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R E P O R T

Alexithymia and Interpersonal Problems

Stijn Vanheule, Mattias Desmet, and Reitske Meganck

Ghent University

Stefan Bogaerts

Tilburg University

This study examines whether alexithymia relates to specific interpersonal problems, based on data collected in a sample of mental health outpatients (N 404) and a student sample (N 157). Linear regression analysis, in which the effects of group, gender, and age were controlled, indicated that two interpersonal problems were significantly and reliably related to alexithymia: cold/distant and nonassertive social functioning. The theoretical relevance of the results for attachment and psychoanalytic theory is indicated, as well as implications of the findings for clinical practice. © 2006 Wiley Periodicals, Inc. J Clin Psychol 63: 109­117, 2007. Keywords: alexithymia; interpersonal; intersubjective; attachment; psychoanalysis; psychotherapy

Introduction Alexithymia is a construct that stems from psychoanalytic thought; it literally means no words for emotions. The concept was introduced to distinguish disturbances with respect to affect regulation from classic psychoneurotic pathology, assuming that in both problems distinct mental processes are prominent (Nemiah & Sifneos, 1970; Taylor, Bagby, & Parker, 1997). The construct primarily refers to a cognitive and affective style marked by difficulties in verbally describing affect and in differentiating mental states from bodily sensations, paucity of fantasy, and utilitarian thinking (Nemiah & Sifneos, 1970; Sifneos, 1996). It was in the context of psychosomatic research that the alexithymia concept was first introduced, but its use clearly extends beyond the field of psychosomatics. Currently, the concept is used in research on diverse psychiatric disorders like depression (e.g., Saarijärvi, Salminen, & Toikka, 2006), substance-related disorders (e.g., Speranza et al.,

Correspondence concerning this article should be addressed to: Stijn Vanheule, Department of Psychoanalysis and Clinical Consulting, Ghent University, H. Dunantlaan 2, B-9000 Ghent, Belgium; e-mail: Stijn. [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 63(1), 109­117 (2007) © 2007 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20324

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2004), or posttraumatic stress disorder (e.g., Sondergaard & Theorell, 2004). Moreover, research on alexithymia is increasingly interdisciplinary, with both psychological research and studies of brain functioning (e.g., Berthoz et al., 2002), the inclusion of experimental (e.g., Coffey, Berenbaum, & Kerns, 2003) and treatment studies (e.g., Özsahin et al., 2003), in addition to classic cross-sectional and longitudinal studies (Taylor & Bagby, 2004). Recent research also has considered the validity of the concept and studied relationships with adjoining concepts such as aspects of personality disorders (Honkalampi et al., 2001) or depression (Saarijärvi et al., 2006). These studies indicate that alexithymia cannot be reduced to any of these concepts. Early on, Nemiah and Sifneos (1970) indicated that alexithymia is concomitant with a specific style of interpersonal relating. However, empirical research into this topic is limited and most knowledge on the specificity of alexithymic patients' interpersonal problems and their mode of interpersonal relating stems from clinical observation. Given the observation from psychotherapy research that the quality of the therapeutic relationship is strongly predictive of the outcome of therapy (Roth & Fonagy, 2006), and that clients' interpersonal problems interfere with the development of a therapeutic relationship (Saunders, 2001), we consider systematic knowledge about the style of interpersonal relating that is linked to alexithymia to be important. Psychotherapists, especially those who work from psychoanalytic or psychodynamic backgrounds, can take this knowledge into account as they consider or intervene in the transference or the therapeutic relationship while treating strongly alexithymic patients. From clinical observations of the interpersonal functioning of alexithymic patients (Grabe, Spitzer, & Freyberger, 2001; Nemiah & Sifneos, 1970; Taylor et al., 1997) and a few empirical studies (Guttman & Laporte, 2002; Vanheule, Desmet, Rosseel et al., in press; Weinryb et al., 1996), we know that alexithymic patients have a tendency toward social conformity and conflict avoidance, and they tend to approach others in an unempathic, cold, or detached way. These patients avoid close social relationships, and if they do relate to others, they tend to position themselves as either dependent or impersonal, such that the relationship remains superficial. Chaotic interpersonal relations have also been observed (Sifneos, 1996), as well as inadequate differentiation between self and other (Blaustein & Tuber, 1998; Taylor et al., 1997). In line with these observations, attachment research indicates that avoidant-dismissing attachment is most typical for this group of patients (Taylor, 2000; Verhaeghe, 2004), and that insecure attachment is manifested in relation to the therapist (Mallinckrodt, King, & Coble, 1998). Systematic research into this topic is scarce; moreover, published empirical studies often start from limited samples or take only one sample into account. In this article, we investigate whether alexithymia relates to specific interpersonal problems. We examine whether a detached and avoidant style of relating with others is typical of alexithymia, as clinical reports suggest. Specifically, we test the hypothesis that cold, distant, socially inhibited, and nonassertive interpersonal functioning are significantly related to alexithymia to the exclusion of other interpersonal problems. Method Samples Data were collected from a substantial clinical outpatient sample and a student sample. The clinical outpatient sample consisted of 404 adult patients (70.8% women) from 35 mental health care centers in the Flemish part of Belgium. Psychiatrists and psychologists from these centers presented our informational letter to their patients in which we

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briefly explained that we were studying mental health and interpersonal functioning, asking them to participate in the study by filling out questionnaires. The participants gave informed consent before filling out the questionnaires, completed the questionnaires individually, and subsequently returned them to us via the psychiatrists or psychologists. Participants ranged in age from 18 to 72 years (M 37.88, SD 10.63), 46.2% lived with a partner, and 44.2% had one or more children. With respect to the highest level of education obtained, 6.8% attended elementary school only, 20.8% completed a first cycle (3 years) in high school, 39.3% completed a second cycle (6 years) in high school, 25.8% obtained a nonacademic degree in higher education, and 7.3% an academic degree in higher education. Of all participants, 40.3% were employed, 22.4% were on sick leave from work, and 37.4% were unemployed. All patients were diagnosed as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) criteria by their treating psychiatrists. They met diagnostic criteria set forth in the DSM-IV on the following Axis I disorders: 44% mood disorders (23% recurrent major depressive disorder, 13% major depressive disorder single episode, 6% dysthymic disorder, 2% bipolar disorder); 19% anxiety disorders; 11% other conditions requiring clinical attention; 6% adjustment disorders; 4% somatoform disorders; 16% other disorders. Forty-seven percent received a diagnosis of Axis II disorders as well. Independent sample t tests indicated that patients with mood disorders had higher scores (TAS-20; Kooiman, Spinhoven, & Trijsburg, 2002) than did patients without mood disorders (t .2.32, df 364, p .02). Patients who had an Axis I diagnosis of other conditions requiring clinical attention had lower scores than patients without this diagnosis (t 2.85, df 364, p .01), and patients with a diagnosis of adjustment disorder also had lower TAS-20 scores than those without this diagnosis (t 2.38, df 364, p .02). For the other Axis I diagnoses and for the Axis II diagnoses, no significant differences could be observed between patients who had the diagnosis and those who did not. The student sample consisted of 157 university (psychology) students (84.7% women). Mean age was 20.73 years (SD 2.53). The students were contacted before a lecture. We explained to them that we were studying the relationship between mental health and interpersonal functioning, told them their information would be used as control data in relation to data from a clinical sample, and asked them to give informed consent. Subsequently they filled out the TAS-20 and the Inventory of Interpersonal Problems (IIP64; Horowitz, Alden, Wiggins, & Pincus, 2000; Vanheule, Desmet, & Rosseel, 2006) and returned the questionnaires to us.

Measures The Dutch translation of the 20-item Toronto Alexithymia Scale (TAS-20) was used to measure alexithymia (Kooiman, Spinhoven, & Trijsburg, 2002). Psychometric research indicates that the original English version (Bagby, Taylor, & Parker, 1994) as well as the Dutch translation (Kooiman et al., 2002) are valid (stability of factor-structure and good convergent validity) and reliable (good test-retest reliability and acceptable internal consistency). Factor-analytic studies demonstrated that the instrument consists of three dimensions that jointly indicate the degree of alexithymia: (a) difficulties in identifying feelings (seven items), which includes questions that, for example, ask for the degree to which people are sometimes puzzled by sensations in the body, or to what extent they have feelings they cannot quite identify; (b) difficulties in describing feelings (five items), which includes items that ask for the degree to which people find it difficult to reveal innermost feelings, or to what extent they find it difficult to find the right words for

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feelings; and (c) externally oriented thinking (eight items), which includes items that ask for the degree to which people are eager to look for hidden meanings in movies or plays, or to what extent they prefer to talk about daily activities rather than about feelings. Each item is scored on a 5-point Likert scale, with five items negatively keyed. Total scores range from 20 to 100, with higher scores indicating more pronounced alexithymia. In our clinical sample the mean TAS-20 score was 56.5 (SD 11.3). Thirty-eight percent of all patients had an alexithymia score 60, which, according to U.S. and Canadian norms (not validated for the Dutch translation), indicates severe alexithymia. In the student sample the mean TAS-20 score was 42.2 (SD 8.6) and 2% had an alexithymia score 60. Clinical and student participants differed significantly with respect to their mean TAS-20 score (t 14.20, df 558, p .01). Interpersonal problems were measured with the Dutch translation of the 64-item Inventory of Interpersonal Problems (IIP-64; Horowitz, Alden, Wiggins, & Pincus, 2000; Vanheule, Desmet, & Rosseel, 2006). The IIP-64 is a self-report questionnaire that inventories interpersonal problems. Its strength is that it simultaneously assesses multiple aspects of interpersonal malfunctioning. The instrument was first developed as a 127-item questionnaire, based on a list of common interpersonal difficulties raised by persons seeking psychotherapy. The 64-item version was created by Alden, Wiggins, and Pincus (1990) specifically to provide a circumplex measure. Their instrument contains 8 subscales that are correlated in the pattern of a circumplex. Each subscale consists of eight items that are scored on a 5-point Likert scale. The subscales are (a) Domineering/Controlling, which indicates difficulties in relinquishing control over others; (b) Vindictive/Self-Centered, which describes problems of hostile dominance and the tendency to fight with others; (c) Cold/Distant, which refers to low degrees of affection for and connection with others; (d) Socially Inhibited, which assesses the tendency to feel anxious and avoidant in the presence of others; (e) Non-Assertive, which measures problems in taking initiative in relation to others and coping with social challenges; (f ) Overly Accommodating, which indicates an excess of friendly submissiveness; (g) Self-Sacrificing, which indicates a tendency to affiliate excessively; and (h) Intrusive/Needy, which describes problems with friendly dominance (Horowitz, 2004; Horowitz et al., 2000). Psychometric research on the instrument in English-speaking communities (e.g., Horowitz et al., 2000; Tracey, Rounds, & Gurtman, 1996) as well as in Dutch-speaking populations (Vanheule et al., 2006) demonstrated the validity (stability of the circumplex structure and of correlations with convergent measures) and the reliability (good internal consistency and test-retest reliability) of the IIP-64. The clinical sample had significantly higher scores on all IIP-64 subscales than did the nonclinical sample.

Data Analysis Linear multiple regression analysis with the enter method was used for analyzing the data. The dependent variable was the total TAS-20 score and the IIP-64 subscales were the independent variables we focused upon. In this analysis, we also included three control variables. The first variable we controlled for was the type of sample. The data were collected from a clinical outpatient sample and a student sample. The clinical sample was included to make sure we obtained results that were relevant to understanding the mental functioning of clinical outpatients. The student sample is included in addition to the clinical one to make sure that the results of our analyses reflect alexithymia instead of severity of psychopathology in outpatients, which could have been an ambiguity of analyzing clinical data alone. However, a consequence of using a student sample as our

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control group that isn't matched to the clinical one is that both groups differ substantially with respect to age and gender. Compared to the clinical group the mean age in the student group was substantially lower (t 19.98; df 554; p .01), which is obvious, as the clinical sample covers the whole range of adulthood, whereas the students are mainly young adults. With respect to gender we also observed considerable differences. The student group contains significantly more women than does the clinical one (MannWhitney U 27,015.50, p .01). This difference is not surprising considering that at all Belgian universities far more women than men are enrolled in psychology courses. Given both differences and given the fact that we included the student sample as a control for psychopathology, age, and gender have also been included as control variables in the analyses. Because numerous variables are included in the regression equation, 95% confidence intervals (CI) have been estimated for all regression coefficients, based on bootstrapping (Davison & Hinkley, 1997; DiCiccio & Efron, 1996). Bootstrapping is a statistical method for calculating reliable estimates of variables that can be considered complementary to the significance test for regression coefficients that regression analysis provides. The method calculates estimates of the sampling distribution based on subsamples or bootstrap samples of the data set. Each bootstrap sample is randomly drawn with replacement from the full sample (i.e., after we randomly draw an observation from the original sample we put it back before drawing the next observation) and has the same size as the complete sample. Bootstrapping is especially well suited for the calculation of confidence intervals, which makes it appropriate for our purpose. In calculating the 95% CI, we made use of 10,000 bootstrap samples. If the 95% CI does not contain 0, the indicator is considered to be stable, which means that it is consistently related to the dependent variable in the same direction. We assume that relevant indicators are both significant according to the t test and stable according to the bootstrapping. Because the IIP-64 is a circumplex scale, multicollinearity could be a problem. Regressing each independent on all the other independent variables, while ignoring the dependent, is a recommended method to check for multicollinearity. Two indices that indicate the results of such regression analysis are the tolerance and the variance inflation factor (VIF): the lower the tolerance and the higher the VIF, the stronger the multicollinearity. We apply the rule that if tolerance .20 and if VIF 4, multicollinearity is present (Fox, 1991). Results A first regression model, in which we examined the relationship between the TAS-20 score and scores on the IIP-64 subscales while also controlling for the variables group (clinical or student), gender, and age, explained a substantial amount of variance in the data: R 2 .46; adjusted R 2 .45. The F-statistic, moreover, indicated that the model was statistically highly significant and that it could be generalized to other samples: F(11,543) 42.83, p .01. Table 1 depicts the results at the level of the independent variables. Two of the 8 IIP-64 subscales explained a significant amount of variance in the dependent variables, Cold/Distant and Non-Assertive. Both variables were positively related to our dependent variable and the 95% CI indicated that across our 10,000 bootstrap samples these subscales were the only IIP-64 variables for which the regression coefficient was stably positive. With respect to our control variables, only group proved to be a significant independent variable. The 95% CI indicated that this variable was stable. The tolerance and VIF statistics listed in Table 1 indicated that multicollinearity was not a fundamental problem for any of the variables included in the analysis. The only

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Table 1 Results From Linear Multiple Regression Analysis With IIP-64 Subscales Predicting TAS-20 Scores With a Control for the Effects of Group, Gender, and Age

Variable (Intercept) Group Gender Age Domineering/Controlling Vindictive/Self-Centered Cold/Distant Socially Inhibited Non-Assertive Overly Accommodating Self-Sacrificing Intrusive/Needy B 26.71 3.80 .32 0.01 0.02 0.13 0.47 0.15 0.29 0.05 0.22 0.01 SE 2.48 0.61 0.48 0.04 0.11 0.12 0.10 0.09 0.10 0.12 0.12 0.10 t 10.79 6.26 0.66 0.15 0.21 1.08 4.71 1.66 2.92 0.38 1.92 0.12 p .01 .01 .51 .88 .83 .28 .01 .10 .01 .71 .06 .91 95% CI 21.96/31.45 4.98/-2.64 1.26/0.65 0.07/0.09 0.25/0.24 0.14/0.48 0.24/0.67 0.04/0.32 0.07/0.48 0.31/0.20 0.01/0.46 0.22/0.20 Tolerance VIF

.48 .88 .55 .47 .34 .35 .34 .30 .23 .30 .53

2.10 1.14 1.81 2.13 2.94 2.83 2.92 3.35 4.36 3.34 1.87

Note. IIP-64 Inventory of Interpersonal Problems; TAS Toronto Alexithymia Scale; B Unstandardized regression coefficient; SE Standard error of measurement; 95% CI 95% confidence interval calculated based on 10,000 bootstrap samples; VIF variance inflation factor.

marginal case was the Overly Accommodating subscale: Tolerance was not lower than .20 but VIF was slightly higher than 4. A regression analysis without the Overly Accommodating subscale in the model did not substantially change the results. Furthermore, correlations indicated that this variable is strongly related to both the Non-Assertive (Pearson r .77) and the Self-Sacrificing (Pearson r .78) subscales. In a next step, we excluded all variables that were not significant in the first regression analysis and included only the significant ones for a second regression model. This regression model proved to be as powerful as the first complete regression model: R 2 .45; adjusted R 2 .45; F(3,556) 153.22, p .01. In this shortened model, all independent variables remained highly significant estimators (Cold/Distant: B 0.62, SE 0.07, t 9.25, p .01; Non-Assertive: B 0.41, SE 0.06, t 6.70, p .01; group: B 8.69, SE 0.96, t 9.04, p .01).

Discussion Although it has frequently been noted from a clinical point of view that alexithymic patients have a specific style of interpersonal relating, systematic research on this topic is scarce. We studied whether alexithymia relates to specific interpersonal problems and we conclude that this is the case. Alexithymia was measured with the TAS-20 and interpersonal problems with the 8 subscales of the IIP-64. The hypothesis we tested was whether detached and avoidant interpersonal functioning, such as indicated by the subscales Cold/ Distant, Socially Inhibited, and Non-Assertive from the IIP-64, are significantly related to the total TAS-20 score, whereas the other IIP-64 subscales are unrelated to it. We analyzed data from an outpatient group and a student sample. The clinical sample was included to make sure we obtained results relevant to understanding the mental functioning of clinical outpatients. The student sample was included in addition to the clinical one to make sure that the results of our analyses did not relate to severity of psychopathology-- which could have been an ambiguity of analyzing clinical data alone--but to the trait of

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alexithymia. A linear regression analysis of the data, in which we controlled for the effects of group, gender, and age, indicated that two interpersonal problems are significantly and stably related to alexithymia: cold/distant and non-assertive social functioning. All other IIP-64 subscales were not significantly related to alexithymia, which implies that the idea that socially inhibited functioning is also typical of alexithymia could not be confirmed. This result is partly in line with our hypothesis. We also observed that the clinical and student groups differed significantly with respect to alexithymia, with substantially higher scores for the clinical group. The two regression analyses we performed-- one with all IIP-64 subscales and with the three control variables and one with the subscales Cold/Distant and Non-Assertive and a control for group--explained a substantial amount of variance. The fact that the items of the TAS-20 and the IIP-64 show no content overlap substantiates that our findings are not artifacts. It implies that the tendency to deny affective states and to refrain from symbolizing affect is empirically linked with distancetaking behavior and low degrees of affection for others on the one hand, and interpersonal passivity and little concern about manifesting one's own desires and needs to others on the other. Both regression analyses explained the same amount of variance, which implies that the variables omitted from the first regression equation hardly had additional explanatory power. On a theoretical level, we conclude that this result is consistent with ideas formulated by attachment theory and psychoanalytic theory. A central idea in current attachment theory is that to regulate affective states people need a symbolic representational system that is acquired through interaction with attachment figures. Attachment figures mirror a child's affective states and help him or her in building mental representations of affect. Parallel to the development of a sense of self and of others, the capacity for affect regulation is acquired (Fonagy, Gergely, Jurist, & Target, 2002; Lemche, Klann-Delius, Koch, & Joraschky, 2004; Taylor et al., 1997). Within this theory, diminished capacities in discerning and handling affective states are seen as concomitant with poor involvement with others. Assuming that alexithymia indicates poor affect regulation (see Lemche et al., 2004), we conclude that our result fits this theoretical idea. From a psychoanalytic perspective alexithymia has been linked to the Freudian category of the actual neuroses, which addresses the inability to mentally master somatic arousal (Taylor, 2003; Taylor et al., 1997; Verhaeghe, 2004). In particular, it has been noted that these patients have difficulty engaging in transference relations (Taylor et al., 1997; Vanheule et al., in press; Verhaeghe, 2004). Assuming that transference implies establishing meaningful relationships with others--albeit in one's own typical style--our observation that alexithymia relates to interpersonal distance taking and withdrawal is consistent with the idea that engaging in transference relationships is a problem for severely alexithymic persons. The result of this study has implications for clinical psychological practice. Because highly alexithymic persons tend to withdraw from others and refrain from sharing experiences, it can be expected that they will be reluctant to engage in psychotherapeutic relationships as well. Attending to their own affective experiences is not their habit, nor is disclosing them to others. We suggest that psychological intervention with these patients should counter both these basic habits. From the very start of an intervention therapists should help highly alexithymic patients to discern manifestations of arousal, to describe these states, and to develop relevant explanations for them. A key activity for therapists to engage in is mirroring affective states without imposing their own explanations. We also suggest that in clinical work with highly alexithymic persons the nature of the therapeutic relationship should be carefully monitored and regularly discussed with these patients. This stimulates patients' capacity to think about relationships and about feelings in relationships (i.e., it counters the tendency to remain distant) while vague unease experienced

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in relationships can explicitly be linked to mental representations. By taking the initiative in discussing the nature of the therapeutic relationship, the psychotherapist can bypass patients' spontaneous nonassertiveness in addressing difficulties they might experience. We think that combining both intervention strategies makes it easier and more personally relevant for highly alexithymic individuals to engage in psychotherapy. Consequently, the risk of drop-out may also be reduced. This study needs to be understood in light of some limitations. First, we only applied self-report instruments. Given that alexithymia is marked by a deficit of self-reflexivity, and that self-report measures ask precisely for self-reflection, the validity of our conclusions is not guaranteed. We recommend additional research that also takes into account clinicians' judgments and interview-based ratings of alexithymia. Second, we studied alexithymia only in a heterogeneous sample of mental health patients and in students. An important question to ask in subsequent studies is whether the pattern of interpersonal functioning we observed is indeed typical of alexithymia in specific diagnostic subgroups of patients, such as those with anxiety disorders or somatization disorders. If the pattern we detected is indeed truly distinctive, we expect this will be the case. Third, we only made use of a student sample as our control group. Results would have been stronger if a control group that was matched for age, gender, and socioeconomic variables had been used. References

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