The 20-Item Toronto Alexithymia Scale. III. Reliability and factorial validity in a community population

Characterizing alcohol cue reactive and non-reactive individuals with alcohol use disorder

PURPOSE

Exposure to alcohol-related cues is thought to elicit a conditional response characterized by increased craving in individuals with alcohol use disorder (AUD). In the context of AUD research, it is important to consider that not all individuals with an AUD are alcohol cue reactive. This study systematically examined subjective alcohol cue reactivity and its clinical and drinking correlates in individuals with an AUD enrolled in a human laboratory pharmacotherapy trial.

METHODS

Individuals with current moderate-to-severe AUD (N = 52) completed a standard alcohol cue exposure paradigm and individual difference assessments as part of a human laboratory pharmacotherapy trial (NCT04249882). We classified participants as cue reactive (CR+) and cue non-reactive (CR-), as indicated by self-reported, subjective alcohol urge, and examined group differences in baseline clinical characteristics and drinking outcomes over the course of the trial.

RESULTS

Twenty participants (38%) were identified as CR+, while 32 participants (62%) were identified as CR-. The CR+ and CR- groups did not differ in baseline drinking and AUD clinical characteristics, but the groups differed in race composition (p = 0.02) and smoking prevalence (p = 0.04) such that the CR+ group had lower prevalence of smokers. The CR+, compared with the CR-, group drank more during the trial titration period (p = 0.03). Both groups reduced drinking across the trial (p's < 0.001), but the CR+ group exhibited a smaller reduction in drinking, compared with the CR- group (time x group, p = 0.029; CR-, p < 0.0001; CR+: p = 0.01).

CONCLUSION

Results indicate that cue reactivity is a heterogenous construct. Recognizing this heterogeneity, and the clinical factors associated with it, is critical to advancing this paradigm as an early efficacy marker in AUD research.

Alterations in resting-state gamma-activity is adults with autism spectrum disorder: A High-Density EEG study

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a wide range of symptoms that include deficits in social cognition and difficulties with social interactions. Neural oscillations in the EEG gamma band have been proposed as an important candidate neurobiological marker of higher order cognitive processes and social interactions. We investigated resting-state gamma-activity of patients with ASD (n=23) in order to delineate alterations as compared to typically developing (TD) subjects (n=24). EEG absolute power was examined in the gamma (30-100Hz) frequency band. We found significantly reduced spectral power across the entire gamma range in the ASD group. The decrease was most pronounced over the inferior-frontal and temporo-parietal junction areas. We also found a significant decrease in gamma-activity over the dorsolateral prefrontal cortex, especially in the left side. Since these brain areas have been associated with social functioning, the reduced gamma-activity in ASD may represent a cortical dysfunction that could underlie a diminished capacity to interpret socially important information, thereby interfering with social functioning. The alterations we found may lend support for an improved diagnosis. Furthermore, they can lead to focused therapies, by targeting the dysfunctional brain activity to improve social cognitive and interaction abilities that are compromised in ASD.

Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia

Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.

Examining the Incremental Validity of the Perth Alexithymia Questionnaire (PAQ) Relative to the 20-Item Toronto Alexithymia Scale (TAS-20)

The 20-item Toronto Alexithymia Scale (TAS-20) is the most widely used instrument for assessing alexithymia, with more than 25 years of research supporting its reliability and validity. The items that compose this scale were written to operationalize the components of the construct that are based on clinical observations of patients and thought to reflect deficits in the cognitive processing of emotions. The Perth Alexithymia Questionnaire (PAQ) is a recently introduced measure and is based on a theoretical attention-appraisal model of alexithymia. An important step with any newly developed measure is to evaluate whether it demonstrates incremental validity over existing measures. In this study using a community sample (N = 759), a series of hierarchical regression analyses were conducted that included an array of measures assessing constructs closely associated with alexithymia. Overall, the TAS-20 showed strong associations with these various constructs to which the PAQ was unable to add any meaningful increase in prediction relative to the TAS-20. We conclude that until future studies with clinical samples using several different criterion variables demonstrate incremental validity of the PAQ, the TAS-20 should remain the self-report measure of choice for clinicians and researchers assessing alexithymia, albeit as part of a multi-method approach.

Addressing psychosomatic symptom distress with mindfulness-based cognitive therapy in somatic symptom disorder: mediating effects of self-compassion and alexithymia

Objective

This study explored the association between self-compassion, alexithymia, and psychosomatic symptom distress in a clinical sample of somatic symptom disorder (SSD) patients participating in a mindfulness-based cognitive therapy (MBCT) program.

Methods

One hundred sixteen SSD patients who had participated in an MBCT program and completed ≥4 intervention sessions were included in a retrospective study (76.7% women, mean age = 40.0, SD = 9.5). Psychometric measures of psychosomatic symptom distress [Brief Symptom Inventory-18 Global Severity Index (BSI-GSI)], self-compassion [Self-Compassion Scale (SCS)], and alexithymia [Toronto Alexithymia Scale (TAS)] were collected upon admission to the MBCT program and at 6-month follow-up following treatment inclusion.

Results

Serial mediation analysis (MBCT→ΔSCS→ΔTAS→ΔBSI-GSI) suggested that changes in both self-compassion and alexithymia had significant indirect effects on improvement in psychosomatic distress [ΔSCS β = -1.810, 95% bootstrap CI (-2.488, -1.160); ΔTAS β = -1.615, bootstrap 95% CI (-2.413, -0.896); ΔSCS→ΔTAS β = -0.621, bootstrap CI (-1.032, -0.315)]. Furthermore, a post-hoc analysis with a reverse sequence (MBCT→ΔTAS→ΔSCS→ΔBSI-GSI) revealed that reduction in alexithymia improved psychosomatic distress and that an increase in self-compassion was a subsequent outcome of alleviation of alexithymia [ΔTAS β = -2.235, bootstrap 95% CI (-3.305, -1.270); ΔSCS β = 0.013, 95% bootstrap CI (-0.600, 0.682); ΔTAS→ΔSCS β = -1.823, bootstrap CI (-2.770, -1.047)].

Conclusion

Both alleviation of alexithymia and improvement in self-compassion play a mediating role in the reduction of psychosomatic distress in SSD patients following an MBCT program. Improvement in self-compassion might be a subsequent outcome of MBCT-related alleviation of alexithymia.

Isolating unique variance in mental health outcomes attributable to personality variables and childhood emotional abuse

Introduction

University students are at high risk for anxiety and depression. Our main objective was to tease apart variance in symptom severity that was uniquely attributable to four associated variables that are frequently confounded: exposure to childhood emotional abuse, alexithymia, sensory processing sensitivity (SPS), and anxiety sensitivity (AS).

Methods

University students (N = 410) completed an online survey designed to measure our four key study variables along with several other potentially relevant variables including sex, physical activity levels, and perceived COVID-19 impacts.

Results

Over half of the participants reported moderate to extremely severe symptoms of anxiety and depression. Females reported stronger signs of SPS and AS and were more likely than males to have increased their moderate/vigorous exercise since the pandemic began. After controlling for the other variables, the best predictors of perceived COVID-19 impacts were SPS, childhood emotional abuse, and current levels of physical activity. Whereas all three personality variables and childhood emotional abuse emerged as significant predictors of both depression and anxiety, neither COVID-19 impacts nor physical activity levels accounted for unique variance in either model. Unexpectedly, male sex emerged as an additional risk factor for depression, raising the possibility that males experience unique stressors and societal pressures that increase their risk of depression.

Discussion

These findings help to clarify the links between childhood emotional abuse, personality traits implicated in emotional awareness and self-regulation, and mental health. They may have important implications for the development and implementation of individualized treatments for common mental disorders.

Alexithymia in Adult Autism Clinic Service-Users: Relationships with Sensory Processing Differences and Mental Health

Mental health difficulties commonly co-occur with autism, especially in autistic people accessing clinic services, impacting substantially on quality-of-life. Alexithymia (difficulty describing/identifying feelings) and sensory processing differences are prevalent traits in autism that have been associated with depression/anxiety in autistic community samples. However, it is important to better understand interrelationships between these traits in clinical populations to improve identification of service-user needs. In this study, 190 autistic adults (65.3% male), seen in a tertiary autism clinic, completed self-report measures of alexithymia (20-item Toronto Alexithymia Scale), sensory processing differences (Adolescent/Adult Sensory Profile) and depression/anxiety (Hospital Anxiety and Depression Scale). Multiple linear regression models and mediation analyses were used to examine associations between alexithymia, sensory processing differences, and depression/anxiety severity. Across the sample, 66.3% of individuals (N = 126) were classified as alexithymic (score ≥ 61). Total alexithymia and difficulty describing/identifying feelings were significantly associated with depression severity (β = 0.30-0.38, highest p < 0.002), and difficulty identifying feelings was significantly associated with anxiety severity (β = 0.36, p < 0.001). Sensory processing differences were also significantly associated with depression severity (β = 0.29, p = 0.002) and anxiety severity across all models (β = 0.34-0.48, highest p < 0.001) Finally, difficulty describing/identifying feelings partially mediated the relationships between sensory processing differences and both depression/anxiety severity. Overall, these results highlight that interventions adapted for and targeting emotional awareness and sensory-related uncertainty may improve mental health outcomes in autistic service-users.

Interoceptive awareness and emotional eating in college women: the role of appetite and emotional awareness

Objective: Emotional eating is prevalent among college women. Deficits in interoceptive awareness, or the ability to perceive and identify internal sensations, are associated with emotional eating. Separately examining the specific components of interoceptive awareness, appetite and emotional awareness, in relation to emotional eating may improve prevention and treatment of emotional eating in college women.Participants: 143 women at an urban Northeastern university.Methods: This was a cross-sectional study using self-report measures of interoceptive awareness, appetite and emotional awareness, emotional eating, and depression. Simultaneous regression analyses examined the independent association of appetite and emotional awareness with emotional eating, controlling for depression.Results: Consistent with hypotheses, lower interoceptive awareness was associated with higher emotional eating. Appetite and emotional awareness, were each uniquely associated with emotional eating independent of depression, even when entered simultaneously.Conclusions: Future prevention and treatment of emotional eating in college women should target improvements in appetite and emotional awareness.

Transdiagnostic failure to adapt interoceptive precision estimates across affective, substance use, and eating disorders: A replication study

Recent computational theories of interoception suggest that perception of bodily states rests upon an expected reliability- or precision-weighted integration of afferent signals and prior beliefs. The computational psychiatry framework further suggests that aberrant precision-weighting may lead to misestimation of bodily states, potentially hindering effective visceral regulation and promoting psychopathology. In a previous study, we fit a Bayesian computational model of perception to behavior on a heartbeat tapping task to test whether aberrant precision-weighting was associated with misestimation of bodily states. We found that, during an interoceptive perturbation designed to amplify afferent signal precision (inspiratory breath-holding), healthy individuals increased the precision-weighting assigned to ascending cardiac signals (relative to resting conditions), while individuals with symptoms of anxiety, depression, substance use disorders, and/or eating disorders did not. A second study also replicated the pattern observed in healthy participants. In this pre-registered study, we aimed to replicate our prior findings in a new transdiagnostic patient sample (N=285) similar to the one in the original study. These new results successfully replicated those found in our previous study, indicating that, transdiagnostically, patients were unable to adjust beliefs about the reliability of interoceptive signals - preventing the ability to accurately perceive changes in their bodily state. Follow-up analyses combining samples from the previous and current study (N=719) also afforded the power to identify group differences within narrower diagnostic groups and to examine predictive accuracy when logistic regression models were trained on one sample and tested on the other. Given the increased confidence in the generalizability of these effects, future studies should examine the utility of interceptive precision measures in predicting treatment outcomes or identify whether these computational mechanisms might represent novel therapeutic targets for improving visceral regulation.

Testing pharmacotherapies for alcohol use disorder with cue exposure paradigms: A systematic review and quantitative synthesis of human laboratory trial methodology

Alcohol cue exposure is a widely used experimental paradigm for screening pharmacotherapies for alcohol use disorder (AUD). Medication-related reductions in cue-reactivity signal early efficacy and inform medications development. Yet, across trials, the design of cue exposure, parameter testing, and outcome reporting is heterogeneous. This systematic review is a quantitative synthesis of trial methodologies and effect size estimation for AUD medication-related craving and psychophysiological outcomes under the cue exposure paradigm. A PubMed search was conducted on January 3, 2022 based on identified pharmacotherapies for peer-reviewed articles reported in English. Study-level characteristics, including sample descriptors, paradigm design, analytic approach, and Cochrane Risk of Bias, along with descriptive statistics for cue-exposure outcomes, were coded by two independent raters. Study-level effect sizes were estimated for craving and psychophysiological outcomes separately and sample-level effect sizes were calculated for each medication. Thirty-six trials, comprising 1640 participants and testing 19 different medications satisfied eligibility criteria. All studies reported on biological sex (71% male participants on average). The exposure paradigms implemented used in vivo (n = 26), visual (n = 8), and audio script (n = 2) cues. Some trials included means for craving by medication condition in text (k = 7) or figures (k = 18). The quantitative synthesis included 63 effect sizes (craving kes  = 47; psychophysiological kes  = 16) from 28 unique randomized trials testing 15 medications for effects on cue reactivity. For cue-induced craving, eight medications (kes range: 1-12) demonstrated small-to-medium effects (Cohen's d range: |0.24-0.64|) compared to placebo, with individuals randomized to receive medication reporting lower craving following cue exposure. Recommendations are provided to promote further consilience, so that the utility of cue exposure paradigms can be maximized in the development of effective AUD pharmacotherapies. Future work should explore the predictive utility of medication-related reductions in cue-reactivity on clinical outcomes.

Investigating two mobile just-in-time adaptive interventions to foster psychological resilience: research protocol of the DynaM-INT study

BACKGROUND

Stress-related disorders such as anxiety and depression are highly prevalent and cause a tremendous burden for affected individuals and society. In order to improve prevention strategies, knowledge regarding resilience mechanisms and ways to boost them is highly needed. In the Dynamic Modelling of Resilience - interventional multicenter study (DynaM-INT), we will conduct a large-scale feasibility and preliminary efficacy test for two mobile- and wearable-based just-in-time adaptive interventions (JITAIs), designed to target putative resilience mechanisms. Deep participant phenotyping at baseline serves to identify individual predictors for intervention success in terms of target engagement and stress resilience.

METHODS

DynaM-INT aims to recruit N = 250 healthy but vulnerable young adults in the transition phase between adolescence and adulthood (18-27 years) across five research sites (Berlin, Mainz, Nijmegen, Tel Aviv, and Warsaw). Participants are included if they report at least three negative burdensome past life events and show increased levels of internalizing symptoms while not being affected by any major mental disorder. Participants are characterized in a multimodal baseline phase, which includes neuropsychological tests, neuroimaging, bio-samples, sociodemographic and psychological questionnaires, a video-recorded interview, as well as ecological momentary assessments (EMA) and ecological physiological assessments (EPA). Subsequently, participants are randomly assigned to one of two ecological momentary interventions (EMIs), targeting either positive cognitive reappraisal or reward sensitivity. During the following intervention phase, participants' stress responses are tracked using EMA and EPA, and JITAIs are triggered if an individually calibrated stress threshold is crossed. In a three-month-long follow-up phase, parts of the baseline characterization phase are repeated. Throughout the entire study, stressor exposure and mental health are regularly monitored to calculate stressor reactivity as a proxy for outcome resilience. The online monitoring questionnaires and the repetition of the baseline questionnaires also serve to assess target engagement.

DISCUSSION

The DynaM-INT study intends to advance the field of resilience research by feasibility-testing two new mechanistically targeted JITAIs that aim at increasing individual stress resilience and identifying predictors for successful intervention response. Determining these predictors is an important step toward future randomized controlled trials to establish the efficacy of these interventions.

Alexithymia and asthma: a systematic review

Growing evidence from scientific research elucidates the important role of alexithymia in chronic immune diseases. This Review aims to explore the presence of alexithymia in patients affected by asthma and clarify its associations with other involved psychological and physical factors. In January 2023, according to PRISMA guidelines, a systematic search using PubMed and Scopus was conducted. Twenty-six studies were eligible based on inclusion criteria. Alexithymia was significantly present in asthma patients, with most studies reporting a higher prevalence (from 9 to 62.8%) than in control groups (approximately 10%). The coexistence of asthma and alexithymia was associated with a worse quality of life, psychiatric comorbidity, poor symptom control, and difficulty in recognizing exacerbations of the disease. These results suggest that alexithymia can negatively impact the management of asthma. For this reason, we recommend an accuracy assessment in clinical settings and the implementation of psychological interventions to promote the emotional and physical wellbeing of asthmatic patients.

A Cross-Sectional Study to Analyze the Correlation Between Alexithymia and Dental Neglect in Persons Pursuing Dental Care

Background Alexithymia is a personality trait involving difficulties in emotional regulation (difficulties in identifying feelings, difficulties in describing feelings, and externally oriented thinking). It has a negative impact on health as it evokes poor personal hygiene, poor nutrition, and unhealthy behaviors in affected subjects. Identifying alexithymia in the dental setup is vital as it can compromise the patient-dentist relationship, especially in subjects neglecting oral hygiene. Aims The present study aimed to establish an association between alexithymia and dental neglect among adult subjects seeking dental care by using Dental Neglect Scale (DNS), and alexithymia was assessed on the 20-item Toronto Alexithymia Scale (TAS-20). Methods The present cross-sectional survey study included adult subjects of age 20 years or more. For all included participants, a structured questionnaire was given to assess dental neglect on demographic profile, six items of the DNS, and alexithymia was assessed on the 20-item TAS-20. The collected data were analyzed using a Chi-square test keeping significance at the p-value of <0.05. Results In 534 adult subjects, females had high scores for both TAS-20 and DNS along with their related factors. With higher education and increasing age, a significant increase in the mean TAS-20 scores and mean DNS scores was seen in the study participants (high mean DNS scores in females (19.55±3.98) compared to male subjects 19.36±4.34). TAS-20 scores were higher in females (59.31±10.78), factor 1 (DIF) (19.54±5.54), factor 2 (DDF) (15.46±4.05), and factor 3 (EOT) (24.34±4.64). Conclusion The present study, considering its limitations, concludes that there is no association between dental neglect and alexithymia in adult subjects seeking dental care. However, higher DNS and TAS-20 scores are seen in females showing them have difficult descriptions and identification of feelings in dental set-up increasing dental neglect among them.

The role of ventrolateral prefrontal cortex on voluntary emotion regulation of social pain

The right ventrolateral prefrontal cortex (rVLPFC) is highly engaged in emotion regulation of social pain. However, there is still lack of both inhibition and excitement evidence to prove the causal relationship between this brain region and voluntary emotion regulation. This study used high-frequency (10 Hz) and low-frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) to separately activate or inhibit the rVLPFC in two groups of participants. We recorded participants' emotion ratings as well as their social attitude and prosocial behaviors following emotion regulation. Also, we used eye tracker to record the changes of pupil diameter to measure emotional feelings objectively. A total of 108 healthy participants were randomly assigned to the activated, inhibitory or sham rTMS groups. They were required to accomplish three sequential tasks: the emotion regulation (cognitive reappraisal) task, the favorability rating task, and the donation task. Results show that the rVLPFC-inhibitory group reported more negative emotions and showed larger pupil diameter while the rVLPFC-activated group showed less negative emotions and reduced pupil diameter during emotion regulation (both compared with the sham rTMS group). In addition, the activated group gave more positive social evaluation to peers and donated more money to a public welfare activity than the rVLPFC-inhibitory group, among which the change of social attitude was mediated by regulated emotion. Taken together, these findings reveal that the rVLPFC plays a causal role in voluntary emotion regulation of social pain and can be a potential brain target in treating deficits of emotion regulation in psychiatric disorders.

Moderators and mediators of change of an internet-based mindfulness intervention for college students: secondary analysis from a randomized controlled trial

Background

Existing evidence suggests internet- and mobile-based interventions (IMIs) improve depressive symptoms in college students effectively. However, there is far less knowledge about the potential mechanisms of change of mindfulness-based IMIs, which could contribute to optimizing target groups and interventions. Hence, within this secondary analysis of data from a randomized controlled trial (RCT), potential moderators and mediators of the effectiveness of the IMI StudiCare Mindfulness were investigated.

Methods

Moderation and mediation analyses were based on secondary data from a RCT that examined the effectiveness of the 7-module IMI StudiCare Mindfulness in a sample of college students (intervention group: n = 217; waitlist control group: n = 127). Assessments were collected before (t0; baseline), 4 weeks after (t1; during intervention), and 8 weeks after (t2; post-intervention) randomization. Longitudinal mediation analyses using structural equation modeling were employed, with depressive symptom severity as the dependent variable. For moderation analyses, bilinear interaction models were calculated with depressive symptom severity and mindfulness at t2 as dependent variables. All data-analyses were performed on an intention-to-treat basis.

Results

Mediation analyses showed a significant, full mediation of the intervention effect on depressive symptom severity through mindfulness (indirect effect, a*b = 0.153, p < 0.01). Only the number of semesters (interaction: β = 0.24, p = 0.035) was found to moderate the intervention's effectiveness on depressive symptom severity at t2, and only baseline mindfulness (interaction: β = -0.20, p = 0.047) and baseline self-efficacy (interaction: β = -0.27, p = 0.012) were found to be significant moderators of the intervention effect on mindfulness at t2.

Conclusion

Our results suggest a mediating role of mindfulness. Moderation analyses demonstrated that the intervention improved depressive symptom severity and mindfulness independent of most examined baseline characteristics. Future confirmatory trials will need to support these findings.

Clinical Trial Registration

The trial was registered a priori at the WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (TRN: DRKS00014774; registration date: 18 May 2018).

Brief Report: An Exploration of Alexithymia in Autistic and Nonautistic Transgender Adults

Background

Research has shown that many autistic people have alexithymia, a psychological trait characterized by difficulties in identifying and describing emotions. It is also now clear that there is a high rate of autism among transgender people, but we know little about the intersection of autism and gender diversity or about the clinical features of autistic transgender individuals.

Methods

Seventy-eight nonautistic transgender, 56 autistic transgender, 106 nonautistic cisgender, and 107 autistic cisgender adults completed the Toronto Alexithymia Scale-20 and the Autism-spectrum Quotient as part of an online study. We also used the General Alexithymia Factor Score-8 as an additional alexithymia score.

Results

We found that nonautistic transgender participants reported significantly higher mean levels of alexithymia than nonautistic cisgender participants, and that there was a significant overrepresentation of individuals in this group who met the clinical cutoff for alexithymia. The difference in alexithymia between autistic cisgender and autistic transgender participants was nonsignificant, with >50% of each group scoring above the clinical cutoff point. Of note, when we used the General Alexithymia Factor Score-8, the difference between autistic transgender participants and autistic cisgender participants was significant, with autistic transgender participants reporting higher mean levels of alexithymia.

Conclusion

Results suggest that nonautistic transgender individuals might be more prone to experience alexithymia (including at clinically significant levels) than nonautistic cisgender people. When autism occurs in transgender people, the average level and clinical rate of alexithymia is higher than among nonautistic transgender people and potentially higher than among autistic cisgender people. Our findings are in keeping with evidence of a subgroup of transgender people with "subclinical autism" and inconsistent with the notion that autism among transgender and gender diverse people is a "phenomimic" of autism. Lastly, our study highlights the potential importance of screening autistic and nonautistic transgender people for alexithymia.

INs and OUTs of faces in consciousness: a study of the temporal evolution of consciousness of faces during binocular rivalry

Contents of consciousness change over time. However, the study of dynamics in consciousness has been largely neglected. Aru and Bachmann have recently brought to the attention of scientists dealing with consciousness the relevance of making inquiries about its temporal evolution. Importantly, they also pointed out several experimental questions as guidelines for researchers interested in studying the temporal evolution of consciousness, including the phases of formation and dissolution of content. They also suggested that these two phases could be characterized by asymmetric inertia. The main objective of the present investigation was to approximate the dynamics of these two phases in the context of conscious face perception. To this aim, we tested the time course of content transitions during a binocular rivalry task using face stimuli and asked participants to map their subjective experience of transitions from one content to the other through a joystick. We then computed metrics of joystick velocity linked to content transitions as proxies of the formation and dissolution phases. We found a general phase effect such that the formation phase was slower than the dissolution phase. Furthermore, we observed an effect specific to happy facial expressions, such that their contents were slower to form and dissolve than that of neutral expressions. We further propose to include a third phase of stabilization of conscious content between formation and dissolution.

Four attachment-based categories of emotion regulation in adolescent psychic troubles

Introduction

Emotion regulation is altered in many psychiatric disorders in adolescence, but the understanding of mechanisms that underlie this alteration is still poor.

Methods

The PERCEPT study explores alexithymia, empathy, facial emotion recognition (FER) and defence mechanisms in a sample of adolescents in psychiatric care (n = 61, 74% of girls, mean age = 15.03 y.o.), in relation with participants' attachment styles.

Results

Results revealed correlations between attachment dimensions and all of the emotion regulation variables, suggesting that attachment modalities have functional links with emotional regulation at its different levels: FER accuracy was inversely correlated with avoidant attachment, while affective empathy, difficulty in identifying feelings (alexithymia) and immature as well as neurotic defence mechanisms were positively correlated with anxious attachment. Moreover, attachment categories delineated distinct emotional perception profiles. In particular, preoccupied attachment included adolescents with the highest levels of facial emotion perception (sensitivity and accuracy) and of affective empathy, whereas detached attachment included adolescents with the lowest levels of these variables. Neurotic defence mechanisms and difficulty to identify feelings were correlated with preoccupied attachment; immature defence mechanisms and difficulty to describe feelings to others characterized fearful attachment.

Discussion

These results suggest that attachment categories underlie emotion regulation processes in psychiatric disorders in adolescence. Theoretical and clinical implications are discussed.

Association between alexithymia and non-suicidal self-injury in psychiatric patients: the mediating role of self-esteem and the moderating role of emotional intelligence

BACKGROUND

Raffagnato's theory claims that if people have no words to express their emotions (alexithymia), they express themselves by venting or through non-suicidal self-injury (NSSI). However, these associations have not been confirmed in psychiatric patients. This study explored the relationship between alexithymia and NSSI in psychiatric patients and the potential underlying psychological mechanisms.

METHODS

This retrospective study involved face-to-face interviews with 449 outpatients consecutively recruited from West China Hospital. Alexithymia, self-esteem, NSSI, and emotional intelligence (EI) were measured. The moderating role of EI and the mediating role of self-esteem between alexithymia and NSSI were also explored. Logistic regressions were used to examine whether sociodemographic, clinical variables and alexithymia were independently associated with NSSI.

RESULTS

The DSM-5 NSSI disorder and alexithymia prevalences were found to be 32.5% and 45.2%. When the other covariables were controlled for, the alexithymic patients were found to be at increased odds (OR 2.76) of engaging in NSSI behaviors. These results confirmed the strong associations between alexithymia, low self-esteem, and NSSI risk. Lower EI was found to be related to the connections between alexithymia and NSSI. Except for the lower risk in anxiety patients, the risk of NSSI was similar for patients with other mental disorders, CONCLUSION: This study revealed the psychological mechanisms through which alexithymia increases the risk of NSSI. Therefore, to reduce NSSI risk, screening for alexithymia should be emphasized. Self-esteem as a targeted psychological intervention could also assist in mitigating the process from alexithymia to NSSI behaviors, and EI training for psychiatric patients could weaken the relationship between alexithymia and NSSI.

Bi-factor and Second-Order Copula Models for Item Response Data

Bi-factor and second-order models based on copulas are proposed for item response data, where the items are sampled from identified subdomains of some larger domain such that there is a homogeneous dependence within each domain. Our general models include the Gaussian bi-factor and second-order models as special cases and can lead to more probability in the joint upper or lower tail compared with the Gaussian bi-factor and second-order models. Details on maximum likelihood estimation of parameters for the bi-factor and second-order copula models are given, as well as model selection and goodness-of-fit techniques. Our general methodology is demonstrated with an extensive simulation study and illustrated for the Toronto Alexithymia Scale. Our studies suggest that there can be a substantial improvement over the Gaussian bi-factor and second-order models both conceptually, as the items can have interpretations of discretized maxima/minima or mixtures of discretized means in comparison with discretized means, and in fit to data.

Emotional recognition across the adult lifespan: Effects of age, sex, cognitive empathy, alexithymia traits, and amygdala subnuclei volumes

The ability to recognize others' emotions is vital to everyday life. The goal of this study was to assess which emotions show age-related decline in recognition accuracy of facial emotional expressions across the entire adult lifespan and how this process is related to cognitive empathy (Theory of Mind [ToM]), alexithymia traits, and amygdala subnuclei volumes in a large cohort of healthy individuals. We recruited 140 healthy participants 18-85 years old. Facial affect processing was assessed with the Penn Emotion Recognition task (ER40) that contains images of the five basic emotions: Neutral, Happy, Sad, Angry, and Fearful. Structural magnetic resonance imaging (MRI) datasets were acquired on a 4.7T MRI system. Structural equation modeling was used to test the relationship between studied variables. We found that while both sexes demonstrated age-related reduction in recognition of happy emotions and preserved recognition of sadness, male participants showed age-related reduction in recognition of fear, while in female participants, age-related decline was linked to recognition of neutral and angry facial expressions. In both sexes, accurate recognition of sadness negatively correlated with alexithymia traits. On the other hand, better ToM capabilities in male participants were associated with improvement in recognition of positive and neutral emotions. Finally, none of the observed age-related reductions in emotional recognition were related to amygdala and its subnuclei volumes. In contrast, both global volume of amygdala and its cortical and centromedial subnuclei had significant direct effects on recognition of sad images.

Sex differences in subjective cognitive impairment and clinical correlates in Chinese patients with subthreshold depression

OBJECTIVE

Subthreshold depression (SD) is a global mental health problem given its high prevalence, comorbidity, functional impairment, and its association with increased service utilization. However, currently little is known about sex differences of SD in cognitive impairment with clinical correlates. This study aims to explore sex differences in subjective cognitive impairment and clinically associated risk factors in Chinese patients with subthreshold depression (SD).

METHODS

A total of 126 patients with SD, 40 males and 86 females, aged 18-45 years, were included in this cross-sectional observational study. Their general information, psychological assessments, and psychiatric symptom assessments were collected online. The Patient Health Questionnaire depression-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Perceived Deficits Questionnaire-Depression (PDQ-D), and Toronto Alexithymia Scale (TAS-20) with 3 subdomains were used. The obtained scores were analyzed with partial correlation and multiple linear regression analysis models.

RESULTS

Our results showed that females had significantly higher PDQ-D-20 total score than males. However, the differences in TAS-20 and subdomain score according to sex were not significant. Notably, TAS-20 and DDF (difficulty describing feelings) subdomain contributed to cognitive impairment in males, whereas both PHQ-9 total score and TAS-20 or DDF subdomain contributed to cognitive impairment in females.

CONCLUSION

These findings revealed significant sex differences in cognitive impairment and clinical correlates in SD, which should be further followed-up in the future.

A Three-Armed Randomized Controlled Trial to Evaluate the Effectiveness, Acceptance, and Negative Effects of StudiCare Mindfulness, an Internet- and Mobile-Based Intervention for College Students with No and "On Demand" Guidance

The college years can be accompanied by mental distress. Internet- and mobile-based interventions (IMIs) have the potential to improve mental health but adherence is problematic. Psychological guidance might promote adherence but is resource intensive. In this three-armed randomized controlled trial, "guidance on demand" (GoD) and unguided (UG) adherence-promoting versions of the seven-module IMI StudiCare Mindfulness were compared with a waitlist control group and each other. The GoD participants could ask for guidance as needed. A total of 387 students with moderate/low mindfulness were recruited. Follow-up assessments took place after 1 (t1), 2 (t2), and 6 (t3) months. Post-intervention (t2), both versions significantly improved the primary outcome of mindfulness (d = 0.91-1.06, 95% CI 0.66-1.32) and most other mental health outcomes (d = 0.25-0.69, 95% CI 0.00-0.94) compared with WL, with effects generally persisting after 6 months. Exploratory comparisons between UG and GoD were mostly non-significant. Adherence was low but significantly higher in GoD (39%) vs. UG (28%) at the 6-month follow-up. Across versions, 15% of participants experienced negative effects, which were mostly mild. Both versions effectively promoted mental health in college students. Overall, GoD was not associated with substantial gains in effectiveness or adherence compared with UG. Future studies should investigate persuasive design to improve adherence.

SOphrology Intervention to Improve WELL-Being in Hospital Staff (SO-WELL): Protocol for a Randomized Controlled Trial Study

INTRODUCTION

Stress at work and psychosocial risks are a major public health problem. Sophrology and neurolinguistic programming (NLP) have demonstrated benefits in terms of mental, physical and social health, both in the general population and in patients, and both in and out of hospital settings. However, these approaches have never been provided at the hospital for the benefit of health professionals at risk of suffering at work. In general, we aim to demonstrate the effectiveness of a hospital sophrology/NLP intervention for health care professionals at risk of stress-related disorders. The secondary objectives are to study (i) within-group, and (ii) between-group): (1) effects on mental, physical, and social health; (2) persistence of effect; (3) relationships between job perception and mental, physical, and social health; (4) intervention success factors (personality and job perception, attendance and practice, other); (5) effects on other stress biomarkers (other measures of autonomic nervous system activity, DHEAS, cortisol, etc.).

METHODS

Our study will be a randomized controlled prospective study (research involving the human person of type 2). The study will be proposed to any health-care workers (HCW) or any non-HCW (NHCW) from a healthcare institution (such as CHU of Clermont-Ferrand, other hospitals, clinics, retirement homes). Participants will benefit from NLP and sophrology interventions at the hospital. For both groups: (i) heart rate variability, skin conductance and saliva biomarkers will be assessed once a week during the intervention period (6 to 8 sophrology sessions) and once by month for the rest of the time; (ii) the short questionnaire will be collected once a week during the whole protocol (1-2 min); (iii) the long questionnaire will be assessed only 5 times: at baseline (M0), month 1 (M1), month 3 (M3), month 5 (M5) and end of the protocol (M7).

ETHICS AND DISSEMINATION

The protocol, information and consent form had received the favorable opinion from the Ethics Committee. Notification of the approval of the Ethics Committee was sent to the study sponsor and the competent authority (ANSM). The study is registered in ClinicalTrials.gov under the identification number NCT05425511 after the French Ethics Committee's approval. The results will be reported according to the CONSORT guidelines.

STRENGTHS AND LIMITATIONS OF THIS STUDY

The psychological questionnaires in this study are self-assessed. It is also possible that responses suffer from variation. For the study, participants need to attend 6 to 8 sophrology sessions and one visit per month for 7 months, which might seem demanding. Therefore, to make sure that participants will complete the protocol, two persons will be fully in charge of the participants' follow-up.

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.

Do alexithymia and negative affect predict poor sleep quality? The moderating role of interoceptive sensibility

OBJECTIVES

Emotion-related hyperarousal is an important core pathology of poor sleep. Studies investigating the interplay of alexithymia and affective experiences in determining sleep quality have yielded mixed results. To disentangle the inconsistency, this study examined the concurrent predictive power of alexithymia, and negative and positive affect, while incorporating interoceptive sensibility (IS) as a possible moderator.

METHODS

A sample of 224 (70.10% were female) participants completed the Toronto Alexithymia Scale, Positive and Negative Affect Schedule, Pittsburgh Sleep Quality Index, Multidimensional Assessment of Interoceptive Awareness (MAIA), and Marlowe-Crowne Social Desirability Scale (for controlling response bias) using paper and pencil. A two-stage cluster analysis of the MAIA was used to capture IS characteristics. Stepwise regression was conducted separately for each IS cluster.

RESULTS

A three-group structure for IS characteristics was found. Higher alexithymia was predictive of poor sleep quality in the low IS group, while higher negative affect predicted poor sleep quality in the moderate and high IS groups. Additionally, alexithymia and positive affect were significantly different in the three IS groups, while negative affect and sleep quality were not.

CONCLUSIONS

Emotion and cognitive arousal may impact sleep quality differently in individuals with different levels of internal focusing ability, depending on physiological versus emotional self-conceptualization. The implications on pathological research, clinical intervention, study limitations and future directions are discussed.

Association between alexithymia and substance use: A systematic review and meta-analysis

Alexithymia has been associated with substance use, but the magnitude of the association has not been evaluated and sub-group differences, if any, are unknown. The aim of this meta-analysis is to systematically review the association between alexithymia and substance use (alcohol or illicit drugs). We identified studies through a systematic review of PubMed and Web of Science and obtained a total of 52 publications using the Toronto Alexithymia Scale-20 scale. Random effects meta-analysis was used to evaluate the overall and sub-group associations. Of the studies, 50 were cross-sectional and two longitudinal. Alexithymia was associated with any substance use (Cohen's d = 0.62, 95% confidence interval [CI] 0.49-0.76), with little difference between estimates for use of alcohol or illicit drugs. A stronger association was observed for the alexithymia dimension "Difficulty in Identifying Feelings" (d = 0.64, 95% CI = 0.47-0.81) and "Difficulty in Describing Feelings" (d = 0.44, 95% CI = 0.32-0.55) than for "Externally Oriented Thinking" (d = 0.19, 95% CI = 0.09-0.28). The association was stronger in studies with clinical patient populations (d = 0.83, 95% CI = 0.62-1.05) than in those investigating general or student populations, and in studies with a majority of male rather than female participants. These findings suggest a strong overall association between alexithymia and substance use and a very strong association among clinical patient populations. The association may be stronger with the emotion-related dimensions than with the cognition-related dimension of alexithymia. As nearly all the studies were cross-sectional, more longitudinal studies are needed.

Furthering the language hypothesis of alexithymia: An integrated review and meta-analysis

Alexithymia, including the inability to identify and express one's own feelings, is a subclinical condition responsible for some of the socioemotional symptoms seen across a range of psychiatric conditions. The language hypothesis of alexithymia posits a language-mediated disruption in the development of discrete emotion concepts from ambiguous affective states, exacerbating the risk of developing alexithymia in language-impaired individuals. To provide a critical evaluation, a systematic review and meta-analysis of 29 empirical studies of language functioning in alexithymia was performed. A modest association was found between alexithymia and multi-domain language deficits (r = -0.14), including structural language, pragmatics, and propensity to use emotional language. A more theoretically-relevant subsample analysis comparing alexithymia levels in language-impaired and typical individuals revealed larger effects, but a limited number of studies adopted this approach. A synthesis of 11 emotional granularity studies also found an association between alexithymia and reduced emotional granularity (r = -0.10). Language impairments seem to increase the risk of alexithymia. Heterogeneous samples and methods suggest the need for studies with improved alexithymia assessments.

Early Trauma and Later Sexual Victimization in College Women: A Multiple Mediation Examination of Alexithymia, Impulsivity, and Alcohol Use

Childhood abuse and sexual violence against women are prevalent in the United States. However, researchers have not fully explored the intersection among important predisposing factors that predict recent sexual violence experienced by women who are also survivors of childhood abuse. The purpose of this study was to examine the relationships among early childhood trauma, alexithymia, impulsivity, alcohol use severity, and sexual victimization in later life among female college students from the United States (n = 1,178). Participants were part of a larger cross-cultural study, conducted between 2012 to 2014, which examined sexual aggression and victimization in the context of alcohol use. The current study aimed to examine if: (a) early trauma, impulsivity, alexithymia, and alcohol use severity impact sexual victimization in later life, and (b) if impulsivity, alexithymia, and alcohol use severity mediate the relationship between early trauma and victimization in later life. It was hypothesized that impulsivity, alexithymia, and alcohol use severity would significantly mediate the relationship between early trauma and sexual victimization in later life. Using a multiple mediation path analysis, results indicated that early childhood trauma was significantly linked with impulsivity, alcohol use severity, and sexual victimization in later life. A partial mediation through impulsivity and alcohol use severity was observed. Alexithymia did not produce mediation effects. These findings align with previous research examining how early childhood trauma influences the occurrence of sexual victimization in later life and provides further recommendations for helping professionals as they attempt to stifle the sexual victimization rates among female college students.

Effective connectivity reveals distinctive patterns in response to others' genuine affective experience of disgust

Empathy is significantly influenced by the identification of others' emotions. In a recent study, we have found increased activation in the anterior insular cortex (aIns) that could be attributed to affect sharing rather than perceptual saliency, when seeing another person genuinely experiencing pain as opposed to merely acting to be in pain. In that prior study, effective connectivity between aIns and the right supramarginal gyrus (rSMG) was revealed to represent what another person really feels. In the present study, we used a similar paradigm to investigate the corresponding neural signatures in the domain of empathy for disgust - with participants seeing others genuinely sniffing unpleasant odors as compared to pretending to smell something disgusting (in fact the disgust expressions in both conditions were acted for reasons of experimental control). Consistent with the previous findings on pain, we found stronger activations in aIns associated with affect sharing for genuine disgust (inferred) compared with pretended disgust. However, instead of rSMG we found engagement of the olfactory cortex. Using dynamic causal modeling (DCM), we estimated the neural dynamics of aIns and the olfactory cortex between the genuine and pretended conditions. This revealed an increased excitatory modulatory effect for genuine disgust compared to pretended disgust. For genuine disgust only, brain-to-behavior regression analyses highlighted a link between the observed modulatory effect and a few empathic traits. Altogether, the current findings complement and expand our previous work, by showing that perceptual saliency alone does not explain responses in the insular cortex. Moreover, it reveals that different brain networks are implicated in a modality-specific way when sharing the affective experiences associated with pain vs. disgust.

Mindfulness-Based Stress Reduction, Cognitive Behavioral Therapy, and Acupuncture in Chronic Low Back Pain: Protocol for Two Linked Randomized Controlled Trials

BACKGROUND

Nonpharmacologic mind-body therapies have demonstrated efficacy in low back pain. However, the mechanisms underlying these therapies remain to be fully elucidated.

OBJECTIVE

In response to these knowledge gaps, the Stanford Center for Low Back Pain-a collaborative, National Institutes of Health P01-funded, multidisciplinary research center-was established to investigate the common and distinct biobehavioral mechanisms of three mind-body therapies for chronic low back pain: cognitive behavioral therapy (CBT) that is used to treat pain, mindfulness-based stress reduction (MBSR), and electroacupuncture. Here, we describe the design and implementation of the center structure and the associated randomized controlled trials for characterizing the mechanisms of chronic low back pain treatments.

METHODS

The multidisciplinary center is running two randomized controlled trials that share common resources for recruitment, enrollment, study execution, and data acquisition. We expect to recruit over 300 chronic low back pain participants across two projects and across different treatment arms within each project. The first project will examine pain-CBT compared with MBSR and a wait-list control group. The second project will examine real versus sham electroacupuncture. We will use behavioral, psychophysical, physical measure, and neuroimaging techniques to characterize the central pain modulatory and emotion regulatory systems in chronic low back pain at baseline and longitudinally. We will characterize how these interventions impact these systems, characterize the longitudinal treatment effects, and identify predictors of treatment efficacy.

RESULTS

Participant recruitment began on March 17, 2015, and will end in March 2023. Recruitment was halted in March 2020 due to COVID-19 and resumed in December 2021.

CONCLUSIONS

This center uses a comprehensive approach to study chronic low back pain. Findings are expected to significantly advance our understanding in (1) the baseline and longitudinal mechanisms of chronic low back pain, (2) the common and distinctive mechanisms of three mind-body therapies, and (3) predictors of treatment response, thereby informing future delivery of nonpharmacologic chronic low back pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02503475; https://clinicaltrials.gov/ct2/show/NCT02503475.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37823.

Alexithymia May Be Associated With Depression in Early-Stage Breast Cancer Patients

Background

Depression, anxiety, or both are common in women with early-stage breast cancer (BC). A relationship is known between low perceived social support (PSS) and depression. We aimed to investigate the relationships between alexithymia, PSS, and Beck Depression Inventory (BDI) score in patients diagnosed with early-stage BC.

Materials and methods

A demographic and medical information form, BDI, the 20-item Toronto Alexithymia Scale (TAS-20), and the Multidimensional Scale of PSS (MSPSS) were given to 200 early-stage BC patients to respond. Two subgroups were created as group A (BDI score < 17) and group B (BDI score ≥ 17) and compared in terms of sociodemographic characteristics, TAS-20, and MSPSS scores.

Results

Twenty-six (18.1%), 48 (33.3%), and 26 (18.1%) patients were with high BDI scores, in low PSS status, and alexithymic, respectively. The median ages of the participants in group A and group B were 53.4 (interquartile range (IQR): 46-60.7) and 46 (IQR: 41.5-59) years, respectively (p = 0.083). The rates of single participants (26.9% versus 11%, p = 0.055), alexithymic participants (42.3% versus 12.7%, p = 0.001), low PSS levels (57.7% versus 28%, p = 0.018), psychiatric treatment history (46.2% versus 22%, p = 0.025), and patients with low income (57.7% versus 22.9%, p = 0.001) were higher in group B than in group A. In the multivariate regression model that contains the parameters mentioned above, psychiatric treatment history (odds ratio (OR): 2.758, 95% confidence interval (CI): 1.034-7.356, p = 0.043), low-income status (OR: 3.503, 95% CI: 1.336-9.182, p = 0.011), and alexithymia (OR: 3.482, 95% CI: 1.229-9.867, p = 0.019) were independent predictive factors for a high BDI.

Conclusion

Alexithymia and low PSS are significantly common in patients with prominent depressive symptoms in early-stage BC patients. Alexithymia may be associated with depression and may also have a role in depression pathogenesis in early-stage BC patients. New studies are needed to investigate whether there is a causal relationship between alexithymia and depression.

Psychoeducation Reduces Alexithymia and Modulates Anger Expression in a School Setting

Bullying and violence are relevant issues in school settings and negatively impact students’ well-being and mental health. Psychoeducation and anti-bullying programs may prevent violence among students by addressing emotional expression and regulation, alexithymia, and anger. We describe the impact of a psychoeducational intervention delivered to 90 male and 101 female school youths (N = 191), aged 12–14 years old, and aimed to improve their emotional recognition and regulation, as well as to reduce alexithymia in order to prevent aggression and bullying episodes. A psychological assessment has been performed before (T0) and after (T1) the intervention including levels of alexithymia, measured with the Toronto Alexithymia Scale-20 (TAS-20), the State-Trait Anger Expression Inventory (STAXI), Empathy Quotient (EQ), and the Emotion Regulation Questionnaire (ERQ). Females have shown higher levels of alexithymia at baseline whereas other characteristics (anger, empathy quotient and emotional regulation) did not differ among sex groups. The psychoeducational program significantly increased the empathy quotient (+10.2%), the emotional regulation reappraisal (+20.3%), and the assertive anger expression (+10.9%); alexithymia significantly decreased after the intervention in all the samples (−14.4%), above all among students scoring ≥61 at TAS-20 (−48.2%). Limitations include a small sample from a single school setting, the lack of a control group without psychoeducation, and an assessment based on self-reported measures. We may conclude that psychoeducation has significantly reduced levels of alexithymia and improved empathy and emotional regulation among adolescents.

Autism traits outweigh alexithymia traits in the explanation of mentalising performance in adults with autism but not in adults with rejected autism diagnosis

Background

Pronounced alexithymia traits have been found in autism spectrum disorder (ASD) and recent research has been carving out the impact alexithymia traits might have on mentalising deficits associated with ASD.

Method

In this cross-sectional study, a large representative referral population for diagnostic examination for possible ASD (n = 400) was screened for clinical alexithymia with a German version of the Reading the Mind in the Eyes test (RME). In contrast to previous attempts to carve out the impact of alexithymia traits on mentalising deficits though, we employed dominance analysis to account for the correlation between predictors. The relative relationship between alexithymia traits and autism traits with RME performance was investigated in the group of individuals with confirmed ASD diagnosis (N = 281) and compared to the clinical referral sample in which ASD was ruled out (N = 119).

Results

Dominance analysis revealed autism traits to be the strongest predictor for reduced mentalising skills in the ASD sample, whereas alexithymia contributed significantly less. In the sample of individuals with ruled out diagnosis, autism traits were the strongest predictor, but alexithymia traits were in sum equally associated to mentalising, with the External-Oriented Thinking subscale as an important predictor of this association.

Limitations

It needs to be considered that the cross-sectional study design does not allow for causal inference. Furthermore, mentalising is a highly facetted capacity and measurements need to reduce this complexity into simple quantities which limits the generalizability of results.

Discussion

While alexithymia traits should be considered for their mental health importance, they do not dominate the explanation of reduced mentalising skills in individuals with ASD, but they might do to a larger degree in individuals with ruled out ASD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-022-00510-9.

Mediating role of depression in the association between alexithymia and nonsuicidal self-injury in a representative sample of adolescents in Taiwan

BACKGROUND

Nock's (2009) integrated theoretical model suggests that specific intrapersonal vulnerability factors caused by distal risk factors contribute to the development of nonsuicidal self-injury (NSSI). Alexithymia and depression have been found to predict NSSI. Based on Nock's model, alexithymia plays a distal risk factor role to increase the risk of depression-an intrapersonal vulnerability factor-and further increase the risk of NSSI. However, small or unrepresentative samples in past studies limit the generalizability of the results. This study examined the roles of depression and alexithymia in predicting NSSI, as well as the mediating effect of depression in the relation between alexithymia and NSSI in a large representative sample of adolescents in Taiwan.

METHODS

Using a cross-sectional study design, a large representative sample of 2,170 senior high school students in Taiwan was assessed by self-report measures of alexithymia, depression, and NSSI. Mediation analyses were performed to examine whether the relation between alexithymia and NSSI was mediated by depression. The questionnaires were administered in classrooms.

RESULTS

Results showed that alexithymia positively predicted NSSI (β = 0.23, p < .001) and depression can also positively predict NSSI (β = 0.41, p < .001). Additionally, the association between alexithymia and NSSI was fully mediated by depression.

CONCLUSIONS

This study data provided evidence for the mediating role of depression between alexithymia and NSSI, which can be explained by Nock's (2009) integrated theoretical model. The implications of the findings for future research and intervention were discussed.

Alexithymia in autism: cross-sectional and longitudinal associations with social-communication difficulties, anxiety and depression symptoms

BACKGROUND

Alexithymia (difficulties in identifying and describing emotion) is a transdiagnostic trait implicated in social-emotional and mental health problems in the general population. Many autistic individuals experience significant social-communication difficulties and elevated anxiety/depression and alexithymia. Nevertheless, the role of alexithymia in explaining individual variability in the quality/severity of social-communication difficulties and/or anxiety and depression symptoms in autism remains poorly understood.

METHODS

In total, 337 adolescents and adults (autism N = 179) were assessed for alexithymia on the Toronto Alexithymia Scale and for social-communication difficulties, anxiety and depression symptoms. A total of 135 individuals (autism N = 76) were followed up 12-24 months later. We used regression models to establish cross-sectional and longitudinal associations between alexithymia, social-communication difficulties, anxiety and depression symptoms.

RESULTS

Autistic individuals reported significantly higher alexithymia than comparison individuals (p < 0.001, r effect size = 0.48), with 47.3% of autistic females and 21.0% of autistic males meeting cut-off for clinically relevant alexithymia (score ⩾61). Difficulties in describing feelings were particularly associated with current self-reported social-communication difficulties [p < 0.001, β = 0.57, 95% confidence interval (CI) 0.44-0.67] and predicted later social-communication difficulties (p = 0.02, β = 0.43, 95% CI 0.07-0.82). Difficulties in identifying feelings were particularly associated with current anxiety symptom severity (p < 0.001, β = 0.54, 95% CI 0.41-0.77) and predicted later anxiety (p = 0.01; β = 0.31, 95% CI 0.08-0.62).

CONCLUSIONS

Our findings suggest that difficulties in identifying v. describing emotion are associated with differential clinical outcomes in autism. Psychological therapies targeting emotional awareness may improve social-communication and anxiety symptoms in autism, potentially conferring long-term benefits.

Investigation of the Relationship Between the Alexithymic Characteristics of Secondary Students and Their Childhood Maltreatment Experiences

This research is a descriptive study aiming at revealing the difference between alexithymia levels and childhood period trauma experience levels according to variables discussed, of students who study in different high schools. In the study, quantitative method and relational survey model have been used. Five hundred ninety-nine students (57.3% female, 42.7% male) studying in 7 different high schools located in a city in the Southeastern Anatolian Region of Turkey in 2018-2019 school year constitutes the study group of the research. A proper sampling method has been used to determine the study group. In the scope of the study, Personal Information Form, Toronto Alexithymia Scale, and Childhood Trauma Questionnaire-Short Form have been used as data collection tools. In data analysis, IBM SPSS 23 Pack software has been used. In the study, it has been observed that according to multivariate analysis of variance test, which is used with the purpose of determining the effects of independent variables, difficulty in expressing feelings and childhood trauma experiences that are the lower dimension of alexithymia become drastically distinct according to school type-class level joint interaction variable. It has been observed that levels of expressing feelings, physical neglect, and emotional neglect become distinct according to school type and childhood trauma experiences, school type-age joint interaction variables.

The process of emotion identification: Considerations for psychiatric disorders

Emotional regulation is important for mental health and behavioral regulation. A relevant precursor to emotional regulation may involve identification of one's emotions. Here, we propose a model of seven components that may provide a foundation for emotion identification. These factors include baseline mood, monitoring, physiological responses, interoception, past personal experiences regarding emotions/metacognition, context, and labeling. We additionally examine how deficits in different components may contribute to the concept of alexithymia, which is defined by difficulty identifying and describing one's own emotions. Ultimately, we explore how the model may support a relationship between specific psychiatric disorders and alexithymia. The proposed model may help explain emotional identification impairment in multiple psychiatric disorders and guide future research and treatment development efforts.

Exploring changes in alexithymia throughout intensive dialectical behavior therapy for eating disorders

OBJECTIVE

Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time.

METHOD

A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months).

RESULTS

Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms.

CONCLUSIONS

Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.

Relevant associations between alexithymia and health-literacy in persons with psoriasis

OBJECTIVE

To explore possible associations between alexithymia and health literacy (HL) in persons with psoriasis.

METHODS

We conducted a cross-sectional study, including 825 persons with moderate to severe psoriasis, using the Toronto Alexithymia Scale, and the Health Literacy Questionnaire. Descriptive statistics compare HL means between alexithymic and not alexithymic participants. Associations between alexithymia and HL are analyzed using a linear multiple regression model.

RESULTS

Twenty-six percent of the participants were characterized as alexithymic, and 26.8% had borderline alexithymia. Higher alexithymia scores were associated with lower education, biological medicines, and more comorbidities, together with lower self-efficacy. The HL domains with the strongest associations with alexithymia were those focusing on managing and getting support for health, as well as the ability to find health information.

CONCLUSION

A more elevated alexithymia score is associated with lower HL. Further studies of these associations may contribute to a more comprehensive perspective of psoriasis. To know a patient's alexithymia level and HL needs may guide health care personnel's understanding of possible associations between health status, clinical presentation, behavior, and response to treatment.

A cross-modal component of alexithymia and its relationship with performance in a social cognition task battery

BACKGROUND

The personality trait alexithymia describes an altered emotional awareness that is associated with a range of social impairments and constitutes a transdiagnostic risk factor for various psychopathologies. Despite the characteristic interoceptive deficits in alexithymia, it is predominantly assessed via self-reports. This can result in unreliable measurements and arguably contributes to the prevailing uncertainty regarding its components, including constricted imaginal processes and emotional reactivity.

METHODS

The current study employed an interview and two validated questionnaires to derive a shared component of multi-modally assessed alexithymia in a German non-clinical sample (n = 78) via prinicipal component analysis. This component was used as a predictor for performance in four behavioural social cognition tasks. The relative importance of this predictor against related variables was assessed via dominance analysis.

RESULTS

The identified component reflected cognitive alexithymia. Higher cognitive alexithymia scores were associated with less affective distress in an ostracizing task. Dominance analysis revealed the dominance of competing autism traits relative to cognitive alexithymia and competing predictors empathy, depression, and anxiety, in predicting affective distress.

LIMITATIONS

Emotional reactivity was only assessed via self-report and no implicit measures of alexithymia were employed. Due to the low reliability of the self-report measure, no measure of emotional reactivity could be included in the principal component analysis.

CONCLUSIONS

Our results provide compelling evidence that cognitive interoceptive deficits are at the core of alexithymia across assessment modalities. Behavioural data suggest that these deficits result in diminished emotional sensitivity to high-pressure social situations, which may cause a lack of behavioural adaptation.

Alexithymia disrupts emotion regulation processes and is associated with greater negative affect and alcohol problems

OBJECTIVE

Alexithymia is common among people who abuse alcohol, yet the mechanisms by which alexithymia exerts its influence remain unclear. This analysis tested a model whereby the three subscales of the Toronto Alexithymia Scale exert an indirect effect on alcohol problems through difficulties with emotion regulation and psychological distress.

METHOD

Men and women (n = 141) seeking alcohol use disorder (AUD) treatment completed the Toronto Alexithymia Scale, the Difficulties with Emotion Regulation Scale, the Brief Symptom Inventory, the Short Inventory of Problems, and the Alcohol Dependence Scale.

RESULTS

The Difficulty Identifying Feelings subscale of the Toronto Alexithymia Scale was positively associated with alcohol problems through emotion dysregulation and psychological distress. The other two subscales, Difficulty Describing Feelings and Externally oriented Thinking, were not associated with any other variables.

CONCLUSION

People with alexithymia may consume alcohol to help regulate undifferentiated states of emotional arousal. Given the prevalence of alexithymia among people who abuse alcohol, treatment supplements that enhance the identification of emotions are needed.

Psychometric evaluation of the Norwegian Toronto Alexithymia Scale (TAS-20) in a multisite clinical sample of patients with personality disorders and personality problems

OBJECTIVE

Psychometric properties of 20-item Toronto Alexithymia Scale (TAS-20) have been widely analyzed, but the validity and psychometric qualities of the TAS-20 in populations with personality disorders are still poorly understood. The aim of the current study was to analyze the factor structure and validity of TAS-20.

METHOD

Data were extracted from a multisite clinical sample of patients with personality disorders or personality-related problems referred to specialist mental health services in Norway.

RESULTS

With one exception, TAS-20 revealed acceptable psychometric properties. Variations of TAS-20 are associated with other clinical measures of distress and severity. Anxiety disorders, borderline, and avoidant personality disorders were all highly related to levels of TAS-20. The TAS-20 also revealed unique variance not accounted for by subjective distress, symptom disorders, or dysfunctional personality traits.

CONCLUSION

The TAS-20 is a relevant instrument for use in assessment of personality disorders, but one subscale should be improved.

How Does Psychological Distress Due to the COVID-19 Pandemic Impact on Internet Addiction and Instagram Addiction in Emerging Adults?

International research has underlined a worrying increase in Internet and Instagram addiction among emerging adults during the COVID-19 pandemic. Although the role played by alexithymia and psychological distress due to COVID-19 has been evidenced, no study has explored their complex relationship in predicting emerging adults' Internet and Instagram addiction. The present study aimed to verify whether peritraumatic distress due to the COVID-19 pandemic mediated the relationship between emerging adults' alexithymia and their Internet/Instagram addiction, in a sample composed of n = 400 Italian emerging adults. Results showed that females had higher peritraumatic distress due to COVID-19 than males, whereas males had higher externally oriented thinking and higher levels of Internet addiction than females. Emerging adults' psychological distress due to COVID-19 significantly mediated the effect of alexithymia on Internet and Instagram addiction. Our findings supported the presence of a dynamic relationship between individual vulnerabilities and the co-occurrence of other psychological difficulties in predicting emerging adults' Internet and Instagram addiction during the pandemic, with important clinical implications.