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The relationship of alexithymia, interpersonal problems and self-understanding to psychological distress in college students.

College counseling centers assess and treat students suffering from psychological distress. This distress typically results from difficulty coping with life stressors and may impact students' abilities to focus on classwork. Most of these stressors involve interpersonal relations such as problems with making friends or finding a romantic partner, or difficulty resolving conflicts with roommates (Diemer, Wang, & Dunkle, 2009; Erdur-Baker, Aberson, Barrow, & Draper, 2006). Development of such psychological distress may be brought about by a relative constriction in emotional functioning or alexithymia (Sifneos, 1973), decreased self-awareness (Luborsky, 1984), and interpersonal problems (Sullivan, 1953). The effects of maladaptive interpersonal patterns and emotional expressivity on psychological problems or distress are not well understood. Thus, we sought to examine the relative impact of alexithymia, interpersonal problems, and levels of self-understanding on the manifestation of psychological distress in college students.

Alexithymia is a multi-dimensional cognitive and affective disturbance characterized by difficulty identifying and distinguishing feelings (Bagby, Parker, & Taylor, 1994a; Parker, Keefer, Taylor, & Bagby, 2008). Awareness of the nuances within one's emotional life may be an important factor in the resolution of interpersonal difficulties. Individuals who are aware of their internal affective states will be better prepared to act or react in an adaptive way when offended. However, people exhibiting alexithymic tendencies may become unresponsive, confused, or react in a hostile manner (Fukunishi, 1994). Therefore, alexithymia may contribute to difficulties understanding and communicating with others. Because of this lack of self-awareness, individuals with alexithymia may develop faulty perceptions of self, or be deficient in self-understanding. This difficulty with self-understanding, or insight, coupled with impaired interpersonal functioning for those with alexithymia are likely to increase psychological distress. Additionally, individuals experiencing alexithymia may also be more likely to be diagnosed with specific disorders as well as experience difficulties in being treated for specific problems such as persistent depression (Ogrodniczuk, Piper, & Joyce, 2004), and interpersonal problems (Vanheule, Desmet, Meganck, & Bogaerts, 2007).

Interpersonal Problems

An important aspect of being human is the need for, and ability to participate in, interpersonal relationships (Frances, 1996). The ability to be interpersonally flexible, or to adjust one's behavior to suit changing interpersonal situations, bears directly on one's psychological adjustment (Cheng, Lau, & Chan, 2014; Leary, 1957). When an individual demonstrating alexithymia and low levels of self-understanding, is confronted with an interpersonally difficult situation, he or she may react by employing an inflexible pattern of behavior (Paulhaus & Martin, 1988). One such pattern or personality capability may be characterized by an individual with symptoms of alexithymia, who might respond in an angry or hostile manner leading to interpersonal loneliness (Qualter, Quinton, Wagner, & Brown, 2009). This becomes problematic as such a response does not facilitate open communication in a dyad, which hampers resolution of the problem at hand.

Self-understanding (i.e., insight) traces its roots back to the origins of psychoanalysis and has been an important factor in dynamic psychotherapy. Freud (1914/1958) stated the primary goal of analysis is to uncover and understand the situations which give rise to symptom formation. Insight, or the affective experiencing and cognitive understanding of current maladaptive patterns of behavior (Strupp & Binder, 1984), then becomes the key to exploration of both the conscious and unconscious realms of existence. The counseling interview is the therapeutic context in which insight can occur. In this interview, the participants actively manage events in order for a common understanding (insight) about their work to be made possible (Patton & Meara, 1992). The importance of this social situation must be stressed. An individual's problems may trace back to patterns of interaction early in his or her life (Sullivan, 1853), and interpersonal interaction, or relationship between the individual (client) and another (therapist), initiates their resolution (Prochaska, 1979). Thus, in the use of psychodynamic therapy, self-understanding is the most important agent of change.

Psychological dysfunction refers to a breakdown in cognitive, emotional or behavior functioning that leads to distress or impairment of functioning (Barlow & Durand, 2005). Thus, this study examines variables which may contribute to psychological distress. For example, individuals with symptoms of alexithymia have difficulties with the affective component of interpersonal relationships, resulting in maladaptive expression of anger (Berenbaum & Irvin, 1996) and anxiety (Karukivi, Hautala, Kaleva, Haapasalo-Pesu, Liuksila, Joukamaa, & Saarijarvi, 2010), which may lead to personal and therapeutic difficulties (Krystal, 1979 & Krystal, 1982-83). Likewise, their capability for, and acquisition of emotional insight would be impaired or impossible (Luminet, Bagby, Wagner, Taylor, & Parker, 1999; Parker, Taylor, & Bagby, 2001).

Individuals identified as alexithymic will also evidence weaknesses in self-understanding, or insight, and impaired or inflexible interpersonal functioning, resulting in increased psychological distress (Liang & West, 2001; Nicolo, et.al, 2011; Spitzer, Siebel-Jurgen, Barnow, Grabe, & Freyberger, 2005;). Thus, the primary purpose of this study was to examine possible predictor variables of psychological distress among college students. Specifically, this study was to ascertain if a significant relationship existed between alexithymia, self-understanding, interpersonal problems, and psychological distress among college students. Then, if significant relationships do exist between the aforementioned variables, to what degree do alexithymia, self-understanding and interpersonal problems predict psychological distress?

METHOD

Participants

The participants in this study were students from a large Midwestern university and a small, private Midwestern college. A total of 234 students completed the questionnaires, 62 (26.5%) men and 172 (73.5%) women. The mean age of the sample was 25.11 (SD = 8.40) with a range of 18 to 58. Of the 234 participants, 205 (87.6%) were Caucasian, 12 (5.1%) were African-American, 5 (2.1%) were Asian, 2 (.85%) were Asian-American, 4 (1.7%) were American Indian, and 5 (2.1%) were Hispanic. One participant indicated "other" as a racial classification (.004%).

The participants included 40 (17.1%) freshmen, 56 (23.9%) sophomores, 59 (25.2%) juniors, 55 (23.5%) seniors and 24 (10.3%) graduate students. In terms of participants' relationship status, 95 (40.1%) had never been married and were not currently in a romantic relationship, 73 (31.2%) were in a relationship with a significant other, 45 (19.2%) were married, 19 (8.2%) were divorced and 2 (.85%) were widowed.

Measures

Demographic Questionnaire. The demographic questionnaire included such items as age, gender, ethnicity, level of education, and current relationship status.

Toronto Alexithymia Scale-20. The Toronto Alexithymia Scale-20 (TAS-20; Bagby, Parker & Taylor, 1994b) is a 20-item, self-report instrument that measures three facets of the alexithymia construct within an adult and late adolescent population (Parker, Eastbrook, Keefer, & Wood, 2010). The first facet is difficulty identifying feelings (e.g., "I am often confused about what emotion I am feeling."). The second facet is difficulty describing feelings (e.g., "It is difficult for me to find the right words for my feelings."). The third facet involves items which elicit externally-oriented thinking (e.g., "I prefer to just let things happen rather than to understand why they turned out that way."). Responses to the TAS-20 are scored on a 5-point Likert scale ranging from 1 = "strongly disagree," to 5 = "strongly agree." Alexithymia is determined by the sum of the items (items 4, 5, 10, 18 & 19 reverse-scored) with scores of 61 or greater indicating a presence of alexithymia and scores 60 and less indicating the absence of alexithymia.

Confirmatory factor analysis of the TAS-20 indicated that the three-factor structure is stable and replicable across clinical and non-clinical populations. Factor analysis yielded three intercorrelated factors that are congruent with the theoretical construct of alexithymia. High coefficient alphas obtained for the full TAS-20 across samples indicated excellent internal consistency (Bagby et al., 1994b). Homogeneity was also confirmed by the values of the mean inter-item correlation coefficients. The TAS-20 also demonstrates good test-retest reliability (Bagby, et al., 1994b). Convergent validity estimates indicate the TAS-20 is consistent with theoretical underpinnings and clinical observations that suggest individuals with alexithymia cope poorly with stress (Bagby, et al., 1994a; Parker, et al., 1993).

Inventory of Interpersonal Problems--Short Circumplex Form. The IIP-SC (Soldz, Budman, Demby, & Merry, 1995;) is a 32-item subset of the 64-item IIP-C "Circumplex Form" developed by Alden, Wiggins, and Pincus (1990) from the original 127-item Inventory of Interpersonal Problems (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988) which has demonstrated adequate psychometric properties with an undergraduate sample (Hopwood, Pincus, DeMoor, & Koonce, 2008). The IIP-SC contains 18 items preceded by the phrase "It is hard for me to" (e.g., "tell a person to stop bothering me," "show affection to people") and 14 items describing interpersonal behaviors a person may do too much (e.g., "I try to control other people too much," "I am too suspicious of other people"). The 32 items are arranged in eight 4-item "octant scales" that factor analysis suggests provide a close representation of the two-dimensional interpersonal circumplex, with its underlying orthogonal Affiliation and Dominance scales. In three samples of clients, the authors report that internal consistency (coefficients) ranged from .69 to .84 for all scales. Test-retest reliabilities for a group of clients in treatment (n = 55, interval = 8 weeks) ranged from .61 to .79 for the eight subscales. Correlations of the 32-item IIP-SC subscales with the corresponding subscales of the 64-item IIP-Circumplex scale ranged from .91 to .98.

Self-Understanding of Interpersonal Patterns, The Self-Understanding of Interpersonal Patterns (SUIP; Connolly, et al., 1999; Gibbons, 2004) is a non-forced choice assessment wherein the participant is presented with 19 interpersonal pattern questions they can respond to with a "yes" or "no" to indicate whether the interpersonal pattern is relevant to their current life. Participants are then instructed to complete a 4-point (A through D) Self-Understanding rating for each item they endorse with "yes." The SUIP was designed to measure self-understanding as the understanding of maladaptive interpersonal patterns. By using Luborsky's Core Conflictual Relationship Theme (CCRT; Luborsky, 1977; Luborsky & Crits-Christoph, 1990), three components of a client's maladaptive relationship patterns are defined: 1) client wishes or needs; 2) perceived responses of others toward client; 3) client responses in interpersonal relationships. Self-understanding is further defined across a continuum from recognition of a problem pattern to understanding of the historical origins of the problem.

The original item pool for the SUIP was selected from three sources: 1) problems in self-understanding reported by psychotherapy clients (Connolly & Strupp, 1996), 2) contributions from expert therapists and graduate students, and 3) the CCRT standard category list (Barber, Crits-Christoph, & Luborsky, 1990). After several iterations, the final version of the SUIP was given to five experts (researchers and clinicians) to rate the content validity of the measure. Five studies, using clinical and non-clinical samples, were then conducted and these studies demonstrated acceptable reliability (both internal consistency and test-retest) as well as content validity, discriminant validity, convergent validity, and construct validity of the SUIP.

Brief Symptom Inventory The BSI (Derogatis, 1993) is a 53-item self-report symptom inventory. Respondents rate the extent to which a given symptom has been distressing them, using a scale ranging from 0 ("not at all") to 4 ("extremely"). Raw scores are obtained by summing the item scores for each dimension. The variable used in this study was the Global Severity Index (GSI) which has been reported to be the best single indicator of a respondent's level of distress (Derogatis, 1993). The GSI raw scores were converted to standardized t-scores using published norms. The test-retest reliability of the GSI for a 2-week period is .90, and excellent convergent and construct validity have been reported (Derogatis, 1993).

Procedure

The packets of questionnaires were distributed, completed and returned during the first part of one class period. Completion of the packets was voluntary. When the packets were returned, each packet was assigned an identification number for data coding purposes, to ensure that individual responses remained anonymous. All participants were invited to contact the primary researcher for debriefing. Each packet consisted of a demographic form and the following instruments: the Toronto Alexithymia Scale-20 (TAS-20; Bagby, Parker & Taylor, 1994b), the Inventory of Interpersonal Problems-32 Short Circumplex Form (IIP-32; Soldz, et al., 1995), the Self-Understanding of Interpersonal Patterns (SUIP; Connolly et al., 1999) and the Brief Symptom Inventory (BSI; Derogatis, 1993). The order of these instruments within packets was randomly assigned.

RESULTS

The means, standard deviations, skewness and kurtosis for all variables are presented in Table 1. The means obtained from this sample on these measures were similar to those obtained by other researchers with college student participants (TAS-20; Bagby, et al., 1994b, Schmitz, 1999; SUIP; Connolly, et al., 1999; BSI; Derogatis, 1993; IIP-32; Soldz, et al., 1995). Consistent with previous research (Fukunishi, 1994; Schmitz, 1999), alexithymia as defined by a score of 61 or greater on the TAS-20 was present in a significant proportion, (29 or 12.4%) of this college student sample. Skew and kurtosis for all measures except the BSI indicate a normal sample distribution (Hayes, 1997).

Scale intercorrelations were examined to 1) determine which predictor variables were significantly correlated with the criterion measure and 2) assess for multicollinearity. The two subscales of the Self-understanding of Interpersonal Patterns Scale (self-understanding and awareness of patterns) were highly and significantly correlated with each other (r = .86 p < .001). To avoid multicollinearity, only the subscale "self-understanding" was retained in the regression analysis. The decision to remove "awareness of patterns," rather than combine the two scales was made given the related nature of the scales. Specifically, the "awareness of patterns" score is a result of the "self-understanding" score (i.e., "awareness of patterns" scores can only occur if the participant answered yes to a "self-understanding" question). As the purpose of this study was to examine self-understanding, and not awareness of patterns per se, the latter was dropped from further analysis.

Internal Consistency Estimates

Internal consistencies in this study were similar to those found for college students by the authors of each instrument (TAS-20; Bagby, et al., 1994b; SUIP; Connolly, et al., 1999; BSI; Derogatis, 1993; IIP-32; Soldz, et al., 1995). Cronbach alphas for all measures were very strong: .78 for self- understanding (SUIP), .86 for alexithymia (TAS-20), .89 for interpersonal problems (IIP), and .86 for psychological distress (BSI).

Primary Analyses

To determine if alexithymia, self-understanding, and interpersonal problems are possible predictors of psychological distress among college students, bivariate correlations were calculated. All correlations were significant at the p < .01 significance level or less. A statistically significant positive relationship exists between alexithymia and psychological distress (r = .48, p < .001); interpersonal problems and psychological distress (r = .57, p < .001); and self-understanding and psychological distress (r = .30, p < .001). These correlations suggest that the students' psychological distress was significantly associated with level of alexithymia present, the number of reported interpersonal problems and level of self-understanding. While the significant positive relationship between self-understanding and psychological distress may at first seem counter intuitive, it will be discussed in the next section.

A Pearson Product Moment Correlation Coefficient demonstrated that the relationship between alexithymia and self-understanding (r = .12, p = .07) was not significant at the .05 level. Thus, alexithymia is not statistically significantly related to self-understanding. Self-understanding is not strongly associated with difficulties expressing or experiencing emotion for the students sampled. A Pearson Product Moment Correlation Coefficient demonstrated that the relationship between alexithymia and interpersonal problems (r = .50, p < .001) was significant. Students who have difficulties expressing or experiencing emotions also appear to report more problems with interpersonal relationships.

Given that all three hypothesized predictor variables were significantly related to psychological distress, a hierarchical regression analysis was conducted. Thus, alexithymia, interpersonal problems and self-understanding were the predictor variables and psychological distress the criterion. Results indicated that the three predictor variables were significantly predictive of psychological distress [F (3, 230) = 48.282, p < .001, [R.sup.2] = .386] (See Table 2). The independent variables alexithymia, interpersonal problems, and self-understanding are significantly predictive of the dependent variable, psychological distress, with self-understanding contributing only a minor, non-significant amount (about 1%) of additional variance over the other two variables combined.

DISCUSSION

As anticipated, the presence of alexithymia and interpersonal problems predicted more psychological distress. The addition of self-understanding provided only a minor additional contribution which was not statistically significant. In addition, college students with alexithymia were more likely to be psychologically distressed and have relationship issues.

Before examining how problems in affect regulation are related to relationship problems and psychological distress, it seems important to discuss how these variables relate to one another in individuals without alexithymia. People who feel confident in their ability to regulate negative or painful moods have an internal locus of control that allows them to take an active role in modulating their emotions (McLean & Pietroni, 1990). The expectations of effective mood regulation allow individuals to self-care and enhance their lives, making them more likely to have good mental health and fewer psychological symptoms (Catanzaro & Greenwood, 1994; Gross & Munoz, 1995; Horton, et. al., 1989).

People who have developed secure attachments (Bowlby, 1969) in early childhood learned that when they experienced an unpleasant emotion, their attachment figure or caregiver was available and responsive to their needs. Therefore, the person knows that when they are having a painful experience, they can turn to others for support (Kobak & Sceery, 1988). Thus, securely attached individuals are able to acknowledge and cope with negative emotions, are self-confident, socially skilled, open to and interested in close relationships with romantic partners, and are likely to form relatively stable and satisfying long-term relationships (Cooper, Shaver & Collins, 1998).

Consistent with previous research (Haviland & Reise, 1996; Horton, 1981; Krystal, 1977; Krystal & Raskin, 1970), students in the present study with an inability to experience a full range of emotions have problems relating with others and more psychological complaints. This was not surprising considering the importance of emotional awareness and regulation on psychological health (Cooper, Shaver & Collins, 1998; Madioni & Mammana, 2001; Saarijarvi, Salminen & Toikka, 2001).

Consistent with the results of this study and previous research (Connolly, et al., 1999), self-understanding was significantly related to interpersonal problems and distress, and was not significantly related to alexithymia. Thus, students were aware of psychological symptoms and problems within their interpersonal lives regardless of a lack of emotional expressivity. This result is conceptually consistent for several reasons. First, a person's self-understanding is enhanced or they become keenly aware when there is an experienced pain or deficit in their needs, wishes and interpersonal reactions (Luborsky, 1977). Additionally, a person who does not effectively understand and express their affect may develop problems or coping styles that would be difficult for partners or friends, such as overeating (Lawless, 1996), drug use (Krystal & Raskin, 1970), depression (Catanzaro & Greenwood, 1994), somatic complaints (Nemiah & Sifneos, 1970) and sexual difficulties (Madioni & Mammana, 2001). While such persons' problems may be reflected back upon them by others (e.g., a friend telling them to get help) they would not be aware of the emotional component of their problems and rely on others for emotional regulation (McLean & Pietroni, 1990). Thus, while alexithymia and self-understanding were predictive of distress, self-understanding was not significantly predictive of psychological distress when interpersonal problems were taken into account.

Implications

This study contributed to the empirical literature in the areas of alexithymia, interpersonal problems, self-understanding and psychological distress. It examined the presence of alexithymia in a non-clinical, college student population while the majority of alexithymia research has examined this condition in outpatient populations. As supported by Fukunishi (1994) and Schmitz (1999), alexithymia was present in a significant proportion 29 or 12.4% of this college student sample.

This research has several implications for counseling practice. First, therapists can help their clients to ameliorate symptoms of psychological distress by employing interpersonal interventions to help address their difficulties in interacting empathically with others. Through careful development of a trusting working alliance, the counselor can facilitate exploration of salient family of origin dynamics to increase a client's awareness of the effects of maladaptive internalized objects and attachment relationships formed early in life. It is through the working alliance or therapeutic relationship that the counselor can model adaptive affect expression by validating the importance of emotion. Additionally, if the client has been raised with a belief that his or her emotions are toxic or unimportant, the therapist can help provide in vivo, corrective emotional experiences designed to provide insight into the helpful nature of emotions. By providing an environment which gently fosters emotional expressivity, through allowing the client to convey emotions in-the-moment, the therapist can set the stage for the client to express affect in everyday life.

Second, counselors may recognize signs of alexithymia and initially play a more active role in helping clients recognize physiological cues that accompany affect to learn to identify and express feelings and to tie cognitive meaning to their emotional states (Freyberger, 1977; Krystal, 1978). The therapist can encourage the client to perceive, differentiate and express bodily feelings as they occur in therapy. Clients can further be encouraged to explore physiological manifestations of affect through creative expression such as the therapeutic use of art or music. Thus, a clinician recognizing an affect-producing stimulus can suggest that clients express their reactions in a novel manner. By doing so, the clients learn more about their emotional states as well as new ways to express affect.

Additionally, counselors can help clients increase relationship satisfaction by exploring their emotional lives and learn how to modulate painful affective states. Queries into the dynamics of specific interpersonal relationship situations may facilitate enhanced awareness of the importance of sharing affective reactions within a relationship.

The main limitation of this study was the homogeneity of the sample. While beneficial for internal validity, the majority of the sample included young, Caucasian women from the midwestern United States. Thus, the sample may not be representative of the diversity found on other college campuses in terms of students' racial and cultural backgrounds. While attempts were made to obtain equal samples of men and women, the actual sample was primarily women. Therefore the generalizability of the results may be limited in terms of conclusions drawn for adults in the general population and college students

To increase external reliability and generalizability, further research should involve changes. That is, research should be conducted with a more culturally diverse sample. While this study looked at psychological distress in a global or general sense, future studies could examine the effects of alexithymia, interpersonal problems and self-understanding on specific clusters of symptoms. It is not known at this time whether differences exist between the effects of alexithymia, interpersonal problems and self-understanding on depressive, anxious, somaticizing or psychotic symptoms.

Based on the results of this study, it can be concluded that problems with affect regulation, interpersonal problems and self-understanding difficulties contribute to psychological distress. College students with symptoms of alexithymia are not able to draw upon their internal, affective states to guide them through interpersonal interactions or help them develop adaptive coping skills. Such individuals may therefore experience greater symptoms of psychological distress.

Individuals with alexithymia may seek therapy for the relief of symptoms of distress and be unaware of the importance of their own emotions. Thus, the therapist must be aware of their clients' family of origin issues that may have led to a lack of awareness and interpersonal difficulties. Counselors so informed may actively work with the students to develop interventions which may improve interpersonal relationships, self-understanding, affective expressivity and in turn, a decrease in symptoms of psychological distress and an improvement in functioning, such as greater focus on college studies.

Steven Schuetz

University of Central Missouri

Karen D. Multon

University of Kansas

Author info: Correspondence should be sent to: Dr. Steven Schuetz, Dept.of Psychological Science, University of Central Missouri, Warrensburg, MO 64093

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North American Journal of Psychology, 2017, Vol. 19, No. 1, 139-154.
TABLE 1 Means, Standard Deviations, Skewness, & Kurtosis Values
for all Variables

Variable     M     Range     SD      Skew    Kurtosis

GSI        58.32    0-80    12.66   -1.445     .78
ALX        44.28   21-85    11.95    .37       -.18
IP         62.74   33-107   15.39    .38       -.23
SUIP       6.74     0-18    4.12     .57       .76

Note. GSI = Global Severity Index of the Brief Symptom Inventory;
ALX = Toronto Alexithymia Scale-20; ; IP = Inventory of
Interpersonal Problems; SUIP = Self-Understanding of Interpersonal
Patterns. N = 234.

TABLE 2 Summary of Multiple Regression Analysis Predicting
Psychological Distress

Variable      B     SE B   [R]     t

Step 1ALX    .51    .06    .48   8.42 *
Step 2ALX    .28    .06    .26   4.48 *
  IP         .35    .05    .44   7.30 *
Step 3 ALX   .29    .06    .28   4.69 *
  IP         .32    .05    .38   5.82 *
SUIP         2.10   1.17   .10    1.80

Note. [R.sup.2] = .234, [cross product][R.sup.2] = .234 for step 1.
[R.sup.2] = .38, [cross product][R.sup.2] = .14 for Step 2.
[R.sup.2] = .39. [bar.[cross product][R.sup.2]] = .01 for Step 3.
(*p < .05) ALX = Toronto Alexithymia Scale-20; IP = Inventory of
Interpersonal Problems; SUIP = Self-Understanding of Interpersonal
Patterns. Psychological Distress measured by the Global Severity
Index of the Brief Symptom Inventory. N = 234.
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Author:Schuetz, Steven; Multon, Karen D.
Publication:North American Journal of Psychology
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Date:Mar 1, 2017
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