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

Improving emotion regulation ability after brain injury: A systematic review of targeted interventions

Emotion dysregulation is a common sequela after a brain injury, and it can have serious negative consequences for individuals, families, and the community. A systematic review of the literature was conducted to identify and evaluate interventions designed to improve emotion regulation ability in adults with acquired brain injury. Studies were identified on ProQuest, PsycInfo, ScienceDirect, Scopus, and Web of Science; last searched on 3 August 2023. A review protocol was prospectively registered on PROSPERO (CRD42020218175). Risk of bias was assessed using the Cochrane Risk-of-Bias tool (version 2). Sixteen studies were included in the review comprising one case series, five pilot studies, four pre-post studies, and six RCTs. There was a total of 652 participants across studies. Fourteen of the sixteen studies reported statistically significant improvements in at least one emotional functioning variable. Ten studies reported medium-large effect sizes. Limitations included inconsistency in the measurement, reporting of intervention outcomes and processes. Future directions are discussed.

Alexithymia profiles and depression, anxiety, and stress

BACKGROUND

Alexithymia is a multidimensional trait comprised of difficulties identifying feelings, difficulties describing feelings, and externally orientated thinking. It is regarded as an important risk factor for emotional disorders, but there are presently limited data on each specific facet of alexithymia, or the extent to which deficits in processing negative emotions, positive emotions, or both, are important. In this study, we address these gaps by using the Perth Alexithymia Questionnaire (PAQ) to comprehensively examine the relationships between alexithymia and depression, anxiety, and stress symptoms.

METHODS

University students (N = 1250) completed the PAQ and the Depression Anxiety Stress Scales-21. Pearson correlations, hierarchical regressions, and latent profile analysis were conducted.

RESULTS

All facets of alexithymia, across both valence domains, were significantly correlated with depression, anxiety, and stress symptoms (r = 0.27-0.40). Regression analyses indicated that the alexithymia facets, together, could account for a significant 14.6 %-16.4 % of the variance in depression, anxiety, and stress. Difficulties identifying negative feelings and difficulties identifying positive feelings were the strongest unique predictors across all symptom categories. Our latent profile analysis extracted eight profiles, comprising different combinations of alexithymia facets and psychopathology symptoms, collectively highlighting the transdiagnostic relevance of alexithymia facets.

LIMITATIONS

Our study involved a student sample, and further work in clinical samples will be beneficial.

CONCLUSIONS

Our data indicate that all facets of alexithymia, across both valence domains, are relevant for understanding depression, anxiety, and stress. These findings demonstrate the value of facet-level and valence-specific alexithymia assessments, informing more comprehensive understanding and more targeted treatments of emotional disorder symptoms.

The association among negative life events, alexithymia, and depressive symptoms in a psychosomatic outpatient sample

BACKGROUND

Depression is a life-threatening mental health problem. Various factors have been demonstrated to be associated with depressive symptoms, including negative life events (NLEs) and alexithymia. A retrospective study was conducted to investigate the relationship among negative life events, alexithymia, and depression symptoms in a psychosomatic outpatient sample in China.

METHODS

A total of 2747 outpatients (aged 18 - 65) were included in this investigation. The Life Events Scale (LES), Toronto alexithymia scale (TAS-26), and 9-item Patient Health Questionnaire (PHQ-9) were used to assess NLEs, alexithymia, and depressive symptoms, respectively. A stepwise regression analysis model was established to investigate the relationship among alexithymia, NLEs, and depressive symptoms.

RESULTS

Overall, 67.0% of the patient sample had a PHQ-9 score of 10 or higher. The stepwise regression analysis model showed a well-fitted model, in which NLEs and alexithymia explain a total of 34.2% of the variance of depressive symptoms in these participants. NLEs (β = 0.256, p < 0.001) and dimensions of alexithymia (difficult describing feelings (β = 0.192, p < 0.001) and identifying feelings (β = 0.308, p < 0.001)) were positively correlated with symptoms of depression.

CONCLUSIONS

Previous studies have confirmed the correlation between NLEs and depression, alexithymia and depression, respectively. In our study, we used a stepwise regression model to explain the relationship among those variables simultaneously, and found that NLEs and alexithymia could function as predictors of depressive symptoms. Based on this discovery, alexithymia-focused treatment strategies could be alternative in depressive patients with alexithymia, but this remains to be verified in the future.

"And how did that make you feel?" - Repeated symptom queries enhance symptom reports elicited by negative affect

OBJECTIVE

Negative affect, alexithymia, and other predisposing traits (such as health anxiety) can influence an individual's symptom perception. In this study, we used the affective picture paradigm (APP, Bogaerts et al., 2010) to induce symptoms using affective picture stimuli. We aimed to cross-sectionally test the effect of high vs low-frequency symptom queries and analyze the time course of the APP, including interactions with health anxiety and somatic symptom distress.

METHODS

Participants (N = 124) completed a modified APP and filled out various questionnaires. In the APP, participants were randomized to either a highly-frequent-query condition (18 symptom checklists) or a less-frequent-query condition (6 checklists). Data were analyzed using ANOVAs, cross-lagged panel models, moderation models, and multilevel models.

RESULTS

Both groups had comparable symptom baseline values, but people in the highly frequent as opposed to less frequent condition reported significantly higher symptom levels once the experiment started (F (1,120) = 14.319, p < .001, η2=.107). Symptom levels stayed stable over the course of the experiment and were best predicted by symptom levels at earlier timepoints in the experiment (β = 0.43 and β = 0.68, both p < .001). Health anxiety levels significantly predicted symptom levels (F(1,121) = 10.054, p = .002, η2=.077) and moderated the relation between condition and symptom levels (F(2,121) = 16.253, p < .001, η2=.212).

CONCLUSION

In terms of the predictive processing model (e.g.,[1]), repeated symptom queries following negative affective cues may activate prior beliefs about symptoms, resulting in elevated levels of symptom reports in interaction with health anxiety.

Interactive relationship between alexithymia, psychological distress and posttraumatic stress disorder symptomology across time

Alexithymia, psychological distress, and posttraumatic stress disorder (PTSD) are highly related constructs. The ongoing debate about the nature and relationship between these constructs is perpetuated by an overreliance on cross-sectional research. We examined the longitudinal interactive relationship between alexithymia, psychological distress, and PTSD. We hypothesised that there is an interactive relationship between the three constructs. Military personnel (N = 1871) completed the Toronto Alexithymia Scale, the Kessler 10 and a PTSD Checklist (PCL-C) at pre-deployment, post-deployment, and at 3-4 years following the post-deployment assessment. We initially tested whether psychological distress is either a moderator or mediator in the relationship between alexithymia and PTSD across the time points. General psychological distress was a partial mediator of total PTSD severity and hyperarousal symptomology at all three time points. Psychological distress fully mediated re-experiencing and avoidance symptomology at all three time points. Our results suggest that those with alexithymia are at longitudinal risk of developing more severe PTSD symptomology and experiencing hyperarousal irrespective of temporal proximity to traumatic exposure. Further, vulnerability to the emergence of re-experiencing and avoidance symptomology for those with alexithymia is increased when one experiences greater distress. Our results show that alexithymia is a persistent risk factor for PTSD symptomology.

What is the relationship between alexithymia and experiential avoidance? A latent analysis using three alexithymia questionnaires

Alexithymia is a clinically relevant personality trait characterized by poor emotional awareness and associated with several psychological and physical health concerns. Individuals with high alexithymia tend to engage in experiential avoidance and this may mediate psychological distress. However, little is known about what specific processes of experiential avoidance are involved, and the nature of the relation between alexithymia, experiential avoidance, and psychological distress remains unclear at a latent construct level. To examine this relationship at the latent construct level, a representative sample of 693 U.S. adults completed alexithymia (TAS-20, BVAQ, PAQ), general distress (DASS-21), multi-dimensional experiential avoidance (MEAQ), and general health (PROMIS-G-10) questionnaires. Structural equation modeling revealed that alexithymia significantly predicted experiential avoidance (β = 0.966, t = 82.383, p < .01), experiential avoidance significantly predicted general distress (β = 0.810, t = 2.017, p < .05), and experiential avoidance fully mediated the relationship between alexithymia and general distress (βindirect = -0.159, t = -0.398, p > .05). Correlations between alexithymia and experiential avoidance subfactors revealed a strong relationship to the repression and denial subfactor. Experiential avoidance is a promising target for clinical interventions, though longitudinal research is necessary to elucidate how the relationship between alexithymia and experiential avoidance unfolds over time.

The role of maladaptive personality traits on psychological stress the mediating effects of COVID-19-related worries and emotional dysregulation

There is increasing evidence that dysfunctional personality traits, related to psychological maladjustment and psychopathology, can play an important role in a person's ability to cope with major stressful events. Relatively little is known about the specific effect of the emotional component on the relationship between maladaptive personality traits and psychological stress. Therefore, the aim of the present study was to investigate the relationship between the maladaptive personality traits of psychoticism, detachment, and negative affect, and psychological stress, considering the effects of COVID-19-related worries and emotional dysregulation. An online survey was administered to 1172 adult participants. A series of path analysis models showed that maladaptive personality traits (psychoticism, detachment, and negative affect) are related to psychological stress. COVID-19-related worries and emotional dysregulation partially explained this association. The results suggest that in the early months of 2022, during the reduction of government restrictions, although the world population was no longer in nationwide lockdown, the COVID-19-related emotional component could still explain, at least in part, the association between maladaptive personality traits and psychological stress.

Posttraumatic Stress and Alexithymia: Symptom Associations

ABSTRACT

There is a demonstrated association between alexithymia and posttraumatic stress disorder (PTSD). However, work has largely focused on male-dominant, high-risk occupation populations. We aimed to explore the relationship between posttraumatic stress (PTS) and alexithymia among 100 trauma-exposed female university students. Participants completed a Life Events Checklist, the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), and the Toronto Alexithymia Scale (TAS-20). Multiple regressions were run to examine whether alexithymia was associated with each of the PCL-5 subscales. The TAS-20 total scores were associated with total PTS scores, β = 0.47, t(99) = 5.22, p < 0.001. On a subscale level, Difficulty in Identifying Feelings (DIF) was positively associated (β = 0.50 to 0.41) with all PCL-5 subscales except for Avoidance. Our results align with research showing that for women, the DIF subscale is most strongly associated with PTS, in contrast with the literature on male samples, showing strongest associations with the Difficulties in Describing Feelings subscale, suggesting sex differences in associations between PTS and alexithymia. Our study supports the universality of the associations between alexithymia and PTS.

Non-suicidal self-injury in Chinese college students with elevated autistic traits: Associations with anxiety, rumination and experiential avoidance

Although existing studies have proved that autistic traits (AT) may have relations to non-suicidal self-injury (NSSI) behaviors, its associations with anxiety, rumination and experiential avoidance (EA) are still unclear. The current study, based on a sample of 1317 Chinese college students, explored the associations between AT, anxiety and NSSI, and the possible modulating roles of rumination and EA in these associations. The results shows that 1) a total of 334 (25.36%) students reported a history of NSSI and 30 (2.28%) students were categorized as high AT; 2) Students with high AT reported higher rates of NSSI than those with low AT (36.67% vs. 25.10%); 3) AT, anxiety, rumination and EA have positive relations with NSSI; 4) AT predicted NSSI indirectly through anxiety; 5) Rumination and EA significantly moderated the effects of AT on NSSI via anxiety. In conclusion, this study confirms the indirect effect of AT on NSSI through anxiety in Chinese college students, and further clarifies the reinforcing effects of rumination and EA on the associations between AT, anxiety and NSSI. These findings suggest that developing adaptive emotion-regulating strategies and positive coping styles might promote the prevention and treatment of NSSI behaviors among autistic individuals.

Feeling difficult to identify: Alexithymia is inversely associated with positive body image in adults from the United Kingdom

BACKGROUND

Research has increasingly examined the ways in which internal bodily experiences influence body image, including the relationship between alexithymia - the reduced ability to identify and describe one's own emotional feelings and bodily sensations - and negative body image. However, relationships between facets of alexithymia and positive body image remain unexplored.

METHODS

To bridge this gap in the literature, we assessed relationships between facets of alexithymia and multiple, core indices of positive body image in an online sample of adults from the United Kingdom. A total of 395 participants (226 women, 169 men) aged 18 to 84 years completed measures of alexithymia, body appreciation, functionality appreciation, body image flexibility, body acceptance by others, and positive rational acceptance.

RESULTS

Once the effects of age had been accounted for, alexithymia was significantly and negatively associated with all five body image constructs in hierarchical multiple regressions. In the final models, the alexithymia facet of Difficulties Identifying Feeling emerged as a significant and negative predictor of all indices of positive body image.

LIMITATIONS

The use of cross-sectional data limits the causal conclusions that can be drawn.

CONCLUSIONS

These findings extend previous work by demonstrating the unique relationship between alexithymia and positive body image, providing important implications for body image research and practice.

The impact of pandemic-related stress on attentional bias and anxiety in alexithymia during the COVID-19 pandemic

The COVID-19 pandemic had negative consequences for mental health, yet it is unknown how and to what extent the psychological outcomes of this stressful event are moderated by individual traits. Alexithymia is a risk factor for psychopathology, and thus likely predicted individual differences in resilience or vulnerability to stressful events during the pandemic. This study explored the moderating role of alexithymia in the relationships of pandemic-related stress with anxiety levels and attentional bias. The participants were 103 Taiwanese individuals who completed a survey during the outbreak of the Omicron wave. Additionally, an emotional Stroop task including pandemic-related or neutral stimuli was used to measure attentional bias. Our results demonstrate that pandemic-related stress had a lesser impact on anxiety in individuals with a higher level of alexithymia. Moreover, we found that in individuals with higher exposure to pandemic-related stressors, a higher level of alexithymia indicated less attentional bias toward COVID-19-related information. Thus, it is plausible that individuals with alexithymia tended to avoid pandemic-related information, which could temporarily relieve stressors during the pandemic.

Alexithymia and emotion regulation

BACKGROUND

Alexithymia is a key transdiagnostic risk factor for emotion-based psychopathologies. Conceptual models specify that this is because alexithymia impairs emotion regulation. However, the extent of these putative emotion regulation impairments remains underexplored. Our aim in this study was to begin to address this gap by examining whether people with high, average, or low levels of alexithymia differ in the types of emotion regulation strategies they typically use.

METHOD

General community adults from the United States (N = 501) completed a battery of alexithymia and emotion regulation measures. Participants were grouped into high, average, and low alexithymia quantiles.

RESULTS

After controlling for demographics and current levels of distress, the high, average, and low alexithymia groups differed in their use of cognitive and behavioral emotion regulation strategies. Compared to the other groups, the high alexithymia group reported lesser use of generally adaptive regulation strategies (cognitive reappraisal, approaching problems, and seeking social support) and greater use of generally maladaptive regulation strategies (expressive suppression, behavioral withdrawal, ignoring).

LIMITATIONS

Our data were cross-sectional and from self-report questionnaires. Future work in other cultural groups would be beneficial.

CONCLUSIONS

Our results support the view that alexithymia is associated with impaired emotion regulation. In particular, people with high alexithymia seem to exhibit a less adaptive profile of emotion regulation strategies. Direct targeting of these emotion regulation patterns in psychotherapy may therefore be a useful pathway for the treatment of emotional disorder symptoms in people with high alexithymia.

Neuropathic pain, cognitive fusion, and alexithymia in patients with multiple sclerosis: Cross-sectional evidence for an explanatory model of anxiety symptoms

Multiple sclerosis (MS) presents a high prevalence, a marked increase worldwide, and a relevant impact on patients, public health, and society. Anxiety often cooccurs with MS and can contribute to the worsening of MS symptoms. However, knowledge about predictors of anxiety in Patients with MS (PwMS) is scarce.

OBJECTIVE

This preliminary study explored a novel model for anxiety symptoms in PwMS, including neuropathic pain (NeP), cognitive fusion (CF), experiential avoidance (EA), and alexithymia as explanatory factors.

METHOD

This cross-sectional study integrated two independent convenience samples: 107 PwMS recruited from the Portuguese Society for Multiple Sclerosis and 97 age- and gender-matched participants without the MS diagnosis (no-MS sample) recruited from the Portuguese general population. Self-report questionnaires that measured the constructs included in the model were administered to both groups.

RESULTS

PwMS showed significantly higher values regarding anxiety symptoms and their explanatory variables (NeP, CF, EA, alexithymia) in comparison to non-MS participants. In the MS sample, no correlations were found between anxiety symptoms and sociodemographic and clinical characteristics. NeP, CF, and alexithymia showed significant correlations with anxiety symptoms and significantly explained this symptomatology in simple linear regression models. Thus, these variables were retained in the multiple linear regression model and emerged as significant regressors that together explained 38% of the variance in anxious symptomatology in PwMS.

CONCLUSIONS

This preliminary study provides novel evidence on NeP and some maladaptive emotion regulation strategies related to EA/psychological inflexibility, as vulnerability to anxiety in PwMS can be considerably increased by CF and alexithymia. Clinical implications were discussed.

The Utility of Assessing Alexithymia, in Addition to Coping, in the Context of Posttraumatic Stress

ABSTRACT

The distinction between alexithymia and coping in relation to posttraumatic stress has not been fully explored. The present study examined the extent to which alexithymia explained unique variance in posttraumatic stress, beyond the variance explained by coping, in a sample of trauma-exposed adults ( N = 706; M age = 19.41 years, SD = 1.5; 77.1% female). Then, we explored the effect of race on these associations, comparing participants who identified as Black ( n = 275) to those who identified as White ( n = 337). Avoidant-emotional coping showed stronger correlations (compared with problem-focused and active-emotional coping) with total alexithymia, difficulty identifying feelings, and difficulty describing feelings. In regression analyses, we found alexithymia explained unique variance in posttraumatic stress severity beyond the effect of coping. Results did not differ by racial identity. These findings suggest that despite some overlap between alexithymia and coping, each shows unique relations with posttraumatic stress.

What about males? Exploring sex differences in the relationship between emotion difficulties and eating disorders

OBJECTIVE

While eating disorders (EDs) are more commonly diagnosed in females, there is growing awareness that men also experience EDs and may do so in a different way. Difficulties with emotion processing and emotion regulation are believed to be important in EDs, but as studies have involved predominantly female samples, it is unclear whether this is also true for males.

METHODS

In a sample of 1604 participants (n = 631 males), we assessed emotion processing and emotion regulation in males with EDs (n = 109) and compared results to both females with EDs (n = 220) and males from the general population (n = 522). We also looked at whether emotion processing and emotion regulation difficulties predicted various aspects of eating psychopathology and whether this was moderated by sex. We assessed emotion processing with the Toronto Alexithymia Scale, emotion regulation with the Difficulties in Emotion Regulation Scale and the Emotion Regulation Questionnaire, and eating psychopathology with the Eating Disorder Examination Questionnaire.

RESULTS

We found that males with ED, like their female counterparts, suffered from emotion processing and emotion regulation deficits. We did find some sex differences, in that males with EDs tended to report more difficulties with their emotions as well as a more externally oriented thinking style compared to females with EDs. Difficulties with emotion processing and emotion regulation were strongly predictive of various aspects of eating psychopathology in both sexes. Importantly, we found that sex moderated the relationship between cognitive reappraisal and eating restraint. As such, low use of reappraisal was found to be associated with higher levels of restraint in females but not in males.

DISCUSSION

Difficulties with emotion processing and emotion regulation are associated with eating psychopathology in both males and females. Reappraisal was not found to be associated with reduced eating psychopathology in males, suggesting a cautious approach to interventions targeting this strategy. Research around explanatory mechanisms and interventions must adopt a broader viewpoint including those that are traditionally overlooked in EDs.

Characterizing emotion profiles in non‐clinical population: A cluster analytical study

Emotion processing and beliefs about pleasure can influence the development and severity of depressive symptoms. This cluster analysis study aimed to profile a large sample of college students using pleasure experience, emotion expression and regulation as well as beliefs about pleasure. We also aimed to validate the resultant clusters in terms of depressive symptoms. A set of checklists capturing beliefs about pleasure and the three facets of emotion processing was administered to 1028 college students. A two-stage cluster analysis was used to analyze the profile of these emotional aspects in these college students. Our results showed that a three-cluster solution best fit the data. Cluster 1 (n = 536) was characterized by moderate levels of beliefs about pleasure, pleasure experience, emotion expression, and regulation; Cluster 2 (n = 402) was characterized by generally high levels of beliefs about pleasure, pleasure experience, emotion expression, and regulation; Cluster 3 (n = 90) was characterized by relatively low levels of beliefs about pleasure, pleasure experience, emotion expression, and regulation. The three clusters differed significantly in the severity of depressive symptoms. Our findings suggest the existence of three emotional subtypes, which may be useful in early detection of youth at risk of developing depression.

Acceptance of Illness, Satisfaction with Life, and Emotional Control in the Early Stage of Autosomal Dominant Polycystic Kidney Disease

INTRODUCTION

Psychological disorders are strong predictors of life expectancy and have an impact on quality of life. Autosomal dominant polycystic kidney disease (ADPKD) is frequently diagnosed before the onset of subjective symptoms. Similar to other disorders of genetic origin, ADPKD may be a source of remarkable psychological discomfort. One way of coping with emotional distress is its suppression, and this could be measured. Our study aimed to provide data on the acceptance of illness, the emotional suppression of anger, and both anxiety and depression as well as satisfaction with life in young patient population of early-stage ADPKD in comparison to healthy demographically matched individuals.

METHODS

Fifty patients in the asymptomatic stage of ADPKD with an eGFR >60 mL/min (4p MDRD) and 50 healthy demographically matched individuals were included in this study. Participants filled out a set of psychological questionnaires: Acceptance of Illness Scale (AIS), Courtauld Emotional Control Scale (CECS), and Satisfaction with Life Scale (SWLS).

RESULTS

Asymptomatic patients with ADPKD had 80% scores indicative of disease acceptance in AIS. As compared to healthy individuals, they presented with significantly stronger suppression of both anxiety and depression but not anger. The ADPKD group had significantly lower satisfaction with life in comparison to the healthy group.

CONCLUSION

Asymptomatic ADPKD patients had a high level of disease acceptance. Anger suppression in this group was comparable to healthy individuals, but anxiety and depression were controlled more intensively. Despite the asymptomatic course of the disease, ADPKD patients revealed lower satisfaction with life in comparison to healthy persons.

Static and treatment-responsive brain biomarkers of depression relapse vulnerability following prophylactic psychotherapy: Evidence from a randomized control trial

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A prospective study of neural biomarkers of relapse in remitted depressed patients.

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Assessed neural response to dysphoric mood-induction before and after psychotherapy.

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Relapse over a 2-year follow-up linked to dysphoria-evoked sensory inhibition.

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Relapse risk was lower when dorsolateral prefrontal reactivity decreased over time.

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Depression prophylaxis may involve reducing dysphoria-evoked sensory inhibition.

Background

Neural reactivity to dysphoric mood induction indexes the tendency for distress to promote cognitive reactivity and sensory avoidance. Linking these responses to illness prognosis following recovery from Major Depressive Disorder informs our understanding of depression vulnerability and provides engagement targets for prophylactic interventions.

Methods

A prospective fMRI neuroimaging design investigated the relationship between dysphoric reactivity and relapse following prophylactic intervention. Remitted depressed outpatients (N = 85) were randomized to 8 weeks of Cognitive Therapy with a Well-Being focus or Mindfulness Based Cognitive Therapy. Participants were assessed before and after therapy and followed for 2 years to assess relapse status. Neural reactivity common to both assessment points identified static biomarkers of relapse, whereas reactivity change identified dynamic biomarkers.

Results

Dysphoric mood induction evoked prefrontal activation and sensory deactivation. Controlling for past episodes, concurrent symptoms and medication status, somatosensory deactivation was associated with depression recurrence in a static pattern that was unaffected by prophylactic treatment, HR 0.04, 95% CI [0.01, 0.14], p < .001. Treatment-related prophylaxis was linked to reduced activation of the left lateral prefrontal cortex (LPFC), HR 3.73, 95% CI [1.33, 10.46], p = .013. Contralaterally, the right LPFC showed dysphoria-evoked inhibitory connectivity with the right somatosensory biomarker

Conclusions

These findings support a two-factor model of depression relapse vulnerability, in which: enduring patterns of dysphoria-evoked sensory deactivation contribute to episode return, but vulnerability may be mitigated by targeting prefrontal regions responsive to clinical intervention. Emotion regulation during illness remission may be enhanced by reducing prefrontal cognitive processes in favor of sensory representation and integration.

Psychological mechanisms connected to dissociation: Generating hypotheses using network analyses

A large number of mechanisms, many relating to the processing of affect, have been proposed to cause dissociation. The aim of this study was to use network analyses to identify psychological processes most closely connected with 'felt sense of anomaly' dissociative experiences. Both an undirected model and a partially directed network model were estimated using data from 6161 general population respondents collected online. The networks were used to identify relationships between dissociation and ten candidate mechanisms: cognitive appraisals, behavioural responses to dissociation, affect intolerance, alexithymia, attentional control, body vigilance, anxiety sensitivity, general self-efficacy, perseverative thinking, and beliefs regarding stress. Both models indicated a highly connected network in which dissociation had direct connections with six psychological processes: cognitive appraisals, behavioural responses, perseverative thinking, alexithymia, general self-efficacy, and beliefs about being overwhelmed. The strongest connection in both networks was between dissociation and cognitive appraisals (causal effect 0.73). The causal direction of connections could not be statistically determined with confidence, apart from the strong probability that dissociation causes meta-cognitions about being overwhelmed (98.54% of 50,000 sampled directed acyclic graphs). Both networks suggest that cognitive appraisals and factors relating to heightened (negative) sensitivity to affect are closely connected to dissociation. Dissociative experiences may arise from a high sensitivity to affect leading to threat-based appraisals that are ruminated upon and maintained by unhelpful behaviours such as avoidance. Investigation of these relationships in clinical groups, and direct causal tests, are required.

Multi-Method Approach in the Assessment of Alexithymia in Patients With Scleroderma: Use of Two Different Tools

Objective: Alexithymia is frequent in patients with some chronic dermatological conditions. The aim of the study was to measure the prevalence of alexithymia in patients with systemic sclerosis (SSc) using two different tools. Methods: Consecutive patients diagnosed with SSc were recruited at day hospital and hospitalization regimen. Alexithymia was measured using the self-administered questionnaire 20-item Toronto Alexithymia scale (TAS-20) and the semi-structured interview 24-item Toronto Structured Interview for Alexithymia (TSIA). Results: The study sample consisted of 67 female patients, aged from 29 to 82 years. According to TAS-20, 22.4% of patients were alexithymic and 17.9% were borderline alexithymic. Also, in our sample mean TAS-20 value was 48.9 and TSIA mean value was 20.3. Spearman's correlation coefficient between TAS-20 total score and TSIA total score was 0.603. A high correlation was observed between TAS total score and the "Affective Awareness" (AA) scale of the TSIA. TSIA total score significantly correlated with the "Difficulty describing feeling to others" (DDF) scale of the TAS-20. The highest correlation between scales of the two instruments was that between TAS-20 DDF and TSIA AA (r = 0.675). Conclusion: The prevalence of alexithymia in SSc patients was higher than in the general population, and similar to that of psoriasis patients. The measurements obtained using the TAS-20 and the TSIA were highly correlated. However, they also showed some diversities in the scales, indicating that they may measure different domains.

Alexithymia and Facial Mimicry in Response to Infant and Adult Affect-Expressive Faces

Facial mimicry is the automatic tendency to imitate facial expressions of emotions. Alexithymia is associated with a reduced facial mimicry ability to affect expressions of adults. There is evidence that the baby schema may influence this process. In this study it was tested experimentally whether facial mimicry of the alexithymic group (AG) is different from the control group (CG) in response to dynamic facial affect expressions of children and adults. A multi-method approach (20-point Toronto Alexithymia Scale and Toronto Structured Interview for Alexithymia) was used for assessing levels of alexithymia. From 3503 initial data sets, two groups of 38 high and low alexithymic individuals without relevant mental or physical diseases were matched regarding age, gender, and education. Facial mimicry was induced by presentation of naturalistic affect-expressive video sequences (fear, sadness, disgust, anger, and joy) taken from validated sets of faces from adults (Averaged Karolinska Directed Emotional Faces) and children (Picture-Set of Young Children's Affective Facial Expressions). The videos started with a neutral face and reached maximum affect expression within 2 s. The responses of the groups were measured by facial electromyographic activity (fEMG) of corrugator supercilii and zygomaticus major muscles. Differences in fEMG response (4000 ms) were tested in a variance analytical model. There was one significant main effect for the factor emotion and four interaction effects for the factors group × age, muscle × age, muscle × emotion, and for the triple interaction muscle × age × emotion. The participants of AG showed a decreased fEMG activity in response to the presented faces of adults compared to the CG but not for the faces of children. The affect-expressive faces of children induced enhanced zygomatic and reduced corrugator muscle activity in both groups. Despite existing deficits in the facial mimicry of alexithymic persons, affect-expressive faces of children seem to trigger a stronger positive emotional involvement even in the AG.

Beyond Face and Voice: A Review of Alexithymia and Emotion Perception in Music, Odor, Taste, and Touch

Alexithymia is a clinically relevant personality trait characterized by deficits in recognizing and verbalizing one's emotions. It has been shown that alexithymia is related to an impaired perception of external emotional stimuli, but previous research focused on emotion perception from faces and voices. Since sensory modalities represent rather distinct input channels it is important to know whether alexithymia also affects emotion perception in other modalities and expressive domains. The objective of our review was to summarize and systematically assess the literature on the impact of alexithymia on the perception of emotional (or hedonic) stimuli in music, odor, taste, and touch. Eleven relevant studies were identified. On the basis of the reviewed research, it can be preliminary concluded that alexithymia might be associated with deficits in the perception of primarily negative but also positive emotions in music and a reduced perception of aversive taste. The data available on olfaction and touch are inconsistent or ambiguous and do not allow to draw conclusions. Future investigations would benefit from a multimethod assessment of alexithymia and control of negative affect. Multimodal research seems necessary to advance our understanding of emotion perception deficits in alexithymia and clarify the contribution of modality-specific and supramodal processing impairments.

Cognitive-emotional processing in alexithymia: an integrative review

Alexithymia is a multifaceted personality construct characterised by difficulties identifying one's feelings and distinguishing them from bodily sensations, difficulties describing one's feelings to others, and an externally oriented cognitive style. Over the past 25 years, a burgeoning body of research has examined how alexithymia moderates processing at the cognition-emotion interface. We review the findings in five domains: attention, appraisals, memory, language, and behaviours. The preponderance of studies linked alexithymia with deficits in emotion processing, which was apparent across all domains, except behaviours. All studies on behaviours and a proportion of studies in other domains demonstrated emotional over-responding. Analysis at the facet level revealed deficits in memory and language that are primarily associated with externally oriented thinking, while over-responding was most often linked to difficulty identifying feelings and difficulty describing feelings. The review also found evidence for contextual modulation: The pattern of deficits and over-responding was not restricted to emotional contexts but also occurred in neutral contexts, and in some circumstances, emotional over-responding in alexithymia was beneficial. Taken together, this review highlights alexithymia as a central personality dimension in the interplay between cognition and emotion.

Associations Between Mental Health, Interoception, Psychological Flexibility, and Self-as-Context, as Predictors for Alexithymia: A Deep Artificial Neural Network Approach

Background: Alexithymia is a personality trait which is characterized by an inability to identify and describe conscious emotions of oneself and others.

Aim: The present study aimed to determine whether various measures of mental health, interoception, psychological flexibility, and self-as-context, predicted through linear associations alexithymia as an outcome. This also included relevant mediators and non-linear predictors identified for particular sub-groups of participants through cluster analyses of an Artificial Neural Network (ANN) output.

Methodology: Two hundred and thirty participants completed an online survey which included the following questionnaires: Toronto alexithymia scale; Acceptance and Action Questionnaire 2 (AQQII); Positive and Negative Affect Scale (PANAS-SF), Depression, Anxiety, and Stress Scale 21 (DAS21); Multidimensional Assessment of Interoceptive Awareness (MAIA); and the Self-as-Context (SAC) scale. A stepwise backwards linear regression and mediation analysis were performed, as well as a cluster analysis of the non-linear ANN upper hidden layer output.

Results: Higher levels of alexithymia were associated with increased psychological inflexibility, lower positive affect scores, and lower interoception for the subscales of “not distracting” and “attention regulation.” SAC mediated the relation between emotional regulation and total alexithymia. The ANNs accounted for more of the variance than the linear regressions, and were able to identify complex and varied patterns within the participant subgroupings.

Conclusion: The findings were discussed within the context of developing a SAC processed-based therapeutic model for alexithymia, where it is suggested that alexithymia is a complex and multi-faceted condition, which requires a similarly complex, and process-based approach to accurately diagnose and treat this condition.

The effects of alexithymia, experiential avoidance, and childhood sexual abuse on non-suicidal self-injury and suicidal ideation among Chinese college students with a history of childhood sexual abuse

BACKGROUND

Although previous studies have shown that childhood sexual abuse (CSA) experiences might be related to suicide-related thoughts and behaviours in later life, the effects of alexithymia and experiential avoidance (EA) on this relationship have remained unclear. The present study aimed to expand prior findings among Chinese college students with a history of CSA in order to further test the effects of alexithymia on the relationship between CSA and non-suicidal self-injury (NSSI) and suicidal ideation (SI), and its indirect effects on NSSI and SI through EA.

METHODS

The Childhood Sexual Abuse Questionnaire, the Toronto Alexithymia Scale-20, the Acceptance and Action Questionnaire-II, the Non-Suicidal Self-Injury Questionnaire, and the Symptom Checklist were completed by 6,834 college students (3,829 female).

RESULTS

Overall, 1404 (20.76%) Chinese college students reported experiences of CSA; students with CSA experiences reported higher rates of SI and NSSI than those without CSA (12.82% vs. 4.50%, 35.11% vs. 20.82%). CSA, alexithymia, and EA were positively related to NSSI and SI. The effect of alexithymia on the relationship between CSA and NSSI and SI were significant. The effects of EA on the relationship between alexithymia and NSSI and SI were significant, too.

LIMITATIONS

The major limitations of this study are its cross-sectional design and the use of self-report scales, especially retrospective self-reports (e.g., the Childhood Sexual Abuse Questionnaire).

CONCLUSIONS

This study cast light on the effects of alexithymia, EA, and CSA on NSSI and SI in Chinese college students with a history of CSA. These findings can contribute to the prevention and treatment of suicide-related thoughts and behaviours.

The effects of childhood emotional maltreatment and alexithymia on depressive and manic symptoms and suicidal ideation in females with bipolar disorder: emotion dysregulation as a mediator

OBJECTIVES

The relations of childhood emotional maltreatment and alexithymia to the clinical course of bipolar disorder (BD) have been widely recognised. Difficulties in regulating emotions may explain these relationships. The current study evaluated the effects of childhood emotional maltreatment and alexithymia on depressive and manic symptoms as well as suicidal ideation in female patients with BD. Emotion dysregulation was evaluated as a mediating factor.

METHODS

Three hundred hospitalised female patients with a diagnosis of BD provided information regarding their history of childhood emotional maltreatment, alexithymia, difficulties in emotion regulation, depressive and manic symptoms, and suicidal ideation. A series of structural equation models (SEMs) were calculated to assess the associations between these variables.

RESULTS

Childhood emotional abuse and difficulty in identifying feelings were indirectly associated with depressive and manic symptoms as well as suicidal ideation. This association was mediated by emotion dysregulation. This association remained significant after depressive and manic symptoms were controlled in the model.

CONCLUSIONS

This study indicates that patients with BD who experienced emotional abuse during childhood and have difficulties identifying emotions report greater emotion dysregulation. These individuals, in turn, are more likely to experience more severe depressive and manic symptoms as well as suicidal ideation.Key pointsChildhood emotional maltreatment and emotional and clinical factors in bipolar disorder were assessed.Childhood emotional abuse indirectly affected clinical factors via emotion dysregulation.Difficulty in identifying feelings was linked to clinical factors via emotional dysregulation.Emotional dysregulation affected the links of childhood emotional maltreatment and difficulty in identifying feelings on suicidal ideation after controlling for clinical symptoms.Emotional dysregulation dimensions of impulse, strategies, and goals emerge in relation to suicidal ideation.

Interoceptive Sensibility, Alexithymia, and Emotion Regulation in Individuals Suffering from Fibromyalgia

INTRODUCTION

People suffering from fibromyalgia syndrome report various difficulties in emotional processing, possibly resulting from changes in bodily perception (interoception). In our study, we investigated the relationships between interoceptive sensibility (IS) and two disease-relevant emotional components (alexithymia and emotion regulation) in fibromyalgia sufferers compared to healthy individuals.

METHODS

Fifty-five fibromyalgia sufferers and 55 healthy individuals, matched with regard to age and gender, participated in our cross-sectional study. All participants completed the following self-report measures: the Multidimensional Assessment of Interoceptive Awareness, the Toronto Alexithymia Scale, and the Emotion Regulation Skills Questionnaire. Depression and anxiety scores served as confounding variables.

RESULTS

Fibromyalgia sufferers reported a stronger tendency to note as well as to avoid (unpleasant) body sensations. IS and psychopathology each explained about thirty percent of the variance in emotion regulation in fibromyalgia sufferers. Alexithymia was related to IS and emotion regulation in controls but not in fibromyalgia sufferers.

CONCLUSION

Disturbances in interoception could be seen as the starting point of emotional difficulties in people with fibromyalgia. Following the fear-avoidance-model, experiential avoidance may restrict patients' ability to adaptively regulate emotional states, possibly initiating a vicious cycle of psychological distress and pain.

Association Between Alexithymia, Social Support, and Duration of Methamphetamine Use Among Male Methamphetamine-Dependent Patients

Introduction: China has 1.18 million methamphetamine abusers. Among the illegal drugs in China, methamphetamine has the highest abuse rate. Although previous studies have indicated a positive relationship between alexithymia and declining social support, the incidence of alexithymia, the total duration of methamphetamine dependence, social support, and the relationships between them among methamphetamine-dependent patients in the Chinese population have been rarely reported. Methods: A total of 113 methamphetamine-dependent patients (all male, mean age 30.45 ± 3.81 years) were enrolled in this cross-sectional study. General demographic data were collected. Alexithymia and social support were measured by Toronto Alexithymia Scale and Social Support Rating Scale. Results: Duration of methamphetamine use among Chinese male methamphetamine-dependent patients in compulsory detoxification was 8.01 ± 3.80 years on average, 23% (26/113) methamphetamine-dependent patients were considered to have alexithymia personality traits. Compared with short-duration methamphetamine-dependent patients (≤8 years), long-duration methamphetamine-dependent patients (> 8 years) were characterized by older age, higher incidence of alexithymia, less subjective social support and support availability, and greater difficulty in identifying feelings. The results of correlation analysis and multiple linear regression analysis indicated that the total duration of methamphetamine use was positively correlated with difficulty in identifying feelings, but negatively correlated with subjective social support. Conclusions: This study provides support for an association between the duration of methamphetamine use and difficulty in identifying feelings or subjective social support. Although the causality is still unclear, this finding should be considered in the psychotherapy of methamphetamine rehabilitation.

Alexithymic and autistic traits: Relevance for comorbid depression and social phobia in adults with and without autism spectrum disorder

LAY ABSTRACT

Adults with autism often develop mental health problems such as depression and social phobia. The reasons for this are still unclear. Many studies found that alexithymia plays an important role in mental health problems like depression. People with alexithymia have difficulties identifying and describing their emotions. Almost every second person with autism has alexithymia. Therefore, we explored in this study whether alexithymia is linked to worse mental health in autistic people. We looked at two common diagnoses, depression and social phobia. We found that alexithymia increased symptoms of depression, while autistic traits increased symptoms of social phobia. Our results suggest that alexithymia and autistic traits can increase the risk of mental health problems. An early assessment could help prevent mental health problems and improve quality of life.

Importance of telling the unutterable: Alexithymia among sexually abused children

Child maltreatment is known to be an etiological factor for developing alexithymia which refers to the difficulty to identify and express feelings. Yet, scarce data is available regarding the vulnerability in child victims of sexual abuse to develop alexithymia. The current study aimed to compare level of alexithymia among a sample of school-aged victims of child sexual abuse (CSA) and a comparison group of non-victimized children. Results also investigated the mediational role of alexithymia in the association between CSA and both internalized and externalized behavior problems. The sample involved 429 sexually abused and 98 non-abused children aged 6 to 12 years old and their parents. The Children's Alexithymia Measure (Way et al., 2010) and the Child Behavior Checklist (Achenbach and Rescorla, 2001) were completed by parents. Clinicians filled out an adapted version of the History of Victimization Form to assess CSA characteristics (Hébert and Cyr, 2010). Analyses revealed that victims of CSA presented significantly higher levels of alexithymia compared to their non-abused counterparts. Results also highlighted the role of alexithymia mediating the association between CSA and both internalized and externalized behavior problems. Focussing on alexithymia is a promising avenue to sustain resilience and prevent further difficulties in sexually abused children.

What is alexithymia? Using factor analysis to establish its latent structure and relationship with fantasizing and emotional reactivity

OBJECTIVE

There is ongoing uncertainty about the structure and definition of alexithymia. Conceptually, alexithymia has traditionally been defined as a multidimensional trait with four components: difficulty identifying feelings, difficulty describing feelings, externally orientated thinking, and difficulty fantasizing. However, some authors suggest that difficulty fantasizing might not be a component, and others suggest low emotional reactivity is a fifth component. In this study, we sought to clarify this issue using factor analysis.

METHOD

In a sample of adults (N = 508), we administered a comprehensive battery of psychometric measures and analyzed their latent structure using exploratory factor analysis.

RESULTS

Subscales assessing difficulty identifying feelings, difficulty describing feelings, and externally orientated thinking all loaded well together on the alexithymia factor. However, none of the subscales assessing aspects of difficulty fantasizing (i.e., daydreaming frequency, vividness, content, or use of daydreams to regulate emotions) loaded on the alexithymia factor. Similarly, no emotional reactivity subscales loaded on the alexithymia factor, and alexithymia was associated with higher (not lower) levels of emotional reactivity for negative emotions.

CONCLUSIONS

Difficulty fantasizing and low emotional reactivity are not components of the latent alexithymia construct. The traditional four-component definition of alexithymia likely warrants refinement to a more parsimonious three-component solution.

Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis

Psoriasis is a chronic dermatological condition that is frequently associated with problematic patterns of emotional reactivity (the way in which patients react to stimuli), alexithymia (their ability to recognize and label the emotional reaction), and emotion regulation (the ability to enhance or reduce their own emotional reaction). A research in the peer-reviewed scientific literature was conducted in order to identify articles describing the association of psoriasis and affective problems. In particular, we first evaluate studies that have investigated abnormal emotional reactivity (in terms of duration, frequency, or type of the experienced emotions) and its impact on patients' quality of life; next, we review the role of alexithymia and emotion regulation in modulating the relationship between emotional reactivity and quality of life in this population. From a critical analysis of the reviewed studies, we highlight that altered emotional processing might be particularly important in the characterization of this condition. In particular, we show that this condition is related to an emotional reactivity characterized by negative emotions that have a stronger impact on patients' quality of life when emotion regulation abilities are weak, especially if patients have alexithymia. Finally, we present suggestions for future directions in both clinical and research fields.

Alexithymia, empathy, negative affect and physical symptoms in patients with asthma

Although alexithymia has been found to be associated with physical symptoms in psychosomatic disorders such as asthma, mechanisms linking this association are unknown. However, affective alexithymic features may be associated with physical symptoms in the presence of deficits in affective characteristics such as low empathy and high negative affect. This study aimed to assess direct effects of alexithymic traits on physical symptoms and indirect effects of these subscales through empathy and negative affect (e.g. depressive, anxious and stress symptoms) by controlling for asthma severity in patients with asthma. Three hundred patients with asthma completed the Toronto Alexithymia Scale-20 (TAS-20), the Basic Empathy Scale (BES), the Depression Anxiety Stress Scales-21 (DASS-21) and the Physical Symptoms Inventory (PSI). After controlling for asthma severity, the results showed that alexithymia subscales of the TAS-20 had no direct effects on physical symptoms, but the difficulty in identifying feelings (DIF) subscale of the TAS-20 was associated with affective empathy and negative affect. Affective empathy was significantly related to negative affect. Affective empathy and negative affect were associated with physical symptoms. The affective subscale of alexithymia on the TAS-20, that is DIF, indirectly affected physical symptoms through affective empathy and negative affect. Findings suggest that patients with asthma who have high levels of DIF may show high physical symptoms in the presence of low affective empathy and high negative affect.

Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis

Numerous studies have examined how alexithymia (difficulty identifying and describing one's emotions and a preference for externally oriented thinking) relates to chronic pain and associated disability. We conducted a systematic review and meta-analysis to summarize individual studies that either assessed alexithymia in individuals with chronic pain vs controls or related alexithymia to pain intensity, physical interference, depression, and anxiety. We searched MEDLINE, Embase, and PsycINFO from inception through June 2017; 77 studies met the criteria (valid assessment of alexithymia in adults or children with any chronic pain condition) and were included in analyses (n = 8019 individuals with chronic pain). Primary analyses indicated that chronic pain samples had significantly higher mean alexithymia scores compared with nonclinical (d = 0.81) and clinical nonpain (d = 0.55) controls. In chronic pain samples, alexithymia was significantly positively associated with pain intensity (d = 0.20), physical interference (d = 0.17), depression (d = 0.46), and anxiety (d = 0.43). Secondary meta-analyses of 14 studies that conducted partial correlations that controlled for negative affect-related measures revealed that alexithymia was no longer significantly related to pain intensity or interference. Meta-analysis findings demonstrated that alexithymia is elevated in individuals with chronic pain and related to greater pain intensity and physical interference, although the latter relationships may be accounted for by negative affect. Critical future work is needed that examines alexithymia assessed using non-self-report measures, develops a person-centered perspective on this construct, and identifies how alexithymia is relevant to the assessment and treatment of individuals with chronic pain.

Negative valence specific deficits in judgements of musical affective quality in alexithymia

Alexithymia is characterised by a lack of words for emotional experiences and it has been implicated in deficits in emotion processing. Research in this area has typically focused on judgements of discrete emotions rather than of affect, which is a precursor to emotion construction. In the current study, higher alexithymia was predicted to be related to more neutral judgements of valence and arousal of music representing a range of emotions. Participants (N = 162) listened to ten 15-second musical pieces that represented five target emotions (happy, sad, tender, angry, and fearful) and rated the valence and arousal of each. Participants also listed emotion words they knew to be expressed in music. Analyses revealed that alexithymia was not related to the number of emotion words generated but was related to valence-specific affect judgements of music. Participants higher in alexithymia rated sad, angry, and fearful pieces as more neutral in valence and arousal. Alexithymia was not related to ratings of valence or arousal for happy and tender pieces. These findings suggest that perceptual deficits in alexithymia may be specific to negative emotions. Our results are consistent with the idea that alexithymia is related to the direction of attention away from negative stimuli.

Impact of Alexithymia on Organ Transplant Candidates' Quality of Life: The Mediating Role of Depressive Symptoms

Solid organ transplant candidates who display alexithymia tend to report psychological distress with some displaying symptoms associated with depression which in turn has a negative impact on their quality of life. This study sought to examine the mediating role of depression on the relationship between alexithymia and physical and psychological quality of life. The sample comprised 707 patients who were under consideration for solid organ transplantation. Mediation models were used to examine the proposed hypotheses, specifically that alexithymia would predict quality of life, and that depression would mediate the relationship between alexithymia and physical and psychological quality of life. Findings revealed that alexithymia predicted both physical and psychological quality of life. Depression scores partially mediated the relationship between alexithymia and both physical and psychological quality of life. Transplant candidates with higher levels of alexithymia who report poor physical and psychological quality of life may be at increased risk for depression. Results highlight the need to assess alexithymia within this unique patient population, who may understate symptoms of depression due to attempts at positive impression management.

The Role of Perspective Taking and Alexithymia in Associations Between Shame, Guilt, and Social Anxiety

The present study expanded previous research concerning relationships between shame, guilt, and social anxiety by examining both internal and external shame and exploring the role of two cognitive constructs relating to emotion regulation, perspective taking, and alexithymia. Findings were consistent with the literature regarding positive associations between shame and social anxiety and no relationship between guilt and social anxiety. Perspective taking was positively related to guilt, while alexithymia was positively related to both shame types. Social anxiety was predicted by shame-proneness, external shame, and alexithymia. There were also small indirect effects for both types of shame on social anxiety through alexithymia. Further replication of relationships between shame, alexithymia, and social anxiety is needed. Alexithymia, with and without concurrent shame, has implications for therapeutic interventions for social anxiety as it may represent a barrier to implementing conventional therapies.