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 Table of Contents  
Year : 2018  |  Volume : 23  |  Issue : 1  |  Page : 57-62

Alexithymia governing neurosis: A comparative study between patients and caregivers

1 Department of Psychiatry and Deaddiction Centre, Lady Hardinge Medical College, New Delhi, India
2 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication2-Nov-2018

Correspondence Address:
Apala Aggarwal
Department of Psychiatry and Deaddiction Centre, Room No. 16, Lady Hardinge Medical College, New Delhi - 110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmhhb.jmhhb_58_17

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Context: Individuals with neurotic disorders are believed to have alexithymia, which not only acts as a substrate for neurosis but also poses difficulties in delivering psychotherapeutic intervention to these patients. Aims: This study aims to study and compare alexithymia among patients of neurosis and their caregivers. Settings and Design: This descriptive cross-sectional study was carried out at the Department of Psychiatry of a Tertiary Government Hospital in Delhi. Materials and Methods: Fifty consecutive patients of neurosis (as per ICD-10) and their caregivers were assessed using Hindi versions of Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7) and Toronto alexithymia scale (TAS-20) after taking written informed consent. Statistical Analysis: Data were analyzed using descriptive statistics, independent t-test, ANOVA, and multiple linear correlation. Results: The mean age of patient and caregiver groups was comparable (35.86 ± 10.6 and 36.04 ± 10.6 years) with no significant difference on socio-demographic parameters. The patient group had significantly higher scores of total TAS and also on parameters of difficulty identifying feelings, difficulty describing feelings and externally oriented thinking (P < 0.000). Total PHQ-9 and GAD-7 scores were significantly correlated to TAS scores (total and 3 domains) in both groups. Females scored higher than males (P = 0.022, PC = 0.324) and age showed negative correlation (P = 0.036, PC = −0.297) with total TAS scores in the patient group. Conclusion: The study shows that alexithymia is more common in patients with neurosis as compared to their caregivers. Besides, it is closely related to neurotic traits in the caregivers who scored high on PHQ-9 and GAD-7 despite being free of a diagnosable illness.

Keywords: Alexithymia, anxiety disorders, caregivers, neurosis

How to cite this article:
Aggarwal A, Kalra D, Kataria D, Verma R. Alexithymia governing neurosis: A comparative study between patients and caregivers. J Mental Health Hum Behav 2018;23:57-62

How to cite this URL:
Aggarwal A, Kalra D, Kataria D, Verma R. Alexithymia governing neurosis: A comparative study between patients and caregivers. J Mental Health Hum Behav [serial online] 2018 [cited 2023 Jun 1];23:57-62. Available from: https://www.jmhhb.org/text.asp?2018/23/1/57/244919

  Introduction Top

Alexithymia, as a concept, was given by Sifneos in 1973 to describe a disturbance in affective and cognitive functions characterized by an inability to find words to describe feelings or emotions.[1] The salient clinical features of alexithymia include difficulty in recognizing and verbalizing feelings, endless description of physical symptoms instead of emotions, concrete speech and thought closely tied to external events and paucity of fantasy life.[2]

The recent international literature mentions high prevalence of alexithymia in personality disorders, substance use disorders, posttraumatic stress disorder (PTSD), Obsessive–Compulsive Disorder (OCD), somatoform disorders, conversion disorders, Generalized Anxiety Disorder (GAD), panic disorder and depression.[3]

An Indian review by Ruth and Padmakumari showed that alexithymia is high not only in psychiatric disorders but medical disorders too. They reported elevated levels of alexithymia in a wide range of conditions including irritable bowel syndrome, cardiac diseases, breast cancer, diabetes, morbid obesity, chronic pain, chronic itching, eating disorders, substance dependence, pathological gambling, fibromyalgia, panic disorder, PTSD, and erectile dysfunction.[4]

It is still controversial whether alexithymia is a state feature or a trait feature. In a German study by Rufer et al., a sample of 42 inpatients with OCD was treated with multimodal cognitive-behavioral therapy.[5] Symptoms of OCD and depression improved significantly following treatment, but no significant changes were found on the total Toronto Alexithymia Scale (TAS-20) score. Pretreatment alexithymia scores correlated significantly with posttreatment scores, indicating relative stability, which suggests high trait alexithymia is these individuals. Interestingly, a 6-year follow-up investigation of 34 patients who participated in the original study revealed significant decreases in total TAS-20 total scores and two of its subscores during this 6-year follow-up period. Higher alexithymia scores were not found to predict the worse long-term outcome of OCD.[6]

In addition, alexithymia has also been studied to postpone or hamper treatment in patients exhibiting it. As for treatment-seeking behavior, a strong relationship is seen between the externally oriented thinking (EOT) facet of alexithymia and the non-use of professional help for anxiety.[7] This type of personality configuration may also lead to a decreased response to treatment and a prolonged course of illness.[8]

While there is some data available on alexithymia in different neurotic disorders, not many studies have collectively compared alexithymia between the various neurotic disorders. The concept remains patchy and incomplete, especially in Indian patients with Neurosis. Since neurotic disorders are commonly present, knowing the sociocultural correlates of alexithymia relevant to our context would be extremely helpful. Keeping these factors in mind, the current study was planned to assess and compare alexithymia in neurotic patients and their caregivers, attending a general hospital psychiatry unit in New Delhi.

  Materials And Methods Top

This study was carried out in the Department of Psychiatry and De-addiction Centre of a Tertiary Care Government Hospital in New Delhi. The study spanned over a period of 3 months and involved cross-sectional assessment of patients and their caregivers. A written consent was taken individually from all the patients and their caregivers. Ethical clearance was taken from the Institutional Ethical Committee. A sample size of 50 in each arm was calculated using the sample size formula for an observational study. Fifty consecutive neurotic patients and their caregivers, who met the inclusion criteria were enrolled in the study.

Inclusion criteria

  1. Patients meeting criteria for F40, F41, F42, F43, F44, F45 as per ICD-10 CDDG[9]
  2. Adults between the age of 18–60 years
  3. Availability of a caregiver
  4. Patient and caregiver willing to give written informed consent.

Exclusion criteria

  1. Patients with any other comorbid psychiatric or medical disorder
  2. Caregivers who are known cases of any psychiatry disorder or medical disorder
  3. Patients and caregivers with intellectual disability.

Assessment tools

  1. Patient Health Questionnaire (PHQ-9) and GAD-7[10] – Hindi Version for screening caregivers
  2. TAS-20 Hindi Version[11] – 20 items 5-point Likert scale, validated with sufficient reliability and validity. There are subscales under three headings-

    • Item 1, 3, 6, 7, 9, 13, 14 – difficulty in identifying feelings (DIF)
    • Item 2, 4, 11, 12, 17 – difficulty in expressing feelings (DEF)
    • Item 5, 8, 10, 15, 16, 18, 19, 20 – Externally oriented thinking.

The socio-demographic information was collected using a brief semi-structured pro forma. Kuppuswamy's Socioeconomic Status Scale, Modified for 2007,[12] was used to assess socioeconomic status of the families. All the tools were in Hindi language to facilitate a good understanding of the questions. Sociodemographically matched caregivers were taken, who were accompanying the patient to the hospital and were willing to give informed consent. Assessment took about 30–40 min. Syndromal psychiatric diagnoses including depression in the patients and caregivers were ruled out by two psychiatrists individually using detailed clinical interviewing. The most appropriate treatment was offered to the patients and the caregivers wherever required. Data were analyzed using SPSSversion 23.[13] Descriptive statistics were used to describe the data. Independent t-tests and ANOVA were used to compare the mean TAS scores and subscores. Multiple linear correlation was used to find out the correlation between TAS scores, subscores, PHQ-9 scores, GAD-7 scores, and sociodemographic variables. The level of statistical significance was kept at P < 0.05 for all the statistical tests.

  Results Top

[Table 1] shows the demographic details of both the patient as well as caregiver groups. Both groups were comparable without any significant difference between both groups [Table 1].
Table 1: Sociodemographic details of patients and caregivers

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Independent t-test was applied to find mean scores of the patients and the caregivers. [Table 2] depicts the mean scores of all the scales and their comparison between the patient and the caregiver groups [Table 2].
Table 2: Comparison of scores between patients and caregivers

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As shown in [Table 3], the patient group was further subdivided into seven illness groups. The percentage of patients in each illness group was calculated along with their mean TAS scores and mean TAS subscores in three domains [Table 3].
Table 3: Comparison of scores of patients according to illness

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Multiple linear correlation analysis was done between all the six scores of patients as well as caregivers. It was seen that all the six scores correlated positively with each other for patients and caregivers at P < 0.05 [Table 4].
Table 4: Correlation of Toronto Alexithymia Scale (total and subscales) scores with Primary Health Questionnaire-9 and Generalized Anxiety Disorder-7 in patients and caregivers

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Comparison of TAS scores for OCD, somatoform disorder, dissociative disorder, MAD, GAD, phobia, and panic disorder among patients was done using one-way ANOVA. The difference was not found to be statistically significant among the patient population (P = 0.066).

However, when one-way ANOVA was used to analyze individual components of TAS, i.e., DEF, DIF, and EOT with respect to different disorders in patient, there was a significant effect of different disorders on EOT as well as DIF at the P < 0.05 level [Table 5].
Table 5: Comparison of Toronto Alexithymia Scale sub-scores within the illness groups

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Among the sociodemographic details, only gender and age had shown correlation with TAS scores. Females scored significantly higher on TAS as compared to males, (

P = 0.022 and PC = 0.324). The age was found to be negatively correlated (P = 0.036 and PC = −0.297) to total TAS scores in the patient group. No other sociodemographic variable showed significant correlation with TAS scores.

  Discussion Top

The study revealed multiple key findings.

Analysis of Toronto alexithymia scale total scores and sub-scores

All our patients scored much higher on TAS total scores and the three subscores as compared to their healthy caregivers, which was statistically significant at P < 0.05. This finding fulfills the main aim of the study and has been previously recorded by various authors in their research. Hence, it strengthens the prevailing understanding that there is a strong association between alexithymia and neurotic disorders, and alexithymia could be a possible substrate for the same.

In a study conducted by Onur et al., patients with major depressive disorder, GAD, and panic disorder scored significantly higher than the nonclinical controls on TAS-20 total score, specifically subfactors of DIF and difficulty describing feelings.[14] Izci et al. observed that panic disorder patients had a significantly higher prevalence of alexithymia (35%) as compared to healthy controls (11.3%). The DIF subscale score was also significantly higher in patients with panic disorder (P = 0.03).[15] In another study by Cox et al., the prevalence of alexithymia in panic disorder and social phobia was found to be 34.0% and 28.3%, respectively,[16] which shows very high prevalence in these disorders as compared to alexithymia in general population, which is about 10%.[17] The level of alexithymia in conversion disorder patients, without any other psychiatric disorder, was also found to be higher than normal controls in a study done by Gulpek et al.[18] Furthermore, in a study evaluating alexithymia in patients with functional motor symptoms, TAS scores and cognitive subscores, except EOT subscale, were significantly higher in patients with functional motor symptoms as compared to healthy controls.[19]

A study by Majohr et al., evaluating the relationship between alexithymia and dissociation in patients with panic disorder revealed a particular association between “DIF” and “depersonalization/derealization.” Patients who showed the pathological form of dissociation had higher levels of alexithymia, with particular regard to “DIF” and to a smaller extent, “difficulty in describing feelings.”.[20] Besides, Kang et al. established that patients (n = 107) with OCD scored significantly higher on TAS as compared to normal controls (n = 130).[21]

In a study conducted in Finland on 5129 individuals aged 30–97 years, alexithymia was associated with somatization independently of somatic diseases, depression and anxiety, and confounding sociodemographic variables. The TAS-20 factor scale “DIF” was the strongest common denominator between alexithymia and somatization.[22]

Although Indian data are sparse on alexithymia in neurotic disorders, a study by Duddu et al., reports high and almost equal scores of alexithymia in patients with depressive disorder and somatoform disorder as compared to normal controls. Compared with normal individuals, those with somatoform and depressive disorder had greater difficulty in identifying bodily sensations and feelings. Patients with the depressive disorder had more DEF compared to somatoform disorder patients.[23]

Another Indian study with 60 female patients showed that alexithymia and abnormal illness behavior are overlapping constructs and reported high TAS scores in anxiety, depressive, and somatoform disorders.[24]

Comparison of Toronto alexithymia scale total scores between illness groups

When divided into seven illness groups, we found that mean TAS was highest for GAD, followed by phobia and least for panic disorder. However, the difference between the illness groups was not statistically significant. Previous studies by Onur et al.[14] also could not find a statistical difference in total TAS scores between the various illness groups (they compared only three illnesses – major depression, GAD, and panic disorder). A possible explanation for this outcome could be that all the patients who came to the hospital for seeking treatment were having significant distress at the time of assessment which led to all of them scoring high on the TAS scale. Probably because of reporting bias, state anxiety would have interfered with trait alexithymia in these patients. It may also mean that alexithymia could be a common link to all the anxiety disorders and hence explains why it could be a possible underlying substrate for the same.

Comparison of Toronto alexithymia scale subscores between illness groups

When one-way ANOVA was used to analyze the three subgroups of TAS, there was a statistically significant difference between EOT and DIF domains within the seven illness groups. Patients of GAD scored highest on DIF and EOT domains, whereas patients of Panic disorder scored least on these two domains. This finding was novel to this study. Previous literature, as mentioned earlier in the discussion, has analyzed the TAS subscores; however, these studies have not compared the TAS subscores between all the neurotic illnesses, possibly because of different designs of these studies. A possible corollary for this finding could be that disturbance or deficit in these domains could be a predictor of a specific neurotic disorder. With literature also supporting high EOT scores in GAD, the former may be a predictor for the latter. However, it needs further research to strengthen this association.

Correlation between Generalized Anxiety Disorder Scale, patient health questionnaire, and Toronto alexithymia scale scores

There was a significant correlation of all the scales with each other on multiple linear correlation at P < 0.05, which means that when a subject scored higher on one scale, he or she also scored higher on other scales. This observation was true for both patients and caregivers despite being free of any diagnosable illness. This outcome reinforces the association of anxiety and alexithymia even further. It also means that even the caregivers of patients, who were family members in most cases, also exhibit high alexithymia, further consolidating it being a possible substrate for neurotic disorders. This finding was also new to our study.

Correlation between sociodemographic variables and Toronto alexithymia scale scores

When all the sociodemographic variables were correlated with TAS scores, gender, and age were significantly correlated with the same. It was found that females scored significantly higher on TAS as compared to males, (P = 0.022 and PC = 0.324). Furthermore, age showed negative correlation (P = 0.036 and PC = −0.297) in the patient group. It means younger female patients had higher alexithymia as compared to older male patients. A possible reasoning for this result in our study could be that since anxiety is most commonly seen in young females, so alexithymia was also found to be higher in them. A previous study by Levant et al.[25] showed that men had higher alexithymia as compared to women in their study. However, the difference in their study was small. Reason for this contradictory finding could be that their study recruited nonclinical males whereas our study had patients of anxiety disorders.

No other sociodemographic variable showed significant correlation with TAS scores.

To sum it all, our study did reveal some very interesting findings which reinforce the strong association of alexithymia and neurosis. Although no difference exists between the different neurotic disorders on total TAS scores, there is surely a significant difference reported on EOT and DIE domains. We also found that young females, as compared to older males, have higher alexithymia which was statistically significant.

Despite these contributions, our study also had some shortcomings. It was a hospital-based study with small sample size. The patient group was subdivided into multiple disorders which further reduced the sample size in subgroups. Another limitation is the difficulty to differentiate between state anxiety and trait alexithymia with the current tool. State anxiety in the acute phase may have given falsely high readings on TAS; the two could not have been differentiated by any possible tool or human interpreter. A large sampled community-based study in remission phase with a tool which only picks up trait alexithymia could have been an ideal study, but the limited resources restricted us to follow the ideal scenario.

The strengths of the study are that we had a control group which could make the comparison possible. We found associations between alexithymia and PHQ-9 and GAD-7 score even in caregivers despite the absence of diagnosable illness. Moreover, we tried to compare various neurotic illness groups, which has not been done so far to the best of our knowledge.

  Conclusion Top

We state that our study, despite having limitations, has contributed immensely to the wealth of existing knowledge. It would be prudent to have more research to further unravel the intricate conundrums of this interesting subject. It shall not only guide the clinicians to understand their patients better, but also help the patients dig deeper into their internal states and come out of the illness sooner and in a better manner. Furthermore, we would be able to formulate more effective strategies for the management of neurotic disorders and pick up the patient profile at a very early stage of the illness.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sifneos PE. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom 1973;22:255-62.  Back to cited text no. 1
Bertagne P, Pedinielli JL, Marliere C. Alexithymia. Evaluation, quantitative and clinical data. Encephale 1992;18:121-30.  Back to cited text no. 2
Kusevic Z, Marusi? K. The relationship between alexithymia and morbidity. Lijec Vjesn 2014;136:44-8.  Back to cited text no. 3
Ruth S, Padmakumari P. Recent trends in alexithymia. Int J Psychol Behav Sci 2014;4:106-11.  Back to cited text no. 4
Rufer M, Hand I, Braatz A, Alsleben H, Fricke S, Peter H, et al. A prospective study of alexithymia in obsessive-compulsive patients treated with multimodal cognitive-behavioral therapy. Psychother Psychosom 2004;73:101-6.  Back to cited text no. 5
Rufer M, Ziegler A, Alsleben H, Fricke S, Ortmann J, Brückner E, et al. A prospective long-term follow-up study of alexithymia in obsessive-compulsive disorder. Compr Psychiatry 2006;47:394-8.  Back to cited text no. 6
Rufer M, Moergeli H, Moritz S, Drabe N, Weidt S. Alexithymia and non-treatment: An internet based study of 312 people with chronic anxiety. Compr Psychiatry 2014;55:179-87.  Back to cited text no. 7
Greenberg RP, Dattore PJ. Do alexithymic traits predict illness? J Nerv Ment Dis 1983;171:276-9.  Back to cited text no. 8
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization; 2007. p. 75-6.  Back to cited text no. 9
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44.  Back to cited text no. 10
Pandey R, Mandal MK, Taylor GJ, Parker JD. Cross-cultural alexithymia: Development and validation of a Hindi translation of the 20-item Toronto alexithymia scale. J Clin Psychol 1996;52:173-6.  Back to cited text no. 11
Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy's socioeconomic status scale-updating for 2007. Indian J Pediatr 2007;74:1131-2.  Back to cited text no. 12
IBM Corp. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY:IBM Corp; 2014.  Back to cited text no. 13
Onur E, Alkın T, Sheridan MJ, Wise TN. Alexithymia and emotional intelligence in patients with panic disorder, generalized anxiety disorder and major depressive disorder. Psychiatr Q 2013;84:303-11.  Back to cited text no. 14
Izci F, Gültekin BK, Saglam S, Koc MI, Zincir SB, Atmaca M, et al. Temperament, character traits, and alexithymia in patients with panic disorder. Neuropsychiatr Dis Treat 2014;10:879-85.  Back to cited text no. 15
Cox BJ, Swinson RP, Shulman ID, Bourdeau D. Alexithymia in panic disorder and social phobia. Compr Psychiatry 1995;36:195-8.  Back to cited text no. 16
Goerlich-Dobre KS, Bruce L, Martens S, Aleman A, Hooker CI. Distinct associations of insula and cingulate volume with the cognitive and affective dimensions of alexithymia. Neuropsychologia 2014;53:284-92.  Back to cited text no. 17
Gulpek D, Kelemence Kaplan F, Kesebir S, Bora O. Alexithymia in patients with conversion disorder. Nord J Psychiatry 2014;68:300-5.  Back to cited text no. 18
Demartini B, Petrochilos P, Ricciardi L, Price G, Edwards MJ, Joyce E, et al. The role of alexithymia in the development of functional motor symptoms (conversion disorder). J Neurol Neurosurg Psychiatry 2014;85:1132-7.  Back to cited text no. 19
Majohr KL, Leenen K, Grabe HJ, Jenewein J, Nuñez DG, Rufer M, et al. Alexithymia and its relationship to dissociation in patients with panic disorder. J Nerv Ment Dis 2011;199:773-7.  Back to cited text no. 20
Kang JI, Namkoong K, Yoo SW, Jhung K, Kim SJ. Abnormalities of emotional awareness and perception in patients with obsessive-compulsive disorder. J Affect Disord 2012;141:286-93.  Back to cited text no. 21
Mattila AK, Kronholm E, Jula A, Salminen JK, Koivisto AM, Mielonen RL, et al. Alexithymia and somatization in general population. Psychosom Med 2008;70:716-22.  Back to cited text no. 22
Duddu V, Isaac MK, Chaturvedi SK. Alexithymia in somatoform and depressive disorders. J Psychosom Res 2003;54:435-8.  Back to cited text no. 23
Sarkar J, Chandra P. Alexithymia and illness behaviour among female Indian outpatients with multiple somatic symptoms. Indian J Psychiatry 2003;45:229-33.  Back to cited text no. 24
[PUBMED]  [Full text]  
Levant RF, Hall RJ, Williams CN, Hasan NT. Gender differences in alexithymia. Psychol Men Masc 2009;10:90-203s.  Back to cited text no. 25


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