Elisabeth Waller

Somatoform disorders as disorders of affect regulation: A study comparing the TAS-20 with non-self-report measures of alexithymia

OBJECTIVE To determine the role of undifferentiated and dysregulated affects in somatoform disorders by using a multimethod assessment approach of alexithymia. METHODS Forty patients with ICD-10 somatoform disorders (SoD) and 20 healthy controls, matched for age, education and sex, were included in the study. Alexithymia was assessed using the Toronto Alexithymia Scale (TAS-20), the Affect Consciousness Interview (ACI), and the Levels of Emotional Awareness Scale (LEAS). All classifications were made blinded with regard to clinical status. RESULTS Scores of the ACI and the TAS-20 showed that alexithymia is higher in SoD than in healthy controls. No differences were found on the LEAS. In terms of the multidimensionality of the alexithymia construct, our results indicate a specific positive association between SoD and a proneness to experience undifferentiated affects. The three subfactors of the TAS-20 were differentially related to non-self-report measures of alexithymia and to negative affectivity (NA). Only the cognitive facet of the TAS-20 (externally oriented thinking [EOT]) was related to the LEAS and the ACI. In contrast, the affective facets of the TAS-20-difficulties identifying feelings (DIF) and difficulties describing feelings (DDF)-were substantially related to NA. CONCLUSION The findings highlight the important role of impaired affect regulation and NA in the process of somatization.

Somatoform disorders as disorders of affect regulation: A development perspective

This paper considers the role of disturbances in affect regulation in the development and course of somatoform disorders. We first give an overview of contemporary theories in the field of psychosomatic medicine that links deficits in emotion regulation to the process of somatization, and then review recent empirical research that focuses on the association between affect regulation and somatoform disorders, with an emphasis on studies investigating the alexithymia construct. Overall, the findings suggest that somatoform disorders are linked to a diminished capacity to consciously experience and differentiate affects and express them in an adequate or healthy way. It must be noted, however, that this result has not been obtained exclusively for somatoform disorders. A promising approach to further our understanding of the developmental roots of impaired affect regulation in somatoform disorders is attachment research. The attachment research reviewed in this paper indicates that a dismissing status of attachment is linked to defensive forms of processing and expressing emotions. We present some new data that not only provide empirical support of a high proportion of dismissing attachment in somatoform disorders but also suggest that the degree to which somatoform disorder patients employ dismissing attachment strategies is strongly related to affect dysregulation. Finally, some implications for psychotherapeutic interventions in patients with somatoform disorders are considered.

Attachment Representation and Illness Behavior in Somatoform Disorders

Somatoform disorders are characterized by high health care utilization and conflictual interactions with health care providers. The aim of the present study was to explore whether patterns of insecure attachment are a prominent feature of somatoform disorder. In addition, the links between insecure attachment and health care utilization were evaluated. Thirty-seven patients with an International Classification of Diseases, 10th Revision diagnosis of somatoform disorders and 20 healthy control subjects matched for age, sex, and education were administered the Adult Attachment Interview. Psychological symptoms and health care utilization were assessed using various self-report measures. There was a clearly higher incidence of insecure attachment in the somatoform group compared with the nonclinical control subjects. In the somatoform group, dismissing attachment occurred approximately twice as frequently as the preoccupied pattern of attachment. The results provide evidence for an association between health care utilization and insecure attachment. Insecure attachment in somatoform disorder may underlie problems in interpersonal functioning and in health care behavior.

Alexithymia and attachment representation in idiopathic spasmodic torticollis.

We investigated alexithymia and the mental representation of attachment in idiopathic spasmodic torticollis (IST). It was hypothesized a) that alexithymia in IST is more prevalent than in a nonclinical control group and b) that significant correlations emerge between alexithymia and a dismissing attachment representation. Twenty patients with IST and 20 healthy controls matched for age and sex were administered the Toronto Alexithymia Scale (TAS-20) and the Adult Attachment Interview (AAI). Attachment was classified using the Attachment Interview Q-sort. IST patients scored significantly higher on the measure of alexithymia than subjects in the comparison group. In IST a dismissing attachment representation was significantly more frequent than in the control group. Across the total sample, externally oriented thinking correlated positively with dismissing attachment, and both externally oriented thinking and difficulty communicating feelings (two of the three subscales of the TAS-20) correlated inversely with secure attachment. Alexithymia is more prevalent in IST than in normals. As was hypothesized, alexithymia in adults is significantly interrelated with the mental representation of attachment.

Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial

OBJECTIVE There are no studies investigating the efficacy of short-term psychodynamic psychotherapy in primary fibromyalgia syndrome (FMS). We conducted a randomized controlled trial evaluating an adapted form of individual short-term psychodynamic psychotherapy (ASTPP) versus primary care management (TAU). The study focused on FMS patients with psychiatric comorbidity. METHODS Forty-six female patients with FMS and an International Classification of Diseases, 10th Revision diagnosis of a comorbid depression or anxiety disorder were recruited in a hospital setting. Participants were randomized to receive either ASTPP (25 sessions, 1 session/week) or TAU (4 consultations/6 months). Outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Hospital Anxiety and Depression Scale (HADS), the Pain Disability Index, the Symptom Checklist 27 and the health-related quality of life. Primary endpoints of the outcome assessment were the FIQ total score and the HADS depression scale at 12-month follow-up. RESULTS Both treatments were effective in reducing the FIQ total score (ES=0.56 and ES=0.75, respectively). Intent-to-treat analyses failed to provide evidence suggesting a marked superiority of individual psychodynamic psychotherapy as compared to TAU. CONCLUSIONS A high-standard routine treatment focusing on the improvement of health behavior and including antidepressant and analgesic medication is equally effective as a short-term individual psychodynamic psychotherapy in improving fibromyalgia-related symptoms.

Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study

OBJECTIVE The purpose of this study was to examine the influence of attachment, social support and the quality of the current partnership on the outcome of bereavement after perinatal loss. METHODS In a prospective cohort design 33 women after perinatal loss were approached on admission to hospital and reassessed four weeks, four months and nine months later. The initial assessment included the Adult Attachment Interview and self-report questionnaires for social support and quality of the current partnership. Bereavement outcome was assessed using measures of grief (MTS), depression and anxiety (HADS), psychological distress (BSI), somatisation (BSI-SOM) and symptoms of PTSD (PDS). RESULTS All measures of outcome showed a significant improvement over time. Standardized effect sizes between the initial assessment and nine month follow-up ranged between .36 for anxiety (HADS) and 1.02 for grief (MTS). Social support, quality of the partnership and secure attachment correlated inversely, and insecure preoccupied attachment correlated positively with the outcome measures. Preoccupied attachment was included as a predictor in two multivariate statistical models of non-linear regression analysis, one with somatisation (adjusted R2=.698, P=.016), the other with posttraumatic stress symptoms at nine month follow-up (adjusted R2=.416, P=.002) as target variable. Initial assessment scores of psychological distress predicted the course of the respective measure during follow-up (adjusted R2=.432, P=.014). CONCLUSION Attachment, social support and the quality of the current partnership have an impact on the course of bereavement after perinatal loss. Secondary prevention after the event may focus on these factors in order to offer specific counselling and support.

Self-reported symptoms of pain and depression in primary fibromyalgia syndrome and rheumatoid arthritis

Abstract Background: Primary fibromyalgia syndrome (FMS) is associated with substantial psychiatric comorbidity. The aim of the present study was to investigate the interrelationship between self-reported symptoms of depression and pain in FMS compared with rheumatoid arthritis (RA). Methods: In a cross-sectional study, 100 patients with FMS and 50 patients with RA were compared with regard to depression and psychopathology using the Symptom Check List (SCL-27). Group comparisons were calculated by parametric and non-parametric tests. The association between pain intensity and depression was determined by correlation analyses and multivariate statistical procedures (CATREG). Results: Pain intensity was significantly higher in FMS compared with RA. FMS patients also scored significantly higher on all subscales of the SCL-27 including the depression scale and the General Symptom Index (GSI) (P < 0.001). These group differences remained stable even after correcting for pain intensity. Correlation analyses revealed an association between pain intensity and depression in FMS but not in RA (R = 0.419, P < 0.001). Conclusion: FMS patients in tertiary referral centers suffer from higher levels of pain intensity than RA patients. Depression predicts levels of pain in FMS but not in RA and is therefore an important target of intervention.

Unresolved trauma in fibromyalgia: A cross-sectional study

This study examined the prevalence of unresolved attachment-related trauma and its association with physical and psychological health status in 34 patients with fibromyalgia. Unresolved trauma was assessed with the Adult Attachment Interview. In addition, participants completed self-report measures of childhood trauma, fibromyalgia-related health status and depression. Of the sample, 50 per cent was classified as unresolved on the Adult Attachment Interview. Neither interview-based ratings of unresolved trauma nor self-reported childhood sexual or physical abuse were associated with health outcomes. Only for self-reported emotional abuse, a positive correlation with depression emerged. The implications of the findings are discussed.

Schmerz, Affekt und Bindung

SummaryVarious psychodynamic processes may underlie the development of psychogenic pain disorder such as conversion, the displacement of affect or narcissistic defences. However, many of the processes suggested are related to a disorder of affect regulation. The term affect regulation in the psychoanalytic literature refers to phenomena which often are described by the concept of alexithymia. Empirical observations suggest that alexithymia is correlated to insecure attachment, especially an insecure dismissing representation of attachment. Psychodynamic psychotherapy in psychogenic pain disorder should focus on the re-integration of split-off affects which may provoke intensive counter-transference and which in order to be used therapeutically must be linked to attachment experiences within and outside of the therapeutic relationship.ZusammenfassungAusgehend von der von Hoffmann und Egle vorgeschlagenen Beschreibung unterschiedlicher psychodynamischer Erklärungsprinzipien psychogener Schmerzen werden Störungen der Affektregulation untersucht, die der Entstehung somatoformer Schmerzen zugrunde liegen. Eine Form der Affektregulationsstörung, die durch eine besonders geringe Zugänglichkeit zum emotionalen Erleben charakterisiert ist, wird in der psychoanalytischen Literatur durch den Alexithymiebegriff beschrieben. Empirische Befunde zeigen, dass Alexithymie in Zusammenhang mit einer unsicheren, insbesondere einer unsicher vermeidenden Bindungsrepräsentation auftritt. Die jeweils spezifische bei Schmerzpatienten beobachtete Störung der Affektwahrnehmung kann auf unterschiedlichen Ebenen der ichstrukturellen Entwicklung angesiedelt sein. Für die Therapie ist wichtig, dass abgespaltene und nicht-integrierte Affekte in der Gegenübertragung Gefühle von Hilflosigkeit und Wut auslösen. Die Verknüpfung dieser Affekte mit den zugehörigen Beziehungserfahrungen innerhalb und außerhalb der therapeutischen Beziehung ist das zentrale Thema der psychoanalytischen Therapie bei dieser Patientengruppe.