Alexithymia as a mediator between childhood trauma and self-injurious behaviors
Introduction
The purpose of this study was to examine the factors contributing to self-injurious behavior (SIB) among college women. We tested a mediational model of effects in which childhood maltreatment contributes to SIB via deficits in emotion regulation. The specific deficit under investigation concerned difficulties identifying and labeling affective experience (alexithymia). College women were selected as the target sample because SIB predominantly occurs among females and, most frequently, females of this age, intelligence level, and socioeconomic status (Favazza, 1996; Osuch, Noll, & Putnam, 1999), and because there is little information on SIB in nonclinical groups. The following review begins with a description of SIB, which is the dependent variable in the proposed mediational model. We then will examine the links between contributing factors and SIB in the proposed model.
Intentional non-lethal self-injury, among non-psychotic and non-developmentally disordered individuals, includes behaviors such as head banging, hair pulling, scratching, burning, and cutting self. The most frequently occurring of these methods is self-cutting (van der Kolk, Perry, & Herman, 1991). Such repetitive self-injury is a defining feature of Borderline Personality Disorder (Diagnostic and Statistical Manual of Mental Disorders IV; American Psychiatric Association, 1994) and a correlate of a number of other psychological disturbances, including depression, obsessive-compulsive disorder, posttraumatic stress disorder, eating disorders, and substance abuse (Favazza & Rosenthal, 1993, Suyemoto & MacDonald, 1995, van der Kolk & Fisler, 1994; Zlotnick, Mattia, & Zimmerman, 2001). The typical self-mutilator is a female adolescent or young adult who is single, intelligent, and from a middle to upper-class family (Darche, 1990, Favazza & Conterio, 1988). Incidence among adolescent inpatients has been estimated as high as 40% (Darche, 1990). However, there is limited information on self-injury in nonreferred groups and actual prevalence in the general population is unknown. It is believed that many individuals who engage in SIB do not seek medical care. Furthermore, cases of self-injury without suicidal intent that do appear at hospital emergency rooms frequently are dismissed as ploys for attention that do not warrant mental health referrals (Romans et al., 1995).
Research suggests that SIB typically begins in adolescence and often stops after 10–15 years (Favazza & Rosenthal, 1993, van der Kolk et al., 1991). Thus, many individuals appear to outgrow this behavior. Nonetheless, while ongoing, there can be few clearer signals of psychological disturbance and dysfunction. Furthermore, the stigma and shame associated with such culturally deviant behavior and disfigurement can lead to alienation and isolation which, in turn, can exacerbate disturbance. For some individuals, there also is the potential for these behaviors to increase in frequency and severity (Favazza & Rosenthal, 1993). Effective intervention to stop the behavior requires understanding the factors contributing to self-injury in order to address the underlying issues.
A history of childhood maltreatment is the predictor variable in the proposed mediational model. Considerable literature supports a link between childhood abuse and neglect and SIB (as well as diagnostic correlates of SIB, such as borderline personality) (Favazza & Rosenthal, 1993). For example, Weilderman, Sansone, and Sansone (1999) found that, among women in a primary care setting, all forms of childhood maltreatment, except physical neglect, were related to an increased likelihood of bodily self-harm. van der Kolk et al. (1991) similarly found that 79% of personality disordered patients who reported self-cutting also reported histories of childhood trauma (physical or sexual abuse, or exposure to family violence) and 89% reported major disruptions in parental care (neglect). These researchers noted that initiation of self-cutting was associated with sexual abuse, but continued cutting into adulthood was most strongly associated with a history of severe neglect. Thus, different types of abuse and neglect may differentially influence the likelihood of engaging in SIB.
There also is a link between a history of childhood maltreatment and difficulties regulating emotional experience. Experiences of abuse and neglect, particularly during periods of emotional development, are thought to impair the capacity for self-regulation of affective states and for utilizing interpersonal relations for affect regulation (van der Kolk et al., 1991). Effective emotion regulation includes the capacity to experience the full range of emotions in order to access the associated orienting information (Fridja, 1986); modulate emotional intensity without being overwhelmed or shutting down; and communicate feelings and needs appropriately in order to elicit interpersonal support (Gross, 1999). External monitoring and responsiveness to a child’s feelings and needs and coaching in appropriate expression are necessary for the child to learn to regulate their own experience and derive comfort from others (Gottman, 1997, Sroufe, 1995, Wheeler & Braod, 1994). Abusive and neglectful environments engender intense negative emotions and, at the same time, these feelings and the associated needs frequently are ignored, invalidated, or violated. These family environments therefore provide limited opportunities for children to learn about and express feelings appropriately, and limited support for coping with painful emotional experiences. Survivors of severe childhood trauma, without effective capacities for emotion regulation can experience intense disorganization in the face of current stress. This can precipitate impulsive or aggressive actions, including SIB, in order to express emotional pain and distress (Kench & Irwin, 2000, van der Kolk et al., 1991).
According to the literature reviewed above, there also is a link between deficits in emotion regulation and SIB. Indeed, the most widely accepted explanation for non-lethal self-injury is that these actions are a response to unmanageable emotional pain and distress. The fundamental difference between behaviors such as self-cutting or burning versus potentially lethal suicidal gestures is that, in the former, motivations concern coping rather than death (Connors, 1996, Osuch et al., 1999). Favazza and Rosenthal (1993) categorized patients’ reported motivations for self-harm. These included reduction of emotional numbness, distraction from emotional pain, release of anger and tension, relief from feelings of loneliness and alienation, and efforts to elicit social support. Osuch et al. (1999) similarly factor analyzed patients’ motivations for self-injury and found that five of six factors referred to modulation or control of emotional experience. Suyemoto and MacDonald (1995) reviewed eight theoretical explanations or functional models of self-cutting among adolescent patients. Common across all models was the regulation and expression of affect, particularly anger and feelings related to control or interpersonal boundaries. In sum, Solomon and Farrand (1996) observe that SIB occurs in women who are not able to express what they want and need, and suggest that these behaviors turn unmanageable emotional pain and distress into more manageable physical pain.
Critical aspects of emotion regulation that seem particularly relevant to SIB are the capacities to identify and express emotional experience appropriately. Deficits in these areas are captured by the construct of alexithymia, which literally means “no words for feelings” (Sifneos, 1973). Alexithymia has been characterized as a deficit in emotional intelligence (Taylor, Bagby, & Parker, 1997). Defining features include difficulties identifying and distinguishing among feelings and bodily sensations, difficulties labeling and communicating emotional experience, and externally oriented thinking (Taylor et al., 1997). Alexithymia is a correlate of a number of psychological disturbances, including borderline personality, eating disorders, substance abuse, and posttraumatic stress (for a review, see Taylor et al., 1997). As noted above, many of these disturbances also are correlates of SIB.
Alexithymia also has been linked to other variables in the proposed model of SIB. First, alexithymia is thought to have a developmental basis in dysfunctional family environments, particularly during periods of emotional development (Krystal, 1978). There is considerable research on the influence of family environments on emotion development, in general (e.g., Gottman, 1997, Gross, 1999, Sroufe, 1995). Recent studies also have examined the impact of family environment on emotional awareness, and the capacity to express and attend to emotional experience, in particular. For example, studies of both clinical (Berenbaum, 1996, Zlotnick et al., 2001) and nonclinical samples (Clayton, 1997, Turner & Paivio, 2002), found that both childhood physical and sexual abuse predicted impairments in emotional awareness and expression (alexithymia). Among university undergraduates, reports of feeling unsafe in childhood (Berenbaum & James, 1994) and low family expressiveness (Kench & Irwin, 2000) also were associated with alexithymia. Low family expressiveness, defined as limiting the extent to which family members are allowed to express opinions and feelings, is likely a feature of abusive and neglectful family environments where emotional expression frequently is ignored, punished, or out of control.
Results of recent studies also supported the view that alexithymia is a transmission mechanism between negative attachment experiences and impaired interpersonal functioning which, in turn, has been linked to SIB. For example, alexithymia mediated the link between childhood fear of separation and poor therapeutic alliances in a sample of clients at a university counseling center (Mallinckrodt, King, & Coble, 1998). Alexithymia also mediated the relationship between childhood maltreatment and social anxiety, which in turn was associated with limited social support among nonreferred university students (Turner & Paivio, 2002). These findings suggest that limited awareness and capacity to communicate feelings interfere with the capacity for intimacy and emotional connectedness. The literature also suggests that these deficits are risk factors for SIB. Self-injury functions to manage tension and intense negative feelings, in the absence of more adaptive self-soothing and interpersonal capacities (Wheeler & Braod, 1994).
In sum, the literature reviewed above suggests a chain of associations between childhood trauma, impaired capacities for emotion regulation, and SIB. Experiences of abuse and neglect generate painful feelings and distress. At the same time, absence of parental support and emotional coaching limits emotional development, particularly, the capacity to attend to, identify, and communicate emotional experience (alexithymia). During times of stress and in the absence of healthy coping strategies, survivors of childhood trauma are at risk for coping with emotional distress through impulsive self-destructive action, including superficial SIB. Although research supports the individual links among childhood trauma, alexithymia, and non-lethal self-harm behaviors, research to date has not examined this more comprehensive theory of the origins of SIB.
The present study, therefore, tested a mediational model of relations whereby childhood maltreatment is associated with SIB via alexithymia. Again, a sample of female college students was selected because self-injury most frequently occurs in young women of this age group, intelligence level, and socioeconomic status (Favazza, 1996, Osuch et al., 1999), and because there is little information on SIB in nonclinical groups. We tested the following four hypotheses: The extent of childhood maltreatment will be positively associated with the extent of both (a) alexithymia and (b) engagement in SIB, (c) alexithymia will be positively associated with SIB, and (d) alexithymia will mediate the relationship between childhood maltreatment and self-injury. Because there is limited information and conflicting findings concerning the differential effects of different types of maltreatment (Briere & Runtz, 1990, van der Kolk et al., 1991, Weilderman et al., 1999), we examined the model in terms of different types of abuse and neglect.
Section snippets
Participants
Participants were 100 female undergraduate students enrolled in Psychology classes at the University of Windsor, which is located in a medium-sized (population: 300,000) industrial city in central Canada. The university serves the post-secondary educational needs of students in the region. Participants in the present study were predominantly Caucasian, single, with no children, and with a mean age of 21 years (SD=1.66).
Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998)
The CTQ is a 28-item retrospective measure of the extent of different types
Descriptive data
Table 1 presents means, standard deviations, and prevalence rates for childhood maltreatment, alexithymia, and SIB for the total sample, as well as participant who engaged in any form of SIB, and those who did not. In terms of abuse and neglect for the total sample, means and standard deviations on CTQ subscales are comparable to those reported in other studies of undergraduate females using the CTQ (e.g., Bernstein & Fink, 1998, Paivio & Cramer, in press, Turner & Paivio, 2002). Prevalence
Discussion
Prevalence of abuse and neglect in the present sample was comparable to rates reported for other nonreferred groups (e.g., Bernstein & Fink, 1998, Paivio & Cramer, in press). Prevalence of alexithymia, however, was higher than rates reported for other samples of university students (e.g., Kench & Irwin, 2000, Turner & Paivio, 2002). In terms of SIB, 41% of the present sample of female undergraduates reported having engaged in at least one form of deliberate self-injury. Consistent with findings
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