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Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1698-1703
The relationship of alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment

1 Department of Psychology, Urmia Branch, Islamic University, Urmia, Iran
2 Department of Psychology, Islamic Azad University, Tonekabon, Iran
3 Department of psychology, Islamic Azad University, Roudehen, Iran
4 Department of Mental Health, Center of Excellence in Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
5 Department of Mental Health, Center of Excellence in Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences(IUMS), Tehran; Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran

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Date of Web Publication11-Jan-2018


Aim and Background:Addicted people suffer from many psychiatric disorders. Therefore, this study was conducted to examine the relationship of alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment referred to Addiction Treatment Centers in the west of Mazandaran, Iran. Materials and Methods: The research method is of correlational type. Statistical population of the study included all 20–50-year-old men referring to Addiction Treatment Centers in the west of Mazandaran. The study sample size included a cluster of 304 members who were randomly chosen among people referred to these centers at the first half of 2015. Sample members who participated in research filled out questionnaires such as Depression, Anxiety, Stress scale 21, Toronto Alexithymia Scale 20, and Fatigue Inventory of Chalder. The obtained data were analyzed using regression test throughSPSSversion22 software. Findings: The findings indicated that there is a significant relationship between alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment(P<0.001). Conclusion: Asignificant correlation is between alexithymia, depression, anxiety, stress, and fatigue was found among the people under addiction treatment and this correlation is as follows: depression(53%), anxiety(54%), stress(46%), and fatigue(52%).

Keywords: Addiction, alexithymia, anxiety, depression, fatigue, stress

How to cite this article:
Nezhad SR, Rad MM, Farrokhi N, Viesy F, Ghahari S. The relationship of alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment. Ann Trop Med Public Health 2017;10:1698-703

How to cite this URL:
Nezhad SR, Rad MM, Farrokhi N, Viesy F, Ghahari S. The relationship of alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Jul 12];10:1698-703. Available from:

   Introduction Top

Drug dependency is one of the serious social-mental problems that destroy personal, familial, social, and cultural life of a society, thereby harming the activity and dynamic of human, labor force, and interests of people. It also affects physical and spiritual dimensions of people and communities by providing service for rehabilitation of addicted persons.[1] Drug abuse has severe negative social, psychological, physical, and economic consequences that not only destroy person's performance but also impose heavy burden on individuals, their family, and society.[2] Drug abuse has been treated as one of the most serious and important concerns and preventable problems in Iran.[3] It is considered as one of the important health issues because it reduces quality of life, increases mortality, eliminates social and moral values, and increases criminal behaviors.[4] Drug abuse is related to some variables such as fatigue,[5] stress,[6] depression, and anxiety.[7] Fatigue is defined as a lack of physical, mental, or inner energy perceivable by an exhausted person and surrounding people interfering with daily activities.[8] Sam Ara et al.[5] found in their studies that drug-dependent people tend to use drug to overcome fatigue. Stressful situations not only create emotional reactions such as anxiety, anger, discouragement, and psychosomatic disorders, but also are effective in the tendency of people toward dysfunctional behaviors such as alcohol abuse, smoking, and drug abuse.[9]

Anxiety is a released and unpleasant sense as well as an obscure and unknown fear along with symptoms such as fatigue, restlessness, heart beating, and dizziness,[10] and almost0/73%of people suffer from this disorder.[11] Depression might be a sign of inability of addicted persons so that this issue is treated as a barrier to some effective behaviors of fighting against addiction or benefitting from the existing coping sources among drug abusers.[12] Researches have determined that anxiety and depression can be described as preexisted or relevant factors to drugs.[13] On the other hand, researches indicate that depression rate among addicted persons is four times more than that of general population.[14]

Alexithymia includes some features such as difficulty in identification and recognition of feelings, difficulty in expressing, describing feelings, and concentration on external experiences.[15] Some studies accepted that alexithymia is a stable characteristic trait that indicates the inability of a person to exert cognitive process of emotions(Picardi et al.,2005)[16] while other researches consider alexithymia as reducing ability of a person to identify and describe feelings and inability in determining the difference between feelings.[17] The other studies consider alexithymia as a characteristic trait that includes inability to perceive physical situations and appropriate cognitive responses to situations(Lemche et al., 2013).[18] The rate of this disorder among teenage girls is not more than teenage boys after 30 years old.[19],[20] Alexithymic persons are exposed to danger of psychosomatic disorders and mood disorders because these persons are not able to regulate their feelings.[21] Alexithymia reduces the quality of life among people.[22] The results of different studies indicate that alexithymia can be observed among patients with psychiatric and clinical disorders.[23]

According to Martínez-Sánchez etal.,[24] there is a positive correlation between alexithymia, depression, and anxiety. Astudy conducted by Hakim Javadi et al.[25] under the title of “Comparing alexithymia, stress, and attachment among couples on the verge of divorce” concluded that there is a significant relationship between alexithymia, stress, and attachment. On the other hand, Bodini et al.[26] indicated in their studies that alexithymia is associated with increased fatigue and depression. Studies by Makvandi et al.[27] and Dalbudak et al.[28] showed relationship between alexithymia and depression.

Due to the relationship between alexithymia and psychiatric disorders, the purpose of this study is to examine the relationship of alexithymia with depression, anxiety, stress, and fatigue among people under addiction treatment.

   Materials and Methods Top

This research is of correlational design. The study population included all addicted persons who were referred to addiction centers in Tonekabon and Ramsar Provinces at the first half of 2015. Sample size included 304 addicted people aged 20–50years who were randomly chosen and questionnaires were distributed among them, and the required information was explained to them. All questions were read to the illiterate and less educated persons, the responses were written down, and the data were analyzed using statistical method or regression through SPSS version22 software.

   Research Instruments Top

Depression, Anxiety, Stress scale

Depression, Anxiety, Stress scale 21(DASS-21) scale is able to diagnosis symptoms of anxiety, depression and stress. This scale is used for adults, and the responding method is based on 4-optional method filling out through self-assessment method. The range of responses is variable from “never” to “always” so that people can select one of the relevant options(never, a little, sometimes, and always) to questions using mark(×). Scoring is based on the range of 0–3 in which, zero is for option “never,” 1 for “a little,” 2 for “sometimes,” and 3 for “always.”

This scale includes 21 items. Each of them evaluates each of the mental variables including “depression,” “anxiety,” and “stress” by 7 phrases. Lovibond and Lovibond (1995) compared the Beck Depression Inventory to DASS within a large 717-member sample and obtained correlation between clinical samples (r=4%). Crawford and Henry (2003) compared this instrument to two other instruments (one of them related to depression and another one to anxiety) within a 1771-member sample in England and obtained its reliability as follows: Cronbach's alpha equal to 95% for depression, 90% for anxiety, 93% for stress and 97% for total scores.[29],[30] Cronbach's alpha was reported to 94% for depression, 92% for anxiety, and 82% for stress in Iran in this study.

The results of calculating correlation between factors in a study by Antony et al.[31] included correlation coefficient of 0/48 between two factors of depression and stress, correlation coefficient of 0/53 between anxiety and stress, and correlation coefficient of 0/28 between anxiety and depression. Validity and reliability of this questionnaire were examined by Samani and Jokar [32] in Iran that validity of retest was reported to be 0/80, 0/76, and 0/77, respectively, for depression, anxiety, and stress, and Cronbach's alpha was reported to be 0/81, 0/74, and 0/78, respectively, for depression, anxiety, and stress.

Toronto Alexithymia Scale

This scale was designed by Taylor in 1986 and revised by Bagby, Taylor, and Parker in 1994.[33] The component of alexithymia is evaluated in this scale within three subscales including difficulty in identifying feelings(DIF), difficulty in describing feelings(DDF), and external-oriented thinking(EOT). This inventory has an appropriate internal consistency and retest reliability. The conducted studies in the field of this instrument reported an optimal internal stability(Cronbach's alpha: 81%) and reliability through retests during 3weeks(r=77%).[34],[35] Shagholnia, Moradi and Kafi (2002) reported Cronbach's alpha coefficient of this scale equal to 74% for DIF, to 61% for DDF, and to 50% for EOT within Iranian version.[36] Afshari [37] reported the validity of this scale to be r = −47% in a 80-member sample using Schutte Emotional Intelligence Scale and its reliability to 75% for total score, 72% for DIF, 73% for drug–drug interactions, and 53% for EOT using Cronbach's alpha method.

Chalder Fatigue Inventory

Chalder etal.[38] designed a 14-item scale to measure physical and mental symptoms of fatigue. Chalder et al.[38] reported the internal consistency coefficient of scale equal to 89% and Cronbach's alpha coefficient equal to 85% for physical fatigue and to 82% for mental fatigue. This scale was validated by Nasri [39] in 2003, and internal consistency coefficients were equal to 88% and 91%, respectively, for student group(60 members) and nurse group(34 members). On the other hand, retest reliability for all scales of physical fatigue and mental fatigue was respectively equal to 85%, 81%, and 74% and reliability coefficient was to 83% (Abolghasemi and Narimani (2005).[40]

   Results Top

Statistical sample of this study included 304 members with age average of34/5distributed as follows in terms of education: lower diploma(48/4), diploma(37/5), associate degree(4/3), BA(5/6), MA(0/07), and not mentioned(3/6);11/8%were single,57/2%were married, 1% were divorced, and29/9%did not mention.

To analyze information and examine research hypotheses, descriptive and inferential statistics were used. Mean and standard deviation were used at descriptive statistics level and regression test was used at inferential statistics part, as shown in [Table1].
Table 1: Mean and standard deviation of studied variables

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The results showed that there is a positive significant correlation between total score of alexithymia and subscales of DIF and DDF with variables of depression, anxiety, stress, and fatigue(P<0.001). According to the results of [Table2], regarding variable of external thinking only, the correlation between this variable and fatigue was significant(P=0.02).
Table 2: Correlation coefficients between alexithymia and its components with depression, anxiety, stress, and fatigue

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To examine the predicting role of alexithymia and its subscales in depression, anxiety, stress, and fatigue, regression was used through “Enter” method.

Significance models were obtained using Enter model. [Table3] represents information about predictor variables entered into the model. According to the table, total score of alexithymia was not significant but two predictor variables were significant. As shown by the results of regression analysis, variables including depression, anxiety, stress, and fatigue were predicted by the components of difficulty in describing feelings and difficulty in identifying feelings. These two subscales would explain 33% variance of depression, 34% variance of anxiety, 29% variance of stress, and 30% variance of fatigue. On the other hand, results indicated that the score of alexithymia cannot predict relevant changes to depression, anxiety, stress, and fatigue.
Table 3: Results of predicting depression, anxiety, stress, and fatigue based on alexithymia and its components

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   Discussion Top

The results showed that there is a significant relationship between alexithymia and depression, anxiety, stress, and fatigue among people under addiction treatment referred to Addiction treatment Centers in the west of Mazandaran, Iran.

This finding is consistent with results obtained from the following studies: Ahadi [41] which showed that alexithymia is an effective predictor for obsessive-compulsive disorder among patients with major depressive disorder; study by Sarijaveri et al.[42] which reported that depression severity is considerably related to alexithymia and there is a positive correlation between alexithymia and depression severity; results of studies by Beshlideh et al.[43] that showed a positive significant relation between alexithymia and perceived stress with depression, anxiety, physical complaints, social function, and general score of mental health; results of study conducted by Bodini et al.[26] that proved the relationship between alexithymia and increase in fatigue and depression severity; research findings by Sepede et al.[44] which showed that the relation between depression and chronic fatigue syndrome was considerably significant leading to increase and severity of alexithymia traits; study by Dubey et al.[45] which showed a relationship between alexithymia and anxiety, hidden depression, posttraumatic stress disorder, anorexia nervosa, bulimia nervosa, psychogenic pain disorder; and also with the results of conducted studies by Martínez-Sánchez etal.,[24] Hakim Javadi et al.,[25] Makvandi et al.,[27] and Dalbudak et al.[28] that showed relationship between alexithymia with depression and anxiety. However, the results of our study are inconsistent with the finding of Bankier [46] that showed that alexithymia is not related to depression, so there is no relationship between these two variables.

It can be concluded that alexithymia is an emotion regulation disorder in which the person cannot identify and determine emotions or effective response to them.[47] People with alexithymia can hardly distinguish between real and original emotions and physical stimulations; for instance, they express emotion about some physical symptoms such as cold body or dry mouth instead of expressing fear emotion.[48] It seems that people who suffer from alexithymia use defensive mechanisms such as denial and repression for their emotions suppressing their feelings, while suppression of feelings not to expressing them would lead to intensity of negative emotions and depression among them.[21]

   Conclusion Top

The results showed that there is a correlation between alexithymia, depression, anxiety, stress, and fatigue among people under addiction treatment referred to addiction treatment centers in the west of Mazandaran and these correlations were equal to 53% for depression, anxiety(54%), stress(46%), and fatigue(52%).

Limitations and suggestions

This research only studied men; hence, it is suggested carrying out such study on addicted women. It is suggested for further studies to consider the relation between alexithymia and depression, anxiety, stress, and fatigue among other addicted persons such as alcohol-dependent persons. Furthermore, we suggest comparing these two groups on addicted and normal people, on these variables in the future.


Authors of this research appreciate all sample members and personnel of addiction treatment in the west of Mazandaran who collaborated and participated in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Shahrbanoo Ghahari
Department of Mental Health, Center of Excellence in Psychiatry, School of Behavioral Sciences and Mental Health; Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_589_17

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