Mothers' alexithymia, depression and anxiety levels

Int J Psychiatry Clin Pract 2014; 18: 190–196. © 2014 Informa Healthcare ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2014.940055

ORIGINAL ARTICLE

Mothers’ alexithymia, depression and anxiety levels and their association with the quality of motherinfant relationship: A preliminary study

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Esra Yürümez1, Ömer Faruk Akça2, Çağatay Uğur3, Runa Idil Uslu3 & Birim Günay Kılıç3 1

Department of Child and Adolescent Psychiatry, Ufuk University Medical School, Ankara, Turkey, Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Medical School, Konya, Turkey, and 3Department of Child and Adolescent Psychiatry, Ankara University Medical School, Ankara, Turkey

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Abstract Objective. To evaluate the relationship between mothers and their developmentally normal infants in terms of maternal alexithymia, depression and anxiety, and marital satisfaction. Methods. Fifty children between 18 and 48 months of age, and their mothers, were referred consecutively to the Infant Mental Health Unit of Ankara University School of Medicine, Department of Child and Adolescent Psychiatry. The sociodemographic features of the families and the depressive symptoms, anxiety, marital satisfaction and alexithymia levels of the mothers were assessed. The relationships between children in normal developmental stages and their mothers were evaluated and rated using a structured clinical procedure. Results. There was a negative correlation between the mothers’ alexithymia scores and the quality of the mother-infant relationship (p ⬍ 0.05). Mothers with high alexithymia showed higher depression and lower relationship qualities than mothers with low alexithymia, according to the correlation analysis. When depression and anxiety were controlled, high alexithymia levels were predictive of a low, impaired mother-infant relationship. Conclusion. Since alexithymia is a trait-like variable which has a negative correlation with impairment in a mother-infant relationship, it must be investigated in the assessment of mothers’ interactions with their babies. Key words: Alexithymia, mother-infant interaction, mother-child relationship, mothers’ depression and anxiety (Received 10 January 2014; accepted 24 April 2014)

Introduction The mother-infant interaction is one of the most predictive factors in the development of many psychiatric disorders. The quality of interaction (i.e., sensitive, positive behaviors and reciprocal attention), which is one of the most acknowledged indices of the parent-child relationship, has implications for subsequent social interactions (Ainsworth et al. 1978) and is known to be associated with further emotional, cognitive and behavioral outcomes (Valentino et al. 2006). Specifically, the pattern and quality of care regulate the infant’s brain function and behavioral expression that determine long-term emotional regulation. The general aspects of the parent-child relationship (such as non-stressful play and social communication) are suggested to be directly relevant to parent-child attachment styles (Pederson and Moran 1999). Additionally, other caregiver-related risk factors such as psychiatric disorders, maltreatment and low socioeconomic status have a negative impact on attachment (Carlson et al. 1989).

Correspondence: Esra Yürümez, Department of Child and Adolescent Psychiatry, Ufuk University Medical School, Mevlana Quarter, number: 86–88, Balgat, Ankara, 06520, Turkey. Tel: ⫹ 90-506-626-8078. Fax: ⫹ 90-312-204-4088. E-mail: [email protected]

Alexithymia is a term used to describe people who have difficulties recognizing, processing and regulating emotions (Dereboy 1990), and is a feature that defines personality rather than a diagnosis (Taylor 1984). It is characterized by an inability to describe and identify feelings, the tendency to utilize an externally focused, analytical cognitive style, and limited fantasy and daydreaming (Tani et al. 2004). In recent years, alexithymia has been accepted as a personality trait that leads to greater risks of several medical and psychiatric disorders. Particularly, it is stated to be a predisposing factor for psychosomatic problems and affective disorders (Feldman et al. 2002). A positive, strong association between alexithymia and depression has been found in both psychiatric (Duddu et al. 2003) and non-psychiatric populations (Mueller et al. 2003). Other studies have noted the relationship between alexithymia and particular psychiatric disorders such as eating disorders, substance use, panic disorder, social phobia and conversion disorders (Parker et al. 1993), and personality disorders such as borderline personality disorder (Deborde et al. 2012). More specifically, high alexithymia has been found to be associated with high anxiety sensitivity (Devine et al. 1999). However, minimal research has been focused on the relationship among depression, anxiety and alexithymia in mothers.


DOI: 10.3109/13651501.2014.940055

In addition to psychiatric disorders, a relationship between attachment style and alexithymia has been indicated in studies on alexithymia (Hexel 2003). More specifically, individuals who have an insecure attachment style have higher alexithymia levels, compared to securely attached subjects (Meins et al. 2008). Therefore, we may conclude that alexithymia is a trait variable which affects attachment style, as well as particular psychiatric and personality disorders. Given that alexithymia is a feature that affects understanding and expressing emotions, we hypothesised that maternal alexithymia levels may affect the quality and nature of the mother-infant relationship. Accordingly, mothers with alexithymia have a limited capacity to experience positive emotions such as joy and happiness in their relationships, and they are unempathetic and ineffective in modulating the emotional states of their children (Goleman 1995). Couple conflict has also been shown to produce a negative emotional climate in the family, which has negative effects on relationships (Cummings and Merrilees 2010). Results suggest that mothers with depressive symptoms report lower levels of marital satisfaction and higher levels of behavioral problems in their children (Meyers and Landsberger 2002). Individuals interact with one another in a family and affect one another through their personal risk factors and the quality of their relationships (couple dyad), which can then have a spillover effect on their relationships with others (Coley and Hernandez 2006). In light of this knowledge, we hypothesized that alexithymia may affect the quality of the relationship between mother and child. This study’s main aim was to explore the alexithymia level of the mother and its association with the quality of the mother-child relationship. The study also aimed to evaluate the impact of the severity of the mother’s depression and anxiety symptoms and her marital satisfaction on the quality of the mother-child relationship. Methods Participants The sample comprised 50 young children and their mothers who were assessed at an outpatient Infant Mental Health Unit of a university hospital. Referrals were mainly from the Child and Adolescent Psychiatry and Pediatrics Departments of the same university hospital. Children having chronic illnesses, mental and developmental retardation, autism spectrum disorders and uncorrected visual and auditory problems were excluded. Of the participants, 43% (n ⫽ 22) were girls and 57% (n ⫽ 29) were boys. The mean age of the children was 32.4 months (18–48 months), and the mean age of the mothers was 31 (22–47) years. The maternal education levels of primary school, high school and university were 33.3%, 27.5% and 39.2%, respectively. Measures Sociodemographic form. A sociodemographic questionnaire that comprised queries on the perinatal and developmental history, mother’s age, education level, profession, number of

Alexithymia and mother-infant relationship 191 children, physical and mental illnesses, social support of the family and other family members, was used. Toronto Alexithymia Scale. The Toronto Alexithymia Scale (TAS) is a validated, self-report questionnaire to measure alexithymia in which participants indicate the extent of their agreement or disagreement with statements on a five-point Likert scale (Bagby et al. 1994). We used the total score and scores of three subscales: difficulty identifying feelings, difficulty describing feelings and externally oriented thinking. The Turkish version of the TAS-20 has been found to have a good internal consistency, and a three-factor structure is consistent with the theoretical construct (Güleç et al. 2009). Beck Depression Inventory. The Beck Depression Inventory (BDI) was developed to determine the risk of depression in the individual and to measure the severity of depressive symptoms and the change in severity. Its original form was developed by Beck (Beck et al. 1988a). Its reliability and validity were studied in Turkey by Hisli (1989). The cutoff score in the Turkish version is 17. Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI) is a Likert-type, self-evaluation scale containing 21 items. A high overall score indicates a high level of anxiety. It was developed by Beck (Beck et al. 1988b), and its reliability and validity study in Turkey was carried out by Ulusoy et al. (1998). Marital Satisfaction Scale. The Marital Satisfaction Scale (MSS) is a Likert-type, self-report scale containing 13 items to assess the marital satisfaction of couples. Internal consistency and test-retest reliability calculations were done by Celik and İnanc (2009). A factor analysis revealed three factors: family, sex and self. Ankara Developmental Screening Inventory. The Ankara Developmental Screening Inventory (ADSI) is a 154-item scale based on a parental report used in Turkey for the assessment and evaluation of social, cognitive and communicative levels of children between 0 and 6 years of age. Its five subscales are language-cognitive, fine motor, gross motor, social interaction skills and self-care abilities (Savaşır et al. 1993). The test-retest reliability values for three age groups (0–12 months, 13–44 months and 45–72 months) were 0.99–0.80. Its internal consistency was 0.99–0.80. Clinical Problem-Solving Procedure. The Clinical ProblemSolving Procedure (CPSP) is a semi-structured observation procedure designed for children between 24 and 54 months of age to assess the caregiver-child interaction and attachment behaviour (Crowell and Fleischmann 1993). Zeanah et al. (1997) have extended the procedure for use with children between 12 and 54 months of age. The actual procedure involves nine separate episodes of varying lengths of time, designed to elicit behaviours indicative of some domains of the infant-parent relationship. These are free play, cleanup, playing bubbles, four teaching tasks, separation and reunion episodes, consecutively.


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Int J Psychiatry Clin Pract 2014;18:190–196

Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, revised edition (DC: 0–3R) (Zero to Three 2005). The DC:0–3R is a classification system of mental health developmental difficulties that defines mental health disorders in the first four years of life. It was utilised in the present study to assess the interaction between the child and the caregiver. Its multi-axial construct allows the clinician to blend the descriptive, relational, physical, neurobiological, environmental and developmental aspects of the infant’s presenting problems to achieve a useful formulation for effective treatment planning. Axis I is for the primary diagnosis, Axis II is for parent-child relationship disorders, Axis III is for physical, neurological and developmental problems of the child, Axis IV is for psychosocial stressors, and Axis V is for the emotional and social functioning of the child. The Parent-Infant Relationship Global Assessment Scale (PIR-GAS), which categorises the severity of the relationship disturbance, is included in the DC:0–3R and is scored between 90 (well adapted) and 10 (grossly impaired). In the present study, we used the PIR-GAS scores and correlated them with alexithymia, depression, anxiety and marital satisfaction scores to assess the association between the quality of the mother-child relationship and the aforementioned variables. Procedure The research protocol was approved by the local Ethical Committee of Ankara University Medical School. The procedures of the study were in accordance with the Declaration of Helsinki, as well as local laws and regulations. The developmental stages of the children were assessed using the ADSI, and the children who showed normal development were included in the study. The mothers of the children were invited to complete the TAS, BDI, BAI, MSS and the sociodemographic forms. After the procedures were explained to the parents, and consent for videotaping was obtained, the mothers and the children were observed in a playroom with a one-way mirror. Each of the presented episodes was conducted in order, and these episodes were observed by trained raters. First, the mother and the child played with toys for 10 min. After free play, the mothers had the children cleaned up all of the toys for about 5 min. Then the mothers blew bubbles for the children to pop for approximately 3 min. Next, the mothers were instructed to teach the children four predesigned tasks, two of which were below and two above the

children’s respective developmental levels. The last two tasks were difficult enough to require each mother’s assistance to her child. After this, the mothers left the room as they would at home and stayed outside the door for no longer than 3 min. Then the mothers re-entered the playroom, calling their children’s names. The following behaviours and skills were assessed: each child’s approach to the tasks (such as being enthusiastic), each child’s persistence and self-reliance, as well as each mother’s supportive presence (such as her attention to and interest in her child), her allowance of her child’s exploration of the tasks, her correct understanding of her child’s behavior, her encouragement of her child’s sense of achievement, her capacity to share her child’s pleasure at the task completion (valuing her child’s experience in his or her performance) and the quality of her assistance (skills in helping her child understand the task’s goal, giving her child the opportunity of independent discovery, and giving the necessary assistance and hints in a flexible way). The motherinfant relationship assessment included the dimensions of affection, negativity, avoidance and controlling behavior. After the administration of the CPSP, the clinical formulation was recorded with the consensus of a group of professionals (child psychiatrists and clinical psychologists), based on the DC:0–3R. The clinicians who observed and coded the Crowell procedure were blind to the measure scores of the mothers. Statistical analyses Statistical analyses were performed using the SPSS for Windows (version 15.0) statistical program. The variables in the present study were examined using descriptive statistics, Pearson correlation, Mann Whitney U and linear regression analyses, and p ⬍ 0.05 was considered as significant. Results The mothers’ total TAS scores were 23–73 points (mean 44), total BDI scores were 0–34 (mean 11), total BAI scores were 0–39 (mean 10), and MSS scores were 20–65 (mean 38). Of the mothers’ reported BDI scores, 29% were above the cutoff score. The PIR-GAS scores were negatively correlated to the total scores and all subscales of the TAS, and these correlations were all mild to moderate. Likewise, the PIR-GAS scores were all negatively (mild to moderate) correlated to the BDI scores. The PIR-GAS scores were not correlated to the BAI and MSS scores (Table I). The correlation analyses of

Table I. Correlation analyses of PIR-GAS, TAS (and subscales), MSS, BAI and BDI and TAS.

DIF DDF EOT BDI BAI MSS PIR-GAS

TAS

DIF

DDF

EOT

BDI

BAI

MSS

0.82*** 0.85*** 0.70*** 0.44** 0.32* 0.17 ⫺ 0.44**

0.67*** 0.23 0.41** 0.36* 0.04 ⫺ 0.31*

0.46** 0.36** 0.11 0.12 ⫺ 0.42**

0.28* 0.11 0.25 ⫺ 0.34*

0.66*** 0.05 ⫺ 0.32*

0.08 ⫺ 0.24

⫺ 0.16

PIR-GAS, Parent-Infant Relationship Global Assesment Scale; TAS, Toronto Alexithymia Scale; DIF, Difficulty Identifying Feelings; DDF, Difficulty Describing Feelings; EOT, Externally-Oriented Thinking; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; MSS, Marital Satisfaction Scale. * ⬍ 0.05, **⬍ 0.01, ***⬍ 0.001.

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the BDI, BAI and total TAS scores revealed positive and moderate to high correlations between each other (Table I). In addition to the correlation analyses, we divided the mothers into two groups, according to the total TAS scores. The high alexithymia group was formed by the mothers who scored higher than the median level of the TAS, and the low alexithymia group was formed by the mothers who scored lower than the median level of the TAS. Each group consisted of 25 subjects, whose members were similar in terms of the ages of the children and the ages and education levels of the mothers and fathers (p ⬎ 0.05). These two groups were compared in terms of the BDI, BAI, MSS and PIR-GAS. The results of the comparisons revealed that the mothers with high alexithymia had higher BDI scores; however, they had lower PIRGAS scores than those of the mothers with low alexithymia (z ⫽ ⫺ 2.0 and z ⫽ ⫺ 2.1, respectively, two-tailed p ⬍ 0.05). After obtaining these results, we conducted a linear regression analysis to determine the effect of alexithymia on the PIR-GAS, in case the effects of depression and anxiety were controlled. According to the linear regression analysis, when the effect of both the BDI and the BAI were controlled, the TAS was predictive for the PIR-GAS (p⫽0.01) (Table II). Discussion The present study’s findings indicate that the mothers’ alexithymia and depression levels are related to the quality of their interactions with their children. However, when the effects of depression and anxiety are controlled in the regression anlysis, alexithymia remains to negatively affect the quality of interaction. To the best of our knowledge, this is the first study investigating the relationship between alexithymia and the quality of the mother-infant relationship. Given the association between the parent-child relationship and the children’s cognitive and emotional development (Bornstein and Suess 2000), when the mothers and their young children have problematic relationship patterns, the children are apt to show delays in language, mental and social development (Akca et al. 2012). Additionally, young children who lack satisfying and appropriate interactions with their mothers show more affect regulation and behavioural problems (Leadbeater et al. 1996). Previous studies suggest that a satisfying and appropriate mother-infant attachment, which is crucial for a child’s cognitive and emotional development, is based on a warm, caring, sensitive and responsive interaction between a mother and her infant (Valentino et al. 2006; DeWolff and van Ijzendoorn 1997; van Ijzendoorn and Sagi 1999). Moreover, optimal mothering involves the synchronous coordination between maternal behavior and

Table II. Linear Regression Analysis of the PIR-GAS.

TAS BDI BAI Constant

B

S.E

p

Beta

⫺ 0.45 ⫺ 0.2 ⫺ 5.2 94

0.18 0.29 0.21 8

0.01 0.48 0.8 ⬍ 0.001

⫺ 0.37 ⫺ 0.12 ⫺ 0.04

PIR-GAS, Parent-Infant Relationship Global Assesment Scale; TAS, Toronto Alexithymia Scale; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory.

the infant’s social readiness (Feldman 2007). This synchronous coordination produces the interactive regulation of the biological synchronicity between the mother and her baby, which is crucial for emotional regulation and attachment (Damasio 1998; Schore 2000). The formation of a securely attached relationship contributes to the right brain development, which is important for affect regulation (Schore 2001). The right hemisphere, more so than the left one, is deeply connected to the limbic system and the sympathetic and parasympathetic components of the autonomic nervous system; therefore, it plays a predominant role in the physiological and cognitive components of emotional processing (Spence et al. 1996). These processes may be disrupted when children undergo adverse social experiences (such as abuse or neglect in the early phases of life) because of the extreme and rapid alterations of the autonomic nervous system (such as sympathetic hyperarousal and parasympathetic hypoarousal that create chaotic biochemical alterations). Additionally, permanent alterations in opiate, corticosteroid, corticotropin-releasing factor, dopamine, noradrenaline and serotonin receptors can be observed, following the stresses in the early ages (Coplan et al. 1996; Ladd et al. 1996; Lewis et al. 1990; Martin et al. 1991; Rosenblum et al. 1994; van der Kolk 1987). As a result of the dysregulating effect of these alterations, a toxic neurochemistry arises in the developing brain (Post et al. 1994). Possibly, the limbic system is one of the most affected regions of the brain from these biochemical alterations. The interruption of the development of the limbic system leads to an attachment pathology, as well as inefficient coping, organisation and adaptation mechanisms (Schore 2001). There is now agreement that repetitive, sustained emotional abuse or neglect is at the core of childhood trauma (O’Hagan 1995; Schore 2001). Furthermore, childhood neglect in the early phase of life is more detrimental to a child’s development than abuse (Schore 2001). To create a link between the alexithymia concept and the mother-child interaction, we suggest that because of the inability of a mother with alexithymia to understand and respond to her baby’s emotions, her caregiving activity may not provide a sensitive interaction with her baby’s emotional requirements. This pattern seems to show similarities with neglectful caregiving in which appropriate care for both the physical and emotional requirements of the baby is not provided by the caregiver. Therefore, we suggest that because mothers with alexithymia are unable to understand and respond correctly to their children’s feelings, they may fail to respond properly to their children’s emotions and emotional needs, leading to the hypothesis that alexithymia may be a risk factor that deteriorates the relationship quality between the child and the mother. Thus, their children may be at risk of emotional and developmental problems because of the mothers’ incapability to respond appropriately to their children’s emotional needs. As previously stated, alexithymia is described as an inability to distinguish one’s feelings from the accompanying bodily sensations, an inability to communicate feelings to others, and an externally oriented cognitive style reflecting an absence of inner thoughts and fantasies (Taylor et al. 1997). In addition to conceptual concerns, recent neuroimaging and clinical


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studies provide further evidence that alexithymic traits are linked to various brain regions, including the limbic system; people with alexithymia also have trouble recognising facial emotions (Aust et al. 2013a; Pedrosa et al. 2008a; Grynberg et al. 2012). Several studies investigating the early-life, familial and parental features of people with alexithymia indicate that alexithymia is related to disturbed family functioning, maternal alexithymia, diminished family expressiveness in childhood, feeling emotionally unsafe during childhood and poor maternal care (Kench and Irwin 2000). Theorists speculate that alexithymic features stem from maladaptive, early-life experiences, usually associated with poor parenting. Trauma, excessive attention given by the caretaker to a child’s bodily rather than emotional needs, and the caretaker’s emotional unavailability or inconsistency are posited as leading to the disturbed affect representation and selfregulation of alexithymia (Krystal and Krystal 1988; Rickles 1986). Thus, the background of alexithymia is stated to be closely related to affective development during early childhood. Although we could not find any study that investigated the relationship between alexithymia and attachment style in early childhood, adult studies suggest that people with alexithymia more frequently have insecure attachment styles than individuals without alexithymia and report more frequent childhood experiences of emotional adversities (Spitzer et al. 2005; Wearden et al. 2003; Pedrosa et al. 2008b; Troisi et al. 2001). Additionally in a recent study, early emotional neglect is reported to be in association with alexithymia, however, early physical or sexual traumata are not related to alexithymia (Aust et al. 2013b). To the best of our knowledge, no studies have investigated the relationship between alexithymia and the quality of the mother-child interaction. Therefore, the present study may contribute to existing knowledge by bridging alexithymia to parent-child relationships. We may conclude that during a child’s early years, the family environment is significant in the development of emotional recognition and expression. In this process, the mother-child interaction may play an important role, and our study’s findings support this hypothesis. On the other hand, the deterioration in the mother-infant relationship may be related to other factors. Various studies suggest that several factors such as communication skills, emotional regulation, attachment style and mother-child relationship may decline because of a mother’s depression (Oztop and Uslu 2007). Moreover, several studies indicate that alexithymia itself is associated with depression (Celikel et al. 2010; Honkalampi et al. 2000; Saarijärvi et al. 2001), and a similar result from our study supports this finding. Although we could not find a relationship between the PIRGAS and the mothers’ anxiety levels, the same confusion may come into question. Therefore, we conducted a linear regression analysis to test the effect of the mothers’ alexithymia on the PIR-GAS, in case the effects of the mothers’ depression and anxiety levels were controlled. We have found that alexithymia negatively predicts the PIR-GAS when the mothers’ depression and anxiety levels are controlled. However, anxiety and depression levels are not predictive when alexithymia scores are controlled. This study contributes to the literature in this respect; alexithymia is


predictive of the low quality of the child-mother interaction, and this relationship is not dependent on the mothers’ depression or anxiety levels. In conclusion, because of their inability to describe and express emotions, mothers with alexithymia may have problems relating to their children, and this difficulty may result in impairment in the quality of the mother-child relationship. Several studies suggest that the development of alexithymia is based on a social learning model in which parents who have difficulties regulating their own emotions (i.e., high levels of alexithymia) also have more difficulties attending to and interpreting their children’s emotions; thus, they are unable to teach their children how to regulate their own emotions (Lumley et al. 1996; Fukunishi et al. 1997; Kooiman et al. 2002). Our study supports this model and suggests that impairment in the child-mother relationship may be an important contributor to this model. Therefore, we suggest that if the mother is encouraged to teach her child to recognise his or her emotions and to learn how to manage them, such an intervention could reduce the transgenerational transmission of alexithymia and may also decrease the risk of lifetime depression in the child. There were some limitations related to our study. First, it was conducted with a relatively small clinical sample. Therefore, its results cannot be generalized to the overall population. Replications with larger community samples will improve our knowledge of this subject. Another limitation is that we did not evaluate the infants’ attachment styles. Further research could involve work with either a more focused comparison of target groups or a much larger community sample. Additionally, evaluating the attachment styles will give us an informed opinion on the role of attachment in alexithymic mother-child interactions. Key points •

•

•

•

The PIR-GAS scores are negatively correlated to the total scores and all subscales of the TAS. It is emphasised that the mothers’ alexithymia levels affect the quality of their interactions with their children. The PIR-GAS scores are all negatively correlated to the BDI scores. It is emphasised that the mothers’ depression levels affect the quality of their interactions with their children. The TAS is predictive of the PIR-GAS when the effects of both the BDI and the BAI are controlled. It is suggested that alexithymia is a predictive factor for the quality of the mother-infant relationship, although depression and anxiety levels are controlled. It is suggested that if the mother is encouraged to teach her child to recognise his or her emotions and to learn how to manage them, such an intervention could reduce the transgenerational transmission of alexithymia and may also decrease the risk of lifetime depression in the child.

Acknowledgements The authors want to thank Necip Coskun for his contribution and editorial support.

DOI: 10.3109/13651501.2014.940055

Statement of interest None of the authors reports conflicts of interest.


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