Document Type : Original Article
Authors
- . Zohreh Khayyam Nekouei
- . Hamid Taher Neshat Doost
- . Alireza Yousefy 1
- . Gholamreza Manshaee
- . Masoumeh Sadeghei 2
1 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences
2 cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan, Iran
Abstract
Background: Although psychological factors are now recognized as playing a significant
and independent role in the development of coronary heart disease (CHD) and its
complications, many of these factors are correlated with each other. The present study is
aimed at examining the association between alexithymia and anxiety depression, stress,
quality of life, and social support in CHD patients. Materials and Methods: In this research
398 patients with coronary heart disease (166 females and 232 males) from the city of
Isfahan were selected using random sampling. The tools used included depression, anxiety,
and stress scale (DASS-21), Health-related to Quality Of Life (HRQOL-26), Multiple Scale
Perceived Social Support (MSPSS-12), and the Toronto Alexithymia Scale (TAS-20). The data
were analyzed using structural equation modeling by using the Statistical Package for Social
Science (SPSS21) (IBM Corp: Armonk, New York.U.S.) and Asset Management Operating
System (AMOS21) SPSS, an IBM Company: Chicago, U.S. Software. Results: Results of
the structural equation model showed an acceptable goodness of fit, for the explanation
alexithymia that was significantly associated with lower HRQOL and social support and
increasing anxiety, depression, and stress. Conclusions: Alexithymia may increase anxiety,
depression, and stress and can be a predisposing factor to poorer HRQOL and social
support.
Keywords
1. Everson‑Rose SA, Lewis TT. Psychosocial factors and cardiovascular
diseases. Ann Rev Public Health 2005;26:469‑500.
2. Suls J, Bunde J. Anger, anxiety, and depression as risk factors
for cardiovascular disease: The problems and implications of
overlapping affective dispositions. Psychol Bull 2005;131:260‑300.
3. Khayyam Nekouei Z, Yousefy A. Application of cognitive‑behavioral
therapy for reducing anxiety in cardiac patients. ARYA Atheroscler
J 2007;3:69‑71.
4. Mikolajczak M, Luminet O, Menil C. Predicting resistance to stress:
Incremental validity of trait emotional intelligence over alexithymia
and optimism. Psicothema 2006;18:79‑88.
5. Mattila AK, Saarnei SI, Salminen JK, Htala H, Sintonen H,
Joukamaa M. Alexithymia and Health‑Related Quality of Life in a
General Population. Psychosomatics 2009;50:59‑68.
6. Nehra1 DK, Sharma NR, Ali G, Margoob MA, Mushtaq H, Kumar P,
et al. Alexithymia and Type “A” Behavior Pattern (TABP) in
Coronary Heart Diseases: A preliminary study. Dali Psychiatry J
2012;15(2):320‑326.
7. Khayyam Nekouei Z, Neshat Doost H, Yousefy A, Sadeghei M,
Manshaee GH. Psychological factors and coronary heart disease.
ARYA Atheroscler J 2013;9(1):1‑10.
8. Khayam Nekouei Z, Yousefy AR, Khayyam Nekouei AR, Sadeqhi M.
The relation between anxiety and quality of life in heart patients.
Health Inf Manage 2009;5:19‑24.
9. Yousefy AR, Ghassemi GR, Sarrafzadegan N, Mallik S, Baghaei AM,
Rabiei K. Psychometric properties of the WHOQOL‑BREF in an
Iranian adult sample. Community Ment Health J 2010;46:139‑47.
10. Yousefy A, Nekouei ZK. Basis of Cognitive‑Behavioral Trainings and
its Applications in Recovery of Chronic Diseases. Iran J Med Educ
2011;10:792‑800.
11. Nekouei ZK, Yousefy AR, Manshaee G. Cognitive‑behavioral therapy
and quality of life: An experience among cardiac patients. J Edu
Health Promot 2012;1:2.
12. Uchino BN. Social Support and Health: A Review of Physiological
Processes Potentially Underlying Links to Disease Outcomes. J of
Behavioral Medicine 2006;29(4):377‑387.
13. Lofvenmark C, Mittiasson AC, Billing E, Edne M. Perceived loneliness
and social support in Patients with chronic heart failure. Eur J
Cardiovasc Nurs 2009;8:251‑8.
14. Barth J, Schneider S, Von Känel R. Lack of social support in the
etiology and the prognosis of coronary heart disease: A systematic
review and meta‑analysis. Psychosom Med 2010;72:229‑38.
15. Williams ED, Nazroo JY, Kooner JS, Steptoe A. Subgroup difference
in psychological factors relating to coronary heart disease in the UK
South Asian population. J Psychosom Res2010;69:379‑87.
16. Krantz DS, McCeney KT. Effects of psychological and social factors
on organic disease: A critical assessment of research on coronary
heart disease. Annu Rev Psychol 2002;53:341‑69.
17. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of
stress. Lancet 2007;370:1089‑100.
18. Rozanski A, Blumenthal AJ, Davidson WK, Saab PG, Kubzansky L.
The epidemiology pathophysiology, and management of
psychosocial risk factors in cardiac practice: The emerging field of
behavioral cardiology. J Am Coll Cardiol 2005;45:637‑51.
19. Uchino BN. Social support and physical health: Understanding the
health consequences of our relationships. New Haven, CT: Yale
University Press; 2004.
20. Wang HX, Mittleman MA, Orth‑Gomer K. Influence of social support
on progression coronary artery disease in women. Soc Sci Med
2005;60:599‑607.
21. Sifneos PE. Affect, emotional conflict, and deficit: An overview.
Psychother Psychosom 1991;56:116‑22.
22. Haviland MG, Reise SP A. California Q‑set alexithymia prototype
and its relationship to ego‑control and ego‑resiliency. J Psychosom
Res 1996;41:597‑608.
23. Taylor GJ. The alexithymia construct: Conceptualization, validation,
and relationships with basic dimensions of personality. New Trends
Exp Clin Psychiatry 1994;10:61‑74.
24. Lumley MA, Stettner L, Wehmer F. How are alexithymia and physical
illness linked? A review and critique of pathways. J Psychosom
Res1996;41:505‑18.
25. Taylor GJ, Bagby RM, Parker JD. The revised Toronto Alexithymia
Scale: Some reliability, validity and normative data. Psychother
Psychosom 1992;57:34‑41.
26. Wise TN, Mann LS. The attribution of somatic symptoms in
psychiatric Outpatients. Compr Psychiatry 1995;36:407‑10.
27. Lumley MA, Neely LC, Burger AJ. The assessment of alexithymia
in medical settings: Implications for understanding and treating
health problems. J Pers Assess 2007;89:230‑46.
28. Shahgolian M, Moradi AR, Kafi M. Alexithymia expressed
excitement about the styles and general health in students. Iran
Psychiatry Clin Psychol 2007;13:238‑48.
29. Lane RD, Sechrest L, Riedel R. Socio demographic correlates of
alexithymia. Compr Psychiatry 1998;39:377‑85.
30. Salminen JK, Saarijärvi S, Aärelä E, Toikka T, Kauhanen J. Prevalence
of alexithymia and its association with sociodemographic
variables in the general population of Finland. J Psychosom Res
1999;46:75‑82.
31. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinamäki H.
Depression is strongly associated with alexithymia in the general
population. J Psychosom Res 2000;48:99‑104.
32. Kokkonen P, Karvonen JT, Veijola J, Läksy K, Jokelainen J,
Järvelin MR, et al. Prevalence and sociodemographic correlates
of alexithymia in a population sample of young adults. Compr
Psychiatry 2001;42:471‑6.
33. Nehra DK, Sharma V, Mushtaq H, Sharma NR, Sharma M, Nehra S.
Emotional Intelligence and Alexithymia in Alcoholics. Behav Sci
2011;12:101‑8.
34. Nekouei ZK, Mazaheri M, Manshaee GH. Alexithymia and autism
spectrum disorders. The first international congress child and
adolescent psychology. 1st to 6th May 2011 Shiraz, Fars, Iran: Fars
Science and Research branch2011.
35. Valkamo M, Hintikka J, Niskanen L. Depression and associated factors
in coronary heart disease. Scand Cardiovasc J 2001;35:259‑63.
36. Valkamoa M, Hintikkaa J, Honkalampia K, Niskanenb L,
Koivumaa‑Honkanena H, ViinamaÈkia H. Alexithymia in patients
with coronary heart diseas. J Psychosomatic Res 2001;50:125‑30.
37. Khauhanen J, Kaplan JA, Cohen RD, Salonen R, Salonen JT.
Alexithymia may influence the diagnosis of coronary heart disease.
Psychosom Med 1994;56:237‑44.
38. Kauhanen J, Kaplan G, Cohen R, Julkunen J, Salonen JT.
Alexithymia and risk of death in middle‑aged men. J Psychosom
Res 1996;41:541‑9.
39. Lumley MA, Tomakowsky J, Torosian T. The relationship of
alexithymia to subjective and biomedical measures of disease.
Psychosomatics 1997;38:497‑502.
40. Henrya JD, Phillip LH, Maylorc EA, Hosieb J, Milneb AB, Meyerc C.
A new conceptualization of alexithymia in the general adult
population: Implications for research involving older adults.
J Psychosomatic Res 2006;60:535‑43.
41. Duddu V, Isaac MK, Chaturvedi SK. Alexithymia in somatoform and
depressive disorders. J Psychosomatic Res 2003;54:435‑8.
42. Bagby RM. Taylor GJ, Parker JD. Construct validity of the Toronto
alexithymia scale. Psychother Psychosom 1988;50:29‑34.
43. Kauhanen J, Julkunen J, Salonen JT. Alexithymia and perceived
symptoms: Criterion validity of the Toronto Alexithymia Scale.
Psychother Psychosom 1991;56:247‑52.
44. Myers LB. Alexithymia and repression: The role of defensiveness
and trait anxiety. Pers lndivid Dif 1995;19:489‑92.
45. Linden W, Lenz JW, Stossel C. Alexithymia, defensiveness and
cardiovascular to stress. J Psychosomatic Res 1999;41:575‑83.
46. Mattila AK, Alanen E, Salminen JK, Kronholm JA, Sintonen H,
Joukamaa M. Health‑related quality‑of‑life profiles in nonalexithymic
and alexithymic subjects from general population. J Psychosomatic
Res 2010;68:279‑83.47. Dion KL. Ethnolinguistic correlates of alexithymia: Toward a cultural
Perspective. J Psychosom Res 1996;41:531‑9.
48. Fukunishi I, Kaji N, Hosaka T, Berger D, Rahe RH. The relationship
of Alexithymia and poor social support to ulcerative changes on
gastrofiberscopy. Psychosomatics 1997;38:20‑6.
49. BagbyRM, Pa rker JD, TaylorGJ. The twenty‑item TorontoAlexithymia
Scale‑I. Item selection and cross‑validation of the factor structure. J
Psychosomatic Res 1994;38:23‑32.
50. Shahgholian M, Moradi A, Kafi SM. Relation of alexithymia with
emotional expression styles and general health in students. Iran J
Psychiatry Clinl Psychological 2007;13:238‑48.
51. Lovibond SH, Lovibond PF. Manual for the Depression anxiety
Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.
52. Samani S, Jokar B. Study the validity and reliability of the Iranian
version of the Depression, Anxiety, Stress Scale. J Soc Humanities
Shiraz University 263; 2007.
53. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA.
Psychometric characteristics of the Multidimensional Scale of
Perceived Social Support. J Pers Assess 1990;55:610‑7.
54. Ghasemi V. Structural equation modeling in social researches using
amos graphics. Tehran: Jameeshenasan Publication; 2010.
55. Saarijarvi S, Salminen JK, Toikka TB. Alexithymia and depression:
A 1‑year follow‑up study in outpatients with major depression.
J Psychosom Res 2001;51:729‑33.
56. Beshart MA. Relation of Alexithymia with depression, anxiety,
psychological helplessness and well being. J Psychol Tabriz Univ
2008;10:17‑40.
57. Morton I, Gencoz T. The Relationship Between the Dimensions
of Alexithymia and the Intensity of Depression and Anxiety. Turk
Psikiyatri Derg 2007;18:333‑43.
58. Hisli Sahin N, Güler M, Basim HN. The relationship between
cognitive intelligence, emotional intelligence, coping and stress
symptoms in the context of type A personality pattern. Turk
Psikiyatri Derg 2009;20:243‑54.
59. Lumley MA, Ovies T, Stettner L, Wehmer F, Lakey B. Alexithymia,
social support and health problems. J Psychosomatic Res
1996;41:519‑30.
60. Verissimo R, Mota‑Cardoso R, Taylor G. Relationships between
alexithymia, emotional control, and quality of life in patients with
inflammatory bowel disease. Psychother Psychosom 1998;67:75‑80.
61. Mattila AK, Saarni SI, Salminen JK, Huhtala H, Sintonen H,
Joukamaa M. Alexithymia and health‑related quality of life in general
population. Psychosomatic 2009;50:59‑68.
62. Salminen JK, Saarijärvi S, Toikka T. Alexithymia and health‑related
quality of life. J Psychosom Res 2002;52:324.
63. Fortune DG, Richards HL, Griffiths CE, Main CJ. Psychological
stress, distress and disability in patients with psoriasis: Consensus
and variation in the contribution of illness perceptions, coping and
alexithymia. Br J Clin Psychol 2002;41:157‑74.
diseases. Ann Rev Public Health 2005;26:469‑500.
2. Suls J, Bunde J. Anger, anxiety, and depression as risk factors
for cardiovascular disease: The problems and implications of
overlapping affective dispositions. Psychol Bull 2005;131:260‑300.
3. Khayyam Nekouei Z, Yousefy A. Application of cognitive‑behavioral
therapy for reducing anxiety in cardiac patients. ARYA Atheroscler
J 2007;3:69‑71.
4. Mikolajczak M, Luminet O, Menil C. Predicting resistance to stress:
Incremental validity of trait emotional intelligence over alexithymia
and optimism. Psicothema 2006;18:79‑88.
5. Mattila AK, Saarnei SI, Salminen JK, Htala H, Sintonen H,
Joukamaa M. Alexithymia and Health‑Related Quality of Life in a
General Population. Psychosomatics 2009;50:59‑68.
6. Nehra1 DK, Sharma NR, Ali G, Margoob MA, Mushtaq H, Kumar P,
et al. Alexithymia and Type “A” Behavior Pattern (TABP) in
Coronary Heart Diseases: A preliminary study. Dali Psychiatry J
2012;15(2):320‑326.
7. Khayyam Nekouei Z, Neshat Doost H, Yousefy A, Sadeghei M,
Manshaee GH. Psychological factors and coronary heart disease.
ARYA Atheroscler J 2013;9(1):1‑10.
8. Khayam Nekouei Z, Yousefy AR, Khayyam Nekouei AR, Sadeqhi M.
The relation between anxiety and quality of life in heart patients.
Health Inf Manage 2009;5:19‑24.
9. Yousefy AR, Ghassemi GR, Sarrafzadegan N, Mallik S, Baghaei AM,
Rabiei K. Psychometric properties of the WHOQOL‑BREF in an
Iranian adult sample. Community Ment Health J 2010;46:139‑47.
10. Yousefy A, Nekouei ZK. Basis of Cognitive‑Behavioral Trainings and
its Applications in Recovery of Chronic Diseases. Iran J Med Educ
2011;10:792‑800.
11. Nekouei ZK, Yousefy AR, Manshaee G. Cognitive‑behavioral therapy
and quality of life: An experience among cardiac patients. J Edu
Health Promot 2012;1:2.
12. Uchino BN. Social Support and Health: A Review of Physiological
Processes Potentially Underlying Links to Disease Outcomes. J of
Behavioral Medicine 2006;29(4):377‑387.
13. Lofvenmark C, Mittiasson AC, Billing E, Edne M. Perceived loneliness
and social support in Patients with chronic heart failure. Eur J
Cardiovasc Nurs 2009;8:251‑8.
14. Barth J, Schneider S, Von Känel R. Lack of social support in the
etiology and the prognosis of coronary heart disease: A systematic
review and meta‑analysis. Psychosom Med 2010;72:229‑38.
15. Williams ED, Nazroo JY, Kooner JS, Steptoe A. Subgroup difference
in psychological factors relating to coronary heart disease in the UK
South Asian population. J Psychosom Res2010;69:379‑87.
16. Krantz DS, McCeney KT. Effects of psychological and social factors
on organic disease: A critical assessment of research on coronary
heart disease. Annu Rev Psychol 2002;53:341‑69.
17. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of
stress. Lancet 2007;370:1089‑100.
18. Rozanski A, Blumenthal AJ, Davidson WK, Saab PG, Kubzansky L.
The epidemiology pathophysiology, and management of
psychosocial risk factors in cardiac practice: The emerging field of
behavioral cardiology. J Am Coll Cardiol 2005;45:637‑51.
19. Uchino BN. Social support and physical health: Understanding the
health consequences of our relationships. New Haven, CT: Yale
University Press; 2004.
20. Wang HX, Mittleman MA, Orth‑Gomer K. Influence of social support
on progression coronary artery disease in women. Soc Sci Med
2005;60:599‑607.
21. Sifneos PE. Affect, emotional conflict, and deficit: An overview.
Psychother Psychosom 1991;56:116‑22.
22. Haviland MG, Reise SP A. California Q‑set alexithymia prototype
and its relationship to ego‑control and ego‑resiliency. J Psychosom
Res 1996;41:597‑608.
23. Taylor GJ. The alexithymia construct: Conceptualization, validation,
and relationships with basic dimensions of personality. New Trends
Exp Clin Psychiatry 1994;10:61‑74.
24. Lumley MA, Stettner L, Wehmer F. How are alexithymia and physical
illness linked? A review and critique of pathways. J Psychosom
Res1996;41:505‑18.
25. Taylor GJ, Bagby RM, Parker JD. The revised Toronto Alexithymia
Scale: Some reliability, validity and normative data. Psychother
Psychosom 1992;57:34‑41.
26. Wise TN, Mann LS. The attribution of somatic symptoms in
psychiatric Outpatients. Compr Psychiatry 1995;36:407‑10.
27. Lumley MA, Neely LC, Burger AJ. The assessment of alexithymia
in medical settings: Implications for understanding and treating
health problems. J Pers Assess 2007;89:230‑46.
28. Shahgolian M, Moradi AR, Kafi M. Alexithymia expressed
excitement about the styles and general health in students. Iran
Psychiatry Clin Psychol 2007;13:238‑48.
29. Lane RD, Sechrest L, Riedel R. Socio demographic correlates of
alexithymia. Compr Psychiatry 1998;39:377‑85.
30. Salminen JK, Saarijärvi S, Aärelä E, Toikka T, Kauhanen J. Prevalence
of alexithymia and its association with sociodemographic
variables in the general population of Finland. J Psychosom Res
1999;46:75‑82.
31. Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinamäki H.
Depression is strongly associated with alexithymia in the general
population. J Psychosom Res 2000;48:99‑104.
32. Kokkonen P, Karvonen JT, Veijola J, Läksy K, Jokelainen J,
Järvelin MR, et al. Prevalence and sociodemographic correlates
of alexithymia in a population sample of young adults. Compr
Psychiatry 2001;42:471‑6.
33. Nehra DK, Sharma V, Mushtaq H, Sharma NR, Sharma M, Nehra S.
Emotional Intelligence and Alexithymia in Alcoholics. Behav Sci
2011;12:101‑8.
34. Nekouei ZK, Mazaheri M, Manshaee GH. Alexithymia and autism
spectrum disorders. The first international congress child and
adolescent psychology. 1st to 6th May 2011 Shiraz, Fars, Iran: Fars
Science and Research branch2011.
35. Valkamo M, Hintikka J, Niskanen L. Depression and associated factors
in coronary heart disease. Scand Cardiovasc J 2001;35:259‑63.
36. Valkamoa M, Hintikkaa J, Honkalampia K, Niskanenb L,
Koivumaa‑Honkanena H, ViinamaÈkia H. Alexithymia in patients
with coronary heart diseas. J Psychosomatic Res 2001;50:125‑30.
37. Khauhanen J, Kaplan JA, Cohen RD, Salonen R, Salonen JT.
Alexithymia may influence the diagnosis of coronary heart disease.
Psychosom Med 1994;56:237‑44.
38. Kauhanen J, Kaplan G, Cohen R, Julkunen J, Salonen JT.
Alexithymia and risk of death in middle‑aged men. J Psychosom
Res 1996;41:541‑9.
39. Lumley MA, Tomakowsky J, Torosian T. The relationship of
alexithymia to subjective and biomedical measures of disease.
Psychosomatics 1997;38:497‑502.
40. Henrya JD, Phillip LH, Maylorc EA, Hosieb J, Milneb AB, Meyerc C.
A new conceptualization of alexithymia in the general adult
population: Implications for research involving older adults.
J Psychosomatic Res 2006;60:535‑43.
41. Duddu V, Isaac MK, Chaturvedi SK. Alexithymia in somatoform and
depressive disorders. J Psychosomatic Res 2003;54:435‑8.
42. Bagby RM. Taylor GJ, Parker JD. Construct validity of the Toronto
alexithymia scale. Psychother Psychosom 1988;50:29‑34.
43. Kauhanen J, Julkunen J, Salonen JT. Alexithymia and perceived
symptoms: Criterion validity of the Toronto Alexithymia Scale.
Psychother Psychosom 1991;56:247‑52.
44. Myers LB. Alexithymia and repression: The role of defensiveness
and trait anxiety. Pers lndivid Dif 1995;19:489‑92.
45. Linden W, Lenz JW, Stossel C. Alexithymia, defensiveness and
cardiovascular to stress. J Psychosomatic Res 1999;41:575‑83.
46. Mattila AK, Alanen E, Salminen JK, Kronholm JA, Sintonen H,
Joukamaa M. Health‑related quality‑of‑life profiles in nonalexithymic
and alexithymic subjects from general population. J Psychosomatic
Res 2010;68:279‑83.47. Dion KL. Ethnolinguistic correlates of alexithymia: Toward a cultural
Perspective. J Psychosom Res 1996;41:531‑9.
48. Fukunishi I, Kaji N, Hosaka T, Berger D, Rahe RH. The relationship
of Alexithymia and poor social support to ulcerative changes on
gastrofiberscopy. Psychosomatics 1997;38:20‑6.
49. BagbyRM, Pa rker JD, TaylorGJ. The twenty‑item TorontoAlexithymia
Scale‑I. Item selection and cross‑validation of the factor structure. J
Psychosomatic Res 1994;38:23‑32.
50. Shahgholian M, Moradi A, Kafi SM. Relation of alexithymia with
emotional expression styles and general health in students. Iran J
Psychiatry Clinl Psychological 2007;13:238‑48.
51. Lovibond SH, Lovibond PF. Manual for the Depression anxiety
Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.
52. Samani S, Jokar B. Study the validity and reliability of the Iranian
version of the Depression, Anxiety, Stress Scale. J Soc Humanities
Shiraz University 263; 2007.
53. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA.
Psychometric characteristics of the Multidimensional Scale of
Perceived Social Support. J Pers Assess 1990;55:610‑7.
54. Ghasemi V. Structural equation modeling in social researches using
amos graphics. Tehran: Jameeshenasan Publication; 2010.
55. Saarijarvi S, Salminen JK, Toikka TB. Alexithymia and depression:
A 1‑year follow‑up study in outpatients with major depression.
J Psychosom Res 2001;51:729‑33.
56. Beshart MA. Relation of Alexithymia with depression, anxiety,
psychological helplessness and well being. J Psychol Tabriz Univ
2008;10:17‑40.
57. Morton I, Gencoz T. The Relationship Between the Dimensions
of Alexithymia and the Intensity of Depression and Anxiety. Turk
Psikiyatri Derg 2007;18:333‑43.
58. Hisli Sahin N, Güler M, Basim HN. The relationship between
cognitive intelligence, emotional intelligence, coping and stress
symptoms in the context of type A personality pattern. Turk
Psikiyatri Derg 2009;20:243‑54.
59. Lumley MA, Ovies T, Stettner L, Wehmer F, Lakey B. Alexithymia,
social support and health problems. J Psychosomatic Res
1996;41:519‑30.
60. Verissimo R, Mota‑Cardoso R, Taylor G. Relationships between
alexithymia, emotional control, and quality of life in patients with
inflammatory bowel disease. Psychother Psychosom 1998;67:75‑80.
61. Mattila AK, Saarni SI, Salminen JK, Huhtala H, Sintonen H,
Joukamaa M. Alexithymia and health‑related quality of life in general
population. Psychosomatic 2009;50:59‑68.
62. Salminen JK, Saarijärvi S, Toikka T. Alexithymia and health‑related
quality of life. J Psychosom Res 2002;52:324.
63. Fortune DG, Richards HL, Griffiths CE, Main CJ. Psychological
stress, distress and disability in patients with psoriasis: Consensus
and variation in the contribution of illness perceptions, coping and
alexithymia. Br J Clin Psychol 2002;41:157‑74.
)