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ORIGINAL ARTICLES |
From the Department of Psychology, McGill University, Montreal, Quebec, Canada.
Address correspondence and reprint requests to Blaine Ditto, PhD, Department of Psychology, McGill University, 1205 Dr. Penfield Ave., Montreal, QC H3A 1B1 Canada. E-mail: blaine.ditto{at}mcgill.ca
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ABSTRACT |
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Method: Healthy young adult blood donors (N = 610) recruited at mobile blood collection clinics completed the TAS-20, pre- and postdonation measures of anxiety, postdonation measures of pain and vasovagal symptoms, and had their blood pressure and heart rate measured before and after giving blood.
Results: Alexithymia score was positively associated with reported anxiety, pain, and vasovagal symptoms. Higher alexithymia was also associated with greater increases in predonation systolic blood pressure in anticipation of blood donation. In general, women and less experienced blood donors reported more vasovagal symptoms than men and more experienced donors, and this corresponded to higher rates of treatment by the nurses, more fainting, and fewer full units of blood obtained. However, despite more reports of vasovagal symptoms by alexithymic donors, alexithymia score was not related to these variables.
Conclusions: The results suggest that individuals with higher alexithymia scores were more anxious in the blood donation setting and more prone to report physical symptoms in the absence of a clear difference in the medical outcome of the blood donation procedure.
Key Words: alexithymia • symptom reporting • cardiovascular reactivity • blood donation • vasovagal reaction • pain
Abbreviations: BDRI = Blood Donation Reactions Inventory; DBP = diastolic blood pressure; GLM = general linear model; HR = heart rate; SBP = systolic blood pressure; STAI = Spielberger State-Anxiety Scale; TAS-20 = Toronto Alexithymia Scale.
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INTRODUCTION |
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Interest in the study of alexithymia has increased in recent years, in part as a result of mounting evidence of its association with a number of psychiatric and medical conditions such as hypertension (5,6), asthma (7), chronic pain syndrome (7), functional gastrointestinal disorders (8), alcoholism and substance abuse (9), anxiety disorders (10,11), and eating disorders (12–14). One particularly striking finding is that alexithymia predicted all-cause mortality after 5 years, even after controlling for demographic and medical risk factors (15). A recent review of the epidemiologic literature is provided by Taylor (16).
Although the association between alexithymia and illness is robust, the nature of this relationship is unclear. Possible pathways linking alexithymia and physical illness have been outlined by Lumley and colleagues (17,18). These include: 1) alexithymia leads to organic disease through physiological mechanisms or unhealthy behaviors; 2) alexithymia leads to illness behavior such as overreporting of symptoms and excessive use of health care; 3) physical illness influences psychologic functioning and leads to alexithymia; and 4) sociocultural and biologic factors comprise a third variable, which causes both alexithymia and physical illness.
The hypothesis that alexithymia leads to organic disease through physiological mechanisms is based on findings of altered physiological arousal, which may result from impaired regulation of emotion in alexithymics (4). In general, results point to greater physiological arousal (e.g., higher heart rate and skin conductance) at rest and, consistent with their reports of lower emotional reactivity to stressors, smaller physiological responses to stimuli such as watching emotional slides (19–22)
An alternative explanation for the link between alexithymia and illness stems from the finding that alexithymics tend to report more symptomatology in the absence of illness, perhaps in lieu of emotional complaints (25). Significant positive correlations have been reported between alexithymia and measures of somatization and hypochondriasis (26,27), possibly as a result of alexithymics’ focusing on, amplifying, and misinterpreting somatic sensations that accompany emotional arousal. In psychiatric populations, two studies found that alexithymics reported more somatic complaints than nonalexithymic patients (28,29). Kauhanen and colleagues (30) found greater reports of symptoms such as nausea, dizziness, heart palpitations, and headaches among those higher in alexithymia. Alexithymia has also been found to be positively associated with reports of experimental (31) and clinical (32) pain. It remains unclear whether symptom reporting is the result of higher rates of illness in alexithymics or whether illness is more frequently diagnosed because misinterpretation and amplification of somatic sensations leads to increased healthcare utilization.
The blood donation clinic provides an interesting environment in which a number of these issues can be studied. First, particularly for inexperienced donors, blood donation can be a stressful experience that is associated with increases in anxiety and blood pressure in the predonation waiting period (38). In the present study, changes in anxiety and cardiovascular activity in relation to alexithymia were studied. Second, the nature of the donation procedure is such that vasovagal reactions are not uncommon. The relatively controlled induction of a limited set of somatic sensations served as a useful manipulation to investigate differences in symptom reporting as they relate to alexithymia. Finally, several fairly controlled painful procedures are conducted as part of the blood donation procedure, providing an opportunity to assess pain experience. The present study examined self-reported anxiety, cardiovascular reactivity, symptom reporting, and reported pain in blood donors varying in alexithymia.
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METHOD |
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Procedure
After registering at the clinic, prospective participants were directed to a research assistant. Once informed consent had been obtained, they completed a short predonation questionnaire that included an abbreviated version of the Spielberger State-Anxiety Scale (STAI (33)) and demographic questions about age, height, weight, and number of previous blood donations. Blood pressure was measured twice using a B-D Assure manual inflate digital blood pressure monitor (Becton, Dickinson and Co., New Jersey) while seated with the arm supported at heart level. These monitors use the oscillometric principle to measure blood pressure and, according to the manufacturer, are accurate to within ±3 mm Hg. In cases in which there was a notable discrepancy between the first and second readings, blood pressure was measured a third time.
People were then seated in a waiting area before being called by a nurse for a health screening. During the screening, a blood sample was obtained by pricking the fingertip with a disposable lancet. Those deemed eligible to give blood proceeded to the first available donation chair and 450 mL of blood was drawn. Immediately after the blood draw, the attending nurse completed a brief questionnaire concerning issues such as the difficulty of needle insertion, whether the donor’s chair had been reclined to treat vasovagal symptoms, and whether a full unit of blood was obtained. With assistance, donors then moved to a rest area where they remained seated on a donation chair for approximately 10 minutes before being met by a research assistant to have blood pressure measurements taken a second time. A set of postdonation questionnaires was provided at this point, which donors completed while consuming refreshments. These questionnaires included the Blood Donation Reactions Inventory (34), a self-report instrument designed to assess vasovagal reactions during blood donation, and the TAS-20. As well, the STAI was administered a second time. Finally, visual analog ratings of pain produced by the predonation finger prick and the venipuncture required to draw blood were requested.
Data Reduction and Analyses
Two predonation and two postdonation blood pressure readings for each subject were averaged to yield one systolic (SBP) and one diastolic (DBP) value at each time point. Similarly, pre- and postdonation heart rate (HR) values were obtained by averaging two HR readings at each time point. To reduce the positive skewness of the Blood Donation Reactions Inventory (BDRI) data, a log transformation (log[BDRI + 1]) was applied to raw scores as in previous research (34). Number of previous blood donations, used as a continuous independent variable representing donation experience, was also subjected to a log transformation to better approximate a normal distribution.
Primary data analyses were conducted within the general linear model (GLM) framework using Systat statistical software (Systat Software, Inc., Point Richmond, CA). Alexithymia, defined as total TAS-20 score, and experience were used as continuous independent variables. Gender was entered as a dichotomous independent variable, along with the interaction effects among gender, alexithymia, and experience. To more closely examine the effects of the blood donation procedure on physiological change in relation to alexithymia, separate analyses of pre- and postdonation blood pressure and HR were conducted, as well as analyses of pre- to postdonation change scores in SBP, DBP, and HR.
Dichotomous yes–no variables such as whether the nurse reclined the donor’s chair to treat vasovagal symptoms and whether a full unit of blood was obtained were analyzed using logistic regression equations using gender, previous donation experience, and alexithymia as predictor variables.
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RESULTS |
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Cardiovascular Activity and Change
There were no significant effects involving alexithymia in the analyses of pre- or postdonation blood pressure or HR, or DBP and HR change scores. However, the analysis of systolic blood pressure change scores produced a significant effect of alexithymia (F[1,593] = 5.02, p = .025). SBP was generally higher while people were waiting to give blood compared with the postdonation refreshment period (t[600] = 14.91, p < .001). This difference was greater among those with higher alexithymia (Fig. 1). The effect remained significant with addition of postdonation SBP, which might be considered the "baseline" in this situation, as well as whether a full unit of blood was obtained as covariates in the model (F[1,591] = 4.75, p = .030).
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Pain Ratings and Vasovagal Symptom Reporting
Analysis of the fingerprick pain ratings yielded only a significant main effect of alexithymia (F[1,590] = 4.42, p = .036). Higher alexithymia scores were associated with higher pain ratings. There were no significant effects in the analysis of the venipuncture pain ratings.
The analysis of BDRI scores produced significant main effects of gender (F[1,597] = 5.12, p = .024), donation experience (F[1,597] = 6.33, p = .012), and alexithymia (F[1,597] = 4.85, p = .028). Women, people with less previous donation experience, and individuals with higher alexithymia scores reported more donation-related symptoms such as dizziness, weakness, and so on.
Medical Characteristics of the Blood Donations
There were no significant effects in the analyses of the nurse’s rating of the ease of needle insertion or time in the donation chair. None of the logistic regression equations predicting whether a needle adjustment was required, whether the donor’s chair was reclined, whether they fainted, or whether a full unit of blood was obtained produced significant effects of alexithymia. This occurred despite the fact that gender and previous blood donation experience, which were also associated with BDRI scores, were significantly related to whether the donor’s chair was reclined to treat a vasovagal reaction, whether the donor fainted, and whether a full unit of blood was obtained (Table 1). Men and more experienced blood donors were less likely to faint or have their chairs reclined and more likely to produce a full unit of blood.
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DISCUSSION |
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The underlying reason for higher symptom reporting by alexithymics has been the subject of considerable discussion. Some have argued that the reports are a reflection of real underlying illness given the associations between alexithymia and many medical disorders, whereas others have suggested that characteristics such as hypochondriasis or somatic attention mediate the relationship. The cluster of potential symptoms elicited during blood donation includes several that are potentially visible to attending staff, e.g., fainting. Although outright fainting was rare (3%), it was not associated with alexithymia score. There was also no association between alexithymia score and whether the nurse believed it necessary to treat the donor by reclining their chair, despite higher symptom reports by alexithymics. This contrasted with the effects of donation experience and gender, in which there was a concordance between higher symptom reports among less experienced donors and women and various objective measures of outcome such as chair reclining. Thus, although the sensations experienced by donors with higher alexithymia scores were construed as significant symptoms according to their BDRI ratings, they were not considered to be sufficiently severe by attending staff to warrant reclining the donation chair. This suggests that alexithymics have an exaggerated inclination to attend to somatic sensations. At a minimum, they suggest a somewhat greater "disconnect" between "objective" physiological state and symptom reports, although the explanation for this disconnect is unclear.
Given that alexithymia, by definition, involves reduced reporting of emotion, the positive association between alexithymia and STAI scores is somewhat surprising. However, in examining responses to individual items in the five-item abbreviated STAI, it was found that this was the result of donors higher in alexithymia reporting feeling less comfortable, calm, relaxed, and pleasant, but not more anxious than donors lower in alexithymia. Thus, these results, as well as the pain data, seem to provide additional evidence of a tendency to report physical discomfort as opposed to negative emotion.
The limited nature of the cardiovascular data makes it difficult to interpret these results, although the apparently greater increase in predonation systolic blood pressure among alexithymics is intriguing. Because most (19–22) but not all (e.g., (24)) previous studies of physiological reactivity in alexithymics have indicated a tendency for reduced rather than exaggerated physiological reactivity to stress, it seems unlikely that this reflects a general tendency for high SBP reactivity. It may have been related to the very salient nature of the "stressor," i.e., anticipation of venipuncture with a large needle and loss of a significant amount of blood, and consistent with what appears to have been a greater state of psychologic distress in this environment, even if it was described in physical terms.
That said, another challenge in the interpretation of the SBP finding is the choice of the appropriate baseline period. For several reasons, we view the SBP finding as indicative of a greater increase in SBP during the stressful predonation period in alexithymics as opposed to a greater decrease after donation. First, both SBP and reported anxiety were significantly higher before than after donation. This was true regardless of whether a full unit of blood was obtained from the donor. Second, measurements of resting blood pressure were obtained in the laboratory in a small subsample of these donors of these donors (N = 28) with similar equipment. There was no difference in postdonation and resting laboratory SBP (mean = 112.3 versus 112.4 mm Hg), whereas predonation SBP was significantly higher than resting laboratory SBP (mean = 116.2 versus 112.3 mm Hg; t[27] = 2.08, p = .024). Finally, researchers commonly operationalize the anticipation period before an aversive event (e.g., electric shock, public speaking, dental examinations) as the stress period and the recovery period as the baseline. The previously discussed results are consistent with this view in the present case. However, this issue needs to be considered with special caution in the present case, especially given the loss of blood inherent in the blood donation procedure.
There are a number of other limitations to the study beyond the lack of an unambiguous baseline period. For example, although there were no significant differences in key demographic characteristics such as age and previous blood donation experience between those high and low in alexithymia, the fact that the present research was not the primary focus of the larger intervention trial meant that limited information was available about other possible characteristics that may have distinguished those high and low in alexithymia. It seems unlikely that there were any obvious nonpsychologic confounds that could explain the results, but this issue should be examined in closer detail. More important, the possible involvement of other psychologic constructs should be addressed in future research. For example, it is possible that the present results could be explained by a general neuroticism or tendency toward negative affectivity associated with alexithymia as opposed to alexithymia per se. Alexithymia is an important psychologic construct that is related to a number of health outcomes. Further research is required to specify the mechanisms of these links and its relations to other health-related personality constructs.
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NOTES |
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This research was supported by grants from the Heart and Stroke Foundation of Quebec and the Fonds de la Recherche en Santé du Québec.
DOI:10.1097/01.psy.0000160471.66399.12
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