In the early 1970s, Sifneos 1 coined the term alexithymia.

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1 in Primary Healthcare Patients AINO K. MATTILA, M.D., OUTI POUTANEN, M.D., PH.D. ANNA-MAIJA KOIVISTO, M.SC., RAIMO K.R. SALOKANGAS, M.D., PH.D., M.A. MATTI JOUKAMAA M.D., PH.D. The relationship between life satisfaction and alexithymia was studied in a sample of 229 patients as a part of a naturalistic follow-up study of depression in Finnish primary health care. The measures were the abbreviated Life Satisfaction Scale and the 20-item Toronto Alexithymia Scale. Depression was assessed by telephone with the short form of the Composite International Diagnostic Interview. Of all subjects, 19.2% were alexithymic, and 9.2% were depressed. Alexithymia was negatively associated with life satisfaction even when depression and other confounding factors were controlled for. Alexithymia is a risk factor for life dissatisfaction in primary-care patients. (Psychosomatics 2007; 48: ) In the early 1970s, Sifneos 1 coined the term alexithymia. Alexithymia means no words for feelings, and it refers to a personality construct characterized by impoverishment of fantasy, poor capacity for symbolic thought, and an inability to experience and verbalize emotions. It is, by definition, considered a stable personality trait. 1,2 Alexithymia has been shown to be associated with several medical conditions and mental health problems, including depression. 2,3 The prevalence of alexithymia in workingage populations has been shown to be about 9% 17% for men and 5% 10% for women. 4 7 At the population level, alexithymia is associated with older age, male sex, lower socioeconomic status, fewer years of education, single marital status, and poorer perceived health. 4 7 An association between alexithymia and dissatisfaction with life has been found in two Finnish population studies, 6,8 two studies on coronary heart disease patients, 9,10 and in a study of outpatients with depression. 11 Le et al. 12 conducted a cross-cultural study finding that life satisfaction was negatively correlated with alexithymia in American students. In a study on adjustment difficulties of expatriates, Fukunishi et al. 13 found that alexithymia was associated with dissatisfaction with life abroad. In their study on emotional intelligence in a sample of generalcommunity dwellers, Palmer et al. 14 found that alexithymia correlated negatively with life satisfaction. However, in none of these studies was the main focus especially on alexithymia and life satisfaction, and no subjects were from a primary-care sample. As far as we know, there are no studies on associations between alexithymia and life satisfaction in primary healthcare patients. We analyzed these associations as a part of a naturalistic follow-up study of depression in Finnish primary care. We hypothesized that life satisfaction and alexithymia were negatively related, independently of depression. Received April 19, 2006; revised October 10, 2006; accepted October 16, From the Tampere School of Public Health, Univ. of Tampere; the Dept. of Psychiatry, Tampere Univ. Hospital; the Medical School, Univ. of Tampere; the Tampere Univ. Hospital Research Unit, Tampere, Finland; and the Dept. of Psychiatry, Univ. of Turku; the Psychiatric Clinic, Turku Univ. Central Hospital; and the Turku Psychiatric Clinic, Turku, Finland. Send correspondence and reprint requests to Aino Mattila, M.D., Tampere School of Public Health, FIN aino.mattila@uta.fi 2007 The Academy of Psychosomatic Medicine Psychosomatics 48:6, November-December

2 METHOD Study Design and Sample The design of the initial study, which was carried out in in the Tampere region (Finland) has been described in detail in earlier publications The aim of the initial study was to investigate the recognition and prevalence of depression in working-age primary-care patients. The study sample at baseline comprised 436 primary healthcare patients in the age range of 18 to 64 years, of whom 14.2% were suffering from major depression and 12.3% from minor depression according to the Present State Examination (PSE, 9th Version). 18 Attempts were made to recontact, in , all the patients who took part in the baseline study. A questionnaire containing the abbreviated Life Satisfaction Scale (LSS B), the 20-item Toronto Alexithymia Scale (TAS 20), and structured questions concerning sociodemographic factors and general health was mailed to 413 patients. Of these, 229 (55.4% of the sample) returned the completed LSS B and the TAS 20 and agreed to be interviewed by telephone. The ethical committee of Tampere University Hospital approved the study procedure, and all subjects gave written informed consent. Measures The characteristics of the participants are shown in Table 1. There were three age categories: 40 years, years, and 60 years. Marital status was divided into two categories: married/cohabiting and other. A sixlevel variable containing information on vocational education comprised the following alternatives: no vocational education, vocational training courses or on-the-job training, vocational school, lower college or institute, higher college or institute, and university or institute of higher education. It was dichotomized as follows: 1) vocational school at most (lower education); or 2) at least college/ higher vocational institutes (higher education). The patients were asked how sufficient they found their own income or that of their family. The answers were categorized into a three-class variable: 1) very or fairly sufficient; 2) moderate; and 3) somewhat or very insufficient. Perceived physical health was classified as good or fairly good, average, and rather poor or poor. The LSS B is an abbreviated form of the Finnish Life Satisfaction Scale (LSS A). 19 It consists of three main components: 1) mental balance; 2) assessment of earlier life; and 3) present happiness. LSS B items are shown in Table 3. This instrument, which has been validated in Finnish, comprises 12 items, scored 1: Yes, I agree; 2: No, I do not agree; and 3: I cannot say. To obtain a total score, responses labeled 2 and 3 were interchanged, and four items were reverse-scored. The total score of the LSS B varies between 12 and 36; the higher the score, the greater the satisfaction with life. The Cronbach for the scale was 0.87 in the present study. For single-item analyses, the LSS B items were dichotomized, combining the classes I agree and I cannot say. Alexithymia was assessed with the TAS 20. Its internal consistency, test retest reliability, as well as convergent, discriminant, and concurrent validity have been demonstrated to be good The psychometric properties of the Finnish version of the TAS 20 have proven to be satisfactory. 25 The TAS 20 consists of three subscales, which reflect the three main facets of the alexithymia construct: the first subscale assesses difficulties in identifying feelings (e.g., I have feelings that I cannot quite identify. ); the second subscale concerns difficulties in describing feelings (e.g., It is difficult for me to find the right words for my feelings. ); and the third subscale reflects concrete, externally-oriented thinking or a preoccupation with the details of external events (e.g., I prefer talking to people about their daily activities, rather than their feelings. ). The Cronbach for the scale was 0.87 in this study. The cut- TABLE 1. Characteristics of the Participants (N 229) Characteristic N (%) Sex Female 151 (65.9) Male 78 (34.1) Age 40 years 46 (20.1) years 106 (46.3) 60 years 77 (33.6) Marital status Married/cohabiting 186 (81.2) Other 43 (18.8) Vocational education a Lower education 160 (70.2) Higher education 67 (29.8) Income level b Very/fairly sufficient 71 (31.3) Moderate 114 (50.2) Somewhat/very insufficient 43 (18.5) Perceived health Good/fairly good 85 (37.1) Average 87 (38.0) Rather poor/poor 57 (24.9) a Data from one case are missing. b Data from two cases are missing Psychosomatics 48:6, November-December 2007

3 Mattila et al. point for alexithymia, according to the recommendation by the developers of the scale, was used: a TAS 20 total score over 60 indicated a subject with alexithymia. 26 A major depressive episode and dysthymia during the month before the follow-up were assessed with parts of the Composite International Diagnostic Interview Short Form (CIDI SF), which is a structured interview. 27,28 Three criteria of the DSM-III R diagnosis of dysthymia were ig- TABLE 2. Demographic and Other Correlates of Life Satisfaction, as Measured by the Life Satisfaction Scale (LSS B), According to a Linear-Regression Model, With 95% Confidence Intervals (CI) and p Values Variable b 95% CI p Sex Female (ref.) Male NS Age 40 years NS years (ref.) 60 years NS Marital status Married/cohabiting (ref.) Other NS Education Lower NS Higher (ref.) Income level Fairly sufficient/sufficient (ref.) Moderate NS Somewhat insufficient/insufficient Perceived physical health Good/fairly good (ref.) Average NS Rather poor/poor Composite International Diagnostic Interview Short Form (CIDI SF) Depression diagnosis None (ref.) Major depression/dysthymia TAS 20 score Constant TABLE 3. Associations of Dichotomous Life Satisfaction Scale (LSS B) Items With Alexithymia, Perceived Physical Health, and Depression, According to Separate Logistic-Regression Analyses TAS 20 Total Score Physical Health b CIDI SF Depression OR 95% CI p OR 95% CI p OR 95% CI p 1. I am very satisfied with my present life. a I am afraid of a lot of things I tend to take things seriously Things are getting worse and worse as I grow older I m having the time of my life. a These are the best years of my life. a I m as happy today as I used to be when I was younger. a Most of the time, life is hard I have a lot to be sad about Compared with other people, I get depressed too often My life could be happier than it is right now I am easily upset OR: odds ratio; CI: 95% confidence interval; p values are adjusted for sex, age, marital status, education, income level, Toronto Alexithymia Scale (TAS 20) score, perceived physical health, and depression diagnosis; only significant results of the TAS 20 score, perceived physical health, and the Composite International Diagnostic Interview Short Form (CIDI SF) Depression scores are presented in the table. a Reverse coded. b Rather poor/poor perceived physical health; in Item 8; also average perceived physical health: OR: 0.38 ( ), p Psychosomatics 48:6, November-December

4 nored: Criterion E ( Has never had a manic episode. ), Criterion F ( Not superimposed on a chronic psychotic disorder, such as schizophrenia or delusional disorder. ), and Criterion G ( It cannot be established that an organic factor initiated and maintained the disturbance. ). A current episode of major depression was considered to override the diagnosis of dysthymia. Interviews were conducted by telephone by three psychiatrists. The interviewers were blind to the initial PSE diagnoses. In order to test the reliability of the study process, we analyzed the distribution of the CIDI SF depression diagnoses. There were no statistically significant differences in the distribution of diagnoses between the three interviewers. Major depression (N 19) and dysthymia (N 2) were combined into a two-class variable: No depression/depression. Statistical Analyses In the case of categorical variables, the v 2 -test was used. The differences in the means of the LSS B score in alexithymic and nonalexithymic groups were tested by one-way analyses of variance. Linear-regression analysis was performed with LSS B score as a dependent variable, using TAS total score, perceived physical health, depression diagnosis, sex, age, educational level, and income level simultaneously as explanatory variables. The groups with the highest levels of life satisfaction were used as reference groups for each categorical variable. The associations of different LSS B items with alexithymia, perceived physical health, depression, and sociodemographic factors were analyzed by binary logistic-regression analyses (method: enter). Significance levels were set at a twotailed p value of 0.05 throughout the study. The computations were carried out with SPSS for Windows, Version 13.0 statistical software. 29 RESULTS A total of 19.2% of the patients were alexithymic. Depression was diagnosed in 9.2% of the patients. Of the alexithymic subjects, 25% had a diagnosis of depression. The corresponding figure for the patients without alexithymia was 5.4%. The difference was statistically significant at p (v 2 [1] 16.34). Life satisfaction was significantly lower in the alexithymic group than in the nonalexithymic patients (mean LSS B scores: 21.45; standard deviation [SD]: 5.77 versus 27.19; SD: 6.07; F[1, 227] 32.36; p 0.001). The findings of the linear-regression analysis with LSS B score as a dependent variable are presented in Table 2. Alexithymia, poor perceived physical health, depression, and insufficient income were negatively associated with life satisfaction. The results of the adjusted logistic-regression analyses of the dichotomized LSS B items are presented in Table 3. The TAS 20 score was negatively associated with all the items. Of the health-related factors, rather poor or poor perceived physical health was negatively associated with seven items, and average health with one, as compared with good or fairly good health. Depression was significantly negatively associated with three items. Of the sociodemographic factors, an age of 60 or over had a significantly positive association with four items: Item 1 (odds ratio [OR]: 3.27; 95% confidence interval [CI]: ; p 0.017), Item 4 (OR: 0.18; CI: ; p 0.005), Item 7 (OR: 2.70; CI: ; p 0.045), and Item 8 (OR: 3.0; CI: ; p 0.040). Somewhat insufficient or insufficient income level was negatively associated with three items: Item 1 (OR: 0.30; CI: ; p 0.018), Item 4 (OR: 0.20; CI: ; p 0.003), and Item 6 (OR: 0.22; CI: ; p 0.018). Marital status other than being married or cohabiting was positively associated with two items: Item 9 (OR: 3.01; CI: ; p 0.038), and Item 12 (OR: 2.92; CI: ; p 0.018). Being male was positively associated with one item, Item 12 (OR: 2.00; CI: ; p 0.046). Lower vocational education was also positively associated with one item, Item 10 (OR: 2.80; CI: ; p 0.009). DISCUSSION The main finding of our study was the strong negative association between alexithymia and life satisfaction. This association remained even when we controlled for confounding factors. In the analyses of the single LSS B items, alexithymia was associated with all the items. Of the health-related factors, perceived physical health was associated with seven items and depression diagnosis with only three items. A negative association between alexithymia, as measured by the TAS 20, and life satisfaction has also been found in a few earlier studies, 6,8 14 but in none of them was this association the main topic. In five studies, 6,8 10 life satisfaction was measured with a dichotomized four-item scale and depression with the BDI 21. In a study with a working-age population (N 2,018), 6 alexithymic subjects had lower life satisfaction than others (after controlling for Psychosomatics 48:6, November-December 2007

5 Mattila et al. depression), and, in the follow-up study (N 1,339), 8 low life satisfaction was one of the factors associated with being depressed and alexithymic. In two other studies, 9,10 with 144 and 153 coronary heart disease patients, respectively (75% of the sample subjects were men), alexithymic features and poor life satisfaction were associated with depression, 9 and alexithymic patients were more commonly depressed and dissatisfied with life than others. 10 In a study of 137 outpatients with depression, (59% women), low life satisfaction and severe depression were independently associated with alexithymia. 11 In two studies, the Satisfaction With Life Scale and the Positive and Negative Affect Schedule were used. In a multicultural study of 300 college students, 12 life satisfaction correlated negatively with alexithymia in the European American and Asian American groups but not in the Asian group. In a study with a community sample (N 107), 14 associations of emotional intelligence and alexithymia with life satisfaction were studied. Although it correlated negatively with life satisfaction in binary analyses, alexithymia was not associated with life satisfaction after controlling for positive and negative affect. The findings from the present study were in line with those from most of the earlier studies. Our study was, however, the first one focusing on alexithymia and life satisfaction in particular and with primary-care patients. Also, in contrast to the earlier studies, we assessed depression by means of a structured interview. According to Diener et al., 30 subjective well-being (SWB) includes emotional responses, domain satisfactions, and global judgments of life satisfaction, with personality being one of the strongest and most consistent predictors of SWB. Costa and McCrae 31 stated that the sense of SWB or happiness is formed from three features: morale, life satisfaction, and hopefulness, and it requires a balance between positive and negative affect. They also viewed negative affect or dissatisfaction as components of neuroticism and found that personality traits predict differences in happiness over a long interval. Alexithymia, for its part, has been associated with both neuroticism and negative affectivity. 21,32,33 It has been shown that, even if alexithymia is associated with depression and negative affectivity, it is a stable personality trait. 36,37 Therefore, it is possible that people with alexithymia are prone to lower SWB and so also to less satisfaction with life. Like the earlier studies on alexithymia and life satisfaction, our findings support this hypothesis. Alexithymia has also been associated with impairment in the recognition of pleasant and unpleasant emotions. 38 These impairments may cause difficulties in judging whether one s life is happy or not. Coping has also been seen as an important factor in SWB. 30 Mature coping strategies have been positively associated with SWB, whereas neurotic coping has been inversely associated with life satisfaction. 30 Correspondingly, alexithymia has been associated with immature coping strategies or lack of adaptive coping strategies. 39,40 It is thus conceivable that alexithymic individuals with coping problems find their lives harder than those who can more easily cope with setbacks. Interpersonal competencies are yet another area of relevance as far as SWB and life satisfaction are concerned. Emmons and Diener 41 found that individuals who are satisfied with their lives are, among other things, warm, sociable, and active, and do not tend to be anxious or critical of others in their interpersonal relations. Alexithymia, on the other hand, has been associated with interpersonal dysfunction such as preoccupied or fearful attachment styles, 42 cold and socially-avoidant behavior, 43 and cynical hostility and anger. 44 It is possible that alexithymic personality traits have an impact on life satisfaction through the vicious circle of interpersonal difficulties or directly by affecting the ways alexithymic individuals interpret their relationships with others. Because our study was cross-sectional with regard to alexithymia, any causative generalizations of the associations between alexithymia, depression, and life satisfaction should be drawn with caution. Even though the present study was a part of a follow-up study of depression in primary health care, the prevalence of depression 7 years after the baseline assessment was not much higher than the 6.5% prevalence of any depressive disorders found in a recent Finnish population study. 45 The prevalence of alexithymia in the present study was higher than that of depression. It was also higher than that found in earlier studies in working-age populations. 4 7 This may be due partly to the fact that some of our subjects were now over 64 years of age. Alexithymia has been found to be more prevalent in older age-groups We cannot tell whether the subjects had already been alexithymic before the depressive episode seen in the baseline assessment or whether they had developed alexithymic personality traits as a consequence of depression. Given that, according to some earlier studies, alexithymia is more prevalent among depressed individuals and alexithymia scores decrease as depression is alleviated, it has been claimed that alexithymia may be a state-dependent phenomenon. 49,50 On the other hand, several studies have yielded evidence on both the absolute and the relative stability of alexithymia, suggesting that alexithymia is a personality trait. 3,36,37 What- Psychosomatics 48:6, November-December

6 ever the sequence of events was, the majority of patients had recovered from depression, but almost one-fifth were alexithymic. It should be noted, however, that depression was diagnosed by different methods at baseline and at follow-up. Therefore, the prevalence figures of depression at these two assessments cannot be considered to be directly comparable. In conclusion, alexithymia is associated with less satisfaction with life in primary healthcare patients even when perceived physical health and depression have been taken into consideration as confounding factors. With caution, it can be considered a risk factor for dissatisfaction with life. Clinically, it could mean that when general practitioners assess the well-being of their patients, they should be aware of the possibility that dissatisfaction with life may sometimes be associated with the patients difficulties in emotional processing, not only with circumstantial factors and health problems. References 1. 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