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REVIEW ARTICLE  
Year : 2021  |  Volume : 63  |  Issue : 2  |  Page : 127-133
Relationship between alexithymia and depression: A narrative review


1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Click here for correspondence address and email

Date of Submission30-Nov-2019
Date of Decision10-Apr-2020
Date of Acceptance28-Feb-2021
Date of Web Publication14-Apr-2021
 

   Abstract 


Alexithymia has been described as difficulty in expressing as well as experiencing feelings. It has been studied in relation with medical as well as psychological conditions and has been seen to impact treatment outcomes. The current review focuses on the relationship of alexithymia with depression and the role of culture in this relationship. The keywords for literature included terms such as depression, alexithymia, depression and alexithymia, Toronto Alexithymia Scale, assessing alexithymia and depression, and alexithymia as a trait. The main findings of the review were that alexithymia and depression are highly correlated, and severity of depression and gender are independently associated with alexithymia and may interfere with treatment outcomes.

Keywords: Alexithymia, depression, Indian culture, review, trait

How to cite this article:
Sagar R, Talwar S, Desai G, Chaturvedi SK. Relationship between alexithymia and depression: A narrative review. Indian J Psychiatry 2021;63:127-33

How to cite this URL:
Sagar R, Talwar S, Desai G, Chaturvedi SK. Relationship between alexithymia and depression: A narrative review. Indian J Psychiatry [serial online] 2021 [cited 2021 May 5];63:127-33. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/2/127/313724





   Introduction Top


Individuals with any medical or psychological illness may struggle with not feeling the “feeling.” It came into focus in the 1970s when MacLean in his work with individuals with psychosomatic illnesses inferred that such patients are not able to verbalize their emotions as efficiently as others.[1] In the same period, Sifneos came up with the term “alexithymia” as an inability of patients in expressing how they feel.[1] It is a type of difficulty in emotion regulation.

Since then, the presence of alexithymia as a trait and as a symptom in varied medical and psychiatric illnesses has been studied, frequently along with the assessment of severity of depression. This article reviews the literature in the last two decades to present a perspective on the relationship between alexithymia and depression and the role of culture in this relationship.

According to Freyberger, alexithymia can be understood in two ways: one as a stable personality trait and the other as a defense mechanism, i.e., primary and secondary alexithymia. Since the trait aspect cannot be altered, psychotherapists work on it as a defense mechanism, and so secondary alexithymia is manageable.[1] It can be said to be a difficulty in identifying emotions, naming them, expressing them, and experiencing them,[1] and eventually, an inability to identify others' emotions correctly. Such individuals, inevitably, face difficulties in socializing and maintaining emotional ties. This inability to identify physical sensations representing emotions leads to incorrect interpretations and hence seeking medical care for nonexisting problems.[2]

Alexithymia as a stable personality or otherwise is seen to be present in a wide variety of psychological disorders, namely depression, anxiety, and schizophrenia.[3] In itself, alexithymia and its association with these problems can be unidirectional or bidirectional. It can be an outcome of the symptoms of the illness, exacerbating the symptoms or, as a stable personality trait, leading to the symptoms. The literature suggests that alexithymia, depression, and anxiety are strongly related. Alexithymia is also present in other pathologies such as substance abuse and dependence, eating disorders, and borderline personality disorder. The most common scale that is used to measure alexithymia is Toronto Alexithymia Scale (TAS-20),[4] which is a 20-item self-report measure consisting of three subscales, namely, difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking.[5],[6]

Depression as a disease state has been seen to be studied widely in association with alexithymia. In the 1970s, when it was suggested by Freyberger that alexithymia can be secondary as a defense mechanism, researchers became interested in studying association between alexithymia and depression. These studies were mostly cross-sectional.[7]


   Materials and Methods Top


An electronic search of literature in the last two decades (1999 to October 2019) highlighting alexithymia, depression, and their relationship with each other was conducted using the following databases: Google Scholar, PubMed, ResearchGate, and JSTOR. The inclusion criteria of the study involved (1) abstracts/full articles published in journals and (2) studies involving patients with different illnesses but reporting either primary depression and alexithymia or physical illness with comorbid depression and alexithymia. For avoiding variations in definitions of the illnesses, we relied on the understanding of the concepts by the authors of the papers. The abstracts, original articles, and review articles published in languages other than English and with incomplete data were excluded. The keywords used for literature search included depression, alexithymia, depression and alexithymia, TAS, assessing alexithymia and depression, and alexithymia as a trait. Overall, 75 relevant articles were utilized for this review. The review describes alexithymia as a personality feature followed by relationship of alexithymia and depression, specifically in the Indian culture. A summary of the articles has been listed in [Table 1].
Table 1: Summary of articles reviewed

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   Discussion Top


Alexithymia as a personality feature

In a study on 46 patients with major depression, it was found that alexithymia is a stable personality trait and is not a state-dependent construct.[8] Alexithymia has been suggested to be a part of personality with cognitive and affective deficits.[9] Alexithymia is a personality style commonly found in those seeking psychotherapeutic management and is seen with depression.[10] A study on college students (n = 199) on alexithymia and its relationship with personality disorders as well as psychopathological dimensions concluded that alexithymia was associated with schizoid, avoidant, paranoid, and depressive traits.[11]

Alexithymia is a personality characteristic. Studies on nonclinical population also found approximately 10% of them dealing with alexithymia, more commonly among males.[12] A review also suggested family and environment as risk factors for having alexithymic features. Maternal psychopathology and inefficient parenting can lead to alexithymia. Adverse events in childhood or inadequate parenting can lead to emotional dysregulation in the person, leading to a stable alexithymia feature, making it a dimension of personality.[12] However, this personality dimension is still questioned by some authors. This review proposed that since alexithymia diminishes as the person improves, it cannot be a stable feature.[12]

A study by Gavazzi et al. concluded that alexithymia as a trait was responsible for response inhibition.[13] It is beyond emotional dysregulation. It manages the inhibitory processes in the brain, and so, it does not cause impulsivity or aggression. As a matter of fact, it enhances impulse control.

Alexithymia is a personality dimension in which there is increased sensitivity to intrinsic bodily arousal, which leads to the enhancement of the emotional component of the arousal and not the cognitive one.[14] They studied participants with high and low alexithymia on decision-making tasks. The results suggested that the higher the alexithymia, more impulsive was the decision. They perceive their bodily arousal with interoceptive sensitivity.

In a study on university students in the United States, it was found that alexithymia was associated with a hostile interpersonal style and goals. Those with alexithymia features had attachment insecurity with romantic partners and a higher power, like God.[15]

The subtype B has higher alexithymia, which becomes a risk factor for a psychiatric illness. This subtype moves through adverse life events.[16] In fact, it is a psychoemotional trait present in psychological disorders.[17]

Alexithymia and depression

In a study on the factors associated with depression in 137 depressed patients, almost half of the patients were alexithymic as measured using TAS-20.[18] Four factors were reported to be independently associated with alexithymia, which included male gender, low level of education, low life satisfaction, and severe depression.[18] In 24 patients with social phobia, alexithymia was found to be independent of depression and anxiety.[19] In a study on patients with anorexia (n = 32) and bulimia (n = 32), it was found that their depression (Hospital Anxiety and Depression Scale, HADS) and alexithymia (TAS-20) scores were highly positively correlated.[20] While assessing the relationship between alexithymia (TAS-20) and anxiety and depression (HADS) in 113 patients diagnosed with depression or anxiety in comparison to a control group, it was concluded that alexithymia was higher in patients as compared to the control group participants. It was also found that depression and alexithymia are different but highly related constructs.[21]

Alexithymia and depression in general Finnish population (n = 2018) using TAS-20 and Beck Depression Inventory (BDI-21), respectively, suggested that they were highly positively correlated.[7] A study on 121 patients with major depressive disorders found that alexithymia features (TAS-20) were common in persons with depression and cluster C Personality Disorders (Structured Clinical Interview for DSM-IV Axis I Disorders-SCID-I and Structured Clinical Interview for DSM-IV Axis II Disorders-SCID-II); further, if alexithymia features did not improve, there was no significant improvement in depression and personality problems.[22] Further, to assess the association between alexithymia (TAS-20) and depression (BDI) in 116 patients with depression and 540 healthy controls, it was concluded that the severity of depression was significantly associated with alexithymia.[23] Most of the patients who did not improve (92%) were alexithymic.[23] Alexithymia (TAS-20) and depression (BDI-21) tested in the general population (n = 1888) found that those participants with high scores on both the scales had highly overlapping factor loadings, suggesting that the two factors may be highly correlated.[24]

In studying alexithymia in 120 patients with major depression (using HAM-D, BDI-21), it was found that it was significantly associated with alexithymia (using TAS-20) and as depression improved, alexithymic features decreased.[25] Patients with functional dyspepsia (n = 30) were found to have depressive symptoms (BDI-21) related to alexithymia (TAS-20), anxiety (Spielberger State-Trait Anxiety Inventory), and anger (Spielberger State-Trait Anger Expression Scale).[26] Alexithymia and depression are mediating factors of eating disorders in college women.[27] Eighty patients with chronic myofascial pain were tested for alexithymia and found that the emotion regulation difficulties in alexithymia (TAS-20) are related to depression.[28]

Alexithymia and depression studied among psychosomatic and alcoholic patients (n = 199) and healthy controls (n = 74) showed that alexithymia (TAS-20) and depression (Self-Rating Depression Scales) were moderately correlated but different constructs.[29] In 69 diabetic mellitus patients, it was found that alexithymia (TAS-26) and depression (BDI-13) were positively correlated.[30] Depression (BDI-II) was associated with low support (Job Content Questionnaire) and high alexithymia (TAS-20) in Japanese workers (n = 120).[31] A study comparing alexithymia (TAS-20) in patients with somatoform disorders and depression (International Statistical Classification of Disease-10 [ICD-10] DCR) using TAS did not report significant difference in the scores on alexithymia.[32]

A study was conducted on persons with drug addiction (n = 128) and healthy controls (n = 128) to assess alexithymia (TAS-20) and depression (BDI-21, BDI-13), and they found that they were positively associated, especially for the factor of difficulty identifying feelings; moreover, the participants from the drug addiction group with no depressive symptomatology were no more alexithymic than the control group participants.[33] Alexithymia (TAS-20) is rare in the general population without depressive symptomatology (BDI-21).[34] In a study on 151 patients with eating disorder, it was concluded that alexithymia (TAS-20) was positively correlated with depression (BDI) and anxiety (Self-Rating Anxiety Scale).[35]

A study on affect regulation in eating disorder patients (n = 35) and healthy controls (n = 30) found that alexithymia (TAS 20, Alexithymia Provoked Response Questionnaire) positively correlated with binge eating and depression (BDI 21).[36] In a study on alexithymia features (TAS-20) and depressive experiences (BDI, Depressive Experiences Questionnaire) in patients with eating disorder (n = 252) and healthy controls (n = 279), it was found that in restricting anorexia and bulimia, the two phenomena are positively associated.[37] There was no significant correlation between alexithymia (TAS-20) and depression (BDI) scores in persons who smoke (n = 24).[38] One hundred and sixteen patients with major depression were studied and found that alexithymia (TAS-20) and depression (BDI-21) were highly correlated.[39]

Alexithymia (TAS-20) was seen to be positively related to depression (Center for Epidemiological Studies Depression Scale) in 77 pregnant women.[40] A study on 58 patients with multiple sclerosis found that depression (BDI) and fatigue (Fatigue Severity Scale) were higher in those with high scores on TAS-20.[41] In a study, depression (n = 16), subthreshold depression (n = 21), and no depression (n = 112) groups were compared for alexithymia (TAS-20) and depression (HADS), and it was found that alexithymia is a state-dependent phenomena in pregnant depressed women and were positively associated.[42] Three hundred and six university students were assessed, and it was found that alexithymia (Farsi TAS-20) and depression (BDI) were significantly positively correlated.[43] Alexithymia (TAS-20) in those without depression (M-CIDI = Munich version of the Composite International Diagnostic Interview; ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th Revision; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition) may be treated as a depressive symptom.[44]

A study on 95 nurses concluded that alexithymia (TAS-20) positively correlated with depression (BDI) and personal achievement.[45] Fifty patients with depression (BDI) were studied, and it was found that functional somatic complaints (Bradford Somatic Inventory) were common among those patients who had high depression, somatosensory amplification (Somatosensory Amplification Scale) scores, and low alexithymia score (Hindi TAS).[46] In 81 depressed patients and 51 healthy persons, a strong positive association between alexithymia (TAS-20) and depression (BDI) was found.[47] In a study on 70 fibromyalgia (FM) patients, 56 chronic low back pain patients, and 72 healthy controls, high scores on alexithymia (TAS 20) were related to high scores on depression, anxiety and somatization (Brief Symptom Inventory and Symptom Interpretation Questionnaire).[2] In a study on 129 patients with functional gastrointestinal disorders, difficulty in identifying feelings (TAS-20) was strongly associated with depression and anxiety (HADS) and severity of gastrointestinal symptoms (Gastrointestinal symptom Rating Scale).[48] Relationship between alexithymia and depression in older adults (50 years and above) diagnosed with depression (n = 134) was examined, and the total scores on TAS-20 correlated with depression severity measured by BDI.[49]

In a study on de novo Parkinson's disease patients (n = 42) and healthy persons (n = 30), alexithymia (TAS-20) and depression (Geriatric Depression Scale Short Form) were found to be positively associated.[50] A study on 729 twins found genetic correlation between alexithymia and depression.[51] There was a strong relationship between alexithymia (Shalling-Sifneos Personality Scale Revised) and depression (Montgomery-Asberg Depression Rating Scale) in 50 suicide attempters.[52] In a study on severe obese patients (n = 49), it was found that they have more difficulty in recognizing emotions (TAS-20) as compared to healthy controls and this was positively associated with depression (BDI).[53]

A meta-analysis suggested that alexithymia measured using TAS-20 is highly associated with depression.[54] One hundred systemic lupus erythematosus patients were assessed, and they did not have any association between alexithymia (TAS-20), depression (BDI), and illness perception.[55] A study on fifty-eight participants diagnosed as having burning mouth syndrome found higher scores on TAS-20, and these correlated with depression scores on Montgomery and Asberg Depression Rating Scale.[56]

Cognitive alexithymia could predispose depression.[57] Seventy five patients with depression were randomized into manualized cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) groups for 4 months and it was found that pretreatment alexithymia has a direct positive correlation with depression and had an effect on psychotherapy process and outcome.[58] They found that pretreatment alexithymia directly affected the change in depression positively and had an effect on psychotherapy process and outcome. Depression and alexithymia in a sample of 181 females with FM and 181 healthy controls were studied. A strong correlation between depression (HADS) and alexithymia (TAS-20) in FM group was noted and this was different in the healthy control group.[59] A study was carried out in chronic pain patients (n = 154) to assess alexithymia (TAS-20) and depression (BDI-II). The effect of alexithymia on pain disability was mediated by depression. Their cooccurrence with a medical condition exacerbated the symptoms of the illness.[60]

Empathy problems (Interpersonal Reactivity Index questionnaire for trait cognitive and emotional empathy and the Multifaceted Empathy Test for state cognitive and emotional empathy) in depression are due to the presence of alexithymia.[61] A study in which depression and anxiety in adolescent males (n = 63) and females (n = 77) in relation to alexithymia (TAS-20) were assessed found that alexithymia was associated with depression and anxiety (Revised Child Anxiety and Depression Scale) and this relationship was more pronounced in females.[62]

Culture, alexithymia, and depression

In a retrospective study on Australian college students with alexithymia, it was concluded that family expressiveness was related to alexithymia.[63] The effect of culture, gender, and parental socialization on alexithymia was studied and they found that all the three factors directly or indirectly affect alexithymia.[64] Expression and experience of emotions is culturally defined[65] with East Asian cultures focusing on restarting in emotional expression.[66],[67]

It has been seen that in South Asian cultures, positive emotions are readily expressed and negative emotions are inhibited.[68] Children are taught by adults how to react in social situations either directly or through observation. They are also taught how to smile and to control themselves if they feel like crying, especially boys.[69]

Alexithymia in Indian culture

In a study conducted on twenty nonpsychotic patients with one medically unexplained somatic complaint in Bengaluru using Diagnostic Criteria for Psychosomatic Research, it was found that 45% of the patients reported alexithymia.[70] The social construction of emotions is culturally defined, and so in Indian culture, there is emphasis on emotional control, with different norms for males and females. In a study on Indian and American students regarding expression of emotions and control, it was found that Indians' expression of emotions was modulated by others' expectations and maintaining group harmony and avoiding situations in which there is possibility of devaluation of self and family.[71]

According to Indian scriptures, emotions arise out of desire; the stronger the desire, the more intense the emotion.[72] In fact, Indians have seen to have alexithymia in psychiatric as well as medical disorders.[73]

Chaturvedi's earlier work on alexithymia in 1988 saw that physical illness was frequently noticed with alexithymia.[74] Alexithymia, as one of the four criteria, was seen as clinically useful in the diagnosis of medically unexplained somatic symptoms.[75] Such somatic symptoms are often reported in a depressive episode.


   Conclusion Top


The review suggests that there is, in fact, a significant relationship between alexithymia and depression and this relationship is more common among females. Alexithymia, when occurring in nonclinical population, is also related to a higher score on depression scales. Furthermore, it was found that alexithymia could be trait based as well as state based. In the Indian context, the picture of alexithymia may be dominated by our cultural norms which encompass the Indian population with control over expression of emotions. Social construction of emotions according to the culture has a great impact on alexithymia and conclusively, on depression. These constructions differ for males and females. Therefore, further research in the picture of alexithymia and its association with depression in the Indian population is relevant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Rajesh Sagar
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
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DOI: 10.4103/psychiatry.IndianJPsychiatry_738_19

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