Alexithymia and Vaginismus: a Preliminary Correlation Perspective

ORIGINAL ARTICLE Alexithymia and vaginismus: a preliminary correlation perspective

G Ciocca1, E Limoncin1, S Di Tommaso1, GL Gravina1, S Di Sante1, E Carosa1, A Tullii2, A Marcozzi2, A Lenzi3 and EA Jannini1

The aim of this study was to measure the prevalence of alexithymia and emotional dysregulation in women with vaginismus not associated with other organic or psychopathological disorders. The study involved the psychometric assessment of 41 patients with vaginismus and 100 healthy women, all of childbearing age. Alexithymia was evaluated by TAS-20 (Toronto Alexithymia Scale). Sexual function was assessed by FSFI (Female Sexual Function Index). In patients with vaginismus, the primary diagnosis of dyspareunia was excluded and an expert psychologist evaluated patients and controls according to DSM IV (Diagnostic and Statistical Manual of Mental Disorders: 4th edition) criteria to exclude mental disorders. Over half (51.1%) of the patients with vaginismus were classified as alexithymic or borderline (alexithymic trend), compared with just 18% of the control group. In addition, there was a significant difference in the TAS-20 total scores between the two groups (Po0.0001). In terms of relative risk, women suffering from vaginismus thus have a 3.8 times higher probability of showing alexithymia than do healthy women. Vaginismus is a complex syndrome and alexithymia is far from being its only characteristic. However, we found a significant correlation between vaginismus and alexithymia. In theory, alexithymia could thus be a risk factor for vaginismus, although future studies are required to demonstrate any chain of causation between these two conditions.

International Journal of Impotence Research (2013) 25, 113–116; doi:10.1038/ijir.2013.5; published online 7 March 2013 Keywords: alexithymia; emotional dysregulation; gynaecological examination; sexual dysfunction; vaginismus

INTRODUCTION Statistical Manual of Mental Disorders: 4th edition) Axis I 14 The word alexithymia is derived from Greek and is defined as the psychopathological disorders. It is a complex symptom that is lack of words for emotions. The term was coined by Peter Sifneos sometimes associated with coital pain (dyspareunia) and in 1973 after conducting clinical observations on psychosomatic sometimes with pre-existing organic disorders. It is found in patients.1 1–2% of post-pubertal women and accounts for 15–17% of clinical Alexithymia has been described in patients with psychosomatic cases in sexology, thus suggesting a very common epidemiolo- 15 disorders.2 Alexithymic individuals are characterised by limited gical diffusion. imaginary processes, as evidenced by a scarcity of fantasy, While vaginismus can have a physical cause, in most impaired ability to identify and communicate emotions, cases its aetiology is psychological. Sufferers are afraid of vaginal externally oriented thinking and tendency to somatisation.3 They penetration and produce an involuntary somatic and genital lack the ability to mentalise and transduce emotional arousal into response to this fear with a neuromuscular reaction which 16 a mental concept. To a certain extent, their emotions are confined prevents such penetration. According to Masters and 17 to a solely bodily level. Johnson, the psychological causes range from strict religious The main aetiological and pathogenetic observations on observance to trauma can also have a fundamental role. Most alexithymia can be attributed to neurophysiological, psychoevolu- authors in fact believe that child abuse, sexual harassment and tionary and psychotraumatological causes.4 sexual abuse or rape are predominant factors in the pathogenesis 18 Neurophysiologically, there is an impaired neural interaction of vaginismus. between the limbic system and the cortex, with specific damage To date, alexithymia has been considered mainly a masculine 19 to the anterior cingulate cortex and failed interhemispheric trait, and has not been explored much in women. The main integration.5,6 purpose of this study is to assess and evaluate any correlation Alexithymia may worsen in the presence of insecure and between alexithymia and vaginismus. avoidant attachment styles.7,8 Moreover, the condition is directly associated with traumatic experiences. In post-traumatic conditions, MATERIALS AND METHODS the psychic system reacts by restricting emotional response.9 Impaired cognitive processing and emotional regulation are also Sample recruitment found in patients with various psychosomatic disorders, including In all, 44 women with lifelong vaginismus and 109 healthy women were male sexual and reproductive dysfunctions.10–13 recruited at the University’s Sexology Unit and assessed by Toronto Alexithymia Scale (TAS-20) and Female Sexual Dysfunction Index (FSFI), Vaginismus is a common, multifaceted sexual dysfunction two widely used and well-validated scales for the assessment of defined as ‘a recurrent and persistent involuntary spasm of the alexithymia20,21 and female sexual function.22 All the sample was musculature of the outer third of the vagina that interferes with recruited sequentially by a gynaecologist and a psychologist, on the sexual intercourse’ not associated with DSM IV (Diagnostic and base of a fundamental criteria absence/presence of vaginismus.

1Department of Clinical, Applied and Biotechnological Sciences, School of Sexology, University of L’Aquila, L’Aquila, Italy; 2Department of Obstetrics and Gynaecology, Teramo Hospital, Teramo, Italy and 3Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy. Correspondence: Professor EA Jannini, Department of Clinical, Applied and Biotechnological Sciences, School of Sexology, Faculty of Psychology, University of L’Aquila (Coppito), Building 2, Via Vetoio, L’Aquila 67100, Italy. E-mail: [email protected] Received 3 May 2012; revised 30 November 2012; accepted 5 February 2013; published online 7 March 2013 Alexithymia and vaginismus G Ciocca et al 114 In fact, after a careful gynaecological examination, patients complaining RESULTS of vaginismus not due to a primary diagnosis of dyspareunia were selected 23,24 Table 1 lists the main sociodemographic characteristics of the study by our gynaecologist for the patient group. population. The mean ages of the control and patient groups were They were evaluated by a psychologist according to DSM IV criteria, to exclude other DSM IV Axis I disorders. The DSM IV diagnostic criteria that 29.3 (s.d. ¼ 5.9) and 29.8 (s.d. ¼ 9) years, respectively, with no we used for the diagnosis of vaginismus were (A) recurrent or persistent significant difference (P ¼ 0.71). There were no statistical differences involuntary spasm of the musculature of the outer third of the vagina that with respect to educational level between the groups (Table 1). interferes with sexual intercourse; (B) the disturbance causes marked The mean of FSFI total score of the control and vaginismic distress or interpersonal difficulty; (C) the disturbance is not better groups were 33.6 (s.d. ¼ 5) and 4.1 (s.d. ¼ 4.3), with a significant accounted for by another Axis I disorder (for example, somatisation difference (Po0.0001). disorder) and is not due exclusively to the direct physiological effects of a There was a significant difference in the TAS-20 scores between general medical condition. the two groups (Po0.0001) (Table 2), with a mean value of 51.6 in Of the 44 patients who were administered the test, 3 were excluded due the patient group against 40.5 in the controls (mean to errors or omissions in completing the TAS-20 test form. A total of 41 women with vaginismus thus took part in the experimental group. They difference ¼ 11.1). Considered as a whole, the patient group had were all of childbearing age (average age 29.8 years). significantly higher values of alexithymia than the healthy An age and education-matched control group consisted of healthy volunteers (Table 2). women with a normal sexual function was also recruited. Of the 109 Using a TAS-20 cutoff score of 61 for the 41 patients diagnosed controls recruited, 9 were excluded due to dysfunctional FSFI scores. The with vaginismus, 26.8% (11/41) were identified as alexithymic, average age of the remaining 100 controls was 29.3 years. 24.3% (10/41) as borderline and 48.7% (20/41) as not alexithymic. Also, the controls were evaluated by a psychologist and a gynaecologist In the control group, 7% (7/100) were identified as to exclude mental or gynaecological disorders. alexithymic, 11% (11/100) as borderline and 82% (82/100) as not alexithymic. These differences are significant (Figure 1). Patient group inclusion criteria The cumulative percentage of patients with alexithymic or Women of childbearing age with lifelong and generalised vaginismus not borderline (alexithymic trend) scores was 51.1% (21/41), indicating associated with a primary diagnosis of dyspareunia or any other organic or that a considerable number of women with vaginismus react in psychopathological condition. such a way as to suggest that their capacity for emotional processing is partly or completely absent. In contrast, the Patient group exclusion criteria cumulative percentage of alexithymic and borderline scores in Women not of childbearing age or menopausal, women with other the control group was just 18% (18/100), significantly lower than gynaecological disorders; women with mental disorders. in the patient group (Po0.0001). In terms of relative risk, women suffering from vaginismus thus have a 3.8 times higher probability Control group inclusion criteria of showing alexithymia than healthy women (relative risk ¼ 3.83; 95% CI: 1.59–9.19; P ¼ 0.0026). Women of childbearing age and in good health. FSFI score of 426.55. The subanalysis showed a significant difference between the groups for TAS-20 subscale F1 (difficulty identifying feelings), F2 Control group exclusion criteria (difficulty in expressing feelings) and F3 (externally oriented thinking) Women not of childbearing age or menopausal, women with other (Table 2). Women with vaginismus essentially demonstrated poor gynaecological or mental disorders. FSFI score of o26.55. cognitive-emotional processing, which seemed to be indicative of a tendency to somatisation. This group also tended to have a Main outcome measures concrete, logical cognitive thinking style not mediated by any The control group and patients group were screened using FSFI (Italian reflective function. However, there was no significant difference version). This is a popular, well-validated psychometric tool used to between the groups in describing feelings, such as joy or distinguish between normal and dysfunctional sexuality in the female uneasiness, to others. population. The score of dysfunctional sexuality is lower 26.55.25–27 Finally, the univariate logistic regression revealed that age (OR Patients and screened controls were assessed by the Italian version of (Odds ratio) ¼ 0.9; 95% CI 0.8–1; P ¼ 0.2), educational level TAS-20. This is a three-factor model, thus evaluating the emotion (OR ¼ 1.3; 95% CI 0.3–4.3; P ¼ 0.6) and to have a relationship regulation by dividing scores into three cognitive-affective areas. The first, (OR 0.6; 95% CI 0.1–2.4; P 0.5) are not significantly correlated considered as dysfunctional (alexithymia), is a score equal to or greater ¼ ¼ than the recommended cutoff of 61. The second, a score between 51 and with alexithymia (Table 1). 60 (within the cutoff rate), is considered as borderline (alexithymic trend) and the third, a score of under 51, is considered as non-dysfunctional. The test assesses different aspects of the alexithymia construct through three Table 1. Sociodemographic characteristics and their impact on subfactors that characterise alexithymic patients to a different extent. These are F1: difficulty in identifying feelings; F2: difficulty in expressing alexithymia feelings; and F3: externally oriented thinking (operational thinking).28 Age Secondary University Have a mean (s.d.) education degree relationship Statistical analysis n (%) n (%) n (%) Continuous variables were represented statistically as means and standard Patient group 29.8 (9) 12/41 (29.3) 29/41 (62.8) 37/41 (90) deviation (s.d.). Variances of the control and experimental groups were (n ¼ 41) compared using Student’s T-test for non-matched data, assuming an equal Control group 29.3 (5.9) 32/100 (32) 53/100 (53) 86/100 (86) variance. (n ¼ 100) Dichotomic variables were represented statistically as absolute and percentage frequencies. The difference between dichotomic variables was Age Education Have a tested using Chi-Square test or Fisher’s exact test when appropriate. relationship Relative risk with a 95% confidence interval (95% CI) was used to measure the correlation between vaginismus and alexithymia, whereas the null Logistic regression analysis OR 0.9493 1.3095 0.6422 hypothesis was rejected by non-parametric statistics using Fisher’s exact 95% CI 0.8737–1.0314 0.3926–4.3684 0.1650–2.4991 test. Each alpha error lower than 5% indicated statistical significance. P-value 0.2188 0.6609 0.5230 Univariate logistic regression was used to test the impact of demographic variables on alexithymia. All tests included the two-tail test and were Abbreviations: CI, confidence intervals; OR, Odds ratio. performed by Medcalc.

International Journal of Impotence Research (2013), 113 – 116 & 2013 Macmillan Publishers Limited Alexithymia and vaginismus G Ciocca et al 115 psychological component.10,11 In fact, the correlation between Table 2. TAS-20 values in the vaginismus patients and control group alexithymia and male sexual dysfunction is even stronger than TAS-20 F1 F2 F3 that found in our study. In the general population too, men are more prone to alexithymia than women.31,32 Patient group 51.6 (11.1)a 18.6 (6.6)a 16 (3.4)b 19.5 (4.4)a The association we found between alexithymia and vaginismus (n ¼ 41) mean (s.d.) was further strengthened by the analysis of the TAS-20 subfactors. Control group 40.5 (10.3) 13.2 (5) 12.7 (2.9) 14.5 (4.3) The differences between the groups in subscale F1 (difficulty (n ¼ 100) mean (s.d.) identifying feelings), F2 (difficulty in expressing feelings) and F3 Abbreviations: F1, difficulty in identifying feelings; F2, difficulty in (externally oriented thinking) suggest that women with vaginismus communicating feelings to other people; F3, externally oriented thinking; essentially experience poor cognitive-emotional processing, which TAS-20, Toronto Alexithymia Scale. is indicative of a tendency to somatisation and operational aPo0.0001. thinking, as previously discussed. bPo0.05 (t-test: two-tailed probability, separate variance estimate). To some extent, our study suffers from clear limitations. The first, as with many studies of vaginismus,18 is the relatively low number of patients. Whether our results are applicable to the general population of women with vaginismus has yet to be 100 demonstrated. Another limitation is the lack of assessment of the *p<0.05; **p<0.001 Patient group quality of the patients’ relationship with their partners.33–35 These 90 aspects together to the relationships among female sexuality, 82 Control Group emotional regulation and other gynaecological disorders are 80 ** currently being examined in our laboratory. 70 In any case, our evidence suggests that there is indeed a correlation between alexithymia and vaginismus, with more than 60 one in two women in our patient group also presenting 48.8 51.1 ** alexithymia/alexithymic trend. This must thus be considered as a 50 risk factor in some patients affected with vaginismus, as this 40 personality trait could exacerbate and perpetuate this psycho-

Percentage (%) genic sexual dysfunction. Counselling could help to explore the 30 26.8 24.3 alexithymic trait as part of an integrated treatment regime for * * vaginismus and female sexual dysfunction. 20 18 11 7 10 CONFLICT OF INTEREST 0 The authors declare no conflict of interest. AlexithymicBorderline Not Alexithymic Alexithymic and Borderline Figure 1. Prevalence of alexithymia into the groups. Percentage ACKNOWLEDGEMENTS distribution respect Toronto Alexithymia Scale (TAS-20) areas into This work is partially supported by the PhD fellowships to GC, EL and GLG and by the two groups (%). There was a significant difference between patient Italian Ministry of Education grants. We thank Dr Alfonso Tiberi and Dr Claudia De group and control group respect the three TAS-20 areas. Then also Sanctis for their contribution to recruit a part of sample. in the alexithymic and borderline areas (alexithymic trend: score X51) there was a great difference between vaginismic patients and the control women. REFERENCES 1 Sifneos PE. The prevalence of ’alexithymic’ characteristics in psychosomatic DISCUSSION patients. Psychother Psychosom 1973; 22: 255–262. The evidence from this study validated the theory that women 2 Waller E, Scheidt CE. Somatoform disorders as disorders of affect regulation. A study comparing the TAS-20 with non-self-report measures of alexithymia. J with vaginismus have a significant prevalence of alexithymia Psychosom Res 2004; 57: 239–247. when compared with an age and educational-matched control 3 Taylor GJ. Alexithymia: concept, measurement, and implications for treatment. group of women with normal sexual function. The findings also Am J Psychiatry 1984; 141: 725–732. support the theory that patients with vaginismus have impaired 4 Taylor GJ, Bagby RM. New trends in alexithymia research. Psychother Psychosom cognitive-emotional responsiveness.29 The prevalence of 2004; 73: 68–77. alexithymia or alexithymic trend in the controls was just 18%, 5 Parker JD, Keightley ML, Smith CT, Taylor GJ. Interhemispheric transfer deficit in including both alexithymic and borderline scores (7 and 11%), in alexithymia: an experimental study. Psychosom Med 1999; 61: 464–468. comparison with over 50% of the patient group (26.8 and 24.3%, 6 Berthoz S, Artiges E, Van De Moortele PF, Poline JB, Rouquette S, respectively). Women suffering from vaginismus thus had a 3.8 Consoli SM et al. Effect of impaired recognition and expression of emotions on frontocingulate cortices: an fMRI study of men with alexithymia. Am J Psychiatry times higher probability of presenting alexithymia than healthy 2002; 159: 961–967. women. However, not all our patients also presented alexithymia, 7 Waerden A, Cook L, Vaughan-Jones J. Adult attachment, alexithymia, symptom and so our findings also confirmed that vaginismus is not a reporting, and health-related coping. J Psychosom Res 2003; 55: 341–347. condition with a ‘blanket’ set of symptoms, but a multifactor, 8 Troisi A, D’Argenio A, Peracchio F, Petti P. Insecure attachment and alexithymia in multifaceted sexual syndrome. Logistic regression revealed that young men with mood symptoms. J Nerv Ment Dis 2001; 189: 311–316. there was no correlation between the TAS-20 score and 9 Krystal JH, Giller Jr EL, Cicchetti DV. Assessment of alexithymia in posttraumatic educational level or age. stress disorder and somatic illness: introduction of a reliable measure. Psychosom Considered as a whole, the group with vaginismus showed Med 1986; 48: 84–94. impaired emotional regulation. Literature evidence suggests that 10 Michetti PM, Rossi R, Bonanno D, Tiesi A, Simonelli C. Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile alexithymia is associated not only with psychosomatic conditions dysfunction (ED). Int J Impot Res 2006; 18: 170–174. such as gastrointestinal disorders or other somatoform disor- 11 Michetti PM, Rossi R, Bonanno D, De Dominicis C, Iori F, Simonelli C. Dysregulation 30 ders, but also with male sexual dysfunctions such as erectile of emotions and premature ejaculation (PE): alexithymia in 100 outpatients. dysfunction and premature ejaculation with an important J Sex Med 2007; 4: 1462–1467.

& 2013 Macmillan Publishers Limited International Journal of Impotence Research (2013), 113 – 116 Alexithymia and vaginismus G Ciocca et al 116 12 Morelli G, De Gennaro L, Ferrara M, Dondero F, Lenzi A, Lombardo F et al. 24 Borg C, de Jong PJ, Schultz WW. Vaginismus and dyspareunia: automatic vs. Psychosocial factors and male seminal parameters. Biol Psycol 2000; 53: 1–11. deliberate disgust responsivity. J Sex Med 2010; 7: 2149–2157. 13 Madioni F, Mammana LA. Toronto Alexithymia Scale in outpatients with sexual 25 Nappi RE, Albani F, Vaccaro P, Gardella B, Salonia A, Chiovato L et al. Use of the disorders. Psychopathology 2001; 34: 95–98. Italian translation of the Female Sexual Function Index (FSFI) in routine gyneco- 14 American Psychiatric Association. DSM IV-TR diagnostic and statistical manual of logical practice. Gynecol Endocrinol 2008; 24: 214–219. mental disorders. 4th edition, text revAPA: Washington DC and London, 2000. 26 Derogatis LR, Conklin-Powers B. Psychological assessment measures of female 15 Spector I, Carey M. Incidence and prevalence of the sexual dysfunction: a critical sexual functioning in clinical trials. Int J Impot Res 1998; 10(Suppl 2): S111–S116. review of the empirical literature. Arch Sex Behav 1990; 11: 19–36. 27 Giraldi A, Rellini A, Pfaus JG, Bitzer J, Laan E, Jannini EA et al. Questionnaires for 16 Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J et al. Report assessment of female sexual dysfunction. a review and proposal for a standar- of the International Consensus Development Conference on female sexual dized screener. J Sex Med 2011; 8: 2681–2706. dysfunction: definition and classification. J Urol 2000; 163: 889–893. 28 Bressi C, Taylor G, Parker J, Bressi S, Brambilla V, Aguglia E et al. Cross validation of 17 Masters WH, Johnson VE. Human Sexual Response. 1st edn. Little Brown: the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multi- London, 1966. centre study. J Psychosom Res 1996; 41: 551–559. 18 Lahaie MA, Boyer SC, Amsel R, Khalife´ S, Binik YM. Vaginismus. a review of the 29 Subic-Wrana C, Beutel ME, Knebel A, Lane RD. Theory of mind and emotional literature on the classification/diagnosis, etiology and treatment. Womens Health awareness deficits in patients with somatoform disorders. Psychosom Med 2010; 2010; 6: 705–719. 72: 404–411. 19 Lane DR, Sechrest L, Riedel R. Sociodemographic correlates of alexithymia. Compr 30 Porcelli P, Todarello O. Psychological factors affecting functional gastrointestinal Psychiatry 1998; 39: 377–385. disorders. Adv Psychosom Med 2007; 28: 34–56. 20 Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale—I. 31 Kokkonen P, Karvonen J, Veijola J, La¨ksy K, Jokelainen J, Jarvelin M-R et al. Item selection and cross validation of the factor structure. J Psychosomatic Res Prevalence and sociodemographic correlates of alexithymia in a population 1994; 38: 23–32. sample of young adults. Compr Psychiatry 2001; 42: 471–476. 21 Bagby RM, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale—II. 32 Mattila AK, Salminen JK, Nummi T, Joukamaa M. Age is strongly associated with Convergent discriminant and concurrent validity. J Psychosom Res 1994; 38: alexithymia in the general population. J Psychosom Res 2006; 61: 629–635. 33–40. 33 Sbarra DA, Law RW, Lee LA, Mason AE. Marital dissolution and blood pressure 22 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R et al. The Female reactivity: evidence for the specificity of emotional intrusion-hyperarousal and Sexual Function Index (FSFI). A multidimensional self-report instrument for the task-rated emotional difficulty. Psychosom Med 2009; 71: 532–540. assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208. 34 Dogan S, Dogan M. The frequency of sexual dysfunctions in male partners of 23 de Kruiff ME, ter Kuile MM, Weijenborg PT, van Lankveld JJ. Vaginismus and women with vaginismus in a Turkish sample. Int J Impot Res 2008; 20: 218–221. dyspareunia: is there a difference in clinical presentation? J Psychosom Obstet 35 Greenstein A, Abramov L, Matzkin H, Chen J. Sexual dysfunction in women Gynaecol 2000; 21: 149–155. partners of men with erectile dysfunction. Int J Impot Res 2006; 18: 44–46.

International Journal of Impotence Research (2013), 113 – 116 & 2013 Macmillan Publishers Limited