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ORIGINAL ARTICLES |
From the Department of Social Psychiatry (M.J.), Tampere School of Public Health, University of Tampere, Tampere, Finland; Department of Psychiatry (M.J.) Tampere University Hospital, Tampere, Finland; Department of Psychiatry (P.K., J.V., K.L., J.T.K.), Oulu University Hospital, Oulu, Finland; Department of Public Health Science and General Practice (J.J., M.R.J.), University of Oulu, Oulu, Finland; and Department of Epidemiology and Public Health (M.R.J.), Imperial College School of Medicine London, United Kingdom.
Address reprint requests to: Matti Joukamaa, PhD, Professor of Social Psychiatry, University of Tampere, Tampere School of Public Health, University of Tampere, FIN-33014 Tampere University, Finland. Email: matti.joukamaa{at}uta.fi
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ABSTRACT |
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METHODS: The study forms part of the prospective Northern Finland 1966 Birth Cohort Project. The original material consisted of all 12,058 live-born children in the provinces of Lapland and Oulu in Finland with an expected delivery date during 1966. The material represents 96% of all births in the region. In 1997 a 31-year follow-up study was made on part of the initial sample. The 20-item version of the Toronto Alexithymia Scale (TAS-20) was given to 5983 participants of the field study. Of them, 85% returned the questionnaire properly completed. Factors indicative of the social situation of the child’s family were already gathered during pregnancy and the time of birth from the mothers, thus eliminating recall bias.
RESULTS: Alexithymia was more common in subjects from rural than urban dwelling areas. Unwanted children or subjects born into families with many children also exhibited an association with alexithymia in adulthood.
CONCLUSIONS: Maternal social situation and environment predict alexithymia in the offspring.
Key Words: alexithymia, • TAS-20, • epidemiological study, • childhood, • social situation, • cohort study.
Abbreviations: OR = odds ratio;; TAS-20 = 20-item version of the Toronto Alexithymia Scale;; 95% CI = 95% confidence interval.
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INTRODUCTION |
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Many theories concerning the origins of alexithymia have been presented (5–11) , but the precise etiology of alexithymia remains unknown. Several authors have proposed that the origins of alexithymia are at least in part related to the affect development during early childhood (12, 13) . However, until now there have been only few studies dealing with the association between a child’s family environment and alexithymia. The results have shown alexithymia in adulthood to be associated with many kinds of difficulties in the childhood family, such as disturbed family functioning and maternal alexithymia (14), diminished family expressiveness in childhood (15, 16) , not feeling emotionally safe during childhood (15), and mother’s poor care (17, 18) . Kauhanen (19) has proposed that alexithymia may be "an accumulative process starting in childhood and developing and reinforcing itself in a social context." All of the above-mentioned studies dealing with associations of alexithymia and different childhood phenomena have been cross-sectional; consequently they are vulnerable to recall bias. Until now no prospective studies have been performed, one of the main reasons being the newness of the alexithymia construct and the earlier lack of a suitable, valid means of measuring it. We had the possibility to study alexithymia as measured in adulthood in relation to different sociodemographic factors of the childhood family measured in a prospective study setting. We hypothesized that poor social situation in the childhood family can also be associated with difficulties in the infant-caregiver relationship and thus be connected to the future alexithymia of the offspring in adulthood.
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MATERIAL AND METHODS |
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Materials
In 1997, 8417 of the original cohort members were living in the two northernmost provinces of Finland and in the capital city (Helsinki) area. As a part of the 31-year follow-up study, they were invited to a clinical examination. Of the invited subjects, 5983 persons participated in the field study and gave their written informed consent. A questionnaire including the 20-item version of the Toronto Alexithymia Scale (TAS-20) was given to all the participants. The TAS-20 questionnaire was properly filled in by 84.0% (5028) of the eligible subjects. The nonrespondents differed from those who participated by being more commonly male, employed, married, and having lower vocational education (22).
Methods
The TAS-20 was used as the measure of alexithymia because, of the different methods for measuring alexithymia, it is the most widely used and presumably the most carefully validated one. Its internal consistency, test-retest reliability, and convergent, discriminant, and concurrent validity have been demonstrated to be good (23, 24) . The psychometric properties of the Finnish version of the TAS-20 have been shown to be satisfactory (21). The TAS-20 has been shown to measure a general dimension of alexithymia (25). The items are rated on a 5-point scale ranging from "strongly disagree" to "strongly agree." The TAS-20 consists of three subscales or "factors" (TAS factors 1–3) that reflect the three main facets of the alexithymia concept: TAS factor 1 assesses difficulties in identifying feelings (eg, "I have feelings that I can’t quite identify"), TAS factor 2 concerns itself with difficulty in describing feelings (eg, "It is difficult for me to find the right words for my feelings"), and TAS factor 3 reflects concrete, externally oriented thinking or a preoccupation with the details of external events (eg, "I prefer talking to people about their daily activities rather than their feelings"). The TAS-20 total score as well as the TAS factors correlate negatively with different measures of psychological mindedness and awareness of own affects (26, 27) . Following the recommendation of the developers of the scale, the cutoff point of alexithymia was also used: TAS-20 total scores >60 are defined as alexithymic cases (26).
Data concerning perinatal social circumstances were gathered by asking the expectant mothers during midgestation at the antenatal clinics. Information on the wantedness of the pregnancy was divided into three classes (wanted, wanted but later, and not wanted); for the present study it was dichotomized (wanted and wanted but later/not wanted). Information about the mother’s mood (normal, depressed, or very depressed) was also requested, and for the present study the variable was dichotomized (normal/depressed or very depressed). Social class was operationalized by using the occupation of the father. If there was no father in the family, the occupation of the mother was used. Social class was divided into three classes: high (those in managerial positions, independent entrepreneurs, businessmen, officials, and foremen), low (skilled and unskilled workers), and farmers. Dwelling area was divided into two classes: urban and rural. The two last-mentioned variables correlated with each other, the majority of farmers living in rural surroundings. One half of the rural sample, however, belonged to the low social class and one fifth to the high social class. Mother’s marital status was dichotomized: unmarried/married and other (the numbers of divorced and widowed mothers were minimal). Maternal age at the time of the delivery was grouped into three classes: <21 years, 21 to 34 years, and >34 years. The number of older children in the family at the time of delivery was categorized as 0, 1 to 3, and 4.
The data were analyzed using SAS software, version 8 (28). The chi-square test was used for statistical analysis in group comparisons of categorical variables, and analysis of variance was used for numerical, continuous variables. Multivariate logistic regression analysis was used to study the independent associations between the explanatory variables and the outcome. Odds ratios (ORs) and 95% confidence intervals (95% CIs) also were calculated.
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RESULTS |
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In the urban subsample, mother being unmarried (p = .001), unwantedness of pregnancy (p = .001), and maternal depression during pregnancy (p = .033) were all associated with alexithymia; but according to the logistic regression analysis conducted simultaneously with these three variables, only unwantedness of pregnancy was significantly associated with alexithymia (OR = 4.5, 95% CI = 2.5–8.0).
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DISCUSSION |
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Of the social factors in childhood, residential area was most clearly associated with alexithymia: subjects from rural regions in childhood were more commonly alexithymic as adults than other subjects. In the only other study we are aware of that deals with residential area and alexithymia, Joukamaa et al. (29) found no difference in the prevalence of alexithymia between urban and rural inhabitants, but that particular study focused on a population sample of 72-year-old subjects. In the present study no difference was found in the prevalence of alexithymia between families with high or low social class, but the children of farmers were more commonly alexithymic than other subjects. This is of course in line with the above dwelling area finding. Earlier studies dealing with alexithymia and socioeconomic status have shown inconsistent findings (30). However, a recent Finnish study with a population sample of working-age people and the TAS-20 as the measure of alexithymia showed a clear association of alexithymia with a low socioeconomic situation (31). In our own earlier study with the same sample, a similar association with alexithymia and social situation in adulthood was also seen (22). It seems that the situation a child experiences in childhood and as an adult can mean different things in this context. Being born into a working class family is not associated with future alexithymia, but being alexithymic can negatively affect achievements and social status later in adulthood.
The proportion of alexithymia was higher in cases in which the pregnancy had been unwanted and in cases where the mother had already had many children before the last pregnancy. It can be assumed that unwanted pregnancies would be associated with young age and unmarried status of the mother. When the associations of these variables were analyzed in the present material, it was found that most of the unmarried mothers were indeed young but that unwanted pregnancies were associated with old age of the mother (>34 years). This means that in this sample alexithymia was associated with two types of mothers: young and unmarried mothers and older (>34 years) mothers having many children before the last pregnancy. Among urban inhabitants alexithymia was particularly well associated with depression in mothers and their being unmarried, reflecting the young age of these mothers. Among rural subjects alexithymia was associated with both unwantedness of the pregnancy and a large number of older siblings, thus meaning older mothers.
Are there some similarities then between being born to a young, unmarried, and probably depressive mother and to an older mother with many earlier deliveries? Some indication can be found from the sparse literature concerning the childhood family situation and future adulthood alexithymia. According to Berenbaum and James (15), alexithymia is associated with not feeling emotionally safe during childhood and with a family environment where members are not permitted to express their feelings. The best predictor of alexithymia in their study was "having grown up in homes in which there was little positive communication." Also Kench and Irwin (16) found that alexithymia in adulthood was associated with poor family expressiveness during childhood. Fukunishi et al. (17, 18) showed that the mothers’ low care in childhood was associated with future alexithymia of the offspring. McDougall (12) has stated that regardless of the etiology of alexithymia, disturbance in the early infant-parent relationship is important in the development of alexithymia. King and Mallinckrodt (32), using retrospective ratings of childhood family dysfunction, stated that "memories of affirmatively healthy family environments, including cohesion, emotional expression, and encouragement of independence, were negatively correlated with alexithymia."
Unwanted pregnancy has been associated with reduced time and attention on the part of mothers to their young children, leading to a lower-quality emotional relationship with the children (33) and to different adverse postpartum outcomes in the family (34). Delivering a baby at a young age poses also a risk for the relationship between the mother and the infant (35) and may be associated with financial, social, and emotional stress (36). On the other hand, large family size and advanced age of the mother during pregnancy can also disturb the mother-baby relationship and lead to different types of problems in the family (37, 38) .
We assume that being born to a young, unmarried mother or to a mother with many older children can disturb the development of the normal early mother-infant intimacy and can reinforce the later alexithymic features of the infant in adulthood. We think that this assumption is in line with a few previous results concerning the childhood family environment and future alexithymia in adulthood. It should, however, be remembered that in this study we were not able to assess the mother-infant relationship and the communication in the childhood family relationship. It is an important topic for research when exploring the origins of alexithymia.
What does it mean that alexithymia was more common among subjects born in rural than urban dwelling areas? We may conclude that the rural way of life itself is linked with alexithymia. We believe that the traditional Finnish lifestyle does not encourage people, especially men, to express their feelings and emotions freely. Some other Finnish authors have also discussed this theme, giving support to this assumption (19, 39, 40) . This cultural peculiarity is probably associated with the sparsely inhabited rural regions with their long winters and short time of sunlight, which are especially typical of the northern parts of Finland. King and Mallinckrodt (32) have stated that "persons who recall a strong emphasis in their family on intellectual curiosity and cultural pursuits are not likely to exhibit the alexithymic feature of external cognitive orientation, which, when present, can be regarded as a lack of introspective capacity" We think that the traditional Finnish rural culture lacked these qualities.
Our study has several limitations. First, the sample consists of only one 31-year-old age group. Second, the findings of this study could have been influenced by cohort phenomena, and it is not clear whether they can be generalized to other, older people. Third, we were unable to analyze any factors concerning family functioning, family communication, mother-infant relationships, or maternal alexithymia, which have previously been shown to be associated with alexithymia in the offspring (14, 15, 17, 18) . Unfortunately no psychiatrists were participating in this project at its onset in 1966. We had the possibility to study only a limited number of variables concerning the childhood family. Fourth, when analyzing the meaning of childhood social situation with future alexithymia after a 31-year-long period, it should be kept in mind that many other events, not controlled for in this study, can also be associated with the development of alexithymia.
The strength of our study was, however, its prospective design: all of the assessments concerning childhood were made at the time of the pregnancy, eliminating recall bias. Although our sample consisted of only one age group, it was drawn from the general population and is therefore representative of all persons of the same age in Finland.
In conclusion, our study showed interesting associations between alexithymia in adulthood and different childhood home circumstances. Being born an unwanted child can challenge the development of the normal infant-mother relationship and can enhance the development of alexithymia. We also believe that the typical Finnish custom, common especially in earlier days, of not talking about emotions was still widespread 30 years ago in the more rural parts of northern Finland. If our conclusions hold true, we think that the results of this study support the idea that the early development of the mother-infant relationship, but also cultural factors, are associated with the nonexpression of emotions, or in other words, with the development of alexithymia. We do not believe, however, that this is the whole truth of the origins of alexithymia. The question of the true etiology of alexithymia remains open, but there can no longer be any doubt that emotional and social conditions can reinforce the development of alexithymia.
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ACKNOWLEDGMENTS |
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Received for publication March 5, 2001.
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