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Psychosomatics 49:317-325, July-August
doi: 10.1176/appi.psy.49.4.317
© 2008 Academy of Psychosomatic Medicine
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Alexithymia and Childhood Abuse Among Patients Attending Primary and Psychiatric Care: Results of the RADEP Study

Matti Joukamaa, M.D., Ph.D., Sinikka Luutonen, M.D., Ph.D., Heinrich von Reventlow, Dipl.-Psych, M.A., Paul Patterson, Hasse Karlsson, M.D., Ph.D., M.A., and Raimo K.R. Salokangas, M.D., Ph.D., M.Sc.

Received September 11, 2006; revised January 5, 2007; accepted January 11, 2007. From the University of Tampere, Tampere School of Public Health; Tampere University Hospital, Psychiatric Department; Department of Psychiatry, University of Turku, Turku, Finland; Psychiatric Clinic, Turku University Central Hospital, Turku, Finland; Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany; School of Psychology, University of Birmingham, Birmingham, UK; Department of Psychiatry, University of Helsinki, Helsinki, Finland; Turku Psychiatric Clinic, Turku, Finland. Send correspondence and reprint requests to Dr. Matti Joukamaa, Tampere School of Public Health, University of Tampere, FIN-33014., e-mail: matti.joukamaa{at}uta.fi
©2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
BACKGROUND: Some authors have suggested that the background of alexithymia is related to affective development during early childhood. OBJECTIVE: Authors studied the associations between alexithymia and childhood emotional neglect and sexual and physical abuse, also taking into account the significance of concomitant psychopathology. METHOD: Associations between childhood difficulties and adulthood alexithymia were studied with samples of primary-care (N=1,033) and mental-health center (N=243) outpatients assessed by The Toronto Alexithymia Scale and questionnaires for depressive, manic, and psychotic symptoms, and childhood difficulties. RESULTS: No association between alexithymia and childhood abuse was found in mental-health center patients. Among primary-care patients, alexithymia total score and difficulty in identifying feelings and difficulty in describing feelings were associated with childhood emotional, sexual, and physical abuse. CONCLUSION: After controlling for psychopathology, there still remained an association with difficulty in identifying feelings and most abuse and neglect variables. These findings serve to strengthen the theory of alexithymia as a developmental process starting in childhood.

Key Words: Alexithymia • Childhood Abuse • Primary Care

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Although the concept of alexithymia has been an object of lively scientific interest during the past 30 years,1 there are still many open questions about it. The etiology of alexithymia is not known, although many theories have been proposed.2–8 Some authors have suggested that the background of alexithymia is related to affective development during early childhood.9,10 There are various studies on alexithymia and childhood adversity showing alexithymia to be associated with disturbed family functioning and maternal alexithymia,11 diminished family expressiveness in childhood,12,13 feeling emotionally unsafe during childhood,12 and poor maternal care.14,15

In recent years, some studies have addressed the relationship between alexithymia in adulthood and various forms of abuse in childhood. Berenbaum16 found an association between childhood abuse, alexithymia (especially with difficulties in identifying feelings), and personality disorder among patients receiving outpatient psychotherapy. The information on childhood abuse history was gathered from the therapists. Using the Beck Depression Inventory, Berenbaum was also able to show that the association of difficulties in identifying feelings and abuse was not an artifact of depression. Cloitre et al.17 found that women who were sexually abused in both childhood and adulthood were more likely to be alexithymic than women sexually abused only in adulthood and women who were never abused. Murthi and Espelage18 tested a new scale to measure childhood sexual abuse-related loss (perceived loss of optimism, loss of self, and loss of childhood) in a sample of 116 college-age women and found alexithymia and depression to be moderately associated with "loss of self" (feeling lost and helpless). In a recent study with 588 female university students,19 it was found that childhood emotional abuse was associated with alexithymia, and, in another study, with 186 male undergraduates,20 that alexithymia and physical neglect in childhood were associated.

In addition to the findings from the above-mentioned studies, however, opposite results have also been reported. Zlotnick et al.21 did not find any relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation; no significant correlation was found between alexithymia and sexual abuse among 103 female psychiatric inpatients. In a recent study with 223 young-adult nonpatients,22 it was proposed that different types of traumatic experiences in childhood would lead to different kinds of mental pathology on adulthood. Alexithymia was associated with domestic violence, but no association was found between alexithymia and sexual abuse in childhood. Paivio and McCulloch,23 in a study with female undergraduate students, did not find an association between alexithymia and childhood sexual abuse. Similarly, in a study by Kooiman et al.24 with 148 consecutive psychiatric outpatients, no association was found between alexithymia and childhood sexual or physical abuse. In a study with 106 patients suffering from major depressive disorder, Honkalampi et al.25 showed an association of stable (persistent) alexithymia with harsh discipline and unhappiness in the childhood home.

The results concerning associations between alexithymia and childhood adversity seem so far to be inconsistent. There may be many reasons for this; there have been various methods for assessing childhood abuse; the samples in some cases have been populations drawn from psychiatric patients or even women abused in childhood. Still, one reason may be the effect of various mental disorders among subjects also suffering from alexithymia. Honkalampi et al.25 noted that the association of alexithymia and adverse childhood experiences is ambiguous in depression patients because an association also exists between adverse childhood experiences and depression in adulthood. In the present study, we wanted to study the associations between alexithymia and childhood emotional neglect, sexual abuse, and physical abuse, also taking into account the significance of concomitant psychopathology.


  MATERIALS AND METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHOD
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Materials
This study is a part of the larger Raisio Depression (RADEP) Study, dealing with patients attending three health centers (primary care [PC]) and three community mental health centers (psychiatric outpatient care [MH]) in southwestern Finland. Both sets of services had identical catchment areas. All study subjects gave written informed consent. The study protocol was approved by the local ethical committee of the University of Turku and the Turku University Central Hospital.

The PC sample comprises consecutive 18+-year-old patients visiting a physician in three health centers, and the MH sample, consecutive 18+-year-old patients visiting a physician (psychiatrist), psychologist, psychiatric nurse, or social worker in three community mental health centers in the spring of 2003 and 2004. At both points in time, the aim was to collect patients until 100 depressive patients for both the PC and the MH sample were found. Collection of study participants lasted about 3 months each spring.

In Spring 2003, a total of 1,075 PC patients and 260 MH patients were invited; of these, 565 PC patients and 163 MH patients participated. In Spring 2004, the corresponding figures (invited/participated) were 1,628 (PC) and 160 (MH) and 785 (PC) and 120 (MH). In all, 1,358 (50.2%) PC patients and 283 (67.4%) MH patients participated. In 2005, 1–2 years after the baseline study, a mailed questionnaire was sent to 1,033 PC and 243 MH patients. Because of a mistake in the mailing process, one set of questionnaires (N=79 cases) was not mailed. Of the PC patients, 67.4% (696) and, of the MH patients, 66.3% (161) returned the questionnaire with the alexithymia measure adequately filled in. They formed the sample of the present study. In the PC sample (age range: 18–86 years; mean: 50.0 years, standard deviation [SD]: 16.0); 29.2% of the subjects were men. For men, the age range was 19–86 years; mean: 53.4 (19.1) years, and for women, 18–84 years; mean: 48.6 (16.1) years, respectively. In the MH sample (age range: 19–71 years, mean: 44.5 (11.4) years; 30.4% were men. The age range and mean (SD) for men was 20–63, 44.9 (10.8), and, for women, 19–71; 44.4 (11.7) years, respectively. When compared with the original sample, men were underrepresented in the present study; no difference was found in mean ages.

Method
In the baseline study, the participants filled in a questionnaire consisting of basic sociodemographic data and of three lists of symptoms. Depressive symptoms were measured with the Depression Scale (DEPS).26 The DEPS includes 10 items and 4 responding alternatives scored 0–3: Not at All, A Little, Quite a Lot, Extremely. The cutoff point for actual depression was an item sum score >8. In a cross-validation study of patients attending primary and psychiatric care, the sensitivity and specificity of the DEPS has been shown to be reasonably good.26 Lifetime manic symptoms were measured by the Mood Disorder Questionnaire (MDQ). This includes 13 questions on the occurrence of manic symptoms. In a sample of psychiatric outpatients, it has proved to be reliable for recognizing bipolar disorders.27 The cutoff point for probable manic disorder, according to the developers of the scale, is >6 symptoms. Lifetime psychotic symptoms were measured with 22 questions (Yes/No) from the Core Psychosis section (G1, G2, G2B, G3-G13, G13B, G14, G17, G18 + G19, G20, G20C, G21, G22) of the Composite International Diagnostic Interview, (CIDI).28 The cutoff was >2 symptoms.

The Trauma and Distress Scale (TADS)29 was developed on the European Prediction of Psychosis (EPOS) Project. The TADS questionnaire includes 46 items of positive and negative experiences, with five responding alternatives, scoring 0–4: (Never, Rarely, Sometimes, Often, Nearly Always). Most of the questions relate to childhood and adolescence. Various items concerning sexual and physical abuse and emotional neglect are included. Because the TADS has not yet been validated, we performed a factor analysis. In a varimax-rotation solution, three major dimensions emerged: sexual abuse (6 items), physical abuse (4 items), and emotional neglect (6 items). Four items dealing with physical abuse, six items dealing with sexual abuse, and six items on emotional neglect are shown in Table 1. The items of the different dimensions were dichotomized (0/1–4). The sum of the dichotomized items is the global indicator, respectively, of sexual abuse, physical abuse, and emotional neglect. For the analyses, these global indicators were also dichotomized as 0 versus >0.


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TABLE 1. Association of Alexithymia Score With All Items of the Physical and Sexual Abuse and Emotional Neglect Scales Among Primary-Care Patients, After Adjusting for Psychopathology



The 20-item version of the Toronto Alexithymia Scale (TAS–20) was used as the measure of alexithymia. Of the various methods for measuring alexithymia, the TAS–20 is the most widely used and presumably the most carefully and thoroughly validated alexithymia measure.30–33 Its internal consistency, test–retest reliability, convergent, discriminant, and concurrent validity have been demonstrated to be good.30–33 The psychometric properties of the Finnish version of the TAS–20 have also been shown to be satisfactory.34 The items are rated on a 5-point scale, ranging from Strongly Disagree to Strongly Agree. The TAS–20 total score correlates negatively with various measures of psychological-mindedness and awareness of one’s own affects.35,36 According to the recommendation of the developers of the scale, the cutpoint for alexithymia was also used: Subjects with a TAS–20 total score >60 are defined as alexithymic.35 The TAS–20 has a three-factor structure; TAS Factor 1 assesses difficulty in identifying feelings (DIF); TAS Factor 2 is concerned with difficulty in describing feelings (DDF); and TAS Factor 3 reflects externally-oriented thinking (EOT).

Statistical Analysis
We performed a confirmatory factor analysis (maximum-likelihood estimation, with an oblique method) to assess the psychometric properties of the TAS–20. According to the method of Taylor et al.,33 the following criteria were used for evaluating goodness of fit: chi-square goodness-of-fit (a nonsignificant chi score), goodness-of-fit index (GFI; score ≥0.85), adjusted goodness-of-fit index (AGFI; score ≥0.80); root mean-square residual (RMS; score ≤0.10); and Steiger’s root mean-square error of approximation (RMSEA; score ≤0.08). The ratio of the chi-square to its degrees of freedom ({chi}2/df ratio) was also used. A value <5, and, preferably, <2, being the criterion for validity. GFI was 0.89 in the PC sample and 0.83 in the MH sample; AGFI: 0.86 in the PC sample and 0.79 in the MH sample; RMS: 0.07 and 0.08; RMSEA: 0.08 and 0.08, respectively. The chi-square score was significant in both groups, which is quite common in the case of large samples. Other reported goodness-of-fit scores have been at a similar level in many other studies with the TAS–20 in different languages and cultures.33

Differences between categorical variables (Table 1) were tested with the chi-square test. Associations between childhood abuse/neglect (dichotomized 0/1–4), and TAS scores were analyzed with general linear models (GLM), where continuous alexithymia variables (TAS–20 total score, DIF, DDF, EOT) were dependent, and the dichotomized abuse/neglect variables were independent variables. In the final model (Table 3), the effects of the three psychopathology measures (the dichotomized DEPS, CIDI, and MDQ variables) were taken into account. Because of multiple comparisons, the level for significance was set at p<0.01.


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TABLE 3. Associations of TAS Variables With Physical and Sexual Abuse and Emotional Neglect Sum Scores According to General Linear-Model Analyses




  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHOD
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
In the PC-patients sample, the prevalence of alexithymia was 17.7% in men and 8.9% in women (p=0.0009). In the MH-patients sample, 44.9% of men and 29.5% of women were alexithymic; the gender difference was not significant (Table 2). In the PC patients, a gender difference was also found in TAS total score and DDF; for the MH patients, the only significant gender difference was in EOT, with men scoring higher than women (Table 2). MH patients were significantly more commonly alexithymic than PC patients when analyzed together and for genders separately. The means of TAS total score, DIF, and DDF were also significantly higher among MH than PC patients.


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TABLE 2. Proportions of Alexithymic, Manic, Psychotic, and Depressive Features in Primary Health Care and Psychiatric Outpatient Care Patients



Table 2 shows the proportions of MDQ-, CIDI-, and DEPS-positives in both groups, all higher in MH than PC patients. No gender difference was found in these variables. Gender differences were seen among PC patients in four items of sexual abuse and in one item of physical abuse, but in only one item of sexual abuse and in two items of emotional neglect in MH patients.

Among PC patients, all measures were, in separate analyses, associated with all continuous alexithymia variables except EOT in both genders and physical abuse and DDF among women.

For DIF, all these associations remained significant (Table 3) after controlling for the psychopathology measures in women and sexual and physical abuse in men. Sexual abuse remained associated with TAS total score and DDF in women, and physical abuse with TAS total score in men. Among MH patients, no significant associations were found.

Among PC patients, the associations of various abuse item variables with the alexithymia measures were also analyzed after adjusting for the psychopathology measures (Table 3). Among women, DIF was associated with all items of sexual abuse, with five of six of emotional neglect and with two of four items of physical abuse. Among men, it was associated with three items of the emotional neglect and one of sexual abuse scales. TAS total score was associated with two items among women, DDF with three items among women and one among men, and EOT with two items among women.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHOD
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
The main finding of the present study was that alexithymia was associated with various aspects of childhood abuse and neglect among primary-care (PC) patients. When the effect of psychopathology was controlled for, there still remained an association of physical abuse and alexithymia in men and an association of alexithymia and abuse among female patients. The associations were still clearer in the alexithymia component DIF, or Difficulty Identifying Feelings. As far as the present authors know, this was the first study showing this association, taking comprehensive account of the effects of concomitant psychopathology. Another interesting finding was that among patients in specialized psychiatric outpatient care, hardly any associations between alexithymia and childhood adversities were found when controlling for the effect of psychopathology.

Among general adult, working-age populations, the prevalence of alexithymia has varied between 9% and 17% in men and 5% and 10% in women.37–40 Among MH patients, alexithymia was much more common. This was expected, because alexithymia has associations with various psychiatric disorders.41 Among PC patients, the difference from general populations was not marked. A similar gender difference in alexithymia as in population samples was found in both patient groups. Different kinds of childhood difficulties were quite common in both patient groups. This finding concurs with earlier studies in Finland42,43 and in other countries.43

In separate analyses, different alexithymia variables were associated with most sum scores of childhood adversities among PC patients. This is not surprising because psychopathology may be a mediating (intervening) variable, and this finding concurs with the results of earlier studies.16–18 What is interesting is that this association remained after adjusting for psychopathology in many variables. When the TAS factors were analyzed separately, we found that the associations were most clear in the case of DIF (difficulties in identifying feelings). Almost all items of the three abuse categories were significantly associated with DIF, especially among female PC patients. This concurs with the findings of Berenbaum,16 who, in a study with psychiatric outpatients receiving psychotherapy, found that DIF was associated with childhood abuse.

An interesting finding was that no clear association emerged between alexithymia and childhood adversities in MH patients. Unfortunately, we were not able to analyze the psychiatric diagnoses of all the patients because the main topic of the project was depression, and, therefore, only the depression screening-positive patients were assessed by a psychiatric interview. One can, however, assume that in the MH patients, the mental problems are more frequent and more severe, and that these patients have more predisposing factors for their symptoms than the PC patients. Therefore, the role of childhood abuse, although it is rather frequent, is not as prominent in the MH patients as in PC patients. One reason may be that the mental disorders are different in these two samples, but it was not possible to address this possibility. In the MH sample, patients’ overt psychopathology may mask alexithymic features and thus diminish the statistical associations with childhood experiences. In a way, the results of Zlotnick et al.21 are similar: among female psychiatric inpatients, no association was found between alexithymia and abuse.

In PC patients, the association of alexithymia with childhood abuse was independent of psychopathology. There may be different reasons for this. Several studies have found that alexithymia is associated with emotional trauma either in childhood or also later in life.41 It is possible that this "independence" is at least partly due to posttraumatic stress disorders among PC patients. Trauma could lead to alexithymia by disrupting the way the individual processes and reflects on emotion. On the other hand, alexithymia is also associated with somatization,41 a common problem in primary care patients apart from the psychopathology measured in our study. It is also possible that alexithymia masks the overt psychopathology.

What do our results imply? Several authors have found that the development of alexithymia is associated with various emotional problems in childhood. It would be important to know how the personality traits and being a victim of neglect and/or abuse during childhood are causally linked. It is possible that the trauma (abuse, neglect) may enhance the development of alexithymic features by disrupting normal emotion. On the other hand, some personality trait or behavior related to alexithymia already present in childhood may add to the risk of being abused or neglected. Such a question cannot be answered in a study with this kind of retrospective setting, but is an interesting topic for future study. Our results support these findings and, in one way, strengthen the theory of Kauhanen,44 that alexithymia may be "an accumulative process starting in early childhood and developing and reinforcing itself in a social context."

When assessing the meaning of these results, the limitations of the present study must be kept in mind. All assessments of psychopathology and adverse experiences were based on information obtained by questionnaire. Alexithymia was also assessed by questionnaire. The method used, the TAS–20, is the first alexithymia measure validated according to modern psychometric principles,30–32 and it has been widely used in various language versions in numerous countries.33 The developers of the TAS–20 scale have recently constructed a new assessment, the Toronto Structured Interview for Alexithymia.45 Studies with this interview are warranted to confirm these results. Another limitation is that the assessments of alexithymia and adverse childhood experiences were made 1–2 years after the data on psychopathology were gathered. On the other hand, we can assume that the possible effect of concurrent psychopathology on recall was small because patients were asked about their adverse experiences later than about mental symptoms. Concerning alexithymia, we do not find this problematic, since alexithymia is a stable personality trait. When asking adult subjects about childhood events, there is always a risk of recall bias. Especially when the age range of the subjects is wide, as in the present study, the recall bias may vary with age; young patients may recall their childhood experiences better than older patients. It is also possible that alexithymic features have an impact on the way a subject remembers and interprets events that happened in childhood. This, of course, is a problem in studies of this type; on the other hand, we do not consider it ethical to ask such questions of children.

The strength of the present study was its large sample size. Because the sampling was focused on consecutive patients, it can be assumed that they represent psychiatric outpatients in Finland, both in primary care and in specialized psychiatric treatment. This was possibly the first study dealing with alexithymia and childhood adversities where it was possible to control for the effect of psychopathology that is associated with both phenomena studied.25


  CONCLUSION

 
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
In PC patients, alexithymia is roughly as common as in the general population, but in MH patients, it is more common. In primary-care, but not in psychiatric patients, alexithymia, and especially its dimension of difficulty in identifying feelings, is significantly associated with childhood neglect and abuse, even when patients’ psychopathology is taken into account. These findings strengthen the theory of alexithymia as a developmental process that begins in childhood.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHOD
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Taylor GJ, Bagby RM: New trends in alexithymia research. Psychother Psychom 2004; 73:68–77
  2. Borens R, Gross-Schulte E, Jaensch V, et al: Is "alexithymia" a social phenomenon? an empirical investigation in psychosomatic patients. Psychother Psychosom 1977; 28:193–198[Medline]
  3. Freyberger H: Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychother Psychosom 1977; 28:337–343[Medline]
  4. Heiberg AN, Heiberg A: A possible genetic contribution to the alexithymia trait. Psychother Psychosom 1978; 30:205–210[Medline]
  5. TenHouten WD, Walter DO, Hoppe KD, et al: Alexithymia and split brain, V: EEG alpha-band interhemispheric coherence analysis. Psychother Psychosom 1987; 47:1–10[Medline]
  6. Kirmayer LJ: Languages of suffering and healing: alexithymia as a social and cultural process. Transcult Psychiatr Res Rev 1987; 24:119–136[CrossRef]
  7. Zeitlin SB, Lane RD, O’Leary DS, et al: Interhemispheric transfer deficit and alexithymia. Am J Psychiatry 1990; 147:955–956[Medline]
  8. Taylor GJ, Bagby RM, Parker JDA: The alexithymia construct: a potential paradigm for psychosomatic medicine. Psychosomatics 1991; 32:153–164[Abstract/Free Full Text]
  9. McDougall J: Alexithymia: a psychoanalytic viewpoint. Psychother Psychosom 1982; 38:81–90[Medline]
  10. Taylor GJ: Recent developments in alexithymia theory and research. Can J Psychiatry 2000; 45:134–142[Medline]
  11. Lumley MA, Mader C, Gramzow J, et al: Family factors related to alexithymia characteristics. Psychosom Med 1996; 58:211–216[Abstract/Free Full Text]
  12. Berenbaum H, James T: Correlates and retrospectively reported antecedents of alexithymia. Psychosom Med 1994; 56:353–359[Abstract/Free Full Text]
  13. Kench S, Irwin HJ: Alexithymia and childhood family environment. J Clin Psychol 2000; 56:737–745[CrossRef][Medline]
  14. Fukunishi I, Kawamura T, Ago Y, et al: Mothers’ low care in the development of alexithymia: a preliminary study in Japanese college students. Psychol Rep 1997; 80:143–146[Medline]
  15. Fukunishi I, Sei H, Morita Y, et al: Sympathetic activity in alexithymics with mother’s low care. J Psychosom Res 1999; 46:579–589[CrossRef][Medline]
  16. Berenbaum H: Childhood abuse, alexithymia, and personality disorder. J Psychosom Res 1996; 41:585–595[CrossRef][Medline]
  17. Cloitre M, Scarvalone P, Difede JA: Posttraumatic stress disorder, self- and interpersonal dysfunction among sexually retraumatized women. J Trauma Stress 1997; 10:437–452[CrossRef][Medline]
  18. Murthi M, Espelage DL: Childhood sexual abuse, social support, and psychological outcomes: a loss framework. Child Abuse Negl 2005; 29:1215–1231[CrossRef][Medline]
  19. Hund AR, Espelage DL: Childhood emotional abuse and disordered eating among undergraduate females: mediating influence of alexithymia and distress. Child Abuse Negl 2006; 30:393–407[CrossRef][Medline]
  20. Mitchell KS, Mazzeo SE: Mediators of the association between abuse and disordered eating in undergraduate men. Eat Behav 2005; 6:318–327[CrossRef][Medline]
  21. Zlotnick C, Shea MT, Pearlstein T, et al: The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Compr Psychiatry 1996; 37:12–16[CrossRef][Medline]
  22. Modestin J, Furrer R, Malti T: Different traumatic experiences are associated with different pathologies. Psychiatr Q: 2005; 76:19–32[CrossRef][Medline]
  23. Paivio SC, McCulloch CR: Alexithymia as a mediator between childhood trauma and self-injurious behaviors. Child Abuse Negl 2004; 28:39–54
  24. Kooiman CG, van Rees Vellinga S, Spinhoven P, et al: Childhood adversities as risk factors for alexithymia and other aspects of affect dysregulation in adulthood. Psychother Psychosom 2004; 73:107–116[CrossRef][Medline]
  25. Honkalampi K, Koivumaa-Honkanen H, Antikainen R, et al: 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. Psychosomatics 2004; 45:197–204[Abstract/Free Full Text]
  26. Salokangas RKR, Poutanen O, Stengård E: Screening for depression in primary care. development and validation of The Depression Scale, a screening instrument for depression. Acta Psychiatr Scand 1995; 92:10–16[Medline]
  27. Hirschfeld RMA, Williams JBW, Spizer RL, et al: Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatry 2000;157:1873-1875
  28. World Health Organisation: Composite International Diagnostic Interview (CIDI), Version 1.0. World Health Organization, Geneva, Switzerland, 1990
  29. Patterson P, Skeate A, Schultze-Lutter F, et al: Trauma and Distress Scale (TADS), 1.2. University of Birmingham, Birmingham, UK, 2002
  30. Bagby RM, Parker JDA, Taylor GJ: The 20-item Toronto Alexithymia Scale, I: item selection and cross-validation of the factor structure. J Psychosom Res 1994; 38:23–32[CrossRef][Medline]
  31. Bagby RM, Taylor GJ, Parker JDA: The 20-item Toronto Alexithymia Scale, II: convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38:33–40[CrossRef][Medline]
  32. Parker JDA, Taylor GJ, Bagby RM: The 20-item Toronto Alexithymia Scale, III: reliability and factorial validity in a community population. J Psychosom Res 2003; 55:269–275[CrossRef][Medline]
  33. Taylor GJ, Bagby RM, Parker JD: The 20-item Toronto Alexithymia Scale, IV: reliability and factorial validity in different languages and cultures. J Psychosom Res 2003; 55:277–283[CrossRef][Medline]
  34. Joukamaa M, Miettunen J, Kokkonen P, et al: The Finnish version of the 20-item Toronto Alexithymia Scale. Nord J Psychiatr 2001; 55:123–127[Medline]
  35. Bagby M, Taylor G: Construct validation, in Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Edited by Taylor GJ, Bagby RM, Parker JDA. Cambridge, UK, Cambridge University Press, 1997, pp 46-66
  36. Taylor GJ, Parker JDA, Bagby RM: Relationships between alexithymia and related constructs, in The (Non)Expression of Emotions in Health and Disease. Edited by Vingerhoets A, van Bussel F, Boelhouwer J. Tilburg, The Netherlands, Tilburg University Press, 1997, pp 103-113
  37. Salminen J, Saarijärvi S, Äärelä E, et al: Prevalence of alexithymia and its associations with sociodemographic variables in the general population of Finland. J Psychosom Res 1999; 46:75–82[CrossRef][Medline]
  38. 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]
  39. Kokkonen P, Karvonen J, Veijola J, et al: Prevalence and sociodemographic correlates of alexithymia in a population sample of young adults. Compr Psychiatry 2001; 42:471–476[CrossRef][Medline]
  40. Mattila AK, Salminen JK, Nummi T, et al: Age is strongly associated with alexithymia in the general population. J Psychosom Res 2006; 61:629–635[CrossRef][Medline]
  41. Taylor GJ, Bagby RM, Parker JDA (eds.): Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge, UK, Cambridge University Press, 1997
  42. Pirkola S, Isometsa E, Aro H, et al: Childhood adversities as risk factors for adult mental disorders: results from The Health 2000 Study. Soc Psychiatry and Psychiatr Epidemiol 2005; 40:769–777[CrossRef]
  43. Springer KW, Sheridan J, Kuo D, et al: The long-term health outcomes of childhood abuse: an overview and a call to action. J Gen Intern Med 2003; 18:864–870[CrossRef][Medline]
  44. Kauhanen J: Dealing with emotions and health: a population study of alexithymia in middle-aged men, in Kuopio University Publications, D: Medical Sciences, Vol 25. Kuopio, Finland, Kuopio University Printing Office, 1993
  45. Bagby RM, Taylor GJ, Parker JDA, et al: The development of The Toronto Structured Interview for Alexithymia: item selection, factor structure, reliability, and concurrent validity. Psychother Psychosom 2006; 75:25–39[CrossRef][Medline]




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