اعتبار ساختاری از متغیرهای آزمون رورشاخ برای آلکسیتیمیا

The construct validity of Rorschach Comprehensive System (CS) variables theoretically linked to alexithymia was evaluated in 92 outpatients with inflammatory bowel disease, 32 of whom were categorized as alexithymic, 15 as indeterminate-alexithymic, and 45 as nonalexithymic, on the basis of Toronto Alexithymia Scale scores. Six sets of Rorschach CS marker variables were selected for analysis: fantasy, affect, adaptive resources, cognition, social adaptation, and projection. Most variables significantly differentiated the three groups. Compared with the other groups, alexithymic subjects were more likely to show an impoverished fantasy life, poorly adapted emotional expression, poor coping resources, concrete and stereotypical thinking, and social conformity with compromised relationships. Alexithymia encompasses a cluster of cognitive and affective characteristics, including difficulty identifying and communicating feelings, trouble distinguishing between feelings and somatic sensations of emotional arousal, an impoverished and restrictive imaginative life, and a concrete and reality-oriented thinking style.1 Lack of introspection, poor dream recall, and social conformity are also considered to be associated with alexithymia.1 Several measures for assessing alexithymia have been developed in the last 25 years,2 including the 20-item Toronto Alexithymia Scale (TAS-20), which has demonstrated strong reliability and validity.3., 4. and 5. (See chapter 3 of the book by Taylor et al.1 for a review of measures of alexithymia.) Inflammatory bowel disease (IBD), a chronic intestinal disease of unknown etiology with intermittent phases of acute relapses and symptom-free periods, encompasses mainly ulcerative colitis (UC) and Crohn's disease (CD). IBD traditionally has been regarded as a psychosomatic disease,6 although recently this view has been criticized.7,8 Nonetheless, clinical observation and empirical studies have suggested that alexithymic characteristics could play important roles in IBD patients. Studies have found that IBD patients are more likely to be alexithymic than comparison subjects.9,10 Despite this association, only about one-third of IBD patients would be classified as alexithymic.11 Furthermore, alexithymia seems to be stable over time and unrelated to IBD activity, unlike psychological distress, which was directly related to level of disease activity in one study with a 6-month follow-up period.12 Although significant associations between alexithymia and IBD have been found, nothing can be said about a causal relationship between the two phenomena. Furthermore, the empirical findings have suggested that IBD patients are not a homogeneous group. Some IBD patients have stable alexithymic characteristics, and others do not. Because of these differences, IBD patients form a suitable population for studying the alexithymia construct. As a group, they have a fairly high prevalence of alexithymia, but many IBD patients do not possess alexithymic characteristics. A more refined psychological description of subgroups of IBD patients may improve clinicians’ understanding of the disease course, responses to treatment, and coping styles that affect patients’ quality of life and their way of relating to this chronic disease. The TAS-20 is a well-established, empirically validated measure of alexithymia. However, it is completed by the patient and thus is dependent on the patient's ability to accurately recognize and honestly endorse face-valid items. Although the reliability and validity of the TAS-20 have been supported by many research studies, questions have been raised about the possible limitations of using a self-report measure to assess the alexithymia construct.13,14 Therefore, heteromethod measures of alexithymia features have been advocated.13,14 A distinct and independent method of measuring alexithymic characteristics would also serve to further the test validity of the TAS-20. The Rorschach test has been used in prior research to evaluate alexithymia.2 Studies involving patients with various medical disorders have shown some common alexithymia characteristics, such as coarctated thinking, low level of imagination, absence of an inner-oriented cognitive style, poor control of emotional expression, coarctated experience, and a repressive coping style.15 Studies investigating alexithymia in patients with IBD have produced equivocal findings. Taylor et al.16 found that alexithymic patients with IBD had less control of emotional expression than psychoneurotic comparison subjects. A heterogeneous group of patients with gastrointestinal disorders, including UC, were found to be not significantly different from patients with organic diseases on the so-called “Rorschach phantasy syndrome”17 developed by Vogt et al.18 However, Acklin and Alexander19 found that Rorschach variables assessing psychological characteristics linked to alexithymia differentiated patients with psychosomatic disorders from healthy subjects. Earlier Rorschach studies investigating alexithymia had methodological shortcomings that limited their interpretation and may explain some of the equivocal findings. First, they used different systems of Rorschach scoring and interpretation, so the possibility of comparing results across studies was weakened. Second, the studies did not provide data on scoring reliability. Third, clinical and comparison groups were not matched for major sociodemographic variables. Fourth, the samples were poorly defined as “psychosomatic” on the basis of the assumption that certain disorders are psychosomatic while others are organic. For instance, the “psychosomatic” gastrointestinal disorder groups often included patients with heterogeneous illnesses, such as peptic ulcer, UC, and irritable bowel syndrome. Fifth, the studies considered alexithymia to be synonymous with psychosomatic disorder rather than directly evaluating alexithymia with a sound assessment instrument. Finally, the comparison groups were often inadequate. For example, psychoneurotic patients were considered comparison subjects, although no definition or inclusion criteria for psychoneurosis were provided. The study reported here was designed to address problems in previous research in several ways. We evaluated the construct validity of the Rorschach variables theoretically linked to alexithymia by using the Rorschach Comprehensive System (CS).20,21 The CS is the most commonly used scoring system, is based on standard administration rules,22 has shown good interrater23,24 and test-retest20 reliability, has generally good construct validity,23 and provides data for reference samples of nonpatients and patients to facilitate interpretation.20 Second, we evaluated scoring reliability in this study. Third, the IBD patients in the study were homogeneous in that they suffered from the same organic disease, but they were not a priori considered to have a psychosomatic condition. Rather, these patients were expected to vary in severity and stability of alexithymia.12 Finally, alexithymia was assessed by a criterion external to the Rorschach, the TAS-20, which is the most frequently used and validated self-report scale for assessing alexithymia.