Personality and Social Psychology Differences in alexithymia and emotional awareness in exhaustion syndrome and chronic fatigue syndrome DANIEL MAROTI, 1 PETER MOLANDER 2,3 and INDRE BILEVICIUTE-LJUNGAR 1,2 1 Department of Clinical Sciences, Karolinska Institutet and Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden 2 Department of Medical and Health Sciences, Link€ oping University and Region € Ostergotland, Link€ oping, Sweden 3 Department of Behavioral Sciences and Learning, Link€ oping University, Link€ oping, Sweden Maroti, D., Molander, P. & Bileviciute-Ljungar, I. (2016). Differences in alexithymia and emotional awareness in exhaustion syndrome and chronic fatigue syndrome. Scandinavian Journal of Psychology. Symptoms of Exhaustion Syndrome (ES) and Chronic Fatigue Syndrome (CFS) are overlapping and create difficulties of differential diagnosis. Empirical studies comparing ES and CFS are scarce. This study aims to investigate if there are any emotional differences between ES and CFS. This cross-sectional study compared self-reported alexithymia and observer-rated emotional awareness in patients with ES (n = 31), CFS (n = 38) and healthy controls (HC) (n = 30). Self-reported alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20) and emotional awareness with an observer-rated performance test, the Level of Emotional Awareness Scale (LEAS). Additionally, depression and anxiety were scored by the Hospital Anxiety and Depression Scale (HADS). Results show that patients with ES expressed higher self-reported alexithymia in the TAS-20 compared to HC, but had similar emotional awareness capacity in the observer-rated performance test, the LEAS. Patients with CFS expressed more difficulties in identifying emotions compared to HCs, and performed significantly worse in the LEAS-total and spent more time completing the LEAS as compared to HC. Correlation and multiple regressions analyses revealed that depression and anxiety positively correlated with and explained part of the variances in alexithymia scores, while age and group explained the major part of the variance in LEAS. Findings of this study indicate that emotional status is different in patients with ES and CFS with respect to both self-reported alexithymia and observer-rated emotional awareness. Emotional parameters should be approached both in clinical investigation and psychotherapy for patients with ES and CFS. Key words: chronic fatigue syndrome, exhaustion syndrome, alexithymia, emotional awareness, depression. Indre Bileviciute-Ljungar, Department of Clinical Sciences, Karolinska Institutet and Department of Rehabilitation Medicine, Danderyd Hospital, Building 39, 3rd floor, SE 182 88 Stockholm, Sweden. Tel/fax: +46 8 6539393; e-mail: indre.ljungar@ki.se INTRODUCTION Both Exhaustion Syndrome (ES) and Chronic Fatigue Syndrome (CFS) are characterized by fatigue, physical and mental exhaustion, worsened by effort or stress. The Swedish Board of Health and Welfare introduced diagnostic criteria for ES, the clinical equivalent of burnout, in 2003. In 2010 it was incorporated into the Swedish version of the 10th revision of the International Classification of Diseases (ICD-10-SE code F43.8A; Socialstyrelsen, 2003, 2010). Different criteria for CFS have been developed under the past years. In research, the so-called “Fukuda criteria” is the most frequently used (see Table 1; Fukuda, Straus, Hickie, Sharpe, MDobbins & Komaroff, 1994). Another set of criteria commonly used is the so-called “Canadian criteria”, first introduced in 2003 and later revised and updated in 2011 (see Table 1; Carruthers, Jain, Meirleir et al., 2003; Carruthers, van de Sande, De Meirleir et al., 2011). The ICD-10-SE code for CFS has the synonymous names of “post-viral fatigue, chronic fatigue syndrome, myalgic encephalomyelitis” (G93.3). There are striking symptom similarities in ES and CFS, at least when the Fukuda criteria for CFS are applied (see Table 1). In both conditions there is a chronic disabling fatigue accompanied by sleep disturbances, pain, difficulties with memory and concentration, as well as significant physical and mental fatigue with lack of endurance. ES is, however, considered a stress- related psychiatric disorder caused by long-term psychological stress that is often, but not exclusively, work related (see Table 1; Socialstyrelsen, 2003). Cross-sectional data indicates that ES is related to high work demands in conjunction with low levels of influence or control (S€ oderstr€ om, Jeding, Ekstedt, Perski &  Akerstedt, 2012). CFS, on the other hand, is considered an organic multi-systemic illness with unknown cause (Carruthers et al., 2003). Approximately 75% of patients with CFS report a relationship between infection(s) and onset of symptoms (Prins, Bleijenberg, Bazelmans et al., 2001). Both ES and CFS are associated with sleep disturbances and cognitive deficits in attention, working- and long-term memory (Cockshell & Mathias, 2010; Grossi, Perski, Osika & Savic, 2015). Associations with physiological findings are inconclusive and sometimes even contradictory (Grossi et al., 2015; van der Meer & Lloyd, 2012). For example, studies of ES have shown positive, negative and non-significant associations between burnout and saliva cortisol. Both ES and CFS lead to a substantially reduced activity level, a high degree of sick leave and symptoms can have detrimental effects on quality of life (Grensman, Acharya, W€ andell, Nilsson & Werner, 2015; Jason, Benton, Valentine, Johnson & Torres-Harding, 2008). There is no consensus on how best to treat either ES (Glise, Hadzibajramovic, Jonsdottii & Ahlborg, 2013) or CFS (van der Meer & Lloyd, 2012), but in both conditions Cognitive Behavioral Therapy (CBT) is the usual psychotherapeutic treatment approach. Prognosis is very different for ES and CFS, where the latter have a particularly worse prognosis. In a randomized control trial for ES, comparing Qi gong alone or in combination with CBT, © 2016 Scandinavian Psychological Associations and John Wiley & Sons Ltd Scandinavian Journal of Psychology, 2016 DOI: 10.1111/sjop.12332