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Alexithymia Is Associated With Increased Cardiovascular Mortality in

Middle-Aged Finnish Men


TOMMI TOLMUNEN, MD, PHD, SOILI M. LEHTO, MD, PHD, MARIA HELISTE, MB, SUDHIR KURL, MD, PHD,
AND JUSSI KAUHANEN, MD, PHD
Objective: To explore the associations between alexithymia and increased somatic morbidity. The mechanisms underlying these
associations, however, are still unclear. Furthermore, data on the association between alexithymia and mortality are scarce.
Methods: A total of 2321 Finnish men, aged 46 to 61 years, were followed up for an average of 20 years. Mortality rates were
obtained from the national register. The associations between baseline alexithymia and cardiovascular disease (CVD), all-cause,
injury, and cancer deaths were examined with adjustments for age and several behavioral (smoking, alcohol consumption, physical
activity), physiological (low- and high-density lipoprotein cholesterol, body mass index, systolic blood pressure, history of CVD),
and psychosocial (marital status, education, depression) factors. Results: After all adjustments, the risk of CVD death was increased
by 1.2% for each 1-point increase in Toronto Alexithymia Scale-26 scores. Conclusions: Alexithymia is associated with increased
cardiovascular mortality. Key words: alexithymia, mortality, cardiovascular.
BDI Beck Depression Inventory; BMI body mass index;
CI confidence interval; CVD cardiovascular disease; HDL-C
high-density lipoprotein cholesterol; HPL Depression Scale Hu-
man Population Laboratory Depression Scale; LDL-C low-density
lipoprotein cholesterol; RR risk ratio; TAS Toronto Alexithy-
mia Scale.
INTRODUCTION
A
lexithymia, a difficulty in identifying, verbalizing, and
expressing emotions (1), increases somatic morbidity. It
is associated with several somatic diseases, such as asthma,
hypertension, chronic pain, and functional gastrointestinal dis-
orders (24). The underlying mechanisms are still unresolved.
Nevertheless, four alternative pathways have been suggested:
alexithymia leads to organic disease through physiological or
behavioral mechanisms; alexithymia leads to illness behavior
(physical symptoms, disability, and excessive healthcare use)
through cognitive or social mechanisms; physical illness leads
to alexithymia; and both alexithymia and physical illness
result from sociocultural or biological factors (5).
Alexithymia and, in particular, its dimension of difficulties in
identifying and communicating emotions have been associated
with poor nutritional habits, a sedentary lifestyle, and substance
abuse (5,6). Alexithymia also affects the reactivity of the auto-
nomic nervous system (7). In the Finnish population, alexithymia
is associated with a low educational level and socioeconomic
status, both of which may increase mortality (8). Studies have
also shown an overlap between alexithymia and depression (9),
whereas depression and exhaustion, in turn, have been shown to
be risk factors for cardiovascular diseases (CVDs) and impaired
heart rate variation (1012). Thus, depression and other psycho-
social factors may confound the association between alexithymia
and somatic conditions.
The impact of alexithymia on mortality is unclear. In our
previous study with this sample, we observed that alexithymic
men had a higher risk of all-cause death and deaths due to
accidents, injury, or violence during a follow-up period of 5.5
years (13). In this study, we investigated whether alexithymia
predicts a higher mortality rate over an average follow-up
period of 20 years. Second, we examined whether adjustments
for lifestyle and somatic or psychosocial factors attenuate the
association between alexithymia and overall mortality.
METHODS
Study Population
The participants in the Kuopio Ischemic Heart Disease Study were se-
lected randomly from the general population in two cohorts (14). Baseline
data were collected between 1984 and 1989 from 2682 (participation rate
82.9%) male participants, aged 42 years, 48 years, 54 years, and 60 years, and
residing in the town of Kuopio and surrounding rural communities. Those
who reported having previously been diagnosed with cancer (n 51; 1.9%)
were excluded. Data were incomplete for 310 men, leaving a total of 2321
men to be analyzed.
The baseline examinations were conducted between March 1984 and
December 1989. Alexithymic characteristics were assessed with a question-
naire in May 1988, or during the baseline examination for those who entered
the study later. Sociodemographic and other background characteristics of the
sample have previously been described (14,15). When the study was initiated
in 1984, Finland and eastern Finland, in particular, was considered to be an
area of high CVD (16). The initial focus of the study was on CVD in men, and
only men were thus included. However, at the 11-year follow-up, the research
scope was widened and 920 women were included in the study. So far, there
has not been a sufficient number of end points in this female population to
enable a reliable examination of the study questions presented in this paper.
Hence, we only included men in this study.
Outcome
All-cause mortality, including deaths due to diseases, injuries, suicides,
and homicides, were ascertained by linkage to the national death registry,
using the Finnish social security number. Deaths were classified according to
the ninth and tenth International Classification of Diseases. All deaths occur-
ring between the assessment of alexithymia and December 31, 2007 were
included. The average follow-up time for the participants was 20 years.
Assessment of Alexithymia
Alexithymia was assessed, using the 26-item version of the Toronto
Alexithymia Scale (TAS-26). The TAS-26 has been validated in other general
adult populations (17,18) and in this study population (1921). Cronbachs
for the TAS-26 was 0.72. We used the previously set cutoff of 74 to indicate
definite alexithymia and the range from 61 to 73 to indicate probable alexi-
thymia (22).
From the Department of Psychiatry (T.T., S.M.L.), Kuopio University
Hospital; Kuopio Psychiatric Center (S.M.L.), Kuopio, Finland; Research
Institute of Public Health (M.H., S.K., J.K.) and the Department of Public
Health and General Practice (J.K.), University of Kuopio, Kuopio, Finland.
Address correspondence and reprint requests to Tommi Tolmunen, Depart-
ment of Psychiatry, Kuopio University Hospital, P.O. Box 1777, FIN-70211
Kuopio, Finland. E-mail: Tommi.Tolmunen@kuh.fi
Received for publication April 27, 2009; revision received September 21, 2009.
DOI: 10.1097/PSY.0b013e3181c65d00
187 Psychosomatic Medicine 72:187191 (2010)
0033-3174/10/7202-0187
Copyright 2010 by the American Psychosomatic Society
Other Characteristics
Participants completed questionnaires relating to their sociodemographic
background, smoking (pack-years were estimated as the product of years
smoked and the number of tobacco products smoked daily at the time of
examination), alcohol consumption (grams per week), education (years), and
marital status (married or living with a partner/not married/separated or
divorced/widowed). The weight and height of the participants were measured
by a research nurse, and the body mass index (BMI) (kg/m
2
) was calculated.
Resting blood pressure was measured between 8 and 10 AM on the first
examination day with a random-zero mercury sphygmomanometer. The mea-
suring protocol included, after 5 minutes of supine rest, three measurements
in the supine position, one in the standing position and two in the sitting
position with 5-minute intervals. The mean of all six systolic pressure values
was used in the analyses. A history of CVD was defined as having a diagnosis
of CVD other than high blood pressure.
A detailed description of laboratory measurements is provided elsewhere
(23). Subjects came for venous blood sampling between 8 and 10 AM. They
were instructed to abstain from alcohol use for 3 days and from smoking and
eating for 12 hours. After a 30-minute rest in the supine position, blood
samples were obtained by venipuncture and collected into vacuum tubes
(Venoject, Terumo, Leuven, Belgium). No tourniquet was used. Serum low-
density lipoprotein cholesterol (LDL-C) was precipitated by using polyvinyl
sulfate (Boehringer Mannheim, Mannheim, Germany) and calculated as the
difference between total and supernatant cholesterol. The serum high-density
lipoprotein cholesterol (HDL-C) concentration was determined after precipi-
tation with magnesium chloride dextran sulfate.
Physical activity was assessed, using the 12-Month Physical Activity
questionnaire (24). The checklist included the most common physical activ-
ities of Finnish middle-aged men, e.g., walking, jogging, skiing, bicycling,
swimming, and ball games. For each activity performed, the subjects were
asked to record the frequency, average duration, and intensity. A research
nurse checked and completed the questionnaire during an interview. The
energy expenditure from physical activity was expressed as kcal/day.
Depressive symptoms were assessed with the 18-item Human Population
Laboratory Depression Scale (HPL Depression Scale) at the time of the
measurements (25). The HPL Depression Scale has been used for examining
depressive symptoms in population samples. A cutoff score of 5 has been
used previously to define elevated depressive symptoms (2628).
Statistics
Differences in the characteristics between those with a definite alexithy-
mia, probable alexithymia, and other participants for continuous variables
were examined with the Kruskal-Wallis test due to the skewed distribution of
values. In addition, we used the
2
test for categorical variables. The risk
ratios (RR) for CVD death were examined, using a Cox proportional haz-
ards model with adjustments for: a) age and examination years (Model 1); b)
behavioral factors (smoking, alcohol consumption, physical activity) (Model
2) and physiological factors (LDL-C, HDL-C, BMI, systolic blood pressure,
history of CVD) (Model 3); and finally c) psychosocial factors (marital status,
education, HPL depression scores) (Model 4). All the variables except marital
status and CVD history were entered into the models as continuous variables.
The RRs for all-cause, cancer, and injury mortality except CVD deaths are
reported only using Model 4. A two-tailed p .05 was considered to indicate
statistical significance. All analyses were conducted with the SPSS statistical
package (version 17.0; SPSS Inc., Chicago, Illinois).
RESULTS
The background variables of subjects in the three alexithymia
categories are presented in Table 1. Those with alexithymia had
a higher BMI, systolic blood pressure, HPL depression scores,
more pack-years of smoking, and less physical activity compared
with other participants. They also more often had a history of
CVD and were living alone. Mean TAS-26 scores in the whole
sample were 68.0 (standard deviation 11.0, range 33107).
A total of 691 (29.8% of the whole sample) deaths occurred
during the follow-up time, which averaged 20 years. Of these,
66 (2.8% of the whole sample) were injury deaths and 625
(26.9% of the whole sample) were disease deaths. The disease
deaths comprised 320 CVD deaths (13.8% of the whole sam-
ple), 183 cancer deaths (7.9% of the whole sample), and 122
other disease deaths (5.3% of the whole sample).
The risk of CVD death increased by 2.3% for each 1-point
increase in the TAS-26 (Model 1). The risk of mortality was
increased by 1.8% after further adjustment for behavioral
TABLE 1. Characteristics of the Study Population (n 2321) of Middle-Aged Finnish Males at the Baseline Divided into Three Groups
According to TAS-26 Scores
No Alexithymia Probable Alexithymia
c
Definite Alexithymia
c
df
a

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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ALEXITHYMIA AND CARDIOVASCULAR MORTALITY
191 Psychosomatic Medicine 72:187191 (2010)