The Twenty-item Toronto Alexithymia Scale--II. Convergent, discriminant, and concurrent validity

The development of the Toronto Structured Interview for Alexithymia: item selection, factor structure, reliability and concurrent validity

BACKGROUND

Assessments of personality constructs increasingly use self-report and structured interview instruments, which allow for a multimethod measurement approach and decrease specific measurement method bias. The aim of this study was to develop a valid and reliable structured interview for assessing the alexithymia construct.

METHODS

Sixty interview questions were written initially, each with a set of scoring criteria and prompts and probes to elicit information assisting in the scoring of the respondents' answers.

RESULTS

After pilot testing, the number of questions was reduced to 43, which were administered to 136 community participants and 97 psychiatric outpatients. A series of item and scale analyses further reduced the item pool to 24 items. Principal component analysis and confirmatory factor analysis of these 24 items revealed preliminary evidence of a hierarchical, four-factor structure, with four lower factors nested within two higher-order latent factors. This structural configuration resulted in the Toronto Structured Interview for Alexithymia (TSIA) with two domain scales and four facet scales. The TSIA and its six scales demonstrated acceptable levels of interrater, internal, and retest reliability. The TSIA and its scales correlated modestly but significantly with the 20-item Toronto Alexithymia Scale and its three factor scales, providing some support for the concurrent validity of this interview.

CONCLUSION

The TSIA appears to be a promising structured interview for assessing alexithymia.

Stability of alexithymia and its relationships with the 'big five' factors, temperament, character, and attachment style

BACKGROUND

Controversy still exists concerning the stability of the alexithymia construct. Also, although alexithymia has been found to be related in a theoretically meaningful way to other personality constructs such as the 'Big Five' factors, few studies have investigated its relationship with influential constructs such as temperament and character, and attachment security.

METHODS

Two hundred twenty-one undergraduate and graduate students were administered the Toronto Alexithymia Scale (TAS-20), the State-Trait Anxiety Inventory (STAI), the Zung Depression Scale (ZDS), the Temperament and Character Inventory (TCI-125), the Big Five Questionnaire (BFQ), and the Experiences in Close Relationships (ECR) questionnaire. After 1 month, 115 participants completed again the TAS-20, STAI, and ZDS.

RESULTS

Alexithymia was only moderately correlated with depression and anxiety. Both the absolute and relative stability of TAS-20 total and subscale scores was high, and a negligible portion of their change over time was accounted for by changes in depression or anxiety. In separate multiple regression models including also gender, age, depression and anxiety, TAS-20 total and subscale scores were correlated with low energy/extraversion, low emotional stability, openness, low friendliness/agreeableness; harm avoidance, low self-directedness, low cooperativeness, low reward dependence; attachment-related avoidance and anxiety.

CONCLUSIONS

Our findings lend support for both absolute and relative stability of alexithymia, corroborate an association between alexithymia and insecure attachment, and contribute to a coherent placing of alexithymia in the broader theoretical network of personality constructs.

Assessing alexithymia and related emotional ability constructs using multiple methods: interrelationships among measures

This study examined relationships among various measures of emotional ability reflecting different methods of assessment: self-report, clinical interview, collateral report, and emotion-relevant performance. On 140 young adults, the authors assessed self-reported alexithymia, emotional approach coping, and trait metamood skills; observer-reported alexithymia; interviewer-rated alexithymia; emotional awareness in response to vignettes; and emotional intelligence test performance. There were moderate magnitude correlations among the self-report measures, but correlations among other measures were relatively low. Confirmatory factor analyses supported a 3-factor model in which explicit self, implicit self, and explicit other measures were differentiated. These emotional ability measures do not form a unitary construct but differ as a function of the person providing the information and whether the measure is explicit or implicit.

The relationship between childhood sexual abuse, complex post-traumatic stress disorder and alexithymia in two outpatient samples: examination of women treated in community and institutional clinics

Relationships between trauma variables, complex post-traumatic stress disorder (complex PTSD), affect dysregulation, dissociation, somatization, and alexithymia were studied in 70 women with early-onset sexual abuse treated in community-based private (n = 25) or clinic outpatient settings (n = 45). Measures were the Toronto Alexithymia Scale-20 and the Psychological Trauma Assessment Program. Compared with the community sample, the clinic sample (1) met diagnostic criteria for both lifetime and current complex PTSD; (2) showed correlations between current affect dysregulation, dissociation, and somatization with alexithymia; and (3) higher levels of alexithymia. Results suggest the clinic sample continued to experience current forms of suffering, risk, and vulnerability associated with early-onset sexual trauma. The findings may have implications regarding types of treatment available in community versus clinic settings.

The relationship of suicide attempt history with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality in substance dependents

The aim of this study was to evaluate the prevalence of suicide in Turkish male substance dependents, and to investigate the relationship of suicide attempt history with childhood abuse and neglect, alexithymia, and temperament and character dimensions of personality. Participants were 154 consecutively admitted male substance dependents. Patients were investigated with the Childhood Abuse and Neglect Questionnaire, Toronto Alexithymia Scale (TAS-20) and Temperament and Character Inventory (TCI). Among substance-dependent patients, 28.6% was considered a group with suicide attempt history (SAH). Current age was lower and rate of being single was higher in the group with SAH. There were no significant differences between groups in terms of employment, educational status and duration of education. Rates of physical, emotional abuse and neglect, self-mutilation and being alexithymic were higher and ages at first substance use and regular substance use were lower in the group with SAH. Mean scores of "difficulty in identifying feelings" (DIF) and "difficulty in describing feelings" (DDF) subscale EOT of the TAS-20 were higher in the SAH group. Among temperament and character dimensions of the TCI, only "Self-directedness" and "Cooperativeness" were lower in SAH and there were no significant differences between groups in terms of other subscales. Age and Self-directedness score of TCI were determinants for suicide attempt. In particular, young drug users with low Self-directedness scores could be the target population in order to prevent suicidal behavior. This study also suggests that in substance-dependent patients, in the background of all suicidal behavior, childhood abuse and neglect must be evaluated.

Feelings you can't imagine: towards a cognitive neuroscience of alexithymia

Alexithymia, or 'no words for feelings', refers to an impairment of the ability to identify and communicate one's emotional state, in addition to diminished affect-related fantasy and imagery. A recent study by Mantani et al. reported reduced activation of the posterior cingulate cortex in people with alexithymia when they imagined a future happy event. This finding augments the emerging understanding of the neural basis of alexithymia, and potentially provides valuable insights into brain systems underlying normal emotion processing.

Mediators of the association between abuse and disordered eating in undergraduate men

The vast majority of ED research has focused on women. However, recent studies have suggested that ED symptomatology in men may be underestimated. Additional investigations are needed to better understand EDs and their correlates among men. This study examined the relationships between childhood abuse experiences and disordered eating in male undergraduates. In addition, potential mediators and moderators of the association between abuse and disordered eating were evaluated. Results indicated that physical abuse and physical neglect were the only adverse childhood experiences associated with disordered eating. In addition, depression mediated the associations between these forms of abuse and ED symptomatology. However, neither anxiety nor alexithymia were significant mediators of the association between abuse and EDs. Social support moderated the association between physical neglect and depression, such that individuals with high social support were less depressed than those with low social support, regardless of their level of physical neglect. These results are somewhat different than those found in exclusively female samples, highlighting the importance of specifically examining EDs and their correlates among men.

NETER alcoholic typology (NAT)

AIMS

To establish an alcohol-dependent drinker's clinical typology, based on patients attending the Alcoholism Unit of Santa Maria's General Hospital in Lisbon, Portugal.

METHODS

A multivariate statistical analysis was used to extract the typology solution.

RESULTS

We obtained five factors: Anxiopathic, typifies anxious functioning; Heredopathic, congregates familiar and genetic influences on alcoholism; Thimopathic, typified by affective symptomatology; Sociopathic, characterized by disruptive behaviours under alcohol influence; and Adictopathic, isolates younger individuals who consume alcohol and other types of psychoactive substances.

CONCLUSIONS

There are increasingly alcoholic polymorphic subtypes derived from the interactive complexity between genetic/family and psychosocial factors.

Does alexithymia differentiate between patients with nonepileptic seizures, patients with epilepsy, and nonpatient controls?

Considering the evidence of an association between alexithymia and somatization, this study aimed to discover whether alexithymia could distinguish patients with psychogenic nonepileptic seizures (NES) from those with epilepsy (ES) and nonpatient controls (C). Toronto Alexithymia Scale (TAS-20) scores were obtained from 21 matched participants from each of these groups, together with measures of anxiety and depression. Overall TAS-20 scores did not differentiate the three groups after controlling for anxiety and depression, but scores on certain subscales of the TAS-20 differed significantly between the patient groups and the controls. Although alexithymia could not discriminate individuals with NES from those with organic manifestations, whether the etiology of alexithymia may differ according to patient group was discussed. Given that 90.5% of NES patients were identified as alexithymic, treatment approaches used for individuals with alexithymia may be usefully applied to those with NES.

Is alexithymia related to negative symptoms of schizophrenia? A preliminary longitudinal study

BACKGROUND

Alexithymic features are close to anhedonia, blunted affect, and alogia that are also characteristics of the negative symptoms of schizophrenia. This study aimed to evaluate whether alexithymia is associated with negative symptoms and is related to the change of schizophrenic symptoms over time.

SAMPLING AND METHODS

A consecutive sample of 29 schizophrenic outpatients was evaluated at baseline and at 3, 6, and 12 months during appropriate treatment. They completed the Positive and Negative Syndrome Scale, the Montgomery and Asberg Depression Rating Scale, the Global Assessment of Functioning Scale, and the 20-item Toronto Alexithymia Scale at any time points.

RESULTS

The psychiatric scale scores showed significant symptom improvement over time but were unrelated to the alexithymia score that was instead stable over time. Hierarchical regression showed that the 20-item Toronto Alexithymia Scale at baseline was the sole predictor of alexithymia at 12 months, after controlling for psychopathology and psychological functioning.

CONCLUSIONS

Alexithymia was unrelated to negative symptoms, suggesting it is an independent and separate construct from schizophrenia. As expected, the negative symptoms were associated instead with illness-related aspects of depression and psychosocial functioning. Caution should be expressed in generalization mainly because this study is limited by the small sample size.

Childhood sexual abuse, social support, and psychological outcomes: a loss framework

OBJECTIVE

The objectives of the study were: (a) to develop a scale to assess CSA-related loss among a college sample of CSA survivors (CSALM), (b) to examine the measure's convergent validity through associations among depression, alexithymia, coping, and social support, and (c) to test whether social support moderates the relation between multiple experiences of CSA and loss.

METHOD

The study involved a survey methodology and included college-age women (n=116) reporting CSA experiences.

RESULTS

Based on the Sexual Victimization Questionnaire (SVQ; [Finkelhor, D. (1979). Sexually victimized children. New York: The Free Press]), 90% of the sample reported CSA before age of 12, 12.3% (n=15) reported CSA before age 12 with an adult over 16, and 42.2% (n=49) reported CSA after age 12 with an adult. Exploratory Factor Analysis of the CSALM revealed a three-factor solution: (a) Loss of Optimism, (b) Loss of Self, and (c) Loss of Childhood. Convergent validity of several scales was evidenced through associations with depression, alexithymia, coping, and social support. Social support from family and friends was found to moderate the association between CSA experiences and loss dimensions.

CONCLUSIONS

Findings provide preliminary psychometric support for the CSALM, a tool that will be useful in future investigations of loss among college-age CSA survivors. Findings also support using a loss framework to understand the current mental health of these survivors.

Alexithymia and interpersonal problems

BACKGROUND

Interpersonal relationships are substantially codetermined by nonverbal communication, e.g. facial affect. Given the deficits of nonverbal affect recognition and expression in alexithymia, we hypothesized that alexithymics had more interpersonal problems than nonalexithymic individuals, and that the various facets of the alexithymia construct are differentially related to interpersonal problems.

METHOD

149 subjects participating in an inpatient group psychotherapy program completed the Toronto Alexithymia Scale (TAS-20) and the Inventory of Interpersonal Problems (IIP-C) at the beginning of the treatment. The IIP-C was also administered to a subgroup at the end of the treatment.

RESULTS

Based on the alexithymia scores, patients were classified as low- (TAS-20 score </=51), moderate- or high-alexithymic (TAS-20 score >/=61). High-alexithymic patients had significantly more interpersonal problems than low alexithymics, particularly in the IIP-C scales indicating hostility and social avoidance. The TAS-20 subscale difficulty describing feelings showed the highest correlations with interpersonal problems (r between 0.23 and 0.55). At the end of the treatment, the high alexithymics still scored highest on the IIP-C, but the magnitude of change in interpersonal problems did not differ across the groups.

CONCLUSIONS

Our findings suggest that the interpersonal style of alexithymic individuals is characterized by a cold and socially avoidant behavior, corresponding to the predominantly insecure attachment pattern found in alexithymia. Additionally, our results indicate that group psychotherapy is as helpful for alexithymic as for nonalexithymic subjects with respect to interpersonal problems. Finally, we propose that alexithymia involves a reduced capacity to use social interactions for affect regulation.

The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder

PURPOSE

The current paper focused on the validity of using self-reports to assess emotion regulation abilities in autism spectrum disorders (ASD). To assess this we sought responses to two alexithymia self-reports and a depression self-report at two time points from adults with and without ASD.

MATERIALS AND METHODS

An initial sample of 27 adults with ASD and 35 normal adults completed the 20-item Toronto alexithymia scale (TAS-20), the Bermond and Vorst alexithymia questionnaire-form B (BVAQ-B), and the Beck depression inventory (BDI), at test time 1. Of these individuals, 19 ASD and 29 controls participated again after a period ranging from 4 to 12 months.

RESULTS

ASD participants were able to report about their own emotions using self-reports. BVAQ-B showed reasonable convergent validity and test-retest reliability in both groups. Scores on both alexithymia scales were stable across the two participant groups. However, results revealed that although the TAS-20 total score discriminated between the two groups at both time points, the BVAQ-B total score did not. Moreover, the TAS-20 showed stronger test-retest reliability than the BVAQ-B.

CONCLUSION

ASD participants appeared more depressed and more alexithymic than the controls. The use of the BVAQ-B, as an additional assessment of alexithymia, indicated that ASD patients have a specific type of alexithymia characterised by increased difficulties in the cognitive domain rather than the affective aspects of alexithymia.

Self-mutilation in substance-dependent patients and relationship with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality

OBJECTIVE

Aim of this study was to evaluate the prevalence of self-mutilation (SM) in Turkish male substance-dependent patients, and to investigate the relationship of SM with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality.

METHODS

Participants were 136 consecutively admitted males with substance dependence (96 alcohol and 40 drug). Substance dependence was diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I), Turkish version. Patients were investigated with the childhood abuse and neglect questionnaire, Toronto alexithymia scale (TAS-20) and temperament and character inventory (TCI).

RESULTS

Among substance-dependent patients 34.6% was considered as a group with SM. Rates of being single and unemployed, histories of physical and sexual abuse and suicide attempts were higher in the SM group. Current age, age at first substance use and age at regular substance use were lower in the group with SM. Mean of TAS-20 and 'difficulty in identifying feelings' (DIF) and 'difficulty in describing feelings' (DDF) subscales of TAS-20 were higher in SM group. There were no significant differences between groups in terms of TCI subscales. Age, childhood physical abuse and suicide attempt history predicted SM in logistic regression.

CONCLUSIONS

Young substance users with childhood physical abuse histories could be the target population to prevent self-mutilating behavior. This study also suggests that whenever self-mutilating behavior is present, the possibility of childhood abuse, alexithymia and suicide attempts must be evaluated.

Male sexuality and regulation of emotions: a study on the association between alexithymia and erectile dysfunction (ED)

Alexithymia is a multidimensional construct that describes a constellation of personality features characterised by difficulties in differentiating, identifying and communicating emotions. The purpose of the present study was to investigate prevalence of alexithymia in outpatients with erectile dysfunction (ED), both in the psychogenic lifelong type (PLED) and in the acquired one (PAED). ED severity was evaluated with the International Index of Erectile Function (IIEF) and alexithymia was measured using the Italian version of the 20-item Toronto Alexithymia Scale (TAS-20). The results suggest a high incidence of alexithymic characteristics in patients with psychogenic ED, a positive correlation between the alexithymia level and ED severity in patients with PAED and statistically significant differences in the alexithymia level between the two subgroups PLED and PAED. We assumed that alexithymia contributes to the origin of the PLED, and to a more severe manifestation of ED, once it appears in the acquired form.

Alexithymia after traumatic brain injury: its relation to magnetic resonance imaging findings and psychiatric disorders

OBJECTIVE

People with traumatic brain injury (TBI) were studied to assess the prevalence of alexithymia and its relationship to magnetic resonance imaging (MRI) findings and psychiatric disorders.

METHODS

Fifty-four participants, 67% men, were evaluated after a median of 30 years since TBI. A control group was matched for age, gender, and severity of depression. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20). In patients with TBI, axis I psychiatric disorders were assessed with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, version 2.1), and axis II disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). MRI examinations were carried out with a 1.5 T MRI scanner.

RESULTS

Alexithymia was significantly more common in patients with TBI than in controls (31.5% versus 14.8%; odds ratio 2.64, 95% confidence interval 1.03-6.80). None of the variables representing TBI, ie, severity of TBI or the presence, laterality, or location of contusions on MRI, was associated with the TAS-20 total scores. Several current axis I and II psychiatric disorders, particularly organic personality syndrome, were connected to higher TAS-20 scores.

CONCLUSION

Alexithymia is common, along with psychiatric disorders, in patients with TBI. Both of them may reflect dysfunction of the injured brain. In clinical practice, alexithymic features should be taken into consideration in psychosocial rehabilitation after TBI.

An investigation of the construct validity of the 20-Item Toronto Alexithymia Scale through the use of a verbalization task

OBJECTIVE

The construct validity of the 20-Item Toronto Alexithymia Scale (TAS-20) was examined through a verbalization task requiring participants to discuss a past distressing event.

METHODS

Verbalizations were transcribed and coded for the frequency and number of different negative and positive emotion words used. Relationships between the TAS-20 and these variables were examined.

RESULTS

Controlling for negative affect (NA), the difficulty identifying feelings (DIF) subscale was positively associated with the frequency of negative emotion words used and negatively associated with the frequency and number of different positive emotion words used during the verbalization task. High, compared with low, scoring TAS-20 participants used a lower frequency of and fewer different positive emotion words.

CONCLUSION

The TAS-20 may be measuring negative emotional expressivity separate from negative affectivity, as well as a reduced capacity to access and elaborate upon positive emotion. Findings are discussed in regard to improving the conceptualization and measurement of emotional deficits in alexithymia.

Processing of Facial Expressions of Negative Emotion in Alexithymia: The Influence of Temporal Constraint

Alexithymia, a characteristic involving a limited affective vocabulary appears to involve three components: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. There is evidence that alexithymic characteristics are associated with differences in emotion information-processing. We examined the role of temporal factors in alexithymic emotion-processing deficits, taking into account the confound between alexithymic characteristics and positive and negative affectivity. One hundred forty-six participants completed the 20-item Toronto Alexithymia Scale and the Positive and Negative Affect Schedule. In a signal-detection paradigm, participants judged facial expressions depicting neutral or negative emotions under slow and rapid presentation conditions. The alexithymia component of difficulty in describing feelings was inversely related to the ability to detect expressions of negative emotion in the speeded condition. This relationship was independent of positive and negative affectivity. Alexithymic components positive and negative affectivity were unrelated to response bias. The results emphasize the influence of difficulty describing feelings within the alexithymia construct and its difference from positive and negative affectivity. They suggest that an alexithymic deficit in describing feelings is associated with a deficit in processing negative emotions that is most apparent when processing capacity is challenged. Theoretical and methodological implications are discussed.

The impact of major depressive disorder on the short- and long-term outcome of Crohn's disease treatment with infliximab

BACKGROUND

Major depressive disorder is the most common psychiatric diagnosis in Crohn's disease. In other chronic diseases, evidence suggests that depression influences the course of the disease. Strong evidence of such a mediating role of major depressive disorder in Crohn's disease has never been found.

AIM

To assess the relationship between major depressive disorder and outcome of treatment of luminal Crohn's disease with infliximab.

METHODS

In this prospective study, 100 consecutive unselected patients underwent assessment of psychosocial, demographical disease-related biological and clinical parameters at baseline and at 4 weeks after infliximab. Major depressive disorder was diagnosed using the Patient Health Questionnaire. Subsequently, the patients were followed up clinically until the next flare or during 9 months.

RESULTS

The Crohn's disease responded in 75% of the patients, and remission was achieved in 60%. The presence of major depressive disorder at baseline predicted a lower remission rate (OR = 0.166, 95% CI = 0.049-0.567, P = 0.004). At follow-up, 88% of the patients needed retreatment. At univariate regression analysis, major depressive disorder significantly decreased time to retreatment (P = 0.001). Multivariate Cox regression confirmed major depressive disorder as an independent determinant of active disease both at baseline and at re-evaluation (hazard ratio = 2.271, 95% CI: 1.36-3.79, P = 0.002).

CONCLUSION

Major depressive disorder is a risk factor for failure to achieve remission with infliximab and for earlier retreatment in patients with active luminal Crohn's disease. Assessment and management of major depressive disorder should be part of the clinical approach to patients with Crohn's disease.

Somatization and alexithymia in young adult Finnish population

BACKGROUND

We assessed alexithymia and alexithymic features among young adult subjects with and without somatization symptoms in an epidemiological setting with a sample of young adults.

METHODS

The sample consisted of urban 31-year-old subjects (N=1002). Data on somatization were gathered from a review of all public health outpatient records. Subjects with four or more somatization symptoms according to the DSM-III-R criteria were considered somatizers. The 20-item version of the Toronto Alexithymia Scale (TAS-20) was used to measure alexithymia. Subjects with a total TAS score over 60 were considered as being alexithymic, and those with a score under 52 were considered nonalexithymic. Subjects with a total TAS score from 52 to 60 were considered as having alexithymic features.

RESULTS

The prevalence of alexithymia was 6.0% among somatizers and 4.8% among subjects without somatization symptoms, and the prevalence of alexithymic features was 7.5% and 12.6%, respectively.

CONCLUSIONS

No association was found between alexithymia and somatization in young adult general population. The earlier theory of the association between alexithymia and somatization may be questionable.

Exploring alexithymia, depression, and binge eating in self-reported eating disorders in women

TOPIC

Binge eating is often a way of life for many women even if the diagnostic criteria for the tentative DSM-IV-TR diagnosis of binge eating disorder is not met.

METHODS

Binge eating was conceptualized as a problem in affect regulation. Affective indices of alexithymia and depression were measure with the Toronto Alexithymia Scale (TAS), the Alexithymia-Provoked Response Questionnaire (APQR), and the Beck Depression Inventory (BDI), respectively. This study was an exploratory study of 65 subjects, 35 of whom self-reported as eating disordered and 30 as non-eating disordered.

FINDINGS

Of the eating-disordered subjects, 95% scored significantly on the Eating Habits Checklist as binge eaters, 18% as anorexic, and 23% as bulimic. Significant relationships were found between alexithymia and binge eating and depression. A stepwise logistic regression found that both alexithymia and depression discriminated between women with and without binge eating at .001 and .002, respectively.

CONCLUSIONS

This study found that alexithymia was more highly correlated with binge eating than with either anorexia or bulimia. In addition, a significant history of trauma and health problems for those who reported as binge eaters was reported. Implications for practice are discussed.

Adolescent anorexia nervosa patients have a discrepancy between neurophysiological responses and self-reported emotional arousal to psychosocial stress

In both clinical practice and research, eating disorder patients are reported to have difficulties in identifying and describing their feelings. They are often described as being unaware of the linkage between their feelings and their behavior. The present study experimentally induced emotions in adolescent anorexia nervosa (AN) patients to examine both self-reported emotional arousal and neurophysiological responses. A group of 10 AN patients and a group of 22 healthy controls (HC) were compared with respect to changes in self-reported emotional arousal and neurophysiological responses, heart rate (HR) and HPA-axis response (cortisol in saliva) during a public speaking test inducing anxious stress. The AN group reported higher levels of anxiety, as a result of stress, but this was not reflected in their HR or cortisol response. By contrast, in the HC group higher levels of self-reported anxiety coincided with clear increases in HR and cortisol. The data indicate that AN patients, in contrast to healthy individuals, show a discordance between self-reported emotional and neurophysiological arousal during psychosocial stress.

The moral affiliations of disgust: a functional MRI study

Recent investigations in cognitive neuroscience have shown that ordinary human behavior is guided by emotions that are uniquely human in their experiential and interpersonal aspects. These "moral emotions" contribute importantly to human social behavior and derive from the neurobehavioral reorganization of the basic plan of emotions that pervade mammalian life. Disgust is one prototypic emotion with multiple domains that include viscerosomatic reaction patterns and subjective experiences linked to (a) the sensory properties of a class of natural stimuli, (b) a set of aversive experiences and (c) a unique mode of experiencing morality. In the current investigation, we tested the hypotheses that (a) the experience of disgust devoid of moral connotations ("pure disgust") can be subjectively and behaviorally differentiated from the experience of disgust disguised in the moral emotion of "indignation" and that (b) pure disgust and indignation may have partially overlapping neural substrates. Thirteen normal adult volunteers were investigated with functional magnetic resonance imaging as they read a series of statements depicting scenarios of pure disgust, indignation, and neutral emotion. After the scanning procedure, they assigned one basic and one moral emotion to each stimulus from an array of six basic and seven moral emotions. Results indicated that (a) emotional stimuli may evoke pure disgust with or without indignation, (b) these different aspects of the experience of disgust could be elicited by a set of written statements, and (c) pure disgust and indignation recruited both overlapping and distinct brain regions, mainly in the frontal and temporal lobes. This work underscores the importance of the prefrontal and orbitofrontal cortices in moral judgment and in the automatic attribution of morality to social events. Human disgust encompasses a variety of emotional experiences that are ingrained in frontal, temporal, and limbic networks.

Emotional awareness deficits in inpatients of a psychosomatic ward: a comparison of two different measures of alexithymia

OBJECTIVE

The TAS 20 has demonstrated strong psychometric properties in a broad variety of studies in healthy populations. Much less work has been done in clinical contexts exploring the validity of the TAS 20 as a measure of the cognitive processing of emotions. The TAS 20, a self-report scale, tends to correlate with self-reported negative affect, but in a clinical context it is important to be able to differentiate between negative affect and the cognitive processing of emotion. We therefore used the TAS 20 and a performance measure, the Levels of Emotional Awareness Scale (LEAS), which in previous studies demonstrated no overlap with measures of negative affect, to explore the ability of the two measures to detect deficits in emotional awareness in a clinical sample.

METHODS

Data from inpatients of a psychosomatic ward were collected at onset (N = 394) and at the end of multimodal psychodynamic treatment (N = 249). The sample consisted of six diagnostic groups (depression; anxiety and compulsive-obsessive disorders, adjustment disorders, somatoform disorders, psychological factors related to somatic disorders, eating disorders). Changes in the TAS 20 and LEAS were compared at the two time points controlling for the effects of gender, age, educational level, and associations with self-reported negative affect.

RESULTS

In contrast to the LEAS, the TAS 20 correlated with negative affect at the onset and the end of treatment. The scores of the TAS 20 decreased with treatment in all diagnostic groups but the change in the TAS 20 was not statistically significant when negative affect was controlled. In contrast, LEAS scores increased with treatment in the groups with somatoform disorders and psychological factors related to somatic disorders, and this change was independent of negative affect.

CONCLUSION

The LEAS captured a change in emotional awareness due to treatment, whereas the TAS 20 captured a change in negative affect. The LEAS appears to be a more specific measure of change in emotional awareness in clinical contexts than the TAS 20.

The negative effect of alexithymia on the outcome of group therapy for complicated grief: what role might the therapist play?

Alexithymia is a patient characteristic that reflects deficits in the cognitive processing and regulation of emotions. It is generally considered to have an adverse effect on the outcome of psychotherapy. Little is known about the processes through which alexithymia exerts this effect. One proposed mechanism suggests that patients with alexithymia trigger negative therapist reactions that contribute to poor outcome for such patients. This study examined whether therapist reactions to a patient mediate the relationship between alexithymia and outcome in group psychotherapy for complicated grief. Alexithymia was assessed with the Toronto Alexithymia Scale-20. Therapist reactions to a patient, reflecting the therapist's perceptions of a patient's positive qualities, personal compatibility, and significance as a group member, were assessed with a cohesion questionnaire. Outcome in several areas of functioning was measured. We found that alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome and that this relationship was mediated by therapist reactions to a patient. The mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. This suggests that therapist reactions to a patient represent a major mechanism through which alexithymia exerts its effect.

Alexithymia and Pain in Three Chronic Pain Samples: Comparing Caucasians and African Americans

OBJECTIVE

African Americans often report greater pain than do Caucasians, but the factors responsible for this discrepancy are not known. We examined whether alexithymia-the trait of difficulty identifying and describing one's feelings and lacking introspection-may contribute to this ethnic group difference. We tested whether the mean level of alexithymia is higher, and whether alexithymia and pain are more highly correlated, among African Americans than among Caucasians in patients with chronic pain disorders.

DESIGN

Three cross-sectional, correlational studies were conducted on three separate samples of patients with chronic pain. Analyses examined the full sample and then Caucasians and African Americans separately.

SETTING AND PATIENTS

Patients were recruited primarily from treatment settings. Samples were patients with rheumatoid arthritis (N = 155), migraine headaches (N = 160), or systemic lupus erythematosus (N = 123), and each sample included only Caucasians or African Americans.

MEASURES

The Toronto Alexithymia Scale-20 assessed global alexithymia and three alexithymia facets. Pain severity, functional disability, or symptoms were also measured on each sample.

RESULTS

Similar findings occurred across all three samples. African Americans had only slightly higher mean alexithymia levels than did Caucasians, and this was partly accounted for by socioeconomic differences between groups. More importantly, alexithymia correlated only weakly with pain or symptom severity for each full sample, but the two ethnic groups showed different patterns. Alexithymia correlated positively with pain severity among African Americans, but was uncorrelated with pain among Caucasians, even after covarying for various socioeconomic variables.

CONCLUSIONS

Alexithymia is more correlated with pain severity among African Americans with chronic pain disorders than among Caucasians, potentially contributing to the higher pain reports among African Americans.

Alexithymia, cardiovascular reactivity, and symptom reporting during blood donation

OBJECTIVE

With blood donation serving as a naturalistic stressor and a controlled medical event, the aim of this study was to examine emotional and cardiovascular reactivity, self-report of vasovagal symptoms, and perceived pain as a function of scores on the Toronto Alexithymia Scale (TAS-20).

METHOD

Healthy young adult blood donors (N = 610) recruited at mobile blood collection clinics completed the TAS-20, pre- and postdonation measures of anxiety, postdonation measures of pain and vasovagal symptoms, and had their blood pressure and heart rate measured before and after giving blood.

RESULTS

Alexithymia score was positively associated with reported anxiety, pain, and vasovagal symptoms. Higher alexithymia was also associated with greater increases in predonation systolic blood pressure in anticipation of blood donation. In general, women and less experienced blood donors reported more vasovagal symptoms than men and more experienced donors, and this corresponded to higher rates of treatment by the nurses, more fainting, and fewer full units of blood obtained. However, despite more reports of vasovagal symptoms by alexithymic donors, alexithymia score was not related to these variables.

CONCLUSIONS

The results suggest that individuals with higher alexithymia scores were more anxious in the blood donation setting and more prone to report physical symptoms in the absence of a clear difference in the medical outcome of the blood donation procedure.

Reduced activation of posterior cingulate cortex during imagery in subjects with high degrees of alexithymia: a functional magnetic resonance imaging study

BACKGROUND

Although the brain areas involved in imagery have been reported, the neural bases of individual differences in imagery remain to be elucidated. People with high degrees of alexithymia (HDA) are known to have constricted imaginal capacities. The purpose of this study was to investigate neural correlates of imagery disturbance in subjects with HDA.

METHODS

A functional magnetic resonance imaging (fMRI) study was undertaken in 10 subjects with HDA and 10 subjects with low degrees of alexithymia (LDA), who were selected according to their scores on the 20-item Toronto Alexithymia Scale (TAS-20). The two groups' regional cerebral activation was compared during various imagery conditions. In those conditions, the subjects imaged a past happy (PH) event, a past sad (PS) event, a past neutral (PN) event, a future happy (FH) event, a future sad (FS) event, and a future neutral (FN) event. The activation levels during these conditions were compared with those during a rest condition (REST).

RESULTS

The t tests showed that the mean subjective ratings of both the vividness of the imagery and the intensity of emotion during the imagery were higher in the subjects with LDA than in those with HDA for the PS and FS imagery conditions. On the other hand, relative to the LDA group, the HDA group showed significantly less activation in the posterior cingulate cortex (PCC) during the PH and FH imagery conditions compared with REST and during the FH imagery condition compared with the FN imagery condition.

CONCLUSION

The present results suggest an association between an HDA and reduced activation of the PCC during happy imagery. Given the function of this brain region, these results might be related to a dysfunction of episodic memory retrieval during happy imagery in subjects with HDA.

Alexithymia in young adulthood: a risk factor for pathological gambling

BACKGROUND

Pathological gambling is more prevalent among postsecondary students than among the general adult population. While the prevalence of pathological gambling in this group has risen over the past decade, factors underlying the development of problem gambling among university students remain largely unexplored. One early study found alexithymia to be associated with pathological gambling. The aim of the present study was to further examine the relationship between alexithymia and gambling among postsecondary students.

METHODS

The relationship between alexithymia and pathological gambling was examined in 562 postsecondary students who completed the South Oaks Gambling Screen (SOGS) and the 20-item Toronto Alexithymia Scale (TAS-20).

RESULTS

Approximately 12% of the sample was classified as alexithymic according to the TAS-20. These individuals were found to have significantly more gambling problems, as measured by the SOGS, than nonalexithymic individuals. Approximately 9% of the sample was classified as pathological gamblers according to the SOGS. These individuals were found to have significantly higher levels of alexithymia, as measured by the TAS-20, than nonproblem gamblers.

CONCLUSIONS

Alexithymia is associated with pathological gambling and may be a risk factor among postsecondary students for developing severe gambling problems.

Personality traits related to chronic pain location

BACKGROUND

Previous research has yielded inconsistent findings on the relationship between personality characteristics and chronic pain. The present study examines measures of alexithymia, somatosensory amplification, attachment, counterdependency, and emotional distress in 140 consecutive general medical outpatients seen in psychiatric consultation.

METHODS

Forty-five subjects having no chronic pain (NP) were compared to 49 subjects with chronic pain restricted to their back and/or extremities (BE) and with 46 subjects having pain involving other regions of the body (OP).

RESULTS

Findings demonstrated marked counterdependency traits in the BE group relative to the other two groups. By contrast, traits of alexithymia and somatosensory amplification, insecure attachment, and a high level of emotional distress characterized the OP group. A multiple logistic regression model combining counterdependency and secure attachment was 86% accurate in predicting BE (c = 0.86).

CONCLUSIONS

The study's findings suggest that personality traits vary according to chronic pain location, although the nature of the relationship still needs to be determined.

Alexithymia and dissociative tendencies in an adolescent sample from Eastern Turkey

Alexithymia and dissociative reactions are two strategies that have been put forward as coping mechanisms to alleviate painful emotions. Adult studies reveal an association between alexithymia and dissociation. In line with the coping hypothesis, it was predicted that the relationship between alexithymia and dissociative tendencies would be partly mediated by current levels of stress and past traumatic experiences. Dissociation may also be related to enhanced fantasizing, although alexithymia has traditionally been associated with an incapacity to fantasize. This relationship has not been studied well in adolescents. In the present study, 173 randomly selected high school students from Eastern Turkey were assessed with the Adolescent Dissociative Experiences Scale, the Beck Depression and Anxiety inventories, the Rosenberg Self-esteem Scale and the Toronto Alexithymia Scale. Correlation analyses followed by stepwise regression analyses were performed. "Difficulty identifying feelings" subscale of Toronto Alexithymia Scale, anxiety level and the history of physical abuse emerged as predictors of dissociative tendencies. It seems that in this group, dissociation is associated with anxiety and with difficulty in identifying feelings. Physical abuse also contributes to dissociation. The adolescent who is alexithymic may be more prone to dissociation when compared to their non-alexithymic peers. Helping alexithymic adolescents describe their body experiences may decrease their tendency to dissociation by increasing their ability to verbally identify their stressors.

Reliability and factorial validity of the Observer Alexithymia Scale-Chinese translation

The purpose of the present study was to develop a Chinese translation of the Observer Alexithymia Scale (OAS-C) and evaluate its reliability and factorial validity. The original English-version of the Observer Alexithymia Scale (OAS) was translated into Chinese and given to 468 Chinese undergraduate students. Students were asked to rate a person (other than themselves) whom they knew well (e.g., a parent, sibling, another relative, or friend). We evaluated internal consistency, test-retest and inter-rater reliability, and factorial validity. Average OAS-C scores were slightly higher than, but comparable to, OAS scores in the normative samples (English-speaking/nonclinical). The OAS-C showed adequate internal consistency (Cronbach's alpha coefficient was 0.84, and the mean inter-item correlation coefficient was 0.14), good stability (test-retest reliability with a 2-week interval was 0.90), and inter-rater reliability (intra-class correlation coefficient was 0.78). Moreover, the OAS five-factor model (Distant, Uninsightful, Somatizing, Humorless, and Rigid) was confirmed: incremental fit index=0.905, comparative fit index=0.904, and root mean square error of approximation=0.086; each represented an adequate model fit. The OAS-C appears to be a reliable and valid observer-rated alexithymia measure. We recommend that researchers collect both self- and observer-rated alexithymia data and, when possible, obtain observer reports from more than one person.

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) for substance users

OBJECTIVE

To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230).

METHODS

Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20.

RESULTS

A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline.

CONCLUSION

The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.

Alexithymia: its prevalence and correlates in a British undergraduate sample

INTRODUCTION

Alexithymia is characterized by a difficulty identifying and describing emotional states, as well as an externally oriented thinking style. This study investigated the prevalence of alexithymia in a British undergraduate sample and assesses its relationship to both parental bonding and dissociation.

METHOD

The Toronto alexithymia scale (TAS-20), the Parental Bonding Instrument (PBI), and the Dissociative Experience Scale (DES) were administered to a sample of 181 male and 190 female undergraduate students from both arts and science subjects.

RESULTS

Rates of alexithymia were comparable with those observed in some other countries. Contrary to predictions, females were found to have higher rates than males, and the highest presence of alexithymia was in female science students. As in previous studies, alexithymia was linked to both dissociation and perceptions of a lack of maternal care, though the degree of association to the latter was small. Dissociative experiences were predicted by both maternal overprotection and difficulties identifying feelings.

DISCUSSION

Some qualified support was found for the relevance of early maternal bonding to later difficulties processing emotions. The presence of greater alexithymia in females, and female science students in particular, was discussed in reference to similar observations elsewhere. There was also an understandable relationship between 'difficulty identifying feelings' (TAS) and both depersonalization/derealization and absorption (DES).

Assessing the reliability and validity of the Bermond-Vorst Alexithymia Questionnaire among U.S. Anglo and U.S. Hispanic samples

OBJECTIVE

The aim of this paper is to assess the psychometric properties of the Bermond-Vorst Alexithymia Questionnaire (BVAQ) in U.S. Anglo and U.S. Hispanic samples of college students.

METHOD

One hundred ninety-four U.S. Hispanics and 304 U.S. Anglos participated in the study. In addition to completing the BVAQ, participants completed the 20-item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory (BDI), and the Eysenck Neuroticism Scale (ENS).

RESULTS

BVAQ and TAS-20 subscales were correlated across groups. While the identifying and verbalizing composites of the BVAQ subscales were predictive of neuroticism and depression across groups in the expected direction, the fantasizing subscale of the BVAQ was negatively predictive of depression and neuroticism across groups.

CONCLUSION

Given the unexpected findings associated with some of the BVAQ subscales, future research should explore the dimensionality of alexithymia.

Assessing alexithymia in French-speaking samples: psychometric properties of the Observer Alexithymia Scale-French translation

In the present study, we evaluated the psychometric properties of the Observer Alexithymia Scale-French translation (OAS-F), a 33-item, observer-rated alexithymia measure. The scale, accessible to lay and professional raters, taps everyday expressions of alexithymia. French university students (N = 159) were asked to rate a person they knew well or ask an acquaintance to rate them. Those being rated (N = 159) were parents, siblings, children, and friends. OAS-F total and subscale scores were comparable to those in the English normative samples. Moreover, OAS scores were reliable, and the scale's five-factor structure (distant, uninsightful, somatizing, humorless, and rigid) was confirmed. Importantly, too, OAS total scores correlated 0.31 with (self-report) 20-item Toronto Alexithymia Scale (TAS) scores. The OAS-F appears to be a psychometrically sound observer-rated alexithymia measure.

Alexithymia Assessment and Relations with Dimensions of Personality

Abstract. This study examines the relationship between alexithymia, impulsiveness, locus of control, irrational beliefs, and both the domain and the facet levels of the Five-Factor Model (FFM) of personality in a sample of 136 undergraduate students by using the 26-Item and the 20-Item Toronto Alexithymia Scales (TAS-26; TAS-20), the Impulsiveness Questionnaire (I7), the Internal, Powerful others, and Chance Scales (IPC), the Malouff and Schutte Belief Scale and the NEO Personality Inventory Revised. The aim of this study is to compare the TAS-26 and the TAS-20, and to explore relations between alexithymia and personality especially regarding aspects that have not been taken into account so far, like impulsiveness and irrational beliefs. As expected, alexithymia overlaps with various dimensions of the FFM, as well as other dimensions like external locus of control and irrational beliefs. Surprisingly, there is no association between alexithymia and impulsiveness. Our results suggest that alexithymia is a cognitive state of externally oriented thinking with an emotional instability associated to the inability to cope with stressful situations.

Are difficulties perceiving and expressing emotions associated with low-back pain? The relationship between lack of emotional awareness (alexithymia) and 12-month prevalence of low-back pain in 1180 urban public transit operators

OBJECTIVE

To assess the association of alexithymia (deficit in emotional awareness) with 12-month prevalence of low back pain (LBP) cross-sectionally in a cohort study of 1180 San Francisco transit operators.

METHODS

Alexithymia was measured by the Toronto Alexithymia Scale (TAS-20). LBP was assessed in medical histories during drivers relicensing exams. Multivariate logistic regression analyses controlled for demographic, behavioral (smoking, alcohol, coping style), and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all the drivers, 31.4% suffered from LBP. Scoring in the upper quartile of alexithymia summary scores was associated with twofold higher odds of LBP (adjusted odds ratio=2.00, 95% confidence interval: 1.31-3.00). The association was stronger in women (adj. OR=4.35) than in men (adj. OR=1.83). The factor "difficulty identifying feelings" showed the strongest association with LBP (adj. OR=2.23).

CONCLUSION

The results support an association between alexithymia and LBP.

Cross-cultural alexithymia: validity of the 20-item Toronto Alexithymia Scale in North American aboriginal populations

OBJECTIVE

The generalizability of the alexithymia construct to North American aboriginal culture was examined by assessing the replicability of the factor structure of the 20-item Toronto Alexithymia Scale (TAS-20) in two different adult samples. The study also assessed the reliability of the scale and the influence of gender, age, and education on alexithymia levels.

METHOD

The first sample was a community-based group of 123 aboriginal men and women; the second sample was 102 male aboriginal offenders. Both samples completed the TAS-20.

RESULTS

The replicability of the three-factor structure for the TAS-20 was supported in both groups using confirmatory factor analysis (CFA). The TAS-20 and its three factors demonstrated adequate internal reliability, and the variables of gender, age, and education accounted for small or nonsignificant amounts of variability in total TAS-20 and factor scale scores.

CONCLUSION

The results provide additional support for the factorial validity of the TAS-20 in diverse cultural groups.