Comment on Alzahrani et al. “Prevalence of alexithymia and associated factors among medical students at King Abdulaziz University: a cross-sectional study”

To The Editor: Alzahrani et al¹ reported an interesting study on alex-ithymia among medical students, where almost half the students had alexithymia and its manifestations. We would like to contest some of the interpretations and conclusions the authors have drawn from their results. Firstly, being a cross sectional study it is difficult to determine a cause and effect relationship. A prospective study would have given an idea if the medical students had low alexithymia scores before joining medical school and later developed alexithymia, and further whether alexithymia reduces after medical training or persists. Secondly, the authors surmise that smoking is a risk factor for alexithymia. Again, the cause and effect is difficult to speculate. A recent report suggests that the affect regulation deficits in alexithymia may play a protective role in the onset or the maintenance of smoking behavior.² Secondary or acquired alexithymia³ may arise out of severe medical diseases, psychosocial stresses and childhood abuse, which was noted in 29% of the medical students. Thirdly, this study reported an association of history of psychiatric illness and childhood abuse. It would have been useful if the authors had studied levels of anxiety, depression or stress related disorders among those with or without alexithymia. Fourthly, the relationships between alexithymia, resilience, and empathy, are worth discussing in the context of medical students. It is shown that empathy and alexithymia are associated with resilience.⁴ Resilience is negatively influenced by alexithymia and positively affected by empathy, which is negatively influenced by alexithymia. A decline of medical students' empathy and resilience occurs as students progress in their training.⁴ Thus training programs for resilience enhancement, and empathy could be useful for medical students. Also, helping students in the understanding of their own emotions and difficulties in expressing feelings could prevent stress and burnout. Alexithymia may be a defence mechanism and may prevent depression, self harm, suicidal behaviours and alcoholism.^3,5 One would wonder if alexithymia is an asset or a liability.

Previous studies report a prevalence of 15-20% of alexithymia. Compared to that, a 49% prevalence may indicate a cultural difference in the manifestations of alexithymia. It is important to use cut-off scores which have local validity rather than using established cut-offs derived in another culture. A control group of nonmedical students of similar age and gender distribution would have thrown some light on this aspect. Thus, this informative study could add value by addressing some of the issues raised here.

Reply

Thank you indeed for appraising our study and we greatly appreciate your valuable feedback. We agree to this point as cross-sectional studies cannot establish causality. Our study was suitable for reporting the burden (prevalence) of the condition, assess associations, and to generate hypotheses. Validated cut-off scores considering the culture context are required. Further, prospective studies including a meta-analysis are needed, and we think our study could be a trigger for more in-depth research in this area.