Alexithymia After Traumatic Brain Injury : Its Relation to Magnetic Resonance Imaging Findings and Psychiatric Disorders

Alexithymia After Traumatic Brain Injury: Its Relation to Magnetic Resonance
Imaging Findings and Psychiatric Disorders
SALLA KOPONEN, MD, TERO TAIMINEN, MD, PHD, KIRSI HONKALAMPI, PHD, MATTI JOUKAMAA, MD, PHD,
HEIMO VIINAMÄKI, MD, PHD, TIMO KURKI, MD, PHD, RAIJA PORTIN, PHD, LEENA HIMANEN, PSLIC, HELI ISONIEMI, MD,
SUSANNA HINKKA, PHLIC, AND OLLI TENOVUO, MD, PHD
Objective: People with traumatic brain injury (TBI) were studied to assess the prevalence of alexithymia and its relationship to
magnetic resonance imaging (MRI) findings and psychiatric disorders. Methods: Fifty-four participants, 67% men, were evaluated
after a median of 30 years since TBI. A control group was matched for age, gender, and severity of depression. Alexithymia was
measured with the 20-item Toronto Alexithymia Scale (TAS-20). In patients with TBI, axis I psychiatric disorders were assessed
with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, version 2.1), and axis II disorders with the Structured
Clinical Interview for DSM-III-R Personality Disorders (SCID-II). MRI examinations were carried out with a 1.5 T MRI scanner.
Results: Alexithymia was significantly more common in patients with TBI than in controls (31.5% versus 14.8%; odds ratio 2.64,
95% confidence interval 1.03– 6.80). None of the variables representing TBI, ie, severity of TBI or the presence, laterality, or
location of contusions on MRI, was associated with the TAS-20 total scores. Several current axis I and II psychiatric disorders,
particularly organic personality syndrome, were connected to higher TAS-20 scores. Conclusion: Alexithymia is common, along
with psychiatric disorders, in patients with TBI. Both of them may reflect dysfunction of the injured brain. In clinical practice,
alexithymic features should be taken into consideration in psychosocial rehabilitation after TBI. Key words: alexithymia, traumatic
brain injury, magnetic resonance imaging, psychiatric disorders.
MRI ? magnetic resonance imaging; TBI ? traumatic brain injury;
a disturbance in the participation of the anterior cingulate
TAS-20 ? 20-item Toronto Alexithymia Scale; OR ? odds ratio;
cortex, one of the essential structures in generating the con-
95% CI ? 95% confidence interval; BDI-13 ? 13-item Beck
scious awareness of feelings, during emotional arousal, has
Depression Inventory; DAI ? diffuse axonal injury.
been suggested (5). The size of the right anterior cingulate
gyrus has been found to correlate with alexithymia (6). Dif-
INTRODUCTION
ferences in anterior cingulate and mediofrontal activity during
More than 30 years ago, Sifneos (1) introduced the con- emotional stimuli processing, detected with functional mag-
cept of alexithymia, literally, “a lack of words for emo-
netic resonance imaging (fMRI), have been linked to alexi-
tions.” Its salient features are (1) difficulty identifying feelings
thymia (7). In a positron emission tomography study, subjects
and distinguishing between feelings and the bodily sensations
with alexithymia showed a lower response in the right hemi-
of emotional arousal; (2) difficulty describing feelings to other
sphere, a higher response in the left hemisphere, and also less
people; (3) constricted imaginal processes, as evidenced by
activation in the anterior cingulate cortex than controls, when
a paucity of fantasies; and (4) a stimulus-bound, exter-
viewing different facial expressions (8). So far, the findings of
nally oriented cognitive style (2). Keen scientific interest has
these individual studies dealing with alexithymia and cerebral
yielded more than 1000 reports mainly on the associations
functioning seem to be somewhat inconsistent. Parker and
between alexithymia and various somatic diseases or psychi-
Taylor (4) have concluded that “alexithymia is associated, at
atric disorders. However, the etiology of the phenomenon is
the very least, with a variation in brain organization.”
still unclear. One theory involves a neurobiological model. In
Many people with traumatic brain injury (TBI) have defi-
their pioneering work, Hoppe and Bogen (3) showed the main
cits in the cognitive processing and regulation of emotions.
features of alexithymia among patients who had undergone
They may present with flattened affect, have difficulties in
cerebral commissurotomies. Since then, several studies have
expressing themselves verbally, become disorganized under
elucidated the association of alexithymia with dysfunction of
stress, and have sudden outbursts without being able to elab-
the brain.
orate the cause. On the basis of neurobiological studies, the
As a neurobiological model of alexithymia, a deficit in
cingulate gyrus and the corpus callosum, the latter being
interhemispheric communication and a dysfunction of the
related to the interhemispheric communication deficit hypoth-
right cerebral hemisphere have been proposed (4). In addition,
esis, are structures associated with alexithymia (3– 8). On the
other hand, they are also regions that can often be damaged in
From the Department of Psychiatry (S.K., T.T.), Department of Radiology
TBI (9,10). Thus, considering the clinical observations
(T.K.), Department of Neurology (R.P., H.I., L.H., O.T.), Turku University
Hospital, Turku, Finland; and Department of Biostatistics (S.H.), Turku
and research findings, it can be hypothesized that traumatic
University, Turku, Finland; Department of Psychiatry, Kuopio University
changes in the brain could produce alexithymia.
Hospital, and University of Kuopio, Kuopio, Finland (K.H., H.V.); School of
To our knowledge, there are only few reports of alexithy-
Public Health, University of Tampere, and Department of Psychiatry, Tam-
pere University Hospital, Tampere, Finland (M.J.).
mia after TBI. One study dealt with the prevalence of alexi-
Address correspondence and reprint requests to Salla Koponen, Department
thymia in 135 family-practice patients and its association with
of Psychiatry, Turku University Hospital, PL 52, FI-20521 Turku, Finland.
a self-reported history of head injury (11). Alexithymia was
E-mail salla.koponen@utu.fi
This study was supported by grants from the Jalmari and Rauha Ahokas
significantly more common in those with a history of TBI
Foundation.
(knocked unconscious) (41%), compared with those with mild
Received for publication February 25, 2005; revision received May 15,
head injury (knocked dizzy/dazed) (9%) or those without
2005.
DOI: 10.1097/01.psy.0000181278.92249.e5
TBI/head injury (10%). A single case study on “organic alexi-
Psychosomatic Medicine 67:807– 812 (2005)
807
0033-3174/05/6705-0807
Copyright © 2005 by the American Psychosomatic Society

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S. KOPONEN et al.
thymia” after TBI has also been published (12). In addition,
ical illness before TBI, (2) clinical symptoms of a nontraumatic neurological
alexithymia has been studied in 48 patients with stroke: 48%
illness that developed after TBI (excluding dementia), (3) insufficient coop-
of subjects with right-hemisphere stroke were alexithymic,
eration, or (4) unavailability of medical records.
Of the 134 patients, 13 did not meet the inclusion criteria according to
compared with 22% of subjects with left-hemisphere stroke
medical records, 1 patient was excluded because of neurological illness before
(13). The more specific location of the lesion had no associ-
TBI, and 2 patients did not have available medical records. The remaining 118
ation with alexithymia.
patients were contacted by mail, and 88 of them replied. Eighty-three of them
We have earlier reported the high occurrence of psychiatric
met the inclusion criteria, but 7 were excluded because of a nontraumatic
disorders in 60 patients with TBI (14). In the present study,
neurological illness, and 16 refused to participate in the study. Of the remain-
ing 60 subjects, 3 were excluded from the present study because of clinical
our hypothesis was that, on the basis of the above mentioned
dementia and 3 because of a missing questionnaire and/or MRI examination,
clinical and research findings, alexithymia is more common in
leaving 54 subjects for the study group. Written informed consent was
patients with TBI than in a control group from the general
obtained after the procedure had been fully explained. The protocol was
population. As several studies have found an association be-
approved by the Ethics Committee of Turku University Hospital.
tween alexithymia and male gender (15–18), older age
For a control group, 54 subjects were drawn from a general population
sample from the District of Kuopio, eastern Finland (17). Table 1 presents the
(15, 16, 19), and depression (17, 20), our study groups were
characteristics of the 54 patients with TBI and their controls. They were
matched for gender, age, and severity of depression. We also
matched for age, gender, and severity of depression. As the age of the patients
assumed that severity of TBI, MRI findings, and current axis
was up to 80 years and the age of the controls only up to 64 years, matching
I and II psychiatric disorders may modify the prevalence of
was done by aiming at equal median ages in the 2 groups. Matching for
alexithymia after TBI.
depression was carried out by using the 13-item Beck Depression Inventory
(BDI-13) (21). The following categories were used: BDI-13 score 0 to 4 no or
minimal depression, score 5 to 7 mild depression, score 8 to 15 moderate
METHODS
depression, and score ?16 severe depression (21).
The subjects were recruited from a group of 210 patients who had suffered
The 20-item Toronto Alexithymia Scale (TAS-20) was applied as it is the
a TBI between 1950 and 1971 and who had then been referred for neurolog-
most widely used and presumably the most carefully validated method for
ical and neuropsychological evaluation to Turku University Hospital (Turku,
measuring alexithymia. Its internal consistency, test-retest reliability, and its
western Finland) between 1966 and 1972. The reason for the referral was
convergent, discriminant, and concurrent validity have been demonstrated to
either a recent traumatic brain injury (TBI) or significant disability after an
be good (22–25). The psychometric properties of the Finnish version of the
earlier TBI.
TAS-20 have been shown to be satisfactory (26). The items are rated on a
Of the original group of 210 patients, 76 had died. The inclusion criteria
5-point scale ranging from “strongly disagree” to “strongly agree.” The
for the remaining 134 patients were (1) a head trauma severe enough to cause
TAS-20 consists of 3 subscales or factors, which reflect the 3 main facets of
TBI and causing neurological symptoms (including headache and nausea)
the alexithymia concept: TAS factor 1 assesses difficulty in identifying
lasting at least 1 week, and (2) at least 1 of the following: loss of conscious-
feelings (eg, “I have feelings that I can’t quite identify”), TAS factor 2
ness for at least 1 minute, posttraumatic amnesia for at least 30 minutes,
concerns itself with difficulty in describing feelings (eg, “It is difficult for me
neurological symptoms (excluding headache and nausea) during the first 3
to find the right words for my feelings”), and TAS factor 3 reflects concrete
days after injury, or neuroradiologic findings suggesting TBI (eg, skull
externally oriented thinking or a preoccupation with the details of external
fracture, intracerebral hemorrhage). The exclusion criteria were (1) neurolog-
events (eg, “I prefer talking to people about their daily activities rather than
TABLE 1.
Characteristics of 54 Patients with Traumatic Brain Injury (TBI) and 54 Controls
Variable
Patients with TBI
Controls
Male gender, N (%)
36
(66.6)
36
(66.6)
Age, median (range)
58.8 (44 To 80)
59.0 (44 To 64)
Education in years, median (range)
9.0 (6 To 15)
9.0 (5 To 20)
BDI-13 score, median (range)a
3.5 (0 To 26)
4.0 (0 To 19)
BDI-13 score, categories, N (%)a
No or minimal depression (0 To 4)
27
(51.9)
29
(53.7)
Mild depression (5 To 7)
8
(15.4)
8
(14.8)
Moderate depression (8 To 15)
14
(26.9)
14
(25.9)
Severe depression (?16)
3
(5.8)
3
(5.6)
Time from TBI in years, median (range)
29.7 (26 To 47)
Severity of TBI, N (%)b
Mild
15
(27.8)
Moderate
13
(24.1)
Severe
8
(14.8)
Very severe
18
(33.3)
Cause of injury, N (%)
Motor vehicle accident
34
(63.0)
Fall
10
(18.5)
Falling object
4
(7.4)
Other
6
(11.1)
a BDI-13 ? 13-item Beck Depression Inventory. Data are missing for 2 patients with TBI.
b The severity of TBI was classified on the basis of the duration of posttraumatic amnesia: ?1 hour, mild; 1 to 24 hours, moderate; 1 to 7 days, severe, and ?7
days, very severe.
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ALEXITHYMIA AFTER TRAUMATIC BRAIN INJURY
their feelings”). According to the recommendation of the developers of
tests or, if necessary, Fisher’s exact tests were applied. Odds ratios (ORs) and
the scale, a TAS-20 total score of ?60 was used as the cutoff point for
95% confidence intervals (95% CIs) are presented where feasible. A 2-sided p
alexithymia (27).
value of less than 0.05 was considered statistically significant. Statistical analyses
In patients with TBI, DSM-IV diagnoses of current axis I psychiatric
were conducted with SAS System for Windows (Release 8.00).
disorders were made using the Schedules for Clinical Assessment in Neuro-
psychiatry (SCAN, version 2.1) (28). Personality disorders were evaluated
RESULTS
with the Structured Clinical Interview for DSM-III-R Personality Disorders
(SCID-II) (29). Organic personality syndrome was assessed according to
Table 2 presents the prevalence of alexithymia and the
DSM-III-R criteria and was divided into the following subtypes: labile,
TAS-20 scores among the patients and the controls. Alexithymia
aggressive, disinhibited, apathetic, and paranoid.
was significantly more common in patients with TBI (31.5%
MRI scans were acquired with a 1.5-T Siemens Magnetom system using
versus 14.8%; OR 2.64, 95% CI 1.03– 6.80). In the TAS-20 total
a standard head coil. The following sequences were used for analysis: (1)
T2-weighted axial turbo spin echo (TSE) 3500/93 ms (repetition time/echo
scores, a significant difference was found between the groups,
time) with 1 acquisition, slice thickness 5.0 mm, data acquisition matrix
and this difference was particularly clear among male subjects.
192 ? 256 and field of view (FOV) 23.0 cm; (2) T1-weighted sagittal
The scores of both “difficulty in identifying feelings” and “dif-
3-dimensional magnetization prepared rapid gradient echo; TR 10, TE 4, flip
ficulty in describing feelings” were significantly higher in the
angle 10°, matrix 192 ? 256, contiguous 1.5-mm slices, 1 acquisition; and (3)
patient group. For “externally oriented thinking,” a significant
T2/PD-weighted coronal TSE 3500/93/19 with 1 acquisition, slice thickness 4.0
mm, data acquisition matrix 192 ? 256, and FOV 23.0 cm. In selected cases,
difference was found only in men.
additional sequences such as gradient echo T2*-weighted sequences were ob-
None of the variables representing TBI was associated with
tained. The images were evaluated blindly by an experienced neuroradiologist.
the TAS-20 total scores. Among the 4 categories of TBI
For statistical analyses, all patients with contusions of a specific brain
severity, the differences in the TAS-20 total scores were
region in the right, left, or both hemispheres were combined into 1 group, as
nonsignificant (ANOVA: in mild TBI 52.5 ? 14.2, in mod-
the number of patients with contusions on MRI was limited (N ? 14), and
contusions were bilateral in the majority of them. The frontal lobe was divided
erate 57.6 ? 11.4, in severe 48.4 ? 10.3, in very severe
into orbital, mesial, and lateral regions. The orbital region included the orbital
53.3 ? 14.2; p ? .46). MRI detected contusions in only 14 out
gyri and the gyrus rectus. The mesial region consisted of the superior and
of 54 patients (25.9%). These were bilateral in 8 subjects,
medial frontal gyri, the anterior cingulate gyrus, and the anterior paracentral
exclusively right hemisphere in 3, and exclusively left hemi-
gyrus. The lateral region included the inferior, middle, and precentral gyri and
sphere in 3. Between the patients with contusions and patients
the opercular and triangular cortex.
Lesions were characterized as diffuse axonal injury (DAI) on the basis of
without contusions, no differences were observed in the
their location and characteristics. In general, hemorrhagic lesions or lesions at
TAS-20 total scores (t test: 54.4 ? 14.4 and 53.0 ? 12.7; p ?
the gray-white matter junction, in the corpus callosum, and in the dorsolateral
.73). Moreover, the differences did not even approach statis-
upper brain stem were characterized as DAI. Well-defined areas of ?2 mm
tical significance for the presence of contusions of the right
with signal characteristics similar to cerebrospinal fluid in white matter or
hemisphere (N ? 11), the left hemisphere (N ? 11), the
deep gray matter were considered lacunar infarcts.
To test for differences in continuous variables, t tests or, if more than 2
frontal lobe (N ? 12), the orbital frontal region (N ? 12), the
categories, ANOVA was used. To test for differences in categorical variables, ?2
mesial frontal region (N ? 8), the lateral frontal region (N ?
TABLE 2.
Alexithymia and TAS-20 Scores in 54 Patients with Traumatic Brain Injury (TBI) and 54 Controls
Variable
Patients
Controls
p Value
OR (95% CI)
Alexithymiaa
All subjects
17 (31.5%)
8 (14.8%)
.040
2.64 (1.03 To 6.80)
Men
13 (36.1%)
6 (16.7%)
.061
2.83 (0.93 To 8.57)
Women
4 (22.2%)
2 (11.1%)
.66
2.29 (0.36 To 14.43)
TAS-20 total score, mean ? SDb
All subjects
53.4 ? 13.0
47.8 ? 12.5
.025
Men
56.4 ? 12.6
48.2 ? 12.9
.0085
Women
47.4 ? 12.2
46.9 ? 11.9
.89
TAS-20 DIF score, mean ? SDb
All subjects
18.0 ? 6.9
15.6 ? 5.5
.049
Men
19.3 ? 7.1
16.2 ? 6.0
.051
Women
15.6 ? 6.1
14.6 ? 4.3
.55
TAS-20 DDF score, mean ? SDb
All subjects
13.7 ? 4.2
12.0 ? 4.2
.043
Men
14.1 ? 4.2
12.1 ? 4.3
.047
Women
12.8 ? 4.4
11.9 ? 4.0
.51
TAS-20 EOT score, mean ? SDb
All subjects
21.6 ? 5.4
20.1 ? 5.5
.15
Men
23.0 ? 4.2
19.9 ? 5.6
.012
Women
19.0 ? 6.5
20.4 ? 5.4
.47
a TAS-20 total score ?60 indicates alexithymia. ?2 Tests and Fisher’s exact tests were used to assess differences between groups.
b DIF ? difficulty in identifying feelings (TAS factor 1), DDF ? difficulty in describing feelings (TAS factor 2), EOT ? externally oriented thinking (TAS factor
3). t Tests were used to assess differences between groups.
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S. KOPONEN et al.
10), the temporal lobe (N ? 10), the parietal lobe (N ? 2), and
becomes even more obvious considering that alexithymia was
the cingulate gyrus (N ? 4). No occipital contusions were
somewhat more common in our controls (14.8%) than in the
found. Nor was DAI on MRI (N ? 6; 5 out of 6 also had
original population sample from which they were drawn
contusions) connected to the TAS-20 total scores. MRI also
(10.3%) (17). This is explained by the matching procedure, as
revealed silent infarcts (N ? 8), which had no association with
the BDI-13 scores and the age of our patients with TBI were
the TAS-20 total scores.
higher than in the original population sample. The rates of
Table 3 presents current psychiatric disorders and their
psychiatric disorders among our patients and controls could
relation to the TAS-20 total scores in patients with TBI.
not be compared as diagnostic interviews were not carried out
Statistically significant associations were observed on both
with the controls. In Finnish community studies, the rate of
axis I and axis II. First, having any axis I disorder or anxiety
alexithymia has varied from 10% to 13% (16,17), being mark-
disorder was associated with significantly higher TAS-20 total
edly lower than the rate of our patients. However, a percentage
scores. Second, patients with any axis II disorder, person-
as high as 34% has been found for 72-year-old Finns (30). A
ality disorder (particularly cluster C disorder), or organic
gender difference in the prevalence of alexithymia that has
personality syndrome (particularly the labile and disinhibited
been observed in population studies (9% to 17% in men versus
subtypes) had significantly higher TAS-20 total scores. Alexi-
5% to 10% in women) (16 –18) was also found among our
thymia was strongly associated with organic personality syn-
patients. However, the relatively small number of women in
drome, as 7 out of 9 patients with this diagnosis (77.8%) were
our study group should be taken into account when drawing
alexithymic. On the other hand, as many as 15 out of 17
conclusions.
patients with alexithymia (88.2%) had psychiatric disorders.
Despite the high rate of alexithymia in our patients, none
No significant differences were found between men and
of the variables representing TBI was associated with the
women in terms of having any axis I disorder (men 12/36,
TAS-20 total scores. No trend was found between severity of
33.3% versus women 6/18, 33.3%; ?2 ? 0.00, p ? 1.00), or
TBI and alexithymic features. In an earlier study with family-
any axis II disorder (men 12/36, 33.3% versus women 5/18,
practice patients, alexithymia was more common in subjects
27.8%; ?2 ? 0.17, p ? .68).
with a self-reported history of a more severe head injury
(knocked unconscious versus knocked only dizzy/dazed) (11).
DISCUSSION
Considering the MRI findings, our statistical analyses were
The patients with TBI were significantly more commonly
complicated by the small number of subjects with contusions
alexithymic than the control subjects, who had been matched
or DAI detectable with postacute MRI. Nonspecific brain
for age, gender, and severity of depression. This difference
atrophy, a potential late sign of DAI, was present in some
TABLE 3.
TAS-20 Total Scores and Psychiatric Disorders in 54 Patients With Traumatic Brain Injury (TBI)
TAS-20 Score, Mean ? SD
Current Psychiatric Disorder
Having the Disorder
p Valuea
Yes
No
Any axis I disorder N ? 18
61.6 ? 10.5
49.3 ? 12.3
.0007
Psychotic disorder, N ? 3b
63.0 ? 12.8
52.8 ? 12.9
Bipolar II disorder, N ? 1
27.0c
53.9 ? 12.6
Major depression, N ? 3
69.0 ? 13.1
52.5 ? 12.6
Anxiety disorder, N ? 10d
62.1 ? 8.0
51.4 ? 13.2
.018
Alcohol abuse or dependence, N ? 4
53.0 ? 8.7
53.4 ? 13.4
Any axis II disorder, N ? 17e
61.4 ? 9.2
49.7 ? 13.0
.0016
Personality disorder, N ? 13
60.3 ? 9.4
51.2 ? 13.3
.027
Cluster A disorder, N ? 7
61.9 ? 11.7
52.1 ? 12.9
.065
Cluster B disorder, N ? 2
53.0 ? 7.1
53.4 ? 13.2
Cluster C disorder, N ? 8
62.0 ? 6.8
51.9 ? 13.3
.042
Organic personality syndrome, N ? 9
65.4 ? 8.1
51.0 ? 12.5
.0017
Labile subtype, N ? 5
66.2 ? 8.2
52.1 ? 12.8
.020
Disinhibited subtype, N ? 6
66.7 ? 7.6
51.7 ? 12.6
.0069
Apathetic subtype, N ? 1
61.0c
53.2 ? 13.1
Paranoid subtype, N ? 2
64.0 ? 14.1
53.0 ? 13.0
a t Tests were used to assess differences between groups. For psychiatric diagnosis groups with ?5 subjects, only data are presented.
b Schizoaffective disorder N ? 1, delusional disorder N ? 1, psychotic disorder not otherwise specified N ? 1.
c SD not available.
d Panic disorder N ? 4, specific phobia N ? 5, social phobia N ? 3, generalized anxiety disorder N ? 1 (1 patient had panic disorder ? specific phobia ? social
phobia, and 1 patient had specific phobia ? social phobia).
e Any axis II disorder ? personality disorder (detected with SCID-II) or organic personality syndrome.
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ALEXITHYMIA AFTER TRAUMATIC BRAIN INJURY
subjects, but since its etiology could not be ascertained, the
alexithymic features are mainly related to current psychiatric
radiological diagnosis of DAI was not made. Because our
disorders, whereas in others they may be more traitlike and
follow-up period was long, our material undoubtedly included
independent of psychiatric disorders.
people whose traumatic lesions were no longer visible, as the
In the literature, the relationships between the constructs of
number of lesions detectable with MRI diminishes with time
alexithymia and depression, and the scales measuring them,
(31). In a stroke study, alexithymia was associated with
have been discussed. As was mentioned above, there are
right-sided lesions but not with the more specific location of
reports of the state-dependent nature of alexithymia in the
the lesion (13). The different quality of stroke and TBI should
presence of depression (20,38). It is possible that depressive
be kept in mind. In stroke, the laterality of the lesion is
symptomatology could endorse alexithymia items (15). In
apparent and the damaged region is more clearly demarcated,
some situations, alexithymia may also be a state phenomenon
whereas TBI usually affects both hemispheres and is generally
secondary to the emotional distress evoked by an illness (42).
more diffuse.
Despite the connection between alexithymia and depression,
The role of the anterior cingulate cortex has been consid-
these constructs have been found to be mainly distinct (43,44).
ered important in alexithymia (5– 8). Furthermore, 2 func-
However, in a subgroup of subjects with depression, an over-
tional subdivisions of the anterior cingulate cortex have been
lap has occurred between the constructs when the TAS-20 and
identified. Its rostral-ventral affective division processes emo-
the 21-item Beck Depression Inventory have been used as
tional information and regulates emotional responses, whereas
measures (44). A corresponding overlap has also been found
its dorsal cognitive division mediates, eg, response inhibition
in subjects with anxiety disorders (43). The psychometric
and error processing (32). In our study, the contusions of the
properties of TAS may possibly need to be further devel-
cingulate gyrus did not have an association with the TAS-20
oped to improve the differentiation of alexithymia and other
total scores, but the number of these patients was small.
constructs.
Moreover, DAI may well disrupt the connections of the cin-
This is one of the few studies on the association between
gulate gyrus without causing macroscopical lesions of the
alexithymia and TBI. Its strengths include the use of a control
region itself (9).
group matched for age, gender, and severity of depression.
The association between psychiatric disorders and alexi-
Both axis I and II psychiatric disorders were assessed with
thymic features was obvious in our patients with TBI. In fact,
standardized interviews in patients with TBI. MRI examina-
nearly all our alexithymic patients had some kind of psychi-
tions were carried out, but the relatively small number of
atric morbidity. As the rates of psychiatric disorders did not
patients with lesions detectable with postacute MRI set limi-
differ significantly between men and women, the gender dif-
tations to the analyses. A more sensitive neuroimaging method
ference in the prevalence of alexithymia does not seem to be
may have been needed. Because the original group of 210
explained by psychiatric disorders. Thus, it could be hypoth-
subjects was referred for examination on a clinical basis, our
esized that besides being more prone to alexithymia in
conclusions may not be generalizable to all patients with TBI.
general, men may have a smaller cerebral reserve capacity for
In conclusion, alexithymia was significantly more common
emotion processing and therefore an increased susceptibility
after TBI than among the general population. Alexithymic
to alexithymia in the case of brain injury. Of axis I psychiatric
features were not associated with MRI findings but with
disorders, significantly higher TAS-20 total scores were found
psychiatric disorders. It seems that both alexithymia and psy-
in patients with any axis I disorder or anxiety disorder (the
chiatric disorders may reflect dysfunction of the injured brain.
number of subjects in other diagnosis groups was low). This
In clinical practice, the identification of alexithymic features is
finding is in line with earlier studies, where, eg, depression
important as they may complicate rehabilitation after TBI.
and anxiety disorders have been associated with alexithymia
Alexithymic patients cannot differentiate and express their
(17,20,33–35). On axis II, especially patients with cluster C
feelings appropriately, nor can they interpret the emotional
personality disorders, which were all avoidant personality
communication of others correctly. This may lead to interper-
disorders, or with the labile and disinhibited subtypes of
sonal difficulties and isolation. To facilitate the adaptation of
organic personality syndrome had significantly more alexithy-
these patients, alexithymic features should be addressed in
mic features. In an earlier study, alexithymia was connected to
psychosocial rehabilitation after TBI by emphasizing elements
schizotypal, dependent, and avoidant personality traits (36). In
increasing emotional awareness and teaching appropriate
addition, alexithymic features have been found to diminish
interpersonal communication. In addition, educating family
less during recovery from depression in subjects with comor-
members and health professionals about alexithymic features
bid cluster C disorders, compared with subjects with depres-
may also improve the social functioning of patients with TBI.
sion only (37). Our finding concerning the strong association
between organic personality syndrome and alexithymia is
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