Myocardial infarction-induced acute stress and post-traumatic stress symptoms: the moderating role of an alexithymia trait – difficulties identifying feelings

ABSTRACT Background It has been acknowledged that medical life-threatening experiences such as an acute myocardial infarction (MI) often lead to acute stress disorder symptoms (ASS), which in turn can result in the development of post-traumatic stress symptoms (PTSS). Previous studies have suggested an association between various traumatic experiences and alexithymia. The association of alexithymia with ASS and PTSS in patients with MI is elusive. Objectives The aim of this study was to examine the association of alexithymia with MI-induced ASS and PTSS in patients at high risk of developing PTSD. Method Patients (N = 154) were examined twice, once within 48 hours, and then again three months after acute MI. All patients completed the self-rating Acute Stress Disorder Scale (ASDS) within 48 hours after the cardiac event. Three months after hospital discharge, all patients completed the Toronto Alexithymia Scale (TAS-20) and underwent the Clinician-Administered PTSD Scale (CAPS), a structured interview to assess the severity of PTSS. Descriptive statistics, correlations, multivariate linear regressions, and moderation analysis were conducted. Results The linear regression model explained 23% of the variance in MI-induced PTSS-symptoms (F(6.109) = 5.58, p < 0.001, R 2 = 0.23. ASS was significantly related to PTSS severity (r (152) = p < 0.001). The scores of the TAS-20 subscale difficulties identifying feelings (DIF) were found to significantly moderate this relationship (R2 = 0.03, p = 0.04). The scores of TAS-20 subscales DDF and EOT as well as the TAS-20 total score had no influence on the relationship between ASS and PTSS (p > 0.05). Conclusion In MI patients with high levels of DIF, ASS predicted the development of PTSS. If replicated, the finding may inform emotion-oriented interventions to investigate whether increasing the capacity to identify feelings following acute MI could be beneficial in preventing the development of PTSS.

[1]  Peggilee Wupperman,et al.  Distinguishing alexithymia and emotion differentiation conceptualizations through linguistic analysis , 2020 .

[2]  Jeffrey L. Birk,et al.  Trajectories of posttraumatic stress in patients with confirmed and rule-out acute coronary syndrome. , 2019, General hospital psychiatry.

[3]  J. Tremmel,et al.  Patient-Reported Psychological Distress After Spontaneous Coronary Artery Dissection , 2019, Journal of cardiopulmonary rehabilitation and prevention.

[4]  K. Goerlich,et al.  Editorial: Alexithymia: State of the Art and Controversies. Clinical and Neuroscientific Evidence , 2019, Front. Psychol..

[5]  D. Pratt,et al.  Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature , 2019, Front. Psychiatry.

[6]  Mark C. Coulson,et al.  Effects of mindfulness-based interventions on alexithymia: a systematic review , 2018, Evidence-Based Mental Health.

[7]  U. Schnyder,et al.  Early Psychological Counseling for the Prevention of Posttraumatic Stress Induced by Acute Coronary Syndrome: The MI-SPRINT Randomized Controlled Trial , 2018, Psychotherapy and Psychosomatics.

[8]  D. Edmondson,et al.  Posttraumatic Stress Disorder and Cardiovascular Disease , 2017, The lancet. Psychiatry.

[9]  Andrew F. Hayes,et al.  A Tutorial on Testing, Visualizing, and Probing an Interaction Involving a Multicategorical Variable in Linear Regression Analysis , 2017 .

[10]  T. Dalgleish,et al.  Acute stress disorder and the transition to posttraumatic stress disorder in children and adolescents: Prevalence, course, prognosis, diagnostic suitability, and risk markers , 2016, Depression and anxiety.

[11]  J. Zhao,et al.  Post-traumatic stress disorder symptoms in first-time myocardial infarction patients: roles of attachment and alexithymia. , 2015, Journal of advanced nursing.

[12]  R. Jorge,et al.  Posttraumatic Stress Disorder , 2015, Continuum.

[13]  M. Karukivi,et al.  Development of alexithymic personality features. , 2014, World journal of psychiatry.

[14]  E. Brähler,et al.  Traumatic experiences, alexithymia, and posttraumatic symptomatology: a cross-sectional population-based study in Germany , 2014, European journal of psychotraumatology.

[15]  A. Gori,et al.  Intimate partner violence: relationships between alexithymia, depression, attachment styles, and coping strategies of battered women. , 2014, The journal of sexual medicine.

[16]  P. Cuijpers,et al.  Four decades of research on alexithymia: moving toward clinical applications , 2013, Front. Psychol..

[17]  U. Schnyder,et al.  Myocardial Infarction - Stress PRevention INTervention (MI-SPRINT) to reduce the incidence of posttraumatic stress after acute myocardial infarction through trauma-focused psychological counseling: study protocol for a randomized controlled trial , 2013, Trials.

[18]  V. Howard,et al.  Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review , 2013, PloS one.

[19]  Janet B W Williams,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[20]  C. Brewin,et al.  Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis , 2013, European journal of psychotraumatology.

[21]  A. Hayes.  Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach , 2013 .

[22]  B. Cohen,et al.  Posttraumatic stress disorder and cardiovascular disease. , 2013, Progress in cardiovascular diseases.

[23]  P. Bennett,et al.  Predicting post-traumatic stress disorder following first onset acute coronary syndrome: Testing a theoretical model. , 2013, The British journal of clinical psychology.

[24]  B. Cohen,et al.  Post-traumatic stress disorder and medication adherence: results from the Mind Your Heart study. , 2012, Journal of psychiatric research.

[25]  R. Bagby,et al.  The Alexithymia Personality Dimension , 2012 .

[26]  T. Widiger.  The Oxford handbook of personality disorders , 2012 .

[27]  Cuneyt Evren,et al.  Relationship between defense styles, alexithymia, and personality in alcohol-dependent inpatients. , 2012, Comprehensive psychiatry.

[28]  M. A. Mills,et al.  Posttraumatic Stress Disorder Prevalence and Risk of Recurrence in Acute Coronary Syndrome Patients: A Meta-analytic Review , 2012, PloS one.

[29]  R. Lanius,et al.  Disturbances of Emotional Awareness and Expression in Posttraumatic Stress Disorder: Meta-Mood, Emotion Regulation, Mindfulness, and Interference of Emotional Expressiveness , 2012 .

[30]  I. Dennis,et al.  Posttraumatic Stress Disorder following Myocardial Infarction: Personality, Coping, and Trauma Exposure Characteristics , 2011, International journal of psychiatry in medicine.

[31]  E. Walker,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[32]  U. Schnyder,et al.  Non-fatal cardiovascular outcome in patients with posttraumatic stress symptoms caused by myocardial infarction. , 2011, Journal of cardiology.

[33]  M. Hyland,et al.  Posttraumatic stress disorder and psychiatric co-morbidity following stroke: The role of alexithymia , 2011, Psychiatry Research.

[34]  R. Bryant.  Acute stress disorder as a predictor of posttraumatic stress disorder: a systematic review. , 2011, The Journal of clinical psychiatry.

[35]  S. Paradiso,et al.  Alexithymia and Aging: A Neuropsychological Perspective , 2010, The Journal of nervous and mental disease.

[36]  S. Vanheule,et al.  Alexithymia and posttraumatic stress: subscales and symptom clusters. , 2010, Journal of clinical psychology.

[37]  H. Saner,et al.  Change over time in posttraumatic stress caused by myocardial infarction and predicting variables. , 2010, Journal of psychosomatic research.

[38]  G. Dupuis,et al.  Post-traumatic stress disorder following myocardial infarction: prevalence and risk factors. , 2010, The Canadian journal of cardiology.

[39]  C. Evren,et al.  Relationship of alexithymia and temperament and character dimensions with lifetime post‐traumatic stress disorder in male alcohol‐dependent inpatients , 2010, Psychiatry and clinical neurosciences.

[40]  U. Schnyder,et al.  Psychometric evaluation and validation of the German version of the Acute Stress Disorder Scale across two distinct trauma populations. , 2009, Journal of traumatic stress.

[41]  D. Leising,et al.  The Toronto Alexithymia Scale (TAS-20): A measure of general psychological distress , 2009 .

[42]  Terry L. Schell,et al.  Anxiety sensitivity and aspects of alexithymia are independently and uniquely associated with posttraumatic distress. , 2009, Journal of traumatic stress.

[43]  U. Schnyder,et al.  Clinical Diagnosis of Posttraumatic Stress Disorder After Myocardial Infarction , 2009, Clinical cardiology.

[44]  A. Steptoe,et al.  Persistence of Posttraumatic Stress Symptoms 12 and 36 Months After Acute Coronary Syndrome , 2008, Psychosomatic medicine.

[45]  D. Silove,et al.  A multisite study of the capacity of acute stress disorder diagnosis to predict posttraumatic stress disorder. , 2008, The Journal of clinical psychiatry.

[46]  R. Lanius,et al.  Meta-analysis of alexithymia in posttraumatic stress disorder. , 2008, Journal of traumatic stress.

[47]  Raluca M. Gaher,et al.  Difficulty Identifying Feelings Predicts the Persistence of Trauma Symptoms in a Sample of Veterans Who Experienced Military Sexual Trauma , 2008, The Journal of nervous and mental disease.

[48]  K. Eagle,et al.  Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE) , 2006, BMJ : British Medical Journal.

[49]  U. Schnyder,et al.  Prevalence of exposure to potentially traumatic events and PTSD , 2006, European Archives of Psychiatry and Clinical Neuroscience.

[50]  A. Steptoe,et al.  Frequency of distress and fear of dying during acute coronary syndromes and consequences for adaptation. , 2005, The American journal of cardiology.

[51]  S. Pedersen,et al.  Posttraumatic Stress Disorder in the Wake of Heart Disease: Prevalence, Risk Factors, and Future Research Directions , 2005, Psychosomatic medicine.

[52]  R. V. van Domburg,et al.  The effect of low social support on short-term prognosis in patients following a first myocardial infarction. , 2004, Scandinavian journal of psychology.

[53]  T. Theorell,et al.  Alexithymia, emotions and PTSD; findings from a longitudinal study of refugees , 2004, Nordic journal of psychiatry.

[54]  Avi Bleich,et al.  Trajectories of posttraumatic stress disorder following myocardial infarction: a prospective study. , 2003, The Journal of clinical psychiatry.

[55]  R. Bagby,et al.  The 20-Item Toronto Alexithymia Scale: IV. Reliability and factorial validity in different languages and cultures , 2003 .

[56]  B. Bermond,et al.  Cognitive and emotional characteristics of alexithymia: a review of neurobiological studies. , 2003, Journal of psychosomatic research.

[57]  N. Tarrier,et al.  Posttraumatic stress disorder following medical illness and treatment. , 2003, Clinical psychology review.

[58]  C. Brewin,et al.  Diagnostic overlap between acute stress disorder and PTSD in victims of violent crime. , 2003, The American journal of psychiatry.

[59]  U. Schnyder,et al.  German Version of Clinician-Administered PTSD Scale , 2002, Journal of traumatic stress.

[60]  M. Zimmerman,et al.  Screening for trauma histories, posttraumatic stress disorder (PTSD), and subthreshold PTSD in psychiatric outpatients. , 2002, Psychological assessment.

[61]  R. Schäfer,et al.  Validitätshinweise der Deutschen Version der TAS-20 , 2002 .

[62]  M. Franz,et al.  [Evidence of validity of the German version of the TAS-20. Contribution to the 52nd conference of the German Board of Psychosomatic Medicine in Bad Honnef (2001)]. , 2002, Psychotherapie, Psychosomatik, medizinische Psychologie.

[63]  Marylene Cloitre,et al.  Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. , 2002, Journal of consulting and clinical psychology.

[64]  Z. Solomon,et al.  Repressive Coping Style, Acute Stress Disorder, and Posttraumatic Stress Disorder After Myocardial Infarction , 2002, Psychosomatic medicine.

[65]  M. Gurevich,et al.  Stress response syndromes and cancer: conceptual and assessment issues. , 2002, Psychosomatics.

[66]  N. Frasure-smith,et al.  Alexithymia following myocardial infarction: psychometric properties and correlates of the Toronto Alexithymia Scale. , 2001, Journal of psychosomatic research.

[67]  C. Bell.  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: DSM-IV-TR Quick Reference to the Diagnostic Criteria from DSM-IV-TR , 2001 .

[68]  A. Alonzo.  The experience of chronic illness and post-traumatic stress disorder: the consequences of cumulative adversity. , 2000, Social science & medicine.

[69]  P. Bennett,et al.  Intrusive memories, post-traumatic stress disorder and myocardial infarction. , 1999, The British journal of clinical psychology.

[70]  J. Parker,et al.  Alexithymia in essential hypertensive and psychiatric outpatients: a comparative study. , 1995, Journal of psychosomatic research.

[71]  A. Taylor,et al.  Effects of varying scoring rules of the Clinician-Administered PTSD Scale (CAPS) for the diagnosis of post-traumatic stress disorder in motor vehicle accident victims. , 1995, Behaviour research and therapy.

[72]  R. Bagby,et al.  Criterion validity of the Toronto Alexithymia Scale. , 1988, Psychosomatic medicine.

[73]  A. Beck,et al.  An inventory for measuring depression. , 1961, Archives of general psychiatry.

[74]  Robert A. Cribbie,et al.  The role of alexithymia in trauma therapy outcomes: Examining improvements in PTSD, dissociation, and interpersonal problems. , 2019, Psychological trauma : theory, research, practice and policy.

[75]  S. Yoo,et al.  The association between alexithymia and posttraumatic stress symptoms following multiple exposures to traumatic events in North Korean refugees. , 2015, Journal of psychosomatic research.

[76]  Raluca A. Topciu,et al.  Association of alexithymia and depression symptom severity in adults aged 50 years and older. , 2010, The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry.

[77]  G. Schelling.  Post-traumatic stress disorder in somatic disease: lessons from critically ill patients. , 2008, Progress in brain research.

[78]  D. L. Barbera,et al.  Alessitimia. Valutazione e trattamento. Roma: Astrolabio, 2005 (Andrea Castiello D'Antonio) , 2006 .

[79]  A. S. Badura.  Theoretical and empirical exploration of the similarities between emotional numbing in posttraumatic stress disorder and alexithymia. , 2003, Journal of anxiety disorders.

[80]  A. Harvey,et al.  Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment , 2000 .

[81]  Erkki Äärelä,et al.  Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland. , 1999, Journal of psychosomatic research.

[82]  M. de Zwaan,et al.  [Validation of the German version of the 20-item Toronto Alexithymia Scale in normal persons and psychiatric patients]. , 1996, Psychotherapie, Psychosomatik, medizinische Psychologie.

[83]  Z. Solomon,et al.  Post-traumatic stress disorder in myocardial infarction patients: prevalence study. , 1994, The Israel journal of psychiatry and related sciences.

[84]  R. Bagby,et al.  The twenty-item Toronto Alexithymia Scale--I. Item selection and cross-validation of the factor structure. , 1994, Journal of psychosomatic research.

[85]  H. Freyberger.  Supportive psychotherapeutic techniques in primary and secondary alexithymia. , 1977, Psychotherapy and psychosomatics.