Abstract
Background: Although the constructs of alexithymia
and emotional control have been associated with physical health, the relationship between
these constructs is unclear and their influence on health-related quality of life has not
been investigated previously. This study examined the relationships between alexithymia,
emotional control, and quality of life in 74 patients with inflammatory bowel disease
(IBD). Methods: The subjects completed the 20-item Toronto Alexithymia Scale
(TAS-20), the Emotional Expression and Control Scale (EEC), and the Inflammatory Bowel
Disease Questionnaire (IBDQ) for assessing quality of life. Results: The TAS-20
correlated negatively and significantly with the IBDQ global score and with subscales
assessing bowel symptoms, systemic symptoms, and emotional functioning; the emotional
control subscale of the EEC correlated positively and significantly with these measures.
Although the TAS-20 correlated significantly and negatively with the emotional control
subscale, alexithymia and quality of life scores were unrelated to subscales of the EEC
assessing tendencies to either hold emotions in or express emotions outwardly. A
hierarchical stepwise multiple regression analysis revealed that alexithymia, and to a
lesser extent emotional control, play a role in predicting quality of life in patients
with IBD. Conclusions: Alexithymia and emotional control are negatively related
constructs and each construct has an independent influence on the subjective health status
of patients with IBD.
Introduction
Several emotion-related constructs
have been linked with increased health problems including alexithymia, emotional control,
inhibition, and the repressive-defensive coping style [1-6]. Although emotional control
and inhibition appear to be very similar constructs, clinicians and researchers sometimes
fail to recognise subtle differences between them and that they are conceptually distinct
from both the alexithymia construct and the repressive coping style [3, 4].
As defined in the literature, the repressive
coping style is largely an unconscious process of holding distressing thoughts and
feelings out of awareness [4, 7]; inhibition and emotional control refer to conscious
processes in which an individual actively restrains or holds back from expressing the
emotions he or she is feeling [2, 8, 9]. In contrast to the defensive nature of either
unconsciously repressing emotional experience or consciously controlling emotional
expression, alexithymia involves a deficit in the mental representation of emotions
[1, 10]. Consequently, although alexithymic individuals show a tendency to experience high
levels of negative emotion, they have difficulty in identifying and verbally expressing
their subjective feelings [1, 11].
Recent studies exploring the relationship
between alexithymia and the repressive coping style have demonstrated that these are
distinct constructs with repressors (identified by high scores on measures of
defensiveness and low scores on measures of trait anxiety) being more like individuals who
score low on self-report measures of alexithymia [12, 13]. To date, the only study
reporting empirical relationships between alexithymia and inhibition and emotional control
was conducted by King, Emmons, and Woodley [4] with a sample of undergraduate students.
The students were administered a large number of questionnaires including the Toronto
Alexithymia Scale (TAS) [14], the Emotional Control Questionnaire (ECQ), which measures
the tendency to inhibit emotional expression [15], and the Rosenbaum Self-Control Schedule
(S-CS), which assesses the ability to employ a variety of self-control methods including
cognitive control of emotional responses [16]. The results of the study were conflicting;
the TAS correlated negatively with the S-CS, but positively with the Emotional Inhibition
subscale of the ECQ. In contrast to the TAS and S-CS, however, the Emotional Inhibition
scale lacked internal reliability.
While the relationship between alexithymia and
emotional control requires further investigation, research is also needed to determine
whether there are different ways in which these constructs might influence mental and
physical health. There is some evidence, for example, that alexithymic characteristics
might influence symptom reporting and treatment-seeking [17-19]. Also, it has been
suggested that alexithymia might be an adaptive mechanism that emerges in some individuals
to help them cope with the emotional impact of a chronic illness or other specific
stressful situations [20, 21]. To date, however, there has been little attempt to examine
the influence of alexithymia and emotional control on the subjective health status
(quality of life) of patients with chronic medical illnesses.
The aims of the present study were to examine
further the relationship between alexithymia and emotional control, and to explore the
impact of each of these constructs on the health- related quality of life in patients with
inflammatory bowel disease.
Method
Subjects
The subjects comprised 74 patients
(26 men and 48 women) with inflammatory bowel disease (IBD) who attended the
gastroenterology outpatient clinic at a large metropolitan hospital in Portugal over a one
year period between April 1995 and March 1996. Patients were invited to participate in the
study if they were the first patient of the day to come to the clinic and had a definite
diagnosis of IBD established both clinically and by means of radiological, endoscopic,
and/or histologic examination. All subjects were Caucasian, had a minimum of 4 years
education, and volunteered to take part in the study. The mean age of the group was 38.1
years (SD = 13.4), and the mean duration of illness was 10.0 years (SD = 7.8). The level
of disease activity of the participants was established by the gastroenterologist’s
ratings on a five-point scale ranging from 0=very good (inactive) and 1=good (mild), to
2=fair (moderate), 3=poor (severe) and 4=very poor (very severe). The mean activity rating
for the group was 1.05 (SD=0.95). According to their IBD activity, patients were taking
5-aminosalicylate – 44(90%) of the CD patients and 23(92%) of the UC patients - alone
or in combination with steroid treatment - 24(49%) of the CD patients and 7(28%) of the UC
patients). The socioeconomic level of the subjects was determined using an adaptation of
the Graffar Index [22] on which scores range from 0 to 25 with higher scores indicating
lower socioeconomic level. The mean socioeconomic index for the IBD group was 15.5 (SD =
3.5), which corresponds to Class III in the Hollingshead Index. The mean number of years
of education was 7.8 (SD = 4.2).
Of the total IBD group, 49 patients (15 men, 34
women) had a diagnosis of Crohn's disease (CD) and 25 patients (11 men, 14 women) had a
diagnosis of ulcerative colitis (UC). The CD subgroup had a mean age of 34.8 years (SD =
12.6), mean education of 8.2 years (SD = 4.2), mean socioeconomic index of 15.4 (SD =
3.6), mean duration of illness of 10.2 years (SD = 8.0) and mean disease activity rating
of 1.2 (SD=1.0). The UC subgroup had a mean age of 44.6 years (SD = 12.9), mean education
of 7.0 years (SD = 4.0), mean socioeconomic index of 15.5 (SD = 3.3), mean duration of
illness of 9.7 years (SD = 7.6) and mean disease activity rating of 0.8 (SD=0.8).
The UC subgroup of patients was found to be
significantly older than the CD subgroup (t [73] = 3.15, p < 0.01).
However, the two subgroups did not significantly differ in education, socioeconomic level,
duration of illness, and disease activity level. A chi-square test revealed no significant
difference in the ratio of men to women across the UC and CD subgroups.
Measures
The Twenty-Item Toronto Alexithymia Scale (TAS-20)
This 20 item self-report scale is a revised
version of the earlier TAS and has been shown to be a psychometrically sound measure of
the alexithymia construct [13, 23]. The English version of the TAS-20 was translated into
Portuguese with special care taken to use popular synonyms without losing connative
equivalence. This draft translation of the scale was then evaluated in some small pilot
studies in which respondents were asked to indicate uncertainties they had about the
meaning of any of the items. Based on this feedback, revisions were made to the
translation of several items, and the final Portuguese TAS-20 was back-translated by a
bilingual colleague who was blind to the original English version of the scale. Comparison
of the back-translation with the original English version of the TAS-20 indicated
excellent cross-language equivalence of the Portuguese TAS-20. Internal reliability of the
translated scale was demonstrated in preliminary testing with samples of college students
(alpha coefficient = .76) and general practice patients (alpha coefficient = .87). The
alpha coefficient in the present study was .67. Although cutoff scores have been
recommended by the developers of the TAS-20, these were not used in the present study as
they have not been validated in the Portuguese culture.
The Emotional Expression and Control Scale (EEC)
This is an 18 item scale with a 4-point
Likert rating format that was developed by Bleiker et al. [6] to assess how
individuals generally act when they are angry, anxious, or depressed. Based in part on
Spielberger's State-Trait Anger Expression Inventory [24] and the Courtauld Emotional
Control Scale devised by Watson and Greer [11], the EEC yields subscale scores for
emotional expression-in (EEI) (e.g., 'When I feel afraid or worried, I hide my worries'),
emotional expression-out (EEO) (e.g., 'When I feel unhappy or miserable, I say what I
feel'), and emotional control (EC) (e.g., 'When I feel angry or very annoyed, I control my
behaviour'). The EEC subscales each contain six items and have demonstrated adequate
internal consistency and test-retest reliability [6]. In the present study the alpha
coefficients for the subscales ranged from .89 to .93.
The Inflammatory Bowel Disease Questionnaire (IBDQ)
This 32 item questionnaire is now widely
used to assess quality of life in patients with IBD [25]. The questionnaire uses a 7-point
Likert scale to rate four aspects of health status -- (a) bowel symptoms, (b) systemic
systems, (c) emotional functioning, and (d) social functioning. Because of reverse scoring
on most of the items, higher scores indicate a better quality of life. Although the IBDQ
measures subjective symptoms that do not necessarily reflect disease activity (i.e., the
degree of inflammation or pathologic change), the assessment of the patient's perception
of illness, functional status, and emotional state, in addition to disease-specific
symptoms, provides a more accurate appraisal of health-related quality of life [26].
Previous research with a group of CD patients found that scores on all four parts of the
IBDQ improved along with improvement in disease activity ratings in response to treatment
with methotrexate [27]. In the present study the internal reliability coefficient alphas
were .92 for the IBDQ and ranged from .77 to .87 for the four subscales.
Procedure
Following medical assessment by a
gastroenterologist, all subjects completed the IBDQ and TAS-20 under the supervision of a
consultation-liaison psychiatrist who also obtained information to establish each
subject's socioeconomic index. Because of time constraints, subjects were then given a
stamped envelope containing the EEC, which they were asked to complete at home and mail
back to the clinic. Of the 74 patients, 62 (84%) spontaneously returned completed
questionnaires either by mail or by hand delivery at the time of their next appointment
within the following four week period.
Statistical Methods
Because alexithymia and emotional
control are dimensional rather than categorical constructs, the relationships among the
TAS-20, EEC, and IBDQ were evaluated by means of the Pearson product moment correlation
test. A hierarchical, stepwise multiple regression analysis was performed to assess which
of the independent variables could predict global IBDQ scores.
Results
Mean scores and standard deviations
for all of the measures are shown in Table1 for the total IBD group as well as separately
for the UC and CD subgroups. There were no significant differences between the UC and CD
subgroups on any of the measures.
Table 1.
Means and standard deviations on the IBDQ, TAS-20, and EEC for the
total IBD group
(N = 74) and for the ulcerative colitis (N = 25) and Crohn's disease
(N = 49) subgroups |
| |
|
Total IBD
group
Mean± SD |
UC group
Mean± SD |
CD group
Mean± SD |
IBDQ |
|
|
|
|
| |
Total |
154.2± 37.2 |
150.2± 41.4 |
156.2± 35.2 |
| |
Bowel |
51.9± 11.8 |
48.8± 13.1 |
53.4± 10.9 |
| |
Systemic |
20.5± 6.9 |
21.3± 6.8 |
20.1± 7.1 |
| |
Emotional |
55.6± 14.6 |
54.1± 16.1 |
56.3± 13.9 |
| |
Social |
26.2± 8.1 |
26.0± 8.4 |
26.4± 8.1 |
TAS-20 |
|
51.2± 9.7 |
50.8± 10.8 |
51.5± 9.3 |
EEC |
|
|
|
|
| |
EC |
14.0± 4.8 |
14.7± 5.3 |
13.7± 4.6 |
| |
EEO |
12.5± 4.1 |
11.7± 3.7 |
12.9± 4.3 |
| |
EEI |
13.2± 4.7 |
12.1± 5.8 |
13.7± 4.1 |
IBD =
inflammatory bowel disease; UC = ulcerative colitis; CD = Crohn's disease; IBDQ =
Inflammatory Bowel Disease Questionnaire; TAS-20 = Twenty-Item Toronto Alexithymia Scale;
EEC = Emotional Expression and Control Scale; EC = Emotional Control; EEO = Emotional
Expression-Out; EEI = Emotional Expression-In |
Note:
Because of missing data, for the EEC scores N = 62 for the total IBD group,
18 for the UC group, and 44 for the CD group. |
For the total IBD group, the
TAS-20 was unrelated to age, but correlated negatively and significantly with the number
of years of education (r = -0.34, p < 0.05) and positively and
significantly with the socioeconomic (Graffar) index (r = 0.28, p <
0.05). Alexithymia scores were not significantly related to the duration of illness or the
level of disease activity. The EEC scales and the IBDQ showed no significant relationships
with age, education, socioeconomic index, and duration of illness and rating of disease
activity.
Table 2.
Correlations between the IBDQ and the measures of alexithymia and
emotional expression and control for the inflammatory bowel disease group |
IBDQ |
TAS-20 |
EC |
EEO |
EEI |
Total |
-0.34** |
0.37** |
-0.11 |
0.04 |
Bowel |
-0.28* |
0.26* |
-0.08 |
0.03 |
Systemic |
-0.37** |
0.42** |
-0.05 |
0.06 |
Emotional |
-0.38** |
0.43** |
-0.09 |
-0.04 |
Social |
-0.18 |
0.18 |
-0.18 |
0.13 |
* p< 0.05 ** p<
0.01 |
IBDQ =
Inflammatory Bowel Disease Questionnaire; TAS-20 = Twenty-Item Toronto Alexithymia Scale;
EC = Emotional Control Scale; EEO = Emotional Expression-Out Scale; EEI = Emotional
Expression-In Scale |
Note:
Because of missing data, N = 62 for correlations between IBDQ and EC, EEO,
and EEI. |
As shown in Table 2, the TAS-20
correlated negatively and significantly with the total score on the IBDQ and with the
scores for bowel symptoms, systemic symptoms, and emotional functioning; there was no
significant correlation between the TAS-20 and social functioning. The EC scale correlated
positively and significantly with the IBDQ global score and with bowel symptoms, systemic
symptoms, and emotional functioning, but the correlation was nonsignificant for social
functioning. Correlations between the IBDQ and the EEO and EEI scales of the EEC were all
nonsignificant.
Examination of the relationships among the
measures of alexithymia and emotional expression and control revealed a significant
negative correlation (r = -0.40, p < 0.05) between the TAS-20 and the EC
scale, but alexithymia was unrelated to emotional expression-in (r = 0.13) and
emotional expression-out (r = -0.17). The EEI scale was negatively correlated with
the EEO scale (r = -0.34, p < 0.01), but uncorrelated with the EC scale (r
= 0.15). The EEO scale also was uncorrelated with the EC scale (r = -0.10).
A hierarchical, stepwise multiple regression
analysis was performed with IBDQ global scores as the dependent variable and education,
Graffar Index, TAS-20 scores, and EC scores as predictor variables. EE0 and EEI scores
were excluded from the regression model because these variables did not correlate with
IBDQ scores; education and socioeconomic index were included in the model because they
correlated significantly with TAS-20 scores. In the first step of the analysis, education
and Graffar Index were entered as a block and accounted for 2.6% of the variance; however,
these variables were nonsignificant predictors. Alexithymia scores and emotional control
scores were then entered into the model in a stepwise fashion; alexithymia scores
accounted for an additional 12.4% of the variance in predicting quality of life. In the
final step of the analysis, emotional control scores (b =0.261) were found to contribute
an additional 5.6% of the variance over and beyond the contributions of education (b =
-0.073), socioeconomic index (b = -0.094), and alexithymia (b = -0.277) (R2 =
.206; F[4,57] = 3.69, p < 0.01).
Discussion
The results of this study demonstrate
that alexithymia and emotional control are negatively related constructs and that each
construct has an influence on the health-related quality of life in patients with IBD.
Patients with a tendency to actively control their emotions subjectively experienced fewer
bowel and systemic symptoms, and better emotional functioning, than patients who were less
disposed to controlling their reactions when they experience distressing emotions.
Patients with high degrees of alexithymia experienced a lower quality of life than
patients with low degrees of alexithymia; the high alexithymic patients reported more
bowel and systemic symptoms and worse emotional functioning. Alexithymia and emotional
control did not influence the patients' social functioning such as attending school, work,
or social engagements, and participating in leisure or sports activities. Collectively,
the results suggest that IBD patients who are the most aware of their subjective feelings
(i.e., least alexithymic), but also exert the greatest control over reacting to their
emotional states, enjoy a higher quality of life than IBD patients who have difficulty
knowing what they are feeling and are less able to control their reactions when
distressing emotions are experienced.
Because of the cross-sectional design of the
study, it is not possible to determine whether alexithymia and emotional control are
antecedant personality traits or emerge in response to having IBD. Both constructs,
however, were unrelated to the duration of illness and the level of disease activity.
Previous studies with IBD patients similarly found alexithymia to be unrelated to the
duration of illness and the level of disease activity [28, 29]. But even if alexithymia is
a secondary phenomenon in some medically ill patients, the finding in the present study
that alexithymia is associated with a lower quality of life fails to support Freyberger's
[21] view that this construct reflects an adaptive coping response in IBD patients. The
findings that alexithymia was associated with less education and lower socioeconomic
status are consistent with similar findings from other recent studies [30-32]. In contrast
to alexithymia, however, education and socioeconomic status did not emerge as significant
predictors of IBDQ global scores in the multiple regression analysis.
The finding of a significant negative
correlation between the TAS-20 and the EC scale in the IBD patients is consistent with the
negative correlation between the TAS and the S-CS obtained by King et al. [4] in a student
sample, but contrasts with the positive correlation these investigators reported between
the TAS and the Emotional Inhibition scale of the ECQ. Inspection of the items on the EC
scale and the Emotional Inhibition scale, however, suggests that the scales measure
somewhat different constructs. Whereas the EC items assess the extent to which individuals
report controlling their (verbal as well as nonverbal) behaviour when particular feelings
are experienced (anxiety, worry, unhappiness, misery, anger, and annoyance) [6], only one
item on the Emotional Inhibition scale [15] refers to the control of feelings; the
remaining items (e.g., 'When someone upsets me I try to hide my feelings'; and 'When I get
upset, I like to talk to someone about it', which is negatively keyed) resemble the items
on the EEI and EEO subscales of the EEC.
As King and her colleagues [4] emphasize, it is
clearly important for investigators to recognize distinctions among the various inhibitory
constructs and to either employ multiple measures or carefully choose a scale that taps
the type of inhibition that corresponds to the researcher's definition of inhibition.
Although definitions of emotional control generally include the inhibition of overt
expression of emotional experience, the EC subscale of the EEC appears to measure an
individual's ability to contain and modulate distressing emotions; this ability includes
cognitive processes, but the tendencies to either actively suppress or verbally express
one's feelings are assessed by the EEI and EEO subscales respectively, neither of which
was associated with quality of life in the present study. Moreover, earlier research has
shown that the EC scale correlates strongly with the Rationality subscale of the
Rationality/Anti-emotionality Scale, which assesses the extent to which an individual uses
reason and logic to manage emotions [6].
Given these measurement considerations, the
finding of an inverse correlation between the TAS-20 and the EC scale is consistent both
with the theoretical view that alexithymia reflects deficits in the cognitive processing
and regulation of emotions [1, 33], and with clinical reports that alexithymic individuals
are prone to outbursts of weeping, anger, or rage [34]. Moreover, there is now empirical
evidence that alexithymic individuals tend to engage in binge eating, alcohol abuse, or
other maladaptive behaviours to regulate affects, in contrast to nonalexithymic
individuals, who tend to regulate distressing affects by reflecting on their feelings,
talking to close friends, or engaging in constructive activities [35].
Crohn's disease and ulcerative colitis are
chronic debilitating diseases that have an adverse impact on patients' lives. The results
of this study suggest that the quality of life for some patients might be improved by
psychotherapeutic interventions aimed at increasing their awareness of, and ability to
identify subjective feelings, and at teaching adaptive strategies for modulating and
controlling distressing emotional states.
