Alexithymia predicts poorer social and everyday functioning in schizophrenia and bipolar disorder
Introduction
Bipolar disorder (BD) primarily features chronic and recurrent affective episodes that negatively affect functional outcome in at least two-thirds of patients (Huxley and Baldessarini, 2007). Additionally, BD patients also present with impaired psychosocial functioning (MacQueen et al., 2001, Sanchez-Moreno et al., 2009), even during affective remission. Initial clinical and demographic predictors of functional status have included older age, depressive symptoms, number of previous mixed episodes and hospitalizations (Rosa et al., 2009). However, subsequent research assessing everyday functioning in BD have demonstrated limited predictive ability of clinical and demographic factors (Martinez‐Aran et al., 2007, Tabarés-Seisdedos et al., 2008), suggesting that additional factors significantly contribute to functional status.
Poor overall functioning, including work, social, and everyday performance, is common among individuals with major psychiatric disorders such as BD and schizophrenia (SZ) (Ormel et al., 2008). Consistently neurocognitive deficits have been associated with lower overall functioning for both BD and SZ patients (Martinez-Aran et al., 2002, Tabarés-Seisdedos et al., 2008). Many BD patients present with impaired performance on neurocognitive domains of attention, memory, and executive function (Martínez‐Arán et al., 2004, Burdick et al., 2007), deficits that are associated with poorer psychosocial and everyday functioning (Martino et al., 2009, Sanchez-Moreno et al., 2009, Burdick et al., 2010). Similarly, SZ patients are impaired on most neurocognitive domains (Keefe et al., 2006) and these deficits are also associated with impaired social and occupational functioning (Bowie et al., 2010, Martinez-Aran et al., 2002). Impaired social cognition is also another predictor of poorer functional outcome, especially for SZ patients (Couture et al., 2006); this relationship exists for certain social cognitive domains, particularly emotion recognition, theory of mind, and social perception. Social cognitive deficits have also been observed in BD, particularly domains of emotion recognition and theory of mind (Bora et al., 2016, Samamé et al., 2012), although its relationship to functioning has been inconclusive (Lahera et al., 2013, Thaler et al., 2014). Current consensus supports the notion that neurocognition and social cognition are overlapping, yet partially separable constructs which contribute to functional status in a non-redundant manner (Mehta et al., 2013). Studies which have assessed the relationship between neurocognition, social cognition and functioning have observed a mediating effect of social cognition on the neurocognitive-functioning relationship in SZ, such that neurocognition predicts functional status through potential underlying social cognitive mechanisms (Schmidt et al., 2011). In BD, interestingly, social cognition has been shown to moderate this same relationship, suggesting the presence of social cognitive heterogeneity (i.e., differential neurocognitive-functioning relationships depending on the individual's social cognitive level) (Ospina et al., 2018). Overall, these relationships suggest that social cognitive ability may be dependent on more basic neurocognitive processes, both of which partially contribute to functional outcome.
While some domains of social cognition, such as theory of mind and emotion recognition, have been commonly examined in the psychiatric literature, alexithymia remains largely unexplored. Alexithymia is defined as a difficulty in recognizing and articulating the emotional experiences of the self (Sifneos, 1972), and may relate to domains of emotion self-regulation and self-awareness (Taylor et al., 1999). Aspects of alexithymia include: 1) difficulty in identifying and describing feelings, 2) difficulty distinguishing feelings from bodily sensations, 3) a deficit in symbolic thinking, and 4) a tendency to focus attention externally. Clinically, individuals with alexithymia avoid speaking about their feelings; instead they describe the logic of their cognitive and behavioral actions. Their speech is monotonous, stilted, and lacks richness. While they may not admit to feeling clinical symptoms, such as depression or anxiety, they may complain about physical symptoms. They are also characterized by an impoverished fantasy life, impaired emotional functioning, and present with difficulty in interpersonal relationships (Taylor, 1984). Given this inability to recognize self-referential cognitive states, alexithymia has been theorized to partially represent deficits in metacognition (Dimaggio et al., 2009), with certain metacognitive strategies correlating with aspects of alexithymia (Babei et al., 2016). Studies in BD have generally shown that BD patients present with higher alexithymia scores, particularly difficulty in identifying and describing feelings, compared to healthy controls (HCs) (Herold et al., 2017, Yilmaz et al., 2016). Interestingly, studies comparing psychotic versus non-psychotic axis I disorders (as well as one study comparing BD to major depressive disorder) revealed no difference in alexithymia between the diagnostic groups (Heshmati et al., 2010, Karayağız and Baştürk, 2016, Picardi et al., 2012), suggesting that alexithymia may not reliably differentiate between mood and psychotic disorders and may in fact be a characteristic of major psychiatric illnesses in general.
Studies in SZ have reported higher alexithymia scores compared to HCs (Cedro et al., 2001, Van't Wout et al., 2007). Furthermore, recent studies have also found alexithymia to predict psychosocial functioning in SZ patients (Kimhy et al., 2012) as well as in individuals at high risk for psychosis (Kimhy et al., 2016), wherein difficulty in describing feelings accounted for a significant amount of variance in predicting psychosocial functioning above and beyond the predictive ability of neurocognitive and other social cognitive domains. Measures of metacognition have also been shown to predict psychosocial and everyday functioning in SZ (Arnon-Ribenfeld et al., 2017, Fogley et al., 2014), and like social cognition, deficits in metacognitive processes have also been shown to mediate the relationship between neurocognition and social functioning in SZ patients (Lysaker et al., 2010). However, while they may share common underlying mechanisms, social cognition and metacognition may represent distinct constructs which relate to social functioning in differing ways (Fogley et al., 2014). To date, only one study in BD has evaluated the effect of alexithymia on functioning, focusing on quality of life; higher alexithymia scores predicted lower quality of life in both BD and depressed patients (Karayağiz et al., 2016). However, it remains unclear whether alexithymia predicts other functional outcomes in BD, as has been shown in SZ.
Most studies have generally shown greater alexithmyia in psychiatric populations compared to HCs, with little to any distinction between specific major psychiatric disorders. Some studies have also demonstrated an association between alexithymia and functioning, particularly in SZ. However, alexithymia research in BD is scant, particularly regarding diagnostic comparisons of alexithymia between BD and other psychiatric disorders, as well as determining alexithymia's predictive ability of functional outcomes in BD. The current study aimed to extend the literature regarding alexithymia in a BD sample, specifically: 1) to compare BD, SZ, and HC groups on alexithymia domains, and 2) assess whether alexithymia domains predict functional outcomes within a BD group. First, we hypothesized that BD would not be distinguishable from SZ on alexithymia domains, given prior research (Karayağız and Baştürk, 2016, Picardi et al., 2012). Second, given commonalities (i.e., clinical, genetic, and neurobiological) between BD and SZ, we posited that alexithymia would predict functioning in BD patients, since this relationship has been observed in SZ individuals (Kimhy et al., 2012). Finally, we aimed to explore the predictive ability of alexithymia above and beyond previously identified factors, such as neurocognition and social cognition, transdiagnostically in our overall sample. Since other social cognitive domains (and to some degree, metacognition) have demonstrated modulating effects on the neurocognitive-functioning relationship (Lysaker et al., 2010, Ospina et al., 2018, Schmidt et al., 2011), we hypothesized that alexithymia would account for some of the predictive variance on functional outcome in our overall sample.
Section snippets
Participants
The sample consisted of 151 participants diagnosed with: either BD I (n = 46) or BD II (n = 10), schizophrenia (n = 23) or schizoaffective disorder (n = 22), and HC (n = 50). All participants were recruited at Icahn School of Medicine at Mount Sinai in an R01-funded study between 2012 and 2017; recruitment advertisements were posted throughout the metropolitan, NYC area. All procedures were approved by the Institutional Review Board and we obtained written informed consent from all
Sample characteristics
Diagnostic group comparisons for demographics, clinical and alexithymia scores are presented in Table 1. BD, SZ and HC groups performed comparably on most demographics; however, HCs were significantly younger than SZs. Also, SZ patients completed fewer years of education compared to the BD and HC groups. Both BD and SZ groups reported higher depressive and manic symptoms and worse premorbid IQ compared to HCs. Regarding alexithymia, both BD and SZ groups had more difficulty in describing and
Conclusion
The present study is the first to investigate differences in alexithymia between BD, SZ, and HC groups, as well as examine the predictive ability of alexithymia on functioning in BD. Additionally, we aimed to identify demographic, clinical, neurocognitive and social cognitive (including alexithymia) predictors of everyday and social functioning for all diagnostic groups simultaneously. Our diagnostic groups were comparable on most demographics, with BD and SZ groups presenting with higher
Acknowledgments
This study was funded by Grants from the National Institute of Mental Health (NIMH) to KEB (R01 MH 100,125; R34 MH101267; R01 MH102257) and the Veterans Administration (VA) Health system to KEB (I01CH000995).
Conflict of interest
Dr. Burdick has served as an advisory board member for Dainippon Sumitomo Pharmaceutical, Otsuka Pharmaceuticals, Neuralstem, and Takeda Lundbeck, which had no impact upon the work presented in this manuscript. All other authors report no competing interests regarding the present study.
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