Somatization Mediates the Structural Relationship of Alexithymia with Anxiety and Depression
,
Abstract
Objective: The study of factors affecting anxiety and depression as the most common emotional disorders has always been at the forefront of psychological research. Among different factors, alexithymia and somatization have considerable importance due to their emotional nature with makes them more integrated with anxiety and depression. Several studies have demonstrated a link between these four concepts, but as far as we know, the quality of the relationship has not been addressed yet. The present paper aims to investigate the mediating role of somatization in the structural relationship of alexithymia with anxiety and depression.
Method: A total of 334 college students were recruited through cluster sampling and were asked to complete the Toronto Alexithymia Scale (TAS), Beck Depression Inventory – Second Edition (BDI-II), Beck Anxiety Inventory (BAI), and Somatization Subscale from the Symptom Checklist-90-Revised Questionnaire. Data were analyzed using correlational as well as structural equation modeling.
Results: Based on the correlation analysis, there was significant relationship between alexithymia, somatization, anxiety, and depression. According to the results of regression weights, there is a moderate relationship between alexithymia and somatization (regression weight = 0.44). The relationship between somatization and depression is at moderate level (regression weight = 0.42) and the relationship of somatization with anxiety is at strong level (regression weight = 0.85). the goodness of fit indices for the hypothetical model showed significant coefficients at P < 0.05 (CFI = 0.98, RMSEA = 0.059).
Conclusion: Findings indicated the important and influential role of somatization in explaining the relationship of alexithymia with anxiety and depression. Therefore, it seems that emotional components such as difficulty in identifying and expressing emotions as well as regulating mood states are important in the psychopathology of emotional disorders.
1. Currow DC, Chang S, Reddel HK, Kochovska S, Ferreira D, Kinchin I, et al. Breathlessness, Anxiety, Depression, and Function-The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults. J Pain Symptom Manage. 2020;59(2):197-205.e2.
2. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand challenges in global mental health. Nature. 2011;475(7354):27-30.
3. Shanahan L, Zucker N, Copeland WE, Bondy CL, Egger HL, Costello EJ. Childhood somatic complaints predict generalized anxiety and depressive disorders during young adulthood in a community sample. Psychol Med. 2015;45(8):1721-30.
4. Bekhuis E, Schoevers RA, van Borkulo CD, Rosmalen JG, Boschloo L. The network structure of depressive, anxiety and somatic symptoms. Journal of Psychosomatic Research. 2016 Jun 1;85:55. https://doi.org/10.1017/s0033291716001550.
5. Bekhuis E, Boschloo L, Rosmalen JG, Schoevers RA. Differential associations of specific depressive and anxiety disorders with somatic symptoms. J Psychosom Res. 2015;78(2):116-22.
6. van Boven K, Lucassen P, van Ravesteijn H, olde Hartman T, Bor H, van Weel-Baumgarten E, et al. Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network. Br J Gen Pract. 2011;61(587):e316-25.
7. Poulsen OM, Persson R, Kristiansen J, Andersen LL, Villadsen E, Ørbæk P. Distribution of subjective health complaints, and their association with register based sickness absence in the Danish working population. Scand J Public Health. 2013;41(2):150-7.
8. Konnopka A, Schaefert R, Heinrich S, Kaufmann C, Luppa M, Herzog W, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81(5):265-75.
9. van der Leeuw G, Gerrits MJ, Terluin B, Numans ME, van der Feltz-Cornelis CM, van der Horst HE, et al. The association between somatization and disability in primary care patients. J Psychosom Res. 2015;79(2):117-22.
10. Lipsanen T, Saarijärvi S, Lauerma H. Exploring the relations between depression, somatization, dissociation and alexithymia--overlapping or independent constructs? Psychopathology. 2004;37(4):200-6.
11. de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. 2004;184:470-6.
12. Huang WL, Chen TT, Chen IM, Ma HM, Lee MT, Liao SC, et al. Depression and anxiety among patients with somatoform disorders, panic disorder, and other depressive/anxiety disorders in Taiwan. Psychiatry Res. 2016;241:165-71.
13. Kriston P, Pikó B. [The role of cognitive emotional self-regulation in adolescence in levels of depression, psychosomatic symptoms and subjective well-being]. Psychiatr Hung. 2017;32(2):168-77.
14. Grover S, Ghosh A. Somatic symptom and related disorders in Asians and Asian Americans. Asian J Psychiatr. 2014;7(1):77-9.
15. Lumley MA, Stettner L, Wehmer F. How are alexithymia and physical illness linked? A review and critique of pathways. J Psychosom Res. 1996;41(6):505-18.
16. Bagby RM, Taylor GJ, Parker JD. The nomological domain of the alexithymia construct. The (non) expression of emotions in health and disease. 1997:95-102.
17. Luminet O, Rimé B, Bagby RM, Taylor G. A multimodal investigation of emotional responding in alexithymia. Cognition and emotion. 2004 Sep 1;18(6) :741-66.
18. Dere J, Falk CF, Ryder AG. Unpacking cultural differences in alexithymia: The role of cultural values among Euro-Canadian and Chinese-Canadian students. Journal of Cross-Cultural Psychology. 2012 Nov;43(8) :1297-312.
19. De Gucht V, Heiser W. Alexithymia and somatisation: quantitative review of the literature. J Psychosom Res. 2003;54(5):425-34.
20. Mattila AK, Kronholm E, Jula A, Salminen JK, Koivisto AM, Mielonen RL, et al. Alexithymia and somatization in general population. Psychosom Med. 2008;70(6):716-22.
21. Öztürk A, Kiliç A, Deveci E, Kirpinar İ. Investigation of facial emotion recognition, alexithymia, and levels of anxiety and depression in patients with somatic symptoms and related disorders. Neuropsychiatr Dis Treat. 2016;12:1047-53.
22. Venugopalan V, Elkal M, Behere RV, Praharaj SK, Kanaradi H. A Study on Alexithymia, Quality of Life, and Facial Emotion Recognition Abilities in Somatoform Disorders. J Postgrad Med Edu Res 2018;52(3) :110-116.
23. Karukivi M, Hautala L, Kaleva O, Haapasalo-Pesu KM, Liuksila PR, Joukamaa M, et al. Alexithymia is associated with anxiety among adolescents. J Affect Disord. 2010;125(1-3):383-7.
24. Hemming L, Haddock G, Shaw J, Pratt D. Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature. Front Psychiatry. 2019;10:203.
25. Honkalampi K, Hintikka J, Saarinen P, Lehtonen J, Viinamäki H. Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychother Psychosom. 2000;69(6):303-8.
26. Guidi J, Fava GA, Picardi A, Porcelli P, Bellomo A, Grandi S, et al. Subtyping depression in the medically ill by cluster analysis. J Affect Disord. 2011;132(3):383-8.
27. Günther V, Rufer M, Kersting A, Suslow T. Predicting symptoms in major depression after inpatient treatment: the role of alexithymia. Nord J Psychiatry. 2016;70(5):392-8.
28. Honkalampi K, Hintikka J, Saarinen P, Lehtonen J, Viinamäki H. Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychother Psychosom. 2000;69(6):303-8.
29. Heaven PC, Ciarrochi J, Hurrell K. The distinctiveness and utility of a brief measure of alexithymia for adolescents. Personality and individual differences. 2010 Aug 1;49(3) :222-7. https://doi.org/10.1016/j.paid.2010.03.039.
30. Bach M, Bach D. Predictive value of alexithymia: a prospective study in somatizing patients. Psychother Psychosom. 1995;64(1):43-8.
31. Ogrodniczuk JS, Piper WE, Joyce AS. Alexithymia as a predictor of residual symptoms in depressed patients who respond to short-term psychotherapy. Am J Psychother. 2004;58(2):150-61.
32. Ryder AG, Yang J, Zhu X, Yao S, Yi J, Heine SJ, et al. The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America? J Abnorm Psychol. 2008;117(2):300-13.
33. Davey GC. Psychopathology: Research, Assessment and Treatment in Clinical Psychology. Malden, MA: Blackwell Publishing, 2008.
34. Kleinman A. Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press, 1988.
35. Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv. 1999;50(6):774-80.
36. Beck JE. A developmental perspective on functional somatic symptoms. J Pediatr Psychol. 2008;33(5):547-62.
37. Sęktas M, Sawicki A, Pianka L, Atroszko PA. Relationship between cynical hostility and values from educational perspectivepreliminary research. Badania i Rozwój Młodych Naukowców w Polsce. Nauki humanistyczne i społeczne‖, Poznań: Młodzi Naukowcy. 2016:98-104.
38. Derogatis LR, Rickels K, Rock AF. The SCL-90 and the MMPI: a step in the validation of a new self-report scale. Br J Psychiatry. 1976;128:280-9.
39. Sayar K, Kirmayer LJ, Taillefer SS. Predictors of somatic symptoms in depressive disorder. Gen Hosp Psychiatry. 2003;25(2):108-14.
40. Mirzai R. evaluation of reliability and validity of SCL-90-R at Iranian community.(dissertation). Iran, Tehran: university of Tehran; 1359
41. Taylor GJ, Bagby RM, Parker JD. Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press; 1999 Oct 7. Chapter in book. doi:10.1001/jama.279.7.555.
42. Ghorbani N, Bing MN, Watson PJ, Davison HK, Mack DA. Self-reported emotional intelligence: Construct similarity and functional dissimilarity of higher-order processing in Iran and the United States. International Journal of psychology. 2002 Oct 1;37(5):297-308., DOI: 10.1080/00207590244000098
43. Beck AT, Steer RA. Manual for the Beck anxiety inventory. San Antonio, TX: Psychological Corporation. 1990.
44. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-7.
45. Kaviani H, Mousavi AS. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran University Medical Journal. 2008 May.
46. Beck AT, Steer RA, Brown GK. Beck Depression Inventory FastScree for Medical Patients. Psychological Corporation; 2000.
47. Dabson KS, MOHAMMAD KP. Psychometric characteristics of Beck depression inventory–II in patients with major depressive disorder. 2007. 82-88.
48. Chou CP, Bentler PM. Estimates and tests in structural equation modeling. Sage Publications. 1995. 37–55.
49. Kline RB. Principles and practice of structural equation modeling. Guilford publications; 2015 Nov 3. Chapter in book.
50. Bentler PM. Bentler PM. EQS structural equations program manual. Encino, CA: Multivariate software; 1995.
51. Rief W, Hennings A, Riemer S, Euteneuer F. Psychobiological differences between depression and somatization. J Psychosom Res. 2010;68(5):495-502.
52. Lundh LG, Simonsson-Sarnecki M. Alexithymia, emotion, and somatic complaints. J Pers. 2001;69(3):483-510.
53. Kani HT, Dural U, Sakalli Kani A, Yanartas O, Kiziltas S, Yilmaz Enc F, Atug O, Deyneli O, Kuscu K, Imeryuz N. Evaluation of depression, anxiety, alexithymia, attachment, social support and somatization in functional dyspepsia. Psychiatry and Clinical Psychopharmacology. 2019 Jan 2;29(1) :45-51. https://doi.org/10.1080/24750573.2018.1480081
54. Taycan O, Özdemir A, Erdoğan Taycan S. Alexithymia and Somatization in Depressed Patients: The Role of the Type of Somatic Symptom Attribution. Noro Psikiyatr Ars. 2017;54(2):99-104.
55. Beck JE, Lipani TA, Baber KF, Dufton L, Garber J, Smith CA, et al. Attentional bias to pain and social threat in pediatric patients with functional abdominal pain and pain-free youth before and after performance evaluation. Pain. 2011;152(5):1061-7.
56. Walker LS, Claar RL, Garber J. Social consequences of children's pain: when do they encourage symptom maintenance? J Pediatr Psychol. 2002;27(8):689-98.
57. Garyfallos G, Adamopoulou A, Karastergiou A, Voikli M, Ikonomidis N, Donias S, et al. Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece. Compr Psychiatry. 1999;40(4):299-307.
58. Eizaguirre AE, de Cabezón AO, de Alda IO, Olariaga LJ, Juaniz M. Alexithymia and its relationships with anxiety and depression in eating disorders. Personality and individual differences. 2004 Jan 1;36(2) :321-31.
59. Marchesi C, Fontò S, Balista C, Cimmino C, Maggini C. Relationship between alexithymia and panic disorder: a longitudinal study to answer an open question. Psychother Psychosom. 2005;74(1):56-60.
60. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62 Suppl 13:22-8; discussion 9-30.
61. Kastrup MC. Cultural aspects of depression as a diagnostic entity: historical perspective. Medicographia. 2011;33(2) :119-24.
2. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand challenges in global mental health. Nature. 2011;475(7354):27-30.
3. Shanahan L, Zucker N, Copeland WE, Bondy CL, Egger HL, Costello EJ. Childhood somatic complaints predict generalized anxiety and depressive disorders during young adulthood in a community sample. Psychol Med. 2015;45(8):1721-30.
4. Bekhuis E, Schoevers RA, van Borkulo CD, Rosmalen JG, Boschloo L. The network structure of depressive, anxiety and somatic symptoms. Journal of Psychosomatic Research. 2016 Jun 1;85:55. https://doi.org/10.1017/s0033291716001550.
5. Bekhuis E, Boschloo L, Rosmalen JG, Schoevers RA. Differential associations of specific depressive and anxiety disorders with somatic symptoms. J Psychosom Res. 2015;78(2):116-22.
6. van Boven K, Lucassen P, van Ravesteijn H, olde Hartman T, Bor H, van Weel-Baumgarten E, et al. Do unexplained symptoms predict anxiety or depression? Ten-year data from a practice-based research network. Br J Gen Pract. 2011;61(587):e316-25.
7. Poulsen OM, Persson R, Kristiansen J, Andersen LL, Villadsen E, Ørbæk P. Distribution of subjective health complaints, and their association with register based sickness absence in the Danish working population. Scand J Public Health. 2013;41(2):150-7.
8. Konnopka A, Schaefert R, Heinrich S, Kaufmann C, Luppa M, Herzog W, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81(5):265-75.
9. van der Leeuw G, Gerrits MJ, Terluin B, Numans ME, van der Feltz-Cornelis CM, van der Horst HE, et al. The association between somatization and disability in primary care patients. J Psychosom Res. 2015;79(2):117-22.
10. Lipsanen T, Saarijärvi S, Lauerma H. Exploring the relations between depression, somatization, dissociation and alexithymia--overlapping or independent constructs? Psychopathology. 2004;37(4):200-6.
11. de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. 2004;184:470-6.
12. Huang WL, Chen TT, Chen IM, Ma HM, Lee MT, Liao SC, et al. Depression and anxiety among patients with somatoform disorders, panic disorder, and other depressive/anxiety disorders in Taiwan. Psychiatry Res. 2016;241:165-71.
13. Kriston P, Pikó B. [The role of cognitive emotional self-regulation in adolescence in levels of depression, psychosomatic symptoms and subjective well-being]. Psychiatr Hung. 2017;32(2):168-77.
14. Grover S, Ghosh A. Somatic symptom and related disorders in Asians and Asian Americans. Asian J Psychiatr. 2014;7(1):77-9.
15. Lumley MA, Stettner L, Wehmer F. How are alexithymia and physical illness linked? A review and critique of pathways. J Psychosom Res. 1996;41(6):505-18.
16. Bagby RM, Taylor GJ, Parker JD. The nomological domain of the alexithymia construct. The (non) expression of emotions in health and disease. 1997:95-102.
17. Luminet O, Rimé B, Bagby RM, Taylor G. A multimodal investigation of emotional responding in alexithymia. Cognition and emotion. 2004 Sep 1;18(6) :741-66.
18. Dere J, Falk CF, Ryder AG. Unpacking cultural differences in alexithymia: The role of cultural values among Euro-Canadian and Chinese-Canadian students. Journal of Cross-Cultural Psychology. 2012 Nov;43(8) :1297-312.
19. De Gucht V, Heiser W. Alexithymia and somatisation: quantitative review of the literature. J Psychosom Res. 2003;54(5):425-34.
20. Mattila AK, Kronholm E, Jula A, Salminen JK, Koivisto AM, Mielonen RL, et al. Alexithymia and somatization in general population. Psychosom Med. 2008;70(6):716-22.
21. Öztürk A, Kiliç A, Deveci E, Kirpinar İ. Investigation of facial emotion recognition, alexithymia, and levels of anxiety and depression in patients with somatic symptoms and related disorders. Neuropsychiatr Dis Treat. 2016;12:1047-53.
22. Venugopalan V, Elkal M, Behere RV, Praharaj SK, Kanaradi H. A Study on Alexithymia, Quality of Life, and Facial Emotion Recognition Abilities in Somatoform Disorders. J Postgrad Med Edu Res 2018;52(3) :110-116.
23. Karukivi M, Hautala L, Kaleva O, Haapasalo-Pesu KM, Liuksila PR, Joukamaa M, et al. Alexithymia is associated with anxiety among adolescents. J Affect Disord. 2010;125(1-3):383-7.
24. Hemming L, Haddock G, Shaw J, Pratt D. Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature. Front Psychiatry. 2019;10:203.
25. Honkalampi K, Hintikka J, Saarinen P, Lehtonen J, Viinamäki H. Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychother Psychosom. 2000;69(6):303-8.
26. Guidi J, Fava GA, Picardi A, Porcelli P, Bellomo A, Grandi S, et al. Subtyping depression in the medically ill by cluster analysis. J Affect Disord. 2011;132(3):383-8.
27. Günther V, Rufer M, Kersting A, Suslow T. Predicting symptoms in major depression after inpatient treatment: the role of alexithymia. Nord J Psychiatry. 2016;70(5):392-8.
28. Honkalampi K, Hintikka J, Saarinen P, Lehtonen J, Viinamäki H. Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychother Psychosom. 2000;69(6):303-8.
29. Heaven PC, Ciarrochi J, Hurrell K. The distinctiveness and utility of a brief measure of alexithymia for adolescents. Personality and individual differences. 2010 Aug 1;49(3) :222-7. https://doi.org/10.1016/j.paid.2010.03.039.
30. Bach M, Bach D. Predictive value of alexithymia: a prospective study in somatizing patients. Psychother Psychosom. 1995;64(1):43-8.
31. Ogrodniczuk JS, Piper WE, Joyce AS. Alexithymia as a predictor of residual symptoms in depressed patients who respond to short-term psychotherapy. Am J Psychother. 2004;58(2):150-61.
32. Ryder AG, Yang J, Zhu X, Yao S, Yi J, Heine SJ, et al. The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America? J Abnorm Psychol. 2008;117(2):300-13.
33. Davey GC. Psychopathology: Research, Assessment and Treatment in Clinical Psychology. Malden, MA: Blackwell Publishing, 2008.
34. Kleinman A. Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press, 1988.
35. Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv. 1999;50(6):774-80.
36. Beck JE. A developmental perspective on functional somatic symptoms. J Pediatr Psychol. 2008;33(5):547-62.
37. Sęktas M, Sawicki A, Pianka L, Atroszko PA. Relationship between cynical hostility and values from educational perspectivepreliminary research. Badania i Rozwój Młodych Naukowców w Polsce. Nauki humanistyczne i społeczne‖, Poznań: Młodzi Naukowcy. 2016:98-104.
38. Derogatis LR, Rickels K, Rock AF. The SCL-90 and the MMPI: a step in the validation of a new self-report scale. Br J Psychiatry. 1976;128:280-9.
39. Sayar K, Kirmayer LJ, Taillefer SS. Predictors of somatic symptoms in depressive disorder. Gen Hosp Psychiatry. 2003;25(2):108-14.
40. Mirzai R. evaluation of reliability and validity of SCL-90-R at Iranian community.(dissertation). Iran, Tehran: university of Tehran; 1359
41. Taylor GJ, Bagby RM, Parker JD. Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press; 1999 Oct 7. Chapter in book. doi:10.1001/jama.279.7.555.
42. Ghorbani N, Bing MN, Watson PJ, Davison HK, Mack DA. Self-reported emotional intelligence: Construct similarity and functional dissimilarity of higher-order processing in Iran and the United States. International Journal of psychology. 2002 Oct 1;37(5):297-308., DOI: 10.1080/00207590244000098
43. Beck AT, Steer RA. Manual for the Beck anxiety inventory. San Antonio, TX: Psychological Corporation. 1990.
44. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-7.
45. Kaviani H, Mousavi AS. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran University Medical Journal. 2008 May.
46. Beck AT, Steer RA, Brown GK. Beck Depression Inventory FastScree for Medical Patients. Psychological Corporation; 2000.
47. Dabson KS, MOHAMMAD KP. Psychometric characteristics of Beck depression inventory–II in patients with major depressive disorder. 2007. 82-88.
48. Chou CP, Bentler PM. Estimates and tests in structural equation modeling. Sage Publications. 1995. 37–55.
49. Kline RB. Principles and practice of structural equation modeling. Guilford publications; 2015 Nov 3. Chapter in book.
50. Bentler PM. Bentler PM. EQS structural equations program manual. Encino, CA: Multivariate software; 1995.
51. Rief W, Hennings A, Riemer S, Euteneuer F. Psychobiological differences between depression and somatization. J Psychosom Res. 2010;68(5):495-502.
52. Lundh LG, Simonsson-Sarnecki M. Alexithymia, emotion, and somatic complaints. J Pers. 2001;69(3):483-510.
53. Kani HT, Dural U, Sakalli Kani A, Yanartas O, Kiziltas S, Yilmaz Enc F, Atug O, Deyneli O, Kuscu K, Imeryuz N. Evaluation of depression, anxiety, alexithymia, attachment, social support and somatization in functional dyspepsia. Psychiatry and Clinical Psychopharmacology. 2019 Jan 2;29(1) :45-51. https://doi.org/10.1080/24750573.2018.1480081
54. Taycan O, Özdemir A, Erdoğan Taycan S. Alexithymia and Somatization in Depressed Patients: The Role of the Type of Somatic Symptom Attribution. Noro Psikiyatr Ars. 2017;54(2):99-104.
55. Beck JE, Lipani TA, Baber KF, Dufton L, Garber J, Smith CA, et al. Attentional bias to pain and social threat in pediatric patients with functional abdominal pain and pain-free youth before and after performance evaluation. Pain. 2011;152(5):1061-7.
56. Walker LS, Claar RL, Garber J. Social consequences of children's pain: when do they encourage symptom maintenance? J Pediatr Psychol. 2002;27(8):689-98.
57. Garyfallos G, Adamopoulou A, Karastergiou A, Voikli M, Ikonomidis N, Donias S, et al. Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece. Compr Psychiatry. 1999;40(4):299-307.
58. Eizaguirre AE, de Cabezón AO, de Alda IO, Olariaga LJ, Juaniz M. Alexithymia and its relationships with anxiety and depression in eating disorders. Personality and individual differences. 2004 Jan 1;36(2) :321-31.
59. Marchesi C, Fontò S, Balista C, Cimmino C, Maggini C. Relationship between alexithymia and panic disorder: a longitudinal study to answer an open question. Psychother Psychosom. 2005;74(1):56-60.
60. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62 Suppl 13:22-8; discussion 9-30.
61. Kastrup MC. Cultural aspects of depression as a diagnostic entity: historical perspective. Medicographia. 2011;33(2) :119-24.
| Files | ||
| Issue | Vol 17 No 2 (2022) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/ijps.v17i2.8904 | |
| Keywords | ||
| Anxiety Alexithymia Depression Somatization | ||
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How to Cite
1.
Farhoumandi N, Zarean M, Nasiri M, Jega M. Somatization Mediates the Structural Relationship of Alexithymia with Anxiety and Depression. Iran J Psychiatry. 2022;17(2):144-153.
