Alexithymia is a multidimensional construct that describes a constellation of personality features characterised by difficulties in differentiating, identifying and communicating emotions. The purpose of the present study was to investigate prevalence of alexithymia in outpatients with erectile dysfunction (ED), both in the psychogenic lifelong type (PLED) and in the acquired one (PAED). ED severity was evaluated with the International Index of Erectile Function (IIEF) and alexithymia was measured using the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20). The results suggest a high incidence of alexithymic characteristics in patients with psychogenic ED, a positive correlation between the alexithymia level and ED severity in patients with PAED and statistically significant differences in the alexithymia level between the two subgroups PLED and PAED. We assumed that alexithymia contributes to the origin of the PLED, and to a more severe manifestation of ED, once it appears in the acquired form.
Alexithymia is a multidimensional construct introduced by Nemiah and Sifneos in the early 1970s to identify a group of affective and cognitive characteristics that a number of studies had observed in patients with the so-called ‘classic’ psychosomatic diseases.
Alexithymia construct describes a set of deficits in the cognitive processing of emotions, or more generally, a disturbance in the regulation of emotions.1 The personality features that characterise alexithymic individuals are: difficulty in identifying emotions and differentiating between emotions and the bodily sensations of emotional arousal; difficulty in communicating emotions to others; reduced imaginal and fantasy activity; externally oriented cognitive style.2, 3
Even if alexithymic characteristics were assumed to be typical of psychosomatic disease,4, 5 there is increasing evidence that alexithymia is prevalent both in medical and in psychiatric illness.1, 3 Alexithymia has been found in healthy populations6, 7 as well as in a large number of clinical situations like psychoactive substance dependency,8 eating disorders,9 risky sexual behaviour.10, 11 An elevated alexithymia was associated with a lower level of natural killer lymphocyte cells12 and worse male seminal parameters.13
The purpose of this study was to investigate the prevalence of alexithymia in outpatients with erectile dysfunction (ED), both in the psychogenic lifelong type (PLED), present since the beginning of the patient's sexual activity, and in the acquired type (PAED), developed after years of satisfactory sexual activity.17, 18
We predicted a significant prevalence of alexithymic features in patients with ED, a positive correlation between alexithymia level and ED severity, and differences between alexithymia scores in patients with PLED and those with PAED.
Unlike previous researches, this study focused on psychogenic ED, evaluating a greater number of subjects and including an accurate clinical diagnosis that allowed a distinction between PLED and PAED, and between situational ED (when its appearance is limited to particular situations, stimulations or partners) and general ED (when it appears in all situations).18
Materials and methods
We enrolled 100 outpatients with a first diagnosis of psychogenic ED, assessed at our Andrology Outpatient's Clinic. The average age was 40.3 (range 20–60) years; patients with previous psychotherapeutic experiences were not included because of the possible influence of psychotherapy on the alexithymia level.3
Diagnosis of psychogenic ED was assigned by clinical anamnesis, andrologic examination and Nocturnal Penile Tumescence (RigiScan test). Colour-doppler ultrasonography, neurological examination and hormonal balance test were performed as additional diagnostic steps, when necessary. An expert interviewer evaluated each patient according to the multiaxial classification criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR)19 to exclude other disorders on the Axis I and to assign patients to the subgroups (42 patients were assigned to the PLED and 58 to the PAED subgroups).
ED severity was evaluated using the points the patient obtained in the Erectile Function domain of the International Index of Erectile Function (IIEF),20, 21 and all patients reporting a score lower than 24 were selected.
A questionnaire collecting demographic and anamnestic data – including possible use of drugs that alter sexual response – was completed by all patients.
Alexithymia was measured through the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20).22, 23, 24, 25 The self-report structure reflects three separate, yet conceptually related, facets of the alexithymia construct: difficulty identifying feelings and distinguishing them from the somatic sensations that accompany emotional arousal (F1), difficulty communicating feelings to other people (F2) and externally oriented thinking (F3). The TAS-20 provides a score for each of the three factors (F1, F2, F3) and a total alexithymia score (TAS-20).
Even if the alexithymia level measured by TAS-20 is a continuous variable normally distributed in the population3, 6, 7 different studies have led to the determination of standard cutoff scores to distinguish alexithymic subjects (TAS-20 above 61) from nonalexithymic subjects (TAS-20 lower than 51), with an intermediate ‘grey area’ for scores between 51 and 61, where borderline subjects can be identified neither alexithymic nor nonalexithymic.3
In this study, we considered both the total alexithymia score (TAS-20) and the three subfactor scores; we also analysed alexithymia both as a dimensional variable and as a categorical variable (according to the standard cutoff points).
All of the 100 enrolled patients could be assessed for alexithymia.
The overall average score of the TAS-20 was 58.62, and so can be placed in the grey area (51<TAS-20<61). However, 34% of the patients can be categorised as alexithymic, 23% in the grey area and 43% as nonalexithymic.
The level of severity of the ED showed a statistically significant correlation with the TAS-20 total score (P=0.001), F1 (P=0.002), F2 (P=0.001) and F3 (P=0.016), so with the increasing of the alexithymia level, the erective ability of patients gets worse (Table 1).
When compared, the averages showed statistically significant differences between the two subgroups PLED and PAED, both in the total alexithymia score (P=0.001) and in the three-factor scores F1 (P=0.002), F2 (P=0.003) and F3 (P=0.016): the alexithymia level was significantly higher in patients with PLED than in those with PAED (Table 2).
The PLED subgroup turned out to have an average TAS-20 total score of 65, which represents a high level of alexithymia, considered at risk and hence is of clinical interest (TAS-20>61). Patients with PLED were 50% alexithymic, 33% in the grey area and 17% nonalexithymic. In the PAED subgroup, the average TAS-20 total score was 54, and therefore in the grey area. In all, 22% of patients with PAED were categorised as alexithymic, 16% in the grey area and 62% as nonalexithymic.
In the PAED subgroup (but not in the PLED group), we found a statistically significant correlation between the severity of the ED and the TAS-20 total score (P=0.007), F1 (P=0.031), F2 (P=0.017) and F3 (P=0.012).
No significant correlation was found between the age of the patients and the alexithymia levels and between the two subgroups defined by the general or situational manifestation of the ED.
Discussion and conclusions
This study supports the findings of previous reports by Madioni and Mammana14 and Wise et al.,15 in which, respectively, 25.1% of 112 patients with sexual disorders and 20.2% of 170 patients with sexual disorders, resulted categorically alexithymic. A possible explanation for the higher percentage of alexithymic patients in our study (34%) can be found both in the larger number of assessed patients with ED, and in the exclusion of patients with organic ED. It is also important to specify that previous studies used the TAS, but not the 20-item version.
Since we focused on the comparison between clinical groups and on the correlation between alexithymia level and ED severity, a further investigation with a normal control group could be interesting to increase the comprehension of this phenomenon, although previous reports suggested that alexithymia level is significantly higher in patients with ED than in the normal sample.14, 15 The cross validation study of the TAS-20 Italian translation reports indicative data about Italian general population: an average TAS-20 total score of 44.7 in a sample of 206 normal adults and a score of 53.6 in a mixed group of 642 medical and psychiatric outpatients.25 The average alexithymia level we found in patients with psychogenic ED is significantly higher.
Our results suggest the association between alexithymic personality features and psychogenic ED with an alexithymia level of clinical interest (TAS-20=65) in patients with PLED. The positive correlation between TAS-20 total score and ED severity leads us to conclude that a high alexithymia level contributes to a more serious manifestation of the sexual disorder. Moreover, the correlation between ED severity and all the three subfactors measured by the TAS-20 seems to suggest that difficulty in identifying feelings and distinguishing them from somatic sensations (F1), difficulty in communicating feelings to other people (F2) and externally oriented thinking (F3) could represent potential risk factors of a more serious manifestation of ED.
The differences discovered between the PLED and PAED subgroups shows a significantly higher alexithymia level in the lifelong type, which otherwise did not present a correlation between alexithymia level and ED severity.
This appears to suggest that an elevated alexithymia level contributes to the origin of the PLED, whereas a lower – but still above the norm – level of alexithymia contributes to a more severe PAED.
The existence of a link between ED and the regulation of emotions represent another confirmation of the importance of the emotive dimension in human sexuality, in particular of the individual capacity to feel and communicate emotions. The limited imaginative activity of alexithymic subjects can also be reflected in a lack of sexual fantasies, considered central to human sexuality.26, 27, 28
These results can be integrated with those of previous studies that suggested the association between psychosocial risk factors and ED. Prospective results from the Massachusetts Male Aging Study (MMAS)29, 30 underlined that the risk of ED can be associated with a submissive personality, but not with depressive symptoms and with the way anger is expressed, although in several cross-sectional studies the prevalence of ED has been shown to be associated both with anger and depression. Further investigations are needed to detect if alexithymic difficulties in identifying and communicating feelings could influence patients self-report on anger and depression.
Considering alexithymia as a possible risk factor that contributes to the cause and maintenance of psychogenic ED can provide useful information for a more complete clinical anamnesis of the patient, assuming particular importance in facing the communication and introspection difficulties that characterise the relationship with alexithymic patients. In this way, the literature reports how an introspective-based psychotherapeutical approach can prove very ineffective with alexithymic patients, and proposes the possible use of a parallel pharmacological treatment and cognitive-behavioural approaches or modified forms of psychodynamic psychotherapy.1, 3, 31, 32
Taking into account how alexithymic characteristics can alter the patient's perception and communication of his own level of discomfort can also contribute to identify the latent demand for ED treatment.
The concept of alexithymia and the regulation of emotions could be useful for future programmes designed to promote sexual health and responsible sexual behaviour.
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Cite this article
Michetti, P., Rossi, R., Bonanno, D. et al. Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile dysfunction (ED). Int J Impot Res 18, 170–174 (2006). https://doi.org/10.1038/sj.ijir.3901386
- regulation of emotions
- erectile dysfunction (ED)
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