شکل گیری فرهنگی آلکسی تایمیا: ارزش ها و تفکر خارجی گرا در نمونه های بالینی چینی

Objective Alexithymia is a multi-faceted personality construct characterized by difficulties in identifying and describing emotional states. Originally based on observations of American psychosomatic patients, the construct is now studied in a variety of cultural contexts. However, few studies have critically examined alexithymia from a cultural perspective. Dere et al. [1] recently found support for the hypothesis that one alexithymia component – externally oriented thinking (EOT) – is linked to cultural values, among Euro-Canadian and Chinese–Canadian students. The current study examines this association in a Chinese clinical sample. Methods Outpatients presenting at three hospital-based psychology clinics in Hunan province, China (N = 268) completed a structured clinical interview and self-report measures of alexithymia and cultural values. All participants endorsed clinically significant levels of depressed mood, anhedonia, and/or fatigue. Results As expected, EOT was negatively predicted by Modernization and Euro-American values. Two other alexithymia components, difficulty identifying feelings and difficulty describing feelings, were unrelated to cultural values. Conclusion These findings suggest that cultural variations in the importance placed on emotional experience must be taken into account in cross-cultural alexithymia research. Such studies should also consider separately the specific components of alexithymia; failure to do so can lead to overestimation of alexithymia in groups where scores are driven by culturally-promoted EOT.

The construct of alexithymia was formally introduced in the early 1970s, in an attempt to operationalize a set of clinical characteristics observed among North American psychosomatic patients. Interest in alexithymia has since expanded considerably, with the literature now encompassing a broad set of research questions and populations. The consequence is that the alexithymia construct is now applied to cultural contexts that diverge considerably from the one in which it was originally developed, thereby increasing the possibility of misinterpretation. The current study provides a cultural examination of alexithymia among Chinese depressed outpatients that raises a more significant concern, beyond simple misinterpretation. We propose that one alexithymia component – externally oriented thinking – can be culturally promoted, and therefore its inclusion in the overarching alexithymia construct may lead to the pathologization of cultural differences in emotion norms. Coined by Sifneos and his colleagues [2] and [3], the literal meaning of alexithymia is ‘a lack of words for emotion’. The concept originated in Sifneos’ observations of psychosomatic patients in Boston, who presented particular challenges in the context of psychoanalytic therapy, the predominant therapeutic approach of the day [4]. Four main features define this construct: (1) difficulty identifying feelings, and distinguishing them from physical sensations of emotional arousal; (2) difficulty describing emotions to others; (3) reduced imaginal capacities; and (4) an externally oriented thinking style, with an emphasis on external, concrete stimuli rather than inner emotions [5]. The introduction of valid and reliable measures has been critical to the advancement of the alexithymia literature in recent decades. The most frequently used and well-validated measure is the Twenty-item Toronto Alexithymia Scale (TAS-20) [6], [7], [8] and [9]. The TAS-20 contains three subscales: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). The measure demonstrates good psychometric properties across a range of samples (e.g., [7] and [8]). The measure has also been translated into at least 18 different languages, including Chinese, with general cross-cultural support for the three-factor structure and for the reliability of the total score and the DIF and DDF subscales [9] and [10]. However, the EOT subscale frequently shows poor internal reliability, particularly in non-English speaking samples [e.g., [9], [10], [11] and [12]]. Whereas a number of studies using the TAS-20 have focused on cross-cultural measurement issues (e.g., [10]), few studies have addressed conceptual questions from a cultural perspective. Alexithymia has, however, been the target of several culturally-based theoretical critiques, with authors highlighting the construct's historical and cultural roots [4] and [13]. In particular, alexithymia has been linked to ‘Western’ norms that emphasize individual emotional experience and the verbal expression of emotion, with the suggestion that this construct would not carry the same meaning or relevance in contexts with different emotion norms [13]. We propose that a cultural perspective is particularly pertinent to EOT, since this component concerns the importance placed on emotional experiences. The importance of emotions is strongly related to cultural values and varies substantially across cultural contexts (e.g., [14] and [15]). Our focus on EOT is based on several converging theoretical observations and empirical findings. First, there is the consistently poor reliability of the EOT subscale in non-English speaking samples. Although this is a psychometric problem, it also suggests potential conceptual problems cross-culturally. Second, EOT stands apart from DIF and DDF in that it is not defined as an emotional deficit but rather a thinking style that de-emphasizes emotion. Finally, Ryder et al. [16] examined alexithymia among Euro-Canadian and Chinese depressed outpatients, and found that higher alexithymia levels among the Chinese were explained by higher levels of EOT; neither DIF nor DDF showed a significant group difference. These authors proposed that EOT may be promoted in a Chinese context due to greater cultural emphasis on social harmony, relationships, and contextual factors, with relatively less emphasis on individual emotional experience [17]. This proposal fits with a substantial literature on cultural differences in emotional processes among those of Chinese versus Western European heritage (e.g., [18]), but requires empirical examination. Building on this work, Dere et al. [1] sought to test the general hypothesis that EOT would be particularly associated with cultural values, in contrast to DIF and DDF, among Euro-Canadian and Chinese–Canadian undergraduate students. Three sets of cultural values were examined — modernization, Euro-American values, and Asian values. Replicating Ryder et al. [16], higher total TAS-20 scores among the Chinese–Canadians were explained by a significant group difference on EOT. As hypothesized, Dere et al. found that modernization and Euro-American values negatively predicted EOT in both groups, while values were unrelated to DIF or DDF. Furthermore, cultural values mediated the effect of group membership on levels of EOT, helping to ‘unpack’ the observed cultural difference. Together, the results of Ryder et al.'s [16] and Dere et al.'s [1] studies suggest the need to further examine the association between alexithymia and values in a Chinese context. The current study investigates the cultural promotion of EOT in a sample of depressed Chinese outpatients. As alexithymia is primarily a psychiatric construct, it is instructive to examine our cultural predictions in a clinical sample. Furthermore, the current participants were recruited in the same region as the Chinese sample in Ryder et al. [16], but cover a wider range of sociodemographics, providing a valuable sample in which to continue this line of research. Based on our theoretical expectations and previous findings, we examined the following hypotheses: (1) of the three TAS-20 subscales, only EOT would be predicted by cultural values; and (2) EOT would be negatively predicted by modernization and by Euro-American values. Although we would expect EOT to be positively predicted by Asian values on a theoretical basis, Dere et al. [1] found that Asian values did not predict EOT; therefore, we did not formulate a specific hypothesis regarding Asian values.