Alexithymia and its association with burnout, depression and family support among Greek nursing staff

Background Few studies have examined the relation between alexithymia (i.e. the inability to recognize and verbalize emotions) and professional burnout. Considering the absence of relevant studies in the Greek scientific literature, the aim of this work was to examine the associations of alexithymia with the three facets of professional burnout, the perception of family support and depression in nursing personnel. Methods The study was performed in one of the largest hospitals in Greece and included 95 nurses. Assessments of alexithymia, burnout, depression and family support were made by means of the Toronto Alexithymia Scale, the Maslach Burnout Inventory, the Beck Depression Inventory and the Julkunen Family Support Scale, respectively. Student's t-test, Pearson's correlation and stepwise linear regression were used for the evaluation of data. Results Alexithymia was correlated positively with depression, emotional exhaustion and depersonalization, and negatively with sense of family support and personal achievement. Additionally, family support was correlated positively with personal achievement and negatively with depression. Conclusion In the scientific literature there is a debate as to whether alexithymia is a stable personality characteristic or if it is dependent on symptoms of mental disorders. We tried to interpret the associations of alexithymia with professional burnout, depressive symptoms and family support. From this study it appears very likely that alexithymia is directly associated with depression and personal achievement, but also - indirectly - with the sense of family support.


Background
Sifneos introduced the notion of alexithymia as the inability to recognize and verbalize emotions [1,2]. Newer studies on alexithymia defined it as weakness in the determination and expression of emotions; moreover, alexithymia encompasses externally directed thought and limited imaginative faculty [3].
Alexithymia appears to be positively associated with depression in the general population [4] and has been shown to be associated with several diseases [5]; in characteristically alexithymic subjects the favourable effect of family and social support on depressive symptomatology is diminished [6,7]. Alexithymia is conceptualized as a stable personality trait; some studies have associated it with psychopathological disorders (such as depression or anxiety) or with somatic diseases [8].
The notion of professional burnout was introduced by Freudenberger, who described overstrain symptoms that he observed in professionals and volunteers in the mental health sector [9]. The most widely accepted definition of burnout was formulated by Maslach, who described it as a mental syndrome (along with bodily exhaustion) that develops in people who have a professional relationship with other persons [10]: the worker loses the interest and positive sentiments that he/she had for patients or customers and develops a negative self-image.
Depression, which is common in mental health workers compared with the general population [11] in a number of reports, is correlated positively with professional burnout [12,13].
Family support refers to the sense of support that an individual perceives he or she receives from his or her familial environment; it constitutes an important element of social support, particularly in the Greek population, with its close-knit families [14]. The positive effect of family support becomes particularly obvious in patients with chronic diseases, as in the case of diabetes [14,15]. Research stresses the negative cross-correlation that is observed between family support and depression [6], while a recent study reports the existence of negative crosscorrelation between family support and professional burnout [16].
Few studies have examined the relationship between alexithymia and professional burnout [17,18]. The findings suggest that alexithymia is significantly associated with burnout even when controlled for confounding factors [18].
Considering the absence of relevant studies in the Greek scientific literature, the aim of this work was to examine the associations of alexithymia with professional burnout, the perception of family support and depression in nursing personnel.

Methods
The study was performed in one of the largest hospitals in Greece. Eighteen men and 82 women of the hospital's nursing staff of 670 were selected randomly; 17 men and 78 women agreed to participate. Mean age ± SD was 36.7 ± 6.5 years, with mean work experience 12.9 ± 6.7 years ( Table 1). The nurses were asked to give answers to questionnaires for professional burnout, depression, alexithymia and sense of family support; all the subjects did so within 20 minutes at most.
Alexithymia was assessed with the 20-item self-answered Toronto Alexithymia Scale (TAS-20) [19][20][21]. Each item is To measure professional burnout we used Maslach's 22item Burnout Inventory (MBI), which assesses emotional exhaustion (for evaluation of the frequency of emotional stress due to work), depersonalization (that reflects reactions of indifference and impersonal handling of patients) and the lack of personal achievement (that measures the sense of sufficiency, efficiency and achievements in the professional sector). Each item was answered on a scale from 0 (never) to 6 (every day). The questionnaire was translated into modern Greek and validated with Greek nurses; emotional exhaustion is associated with values higher than 30, depersonalization is associated with levels higher than 11 and lack of personal achievement with values higher than 35, in the relevant subscales [22].
For depression, Beck's Depression Inventory (BDI) was used. It assesses depression through answers in 21 items (rated on a scale from 0 to 3) [23,24]. Its internal validity is high and its test-retest reliability is 0.480.86 for clinical and 0.600.90 for non-clinical subjects, respectively. External validity vis-à-vis a clinical diagnosis of depression is considered to be satisfactory; scores ≥ 14 indicate moderate to severe depression.
To measure perception of family support we used, as in previous studies, Julkunen's 13-item questionnaire [6,15,25,26]. All 13 items of the scale (e.g. item 1: "My family supports me in all my efforts" and item 5: "I am always the one to blame when our home is a mess") are rated on a five-point scale; scores > 37 indicate an increased sense of family support. The questionnaire's adaptation in modern Greek presented good reliability (alpha = 0.80). Individuals living by themselves (16 of the total sample) did not answer the questionnaire.
Student's t-test, Pearson's correlation and stepwise linear regression were used for the evaluation of data. Two-tailed statistical significance was set at p ≤ 0.05. The computations were carried out with SPSS for Windows, version 15.0, statistical software.
The study was briefly explained to the participants. The confidentiality of the participants' answers was guaranteed. No financial support was necessary. Women had lower scores than men in the personal achievement subscale of MBI (t-test p < 0.05), as well as in their perception of family support (Table 2).
Alexithymia was correlated positively with depression, emotional exhaustion and depersonalization and negatively with sense of family support and personal achievement (Table 3). Family support was correlated positively with personal achievement and negatively with depression (Table 3). Controlling for alexithymia, these correlations did not reach statistical significance (Table 4).
Stepwise linear regression showed that 28.9% and 12.2% of depression values were attributed to alexithymia and emotional exhaustion, respectively. Alexithymia accounted for 24.7% of family support values. Emotional exhaustion was accounted-for mostly by depersonalization (27%) and depression (11.5%). Emotional exhaustion was attributed to 27% of depersonalization; the latter was attributed at 6.2% to personal achievement. Personal achievement was attributed to alexithymia (23.6%) and to depersonalization (4.3%).

Discussion
There is an ongoing scientific debate regarding the stable or dependent characteristics of alexithymic symptoms, particularly vis-à-vis the relationship between alexithymia and depression [8,18]. Our results lend credence to the  relationship between alexithymia and depression, without looking into the above-mentioned debate, which is beyond this study's scope.
Additionally, our findings are in accordance to a previous study [18], which concluded that both alexithymia and depression are associated with burnout, even though they suggest that alexithymia may be an independent risk factor for burnout. Furthermore, it seems that subjects with depressive characteristics show increased vulnerability to burnout because of their innate lack of ability to derive satisfaction from their work [13].
That family support correlates positively with personal achievement is in accordance with previous studies [13].
In these studies, it appeared that increased engagement in family support acts protectively against the development of burnout. On the other hand, it seems possible that individuals with alexithymic characteristics might be unable to benefit from their family support.
This study has limitations; in particular, the workplace conditions per se were not quantified or included in the study's parameters. The inclusion of such parameters is warranted in further studies.

Conclusion
We tried to interpret the associations of alexithymia with professional burnout, depressive symptoms and family support. Alexithymia was directly associated with depression and personal achievement, but also indirectly with the sense of family support.
Although we did not evaluate the effect of specific interventions (such as support groups or family therapy techniques) in individuals with overtly alexithymic characteristics, we believe that alexithymia should be taken into account in interventions targeting depression and/or burnout.