This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Carroll, R. E. Articles by North, N. T. Search for Related Content PubMed PubMed Citation Articles by O’Carroll, R. E. Articles by North, N. T. Related Collections Consultation Psychiatry Neurology Personality Stress and Coping

Alexithymia and Sense of Coherence in Patients With Total Spinal Cord Transection

From the School of Psychology (R.E.O., R.A., S.M.O.), University of St. Andrews, St. Andrews, Fife; and Department of Clinical Psychology (N.T.N.), Salisbury District Hospital, Salisbury, United Kingdom.

Address reprint requests to: R. E. O’Carroll, BSc, MPhil, PhD, School of Psychology, University of St. Andrews, St. Andrews, Fife, KY16 9JU, United Kingdom. Email: ronan{at}st-and.ac.uk

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: The study investigated the possibility that total spinal cord transection leading to tetraplegia would affect the ability to experience and identify emotions. It also examined whether the dispositional orientation of "sense of coherence" contributed to self-rated quality of life after spinal cord transection.

METHODS: Twenty patients with total spinal cord transection at the level of the sixth cervical vertebrae and 20 age- and sex-matched healthy control subjects completed measures of alexithymia, sense of coherence, and quality of life.

RESULTS: There were no differences between the two groups on alexithymia scores. However, spinal injury patients reported significantly decreased quality of life relative to matched healthy control subjects. A strong sense of coherence was associated with better self-reported quality of life. This relationship remained after controlling for current affective status.

CONCLUSIONS: We conclude that 1) loss of afferent feedback to the brain via the spinal cord does not have a significant effect on alexithymia scores, particularly factor 1 (difficulty in identifying feelings), and 2) sense of coherence may be an important factor in determining psychological adjustment after serious injury.

Key Words: sense of coherence • spinal cord injury • emotion • alexithymia.

Abbreviations: HADS = Hospital Anxiety and Depression Scale; SOC = sense of coherence; TAS-20 = Toronto Alexithymia Scale; WHOQOL = World Health Organization Quality of Life Scale.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
The cognitive neuroscience of emotional experience has been intensively studied over the past decade, and there has been an increasing focus on the role of physiological feedback influencing conscious and unconscious experience in humans. Patients who have suffered total spinal cord transection have drastically reduced feedback from periphery to brain. For many years the effects of spinal transection on psychological functioning have been debated, but there has been relatively little human experimental work in this area. Hohmann (1) is generally credited with writing one of the most influential papers in this area. He suffered a spinal injury, and this prompted him to conduct a survey of emotional experience in 24 fellow patients. He found that most reported significant decreases in experienced feelings of anger and sexual excitement. Hohmann concluded that disruption of the autonomic nervous system and its afferent return caused notable changes in emotional feelings. Montoya and Schandry (2) also reported impaired emotional experience and heartbeat perception in patients with spinal injury. The view that spinal cord damage impairs emotional perception and experience is widely held. For example, in the recent textbook An Introduction to Brain and Behavior, Kolb and Whishaw (3) state, "Spinal injury reduces the experience of emotion. The extent of emotional loss is greatest when the lesion is high on the spine." Furthermore, in his formulation of the currently influential somatic marker hypothesis, Damasio (4) stated, "Were you to cut only the signals from the body proper to the brain, your mind would change too. Even partial blocking of brain-body traffic, as happens in patients with spinal cord injury, causes changes in mind state."

Alexithymia is a concept that has received increasing attention in psychosomatic research. The alexithymia construct involves "difficulty identifying and describing feelings and difficulty in distinguishing between feelings and the bodily sensations of emotional arousal" (5). A central feature of alexithymia is therefore a proposed impairment in accessing, experiencing, or describing emotional states. Given that perception of visceral states through afferent feedback may be implicated in the experience of emotion (6), we tested the hypothesis that patients with total spinal cord transection would score significantly differently from matched control subjects on a valid and reliable measure of alexithymia. A relatively new application of the concept of alexithymia is its use in the testing of models in cognitive neuroscience; an example of this is the proposal of an interhemispheric transfer deficit in alexithymic individuals (5). In the present study we tested the hypothesis that spinal injury patients would have significantly elevated scores on the alexithymia measure, the TAS-20 (7), particularly factor 1, difficulty identifying feelings. This factor contains items such as "I am often confused about what emotion I am feeling," "When I am upset, I don’t know if I am sad, frightened or angry," and "I have feelings that I can’t quite identify."

Spinal cord injury is obviously a devastating injury that can lead to marked handicap, disability, and psychosocial distress (8). It is important to try to identify factors that may be associated with optimal psychosocial outcome after traumatic, life-changing, and disabling life events. One theoretical construct that has been proposed as a predictive dispositional variable is "sense of coherence" (9). Sense of coherence (SOC) is a "global orientation, a way of looking at the world" (10) rather than a personality trait. Individuals with a strong sense of coherence believe that the world around them is structured, explicable, and predictable; that the resources needed to meet the demands of the world are available to them; and that these demands are worthy of investment. There are three domains within the construct: comprehensibility, manageability, and meaningfulness. SOC is measured by a 29-item scale (SOC-29) that includes items such as "Do you think that there will always be people whom you’ll be able to count on in the future?" In our second experiment we tested the hypothesis that spinal injury patients who score highly on sense of coherence will also score highly on self-rated quality of life, controlling for current levels of anxiety and depression. In this second hypothesis we view SOC as a stable construct and expected that high scores would be associated with higher self-rated quality of life after a devastating injury, that is, that SOC could serve a protective function in enabling individuals to cope better with adversity, in this case C6 spinal cord transection.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
Twenty patients with spinal cord damage were compared with 20 age-, sex-, and education-matched control subjects. There were 5 women and 15 men in each group. Subjects were excluded if they had any previous evidence of head injury, alcohol/drug abuse, or psychiatric history. Patients were assessed in a specialist spinal injuries unit by a consultant in spinal injury. Mean (SD) time since injury was 2.9 (0.98) years. Patients were assessed using the American Spinal Injury Association’s Standards for Neurological and Functional Classification of Spinal Cord Injury (11). This system generates several measures of neurological damage, including the neurological, sensory, and motor level of the lesion. The standardized assessment system enables the clinician to determine the completeness of the injury. All patients were assessed as having a complete transverse lesion of the spinal cord at the C6 level, in the absence of head trauma. The functional consequences of a lesion at this level are that the patient is rendered quadriplegic, paralyzed from the shoulders down with no control over bowels and bladder. All patients can breathe unaided but are wheelchair bound and are unaware of physical sensations from below the shoulders.

Measures
All subjects completed the following measures: the Hospital Anxiety and Depression Scale (HADS), the Toronto Alexithymia Scale (TAS-20), the World Health Organization Quality of Life Scale (WHOQOL-BREF), and the Sense of Coherence Scale (SOC-29).

HADS.
The HADS aims to facilitate the detection and management of anxiety and depression in patients being investigated and treated for medical disorders (12). It has been widely used in clinical and nonclinical populations, and has been found to provide valid and distinct measures of anxiety and depression without being confounded by somatic symptoms of concurrent physical disorders in various populations (13). HADS contains seven items each for anxiety and depression. Items are scored so that a higher score indicates greater severity of symptoms; for example, "I can sit at ease and feel relaxed": definitely (0), usually (1), not often (2), or never (3).

TAS-20.
The Toronto Alexithymia Scale (14, 15) is a 20-item Likert scale to measure alexithymia. A higher score indicates a greater degree of alexithymia, and empirically derived cutoff scores differentiate between clinical and nonclinical groups. Bagby et al. (14) proposed a three-factor solution to the TAS-20: difficulties identifying feelings, difficulties describing feelings, and externally oriented thinking. Recently, Loas et al. (16) used LISREL analysis on the TAS-20 and confirmed the three-factor solution as a valid and robust measure of alexithymia.

WHOQOL-BREF.
This brief version of the six-domain World Health Organization WHOQOL-100 measures subjective quality of life, defined as "an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns." (17). WHOQOL-BREF addresses concerns that the 100-item scale is too lengthy and arduous for respondents in some clinical populations and responds to recent analyses suggesting that a four-domain solution is more appropriate. The WHOQOL-BREF uses 24 items, presented in Likert format, each assessing a different factor of quality of life. These items can be grouped into four domains of functioning: physical (seven items), psychological (six items), social (three items), and environmental (eight items). Weightings are applied to each domain’s total to give a score out of 20 for each domain, with higher scores indicating greater quality of life.

SOC-29.
The SOC-29 (9) is a 29-item measure with a seven-point Likert-type response format yielding an overall score between 0 and 203. The measure has shown respectable internal consistency and reliability (Cronbach’s , 0.84–0.93). Items reflect the three components of the sense of coherence construct: 11 comprehensibility items, 10 manageability items, and 8 meaningfulness items. However, factor analysis of sample data has demonstrated that the three component scores are not empirically separable; therefore, scores on the SOC-29 reflect an individual’s overall sense of coherence. Sample items include "Has it happened in the past that you were surprised by the behavior of people whom you thought you knew well?"; "Do you think that there will always be people whom you’ll be able to count on in the future?"; and "How often do you have the feeling that there’s little meaning in the things you do in your daily life?"

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
There were no differences between the groups on age, education, sex ratio, or occupational status, confirming that the two groups were well matched. In addition, there was no difference between the groups on HADS anxiety or depression scores (see Table 1). To test our first hypothesis, the two groups were compared on TAS-20 total and factor scores. There were no significant between-group differences on any of the TAS scores (see Table 2); therefore, total spinal cord sectioning at the C6 level was without detectable effect on alexithymia scores.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
The spinal injury and control groups were demographically well matched with no significant differences between the groups in terms of age, gender, education, and occupation. Additionally, no significant differences were found between the groups in terms of anxiety and depression as measured by HADS. This indicates that any differences in self-reported alexithymia, quality of life, or sense of coherence found between the groups cannot be attributed to socioeconomic background or affective status.

No significant differences were detected in TAS scores; therefore, absence of afferent feedback via the spinal cord to the brain had no detectable impact on self-rated alexithymia. Therefore, the prediction that absence of afferent feedback to the brain from the periphery via the spinal cord has a detectable effect on self-rated alexithymia was not supported. However, clearly other afferent feedback systems were still functioning in the spinal cord injury patients, including feedback via the vagus and other cranial nerves and hormonal feedback to the brain via the bloodstream. It is possible that these nonspinal feedback systems may have a significant role to play in emotional perception, identification, and experience.

Quality of life was found to be significantly lower for the spinal injury group compared with the control group across all four domains. Thus, C6 injury is associated with lower subjective quality of life, but this neither results in nor is mediated by increased levels of depression or anxiety as measured by HADS. Instead, the results indicate widespread impairment in quality of life in patients with spinal injury, affecting psychological, physical, environmental, and social domains.

There was no significant difference between the spinal injury and control groups on SOC scores. SOC scores stabilize at around 30 years of age and are not easily amenable to change (10); however, there is little empirical data on the stability of the construct after serious life events such as spinal cord injury.

The correlational analysis run on the spinal injury group revealed that a strong SOC (ie, high scores on the SOC-29) was associated with good self-rated quality of life. Correlations between SOC and all four domains of the WHOQOL were all highly significant (r = 0.62–0.76). This finding is congruent with other studies on SOC. For example, Motzer and Stewart (20) found that SOC explained 50% of the variance in quality-of-life scores in patients who had survived a cardiac arrest, and Johansson et al. (21) reported that elderly hip fracture patients who had stronger SOC scores reported higher overall quality of life 4 months after discharge from the hospital.

It has been suggested, however, that SOC may be simply tapping into negative affectivity (18,19). However, controlling for anxiety and depression did not alter the general finding that a strong SOC was associated with better quality of life. There are relatively few studies investigating SOC while controlling for negative affectivity; however, one study examining general health in farm workers also found that SOC scores remained as predictors of health after controlling for negative affectivity (22). Our results therefore suggest a role for SOC in predicting quality of life after serious spinal injury, controlling for current affective status. Nonetheless, we must acknowledge that the analysis we are presenting views SOC as a stable dispositional characteristic that predicts adaptation to adverse life events, although we only have postinjury data. A better design (though impractical) would be to collect SOC and quality-of-life data before and after spinal cord injury in a longitudinal design. At present, we cannot rule out the possibility that sense of coherence (is changed by traumatic life events.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
Our first hypothesis, that spinal injury patients would have altered alexithymia scores due to reduced somatic feedback to the brain via the spinal cord, was not supported.

Our second hypothesis, that high SOC would be associated with better quality of life after a devastating life event (total spinal cord transection), was supported even after controlling for current affective status.

	ACKNOWLEDGMENTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 
We thank the participants and staff for their participation.

Received for publication September 28, 2001.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS ACKNOWLEDGMENTS REFERENCES

 

1. Hohmann GW. Some effects of spinal cord lesions on experienced emotional feelings. Psychophysiology 1966; 3: 143–56.[Medline]
2. Montoya P, Schandry R. Emotional experience and heartbeat perception in patients with spinal cord injury and control subjects. J Psychophysiol 1994; 8: 289–96.
3. Kolb B, Whishaw IQ. An introduction to brain and behavior. New York: Worth; 2001.
4. Damasio AR. Descartes’ error. London: Papermac/Macmillan; 1994.
5. Parker JD, Keightley ML, Smith CT, Taylor GJ. Interhemispheric transfer deficit in alexithymia: an experimental study. Psychosom Med 1999; 61: 464–8.[Abstract/Free Full Text]
6. James W. What is emotion? Mind 1884; 9: 188–205.
7. Taylor GJ. The alexithymia construct: conceptualization, validation, and relationship with basic dimensions of personality. New Trends Exp Clin Psychiatry 1994; 10: 61–74.
8. North NT. The psychological effects of spinal cord injury: a review. Spinal Cord 1999; 37: 671–9.[CrossRef][Medline]
9. Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med 1993; 36: 725–33.
10. Antonovsky A. Unraveling the mysteries of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987.
11. ASIA. ASIA-f: standards for neurological and functional classification of spinal cord injury. Chicago: American Spinal Injury Association; 1992.
12. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–70.[Medline]
13. Johnston M, Pollard B, Hennessey P. Construct validation of the Hospital Anxiety and Depression Scale with clinical populations. J Psychosom Res 2000; 48: 579–84.[CrossRef][Medline]
14. Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale. I. Item selection and cross-validation of the factor structure. J Psychosom Res 1994; 38: 23–32.[CrossRef][Medline]
15. Bagby RM, Taylor GJ, Parker JDA. The twenty-item Toronto Alexithymia Scale. II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38: 33–40.[CrossRef][Medline]
16. Loas G, Corcos M, Stephan P, Pellet J, Bizouard P, Venisse JL, Perez-Diaz F, Guelfi JD, Jeammet P. Factorial structure of the 20-item Toronto Alexithymia Scale: confirmatory factorial analyses in nonclinical and clinical samples. J Psychosom Res 2001; 50: 255–61.[CrossRef][Medline]
17. Harper A, Power M. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med 1998; 28: 551–8.[CrossRef][Medline]
18. Gibson LM, Cook MJ. Neuroticism and sense of coherence. Psychol Rep 1996; 79: 343–9.[Medline]
19. Kravetz S, Drory Y, Florian V. Hardiness and sense of coherence and their relation to negative affect. Eur J Pers 1993; 7: 233–44.
20. Motzer S, Stewart BJ. Sense of coherence as a predictor of quality of life in persons with coronary heart disease surviving cardiac arrest. Res Nurs Health 1996; 19: 287–98.[CrossRef][Medline]
21. Johansson I, Larsson G, Hamrin E. Sense of coherence, quality of life, and function among elderly hip fracture patients. Aging Clin Exp Res 1998; 10: 377–84.
22. Strumpfer DJ. Sense of coherence, negative affectivity, and general health in farm supervisors. Psychol Rep 1997; 80: 963–7.[Medline]

This article has been cited by other articles:

				M. Eriksson and B. Lindstrom Antonovsky's sense of coherence scale and its relation with quality of life: a systematic review J Epidemiol Community Health, November 1, 2007; 61(11): 938 - 944. [Abstract] [Full Text] [PDF]

				A. Nicotra, H. D. Critchley, C. J. Mathias, and R. J. Dolan Emotional and autonomic consequences of spinal cord injury explored using functional brain imaging Brain, March 1, 2006; 129(3): 718 - 728. [Abstract] [Full Text] [PDF]

				D. C. Lustig The Adjustment Process for Individuals With Spinal Cord Injury: The Effect of Perceived Premorbid Sense of Coherence Rehabil Couns Bull, April 1, 2005; 48(3): 146 - 156. [Abstract] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Carroll, R. E. Articles by North, N. T. Search for Related Content PubMed PubMed Citation Articles by O’Carroll, R. E. Articles by North, N. T. Related Collections Consultation Psychiatry Neurology Personality Stress and Coping