Prevalence and correlates of alexithymia in older persons with medically (un)explained physical symptoms, 2022, Bos et al

Andy

Andy

Retired committee member
Abstract

Objectives
Much is unknown about the combination of Medically Unexplained Symptoms (MUS) and alexithymia in later life, but it may culminate in a high disease burden for older patients. In the present study we assess the prevalence of alexithymia in older patients with either MUS or Medically Explained Symptoms (MES) and we explore physical, psychological and social correlates of alexithymia.

Methods and Design
A case control study was performed. We recruited older persons (>60 years) with MUS (N = 118) or MES (N = 154) from the general public, general practitioner clinics and hospitals. Alexithymia was measured by the 20-item Toronto Alexithymia Scale, correlates were measured by various questionnaires.

Results
Prevalence and severity of alexithymia were higher among older persons with MUS compared to MES. Alexithymia prevalence in the MUS subgroup was 23.7%. We found no association between alexithymia and increasing age. Alexithymia was associated with depressive symptoms, especially in the MUS population.

Conclusions
Alexithymia prevalence was lower than generally found in younger patients with somatoform disorder, but comparable to studies with similar diagnostic methods for MUS. Considering the high prevalence and presumed etiological impact of alexithymia in older patients with MUS, as well as its association with depression, this stresses the need to develop better understanding of the associations between alexithymia, MUS and depression in later life.

Open access, https://onlinelibrary.wiley.com/doi/10.1002/gps.5736
 
Presence of hypochondriac cognitions was assessed by the Whitely Index in which 14 statements have to be answered ‘yes’ or ‘no’ with higher scores indicating more hypochondriac cognitions.
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Ignore the factor loading bit of this table which I found online. I've copied the image here because I think it's not an appropriate index to use with people with conditions like ME where some of the questions the rational answer is yes because of ME symptoms and clinicians telling us there's nothing wrong.

2-Table1-1.png
 
I found a copy of the 20-item Toronto Alexithymia Scale on an Autism website:
https://embrace-autism.com/toronto-alexithymia-scale/#Taking_the_test

Toronto Alexithymia Scale (TAS-20)
Choose one response that best describes how each item applies to you:

1. I am often confused about what emotion I am feeling.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
2. It is difficult for me to find the right words for my feelings.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
3. I have physical sensations that even doctors don’t understand.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
4. I am able to describe my feelings easily.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
5. I prefer to analyze problems rather than just describe them.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
6. When I am upset, I don’t know if I am sad, frightened, or angry.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
7. I am often puzzled by sensations in my body.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
8. I prefer to just let things happen rather than to understand why they turned out that way.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
9. I have feelings that I can’t quite identify.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
10. Being in touch with emotions is essential.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
11. I find it hard to describe how I feel about people.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
12. People tell me to describe my feelings more.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
13. I don’t know what’s going on inside me.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
14. I often don’t know why I am angry.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
15. I prefer talking to people about their daily activities rather than their feelings.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
16. I prefer to watch “light” entertainment shows rather than psychological dramas.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
17. It is difficult for me to reveal my innermost feelings, even to close friends.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
18. I can feel close to someone, even in moments of silence.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
19. I find examination of my feelings useful in solving personal problems.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
20. I look for hidden meanings in movies or plays.
  1. Strongly Disagree
  2. Disagree
  3. Neither Agree nor Disagree
  4. Agree
  5. Strongly Agree
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Scoring
  • Total scores can range from 20–100, with higher scores indicating greater impairment/challenges.
  • Each item is scored on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree).
  • Five of the items are reverse-scored: 4, 5, 10, 18, and 19.
The total alexithymia score is the sum of responses to all 20 items, while the score for each subscale factor is the sum of the responses to that subscale.

The TAS-20 uses cutoff scoring:

  • Scores equal to or less than 51 = no alexithymia.
  • Scores of 52–60 = possible alexithymia.
  • Scores equal to or greater than 61 = alexithymia.
The TAS-20 has 3 subscales:

  • Difficulty Describing Feelings: 5 items (2, 4, 11, 12, 17).
  • Difficulty Identifying Feelings: 7 items (1, 3, 6, 7, 9, 13, 14).
  • Externally-Oriented Thinking: 8 items (5, 8, 10, 15, 16, 18, 19, 20).
Your highest average score on the subtypes shows what part of alexithymia you have the greatest challenge with.
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Edit: Note the bit about some questions being reverse scored - that confused me at first.

If you go to the website I linked, you can take the test for yourself and it will automatically score it for you and give you the subscores for the 3 subsections.

To me it seems inappropriate for someone with MUS, ME/CFS etc because some questions that would contribute to the score are actually about having unexplained symptoms.

For example:

2. It is difficult for me to find the right words for my feelings.
3. I have physical sensations that even doctors don’t understand.
7. I am often puzzled by sensations in my body.
17. It is difficult for me to reveal my innermost feelings, even to close friends.

It is perfectly reasonable for someone with ME/CFS to score high on these without it reflecting alexithymia at all. 2 because of cognitive dysfunction, and 3 and 7 because the whole point of medically unexplained symptoms is that the doctor doesn't understand them, The clue is in the name.
And 17 because having severe ME cuts a lot of us off from close friendships and exhaustion levels can preclude heart to heart conversations even if our close friends believe how sick we are. Emoting is exhausting.

So the whole stuff about differences between MUS and MES groups is just down to unsuitable questionnaires, not differences in alex..wotsit.
 
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The paper said:
Medically Explained Symptoms
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What would those be? There is nothing known about the biology of symptoms, all there is is association: this symptom is associated with this diagnosis or disease process. That's not an explanation. It's completely arbitrary, especially since it depends on perception of the disease, so that symptoms of cancer will be considered explained, while the same symptoms in ME will be dismissed, not because the symptoms themselves are explained, but based entirely on the recognition and perception of the diagnosis in medicine.

The conclusion is ridiculous. This is not a serious field of study.
 
As to statement number 3 in Trish's post:

"I have physical sensations even my doctors don't understand."

Yes, right up until Covid. Now that many people have experienced long-covid -- surprise -- much understanding has ensued.

These MUS that had in the past been systematically reframed as health anxiety so as to easily be ignored now turn out to be a real physical health issue as understood by the many health care practitioner's who now suffer these symptoms.

And still the band plays on for the MUS/BPS cabal. They are deeply invested in there alternative reality and can't let go. I think that's a mental health issue.
 
About alexithymia :

" The concept itself is debated and does not appear in international nosographic classifications." https://fr.wikipedia.org/wiki/Alexithymie

Thus, alexithymia isn't even in the DSM-5, the bible of psychiatrists. It is one of many concepts from psychoanalysis and psychosomatic theory. Here is its origin and on what basis it has been developed :

" Dr Sifneos’s * interest in psychosomatic medicine started early in his career when treating patients with so called psychosomatic illness. He observed that they often had an inability to find the appropriate words to describe their feelings. He discussed this at length with Dr John Nemiah, a close friend, who affirmed the observation. As a result, in 1972 Dr Sifneos introduced the term alexithymia from the Greek a for lack, lexis for word, and thymos for emotion, meaning lack of words for emotions. The term described a marked difficulty in experiencing, identifying, differentiating and expressing feelings; as well as a paucity of fantasies and a utilitarian (stimulus bound and tied to reality) way of thinking."
https://news.harvard.edu/gazette/story/2010/05/peter-emanuel-sifneos/

Thereby, the study authors of this thread wrote :

The idea that patients with alexithymia misinterpret physiological arousal associated with emotion as somatic symptoms18 has made alexithymia a presumed etiological factor in Medically Unexplained Symptoms (MUS).
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We know that's what they (authors) tend to think (irrepressible desire, perhaps ?), unfortunately for them, 76.3% of MUS patients did not have alexithymia according to their study !


* Peter Emanuel Sifneos, M.D. Professor Emeritus of Psychiatry at Harvard Medical School

* John Case Nemiah, Professor Emeritus of Psychiatry at both Harvard Medical School and Dartmouth Medical School
 
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