7% men; {chi}2=1.38; p=0.239) differences between responders and nonresponders. Furthermore, there were no significant differences in the course of illness. Forty-four responders versus 14 nonresponders were having a first episode of CSC, whereas 13 versus 7 patients were suffering a relapse ({chi}2=0.89; p=0.345).

Because certain risk factors associated with CSC have been discussed in the literature, we carefully assessed potential risk factors such as regular intake of sympathomimetic medication,14 corticosteroid medication,15,16 antibiotic use,16 psychopharmacologic medication,15 pregnancy,16 hypertension,15,16 allergic respiratory disease,16 organ transplantation,17 and excessive alcohol use16 by means of medical records and a self-report questionnaire.

As far as somatic risk factors are concerned, no CSC patient had taken any antibiotic on a regular basis. One patient (1.8%) had taken sympathomimetic medication, two patients (3.5%) had been prescribed psychopharmacologic medication, and one patient (1.8%) reported regular intake of systemic corticosteroid medication.

Among the female patients, there had been one pregnancy in the 12 months preceding the onset of symptoms. Eighteen patients (31.6%) suffered from hypertension; nine of these patients took antihypertensive medication on a regular basis. Two patients (3.5%) suffered from allergic respiratory disease; no patient had undergone organ transplantation.

Regarding alcohol consumption, five patients (8.8%) reported daily use of up to 6 drinks of alcohol. Thirty-nine patients reported drinking alcohol casually, but not daily or in excessive doses.

Because we were interested in a better understanding of a possible role of alexithymic personality features in the development of CSC, we included only newly diagnosed patients with CSC who had no known somatic risk factors for the development of CSC. Consequently, a total of 26 patients with a relapse of CSC and/or any somatic risk factor were excluded. Thus, our final study sample consisted of 31 newly diagnosed patients with CSC without any (known) somatic risk factor.

In these 31 newly diagnosed patients, the mean time between onset of symptoms and our investigation was 4.9 weeks (standard deviation [SD]: 4.6 weeks); range: 1–12 weeks. The mean value for visual acuity (Snellen) was 0.57 (SD: 0.25; calculated in decimal numbers). Patients assessed the severity of CSC by a visual-analog scale ranging from 1: Not Severe to 4: Very Severe (mean: 2.4 [0.84]). With regard to symptoms, all patients presented with visual loss; 11 patients (35.5%) suffered from metamorphopsia; 5 patients (16.1%) suffered from micropsia.

As a control group, we used a group of 31 age- and gender-matched healthy volunteers. Our control subjects were drawn from a pool of 161 volunteers (75 men, 86 women), who were recruited by advertisements to take part in a psychological study in the period between March 2001 and April 2003. Only volunteers without any current psychiatric or organic illness were included. Matching took place on a concurrent basis, meaning that each time a new patient was enrolled, the best match was drawn from the pool of volunteers on the basis of gender and age. The colleague performing the matching procedure was blind to any hypotheses of our study as well as to the results of psychodiagnostic questionnaires. Sociodemographic characteristics of both groups are presented in Table 1.


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TABLE 1. Sociodemographic Characteristics, N(%)



There were no significant differences between groups on any of the sociodemographic variables.

Psychometric Instruments
In stress measurement, it is possible to distinguish between the assessment of the cognitive stress appraisal and the measurement of the emotional response to stress. We focused on the measurement of the emotional response to stress, which can be subsumed under the term "emotional distress."18 Emotional distress and psychopathology were assessed by the German version19 of the Symptom Checklist–90-R (SCL–90-R20). The SCL–90-R generates nine primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) as well as a Global Severity Index, indicating overall emotional distress.20 The SCL–90-R is a reliable measure and is reported to have adequate indices of concurrent criterion-oriented validity, as well as construct validity.

Life events in the 1-year period before the initial manifestation of CSC were assessed by the Münchener Ereignis Liste (MEL; Munich, Germany, Event List).21 Healthy-control subjects were asked about critical life events within the last year. The MEL consists of 53 items asking for specific critical life events in the following 10 categories: employment, partnership, family (children/relatives), friends/social activity, bereavement, health (personal), health (others), finances, housing, other. Because the MEL investigates a wide range of different life events, it can give an exact account of possible stressors.21

Alexithymia was measured dimensionally with the German version of the 20-Item Toronto Alexithymia Scale (TAS–20),22 which was originally developed by Bagby and colleagues.23 The German version of the TAS is a 20-item self-report instrument that has been demonstrated to have good internal consistency (Cronbach {alpha}=0.70 [sum value for alexithymia]) and good reliability, as well as construct and criterion validity to measure alexithymic characteristics. The TAS comprises the following subscales: F1: Difficulty in Identifying Feelings (e.g., "When I lose my composure, I often do not know whether I am sad, angry, or anxious."); F2: Difficulty in Describing Feelings (e.g., "It is difficult for me to find words for my feelings."); F3: Externally-Oriented, Analytic Thinking (e.g., "I do not like to talk with others about their feelings; I prefer talking about their daily activities.").

Statistical Analysis
Descriptive statistics were compiled for clinical and sociodemographic data as well as for psychometric tests. Analysis of covariance (ANCOVA), t-tests, and chi-square tests were used, depending on scale levels, to analyze group differences. Correlations within both groups were calculated according to Spearman. Results with p≤0.05 were regarded as significant. To account for cumulative alpha error, results of group comparisons without a priori hypotheses were Bonferroni-corrected.24,25 Because we performed approximately 15 explorative between-group comparisons, p<0.05/15 (0.0033) was regarded as significant.24 Spearman coefficients between 0.20 and 0.35 were evaluated as weak; coefficients between 0.36 and 0.55 as moderate.24


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
The results of the SCL–90-R on emotional distress and psychopathology are presented in Figure 1. Our first hypothesis (H-1) could be confirmed. Compared with healthy-control subjects, CSC patients showed elevated distress as measured by the Global Severity Index; in particular, the subscale levels for somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, and paranoid ideation were increased. There was only a weak correlation between patients’ assessment of the severity of the eye ailment and their emotional distress (r=0.28; p=0.126). There was no association between visual acuity and emotional distress (r =–0.07; p=0.715) or the time since onset of symptoms and emotional distress (r = –0.04; p=0.842).


Figure 1
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FIGURE 1.  Results of the Symptom Checklist (SCL 90–R; t-tests)

at = –4.31, p<0.0001.

bt = –4.20, p<0.0001.

ct = –4.60, p<0.0001.

dt = –3.52, p=0.001.

et = –4.21, p<0.0001.

ft = –3.60, p=0.001.

gt = –3.17, p=0.003.

ht = –2.68, p=0.011 (ns).

it = –3.31, p=0.002.

jt = –2.94, p=0.006 (ns).

All df: 60.


At least one critical life event in the previous year was experienced by 21 patients (67.7%). The mean number of critical life events in the study group was 1.9 (SD: 2.0), as compared with 2.3 (SD: 2.3) in the control group (t[60]=0.707; p=0.482), meaning that our second hypothesis (H-2) could not be confirmed. Table 2 reveals that the most common events were those concerning employment, partnership, friends, finances, and family. Categorization was made according to the MEL. There was only a weak correlation between the number of critical life events and distress as measured by the SCL 90–R (r=0.26; p=0.162) in the study group.


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TABLE 2. Frequency of Critical Life-Events (CLE) Within 1 Year, Categorized According to The Munich Event List



Finally, we analyzed the results of the TAS–20. Given that alexithymia scores can be biased because of depression, anxiety, and other psychopathological symptoms,9–11 we calculated a univariate analysis of covariance, controlling for psychopathology as measured by the Global Severity Index of the SCL 90–R. Results are presented in Figure 2.


Figure 2
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FIGURE 2.  Results of the Toronto Alexithymia Scale (TAS–20) ANCOVA (covariate: Global Severity Index)

F1 (Difficulty in Identifying Feelings) ANCOVA: Fgroup=3.32; p=0.073 (ns).

F2 (Difficulty in Describing Feelings) ANCOVA: Fgroup=5.04; p=0.029 (ns).

F3 (Externally-Oriented, Analytic Thinking) ANCOVA: Fgroup=7.01; p=0.010 (ns).

FSum ANCOVA: Fgroup=12.09; p=0.001.


Our third hypothesis (H-3) could be confirmed. The sum scale for alexithymia was significantly elevated in the study group, as compared with the control subjects (47.48 [SD: 8.7] versus 38.74 [SD: 6.7]). There was a weak negative correlation between visual acuity and alexithymia (r = –0.20; p=0.275). There was no association between the subjective assessment of the severity of illness and alexithymia (r=0.14; p=0.450) and between the time since the onset of symptoms and alexithymia (r = –0.18; p=0.108). Table 3 presents the correlations between the alexithymia sum score and the scales of the Symptom Checklist–90-R.


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TABLE 3. Spearman Correlation Coefficients Between TAS–20 (Toronto Alexithymia Scale) Sum Scores and The Symptom Checklist 90–R



In the control group, the alexithymia sum score showed significant moderate-sized correlations with emotional distress and the subscales obsessive-compulsive trait, depression, and psychoticism. In our study group, there was no relevant association between the alexithymia sum score, on the one hand, and general emotional distress, somatization, depression, and anxiety, on the other, meaning that Hypotheses 4–7 could not be confirmed. Interestingly, only our last hypothesis (H-8) proved to be true. The only significant association was shown between alexithymia and hostility (r=0.43; p=0.017).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
Our study is the first to investigate distress and alexithymia in a sample of newly-diagnosed patients without any confounding somatic risk factors for the development of central serous chorioretinopathy. Compared with a group of healthy-control subjects, we found evidence for increased emotional distress, which confirms results of previous studies.5,6,26 Moreover, our study group showed elevated scores on the subscales for somatization, depression, and hostility, which is in keeping with the only other study assessing psychopathology by use of the unabridged version of the SCL–90-R.5 Previous studies found convincing evidence for increased emotional distress in CSC also, as compared with other eye diseases, such as traumatic eye diseases6 and ocular histoplasmosis.26 An endocrine state of stress, as measured by endogenous hypercortisolism, was found in comparison to patients with unilateral retinal detachment.27

To improve our understanding of factors that might contribute to emotional distress in CSC patients, we investigated the importance of stressors and specific personality traits. As far as psychosocial stressors are concerned, about 68% of the newly-diagnosed patients, versus 71% of healthy-control subjects, reported at least one critical life event within the preceding 1-year period. Moreover, there was only a weak association between the number of critical life events and distress (r=0.26; p=0.162). Probably the most cited study investigating critical life events in CSC, inspiring further studies in this field, reported a critical life event in 91% of 33 patients almost immediately (average of 7 days) before the outbreak of illness.28 We think that the results of the previous study may have been seriously affected by selection bias, because CSC patients were not recruited consecutively. Moreover, in keeping with the findings of the majority of previous studies, we did not find differences between controls and CSC patients concerning the number of critical life-events preceding the onset of symptoms.6,29 According to the cognitive-transactional stress theory of Lazarus, stress develops when a certain situation is appraised by the individual as being taxing or exceeding his or her resources and endangering his or her well-being.3 This theory emphasizes that the subjective appraisal of a life-event as unpredictable or uncontrollable is crucial to generate stress. Thus, future studies in CSC patients should emphasize these cognitive processes and the subjective impact of critical life-events.

Recent stress theory points to the fact that it can be subsumed under the broader field of emotion research, because it largely deals with emotional responses to a negative individual/environmental relationship.3 Obviously, personality traits contributing to difficulties in emotional regulation can affect these responses unfavorably. The findings of our study point to difficulties in emotional regulation in patients with CSC. The Toronto Alexithymia Scale is a reliable measure that assesses personality characteristics associated with the identification and verbal communication of emotion. Because we controlled for the influence of emotional distress and because alexithymia scores were neither affected by the duration of CSC nor by the subjective assessment of illness severity, our data point to a stable personality trait, rather than a state-dependent phenomenon. In our study group, alexithymia is especially related to one important facet of general emotional distress as measured by the SCL 90–R: a tendency to feel anger in a vast amount of situations, which is subsumed under the term Hostility. Interestingly, in recent research hostility is seen as the critical component of Type A behavior,9 which is thought to contribute to the development of CSC,7 as well as the development of hypertension and coronary heart disease.30

To better understand the possible contribution of psychosocial factors to the development of CSC, it is important to understand its pathophysiology. There is broad evidence that CSC is often associated with increased sympathetic nervous system stimulation, either induced by medication14 or as a consequence of emotional distress associated with endocrine alterations such as elevated levels of cortisol27 or catecholamines.31 It is believed that vasomotor instability from sympathetic nervous stimulation due to an interaction of catecholamines and corticosteroids,2,32 with adrenergic receptors within the vascular bed of the choroid2 may induce local weaknesses in Bruch’s membrane, the transparent innermost layer of the choroid. Such weaknesses allow serous fluid to extravasate from the choriocapillaris under the macula. Fluid would then pool underneath the retinal pigment epithelium (RPE) cell layer, causing a serous retinal pigment epithelial detachment. Next, two different pathophysiologic mechanisms might affect RPE. First, RPE cells may undergo apoptosis after exposure to elevated levels of epinephrine, and fluid might leak into the subretinal space.33 Second, with stretching of the RPE cells, a mechanical breakdown of the blood–retinal barrier might occur, with leakage of fluid through the RPE cell junctions into the subretinal space.34

Given this pathophysiology, personality traits leading to psychological states associated with increased sympathetic arousal, such as general emotional distress and/or hostility, might contribute to the development of CSC. There is broad evidence that alexithymia is associated with an increased tonic sympathetic arousal as measured by psychophysiologic35–37 or endocrine measures.38 Moreover, alexithymia is an important risk factor for the development of hypertension,39 which is an important somatic risk factor for the development of CSC.15,16

In conclusion, our study identified alexithymia as a potential risk factor for the development of CSC. Because there are relatively few therapy options regarding acute CSC,2,34 and there are no treatments preventing patients from a relapse,2,34 we suggest enhancing research concerning a possible positive effect of psychotherapeutic techniques to reduce sympathetic arousal in affected individuals. Autogenic relaxation techniques35 or a modified form of expressive writing40 might prove to be economical therapy options, which could reduce sympathetic arousal even in CSC patients with difficulties in emotional regulation.

Obviously, our study has certain limitations. First, we investigated only a relatively small number of patients (N=31), which facilitates only the detection of large group differences. Second, there should be caution about causality in a cross-sectional study design. A possible involvement of personality-based difficulties in emotional regulation in the development of CSC needs to be confirmed in further studies.


  ACKNOWLEDGMENTS

 
We are very grateful to Ms. N. Stifanus, Ms. D. Kohla, and Ms. G. Trivelli for their help in data collection and their technical assistance.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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