Alexithymia, Depression, and Self-Mutilation in Adolescent Girls

Aurlie Lambert and Anton F. de Man

Bishops University
Fifteen adolescent French girls with a recent history of self-mutilation and 18 adolescent girls without such a history participated in a study of the relationship between alexithymia, depression, and self-mutilation. Results of correlational analyses showed that depression and alexithymia -particularly its difficulty in identifying feelings and differentiating them from bodily sensations factor- were significantly related to selfmutilation. Sequential logistic regression analysis showed that depression and the alexithymia factor as a set reliably distinguished between those who self-mutilated and those who did not. Of the two independent variables, depression was identified as the better predictor of selfmutilating behavior. Although the difficulty in identifying feelings and differentiating them from bodily sensations factor of alxithymia did have an effect independent of depression, much of the relationship between this factor and self-mutilation appeared to be the result of mediation by depression.

Self-mutilation may be defined as a volitional act to harm ones own body without intention to cause death (Yaryura-Tobias, Neziroglu, & Kaplan, 1995, p. 33). This deliberate, physically violent but non-suicidal act done to oneself by oneself (Alderman, 1997) may take many forms. Some of these are culturally sanctioned (e.g., tattooing, body piercing) whereas others are pathological in nature (Favazza, 1996). Pathological self-mutilation may be categorized into major, stereotypic, and superficial/moderate self-mutilation (Favazza, 1998; Favazza, & Rosenthal, 1993). Major self-mutilation involves acts which result in significant tissue damage (e.g., castration) and are usually associated with psychosis and intoxication. Stereotypic self-mutilation consists of stereotypic, rhythmic acts such as head banging and self-biting, commonly seen in conditions such as severe mental retardation and Tourettes syndrome. Superficial/moderate self-mutilation consists of superficial behavior such as skin cutting, burning, and scratching. The present study concerned itself with this last category. More specifically, it focused on adolescent girls showing self-cutting behavior. Self-mutilation usually begins in late childhood or early adolescence and can continue for up to 20 years (Favazza & Rosenthal, 1993); the
Author info: Correspondence should be sent to: Dr. A. F. de Man, Department of Psychology, Bishops University, Sherbrooke, J1M 0C8, Canada. (ademan@ubishops.ca) North American Journal of Psychology, 2007, Vol. 9, No. 3, 555-566. NAJP

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rates are highest among adolescents. Although the behavior has been observed in boys (Ross & Heath, 2004), the typical self-mutilator is a single, adolescent or young adult female (Favazza & Conterio, 1989; Pattison & Kahan, 1983; Raine, 1982; Suyemoto & MacDonald, 1995). Self-mutilation is repetitive in nature and distinct from suicidal behavior. Self-mutilators usually cut more than once (Bach-y-Rita, 1974; Himber, 1994; Simpson, 1980) but have no intention to cause death (Graff & Mallin, 1967). They distinguish between self-mutilative acts and suicidal ones (Herpertz, Steinmeyer, Marx, Oidtmann, & Sass, 1995), and, unlike suicide attempters, generally experience a feeling of relief following the act (Alderman, 1997; Favazza, 1996; Pattison & Kahan, 1983). Solomon and Farrand (1996) suggested that self-mutilation may be an adaptive alternative to suicide; however, those who cut themselves can have suicidal ideation which can lead to suicidal behavior. In fact, Stanley, Gameroff, Michalson, and Mann (2001) reported that between 55% and 85% of self-mutilators have made at least one suicide attempt. Although there has been a growing interest in early trauma as a factor in the development of self-mutilative behavior (e.g., Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Low, Jones, MacLeod, Power, & Dugan, 2000; Van der Kolk, Perry, & Herman, 1991), relatively little is known about what motivates self-mutilators and many professionals are at a loss to understand the behavior (MacAniff Zila & Kiselica, 2001). Because tension relief is a correlate of self-mutilation, it has been speculated that the act is a specific method of coping with emotional distress that leads to an immediate reduction in tension. (Alderman, 1997; Favazza, 1996; Favazza & Conterio, 1989; Himber, 1994; Van der Kolk, Perry, & Herman, 1991; Winnicott, 1989; Yaryura-Tobias et al., 1995). Van der Kolk et al. (1991) suggested that this is a way for individuals who lack more adaptive coping techniques to achieve psychological equilibrium. Self-mutilators generally are unable to verbally describe their intolerable affect (Zlotnick, Shea, Pearlstein, Simpson, Costello, & Begin, 1996), and the act of self-mutilation itself becomes an expression of these unspoken feelings of despair. Individuals who cannot verbally express negative affects may be described by the term alexithymia. The latter concept derived from clinical observations that psychosomatic patients were unimaginative and limited in their ability to verbally and symbolically express emotions (Ruesch, 1948). They were constricted in emotional functioning, had a barren fantasy life, found it difficult to differentiate feelings from bodily sensations, and had trouble talking about their emotions (Sifneos, 1972, 1973, 2000). Alexithymia therefore has been defined as a personality construct characterized by a difficulty in identifying and communicating feelings; a problem in distinguishing between feelings and bodily

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sensations; a relative lack of fantasy and imaginative activity; and a preference for focusing on external events over internal experiences (Taylor, Doddy, & Newman, 1981). Longitudinal studies suggest that it is a stable trait rather than a state effect of psychological or medical distress (Taylor, Bagby, & Luminet, 2000). Alexithymia is highly predictive of a broad range of physical and mental problems. Associations have been found with hypertension (Todarello, Taylor, Parker, & Fanalli, 1995), inflammatory bowel disease (Porcelli, Zaka, Leoci, Centonze, Taylor, & Parker, 1995), chronic pain disorder (Lumley, Asselin, & Norman, 1997), somatoform disorders (Cox, Kuch, Parker, Shulman, & Evans, 1994), eating disorders (De Groot, Rodin, & Olmstead, 1995), depression (Grabe, Spitzer, & Freyberger, 2004; Honkalampi, Hintikka, Laukkanen, Lehtonen, & Viinamaki, 2001; Wise, Mann, & Hill, 1990), dissociation (Grabe, Rainermann, Spitzer, Gnsicke, & Freyberger, 2000), panic disorder (Zeitlin & McNally, 1993), anxiety, phobia, obsessionality, interpersonal sensitivity, aggression, paranoia, and psychoticism (Grabe et al., 2004). Because alexithymia has proven to be such a strong predictor of a broad range of pathology, a relationship with self-mutilation might be expected. The inability to differentiate and verbally express emotions that characterize alexithymics is also a characteristic of self-mutilators (MacAniff Zila & Kiselica, 2001). It is therefore not surprising that, compared to non-mutilators, self-mutilators have been found to report a greater degree of alexithymia (Zlotnick, et al., 1996). Many studies of the relationship between alexithymia and other forms of pathology have not integrated in their analyses an assessment of depression. It has been reported that alexithymia is moderately to strongly related to depression (Grabe, et al., 2004; Hintikka, Honkalampi, Lehtonen, & Viinamki, 2001; Honkalampi, et al. 2001; Honkalampi, Hintikka, Tanskanen, Lehtonen, & Viinamki, 2000; Speranza, Corcos, Guilbaud, Loas & Jeammet, 2005; Wise et al., 1990) and that the latter variable acts as a powerful mediator between alexithymic features (particularly the difficulty in identifying feelings and differentiating them from bodily sensations factor) and psychopathology (Honkalampi et al., 2000; Speranza, Corcos, Stphan, Loas, Prez-Diaz, Lang, Venisse, Bizouard, Flament, Halfon, & Jeammet, 2004). For this reason, the present investigation analyzed the relationship between alexithymia and self-mutilation while taking into consideration the possible mediating effect of depression in order to ascertain whether or not alexithymia makes an independent contribution to self-mutilation separate from depression.

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METHOD Participants Participants were 15 adolescent French girls ranging in age from 13 to 19 years (M = 16.8, SD = .4) who had a recent history of selfmutilating behavior (i.e., cutting themselves with a knife, scissors, piece of glass, utility knife, tool, razor blade, pair of compasses, or paper sheet). This clinical group constituted a convenience sample of selfmutilators who over the course of a two-month period contacted the psychological health service of a hospital for assistance. The girls who showed physical signs of self-cutting and who reported that they engaged in the behavior were invited to participate in the study. The participation rate was 100%. Besides cutting themselves, 10 of the 15 girls had made at least one suicide attempt. The study further included 18 adolescent French girls from the same geographical area who ranged in age from 14 to 20 (M = 17.5, SD = .4) and had no history of self-mutilation, suicide attempts, or psychiatric problems. Materials Participants were asked for information concerning their age, the method used to cut themselves (clinical group only), and whether or not they had ever made an attempt to commit suicide. Alexithymia was assessed with the French version (Loas, Otmani, Verrier, Fremaux, & Marchand, 1996; Loas, Parker, & Otmani, 1997) of the Toronto Alexithymia Scale (TAS-20; Bagby, Taylor, & Parker, 1994a, 1994b). This 20-item measure comprises three subscales: difficulties identifying feelings and differentiating them from bodily sensations (Factor 1), difficulties describing feelings to others (Factor 2), and externally oriented thinking (Factor 3). Responses to the items are scored on 5-point Likert-type rating scales ranging from 1 (strongly disagree) to 5 (strongly agree). The instrument provides an overall alexithymia score (overall TAS) as well a score for each of the three factors. The present study focused on the respective alexithymia factors. The Toronto Alexithymia Scale is a well-validated and reliable device (Bagby, et al. 1994a, 1994b) and is one of the most widely used measures of alexithymia (Taylor, 2000). Confirmatory factor analysis for the French version replicated the three-factor model of the English scale (Loas, et al., 1997). Concurrent validity was demonstrated by positive correlations (.61; .79) with two versions of the Bermond-Vorst Alexithymia Questionnaire (Taylor, et al., 2000). Internal consistency was evidenced by a Cronbach alpha of .79 and item-total score correlations ranging from .19 to .69 (Loas, Fremaux, & Marchand, 1995). Depression was measured with the French version (Beck, Steer, & Brown, 1996) of the second edition of the Beck Depression Inventory

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(BDI-II). The BDI-II consists of 21 items, each with 4 answer options. Scores per item may range from 0 to 3; the maximum total score is 63. Alpha coefficients for the BDI-II were .92 for a sample of out-patients and .93 for students; item-total score correlations ranged from .39 to .70 for the first sample and from .27 to .74 for the second group. Test-retest reliability was .93 over a seven day period. Scores on the scale were significantly related to scores on the Beck Hopelessness Scale (.68), the Scale for Suicide Ideation (.37), the Beck Anxiety Inventory (.60), the Revised Hamilton Rating Scale for Depression (.71) and the Revised Hamilton Anxiety Rating Scale (.47) (Beck, Steer, & Brown, 1996). RESULTS A survey of the data showed a difference in age between selfmutilators and non-mutilators (M = 16.8 versus M = 17.5), but a t-test of the observed difference was not significant, t(31) = 1.15. Because 10 self-mutilators had made at least one suicide attempt whereas 5 had not, the associations between presence or absence of suicide attempt and the variables of depression, overall TAS, and the three factors were assessed: no significant results were obtained. These findings indicated that it was not necessary to include age in the analyses nor was there a need to subdivide the self-mutilators into attempters and non-attempters. The means and standard deviations for depression, overall TAS, and the three factors are presented in Table 1. Separate values for selfmutilators and non-mutilators are reported, together with corresponding t-test statistics. The mean depression score for self-mutilators was significantly higher than the one for non-mutilators. Using cut-off points

TABLE 1 Means and Standard Deviations for Self-Mutilators and NonMutilators and Associated T-Test Values

Self-Mutilators Non-Mutilators M
Depression Overall Alexithymia Factor 1 Factor 2 Factor 3 27.60 56.67 22.53 15.00 19.13

SD
11.40 9.55 4.37 3.49 5.62

M
8.78 48.83 16.28 13.56 19.00

SD
5.46 9.67 4.66 4.63 3.34

t
-5.86 -2.33 -3.95 -1.00 -.08

df
31 31 31 31 31

Sig.
.0001 .026 .0001 .32 .94

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provided in the BDI-II manual it was found that 40% of the selfmutilators reported moderate depression whereas 47% reported severe depression. In comparison, 72% of the non-mutilators reported minimal depression and 28% reported light depression. The mean scores for overall TAS and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) were also higher for the selfmutilators. To assess their clinical significance, these scores were compared to normative scores provided by Parker, Taylor, and Bagby (2003). The self-mutilators mean score for overall TAS fell more than 1 standard deviation above the normative score; the corresponding score for Factor 1 was 1.5 standard deviations above the norm. Sixty percent of the self-mutilators had overall TAS scores that were at least 1 standard deviation above the norm, compared to 22% of the non-mutilators. Similarly, 60% of the self-mutilators had Factor 1 scores that were at least 1 standard deviation higher than the norm, compared to 28% of the non-mutilators. No significant differences were found between the mean scores of self-mutilators and non-mutilators for Factors 2 and 3. Correlation coefficients assessed the interrelationships between overall TAS, the three factors, and presence/absence of self-mutilation (see Table 2). Overall TAS and self-mutilation were significantly related.

TABLE 2 Correlations between Self-Mutilation (MUT), Depression (DEP), Overall Alexithymia (TAS-20), and the Three Alexithymia Factors (F1, F2, F3)

MUT

DEP

TAS-20

F1

F2

F3

MUT DEP TAS-20 F1 F2 F3

*** p < .0001

-.75*** .39* .59*** .18 .02

-.27 .50** .17 -.14

-.82*** .73*** .62***

* p < .026

-.48** .22

-.17

--

** p < .005

Similarly, Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) was significantly associated with selfmutilation, but Factors 2 and 3 were not. Depression was significantly

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related to presence/absence of self-mutilation and to Factor 1; no significant relationships were found with overall TAS, Factor 2 or Factor 3. Because the latter two factors were not significantly related with selfmutilation and depression, and because overall TAS was not related to depression, these variables were excluded from subsequent analyses. To test the mediational hypothesis, a sequential logistic regression was performed with presence/absence of self-mutilation as dependent variable and depression and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations) as predictors. Although the present study used a small sample, the rule of thumb that there should be at least 10 cases in the sample for each independent variable was met. Because the likelihood ratio test is considered more reliable for small samples than the Wald statistic (Agresti, 1996), the likelihood ratio test of individual parameters was used to assess the relative importance of the independent variables (see Table 3).

TABLE 3 Tests of Model Coefficients

Chi-square

df

Sig

Full Model Reduced Model Difference

30.60 25.37 -5.24

2 1 1

.0001 .0001 .022

The test of the full model was significant, indicating that depression and Factor 1 make a difference in predicting presence/absence of selfmutilation. The model was run again with Factor 1 removed. The test for this reduced model was significant, but, more importantly, so was the difference between the full model and the reduced model. These findings indicate that the two models are significantly different and that it is not justified to drop Factor 1 from the model. The full model correctly predicted 86.7% of the self-mutilators and 94.4% of the non-mutilators, for an overall success of 90.9%. The histogram of predicted probabilities was U-shaped with 2 false positives and 1 false negative. Nagelkerkes R2 was .81 for the full model and .72 for the reduced model. The partial and semi-partial correlations for depression were .65 and .53 respectively; the corresponding values for Factor 1 were .36 and .24.

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The sample size of the present study was small because, as is the case with many clinical investigations, practical restrictions limited access to participants. A small sample may present a problem in statistical analyses as it may reduce the ability to detect significant results, especially when effect size is small. Following Heplers (1992) suggestion, post-hoc power analyses were performed to test the validity of the findings and to determine the sample size needed to obtain significance. The analyses produced an observed power of 1 and an effect size (f2) of 1.58. The sample size needed to obtain the observed statistical results with an alpha level of .05, a power level of .90, and an effect size of 1.58 was 12. The sample size of the present study was 33 and thus deemed sufficient. DISCUSSION The analysis of the means and the distribution of scores showed that the self-mutilators in this study are a clinically significant group. In addition to their self-cutting behavior, most of these girls have considerable depressive symptomatology and elevated levels of alexithymia, particularly in terms of identifying feelings and differentiating them from bodily sensations. Moreover, the majority has made one or more suicide attempts. A survey of the correlations confirms that self-mutilation, alexithymia (overall TAS and Factor 1), and depression are interrelated. The observed relationship between self-mutilation and overall alexithymia is consistent with Zlotnick, et al.s (1996) finding that self-mutilating women have greater alexithymia. Zlotnick et al., however, did not consider the three factors in their analysis. The present study did, and the results show that there is a relatively strong association between self-mutilation and Factor 1 (difficulties identifying feelings and differentiating them from bodily sensations). This suggests that self-mutilators particularly face confusing emotional perceptions which they cannot transform into meaningful feelings. The results further show that self-mutilation is related to depression, supporting Ross and Heaths (2004) finding that adolescent self-mutilators report significantly more depressive symptomatology than their peers who do not engage in such behavior. Depression, in turn, is related to the difficulties identifying feelings and differentiating them from bodily sensations factor. This finding is consistent with Speranza et al.s (2005) observation that the correlation between this factor and depression tends to vary between .42 and .65. Factors 2 and 3 are not significantly related to self-mutilation and depression, and overall TAS is not related to depression, leaving only Factor 1 of the alexithymia construct for inclusion in the analysis of possible mediation. This pattern of significant and nonsignificant relationships between the various alexithymia scores and the other

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variables is typical of measures of multifaceted constructs. Parker et al. (2003) noted that the TAS-20 factors show discriminability when they are correlated with constructs that overlap with one or two facets of alexithymia but not with the entire alexithymia construct. Hence, it seems that in the present study self-mutilation and depression overlap with the difficulties identifying feelings and differentiating them from bodily sensations aspect of alexithymia but not with the other features. The fact that the analysis identifies the (in)ability to identify ones feelings and to distinguish them from bodily sensations as the relevant variable, supports Haviland, Shaw, Cummings, and MacMurrays (1988) suggestion that this TAS-20 subscale captures the alexithymia construct better by itself than when combined with the other two subscales to create the total TAS score. The outcomes of the logistic regression indicate that depression and the alexithymia factor as a set reliably distinguish (with a success rate of 90.9%) between those who self-mutilate and those who do not. The fact that the Chi-square difference (full model versus reduced model) is significant indicates that the difficulties identifying feelings and differentiating them from bodily sensations factor does have an effect by itself. However, the change in Nagelkerkes R2 (full model versus reduced model) and the respective values of the zero-order, partial, and semi-partial correlations show that depression is not only the more powerful predictor of the two, but that it also controls the relationship between the alexithymia factor and self-mutilation to a certain degree. In summary, there is a relationship between the (in)ability to identify ones feelings and to differentiate them from bodily sensations and selfmutilation. Although the initial correlation analysis shows a relatively strong relationship between this alexithymia factor and self-mutilation, it is clear that a large part of this association is mediated by depression. This latter variable is of greater practical importance in differentiating between self-mutilators and non-mutilators. Nevertheless, the results show that the alexithymia factor by itself is associated with selfmutilation and as such may be taken as a predictor of the latter, independent of depression. REFERENCES
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