Alexithymia, anxiety and depression in patients with psoriasis: a case–control study
Annals of General Psychiatry
Alexithymia, anxiety and depression in patients with psoriasis: a case-control study
Panagiota Korkoliakou 0
Christos Christodoulou 0
Anargyros Kouris 2
Evgenia Porichi 0
Vasiliki Efstathiou 0
Eythymia Kaloudi 0
Anna Kokkevi 1
Nikolaos Stavrianeas 2
Charalabos Papageorgiou 0 1
Athanasios Douzenis 0
0 Second Department of Psychiatry, University of Athens Medical School, Attikon University General Hospital , Athens 12462 , Greece
1 University Mental Health Research Institute (UMHRI) , Athens 15601 , Greece
2 Second Department of Dermatology, University of Athens Medical School, Attikon University General Hospital , Athens 12462 , Greece
Background: Alexithymia, the difficulty in describing or recognizing emotions, has been associated with various psychosomatic pathologies including psoriasis. The aim of this study was to examine the prevalence of alexithymia and its association with anxiety and depression in patients with psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables. Methods: One hundred and eight psoriatic patients and 100 healthy participants from the general population completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS). The severity of patients' psoriasis was clinically assessed using the Psoriasis Area and Severity Index (PASI). Results: Psoriatic patients had higher levels of alexithymia compared with healthy participants. While a rather high rate of psoriatic patients presented anxiety and depression as defined by the HADS, the differences that were found in comparison with the control group were not significant. Neither alexithymia nor its dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT), were associated with gender or psoriasis severity. Age was associated only with EOT, which was independent of depression and anxiety. Higher anxiety and depression were connected with higher alexithymia and DIF, while higher anxiety with higher DDF as well. Conclusions: The alexithymia prevalence was higher in psoriatic patients than that in healthy participants, while it was positively correlated with anxiety and depression. Difficulty in identifying feelings was connected with both anxiety and depression, whereas difficulty in describing them was only with anxiety. Finally, externally oriented thinking was predicted only from age.
Alexithymia; Anxiety; Depression; Psoriasis; TAS-20
The term alexithymia was coined by Sifneos  in order
to describe the deficiency in understanding, processing
and describing emotions . Alexithymia is considered a
personality trait that consists of reduced symbolic thought,
restricted fantasy life, externally oriented cognitive
thinking, difficulty in distinguishing feelings from bodily
sensations and inadequacy in intuition and empathy . The
authors of relevant studies have differentiated between
primary alexithymia, which is developed prematurely in
the first period of life due to fixations and structural
neurological deficits and secondary alexithymia which
arises after trauma or severe pathology.
In the literature, alexithymia is considered to act as a
triggering factor of general susceptibility to diseases,
among other variables . A view of alexithymia is that
it constitutes a risk factor for psychiatric and behavioural
problems and also for the development, maintenance or
exacerbation of medical or physical health problems .
The majority of studies regarding the relationship
between alexithymia, depression and anxiety conclude that
they are strongly related [4,5]. Alexithymia is not
unusual among patients with certain skin disorders .
Its presence has been incriminated in the genesis and in
the maintenance of psoriasis, which has been classified
among psychosomatic illnesses . Psoriasis is a chronic,
inflammatory, relapsing skin disease. Both genetic and
environmental factors are believed to play an important role
in the pathogenesis of the disorder . Psoriasis affects
2%3% of the population and has an equal distribution
between the genders, and its onset may occur at any age.
Incidents of psoriasis have been connected to pathological
states of stress and anxiety such as impatience, depression
and pathological worry . Despite the existence of the
psychosomatic hypothesis, only a few researchers have
studied the association between alexithymia and psoriasis
and most of them without using a control group or in case
they did; this consisted of a relatively small number of
participants [9,10]. In spite of the aforementioned limitation,
the majority of studies have found a significant difference
in the levels of alexithymia between patients with psoriasis
and healthy individuals [11-13]. Furthermore, most studies
concerning alexithymia in psoriatic patients have not
taken into account important factors, which are associated
with both psoriasis and alexithymia, such as depression or
anxiety, or they have evaluated them using psychometric
tools that contain somatic aspects which may also be
common in psoriasis . In Greece, studies have mainly
focused on the relationship between psoriasis and
Considering the paucity of relevant studies in the
scientific literature as well as the aforementioned limitations of
the earlier studies, the purposes of the present study are
(a) to examine the prevalence of alexithymia among
patients with psoriasis, in comparison with healthy
individuals from the general population, and (b) to assess the
relationship between depressive and anxiety symptoms
and alexithymia, as well as its three dimensions, difficulty
in indentifying feelings (DIF), difficulty in describing
feelings (DDF) and externally oriented thinking (EOT), by
taking into account demographic and clinical data of the
Sample and procedure
The list of scheduled appointments of the dermatologic
clinic was used in order to recruit 108 patients with
confirmed diagnosis of chronic plaque psoriasis, with a
minimum of 6 years of education and ability to comprehend
the Greek language. Patients were asked to participate
in the study between January 2009 and October 2010 in
Attikon University General Hospital. The Toronto
Alexithymia Scale (TAS-20) and the Hospital Anxiety
and Depression Scale (HADS) were administered to the
psoriatic patients, while demographic and clinical data
were collected as well. Main exclusion criteria were
comorbidity with a diagnosed physical or psychiatric
disorder and receiving medication that could have affected
their mental condition, including illegal substances and
As a control group, we used 100 healthy individuals
from the general population, matched for age and
gender with the patients, who were recruited during the
same time period. They were included provided that
they were not diagnosed with any physical or/and
psychiatric disorders, had a minimum of 6 years of
education and ability to comprehend the Greek language.
The TAS-20 and the HADS were also completed by the
control group, and demographic data were obtained as
The participation of both patients and healthy controls
was voluntary, without any financial compensation. The
research protocol was approved by the ethics committee
of the Attikon University General Hospital. All
participants provided written informed consent, and the study
was carried out in accordance with the declaration of
Alexithymia was assessed using the 20-item self-report
TAS-20. The scale includes 20 items rated on a 5-point
Likert scale, ranging from 1 (strongly disagree) to 5
(strongly agree). The total score of the scale ranges
from 0 to 100. It consists of three subscales, measuring
the difficulty in identifying feelings (DIF), the difficulty
in describing feelings (DDF) and the externally oriented
thinking (EOT), respectively. According to the accepted
standard, a total score above 61 indicates alexithymia, a
score between 52 and 60 suggests intermediate/borderline
alexithymia and a score lower than 51 indicates absence of
alexithymia . The TAS-20 has been translated and
validated in Greek .
The HADS is a self-report rating scale of 14 items,
designed to measure anxiety (HADS-A) and depression
(HADS-D), with each subscale consisting of 7 items. It is
worth noting that items referring to depressive symptoms
that describe somatic aspects of depression (e.g. insomnia
and weight loss) are not included in the scale. Thus, this
scale is often used for the assessment of depression and
anxiety in patients with physical illnesses. The HADS has
been translated and validated in Greek . In this study,
a cutoff score above 8 is used to indicate the possible
presence of anxiety or depression, which is suggested for
detecting them in general population and in somatic patient
The severity of psoriasis was assessed by a
dermatologist using the Psoriasis Area and Severity Index (PASI
score) . The PASI incorporates the clinical extent of
psoriasis (surface area of skin affected) and clinical
severity of its manifestations (erythema, desquamation and
induration). In this study, a score above 10 is used to
diagnose severe psoriasis. The mild or moderate form of
psoriasis is given a score of less than 10.
Normality was assessed by Kolmogorov-Smirnovs Z test.
Descriptive statistics were measured and independent
sample t tests were performed in order to examine whether
there were any significant differences in the TAS total score
and in its three subscales scores, as well as in the HADS
total score and in its two subscales scores between patients
with psoriasis and the control group and between male and
female participants. Chi-square tests were applied for
comparisons between male and female participants,
HADS-A subscale and TAS scores and HADS-D
subscale and TAS scores. Correlations were measured by
Pearsons r correlation coefficient between TAS, its
subscales and age and between TAS and HADS and their
subscales. A series of linear regression analyses were
performed for the psoriatic patients group, in order
estimate the prediction of alexithymia and its constitutes,
DIF, DDF and EOT (dependent variables) from gender,
age, severity of psoriasis, depression or anxiety.
Statistical significance level was set at p < 0.05 (corrected where
applicable) and statistical analyses were conducted using
SPSS software package ver. 17.00 (SPSS Inc., Chicago,
The current study included 108 patients with psoriasis,
52 male and 56 female (x2 = 0.15, df = 1, p = 0.7 NS). The
mean age of the patients was 52.53 (16.41) years.
Regarding alexithymias prevalence in the patients with
psoriasis based on the aforementioned TAS-20
standards, 35 (32.4%) patients were classified as alexithymic,
24 (22.2%) as borderline and 49 (45.4%) as nonalexithymic.
The mean TAS score was 52.62 (13.46) for the patients
and 39.63 (10.20) for the controls.
Twenty-five of the total 108 patients were diagnosed
with severe psoriasis (PASI score > 10) and presented a
mean TAS score of 55.56 13.23, which did not differ
significantly from the total patients mean TAS score
(t = 1.24, df = 106, two-tailed p = 0.22, NS). There was
no significant correlation between the severity of psoriasis
(PASI score) and alexithymia (r = 0.22, p > 0.05, NS).
The total group of patients with psoriasis compared
with the 100 healthy controls (48 males and 52 females)
matched for age (t = 1.92, df = 206, p > 0.05 NS) and
gender (x2 = 0.014, df = 1, p = 0.90 NS) had significantly higher
levels of alexithymia (t = 7.88, p < 0.001) (Table 1). As
far as depression and anxiety are concerned, there were
no significant differences between psoriatic patients and
healthy controls (Table 1).
There were no any significant differences in the TAS
total score and in its subscales scores, DIF, DDF and
EOT, as well as in the HADS total score and in its
subscales scores, HADS-A and HADS-D, in the psoriatic
patients group between male and female participants as
Table 1 Descriptive statistics and comparisons between
patients with psoriasis and healthy controls
indicated by the independent sample t tests and thus
these results are not presented. Concerning age, it was
revealed that it was positively correlated with EOT, but
not with TAS, DIF or DDF (Table 2).
In the HADS-D subscale, 24% of the patients scored
above the cutoff score and 65.4% of them also presented
alexithymia (x2 = 63.63, df = 1, p = 0.000). Additionally,
31.5% of the patients scored above the cutoff score in
the HADS-A and 61.8% of them were also alexithymic
(x2 = 56.74, df = 1, p = 0.000).
The HADS and both its subscales were significantly
positively correlated with the TAS total score, as well as
with its subscale DIF. The HADS total score and
HADS-A subscale were also significantly positively
correlated with DDF, whereas EOT was not correlated with
either HADS total score or its subscales (Table 2).
A series of linear regression analyses were performed
for the psoriatic patients group in order to determine
whether gender, age, severity of psoriasis, anxiety or
depression could predict alexithymia or its main
characteristics, DIF, DDF and EOT (Table 3). The linear regression
analyses revealed that the age of the patients was a
significant predictor only of EOT explaining 8% of its variation,
whereas neither gender nor the severity of psoriasis (PASI)
were able to predict any of the dependent variables. Anxiety
contributed significantly to the prediction of alexithymia,
Table 2 Correlations between TAS, its subscales and age
and TAS and HADS and their subscales (n = 108, df = 106)
Dependent variable Predictors R2 F r
(1, 106) = 2.57
(1, 106) = 0.56
(1, 106) = 10.02
(1, 106) = 4.27
(1, 106) = 2.85
(1, 106) = 0.08
(1, 106) = 0.29
(1, 106) = 11.33
(1, 106) = 4.30
(1, 106) = 0.14
(1, 106) = 0.73
(1, 106) = 1.23
(1, 106) = 10.08
(1, 106) = 2.03
(1, 106) = 0.002
(1, 106) = 9.68
(1, 106) = 1.20
(1, 106) = 1.14
(1, 106) = 2.57
Linear regression analyses for TAS and its subscales from demographic variables, PASI, HADS-A and HADS-D in patients with psoriasis.
*Statistically significant difference.
DIF and DDF, explaining 9%, 10% and 9% of their
variation, respectively. Depression contributed significantly to
the prediction of alexithymia, explaining 4% of its
variation, and of DIF and explaining 4% as well, but not of
DDF. Finally, the prediction of EOT from anxiety and
depression was not significant (Table 3).
The purposes of the current study were (a) to examine
the prevalence of alexithymia among patients with
psoriasis, in comparison with healthy individuals from the
general population and (b) to assess the association between
depressive and anxiety symptoms and alexithymia, as well
as its three dimensions, by taking into consideration
demographic and clinical data of the patients.
The present study confirms that the prevalence of
alexithymia is higher in patients with psoriasis than that in
healthy individuals from the general population. This
finding suggests that psoriasis could be ranked among the
diseases associated with the deregulation of emotion, while
the lack of recognition and expression of emotions might
be an important aggravating factor in the appearance of
the disease. This result is in accordance with most studies
[11,13] although some researchers do not confirm this
In our study, there were no significant differences in
the TAS score or in its subscales by gender, regarding
patients with psoriasis. The majority of studies, mainly
in the general population, reveal a higher prevalence of
alexithymia, as a personality trait, in male than female
Regarding the possible effect of the severity of psoriasis
on alexithymia, no significant differences of alexithymia
and its dimensions between patients with severe and not
severe psoriasis were observed, as classified by the PASI
score. Moreover, there was no significant correlation
between the severity of psoriasis and TAS score either.
Richards and colleagues  did not find any
correlations between alexithymias score and age, age onset,
disease duration and clinical severity of psoriasis
As far as anxiety and depression are concerned, no
significant differences were detected between patients with
psoriasis and healthy controls. A similar finding was
reported by Magin and colleagues, who have also used
HADS to evaluate depression and anxiety . While
some previous studies have reported that patients with
psoriasis were more likely to have higher depression
levels than the general population, this may be due to
the fact that they have used psychometric instruments
containing somatic aspects, such as the Beck Depression
Inventory, which may also be common in psoriasis .
Furthermore, as far as anxiety levels are concerned,
conflicting findings have been reported when comparing
psoriatic patients with healthy controls .
Nevertheless, despite the fact that depression and anxiety did not
differ significantly between patients with psoriasis and
healthy controls, it is noteworthy that 24% and 31.5% of
the psoriatic patients scored above the cutoff score in
the HADS-D and HADS-A subscale, respectively, a
finding that is consistent with previous studies and which
suggests that psychological morbidity is a clinically
important concern in patients with psoriasis [19,21].
Additionally, a considerable rate of the psoriatic patients
with depression was also alexithymic (65.4%). Several
studies show the positive relationship between alexithymia
and depression . The same applies to anxiety, as the
majority of the psoriatic patients with anxiety (61.8%)
demonstrated increased levels of alexithymia. It seems
that certain personality factors may make psoriatic
patients more vulnerable to stress and thus contribute
to the stress reactivity of the disease .
The aforementioned association between alexithymia,
depression and anxiety is also confirmed by the
correlations that were conducted between TAS and HADS,
which revealed that both anxiety and depression were
positively correlated with alexithymia. Furthermore, it
was found that higher anxiety and depression were
positively correlated with higher DIF, which might indicate
that increased anxiety and depression in psoriatic
patients may lead them to the difficulty in identifying
feelings and distinguishing them from bodily sensations. In
addition, the significant correlation that was found
between HADS-A and DDF indicated that the psoriatic
patients with anxiety symptoms, apart from their difficulty
in identifying and understanding their feelings were not
able to communicate them either. This might indicate
that alexithymia plays a role in emotional avoidance
. Several studies in different patient populations
reveal that depression and anxiety are related to the TAS
subscales either DIF or/and DDF and via them to the
total score of TAS [5,23,24].
Similar findings are suggested by the linear regression
analyses. The analyses indicated that psoriasis constitutes
a significant predictor for the performance in the TAS,
regardless of the gender, age and the severity of psoriasis.
Anxiety mainly and, to a lesser degree, depression are
significant predictors of alexithymia. Both anxiety and
depression contribute significantly to the prediction of DIF,
while anxiety to the prediction of DDF as well. On the
contrary, EOT was significantly predicted only from the
age of the patients. Bonnet and colleagues  found
significant relationships between affective symptoms and the
emotional dimensions (DIF and DDF) of alexithymia. In
the same study, however, they found that only anxiety
contributed significantly to the aforementioned two
dimensions of alexithymia [5,23]. Leweke and colleagues
using multiple hierarchical regression suggested that
higher TAS scores were associated with anxiety and
depression disorders and that DDF subscale was significantly
related to depressive disorder .
It has been found that EOT is not related to
depression and anxiety . This is confirmed in our study as
well, since only age contributed significantly to the
prediction of EOT. This, along with the positive correlation
between age and EOT, implies that as the years pass, the
psoriatics in our sample become rather dependent on
external reality and unable to attribute the causes of
their symptoms to emotional. Tolmunen and colleagues
report that a higher age is independently associated with
increase in TAS scores .
Our results indicate that alexithymia in patients with
psoriasis is independent from the age, the gender and
the severity of the disease, but there is a significant
association between anxiety or/and depression and
alexithymia. This relationship is mainly due to its subscales
rather than to the total alexithymia per se. According to
these results, alexithymia does not seem to be a stable
condition among our psoriatic patients with anxiety and
depressive symptoms. Nevertheless, alexithymia seems
to be independent of the age, the gender and the severity
of illness among the psoriatic patients. Therefore,
alexithymic individuals, who have difficulties in
communicating their feelings, are at risk of developing specific
diseases. Therefore, Allegranti and colleagues
recommended psychotherapy for dermatologic alexithymic
patients to help them recognize their feelings and use
them as signals of emotional stress .
Some limitations of our study should be mentioned. In
spite of the fact that the present study in comparison
with previous ones uses a rather high sample, this could
be larger in order to ensure that its findings could be
safely generalized. Another limitation is that there was
no follow up or a repeated examination.
In conclusion, the current study revealed that the
prevalence of alexithymia in patients with psoriasis is higher
than that in healthy individuals from the general
population. Nevertheless, they do not present significant
differences in depression or anxiety levels. Furthermore, there
is no significant difference in alexythimias levels
between male and female psoriatic patients. Higher anxiety
and depression levels are associated with higher
alexithymia, which is independent of gender, age and severity of
psoriasis. Regarding alexithymias dimensions, difficulty
in identifying feelings is associated with both anxiety
and depression, whereas difficulty in describing them is
related only with anxiety. On the contrary, externally
oriented thinking is independent of both anxiety and
depression, but it is predicted only from age. To our
knowledge, no other casecontrol study exists addressing the
relationship between psoriasis and alexithymia that either
uses such a samples size or takes into consideration
depression and anxiety without including somatic aspects
in their assessment.
Alexithymia should be taken into consideration by
clinicians, in order to design appropriate interventions. The
relationship between alexithymia and psoriasis in patients
with psoriasis needs further investigation.
DIF: Difficulty in indentifying feelings; DDF: Difficulty in describing feelings;
EOT: Externally oriented thinking; HADS: Hospital Anxiety and Depression
Scale; TAS-20: Toronto Alexithymia Scale; HADS-D: Hospital Anxiety and
Depression Scaledepression subscale; HADS-A: Hospital Anxiety and
Depression Scaleanxiety subscale; PASI: Psoriasis Area and Severity Index.
The authors declare that they have no competing interests.
PK was a co-designer of the study and wrote the manuscript. CC was a
co-designer of the study and drafted the manuscript. AnK participated in the
data collection and processing. EP participated in the data collection, statistical
analysis and interpretation of the data. VE participated in the statistical analysis
and interpretation of the data and revised the manuscript. EK and AnnK
participated in the data collection and processing. NS participated in data
collection and drafted the manuscript. CP reviewed the final version of the
manuscript. AD was a co-designer of the study and gave final approval to
the published version. All authors read and approved the final manuscript.
1. Sifneos PE : The prevalence of 'alexithymic' characteristics in psychosomatic patients . Psychother Psychosom 1973 , 22 : 255 - 262 .
2. Picardi A , Pasquini P , Cattaruzza MS , Gaetano P , Baliva G , Melchi CF , Tiago A , Camaioni D , Abeni D , Biondi M : Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study . J Psychosom Res 2003 , 55 : 189 - 196 .
3. Taylor GJ , Bagby RM , Parker JDA : Disorders of affect regulation: alexithymia in medical and psychiatric illness . Cambridge : Cambridge University Press ; 1997 .
4. Saarijrvi 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 - 733 .
5. Bonnet A , Brjard V , Pasquier A , Pedinielli JL : Affectivity and alexithymia: two dimensions explicative of the relationship between anxiety and depressive symptoms . Affectivit et alexithymie 2012 , 38 : 187 - 193 .
6. Willemsen R , Roseeuw D , Vanderlinden J : Alexithymia and dermatology: the state of the art . Int J Dermatol 2008 , 47 : 903 - 910 .
7. Allegranti I , Gon T , Magaton-Rizzi G , Aguglia E : Prevalence of alexithymic characteristics in psoriatic patients . Acta Dermato-Venereologica, Suppl 1994 , 186 : 146 - 147 .
8. Swerlick RA , Lawley TJ : Eczema, psoriasis, cutaneous infection, acne and other common skin disorder . In Harrison's Principles of Internal Medicine . 14th edition. Edited by Fauci. New York : McGraw-Hill Inc ; 1998 : 298 - 300 .
9. Fortune DG , Richards HL , Main CJ , Griffiths CEM : What patients with psoriasis believe about their condition . J Am Acad Dermatol 1998 , 39 : 196 - 201 .
10. Rubino IA , Sonnino A , Stefanato CM , Pezzarossa B , Ciani N : Separation-individuation, aggression and alexithymia in psoriasis . Acta Dermato-Venereologica Suppl 1989 , 69 : 87 - 90 .
11. Chaudhury S , Das AL , John RT , Ramadasan P : Psychological factors in psoriasis . Indian J Psychiatry 1998 , 40 : 295 - 299 .
12. Fava GA , Perini GI , Santonastaso P , Fornasa CV : Life events and psychological distress in dermatologic disorders: psoriasis, chronic urticaria and fungal infections . Br J Med Psychol 1980 , 53 : 277 - 282 .
13. Masmoudi J , Maalej I , Masmoudi A , Rached H , Rebai A , Turki H , Jaoua A : Alexithymia and psoriasis: a case-control study of 53 patients . Alexithymie et psoriasis 2009 , 35 : 10 - 17 .
14. Karanikas E , Harsoulis F , Giouzepas I , Griveas I , Chrisomallis F : Neuroendocrine stimulatory tests of hypothalamus-pituitary-adrenal axis in psoriasis and correlative implications with psychopathological and immune parameters . J Dermatol 2009 , 36 : 35 - 44 .
15. Tsaousis I , Taylor G , Quilty L , Georgiades S , Stavrogiannopoulos M , Bagby RM : Validation of a Greek adaptation of the 20-item Toronto Alexithymia Scale . Compr Psychiatry 2010 , 51 : 443 - 448 .
16. Michopoulos I , Douzenis A , Kalkavoura C , Christodoulou C , Michalopoulou P , Kalemi G , Fineti K , Patapis P , Protopapas K , Lykouras L : Hospital anxiety and depression scale (HADS): validation in a Greek general hospital sample . Ann Gen Psych 2008 , 7 : 4 .
17. Fredriksson T , Pettersson U : Severe psoriasis: oral therapy with a new steroid . Dermatologica 1978 , 157 : 238 - 244 .
18. Richards HL , Fortune DG , Griffiths CEM , Main CJ : Alexithymia in patients with psoriasis: clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20 . J Psychosom Res 2005 , 58 : 89 - 96 .
19. Rieder E , Tausk F : Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments . Int J Dermatol 2012 , 51 : 12 - 26 .
20. Devrimci-Ozguven H , Kundakci N , Kumbasar H , Boyvat A : The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients . J Eur Acad Dermatol Venereol 2000 , 14 : 267 - 271 .
21. Richards HL , Fortune DG , Griffiths CEM , Main CJ : The contribution of perceptions of stigmatisation to disability in patients with psoriasis . J Psychosom Res 2001 , 50 : 11 - 15 .
22. Honkalampi K , Koivumaa-Honkanen H , Lehto SM , Hintikka J , Haatainen K , Rissanen T , Viinamki H : Is alexithymia a risk factor for major depression, personality disorder, or alcohol use disorders? A prospective population-based study . J Psychosom Res 2010 , 68 : 269 - 273 .
23. Motan I , Genz T : The relationship between the dimensions of alexithymia and the intensity of depression and anxiety . Turk Psikiyatri Derg 2007 , 18 ( 4 ): 333 - 343 .
24. Sayar K , Gulec H , Topbas M : Alexithymia and anger in patients with fibromyalgia . Clin Rheumatol 2004 , 23 : 441 - 448 .
25. Leweke F , Leichsenring F , Kruse J , Hermes S : Is alexithymia associated with specific mental disorders? Psychopathology 2012 , 45 : 22 - 28 .
26. Tolmunen T , Heliste M , Lehto SM , Hintikka J , Honkalampi K , Kauhanen J : Stability of alexithymia in the general population: an 11-year follow-up . Compr Psychiatry 2011 , 52 : 536 - 541 .