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Alexithymia and chronic diseases: The state of the art

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Giornale Italiano di Medicina del Lavoro ed Ergonomia
© PI-ME, Pavia 2011
http://gimle.fsm.it
Ilaria Baiardini1,2, Silvia Abbà2,3, Margherita Ballauri2,3, Giulia Vuillermoz2,3, Fulvio Braido1
Alexithymia and chronic diseases: the state of the art
1 Allergy & Respiratory Disease Clinic, Genoa University
2 Scuola di Psicoterapia Cognitiva, Centro Clinico Crocetta, Torino
3 Clinical psychologist
ABSTRACT. Background. Alexithymia is a disorder of the
regulatory mechanism of the emotion elaboration; it is
characterized by difficulties in differentiating and describing
feelings. Research indicates that alexithymia can be considered
as a possible risk factor for a variety of medical conditions as it
may increase susceptibility to disease development. The interest
in alexithymia has increased considerably over the past decade.
The present review was aimed at providing a state of the art of
recent research on alexithymia in patients with chronic diseases.
Methods. We reviewed most relevant papers on alexithymia and
its relationships with chronic diseases. Results. Numerous
investigations have been conducted in the fields of clinical
research, cognitive psychology, neurobiology, and psycho-neuro
endocrinology. Some researchers link alexithymia with insecure
parental attachment and adverse childhood experiences.
Alexithymia seems to be associated with different pathologies
and it seems to be an element of co-morbidity associated with an
increased risk of mortality. Moreover has been underlined the role
of alexithymia in influencing illness behaviours and as a
consequence it influences clinical and patients reported outcomes.
Conclusion. Several processes or mechanisms by which
alexithymia may influence health and illness have been explored.
Present research findings on alexithymia suggest important
implications for the management of chronic diseases.
Key words: alexithymia, chronic diseases, medical setting.
RIASSUNTO. ALESSITIMIA E PATOLOGIE CRONICHE:
LO STATO DELL’ARTE. Razionale. L’alessitimia è un disturbo
della regolazione affettiva caratterizzato dalla difficoltà di
riconoscere e descrivere le emozioni. La ricerca mostra come
l’alessitimia possa essere considerata un possibile fattore
di rischio per le patologie somatiche e possa aumentare la
suscettibilità allo sviluppo di malattie. L’interesse per
l’alessitimia è aumentato considerevolmente negli ultimi dieci
anni. Lo scopo del presente lavoro di revisione è quello
di fornire lo stato dell’arte della ricerca sull’alessitimia nei
pazienti con patologie croniche. Metodo. Sono stati rivisti
i lavori più rilevanti circa l’alessitimia e le sue relazioni con
le malattie croniche Risultati. Numerosi studi sull’alessitimia
sono stati condotti nel campo della ricerca clinica, della
psicologia cognitiva, della neurobiologia e della psico-neuro
endocrinologia. Alcuni ricercatori hanno associato l’alessitimia
ad uno stile di attaccamento insicuro e ad esperienze infantili
negative. L’alessitimia sembra associata con diverse patologie
e sembra costituire un elemento di comorbilità correlato ad un
aumento del rischio di mortalità. Inoltre è stato sottolineato
come l’alessitimia influenzi i comportamenti connessi alla
salute, con implicazioni per gli indicatori di risultato, sia clinici
che riferiti dal paziente. Conclusioni. Sono stati esplorati diversi
meccanismi e processi attraverso i quali l’alessitimia può
influenzare la salute e la malattia. Quanto emerso dalla
letteratura circa l’alessitimia suggerisce importanti implicazioni
per la gestione dei pazienti con patologie croniche.
Parole chiave: alessitimia, patologie croniche, setting medico.
Supplemento A, Psicologia
2011; Vol. 33, N. 1: A47-A52
ISSN 1592-7830
Introduction
The term alexithymia, literally meaning “absence of
words for emotions” (from the Greek “alexis”: no words
and “thymos ”: emotion), was coined by Sifneos in 1973
(1) to describe specific difficulty in identifying and ver-
bally expressing emotions. Interest in alexithymia has
increased considerably over the past decade, moving on
an interdisciplinary level with numerous investigations
in the fields of clinical research, cognitive psychology,
neurobiology, and psycho-neuro endocrinology (2).
From the first introduction of the term, the construct of
alexithymia has been evaluated, criticized and modified
(3, 4).
At present alexithymia is considered as a dimension-
al personality construct that encompasses a cluster of
cognitive and affective characteristics relating to: diffi-
culty in identifying feelings and distinguishing between
feelings and bodily sensations; difficulty in describing
feelings; constricted imaginative processes; and a stim-
ulus-bound, externally oriented cognitive style (4). Ad-
ditional characteristics associated with the alexithymia,
although not included in its definition, are a tendency
towards social conformity, and towards action to ex-
press emotion or to avoid conflicts, lack of dreams,
somewhat stiff wooden posture, paucity of facial emo-
tional expressions (4), less engagement in the psy-
chotherapeutic process (5), cold/distant and non-as-
sertive personality styles (6).
Some authors have differentiated between a primary
alexithymia which is developed very prematurely in the
first phases of life and a secondary alexithymia which
arises after a trauma or a severe pathology (7).
Although alexithymia has been introduced to explain
psychosomatic diseases, in recent years many resear-
ches have recognized its relationship also with psychi-
atric and organic pathologies, in particular in chronic
situations (8, 9), like one of several possible risk factors
to alter the general susceptibility to stress (2, 3, 10-12).
It has been observed that it seems to increase unhealthy
behaviours (13) and susceptibility to organic diseases
(14) notably immune-mediated disorders (15-17)
via physiological, behavioural, cognitive or social path-
ways (13).
A48
The prevalence of Alexithymia
Alexithymia is not an all-or-none phenomenon, but it
is considered as a personality trait normally distributed in
the general population, where the prevalence range is 10-
13% (18-20). Studies have evidenced higher levels of
alexithymia in people with somatic diseases (21-24) and
in patients suffering from psychiatric and psychological
disorders (25-29).
The influence of gender is not well established (30),
but most studies confirmed that men were more common-
ly alexithymic than women (31). A strong correlation of
alexithymia has been found with increasing age and its
negative association with the level of education and in-
come have been found (31).
The assessment of Alexithymia
The most common method to explore alexithymia in
clinical practice is the judgment based on the interaction
with the patient. Obviously, this approach has all the lim-
its of non standardized methods.
A critical review of Kooiman (32) listed various in-
struments used to measure alexithymia. Some of these are
structured interview: the Beth Israel Psychosomatic Ques-
tionnaire (BIQ) (33) the Alexithymia Provoked Response
Questionnaire (APRQ)(25, 34) and Karolinska Psychody-
namic Profile (KAPP) (35). The Scored Archetypal Test
(SAT9) (36) and the Rorschach, Levels of Emotional
Awareness Scale (LEAS) (37) are projective instruments.
The California Q-set (CAQ) (38) is a self-report tool that
can be filled in by the patient himself or by an observer,
while the Observer Alexithymia Scale (OAS) (39) must be
completed by a subject’s acquaintance or relative. The
Schalling-Sifneos Personality Scale (SSPS) (33), MMPI
alexithymia subscale (40), the Amsterdam Alexithymia
Scale (AAS) (41), the 20-item Toronto Alexithymia Scale-
20 (TAS-20) (42) and the Bermond-Vorst Alexithymia
Questionnaire (BVAQ) (43) are self-report scales to be
filled in by the patient himself. Moreover, an international
group of psychosomatic developed the Diagnostic Criteria
for Psychosomatic Research (DCPR) (44), which consists
of a structured interview and diagnostic criteria for a num-
ber of psychosomatic syndromes, including alexithymia.
Among these tools the TAS-20 (42) is certainly the most
frequently used scale to assess alexithymia (2, 3).
The first TAS version, composed by 41 items, has been
developed more or less in the middle of the 80s from the
Toronto’s group (42) and its version constituted by 20
items which was introduced in 1994. The Italian investi-
gators (45) have been one of the first to have it translated
into their own language and cross-validated the TAS-20,
which demonstrates reliability and factorial validity also
in various cultures and languages.
The questionnaire measures three factors congruent
with the alexithymia construct on a five-point Likert scale
to utter own agreement or disagreement with each state-
ment (five items are negatively keyed). The three factors
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol
http://gimle.fsm.it
are: difficulty in identifying feelings, difficulty in describ-
ing feelings and externally oriented thinking. Total scores
range from 20 to 100: a 61 and further score indicates the
presence of alexithymia; a 51 or less score suggests there
is no alexithymia; a score between 51 and 61 is considered
indeterminate alexithymia. The results were also ex-
pressed as three factorial scores.
Some criticisms have been moved against TAS-20: it is
difficult to replicate its factor structure and it is associated
with negative affectivity (32, 46); Lane et al. (47) ques-
tioned the ability of the questionnaire to detect the most
severe cases of alexithymia. Nevertheless TAS-20 remains
the most widely used measure of alexithymia. Since alex-
ithymia is marked by a deficit of self-reflexivity, and that
self-report measures precisely for self-reflection, it is ad-
visable to place TAS-20 side by side to other not self-re-
ported instruments (6, 48).
Etiopathogenesis
The aetiology of alexithymia seems include many fac-
tors, including genetic influence, neurobiologic deficits,
variation in brain organization. Neuroimaging studies on
healthy subjects suggested that alexithymic people have ab-
normal frontal function: reduction of regional cerebral
blood flow in both dorsal and ventral anterior cingulate (49-
50), during movie-induced emotions or projection of angry
faces (51) and in the right insular, frontal and parietal cor-
tices in response to angry and sad faces (51). However, it is
important to note that other studies support an association of
alexithymia with early traumatic experiences (52) or inse-
cure attachment with caregivers (53) Specifically, research
indicates that in alexithymic patients, it is typical to find a
type of avoidant attachment (54, 55). These patients, in fact,
tend to approach others in a non-empathic, cold and de-
tached way; they avoid relationships and if they do, they re-
late in an impersonal way. These results indicate that at-
tachment style may not be the primary cause of alexithymia,
but at least one risk nonspecific factor.
Association between Alexithymia and chronic diseases
A leading view of alexithymia is that it constitutes a
risk factor not only for psychiatric and behavioral problems
but also for the development, maintenance, or exacerbation
of medical or physical health problems that are influenced
by disordered affect regulation (4). Alexithymia has been
associated with an expanding range of somatic pathologies
such as inflammatory bowel disease (21), myocardial in-
farction (22), chronic respiratory diseases (23, 24, 56, 57),
dermatologic conditions (12), coeliac disease (58), neuro-
muscular disorders (11), diabetes (59).
Studies of the group of Kauhanen (14, 60) have shown
that alexithymia is an element of comorbidity and it is as-
sociated with twice the risk of mortality, and in particular
the risk of cardiovascular disease death was increased by
1.2% for each 1-point increase in Toronto Alexithymia
Scale (61).
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol
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Several possible alternative explanations for the re-
current finding that alexithymia is elevated in patients
with various health problems have been proposed (13,
62). For example, alexithymia is thought to avoid the suc-
cessful regulation of negative emotions, resulting in in-
creased negative affect, elevated resting sympathetic
arousal and immune impairments, which may contribute
to the development or exacerbation of somatic disease
and pain. Another hypothesis relates alexithymia to ill-
ness behavior, including patient’s ideas, affects, attitudes,
and behaviors in relation to illness and the sick role (62).
According to this hypothesis, alexithymia may lead to so-
matic diseases throughout behavioral, maladaptive strate-
gies and unhealthy actions. Alexithymia - by leading to
the failure to regulate affect - may prompt people to en-
gage in behaviors that are risky for health. For example,
high level of alexithymia are present in people with eat-
ing disorders (63-65), alcohol or drug abuse or depen-
dence (66-69), a sedentary lifestyle (70), and a greater
body mass index (69).
This disregulation, typical of alexithymia, interacting
with other aspects (from genetic to behavioural and to
psychological conditions), could represent a risk factor for
somatic diseases in general.
Several studies focused on the relationship between
alexithymia and somatic symptoms at four different lev-
els: the interaction with the physiological processes of ac-
tivation, somato-sensorial amplification, persistence of
physical symptoms and symptoms’ perception.
It was shown that the association of alexithymia with
an increased sympathetic activity (heart beat and acceler-
ated electrodermal activity and a lower oxygen consump-
tion) (71, 72). This stable hyperactivity of autonomic
functioning suggests that alexithymic subjects may have
the same physiological arousal observed under chronic
stress conditions, whereas distress remains emotionally
unreadable. The amplification of perceived somatic symp-
toms and the recognition of somatization disorder in pa-
tients with alexithymia were found in several studies: in
patients with chronic conditions, alexithymia was not re-
lated to the presence or severity of organic disease but to
perceived symptoms (73). The close association between
alexithymia and pain was detected in cancer patients. The
results of two studies of an Italian group (74, 75) suggest
that patients with cognitive difficulties in processing and
identifying feelings are more prone to experience higher
pain intensity and to describe pain sensations more dra-
matically. Moreover alexithymia has been shown to be
predictive of symptoms persistence within six months af-
ter treatment in patients with functional gastrointestinal
disorders (76) and the following year to surgical cholec-
tystectomy in patients with cholelithiasis (77).
Symptoms’ perception is a crucial factor for a correct
self-management of chronic diseases. Several studies
showed as alexithymia may be associated to difficulties in
perceiving symptoms. For example, in many episodes of
near fatal asthma (NFA), a surprising delay in seeking
medical assistance has been shown (78). Several authors
have suggested that, in certain patients, this could be re-
lated to a deficit in the perception of symptoms, such as
A49
dyspnoea, or to a lack of response to the hypoxaemia
and/or hypercapnia produced during a severe asthma ex-
acerbation (80-81).
Brown et al. (82) studied 270 asthmatics during a se-
vere attack, and, after adjusting for age, they observed that
alexithymic asthmatics gave significantly lower scores for
nine symptom/sign categories on the Asthma Symptom
Checklist scale. The authors interpreted these results as
evidence that alexithymic individuals underestimate both
physical and emotional components of asthma exacerba-
tions, independently of the prior severity of the disease. A
greater frequency of asthma-induced recurrent hospital-
ization was found in alexithymic patients (37.4 versus
28.4% over 6 months), suggesting that their difficulty in
expressing the intensity and frequency of symptoms could
lead physicians to underestimate asthma severity (83).
Clinical implications
Alexithymia was first described in people with classic
psychosomatic disorders and subsequent research has con-
firmed high levels of alexithymia in patients with organic
diseases. Moreover, an association between alexithymia
and dimensions that are relevant for health behaviors (i.e.
locus of control, coping strategies, attachment style) has
been found (84).
The growing evidence that this personality trait is not
specific to psychosomatic disorders has led to the view of
alexithymia as a risk factor for those medical conditions
that are influenced by disordered affect regulation (4).
Despite little has been written regarding the value of
evaluating alexithymia in medical settings, research find-
ings provide important clinical suggestions for physicians,
psychologists, nurses and therapists involved in care of
physically ill patients, as effectively underlined by several
Authors (24, 63, 66, 85).
• The links between alexithymia, immune function and
psychophysiologic activity, stress the importance of
considering the patient as a whole. In other words, the
awareness of the bidirectional (“topdown and bottom-
up”) interactions between mind/brain and body may be
particularly effective in treating the range of symptoms
associated with many chronic diseases. A global ap-
proach directed toward addressing functional links be-
tween mind/brain and body would be particularly
adapt in managing the range of symptoms associated
with many chronic diseases.
• The construct of alexithymia permits to better under-
stand the perspective of some patients suffering from
medical conditions. Traditionally, a lack of emotional
expression has been considered as the consequence of
active defenses strategies (avoidance, inhibition, de-
nial, or repression). This view leads to certain expecta-
tions about patients, their relationships with clinicians,
and optimal treatment management. In other words,
defensive or avoidant patients are viewed as owning
the capacity for emotional insight and expression if on-
ly they would overcome their defenses. The belief that
A50
a patient is defensive can lead to frustration because
the patient is viewed as holding back or not trusting the
caregiver. In contrast, the construct of alexithymia
constitutes an alternative way of considering these pa-
tients, - that the patient has an emotional limitation, or
confusion rather than active avoidance. Viewing the
patient as someone who has difficulty, who “cannot”
rather than “will not”, to identify, distinguish and ver-
bally express emotions may improve the clinician’s
empathy and permit alternative interventions to be ex-
plored.
• Knowing that a patient is alexithymic may also help
the clinician to better comprehend the patient’s symp-
toms. In fact, alexithymic patients tend not to adopt
nuances in describing and discriminating feelings.
They are more likely to express themselves in terms of
bodily symptoms, providing excessive details of their
health condition, behaviors, and daily events. Such
communication about one’s symptoms or practical de-
tails should be viewed as valid attempts to describe
personal experience, which likely is more somatic or
external than affective and psychological
• Unhealthy behaviors of alexithymic patients might be
explained, in part, as a personal, maladaptive strategy
to cope with an harmful, difficult to understand, state
of physical arousal. Feedback to the patient about the
specific role of affect regulation in causing these be-
haviors may constitute the first step in helping patients
to explore more adaptive strategies.
• Taking into account the specific difficulties of patients
with alexithymia, the professional caregiver, particu-
larly with these patients, should be able to provide con-
tinuity, have good inter-personal abilities, and be sen-
sitive to hidden messages, avoiding a judging attitude.
Although little research has been conducted on inter-
ventions for alexithymia, cognitive behavioral strategies
aimed at the patient’s awareness of their emotions have
been described (2). Some simple suggestions for a better
management of alexithymic patients may be adopted also
in a medical setting (63) (Table I). Identifying and facili-
tating the appropriate expression of feelings may represent
one of the main objectives of psychosocial interventions,
as suggested by the Adjuvant Psychological Therapy (86).
Further studies aimed at exploring the effects of inter-
ventions for alexithymia on physical and psychological
outcomes are needed.
Table I. Strategies for a better management
of alexithymia in medical settings
• explain to the patients that they tend to experience their
emotions as physical reactions rather than as feelings
• help patients to understand their lack of empathy
• help patients to overcome inhibitions in self-care
• encourage patients to identify, differentiate, monitor and
manage their emotions
• enable patients to acquire the vocabulary to express feelings
accurately and appropriately
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol
http://gimle.fsm.it
Acknowledgements
Authors thank ARMIA (Associazione Ricerca Malattie Immuno-
logiche e Allergiche) and ASPADIRES (Associazione Disturbi Respira-
tori nel Sonno). Authors acknowledge Dr Patricia Gennari and Dr Mari-
anna Bruzzone for linguistic assistance with the manuscript.
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Reprint request: Ilaria Baiardini, University of Genoa, Allergy & Respiratory Disease Clinic, Department of Internal Medicine, Pad.
Maragliano, Largo Rosanna Benzi 10, 16132 Genova, Italy, Tel: +390103538933, Fax: +390103538904, E-mail: ilaria.baiardini@libero.it
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