Correlations between TSIA and TAS-20 and their relation to self-reported negative affect: A study using a multi-method approach in the assessment of alexithymia in a nonclinical sample from Italy

"Our similarities are different" The relationship between alexithymia and depression

Alexithymia is a multi-faceted personality trait, which is the inability to recognize and describe emotions. It is associated with a multitude of mental health problems, and its implication for the diagnosis and treatment of depression remains unclear. The current study explored the nuances of the relationship between alexithymia and depression in a sample of 210 patients with depression. We assessed alexithymia with the 20-Item Toronto Alexithymia Scale (TAS-20) and depression with the Beck Depression Inventory (BDI-I). The mean TAS-20 score was 57.47 ± 10.63, and the mean BDI-I score was 49.33±9.24. We explored the network structure of alexithymia and depression. Items related to difficulties in identifying, describing, and expressing feelings were prominent in the alexithymia network. Joy, guilt, and self-dislike stand out in the depression network. In our analysis, we were able to show the crescent relationship between depression and alexithymia, with an inflection point at a TAS-20 score of 53. Although the correlation-concordance index was moderate (0.41; 95 %CI: 0.29-0.51), both scales greatly overlap. In the joint network of alexithymia and depression, we could identify bridge (i.e., connecting) items between alexithymia and depression. These were difficulties understanding and relating feelings to physical and body sensations on the alexithymia side, and self-dislike, crying, and somatic concern on the depression side. Taken together, they point to the pivotal role of alexithymia in the somatization/embodiment of emotions and feelings in depression.

Measuring facial mimicry: Affdex vs. EMG

Facial mimicry is the automatic imitation of the facial affect expressions of others. It serves as an important component of interpersonal communication and affective co-experience. Facial mimicry has so far been measured by Electromyography (EMG), which requires a complex measuring apparatus. Recently, software for measuring facial expressions have become available, but it is still unclear how well it is suited for measuring facial mimicry. This study investigates the comparability of the automated facial coding software Affdex with EMG for measuring facial mimicry. For this purpose, facial mimicry was induced in 33 subjects by presenting naturalistic affect-expressive video sequences (anger, joy). The response of the subjects is measured simultaneously by facial EMG (corrugator supercilii muscle, zygomaticus major muscle) and by Affdex (action units lip corner puller and brow lowerer and affects joy and anger). Subsequently, the correlations between the measurement results of EMG and Affdex were calculated. After the presentation of the joy stimulus, there was an increase in zygomaticus muscle activity (EMG) about 400 ms after stimulus onset and an increase in joy and lip corner puller activity (Affdex) about 1200 ms after stimulus onset. The joy and the lip corner puller activity detected by Affdex correlate significantly with the EMG activity. After presentation of the anger stimulus, corrugator muscle activity (EMG) also increased approximately 400 ms after stimulus onset, whereas anger and brow lowerer activity (Affdex) showed no response. During the entire measurement interval, anger activity and brow lowerer activity (Affdex) did not correlate with corrugator muscle activity (EMG). Using Affdex, the facial mimicry response to a joy stimulus can be measured, but it is detected approximately 800 ms later compared to the EMG. Thus, electromyography remains the tool of choice for studying subtle mimic processes like facial mimicry.

Attachment and alexithymia predict emotional-behavioural problems of institutionalized, late-adopted and community adolescents: An explorative multi-informant mixed-method study

OBJECTIVE

Compared to community adolescents (COM), adolescents placed in residential care (RC) or late adopted (LA) appear to show more emotional-behavioural problems. They also appear vulnerable in variables linked to emotional-behavioural problems, such as insecure-disorganized attachment and alexithymia. This study employs a mixed-method multi-informant approach to (1) compare adolescents placed in RC, LA and COM in emotional-behavioural problems, attachment and alexithymia and (2) investigate relationships and interplay of attachment and alexithymia concerning emotional-behavioural problems in these three groups.

METHOD

Participants were 174 adolescents (50 RC, 33 LA and 91 COM; Mage  = 15, 53% boys and 47% girls). Adolescents' internalizing and externalizing problems were assessed through both caregiver-reported and self-reported questionnaires, while attachment and alexithymia were assessed with a mixed method, using interviews and self-report questionnaires.

RESULTS

The results showed RC adolescents as more vulnerable in all variables, while LA and COM did not differ. Accounting for the group, attachment and alexithymia cumulatively predicted 25-43% of internalizing problems, and 19-43% of externalizing problems depending on the method of assessment or problems' informant (all p < 0.01). Alexithymia was both an independent predictor and interacted with preoccupied attachment in predicting internalizing problems, while no predictors were isolated for externalizing ones, and the group never indicate an effect on problems' rates.

CONCLUSIONS

The authors discuss the utility to maintain a research focus on attachment and alexithymia, also suggesting future directions of research. A need to determine potential distortions of results because of problems' informant and method of assessment is also highlighted.

Revisiting the Concept of Pensée Opératoire: Some Conceptual, Empirical, and Clinical Considerations

The concept of pensée opératoire (operational thinking) was introduced by French psychoanalysts in 1963 and a decade later was included as an essential component of the alexithymia construct as formulated by the U.S. analysts John Nemiah and Peter Sifneos. Despite a large body of research on alexithymia, the pensée opératoire component is not well understood, especially among clinicians and researchers who are not familiar with French psychoanalytic literature. In this article we clarify the definition and metapsychological conceptualization of the concept, review findings from some relevant empirical studies, and critique a recent proposal for redefining the alexithymia construct that departs from the original understanding of pensée opératoire. We also discuss some clinical implications of the concept and some strategies that psychotherapists can employ in the treatment of patients with this mode of thinking.

Effects of rational emotive behavior therapy on alexithymia, anxiety, depression and sleep quality of older people in nursing homes: a quasi-experimental study

BACKGROUND

Alexithymia, a subclinical cognitive-affective impairment, is prevalent in older people and increases the risk of mental disorders. There is a vast alexithymia treatment gap, with majority of older people in nursing homes lacking access to adequate mental health care. The study aimed to evaluate the effects of rational emotive behavior therapy (REBT) on alexithymia, anxiety, depression and sleep quality of older people in nursing homes.

METHODS

This quasi-experimental study was conducted with two groups (the control group and intervention) from March to November 2021. This study enrolled 86 participants, two of whom were lost to follow-up; 42 received usual care (control group) and 42 received REBT based on usual care (intervention group) in nursing homes. The older people in both groups were evaluated at baseline (T0), within one-week post-intervention (T1), and at 3-month follow-up (T3). Generalized estimating equations were used by SPSS version 26 to assess the differential change in the outcomes between the two groups.

RESULTS

The intervention group shows significantly greater improvement in alexithymia than the control group at both T1 (β = -8.167, 95%CI= -10.965, -5.368, P < 0.001) and T2 (β=-4.119, 95%CI= -7.171, -1.067, P = 0.008). The two groups showed significant differences at both T1 and T2 in both difficulty identifying feelings and difficulty describing feelings. Compared to the control group, the intervention group shows a significant improvement in sleep quality at T2 (β = -2.048, 95%CI=-4.004, -0.091, P = 0.040). The two groups showed significant differences at both T1 and T2 in both sleep disturbance and daytime dysfunction. For depression and anxiety, no significant differences were found between the intervention and control groups.

CONCLUSIONS

REBT showed to be an effective method for improving alexithymia and sleep quality of older people in nursing homes. However, it failed to significantly alleviate anxiety and depression at least in a short-term trial. Refining this intervention may have a broader, more substantial impact on future research.

Associations among alexithymia, disordered eating, and depressive symptoms in treatment-seeking adolescent military dependents at risk for adult binge-eating disorder and obesity

PURPOSE

Evidence suggests that difficulties identifying and describing one's feelings, core components of alexithymia, are associated with attitudinal and behavioral symptoms of disordered eating; depressive symptoms also may underlie these associations. Specifically, research indicates that alexithymia is positively related to depressive symptoms, which in turn may promote both disordered-eating attitudes and certain disinhibited-eating behaviors (e.g., emotional eating). Findings also suggest that military-dependent youth with high weight may exhibit elevated depressive symptoms and disordered eating. As such, understanding associations among alexithymia, depressive symptoms, and disordered eating is particularly relevant for this vulnerable population.

METHODS

We examined 149 adolescent military dependents (14.4 ± 1.6y; 55.0% female; 20.0% non-Hispanic Black; BMIz: 1.9 ± 0.4) at high risk for binge-eating disorder and obesity in adulthood. Participants completed questionnaires assessing two components of alexithymia (difficulty identifying feelings [DIF] and difficulty describing feelings [DDF]), depressive symptoms, emotional eating, and trait anxiety; disordered-eating attitudes were assessed via semi-structured interview.

RESULTS

A series of regression-based models examined indirect relationships of DIF and DDF with disordered-eating attitudes and emotional eating through depressive symptoms. Bootstrapped 95% confidence intervals revealed a significant indirect path from each of the alexithymia components to disordered-eating attitudes via depressive symptoms; indirect paths to emotional eating were non-significant.

CONCLUSION

Results support the salience of depressive symptoms in the relationship between alexithymia and disordered-eating attitudes. Future research should utilize prospective designs and explore direct and indirect associations of alexithymia with other disordered-eating behaviors.

LEVEL OF EVIDENCE

Level III, evidence obtained from a well-designed cohort study.

Alexithymia and internet gaming disorder in the light of depression: A cross-sectional clinical study

BACKGROUND

Social and emotional deficits are assumed to be involved in the development and maintenance of internet gaming disorder (IGD). Alexithymia refers to a personality construct, which is characterized by deficits in emotional awareness and processing. The constructs of alexithymia and depression share similarities, and depression is a common comorbidity of IGD patients. The aim of this study was to analyze the relationship between alexithymia and IGD when controlling for depression symptom severity. Moreover, we compared alexithymia traits of IGD patients with those of non-pathological video gamers.

METHODS

In a cross-sectional study n = 38 male IGD patients (EG) were recruited at specialized healthcare services in Germany. In addition, n = 39 male non-pathological video gamers (CG) were recruited via social media and bulletin board announcement. Both groups completed questionnaires measuring alexithymia (TAS-20), depression symptom severity (BDI) and IGD severity (s-IAT).

RESULTS

Alexithymia and depression symptom severity both predicted IGD severity. Yet, when including both factors in multiple regression analysis, only alexithymia predicted IGD severity. The prevalence of alexithymia in the EG was 34.2 % (n = 13). None of the non-pathological video gamers scored above the cut-off indicating alexithymia. IGD patients showed higher traits of alexithymia in general and on each subscale, irrespective of whether or not they were currently consuming video games. As previously observed, depression symptom severity was significantly greater in IGD patients compared to healthy video gamers. Yet, group differences in alexithymia traits remained stable, with a ~29 % decrease of effectiveness in the relationship, when controlling for depression symptom severity and sociodemographic factors.

CONCLUSION

The results reveal that alexithymia is associated with and predicts IGD severity independently of depression symptom severity. Moreover, alexithymia is highly prevalent in IGD patients.

Can alexithymia be assessed through an interview in adolescents? The Toronto Structured Interview for Alexithymia: Reliability, concurrent validity, discriminant validity, and relationships with emotional-behavioral symptoms

Alexithymia is connected to adolescents' psychopathology, but the current methods of assessment present limitations. The Toronto Structured Interview for Alexithymia (TSIA) was developed to overcome the limits of the main used self-rating scale in adults, but no studies investigated its feasibility with adolescents. This study involved 95 community adolescents aged 12-19 years. Adolescents were assessed with the TSIA, the 20-item Toronto Alexithymia Scale (TAS-20), the Verbal Comprehension Index of the WISC-IV for verbal skills, and the Child Behavior Checklist and Youth Self Report for emotional-behavioral symptoms. The aims were to investigate the TSIA internal consistency, concurrent validity with the TAS-20, discriminant validity with participants' verbal skills, and relationships with emotional-behavioral symptoms. TSIA showed good internal consistency, concurrent validity with the TAS-20 (except for factor DDF), and independence by participants' verbal skills, but few relationships with emotional-behavioral symptoms. In conclusion, TSIA showed some good psychometric proprieties but little convergence with research findings obtained with the TAS-20, suggesting the need for further research to check the feasibility of using the TSIA with adolescents. Meanwhile, a precautionary multi-method assessment of alexithymia is recommended.

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.

Improving the measurement of alexithymia in autistic adults: a psychometric investigation of the 20-item Toronto Alexithymia Scale and generation of a general alexithymia factor score using item response theory

BACKGROUND

Alexithymia, a personality trait characterized by difficulties interpreting emotional states, is commonly elevated in autistic adults, and a growing body of literature suggests that this trait underlies several cognitive and emotional differences previously attributed to autism. Although questionnaires such as the 20-item Toronto Alexithymia Scale (TAS-20) are frequently used to measure alexithymia in the autistic population, few studies have investigated the psychometric properties of these questionnaires in autistic adults, including whether differential item functioning (I-DIF) exists between autistic and general population adults.

METHODS

This study is a revised version of a previous article that was retracted due to copyright concerns (Williams and Gotham in Mol Autism 12:1-40). We conducted an in-depth psychometric analysis of the TAS-20 in a large sample of 743 cognitively able autistic adults recruited from the Simons Foundation SPARK participant pool and 721 general population controls enrolled in a large international psychological study. The factor structure of the TAS-20 was examined using confirmatory factor analysis, and item response theory was used to generate a subset of the items that were strong indicators of a "general alexithymia" factor. Correlations between alexithymia and other clinical outcomes were used to assess the nomological validity of the new alexithymia score in the SPARK sample.

RESULTS

The TAS-20 did not exhibit adequate model fit in either the autistic or general population samples. Empirically driven item reduction was undertaken, resulting in an 8-item general alexithymia factor score (GAFS-8, with "TAS" no longer referenced due to copyright) with sound psychometric properties and practically ignorable I-DIF between diagnostic groups. Correlational analyses indicated that GAFS-8 scores, as derived from the TAS-20, meaningfully predict autistic trait levels, repetitive behaviors, and depression symptoms, even after controlling for trait neuroticism. The GAFS-8 also presented no meaningful decrement in nomological validity over the full TAS-20 in autistic participants.

LIMITATIONS

Limitations of the current study include a sample of autistic adults that was majority female, later diagnosed, and well educated; clinical and control groups drawn from different studies with variable measures; only 16 of the TAS-20 items being administered to the non-autistic sample; and an inability to test several other important psychometric characteristics of the GAFS-8, including sensitivity to change and I-DIF across multiple administrations.

CONCLUSIONS

These results indicate the potential of the GAFS-8 to robustly measure alexithymia in both autistic and non-autistic adults. A free online score calculator has been created to facilitate the use of norm-referenced GAFS-8 latent trait scores in research applications (available at https://asdmeasures.shinyapps.io/alexithymia ).

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.

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.

Improving the measurement of alexithymia in autistic adults: a psychometric investigation and refinement of the twenty-item Toronto Alexithymia Scale

BACKGROUND

Alexithymia, a personality trait characterized by difficulties interpreting one's own emotional states, is commonly elevated in autistic adults, and a growing body of literature suggests that this trait underlies a number of cognitive and emotional differences previously attributed to autism, such as difficulties in facial emotion recognition and reduced empathy. Although questionnaires such as the twenty-item Toronto Alexithymia Scale (TAS-20) are frequently used to measure alexithymia in the autistic population, few studies have attempted to determine the psychometric properties of these questionnaires in autistic adults, including whether differential item functioning (I-DIF) exists between autistic and general population adults.

METHODS

We conducted an in-depth psychometric analysis of the TAS-20 in a large sample of 743 verbal autistic adults recruited from the Simons Foundation SPARK participant pool and 721 general population controls enrolled in a large international psychological study (the Human Penguin Project). The factor structure of the TAS-20 was examined using confirmatory factor analysis, and item response theory was used to further refine the scale based on local model misfit and I-DIF between the groups. Correlations between alexithymia and other clinical outcomes such as autistic traits, anxiety, and quality-of-life were used to assess the nomological validity of the revised alexithymia scale in the SPARK sample.

RESULTS

The TAS-20 did not exhibit adequate global model fit in either the autistic or general population samples. Empirically driven item reduction was undertaken, resulting in an eight-item unidimensional scale (TAS-8) with sound psychometric properties and practically ignorable I-DIF between diagnostic groups. Correlational analyses indicated that TAS-8 scores meaningfully predict autistic trait levels, anxiety and depression symptoms, and quality of life, even after controlling for trait neuroticism.

LIMITATIONS

Limitations of the current study include a sample of autistic adults that was overwhelmingly female, later-diagnosed, and well-educated; clinical and control groups drawn from different studies with variable measures; and an inability to test several other important psychometric characteristics of the TAS-8, including sensitivity to change and I-DIF across multiple administrations.

CONCLUSIONS

These results indicate the potential of the TAS-8 as a psychometrically robust tool to measure alexithymia in both autistic and non-autistic adults. A free online score calculator has been created to facilitate the use of norm-referenced TAS-8 latent trait scores in research applications (available at http://asdmeasures.shinyapps.io/TAS8_Score ).

Affective agnosia: a core affective processing deficit in the alexithymia spectrum

Affective agnosia, an impairment in knowing how one feels emotionally, has been described as an extreme deficit in the experience and expression of emotion that may confer heightened risk for adverse medical outcomes. Alexithymia, by contrast, has been proposed as an over-arching construct that includes a spectrum of deficits of varying severity, including affective agnosia at the more severe end. This perspective has been challenged by Taylor and colleagues, who argue that the concept of affective agnosia is unnecessary. We compare these two perspectives by highlighting areas of agreement, reasons for asserting the importance of the affective agnosia concept, errors in Taylor and colleagues’ critique, and measurement issues. The need for performance-based measures of the ability to mentally represent emotional states in addition to metacognitive measures is emphasized. We then draw on a previously proposed three-process model of emotional awareness that distinguishes affective response generation, conceptualization and cognitive control processes which interact to produce a variety of emotional awareness and alexithymia phenotypes - including affective agnosia. The tools for measuring these three processes, their neural substrates, the mechanisms of brain-body interactions that confer heightened risk for adverse medical outcomes, and the differential treatment implications for different kinds of deficits are described. By conceptualizing alexithymia as a spectrum of deficits, the opportunity to match specific deficit mechanisms with personalized treatment for patients will be enhanced.

Alexithymia Profile in Relation to Negative Affect in Parents of Autistic and Typically Developing Young Children

In our study, we explored the construct of alexithymia in parents of children with and without ASD using a multi-method approach based on self-rated and external rater assessment. We also assessed the level of self-report measures of negative affect states such as trait anxiety and depression, and investigated the correlation between the alexithymia construct, trait anxiety, and depression within the broader autism phenotype (BAP). A total sample of 100 parents (25 mothers and 25 fathers in each group) were administered the TAS-20 and the TSIA to measure self-reported and observer-rated alexithymia traits, as well as self-report measures of anxiety and depression. Study results showed that the TSIA but not the TAS-20 was able to detect significant group differences in alexithymia traits among parents of children with and without ASD, with parents of ASD children displaying significantly higher levels of alexithymia. Furthermore, differently from the TAS-20, no significant correlations between the TSIA and measures of anxiety and depression were detected. Taken together, our results suggest the importance of using multi-method approaches to control for potential measurement bias and to detect psychological constructs such as alexithymia in subclinical samples such as parents of children with ASD.

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.