Alexithymia and Cognitive Schemas

The article deals with the issue of emotional difficulties resulting from unfavorable events in early childhood. The aim of the study was to investigate the relationship between the severity of alexithymia and the severity of maladaptive cognitive schemas. The study involved 79 people aged 20–45 years. The Polish adaptation of the Bermond–Vorst Alexithymia Questionnaire (ALEX-40) and an abridged version of the Young Schema Questionnaire (YSQ-3-PL) was used during the study. It was found that there are significant correlations between the symptoms characteristic of alexithymia and the intensity of some cognitive schemas. The dimension of verbalization of emotional sensations is significantly related to the person’s manifestation of intensified schemas: emotional inhibition, following merciless norms, social isolation, emotional deprivation and a tendency to inflict penalties on themselves. Correlations with the dimension of the degree of imagination formation and cognitive schemas are low and concern schemas of subordination, privilege/domination, insufficient self-control/discipline and pessimism.


INTRODUCTION
The number of people experiencing various types of mental problems is constantly growing, and medical and psychotherapeutic practice meets not only people experiencing emotional crises or mental problems but also more and more often people complaining about ailments, such as chronic fatigue or pain, without any medical justification (Shibata, Ninomiya, Jensen, Anno, Yonemoto, Makino, Iwaki, Yamashiro, Yoshida, Imada, Kubo, Kiyohara, Sudo, Hosoi, 2014;10.17951/j.2020.33.3.191-203 Wiśniewska, Mącik, 2016). The sources of these problems seem to be diverse, but more and more research presents the relationship between chronic pain, fatigue or depression and alexithymia syndrome or cognitive schemas. This presented research addresses the relationship between the formation of non-adaptive cognitive schemas and the symptoms of alexithymia, and the role that individual schemas can play in the formation and maintenance of alexithymia.

ALEXITHYMIA
Alexithymia is a complex personality structure that includes specific emotional and cognitive deficits. This term, taken from Greek (a -"lack of", lexis -"word", thymos -"emotion"), initially was described by psychoanalytic clinicians as "emotional illiteracy" (Laforge, Leary, Naboisek, Coffey, Freedman, 1954). Currently, there are many reflections and analyses trying to define alexithymia and explore its etiology and effects on the life of an individual. Therefore, it is treated as a multidimensional concept and the dominant symptoms are associated with difficulties "in identifying and differentiating emotions and somatic symptoms accompanying emotional arousal, as well as in verbalizing and describing emotions, operation, task-based style of thinking, and impoverishment of imaginary life" (Płońska, Czernikiewicz, 2006). However, some research has shown that people with an elevated level of alexithymia do not differ in their vocabulary in terms of emotions from those with its normal level (Irvin, Melbin-Helberg, 1997). Probably then not the scope of the dictionary is a feature of alexithymia. The inability to describe one's own feelings, according to the authors of the research, may be a result of dissociation between the sphere of emotions and verbal processes.
Etiological theories of alexithymia can be divided into three groups. The first one goes back to the psychodynamic roots, according to which the sources of alexithymia formation can be seen in the preverbal period. The child's affect, which is infantile, undifferentiated and associated with somatization, should transform over time into more precise, verbalizable and desomatized emotions (Krystal, 1988). Injury during this period can block the process of cognitive analysis of the affect, which makes the emotions incomprehensible, undifferentiated and somatized for the person, which may be manifested by alexithymia. Modern cognitive theories treat alexithymia as a deficit in the perception and use of emotional knowledge (Frawley, Smith, 2001). Due to cognitive deficits, an individual does not have full access to the mental representation of emotions and its behavioral and physiological indicators. However, according to the neurobiological model, the essence of alexithymia is a disturbance in the process of automatic processing of emotional arousal, formed at the level of the central nervous system. As the flow of impulses between the right and left hemisphere, as well as the limbic system and cerebral cortex, play a fundamental role in emotional regulation proc-esses, the structure of the nervous pathways connecting these areas determines the intensity of emotional states, accompanying physiological reactions, cognitive acts, including the awareness of the emotional state experienced. Alexithymia is assumed to be caused by a deficit of connections between the two hemispheres of the brain, as well as the limbic system and the cortex, particularly in the speech center area (Taylor, 2000;Taylor, Bagby, 2004) Alexithymia occurs in 13% of the population and is a feature with a normal distribution in both men and women (Płońska, Czernikiewicz, 2006). In everyday life, people with alexithymia face many difficulties because the ability to perceive and analyze their and others' emotions is crucial both for maintaining mental wellbeing and for effective social functioning (Schwartz, Pell, 2012). The difficulties in this aspect are often related to reduced quality of life (Joukamaa, Saarijarvi, Muuriaisniemi, Salokangas, 1996) and relationship well-being (Carton, Kessler, Pape, 1999). People with high levels of alexithymia are more likely to suffer from depression (Taylor, Bagby, 2004;Honkalampi, Saarin, Hintikka, Virtanen, Viinamaki, 1999) and longitudinal studies show that changes in the severity of alexithymia cause changes in the severity of depressive symptoms (Honkalampi, Hintikka, Laukkanen, Lehtonen, Viinamaki, 2001). Deficits in the processing of emotions, leading to difficulties in reducing negative affect, are also considered to be an important factor in the creation and persistence of chronic pain (Lumley, Radcliff, Macklem, Mosley-Williams, Leisen, 2005;Mehling, Krause, 2005;Shibata et al., 2014), anorexia, bulimia (Taylor, Parker, Bagby, Bourkes, 1996), addiction or PTSD (Taylor, 2000;Taylor, Bagby, Parker, 1997) as well as social difficulties, especially with regard to functioning in relationships based on closeness and intimate communication such as marriage (Eid, Boucher, 2012).

EARLY MALADAPTIVE SCHEMAS
Early maladaptive schemas (EMSs) are defined as broad, unconscious beliefs about oneself and relationships with other people, created during childhood and developed during life, which are largely dysfunctional (Young, Klosko, Weischaar, 2003). This concept assumes that the schemas have a role superior to that of the individual, and probably also to his or her emotional reactions (Beck, Freeman, Davis, 2005) and the prevailing non-adaptive schemas in individuals are responsible for the emotional difficulties experienced by the person and non-adaptive behaviors that can cause the persistence of mental difficulties and disorders (Bamelis, Evers, Spinhoven, Arntz, 2014;Calvete, Orue, Hankin, 2013) The authors of the concept described 18 cognitive schemas dividing them into 5 main categories (Young et al., 2003): 1. Lack of bond and rejection -convictions created by the frustration of the need for safe bond and acceptance. The individual expects that his or her needs for security, stability and sensitivity and empathy will not be met and therefore expects to be rejected in close relationships. 2. Limited autonomy and lack of achievements -arises from the frustration of the need for autonomy, competence, identity. It is a person's conviction that without others he or she cannot exist and cannot cope on his or her own. 3. Broken boundaries -the frustration of the need for realistic constraints and self-control. A person manifests a deficit of internal borders, the inability to take responsibility for oneself, to achieve one's life goals, as well as difficulties in working with others and being responsible for common goals. 4. Focusing on others -it is a result of frustration of the need for any expression of needs and emotions. It manifests itself in an excessive focus on the needs and feelings of others while disregarding one's own. This behavior is dictated by the search for acceptance and love and involves suppressing one's own anger. 5. Excessive vigilance -an effect of the frustration of the need for spontaneity and fun. It manifests itself in the emphasis on suppressing spontaneous impulses and feelings, and following rigid, internalized rules. This is done at the cost of relaxation, sense of happiness, free expression, close relations and health (Sieński, Ziarko, Łuczak, 2018). The emergence of the EMS, such as alexithymia, is related to the experience of permanently failing to satisfy one or more core needs during childhood (Young, 1999). Experiences from this period leave permanent schemas of functioning and self-confidence, and the emergence of key maladaptive cognitive schemas for the individual becomes the cause of mental problems, feelings of helplessness and emotional dependence (Flangan, 2010;Young et al., 2003). Among the core needs described by Young, we can include: (1) Secure attachment to others, sense of security, stability, acceptance; (2) Autonomy, sense of competence, sense of identity; (3) Possibility to express one's own needs and emotions; (4) Possibility of spontaneous behavior and free play; (5) Realistic limitations and self-control (Young et al., 2003). The frustration of the child's basic needs causes impairment in the development of functions related to emotional regulation and those related to establishing interpersonal relationships (Shipman, Edwards, Brown, Swinsher, Jennings, 2005;Shipman, Zeman, Penza, Champion, 2000). Both cross-sectional and longitudinal studies have confirmed the existence of significant links between EMS and a child's experience of trauma related to the family situation (Blissett, Walsh, Harris, Jones, Leung, Meyer, 2006;Cecero, Nelson, Gillie, 2004;Simard, Moss, Pascuzzo, 2011), alexithymia (Saariaho, Saariaho, Mattila, Karukivi, Joukamaa, 2015), as well as the relationship between the EMS and pathological personality traits -the higher the severity of pathological personality traits, the higher the severity of maladaptive schemas (Bach, Lee, Mortensen, Simonsen, 2016;Bach, Simonsen, Christoffersen, Kriston, 2017;Mącik, 2016). Both the formation of alexithymia and EMS are associated with experiencing traumatic events in early childhood, and their consequence is the occurrence of emotional and interpersonal problems in adult life (Thimm, 2013;Vanheule, Desmet, Meganck, Bogaerts, 2007). Alexithymia, described as emotional blindness and EMSs, representing dysfunctional cognitions and emotional states, describe slightly different dimensions of functioning. The purpose of this study is to identify and describe the relationships that exist between maladaptive cognitive schemas and alexithymia, as well as to identify typical non-adaptive schemas in individuals with high level of alexithymia, so the research question is: are there the correlations between the severity of the maladaptive cognitive schemas and the severity of alexithymia? What is this relationship? Which of the maladaptive schemas predict alexithymia?
On the basis of the research, it is possible to formulate a hypothesis confirming the relationship between EMS and alexithymia (Saariaho et al., 2015). However, there is no research that would allow for directional hypotheses, so this study aims to verify the hypothesis and to explore the area of the relationship between EMS and alexithymia, while having a chance to become a starting point for further studies.

Participants
The study participants were 79 people aged 20-45. The research was anonymous and was conducted in January and May 2020.

Measures and procedure
The Polish adaptation of the Bermond-Vorst questionnaire, made by Tomasz Maruszewski and Elżbieta Zdankiewicz-Ścigała (1998), was used to examine the alexithymia. The tool consists of 40 statements grouped into 5 scales: verbalization of emotional experience, degree of use of imagination, insight into one's own emotional experience, emotional excitability and operational style of thinking. The task of the respondent is to determine to what extent he or she agrees with the given statements on a 5-point scale (1 -It fully characterizes me, 5 -It completely does not characterize me). The examined person may obtain results indicating a low level of alexithymia (40-70 points), manifestations, or lack of alexithymia (70-110 points), or a high level of alexithymia (110-200 points). Cronbach's alpha in the studied group was 0.86.
For the measurement of the cognitive schemas variable, the abbreviated version of YSQ in Justyna Oettingen, Jan Chodkiewicz, Dorota Mącik, and Ewa Gruszczyńska's adaptation (2017) was used. This tool is currently used most frequently in research on the measurement of maladaptive cognitive schemas. It operates in two versions: full and abridged. Originally it contained 206 questions, but by means of the principal component analysis (PCA) an abridged version was developed, containing 5 items with the highest loads for each of the 18 scales. The questionnaire consists of 90 statements and allows to determine the layout of the person-specific schemes based on the self-description. It has been shown that the abridged version has similar psychometric properties as the full version (Stopa, Thorne, Waters, Preston, 2001). The respondent answers to the questionnaire item on a scale from 1 to 6, where 1 means completely untrue and 6 -perfectly describes me. The statements concern the beliefs that the person under investigation has about himself/herself, the world, and relationships with others. The results obtained by the respondent for each schema are between 5 and 30, and for the whole scale between 90 and 540. The higher the person's score, the greater the strength of the dysfunctional beliefs tested by a particular scale. In this research, the reliability measured by the Cronbach's alpha factor was 0.89.

RESULTS
In the first step, the normal distribution of results was checked. The results of the Shapiro-Wilk test showed that the distribution of variables is compatible with normal distribution. In order to check the occurrence of relationships between non-adaptive schemes and alexithymia, r-Pearson correlation analysis was used. The list of analyses is presented in Table 1. It is worth noting that as many as 8 schemes show statistically significant correlations with the dimensions of alexithymia, and these correlations range from low (e.g. between self-punitiveness and verbalization of emotional experience) to medium (between emotional inhibition and verbalization of emotional experience).
The relationships between aspects of alexithymia and the individual domains of cognitive schemas, as shown in Table 2, have also been calculated. Significant correlations exist between the four domains and the individual dimensions of alexithymia. Next, a regression analysis was performed to indicate which domains of cognitive schemas are associated with alexithymia. The results are presented in Table 3. The results show no statistically significant correlation between five domains of cognitive schemas and alexithymia overall score. In the next step, a regression analysis for domains of maladaptive schemas and dimensions of alexithymia separately was performed. Table 4 presents only statistically significant results. The above analysis allows to partially accept the hypothesis of the present study, concerning the relationship between the intensity of maladaptive cognitive schemas and alexithymia. Results indicate that domains of maladaptive schemas do not predict alexithymia overall. However, regression analysis for dimensions of alexithymia separately shows that domains of maladaptive schemas predict two out of five dimensions of alexithymia. Due to main domains of maladaptive schemas, the variance of verbalization of emotional experience is explained in 18%, whereas the degree of formation of the imagination is explained in 16%.

DISCUSSION
The research indicates that there are interesting relationships between the intensity of cognitive schemas and alexithymia. The first of the non-adaptive schemas that seem to be particularly related to alexithymia concerns the setting of merciless standards by an individual (Unrelenting Standards / Hypercriticalness). This result is interesting in light of Marta Wiśniewska and Dorota Mącik's (2016) study on perfectionism and cognitive schemas in women experiencing chronic fatigue. According to them, the correlation coefficient between the schema of Unrelenting Standards / Hypercriticalness and perfectionism is the highest of all Young's schemas. It is also worth noting that studies on people experiencing chronic fatigue indicate an elevated degree of alexithymia in these people (Wise, Sheridan, 2007). High demands on oneself, visible as setting very high standards and low ability to give up seem to be connected not only with perfectionism but also with alexithymia. This study has revealed that the highest relationship exists between the schema of Unrelenting Standards / Hypercriticalness and the verbalization dimension of emotional experience. At the same time, it is worth noting that regression results show that verbalization of emotion is one of the dimensions predicted by domains of maladaptive schemas. This dimension is also significantly related to the person's manifestation of the intensity of the schemas: Emotional Inhibition, Social Isolation and Emotional Deprivation. This gives an image of a person who feels a lack of love and tenderness on the part of others (Emotional Deprivation), has great difficulty in showing others his or her feelings and his or her own spontaneity (Emotional Inhibition) and sets extremely high standards for himself or herself (Unrelenting Standards / Hypercriticalness).
The schemas of Abandonment / Instability and Social Isolation are particularly related to two dimensions of alexithymia: emotional excitability and an operational style of thinking. The high outcome of the dimension of emotional excitability in the context of alexithymia means that a person's emotional excitability is low and does not react with feelings in emotional situations. People with alexithymia, who are characterized by lower emotional excitability, are sometimes judged to be cool by nature. The Abandonment /Instability schema, on the other hand, is a constant anxiety of an individual that the people he or she cares about will abandon him or her and it correlates negatively with the two dimensions mentioned above. The perception of reality distorted by the Abandonment / Instability schema is therefore associated with increased emotional excitability. It is also worth mentioning the relationship between the domain of excessive vigilance and verbalization of emotional sensations and insight into one's own emotional experience. This domain, according to Jeffrey Young, Janet S. Klosko, and Marjorie E. Weishaar (2003), is associated with the frustration of the need for spontaneity; a person from childhood suppresses spontaneous reactions and feelings according to his or her own schema.
Over-vigilance and Inhibition is associated with insight into one's own emotions and their verbalization and can be a source of problems for an individual who enters into relationships with other people both in the workplace and in personal life (Thimm, 2013;Vanheule, Desmet, Meganck, Bogaerts, 2007).
In conclusion, some non-adaptive schemas seem to play a special role in the context of the presence of symptoms of alexithymia. Schemas, whose correlations seem to indicate the existence of a link that requires further study, are primarily the setting of Unrelenting Standards / Hypercriticalness, Social Isolation and a domain representing Over-vigilance and Inhibition. The conclusions of the above research enrich the knowledge available at this point in time on alexithymia and cognitive schemas and seem to encourage further exploration of the subject, which will make it possible to confirm the results obtained and to draw more farreaching conclusions. An extremely interesting question that can be posed in this context is the possibility of influencing the symptoms of alexithymia by working on the maladaptive schemas presented above. This can positively influence therapeutic work with such people and increase the chance of success.
It is also worth taking into account the limitations of the above research. Certainly, the formation of alexithymia is associated with the participation of many factors that are worth considering in subsequent studies. The experience of early childhood trauma or co-occurrence of other disorders could be taken into account and would allow us to look at the presented variables from many angles. A larger sample will be the starting point for the possibility of generalizing results and developing further studies.