during the recent decade , a number of researchers have described the growing psychosocial risk factors for coronary heart disease ( chd ) , which include depression , anxiety , stress , and alexithymia that decrease the health - related quality of life and protective factors such as social support .
studies carried out internationally highlight that besides negative psychological factors like depression , anxiety , and stress , positive factors such as social support play a protective role in the onset and progress of chd . in 1973 , sifnoes proposed the term 
alexithymia to imply a cognitive  affective disturbance , characteristic of persons who can not describe their feelings or elaborate their fantasies .
it has been characterized more generally as an emptiness of feeling , a poverty of imagination or a life of fantasy , difficulty in communicating with others , and a lack of positive emotions with a high prevalence of negative emotions .
alexithymia is associated with states of negative affect . which increase the possibility of somatic complaints .
the assumption is that these characteristics would lead to a deficiency in cognitive processing and regulation and adjustment of emotions , and are associated with starting and/or continuing some of the psychiatric and medical disorders .
some researchers believe that dysfunction in the limbic system , brain abnormal lateralization , and/or difficulty in the efficiency of hemispheric communication are the causes of its emergence . the prevalence of alexithymia in working age populations has been shown to be about 9 - 17% for men and 5 - 10% for women . at the population level , alexithymia is associated with older age , lower socioeconomic status , fewer years of education , single marital status , and poorer perceived health .
alexithymia has been shown to be associated with several medical conditions and mental health problems .
an association between alexithymia and dissatisfaction with life has been found in some studies of coronary heart disease patients .
one study investigated factors associated with alexithymia in patients ( n = 153 ) with coronary heart disease verified by coronary angiography . in chd patients , alexithymia was unrelated to cardiovascular diseases , but was related to depression and decreased life satisfaction . in the kuopio
ischemic heart disease risk - factor study , 2682 middle - aged men were studied using the 26-item toronto alexithymia scale ( tas ) .
alexithymia was associated with greater self - reporting of symptoms during exercise - tolerance testing and it was found that the extent of carotid atherosclerosis was inversely related to the degree of alexithymia , suggesting a biological connection to atherosclerosis . in this study ,
men in the highest alexithymia quintile were at a two - fold greater risk of death from any cause , while no association was found between behavioral or physiological risk factors and mortality .
lumley et al . , observed that the degree of alexithymia ( tas-20 ) was associated with the presence or absence of chest pain during exercise testing , but not with chd ( n = 180 ) .
they concluded that alexithymia was associated with an increased risk of illness - related behavior , but not necessarily with the presence or severity of chd .
one study to testing the validity of existing conceptualizations of the alexithymia concept in the general adult population described that older adults engaged in less introspective thoughts , traditionally thought to denote increased alexithymia .
difficulty in identifying and describing emotions did not differentiate older and younger adults , but they were both associated with heightened depression , anxiety , and poor perceived quality of life .
alexithymia in somatoform and depressive disorders ( 2003 ) was investigated in one study ( two groups of 30 subjects each , bearing diagnoses of somatoform disorder and depressive disorder , respectively , and one group of 30 normal controls ) and the results showed that the mean of alexithymia scores in the somatoform ( 60.4 ) and depressive disorder groups ( 62.5 ) were higher than in normal subjects ( 54.2 ) . even as the total alexithymia scores did not differentiate somatoform from depressive disorders , the depressed subjects had greater difficulty in expressing their feelings .
kauhanen et al . , noted more physical symptom - reporting with high alexithymia , and myers observed alexithymia - elevated anxiety scores .
linden et al . , noted that high alexithymia showed smaller heart rate responses to the stress task and more anger in behavior .
2009 ) investigated the relationship between alexithymia and the health - related quality of life ( hrqol ) in a nationally representative population sample of 5,418 subjects , of age 30 to 97 years , and concluded that alexithymia could be a predisposing factor to a poorer hrqol .
a study investigated the relationship between alexithymia and the health - related quality of life ( hrqol ) and concluded that the alexithymic group had significantly ( p < 0.001 ) lower mean scores on every dimension of hrqol , even after controlling for confounding demographic variables , somatic diagnoses , and depressive and anxiety disorders .
this research was a cross - sectional study that examined the causal relationship between alexithymia and dass ( depression , anxiety , stress ) , quality of life , and social support .
the sample consisted of 398 chd patients ( 166 females and 232 males and age : 40 - 70 years ) , who were randomly selected from the isfahan chamran heart center and isfahan cardiovascular research center ( icrc ) ( 2013 ) and the other heart clinical center .
the patients filled in five questionnaires assessing depression , anxiety , stress ( dass-21 ) , alexithymia ( tas-20 ) , health - related to quality of life ( whoqol-26 ) , multiple scale of perceived social support ( mspss-12 ) , and another questionnaire , which obtained demographic information . before attending the study , each patient had been examined by a cardiologist , who had confirmed the diagnosis as coronary heart disease .
alexithymia - tas-20 scale : the tas is a 20-item instrument that is one of the most commonly used measures for alexithymia . the tas-20 has three subscales : 1.1 .
- difficulty describing feelings subscale ( ddf ) is used to measure the difficulty in describing emotions .
, which has five items : 2 , 4 , 7 , 12 , 17 . 1.2 .
- difficulty identifying feelings subscale ( dif ) is used to measure the difficulty in identifying emotions .
, which has seven items : 1 , 3 , 6 , 11 , 9 , 13 , 14
- externally - oriented thinking subscale ( eot ) is used to measure the tendency of individuals to focus their attention externally , which has eight items : 5 , 8 , 10 , 15 , 16 , 18 , 19 , 20 .
the items are rated using a five - point likert scale whereby 1 = strongly disagree and 5 = strongly agree .
the total alexithymia score is the sum of responses to all the 20 items , while the score for each subscale factor is the sum of the responses to that subscale .
the tas-20 uses cutoff scoring : equal to or less than 51 = non - alexithymia , equal to or greater than 61 = alexithymia .
it demonstrates good internal consistency in the normal iranian sample ( cronbach 's alpha = 0.81 ) and test  retest reliability ( 0.77 , p < 0.01 ) .
the internal consistency reported in a clinical sample from iran , using cronbach 's alpha for the total tas-20 scale and subscales of dif , ddf , and eot , were .
66 , respectively , and the total validity using test  retesting for tas-20 and its subscales dif , ddf , and eot were .
2-dass scale-21 : the dass scale is a set of three self - report scales designed to measure the negative emotional states of depression , anxiety , and stress .
each of the three dass scales contains seven items , divided into subscales of two to five items with a similar content .
the depression scale assesses dysphoria , hopelessness , devaluation of life , self - deprecation , lack of interest / involvement , anhedonia , and inertia .
the anxiety scale assesses autonomic arousal , skeletal muscle effects , situational anxiety , and subjective experience of anxious affect . 2.3 .
it assesses difficulty in relaxing , nervous arousal , and being easily upset / agitated , irritable / over - reactive and impatient .
subjects are asked to use the four - point severity / frequency scales to rate the extent to which they have experienced each state over the past week .
scores for depression , anxiety , and stress are calculated by summing the scores for the relevant items .
the assumption on which the dass development has been based ( and which has been confirmed by the research data ) is that the differences between depression , anxiety , and stress experienced by normal subjects and the clinically disturbed , are essentially differences of degrees .
the validity and reliability of this scale was reviewed by samani and joker ( 2007 ) , who reported that reliabilities for depression , anxiety , and stress scale were .
3 . multiple scale perceived social support : the 12-question multidimensional scale of perceived social support ( mspss ) was used to measure the degree of social support each participant felt he or she had .
high levels of perceived social support are generally associated with low levels of depression and anxiety .
family ; 2 . friends ; 3 . significant others ) based on the seven - point likert measures , which measures the respondents perceptions of the availability of various types of social support such as family , friends , and significant others
the remaining 24 items comprise four dimensions of health including , physical , psychological , social , and environmental .
all scores are transformed to reflect 4 - 20 for each domain , with the higher scores corresponding to a better qol .
the individual 's perception of quality of life is measured by summing the total scores for each particular domain .
all domain scores are scaled in a positive direction ( higher score indicates a higher qol ) .
this questionnaire was standardized on a sample of 2,956 healthy and 2,936 unhealthy rural and urban inhabitants ( age 30 years and above ) from isfahan , najaf - abad , and arak , who participated in the  isfahan healthy heart program ( ihhp ) from two dissimilar iranian provinces , during 2006 .
demographic questionnaire : this questionnaire consists of questions about age , sex , marital status , education , and so on .
table 1 shows the patients sociodemographic characteristics based on age , sex , marital status , and education .
patients sociodemographic characteristics ( n = 398 ) table 2 shows patients descriptive characteristics such as mean and standard deviation .
patients descriptive characteristics cronbach 's alpha was calculated as 0.74 for the toronto alexithymia scale ( tas ) , 0.89 for the depression , anxiety , and stress scale ( dass ) , 0.87 for the multidimensional scale of perceived social support ( mspss ) , and 0.90 for the world health organization quality of life questionnaire ( whoqol ) . based on the conceptual model
[ figure 1 ] of the study , the structural model of variables ( i.e. , tas , dass , mspss , and whoqol scores ) was presented using the outputs of amos .
although in traditional statistical methods , the researcher uses a single measure to verify the null hypothesis , the complexity of the structural equation modeling eliminates this single measure .
therefore , three main groups of indices ( absolute fit , comparative fit , and parsimonious fit indices ) are used to fit a model .
the conceptual model of alexithymia according to table 3 [ relative chi - square ( cmin / df ) = 2.580 and df = 58 for default model ] , the model fitted well . even as most experts consider relative chi - square values of 2 - 3 to show a good fitting model , schumacher and lomax expanded the range to 1 - 5 .
chi - square ( cmin ) values and number of parameters table 4 shows the absolute fit indices .
goodness of fit index ( gfi = 0.94 ) and adjusted goodness of fit index ( agfi = 0.91 ) suggested good fitting of the default model ( values between 0 and 1 for these two indices indicate good fitting ) .
table 5 shows the comparative fit index ( cfi ) , parsimony comparative fit index ( pcfi ) , and root mean square error of approximation ( rmsea ) . as is seen , the calculated values ( cfi = 0.96 and pcfi = 0.71 ) suggest a good fit for the default model ( cfi > 0.90 and pcfi > 0.50 are favorable ) .
rmsea can be calculated for confidence intervals , to determine the significance of the difference between the obtained value for the model and zero .
as rmsea < 0.08 is acceptable , our default model fitted well ( rmsea = 0.06 ) . in addition , the holter index of 204 was again indicative of a well - fitting model .
comparative and parsimonious fit indices according to all the mentioned indicators , the default model presented a good fit for the relationship between alexithymia and depression , anxiety , stress , quality of life , and social support .
based on the conceptual model [ figure 1 ] of the study , the structural model of variables ( i.e. , tas , dass , mspss , and whoqol scores ) was presented using the outputs of amos .
although in traditional statistical methods , the researcher uses a single measure to verify the null hypothesis , the complexity of the structural equation modeling eliminates this single measure .
therefore , three main groups of indices ( absolute fit , comparative fit , and parsimonious fit indices ) are used to fit a model .
the conceptual model of alexithymia according to table 3 [ relative chi - square ( cmin / df ) = 2.580 and df = 58 for default model ] , the model fitted well . even as most experts consider relative chi - square values of 2 - 3 to show a good fitting model , schumacher and lomax expanded the range to 1 - 5 .
chi - square ( cmin ) values and number of parameters table 4 shows the absolute fit indices .
goodness of fit index ( gfi = 0.94 ) and adjusted goodness of fit index ( agfi = 0.91 ) suggested good fitting of the default model ( values between 0 and 1 for these two indices indicate good fitting ) .
table 5 shows the comparative fit index ( cfi ) , parsimony comparative fit index ( pcfi ) , and root mean square error of approximation ( rmsea ) .
as is seen , the calculated values ( cfi = 0.96 and pcfi = 0.71 ) suggest a good fit for the default model ( cfi > 0.90 and pcfi > 0.50 are favorable ) .
rmsea can be calculated for confidence intervals , to determine the significance of the difference between the obtained value for the model and zero .
as rmsea < 0.08 is acceptable , our default model fitted well ( rmsea = 0.06 ) . in addition , the holter index of 204 was again indicative of a well - fitting model .
comparative and parsimonious fit indices according to all the mentioned indicators , the default model presented a good fit for the relationship between alexithymia and depression , anxiety , stress , quality of life , and social support .
alexithymia , a condition of inability to use words to understand the emotional states of oneself or others , prevents individuals from adjusting to their emotions .
the present study has examined the predictive value of alexithymia in changes in depression , anxiety , stress , social support , and quality of life among patients with coronary heart disease . after fitting all the data
, alexithymia shows significant positive relationships with depression , anxiety , and stress , as previous research has described . in other words ,
increasing levels of alexithymia and its two dimensions would worsen depression and anxiety in patients .
sarrijarri has shown that exacerbation of depressive symptoms will cause difficulty in identifying , describing , and sharing their feelings with others .
similarly , research has shown that alexithymia is more common in people with anxiety disorders and that anxiety is related to the two mentioned aspects of alexithymia .
alexithymia is a cognitive - emotional disorder that impairs the adjustment of emotions , concentration , processing , and evaluation of cognitive - emotional information .
therefore , individuals with alexithymia fail to manage their cognitive - emotional system and properly deal with stressful situations , particularly diseases .
this strengthens the feelings of inadequacy and insufficiency in this group and intensifies negative emotions such as anxiety and depression .
moreover , since emotional arousal is associated with physiological arousal , negative emotions ( e.g. anxiety and depression ) will bring about physical symptoms including pain , fatigue , and dizziness .
finally , disruption of psychological defenses in subjects with alexithymia leads them to deny their emotions and makes them incapable of describing them .
we also found difficulty in identifying feelings and difficulty in describing feelings to be related to depression and anxiety .
matn and jenakar suggested difficulty in identifying feelings as the only aspect of alexithymia that predicts depressive symptoms .
furthermore , they reported difficulty in both identifying and describing feelings as predictors of anxiety symptoms .
previous studies have indicated consistent results in terms of the relationship between alexithymia and stress and inadequacy of coping styles with stress .
this finding can be justified by considering the poor emotional intelligence of people with alexithymia , which combines with difficulties in identifying and describing feelings and reduces the ability of dealing with stressful situations . as the inability to cope with difficult situations imposes a lot of stress on the individual , a positive relationship exists between alexithymia and stress .
another finding of this study was the negative relationship between alexithymia and social support and its aspects , that is , increasing alexithymia decreases social support .
in fact , patients with alexithymia can not receive adequate social support from their family , friends , and/or significant others .
seemingly , impaired emotional intelligence in these individuals results in their poor interpersonal skills and inability to receive social support .
the results indicated that there is a negative relationship between alexithymia and quality of life .
the strongest relationships were identified between difficulty in identifying feelings and psychological aspect of the quality of life ( r = - 0.48 ; p < 0.01 ) , physical aspect of quality of life ( r = - 0.43 ; p < 0.01 ) , social aspect of quality of life ( r = - 0.34 ; p < 0.01 ) , and environmental aspect of quality of life ( r = -0.24 ; p < 0.01 ) .
available evidence about the association between the difficulty in identifying feelings and somatoform disorder can explain the negative effects of alexithymia on the quality of life .
it also seems that difficulty in identifying feelings results in a false interpretation of physical feelings and decreases the health - related quality of life . in other words , alexithymia is not only an inner state , but is also associated with health outcomes .
research has shown that people with alexithymia do not use normal coping styles , and may hence , have a higher tendency toward unhealthy behaviors such as suppression of emotions and drinking .
patients might experience problems in different aspects of life , that is , negative emotions may cause psychological problems , wrong interpretation of physical health may lead to physical problems , social relations may be affected by difficulty in establishing good social relations , and environmental quality of life can be decreased due to inappropriate interactions with the environment .
according to the results of the present study it is important to pay attention to alexithymia as an important variable associated with ( depression , anxiety , stress ) , social support , and quality of life of patients with coronary heart disease .
it can be concluded that alexithymia is connected with the pathological indicators of cardiac disease ( depression , anxiety , and stress ) and its protective parameters ( social support and quality of life ) .
most patients with heart disease are elderly and alexithymia is also more common among older people .
therefore , conducting a longitudinal study to determine the precise role of alexithymia in the psychiatric pathology of cardiac diseases is essential .
this research showed the relation between alexithymia and ( depression , anxiety , stress ) , social support , and quality of life , as a psychological structural model in chd .
most of the relationships were associated with alexithymia , depression , anxiety , and stress ( dass : 49% ) and the lowest relationship was between alexithymia and social support ( mspss : 09% ) . of particular interest in the findings
if alexithymia is considered to be a personality trait or state - dependent trait , alexithymic individuals are at risk for medical or psychiatric disorders and negative emotions .
increasing our knowledge regarding the role of a negative affect may have a major implication on how future interventions are targeted , for example , if evidence supports the lack of emotional awareness ( e.g. depression , anxiety , and stress ) as an underlying factor for a subset of patients seeking interdisciplinary treatment , then intervention can be modified to focus on processes related to increasing emotional awareness and identification , with a hope to improve the quality of life in patients with coronary heart diseases .
the limitations of the study were : inability to control the behaviors that were associated with alexithymia and could thus affect the relationship between alexithymia and depression , anxiety , stress , social support , and quality of life
. as the study population was limited , generalization of the results to other patients had to be made with caution .
the present study showed the structural relations between the psychological factors associated with alexithymia in coronary heart disease .
the results highlight the importance of alexithymia as a risk factor associated with neuroticism ( anxiety , depression , and stress ) and social support which reduces the quality of life among coronary heart disease patients . in this
regard , psychological interventions are recommended to reduce the consequences of this disorder , especially among coronary heart disease patients .
conducting longitudinal studies in this area may lead to more interesting and favorable results , which is recommended to the researchers interested in this field .
 background : although psychological factors are now recognized as playing a significant and independent role in the development of coronary heart disease ( chd ) and its complications , many of these factors are correlated with each other . 
 the present study is aimed at examining the association between alexithymia and anxiety depression , stress , quality of life , and social support in chd patients.materials and methods : in this research 398 patients with coronary heart disease ( 166 females and 232 males ) from the city of isfahan were selected using random sampling . the tools used included depression , anxiety , and stress scale ( dass-21 ) , health - related to quality of life ( hrqol-26 ) , multiple scale perceived social support ( mspss-12 ) , and the toronto alexithymia scale ( tas-20 ) . 
 the data were analyzed using structural equation modeling by using the statistical package for social science ( spss21 ) ( ibm corp : armonk , new york.u.s . ) and asset management operating system ( amos21 ) spss , an ibm company : chicago , u.s . 
 software.results:results of the structural equation model showed an acceptable goodness of fit , for the explanation alexithymia that was significantly associated with lower hrqol and social support and increasing anxiety , depression , and stress.conclusions:alexithymia may increase anxiety , depression , and stress and can be a predisposing factor to poorer hrqol and social support . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
Structural model to explain Alexithymia
DISCUSSION
CONCLUSIONS