http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2015; 24(3): 150–154 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2015.1019055
ORIGINAL ARTICLE
Difficulty describing feelings and post-traumatic symptoms after a collective trauma in survivors of L’Aquila earthquake Alessandra Di Giacinto1, Carlo Lai2, Filippo Cieri1, Eduardo Cinosi1, Giuseppe Massaro2, Viviana Angelini1, Anna Pasquini1, Liborio Stuppia3, and Massimo di Giannantonio1 1
Department of Neuroscience and Imaging, Institute for Advanced Biomedical Technologies, D’Annunzio University of Chieti-Pescara, Chieti, Italy, Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy, and 3Department of Psychological, Humanities and Territorial Sciences, Laboratory of Molecular Genetics, D’Annunzio University of Chieti-Pescara, Chieti, Italy
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Abstract
Keywords
Background: The association between alexithymia and post-traumatic stress disorder (PTSD) symptoms has been demonstrated in several studies, but never in victims of a collective trauma such as a natural disaster, which has an impact on an entire community. Aims: The aim was to assess the relationship between alexithymia and post-traumatic symptoms in a group of people who lived in L’Aquila exposed to the earthquake that hit the town in 2009. Methods: Eighty-seven participants were included and assessed for alexithymia, PTSD symptoms, depression, anxiety, and psychiatric symptoms. Linear regression models were used to test the hypothesis. Results: The main finding was an association between ‘‘Difficulty-Describing-Feelings’’ and the intensity of post-traumatic symptoms in the worst month after trauma. Depression, anxiety and psychiatric comorbidity also showed a significant association with PTSD symptoms. Conclusions: In the present study of a collectively shared trauma, the alexithymic factor ‘‘difficulty-describing-feelings’’ was significantly associated with the intensity of post-traumatic symptoms.
Alexithymia, collective trauma, difficulty describing feelings, post-traumatic stress
Introduction The relationship between traumatic events and related psychiatric, psychological, and somatic issues is demonstrated in published literature (Dirkzwager et al., 2007; Solomon et al., 1997), also with regard to natural disasters (North et al., 2004). Moreover, a recent review showed the association between post-traumatic stress disorder (PTSD) and suicide (both suicidal ideation and suicide attempts), confirmed by the presence of risk factors and high rates of comorbidity (Pompili et al., 2013). Also, this association has been confirmed in case of collective trauma (Suzuki et al., 2011; Wu et al., 2006). Trauma has been defined as an ‘‘invisible epidemics’’ (Bremner, 2000). Different studies have shown a significant reduction of hyppocampal volume in victims of different traumatic events with a subsequent impact on memory, attention processes, and stress management (Bremner, 2004). On the other hand, PTSD patients treated with paroxetine
Correspondence: Carlo Lai, PhD, Department of Dynamic and Clinical Psychology, Sapienza University of Rome, via degli Apuli 1, 00185, Roma, Italy. Tel: (+39) 389 1039258. Fax: (+39) 06 49917903. E-mail: [email protected]
History Received 4 December 2014 Revised 20 January 2015 Accepted 25 January 2015
have showed an increase in hyppocampal volume and an improvement in the above-mentioned areas (Vermetten et al., 2003). One of the main effects of traumatic events has been identified as the ‘‘integrative failure of traumatic memories’’ (Van der Kolk et al., 1996). Traumatic memories can become subconscious and difficult to process, but extremely intrusive, and thus capable of influencing perceptions, emotions and behaviors (Caretti et al., 2005). This can be considered as a form of dissociation (Taylor, 2010), and can be seen as an ‘‘anti-reflective defense’’ (Fonagy & Target, 1997). Similarly, alexithymia (difficulty identifying and describing feelings) indicates poor symbolization (Sotres-Bayon et al., 2006; Taylor & Bagby, 2004). Many studies have reported a positive relationship between alexithymia levels and post-traumatic symptoms, which involve re-experiencing, avoidance/numbing, and hyper-arousal (Frewen et al., 2008; Lilly & Valdez, 2012; Zahradnik et al., 2009). This has been particularly verified for veterans (Monson et al., 2004; O’Brien et al., 2008; Ouanes et al., 2014), first responders (Heinrichs et al., 2005), victims of abuse (Hund & Espelage, 2006), refugees (So¨ndergaard & Theorell, 2004). At present, none of these studies investigated such relationship between alexithymia and post-traumatic symptomatology in the victims of a natural disaster.
Alexithymia and collective trauma
DOI: 10.3109/09638237.2015.1019055
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With regard to the type of traumatic event, unlike individual traumas, earthquakes are generally characterized by the high number of people involved within a circumscribed area. This makes the event somehow easier to accept and process. It is also more difficult for victims to implement avoidance behaviors (Nolen-Hoeksema & Morrow, 1991). For these reasons, it has been suggested that the shared traumatic experiences can prevent self-rumination and its negative effects on depression and post-traumatic symptoms (NolenHoeksema & Morrow, 1991; Pennebaker, 1995). The aim of the present research is to investigate the relationship between alexithymia and post-traumatic symptomatology in a group of participants exposed to the 2009 L’Aquila earthquake. We hypothesized that higher levels of alexithymia will be associated with more severe posttraumatic symptoms.
Methods Participants Between June 2012 and March 2013, 87 participants were recruited by researchers and staff of the D’Annunzio University of Chieti and the Sapienza University of Rome. Participation was solicited by means of advertisements (with contact information) placed in schools and local associations. Inclusion criteria were that participants’ age should be between 18 and 80 years, they had been residing in L’Aquila or in the nearby region (subsequently called ‘‘Seismic Crater’’ by the Italian Civil Protection) for at least 1 year before the 6 April 2009, and that they were present in the Seismic Crater that very day, at 3.32 am, when a violent earthquake caused extensive collapse of buildings and 309 deaths. The participants were interviewed face to face mostly in their homes, or alternatively in the Department of Neuroscience and Imaging in Chieti by two clinical psychologists and one psychiatrist. A Data Sheet, Clinician Administered PTSD Scale (CAPS), Toronto Alexithymia Scale 20 (TAS-20), Hamilton Depression Rating Scale (HamDep), Hamilton Anxiety Rating Scale (HamAnx) and Mini International Neuropsychiatric Interview (M.I.N.I.) were administered during the interview. The study was submitted to the Ethics Committee of the D’Annunzio University of Chieti. Procedure All participants gave written informed consent after the study was described by the interviewer. Then, the data sheet was completed. Following this, the interviewer carried out the psychological assessment using the CAPS, the TAS-20, HamDep, HamAnx, and M.I.N.I. The CAPS is a 30-item structured interview that corresponds to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders – Text Revision (American Psychiatric Association, 2000) criteria for PTSD (Blake et al., 1995). The CAPS evaluates the Current (past month: C.At.Tot.) and the Lifetime (worst month since the event happened: C.Lt.Tot.) PTSD symptoms. It also evaluates the frequency and intensity of five associated symptoms: guilt over acts, survivor guilt, gaps in awareness, depersonalization, de-realization (Associated Symptoms to Lifetime
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measures: C.Lt.Ass. and Associated Symptoms to Current measures: C.At.Ass.). The CAPS has shown an inter-rater reliability ranging from 0.92 to 1.00 (Hovens et al., 1994) and a test–retest reliability from 0.77 to 0.96 (American Psychiatric Association, 2000). The TAS-20 is a self-administered questionnaire based on a 5-point Likert Scale, which reflects a three-factor structure: difficulty identifying feelings (DIF/TasF1), difficulty describing feelings (DDF/TasF2) and externally oriented thinking (EOT/TasF3). The scale showed good internal consistency (Cronbach’s a ¼ 0.81), and good test–retest reliability (0.77) (Bagby et al., 1994a,b; Kooiman et al., 2002). HamDep (Hamilton, 1960, 1980) rates the severity of depression symptoms. It is composed of 21 items which are compiled by the interviewer, based on the observation and on the clinical interview. Several studies demonstrated a good reliability of the scale, with a pooled mean for a coefficient of 0.789 (Trajkovic´ et al., 2011). HamAnx (Hamilton, 1959) evaluates the severity of anxiety symptoms. It is composed of 14 items, seven related to psychological anxiety and seven related to its somatic manifestation. They are compiled by the interviewer by means of observation and of interview. The reliability and the concurrent validity of the scale is sufficient, while its internal validity is insufficient (Maier et al., 1988). Both the HamAnx and the HamDep assess their respective constructs at a statelevel rather than at a trait-level (Strauss & Paulsen, 1990). The M.I.N.I. is a short, structured diagnostic interview for DSM-IV and International Classification of Diseases, Tenth Revision (ICD-10) psychiatric disorders. Inter-rater and test– retest reliability are good (Lecrubier et al., 1997). Statistical analyses Correlational analyses (Pearson’s r) were conducted in order to evaluate the relationship between CAPS values and the other psychological variables and between age and all the variables. A linear regression model was implemented to evaluate the association between psychological variables and the intensity of post-traumatic symptomatology.
Results In the final sample of the present study, 87 survivors of the L’Aquila earthquake were recruited and interviewed (78 interviewed in their home and 9 in the Department of Neuroscience and Imaging in Chieti). They were 28 men and 59 women (32% and 68%, respectively), with ages ranging from 19 to 76 years. Total mean age was 38.4 ± 16.0 (43.1 ± 16.2 for the male group and 36.0 ± 15.5 for the female group). With regard to PTSD diagnosis, 40 participants (46% of sample), of which 14 men (50% of male sample) and 26 women (44% of female sample) were positive for lifetime PTSD (worst month after the event); 11 participants (13% of sample) of which 4 men (14% of male sample) and 7 women (12% of female sample) were positive for current PTSD (month before the assessment). As shown in Table 1, the CAPS scores (C.At.Tot., C.At.Ass., C.Lt.Tot., C.Lt.Ass.) were correlated with TasTot, TasF1, TasF2, TasF3, HamAnx, HamDep, and
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Table 1. Correlations (Pearson r) between the clinical variables (TasF1, TasF2, TasF3, TasTot, HamAnx, HamDep, MINI) and Caps scores, and between age and both: Clinical variables and Caps scores.
Table 2. Linear regression on CAPS scores with the significant (p50.05 correlational analyses) clinical variables as predictors. b
TasF1 TasF2 TasF3 TasTot HamAnx HamDep MINI
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Age
Age
C.At.Tot.
C.At.Ass.
C.Lt.Tot.
C.Lt.Ass.
0.25 p ¼ 0.017 0.002 p ¼ 0.986 0.22 p ¼ 0.044 0.2 p ¼ 0.042 0.08 p ¼ 0.466 0.05 p ¼ 0.651 0.09 p ¼ 0.412 1
0.22 p ¼ 0.045 0.17 p ¼ 0.106 0.00 p ¼ 0.994 0.19 p ¼ 0.074 0.37 p ¼ 0.001 0.35 p ¼ 0.001 0.33 p ¼ 0.002 0.19 p ¼ 0.077
0.12 p ¼ 0.280 0.03 p ¼ 0.744 0.12 p ¼ 0.263 0.03 p ¼ 0.779 0.18 p ¼ 0.102 0.20 p ¼ 0.058 0.34 p ¼ 0.001 0.08 p ¼ 0.435
0.31 p ¼ 0.004 0.27 p ¼ 0.013 0.02 p ¼ 0.833 0.29 p ¼ 0.006 0.32 p ¼ 0.002 0.33 p ¼ 0.002 0.19 p ¼ 0.072 0.20 p ¼ 0.064
0.24 p ¼ 0.024 0.19 p ¼ 0.077 0.04 p ¼ 0.732 0.23 p ¼ 0.034 0.19 p ¼ 0.070 0.25 p ¼ 0.019 0.28 p ¼ 0.009 0.10 p ¼ 0.348
C.At.Tot., total current caps score; C.At:Ass, Associated Symptoms Current Caps score; C.Lt.Tot., total lifetime caps score; C.Lt.Ass., associated symptoms lifetime caps score; TasF1, difficulty identifying feelings; TasF2, difficulty describing feelings; TasF3, externally oriented thinking; TasTot, total toronto alexithymia scale (20 item) score; HamAnx, Hamilton anxiety rating scale; HamDep, Hamilton depression rating scale; MINI, mini international neuropsychiatric interview.
MINI. Age was also correlated with all the variables. Significant correlations were: age with TasF1 (r ¼ 0.2546; p ¼ 0.017), TasF3 (r ¼ 0.22; p ¼ 0.044), TasTot (r ¼ 0.22; p ¼ 0.042); C.At.Tot. with TasF1 (r ¼ 0.22; p ¼ 0.045), HamAnx (r ¼ 0.37; p ¼ 0.001), HamDep (r ¼ 0.35; p ¼ 0.001), MINI (r ¼ 0.33; p ¼ 0.002); C.At.Ass. with MINI (r ¼ 0.34; p ¼ 0.001); C.Lt.Tot. with TasF1 (r ¼ 0.31; p ¼ 0.004), TasF2 (r ¼ 0.27; p ¼ 0.013), TasTot (r ¼ 0.29; p ¼ 0.006), HamAnx (r ¼ 0.32; p ¼ 0.002), HamDep (r ¼ 0.33; p ¼ 0.002); C.Lt.Ass. with TasF1 (r ¼ 0.24; p ¼ 0.024), TasTot (r ¼ 0.23; p ¼ 0.034), HamDep (r ¼ 0.25; p ¼ 0.019), MINI (r ¼ 0.28; p ¼ 0.009). All the significant (p50.05) correlational analyses’ clinical variables were inserted into a mathematical linear regression model, as predictors of each CAPS variable (Table 2). For C.At.Tot., the model was significant (R ¼ 0.43; R2 ¼ 0.18; R2 adj. ¼ 0.16; F(3,83) ¼ 6.28; p50.001). HamAnx (b ¼ 0.25; B ¼ 0.65; t(83) ¼ 2.22; p ¼ 0.029) predicted C.At.Tot. scores, but MINI (b ¼ 0.22; B ¼ 4.46; t(83) ¼ 1.98; p ¼ 0.050) and TasF2 (b ¼ 0.12; B ¼ 0.44; t(83) ¼ 1.17; p ¼ 0.245) did not. For C.At.Ass., the model was significant (R ¼ 0.35 R2 ¼ 0.12 R2 adj. ¼ 0.10 F(2,84) ¼ 5.99 p50.004). MINI (b ¼ 0.33; B ¼ 1.18; t(84) ¼ 3.25; p ¼ 0.002) predicted C.At.Ass. scores, while TasF3 (b ¼ 0.11; B ¼ 0.08; t(84) ¼ 1.05; p ¼ 0.296) did not. For C.Lt.Tot., the model was significant (R ¼ 0.39 R2 ¼ 0.15 R2 adj. ¼ 0.13; F(2,84) ¼ 7.73 p50.001). HamDep (b ¼ 0.29; B ¼ 1.14; t(84) ¼ 2.90; p ¼ 0.005), and TasF2 (b ¼ 0.22; B ¼ 1.31; t(84) ¼ 2.19; p ¼ 0.031) both predicted C.Lt.Tot. scores. For C.Lt.Ass., the model was significant (R ¼ 0.36 R2 ¼ 0.13 R2 adj. ¼ 0.09; F(3,83) ¼ 4.00 p50.010). MINI (b ¼ 0.23; B ¼ 1.76; t(83) ¼ 2.24; p ¼ 0.027) and TasTot (b ¼ 0.29; B ¼ 0.18; t(83) ¼ 2.12; p ¼ 0.036) predicted
b SE
B
B SE
t(83)
p
Linear regression on total current CAPS (C.At.Tot.) scores. R ¼ 0.43, R2 ¼ 0.18, R2 Adj. ¼ 0.16, F(3.83) ¼ 6.28, p50.00068. Intercept 2.69 5.30 0.51 0.613 HamAnx 0.25 0.11 0.65 0.29 2.22 0.029 MINI 0.22 0.11 4.46 2.25 1.98 0.050 TpasF2 0.12 0.10 0.44 0.37 1.17 0.245 Linear regression on Associated Symptoms Current CAPS (C.At.Ass.) scores. R ¼ 0.35, R2 ¼ 0.12, R2 Adj. ¼ 0.10, F(2.84) ¼ 5.99, p50.00371. Intercept 2.27 1.38 1.65 0.102 MINI 0.33 0.10 1.18 0.36 3.25 0.002 TasF3 0.11 0.10 0.08 0.077 1.05 0.296 Linear regression on total lifetime CAPS (C.Lt.Tot.) scores. R ¼ 0.39, R2 ¼ 0.15, R2 adj. ¼ 0.13, F(2.84) ¼ 7.73, p50.00083. Intercept 18.92 8.56 2.21 0.030 HamDep 0.29 0.10 1.14 0.39 2.90 0.005 TasF2 0.22 0.10 1.31 0.60 2.19 0.031 Linear regression on associated symptoms lifetime CAPS (C.Lt.Ass.) scores. R ¼ 0.36, R2 ¼ 0.13, R2 adj. ¼ 0.09, F(3.83) ¼ 4.00, p50.01026. Intercept 0.01 3.16 0.00 0.998 MINI 0.23 0.10 1.76 0.78 2.24 0.027 TasTot 0.29 0.14 0.18 0.08 2.12 0.036 TasF3 0.14 0.14 0.23 0.22 1.05 0.296 TasF2, difficulty describing feelings; TasF3, externally oriented thinking; TasTot, total toronto alexithymia scale (20 item) score; HamAnx, Hamilton anxiety rating scale; HamDep, Hamilton depression rating scale; MINI, mini international neuropsychiatric interview.
C.Lt.Ass. scores, while TasF3 (b ¼ 0.14; B ¼ 0.23; t(83) ¼ 1.05; p ¼ 0.296) did not.
Discussion In accordance with previous studies carried out on veterans (Monson et al., 2004; O’Brien et al., 2008), first responders (Heinrichs et al., 2005), victims of abuse (Hund et al., 2006), refugees (Frewen et al., 2008; So¨ndergaard & Theorell, 2004), the main finding of the present study was an association between alexithymic factors and the intensity of PTSD symptoms. However, in the present study only the difficulty describing feelings factor (alexithymia Factor 2, F2) had an association with PTSD symptoms in the acute phase. This result is peculiar considering that in previous studies difficulty identifying feelings (Frewen et al., 2008; Heinrichs et al., 2005; Hund et al., 2006; Monson et al., 2004; O’Brien et al., 2008; So¨ndergaard & Theorell, 2004) and externally oriented thinking (Monson et al., 2004) were found to be the best predictors of the intensity of PTSD symptoms. A possible explanation for this peculiarity is that the collective nature of the traumatic event in L’Aquila affected the specific association between difficulty describing feelings and post-traumatic symptoms. The peculiarities of a collective traumatic event include community relationships and social support in dealing with the shared trauma. As already pointed out (Nolen-Hoeksema & Morrow, 1991; Pennebaker, 1995), social sharing could promote some form of mentalization also in alexithymic individuals after a collective trauma. However, it is possible that the difficulty describing feelings (F2) could
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DOI: 10.3109/09638237.2015.1019055
prevent these persons from sharing their emotional experiences with others, becoming the main alexithymic factor hindering trauma processing in this case, and determining post-traumatic suffering. This interpretation is coherent with the hypotheses recently formulated where the affect evoked by trauma produces a disorganizing hyper-arousal that could overwhelm the mind’s ability to think and to process experiences (Bromberg, 2008, 2010). The ability to mentalize feelings and to share them with others after a traumatic event seems to prevent severe post-traumatic symptoms. Confirming previous studies, the post-traumatic stress associated symptoms (guilt over acts, survivor guilt, gasp in awareness, depersonalization, de-realization) were also associated with the presence of alexithymia (Declercq et al., 2010), psychiatric disorders (Daini et al., 2006; Simeon et al., 2009), depression (Felker et al., 2007; Ginzburg et al., 2010; Goenjian et al., 2011), anxiety (Smid et al., 2011; Zahradnik et al., 2009), suicidal ideation and suicide attempts (Pompili et al., 2013). A limitation of the present study was that despite other similar studies took into account, the PTSD cluster structure, in the present research, considers only the PTSD global (Current and Lifetime) scores, together with the associated symptoms. Moreover, the small sample size and crosssectional nature of the study design limit the generalization of the results. Further research and analysis considering each PTSD symptoms cluster scores would be interesting and helpful to better understand the association between difficulty describing feelings and PTSD symptoms also in the acute phase. In conclusion, the findings suggest a clear association between difficulty describing feelings and post-traumatic symptoms after a collective trauma. Alexithymia is also associated with PTSD-associated symptoms (guilt over acts, survivor guilt, gasp in awareness, depersonalization, derealization). The ability to mentalize feelings and especially the ability to share them with others after a natural disaster and a collective trauma seem to be an important factor in processing traumatic memories and preventing severe posttraumatic suffering (Xu & Deng, 2013).
Acknowledgements The authors thank the Proof-Reading-Service for their English language editing.
Declaration of interest The authors do not have any conflicts of interest to declare.
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ORIGINAL ARTICLE
Difficulty describing feelings and post-traumatic symptoms after a collective trauma in survivors of L’Aquila earthquake Alessandra Di Giacinto1, Carlo Lai2, Filippo Cieri1, Eduardo Cinosi1, Giuseppe Massaro2, Viviana Angelini1, Anna Pasquini1, Liborio Stuppia3, and Massimo di Giannantonio1 1
Department of Neuroscience and Imaging, Institute for Advanced Biomedical Technologies, D’Annunzio University of Chieti-Pescara, Chieti, Italy, Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy, and 3Department of Psychological, Humanities and Territorial Sciences, Laboratory of Molecular Genetics, D’Annunzio University of Chieti-Pescara, Chieti, Italy
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Abstract
Keywords
Background: The association between alexithymia and post-traumatic stress disorder (PTSD) symptoms has been demonstrated in several studies, but never in victims of a collective trauma such as a natural disaster, which has an impact on an entire community. Aims: The aim was to assess the relationship between alexithymia and post-traumatic symptoms in a group of people who lived in L’Aquila exposed to the earthquake that hit the town in 2009. Methods: Eighty-seven participants were included and assessed for alexithymia, PTSD symptoms, depression, anxiety, and psychiatric symptoms. Linear regression models were used to test the hypothesis. Results: The main finding was an association between ‘‘Difficulty-Describing-Feelings’’ and the intensity of post-traumatic symptoms in the worst month after trauma. Depression, anxiety and psychiatric comorbidity also showed a significant association with PTSD symptoms. Conclusions: In the present study of a collectively shared trauma, the alexithymic factor ‘‘difficulty-describing-feelings’’ was significantly associated with the intensity of post-traumatic symptoms.
Alexithymia, collective trauma, difficulty describing feelings, post-traumatic stress
Introduction The relationship between traumatic events and related psychiatric, psychological, and somatic issues is demonstrated in published literature (Dirkzwager et al., 2007; Solomon et al., 1997), also with regard to natural disasters (North et al., 2004). Moreover, a recent review showed the association between post-traumatic stress disorder (PTSD) and suicide (both suicidal ideation and suicide attempts), confirmed by the presence of risk factors and high rates of comorbidity (Pompili et al., 2013). Also, this association has been confirmed in case of collective trauma (Suzuki et al., 2011; Wu et al., 2006). Trauma has been defined as an ‘‘invisible epidemics’’ (Bremner, 2000). Different studies have shown a significant reduction of hyppocampal volume in victims of different traumatic events with a subsequent impact on memory, attention processes, and stress management (Bremner, 2004). On the other hand, PTSD patients treated with paroxetine
Correspondence: Carlo Lai, PhD, Department of Dynamic and Clinical Psychology, Sapienza University of Rome, via degli Apuli 1, 00185, Roma, Italy. Tel: (+39) 389 1039258. Fax: (+39) 06 49917903. E-mail: [email protected]
History Received 4 December 2014 Revised 20 January 2015 Accepted 25 January 2015
have showed an increase in hyppocampal volume and an improvement in the above-mentioned areas (Vermetten et al., 2003). One of the main effects of traumatic events has been identified as the ‘‘integrative failure of traumatic memories’’ (Van der Kolk et al., 1996). Traumatic memories can become subconscious and difficult to process, but extremely intrusive, and thus capable of influencing perceptions, emotions and behaviors (Caretti et al., 2005). This can be considered as a form of dissociation (Taylor, 2010), and can be seen as an ‘‘anti-reflective defense’’ (Fonagy & Target, 1997). Similarly, alexithymia (difficulty identifying and describing feelings) indicates poor symbolization (Sotres-Bayon et al., 2006; Taylor & Bagby, 2004). Many studies have reported a positive relationship between alexithymia levels and post-traumatic symptoms, which involve re-experiencing, avoidance/numbing, and hyper-arousal (Frewen et al., 2008; Lilly & Valdez, 2012; Zahradnik et al., 2009). This has been particularly verified for veterans (Monson et al., 2004; O’Brien et al., 2008; Ouanes et al., 2014), first responders (Heinrichs et al., 2005), victims of abuse (Hund & Espelage, 2006), refugees (So¨ndergaard & Theorell, 2004). At present, none of these studies investigated such relationship between alexithymia and post-traumatic symptomatology in the victims of a natural disaster.
Alexithymia and collective trauma
DOI: 10.3109/09638237.2015.1019055
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With regard to the type of traumatic event, unlike individual traumas, earthquakes are generally characterized by the high number of people involved within a circumscribed area. This makes the event somehow easier to accept and process. It is also more difficult for victims to implement avoidance behaviors (Nolen-Hoeksema & Morrow, 1991). For these reasons, it has been suggested that the shared traumatic experiences can prevent self-rumination and its negative effects on depression and post-traumatic symptoms (NolenHoeksema & Morrow, 1991; Pennebaker, 1995). The aim of the present research is to investigate the relationship between alexithymia and post-traumatic symptomatology in a group of participants exposed to the 2009 L’Aquila earthquake. We hypothesized that higher levels of alexithymia will be associated with more severe posttraumatic symptoms.
Methods Participants Between June 2012 and March 2013, 87 participants were recruited by researchers and staff of the D’Annunzio University of Chieti and the Sapienza University of Rome. Participation was solicited by means of advertisements (with contact information) placed in schools and local associations. Inclusion criteria were that participants’ age should be between 18 and 80 years, they had been residing in L’Aquila or in the nearby region (subsequently called ‘‘Seismic Crater’’ by the Italian Civil Protection) for at least 1 year before the 6 April 2009, and that they were present in the Seismic Crater that very day, at 3.32 am, when a violent earthquake caused extensive collapse of buildings and 309 deaths. The participants were interviewed face to face mostly in their homes, or alternatively in the Department of Neuroscience and Imaging in Chieti by two clinical psychologists and one psychiatrist. A Data Sheet, Clinician Administered PTSD Scale (CAPS), Toronto Alexithymia Scale 20 (TAS-20), Hamilton Depression Rating Scale (HamDep), Hamilton Anxiety Rating Scale (HamAnx) and Mini International Neuropsychiatric Interview (M.I.N.I.) were administered during the interview. The study was submitted to the Ethics Committee of the D’Annunzio University of Chieti. Procedure All participants gave written informed consent after the study was described by the interviewer. Then, the data sheet was completed. Following this, the interviewer carried out the psychological assessment using the CAPS, the TAS-20, HamDep, HamAnx, and M.I.N.I. The CAPS is a 30-item structured interview that corresponds to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders – Text Revision (American Psychiatric Association, 2000) criteria for PTSD (Blake et al., 1995). The CAPS evaluates the Current (past month: C.At.Tot.) and the Lifetime (worst month since the event happened: C.Lt.Tot.) PTSD symptoms. It also evaluates the frequency and intensity of five associated symptoms: guilt over acts, survivor guilt, gaps in awareness, depersonalization, de-realization (Associated Symptoms to Lifetime
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measures: C.Lt.Ass. and Associated Symptoms to Current measures: C.At.Ass.). The CAPS has shown an inter-rater reliability ranging from 0.92 to 1.00 (Hovens et al., 1994) and a test–retest reliability from 0.77 to 0.96 (American Psychiatric Association, 2000). The TAS-20 is a self-administered questionnaire based on a 5-point Likert Scale, which reflects a three-factor structure: difficulty identifying feelings (DIF/TasF1), difficulty describing feelings (DDF/TasF2) and externally oriented thinking (EOT/TasF3). The scale showed good internal consistency (Cronbach’s a ¼ 0.81), and good test–retest reliability (0.77) (Bagby et al., 1994a,b; Kooiman et al., 2002). HamDep (Hamilton, 1960, 1980) rates the severity of depression symptoms. It is composed of 21 items which are compiled by the interviewer, based on the observation and on the clinical interview. Several studies demonstrated a good reliability of the scale, with a pooled mean for a coefficient of 0.789 (Trajkovic´ et al., 2011). HamAnx (Hamilton, 1959) evaluates the severity of anxiety symptoms. It is composed of 14 items, seven related to psychological anxiety and seven related to its somatic manifestation. They are compiled by the interviewer by means of observation and of interview. The reliability and the concurrent validity of the scale is sufficient, while its internal validity is insufficient (Maier et al., 1988). Both the HamAnx and the HamDep assess their respective constructs at a statelevel rather than at a trait-level (Strauss & Paulsen, 1990). The M.I.N.I. is a short, structured diagnostic interview for DSM-IV and International Classification of Diseases, Tenth Revision (ICD-10) psychiatric disorders. Inter-rater and test– retest reliability are good (Lecrubier et al., 1997). Statistical analyses Correlational analyses (Pearson’s r) were conducted in order to evaluate the relationship between CAPS values and the other psychological variables and between age and all the variables. A linear regression model was implemented to evaluate the association between psychological variables and the intensity of post-traumatic symptomatology.
Results In the final sample of the present study, 87 survivors of the L’Aquila earthquake were recruited and interviewed (78 interviewed in their home and 9 in the Department of Neuroscience and Imaging in Chieti). They were 28 men and 59 women (32% and 68%, respectively), with ages ranging from 19 to 76 years. Total mean age was 38.4 ± 16.0 (43.1 ± 16.2 for the male group and 36.0 ± 15.5 for the female group). With regard to PTSD diagnosis, 40 participants (46% of sample), of which 14 men (50% of male sample) and 26 women (44% of female sample) were positive for lifetime PTSD (worst month after the event); 11 participants (13% of sample) of which 4 men (14% of male sample) and 7 women (12% of female sample) were positive for current PTSD (month before the assessment). As shown in Table 1, the CAPS scores (C.At.Tot., C.At.Ass., C.Lt.Tot., C.Lt.Ass.) were correlated with TasTot, TasF1, TasF2, TasF3, HamAnx, HamDep, and
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Table 1. Correlations (Pearson r) between the clinical variables (TasF1, TasF2, TasF3, TasTot, HamAnx, HamDep, MINI) and Caps scores, and between age and both: Clinical variables and Caps scores.
Table 2. Linear regression on CAPS scores with the significant (p50.05 correlational analyses) clinical variables as predictors. b
TasF1 TasF2 TasF3 TasTot HamAnx HamDep MINI
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Age
Age
C.At.Tot.
C.At.Ass.
C.Lt.Tot.
C.Lt.Ass.
0.25 p ¼ 0.017 0.002 p ¼ 0.986 0.22 p ¼ 0.044 0.2 p ¼ 0.042 0.08 p ¼ 0.466 0.05 p ¼ 0.651 0.09 p ¼ 0.412 1
0.22 p ¼ 0.045 0.17 p ¼ 0.106 0.00 p ¼ 0.994 0.19 p ¼ 0.074 0.37 p ¼ 0.001 0.35 p ¼ 0.001 0.33 p ¼ 0.002 0.19 p ¼ 0.077
0.12 p ¼ 0.280 0.03 p ¼ 0.744 0.12 p ¼ 0.263 0.03 p ¼ 0.779 0.18 p ¼ 0.102 0.20 p ¼ 0.058 0.34 p ¼ 0.001 0.08 p ¼ 0.435
0.31 p ¼ 0.004 0.27 p ¼ 0.013 0.02 p ¼ 0.833 0.29 p ¼ 0.006 0.32 p ¼ 0.002 0.33 p ¼ 0.002 0.19 p ¼ 0.072 0.20 p ¼ 0.064
0.24 p ¼ 0.024 0.19 p ¼ 0.077 0.04 p ¼ 0.732 0.23 p ¼ 0.034 0.19 p ¼ 0.070 0.25 p ¼ 0.019 0.28 p ¼ 0.009 0.10 p ¼ 0.348
C.At.Tot., total current caps score; C.At:Ass, Associated Symptoms Current Caps score; C.Lt.Tot., total lifetime caps score; C.Lt.Ass., associated symptoms lifetime caps score; TasF1, difficulty identifying feelings; TasF2, difficulty describing feelings; TasF3, externally oriented thinking; TasTot, total toronto alexithymia scale (20 item) score; HamAnx, Hamilton anxiety rating scale; HamDep, Hamilton depression rating scale; MINI, mini international neuropsychiatric interview.
MINI. Age was also correlated with all the variables. Significant correlations were: age with TasF1 (r ¼ 0.2546; p ¼ 0.017), TasF3 (r ¼ 0.22; p ¼ 0.044), TasTot (r ¼ 0.22; p ¼ 0.042); C.At.Tot. with TasF1 (r ¼ 0.22; p ¼ 0.045), HamAnx (r ¼ 0.37; p ¼ 0.001), HamDep (r ¼ 0.35; p ¼ 0.001), MINI (r ¼ 0.33; p ¼ 0.002); C.At.Ass. with MINI (r ¼ 0.34; p ¼ 0.001); C.Lt.Tot. with TasF1 (r ¼ 0.31; p ¼ 0.004), TasF2 (r ¼ 0.27; p ¼ 0.013), TasTot (r ¼ 0.29; p ¼ 0.006), HamAnx (r ¼ 0.32; p ¼ 0.002), HamDep (r ¼ 0.33; p ¼ 0.002); C.Lt.Ass. with TasF1 (r ¼ 0.24; p ¼ 0.024), TasTot (r ¼ 0.23; p ¼ 0.034), HamDep (r ¼ 0.25; p ¼ 0.019), MINI (r ¼ 0.28; p ¼ 0.009). All the significant (p50.05) correlational analyses’ clinical variables were inserted into a mathematical linear regression model, as predictors of each CAPS variable (Table 2). For C.At.Tot., the model was significant (R ¼ 0.43; R2 ¼ 0.18; R2 adj. ¼ 0.16; F(3,83) ¼ 6.28; p50.001). HamAnx (b ¼ 0.25; B ¼ 0.65; t(83) ¼ 2.22; p ¼ 0.029) predicted C.At.Tot. scores, but MINI (b ¼ 0.22; B ¼ 4.46; t(83) ¼ 1.98; p ¼ 0.050) and TasF2 (b ¼ 0.12; B ¼ 0.44; t(83) ¼ 1.17; p ¼ 0.245) did not. For C.At.Ass., the model was significant (R ¼ 0.35 R2 ¼ 0.12 R2 adj. ¼ 0.10 F(2,84) ¼ 5.99 p50.004). MINI (b ¼ 0.33; B ¼ 1.18; t(84) ¼ 3.25; p ¼ 0.002) predicted C.At.Ass. scores, while TasF3 (b ¼ 0.11; B ¼ 0.08; t(84) ¼ 1.05; p ¼ 0.296) did not. For C.Lt.Tot., the model was significant (R ¼ 0.39 R2 ¼ 0.15 R2 adj. ¼ 0.13; F(2,84) ¼ 7.73 p50.001). HamDep (b ¼ 0.29; B ¼ 1.14; t(84) ¼ 2.90; p ¼ 0.005), and TasF2 (b ¼ 0.22; B ¼ 1.31; t(84) ¼ 2.19; p ¼ 0.031) both predicted C.Lt.Tot. scores. For C.Lt.Ass., the model was significant (R ¼ 0.36 R2 ¼ 0.13 R2 adj. ¼ 0.09; F(3,83) ¼ 4.00 p50.010). MINI (b ¼ 0.23; B ¼ 1.76; t(83) ¼ 2.24; p ¼ 0.027) and TasTot (b ¼ 0.29; B ¼ 0.18; t(83) ¼ 2.12; p ¼ 0.036) predicted
b SE
B
B SE
t(83)
p
Linear regression on total current CAPS (C.At.Tot.) scores. R ¼ 0.43, R2 ¼ 0.18, R2 Adj. ¼ 0.16, F(3.83) ¼ 6.28, p50.00068. Intercept 2.69 5.30 0.51 0.613 HamAnx 0.25 0.11 0.65 0.29 2.22 0.029 MINI 0.22 0.11 4.46 2.25 1.98 0.050 TpasF2 0.12 0.10 0.44 0.37 1.17 0.245 Linear regression on Associated Symptoms Current CAPS (C.At.Ass.) scores. R ¼ 0.35, R2 ¼ 0.12, R2 Adj. ¼ 0.10, F(2.84) ¼ 5.99, p50.00371. Intercept 2.27 1.38 1.65 0.102 MINI 0.33 0.10 1.18 0.36 3.25 0.002 TasF3 0.11 0.10 0.08 0.077 1.05 0.296 Linear regression on total lifetime CAPS (C.Lt.Tot.) scores. R ¼ 0.39, R2 ¼ 0.15, R2 adj. ¼ 0.13, F(2.84) ¼ 7.73, p50.00083. Intercept 18.92 8.56 2.21 0.030 HamDep 0.29 0.10 1.14 0.39 2.90 0.005 TasF2 0.22 0.10 1.31 0.60 2.19 0.031 Linear regression on associated symptoms lifetime CAPS (C.Lt.Ass.) scores. R ¼ 0.36, R2 ¼ 0.13, R2 adj. ¼ 0.09, F(3.83) ¼ 4.00, p50.01026. Intercept 0.01 3.16 0.00 0.998 MINI 0.23 0.10 1.76 0.78 2.24 0.027 TasTot 0.29 0.14 0.18 0.08 2.12 0.036 TasF3 0.14 0.14 0.23 0.22 1.05 0.296 TasF2, difficulty describing feelings; TasF3, externally oriented thinking; TasTot, total toronto alexithymia scale (20 item) score; HamAnx, Hamilton anxiety rating scale; HamDep, Hamilton depression rating scale; MINI, mini international neuropsychiatric interview.
C.Lt.Ass. scores, while TasF3 (b ¼ 0.14; B ¼ 0.23; t(83) ¼ 1.05; p ¼ 0.296) did not.
Discussion In accordance with previous studies carried out on veterans (Monson et al., 2004; O’Brien et al., 2008), first responders (Heinrichs et al., 2005), victims of abuse (Hund et al., 2006), refugees (Frewen et al., 2008; So¨ndergaard & Theorell, 2004), the main finding of the present study was an association between alexithymic factors and the intensity of PTSD symptoms. However, in the present study only the difficulty describing feelings factor (alexithymia Factor 2, F2) had an association with PTSD symptoms in the acute phase. This result is peculiar considering that in previous studies difficulty identifying feelings (Frewen et al., 2008; Heinrichs et al., 2005; Hund et al., 2006; Monson et al., 2004; O’Brien et al., 2008; So¨ndergaard & Theorell, 2004) and externally oriented thinking (Monson et al., 2004) were found to be the best predictors of the intensity of PTSD symptoms. A possible explanation for this peculiarity is that the collective nature of the traumatic event in L’Aquila affected the specific association between difficulty describing feelings and post-traumatic symptoms. The peculiarities of a collective traumatic event include community relationships and social support in dealing with the shared trauma. As already pointed out (Nolen-Hoeksema & Morrow, 1991; Pennebaker, 1995), social sharing could promote some form of mentalization also in alexithymic individuals after a collective trauma. However, it is possible that the difficulty describing feelings (F2) could
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DOI: 10.3109/09638237.2015.1019055
prevent these persons from sharing their emotional experiences with others, becoming the main alexithymic factor hindering trauma processing in this case, and determining post-traumatic suffering. This interpretation is coherent with the hypotheses recently formulated where the affect evoked by trauma produces a disorganizing hyper-arousal that could overwhelm the mind’s ability to think and to process experiences (Bromberg, 2008, 2010). The ability to mentalize feelings and to share them with others after a traumatic event seems to prevent severe post-traumatic symptoms. Confirming previous studies, the post-traumatic stress associated symptoms (guilt over acts, survivor guilt, gasp in awareness, depersonalization, de-realization) were also associated with the presence of alexithymia (Declercq et al., 2010), psychiatric disorders (Daini et al., 2006; Simeon et al., 2009), depression (Felker et al., 2007; Ginzburg et al., 2010; Goenjian et al., 2011), anxiety (Smid et al., 2011; Zahradnik et al., 2009), suicidal ideation and suicide attempts (Pompili et al., 2013). A limitation of the present study was that despite other similar studies took into account, the PTSD cluster structure, in the present research, considers only the PTSD global (Current and Lifetime) scores, together with the associated symptoms. Moreover, the small sample size and crosssectional nature of the study design limit the generalization of the results. Further research and analysis considering each PTSD symptoms cluster scores would be interesting and helpful to better understand the association between difficulty describing feelings and PTSD symptoms also in the acute phase. In conclusion, the findings suggest a clear association between difficulty describing feelings and post-traumatic symptoms after a collective trauma. Alexithymia is also associated with PTSD-associated symptoms (guilt over acts, survivor guilt, gasp in awareness, depersonalization, derealization). The ability to mentalize feelings and especially the ability to share them with others after a natural disaster and a collective trauma seem to be an important factor in processing traumatic memories and preventing severe posttraumatic suffering (Xu & Deng, 2013).
Acknowledgements The authors thank the Proof-Reading-Service for their English language editing.
Declaration of interest The authors do not have any conflicts of interest to declare.
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