Attention-deficit/hyperactivity disorder and alexithymia: a pilot study

Although the relationship between alexithymia and psychopathology has been studied extensively in adults, research is lacking on alexithymia in childhood psychopathology. The aim of this study was to investigate the relationship between alexithymia and attention-deficit/hyperactivity disorder (ADHD). The Italian version of the Alexithymia Questionnaire for Children was administered to a sample of 50 children with a DSM-IV diagnosis of ADHD, as assessed by means of the K-SADS PL, and to 100 healthy, age- and sex-matched children without ADHD. The total alexithymia score as well as the difficulty in identifying feelings (DIF) and externally oriented thinking factors were significantly associated with ADHD. The total alexithymia score, the DIF, and the difficulty in describing feelings factors were also significantly associated with symptoms of hyperactivity/impulsivity. No significant relationship between alexithymia and inattentiveness symptoms emerged. Results provide preliminary data on the relationship between alexithymia and ADHD. Findings point to an association between difficulty in identifying emotions and hyperactivity/impulsivity. Future studies conducted on larger patient samples, as well as longitudinal designs, are warranted to confirm our findings.     

Gender, Suicide, and the Sociocultural Context of Deliberate Self-Harm in an Urban General Hospital in Mumbai, India

Recognizing the complementary effects of social contexts and psychiatric disorders, this study clarifies the role of gender in suicidal behavior in urban Mumbai by considering psychiatric diagnoses and patient-identified sociocultural features. The cultural epidemiological approach suggests the critical impact of situational sociocultural factors that complement the customary psychopathological accounts for those who harm or kill themselves. The cultural epidemiology of deliberate self-harm (DSH), it is argued, is critical to planning for suicide prevention, community mental health and psychiatric practice. This study, based on a cultural epidemiological framework, compares male and female admissions for DSH, evaluating conditions with SCID-I and EMIC interviews. We assessed features and narratives of suicidal behavior, patient-identified underlying problems, their perceived causes and triggers. The study included 92 women and 104 men. A diagnosis of depressive disorder was made for 48.9 percent of women and 39.4 percent of men. Many patients (50.0 percent of women and 41.3 percent of men) did not fulfill the criteria for any diagnosis, or did so only for an adjustment disorder or a V-code. Men typically explained DSH with reference to work problems, financial problems and problem drinking. Women typically discussed domestic problems, in-law relations and victimization. Problem drinking affected women living with men who drank. Social and situational factors appear to play a relatively greater role than psychiatric illness in self-harm and suicide in Mumbai, as in other Asian studies, compared with Europe and North America.     

The alexithymic brain: the neural pathways linking alexithymia to physical disorders

Alexithymia is a personality trait characterized by difficulties in identifying and describing feelings and is associated with psychiatric and psychosomatic disorders. The mechanisms underlying the link between emotional dysregulation and psychosomatic disorders are unclear. Recent progress in neuroimaging has provided important information regarding emotional experience in alexithymia. We have conducted three brain imaging studies on alexithymia, which we describe herein. This article considers the role of emotion in the development of physical symptoms and discusses a possible pathway that we have identified in our neuroimaging studies linking alexithymia with psychosomatic disorders. In terms of socio-affective processing, alexithymics demonstrate lower reactivity in brain regions associated with emotion. Many studies have reported reduced activation in limbic areas (e.g., cingulate cortex, anterior insula, amygdala) and the prefrontal cortex when alexithymics attempt to feel other people’s feelings or retrieve their own emotional episodes, compared to nonalexithymics. With respect to primitive emotional reactions such as the response to pain, alexithymics show amplified activity in areas considered to be involved in physical sensation. In addition to greater hormonal arousal responses in alexithymics during visceral pain, increased activity has been reported in the insula, anterior cingulate cortex, and midbrain. Moreover, in complex social situations, alexithymics may not be able to use feelings to guide their behavior appropriately. The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice. The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level and less in the cognitive-experiential domains of the emotional response system. Affects may play an important role in alleviating intrinsic physiologic reactions and adapting to the environment. Deficient development of emotional neural structures may lead to hypersensitivity to bodily sensations and unhealthy behaviors, a possible mechanism linking alexithymia to psychosomatic disorders.     

Dreaming correlates of alexithymia among sleep-disordered patients.

Increasing evidence supports the clinical view that alexithymia is associated with disturbed dreaming. However, a consistent, replicable pattern of relationships between alexithymia and different dreaming components has not yet been identified. Groups of sleep-disordered outpatients (N = 580; 46.0 ± 13.2 years) and nonclinical controls (N = 145; 22.9 ± 4.2 years) were administered the Toronto Alexithymia Scale (TAS-20) and a 14-item Dreaming Questionnaire. Sleep diagnoses were assessed from polysomnography and clinical histories following the American Academy of Sleep Medicine classification system. The Dreaming Questionnaire was reduced by principal-components analysis to a 3-factor solution that distinguishes nightmare distress, dream recall, and dream meaning items. Factor coefficients were correlated with TAS total score and TAS subscales while age was controlled as a covariate. TAS total score was found to correlate positively with nightmare distress and negatively with dream recall for both clinical and nonclinical groups and for both men and women considered separately. TAS total score also correlated negatively with dream meaning for nonclinical participants. TAS subscales were differentially correlated with the 3 dream factors: difficulty identifying feelings (DIF) with increased nightmare distress, difficulty describing feelings (DDF) with decreased dream recall and externally oriented thinking (EOT) with decreased dream meaning. With some exceptions, these patterns were obtained independently for clinical and nonclinical groups and for men and women within these groups. Findings suggest a consistent and replicable pattern of relationships between alexithymia and dreaming components that implicates processes regulating emotion during both wakefulness and dreaming, for example, affect distress, expressive anxiety, and openness to experience. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Empathy in Clinical Practice: How Individual Dispositions,Gender, and Experience Moderate Empathic Concern,Burnout, and Emotional Distress in Physicians

To better understand clinical empathy and what factors can undermine its experience and outcome in care-giving settings, a large-scale study was conducted with 7,584 board certified practicing physicians. Online validated instruments assessing different aspects of empathy, distress, burnout, altruistic behavior, emotional awareness, and well-being were used. Compassion satisfaction was strongly associated with empathic concern, perspective taking and altruism, while compassion fatigue (burnout and secondary traumatic stress) was more closely related to personal distress and alexithymia. Gender had a highly selective effect on empathic concern, with women displaying higher values, which led to a wide array of negative and devalued feelings. Years of experience did not influence dispositional measures per se after controlling for the effect of age and gender. Participants who experienced compassion fatigue with little to no compassion satisfaction showed the highest scores on personal distress and alexithymia as well as the strongest indicators of compassion fatigue. Physicians who have difficulty regulating their negative arousal and describing and identifying emotions seem to be more prone to emotional exhaustion, detachment, and a low sense of accomplishment. On the contrary, the ability to engage in self-other awareness and regulate one’s emotions and the tendency to help others, seem to contribute to the sense of compassion that comes from assisting patients in clinical practice.     

Essential fatty acids and their role in the treatment of impulsivity disorders

Essential fatty acids (EFAs) have been shown to benefit patients with depression, schizophrenia and dementia. More recently, their role in disorders characterised by impulsivity has attracted some attention. The psychiatric conditions of attention-deficit hyperactivity disorder and borderline personality disorder as well as the phenomena of deliberate self-harm and violence have been ameliorated by the supplementation of EFAs in a number of recent clinical trials. This paper summarises the burgeoning clinical and basic research indicating the existence of significant deficits of EFAs in impulsivity disorders and the supplementation studies of EFAs in these diverse conditions, all of which remain a major therapeutic challenge.     

How Does Emotional Context Modulate Response Inhibition in Alexithymia: Electrophysiological Evidence from an ERP Study

Background

Alexithymia, characterized by difficulties in identifying and describing feelings, is highly indicative of a broad range of psychiatric disorders. Several studies have also discovered the response inhibition ability impairment in alexithymia. However, few studies on alexithymic individuals have specifically examined how emotional context modulates response inhibition procedure. In order to investigate emotion cognition interaction in alexithymia, we analyzed the spatiao-temporal features of such emotional response inhibition by the approaches of event-related potentials and neural source-localization.

Method

The study participants included 15 subjects with high alexithymia scores on the 20-item Toronto Alexithymia Scale (alexithymic group) and 15 matched subjects with low alexithymia scores (control group). Subjects were instructed to perform a modified emotional Go/Nogo task while their continuous electroencephalography activities were synchronously recorded. The task includes 3 categories of emotional contexts (positive, negative and neutral) and 2 letters (“M” and “W”) centered in the screen. Participants were told to complete go and nogo actions based on the letters. We tested the influence of alexithymia in this emotional Go/Nogo task both in behavioral level and related neural activities of N2 and P3 ERP components.

Results

We found that negatively valenced context elicited larger central P3 amplitudes of the Nogo–Go difference wave in the alexithymic group than in the control group. Furthermore, source-localization analyses implicated the anterior cingulate cortex (ACC) as the neural generator of the Nogo-P3.

Conclusion

These findings suggest that difficulties in identifying feelings, particularly in negative emotions, is a major feature of alexithymia, and the ACC plays a critical role in emotion-modulated response inhibition related to alexithymia.     

Dorsal Anterior Cingulate Thickness Is Related to Alexithymia in Childhood Trauma-Related PTSD

Alexithymia, or “no words for feelings”, is highly prevalent in samples with childhood maltreatment and posttraumatic stress disorder (PTSD). The dorsal anterior cingulate cortex (dACC) has been identified as a key region involved in alexithymia, early life trauma, and PTSD. Functional alterations in the dACC also have been associated with alexithymia in PTSD. This study examined whether dACC morphology is a neural correlate of alexithymia in child maltreatment-related PTSD. Sixteen adults with PTSD and a history of childhood sexual abuse, physical abuse, or exposure to domestic violence, and 24 healthy controls (HC) completed the Toronto Alexithymia Scale 20 (TAS–20) and underwent magnetic resonance imaging. Cortical thickness of the dACC was measured using FreeSurfer, and values were correlated with TAS–20 scores, controlling for sex and age, in both groups. Average TAS–20 score was significantly higher in the PTSD than the HC group. TAS–20 scores were significantly positively associated with dACC thickness only in the PTSD group. This association was strongest in the left hemisphere and for TAS–20 subscales that assess difficulty identifying and describing feelings. We found that increasing dACC gray matter thickness is a neural correlate of greater alexithymia in the context of PTSD with childhood maltreatment. While findings are correlational, they motivate further inquiry into the relationships between childhood adversity, emotional awareness and expression, and dACC morphologic development in trauma-related psychopathology.     

Neuroimaging studies of alexithymia: physical,affective, and social perspectives

Alexithymia refers to difficulty in identifying and expressing one’s emotions, and it is related to disturbed emotional regulation. It was originally proposed as a personality trait that plays a central role in psychosomatic diseases. This review of neuroimaging studies on alexithymia suggests that alexithymia is associated with reduced neural responses to emotional stimuli from the external environment, as well as with reduced activity during imagery, in the limbic and paralimbic areas (i.e., amygdala, insula, anterior/posterior cingulate cortex). In contrast, alexithymia is also known to be associated with enhanced neural activity in somatosensory and sensorimotor regions, including the insula. Moreover, neural activity in the medial, prefrontal, and insula cortex was lowered when people with alexithymia were involved in social tasks. Because most neuroimaging studies have been based on sampling by self-reported questionnaires, the contrasted features of neural activities in response to internal and external emotional stimuli need to be elucidated. The social and emotional responses of people with alexithymia are discussed and recommendations for future research are presented.     

Alexithymia and the Processing of Emotional Facial Expressions (EFEs): Systematic Review, Unanswered Questions and Further Perspectives

Alexithymia is characterized by difficulties in identifying, differentiating and describing feelings. A high prevalence of alexithymia has often been observed in clinical disorders characterized by low social functioning. This review aims to assess the association between alexithymia and the ability to decode emotional facial expressions (EFEs) within clinical and healthy populations. More precisely, this review has four main objectives: (1) to assess if alexithymia is a better predictor of the ability to decode EFEs than the diagnosis of clinical disorder; (2) to assess the influence of comorbid factors (depression and anxiety disorder) on the ability to decode EFE; (3) to investigate if deficits in decoding EFEs are specific to some levels of processing or task types; (4) to investigate if the deficits are specific to particular EFEs. Twenty four studies (behavioural and neuroimaging) were identified through a computerized literature search of Psycinfo, PubMed, and Web of Science databases from 1990 to 2010. Data on methodology, clinical characteristics, and possible confounds were analyzed. The review revealed that: (1) alexithymia is associated with deficits in labelling EFEs among clinical disorders, (2) the level of depression and anxiety partially account for the decoding deficits, (3) alexithymia is associated with reduced perceptual abilities, and is likely to be associated with impaired semantic representations of emotional concepts, and (4) alexithymia is associated with neither specific EFEs nor a specific valence. These studies are discussed with respect to processes involved in the recognition of EFEs. Future directions for research on emotion perception are also discussed.     

Evaluation of selected personality features in patients with various clinical forms of bronchial asthma]

Psychological factors are of importance in the onset and clinical course of the bronchial asthma. Marked emotional disorders are seen in patients with atypical asthma. This study aimed at evaluating selected personality features in patients with various clinical forms of the bronchial asthma. Statistical analysis included 91 asthmatic patients and 30 healthy individuals being a control group. Selected personality features were evaluated with three psychological tests: Eysenck Personality Inventory, Minnesota Multiphasic Personality Inventory, and Cattel's Self cognition Chart. The obtained results have shown that the index of psychopathologies is higher in patients with non-atopic bronchial asthma than in patients with atopic asthma. Therefore, psychotherapy of asthmatic patients, especially with non-atopic form of the disease, should emphasize disturbances of experienced feelings in such patients.     

Emotional Eating,Alexithymia, and Binge‐Eating Disorder in Obese Women

Objective: To investigate the relationships between alexithymia and emotional eating in obese women with or without Binge Eating Disorder (BED). Research Methods and Procedures: One hundred sixty‐nine obese women completed self‐report questionnaires, including the Beck Depression Inventory, the State Trait Anxiety Inventory, the Stress Perceived Scale, the Dutch Eating Behaviour Questionnaire, and the Toronto Alexithymia Scale. The presence of BED, screened using the Questionnaire of Eating and Weight Patterns, was confirmed by interview. Results: Forty obese women were identified as having BED. BED subjects and non‐BED subjects were comparable in age, body mass index, educational level, and socioeconomic class. According to the Dutch Eating Behaviour Questionnaire, BED subjects exhibited higher depression, anxiety, perceived stress, alexithymia scores, and emotional and external eating scores than non‐BED subjects. Emotional eating and perceived stress emerged as significant predictors of BED. The relationships between alexithymia and emotional eating in obese subjects differed between the two groups according to the presence of BED. Alexithymia was the predictor of emotional eating in BED subjects, whereas perceived stress and depression were the predictors in non‐BED subjects. Discussion: This study pointed out different relationships among mood, alexithymia, and emotional eating in obese subjects with or without BED. Alexithymia was linked to emotional eating in BED. These data suggest the involvement of alexithymia in eating disorders among obese women.     

Alexithymia impact on EEG activity of anterior and posterior regions of the right hemisphere while experiencing positive and negative emotions

The present study was aimed to assess the influence of alexithymia (an emotional disorder associated with difficulties in identification and describing personal feelings) on regional activity while experiencing positive or negative emotional activation. The 62-channels EEG was recorded in non-alexithymic (n = 27) and alexithymic (n = 17) subjects viewing emotional film clips. Effects of alexithymia were found in the upper theta, low and upper alpha frequency bands; for all the bands the alexithymics exhibited greater reactivity of the right hemisphere, suggesting enhanced avoidance motivational tendencies, negative effect and autonomic arousal. The present phenomenon suggests engagement of additional cognitive resources in identification of emotional feelings. Such a 'cognitive effort' can be a result of impaired referential links and deficit of symbolic processing of emotions.     

Early childhood sexual abuse increases suicidal intent

Childhood sexual abuse has been consistently associated with suicidal behavior. We studied suicide attempt features in depressed individuals sexually abused as children. On average, sexual abuse started before age 9. It frequently coexisted with physical abuse. Suicide attempters more often had personality disorders and had endured abuse for longer, but did not differ in terms of other clinical characteristics from non‐attempters. Earlier onset of sexual abuse and its duration were associated with more suicide attempts. However, when personality disorders were included in the regression model, only these disorders predicted number of attempts. The severity of sexual abuse and the coexistence of physical abuse were correlated with age at first suicide attempt. However, only severity of sexual abuse was marginally associated with age at first suicide attempt in the regression model. Finally, the earlier the age of onset of sexual abuse, the higher the intent, even after controlling for age, sex and personality disorders. This suggests that the characteristics of childhood sexual abuse, especially age of onset, should be considered when studying the risk for suicidal behavior in abused populations.     

Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey

Data on the prevalence of psychiatric disorders in late life are lacking. The present study addresses this gap in the literature by examining the prevalence of the broadest range of psychiatric disorders in late life to date; comparing prevalences across older adult age groups using the largest sample of adults aged 85+; and exploring gender differences in the prevalence of psychiatric disorders in late life. Using data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, we examined the prevalence of past-year mood, anxiety, and substance use disorders, and lifetime personality disorders in a nationally representative sample of 12,312 U.S. older adults. We stratified our analyses by gender and by older age groups: young-old (ages 55-64), middle-old (ages 65-74), old-old (ages 75-84), and oldest-old (ages 85+). The proportion of older adults who experienced any past-year anxiety disorder was 11.4%, while the prevalence of any past-year mood disorder was 6.8%. A total of 3.8% of older adults met criteria for any past-year substance use disorder, and 14.5% of older adults had one or more personality disorder. We observed a general pattern of decreasing rates of psychiatric disorders with increasing age. Women experienced higher rates of mood and anxiety disorders, while men had higher rates of substance use disorders and any personality disorder. Gender differences in rates of most psychiatric disorders decreased with increasing age. These data indicate that psychiatric disorders are prevalent among U.S. older adults, and support the importance of prevention, diagnosis, and treatment of psychiatric disorders in this population.     

Self-harm: 2. Deliberate nonfatal self-harm.

The incidence of deliberate acts of self-harm, such as drug overdoses, has greatly increased in the past two decades. The term "suicide attempt" is really a misnomer. For most people who harm themselves the primary motivation is rarely to die. As well, there are many differences between self-harm patients and patients who have committed suicide. The former tend to be characterologically disturbed and socially disadvantaged. Intervention narrowly focused on suicide prevention will lead to lengthy hospital stays in high-risk cases and ineffective treatment for most self-harm patients, who tend not to comply with outpatient treatment. Crisis-oriented intervention with a brief hospital stay in all cases of self-harm may provide more effective assessment and management.     

Borderline personality disorder

BORDERLINE PERSONALITY DISORDER is a chronic psychiatric disorder characterized by marked impulsivity, instability of mood and interpersonal relationships, and suicidal behaviour that can complicate medical care. Identifying this diagnosis is important for treatment planning. Although the cause of borderline personality disorder is uncertain, most patients improve with time. There is an evidence base for treatment using both psychotherapy and psychopharmacology. The clinical challenge centres on managing chronic suicidality.CaseColleen, a 22-year old student, is seen for a psychiatric assessment after presenting to the emergency department because of taking an overdose of acetaminophen pills. Although the immediate precipitant to her suicide attempt was a break-up with her boyfriend, she has a history of multiple suicide attempts since the age of 14. Colleen reports that she has daily mood swings, from depression to intense anger, and that she often cuts herself on the wrists and arms to relieve dysphoria. When stressed, she experiences feelings of unreality, sometimes hearing a voice telling her to kill herself. Colleen has had highly problematic relationships with men, falling quickly in and out of love and feeling that her life depends on them, even when they have behaved abusively toward her. What is the appropriate diagnosis and management of this patient?Personality disorders constitute a major group in the classification of mental disorders. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR),¹ these conditions are defined by maladaptive personality characteristics beginning early in life that have consistent and serious effects on functioning. Borderline personality disorder (BPD) is frequently seen in clinical practice.² Characterized by emotional turmoil and chronic suicidality (suicide ideation and attempts), this type of personality disorder presents some of the most difficult and troubling problems in all of psychiatry.     

D4 dopamine-receptor (DRD4) alleles and novelty seeking in substance-dependent, personality-disorder, and control subjects.

Two reports have been published suggesting an association between the personality trait of novelty seeking and the DRD4*7R allele at the D4 dopamine-receptor locus (with heterozygotes or homozygotes for DRD4*7R having higher novelty seeking). We studied novelty seeking and four coding-sequence polymorphisms affecting protein structure in the D4 dopamine-receptor gene (DRD4) in a sample of 341 American subjects, of whom 224 are of primarily European ancestry and 117 are of primarily African ancestry. These subjects had diagnoses of substance dependence or personality disorder (PD) or were screened to exclude major psychiatric diagnosis. We found that, although the substance-dependent subjects had significantly higher novelty seeking than the control and PD subjects, they did not differ in DRD4*7R allele frequency. There was no association between any DRD4 polymorphism and novelty seeking in any population or diagnostic group, except for a significant association between the DRD4*7R allele and lower novelty seeking among European American females and African American substance abusers. The novelty seeking of subjects heterozygous for a null mutation did not differ from that of subjects with two functional alleles. We conclude that the most likely explanation of these results is that the DRD4 VNTR does not influence directly the trait of novelty seeking, in these samples.     

Features of EEG in patients with disorders due to psychoactive substance use during olfactory stimulation

Electroencephalographic (EEG) spectra have been analyzed under baseline conditions and during olfactory stimulation in substance-dependent and healthy subjects. The intergroup differences in the EEG spectra resulting from an increase in the power of cortical bioelectric potentials in patients with disorders due to psychoactive substance use were recorded in the parietal and temporal EEG leads. Interhemispheric differences have been found in the contribution of different frequencies to the spectral characteristics of the EEG. In patients with addictive disorders, in the temporal area of the left hemisphere, in the high-frequency range, a significant increase in the power of bioelectric potentials was recorded under baseline conditions and during olfactory stimulation. An increased power of α activity was typical of the temporal area of the right hemisphere in patients with disorders due to psychoactive substance use compared to the healthy subjects. The neurophysiological patterns found may be related to the psychological and behavioral features of addictive disorders.