Journal of the American
Psychoanalytic
Association
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Alexithymia, Cognitive Complexity, and Defensive Avoidance of Emotion in a
Situation of Experimentally Induced Sadness
Serge Lecours, Frédérick Philippe, Stéphanie Arseneault, Marie-Ève Boucher and Lola
Ahoundova
J Am Psychoanal Assoc 2013 61: 573
DOI: 10.1177/0003065113490024
The online version of this article can be found at:
http://apa.sagepub.com/content/61/3/573

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Poster Summaries

immersion credit for a six-month period of preparatory psychotherapy
was approved. First-year candidates will be assigned supervisors at thestart of classes and will be expected to discuss their psychotherapy caseswith these supervisors with a view toward analytic listening and, whenappropriate, beginning a conversion process. This work will be given
credit toward the immersion requirement for graduation, even if thepatient is not converted to psychoanalysis.
Additionally, a brief course on “the dropout experience” is being
added for fourth- and fifth-year candidates. This will be a clinicallyfocused course, with presentation of cases that have dropped out early.
The plan is to eventually move this class to the end of the first year. Asof yet, there is no direct program for supervisors regarding this issue.
REFERENCES

Frayn, D.H. (1995). Premature termination issues in psychoanalytic control
cases. Canadian Journal of Psychoanalysis 3:17–41.
Hamilton, M., Wininger, L., & Roose, S.P. (2009). Dropout rate of trainingcases: Who and when. Journal of the American Psychoanalytic Association 57:695–702.
Margaret Hamilton
170 West End Avenue, Suite 1E
New York, NY 10023
E-mail: mis3@columbia.edu

A L E X I T H Y M I A , C O G N I T I V E C O M P L E X I T Y, A N D
D E F E N S I V E AV O I D A N C E O F E M O T I O N I N A S I T U AT I O NO F E X P E R I M E N TA L LY I N D U C E D S A D N E S S

Serge Lecours (Université de Montréal)
Frédérick Philippe (Université du Québec à Montréal)
Stéphanie Arseneault, Marie-Ève Boucher, andLola Ahoundova (Université de Montréal)
DOI: 10.1177/0003065113490024

Alexithymia, a cognitive deficit in the experience of emotion, is associated with emotional dysregulation. Alexithymia as measured with the573
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Po s t e r S u m m a r i e s20-item Toronto Alexithymia Scale (TAS-20) has been widely studied
and related to a good number of clinical outcomes, both self-reported andobserver-rated. However, it is not clear what kind of cognitive deficits theTAS-20 actually assesses and how they translate into “real-life” problemsof emotion regulation. This study is an attempt to shed further light on
the mechanisms involved in alexithymia and to evaluate how these mechanisms contribute to an experimentally induced performance of emotion
regulation in a prospective design. The study has been supported in partby the APsaA Fund for Psychoanalytic Research.
Background

The original formulation of alexithymia, stemming from the psychoanalytic observation of psychosomatic patients, emphasized a deficit inmentalization. The emblematic alexithymic patient suffered from what
French psychoanalysts called operatory thinking (pensée opératoire), a
profound “cognitive” deficit produced by the eradication of emotional
representations. For those French analysts, the unavailability of representations for emotions was due to the massive use of a primitive form ofsuppression (répression in French) that weakened the preconscious system of operatory patients. The thinking of these extremely alexithymic
individuals was found to be concrete and action-based. This formulationof alexithymia views it as the result of a deficit in representation andcognition.
Later formulations introduced the notion of a reversible form ofalexithymia brought about by the defensive avoidance of emotional representations. A regression in affect differentiation and desomatization
was seen as a way to cope with trauma or excesses of negative affects.
Alexithymia was seen not as a deficit in representational resources, then,but as the manifestation of a defensive process. In empirical researchstudies, dissociation, primitive defenses, and neurotic defenses, usually
measured using questionnaires, have also been found to be related toalexithymia.
So what kind of alexithymia does the TAS-20 assess? Clinicians
often have the “operatory” kind of alexithymia in mind when imagining
clinically significant alexithymia. It is doubtful, however, that this kind ofalexithymia would characterize the significantly alexithymic individuals
found in student populations, where levels of “true” alexithymia canreach 10.9%. It is also doubtful that a self-report approach could
adequately reveal significant deficits in representation and cognition.
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Poster Summaries

This study explores the mechanisms underlying the reduced accessto representations of emotions (cognitive or defensive) in alexithymia asmeasured with the TAS-20 by using a situation of experimentally induced
sadness. Methodologically, the study does three important things: (1) it
uses a prospective design, measuring alexithymia before the evaluation of
the quality of emotion regulation, thus clarifying the relationship between
alexithymia and regulation (when alexithymia and its regulation outcome
are measured at the same time, it is not possible to determine if alexithymia is the cause or the result of the emotional condition). (2) It
assesses the regulation process with an observer-rated method. (3) It
forces a “live” performance of emotion regulation by use of an experimental procedure (induction by film). We hypothesize that alexithymia
will be more strongly associated with defensive mechanisms given thatthe sample is composed of undergraduate students in a psychology program and that the regulation task is benign.
MethodParticipants and procedure. One hundred twenty-eight undergraduate students (86% female, mean age = 22.8 years) first completed a seriesof self-report questionnaires online, which included the TAS-20 and ashort version of the Defensive Style Questionnaire. The participants werethen seen individually and asked to complete the PANAS (see below); toview the initial three minutes of Kenneth Lonergan’s 2000 movie YouCan Count on Me, which depicts two children crying at their parents’
funeral; to complete the PANAS again; and to describe their emotional
reaction to the film excerpt. The interviewers were a female and a male
graduate student with clinical experience. The interviewers wereinstructed to help the participants clarify and elaborate their response.
The interviews, which lasted from ten to fifteen minutes, were recorded
and transcribed. The interviews ended after three verbal fluency tasks
were performed. After a participant left the room, the interviewer rated
aspects of the participant’s observable reactions to the interview withscales designed for this study. Both interviewers were blind to the questionnaire data and hypotheses.
Measures. The Positive and Negative Affect Schedule (PANAS) is a
20-item scale that measures the dimensions of negative affects (10 items)
and positive affects (10 items). Four items on sadness, taken from theinstrument’s original item pool (PANAS-X), were added. The mean ofthese four items was used to evaluate the experience of sadness before
and after induction (sadness induction = post – pre).
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Po s t e r S u m m a r i e sTable 1. Correlations among the variables used in the study
N = 128
TAS – F1
TAS – F2
TAS – F3
Sadness
inductComplexN–avoid
Splitting
Isolation#negativeemotion
words(n = 87)

TAS total

F1F2

F3.88**.86**.60**–.08.69**.22*–.09.33**
–.04

–.04

–.36**–.32**.46**.68**–.14–.34**–.30**
.44**
.48**
–.06

–.32**–.30**
.39**
.76**
–.18

–.16
–.14.22*
.36**
–.13

Sad
Ninduc Complex avoidSplit

Isol

.19*
.16
–.10.01.11.32**.14–.17.76**–.15–.28**.26*–.10–.34**.18

The Toronto Alexithymia Scale (TAS-20), a 20-item measure of alexithymia, evaluates three factors: F1, difficulty identifying emotions; F2,difficulty expressing emotions; F3, externally oriented thinking. A cutoff
score of ≥ 61 indicates the presence of significant alexithymia. The total
score was used here.
The Defensive Style Questionnaire (DSQ-20) is a selection, based on
factor analyses obtained from an earlier student sample, of 20 items fromthe DSQ-60, which because of its factorial instability was not used. These
items formed seven scales: adaptive, humor, altruism, image distortion,
isolation of affect, splitting, and physical isolation. Only the two scales
most strongly associated with alexithymia and the postinduction scales
were retained (isolation and splitting).
To quantify postinduction interviewer observation of participants’emotion regulation, 31 items to be rated on a 9-point Likert scale werecreated for the interviewer’s assessment of manifestations of emotion
regulation in the participant during the postinduction interview. The
items cover aspects of cognitive elaboration, emotion avoidance, and fearof expression of emotions. Nine interviewer observation items were significantly correlated with alexithymia at r above .24, and a factor analysis
found that they formed a single factor explaining 61% of the variance.
These items were divided into two conceptually distinguishable scales:cognitive complexity (e.g., interviewer observed a complex emotional
life: a = .88, 4 items) and emotion avoidance (e.g., interviewer observed
a denial of emotions: α = .86, 5 items).
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Poster Summaries

Table 2. Hierarchical regression analysis for the prediction of
total alexithymia by the postinduction regulation complexityand nonavoidance scales
N = 128
Model: R2 = .134, p = .000
Complexity
Nonavoidance

βpPart correlation–.27–.12.040.364–.17–.08

In the verbal fluency tasks, participants were asked to give as manydifferent words as they could in 60 seconds that (1) begin with the letterp; (2) name animals; (3) name negative emotions. The only task associated with alexithymia or the postinduction scales was the number ofnegative emotion words.
Findings

Participants presented the following levels of alexithymia (meantotal score = 44.2, SD = 11.0; n = 12 or 9.4% = alexithymic). Inductionof sadness was successful, with a significant difference between pre- andpostinduction measurements of sadness (Cohen’s d of .56, which indicates a medium effect).
Cognitive complexity and nonavoidance of emotion were strongly
correlated (see Table 1: r = .76**), which was expected because they both
initially formed a single factor. However, both scales were slightly morecorrelated to their expected cognitive or defensive target: cognitive complexity was more strongly related to fluency of negative emotion words(n = 87, r = .26* vs. r = .18), and nonavoidance was more strongly related
to isolation of affect (r = –.34** vs. r = –.28**). The latter comparisonswere presented in order to support the concurrent validity of the observerrated scales. However, the comparisons tend to indicate that the two factors are more similar than different.
Total alexithymia was moderately correlated with both observerrated manifestation of the participants’ emotion regulation: complexity:r = -.36**; nonavoidance: r = -.32**. A regression analysis showed thatcognitive complexity had the only unique significant contribution to total
alexithymia when entered together with emotion nonavoidance (seeTable 2: R2 = .134**, complexity: β = -.27*).

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Po s t e r S u m m a r i e s

Discussion

Overall, the findings tend to picture alexithymia, as measured with
the TAS-20, as combining cognitive and defensive-avoidant features in a
student sample, with a small predominance of reduced cognitive complexity. This result somewhat contradicts our initial expectation that adefensive-avoidant attitude would predominate in the reactions of students to this benign exposure to sadness. However, the facet of cognitive
complexity assessed here is not operatory thinking. This more benign
form of cognitive deficit is more difficult to differentiate from emotional
avoidance, as the former can be the result of the latter. In other words, it
is likely that emotional avoidance and a lack of cognitive complexity are
intimately related, and that one contributes to increase the other. Also, astudent sample will not provide the entire range of alexithymic reactions
seen in clinical settings.
The authors of this paper received the Robert J. Stoller Travel Award.
Serge Lecours
Department of Psychology
University of Montreal
C.P. 6128, succ. Centre-villeMontreal, Quebec H3C 3J7
CANADAE-mail: serge.lecours@umontreal.ca

N AT U R A L I S T I C O U T C O M E S O F E V I D E N C E - B A S E D
THERAPIES FOR BORDERLINE PERSONALITY
D I S O R D E R AT A U N I V E R S I T Y C L I N I C :A QUASI-RANDOMIZED TRIAL

Shilpa Sachdeva, Gregory Goldman, Georgian Mustata,
Evan Deranja, and Robert J. Gregory(SUNY Upstate Medical University, Syracuse)
DOI: 10.1177/0003065113490637

Both Dialectical Behavior Therapy (DBT) and Dynamic Deconstructive
Psychotherapy (DDP) are listed in the National Registry of EvidenceBased Programs and Practices based on independent reviews of their578
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