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Psychosomatic Medicine 62:768-778 (2000)
© 2000 American Psychosomatic Society

ORIGINAL ARTICLES

Is Alexithymia a Risk Factor for Unexplained Physical Symptoms in General Medical Outpatients?

Cornelis G. Kooiman, MD, Jan H. Bolk, PhD, Ronald Brand, PhD, Rutger W. Trijsburg, PhD and Harry G. M. Rooijmans, PhD

From the Departments of Psychiatry (C.G.K., H.G.M.R.), General Internal Medicine (J.H.B.), and Medical Statistics (R.B.), Leiden University Medical Center, Leiden; and Department of Medical Psychology and Psychotherapy (R.W.T.), Erasmus University Rotterdam, Rotterdam, The Netherlands.

Address reprint requests to: Cornelis G. Kooiman, Department of Psychiatry B1P, Leiden University Medical Center, 2300 RC Leiden, The Netherlands. Email: cgkooiman{at}lumc.nl


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 AIM OF THE STUDY
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: Alexithymia is presumed to play an important predisposing role in the pathogenesis of medically unexplained physical symptoms. However, no research on alexithymia has been done among general medical outpatients who present with medically unexplained physical symptoms as their main problem and in which anxiety and depression have been considered as possible confounding factors. This study investigated whether patients with medically unexplained physical symptoms are more alexithymic than those with explained symptoms and whether, in patients with unexplained symptoms, alexithymia is associated with subjective health experience and use of medical services.

METHODS: We conducted a cross-sectional study among patients attending an internal medicine outpatient clinic. All patients were given a standardized interview and completed a number of questionnaires.

RESULTS: After complete physical examinations, 169 of 321 patients had unexplained physical symptoms according to two independent raters. Patients with medically unexplained symptoms more often had a mental disorder, but overall they were not more alexithymic. In patients with unexplained physical symptoms, alexithymia was not associated with subjective health experience or use of medical services. However, patients with both unexplained symptoms and a mental disorder who also denied any possible connection between emotional problems and their physical symptoms did have more alexithymic traits.

CONCLUSIONS: In the majority of patients with medically unexplained physical symptoms, alexithymia does not play a role of clinical significance. Patients with unexplained physical symptoms are heterogeneous with respect to psychiatric syndrome pathology and probably also with respect to personality pathology.

Key Words: alexithymia, • somatization • anxiety, • depression • dissociation.

Abbreviations: ANOVA = analysis of variance; CI = confidence interval; DDF = difficulties in describing feelings; DES = Dissociative Experience Scale; DIF = difficulties in identifying feelings; EOT = externally oriented thinking; EPS = explained physical symptoms; HADS = Hospital Anxiety and Depression Scale; HADSa = HADS Anxiety scale; HADSd = HADS Depression scale; MOS-36 = 36-item Medical Outcomes Study short form; OR = odds ratio; PSQ = Physical Symptoms Questionnaire; SCL-90-R = revised 90-item Symptom Check List; TAS = Toronto Alexithymia Scale; UPS = unexplained physical symptoms; WI = Whitely Index.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
AIM OF THE STUDY
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Patients with physical symptoms for which no medical explanation can be found are relatively common in medical practice. The literature reports incidences ranging from 10 to 50%, with higher percentages in specialty practices (1, 2). Most studies of medically unexplained physical symptoms use a cross-sectional design. The aim of such studies is to investigate whether these symptoms could be the expression of a mental disorder and whether they are associated with factors generally considered to be of a predisposing or precipitating nature.

It seems that medically unexplained physical symptoms in patient populations are indeed associated with psychiatric pathology. In particular, medically unexplained physical symptoms have been found to be associated with anxiety and depression (1, 3–10) and dissociative symptoms (11–14). It is of clinical importance that the majority of patients with medically unexplained physical symptoms are able to recognize that their physical symptoms may be related to their depression or anxiety disorder (7, 15).

Medically unexplained physical symptoms are also strongly linked to personality pathology. Various studies have shown that high percentages of patients with somatoform disorders have personality disorders (3, 4, 16–20). In addition, medically unexplained physical symptoms have been found to be associated with such personality characteristics as hypochondriac preoccupation and excessive illness behavior (21, 22). It is assumed that personality pathology is a predisposing factor in the development of medically unexplained physical symptoms (23–25), and in this context alexithymia is thought to play an important role.

The concept of alexithymia was first introduced in 1973 by Sifneos (26). Alexithymia is seen as a personality trait characterized by difficulties in differentiating and describing feelings and by a mode of thinking that focuses on the factual aspects of external reality rather than the psychological experience of it. As a result, alexithymic patients find it hard to recognize that physical sensations are sometimes the somatic concomitants of affect. This feature has led to the suggestion that alexithymia may play a central role in the pathogenesis of medically unexplained physical symptoms (27–29).

In several studies alexithymia indeed proved to be associated with the reporting of physical symptoms. However, many of these studies have been conducted in student or general psychiatric populations. The presence of physical symptoms in these studies has often been assessed with self-report questionnaires, such as the Somatization scale of the SCL-90-R. In only a few of these studies were the patients physically examined. Therefore, the physical symptoms of the respondents in these studies are not necessarily of clinical importance, they are not necessarily medically unexplained, and they are not necessarily the somatic concomitants of emotional turmoil. Furthermore, only a few studies controlled for anxiety and depression as possible confounding factors, which is of importance because the results of several studies (30–34) suggest that the degree of alexithymia is partly dependent on mood state (35).

Some studies on alexithymia have been conducted among patients with a somatoform disorder. Using cutoff scores of the TAS-20, 53% of 55 patients with a pain disorder after a motor vehicle accident were found to be alexithymic (36). Bach and Bach (37) found that, controlling for the degree of anxiety and depression, psychiatric inpatients with a somatoform disorder were more alexithymic than patients with a chronic physical illness and in particular that the somatoform patients had more difficulties in identifying feelings. Furthermore, in the group of patients with a somatoform disorder, but not in the chronic physical illness group, the degree of alexithymia was associated with the SCL-90-R Somatization scale score. However, in a study conducted by Cohen et al. (38), patients with a pain disorder were not more alexithymic (TAS-26) than a group of psychotherapy patients or a group of patients who presented for routine dental care.

The results of these studies suggest an association between alexithymia and the reporting of physical symptoms, but the results of these studies are not unambiguous, and to our knowledge no studies have been conducted among patients of general medical outpatient departments who present with medically unexplained physical symptoms.


   AIM OF THE STUDY
TOP
 ABSTRACT
 INTRODUCTION
 AIM OF THE STUDY
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The primary aim of this study was to investigate whether somatic outpatients with medically unexplained physical symptoms as their primary symptoms have more alexithymic traits than those with medically explained physical symptoms. In addition, we studied in patients with unexplained physical symptoms whether alexithymia is associated with the duration of the presenting symptom, with the number of all physical symptoms experienced by the patient, and with increased healthcare utilization. Finally, we examined whether there is an association between alexithymia and the patient’s opinion that his or her unexplained physical symptoms might be caused by emotional problems.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 AIM OF THE STUDY
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patient Selection
All new patients between 18 and 65 years of age who were referred to the general internal medicine outpatient clinic at Leiden University Medical Center between January 1, 1998, and August 1, 1998, were considered for this study. Exclusion criteria included neurological disorders, organic mental disorders, mental retardation, psychotic disorders, use of neuroleptic agents, preoperative investigations, genetic counseling, sensory disorders, insufficient knowledge of the Dutch language, or serious medical conditions preventing one from participating in the study.

During the first meeting with the internist, the patient was given both verbal and written information about the nature and aim of the study. Patients who returned completed questionnaires were interviewed after their second visit to the internist at the outpatient clinic.

All patients underwent a complete medical examination, including a medical history, a full physical examination, and hematological and blood chemistry laboratory tests. If necessary, additional tests, such as serological or hormonal tests, X-rays, or endoscopic examinations, were conducted.

Instruments
A structured interview was used to question the patients about their current work and family circumstances; their medical and psychiatric histories; their use of alcohol and drugs; the nature, duration, and subjective severity of the presenting symptom and any additional symptoms; their medication intake; and their thoughts on whether their physical symptoms might be caused by emotional problems.

The degree of alexithymia was measured using the TAS-20 (39, 40). The TAS-20 is a self-report questionnaire with 20 items rated on a five-point scale with a three-factor structure. The three factors are DIF, DDF, and EOT. TAS scores can be used dimensionally as well as nominally, with a total score >60 indicating alexithymia (41). In several studies the reliability and validity of the TAS-20 has been proven to be satisfactory (42). The Dutch translation of the TAS-20 has been studied in students and in psychiatric outpatients. The discriminative validity (students vs. psychiatric outpatients) was good (C. G. Kooiman et al., unpublished). The internal consistency of the subscales and the overall questionnaire in the present study were moderate to good ({alpha} = 0.84, 0.73, and 0.63; overall {alpha} = 0.84).

Hypochondriac preoccupation was measured using the WI (22, 43). The WI is a self-report questionnaire comprising 14 yes/no questions. The questionnaire was translated into Dutch by Speckens et al. (44). The internal consistency, test-retest reliability, and discriminating validity of this questionnaire are all good (44, 45). In this study the internal consistency of the WI was reasonable ({alpha} = 0.74).

The DES-II (46–48) was used to measure dissociation. This scale was translated into Dutch by Draijer and Boon (49). The DES is a self-report questionnaire with 28 items measuring dissociative experiences rated on a percentage scale. The DES consists of three scales: Absorption, Amnesia, and Derealization. A total score of 25 or above on the DES implies that a dissociative disorder is likely (49). The reliability and validity of the Dutch version of the DES is good (50, 51). The internal consistency of the individual scales and the overall questionnaire in this study was reasonable to good ({alpha} = 0.77, 0.63, and 0.74, respectively; overall {alpha} = 0.87).

Anxiety and depression were determined by means of the HADS (52), which was translated into Dutch by Spinhoven et al. (53). The HADS is a 14-item self-report questionnaire and was developed for use among patients with somatic symptoms. The items of the HADS do not represent somatic anxiety and depression symptoms. The HADS differentiates between anxiety and depression; the scores on the Anxiety and Depression scales (HADSa and HADSd, respectively) provide a reliable measure of the severity of the psychiatric condition. A score of 11 or more on either of the scales indicates that an anxiety disorder or depression is likely (53–55). The internal consistency of the individual scales and the overall questionnaire in this study was reasonable to good ({alpha} = 0.80 and 0.84, respectively; overall {alpha} = 0.88).

We constructed a list of questions (PSQ) pertaining to physical symptoms that were rated on a four-point scale (never, sometimes, regularly, and frequently). The items represent the physical symptoms in the somatoform disorders section of the Schedules for Clinical Assessment in Neuropsychiatry (56), supplemented with a number of questions about fatigue. The total score represents the total number of symptoms that the patient reported as occurring either regularly or frequently, corrected for the difference in number of items between women (79 items) and men (73 items).

The MOS-36 (57) is a questionnaire designed to investigate the general health experience and the influence of symptoms on daily life. This questionnaire was translated into Dutch by Van der Zee and Sanderman (58). The MOS-36 has 36 items and consists of eight scales: Physical Functioning, Social Functioning, Role Limitations–Physical (due to physical symptoms), Role Limitations–Emotional (due to emotional problems), Mental Health, Vitality, Pain, and Perception of General Health. One item that asks the respondent about perceived changes in health was added to the Dutch version. A higher score indicates a better state of health. English (59) and Dutch researchers (58) have demonstrated that the MOS-36 has sufficient variability in the scale scores and a good construct validity. The internal consistency of the individual scales was, in general, good ({alpha} = 0.92, 0.84, 0.87, 0.86, 0.85, 0.84, 0.85, 0.78, respectively; Perceived Changes in Health scale has only 1 item).

Statistical Analyses
The data were analyzed using SPSS for Windows, version 8.0.0. Bivariate comparisons were performed using Student’s t tests for interval variables, Mann-Whitney U tests for nonnormally distributed variables, {chi}2 tests for trends for ordinal variables, and {chi}2 tests or Fisher’s Exact tests for nominal variables. Bivariate correlations were calculated using Pearson’s correlation coefficient and, in the case of nonnormally distributed data, using Spearman’s rank order correlation. Logistic regression analysis was used to determine the relative significance of alexithymia as a predictive variable for the development of medically unexplained physical symptoms. Linear regression analysis was used to determine the relative significance of alexithymia as a predictive variable for healthcare utilization in patients with unexplained physical symptoms. One-way ANOVA with Tukey Honestly Significant Difference post hoc analysis was applied to test the difference in means in more than two groups. For all tests, statistical significance was set at the 5% level.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 AIM OF THE STUDY
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
During the study period 635 patients attended the general internal medicine outpatient clinic. One hundred nine patients met one or more exclusion criteria. On the basis of the results of the internist’s final diagnosis, two investigators (J.H.B. and C.G.K.) independently assigned the presenting symptoms into one of two groups: 1) medically explained physical symptoms (presence of objective pathological findings that satisfactorily explained the symptoms) and 2) medically unexplained physical symptoms. This second group consisted of 1) functional symptoms (such as food intake-related obesity, hyperventilation, or irritable bowel syndrome) and 2) symptoms with no pathological findings. There was no difference between these two subgroups in terms of important aspects such as alexithymic characteristics and psychiatric symptomatology. The degree of agreement between the evaluations made by the two investigators was excellent (Cohen’s {kappa} = 0.94). After the independent evaluations, the investigators held a consensus meeting, after which 269 (51%) of all included patients were classified as having medically unexplained physical symptoms and 257 (49%) patients were classified as having medically explained physical symptoms.

Of the 526 patients who satisfied the inclusion criteria, 205 (39%) chose not to participate in the study. There was no difference between the participants and those who declined to participate in terms of gender, age, major medical diagnosis, and number of additional diagnoses.

Comparison of UPS and EPS Patients
Of the 321 patients who participated in the study, 169 (53%) patients were classified as having medical unexplained physical symptoms (UPS patients) and 152 (47%) patients had medically explained physical symptoms (EPS patients). The patients with unexplained symptoms were, on average, younger and less likely to have children living at home ( Table 1). There was no difference between the two groups in terms of gender, marital status, highest level of education, profession, and whether they were receiving a social security allowance (Table 1).


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  		Table 1. Demographic Characteristics and Physical Symptoms
 
UPS patients had suffered longer from the presenting symptom and reported more physical symptoms in addition to their main symptoms (PSQ) than EPS patients. Also, they reported that they suffered more and more frequently from their symptoms and felt more hampered by their symptoms in their activities with family, friends, neighbors, or others. Compared with the EPS patients, they reported having less energy and considered their general state of health to be worse. Fifty percent of all patients revealed that in addition to the presenting symptom, they also suffered during the previous month from other symptoms for which they had to take medication, consult a doctor (usually a family physician), or restrict their daily life. However, UPS patients did not differ in this respect from EPS patients. It is of interest to note that there was no difference between the two groups in terms of the degree to which they considered their presenting symptom to be the result of emotional problems ( Table 2).


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  		Table 2. Perception of Health, Use of Medical Services, and Physical Symptoms
 
UPS patients reported more anxiety and depressive symptoms, but they did not report more dissociative symptoms, than EPS patients. UPS patients suffered more frequently from an anxiety disorder or depression. Also, UPS patients generally had a higher score on the Hypochondriac Preoccupation scale (WI). However, dissociative disorders as well as alcohol misuse were not more common in UPS patients. Virtually no patients reported taking drugs (eg, cannabis, opiates, or speed) ( Table 3).


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  		Table 3. Syndrome Pathology, Hypochondria, Alexithymia, and Physical Symptoms
 
Compared with EPS patients, UPS patients had more difficulties in identifying feelings (higher DIF score). However, the two groups did not differ in terms of their ability to describe feelings (DDF), externally oriented thinking (EOT), and the total alexithymia score. UPS patients were slightly more often classified as alexithymic, but the difference was not statistically significant (Table 3).

We investigated whether the alexithymic dimensions would be predictive for UPS over and above the predictive value of age and the degree of anxiety and depression. Age, HADSa, and HADSd were first entered in the logistic regression model with UPS as a dependent variable. Only anxiety (OR = 1.1, 95% CI = 1.01–1.18, p < .05) and age (OR = 0.97, 95% CI = 0.95–0.99, p < .01) were significantly associated with UPS. This implies, for example, that the odds of UPS increases by a factor 1.6 (60%) for each 5 points of increase on the HADSa scale and that the odds of UPS decreases by a factor 0.74 (26%) for each 10 years of increase in age. Thus, the younger and more anxious a patient is, the less likely a medical explanation can be found for his or her symptoms. In the second step, the alexithymic dimensions DIF and DDF and Hypochondriac Preoccupation (WI) were entered (stepwise forward) in the regression model. None of these variables proved to have a predictive value above anxiety and age. Even when age was removed as a potential covariable, none of the TAS scales was predictive.

It is possible to obtain an estimate of the 95% CI of the effect of the alexithymia dimensions by forcing these (insignificant) variables into the model. To quantify this in a clinically relevant and interpretable way, we computed the interval as the OR for UPS to be associated with a difference in the DIF or DDF scores of 1 SD (as observed in our study population). The 95% CI is 0.94 to 1.65 for DIF and 0.72 to 1.19 for DDF. This implies that the impact of a 1-SD increase in alexithymia scores (about 6 points on the DIF scale and 4 points on the DDF scale) on the probability of having UPS does not exceed 1.65 and 1.19, respectively (with 95% certainty).

Alexithymia and Secondary Aspects of Somatization in UPS Patients
We investigated in UPS patients whether alexithymia is associated with such aspects of somatization as duration of the presenting symptom, number of physical symptoms the patient suffers from, healthcare utilization, and whether the patient considers it possible that the physical symptoms may be caused by emotional problems.

In UPS patients, difficulties in identifying feelings were indeed associated with the number of secondary symptoms on the PSQ (r = 0.36, p < .001), but this association disappeared when the data were adjusted for the degree of anxiety and depression. Furthermore, the various alexithymic dimensions were not associated with the presence of secondary symptoms that prompted the patient to seek medical attention, take medication, or make adjustments in daily life. Nor were the alexithymic dimensions in UPS patients in any way associated with the duration of the presenting symptom ( Table 4).


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  		Table 4. Alexithymia and Health Experience in Patients With Unexplained Physical Symptoms
 
Contrary to expectations, in UPS patients there was hardly any association of alexithymia with healthcare utilization. Only DIF in UPS patients was weakly associated with the number of visits made to the general practitioner during the previous year (Spearman’s r = 0.15, p = .047). The various alexithymia dimensions were not found to be associated with any other measures of use of medical services, such as the number of visits in the previous 2 years to an emergency department without an associated admission, number of specialists consulted, or number of alternative forms of medicine tried during the previous 2 years. To study which variables best predicted the number of consultations to a general practitioner, we performed a backward stepwise analysis using a linear regression model with the log transform of the number of consultations as a dependent variable because of its very skewed distribution. HADSa, HADSd, DES total score, DIF, WI, and the MOS-36 variables Perception of General Health, Perceived Changes in Health, Pain, and Perceived Vitality were entered in the model as independent variables. The variables that significantly contributed to the prediction (F(3,163) = 18.646, p < .001, adjusted R2 = 0.25) were hypochondriasis (WI) (B = 0.03 (0.008), ß = 0.30, p < .001), Perceived Changes in Health (B = 0.003 (0.001), ß = 0.24, p < .01), and Pain (B = 0.002 (0.001), ß = 0.18, p < .05). Even when only WI and DIF were entered in the regression model, only hypochondriasis (WI) (B = 0.04 (0.008), ß = 0.39, p < .001) significantly contributed to the prediction of the number of general practitioner consultations (F(1,166) = 28.855, p < .001, adjusted R2 = 0.14).

UPS patients who, on questioning, believed that their physical symptoms could (in part) be the result of emotional problems had more difficulties in identifying their feelings than those who did not feel that way (Table 4). It may be assumed that especially patients with psychiatric pathology may consider the possibility of their physical symptoms to be caused by emotional problems. This indeed seems to be true. Of the 169 UPS patients, 52 (31%) had a mental disorder according to the HADS and DES scores. Thirty-four (65%) of these UPS patients believed that their physical symptoms could be the result of emotional problems, whereas only 42 (36%) of the 117 patients without mental disorder believed this could be the case (Fisher’s Exact test, p < .001). After stratification according to the absence or presence of a mental disorder and the patient’s judgment that emotional problems might contribute to the existence of physical symptoms, we found that the patient groups differed in terms of the degree to which they have difficulties in identifying feelings (DIF) (ANOVA, F(3,165) = 21.081, p < .001) and, to a certain extent, in terms of the degree to which they have difficulties in describing feelings (DDF) (ANOVA, F(3,164) = 4.461, p = .005). In general, patients with a mental disorder tend to have higher alexithymic ratings. However, UPS patients with a mental disorder who had the strong conviction that emotional problems did not contribute to the presenting physical symptoms also reported more difficulties in identifying feelings than UPS patients without a mental disorder who did not feel that emotional problems contributed to their physical symptoms (Table 4).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 AIM OF THE STUDY
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Somatization has been defined in a number of ways in different studies (2, 60–62). According to Kellner (2), somatization indicates one or more physical complaints and either 1) appropriate evaluation uncovers no organic pathology or pathophysiological mechanism to account for the physical complaints or 2) when there is related organic pathology, the physical complaints or resulting social or occupational impairment is grossly in excess of what would be expected from the physical findings. In correspondence with Kellner’s definition, we defined medically unexplained physical symptoms as physical symptoms that after appropriate medical evaluation could not be attributed to a somatic illness. This elementary definition fits with the presumption that emotional problems may play an important role in many of the patients with these symptoms.

Our study confirmed this presumption in terms of psychiatric syndrome pathology. Similar to other authors (1, 3–10), we found a higher prevalence of psychiatric pathology among UPS patients. Using the HADS and the DES, we found that 31% of the UPS patients, compared with only 16% percent of the EPS patients, had a mental disorder. These results are similar to those of an earlier study in the same patient population, in which the Present State Examination was administered (1). In addition, the prevalence of mental disorders among EPS patients corresponds with the prevalence of mental disorders in the general Dutch population (mesured with the Composite International Diagnostic Interview) (63). These data indicate that UPS patients, unlike EPS patients, have nearly twice the risk of mental disorder. It is our clinical impression, however, that overall these mental disorders are of moderate severity.

The main issue of this study was the association of medically unexplained physical symptoms with alexithymia. Contrary to our expectations, UPS patients were not evidently more alexithymic than EPS patients. UPS patients had slightly higher DIF scores than EPS patients, but UPS patients did not differ from EPS patients in other alexithymia dimensions or total alexithymia score. There was a trend toward UPS patients being alexithymic more frequently than EPS patients (20 vs. 13%), but this difference did not reach statistical significance. Moreover, in logistic regression analysis anxiety, not alexithymia, proved to be predictive of the classification of the presenting symptoms as medically unexplained.

In agreement with other studies (64–66), we found an association in UPS patients between the degree of alexithymia and the number of (secondary) physical symptoms reported on a self-report questionnaire, although, as reported by Rief et al. (66), this association disappeared after controlling for the level of anxiety and depression. More importantly, however, the alexithymia dimensions were not associated with the number of secondary symptoms reported in the interviews that gave rise to illness behavior resulting in a restriction of normal daily activities, taking medication, or seeking medical assistance. As in other studies among students (67) and frequent attendance patients (68), we found with respect to healthcare utilization that UPS patients who had more problems identifying feelings consulted their general practitioner slightly more often. However, as was found in these earlier studies (67, 68), this relationship was not strong, and when other variables were controlled for, alexithymia once again did not play a significant role.

UPS patients who believed that their physical symptoms could be (in part) the result of emotional problems had more difficulties in identifying their feelings than those who did not have that opinion. However, this proved to be a spurious association caused by the association of both variables with psychiatric pathology. As in the study of Kirmayer et al. (7), most UPS patients (as well as EPS patients) with a mental disorder consider it possible that their physical symptoms could be (partly) caused by emotional problems, although in interviewing these patients it turned out that patients differ significantly in their capacity to elaborate meaningfully on these problems. However, a relatively small number (11%) of UPS patients with a mental disorder denied any possible influence of emotional problems on their physical functioning, and they reported more alexithymic features. In these patients alexithymia may be a factor of clinical significance, leading to, for example, a request for medical assistance for the somatic symptoms that accompany depression or an anxiety disorder.

On various criteria UPS patients reported their symptoms as more severe than EPS patients did. They also reported more secondary symptoms, although there was no difference between the two groups in terms of the actual existence of other symptoms that were so severe that the patients had to restrict their daily activities, take medication, or consult a physician. The UPS patients did not make greater use of medical services than the EPS patients, and neither group of patients consulted their general practitioner more often than the general population (69). Thus, based on the illness behavior of the UPS patients, it must be concluded that the UPS patients we investigated do not typically have the characteristics of patients with a severe form of somatization (70). This may explain why we found no strong association between alexithymia and unexplained physical symptoms, unlike other authors (36, 37) who studied patients with a somatoform disease.

The strength of this study is that all patients had a complete medical examination, after which the categorization of EPS and UPS was decided by two independent raters, who had excellent interrater agreement. Furthermore, to our knowledge this is the first study of alexithymia in a nonpsychiatric clinical sample of patients with medically unexplained physical symptoms. However, this is a cross-sectional study from which, strictly speaking, no causal conclusions can be drawn. Nevertheless, assuming that alexithymia is an important predisposing personality trait for the development of medically unexplained physical symptoms, we expected a higher prevalence of alexithymic features in UPS patients. Of course, one may object that people who are alexithymic may not always be able to report this adequately on a self-report questionnaire. However, in several studies the TAS-20 was shown to have good criteria and construct validity (42).

We conclude from our study that patients who present with medically unexplained physical symptoms are a heterogeneous group. In a substantial number of these patients the unexplained symptoms are associated with psychiatric syndrome pathology that usually seems to be moderately severe. In only a minority of the patients are medically unexplained physical symptoms associated with alexithymia. Additional empirical research is needed to clarify which personality features, other than alexithymia, are of pathogenetic importance for the development and persistence of medically unexplained physical symptoms.

Received for publication September 20, 1999.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 AIM OF THE STUDY
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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C. G. Kooiman, J. H. Bolk, H. G. M. Rooijmans, and R. W. Trijsburg
Alexithymia Does Not Predict the Persistence of Medically Unexplained Physical Symptoms
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