Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 15, 2019

Alexithymia Affects Pre-Hospital Delay of Patients with Acute Myocardial Infarction: Meta-Analysis of Existing Studies



Antonio Preti, Federica Sancassiani, Federica Cadoni , Mauro Giovanni Carta*
Department of Public Health, Clincial and Molecular Medicine, University of Cagliari and Center for Consultation-Liaison Psychiatry and Psychosomatics, University Hospital of Cagliari, Cagliari, Italy

Abstract

Background:

The time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with acute myocardial infarction (AMI). Any delay in seeking help will affect patient’s outcome. Alexithymia can influence the information processing but also the skills to detect the signal of an ongoing AMI.

Method:

Systematic review and meta-analysis of studies investigating the role of alexithymia in pre-hospital delay after AMI. Pubmed/Medline and PsychINFO/Ovid search from 1990 until 2012.

Results:

Out of 29 studies investigating the role of psychological factors in pre-hospital delay after AMI, 3 studies specifically assessed alexithymia, involving 258 patients. All studies used the Toronto Alexithymia Scale to group patients into clusters by time to presentation after AMI. Meta-analysis of data showed that the patients with higher emotional awareness (i.e., low alexithymia) had shorter time to presentation after AMI.

Conclusions:

Preliminary evidence indicates that alexithymia may have a role in seeking help delay after AMI. Further studies are necessary to better appreciate how alexithymia influence help-seeking in patients with an evolving AMI and in what extent their ineffective behavior can be changed.

Keywords: Pre-hospital delay, acute myocardial infarction, alexithymia, psychological factors, care seeking behavior.


Article Information


Identifiers and Pagination:

Year: 2013
Volume: 9
First Page: 69
Last Page: 73
Publisher Id: CPEMH-9-69
DOI: 10.2174/1745017901309010069

Article History:

Received Date: 14/1/2013
Revision Received Date: 28/2/2013
Acceptance Date: 4/2/2013
Electronic publication date: 19/4/2013
Collection year: 2013

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© Preti et al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Center for Consultation-Liaison Psychiatry and Psychosomatics, University Hospital of Cagliari Via Ospedale 117, 09124 Cagliari, Italy; Tel: +39 3335 499994; Fax: +39 070 6093498; E-mail: mgcarta@tiscali.it





1. INTRODUCTION

The time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with acute myocardial infarction (AMI). The degree of myocardial necrosis is related to the length of the ischemic episode [1Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour Lancet 1996; 21: 771-5., 2De Von HA, Hogan N, Ochs AL, Shapiro M. Time to treatment for acute coronary syndromes: the cost of indecision J Cardiovasc Nurs 2010; 25(2): 106-4.]. Survival after AMI depends of the early application of medical interventions as thrombolytic and other reperfusion techniques. Any delay in seeking help will affect patient’s ultimate outcome.

The decision of seeking help is based on both somatic (signs of the incoming infarction) and psychological (the emotional reaction to the event, the capacity of dealing with stress) factors. In the study of the determinant of pre-hospital delay in seeking help, clinical variables were given priority, such as previous infarction, atypical symptoms presentation, or co-morbidity with other medical diseases (i.e., diabetes), symptoms onset context (i.e.: being/living alone) and first consulting with a family member or a physician. Factors such as older age, female sex, and lower socio-economic status were also related to pre-hospital delay after AMI. However, all these factors were found to contribute to decisional time but did not explain delay independently.

Psychological factors are likely to be implied in the patient’s decisional delay. Patients were reported to have poor appraisal of symptoms, or to express wrong causal beliefs about them; ineffective coping strategies, external health locus of control, low neuroticism and depressed mood were also related to increased time to seeking help after AMI [3Kenyon LW, Ketterer MW, Preisman RC. Psychological factors relevant to the prehospital and in-hospital phases of acute myocardial infarction Henry Ford Hosp Med J 1991; 39(3-4): 176-83.-8Gärtner C, Walz L, Bauernschmitt E, Ladwig KH. The causes of prehospital delay in myocardial infarction Dtsch Arztebl Int 2008; 105(15): 286-91.]. Alexithymia might be an overarching element behind many of the psychological factors implied in pre-hospital delay after AMI [9Sancassiani F, Preti A, Cadoni F, Carta MG. The role of psychological factors and alexithymia in seeking care during acute myocardial infarction: a systematic review PloS ONE 2013. [submitted]].

Alexithymia was defined as a deficiency in understanding, processing, or describing emotions [10Sifneos PE. The prevalence of 'alexithymic' characteristics in psychosomatic patients Psychother Psychosom 1973; 22(2): 255-62.]. The alexithymia construct is composed by four major factors; 1) difficulty in identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal; 2) difficulty in describing feelings to other people; 3) poor imaginative processes, as evidenced by a paucity of fantasies; and 4) a stimulus-bound, externally oriented cognitive style [11Richards HL, Fortune DG, Griffiths CE, Main CJ. Alexithymia in patients with psoriasis: clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20 J Psychosom Res 2005; 58(1): 89-96.-13Taylor GJ, Bagby RM, Ryan DP, Parker JDA, Doody KF, Keefe P. Criterion validity of the Toronto Alexithymia Scale Psychosom Med 1988; 50: 500-9.]. Alexithymia can influence the information processing but also the skills to detect the signal of illness. People with alexithymia are more likely to experience wrong appraisal and interpretation of symptoms, and because their difficulty in describing feelings to other people, they can be poor in reporting symptoms at the first consultation with a physician.

In so far, a few studies only had investigated the role of alexithymia in pre-hospital delay after AMI, and obtained ambiguous results [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.-16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]]. There is agreement that meta-analysis is the best method to summarize data, even when the studies are a few [17Valentine JC, Pigott TD, Rothstein HR. How many studies do you need? a primer on statistical power for meta-analysis J Educ Behav Stat 2010; 35: 215-47.]. This study reports the first systematic review and meta-analysis of the studies that assessed the role of alexithymia in pre-hospital delay after AMI.

2. METHODS

The electronic databases Pubmed/Medline and PsychINFO/Ovid were searched for articles meeting the following inclusion criteria: (1) original papers written in English, (2) published from the period 1990 until 2012 and (3) containing the key words: “prehospital delay” OR “patient delay” OR “care seeking behavior” OR “alexithymia” AND “myocardial infarction”. Latest search performed on August 31, 2012.

Review papers and studies that did not clearly define pre-hospital or decisional delay, and those that did not considered psychological factors as determinant of delay were excluded.

The meta-analysis was carried out with the Comprehensive Meta-Analysis (version 2.2) software (http://www.meta-analysis.com/). Effect sizes were calculated as Hedges’ adjusted g with 95% Confidence of interval (CI).

3. RESULTS

The initial search identified 1687 articles from PubMed and PsychInfo. After exclusion of duplicate, reviews and articles unrelated to the topics on the basis of the abstract, a total of 48 articles were considered in detail, 29 of them investigated psychological factors. We found two studies that specifically assessed alexithymia as a factor involved in pre-hospital delay after AMI; a third study was done by our group and it is still in press (Table 1). The three studies investigated levels of alexithymia with different version of the Toronto Alexithymia Scale (TAS) [12Taylor GJ, Bagby RM, Parker JD. The 20-item Toronto Alexithymia Scale, IV. Reliability and factorial validity in different languages and cultures J Psychosom Res 2003; 55: 277-83., 13Taylor GJ, Bagby RM, Ryan DP, Parker JDA, Doody KF, Keefe P. Criterion validity of the Toronto Alexithymia Scale Psychosom Med 1988; 50: 500-9.], albeit congruent in the use of cut-off to define alexithymia caseness. Further details on alexithymia scores in Table 2 and 3.

Table 1

Included Studies




Table 2

Results of Kenion et al, 1991 and Carta et al, 2012




Table 3

Results of O’Carrol et al., 2001 and Carta et al., 2012




3.1. Summary of Results

Kenion et al. [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.] found no association of patients’ delay with demographic or medical history variables. Instead, they found that patients more capable of identifying inner experiences of emotions and/or bodily sensations sought treatment significantly earlier than patients with low emotional or somatic awareness, i.e. those with higher scores on the measure of alexithymia.

O’Carrol et al. [15Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction Circulation 1991; 84(5): 1969-76.] found that patients who delayed presentation for medical help after AMI had lower scores on a measure of neuroticism and higher scores on a measure of denial. They also grouped patients by time of presentation after AMI into three clusters of “high alexithymics”, “intermediate alexithymics” and “low alexithymics”: prompt presenters (< 4 hours) were less likely to be “high alexithymics” than the delayed presenters (>4 hours), but these differences did not reach the threshold for statistical significance.

In a case-control study, Carta et al. [16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]] included 83 AMI patients (61 [73,5%] males). In this study the time to presentation was calculated as the estimated interval from symptoms’ onset to first EEG. In the sample, 36 patients (43.4%) had more than 120 minutes of time to presentation and were enrolled in the Group of late responders (mean ± sd “time to presentation” = 320,72 ± 309,44); 47 patients (56.6%) had less than 120 minutes of time to presentation and were enrolled in the Group of early responders (66,47 ± 29,66). Higher alexithymia scores (TAS-20 ≥ 61) (OR 3.7, Cl 95% 1.3-10.1, p<0.01) and having contact with primary care (OR 3.5, Cl 95% 1.3-9.3, p<0.01) were associated with increased time to treatment in AMI. Socio-demographic or clinical variables were not related with time to presentation.

3.2. Results of the Meta-Analysis

In the study of Kenyon et al. [15Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction Circulation 1991; 84(5): 1969-76.] the overall mean of time of presentation was compared in two groups of “alexithymics” and “not alexithymics”, therefore we subdivided data bank of the study of Carta et al. (2012) in the same way. The study of O’Carrol et al. [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.] compared the alexithymia in a group of patient with AMI prompt presenters (< 4 hours) and a group of AMI delayed presenters (>4 hours). For this comparison we re-analyzed data of the study of Carta et al. [16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]] subdividing in same way the sample.

Table 1 and Fig. (1) present the results of the meta-analysis summarizing the data of the study of Carta et al. [16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]] with that of Kenion et al. [15Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction Circulation 1991; 84(5): 1969-76.]. The pooled data showed statistically significant differences between “low and Intermediate emotional awareness (TAS ≥61)” and “high emotional awareness” (TAS <61)” subgroups, with patients with “high emotional awareness” showing a shorter time to presentation.

Fig. (1)

Meta-analysis of the studies of Kenion et al., 1991 and Carta et al., 2012.



Fig. (2)

Meta-analysis of the studies of O’Carrol et al., 2001 and Carta et al., 2012.



Table 2 and Fig. (2) presents the results of the meta analysis summarizing the data of the study of Carta et al. [16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]] with the O’ Carrol et al. [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.] study. In the sample of Carta’s study a very few people had a delayed time outmatching 4 hours (9,10.8%). The pooled data showed statistically significant differences between the mean scores at TAS between “prompt” (elapsed time <4 hours) and “delayed” (>4hours) groups, with patients in the prompt group showing lowers scores on the TAS.

4. DISCUSSION

Three studies in so far explored the role of alexithymia in pre-hospital delay after AMI. Higher levels of alexithymia associated with higher delay time in seeking medical help after AMI [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.-16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]]. The finding was clearer in the Kenion et al. [15Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction Circulation 1991; 84(5): 1969-76.] and in the Carta et al. [16Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]] study than in the O’Carroll et al. [14O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.] study. Nevertheless, in the study of O’Carroll and colleagues, alexithymia levels were, non-significantly, higher in “delayers” than in “prompt attenders” (TAS-20 mean scores: 56.7 ± 8.9 vs 53.9 ± 11.1), albeit with a too long threshold to identify “prompter attender”: “< 4 hours”.

Alexithymia may affect the experience and reporting of physical symptoms, thus having an impact on the seeking of treatment [18Lumley MA, Neely LC, Burger AJ. The assessment of alexithymia in medical settings: implications for understanding and treating health problems J Pers Assess 2007; 89(3): 230-46.]. It can be hypothesized that AMI is unrecognized by alexithymic patients, because they fail to notice or report the event to the physician, or make the physician unable to diagnose it because they report confusedly their symptoms. In a past study, Theisen and collegues [19Theisen ME, MacNeill SE, Lumley MA, Ketterer MW, Goldberg AD, Borzak S. Psychosocial factors related to unrecognized acute myocardial infarction Am J Cardiol 1995; 75(17): 1211-3.] found that those patients who failed to recognize an ongoing AMI (n = 30) had higher alexithymia scores on the Alexithymia Provoked Response Interview than those patients (n = 40) who correctly sought treatment when symptoms of AMI started. Patients unable to correctly identify their ongoing AMI also were more likely to hold the belief that chance factors determine their health (as assessed with the Multidimensional Health Locus of Control Scale). Poor awareness of psychological factors was suggested a factor preventing AMI symptom perception or recognition, alexithymia possibly contributing to the belief that chance or fate do determine health, so inhibiting treatment seeking [19Theisen ME, MacNeill SE, Lumley MA, Ketterer MW, Goldberg AD, Borzak S. Psychosocial factors related to unrecognized acute myocardial infarction Am J Cardiol 1995; 75(17): 1211-3.].

5. CONCLUSION

Findings must be considered preliminary, nevertheless the evidence suggest that alexithymia may have a role in pre-hospital delay after AMI. It can be hypothesized that patients more capable of identifying inner experiences of emotions and bodily sensations would be more likely to seek right treatment earlier for symptoms of AMI. In the past alexithymia was conceived an unchangeable trait dimension, but it was demonstrated that it may display sensitivity to change in specific situations [20Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression Psychother Psychosom 2001; 70: 254-60.-23Carta MG, Balestrieri M, Murru A, Hardoy MC. Adjustment Disorder: epidemiology, diagnosis and treatment Clin Pract Epidemiol Ment Health 2009; 5: 15.]. Preliminary findings suggest that intranasal oxytocin may improve social-emotional abilities of individuals with alexithymia [24Luminet O, Grynberg D, Ruzette N, Mikolajczak M. Personality-dependent effects of oxytocin: greater social benefits for high alexithymia scorers Biol Psychol 2011; 87(3): 401-6.]. Due to paucity of current evidence, further studies are necessary to better appreciate how alexithymia influence help-seeking in patients with an evolving AMI and in what extent their ineffective behavior can be changed.

ACKNOWLEDGEMENT

MGC had the idea and organized the study; he also wrote the first draft of the article. FS did the systematic review and contributed to the study design and to the first draft of the article. AP contributed to the systematic review, to the study design and to the first draft of the article; he also did the meta-analysis. FC contributed to the study design and to the first draft of the article. All authors contributed to the writing of the final manuscript, which they all approved for submission. Each author has studied the manuscript in the submitted form, has agreed to be cited as co-author, and has accepted the order of authorship;

CONFLICT OF INTEREST

The authors confirm that this article content has no conflicts of interest.

REFERENCES

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[10] Sifneos PE. The prevalence of 'alexithymic' characteristics in psychosomatic patients Psychother Psychosom 1973; 22(2): 255-62.
[11] Richards HL, Fortune DG, Griffiths CE, Main CJ. Alexithymia in patients with psoriasis: clinical correlates and psychometric properties of the Toronto Alexithymia Scale-20 J Psychosom Res 2005; 58(1): 89-96.
[12] Taylor GJ, Bagby RM, Parker JD. The 20-item Toronto Alexithymia Scale, IV. Reliability and factorial validity in different languages and cultures J Psychosom Res 2003; 55: 277-83.
[13] Taylor GJ, Bagby RM, Ryan DP, Parker JDA, Doody KF, Keefe P. Criterion validity of the Toronto Alexithymia Scale Psychosom Med 1988; 50: 500-9.
[14] O’Carroll RE, Smith KB, Grubb NR, Fox KAA, Masterton G. Psychological factors associated with delay in attending hospital following a myocardial infarction J Psychosomat Res 2001; 51: 611-4.
[15] Kenyon LW, Ketterer MW, Gheorghiade M, Goldstein S. Psychological factors related to prehospital delay during acute myocardial infarction Circulation 1991; 84(5): 1969-76.
[16] Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction Psychother Psychosom 2013. [E-pub ahead of print]
[17] Valentine JC, Pigott TD, Rothstein HR. How many studies do you need? a primer on statistical power for meta-analysis J Educ Behav Stat 2010; 35: 215-47.
[18] Lumley MA, Neely LC, Burger AJ. The assessment of alexithymia in medical settings: implications for understanding and treating health problems J Pers Assess 2007; 89(3): 230-46.
[19] Theisen ME, MacNeill SE, Lumley MA, Ketterer MW, Goldberg AD, Borzak S. Psychosocial factors related to unrecognized acute myocardial infarction Am J Cardiol 1995; 75(17): 1211-3.
[20] Luminet O, Bagby RM, Taylor GJ. An evaluation of the absolute and relative stability of alexithymia in patients with major depression Psychother Psychosom 2001; 70: 254-60.
[21] Beresnevaite M. Exploring the benefits of group psychotherapy in reducing alexithymia in coronary heart disease patients: a preliminary study Psychother Psychosom 2000; 69(3): 117-22.
[22] Tulipani C, Morelli F, Spedicato MR, Maiello E, Todarello O, Porcelli P. Alexithymia and cancer pain: the effect of psychological intervention Psychother Psychosom 2010; 79(3): 156-63.
[23] Carta MG, Balestrieri M, Murru A, Hardoy MC. Adjustment Disorder: epidemiology, diagnosis and treatment Clin Pract Epidemiol Ment Health 2009; 5: 15.
[24] Luminet O, Grynberg D, Ruzette N, Mikolajczak M. Personality-dependent effects of oxytocin: greater social benefits for high alexithymia scorers Biol Psychol 2011; 87(3): 401-6.

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