The Role of Relationships in Understanding the Alexithymia-Depression Link

European Journal of Personality, Eur. J. Pers. 27: 470–480 (2013)Published online 28 September 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/per.1887

The Role of Relationships in Understanding the Alexithymia–Depression Link

HEATHER M. FORAN1*,† and K. DANIEL O’LEARY2

1Technische Universität Braunschweig, Germany2Stony Brook University, NY USA

*CorrInstituund DE-mai

†Thisin parPoggiMeyeaspect

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Abstract: Alexithymia is associated with increased depressive symptoms in both clinical and community samples. One waythat alexithymia may lead to depression is through its impact on interpersonal relationships. Individuals with alexithymiareport lower perceived social support, intimacy, and relationship satisfaction. Furthermore, poor relationship functioningis a clear risk factor for depressive symptoms. Given the established alexithymia–depression link and marital dysfunction–depression link, a logical next step is to examine whether relationship dysfunction (low social support, intimacy, negativerelationship behaviours, and relationship dissatisfaction) mediates the association between alexithymia and depressivesymptoms. The hypothesized mediation model was assessed in a sample of 104 community couples with two analyticalapproaches—first with cross-sectional measures using path analysis and second with daily diary measures collected overa seven-day period using a multilevel modelling approach. Poor relationship functioning mediated the association betweenalexithymia and depressed mood in the daily diary data and partially mediated that association with the cross-sectionalmeasures. These results identify alexithymia as an important variable in understanding the marital functioning–depressionassociation, and this finding has implications for treatment. Copyright © 2012 European Association of Personality Psychology

Key words: alexithymia; relationship satisfaction; depressive symptoms; social support; marriage

INTRODUCTION

Alexithymia is a multifaceted construct that includes thefollowing main components: (i) difficulty describing emo-tions; (ii) difficulty identifying emotions; and (iii) externallyoriented thinking (Taylor, 1994; Taylor, Bagby, & Parker,1991). It is derived from the Greek roots ‘a =without’,‘lexus =words’, and ‘thymos = emotions’, and literallymeans ‘a lack of words for emotion’ (Sifneos, 1973). It isviewed as a relatively stable trait that is normally distributedin the general population and is often measured with self-report or observer-report measures (Haviland, Warren, &Riggs, 2000; Taylor, Ryan, & Bagby, 1985).

Alexithymia is theorized to result in a deficit in processingemotional experiences that lead to impairments in the ability toregulate emotions and utilize emotional information to act in away to reduce negative emotional experiences. Individuals withalexithymia may feel helpless to change their situation andexperience the emotional information as overwhelming andconfusing. This may make them particularly vulnerable todepression. In fact, there is a consistent moderate associationbetween alexithymia and depression (Taylor & Bagby, 2004).Furthermore, in longitudinal samples, change in alexithymia

espondence to: Heather M. Foran, Technische Universität Braunschweig,t für Psychologie, Abteilung für Klinische Psychologie, Psychotherapieiagnostik, Humboldtstr 33, 38106 Braunschweig, Germany.l: [email protected]

work was conducted while Heather Foran was at Stony Brook Universitytial fulfilment of her doctoral dissertation. We would like to thank Gwen, Katie Sinnott, Jackie Clair, Margarita Khanina, Nicasia Jackson, Jonathanrs, and Denise Dubron-Vander Veer for their assistance with variouss of the project.

right © 2012 European Association of Personality Psychology

predicts change in depressive symptoms over time (Honka-lampi, Hintikka, Laukkanen, Lehtonen, & Viinamäki, 2001;Saarijarvi, Salminen, & Toikka, 2001).

Alexithymia, mood, and marital functioning

In addition to leading to depression directly, alexithymia mayalso lead to problems in interpersonal relationships, which inturn exacerbate depressive symptoms (Hesse & Floyd, 2008).Individuals with alexithymia and their partners show signifi-cantly lower dyadic adjustment, intimacy, and social supportthan those without deficits (Eizaguirre, 2002; Foran, O’Leary,& Williams, 2012; Humphreys, Wood, & Parker, 2009;Mallinckrodt & Wei, 2005; Schutte, Mallouff, & Bobik, 2001).

Further, it is well established that marital dissatisfaction issignificantly linked to depression (Whisman, 2001), and coupleswith a depressed partner report lower intimacy in the relation-ship (Basco, Prager, Pita, Tamir, & Stephens, 1992). Longitudi-nal studies have shown that marital dissatisfaction predictsincreased depressive symptoms and risk for developing a mooddisorder (Beach & O’Leary, 1993; Overbeek et al., 2006;Whisman & Bruce, 1999) and that increases in depressivesymptoms can also exacerbate marital problems (Davila, Karney,Hall, & Bradbury, 2003; Whisman & Uebelacker, 2009).

Consistent with the marital discord model of depression,deficits in emotional expression are one of the mechanismstheorized to play a role in marital deterioration and subsequentdepressive symptoms (Beach, Sandeen, & O’Leary, 1990).Individuals who are unable to communicate their emotions maybe less able to solicit social support that protects against onsetof depressive symptoms. The ability to engage in the intimacy

Received 20 September 2011Revised 4 June 2012, Accepted 20 June 2012

Alexithymia and relationships 471

process may also be difficult for alexithymic individuals becauseintimacy requires the ability to disclose emotional, personalinformation and respond with the appropriate emotional tone toanother’s expression of vulnerability (e.g. see Reis, 1990).

The role that alexithymia plays in the marital relationshipand onset of depression may help explain the gender differencein rates of depression. Women are approximately twice as likelyto be depressed as men (Nolen-Hoeksema, 1987). These find-ings are particularly interesting given the literature suggestingthat women may be more susceptible to depression in responseto marital distress than men (Dehle & Weiss, 1998; Fincham &Bradbury, 1993; Whisman, 2001). There is some evidence tosuggest that men may be less likely to disclose their emotionsand have slightly higher rates of alexithymia than women(Carpenter & Addis, 2001; Dindia & Allan, 1992). It may bethat women’s increased vulnerability to marital distress anddepression may be facilitated by their partners’ alexithymia.

Current study

Although there is clear evidence for a link between maritaldistress and depression, and preliminary support for the linkbetween marital distress and alexithymia, it is unclearwhether alexithymia leads to depressive symptoms throughthe impact on relationship functioning. One previous studyexamined affectionate experience in individuals with alex-ithymia and found this partially mediated the alexithymiaand depressive symptoms association (Hesse & Floyd,2008). Building on this past work, we examined an aspectof the marital discord model of depression (Beach et al.,1990) by further assessing the impact of alexithymia ondepressive symptoms through a relationship lens. If alexithy-mia is identified as an important variable in understandingthe marital functioning–depression association in a sampleof couples seeking relationship assessments and treatmentreferrals, this finding can have implications for treatment.Alexithymia may be modifiable with interventions targetingemotional discrimination training such as emotion-focusedtherapy for couples (Johnson & Greenberg, 1985).

Hypothesized Model of Alexithymia, Relationship Fun

Note. Dotted lines represent hypothesized non-signifi

Men’s 1.Support2. Intimacy3. Satisfact

Women’s 1.Support2. Intimacy3. Satisfact

Women’s Alexithymia

Men’s Alexithymia

Figure 1. Hypothesized model of alexithymia, relationship functioning, and depress

Copyright © 2012 European Association of Personality Psychology

We hypothesized that the impact of alexithymia onrelationship functioning will be broad, affecting a variety ofrelationship domains including intimacy, social support,relationship behaviours, and global satisfaction with therelationship. Thus, relationship functioning was measuredin several ways. The hypothesized mediation model is shownin Figure 1. First, the model shown in Figure 1 was testedwith path analyses, cross-sectionally. This methodologicalapproach, using the Actor Partner Interdependence Model(APIM; Kashy & Kenny, 2000), permits examination of theboth self and partner effects simultaneously.

Second, mediation was also tested utilizing daily diarymethodology. Specifically, we examined whether dailyrelationship functioning (intimacy, satisfaction, and negativepartner behaviours) mediated the association between selfand partner alexithymia and daily negative affect over aseven-day period. Daily diary methodology is not limited byrecall biases to the extent that is the case for standard self-reportmethods, and studies have shown that results may be differentwhen using the two methods (e.g. Halford, Keefer, & Osgarby,2002; Stone, Broderick, Shiffman, & Schwartz, 2004).Therefore, this multi-method dyadic approach was utilized topermit the interrelationship between alexithymia, relationshipfunctioning, and mood to be tested in a variety of ways,providing an opportunity for replication across methods.

METHODS

Participants

One hundred and nine married or cohabitating couples wererecruited through advertisements in local newspapers andcommunity flyers to participate in a study in which theywould receive a free relationship assessment and treatmentreferrals. Eligible couples also received $50 for participationand a chance to win a hand-held computer. Couplescompleted a feedback evaluation at the end of participation,and the majority of couples reported their motivation forparticipation was to receive the relationship assessment.

ctioning, and Depressive Symptoms

cant paths

ion

ion

Women’sDepressive Symptoms

Men’s Depressive Symptoms

ive symptoms. Note: Dotted lines represent hypothesized non-significant paths.

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472 H. M. Foran and K. D. O’Leary

Couples who were cohabitating and/or married for one yearor more, at least 18 years old and who were fluent in Englishwere eligible to participate. Age of participants ranged from18 to 77 years (mean age men = 42.7, SD= 13.5; mean agewomen = 41.4, SD = 13.6). The majority of the couples weremarried (84.6%), and the average length of marriage was12.5 years (SD = 11.1). Mean family income was 83 487dollars (SD= 45 667), and approximately half of the samplehad completed some college education (men = associates’= 9.6%; bachelor’s = 23.1%; graduate training = 21.2%;women = associates’ = 9.6%; bachelor’s = 20.2%; graduatetraining = 28.8%). The majority of the sample was Caucasian(82.7% men; 85.6% women), followed by Asian (4.8% men;5.8% women), Latino/Hispanic (3.8% men; 4.8% women),African American (2.9% men; 2.9% women) and otherraces/ethnicities (4.8% men; 0.9% women).

Procedure

Eligible couples made two visits to the University MaritalClinic scheduled eight days apart between 2005 and 2008. Thisstudywas approved by the institutional human subject researchreview board. During the first visit, each member of the couplecompleted computerized questionnaires in separate rooms. Atthe end of the visit, they were given instructions on how tocomplete the daily hand-held computer surveys.

During the subsequent seven days, couples independentlycompleted a 5- to 10-minute daily survey at the end of theday during a time frame specified during the first visit (e.g. after2000 h for that day). The electronic diaries were automaticallytime-stamped with the starting and ending points of surveycompletion each day in order to assess compliance. Partici-pants who missed a day of the survey were given the optionto fill out the survey for ‘yesterday’ during the next day. Theywere prompted with the question, ‘Would you like to fill outthe survey for today or yesterday’ at the beginning of everysurvey. In addition, couples who completed all seven dailyentries were entered into a raffle to win a hand-held computer,and the winner was notified at the end of the study.

Couples returned to the clinic one week after their firstvisit. During the second visit, couples completed anothercomputerized questionnaire, participated in a brief structuredinterview, and engaged in two 10-minute discussion tasks.Additionally, couples received their marital assessments,referrals, and the remainder of payment.

Measures

Toronto Alexithymia ScaleThe Toronto Alexithymia Scale (TAS) is a commonly used20-item self-report measure of alexithymia (Bagby, Parker,& Taylor, 1994). The psychometric properties of the TAShave been examined in over a dozen studies across manycultures (e.g. Kauhanen, Julkunen, & Salonen, 1992).Cut-off criteria differentiating alexithymic (above 61) fromnon-alexithymic individuals have been established and arewidely utilized (Bagby, Taylor, & Parker, 1994). In thecurrent study, the internal consistency of the overall scalewas adequate for men (a= .86) and for women (a= .85).


Dyadic Adjustment Scale (Spanier, 1976)The Dyadic Adjustment Scale (DAS) was used to assessrelationship satisfaction. Scores range from 0 to 151 withhigher scores indicating more satisfaction. Cut-off criteriaof approximately 100 are generally used to differentiatedistressed and non-distressed couples with scores below 85indicating serious relationship discord (e.g. O’Leary &Beach, 1990; Spanier, 1976). Internal consistency of theDAS in this sample was high (Cronbach’s a= .90 men,a= .91 women).

Interpersonal Support Evaluation ListPerceived social support was assessed with a 40-item scalecommonly used to measure various forms of global socialsupport (Cohen & Hoberman, 1983; Cohen, Mermelstein,Kamarck, & Hoberman, 1985). Types of support assessedinclude tangible, appraisal, belonging, and self-esteem sup-port. Previous studies have documented that this measurehas good internal consistency, structural validity, test–retestreliability, and convergent validity with social support mea-sures (e.g. Brookings & Bolton, 1988; Cohen & Hoberman,1983; Cohen & Wills, 1985; Cohen et al., 1985). Participantsindicate whether each item is ‘probably true’ or ‘probablyfalse’ about them. For example, an item assessing tangiblesupport states, ‘If I needed a ride to the airport very earlyin the morning, I would have a hard time finding anyone totake me’. The internal consistency of the InterpersonalSupport Evaluation List in this study was a= .86 for menand a= .88 for women.

Personal Assessment of Intimacy in RelationshipsIntimacy was assessed with the Personal Assessment ofIntimacy in Relationships (PAIR) emotional and intellectualsubscales (Schaefer & Olson, 1981). Six items assessedemotional intimacy (e.g. ‘I can state my feelings withouthim/her getting defensive’), and six items assessed intellectualintimacy (e.g. ‘My partner helps me clarify my thoughts’). ThePAIR subscales have adequate convergent and discriminantvalidity, internal consistency, and split-half reliability(Schaefer & Olson, 1981). Cronbach’s as in this study were.91 for men and .93 for women.

Beck Depression Inventory—IIDepressive symptoms were assessed with the 21-item BeckDepression Inventory—II (BDI-II; Beck, Steer, & Brown,1996) at visit two. This measure has demonstrated goodfactorial and convergent validity (Beck et al., 1996; Steer &Clark, 1997). Internal consistency of this measure for menwas .90 and for women was .93.

Daily diary measures

Daily relationship satisfactionDaily relationship satisfaction was measured with a singleitem that has been used in previous studies (e.g. Johnson &O’Leary, 1996). Participants rated the degree that they aresatisfied or dissatisfied with their relationship on a 9-pointscale with higher scores indicating more relationshipsatisfaction.

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Daily relationship behavioursNegative relationship behaviours were assessed with 10items derived from the Spouse Observational Checklist(SOC; Weiss & Perry, 1983). Each member of the couplereported on their partners’ negative daily relationshipbehaviours. This subset of the SOC was selected because ofprevious research indicating that these items were significantpredictors of marital satisfaction and was a manageableamount of items to be reported each day, in contrast to thetotal SOC that is too burdensome to the participants, resultingin limited compliance (Johnson & O’Leary, 1996). Dailybehaviours (e.g. ‘My partner did something to spite me’ and‘My partner said something unkind to me’) were rated on ascale from ‘0= not at all true‘ to ‘4= extremely true’.

Daily relationship intimacyDaily intimacy was measured by asking couples to rate theoverall quality of closeness in the relationship each day ona scale from 0 to 4. This measure was highly correlated withreports of intimate interactions as measured by theInteraction Record Form (Prager & Buhrmester, 1988)(r= .85, p< .001, N = 102 for women; r= .82, p< .001,N= 102 for men), supporting the convergent validity.

Daily negative affectDaily negative affect was assessed with the Positive andNegative Affect Schedule (PANAS; Watson, Clark, &Tellegen, 1988). Participants were asked to rate on a 1 to 5scale, the degree to which 10 adjectives describing negativeaffective states is experienced that day. This scale has beenshown to be valid for varied time frames such as daily reportsto weekly reports.

Daily diary sample

Two hundred and four individuals had analyzable daily diarydata after two couples were removed for missing more thanhalf the survey days. This resulted in 1428 days of data ofwhich 89.1% of days were complete for men and 94.4% ofdays were complete for women. Missing days were primarilydue to a software glitch with the hand-held computers inwhich entries were rejected. Six days or more were com-pleted by 93.1% of women and 81.4% of men; five dayswere completed by 11.8% of men and 6.9% of women.Overall, 87.3% of participants had one or zero days missing,9.3% had two days missing, 2.5% had three days missing,and 1.0% had four days missing. Graphical examination ofdaily variation in relationship satisfaction, intimacy, mood,and relationship behaviours indicated ample variabilitywithin couples across the week.

Data analytic strategy

Mediation analysesPath analysis with Mplus 5.1 software (Muthén & Muthén,2007) was used to test whether relationship functioningmediated the link between alexithymia and depression withan APIM framework (Kashy & Kenny, 2000). Full informa-tion maximum likelihood estimation was used to account for


the small amount of missing data (<5%) (N= 208, 104couples). Model fit was evaluated by the following: (i) non-significant chi-square values; (ii) Comparative Fit Index.90; (iii) Tucker–Lewis Index> .90; and (iv) standardizedroot mean square residual< .08. Robust test statistics wereused to account for non-normality in the data (e.g. slightskew in DAS and BDI-II).

First, the initial model as hypothesized in Figure 1 with-out the direct effects from alexithymia to depression wastested. Second, a model with the direct effects included wastested. The model fit of these two nested models was com-pared. The difference between the robust chi-square valuesfor Models 1 and 2 was calculated to determine whetherModel 2 resulted in a significant improvement in model fitover Model 1 using the comparison approach recommendedby Muthén and Muthén for robust chi-square differencetesting (2008). A significant chi-square value indicates thatModel 2 is a better fit to the data than Model 1. To examinewhether the mediation was statistically significant, the signif-icance of the indirect paths was examined with Sobel’s Z.

Lastly, partner effects were examined to see whether theywould improve model fit. Adding paths from alexithymia topartner’s depression and paths from relationship functioning topartner’s depression was tested. All significant partner effectsare included as ‘Model 3’. When partner effects were present,we tested whether there were also significant mediation ofalexithymia, relationship functioning, and depressive via apartner effect rather than the actor effect (e.g. men’s alexithymiapredicting women’s depression through women’s relationshipsatisfaction) and whether Model 3 resulted in a significantreduction in chi-square compared with Model 2.

Daily diary mediation analysesIn a second set of analyses, the mediation models were testedusing a different method of measuring relationship function-ing and mood. Specifically, daily relationship functioning(daily intimacy, satisfaction, and partner negative beha-viours) was hypothesized to mediate the link between one’sown alexithymia (as assessed at Time 1) and daily negativemood for both men and women. Mediation analyses wereconducted following the guidelines provided by Baron andKenny (1986). SAS PROC MIXED was used to accountfor the multilevel nature of the data (see Patrick, Knee,Canevello, & Lonsbary, 2007, for a similar application ofSAS PROCMIXED to test mediation). Although the averageweekly levels of mood, relationship satisfaction, intimacy,and negative behaviours were of interest, simply aggregatingthe results across days for the analyses can result in errone-ous standard errors and significance levels. A multilevelmodelling approach allows for within days variance to beincorporated into the regression equations and account forthe unreliability of daily estimates. In addition to structuringthe equation to allow for random error in the within subjectsmeasures (daily mood and daily satisfaction), the autocorre-lation of errors between days closer in time was included inthe models. Frequently, estimates of daily mood, for exam-ple, may be more correlated one day apart than they are sixdays apart. SAS PROC Mixed sp (pow) function was usedto control for this pattern. All analyses were conducted first

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examining mediation of one’s own alexithymia, relationshipfunctioning, and negative mood. An additional set ofanalyses was conducted to examine partner effects.

RESULTS

Characteristics of the sample

Briefly, scores on the BDI-II, DAS, and TAS are detailed inorder to clarify the composition of the sample because eachof these measures has established clinically meaningful cut-off criteria. The majority of men and women in the samplewere not clinically depressed; 6.8% of men and 13.5% ofwomen scored in the mild range on the BDI-II (scores between15 and 19). Moderate or severe depressive symptoms werereported by 5.7% of men and 12.5% of women (BDI-II scoresabove 19). The mean score on the TASwas 45.80 (SD=11.38)for men and 45.26 (SD=10.65) for women; 10.7% of men and9.6% of women scored in the alexithymic range on the TAS(scores 61 or greater). The average relationship satisfactionlevel was 112.84 for men and 109.64 for women. One quarterof the sample scored below 100 of the DAS, indicating at leastsome level of marital distress, and 11.5% scored below 85,indicating severe marital distress. These data indicate that thesample is similar to other community samples on alexithymia,depressive symptoms, and relationship satisfaction.

Mediation analyses—Results

The three models (as described earlier in the Methodssection) are reported in Table 1. As can be seen in the table,chi-square difference tests between the nested models indi-cated that Model 2 (inclusion of direct paths from alexithy-mia to depressive symptoms) resulted in a significant

Table 1. Mediation results—Global measures

Model fit parameters

w2 df CFI TLI SRM

TAS-social support-BDIModel 1 14.99* 6 0.95 0.88 0.0Model 2 6.23 4 0.99 0.96 0.0Model 3 2.68 3 1.0 1.0 0.0

TAS-intimacy-BDIModel 1 31.74*** 6 0.77 0.46 0.1Model 2 8.74 4 0.96 0.85 0.0Model 3 1.33 3 1.0 1.0 0.0

TAS-relationship satisfaction-BDIModel 1 42.17*** 6 0.69 0.27 0.1Model 2 13.12* 4 0.92 0.72 0.0Model 3 1.20 2 1.0 1.0 0.0

Note: CFI and TLI scores of 1.0 indicate that the chi-square value is smaller than tattention should be paid to the other fit estimates provided. CFI, Comparative Fit InToronto Alexithymia Scale; TLI, Tucker–Lewis Index; SRMR, Standardized RooaTest of mediation from men’s TAS to men’s BDI mediated by women’s DAS.bTest of mediation from men’s TAS to women’s BDI mediated by women’s DAS***p< .001; **p< .01; *p< .05.


reduction in chi-square values compared with Model 1.When significant partner effects were also included, Model3 resulted in a significant reduction in chi-square estimatescompared with Model 2. Thus, Model 3 was the best fitacross all three relationship mediators examined. Finalmodels (Model 3) are shown in Figures 2–4, illustrating thesignificant actor and partner effects.

Significant indirect paths supporting mediation (Sobel’s Z)were found for intimacy and social support as mediators(Table 1). Women’s social support fully mediated therelationship between women’s alexithymia and women’sdepressive symptoms. In addition, women’s perceived socialsupport partially mediated the association between men’salexithymia and women’s depressive symptoms (i.e. a partnereffect). Men’s intimacy and social support partially mediatedthe link between their alexithymia and depressive symptom;women’s intimacy, however, was not a significant mediator.Relationship satisfaction was not a significant mediator ofalexithymia and depressive symptoms. For thismodel (Figure 4),direct paths from one’s own alexithymia continued to predictsignificant variance in depression symptoms for men andwomen. Taken together, these results indicate that relationshipfunctioning partially explains the association betweenalexithymia and depressive symptoms, but alexithymia alsohas a direct effect on depressive symptoms in addition torelationship functioning.

Daily diary mediation analyses—Results

Results for the daily diary mediation analyses are presentedin Tables 2 and 3 for men and women, respectively (see theDaily Diary Mediation Analyses section for a description ofthe data analytical strategy). Parameter estimates and t-valuesfor each step of mediation are provided in the tables.Whether there was evidence of significant autocorrelated

Sobel’s Z

R Δw2 Men Women Partner

76 9.23** 3.67*** 3.86***3 4.49* 3.63*** 3.50*** 3.26**

17 28.15*** 3.02** 1.812 10.50** 3.02** 1.63 1.53

28 36.95*** 1.33 1.922 9.98** �0.08 1.85 1.32a

1.63b

he degrees of freedom, rather than a ‘perfect’ model fit. In these cases, moredex; BDI, Beck Depression Inventory; DAS, Dyadic Adjustment Scale; TAS,t Mean Square Residual.

.

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Figure 2. Model of alexithymia [Toronto Alexithymia Scale (TAS)], social support, and depressive symptoms. Standardized parameter estimates for Model 3.***p< .001; **p< .01; *p< .05.

Figure 3. Model of alexithymia [Toronto Alexithymia Scale (TAS)], intimacy, and depressive symptoms. Standardized parameter estimates for Model 3.***p< .001; **p< .01; *p< .05.

Figure 4. Model of alexithymia [Toronto Alexithymia Scale (TAS)], relationship satisfaction, and depressive symptoms. Standardized parameter estimates forModel 3. ***p< .001; **p< .01; *p< .05.


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Table 2. Men’s daily diary mediation results

b SE b t Auto r Z

Step 1: Alexithymia predicting negative affect (NA)TAS .002 .001 2.48* �.00

Step 2: Alexithymia predicting relationship functioningTAS-relationship satisfaction �.045 .012 �3.70*** .15*TAS-negative partner behaviours .005 .003 2.09* .13*TAS-intimacy �.023 .009 �2.45* .10

Step 3a: Relationship functioning predicting NARelationship satisfaction �.026 .003 �7.94*** �.00Negative partner behaviours .121 .011 10.92*** .03Intimacy �.018 .005 �3.92*** .00

Step 3b: Alexithymia and relationship functioning predicting NATAS-relationship satisfaction-NA .01 3.42***Relationship satisfaction-NA �.025 .003 �.7.63***TAS-NA .001 .001 1.12TAS-negative partner behaviours-NA .02 1.65Negative partner behaviours-NA .119 .011 10.67***TAS-NA .001 .001 1.79TAS-intimacy-NA .00 2.08*Intimacy-NA �.018 .005 �3.81***TAS-NA .002 .001 2.01*

Note: TAS, Toronto Alexithymia Scale.***p< .001, **p< .01, *p< .05.

Table 3. Women’s daily diary mediation results

b SE b t Auto r Z

Step 1: Alexithymia predicting negative affect (NA)TAS .002 .001 2.31* .11

Step 2: Alexithymia predicting relationship functioningTAS-relationship satisfaction �.033 .014 �2.38* .16**TAS-negative partner behaviours .004 .003 1.34 .10TAS-intimacy �.025 .011 �2.21* .19***

Step 3a: Relationship functioning predicting NARelationship satisfaction �.036 .003 �12.24*** .11*Negative partner behaviours .140 .010 13.87*** .11*Intimacy �.024 .004 �5.53*** .12*

Step 3b: Alexithymia and relationship functioning predicting NATAS-relationship satisfaction-NA .11* 2.31*Relationship satisfaction-NA �.035 .003 �.12.05***TAS-NA .001 .001 1.19TAS-intimacy-NA .12* 2.11*Intimacy-NA �.023 .004 �5.31***TAS-NA .002 .001 1.72

Note: TAS, Toronto Alexithymia Scale.***p< .001; **p< .01; *p< .05.


error terms is also presented in the tables. The bivariate asso-ciations for the first two criteria of mediation are providedunder headings ‘Step 1’ and ‘Step 2’ in the tables. Forwomen, negative partner behaviour was not significantlyassociated with alexithymia and disqualified from furthertesting as a mediator of the association between alexithymiaand daily negative affect. Regression analyses of relationshipfunctioning predicting negative mood are provided under theheading ‘Step 3a’. Higher relationship satisfaction, higherintimacy, and less negative partner behaviours predictedlower reported negative mood for men and women.


Results from regression models with alexithymia andrelationship functioning both included in a model predictingdaily negative affect are provided under the heading ‘Step 3b’in Tables 2 and 3. Results support mediation if the path betweenthe relationship variable and negative mood is significant andthe path from alexithymia to negative mood is not. Whetherthe indirect path through the mediator is statistically significantwas calculated via Sobel’s Z and is provided in the tables. Ascan be seen in the tables, intimacy fully mediated and relation-ship satisfaction at least partially mediated the link betweenalexithymia and daily negative mood for men and women.

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Negative partner behaviour was not a significant mediator.Overall, results were consistent with mediation model resultspresented earlier, supporting relationship functioning as amediator between alexithymia and negative mood.1

Mediation analyses—Partner effects

Mediation analyses with SAS PROCMixed were conducted asecond time to examine partner effects. All analyses wereconducted with both one’s own and one’s partner’s alexithy-mia included simultaneously in the equations to determine ifone’s partner’s alexithymia made unique contributions aftercontrolling for one’s own alexithymia. To quality for media-tion analysis, one’s partner’s alexithymia must be significantlyassociated with negative mood (step 1) and relationship func-tioning (step 2). No partner variables met these criteria, andthus, there was little support for daily relationship functioningmediating the relationship between partners’ alexithymia anddaily mood after accounting for one’s own abilities.

DISCUSSION

Previous research has consistently indicated that alexithymia islinked to negative mood and depression in clinical and commu-nity samples (e.g. Carpenter & Addis, 2001; Honkalampi et al.,2001). Studies have also shown that alexithymia predicts changein depressive symptoms and response to treatment (Honkalampiet al., 2007; Luminet, Bagby, & Taylor, 2001; Saarijarvi et al.,2001). However, little work has examined poor relationshipfunctioning as a mediator of this association despite theoreticalexplanations often pointing to impairment in interpersonalfunctioning as one of the detrimental effects of alexithymia.Results across cross-sectional and daily diary methods partiallysupported relationship dysfunction as a significant mediatorof the alexithymia–negative mood link, consistent with thefindings of Hesse and Floyd (2008).

Partner effects

In addition to the impact of one’s own alexithymia and rela-tionship functioning, several cross-partner effects were foundin the cross-sectional data. The most consistent partner effectfound (across all three relationship variables) was that men’salexithymia had a direct association with women’s

1Although the results from both global and daily assessments supported thehypothesized mediation models, an alternative explanation for the results wasconsidered. Daily diary results may have been more likely to support mediationgiven that relationship functioning was assessed with daily methodologysimilar to daily negative mood and alexithymia, which were assessed at a singletime point. Hence, results could be biased to support mediation by theassessment methodology selected. To address this concern, analyses were rerunwith two Time 1 variables (alexithymia and relationship functioning) and onedaily variable (negative mood). The correlation between the daily diary andTime 1 relationship functioning constructs ranged from r= .69 to r= .75,indicating that they were assessing the same construct and were appropriatefor comparative analyses. If the results were due to common method variance,then alexithymia would be less likely to be reduced to a non-significantpredictor of negative mood when Time 1 relationship functioning was addedto the equation. Results of these analyses were consistent with the mediationresults presented in Tables 2 and 3, suggesting that the daily diary mediationfindings were not due to common method variance.


depressive symptoms, even after controlling for the covari-ance between relationship functioning of partner’s and one’sown alexithymia by using an APIM framework. Thisadditional risk factor for women may partially explain whywomen may be more vulnerable to depressive symptomson the basis of interpersonal factors (Dehle & Weiss, 1998;Fincham & Bradbury, 1993).

However, mediation of the alexithymia–negative moodlink through partners’ alexithymia was not supported. Onlyone of the models with the cross-sectional data found signif-icant mediation through partner effects (Figure 2), andpartner effects were not detected in the daily diary analyses.This indicates that although partners’ alexithymia mayimpact their spouses’ relationship functioning and depressivesymptoms (at least globally), the pathway through whichpoor relationship functioning leads to increased depressivesymptoms via alexithymia is better accounted for by one’sown scores, rather than one’s partners.

The alexithymia–depression linkThis study replicated the well-established finding that higheralexithymia is associated with increased depressive symptomsone week later (Taylor & Bagby, 2004). Alexithymia signifi-cantly predicted daily negative affect across a seven-day period.Various explanations for this association have been proposed(Taylor, Bagby, & Parker, 1997). One of the most prominentexplanations for the association is that individuals with alexithy-mia are not able to effectively utilize emotional information tocope with arising stressors. Instead, they feel confused andhelpless in emotionally arousing situations and avoid cognitiveprocessing and verbalization of the emotional experience. Thisconfusion leads to a general pattern of emotional dysregulationthat may account for the widespread association betweenalexithymia and various forms of psychopathology. Individualswith alexithymia, when experiencing emotional distress, mayturn to dysfunctional coping mechanisms such as substanceabuse (Cecero & Holmstrom, 1997), problematic eating(Zonnevijlle-Bender, van Goozen, Cohen-Kettenis, van Elburg,& van Engeland, 2002), somatization of symptoms (Duddu,Isaac, & Chaturvedi, 2003), and general hopelessness.

Hence, it is understandable that although there wassignificant partial mediation of the alexithymia–depression linkthrough relationship dysfunction, there was also substantialsupport for direct effects of alexithymia to depressivesymptoms from the cross-sectional analyses. Interestingly,support for direct effects was less consistent in the daily diarymediation analyses with most of the models supporting fullmediation instead. This differential result across methodologiesdoes not appear to be due to common method variance, as thispotential explanation was considered by examining Time 1alexithymia and Time 1 relationship functioning, predictingdaily negative affect. Results with this approach were similarto the daily diary results with daily relationship functioningand daily negative affect. It is possible that differences in dailynegative affect and depressive symptoms may explain theresults. The daily level of analyses may better capture themediating effect that poor relationship functioning has onmood. Couples may feel upset when interactions with theirpartner do not go the way they wish or hoped, resulting in

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increased negative affect that day. Depressive symptoms,assessed with a global self-report, may instead capture a varietyof ways that alexithymia impairs individual functioning in andoutside the relationship. The results with perceived socialsupport as a mediator provided some preliminary evidence forthis hypothesis. Social support was assessed with a globalmeasure of support, rather than a measure specific only to theromantic relationship. Social support was the most highlycorrelated relationship variable with depressive symptoms. Itmay be accounting for more variance in depressive symptomsbecause it not only accounts for the variance of romanticrelationship dysfunction but also for the variance from globalinterpersonal dysfunction. Results indicated that social supportmediated the alexithymia and depressive symptoms link in allthe models for both men and women. Hence, the alexithymia–depressive symptoms linkmay be best explained by a number offactors including intimate partner as well as other relationshipssuch friends and colleagues.

Alternatively, the tendency of BDI as an outcome to besignificantly predicted by alexithymia may reflect anotheroutcome of alexithymia not assessed with the daily moodratings on the PANAS. Some of the items of the BDI assesssomatic symptoms, whereas the PANAS assesses only mooditems. A significant association between somatization andalexithymia is well established (De Gucht & Heiser, 2003).The tendency of individuals with alexithymia to somatizemay explain the direct unaccounted association betweenalexithymia and depressive symptoms that was not mediatedby relationship functioning.

LimitationsSeveral limitations of this study deserve mention. First, itshould be noted that because of the correlational and cross-sectional nature of the study, conclusions about directionalitycannot be confirmed. The mediation modelling results canonly suggest a theorized direction, and an experimentaldesign is needed before conclusions about directionality canbe confirmed. As noted earlier, depressive symptoms may alsoexacerbate marital distress (Whisman & Uebelacker, 2009),and thus, this relationship is likely reciprocal in nature. Second,alternative ways of understanding the impact of alexithymia onrelationship functioning were beyond the scope of this projectbut are mentioned here as a limitation. Discrepancy betweenpartner’s alexithymia may further explain relationship problemsand depressive symptoms (Croyle & Waltz, 2002). It is alsoplausible that alexithymia and relationship functioning mayinteract to predict mood. Gallagher and Vella-Brodrick (2008)found emotional intelligence (EI) and social support from aromantic partner interacted to predict positive mood, but noneof the other interactions with EI tested were significant. EI andsocial support did not interact to predict negative mood in theirstudy. However, variables can function as both mediations andmoderators (Judd, Kenny, & McClelland, 2001), and thecombined mediation and moderation effects of alexithymiaand relationship functioning should be explored in futurestudies with larger sample sizes. Third, this study consistedof a community sample of couples in committed relationships,and results may not be generalizable to underrepresentedminority groups, casually dating couples, or clinical samples.


Summary and clinical implicationsAlexithymia was found to be significantly associated withrelationship functioning and negative mood across dailyand global assessment methods. Further, results in this studysuggest that one way alexithymia may lead to negative moodis through their negative impact on intimacy, perceivedsocial support, and relationship satisfaction. However, inthe cross-sectional models, the impact of alexithymia ondepressive symptoms could not be entirely accounted forby relationship functioning, and both direct and indirectpaths best predict depressive symptoms. In contrast, dailyrelationship intimacy and satisfaction fully mediated the linkbetween alexithymia and daily mood.

These results indicate that alexithymia may be a potentiallyuseful target for treatment, not only for the impact alexithymiamay have on interpersonal relationship functioning, but also itsimpact on mood functioning directly. Interventions that focuson improving alexithymia have evidenced some effectivenessin improving relationships (e.g. Emotional Focused CouplesTherapy; Johnson & Greenberg, 1985), reducing depressivesymptoms (Greenberg & Watson, 2006; Watson, Gordon,Stermac, Kalogerakos, & Steckley, 2003), and reducing riskfor negative physical health outcomes (Beresnevaite, 2000).In a preliminary study of coronary heart disease patients withalexithymia, a four-month treatment programme resulted insignificant reductions in alexithymia symptoms on the TAScompared with the a comparison control group not providedwith treatment for alexithymia. Patients in the treatment groupwith reduced alexithymia scores were at lower risk for negativecardiac events over a two-year follow-up period compared withthe control patients (Beresnevaite, 2000). Hence, interventionsgeared at alexithymia may have a vast reaching impact on bothpsychological and physical health.

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The Role of Relationships in Understanding the Alexithymia-Depression Link