The Mediating Role of Alexithymia in the Relationship between Maladaptive Object Relations Patterns and Depression
,
Abstract
Objective: Depression is a prevalent psychological condition that severely impacts quality of life. Psychodynamic theories highlight early interpersonal experiences and maladaptive object relations as key factors in vulnerability to psychopathology. Alexithymia, characterized by difficulty identifying and expressing emotions, is a transdiagnostic risk factor strongly linked to depression. This study examines the mediating role of alexithymia in the relationship between maladaptive object relations and depression.
Method: This cross-sectional study used a path-analysis method. A total of 245 dormitory students (145 males and 100 females) from Iran University of Medical Sciences were selected via two-stage cluster sampling. Data were collected using the Bell Object Relations and Reality Testing Inventory (BORRTI), Toronto Alexithymia Scale (TAS-20), and Beck Depression Inventory–Short Form (BDI-S). Pearson correlation, regression analysis, and the Sobel test were conducted using SPSS version 20.
Results: Path analysis showed significant direct effects of maladaptive object relations (alienation, insecure attachment, egocentricity, social incompetence) on both alexithymia (β = 0.395–0.444, P < 0.001) and depression (β = 0.365–0.562, P < 0.001). Alexithymia also directly affected depression (β = 0.176–0.287, P ≤ 0.003). Indirect effects of alexithymia in the relationship between object relations and depression ranged from 0.077 to 0.113, with all paths significant per the Sobel test.
Conclusion: Alexithymia significantly mediates the relationship between maladaptive object relations and depression, suggesting that early unhealthy relational patterns may foster depression by impairing emotional awareness. Therapeutic interventions should focus on enhancing emotional processing to promote sustainable recovery.
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25. Kernberg OF. Psychoanalytic object relations theory revised: Affect systems and the notion of drives. Int J Psychoanal. 2024;105(5):790-803.
26. Scheerer NE, Boucher TQ, Iarocci G. Alexithymia is related to poor social competence in autistic and nonautistic children. Autism Res. 2021;14(6):1252-9.
27. Zhang J, Zhang Y, Mao Y, Wang Y. The relationship between insecure attachment and alexithymia: A meta-analysis. Current Psychology. 2024;43(7):5804-25.
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29. 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):144-53.
30. Preece DA, Mehta A, Petrova K, Sikka P, Bjureberg J, Becerra R, et al. Alexithymia and emotion regulation. J Affect Disord. 2023;324:232-8.
31. Li R, Kajanoja J, Karlsson L, Karlsson H, Karukivi M. Sex-specific role of alexithymia in associations between parental bonding and mental health: A moderated mediation model. J Clin Psychol. 2023;79(1):126-42.
32. Elling C, Forstner AJ, Seib-Pfeifer LE, Mücke M, Stahl J, Geiser F, et al. Social anxiety disorder with comorbid major depression - why fearful attachment style is relevant. J Psychiatr Res. 2022;147:283-90.
33. Liu Y, Duan L, Shen Q, Xu L, Zhang T. The relationship between childhood psychological abuse and depression in college students: internet addiction as mediator, different dimensions of alexithymia as moderator. BMC Public Health. 2024;24(1):2744.
34. Lu X, Li Z, Zhu X, Li D, Wei J. The Role of Alexithymia and Moral Disengagement in Childhood Physical Abuse and Depressive Symptoms: A Comparative Study Among Rural and Urban Chinese College Students. Psychol Res Behav Manag. 2024;17:3197-210.
35. Li M, D'Arcy C, Meng X. Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: systematic review, meta-analysis, and proportional attributable fractions. Psychol Med. 2016;46(4):717-30.
36. Cresci M. Winnicott’s true self/false self concept: Using countertransference to uncover the true self. Psychoanalytic Perspectives on Knowing and Being Known: Routledge; 2019. p. 101-9.
37. Preece DA, Mehta A, Becerra R, Chen W, Allan A, Robinson K, et al. Why is alexithymia a risk factor for affective disorder symptoms? The role of emotion regulation. J Affect Disord. 2022;296:337-41.
38. Greenberg L. Changing emotion with emotion. Person-centered & experiential psychotherapies. 2023;22(4):368-83.
39. Abbass A, Town J. Intensive Short-Term Dynamic Psychotherapy for Complex, Chronic, and Treatment-Resistant Conditions. Am J Psychother. 2025:appipsychotherapy20240024.
40. Spain D, Musich FM, White SW. Psychological therapies for adults with autism: Oxford University Press; 2022.
41. Beygi Z, Tighband Jangali R, Derakhshan N, Alidadi M, Javanbakhsh F, Mahboobizadeh M. An Overview of Reviews on the Effects of Acceptance and Commitment Therapy (ACT) on Depression and Anxiety. Iran J Psychiatry. 2023;18(2):248-57.
2. Shahid H, Hasan MA, Ejaz O, Khan HR, Idrees M, Ashraf M, et al. The Severity of Depression, Anxiety, and Stress: Recommendations From Joint Work of Research Center and Psychology Clinics in COVID-19 Pandemic. Front Psychiatry. 2022;13:839542.
3. Andersen MB, de Queiroz FS. Psychodynamic models. Routledge handbook of applied sport psychology: Routledge; 2023. p. 193-202.
4. Summers F. Object relations theories and psychopathology: A comprehensive text: Routledge; 2024.
5. Shahar G. Reformulated Object Relations Theory: A Bridge Between Clinical Psychoanalysis, Psychotherapy Integration, and the Understanding and Treatment of Suicidal Depression. Front Psychol. 2021;12:721746.
6. Bell MD. Bell object relations and reality testing inventory: BORRTI: Western Psychological Services; 2007.
7. Preece DA, Gross JJ. Conceptualizing alexithymia. Pers Individ Dif. 2023;215:112375.
8. Sagar R, Talwar S, Desai G, Chaturvedi SK. Relationship between alexithymia and depression: A narrative review. Indian J Psychiatry. 2021;63(2):127-33.
9. Liu Z, He S, Hou C. The effect of alexithymia on depression: evidence from meta-analysis. Front Psychol. 2025;16:1465286.
10. Fonagy P, Gergely G, Jurist EL. Affect regulation, mentalization and the development of the self: Routledge; 2018.
11. Taylor GJ, Bagby RM. Examining Proposed Changes to the Conceptualization of the Alexithymia Construct: The Way Forward Tilts to the Past. Psychother Psychosom. 2021;90(3):145-55.
12. Kealy D, Ogrodniczuk JS, Howell-Jones G. Object relations and emotional processing deficits among psychiatric outpatients. The Journal of nervous and mental disease. 2011;199(2):132-5.
13. Faryabi M, Akrami N. Predicting Melancholic Depression by Mental Pain Mediation: The Roles of Object Relations and Childhood Trauma. Psychological Studies. 2024;20(2).
14. Kline RB. Principles and practice of structural equation modeling: Guilford publications; 2023.
15. Hadinezhad H, Tabatabaeian M, Dehghani M. A Preliminary Study for Validity and Reliability of Bell Object Relations and Reality Testing Inventory. Iranian Journal of Psychiatry and Clinical Psychology. 2014;20(2):162-9.
16. Besharat MA. Reliability and factorial validity of a Farsi version of the 20-item Toronto Alexithymia Scale with a sample of Iranian students. Psychological reports. 2007;101(1):209-20.
17. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian-language version of the Beck Depression Inventory--Second edition: BDI-II-PERSIAN. Depress Anxiety. 2005;21(4):185-92.
18. Yang L, Zhang X, Chen J. Winsorization greatly reduces false positives by popular differential expression methods when analyzing human population samples. Genome Biol. 2024;25(1):282.
19. Igartua JJ, Hayes AF. Mediation, Moderation, and Conditional Process Analysis: Concepts, Computations, and Some Common Confusions. Span J Psychol. 2021;24:e49.
20. Adelowo AB. TEXILA INTERNATIONAL JOURNAL OF ACADEMIC RESEARCH. ACADEMIC RESEARCH. 2022.
21. Richter M, Mota S, Hater L, Bratek R, Goltermann J, Barkhau C, et al. Narcissistic dimensions and depressive symptoms in patients across mental disorders in cognitive behavioural therapy and in psychoanalytic interactional therapy in Germany: a prospective cohort study. Lancet Psychiatry. 2023;10(12):955-65.
22. Spruit A, Goos L, Weenink N, Rodenburg R, Niemeyer H, Stams GJ, et al. The Relation Between Attachment and Depression in Children and Adolescents: A Multilevel Meta-Analysis. Clin Child Fam Psychol Rev. 2020;23(1):54-69.
23. McIlveen R, Mitchell R, Curran D, Dyer K, Corry M, DePrince A, et al. Exploring the relationship between alienation appraisals, trauma, posttraumatic stress, and depression. Psychol Trauma. 2022;14(6):998-1006.
24. Fung HW, Lam SKK, Chien WT, Hung SL, Ling HW, Lee VWP, et al. Interpersonal stress mediates the relationship between childhood trauma and depressive symptoms: Findings from two culturally different samples. Aust N Z J Psychiatry. 2023;57(7):1052-61.
25. Kernberg OF. Psychoanalytic object relations theory revised: Affect systems and the notion of drives. Int J Psychoanal. 2024;105(5):790-803.
26. Scheerer NE, Boucher TQ, Iarocci G. Alexithymia is related to poor social competence in autistic and nonautistic children. Autism Res. 2021;14(6):1252-9.
27. Zhang J, Zhang Y, Mao Y, Wang Y. The relationship between insecure attachment and alexithymia: A meta-analysis. Current Psychology. 2024;43(7):5804-25.
28. Preece DA, Mehta A, Petrova K, Sikka P, Pemberton E, Gross JJ. Alexithymia profiles and depression, anxiety, and stress. J Affect Disord. 2024;357:116-25.
29. 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):144-53.
30. Preece DA, Mehta A, Petrova K, Sikka P, Bjureberg J, Becerra R, et al. Alexithymia and emotion regulation. J Affect Disord. 2023;324:232-8.
31. Li R, Kajanoja J, Karlsson L, Karlsson H, Karukivi M. Sex-specific role of alexithymia in associations between parental bonding and mental health: A moderated mediation model. J Clin Psychol. 2023;79(1):126-42.
32. Elling C, Forstner AJ, Seib-Pfeifer LE, Mücke M, Stahl J, Geiser F, et al. Social anxiety disorder with comorbid major depression - why fearful attachment style is relevant. J Psychiatr Res. 2022;147:283-90.
33. Liu Y, Duan L, Shen Q, Xu L, Zhang T. The relationship between childhood psychological abuse and depression in college students: internet addiction as mediator, different dimensions of alexithymia as moderator. BMC Public Health. 2024;24(1):2744.
34. Lu X, Li Z, Zhu X, Li D, Wei J. The Role of Alexithymia and Moral Disengagement in Childhood Physical Abuse and Depressive Symptoms: A Comparative Study Among Rural and Urban Chinese College Students. Psychol Res Behav Manag. 2024;17:3197-210.
35. Li M, D'Arcy C, Meng X. Maltreatment in childhood substantially increases the risk of adult depression and anxiety in prospective cohort studies: systematic review, meta-analysis, and proportional attributable fractions. Psychol Med. 2016;46(4):717-30.
36. Cresci M. Winnicott’s true self/false self concept: Using countertransference to uncover the true self. Psychoanalytic Perspectives on Knowing and Being Known: Routledge; 2019. p. 101-9.
37. Preece DA, Mehta A, Becerra R, Chen W, Allan A, Robinson K, et al. Why is alexithymia a risk factor for affective disorder symptoms? The role of emotion regulation. J Affect Disord. 2022;296:337-41.
38. Greenberg L. Changing emotion with emotion. Person-centered & experiential psychotherapies. 2023;22(4):368-83.
39. Abbass A, Town J. Intensive Short-Term Dynamic Psychotherapy for Complex, Chronic, and Treatment-Resistant Conditions. Am J Psychother. 2025:appipsychotherapy20240024.
40. Spain D, Musich FM, White SW. Psychological therapies for adults with autism: Oxford University Press; 2022.
41. Beygi Z, Tighband Jangali R, Derakhshan N, Alidadi M, Javanbakhsh F, Mahboobizadeh M. An Overview of Reviews on the Effects of Acceptance and Commitment Therapy (ACT) on Depression and Anxiety. Iran J Psychiatry. 2023;18(2):248-57.
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How to Cite
1.
Bagheri Salami J, Jangi Z. The Mediating Role of Alexithymia in the Relationship between Maladaptive Object Relations Patterns and Depression. Iran J Psychiatry. 2025;:1-8.
