Mental health of patients with heart disease: analysis of alexithymia and family social support
- *Corresponding Author:
- Mostafa Alikhani
Substance Abuse Prevention Research Center Kermanshah University of Medical Sciences
Accepted date: April 16, 2016
The present study was conducted to determine the relationship of alexithymia and family social support with the mental health of patients with cardiac condition. The correlational method was used in the study. 200 individuals were selected as sample, using consecutive sampling method, from patients with cardiac condition who visited Imam Ali Hospital in Kermanshah, Iran during March and April 2014. The data collection instruments were the Mental Health Inventory (GHQ-28), Alexithymia (TAS_20) and Perceived Social Support from Family (PSS-Fa). The data were analyzed using Pearson’s correlation coefficient and stepwise regression analysis. The results of the study showed that there was a positive association of alexithymia, the components of difficulty identifying feelings (DIF) and difficulty describing feelings (DDF) with mental health. Negative correlation was obtained between family social support and mental health. The results of the regression analysis showed that DIF and family social support had the ability to predict mental health. Considering the results, in treatment of cardiac diseases, it is recommended to provide psychological interventions, especially paying attention to the patients’ emotions and their family’s social support, in addition to doing medical actions.
Mental health, Alexithymia, Family social support, Heart disease, Patient
Cardiovascular diseases are chronic diseases that affect blood flow to the heart, brain, or the peripheral regions of the body . Today, cardiovascular diseases have led to considerable number of mortalities in the world and the number of deaths is estimated to reach 11.1 million by 2020, up from 7.1 million in 1999 . In Iran, cardiovascular diseases are considered the leading cause of deaths and the cause of nearly 50% of the total number of deaths annually . In most cases of cardiovascular diseases, psychological disorders are also observed as a comorbid disease along with the complications of cardiac conditions . This will have severe impacts on the health, recovery, and life quality of the patients and will lead to increase in utilizing of health care, early disability and imposition of economic burden on the individuals and security systems of the society . The recognition of the factors impacting the mental health of cardiac patients can help them in undergoing treatment.
It seems that alexithymia is one of the relevant factors impacting mental health of cardiac patients. Alexithymia, as a personality character, is the lack or problem in identifying, describing and dealing with personal feelings and often leads to misunderstanding of other people’s feelings . This characteristic results in defective cognitive process, emotional adjustment, and adaptation which are relevant in commencement and advancement of psychological and medical disorders . People with this complication are extremely affected by the physical and emotional correlates which are not verbalized. These deficiencies hinder the adjustment of emotions and complicate the successful adaptation . In contrast, individuals who are emotionally more capable are more successful in coping with negative experiences and show better adjustment to the environment and the others . The results of several studies have indicated that the deficiency in regulating emotions is related to the occurrence of symptoms of psychopathology [10,11], depression [12-15], anxiety [12,15,16], phobia , suicidal thoughts  and mental health problem [9,18,19]. Social support is one of the determining factors in social health and it deals with the importance of the human social dimension and has attracted significant attention in recent years . Studies have shown that social support has positive effects on cardiovascular and immune systems of the body  and social support paucity perceived by patients with cardiac condition has a strong correlation with intensity and duration of the disease. Social support acts as a protector against stressful life events and increases commitment toward medical treatments and recovery . Emotional quality is accompanied by the sense of belonging and provides the needed information to minimize the physical or psychological harmful effects of life events . McCorkle et al. found out that social support plays a role in increasing welfare and decreasing psychological symptoms, especially symptoms of depression .
Considering high prevalence of cardiac diseases and its effect on psychological state of the patients, paying attention to the factors that impact mental health plays a significant role in performance, life quality and cooperation of the patients in the treatment procedure. These factors can be effective in prognosis of the disease. Given the importance of the issue, the present study was carried out to determine the correlation of alexithymia and family social support with the mental health of patients with cardiac condition.
Materials and Methods
This study is cross-sectional and of correlational type. The statistical population of study comprised of all patients with cardiac condition who visited Imam Ali Hospital of Kermanshah, Iran in March and April 2014. The inclusion criteria included having a cardiac condition, a minimum of 9 years of education, no history of significant mental disease, and having at least one-year history of cardiac disease. Regarding the population, a sample size of 200 individuals was selected using convenience sampling method. The selected patients began to fill out the questionnaires after declaring consent to participate in the study and gaining the required assurance of privacy of information. The patients then completed the questionnaires individually and in the presence of the researcher and then the questionnaires were collected. The SPSS software for Windows (ver. 19.0) was used to analyze the data and mean, standard deviation, Pearson correlation coefficient, and stepwise regression analysis result were reported.
1. The General Health Questionnaire-28 (GHQ-28): was used to assess the mental health of the subjects. This questionnaire was developed by Goldberg in 1972 and exists in forms with 12, 28, 30, and 60 items. The 28-item form was used in this study. The 28-item general health questionnaire is comprised of four subscales of seven questions which assess physical symptoms, anxiety, social performance disorder, and depression. All items of the GHQ have four options with two kinds of rating methods. One is rated in form of (0-0-1-1) and the second is Likert rating scale in which the items are rated as (0-1-2-3) . Shigemi and Tseuda obtained Cronbach’s alpha of 0.90 after using this questionnaire on Japanese office workers . In normalization of the GHQ in Iran, Houman reported the internal consistency of the subscales of this questionnaire, using Cronbach’s alpha, being 0.85, 0.87, 0.70  and 0.91 respectively and reported the internal consistency for the whole scale which shows the general health being 0.85.
2. Toronto Alexithymia Scale (TAS-20) is a 20-item test which assesses 3 subscales of difficulty identifying feelings (DIF) consisted of 7 items, difficulty describing feelings (DDF) consisted of 5 items, and externally-oriented thinking (EOT) consisted of 8 items using 5-point Likert scale from 1 (totally agree) to 5 (totally disagree). A total score is also obtained by summing up the three subscales for the alexithymia . The psychometric properties of TAS-20 have been evaluated and confirmed in various studies . In the Farsi version of the TAS-20, the Cronbach’s alpha for the total alexithymia and the three subscales of DIF, DDF and EOT were obtained being 0.85, 0.82, 0.75, and 0.72, respectively which indicate a good internal correlation of the scale. The test-retest reliability of the TAS-20 was confirmed two times with a four-week interval from r=0.85 to r=0.87 for the total alexithymia and several subscales in a sample size of 67 individuals. The simultaneous validity of the TAS-20 scale was evaluated and confirmed in terms of correlation between subscales of this scale and scales of emotional intelligence, psychological welfare, and psychological hopelessness. The results of Pearson’s correlation coefficient showed that there was a significant correlation between the scores of the tested individuals in alexithymia scale and emotional intelligence, psychological welfare, and psychological hopelessness. The correlation coefficients between alexithymia subscales and the above variables were also significant. The confirmatory factor analysis results also confirmed the existence of three indicators of DIF, DDF and EOT in the Farsi version of TAS-20 . In the study by Karami, Zakiee and Alikhani (2013) Cronbach’s alpha of the total questionnaire was obtained being 0.93 . In the present study, the Cronbach’s alpha was 0.64.
3. Perceived Social Support from Family (PSS-Fa) is a questionnaire designed by Procidano and Heller (1983) in 20 items to measure the social support of family. The scoring method is in the form of Yes, No, I don’t know. The maximum point for each item is +1 and the total range of points is between 0 and 20. The higher points indicate higher social support of the family . The Cronbach’s alpha of the questionnaire was obtained being between 0.88 and 0.91 . In the present study, the Cronbach’s alpha was obtained being 0.84.
From the total 200 studied individuals, there were 125 males and 75 females with age range of 21 to 78 years with the mean age of 55.79 years. The average duration of their illness was 3.65 years. 95% of the individuals under the survey were married and most of them had 9 years of education (65.5%) and 43% of them were self-employed (Table 1).
|Duration of Heart disease (year)||3.65 (4.56)||24-Jan|
|Frequency (n)||Percentage (%)|
|9 years of education||131||65.5|
|High school diploma||Education||50||25|
|Bachelor's Degree & above||8||4|
Table 1: Demographic information on the sample.
As shown in Table 2, there was a significant association of the components of DIF, DDF and alexithymia total score with mental health with correlation coefficients of 0.35 (p<0.01), 0.16 (p<0.5) an 0.27 (p<0.01) respectively . There was no significant correlation between EOT and mental health. The results showed that there was a correlation between family social support and mental health (r=-0.34, P˂0.01).
|1. DIF||19.16 (4.96)||1|
|2 DDF||15.16 (2.82)||0.40**||1|
|3. EOT||23.77 (3.43)||0.08-||0.01||1|
|5.Family Social Support||16.42 (3.66)||0.07-||0.10-||0.04-||0.08-||1|
|6. Mental Health||28.75 (12.28)||0.35**||0.16*||0.01||0.27**||0.34**-||1|
Table 2: Matrix of correlation of alexithymia (its components) and family social support with mental health.
Stepwise regression analysis was used to predict mental health by alexithymia and family social support. The results indicated that the prediction takes place in two steps and variables of DIF and family social support together explain 0.23% of the relevant changes of mental health. The results of the regression coefficients showed that the DIF and family social support can predict mental health with beta coefficients of 0.32 and -0.31 respectively (Table 3).
|Family Social Support||X2||-1.07||-0.31||-5.08||0.001|
Table 3: Stepwise regression analysis method to predict Mental Health according to Alexithymia and Family Social Support.
Discussion and Conclusion
Heart is one of the most important and sensitive organs of the body and any damage to it can negatively affect individual’s mental and psychological state. Any damage to the heart intensifies the illness in patients with cardiac condition; hence recognizing and considering the relevant factors of the mental health in cardiac patients can help in finding appropriate approaches to improve prognosis and hospitalization duration and also to improve the mental health level and life quality of such patients. Therefore, considering the importance of the issue, the present study was carried out to determine the correlation of alexithymia and family social support with the mental health of cardiac patients. The results of the study showed that there was a positive correlation of alexithymia, DIF and DDF with mental health. However, no significant correlation was found between EOT and the mental health. The results indicate that higher range of alexithymia is accompanied by lower mental health and higher psychological disorders and on the other hand; decreasing alexithymia improves mental health (higher rates in mental health questionnaire shows less mental health). Among the indicators of alexithymia, DIF has the potentiality to predict mental health of the cardiac patients with the beta coefficient of 0.32.
The results of several studies have indicated that the deficiency in regulating emotions is related to the occurrence of symptoms of psychopathology [10,11], depression [12-15], anxiety [12,15,16], phobia , suicidal thoughts  and mental health problem [9,18,19]. When confronted by a traumatic event, people with high alexithymia encounter emotional agitation due to inability in regulating and managing feelings. In fact, they experience distinguished feelings which are generally accompanied by a physiological arousal. However, due to difficulty in distinguishing and description, the arousal remains active and does not disappear. These people are unable to recognize the emotion arising from their physical feelings and just focus on physical feelings. This emphasis on physical feelings intensifies these symptoms and, through a defective circle, creates disorder in automatic nervous system and immunity system which ultimately intensify cardiac condition. In addition, these people are unable to understand their own and others’ emotions and show little potential for communion and therefore, are susceptible to get affected by different kinds of psychological disorders. On the other hand, those with low alexithymia show great communication and adjustment abilities. People who can recognize their feelings and express their own emotional conditions better can easily encounter the adversities of life and cope with problems in the environment and thus, have a better mental health. The results of this study revealed that there is a negative correlation between family social support and the mental health of the cardiac patients, meaning the more family social support, the better the mental health an individual can have. On the contrary, the less the family social support, the worse the mental health would be. The family social support can predict mental health of cardiac patients as much as 0.31%. These results are in line with the findings of McCorkle et al. that showed family social support is effective in increasing welfare and decreasing psychological symptoms, especially those of depression . Meanwhile, the social support on the part of the family helps in coping with the cardiac condition in affected people and improves individual’s cognitive evaluation and beliefs about the world. Moreover, social support can act as a shield against stress and alleviate psychological and mental symptoms. Since the cardiac condition is a stressful event, social support by the patient’s family can play a major role in accelerating the improvement of cardiac condition. Considering the results, in treatment of cardiac diseases, it is recommended to provide psychological interventions, especially paying attention to the patients’ emotions and their family’s social support, in addition to doing medical actions. Also, the evaluation of these variables should be done in patients with other chronic diseases. The study was conducted on cardiac patients in Kermanshah hospital, Iran, therefore caution should be taken when expanding the results.
The present study was financially supported by Kermanshah University of Medical Sciences and the authors would like to thank all the staff of the Kermanshah University of Medical Sciences.
- Hallerod B, Gustafsson J. A longitudinal analysis of the relationship between changes in socioeconomic status and changes in health. Social science & medicine 2011;72: 116-123.
- Grau M, Bongard V, Fito M, Ruidavets J, Sala J, Taraszkiewicz D. Prevalence of cardiovascular risk factors in men with stable coronary heart disease in France and Spain. Arch Cardiovascular Dis 2010; 103: 80-89.
- Hatmi Z, Tahvildari S, Motlag AG, Kashani AS. Prevalence of coronary artery disease risk factors in Iran: A population based survey. BMC Cardiovasc Disord 2007; 7: 32.
- Stoudmire A, Mcdaniel J. History, classification and trends in psychosomatic medicine. In:Kaplan & Sadock S. Comprehensive text book of psychiatry: From Williams & Williams. USA: Lippin cott; 2000.
- Herrmann-Lingen C. Anxiety and depression in cardiology patients: how to diagnose, how to treat? Herz 2001; 26: 326-334.
- Paivio S, McCilloch C. Alexithymia as a mediator between childhood trauma and self- injurious behaviors. Child Abuse Negl 2004; 28: 339-354.
- Lumley M, Neely L, Burger A. The assessment of alexithymia in medical settings: Implications for understanding and treating health problems. J Press Assess 2007; 89: 230-246.
- Taylor G, Bagby R, Parker J, Grotstein J. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge Cambridge University Press; 1999.
- Shahgholian M, Moradi A, Kafee S. The relationship alexithymia with expressive emotion styles and general health. Iran Psychiatr Clin Psychol 2007; 13: 238-248.
- Taylor G, Bagby R. An overview of the alexithymia construct. In: Bar-On R, Parker JD, Editors. The handbook of emotional intelligence: theory, development, assessment, and application at home, school and in the workplace. San Francisco: Jossey-Bass; 2000.
- Maggini C, Raballo A. Alexithymia and schizophrenic psychopathology. Acta BioMedica. 2004; 75: 40-49.
- Spindler H, Kruse C, Zwisler A, Pedersen S. Increased anxiety and depression in Danish cardiac patients with a type D personality: Cross-validation of the type D scale (DS14). Int J Behav Med. 2009; 16: 98-107.
- Hintikka J, Honkalampi K, Koivumaa-Honkanen H, Antikainen R, Tanskanen A, Haatainen K. Alexithymia and suicidal ideation: A 12-month follow-up study in a general population. Compr Psychiatry. 2004; 45: 340-345.
- Lee N, Romas M, Munoz R. The relationship between Alexithymia and perinatal depressive symptomatology J Psychosom Res. 2007; 62: 215-222.
- Mazaheri M, Afsahr H. The relationship between alexithymia and depression and anxiety in psychiatric patients. Journal of Fundamentals of Mental Health. 2010; 2: 470-479.
- Berthoze S, Consoli S, Peterz-Diaz F, Jouvent R. Alexithymia and anxiety: Compounded relationships?A psychometric study. Eur Psychiatry. 1999; 14: 372-378.
- Cox B, Swinson R, Shulman I, Bourdeau D. Alexithymia in panic disorder and social phobia. Compr Psychiatry. 1995; 36:195-198.
- Zakiee A, Karami J, Alikhani M, Ghasemi R, Gilan NR. The relationship between alexithymia, irrational beliefs, positive and negative emotions with mental disorders. Medical Journal. 2014; 18: 435-446.
- Issazadegan A, Sheikhy S, Basharpoor S. The relationship of alexithymia with type personality and general health. Urmia Medical Journal. 2012; 22: 530-538.
- Lang A, Stein M. Anxiety disorders. How to recognize and treat the medical symptoms of emotional illness. Geriatrics 2001; 56: 24-27.
- Streeter C, Franklin C. Defining and measuring social support: Guidelines for social work practitioners. Research on Social Work Practice 1992; 2: 81-98.
- DiMatteo M. Social support and patient adherence to medical treatment: A meta-analysis. Health Psychol. 2004; 23: 207-218.
- Connelly C. Hopefulness, self-esteem, and perceived social support among pregnant and no pregnant adolescents. West J Nurs Res 1998; 20: 195-209.
- McCorkle B, Dunn E, Mui WY, Gagne CW. Increasing Social Support for Individuals with Serious Mental Illness: Evaluating the Compeer Model of Intentional Friendship. Int J Soc Psychiatry. 2009; 55: 291-305.
- Goldberg D. The detection of psychiatric illness by questionnaire: A technique for the identification and assessment of non-psychotic psychiatric illness1972.
- Shigemi T, Toshihide T. Stability of Factor structure and correlation with perceived job stress in General Health Questionnaire: a three way survey over one year in Japanese workers. J Occu Heal. 2000; 42: 284-291.
- Houman A. tandardization and Normalization of the General Health Questionnaire for the BA Students of Tarbiat-e Moallem University. Tehran: Tarbiat-e Moallem UniversityResearch Institute; 1997.
- Henry J, Phillips L, Maylor E, Hosie J, Milne A, Milne C. A New conceptualization of alexithymia in the general adult population: implications for Research involving older adults J Psychosom Res. 2006; 60: 535-543.
- Parker J, Taylor G, Bagby R. The 20-Item Toronto Alexithymia Scale III. Reliability and factorial validity in a community population. Journal of Psychosomatic Research 55: 269-275.
- Besharat MA. Reliability and factorial validity of Farsi version of the Toronto alexithymia Scale with a sample of Iranian students. Psychol Rep. 2007; 101: 209-220.
- Karami J, Zakiee A, Alikhani M. The Role of Gender Differentiation and Attachment Styles in Predicting the Incidence Alexithymia. Med J Tabriz Univ Med Sci. 2013; 35: 81-74.
- Eskin M. Suicidal behaviour as related to social support and assertiveness among Swedish and Turkish high school students: a cross-cultural investigation. Journal of Clinical Psychology 1995; 51: 158-172.
- Sanaei B. The Evaluation Scales of the Family and Marriage Tehran: Besat Publication; 2008.