Alexithymia and Posttraumatic Stress: Subscales and Symptom Clusters

de ric Declercq and Stijn Vanheule Fre

Ghent University m m

John Deheegher
Centre for Mental Health and Crisis Psychology
This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difculty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed. & 2010 Wiley Periodicals, Inc. J Clin Psychol 66:10761089, 2010. Keywords: alexithymia; posttraumatic stress; military nurses; military ambulance personnel

Introduction Posttraumatic stress disorder (PTSD) is a mental disorder that potentially develops after an event in which the individual experienced, witnessed, or was confronted with either actual or threatened loss of life or serious injury invoking a response of fear, helplessness, or horror. According to the fourth version of the Diagnostic and
The authors would like to thank the Centre for Mental Health and Crisis Psychology at the Military HospitalQueen Astrid for their help in the collection of the data. This research was made possible thanks to the kind permission of the Medical Component of Belgian Defence. de ric Declercq, Department of Correspondence concerning this article should be addressed to: Fre Psychoanalysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, H. Dunantlaan 2, 9000 Ghent, Belgium; e-mail: frederic.declercq@ugent.be

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(10), 10761089 (2010) Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jclp.20715

& 2010 Wiley Periodicals, Inc.

Alexthymia and Posttraumatic Stress

1077

Statistical Manual of Mental Disorders (DSM-IV), PTSD symptoms are subdivided into three categories: reexperiencing of the trauma, numbing of affect and avoidance of trauma-related stimuli, and symptoms of excessive arousal that were not present before the critical event (American Psychiatric Association, 2000). However, there is mounting evidence that these three symptom clusters, specically the amalgamation of avoidance and numbing symptoms, may not accurately reect PTSD symptomatology. Drawing upon Foa, Riggs, and Gershunys (1995) suggestion that avoidance and numbing should be considered two separate factors, researchers have found evidence for a four-factor symptom cluster that distinguishes avoidance and emotional numbing (Cordova, Studts, Hann, Jacobson, & Andrykowski, 2000; King, Leskin, King, & Weathers, 1998; Marshall, 2004; Mc Williams, Cox, & Asmundson, 2005), while others have argued in favor of a ve-factor structure that, in addition to splitting avoidance and emotional numbing, also distinguishes between hyperarousal and sleep disturbance (Simms, Watson, & Doebbeling, 2002; Witteveen et al., 2006). In sum, both research lines found evidence for treating avoidance and numbing as two distinct constructs. A consistent body of empirical studies has also shown that there is not a linear, causal relationship between a critical incident and the degree of posttraumatic stress (Breslau et al., 1998; Flannery, 1999). Because only a subgroup of individuals exposed to the same qualifying event have been shown to develop PTSD (Engdahl, Dikel, Eberly, & Blank, 1997; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler et al., 1999; Lee & Young, 2001; Paris, 2000; Perkonigg, Kessler, Stortz, & Wittchen, 2000), research has focused on the factors mediating between the experience of a critical incident and the development of posttraumatic distress (Dieperink, Leskela, Thuras, & Engdahl, 2001; Marmar, 2006; Mollica, McInnes, Poole, & Tor, 1998; Resnick, Kirkpatrick, Best, & Kramer, 1992). Alexithymia is a clinically derived concept that refers to problems in affect regulation, such as difculties with identifying, processing, and regulating emotions (Taylor, Bagby, & Parker, 1997). The most frequently used instrument to measure alexithymia is the 20-item Toronto Alexithymia Scale (TAS-20), which comprises three subscales: difculty identifying feelings (DIF), difculty describing feelings (DDF), and externally oriented thinking (EOT; Bagby, Parker, & Taylor, 1994; Bagby, Taylor, & Parker, 1994). The construct of alexithymia has been investigated in relation to various psychiatric disorders (for an overview, see Corcos & Speranza, 2003), including posttraumatic distress. A growing body of empirical evidence has shown that higher levels of alexithymia are consistently associated with higher levels of posttraumatic distress. Indeed, the elicitation of paroxysmal emotions (like, fear, horror, rage and so on) is a dening feature of a traumatic event or stressor. Therefore, the inability or difculty with identifying, processing, and regulating feelings has been found to be a risk factor for the development of a posttraumatic stress response. In a meta-analysis of the prevalence of alexithymia among 1,095 individuals with PTSD, both PTSD and alexithymia appeared to be signicantly and positively linked (Frewen et al., 2008). This correlation between alexithymia and the amount and degree of posttraumatic stress has also been demonstrated in a variety of other samples, namely, sexually abused children (Cloitre, Koenen, Cohen, & Han, 2002; Hund & Espelage, 2006), rape survivors (Zeitlin, McNally, & Cassiday, 1993), combat veterans (Badura, 2003; Hyer, Woods, Summers, Boudewyns, & Harrison, 1990; Monson, Price, Rodriguez, Ripley, & Warner, 2004; Ramirez et al., 2001), veterans who experienced military sexual trauma (OBrien, Gaher, Pope, & Smiley, 2008), holocaust survivors (Yehuda et al., 1997), and refugees (Sondergaard &
Journal of Clinical Psychology DOI: 10.1002/jclp

1078

Journal of Clinical Psychology, October 2010

Theorell, 2004). However, professionals involved in critical incidents seem to be underrepresented in current research, as only three studies were found to be devoted to this particular area: one examined re ghters (Heinrichs et al., 2005) and two others focused on police ofcers (Marmar, 2006; Mc Caslin et al., 2006). To the best of our knowledge, no studies have focused on nurses or ambulance personnel, military-related or not, despite the fact that emergency personnel must cope with a large variety of duty-related critical incidents. To examine the nature of the association between alexithymia and PTSD more closely, some research has been dedicated to examining the relationships between alexithymia total scores and the three PTSD clusters: reexperiencing, avoidance, and hyperarousal. For instance, in a sample of 166 police ofcers, McCaslin et al. (2006) found a signicant relation between alexithymia total scores and all three PTSD clusters. The studies of Yehuda et al. (1997), Sondergaard and Theorell (2004), and Monson et al. (2004) conrmed this close association between alexithymia total scores and all symptom clusters of PTSD in holocaust survivors, refugees, and combat veterans, respectively. However, Badura (2003) found only a signicant association between alexithymia total scores and numbing with veterans. In a nonspecied population of individuals with PTSD, Frewen et al. (2008) found the strongest correlations between alexithymia total scores and numbing and hyperarousal. Alexithymia total scores also appeared to be a robust predictor of numbing in Zahradnik, Stewart, Marshall, Schell, and Jaycoxs study (2009) of adult survivors of trauma requiring hospitalization. As studies rarely have compared the subdimensions of alexithymia, it is not clear whether individuals suffering from posttraumatic distress display all characteristics of alexythimia or only specic ones, and if so, which ones. Only four research groups have investigated these subdimensions more thoroughly by examining the relation between the PTSD symptom clusters and the three alexithymia dimensions: DIF, DDF, and EOT. In terms of these studies specically, the results appear more mixed. In a sample of 85 combat veterans, Monson et al. (2004) found that EOT predicted all three PTSD clusters, whereas DDF was associated only with reexperiencing. When avoidance and numbing were separated, however, EOT was associated with avoidance but not with numbing. Conversely, in a prospective study of 66 re ghters, Sondergaard and Theorell (2004) found that DIF and, to a lesser degree, DDF were correlated with all three symptom clusters. OBrien et al.s results (2008) with veterans who experienced military trauma are coherent with the latter study, as only DIF was related to the persistence of PTSD symptoms. Last, Zahradnik et al.s study (2009) found that DIF was uniquely associated with acute posttraumatic distress symptoms. The present study aims to contribute to knowledge on alexithymia and its relation to posttraumatic distress. First, it attempted to verify if the detrimental role of alexithymia in the occurrence of posttraumatic distress found in other samples also applied to a nonclinical population of professionals who experience a high amount of critical incidents. Our hypothesis was that there would be a correlation between alexithymia, as measured with the TAS-20, and the degree of posttraumatic distress experienced. Second, to examine the nature of this association more closely, the relation between the three TAS-20 subscales and the four PTSD symptom clusters was explored. As conrmatory factor analysis studies (Andrews, Joseph, Shevlin, & Troop, 2006; King et al., 1998) and research data have indicated that numbing and avoiding might have different underlying mechanisms (Flack, Litz, Hsieh, Kaloupek, & Keane, 2000; Litz, Orsillo, Kaloupek, & Weathers, 2000), the latter were examined separately in the present research.
Journal of Clinical Psychology DOI: 10.1002/jclp

Alexthymia and Posttraumatic Stress

1079

Method Participants Three hundred twenty-nine Dutch-speaking nurses and ambulance personnel who are currently, or were previously, working in the Belgian Army were identied through computerized records from the military hospital during 2005. Seventy percent (n 5 89) of the respondents were male and 30% (n 5 37) were female. The ages ranged from 20 to 51 years with a mean of 36.6 (standard deviation [SD] 5 7.08). Forty-six percent (n 5 57) of the sample was married, 30% (n 5 40) cohabiting, 6% (n 5 5) divorced, and 18% (n 5 22) single. Twenty-three percent (n 5 27) of the sample had an educational level of 02, according to the International Standard Classication of Education (ISCED, 1997). Forty-seven percent (n 5 58) had an educational level of 3 and 30% (n 5 39) had an educational level of 46. On average, the respondents were active in their current function for a period of 9.6 years (SD 5 7.88), with a minimum of zero years and a maximum of 30 years. Procedure Self-report questionnaires were sent to the participants at their workplace. There was no cost to return the questionnaires because the correspondence was internal. No incentive was given. One hundred fteen of the respondents answered the rst mailing in the summer of 2005, and an additional 21 replied to the second mailing in the fall of 2005. A total of 136 participants responded to the condential questionnaires, which means that the response rate was 41%. Twenty-eight percent of the sample (n 5 37) was currently working as a nurse, 60% (n 5 79) was working as ambulance personnel, and 12% (n 5 16) was no longer working in either function. The three professional groups (nurses, ambulance personal, and those no longer working in either function) were compared in terms of gender, marital status, educational level (using chi-square test), age, and time in service (using ANOVA). There was a slight difference between groups in terms of gender, because there were somewhat less men working as nurses and somewhat more men working as ambulance personnel (Pearson w2 5 7.250, degree of freedom [df] 5 2, p 5 0.027). There was, on the other hand, a rather large difference between groups with respect to educational level because nurses had more education than ambulance personnel (Pearson w2 5 103,767, df 5 4, p 5 0.000). Measures Age, gender, education, marital status, function, and time in service were collected using self-report. Based on the literature and experience, a tentative inventory of work-related critical incidents that could potentially be encountered by nurses and ambulance personnel was listed. This initial inventory was reviewed and completed by a small sample of nurses and ambulance personnel that were not part of this research. This resulted in a list of 27 critical incidents. Next, respondents were asked to answer which types of critical incidents they had encountered. To meet the DSM-IV-A2 criterion, the respondents were asked to indicate the degree of fear, helplessness, or horror they had experienced at the time of the critical incident. This degree of peritraumatic distress was measured on a 5-point Likert scale, ranging from no fear, helplessness, or horror to intense fear, helplessness, or horror. Indeed, the DSM-IV denition of the PTSD stressor introduced the A2 criterion, which requires that the
Journal of Clinical Psychology DOI: 10.1002/jclp

1080

Journal of Clinical Psychology, October 2010

persons response to a stressor involves intense fear, helplessness, or horror. The underlying principle behind the shift of the DSM-IV is that posttraumatic distress would be considered a function of the individuals reaction to a critical event rather than the events magnitude. Most of the research investigating the impact of the A2 criterion has been rather consistent, in that it shows that the latter criterion predicts PTSD more strongly than the DSM-III-R denition. In other words, events that did not involve intense fear, helplessness, or horror for the victim rarely resulted in PTSD (Breslau & Kessler, 2001). This outcome was found in community settings (Breslau & Kessler), civilian victims of traumatic events (Breslau & Alvarado, 2007), crime victims (Brewin, Andrews, & Rose, 2000), re ghters (Del Ben, Scotti, Chen, & Fortson, 2006), and soldiers (Engelhard & Van Den Hout, 2007). Posttraumatic stress was assessed by means of the Davidson Trauma Scale (DTS). The DTS self-report questionnaire comprises 17 questions that are scored on a 4-point Likert scale. Respondents are asked to rate the items that refer to a particular traumatic event in terms of frequency and severity. The DTS is based on the 17 DSM-IV criteria for PTSD. Previous studies reported the DTSs internal consistency to be as high as 0.99 (Davidson, Tharwani, & Connor, 2002; Davidson et al., 1997). In the present research, Cronbach as were good for the reexperience subscale (a 5 0.87), avoidance subscale (a 5 0.87), numbing subscale (a 5 0.85), hyperarousal subscale (a 5 0.88), and for the total DTS scale (a 5 0.93). Alexithymia was assessed by means of the 20-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker et al., 1994). The TAS-20 is a self-report measure used to assess alexithymia. Responses to each item are scored on a 5-point Likert scale. Empirically validated, the TAS-20 comprises three subfactors: DIF, DDF, and EOT (Bagby, Taylor et al., 1994; Meganck, Vanheule, & Desmet, 2008). In the current sample, Cronbach as of the DIF subscale and the total TAS-20 scale were good (a 5 0.85 and a 5 0.83, respectively). For the DDF subscale, Cronbach as were still acceptable (a 5 0.74), but for the EOT subscale, internal consistency was rather low (a 5 0.61). Mean scores and standard deviations for all (sub)scales can be found in Table 1. Table 1
Means and Standard Deviations of Scores
Scale Peritraumatic distress DTS Intrusion DTS Avoidance DTS Numbing DTS Hyperarousal DTS Total TAS DIF TAS DDF TAS EOT TAS Total Mean (SD) 2.81 5.96 1.16 3.06 4.90 15.09 13.26 12.74 19.95 45.94 (1.09) (6.13) (2.63) (5.37) (6.75) (16.90) (5.55) (4.03) (4.34) (10.64)

Note. SD 5 standard deviation; DTS Intrusion 5 Intrusion subscale Davidson Trauma Scale; DTS Avoidance 5 Avoidance subscale Davidson Trauma Scale; DTS Numbing 5 Numbing subscale Davidson Trauma Scale; DTS Hyperarousal 5 Hyperarousal subscale Davidson Trauma Scale; DTS Total 5 Total score Davidson Trauma Scale; TAS DIF 5 Difculty Identifying Feelings subscale Toronto Alexithymia Scale20; TAS DDF 5 Difculty Describing Feelings subscale Toronto Alexithymia Scale20; TAS EOT 5 Externally Oriented Thinking subscale Toronto Alexithymia Scale20; TAS Total 5 Total score Toronto Alexithymia Scale20. Journal of Clinical Psychology DOI: 10.1002/jclp

Alexthymia and Posttraumatic Stress

1081

Data Analysis Data were analysed using SPSS version 12.0 for Windows. One-way analyses of variance (ANOVAs) were used to examine differences in peritraumatic distress, PTSD symptoms, and alexithymia by professional group, gender, marital status, and educational level. Pearson correlations were computed for PTSD symptoms, alexithymia, and some relevant demographic predictors of PTSD symptoms, namely, age and time in service. The sample size varies because outliers above or below three standard deviations from the mean were excluded from the analysis. Next, two series of hierarchical multiple linear regressions were carried out to explore whether alexithymia was associated with the PTSD symptom outcomes independently of peritraumatic distress. In other words, it was tested whether the variance in PTSD symptoms explained by alexithymia remained after taking into account the effect of the emotions of fear, helplessness, or horror that were experienced at the time of the critical incident. In a rst series of regression analyses, peritraumatic distress was introduced in the rst step and TAS-20 total scores were introduced in the second step. To determine which specic TAS-20 subscale was the most relevant predictor for PTSD symptoms, a second series of hierarchical regressions were carried out, in which peritraumatic distress was introduced in the rst step and DIF, DDF and EOT were introduced in the second. Results Peritraumatic Distress, PTSD, Alexithymia, and Demographic Variables ANOVA was used to detect differences in peritraumatic distress and all subscales and total scores of the DTS and TAS-20 by professional group, gender, marital status, and educational level. When a signicance interval of 99% was applied, signicant differences were found between men and women with regard only to alexithymia. Women scored signicantly lower on difculty describing feelings, F(1,125) 5 8.734, p 5 0.004, externally oriented thinking, F(1,125) 5 10.846, p 5 0.001, and TAS-20 total scores, F(1,125) 5 8.949, p 5 0.003. No signicant difference was found for difculty identifying feelings. Correlations between peritraumatic distress, PTSD symptoms, alexithymia, and the demographic variables age and time in service were also examined (see Table 1). Age and time in service were mostly uncorrelated with peritraumatic distress, PTSD symptoms, and alexithymia, with the exception of marginally signicant correlations between time in service and DTS total score, on the one hand, and time in service and the EOT subscale, on the other hand. Because demographic variables made little to no difference on the variables of interest in this research, they were not included in subsequent hierarchical multiple linear regressions. Peritraumatic Distress, PTSD Scores, and Alexithymia Pearson correlations indicate a strong association between peritraumatic distress after critical incidents and PTSD symptoms (see Table 2). More specically, signicant correlations were found between peritraumatic distress and reexperiencing, numbing, and hyperarousal symptoms and the total scores for PTSD. No signicant correlation with avoidance emerged. Concerning alexithymia, the association with PTSD symptoms were more differentiated. DIF, DDF, and alexithymia total scores were signicantly correlated
Journal of Clinical Psychology DOI: 10.1002/jclp

1082

Table 2
DTS Numbing Age TAS DIF TAS DDF DTS Hyperarousal PTSD total Time in service Peritraumatic distress

Correlation Matrix of Variables Under Study

TAS EOT

DTS Intrusion

DTS Avoidance

DTS Intrusion DTS Avoidance

DTS Numbing

DTS Hyperarousal

PTSD total

Age

Journal of Clinical Psychology 0.702 n 5 123 0.609 n 5 120 0.060 n 5 123 0.137 n 5 117 0.213 n 5 121 0.377 n 5 124 0.267 n 5 124 0.055 n 5 124 0.277 n 5 124 0.737 n 5 122 0.078 n 5 125 0.125 n 5 119 0.315 n 5 123 0.361 n 5 128 0.215 n 5 128 0.019 n 5 128 0.214 n 5 123 0.063 n 5 122 0.183 n 5 117 0.373 n 5 121 0.392 n 5 124 0.259 n 5 124 0.020 n 5 124 0.219 n 5 123 0.705 n 5 116 0.070 n 5 119 0.068 n 5 126 0.068 n 5 126 0.081 n 5 126 0.025 n 5 126 0.131 n 5 114 0.045 n 5 121 0.129 n 5 121 0.209 n 5 121 0.113 n 5 120 0.300 n 5 125 0.146 n 5 125 0.116 n 5 125 0.141 n 5 124 0.577 n 5 128 0.156 n 5 128 0.792 n 5 127

Time in service

Peritraumatic distress

TAS DIF

Journal of Clinical Psychology, October 2010

DOI: 10.1002/jclp

TAS DDF

TAS EOT

TAS Total

0.461 n 5 125 0.503 n 5 122 0.592 n 5 124 0.715 n 5 122 0.058 n 5 124 0.037 n 5 119 0.388 n 5 123 0.168 n 5 126 0.036 n 5 126 0.189 n 5 126 0.019 n 5 125

0.414 n 5 121 0.437 n 5 123 0.522 n 5 121 0.008 n 5 123 0.093 n 5 118 0.109 n 5 122 0.046 n 5 125 0.108 n 5 125 0.010 n 5 125 0.017 n 5 124

0.373 n 5 128 0.824 n 5 127

0.613 n 5 127

Note. DTS Intrusion 5 Intrusion subscale Davidson Trauma Scale; DTS Avoidance 5 Avoidance subscale Davidson Trauma Scale; DTS Numbing 5 Numbing subscale Davidson Trauma Scale; DTS Hyperarousal 5 Hyperarousal subscale Davidson Trauma Scale; DTS Total 5 Total score Davidson Trauma Scale; TAS DIF 5 Difculty Identifying Feelings subscale Toronto Alexithymia Scale20; TAS DDF 5 Difculty Describing Feelings subscale Toronto Alexithymia Scale20; TAS EOT 5 Externally Oriented Thinking subscale Toronto Alexithymia Scale20; TAS Total 5 Total score Toronto Alexithymia Scale20. po.05; po.01.

Alexthymia and Posttraumatic Stress

1083

with numbing symptoms, hyperarousal symptoms, and PTSD total scores. Conversely, EOT was not associated with numbing, hyperarousal, or PTSD total scores. Moreover, a negative association appeared with reexperiencing symptoms. No signicant associations were found between the alexithymia scales and avoidance symptoms. Hierarchical Linear Regression Predicting PTSD Symptoms Table 3 shows the results of the hierarchical linear regressions with the DTS total scores and four subscale scores as the dependent variable, respectively. In each regression, peritraumatic distress was entered in the rst step and alexithymia total scores in the second. The results show that in the rst step, peritraumatic distress explained 12% of the variance in DTS total scores (po.01), whereas in the second step, alexithymia explained an additional 3%, which is a signicant contribution (po.05). The model including peritraumatic distress and alexithymia accounted for 15% of the variance in PTSD symptoms, with peritraumatic distress and TAS-20 total score being signicant predictors. When considering the results for the DTS subscales, they indicate that peritraumatic distress contributes signicantly to the explanation of PTSD symptom cluster scores, except avoidance. Alexithymia contributed signicantly to the explanation of scores for the symptom clusters of numbing and hyperarousal, but not reexperiencing or avoidance. In the case of numbing

Table 3
Hierarchical Multiple Regression Analysis Prediction of PTSD Symptoms
Step Predictor B SE B b 0.362 0.338 0.180 0.388 0.391 0.023 0.088 0.090 0.018 0.213 0.183 0.242 0.315 0.287 0.188 DR2 (Step) 0.131 0.032 0.150 0.001 Adjusted R2 (Model)

DTS Total Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS Total DTS Intrusion Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS Total DTS Avoidance Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS Total DTS Numbing Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS Total DTS Hyperarousal Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS Total

3.974 3.717 0.215 2.046 2.064 0.013 0.175 0.180 0.004 0.909 0.781 0.112 1.786 1.628 0.114

0.943 0.937 0.102 0.444 0.450 0.048 0.182 0.185 0.020 0.383 0.376 0.040 0.490 0.488 0.052

0.124 0.148

0.143 0.137

0.008 0.000 0.045 0.058 0.099 0.035

0.001 0.009

0.037 0.088

0.092 0.119

Note. SE 5 standard error; DTS Total 5 Total score Davidson Trauma Scale; DTS Intrusion 5 Intrusion subscale Davidson Trauma Scale; DTS Avoidance 5 Avoidance subscale Davidson Trauma Scale; DTS Numbing 5 Numbing subscale Davidson Trauma Scale; DTS Hyperarousal 5 Hyperarousal subscale Davidson Trauma Scale; TAS Total 5 Total score Toronto Alexithymia Scale20. po.05; po.01. Journal of Clinical Psychology DOI: 10.1002/jclp

1084

Journal of Clinical Psychology, October 2010

and hyperarousal symptoms, TAS-20 total scores explained an additional 5% and 3%, respectively, of the variance over and above the variance explained by peritraumatic distress. In both cases, the inclusion of TAS-20 total scores improved the predictive model signicantly. All signicant regression coefcients were positive. Table 4 shows the explanatory value of the three TAS-20 subscales separately in relation to PTSD symptoms. These hierarchical regressions make clear that only the DIF subscale explains signicant amounts of variance in the PTSD symptom scores, and that the DIF score contributes signicantly to the explanation of PTSD total scores as well as to numbing and hyperarousal scores. All signicant regression coefcients were positive. DDF and EOT, however, did not explain signicant amounts of variance. Table 4
Hierarchical Multiple Regression Analysis Prediction of PTSD Symptoms
Step Predictor B SE B b 0.373 0.284 0.262 0.090 0.026 0.388 0.340 0.103 0.001 0.162 0.109 0.099 0.054 0.150 0.040 0.213 0.094 0.271 0.158 0.150 0.315 0.209 0.281 0.056 0.116 DR2 (Step) 0.139 0.093 Adjusted R2 (Model)

DTS Total Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS DIF TAS DDF TAS EOT DTS Intrusion Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS DIF TAS DDF TAS EOT DTS Avoidance Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS DIF TAS DDF TAS EOT DTS Numbing Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS DIF TAS DDF TAS EOT DTS Hyperarousal Step 1: Peritraumatic distress Step 2: Peritraumatic distress TAS DIF TAS DDF TAS EOT

4.370 3.327 0.624 0.285 0.077 2.036 1.787 0.107 0.002 0.214 0.223 0.203 0.022 0.082 0.020 0.909 0.402 0.241 0.189 0.165 1.786 1.185 0.323 0.088 0.167

0.998 1.007 0.249 0.340 0.260 0.440 0.465 0.112 0.158 0.120 0.186 0.198 0.048 0.067 0.051 0.383 0.386 0.095 0.129 0.101 0.490 0.501 0.121 0.170 0.129

0.132 0.206

0.150 0.029

0.143 0.152

0.012 0.013

0.004 0.008

0.045 0.127

0.037 0.144

0.099 0.090

0.092 0.162

Note. SE 5 standard error; DTS Total 5 Total score Davidson Trauma Scale; DTS Intrusion 5 Intrusion subscale Davidson Trauma Scale; DTS Avoidance 5 Avoidance subscale Davidson Trauma Scale; DTS Numbing 5 Numbing subscale Davidson Trauma Scale; DTS Hyperarousal 5 Hyperarousal subscale Davidson Trauma Scale; TAS DIF 5 Difculty Identifying Feelings subscale Toronto Alexithymia Scale20; TAS DDF 5 Difculty Describing Feelings subscale Toronto Alexithymia Scale20; TAS EOT 5 Externally Oriented Thinking subscale Toronto Alexithymia Scale20. po.05; po.01. Journal of Clinical Psychology DOI: 10.1002/jclp

Alexthymia and Posttraumatic Stress

1085

Discussion Alexithymia was found to contribute positively to the development of PTSD symptoms in a signicant way, meaning that alexithymia is relevant to the symptomatic response to the critical event. The results found for this nonclinical population of professionals who deal with critical incidents are, thus, in line with those found in a large variety of samples, such as high risk professionals, victims of sexual assault, combat veterans, holocaust survivors, and so on. Hence, the present ndings add some empirical support that alexithymia contributes to the development of posttraumatic distress as a consequence of a critical incident. Looking at the relation between alexithymia and posttraumatic distress in greater depth, the former appeared to be signicantly related to the numbing and hyperarousal, but not to the reexperiencing and avoidance subscales. This noncorrelation with avoidance is coherent with the noncorrelation with peritraumatic distress found in the present study, as was well as with clinical and conrmatory factor analytic studies that have found that avoidance and numbing could be separate constructs, with avoidance being aspecic to posttraumatic distress (Cordova et al., 2000; King et al., 1998; Marshall, 2004; Mc Williams et al., 2005). Some studies have also argued in favor of a ve-factor cluster in which avoidance and emotional numbing are split as well as hyperarousal and sleep disturbance (Simms et al., 2002; Witteveen et al., 2006). In the present study, the four-factor model was used because the structure of the DTS does not allow for the ve-factor one. Indeed, a minimum of two items per factor is required. Because the DTS does not meet that standard, hyperarousal and sleep disturbance could not be distinguished. However, future research might address the issue of a four-factor or ve-factor cluster. To conclude, the present results add empirical evidence to the ndings that contradict the DSM-IV-driven, three-cluster structure of PTSD, in which numbing and avoidance are assimilated into one factor. When examining further which precise aspects of alexithymia accounted for this association, the data revealed that the alexithymia subscale of DIF contributed most to numbing and hyperarousal. As mentioned, very few studies appear to have investigated this relation. Our nding contradicts that of Monson et al.s (2004), but it is in line with Sondergaard and Theorells (2004), OBrien et al.s (2008), and Zahradnik et al.s (2009) studies, where DIF was also found to be the main underlying factor after psychological trauma or PTSD. This link between DIF and numbing and hyperarousal symptoms is also consistent with a body of research and clinical ndings, which have provided evidence indicating that numbing and hyperarousal could be phasically related (Flack et al., 2000; Gross & Levenson, 1993; Horowitz, 1986; Krystal, 1988; Litz & Gray, 2002; Litz et al., 2000). This relation could be interpreted in two ways. On the one hand, research has shown that emotional numbing could be the result of emotional depletion, caused by chronic hyperarousal (Litz, 1992). On the other hand, research ndings have also shown that suppressing emotional reactions to stimuli provokes higher arousal (Gross & Levenson). It is possible, of course, that both interpretations could hold true and that both, in fact, reinforce each other. Either way, DIF seems to be at issue with respect to hyperarousal and numbing, but not with avoidance and reexperiencing symptoms. The relation between DIF and numbing and hyperarousal may be clinically signicant, in that therapeutic interventions aimed at tackling the diminished interest in signicant activities, feelings of estrangement, restricted range of affect (numbing),
Journal of Clinical Psychology DOI: 10.1002/jclp

1086

Journal of Clinical Psychology, October 2010

and hyperarousal symptoms might address the individuals difculty in identifying feelings. Also, focusing on the patients ability to identify emotions might lay the groundwork for further treatment, namely, the cognitive processing of the traumatic experience (Frewen et al., 2008). Indeed, trauma victims tend to misinterpret their psychological distress as a diffuse, physical tension rather than an emotional condition. As an individual participating in an aforementioned study expressed it: I dont know what I feel. Its like my head and my body arent connected y having a bubble bath and being burned or raped is the same feeling. My brain doesnt feel (Litz et al., 2000, p. 36). As alexithymic individuals have no insight or conscious awareness of their affects, the latter cannot be integrated and processed and might instead maintain or enhance hyperarousal symptoms. With the exception of gender, no signicant demographic differences were found. In the present population, women signicantly scored higher on the PTSD subscale of reexperiencing, on the one hand, and lower on DDF, EOT, and alexithymia total scores, on the other hand. With respect to alexithymia, many studies have found it to be more common in men than women, and it has been hypothesized that mild levels of alexithymia would be normative in men (Carpenter & Addis, 2000; Honkalampi et al., 2004; Levant, 2001; Levant et al., 2003; Taylor, Pole, & Odera, 2005). Further research might address this issue. There are several limitations to this study. First and foremost is its correlational nature, which makes it impossible to make causal interpretations for the associations found. Second, the application of the current ndings need replication because of the unique population studied. Research with other samples would increase the generalizability of the present results. Another limitation concerns the exclusive use of self-report assessment. Respondents with emotional disturbances and a condition such as posttraumatic distress may have inherent difculty reporting their emotions and symptoms. Therefore, clinical interviews and collateral reports would shed additional light on these issues. Also, a multimodal assessment of alexithymia could be recommended, particularly the combination of self-report and observerrated measures, like the Observer Alexithymia Scale.

References
Andrews, L., Joseph, S., Shevlin, M., & Troop, N. (2006). Conrmatory factor analysis of posttraumatic stress symptoms in emergency personnel: An examination of seven alternative models. Personality and Individual Differences, 41, 213224. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th Edition text revision). Washington, DC: Author. Badura, A.S. (2003). Theoretical and empirical exploration of the similarities between emotional numbing in posttraumatic stress disorder and alexithymia. Journal of Anxiety Disorders, 17, 349360. Bagby, R.M., Parker, J.D.A., & Taylor, G.J. (1994). The twenty-item Toronto Alexithymia Scale: I. Item selection and cross validation of the factor structure. Journal of Psychosomatic Research, 38, 2332. Bagby, R.M., Taylor, G.J., & Parker, J.D.A. (1994). The twenty-item Toronto Alexithymia Scale: II. Convergent, discriminant, and concurrent validity. Journal of Psychosomatic Research, 38, 3340. Breslau, N., & Alvarado, G.F. (2007). The clinical signicance criterion in DSM-IV post-traumatic stress disorder. Psychological Medicine, 37, 14371444.
Journal of Clinical Psychology DOI: 10.1002/jclp

Alexthymia and Posttraumatic Stress

1087

Breslau, N., & Kessler, R.C. (2001). The stressor criterion in DSM-IV posttraumatic stress disorder: An empirical investigation. Biological Psychiatry, 50, 699704. Breslau, N., Kessler, R.C., Chilcoat, H.D., Schultz, L.R., Davis, G.C., & Andreski, P. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry, 55, 626632. Brewin, C.R., Andrews, B., & Rose, S. (2000). Fear, helplessness and horror in post-traumatic stress disorder: Investigating DSM-IV criterion A2 in victims of violent crime. Journal of Traumatic Stress, 13, 499509. Carpenter, K.M., & Addis, M.E. (2000). Alexithymia, gender and response to depressive symptoms. Sex Roles, 43, 629644. Cloitre, M., Koenen, K.C., Cohen, L.R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 10671074. Corcos, M., & Speranza, M. (2003). Psychopathologie de lalexithymie [Psychopathology of alexithymia]. Paris: Dunod. Cordova, M.J., Studts, J.L., Hann, D.M., Jacobson, P.B., & Andrykowski, M.A. (2000). Symptom structure of PTSF following breast cancer. Journal of Traumatic Stress, 13, 301319. Davidson, J.R.T., Book, S.W., Colket, J.T., Tupler, L.A., Roth, S., David, D., et al. (1997). Assessment of a new self-rating scale for posttraumatic stress disorder. Psychological Medicine, 27, 153160. Davidson, J.R.T., Tharwani, H.M., & Connor, K.M. (2002). Davidson Trauma Scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trails. Depression and Anxiety, 15, 7578. Del Ben, K.S., Scotti, J.R., Chen, Y.C., & Fortson, B.L. (2006). Prevalence of post-traumatic stress disorder in reghters. Work and Stress, 20, 3748. Dieperink, M., Leskela, J., Thuras, P., & Engdahl, B. (2001). Attachment style classication and posttraumatic stress disorder in former prisoners of war. American Journal of Orthopsychiatry, 71, 374378. Engdahl, B., Dikel, T.N., Eberly, R., & Blank, A. (1997). Posttraumatic stress disorder in a community group of former prisoners of war: A normative response to severe trauma. American Journal of Psychiatry, 154, 15761581. Engelhard, I.M., & van den Hout, M.A. (2007). Preexisting neuroticism, subjective stressor severity and posttraumatic stress in soldiers deployed to Iraq. Canadian Journal of Psychiatry, 52, 505509. Flack, W.F., Litz, B.T., Hsieh, F.Y., Kaloupek, D.G., & Keane, T.M. (2000). Predictors of emotional numbing, revisited: A replication and extension. Journal of Traumatic Stress, 13, 611618. Flannery, R.B. (1999). Psychological trauma and posttraumatic stress disorder: A review. International Journal of Emergency Mental Health, 2, 135140. Foa, E.B., Riggs, D.S., & Gershuny, B.S. (1995). Arousal, numbing, and intrusionSymptom structure of PTSD following assault. American Journal of Psychiatry, 152, 116120. Frewen, P.A., Lanius, R.A., Dozois, D.J., Neufeld, W., Pain, C., Hopper, J., et al. (2008). Clinical and neural correlates of alexityhymia in posttraumatic stress disorder. Journal of Abnormal Psychology, 117, 171181. Gross, J.J., & Levenson, R.W. (1993). Emotional suppression: Physiology, self-report and expressive behaviour. Journal of Personality and Social Psychology, 64, 970986. Heinrichs, M., Wagner, D., Schoch, W., Soravia, L.M., Hellhammer, D.H., & Ehlert, U.E. (2005). Predicting posttraumatic stress symptoms from pre-traumatic risk factors: A 2-year prospective follow-up study in re-ghters. American Journal of Psychiatry, 162, 22762286.
Journal of Clinical Psychology DOI: 10.1002/jclp

1088

Journal of Clinical Psychology, October 2010

Honkalampi, K., Koivumaa, H., Hintikka, J., Antikainen, R., Haatainen, K., Tanskanen, A., et al. (2004). Do stressful events or sociodemographic variables associate with alexithymia among a general population? A 3-year follow-up study. Comprehensive Psychiatry, 45, 254260. Horowitz, M. (1986). Stress response syndrome (2nd ed.). Northvale, NJ: Jason Aronson. Hund, A.R., & Espelage, D.L. (2006). Childhood emotional abuse and disordered eating among undergraduate females: Mediating inuence of alexithymia and distress. Child Abuse and Neglect, 30, 393407. Hyer, L., Woods, M.G., Summers, M.N., Boudewyns, P., & Harrison, W.R. (1990). Alexithymia among Vietnam veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry, 51, 243247. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 10481060. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C.B., & Breslau, N. (1999). Epidemiological risk factors for trauma and PTSD. In R. Yehuda (Ed.), Risk factors for posttraumatic stress disorder (pp. 2359). Washington, DC: American Psychiatric Press. King, D.W., Leskin, G.A., King, L.A., & Weathers, F.W. (1998). Conrmatory factor analysis of the Clinical-Administered PTSD Scale: Evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment, 10, 9096. Krystal, H. (1988). Integration and self-healing. Affect, Trauma, Alexithymia. Hillsdale, NJ: The Analytic Press. Lee, D., & Young, K. (2001). Posttraumatic stress disorder: Diagnostic issues and epidemiology in adult survivors of traumatic events. International Review of Psychiatry, 13, 150158. Levant, R.F. (2001). Desperately seeking language: Understanding, assessing and treating normative male alexithymia. In G.R. Brooks & G.E. Good (Eds.), The new handbook of counseling and psychotherapy for men (Vol. 1, pp. 355368). San Francisco: Jossey-Bass. Levant, R.F., Richmond, K., Majors, R.G., Inclan, J.E., Rossello, J.M., Heesacker, M., et al. (2003). A multicultural investigation of masculine ideology and alexithymia. Psychology of Men and Masculinity, 4, 9199. Litz, B.T. (1992). Emotional numbing in combat-related posttraumatic stress disorder: A critical review and reformulation. Clinical Psychology Review, 12, 417432. Litz, B.T., & Gray, M.J. (2002). Emotional numbing in posttraumatic stress disorder: Current and future research directions. Australian and New Zealand Journal of Psychiatry, 36, 198204. Litz, B.T., Orsillo, S.M., Kaloupek, D., & Weathers, F. (2000). Emotional processing in posttraumatic stress disorder. Journal of Abnormal Psychology, 109, 2639. Marmar, C.R. (2006). Alexithymia and PTSD symptoms in urban police ofcers: Crosssectional and prospective ndings. Journal of Traumatic Stress, 19, 361373. Marshall, G.N. (2004). Posttraumatic stress disorder symptom check-list: Factor structure and English-Spanish measurement invariance. Journal of Traumatic Stress, 17, 223230. Mc Caslin, S.E., Metzler, T.J., Best, S.R., Liberman, A., Weiss, D.S., Fagan, J., et al. (2006). Alexithymia and PTSD symptoms in urban police ofcers: Cross sectional and prospective ndings. Journal of Traumatic stress, 19, 361373. Mc Williams, L.A., Cox, B.J., & Asmundson, G.J.G. (2005). Symptom structure of posttraumatic stress in a nationally representative sample. Anxiety Disorders, 19, 626641. Meganck, R., Vanheule, S., & Desmet, M. (2008). Factorial validity and measurement invariance of the 20-item Toronto Alexithymia Scale in clinical and non-clinical samples. Assessment, 15, 3647.
Journal of Clinical Psychology DOI: 10.1002/jclp

Alexthymia and Posttraumatic Stress

1089

Mollica, R., McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationships of trauma to symptoms of depression and posttraumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482488. Monson, C.M., Price, J.L., Rodriguez, B.F., Ripley, M.P., & Warner, R.A. (2004). Emotional decits in military-related PTSD: An investigation of content and process disturbances. Journal of Traumatic Stress, 17, 275279. OBrien, C., Gaher, R.M., Pope, C., & Smiley, P. (2008). Difculty identifying feelings predicts the persistence of trauma symptoms in a sample of veterans who experienced military trauma. Journal of Nervous and Mental Disease, 196, 252255. Paris, J. (2000). Predispositions, personality traits and posttraumatic stress disorder. Harvard Review of Psychiatry, 8, 175183. Perkonigg, A., Kessler, R.C., Stortz, S., & Wittchen, H.U. (2000). Traumatic events and posttraumatic stress disorder in the community: Prevalence, risk factors and comorbidity. Acta Psychiatrica Scandinavica, 101, 4659. Ramirez, S.M., Glover, H., Ohlde, C.D., Mercer, R.G., Goodnick, P., Hamlin, C.L., et al. (2001). Relationship of numbing to alexithymia, apathy, and depression. Psychological Reports, 88, 189200. Resnick, H., Kirkpatrick, D., Best, C., & Kramer, T. (1992). Vulnerability-stress factors in development of posttraumatic stress disorder. Journal of Nervous and Mental Disease, 180, 424430. Simms, L.J., Watson, D., & Doebbeling, B.N. (2002). Conrmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. Journal of Abnormal Psychology, 111, 637647. Sondergaard, H.P., & Theorell, T. (2004). Alexithymia, emotions and PTSD: Findings from a longitudinal study of refugees. Nordic Journal of Psychiatry, 58, 185191. Taylor, G.J., Bagby, R.M., & Parker, J.D.A. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge: Cambridge University Press. Taylor, W., Pole, N., & Odera, L. (2005). Trauma, alexithymia and PTSD symptoms: Does gender matter? Depression and Anxiety, 22, 242251. Witteveen, A.B., Van der Ploeg, E., Bramsen, I., Huizink, A.C., Slottje, P., Smid, T., et al. (2006). Dimensionality of the posttraumatic stress response among police ofcers and re ghters: An evaluation of the two self-report scales. Psychiatric Research, 141, 213228. Yehuda, R., Steiner, A., Kahana, B., Binderbrynes, K., Southwick, S.M., Zemelman, S., et al. (1997). Alexithymia in holocaust survivors with and without PTSD. Journal of Traumatic Stress, 10, 9399. Zahradnik, M., Stewart, S.H., Marshall, G.N., Schell, T., & Jaycox, L.H. (2009). Anxiety sensitivity and aspects of alexythimia are independently and uniquely associated with posttraumatic distress. Journal of Traumatic Stress, 22, 131138. Zeitlin, S.B., McNally, R.J., & Cassiday, K.L. (1993). Alexithymia in victims of sexual assault: An effect of repeated traumatization? American Journal of Psychiatry, 150, 661663.

Journal of Clinical Psychology

DOI: 10.1002/jclp

Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.