May 2012  << Back  

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 LETTERS TO THE EDITOR

Does alexithymia differ in combat veterans of different eras with posttraumatic stress disorder?

Roy R. Reeves, DO, PhD

G.V. (Sonny) Montgomery VA Medical Center, Mental Health Service, Department of Psychiatry, University of Mississippi School of Medicine, Jackson, MS, USA

Roy H. Hart, MD

G.V. (Sonny) Montgomery VA Medical Center, Mental Health Service, Department of Psychiatry, University of Mississippi School of Medicine, Jackson, MS, USA

Randy S. Burke, PhD

G.V. (Sonny) Montgomery VA Medical Center, Mental Health Service, Department of Psychiatry, University of Mississippi School of Medicine, Jackson, MS, USA

Amee J. Epler, PhD

G.V. (Sonny) Montgomery VA Medical Center, Mental Health Service, Department of Psychiatry, University of Mississippi School of Medicine, Jackson, MS, USA

Judith A. Lyons, PhD

G.V. (Sonny) Montgomery VA Medical Center, Mental Health Service, Department of Psychiatry, University of Mississippi School of Medicine, Jackson, MS, USA

KEYWORDS: alexithymia, posttraumatic stress disorder, TAS-20

ANNALS OF CLINICAL PSYCHIATRY 2012;24(2):174-175

TO THE EDITOR:

Alexithymia, difficulty in recognizing and expressing feelings and emotions, occurs in many individuals with posttraumatic stress disorder (PTSD).1 A meta-analysis of 12 studies examining alexithymia in 1,095 individuals with PTSD and 460 controls had a mean effect size of 0.80 when PTSD patients were compared with control samples, with higher mean effect size for males with combat-related PTSD.2 We investigated differences in alexithymia among combat veterans of different eras with and without PTSD.

Participants in this institutional review board-approved study were male combat veterans from the World War II/Korea, Vietnam, and Iraq/Afghanistan eras. Forty participants from each era who met diagnostic criteria for PTSD and 40 from each era who did not completed the Toronto Alexithymia Scale (TAS-20),3 a 20-item self-report measure of alexithymia with subscales measuring difficulty identifying feelings (DIF); difficulty describing feelings (DDF); and externally oriented thinking (EOT). Total scores ranged from 20 to 100 with scores >61 considered alexithymic.4

Two-way analyses of variance (ANOVAs) were used to determine statistically significant between-group differences on the TAS-20 for both PTSD status and combat era. Post-hoc, pairwise comparisons were tested using the least significant difference method. Because age was highly correlated with combat era (r=–0.963, P < .001), age was not included as a covariate in the ANOVAs.

The interaction between PTSD status and combat era was significant for total TAS-20 scores (F[2,234]=9.74, P < .001) (TABLE); for the DIF subscale (F[2,234]=5.36, P < .01); and for the DDF subscale (F[2,234]=5.77, P < .01). Participants without PTSD did not differ across era of service on these 3 outcomes. However, among patients with PTSD, World War II/Korea veterans had significantly lower scores compared with Vietnam and Iraq/Afghanistan veterans, who were not significantly different from one another.

The interaction between PTSD status and combat era was not significant for the EOT subscale (F[2,234]=2.61, P=.076). However, collapsing across combat eras, patients with PTSD (F[1,236]=40.84, P < .001) had higher levels of alexithymia overall. Collapsing across PTSD status, participants who served in Vietnam or Iraq/Afghanistan (F[2, 236]=5.55, P < .01) had higher levels of alexithymia compared with those who served in World War II/Korea.

Mean total TAS-20 and all subscale scores for veterans with PTSD from all 3 eras of combat were above non-clinical mean scores. The mean score of 72.5 for Vietnam veterans and 70.3 for Iraq/Afghanistan veterans are well above the cutoff alexithymia score of 61, and the mean score of 60.6 for World War II/Korea veterans approaches the cutoff. Lower TAS-20 total scores for the World War II/Korea group appear related to lower DIF and DDF subscales scores. EOT subscale scores did not differ significantly among groups, although the subscale scores were higher across all 3 combat eras than scores in a community sample of individuals without PTSD.3 However a previous study of veterans with military-related trauma found EOT to be predictive of PTSD symptoms.1

Reasons for lower alexithymia scores among World War II/Korea veterans are unclear but may be related to more positive public perception and support of the war effort during the World War II/Korea conflict or generational differences in terms of disclosing symptomatology. It is important to note that it is not possible to determine unequivocally whether significant effects are due to age or combat era because of the inherent relationship between the 2. Veterans in the different groups also might represent patients at different stages of PTSD. By the time of our study, the World War II/Korea veterans may have learned to recognize and express emotions more effectively, while younger patients from later eras may not have done so yet. Therefore, lower alexithymia scores for older veterans might suggest lessening of PTSD symptoms over time.


Table

TAS-20 total and subscale scores by PTSD diagnostic status and era of service

  No PTSD PTSD
WW II/Korea Vietnam Iraq/Afghanistan WW II/Korea Vietnam Iraq/Afghanistan
DIF subscale 15.2 (5.5)a 15.3 (4.8)a 16.5 (4.1)a 22.7 (6.6)b 28.1 (4.7)c 26.5 (4.7)c
DDF subscale 12.1 (3.1)a 12.2 (2.8)a 12.5 (3.2)a 16.3 (4.7)b 19.9 (2.9)c 19.0 (3.3)c
EOT subscale 19.9 (3.7)a 20.8 (3.0)a 20.3 (3.0)a 21.6 (5.3)a 24.5 (4.8)b 24.9 (3.9)b
Total score 47.2 (6.6)a 48.2 (5.8)a 49.3 (6.4)a 60.6 (11.0)b 72.5 (9.3)c 70.3 (7.8)c
All values are expressed as mean (SD).
Superscripts designate significant between group differences.
DDF: difficulty describing feelings; DIF: difficulty identifying feelings; EOT: externally oriented thinking; PTSD: posttraumatic stress disorder; TAS-20: 20-item Toronto Alexithymia Scale; WW II: World War II.

Limitations of our study include the small number of participants, an all male population, and not assessing for non-combat PTSD. Our findings suggest an association between difficulties identifying and describing feelings and PTSD symptoms that might attenuate over time. Because cognitive-behavioral therapies have demonstrated efficacy in treating PTSD symptoms and cognitive-behavioral techniques can be used to improve abilities to identify and describe feelings,5 supplementing PTSD treatment with these techniques for alexithymia is worth exploring.

DISCLOSURES: The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

    REFERENCES

  1. Monson CM, Price JL, Rodriquez BF, et al. Emotional deficits in military-related PTSD: an investigation of content and process disturbances. J Trauma. 2004;17:275–279.
  2. Frewen DJA, Dozois JL, Neufeld RWJ, et al. Meta-analysis of alexithymia in posttraumatic stress disorder. J Trauma. 2008;21:243–246.
  3. Parker JD, Taylor GJ, Bagby RM. The 20-item Toronto Alexithymia Scale III.Reliability and factorial validity in a community sample. J Psychosom Res. 2003;55:269–275.
  4. Bagby RM, Taylor GJ. Measurement and validation of the alexithymia construct. In Taylor GJ Bagby RM, Parker JDA, eds. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge, United Kingdom: Cambridge University Press; 1997:44–66.
  5. Baker R, Owens M, Thomas S, et al. Does CBT facilitate emotional processing? Behav Cogn Psychother. 2012;40:19–37.

CORRESPONDENCE: Roy R. Reeves, DO, PhD, Chief of Mental Health (11M), VA Medical Center, 1500 E. Woodrow Wilson Drive, Jackson, MS 39216 USA, E-MAIL: roy.reeves@va.gov