Beruflich Dokumente
Kultur Dokumente
2
p
(n 585) (n 983) (n 753)
Age (years) 52.67 (5.23) 53.00 (5.32) 53.66 (4.61) 2 4.87 .09
a
TAS-26 scores 53.87 (5.31) 67.07 (3.60) 80.11 (5.28) 2 2028.96 .001
a
Physical activity (kcal/day) 147.18 (146.47) 155.04 (186.55) 122.35 (178.68) 2 44.87 .001
a
Alcohol/week (grams) 63.95 (88.97) 71.68 (138.60) 83.19 (129.35) 2 2.80 .25
a
Smoking (pack-years) 6.68 (14.14) 7.27 (16.09) 10.55 (18.36) 2 29.22 .001
a
Body mass index (kg/m
2
) 26.93 (3.44) 26.69 (3.44) 26.89 (3.79) 2 2.40 .30
a
Systolic blood pressure (mm Hg) 133.14 (16.21) 133.63 (16.83) 135.23 (17.96) 2 6.28 .04
a
HDL-C 1.29 (0.29) 1.29 (0.30) 1.31 (0.33) 2 0.18 .92
a
LDL-C 3.99 (1.02) 4.02 (1.00) 4.10 (1.03) 2 4.29 .12
a
History of cardiovascular disease, n (%) 192 (32.8) 356 (36.2) 325 (43.2) 2 16.42 .001
b
HPL depression scores 1.19 (1.59) 1.70 (1.92) 2.60 (2.41) 2 166.23 .001
a
Marital status, living alone (%) 48 (8.2) 122 (12.4) 140 (18.6) 2 32.10 .001
b
Years of education 9.84 (3.96) 8.66 (3.18) 7.74 (2.78) 2 112.89 .001
a
a
Kruskal-Wallis test.
b
2
test.
c
Cutoff of 74 was used to indicate definite alexithymia and the range from 61 to 73 indicated probable alexithymia.
df degrees of freedom; TAS Toronto Alexithymia Scale; HDL-C high-density lipoprotein cholesterol; LDL-C low-density lipoprotein cholesterol; HPL
Depression Scale Human Population Laboratory Depression Scale.
T. TOLMUNEN et al.
188 Psychosomatic Medicine 72:187191 (2010)
factors (Model 2), by 1.5% after further adjustment for phys-
iological factors (Model 3), and by 1.2% after further adjust-
ment for psychosocial factors (Model 4) (Table 2) for each
1-point increase in the TAS-26. Age, alcohol consumption,
smoking, BMI, systolic blood pressure, LDL-C levels, and
CVD history were also independently associated with in-
creased mortality in Model 4 (Table 3). Correlations of the
variables entered into the multivariate analysis are presented
in Table 4. The TAS-26 correlated with age, smoking, LDL-C
lipoprotein levels, systolic blood pressure, education, and HPL
depression scores.
TABLE 2. Increase of Risk Ratios (95% Confidence Intervals) for
CVD Death During an Average Follow-Up Period of 20 yr Using Cox
Proportional Hazards
RR
a
(95% CI) in
Probable Alexithymia
df Wald p
Model 1 1.023 (1.0131.034) 6 19.16 .001
Model 2 1.018 (1.0081.029) 9 12.05 .001
Model 3 1.015 (1.0041.025) 14 7.25 .007
Model 4 1.012 (1.001.023) 17 4.14 .042
a
RR shows the increase in the risk of cardiovascular disease death with each
1-digit increase in Toronto Alexithymia Scale (TAS)-26 scores.
RR risk ratio; CI confidence interval; df degrees of freedom; Model
1 Adjusted for age examination year; Model 2 Model 1 and further
adjustment for smoking (pack-years), weekly alcohol consumption, physical
activity; Model 3 Model 2 further adjusted for low-density lipoprotein
cholesterol, high-density lipoprotein cholesterol, body mass index, hyperten-
sion, cardiovascular diseases; Model 4 Model 3 further adjusted for marital
status, education, and Human Population Laboratory Depression Scale scores.
TABLE 3. CVD Death RRs (95% CIs) for the Model 4
a
Covariates
During an Average Follow-Up Period of 20 Years
RR
b
(95% CI) p Wald
Age (years) 1.083 (1.0521.115) .001 28.39
Physical activity (kcal/day) 1.000 (1.0001.001) .19 1.70
Alcohol/week (grams) 1.001 (1.0001.002) .01 6.69
Smoking (pack-years) 1.038 (1.0291.047) .001 66.86
BMI (g/m
2
) 1.062 (1.0291.097) .001 13.91
Systolic blood pressure
(mean of 6
measurements)
1.015 (1.0091.021) .001 23.71
HDL-C 0.77 (0.5011.177) .23 1.47
LDL-C 1.174 (1.0461.32) .007 7.37
History of cardiovascular
disease
1.970 (1.5462.510) .001 30.04
HPL depression scores 1.015 (0.9601.073) .60 0.28
Marital status (four classes) 1.098 (0.9311.296) .27 1.23
Years of education 0.981 (0.9421.022) .37 0.82
a
All variables were entered into the model simultaneously together with
examination years and Toronto Alexithymia Scale (TAS)-26 scores. All
variables except history of cardiovascular disease and marital status are
continuous.
b
RR shows the increase in the risk of CVD death for each 1-digit increase in
the value of the variable.
CVD cardiovascular disease; RRs risk ratios; CIs confidence inter-
vals; BMI body mass index; HDL-C high-density lipoprotein choles-
terol; LDL-C low-density lipoprotein cholesterol; HPL depression
scores Human Population Laboratory Depression Scale scores.
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.
ALEXITHYMIA AND CARDIOVASCULAR MORTALITY
189 Psychosomatic Medicine 72:187191 (2010)
When we further examined different death types, the in-
creased risk for an increase in TAS-26 scores almost reached
significance in cases of all-cause mortality (Model 4: odds
ratio [OR] 1.006; 95% Confidence Interval [CI] 0.999
1.014; p .10) and injury death (Model 4: OR 1.010; 95%
CI 0.9861.035; p .42), whereas the risk for cancer death
was not increased (Model 4: RR 0.996; 95% CI 0.982
1.011; p .63).
DISCUSSION
Summary of Main Findings
Each 1-point increase in TAS-26 scores increased the risk
of CVD death by 2.3% during an average follow-up of 20
years after adjustment for age and examination year. After
adjustments for biological, behavioral, and psychosocial fac-
tors, the risk was increased by 1.2% for each 1-point increase
in the TAS-26 scores.
Strengths and Limitations
The main strength of our study is its large, regionally com-
prehensive sample. In addition, we had a high sample inclusion
rate and employed a wide range of well-validated measures.
Furthermore, the long follow-up period adds to the reliability of
the results. Because our participants were middle-aged men, the
results may not be generalizable to women and other age groups.
Alexithymic features were only measured at baseline, and may
thus have changed over time. However, this is unlikely because
we have previously shown in the same sample that TAS scores
remain stable over time (19).
Poor mortality register coverage could have biased our
findings. However, in Finland, as in the other Nordic coun-
tries, there is a nationwide system of registers that covers all
data on births, deaths, and official causes of death. These
registers have been widely utilized in epidemiological studies
(27,29). Worldwide, these registers are considered to have
extremely good coverage. Circumstances in Finland are ideal
for proper cause-of-death determination and death certifica-
tion for several reasons. First, all medical students receive
instruction on these issues. Second, autopsy rates both in
medico-legal and clinical deaths are at high levels, and cause-
of-death determination and death certification practices at the
local and provincial levels are directed, supervised, and in part
carried out by medical examiners. Third, the death certificate
panel of Statistics Finland queries the certifying physician in
the case of ambiguous or incomplete medical information in
death certificates (29).
Alexithymia may also be partly secondary to depression
(30). Adjustment for psychosocial factors including depres-
sive symptoms decreased slightly the mortality risk in our
study. In an earlier study on patients with coronary heart
disease, alexithymia was associated with being a blue-collar
worker and reporting depression and life dissatisfaction. No
associations were detected between alexithymia and cardio-
vascular risk factors or exercise capacity (31). Diagnostic
interviews were not carried out when screening for depression,
which can be considered as a limitation.
Comparison With Existing Literature
Several factors may explain the association between in-
creased CVD mortality and alexithymia. We found that alexi-
thymic subjects smoked more and performed less physical
activity than those with no alexithymia. However, correlations
between biological variables and alexithymia scores were
relatively low.
It has been suggested that alexithymia influences cardio-
vascular morbidity through social and emotional pathways
rather than through behavioral or physiological factors (32).
Moreover, Peters and Lumley observed that alexithymia cor-
related strongly with socioeconomic and emotional variables,
but only minimally with behavioral or physiological factors
(32). Our findings partly support these observations, although
those with definite alexithymia had almost twice as many
pack-years compared with controls. Nevertheless, alexithymia
associated with living alone, which might in turn lead to
harmful life habits, such as poor nutrition or alcohol consump-
tion. However, findings concerning marital status and alexi-
thymia are controversial. In some studies, the prevalence of
alexithymia has been pronounced in unmarried and widowed
subjects (33), whereas in other studies, there has been no
association between alexithymia and marital status (9).
Alexithymia had a high inverse correlation with the years
of education, which in turn had positive correlations with all
the protective factors, except HDL-C and inverse correlations
with several risk factors of CVD. Education probably has
complex relationships with many factors affecting mortality.
Furthermore, alexithymia was associated with HPL depression
scores. Although the HPL Depression Scale did not predict
CVD death independently when entered into the models as a
continuous variable, it did so when entered as a categorized
variable utilizing a cutoff designed to detect subjects with
elevated depressive symptoms (data not shown). Future re-
search is warranted to further examine the association between
depression and alexithymia with regard to CVD morbidity.
The 32.3% prevalence of alexithymia in our sample was
considerably higher than that reported by some other studies,
probably due to the relatively high age (mean 52 years) of
the participants. Other Finnish population studies have also
shown the effects of age and generation on alexithymia. In a
previous Finnish population study with younger participants
(mean age 40 years), the TAS-20 prevalence of alexithymia
in men was 17% (8), whereas an older sample with a mean age
of 72 years presented a 34% prevalence (34). Furthermore,
alexithymia has been associated with age in three large Finn-
ish population-based samples (8,9,33). In contrast to the find-
ings in Finnish samples, in a Japanese sample of subjects aged
14 years to 84 years, the prevalence of alexithymia was higher
in those aged 30 years, whereas the prevalence remained
unaltered in older age groups (35).
At present, the reasons for these cultural differences in the
association between age and TAS scores remain unclear.
Traumatic childhood experiences from the World War II and
post war period may have contributed to the observed high
T. TOLMUNEN et al.
190 Psychosomatic Medicine 72:187191 (2010)
prevalence in the studied generation. In line with our obser-
vations, Pasini and co-workers found in their study with
participants aged from 21 years to 64 years that high alexi-
thymia scores was associated with older age (36). However,
no such findings were observed in a German population-based
sample of subjects aged 60 years (37). In Finland, alexithy-
mia has also been associated with a rural upbringing, and the
rapid urbanization of Finland during the 20th century could
thus partly explain our observations (38).
Implications for Future Research or Clinical Practice
Alexithymia is an independent risk factor for increased
cardiovascular mortality. Future research is warranted to ex-
amine the mechanisms underlying this association.
We thank the personnel of the Research Institute of Public Health for
their valuable contribution to this study.
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