Validation of a Greek adaptation of the 20-item Toronto Alexithymia Scale

Alexithymia in Patients with Somatization Difficulties and Tinnitus-Related Distress: A Systematic Review

Chronic tinnitus, the perception of sound without an external source, can significantly affect individuals' well-being. As an often medically unexplained symptom, chronic tinnitus can present as a "somatoform" or "functional" difficulty. Some evidence has pointed to alexithymia as a transdiagnostically relevant risk factor for both symptom clusters. Using a two-part rapid review-searching within EBSCO, Embase by Ovid, PubMed, Web of Science-we summarize psychological studies regarding alexithymia, i.e., difficulties in recognizing and expressing emotions and (1) somatoform conditions and (2) chronic tinnitus. For the former (inclusion criteria: (1) adult human beings with different kinds of somatization, (2) longitudinal study designs, (3) publication between 2001 and 2021, (4) full-text in English or German) we identified eight studies that revealed significant links between alexithymia and somatoform conditions. Psychotherapy improved alexithymia in most studies. Additionally, alexithymia was associated with broader treatment outcomes such as improvements in pain intensity, gastrointestinal symptoms, and patient-therapist alliance. The 'Risk Of Bias In Non-randomized Studies-of Interventions' tool (ROBINS-I) and 'Revised Cochrane risk-of-bias tool for randomized trials' (RoB 2) were used for risk of bias assessment. Summarizing all available studies on alexithymia and chronic tinnitus, we identified three studies. Inclusion criteria were: (1) adult human beings with chronic tinnitus, (2) publication between 2001 and 2021, (3) full-text in English or German. Risk of bias was assessed by the 'JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies'. The available studies suggested a high rate of alexithymia (65.7%) in patients with chronic tinnitus. Tinnitus-related distress was significantly associated with alexithymia in two studies, one of which, however, found no differences in alexithymia between patients with bothersome versus non-bothersome tinnitus. Conversely, one study reported high levels of alexithymia in patients with low levels of tinnitus-related distress. Overall, alexithymia may be a transdiagnostic psychological indicator of somatization phenomena, which might include some chronic tinnitus presentations. Psychotherapy likely improves alexithymia as well as somatoform symptom presentations.

Assessing Alexithymia across Asian and Western Cultures: Psychometric Properties of the Perth Alexithymia Questionnaire and Toronto Alexithymia Scale-20 in Singaporean and Australian Samples

Alexithymia refers to difficulties identifying feelings (DIF), describing feelings (DDF), and externally orientated thinking (EOT). Originally conceptualized by American psychiatrists, some researchers have since questioned the validity and application of this construct in Asian cultures. However, to date, there is little empirical work formally assessing the invariance of alexithymia across Asian and Western cultures. The present study aimed to help address this gap, by examining the psychometric properties and measurement invariance of two alexithymia measures, the Perth Alexithymia Questionnaire (PAQ) and Toronto Alexithymia Scale-20 (TAS-20), across samples from Singapore (n = 434) or Australia (n = 489). The same theoretically congruent factor structure was supported across both samples; this structure was fully invariant across samples for the PAQ, and partially invariant for the TAS-20. Both measures had good internal consistency and concurrent validity across samples, except the TAS-20 EOT subscale which had low internal consistency and factor loadings in both samples. The Singaporean sample reported higher DIF and DDF for positive emotions than the Australian sample. Overall, our results support the cross-cultural validity and application of the alexithymia construct. The PAQ and TAS-20 both appear to have good utility in this respect, though the PAQ may provide a more detailed facet-level profile.

Psychopathology and Alexithymia in Patients with Moderate-to-Severe Psoriasis: Development of a Novel Index with Prognostic Value

BACKGROUND

Psoriasis is a chronic, relapsing, inflammatory disease with a high risk of developing mental health difficulties.

OBJECTIVE

The purposes of the study were to evaluate in moderate-to-severe psoriasis (a) the prevalence of depression and psychopathology, (b) the relationship between depression, psychopathology symptoms, and alexithymia, including its three dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF), and externally oriented thinking (EOT), and (c) to establish a novel index for the development of depression according to patients' psychopathological profile.

METHODS

In 104 patients, alexithymia was evaluated with the Toronto Alexithymia Scale (TAS-20), depression with the Beck Depression Inventory (BDI), and psychopathology with the Brief Symptom Inventory SCL-90 (SCL90). A psychopathology index that combines information from the BDI and SCL90 scales was constructed and the performance of the index with alexithymia was examined.

RESULTS

Female patients and active smokers score higher on BDI and SCL90 scales. Overweight patients tend to score arithmetically higher. The psychopathology index developed correlates significantly with age, DIF, DDF, and TAS-20. DIF, DDF, and TAS-20 are significant predictors of the psychopathology index. Patients with alexithymia/possible alexithymia are six times as likely to score higher in one of the psychopathology scales.

CONCLUSIONS

Alexithymia is a significant factor in the development of psychopathology in psoriasis patients. The use of the proposed novel psychopathology index could be essential in order to identify patients with moderate-to-severe psoriasis who are more likely to experience depression and psychopathology. This could have an impact on the decision-making of psoriasis treatment and monitoring of the patient.

Twenty-five years with the 20-item Toronto Alexithymia Scale

OBJECTIVE

Twenty-five years ago, this journal published two articles reporting the development and initial validation of the 20-Item Toronto Alexithymia Scale (TAS-20). Since then the literature on alexithymia has burgeoned with the vast majority of this research using the TAS-20, including multiple language translations of the scale.

METHOD

In this article we review the psychometric literature evaluating various aspects of the reliability and validity of the TAS-20 and examine some of the controversies surrounding the scale and the construct it assesses. We reflect on the ways in which the TAS-20 has advanced the measurement of the construct and theory of alexithymia. We also discuss recent developments and some future directions for the measurement of alexithymia.

RESULTS

Although not without some controversy, the preponderance of the accumulated evidence over a 25-year period supports various aspects of the reliability and validity of the TAS-20, including findings from confirmatory factor analytic and convergent and discriminant validity studies which are consistent with Nemiah et al.'s (Nemiah et al., 1976 [3]) and Taylor and colleagues (Taylor et al., 1997 [9]) theoretical formulations and definition of the alexithymia construct.

CONCLUSIONS

Based on the accumulated empirical evidence of 25 years, we conclude that the TAS-20 is a reliable and valid instrument and accurately reflects and measures the construct as it was originally defined by Nemiah et al. Nemiah et al. (1976) [3] as composed of deficits in affect awareness and expression and pensée opératoire (operational thinking). Clinicians and researchers can use the TAS-20 to confidently measure alexithymia, the roots of which have foundations in psychosomatic medicine.

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) in Brazil

Internationally, the most widely used self-report instrument to assess alexithymia (a clinical condition characterized by serious deficits in the cognitive processing of emotions) is the Toronto Alexithymia Scale (TAS-20). Because this measure has been poorly investigated in Brazil and emerging research suggests that TAS-20 scores might vary from one culture to another, we sought to: (1) investigate the psychometric properties of a Brazilian TAS-20; and (2) examine the degree to which Brazilian non-clinical TAS-20 scores differ from the scores of non-clinical samples from other cultures. A sample of 850 non-clinical Brazilian adults were administered a number of questionnaires and performance-based measures via online data collection. Data analyses inspected internal consistency and factor structure of the TAS-20, and tested the association of TAS-20 scores to emotional functioning and psychopathology. In line with previous international research, the Brazilian TAS-20 showed acceptable to adequate psychometric properties. Furthermore, TAS-20 scores associated negatively with empathy and emotional perception, and positively with emotion dysregulation and personality traits like dependency, abrupt changes in mood, and avoidance of criticism. Also noteworthy, our non-clinical Brazilian TAS-20 scores were very similar to those observed in other previously published non-clinical TAS-20 scores from seven non-Brazilian cultures.

Toronto Alexithymia Scale-20: Examining 18 Competing Factor Structure Solutions in a U.S. Sample and a Philippines Sample

The Toronto Alexithymia Scale-20 is arguably the most utilized measure of alexithymia. Although a three-factor solution has been found by numerous studies, these findings are not universal. This article examined and compared 18 competing factor structures for the Toronto Alexithymia Scale-20, which included between one and four correlated latent factor structures, common methods models that accounts for negatively worded items, and bifactor models. Although the two-factor bifactor model with a common methods factor had the better model fit compared with the other 17 models examined, it still did not achieve the requisites of a good model fit across all model fit indices. Issues stemmed primarily from the externally oriented thinking factor and the negatively worded items. Post hoc analyses indicated that a two-factor bifactor model with the negatively worded items dropped achieved the requisites of a good model fit and can be treated as a unidimensional measure despite the presence of multidimensionality. Multiple-group analysis indicated that the factor loadings were invariant across U.S. and Philippines samples. After controlling for noninvariance at the item intercept level, the Philippines sample had a higher alexithymia general score compared with the U.S. sample.

Measurement Invariance of English and French Language Versions of the 20-Item Toronto Alexithymia Scale

Abstract. The alexithymia construct is commonly measured with the 20-Item Toronto Alexithymia Scale (TAS-20), with more than 20 different language translations. Despite replication of the factor structure, however, it cannot be assumed that observed differences in mean TAS-20 scores can be interpreted similarly across different languages and cultural groups. It is necessary to also demonstrate measurement invariance (MI) for language. The aim of this study was to evaluate MI of the English and French versions of the TAS-20 using data from 17,866 Canadian military recruits; 71% spoke English and 29% spoke French as their first language. We used confirmatory factor analyses (CFAs) to establish a baseline model of the TAS-20, and four increasingly restrictive multigroup CFA analyses to evaluate configural, metric, scalar, and residual error levels of MI. The best fitting factor structure in both samples was an oblique 3-factor model with an additional method factor comprised of negatively-keyed items. MI was achieved at all four levels of invariance. There were only small differences in mean scores across the two samples. Results support MI of English and French versions of the TAS-20, allowing meaningful comparisons of findings from investigations in Canadian French-speaking and English-speaking groups.

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.

Psychopathology and alexithymia in patients with psoriasis

Background

Psoriasis is a chronic, inflammatory, relapsing skin disease that has a psychosocial impact on the patients' life.

Objective

This study aimed to investigate psychopathology in patients with psoriasis based on a valid psychometric instrument, as well as on the relationship between psychopathology and alexithymia.

Methods

108 patients with psoriasis were included in the study. Psychopathology was evaluated with the Symptom Checklist-90-Revised (SCL-90-R) and alexithymia with the Toronto Alexithymia Scale (TAS-20). Disease severity was clinically assessed using the Psoriasis Area and Severity Index.

Results

As regards the psychopathological dimensions, female patients presented with statistically significant higher somatization, depression, anxiety, phobic anxiety, and psychoticism than males. Patients with alexithymia presented with statistically significant higher somatization, interpersonal sensitivity, anxiety, and phobic anxiety than non-alexithymic patients. Alexithymia positively correlated with somatization (r = 0.26, p < 0.01), interpersonal sensitivity (r = 0.24, p < 0.05), depression (r = 0.27, p < 0.01), anxiety (r = 0.26, p < 0.01), and phobic anxiety (r = 0.26, p < 0.01). In addition, alexithymia also contributed to the prediction of these conditions.

Study Limitations

A larger study sample could yield safer generalized results. Nevertheless, to the best of our knowledge, this was the first study to investigate various psychopathological dimensions in patients with psoriasis.

Conclusions

Our study results indicate that alexithymia and female sex were associated with several psychopathological dimensions in patients with psoriasis. It may be suggested that alexithymia constitutes an important factor in the development of mental disorders among patients with psoriasis.

Do alexithymic individuals avoid their feelings? Experiential avoidance mediates the association between alexithymia, psychosomatic, and depressive symptoms in a community and a clinical sample

OBJECTIVE

Alexithymia is defined as the trait associated with difficulty in identifying and describing feelings as well as poor fantasy and imagery. While alexithymia is related to psychopathology in general, it has been associated with increased reporting of medically unexplained symptoms and depression in particular. This study attempts to assess the extent to which alexithymia represents a learned, avoidant coping strategy against unwanted emotions. In this way the study aims to identify a potential mechanism that may elucidate the relationship between alexithymia and psychological symptoms.

METHOD

Alexithymia is examined in two different samples, students from two universities in Cyprus and intensive outpatients/residents in an American anxiety disorder treatment program. We examine whether alexithymia predicts psychosomatic and depressive symptoms respectively through the mediating role of experiential avoidance, a coping mechanism believed to be reinforced because of the immediate relief it provides.

RESULTS

Experiential avoidance was found to correlate strongly with alexithymia, especially its difficulty in identifying feelings factor, while the mediation hypothesis was supported in all models tested. Furthermore, results from the clinical sample suggest that clinical improvement in depression was associated with a decrease in alexithymia, especially difficulty in identifying feelings, mediated by decreased experiential avoidance.

CONCLUSIONS

Alexithymia, and more specifically its difficulty in identifying feelings aspect, may be a learned behavior used to avoid unwanted emotions. This avoidant behavior may form the link between alexithymia and psychopathology. Implications for alexithymia theory and treatment are discussed.

Toronto alexithymia scale for patients with eating disorder: [corrected] performance using the non-parametric item response theory

BACKGROUND

The aim of this study was to investigate the performance of the Toronto Alexithymia Scale (TAS-20) in patients with eating disorders. As a secondary objective, we analyzed a subset of items in order to determine whether the total score is a good tool for classifying these patients and whether the items are ordered according to the difficulty of choosing a particular answer depending on the severity of the patient's condition.

SUBJECTS AND METHODS

We administered the TAS-20 to 103 consecutive patients who met DSM-IV-R criteria for anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified. Mokken scale analysis, nonparametric item response theory (NIRT), and confirmatory factor analysis (CFA) were used to test the psychometric properties of the scale. To improve our understanding of the structure underlying the TAS-20, we used an automated item selection procedure based on the Mokken scale.

RESULTS

We identified a subset of 13 independent and clinically interpretable items that are potentially sufficient to rate patients with alexithymia. This subset was considered a unidimensional reduction of the TAS-20. However, the scale composed of this subset needs to be validated. Thirteen of the 20 items were maximally related to alexithymia because they have a one-dimensional structure. The NIRT and CFA enabled us to identify a maximal subset of items that conform to the requirements for good measurement of alexithymia in patients with eating disorders.

Alexithymia, anxiety and depression in patients with psoriasis: a case-control study

BACKGROUND

Alexithymia, the difficulty in describing or recognizing emotions, has been associated with various psychosomatic pathologies including psoriasis. The aim of this study was to examine the prevalence of alexithymia and its association with anxiety and depression in patients with psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables.

METHODS

One hundred and eight psoriatic patients and 100 healthy participants from the general population completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS). The severity of patients' psoriasis was clinically assessed using the Psoriasis Area and Severity Index (PASI).

RESULTS

Psoriatic patients had higher levels of alexithymia compared with healthy participants. While a rather high rate of psoriatic patients presented anxiety and depression as defined by the HADS, the differences that were found in comparison with the control group were not significant. Neither alexithymia nor its dimensions, difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT), were associated with gender or psoriasis severity. Age was associated only with EOT, which was independent of depression and anxiety. Higher anxiety and depression were connected with higher alexithymia and DIF, while higher anxiety with higher DDF as well.

CONCLUSIONS

The alexithymia prevalence was higher in psoriatic patients than that in healthy participants, while it was positively correlated with anxiety and depression. Difficulty in identifying feelings was connected with both anxiety and depression, whereas difficulty in describing them was only with anxiety. Finally, externally oriented thinking was predicted only from age.

Sub-optimal parenting is associated with schizotypic and anxiety personality traits in adulthood

Part of the variation in personality characteristics has been attributed to the child-parent interaction and sub-optimal parenting has been associated with psychiatric morbidity. In the present study, an extensive battery of personality scales (Trait Anxiety Inventory, Behavioural Inhibition/Activation System questionnaire, Eysenck Personality Questionnaire-Revised, Temperament and Character Inventory, Schizotypal Traits Questionnaire, Toronto Alexithymia Scale) and the Parental Bonding Instrument (PBI) were administered in 324 adult healthy males to elucidate the effects of parenting on personality configuration. Personality variables were analysed using Principal Component Analysis (PCA) and the factors "Schizotypy", "Anxiety", "Behavioural activation", "Novelty seeking" and "Reward dependence" were extracted. Associations between personality factors with PBI "care" and "overprotection" scores were examined with regression analyses. Subjects were divided into "parental style" groups and personality factors were subjected to categorical analyses. "Schizotypy" and "Anxiety" were significantly predicted by high maternal overprotection and low paternal care. In addition, the Affectionless control group (low care/high overprotection) had higher "Schizotypy" and "Anxiety" compared with the Optimal Parenting group (high care/low overprotection). These results further validate sub-optimal parenting as an important environmental exposure and extend our understanding on the mechanisms by which it increases risk for psychiatric morbidity.

Psychometric Properties of the Five Facets Mindfulness Questionnaire (FFMQ) in a Meditating and a Non-meditating Sample

The factor structure, internal consistency, construct validity, and predictive validity of the Dutch version of the Five Facet Mindfulness Questionnaire (FFMQ-NL) were studied in a sample of meditators ( n = 288) and nonmeditators ( n = 451). A five-factor structure was demonstrated in both samples, and the FFMQ-NL and its subscales were shown to have good internal consistencies. Meditators scored higher on all facets of the FFMQ-NL than the participants in the nonmeditating sample. For both samples, expected negative correlations between most mindfulness facets (all except for the Observing facet) and the constructs of alexithymia, thought suppression, rumination, worry, and dissociation were found. The Observing facet of the FFMQ-NL showed an unexpected positive correlation with thought suppression in the nonmeditating sample. Furthermore, as expected, mindfulness facets were negatively related to psychological symptoms, and all mindfulness facets except for Observing and Describing significantly predicted psychological symptoms. Overall, the Dutch FFMQ demonstrated favorable psychometric properties, commensurate with its (original) English language version.