Alexithymia Is Associated with Depression in de novo Parkinson’s Disease

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Letter to the Editor Received: April 15, 2010 Accepted after revision: October 6, 2010 Published online: $ $ $


Psychother Psychosom 322029 DOI: 10.1159/000322029

Alexithymia Is Associated with Depression in de novo Parkinson’s Disease Michele Poletti a, b, Daniela Frosini b, Cristina Pagni b, Claudio Lucetti a , Paolo Del Dotto a , Roberto Ceravolo b, Ubaldo Bonuccelli a, b a



Neurology Unit, USL of Viareggio, Viareggio, and Department of Neuroscience, University of Pisa, Pisa, Italy


Alexithymia is a phenomenon related to an alteration in affect regulation. Its characteristics include the inability to identify and describe feelings, difficulty distinguishing feelings from bodily sensations of emotional arousal, impaired symbolization and an externally oriented cognitive style [1]. Alexithymia has been found to be strongly associated with depression in both general [2] and clinical populations [3]. Alexithymic and depressive symptoms may be partially overlapping, but not all are correlated with depressive symptoms, thus underlining the relative independence of the two disorders [4]. Parkinson’s disease (PD) is a clinical condition often characterized by depression and an altered emotional processing [5]. In medicated PD patients alexithymia has a prevalence of 21% [6, 7] and is related to depression [7]. To our knowledge, alexithymia has never been investigated in newly diagnosed untreated (de novo) PD patients before the administration of dopaminergic therapy; this topic is of particular clinical interest considering that affective symptoms may precede the clinical motor onset of PD [8, 9]. This study was aimed at investigating the prevalence of alexithymia in de novo PD patients and its relation to depression. To estimate the prevalence of alexithymia and its relation to depression in de novo PD patients we administered the TwentyItem Toronto Alexithymia Scale (TAS-20) [10] and the Geriatric Depression Scale Short Form (GDS-15) [11] to 42 de novo PD patients and 30 age-matched healthy controls (HC). The de novo PD patients were enrolled in two Italian movement disorder tertiary clinics (Versilia Hospital, Viareggio; Neurological Clinic, University of Pisa). All enrolled patients fulfilled research diagnostic criteria for idiopathic PD [12]. Patients who had clinical features suggestive of primary atypical parkinsonism, such as multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, and those with diagnosis of dementia according to DSM-IV criteria were not included. Magnetic resonance imaging showed no signs of atypical parkinsonism, normal pressure hy-

drocephalus, moderate-to-severe vascular abnormalities, and tumors. Exclusion criteria were the presence of a comorbid psychiatric mental disorder or a history of drug abuse. In all de novo PD patients we recorded gender, age, years of education, and the side and the type of motor symptoms’ onset. The severity of motor symptoms was measured by the Unified Parkinson’s Disease Rating Scale (UPDRS II and III) [13]. In all enrolled subjects the global cognitive status was assessed with the Mini-Mental State Examination (MMSE) [14]. Informed consent was obtained in compliance with research standards for human research for all participating institutions and in accordance with the Helsinki Declaration. The TAS-20 is an extensively validated self-report questionnaire comprised of three subscales that investigate the following factors: F1 = difficulty identifying feelings, F2 = difficulty describing feelings, and F3 = difficulty focusing on inner affective experience. The total score on the questionnaire allows categorizing subjects as nonalexithymic (scores ranging from 20 to 51), borderline alexithymic (scores ranging from 52 to 60), or alexithymic (scores 661). A ␹2 test was used for the comparison between qualitative characteristics of the de novo PD subgroups; the Wilcoxon test was used for the comparison of quantitative variables for independent data. All de novo PD patients and all HC were cognitively preserved. Demographic and clinical characteristics of de novo PD patients and HC are reported in table 1. No differences were found for age, education, cognitive status (MMSE), alexithymia (TAS-20 score) and depression (GDS-15 score) between de novo PD patients and HC. A statistically significant difference was approached for the subscale F2 (p = 0.07). In the group of de novo PD patients, cutoff scores of the TAS-20 identified 10 alexithymic patients (23.80%), 11 borderline alexithymic patients (26.19%) and 21 nonalexithymic patients (50.01%). In the group of HC, 5 subjects were alexithymic (16.6%), 7 subjects were borderline alexithymic (23.3%) and 18 were nonalexithymic (60.1%) (table 1). The difference between frequencies of alexithymia in de novo PD patients (23.80%) and HC (16.6%) was not statistically different (p = 0.33). In the group of de novo PD patients, any difference was found for age, education, cognitive status (MMSE) and motor severity (UPDRS II and III) between alexithymic, borderline alexithymic and nonalexithymic de novo PD patients. Either in the sample of de novo PD patients or in the sample of HC, alexithymic subjects were more depressed at the GDS-15 than nonalexithymic or borderline alexithymic subjects (p ! 0.01) and borderline alexithymic subjects were more depressed than nonalexithymic subjects (p ! 0.01). In the sample of de novo PD patients, the TAS-20 significantly correlated with age (r = 0.343; p = 0.026), with education (r =

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Table 1. Sociodemographic, clinical and neuropsychological features of de novo PD patients and HC

Age Sex, M/F Education Raw MMSE UPDRS II UPDRS III GDS-15 TAS-20 total score TAS-20 F1 TAS-20 F2 TAS-20 F3

HC (n = 30)

De novo PD patients (n = 42)

Alexithymic PD patients (n = 10)

Borderline alexithymic PD patients (n = 11)

Nonalexithymic PD patients (n = 21)

65.3087.89 20/10 8.7683.56 28.9681.20 – – 4.4983.76 50.70811.89 15.5985.83 13.6884.64 21.7885.03

64.9787.87 28/14 9.3384.31 28.9281.52 6.3382.52 14.3388.99 4.5483.52 50.55812.47 15.7985.36 14.3785.27 20.9585.09

68.1083.60 10/0 7.6083.64 27.4281.91 9.2580.95 20.7586.70 6.9084.35 66.9084.20 22.2083.32 19.6082.83 25.7083.30

63.5587.56 7/4 8.6484.03 29.4580.82 6.6682.51 17.6688.62 4.9183.04 54.9182.80 14.9082.84 16.0081.94 23.8082.48

64.2489.32 11/10 10.5284.52 28.8681.76 5.1882.08 11.0988.82 3.2482.77 40.4887.52 12.7284.24 10.5684.61 16.7283.25

–0.356; p = 0.021) and with the GDS-15 (r = 0.412; p = 0.007). Considering the TAS-20 subscales, only the subscale F1 significantly correlated with the GDS-15 (r = 0.585; p ! 0.001). The GDS-15 did not correlate with age and education. In the sample of HC, the TAS20 significantly correlated with the GDS-15 (r = 0.780; p ! 0.001) but not with age and education. Considering the TAS-20 subscales, only the subscales F1 and F2 significantly correlated with the GDS15 (respectively, r = 0.797, p ! 0.001; r = 0.666, p ! 0.001). In the group of de novo PD patients, males were more alexithymic (mean TAS-20 score 53.17 8 13.74) than females (45.28 8 7.32; (p = 0.03), but not more depressed (mean GDS-15 scores, respectively, 3.79 8 2.23 and 4.93 8 3.99; p = 0.51). In the group of HC, any gender difference emerged for alexithymia and depression. The main finding of this study is that alexithymia is associated with depression in de novo PD patients, as reported in healthy samples [2] and in medicated PD patients [7]. Alexithymia in de novo PD has a prevalence of 23.8%, confirming findings of previous studies [6, 7] and suggesting that alexithymia may frequently occur in PD patients. Considering that 26% of de novo PD patients reported borderline scores on the TAS-20, it may be argued that about half of the PD patients may present mild to severe difficulties in affect regulation since the early clinical stages of the disease. The finding that the prevalence of alexithymia is similar in de novo PD patients and in HC suggests that the dopamine depletion that precedes the clinical motor onset of PD scarcely impacts on alexithymia; this is also suggested by a similar prevalence of alexithymia in PD patients before (23.8%) and after (21%) the treatment with dopaminergic drugs [6, 7]. However, the effect of dopaminergic drugs on alexithymia has to be directly investigated, assessing longitudinally this affective disorder in the same sample of PD patients before and after the administration of dopaminergic drugs. Considering gender differences, male de novo PD patients were more alexithymic than female de novo PD patients, as reported in healthy elderly subjects [15]; finally, the finding that male patients were more alexithymic but not more depressed than female patients confirms that alexithymia and depression are partially overlapping but independent affective disorders [4]. In conclusion, this brief report suggests the usefulness of an early neuropsychiatric assessment of affect regulation difficulties in PD patients.


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Disclosure Statement Full financial disclosures of all authors for the past 3 years: Stock ownership in medically related fields: none. Consultancies: none. Advisory boards: U. Bonuccelli: GSK, Lundbeck, Novartis, UCB; R. Ceravolo: Boehringer Ingelheim. Partnerships: none. Honoraria: U. Bonuccelli for speeches at meetings by Boehringer, GSK, Novartis; R. Ceravolo for speeches at meetings by Boehringer, GSK; P. Del Dotto for speeches at a meeting by Novartis. Grants: Regione Toscana Health Authority. Intellectual property rights: U. Bonuccelli from Sperling & Kupfer for a book authorship. Expert testimony: none. Employment: USL 12 Viareggio (C. Lucetti, P. Del Dotto) and University of Pisa (M. Poletti, D. Frosini, C. Pagni, R. Ceravolo, U. Bonuccelli). Contracts: none. Royalties: none. Others: none.

References 1 Taylor GJ, Bagby RM, Parker JDA: The alexithymia construct: a potential paradigm for psychosomatic medicine. Psychosomatics 1991; 32: 153–164. 2 Honkalampi K, Hintikka J, Tanskanen A, Lehtonen J, Viinamaki H: Depression is strongly associated with alexithymia in the general population. J Psychosom Res 2000;48:99–104. 3 Honkalampi K, Saarinen P, Hintikka J, Virtanen V, Viinamaki H: Factors associated with alexithymia in patients suffering from depression. Psychother Psychosom 1999;68:270–275. 4 Hintikka J, Honkalampi K, Lehtonen J, Viinamaki H: Are alexithymia and depression distinct or overlapping constructs? A study in a general population. Compr Psychiatry 2001;42:234–239. 5 Reijnders JS, Ehrt U, Weber WE, Aarsland D, Leentjens AF: A systematic review of prevalence studies of depression in Parkinson’s disease. Mov Disord 2008;23:183–189. 6 Costa A, Peppe A, Carlesimo GA, Salamone G, Caltagirone C: Prevalence and characteristics of alexithymia in Parkinson’s disease. Psychosomatics 2010;51:22–28. 7 Costa A, Peppe A, Carlesimo GA, Pasqualetti P, Caltagirone C: Alexithymia in Parkinson’s disease is related to depressive symptoms. Eur J Neurol 2006;13:836–841. 8 Ishihara L, Brayne C: A systematic review of depression and mental illness preceding Parkinson’s disease. Acta Neurol Scand 2006; 113: 211– 220.

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9 Ishihara-Paul L, Wainwright NW, Khaw KT, Luben RN, Welch AA, Day NE, Brayne C, Surtees PG: Prospective association between emotional health and clinical evidence of Parkinson’s disease. Eur J Neurol 2008;15:1148–1154. 10 Bagby RM, Parker JDA, Taylor GJ: The Twenty-Item Toronto Alexithymia Scale I: item selection and cross-validation of the factor structure. J Psychosom Res 1994;38:23–32. 11 Sheik JI, Yesavage JA: Geriatric Depression Scale (GDS): recent evidence and development of a shorter version; in Clinical Gerontology. A Guide to Assessment and Intervention. Binghamton, The Haworth Press, 1986, pp 165–173. 12 Hugues AJ, Daniel SE, Kilford L, Lees AJ: Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry 1992;155:181–184. 13 Fahn S, Elton RL, Members of the UPDRS Development Committee: Unified Parkinson’s disease rating scale; in Fahn S, Marsden CD, Calne

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DB, Goldstein M (eds): Recent Developments in Parkinson’s Disease. Florham Park, Macmillan Health Care Information, 1987, vol 2, pp 153–164. 14 Folstein MF, Folstein SE, McHugh PR: ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatry Res 1975;12:189–198. 15 Mattila AK, Salminen JK, Nummi T, Joukamaa M: Age is strongly associated with alexithymia in the general population. J Psychosom Res 2006;61:629–635.

Prof. Ubaldo Bonuccelli Department of Neuroscience, University of Pisa Via Roma 67, IT–56100 Pisa (Italy) Tel./Fax +39 0584 6059 539 E-Mail u.bonuccelli @  



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