The association between alexithymia and posttraumatic stress symptoms following multiple exposures to traumatic events in North Korean refugees

https://doi.org/10.1016/j.jpsychores.2014.09.007Get rights and content

Highlights

  • TAS-20 scores and number of traumas experienced were correlated with IES-R scores.

  • Number of traumas experienced interacted with TAS-20 scores for IES-R scores.

  • TAS-20 scores moderate the relationship between number of traumas and IES-R scores.

Abstract

Objective

The present study aimed to investigate the effect of the interaction between the number of traumas experienced and alexithymia, on posttraumatic stress disorder (PTSD) symptoms.

Methods

The sample comprised 199 North Korean refugees. Participants completed the Trauma Exposure Check List for North Korean Refugees, Impact of Event Scale-Revised (IES-R), Toronto Alexithymia Scale-20 (TAS-20), and Center for Epidemiological Studies-Depression Scale (CES-D).

Results

TAS-20 scores were positively correlated with IES-R scores (r = 0.21, p < 0.01), after controlling for gender, age, and CES-D scores. The number of traumas experienced was also positively correlated with IES-R scores (r = 0.32, p < 0.001), but not with TAS-20 scores, after controlling for gender, age, and CES-D scores. A hierarchical multiple regression analysis revealed a significant interaction between the number of traumas experienced and TAS-20 scores, for IES-R scores (t = 2.10, p < 0.05). Moderation analysis further revealed that TAS-20 scores moderate the relationship between the number of traumas experienced and IES-R scores (t = 2.90, p < 0.01). For refugees with higher TAS-20 scores, those who had experienced more traumas had higher IES-R scores. However, within refugees with lower TAS-20 scores, IES-R scores were not significantly different for those who had experienced a higher number of traumas compared with those who had experienced a lower, or average, number of traumas.

Conclusion

The results of the current study suggest that, as individuals experience more traumatic events, clearly identifying and expressing emotions become more crucial for reducing PTSD symptoms.

Introduction

Posttraumatic stress disorder (PTSD) is a mental disorder that can develop following exposure to traumatic events. Symptoms of PTSD include intrusion, avoidance, negative cognition or mood, and alterations in levels of arousal or reactivity [1]. Because not every individual who experiences traumatic events eventually develops PTSD [2], [3], [4], identifying PTSD risk factors has become a central focus of investigation. Identified risk factors encompass numerous variables, including prior history of traumatic exposure or mental disorders, lower socioeconomic status or education, the type/frequency/duration of traumatic events, peri-traumatic emotional responses, and posttraumatic factors (e.g. lack of social support and other life stress) [1], [4], [5], [6], [7].

In particular, repeated exposure to a variety of traumatic events has been associated with poorer outcomes such as a higher rate, and greater severity, of PTSD [6], [8], [9], [10], and more severe depression [6], [11], [12], [13]. These findings on the greater negative impact of multiple exposures to traumatic events might support a dose–response model of trauma, which posits that an individual's risk of illness would be elevated as severity of the stressor increases. Nevertheless, some studies have failed to reveal significant relationship between magnitude of traumatic stress and PTSD severity [14], [15], [16], [17]. For instance, the number of torture exposure in the imprisoned political activists did not predict PTSD severity [14]. Therefore, the dose–response model may not fully account the risk of PTSD. Other risk factors might play a moderating role in the relationship between the severity of traumatic experiences and the negative consequences following traumatic events.

Alexithymia has been proposed as another strong risk factor for PTSD. Alexithymia refers to difficulty in identifying, describing and/or expressing emotions, in addition to an externally oriented thinking style [18], [19]. Prior studies demonstrated that individuals with PTSD were more alexithymic than both a non-psychiatric control group [20] and psychiatric outpatients without PTSD [21]. A positive correlation between alexithymia and PTSD symptoms has also been reported [22], [23], [24], and alexithymia has been shown to predict treatment outcomes in PTSD [25].

PTSD has been found to be associated with many other risk factors besides alexithymia. Many of these risk factors for PTSD were also reported to be associated with alexithymia. Alexithymia has been reported to be related with physical/emotional neglect during childhood, lower socioeconomic status, lower level of education, and repeated exposure to traumatic events [21], [26], [27], [28]. Given the substantial inter-relationship between alexithymia, PTSD and its risk factors, it would be imperative to examine whether individual's difficulty dealing with emotions is solely accountable for the negative outcomes following traumatic experiences, or whether alexithymia acts as a moderator within the context of other risk factors such as more number of traumas experienced.

Notwithstanding growing evidence that either multiple exposures to traumatic events, or alexithymia, may be associated with PTSD, few investigations have addressed the relationship between the number of traumas experienced, alexithymia, and PTSD symptoms. It has been reported that the number of combat exposure, alexithymia, and PTSD symptoms were correlated with each other [27]. Another study reported that rape victims who had experienced multiple assaults were more alexithymic, and more likely to develop PTSD, compared to victims of a single assault [28]. However, prior studies did not elucidate whether and how these two factors (i.e., alexithymia and number of traumas experienced) interact during the development of PTSD. Moreover, not every victim with multiple traumas met the criteria for PTSD, and thus the number of traumas experienced alone might not be enough for developing PTSD. Therefore, actual development of PTSD might be moderated by the individuals' level of alexithymia. That is, even though an individual has been repeatedly exposed to traumatic events, the extremely stressful experiences do not decisively yield posttraumatic stress symptoms if the person does not show any difficulty in affect regulation. In addition, an individual with higher level of alexithymia may not suffer from PTSD symptoms if stress level of the trauma is low.

Therefore, the major objective of the present study was to explore whether multiple traumatic experiences interact with alexithymia during the development of PTSD symptoms. To this end, the number of traumas experienced by a group of North Korean refugees was measured. North Korean refugees were regarded as an appropriate sample because they appear to have repeatedly experienced a variety of traumatic events, and demonstrate a high prevalence of PTSD [29]. In addition, depression should be regarded as a confounding factor, because numerous prior findings have demonstrated that depression is strongly associated with both alexithymia [30], [31] and the number of traumas experienced [6], [10], [11], [12]. Based on numerous reports of an association between alexithymia and PTSD, the current study investigated their relationship in terms of the number of traumatic events experienced.

Section snippets

Participants

Two hundred and thirteen North Korean refugees, who had settled in South Korea between 2000 and 2012, participated in the study. Of the initially recruited participants, 14 failed to complete the questionnaires and their data were excluded. The excluded participants did not differ from the included participants, for either gender or age. Of the remaining 199 participants, 147 were female (73.9%), and the average age was 38.56 ± 12.26 years (range: 19–74 years).

Procedure

The study was approved by the

Demographic characteristics and psychiatric questionnaire scores

Table 1 displays participants' demographic characteristics and psychiatric questionnaire scores. Only nine (4.5%) participants reported having experienced no traumas: 179 (89.9%) reported experiencing between 2–23 different types of trauma. The five most-frequently experienced traumas were witnessing public executions (69.8%), witnessing deaths of family members or friends from starvation (56.8%), personally experiencing life-threatening starvation (48.2%), witnessing serious physical assaults

Discussion

The present study purposed to investigate the interaction between the number of traumas experienced and alexithymia, and its relationship with PTSD symptoms. It has been reported previously that both the number of traumas experienced [6], [8], [9], [10] and alexithymia [20], [21], [22], [23], [24], [25] are crucial risk factors for PTSD. This study extends the prior researches by demonstrating that these two factors also interact with each other.

In particular, difficulty identifying and

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgment

The present study was funded by National Research Foundation of Korea (NRF) (No. 2013R1A1A2A10007021).

References (41)

  • BL Green et al.

    Outcomes of single versus multiple trauma exposure in a screening sample

    J Trauma Stress

    (2000)
  • EJ Ozer et al.

    Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis

    Psychol Bull

    (2003)
  • N Breslau et al.

    Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit area survey of trauma

    Am J Psychiatry

    (1999)
  • VS Harder et al.

    Multiple traumas, postelection violence, and posttraumatic stress among impoverished Kenyan youth

    J Trauma Stress

    (2012)
  • S Vrana et al.

    Prevalence of traumatic events and posttraumatic psychological symptoms in a nonclinical sample of college-students

    J Trauma Stress

    (1994)
  • VM Follette et al.

    Cumulative trauma: the impact of child sexual abuse, adult sexual assault, and spouse abuse

    J Trauma Stress

    (1996)
  • J McCauley et al.

    Clinical characteristics of women with a history of childhood abuse: unhealed wounds

    JAMA

    (1997)
  • SL Williams et al.

    Multiple traumatic events and psychological distress: the South Africa stress and health study

    J Trauma Stress

    (2007)
  • M Başoğlu et al.

    Psychological effects of torture: a comparison of tortured with nontortured political activists in Turkey

    Am J Psychiatry

    (1994)
  • D Kaysen et al.

    Duration of exposure and the dose–response model of PTSD

    J Interpers Violence

    (2010)
  • Cited by (0)

    View full text