Methods and Procedures

            The purpose of this research was to test the hypothesis that alexithymia is more significantly associated with PD than with other mental health diagnoses. Alexithymia has been associated with disorders that manifest panic, depression, anxiety, substance abuse, poor impulse control, PTSD and phobia; so this study used an experimental group of individuals with PD, and a control group of individuals with a cross-section of mental health diagnoses characterized by other symptoms associated with alexithymia. Given the extent of somatization and confusion between physiological and psychological sensations in PD, this study also tested for significant differences between the groups on F1 of the TAS-20 in addition to testing for differences on F2 and F3. Also tested for was a significant variance in alexithymia prevalence between panic disordered individuals with, and those without, agoraphobia. It was also considered important to test for significant alexithymia differences by age and gender.

Participants

            This total study consisted of 60 participants from the ages of 17 to 63. All the participants in this retrospective research project were drawn from my own clinical caseload at a freestanding but hospital affiliated outpatient mental health clinic. The clinic is located in a predominately Caucasian, middle class Detroit suburban community. All participants in this study voluntarily sought mental health treatment, and were diagnosed according to DSM-IV criteria.

            The experimental PD group and control group each comprise 30 individuals. The experimental group consisted of 16 individuals with PD without agoraphobia, and 14 with PD and agoraphobia. A diagnostic breakdown of the control group is as follows: Adjustment Disorder with Depression and Anxiety (4); Alcohol Dependence (2); Anxiety Disorder (1); Dysthymic Disorder (10); Generalized Anxiety Disorder (GAD) (7); Posttraumatic Stress Disorder (PTSD) (3); Social Phobia (2); Specific Phobia (1).

            The experimental group consisted of 18 men and 12 women, with an age range of 17 to 63 and a mean age of 37.0. The control group consisted of 15 men and 15 women, with an age range of 23 to 63 with a mean age of 38.2. Composition by race of the experimental group was: 1 African American and 29 Caucasian. Composition by race of the control group was: 1 African American and 29 Caucasian.

Participant Selection

            In January 2002, I began administering the TAS-20 to all new clients who, in their presentation at intake, cited symptoms associated with the alexithymia construct. I continued to administer the scale until I obtained valid scales on 30 individuals who met DSM-IV criteria for PD, and 30 individuals who met DSM-IV criteria for disorders characterized by clinical features that have been conceptually associated with the alexithymia construct. Those 30 with a diagnosis of PD (with or without agoraphobia) constituted the experimental group, and those 30 with other diagnoses that have been associated with the alexithymia construct constituted the control group.

Materials

            The test used for this research study is the psychometrically improved revision of the original Toronto Alexithymia Scale (TAS). The revised version, the TAS-20, is a 20 item self-report instrument that assesses alexithymia (Bagby, Parker & Taylor, 1994). A copyright fee was paid to the test originators for a copy of the test, scoring, and information packet concerning construction, reliability and validity. It has a three-factor structure that is theoretically consistent with the alexithymia construct. The three factors comprise three subscales: Factor 1 (F1) – difficulty identifying feelings; Factor 2 (F2) – difficulty describing feelings; and Factor 3 (F3) – externally oriented thinking.

            The TAS-20 was developed using a combined rational and empirical method of scale construction. The reliability and validity of the TAS-20 has been supported by factor analysis, good internal consistency (Cronbach’s alpha = 0.81), and high test-retest correlations (r = 0.77; p < 0.01) over a 3-week period, consistent with the trait perspective of alexithymia. The TAS-20 also demonstrates high correlations with the Minnesota Multiphasic Personality Inventory-2 and Beth Israel Hospital Questionnaire. Consensual validity was also demonstrated by a positive correlation (r = 0.53; p = < 0.01) between observer ratings of alexithymia and TAS-20 scores in a psychiatric population (Parker, Bagby, Taylor, Endler & Schmitz, 1993). The TAS-20 authors indicate studies have supported the convergent and discriminant validity of the instrument, which they state also provides validity of the alexithymia construct (Taylor, Bagby & Parker, 1997).

            A 1993 study by Parker et al. found that men tend to have significantly higher TAS-20 scores than do women. This contrasts with three earlier studies that used the original TAS, which demonstrated no significant gender difference (Bagby, Taylor & Atkinson, 1988; Parker, Taylor & Bagby, 1989; Taylor, Parker, Bagby & Acklin, 1992). Men may demonstrate a higher degree of alexithymia than women since the processing of emotion involves lateralized cerebral functions and women appear to have a lesser degree of hemispheric specialization than men. This would also be consistent with studies that have demonstrated that women communicate information about health problems and emotions more effectively than men (Parker et al., 1993). Age has been demonstrated to have a weak correlation with total TAS-20 scores.

             The TAS-20 utilizes a five-point Likert scale with five of the items inversely scored. It is hand scored with a maximum score of 100. It uses cutoff scoring: equal to or less than 51 = non-alexithymia, equal to or greater than 61 = alexithymia. Scores of 52 to 60 = possible alexithymia. The maximum scores for each of the subscales are: Factor 1 (7 items): 35; Factor 2 (5 items): 25; Factor 3 (8 items): 40. There are no cutoff scores established for each of the three factor subscales. The following are the 20 TAS items, numbered in sequence as they appear on the test, but grouped by factor:

F1 - Difficulty Identifying Feelings

            1.   I am often confused about what emotion I am feeling.

            3.   I have physical sensations that even doctors don’t understand.

            6.   When I am upset, I don’t know if I am sad, frightened, or angry.

            7.   I am often puzzled by sensations in my body.

            9.   I have feelings that I can’t quite identify.

            13. I don’t know what’s going on inside me.

            14. I often don’t know why I am angry.

F-2 - Difficulty Describing Feelings

            2.   It is difficult for me to find the right words for my feelings.

            4.   I am able to describe my feelings easily.

            11. I find it hard to describe how I feel about people

            12. People tell me to describe my feelings more.

            17. It is difficult for me to reveal my innermost feelings, even to close friends.

F-3 - Externally-Oriented Thinking

            5.   I prefer to analyze problems rather than just describe them.

            8.   I prefer to just let things happen rather than to understand why they turned out that way.

            10. Being in touch with emotions is essential.

            15. I prefer talking to people about their daily activities rather than their feelings.

            16. I prefer to watch “light” entertainment shows rather than psychological dramas.

            18. I can feel close to someone, even in moments of silence.

            19. I find examination of my feelings useful in solving personal problems.

            20. Looking for hidden meanings in movies or plays distracts from their enjoyment.

            Note: Items 4, 5, 10, 18, and 19 are inversely keyed.

Procedure

            Participants signed informed consent forms both for treatment as well as participation in this study. (See Appendix A for complete Consent Form). Informed consent for a minor was obtained from both the minor and parent. Participants were asked to complete the TAS-20 after an explanation was provided regarding the construct being measured as well as the purpose of this study. As the participants were entering psychotherapy with me, I explained the value of evaluating for possible involvement of alexithymia, both for their treatment as well as for this research project. The TAS-20 was administered during the first history-taking, initial evaluation session, before treatment was initiated. I was responsible for administering and scoring all tests. 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.