The assessment of alexithymia: a critical review of the literature and a psychometric study of the Toronto Alexithymia Scale-20

Psychometric Properties of the 20-Item Toronto Alexithymia Scale in the Chilean Population

Alexithymia can be defined as inability to identify and describe emotions in the self. Has shown to be related to several psychological and pathological processes that can result in unsatisfactory interpersonal relationships and decreased social adjustment. Advances in research of alexithymia require the development and validation of assessment instruments, and its application to different population. With this aim, we studied the psychometric properties of the Twenty-Item Toronto Alexithymia Scale (TAS-20) in Chilean population using various modeling procedures (e.g., CFA, ESEM) in different structures (i.e., Correlated, Unidimensional, Hierarchical or Wording factors). Among the 10 models tested, the four-dimensional structure offered the best fit but with item-loading problems in the last factor (Pragmatic Thinking). We suggest that the studied version of the scale needs improvement (theoretical and empirical) to ensure optimal indices of validation for Chilean population.

The relationship between alexithymia and headache impact: the role of somatization and pain catastrophizing

PURPOSE

The present study compared psychological factors (i.e., alexithymia, somatization, pain catastrophizing (PC), anxiety, and depression) and QOL for headache patients and headache-free individuals, and examined whether somatization and PC mediate the relationship between alexithymia and headache impact in headache patients.

METHODS

Study participants consisted of 123 headache patients from an outpatient clinic at a university hospital and 124 headache-free individuals in Daegu, Korea. The survey employed the somatization and anxiety subscales of the Symptom Checklist-90-revised, the Patient Health Questionnaire-9, Pain Catastrophizing Scale, Toronto Alexithymia Scale, Short-Form Health survey-8 (SF-8), and the Headache Impact Test-6.

RESULTS

Headache patients showed a higher level of all psychological factors and lower level of two summary scores (physical and mental health) as well as the seven dimensions of the SF-8 compared with headache-free individuals. Examination employing the SPSS Process macro found that the direct effect of alexithymia on headache impact was not significant after controlling for somatization and PC. The total indirect effects of alexithymia on headache impact were significant without anxiety and depression as covariates with the significant indirect effects of alexithymia on headache impact via somatization or via PC as well as via somatization and PC. However, after controlling for anxiety and depression, PC was the only significant pathway through which alexithymia was related to headache impact.

CONCLUSIONS

Headache patients may benefit from interventions aiming at improving psychological factors in order to improve the functioning and QOL of headache patients.

Alexithymia according to Bucci's multiple code theory: A preliminary investigation with healthy and hypertensive individuals

OBJECTIVE

To evaluate the relation between alexithymia and Referential Activity (RA), a linguistic measure of the process by which non-verbal emotional experience is connected to language.

METHODS

The 20-Item Toronto Alexithymia Scale (TAS-20) and the Toronto Structured Interview for Alexithymia (TSIA) were administered to 20 postgraduate students and 15 outpatients with hypertension. The Weighted Referential Activity Dictionary (WRAD) and other linguistic measures (Reflection, Disfluency, and Somatic Sense) were applied to texts derived from the TSIA using the Discourse Attributes Analysis Program (DAAP).

RESULTS

Multiple linear regressions performed in the whole sample showed a relation between TSIA scores and Somatic Sense. Comparing the two groups, hypertensive subjects yielded higher scores on the TSIA than the young adult sample; no differences in DAAP measures emerged. A significant negative correlation was found between the TAS-20 Difficulty Describing Feelings score and the DAAP measure of references to body activations (Somatic Sense) both in the young adult sample and in hypertensives. In the young adult sample, negative relations emerged between different TSIA factors, WRAD score, and Somatic Sense; a positive relation with fragmented speech (Disfluency) and use of rationalization (Reflection) was also found. In hypertensive subjects, using the TSIA, a negative correlation between alexithymia and Somatic Sense and a positive correlation between alexithymia and the Mean High WRAD (a measure of intensity of engagement during the speech) were found.

CONCLUSION

The TSIA seems to be a more adequate instrument than the TAS-20 to explore relations between alexithymia and RA. Results appear to suggest a complex, nonlinear relation between alexithymia and RA, presumably influenced by subject-specific characteristics.

PRACTITIONER POINTS

A relation between alexithymia and RA has been proposed on theoretical grounds, but there has been minimal empirical investigation. This was the first study to employ both a self-report measure and a structured interview for measuring alexithymia in relation to RA. The results of this study suggest a complex, nonlinear relation between alexithymia and RA; this finding is essentially obtained with the structured interview measure of alexithymia. This relation is presumably influenced by subject-specific characteristics.

Alexithymia in Young Adults With Substance Use Disorders: Critical Issues About Specificity and Treatment Predictivity

Several studies have reported high rates of alexithymia in drug-dependent individuals, but supporting evidence attests association between alexithymia and a variety of psychiatric disorders, raising doubts about its specificity. Moreover, controversies are emerging about alexithymia assessment: self-report measures present shortcomings with respect to discriminant validity and reliability. As regards treatment for substance use disorders (SUDs), alexithymia has been linked to poorer outcomes, but the results are inconsistent. The aim of the present study is to investigate alexithymia in substance-dependent young adults by examining: (a) the specificity of alexithymia in drug-dependent inpatients, compared to healthy individuals and patients with psychiatric disorders (behavioral and emotional disorders) and (b) the predictivity of alexithymia in determining treatment outcomes in terms of relapses, drop-outs from treatment and the rate of relapse per month of treatment. Two studies were conducted to fulfill these aims: Study 1 and Study 2. Study 1 involved 90 late adolescents, aged 17-21. To fulfill the first aim, 30 inpatients diagnosed with SUD were compared with 30 healthy controls and 30 individuals referred to an outpatient neuropsychiatric unit (a). The participants completed the Toronto Alexithymia Scale-20 (TAS-20) and the Symptom Checklist-90-Revised (SCL-90-R). The results indicated that both clinical groups reported higher TAS-20 scores than the non-clinical subjects, but they did not differ from each other (a); moreover, a large correlation was detected between alexithymia and depressive symptoms, as assessed by the SCL-90-R. Study 2 involved 55 inpatients with SUD recruited in a therapeutic community. The participants completed the TAS-20, and clinicians filled out the Observer Alexithymia Scale (OAS). No association was found between self-report and observational measures. Neither self-reported nor observed alexithymia predicted the number of relapses, drop-out from treatment, or the rate of relapses per month of treatment (b). When the interaction with gender was explored, the global score of alexithymia and the "Distant" OAS subscale predicted the number rate relapses only in males. The TAS-20 did not discriminate between the clinical groups. The limited ability of both observed and self-reported measures in predicting treatment outcome raises questions on the specificity of alexithymia among the substance-dependent inpatient population.

The Relationship Between Alexithymia and Emotional Awareness: A Meta-Analytic Review of the Correlation Between TAS-20 and LEAS

Background: Alexithymia and emotional awareness may be considered overlapping constructs and both have been shown to be related to psychological and emotional well-being. However, it is not clear how the constructs relate to each other empirically or if they may overlap more or less in different populations. The aim of this review was therefore to conduct a meta-analysis of correlations between the most commonly used measures of alexithymia (i.e., the self-report instrument Toronto Alexithymia Scale; TAS-20) and emotional awareness (i.e., the observer-rated instrument Level of Emotional Awareness Scale; LEAS) and to explore potential moderators of their relationship.

Methods: Electronic databases were searched for studies published until the end of February 2018. Study samples were coded as medical conditions, psychiatric disorders and/or healthy controls and sample mean age and gender distribution were extracted. Correlations between the TAS-20 and the LEAS were subjected to a random effect of meta-analysis and moderators were explored in subgroup analyses and meta-regressions. Publication bias was considered.

Results: 21 studies reporting on 28 independent samples on correlation analysis were included, encompassing a total of 2857 subjects (57% women). The aggregated correlation between TAS-20 and LEAS was r = −0.122 (95% CI [−0.180, −0.064]; Z = −4.092; p < 0.001), indicating a significant, but weak, negative relationship between the measures. Heterogeneity was moderate, but we found no indication of significant differences between patients with medical conditions, psychiatric disorders or healthy controls, nor that mean age or percentage of female subjects moderated the relationship. The overall estimate became somewhat weaker after adjusting for possible publication bias.

Conclusions: Our results indicate that TAS-20 and LEAS measure different aspects of emotional functioning. The small overlap suggests that alexithymia and emotional awareness are distinct constructs of emotional well-being. Clinicians need to assess both aspects when considering treatment options for individual patients. Moreover, from the clinical standpoint, an easy reliable and valid way of measuring emotional awareness is still needed. More research should be focus on the differences between alexithymia and emotional awareness in specific conditions, but also how to integrate self-report instrument and observed based measures in a clinical situation.

Alexithymia in Gastroenterology and Hepatology: A Systematic Review

Background: Alexithymia is a multifaceted personality construct that represents a deficit in the cognitive processing of emotions and is currently understood to be related to a variety of medical and psychiatric conditions. The present review aims to investigate the relationship of alexithymia with gastrointestinal (GI) disorders as functional gastrointestinal disorders (FGID, as irritable bowel syndrome (IBS) and functional dyspepsia) and inflammatory bowel disease (IBD) [ulcerative colitis (UC) and Crohn's disease (CD)] and liver diseases as chronic hepatitis C (CHC), cirrhosis, and liver transplantation. Methods: The articles were selected from the main electronic databases (PsycInfo, Medline, PubMed, Web of Science, Scopus, Cochrane, and ScienceDirect) using multiple combinations of relevant search terms (defined GI and liver diseases, articles in English, use of the Toronto scales [TAS] for alexithymia). The TAS was selected as inclusion criterion because it is the most widely used measure, thus allowing comparisons across studies. Results: Forty-eight studies met the inclusion criteria, of which 38 focused on GI disorders (27 on FGID and 11 on IBD) and 10 on liver diseases. Most studies (n = 30, 62%) were cross-sectional. The prevalence of alexithymia was higher in FGID (two third or more) than IBD and liver diseases (from one third to 50% of patients, consistent with other chronic non-GI diseases) than general population (10-15%). In functional disorders, alexithymia may be viewed as a primary driver for higher visceral perception, symptom reporting, health care use, symptom persistence, and negative treatment outcomes. Also, it has been found associated with psychological distress and specific GI-related forms of anxiety in predicting symptom severity as well as post-treatment outcomes and is associated with several psychological factors increasing the burden of disease and impairing levels of quality of life. A number of critical issues (small sample sizes, patients referred to secondary and tertiary care centers, cross-sectional study design, use of one single scale for alexithymia) constitutes a limitation to the generalization of findings. Conclusions: Alexithymia showed to play different roles in gastroenterology according to the clinical characteristics and the psychological burden of the various disorders, with main relevance in increasing subjective symptom perception and affecting negatively post-treatment outcomes.

The Emotion Mapping Activity: Preliminary evaluation of a mindfulness-informed exercise to improve emotion labeling in alexithymic persons

Alexithymia is a psychoemotional trait associated with many treatment-resistant psychological and social difficulties. Research suggests that these difficulties stem primarily from an inability to appropriately apply linguistic labels to emotional experiences and content. The present research introduces and preliminarily evaluates a novel mindfulness-informed exercise to improve emotion-labeling ability in alexithymic persons. Based in culturally universal patterns of somatic experience, the Emotion Mapping Activity (EMA) directs alexithymic persons to reflect on their internal, somatic experiences as a source of information for interpreting and labeling emotional experiences. In the present study, 67 alexithymic persons completed a series of emotion-labeling tasks either with or without assistance of the EMA. Results suggest that completion of the EMA may improve ability to label emotions that would be otherwise misinterpreted - without interfering with labeling that is already intact. Though further research is necessary, the present study suggests that the EMA may hold the potential to be incorporated into psychotherapy protocols as an exercise for improving emotion-labeling ability in alexithymic clients.

Inter-individual Differences in Heart Rate Variability Are Associated with Inter-individual Differences in Empathy and Alexithymia

In the present study, we investigated whether inter-individual differences in vagally mediated heart rate variability (vmHRV) would be associated with inter-individual differences in empathy and alexithymia. To this end, we determined resting state HF-HRV in 90 individuals that also completed questionnaires assessing inter-individual differences in empathy and alexithymia. Our categorical and dimensional analyses revealed that inter-individual differences in HF-HRV were differently associated with inter-individual differences in empathy and alexithymia. We found that individuals with high HF-HRV reported more empathy and less alexithymia than individuals with low HF-HRV. Moreover, we even found that an increase in HF-HRV was associated with an increase in empathy and a decrease in alexithymia across all participants. Taken together, these findings indicate that individuals with high HF-HRV are more empathetic and less alexithymic than individuals with low HF-HRV. These differences in empathy and alexithymia may explain why individuals with high HF-HRV are more successful in sharing and understanding the mental and emotional states of others than individuals with low HF-HRV.

Do Emotional Components of Alexithymia Mediate the Interplay between Cyberbullying Victimization and Perpetration?

A substantial amount of research has revealed that cyberbully-victims have more emotional and behavioral problems than either cyberbullying victims or perpetrators. However, until now, little research has been conducted into the factors that contribute to the interplay between cyberbullying victimization and perpetration. The purpose of this study was to examine the relationship between cyberbullying victimization, perpetration, and two emotional components of alexithymia, namely difficulties in identifying and describing one’s own feelings. Self-report questions were administered to 1549 adolescents between 12 and 18 years old (M = 14.51; SD = 1.68; 42.1% (n = 652) male) from Germany and Thailand. Results showed that cyberbullying victimization and alexithymia are associated with cyberbullying perpetration. Moreover, alexithymia mediated the associations between cyberbullying victimization and adolescents’ cyberbullying perpetration. Consequently, we suggest that the ability to describe and identify one’s own feelings might be important for understanding the link between cyberbullying, victimization, and perpetration. The results may help develop prevention and intervention programs focused on reducing cyberbullying.

Alexithymia in eating disorders: Systematic review and meta-analyses of studies using the Toronto Alexithymia Scale

OBJECTIVE

The aim of this review was to synthesise the literature on the use of the Toronto Alexithymia Scale (TAS) in eating disorder populations and Healthy Controls (HCs) and to compare TAS scores in these groups.

METHOD

Electronic databases were searched systematically for studies using the TAS and meta-analyses were performed to statistically compare scores on the TAS between individuals with eating disorders and HCs.

RESULTS

Forty-eight studies using the TAS with both a clinical eating disorder group and HCs were identified. Of these, 44 were included in the meta-analyses, separated into: Anorexia Nervosa; Anorexia Nervosa, Restricting subtype; Anorexia Nervosa, Binge-Purge subtype, Bulimia Nervosa and Binge Eating Disorder. For all groups, there were significant differences with medium or large effect sizes between the clinical group and HCs, with the clinical group scoring significantly higher on the TAS, indicating greater difficulty with identifying and labelling emotions.

CONCLUSION

Across the spectrum of eating disorders, individuals report having difficulties recognising or describing their emotions. Given the self-report design of the TAS, research to develop and evaluate treatments and clinician-administered assessments of alexithymia is warranted.

Emotion awareness and cognitive behavioural therapy in young people with autism spectrum disorder

Young people with autism spectrum disorder experience high levels of emotional problems, including anxiety and depression. Adapted cognitive behavioural therapy is recommended for such difficulties. However, no evidence suggests whether emotion awareness is important in treatment outcome for young people on the autism spectrum. This study aimed to investigate the potential differences in emotion awareness between (1) young people on the autism spectrum and typically developing youth and (2) young people on the autism spectrum with and without experience of cognitive behavioural therapy. Three groups (aged 11-20 years) participated: (1) typically developing young people ( n = 56); (2) young people on the autism spectrum with no experience of cognitive behavioural therapy ( n = 23); and (3) young people on the autism spectrum who had attended cognitive behavioural therapy ( n = 33). All participants completed the Emotion Awareness Questionnaire-30 item version. Young people on the autism spectrum differed significantly from typically developing young people on the emotional awareness measure. Young people on the autism spectrum who had attended cognitive behavioural therapy scored significantly lower on the Differentiating Emotions subscale, and significantly higher on the Attending to Others' Emotions subscale, compared to young people on the autism spectrum who had not attended cognitive behavioural therapy. This study highlights the importance of psycho-educational components of cognitive behavioural therapy when adapting for young people on the autism spectrum.

Illuminating the clinical significance of alexithymia subtypes: A cluster analysis of alexithymic traits and psychiatric symptoms

BACKGROUND

Alexithymia is a personality construct involving difficulties identifying and verbalizing feelings, and an externally oriented thinking style. There is preliminary evidence for alexithymia subtypes that may carry different risk profiles for psychiatric illness. The aim of this study was to gain support for the existence of alexithymia subtypes and further characterize their clinical relevance.

METHODS

To identify possible subtypes, a cluster analysis was conducted for individuals with high alexithymic traits (N=113). Current depressive and anxiety symptoms, self-reported psychiatric medical history, and self-reported early life adversity were compared between subtypes. The cluster analysis was replicated with the low (N=2471) and moderate (N=290) alexithymia groups.

RESULTS

We identified two alexithymia subtypes. Compared to type A, type B alexithymia was associated with higher levels of difficulties in identifying feelings, and was more strongly associated with current depressive (Cohen's d=0.77, p<0.001) and anxiety symptoms (Cohen's d=0.82, p<0.001), and self-reported early life adversity (Cohen's d 0.42, p=0.048). Compared to type A, type B alexithymia was also associated with a higher prevalence of self-reported diagnosis of major depressive- (30.2% vs. 8.3%) and anxiety disorder (18.9% vs. 3.3%).

CONCLUSIONS

The results of this study support the hypothesis of alexithymia subtypes, and add support to the growing evidence showing that alexithymia is likely a heterogeneous and dimensional phenomenon. The subtype (type B) with most pronounced difficulties in identifying feelings may be associated with a higher risk for psychiatric illness compared to type A alexithymia, and may exhibit a more severe history of early life adversity.

The measurement of alexithymia in children and adolescents: Psychometric properties of the Alexithymia Questionnaire for Children and the twenty-item Toronto Alexithymia Scale in different non-clinical and clinical samples of children and adolescents

This study had two aims. Firstly, the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) and the Alexithymia Questionnaire for Children (AQC) that measure the three dimensions of alexithymia (DIF, difficulty identifying feelings; DDF, difficulty describing feelings; EOT, externally-oriented thinking) were explored in various samples of children, adolescents or young adults to detect the best factor-structure and to examine if the Externally-Oriented Thinking (EOT) factor must be deleted or not. Secondly, the capacity for adolescents to distinguish between alexithymia and depression was studied using factorial analyses of items of self-report of alexithymia and depression scales. Four groups were examined (80 healthy children, 105 adolescents with various psychiatric disorders, 333 healthy older adolescents and 505 young adults recruited from universities). The first two groups filled out the AQC and the latter two the TAS-20. Confirmatory factorial analyses (CFA) showed that the two-factor model (DIF, DDF) provided acceptable fits and had significant advantages over the three-factor model (DIF, DDF, EOT). Low alpha coefficients for the EOT subscale were reported (range from 0.18–0.61). Except for the children sample, exploratory factorial analyses (EFA) were performed on the items of the TAS-20 or AQC without the EOT items and the Beck depression inventory-II (BDI-II) or the Zung Self-Rating Depression Scale (SDS). The items of the AQC and BDI-II or items of the TAS-20 and SDS loaded on separate factors with only a minor overlap suggesting that adolescents were able to differentiate alexithymia and depression when self-assessments were used. Alexithymia can be reliably assessed in adolescents using the TAS-20 or AQC without the eight items rating the EOT dimension.

Emotion dysregulation in hypochondriasis and depression

BACKGROUND

The aim of this study was to explore whether certain aspects of emotion dysregulation (i.e., facets of alexithymia and rumination) are more closely linked to hypochondriasis than to depression and vice versa.

METHODS

Nineteen patients with hypochondriasis (HYP), 33 patients with depression, and 52 healthy control participants completed the Toronto Alexithymia Scale, the Response Styles Questionnaire, and additional symptom and illness behaviour scales. A clinical interview was used to establish DSM-IV diagnoses and to exclude all cases with more than one axis I diagnosis.

RESULTS

Depression patients reported more difficulties describing feelings and more symptom- and self-focused rumination than both HYP patients and healthy individuals, whereas HYP patients differed only from healthy individuals in regard to more difficulties in identifying feelings and more symptom-focused rumination. Multiple regression analyses, including all assessed facets of emotion dysregulation, showed that the degree of somatoform features (somatic symptoms, health anxiety, and illness behaviour) was specifically predicted by higher difficulties in identifying feelings scores, whereas depressive symptom levels were specifically predicted by higher rumination scores.

CONCLUSIONS

Specific associations were found between difficulties in identifying feelings and key features of HYP, whereas depression was linked to a more generalized pattern of emotion regulation deficits.

KEY PRACTITIONER MESSAGE

Emotion dysregulation can be found in hypochondriasis and depression Difficulties in identifying own feelings are specifically linked to somatic symptoms, health anxiety, and illness behaviour, whereas a more generalized pattern of emotion dysregulation is found in relation to depression Further research is needed to investigate whether the effectiveness of current treatments for depression, hypochondriasis, health anxiety, and related disorders could be improved by additional emotion regulation interventions.

A systematic review of the association between emotions and eating behaviour in normal and overweight adult populations

A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of four electronic databases (2004–2015) yielded 60,017 articles, of which 29 met inclusion criteria. Included studies performed poorly on data quality analysis in terms of randomisation and controlling for confounding factors. Participant’s body mass index scores range from 19.73 (standard deviation = 1.54) to 28.4 (standard deviation = 1.4) kg/m2. Where positive and negative affects were compared, food was more likely to be consumed in response to positive affect. With regard to discrete emotions; stress, depression and sadness consistently elicited eating behaviours that fall outside of nutritional recommendations (e.g. increased food intake or poor nutritional food choices). The role of moderators including individual differences in dietary restraint and emotional eating, as well as methodological considerations, such as means of eliciting and measuring emotions, may account for equivocality with regard to some emotion and eating associations. This article concludes with recommendations for future research and implications for practice.

Suicidality in patients with somatoform disorder - the speechless expression of anger?

OBJECTIVE

To identify emotion-associated risk factors for suicidality in patients with somatoform disorders.

METHODS

A sample of 155 consecutive patients diagnosed with somatoform disorders at the Psychosomatic Ambulance of Bonn University Hospital filled in several questionnaires including the Symptom Checklist 90-Revised Version (SCL-90-R), the Toronto Alexithymia Scale (TAS-20), and the State Trait Anger Expression Inventory (STAXI). Our aim was to compare patients with suicide attempts to patients without suicide attempts via a MANCOVA (IV: Group; DV: SCL-90-R, TAS-20, STAXI; covariates: sex, age, depression, borderline personality disorder).

RESULTS

Lifetime suicide attempts were documented in 20 patients (12.9%), current active suicidal ideation in 33.6%, and thoughts of death or dying in 55.9%. Patients with lifetime suicide attempts showed significantly more psychological distress, a significantly higher alexithymia sum score, a significantly higher score on trait anger, state anger, and a stronger tendency to express anger.

CONCLUSION

Somatoform disorder patients with lifetime suicide attempts might have greater difficulties in identifying and describing emotions, and a tendency to intensely experience and express anger. Future longitudinal studies should further investigate possible links between difficulties in coping with anger and suicidality to improve prophylaxis and treatment of suicidal behaviour in somatoform disorder patients.

Testing a Model of Functional Impairment in Telephone Crisis Support Workers

BACKGROUND

It is well known that helping professionals experience functional impairment related to elevated symptoms of psychological distress as a result of frequent empathic engagement with distressed others. Whether telephone crisis support workers are impacted in a similar way is not currently reported in the literature.

AIMS

The purpose of this study was to test a hypothesized model of factors contributing to functional impairment in telephone crisis support workers.

METHOD

A national sample of 210 telephone crisis support workers completed an online survey including measures of emotion regulation, symptoms of general psychological distress and suicidal ideation, intentions to seek help for symptoms, and functional impairment. Structural equation modeling was used to test the fit of the data to the hypothesized model.

RESULTS

Goodness-of-fit indices were adequate and supported the interactive effects of emotion regulation, general psychological distress, suicidal ideation, and intentions to seek help for ideation on functional impairment.

CONCLUSION

These results warrant the deliberate management of telephone crisis support workers' impairment through service selection, training, supervision, and professional development strategies. Future research replicating and extending this model will further inform the modification and/or development of strategies to optimize telephone crisis support workers' well-being and delivery of support to callers.

Alexithymia, but not autism spectrum disorder, may be related to the production of emotional facial expressions

Background

A prominent diagnostic criterion of autism spectrum disorder (ASD) relates to the abnormal or diminished use of facial expressions. Yet little is known about the mechanisms that contribute to this feature of ASD.

Methods

We showed children with and without ASD emotionally charged video clips in order to parse out individual differences in spontaneous production of facial expressions using automated facial expression analysis software.

Results

Using hierarchical multiple regression, we sought to determine whether alexithymia (characterized by difficulties interpreting one’s own feeling states) contributes to diminished facial expression production. Across groups, alexithymic traits—but not ASD traits, IQ, or sex—were associated with quantity of facial expression production.

Conclusions

These results accord with a growing body of research suggesting that many emotion processing abnormalities observed in ASD may be explained by co-occurring alexithymia. Developmental and clinical considerations are discussed, and it is argued that alexithymia is an important but too often ignored trait associated with ASD that may have implications for subtyping individuals on the autism spectrum.

The impact of emotion awareness and regulation on social functioning in individuals at clinical high risk for psychosis

BACKGROUND

Social functioning (SF) difficulties are ubiquitous among individuals at clinical high risk for psychosis (CHR), but it is not yet clear why. One possibility is suggested by the observation that effective SF requires adaptive emotion awareness and regulation. Previous reports have documented deficits in emotion awareness and regulation in individuals with schizophrenia, and have shown that such deficits predicted SF. However, it is unknown whether these deficits are present prior to the onset of psychosis or whether they are linked to SF in CHR individuals.

METHOD

We conducted a cross-sectional comparison of emotion awareness and regulation in 54 individuals at CHR, 87 with schizophrenia and 50 healthy controls (HC). Then, within the CHR group, we examined links between emotion awareness, emotion regulation and SF as indexed by the Global Functioning Scale: Social (Cornblatt et al. 2007).

RESULTS

Group comparisons indicated significant differences between HC and the two clinical groups in their ability to identify and describe feelings, as well as the use of suppression and reappraisal emotion-regulation strategies. Specifically, the CHR and schizophrenia groups displayed comparable deficits in all domains of emotion awareness and emotion regulation. A hierarchical multiple regression analysis indicated that difficulties describing feelings accounted for 23.2% of the SF variance.

CONCLUSIONS

The results indicate that CHR individuals display substantial emotion awareness and emotion-regulation deficits, at severity comparable with those observed in individuals with schizophrenia. Such deficits, in particular difficulties describing feelings, predate the onset of psychosis and contribute significantly to poor SF in this population.

Associations among Alexithymia, Positive and Negative Emotions, and Self-Defeating Personality

This study examined the associations among 210 college students' alexithymia scores and three emotional orientation scores. Students completed the following three self-report instruments: 20-item Toronto Alexithymia Scale, 20-item Positive and Negative Affect Scale, and 24-item Self-defeating Personality Scale. As predicted, a linear regression model indicated that alexithymia was associated with negative emotional activation, self-defeating personality, and inversely associated with positive emotional activation. These three affect orientations accounted for 27% of the variance associated with subjects' cognitive-affective communication difficulties expressing their emotions. A second linear regression model indicated that negative emotion activation was significantly associated with self-defeating personality, and positive emotion activation was significantly inversely associated with self-defeating personality.

Association between the Catechol-O-Methyltransferase (COMT) Val¹⁵⁸Met Polymorphism and Alexithymia in Patients with Obsessive-Compulsive Disorder

PURPOSE

Alexithymia, defined as a deficit in the ability to recognize and describe one's own feelings, may be related to the development and maintenance of obsessive-compulsive symptoms. The aim of this study was to evaluate the association between the catechol-O-methyltransferase (COMT) Val¹⁵⁸Met polymorphism and alexithymia in patients with obsessive-compulsive disorder (OCD).

MATERIALS AND METHODS

We recruited 244 patients with OCD (169 males, 75 females). Alexithymia was assessed using the 20-item Toronto Alexithymia Scale (TAS-20), and genotyping of the COMT Val¹⁵⁸Met polymorphism was evaluated.

RESULTS

Patients with the COMT Val/Val genotype had significantly higher total and "difficulty identifying feelings" (DIF) subdimension scores than those with the Val/Met or Met/Met genotypes. Patients with the COMT Val/Val genotype had significantly higher "difficulty describing feelings" (DDF) subdimension scores than those with the COMT Val/Met genotype. However, there were no differences in the scores for the "externally oriented thinking" (EOT) subdimension among the three genotypes.

CONCLUSION

These results indicate that the high-activity Val allele of the COMT Val¹⁵⁸Met polymorphism is associated with increased alexithymic traits in patients with OCD. The present finding suggests that alexithymia is an endophenotype of OCD that is mediated by the COMT Val¹⁵⁸Met polymorphism.

Exploring Anger Among Offenders: The Role of Emotion Dysregulation and Alexithymia

This study tests whether specific dimensions of emotion dysregulation predict maladaptive anger expression among offenders from Italy and Australia. In particular, it examines the unique associations among emotion dysregulation dimensions and different aspects of anger expression and control, in both inmates and offenders on parole. Multiple regression analyses reveal that difficulties controlling impulsive behaviour when distressed are related to state anger, trait anger, and chronic anger expression. On the other hand, alexithymia predicts the maladaptive expression of anger inwardly directed. Finally, lack of emotional awareness and limited access to emotion regulation (ER) strategies are negatively related to anger control, suggesting that they may represent useful treatment targets. Interestingly, incarcerated offenders reported significantly higher levels of state anger and lower levels of anger control out (i.e. seeking support from others) than offenders living on parole in the community, highlighting the importance of contextual influences in the emotional life of offenders.

Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Understanding the role of personality and alexithymia in food preferences and PROP taste perception

Taste perception and food preferences are influenced by a variety of factors, including personality characteristics. The aims of this study were to examine the role of personality characteristics, such as alexithymia (a personality construct characterized by inability to identify, describe, and work with one's own feelings), in: 1) taste responses to the bitter genetic taste-marker PROP and 2) food liking. We studied 649 healthy subjects residing in six genetically-isolated villages of Northeast Italy. Data on PROP taste responsiveness, food liking, personality characteristics and TAS2R28 genotypes were collected. Results showed that PROP non-tasters had higher alexithymia scores than PROP tasters. Moreover, the presence of alexithymia in heterozygous individuals for the rs1726886 polymorphism of the TAS2R38 gene was associated with a reduction in the perceived intensity of PROP. Finally, higher alexithymia scores were associated with liking of alcohol, sweets and fats/meats whereas lower alexithymia scores were related to liking of vegetables, condiments and strong cheeses, Measures of temperament, character, anxiety and depression were also related to food liking. Our findings suggest that: 1) alexithymia, in addition to the TAS2R38 polymorphism, may play a role in responsiveness to the aversive and bitter taste of PROP; and 2) alexithymia, in combination with other personality traits, may provide important insights for better understanding food liking.

A study examining the relationship between alexithymia and challenging behaviour in adults with intellectual disability

BACKGROUND

Research suggesting that people with intellectual disabilities (ID) have difficulties in recognising emotions provides a rationale for studying alexithymia in this population. A number of studies have found a relationship between alexithymia and challenging behaviours in various populations and this study aims to discover if this is the case for people with ID.

METHOD

Cross-sectional data were collected from 96 participants with ID and 95 of their carers. The service user participants completed an alexithymia questionnaire for children while carers completed the checklist for challenging behaviour and the observer alexithymia scale. Correlational analyses were employed to explore relationships between the variables.

RESULTS

The relationship between service user and carer-rated alexithymia was very weak. The analysis did show significant associations between observer-rated alexithymia and challenging behaviour frequency, management difficulty and severity, but there was no significant relationship between challenging behaviour and alexithymia as rated by service users themselves.

CONCLUSIONS

This study suggests that observer-rated alexithymia is important in understanding challenging behaviour presented by people with ID. Service user-rated alexithymia had no association with challenging behaviour, in contrast to the results from similar research with other challenging populations.

Theory of Mind and Emotional Awareness in Chronic Somatoform Pain Patients

Objective

The present study aimed at investigating whether chronic pain patients are impaired in Theory of Mind (ToM), or Emotional Awareness.

Methods

Thirty inpatients suffering from chronic somatoform pain, as well as thirty healthy controls matched for age, sex, and education were recruited. ToM abilities were measured using the Frith-Happé animation task, in which participants interpret video-clips depicting moving geometric forms that mimic social interactions. The responses given were scored for appropriateness and the degree of inferred intentionality according to established protocols. Emotional awareness was measured using the Levels of Emotional Awareness Scale (LEAS), for which participants provide written descriptions of feelings in imaginary emotional situations. Standardized scoring was performed to capture the number and quality of emotional terms used.

Results

Responses lengths were similar in both groups and for both tasks. Patients attained significantly lower intentionality but not appropriateness scores when interpreting ToM interactions. No significant group differences were found when interpreting goal directed interactions. Emotional awareness scores were significantly lower in patients compared to healthy controls.

Conclusions

Our results suggest that chronic pain patients are impaired in mentalizing and emotional awareness. Future studies are needed to determine whether these ToM and emotional awareness deficits contribute to the etiology of somatoform pain and whether addressing these deficits in therapeutic interventions can improve polymodal pain therapy.

Metabolic mapping reveals sex-dependent involvement of default mode and salience network in alexithymia

Alexithymia, a personality construct marked by difficulties in processing one's emotions, has been linked to the altered activity in the anterior cingulate cortex (ACC). Although longitudinal studies reported sex differences in alexithymia, what mediates them is not known. To investigate sex-specific associations of alexithymia and neuronal markers, we mapped metabolites in four brain regions involved differentially in emotion processing using a point-resolved spectroscopy MRS sequence in 3 Tesla. Both sexes showed negative correlations between alexithymia and N-acetylaspartate (NAA) in pregenual ACC (pgACC). Women showed a robust negative correlation of the joint measure of glutamate and glutamine (Glx) to NAA in posterior cingulate cortex (PCC), whereas men showed a weak positive association of Glx to NAA in dorsal ACC (dACC). Our results suggest that lowered neuronal integrity in pgACC, a region of the default mode network (DMN), might primarily account for the general difficulties in emotional processing in alexithymia. Association of alexithymia in women extends to another region in the DMN-PCC, while in men a region in the salience network (SN) was involved. These observations could be representative of sex specific regulation strategies that include diminished internal evaluation of feelings in women and cognitive emotion suppression in men.

The Relation of Alexithymic Traits to Affective Theory of Mind

Little research has focused on the contributors to adult theory of mind (ToM) even though there is reason to suspect individual differences in performance in neurotypical samples. Alexithymia, a term that references an impaired ability to attend to and verbally label emotions via ongoing introspection, is a useful construct through which to explore how socially relevant dimensions of emotion processing enable ToM. As 1 study has explored alexithymia vis-à-vis cognitive ToM, this study examined the relationships between facets of alexithymia and affective ToM while controlling for the potential confounds of empathy, verbal ability, and negative affect. A nonclinical sample of adults (N = 86) completed the Toronto Alexithymia Scale, the Reading the Mind in the Eyes Test, the Mehrabian and Epstein Scale of Emotional Empathy, the Profile of Mood States, and the Wechsler Abbreviated Scale of Intelligence. Hierarchical regression analysis showed that externally oriented thinking contributed unique variance to affective ToM, confirming an inverse relationship between alexithymia and affective ToM but highlighting the need to parse alexithymia into discrete facets when exploring its relevance to social cognition.

Engagement in dance is associated with emotional competence in interplay with others

This study has explored the relation between dance achievement and alexithymia in a larger Swedish population sample (Swedish Twin Registry) with a study sample of 5431 individuals. Dance achievement (CAQ) was assessed in relation to Alexithymia (Toronto Alexithymia Scale, TAS-20) including the three subscales: Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), and Externally Oriented Thinking (EOT). The results show a significant negative association between the TAS subscale (EOT) and creative achievement in dance. A high EOT score corresponds to poor ability to communicate feelings to the environment. There was no consistent association between the other factors DIF and DDF and dance achievement. Dance activity and training seem to be involved in the body’s emotional interplay with others. Embodied cognition, emotional perception, and action are discussed as factors relevant to measuring the skill of a dancer.

How do maternal PTSD and alexithymia interact to impact maternal behavior?

Maternal interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) is known to be associated with impairment of a mother's capacity to participate in mutual emotion regulation during her child's first years of life. This study tested the hypothesis that maternal difficulty in identifying feelings in self and other, as an important dimension of the construct of alexithymia, together with maternal IPV-PTSD, would be negatively associated with maternal sensitivity. Maternal sensitivity to child emotional communication is a marker of maternal capacity to engage in mutual regulation of emotion and arousal. Following diagnostic interviews and administration of the Toronto Alexithymia Scale, 56 mothers and their toddlers (ages 12-42 months) were filmed during free-play and separation/novelty-exposure. Observed maternal sensitivity was coded via the CARE-Index. Maternal IPV-PTSD severity, difficulty in identifying emotions, and lower socio-economic status were all associated with less maternal sensitivity, and also with more maternal controlling and unresponsive behavior on the CARE-Index.

Alexithymia in anorexia nervosa: the mediating role of depression

The role of depression in the expression of alexithymia in anorexia nervosa (AN) has been controversially explained and several variables that may mask or increase the presence of emotional difficulties have scant examination in previous studies. This study aims to analyze the associations between alexithymia and state variables, such as age, BMI, illness duration, treatment duration, and medication status in AN participants, and to test the mediating role of depression in emotional difficulties. The Toronto Alexithymia Scale (TAS-20) and the Zung Self-Rating Depression Scale were administrated to 160 females: 80 participants with AN and 80 healthy controls. High levels of alexithymia were not a function of state variables. The mediating role of depression differed by the alexithymia dimension, with total mediation found for the TAS-DDF and partial mediation found for the TAS-DIF. Alexithymia is a relevant feature throughout the spectrum of AN and does not seem to be related to developmental maturation and some clinical features. Depression is probably the variable that best accounts for the variance in alexithymia, but is not a complete explanation for the known cognitive-affective disturbances in AN. Specific emotional competencies require scrutiny during psychiatric treatment.

The Relationship between Alexithymia and Intolerance of Uncertainty in Anorexia Nervosa

BACKGROUND

Alexithymia and intolerance of uncertainty (IU) are relevant factors in social and emotional processing abilities in anorexia nervosa (AN) eventually rendering emotional coping difficult. However, the link potentially existing in AN between IU and alexithymia has been so far understudied.

SAMPLING AND METHODS

Sixty-one patients affected by AN and 59 healthy controls (HC) were enrolled and assessed for study purposes. All participants completed the following self-report questionnaires: Intolerance of Uncertainty Scale, State Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI) and Toronto Alexithymia Scale.

RESULTS

IU and alexithymia were greater in patients with AN when compared to HC. Moreover, in both AN and HC groups, IU and alexithymia significantly correlated with each other as well as with anxiety (STAI score) and depression (BDI score). No correlations were found between alexithymia and age. Patients' duration of illness was negatively correlated with two alexithymia subscales. After adjusting for anxiety, depression, body mass index and duration of illness (for AN), the correlation between IU and alexithymia remained significant.

CONCLUSIONS

In addition to confirming previous findings on marked levels of IU and alexithymia in AN, this study showed for the first time a correlation between IU and alexithymia in both AN and HC. Moreover, this result remained significant after controlling for a number of clinical variables. Taken together, these findings may have useful clinical implications for the treatment of AN sufferers. © 2015 S. Karger AG, Basel.

Global stress response during a social stress test: impact of alexithymia and its subfactors

OBJECTIVES

Alexithymia is a personality trait characterized by difficulties in identifying, describing and communicating one's own emotions. Recent studies have associated specific effects of this trait and its subfactors with hypothalamo-pituitary-adrenal (HPA) axis markers during stress. The aim of this study was to analyze the association between alexithymia and its subfactors with HPA and sympatho-adrenal medullar (SAM) activity. Stress was induced experimentally using a public-speaking paradigm. Salivary cortisol, alpha-amylase (AA), chromogranin A (CgA) and heart rate (HR) were collected during the defined periods of baseline, stress, and recovery in 19 males and 24 female healthy university students.

RESULTS

Subjects reacted to the stressor with a significant cortisol and SAM response. Subjects scoring high on alexithymia reacted significantly more intensely than low scorers in basal anticipatory as well as peak cortisol and area under the curve. Regression analyses revealed that the increased HPA activity was related to only one alexithymia subfactor, the difficulty in differentiating feelings and distinguishing them from bodily sensations and emotion arousal.

CONCLUSION

Alexithymia and its subfactors were specifically related to cortisol responses. This research should be replicated with more subjects and should take into account more parameters reflecting sympathetic and/or parasympathetic activation, as well as HPA axis. Factors such as coping strategies and the perception of the situation as a challenge have also to be explored.

Disease control in patients with asthma is associated with alexithymia but not with depression or anxiety

This observational cohort study investigated the relationship between alexithymia, coping strategies, anxiety, depression, pulmonary function, and disease control in bronchial asthma (BA) patients who attended a tertiary care center between December 2010 and November 2011. Participants (N = 117) were administered self-report scales measuring anxiety, depression, alexithymia, and coping strategies. Pulmonary function expressed as forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), forced expiratory flow rate over the middle 50% of the FVC (FEF25-75) as% predicted and FEV1/FVC as%, fractional exhaled nitric oxide (FeNO) in ppb and the Asthma Control Test (ACT) were recorded. A hierarchical cluster analysis revealed two clusters of patients with different FEV1 values (p < .001) and alexithymia scores (p < .001). The cluster with lower FEV1 and higher alexithymia used more maladaptive coping strategies (p < .05), and had lower ACT scores (p < .05). Alexithymia was significantly associated with the severity of depression and anxiety symptoms (p < .001 for each comparison). In BA patients, alexithymia was associated with worse pulmonary function and disease control and a more frequent use of maladaptive coping strategies. These results support a multidimensional approach to asthmatic patients, including psychoeducational and behavioral interventions aimed at reducing maladaptive coping strategies.

Anxiety sensitivity and alexithymia as mediators of postconcussion syndrome following mild traumatic brain injury

OBJECTIVE

To examine the influence of anxiety sensitivity (AS) and alexithymia as potential mediators for the development of psychological distress and postconcussion syndrome after mild traumatic brain injury (mTBI).

PARTICIPANTS

Sixty-one patients with mTBI assessed at a mean of 2.38 weeks after injury and demographically matched healthy controls (n = 61).

MEASURES

Twenty-item Toronto Alexithymia Scale, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, and Rivermead Post Concussion Questionnaire.

RESULTS

The mTBI group reported significantly higher levels of AS, alexithymia, psychological distress, and postconcussion (PC) symptom scores than controls. High AS and alexithymia in the mTBI group were associated with a greater number of PC symptoms and higher levels of psychological distress than patients scoring low on these measures and controls. In the mTBI group, a combination of AS and low mood explained 52.6% of the variance in PC symptom reporting. A combination of trait-anxiety, alexithymia, and PC symptoms explained 77.2% of the variance in levels of mood.

CONCLUSION

A combination of low mood and high AS may act as a psychological diathesis for the development of persisting PC symptoms. Early identification could provide a focus for early intervention to prevent the development of postconcussion syndrome after mTBI.