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Psychosomatic Medicine 63:944-950 (2001)
© 2001 American Psychosomatic Society

ORIGINAL ARTICLE

Alexithymic Features in Stroke: Effects of Laterality and Gender

Gianfranco Spalletta, MD, Augusto Pasini, MD, Alberto Costa, BSc, Domenico De Angelis, MD, Nicola Ramundo, MD, Stefano Paolucci, MD and Carlo Caltagirone, MD

From IRCCS Fondazione Santa Lucia (G.S., A.C., D.D., N.R., S.P., C.C.), Rome; and the Departments of Psychiatry (A.P.) and Neuroscience (G.S., C.C.), University of Tor Vergata, Rome, Italy.

Address reprint requests to: Gianfranco Spalletta, IRCCS Santa Lucia, Laboratorio di Neuropsicologia Clinica e Comportamentale, Via Ardeatina, 306, 00179 Roma, Italy. Email: g.spalletta{at}hsantalucia.it


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: Stroke patients suffer from a high rate of behavioral disorders, and the laterality of the lesion may affect the expression of emotional disturbances. This study tested the hypothesis that stroke patients with a lesion in the right hemisphere are at high risk of developing alexithymic features.

METHODS: Forty-eight patients were interviewed with the Structured Clinical Interview for DSM-IV (patient edition), the Mini-Mental State Examination, the State-Trait Anxiety Inventory (state form), the Beck Depression Inventory, and the Toronto Alexithymia Scale (20-item version). Alexithymic differences between stroke patients with a lesion in the right hemisphere and those with a lesion in the left hemisphere were computed by analysis of covariance, using scores on the Mini-Mental State Examination, Beck Depression Inventory (psychic subscore), and State-Trait Anxiety Inventory as covariates and the score on the Toronto Alexithymia Scale as the dependent variable. A multivariate analysis of covariance and a series of follow-up analyses of covariance with the same covariates were used to discriminate differences in subscores on the Toronto Alexithymia Scale. An exploratory analysis of covariance was also performed to determine the effect of gender on alexithymic features in both groups of stroke patients.

RESULTS: The 21 stroke patients with a lesion in the right hemisphere were more alexithymic than the 27 patients with a lesion in the left hemisphere. This evidence was strengthened by the categorical analysis: 48% of the patients with a right-hemisphere lesion had alexithymia, compared with 22% of patients with a left-hemisphere lesion. Univariate analyses of covariance showed significant differences between the two groups in difficulty identifying feelings and difficulty describing feelings, but not in externally oriented thinking. The last exploratory analysis of covariance suggested that gender may influence alexithymic features.

CONCLUSIONS: This study provides direct evidence that alexithymia, and more specifically difficulty identifying feelings and difficulty describing feelings, is more common in stroke patients with a right-hemisphere lesion than in those with a left-hemisphere lesion. It also provides preliminary evidence that gender may affect alexithymic expression.

Key Words: alexithymia, • laterality, • gender, • stroke.

Abbreviations: ACA = anterior cerebral artery;; ANCOVA = analysis of covariance;; BDI = Beck Depression Inventory;; BDI-PSY = psychic subscore of the BDI;; BI = Barthel Index;; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth edition;; LBD = brain damage in left hemisphere;; LSA = lenticulostriate artery;; MANCOVA = multivariate analysis of covariance;; MCA = middle cerebral artery;; MMSE = Mini-Mental State Examination;; MRI = magnetic resonance imaging;; PCA = posterior cerebral artery;; RBD = brain damage in right hemisphere;; SCID-P = Structured Clinical Interview for DSM-IV–patient edition;; SD = standard deviation;; STAI-S = State-Trait Anxiety Inventory–state form;; TAS-20 = 20-item Toronto Alexithymia Scale.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Because stroke has been associated with a high rate of behavioral disorders, researchers have hypothesized that the laterality of brain damage may facilitate the expression of emotional or affective disturbances (1). At the same time, there have been two major developments: First, in the field of neuropsychology, interest has focused on the difficulty of perception, decoding, and expression of emotions during emotional stimuli (2–5), and it has been shown that patients with brain damage in the right hemisphere (RBD) perform worse than patients with damage in the left hemisphere (LBD) (6). In particular, Blonder et al. (7), observing a reduced capacity to judge the emotional content of sentences in patients with RBD, hypothesized a preferential hemispheric involvement in the communicative expression of emotions. Zoccolotti et al. (8) and Caltagirone et al. (9) reported that the autonomic responses during vision of crude scenes were clearly reduced in patients with RBD, whereas responses of patients with LBD were similar to those of control subjects. In addition, the control of facial emotional expressiveness was not lateralized, confirming that the cognition of the emotional meaning of the presented scenes was maintained in patients with RBD as well as those with LBD. These data suggest that processing and communicative aspects of emotions are not regulated properly in patients with right-hemisphere lesions. Compared with the left hemisphere, the right hemisphere seems to be superior in processing and organizing emotional experience (1). However, neuropsychological research does not give a very coherent picture (1, 5).

Second, from the psychiatric point of view, past and recent studies of biological correlates, in patients and normal subjects who have difficulty identifying and describing their emotions and an externally oriented cognitive style, have highlighted an interhemispheric transfer deficit (10–12). The psychopathological dimension that encompasses the above-mentioned affective-cognitive construct is called alexithymia (13, 14), and it is correlated with, but independent of, both anxiety and depression (15). In addition, alexithymic subjects, like patients with RBD, show impaired nonverbal recognition of emotional stimuli (16, 17).

To our knowledge, a direct scientific finding of alexithymic characteristics in neurological patients with hemispheric lesions is not present in the literature, even though there are some clinical suggestions that the manifestations of alexithymia could be associated with RBD (18, 19). Moreover, there is one report showing the relationship between alexithymia and left hemispheric lateralization in normal subjects (20). Another study suggested that the correlation between alexithymia and a possible deficit in right hemispheric function of college students can be identified in men only (21).

Considering that alexithymia, primarily or secondarily, may influence the severity of mood (22) and other psychiatric disorders (23–26), and in turn that psychiatric comorbidity may impair the rehabilitation process in patients with brain damage (27), it could be useful to clarify whether brain-damaged patients present alexithymic features connected with lesion laterality. In addition, it is important to improve our understanding of the mechanisms underlying the disturbance because alexithymic patients seem to communicate their feelings by means of physical complaints and physicians tend to be confused by this kind of symptom expression and "tend to mistake these physical symptoms for undetected organic pathology" (14). This phenomenon may increase the length of hospitalization, even in patients with organic pathology, and may contribute to an excessive demand for health care (14, 28).

The primary aim of this study was to confirm the hypothesis that RBD contributes to the development of alexithymia in stroke patients. The secondary aim was to detect which of the individual dimensions of alexithymia is associated with the laterality of the brain damage. Finally, we sought to verify, as a preliminary investigation, the influence of gender on the alexithymic features in stroke patients with a lesion in the right hemisphere and those with a lesion in the left hemisphere.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The data were collected in a large urban hospital specializing in neurological rehabilitation. Consecutive inpatients who were diagnosed with stroke and who underwent a physical rehabilitation process were approached.

The inclusion criteria were as follows: stroke diagnosis according to the Stroke Data Bank (29), a minimum of 15 days since the acute stroke, and an MMSE (30) score >=5. The diagnosis of stroke was based on the clinical history and MRI findings. Exclusion criteria included the following: severe cognitive deficit; severe aphasia as evaluated by the aphasia scale, a clinical scale ranging from 0 (no aphasia) to 3 (severe aphasia); prior history of head trauma or other brain diseases; major medical illness; left-handedness; and bihemispheric cerebrovascular accident (determined by MRI).

Of the original sample of 100 patients, recruited between September 1999 and March 2000, 48 patients entered in the study. Written informed consent was obtained from all participants. Twenty-one subjects were excluded because their aphasia or cognitive impairment was so severe that it precluded both the interview and administration of the questionnaires, 19 were excluded because of bilateral damage or other brain diseases, and 6 were excluded because of major medical illnesses. In addition, 3 patients were left-handed, and 3 declined to participate.

Three assessors, who were unaware of the aims of the study and the results of MRI, were trained until they demonstrated an interrater reliability of 0.80 ({kappa} coefficient) on the psychometric tests and the SCID-P (31). Patients were interviewed between day 7 and 14 of hospitalization and were administered the Italian-language version of the STAI-S (32), the BDI (33), and the TAS-20 (34). The information required to evaluate previous psychiatric disorders was obtained from interviews with the patients and caregivers by using the SCID-P. To measure functional disability, a clinical neurologist, who was unaware of the aims of the study and the results of MRI, used the BI (35).

None of the patients included in the study were taking antidepressants at the time of clinical assessment.

For the statistical analysis we considered the total score of the STAI-S and the BDI-PSY (ie, the first 13 items of the BDI) to avoid the interference of somatic symptoms, directly or indirectly derived from the stroke, on the depression score (36). However, the total score on the BDI is reported. In addition, the total score on the TAS-20, a questionnaire with a score ranging from 20 to 100, was subsequently divided into three subscores to evaluate the independent dimensions of alexithymia. The three subscores were as follows: F1, difficulty identifying feelings (items 1, 3, 6, 7, 9, 13, and 14); F2, difficulty describing feelings (items 2, 4, 11, 12, and 17); and F3, externally oriented thinking (items 5, 8, 10, 15, 16, 18, 19, and 20). Apart from continuous values, the scale allowed us to categorize subjects as nonalexithymic (score ranging from 20 to 51), borderline alexithymic (score ranging from 52 to 60), or alexithymic (score >=61). The TAS-20 score and subscores, categorical results, and statistical findings are given in Table 1.


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  		Table 1. TAS-20 Continuous and Categorical Data of Patients With LBD and Patients With RBD
 
Brain-imaging findings were assessed independently by a neurologist and a psychiatrist who were blind to the aims of the study. In the event of disagreement, the final interpretation was reached by consensus. Cerebral lesions were classified in the right and left hemispheres as follows: frontal lobe of ACA territory, frontal-temporal-parietal lobes of MCA territory, temporal-parietal lobes of MCA territory, parietal lobe of MCA territory, occipital lobe of PCA territory, subcortical area of MCA territory, mixed cortical-subcortical area, lenticulocapsular area of LSA territory, thalamus, pons, and cerebellum. The size of the lesion was categorized as small (maximum diameter, 1<=2 cm), medium (>2 to <=4 cm), or large (>4 cm). However, these data, shown in Table 2, were not considered for statistical analysis because of the small number of subjects included in each group of lesions.


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  		Table 2. Description of Location, Type, and Extent of Stroke in Patients With LBD and Patients With RBD
 
To statistically verify whether there were differences in the brain lesions between patients with LBD and those with RBD, we categorized lesion location as follows, according to the method published by Gainotti et al. (37): 1) cortical, subcortical (ie, basal ganglia, thalami, etc), or mixed cortical-subcortical damage; and 2) anterior, central, or posterior damage. Table 3 provides a detailed description of these data.


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  		Table 3. Differences in Lesion Location between Patients With LBD and Patients With RBD
 
A clinical description of patients’ neurological symptoms is presented in Table 4.


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  		Table 4. Clinical Description of Neurological Symptoms in Patients With LBD and Patients With RBD
 
Statistical analyses were performed with Statview and Superanova software. Taking into consideration the groups of patients with RBD and patients with LBD, comparisons with respect to categorical variables were made by using the {chi}2 test, and Student’s t test was used to detect differences in means for continuous values. To control for the effect of cognitive level, psychic symptoms of depression, and anxiety on the alexithymic difference between patients with a right-hemisphere stroke and those with a left-hemisphere stroke, we used an ANCOVA with MMSE, BDI-PSY, and STAI-S scores as covariates and TAS-20 score as the dependent variable. A MANCOVA and a series of follow-up ANCOVAs with the same covariates were used to discriminate differences between TAS-20 subscores.

An ANCOVA was performed to determine whether TAS-20 score varied as a function of gender in both groups of patients (groups: men with right-hemisphere stroke vs. men with left-hemisphere stroke vs. women with right-hemisphere stroke vs. women with left-hemisphere stroke). Covariates included MMSE, BDI-PSY, and STAI-S scores. In the event of a significant main effect involving gender in patients with RBD or LBD, post hoc Fisher’s protected least significant difference tests were conducted to determine the differences among the four groups on TAS-20 scores. A MANCOVA with the same covariates was used to discriminate differences among the four groups on TAS-20 subscores. We considered as preliminary these last exploratory investigations of gender effect on alexithymic features because of the small number of subjects included in each of the four groups.

All tests were two-tailed, and the level of statistical significance was defined as p < 0.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Table 5 shows the sociodemographic and clinical variables of both groups of patients. t and {chi}2 values and statistical significance are also shown.


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  		Table 5. Sociodemographic and Clinical Variables of Patients With LBD and Patients With RBD
 
Brain-imaging results did not differ between patients with RBD and those with LBD (see Table 3).

An ANCOVA was used to assess the effect of the laterality of brain damage on the TAS-20 score after controlling for MMSE, BDI-PSY, and STAI-S scores. The difference between the two groups was statistically significant (F(1,43) = 7.89, p = .007) with right-hemisphere stroke patients showing more alexithymic features than left-hemisphere stroke patients. Moreover, the effect of the BDI-PSY covariate approached statistical significance (F(1,43) = 3.88, p = .055).

To further investigate which of the TAS-20 subscores differed between patients with right-hemisphere stroke and those with left-hemisphere stroke, a MANCOVA was used with group (ie, right vs. left) as a main effect and MMSE, BDI-PSY, and STAI-S scores as the covariates. The Wilks’ {lambda} of 0.83 (F(3,41) = 2.87, p = .048) indicated a global difference on the TAS-20 subscores. Furthermore, there was an effect, statistically significant, of the BDI-PSY on TAS-20 subscores between the two groups (Wilks’ {lambda} = 0.80; F(3,41) = 3.32, p = .029). Subsequent univariate ANCOVAs showed significant differences between the two groups on the F1 (F(1,43) = 4.82, p = .034) and F2 (F(1,43) = 5.00, p = .031) but not the F3 (F(1,43) = 0.04, p = .839) TAS-20 subscores. The effect of the BDI-PSY covariate was statistically significant for both the F1 (F(1,43) = 6.07, p = .018) and F2 (F(1,43) = 5.17, p = .028) TAS-20 subscores.

The exploratory investigation indicated that there was a significant effect of gender on TAS-20 levels in patients with RBD and those with LBD (F(3,41) = 3.46, p = .025). Post hoc Fisher’s protected least significant difference tests revealed that men with right-hemisphere stroke had a significantly higher (p = .009) TAS-20 score (mean = 60.60, SD = 8.60) than men with a left-hemisphere stroke (mean = 52.23, SD = 6.95). The difference between women with right-hemisphere stroke (mean = 60.36, SD = 6.77) and women with left-hemisphere stroke (mean = 57.00, SD = 7.94) was not significant. The MANCOVA, used with the four groups as a main effect and MMSE, BDI-PSY, and STAI-S scores as the covariates, did not indicate a significant global difference on the TAS-20 subscores (Wilks’ {lambda} = 0.69; F(3,39) = 1.75, p = .089).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The hypothesis that patients with RBD would experience a greater level of alexithymia was confirmed. Indeed, our results show that having a right-hemisphere stroke was associated with an increased likelihood of an alexithymic affective-cognitive style. The evidence is strengthened by the categorical analysis: only 22% of patients with a left-hemisphere stroke suffered from alexithymia, compared with 48% of patients with a right-hemisphere stroke. Furthermore, 5% of patients with a right-hemisphere stroke and 30% of those with a left-hemisphere stroke were nonalexithymic.

It is worth noting that the results are significant both before and after controlling for the most important confounding variables (ie, general cognitive level, anxiety, and depressive psychopathology). In addition, there were no differences in the present or past rate of mental disorders between the two groups. Nevertheless, the effect of the psychic depression covariate was significant on the differences of both the total score and the F1 and F2 subscores, strengthening the previously documented relationship between alexithymia and depression but confirming that the two dimensions are distinct (22).

These results integrate previously published findings and corroborate hypotheses on the biological correlates of alexithymia. In a recent study Parker et al. (10), by means of a tactile finger localization task in alexithymic subjects without psychiatric disorders, confirmed the previously reported (11, 12) interhemispheric transfer deficit, indicating that the impaired performance was bidirectional and not due to dysregulation in a single hemisphere. The hallmark of this neurobiological model of alexithymia is difficulty integrating affective experiences, which are processed by the right hemisphere, with the communicative one, which is mediated by the left hemisphere. However, the authors did not exclude a possible effect of the right hemispheric dysfunction in the information processing linked to the alexithymic feature. Taking into consideration the core components of the alexithymic construct (ie, impaired emotional awareness and processing of verbal and nonverbal stimuli and responses; Refs. 16 and 20), it is not surprising that patients with RBD may experience a high level of this disturbance, considering that the right hemisphere is classically described as dominant in the perception of emotions (38).

Regarding the TAS-20 subscales, a MANCOVA and subsequent follow-up ANCOVAs clarified that difficulties in both identifying and describing feelings, and not externally oriented cognitive style, distinguished patients with right-hemisphere stroke from those with left-hemisphere stroke. This is an intriguing result, indicating that the right hemisphere may have a role in some but not all aspects of alexithymic construct.

These data only partially parallel the previously reported neuropsychological results that evidenced changes in communication and processing of emotions in patients with RBD, with emotional indifference and reduced autonomic responses but normal description of the emotional meaning of crude scenes (3, 5).

Another interesting result emerged by splitting the two groups of patients (those with RBD and those with LBD) into men and women. After comparing the resulting four groups for alexithymic levels, men with right-hemisphere stroke had a high level of alexithymia and were more alexithymic than those with left-hemisphere stroke. On the other hand, there was no difference, on alexithymic levels, between women with right-hemisphere stroke and women with left-hemisphere stroke, and both groups had a high level of alexithymic features. These results only partially agree with those of Lumley and Sielky (21), who, in a sample of college students selected for high scores on the TAS-20, found that right hemispheric functional deficit was associated with alexithymia in men only. To better understand this partial discrepancy between the two findings, it is necessary to consider that our sample included older brain-damaged patients, whereas Lumley and Sielky’s sample (21) included young people without brain lesions who had, at most, altered performance on lateralization tasks.

Regarding lesion location, in our sample we did not find differences between patients with LBD and those with RBD. However, one must consider that many patients suffered from very large brain lesions, and this is why we preferred to statistically compare only cortical with subcortical lesions or anterior with posterior lesions. This type of categorization can give us little specific information about the relationship between selective brain lesions and alexithymic features, especially about the effect of gender on affective-cognitive style.

At this level of scientific knowledge, and in view of past and recent evidence of precise brain areas (like anterior cingulated cortex) correlated with emotional experience (1, 39, 40), we suggest that it is important to detect more accurately the problem of the neurobiological basis of alexithymia with specific structural and functional brain-imaging studies. In particular, the possible lesion location or locations associated with the alexithymic feature need to be studied with morphovolumetric MRI procedures of anatomic reconstruction, integrated by functional investigations such as single-photon emission computerized tomography or positron emission tomography. Moreover, neuropsychological and psychiatric evaluation of emotions need to be performed together in the same psychiatric and neurological subjects to detect methodologic similarities and differences and to permit data confrontation.

A better understanding of the neurobiological factors of alexithymia in brain-damaged patients is not a mere theoretical problem. Indeed, clinicians ought to apply ad hoc processes of rehabilitation taking into consideration, in conjunction with psychological and social aspects, both lesion location and affective-cognitive correlates (such as alexithymia) because of the different course and outcome in different alexithymic expressions (14, 16, 28).

In conclusion, this study provides direct evidence that alexithymia, particularly difficulty identifying feelings and difficulty describing feelings, is more common in patients with RBD than in patients with LBD, supporting the previously described hypothesis of a neurobiological mechanism as the correlate of some expression of alexithymic features. In future research, gender should be studied and confirmed as a variable contributory factor to alexithymia in patients with LBD and those with RBD.

Received for publication December 21, 2000.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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S. Koponen, T. Taiminen, K. Honkalampi, M. Joukamaa, H. Viinamaki, T. Kurki, R. Portin, L. Himanen, H. Isoniemi, S. Hinkka, et al.
Alexithymia After Traumatic Brain Injury: Its Relation to Magnetic Resonance Imaging Findings and Psychiatric Disorders
Psychosom Med, September 1, 2005; 67(5): 807 - 812.
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H. Gundel, A. Lopez-Sala, A. O. Ceballos-Baumann, J. Deus, N. Cardoner, B. Marten-Mittag, C. Soriano-Mas, and J. Pujol
Alexithymia Correlates With the Size of the Right Anterior Cingulate
Psychosom Med, January 1, 2004; 66(1): 132 - 140.
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