Downloaded from http://journals.lww.com/jonmd by BhDMf5ePHKbH4TTImqenVCREHB2bGU1v5FvqfW4RPMma9M8RVBBBkWC3CeP5URcj on 12/14/2018 An Initial Study of Alexithymia and Its Relationship With Cognitive Abilities Among Mild Cognitive Impairment, Mild Alzheimer's Disease, and Healthy Volunteers Daniela Smirni, PhD,*† Janelle N. Beadle, PhD,‡ and Sergio Paradiso, MD, PhD§|| Abstract: The present study examined the degree to which alexithymia is greater in mild Alzheimer's disease (AD) and mild cognitive impairment (MCI) relative to healthy volunteers (healthy comparison [HC]), and investigated rela- tionships between alexithymia and cognition. Eighty-five participants (MCI = 30, AD = 21, HC = 34) underwent a comprehensive neuropsychological exami- nation and completed the 20-item Toronto Alexithymia Scale (TAS-20). Relative to HC, MCI and AD reported greater alexithymia total scores and higher scores on the TAS factor difficulty in identifying feelings (DIF). The remaining two fac- tors, difficulty in describing feelings (DDF) and externally oriented thinking showed no significant group differences. In MCI, TAS-20 and DIF were nega- tively correlated with working and long-term verbal memory. In AD, TAS-20 was negatively correlated with general cognition, attention, memory, and visual spatial constructive and executive abilities. Also in AD, DIF was negatively cor- related with general cognition, memory, and executive abilities. The correlation between DIF and long-term verbal memory in both MCI and AD suggests a poten- tial common mechanism for alexithymia in these neurocognitive disorders. De- clines in verbal memory may hinder a patient's ability to recall an association between a given sensation and the episodic experience of that sensation, thus lead- ing to difficulty identifying feelings, as measured by the DIF factor of the TAS-20. Key Words: Alexithymia, cognition, attention, executive functions, memory (J Nerv Ment Dis 2018;206: 628–636) W idely recognized as an inability to identify and express emotion (Sifneos, 1972), alexithymia has gained clinical relevance be- cause of its potential to predict outcome (Epifanio et al., 2014; Jula et al., 1999; Porcelli et al., 2017) and treatment response (Fassino et al., 2010) in medical and psychiatric conditions. Several studies have linked alexithymia to cognitive functioning (Hornak et al., 1996; Lane and Schwartz, 1987; Taylor et al., 1997; Larsen et al. 2003 for a review). For example, in healthy volunteers, alexithymia and executive functions were negatively correlated, such that individuals with higher alexithymia had poorer executive functions (including verbal initiation and mainte- nance of effort; Paradiso et al., 2008). Onor et al. (2010) confirmed and extended these findings in a sample of Italian adults, finding that greater alexithymia was associated with poorer performance on several cognitive domains including language, attention, visual spatial abilities, and long-term and working memory. Studies examining samples of healthy adults showed that proxies for general cognition including lower education (Pasini et al., 1992) and older age (Onor et al., 2010) also correlated with alexithymia. Among American veterans, there was a negative correlation between alexithymia and language performance (Lamberty and Holt, 1995). Relationships between alexithymia and cognition have also been found in patients experiencing a psychiatric or medical illness. For instance, a negative correlation between alexithymia and verbal abilities was found in patients with panic disorder (Galderisi et al., 2008). An association between alexithymia and cognitive abilities was also observed among asymptomatic HIV-positive participants. In this sample, severity of alexithymia was associated with poorer perfor- mance on attention, working memory, category fluency, spatial reason- ing, and visual spatial organization (Bogdanova et al., 2009). In sum, several studies examining direct and indirect measures of cognition have shown that greater alexithymia scores are associated with poorer cognitive abilities. Specifically, several studies have found that alexithymia is associated with poorer cognition in the domains of language and executive functions (Galderisi et al., 2008; Henry et al., 2006; Lamberty and Holt, 1995; Paradiso et al., 2008; Santorelli and Ready, 2015). Other studies have found that higher alexithymia corre- lated with poorer attention and memory (Bogdanova et al., 2009; Onor et al., 2010). These studies suggest that the mental skills required to ac- cess personal emotional knowledge are in part supported by cognitive functions that process nonemotional material. Because of the growing life expectancy of the world population, age-related cognitive decline is becoming one of the greatest health threats of the coming years (Hebert et al., 2003; MacPherson et al., 2017). Mild cognitive impairment (MCI) is the prevailing term used to describe an intermediate state of cognitive impairment that falls be- tween normal aging and dementia (Luis et al., 2003; Petersen et al., 1999). MCI is defined as impairment in one or more cognitive domains (typically memory, but also executive function, attention, language, and visual spatial skills may be included). Cognitive decline is mild com- pared with patients with Alzheimer's disease (AD) but greater than ex- pected for age or educational background (Petersen et al., 2001) and reflects reduced functioning relative to one's previous level of cognitive functioning (Albert et al., 2011). AD is characterized by profound mem- ory impairment, diminished self-care capacity, behavioral, psychologi- cal and emotional symptoms (Forrester et al., 2015; Sacuiu et al., 2016). The expected increase in rates of age-related neurocognitive disorders will lead to an increased need for treatment, care, and reha- bilitation for the affected persons (Caley and Sidhu, 2010; Rice and Fineman, 2004; Spillman and Lubitz, 2000). Alexithymia has been re- cently shown to be elevated among individuals with cognitive decline, including AD and MCI (Yuruyen et al., 2017). Patients with mild AD and MCI have significantly more alexithymia than participants older than 60 years with complaints of memory loss (Yuruyen et al., 2017). Because alexithymia has been negatively associated with treatment re- sponse and outcome (Lumley et al, 2007; Ogrodniczuk et al., 2011 for a review), elevated rates of alexithymia among individuals with cognitive disorders may be expected to hinder treatment and rehabilitation efforts among patients with cognitive decline. The extant literature shows that alexithymia affects rehabilitation and treatment efforts in many neuropsychiatric conditions including anxiety and somatoform disorders (Bach and Bach, 1995), depression (Ogrodniczuk et al., 2004), alcoholism (Cleland et al., 2005; Loas et al., 1997), eating disorders (Nowakowski et al., 2013; Speranza et al., 2007; Westwood et al., 2017), functional gastrointestinal disorders *Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo; †NeuroTeam Life and Science, Palermo, Italy; ‡Department of Gerontology, University of Nebraska at Omaha, Omaha, Nebraska; §Instituto de Neurologia Cognitiva (INECO); and ||Universidad Favaloro, CABA, Argentina. Send reprint requests to Daniela Smirni, Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università degli Studi di Palermo, viale delle Scienze, Ed.15, 90128 Palermo, Italy. E‐mail: daniela.smirni@unipa.it. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/18/20608–0628 DOI: 10.1097/NMD.0000000000000853 ORIGINAL ARTICLE 628 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 206, Number 8, August 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.