Factorial validity and measurement invariance of the 20-item Toronto Alexithymia Scale in clinical and nonclinical samples

Alexithymia and interpersonal problems in healthy young individuals

BACKGROUND

Alexithymia refers to a multidimensional personality trait with the facets difficulties identifying feelings (DIF), difficulties describing feelings (DDF), and externally orientated thinking (EOT). Alexithymia is a risk factor for mental and somatic disorders. Previous research with patients suffering from various disorders showed positive relationships between alexithymia and interpersonal problems. Only one study analyzed the link between alexithymic features and interpersonal difficulties in healthy individuals but yielded inconclusive findings because participants' negative affects were not controlled. A widely accepted conceptualization of interpersonal problems relies on the interpersonal circumplex, which is defined by two orthogonal dimensions, agency and communion. In the present study, we analyzed which facets of alexithymia are associated with the two interpersonal problem dimensions and the global severity of interpersonal distress, after adjusting for negative affect.

METHODS

Two-hundred healthy young individuals (100 women) participated in the study. Alexithymic features were assessed using the 20-Item Toronto Alexithymia Scale (TAS-20). Interpersonal problems were measured with the Inventory of Interpersonal Problems (IIP-D). Participants' state and trait anxiety, depressive symptoms, and verbal intelligence were also assessed.

RESULTS

All alexithymia scales were positively correlated with general interpersonal distress. Regression results suggested that the TAS-20 subscale DIF was the primary predictor of general interpersonal distress after controlling for negative affectivity. The scale DDF correlated negatively with the IIP-D dimension agency. According to our regression analysis, DDF was a predictor of (low) agency controlling for negative affects. Moreover, DDF correlated negatively with the IIP-D dimension communion. Our regression results indicate that DDF was a predictor of (low) communion independent of negative affect. Correlations between alexithymia facets and IIP-D subscales did not differ between genders.

CONCLUSIONS

Difficulties identifying feelings seem to be linked to a high level of general interpersonal distress. Difficulties in recognizing one's feelings may disrupt emotion regulation, which could heighten the general risk of interpersonal problems. Difficulties describing feelings could be a central factor contributing to interpersonal problems related to low communion as well as low agency, since emotion expression and communication are crucial in establishing experiences of social closeness and directing other people's behavior.

Weak Hand Grip Strength Is Associated with Alexithymia in Outpatients in a Mexican Population

Hand grip strength has been considered as a possible marker for metabolic and psychiatric disease. To date, however, no research has focused on the association between alexithymia and hand grip strength. The objective of the present study was to investigate the correct association between hand grip strength and alexithymia. A cross-sectional study was carried out in Comalcalco, Tabasco, México. A total of 246 individuals were included. Hand grip strength was evaluated in the dominant hand using a Takei^® portable digital dynamometer. Alexithymia was measured using the Toronto Alexithymia Scale (TAS-20). Two linear regression models adjusted by confounders were used to determine the association between alexithymia and hand grip strength. The rate for positive alexithymia was 39.0% (n = 94). Individuals with alexithymia showed a weaker hand grip strength than the comparison group (t = 2.4, 244 df, p = 0.01). Individuals with alexithymia had significantly reduced levels of hand grip strength (β = −0.39 ± 0.14; p = 0.006); after additional adjustment for clinical variables, decreased hand grip strength remained (β = 8.00 ± 1.86; p ≤ 0.001). Our results suggest that a decrease in hand grip strength could be associated with alexithymia. This measurement could be useful as a predictive marker for the identification of alexithymia in Mexican individuals who attend outpatient clinics.

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.

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.

Measurement invariance of the distress tolerance scale among university students with and without a history of non-suicidal self-injury

Non-suicidal self-injury (NSSI) is the intentional damage to one's body tissue in the absence of suicidal intent. NSSI primarily serves an emotion regulation function, with individuals engaging in self-injury to escape intense or unwanted emotion. Low distress tolerance has been identified as a mechanism that underlies self-injury, and is commonly assessed using the self-report Distress Tolerance Scale. There are mixed findings regarding the factor structure of the Distress Tolerance Scale, with some researchers utilising a higher-order distress tolerance score (derived from the scores on the four lower-order subscales) and other researchers using the four subscales as unique predictors of psychological outcomes. Neither of these factor structures have been assessed among individuals with a history of self-injury. Of note, an inability to tolerate distress (thought to underlie NSSI) may limit an individual's capacity to accurately observe and report specific thoughts and emotions experienced in a state of heightened distress, which may impact the validity of scores on the Distress Tolerance Scale. Therefore, measurement invariance should be established before attributing NSSI-related differences on the scale to true differences in distress tolerance. We compared the Distress Tolerance Scale higher-order model with the lower-order four factor model among university students with and without a history of NSSI. Our results indicated that the lower-order four factor model was a significantly better fit to the data than the higher-order model. We then tested the measurement invariance of this lower-order factor model among individuals with and without a history of NSSI, and established configural and full metric invariance, followed by partial scalar and full residual error invariance. These results suggest the four subscales of the Distress Tolerance Scale can be used to confidently discern NSSI-related differences in distress tolerance.

Situational context influences the degree of hostile attributions made by individuals with schizophrenia or autism spectrum disorder

OBJECTIVES

Previous work has demonstrated that the tendency to make hostile attributions is not a stable trait but varies across different social situations. Therefore, we sought to investigate whether hostile attributions within clinical samples are better understood as a persistent characteristic or one that varies across contexts.

METHODS

The current analyses investigated patterns of attributions among people diagnosed with schizophrenia (SCZ, n = 271) or autism spectrum disorder (ASD, n = 100) and non-clinical control participants (NCC, n = 233) in an existing data set.

RESULTS

Results showed that specific relational features in vignettes portraying different social encounters influence the way people make attributions and that variability across contexts is present in both non-clinical and clinical populations. Like non-clinical participants, participants diagnosed with ASD ascribed the greatest hostility to a scene involving an authority figure. In contrast, SCZ participants reported the greatest hostility in response to a scene involving a friend.

CONCLUSIONS

These findings suggest that salient environmental factors should be considered when assessing social cognitive skills and biases.

PRACTITIONER POINTS

Hostile attributions should be perceived as situational constructs rather than stable and persistent characteristics. Hostile attributions were most prevalent among persons diagnosed with schizophrenia; however, on average, all participants showed greater hostility for situations involving an authority figure, an acquaintance, or a friend relative to those involving a co-worker or stranger. Psychotherapists and clinicians working with people diagnosed with schizophrenia or autism spectrum disorder could work on identifying situation triggers, which may prompt hostile attributions. Psycho-educational and psychotherapeutic interventions can be altered based on individual triggers of hostile attributions, and attempts can be made to lessen these attributions. Paranoia appears to be linked to hostile attributions regardless of the specific clinical diagnosis and should be considered in the therapeutic process.

Assessing alexithymia in forensic settings: Psychometric properties of the 20-item Toronto Alexithymia Scale among incarcerated adult offenders

BACKGROUND

Alexithymia is a trait involving difficulty identifying feelings (DIF), difficulty describing feelings (DDF) and externally orientated thinking (EOT). It is a risk factor for criminal behaviour. It is commonly assessed with the Toronto Alexithymia Scale (TAS-20), but the psychometrics of the TAS-20 have not been tested across the range of offender populations, and it has been suggested it might be unsuitable in incarcerated offenders.

AIM

To establish the psychometrics of the TAS-20 among incarcerated offenders.

METHODS

Factorial validity was examined using confirmatory factor analyses, and the invariance of this factor structure was tested against a published community sample. Reliability coefficients were calculated.

RESULTS

One hundred and forty six incarcerated offenders were recruited. The factor structure of the TAS-20 was invariant across the samples. The intended factor structure composed of DIF, DDF and EOT factors performed well overall (with a reverse-scored method factor added), but six EOT items had low factor loadings. The total scale score and DIF and DDF subscales had acceptable reliability, but EOT did not.

CONCLUSIONS

Our results suggest that the TAS-20 functions similarly in offender and community samples. Its total scale score, and DIF and DDF subscale scores can be used confidently, but the assessment of externally oriented thinking may not be adequate with this scale alone. In sum, the TAS-20 can facilitate robust assessment of alexithymia in closed criminal justice settings as well as in the wider community.

Psychometric Properties and Measurement Invariance Across Sex of the Wong and Law Emotional Intelligence Scale in Chinese adolescents

The aim of this study was to validate the Wong and Law Emotional Intelligence Scale (WLEIS) in Chinese adolescents by examining factor structure, sex-related measurement invariance and latent mean differences, reliability, and criterion-related validity.A total of 1674 Chinese adolescents aged 12-17 years old (M_age = 15.26, SD = .58) were recruited. Results of confirmatory factor analysis (CFA) supported the four-factor model of the WLEIS as the best fit to the data. Multi-group CFA suggested that the measurement structure of the WLEIS was invariant across sex. Testing for the latent mean differences showed that male adolescents scored lower on the Other-Emotional Appraisal subscale, but scored higher on the Regulation of Emotion subscale than female adolescents. Furthermore, all the subscales of male and female adolescents had satisfactory composite reliability. Finally, the WLEIS had favorable criterion-related validity with self-esteem, life satisfaction, positive affect, negative affect and perceived stress. These findings suggested that the WLEIS is a reliable and valid instrument for assessing trait emotional intelligence of adolescents and can be generalized across sex.

College Students’ Entrepreneurial Mindset: Educational Experiences Override Gender and Major

Entrepreneurship education has been popularly adopted in higher education contexts. Although evidence-based implementations of such education are widely acknowledged as beneficial, valid assessments of it are sparse. One possible outcome of entrepreneurship education is a change in students’ entrepreneurial mindset, which can be measured by the recently validated College Students’ Entrepreneurial Mindset Scale (CS-EMS). However, this scale awaits evidence regarding measurement invariance. This study aims to (1) examine measurement invariance of the CS-EMS; (2) compare the latent and observed means across groups based on gender, major, and educational experiences; and (3) investigate the conditional effects of the three grouping variables. Using data from 317 Korean college students’ survey responses, we conducted sequential tests of factorial invariance and latent mean comparisons using multiple-group confirmatory factor analysis. Additionally, the conditional effects of the gender, major, and educational experiences were tested by structural equation modeling. The results indicate that strict invariance held for the groups compared by either gender or educational experiences, while scalar invariance held between the engineering and non-engineering groups. While the male, engineering, and educational experience groups generally scored higher on both the latent and observed sub-scales, the results of the conditional effects of grouping variables indicated that educational experiences mattered most. One practical implication for the educators is that the CS-EMS is a promising assessment tool for addressing the effectiveness of entrepreneurship education, especially when the targeted educational goals are any of its sub-constructs.

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.

Consistent evidence of a link between Alexithymia and general intelligence

Alexithymia is a personality construct characterised most notably by a difficulty in identifying and expressing feelings. Although the emotional difficulties in alexithymia are well established, to date little work has examined its relationship to broader cognitive abilities, such as general intelligence. Across three independent, healthy adult samples (Ns = 389, 318, & 273), we examined whether alexithymia was associated with general intelligence. In all three samples, we observed a significant negative association between alexithymia and general intelligence. In two of the samples, general intelligence was a significant predictor of alexithymia even when accounting for performance on tests of facial emotion recognition ability and supramodal emotion recognition ability (measured with faces, bodies, and voices). From a theoretical perspective, these results suggest that models of alexithymia need to incorporate a role for more generalised cognitive functioning. From a practical perspective, studies examining links between alexithymia and clinical disorders, many of which have known links to general intelligence, should consider including a measure of general intelligence in order to adjust for this potentially confounding factor.

Psychometric Properties and Configural Invariance of the Polish - Language Version of the 20-Item Toronto Alexithymia Scale in Non-clinical and Alcohol Addict Persons

AIM

The development and assessment of the psychometric properties of the Polish-language version of the Toronto Alexithymia Scale (Bagby et al., 1994a, b) is described in this article. The aim of this study was to translate the TAS - 20 into Polish and establish the psychometric properties of this instrument evaluating alexithymia.

MATERIALS AND METHODS

Data were collected via self-report measures from a total sample of 676 participants: a total of 180 participants (115 males and 65 females) diagnosed with alcohol dependence, and 496 control group (347 males and 149 females).

RESULTS

Confirmatory factor analyses found the factor structure of the original English-language TAS 20 for the three subscales translated into Polish: Difficulty in Identifying Feeling (DIF); Difficulty in Describing Feeling (DDF); Externally Oriented Thinking (EOT). All three subscales showed good internal consistency in non-clinical group and two subscales, DIF and DDF in alcohol addict group. Several EOT items loaded poorly on their intended factor.

CONCLUSION

The results from the present study indicate that the Polish version of the TAS - 20 is a reliable and valid measure of alexithymia with good levels of internal consistency, homogeneity, and construct validity. We conclude that the TAS-20 has, for the most part, adequate psychometric properties, though interpretation should focus only on the total scale score and DIF and DDF subscales, especially in clinical groups.

Influence of alexithymia on the management of Latin American patients with asthma: A cross-sectional study

Objectives:

In asthmatic patients, studies suggest that alexithymia leads to negative consequences and emotions that can affect physical, psychological, and social aspects of life. We designed this study to determine the frequency of alexithymia in Latin American patients with asthma, as well as to understand how this personality trait and each of its components interact with asthma severity and demographic variables, and their implications on treatment adherence and disease control under such setting.

Methods:

We conducted a cross-sectional study, involving 265 Latin American patients with asthma. Patient demographics and clinical characteristics were reported. The presence of alexithymia, asthma severity, and control, as well as treatment adherence, was analyzed. To assess the presence of alexithymia, the 20-item Toronto Alexithymia Scale was used. For the statistical analyses, we performed Kendall’s tau-b correlation coefficient, chi-square tests for association, and one-way analysis of variance.

Results:

A total of 265 patients participated in the study with a gender distribution of 69.4% female and an average age of 54.7 years. In total, 30.2% of individuals presented alexithymia. There was a statistically significant correlation between educational level and 20-item Toronto Alexithymia Scale categories (p < .001), as well as a higher proportion of severe (35.1%, p = .001) and uncontrolled (50.0%, p = .185) asthma in patients with alexithymia. A higher proportion of patients with some level of non-adherence was seen on those with uncontrolled asthma (68.5%, p = .008).

Conclusion:

Our results suggest that in our sample, 3 in 10 Latin American asthma patients have alexithymia, and such mental condition is more common in those individuals with lower educational levels. Individuals with alexithymia present with severe asthma more frequently than do patients with possible or no alexithymia and are also more likely to have their disease uncontrolled.

Association between parental alexithymic traits and self-reported postnatal reflective functioning in a birth cohort population. Findings from the FinnBrain Birth Cohort Study

Parental reflective functioning (PRF) refers to a parent's effort to see his/her child as a separate individual person from early on, and to be curious of the child's own thoughts and feelings. Parenting abilities are affected by the parent's emotion regulation and emotional availability. Alexithymia as a personality construct with emotional deficits and poor imagination could potentially affect also PRF, but studies on parental alexithymia are still scarce. The aim of the present study was to examine the association between parental alexithymic traits and PRF, which to date has not been explored. As most of the parenting research concern only mothers, an additional aim was to study also fathers. The 20-item Toronto Alexithymia Scale (TAS-20) and the 14-item Parental Reflective Functioning Questionnaire (PRFQ-Fi) were filled by 1882 mothers and 994 fathers at six months postpartum as part of the FinnBrain Birth Cohort Study. A significant negative association between TAS-20 total score and PRFQ-Fi total score among both genders was found. The main alexithymia dimension responsible for this association was Externally Oriented Thinking. The results suggest that alexithymic traits indeed are related to parental reflective functioning, but more studies are needed to explore the direction of this relation.

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.

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

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

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

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

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

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

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

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

Assessing Emotional Reactivity: Psychometric Properties of the Perth Emotional Reactivity Scale and the Development of a Short Form

The Perth Emotional Reactivity Scale (PERS) is a 30-item self-report measure of trait levels of emotional reactivity. In this article, we examine the psychometric properties of the PERS subscale and composite scores in an adult community sample (N = 428), and develop an 18-item short form of the measure (PERS-S). The PERS and PERS-S are designed to assess the typical ease of activation, intensity, and duration of one's emotional responses, and do so for positive and negative emotions separately. Our confirmatory factor analyses supported that the PERS and PERS-S both had the same theoretically congruent factor structure, and that all subscale and composite scores displayed high internal consistency reliability. Correlations with scores from established measures of psychopathology and emotion regulation also supported the validity of PERS and PERS-S scores. Our data therefore suggest that the PERS-S subscale and composite scores retain the psychometric strengths of their longer PERS counterparts. We conclude that both forms of the measure have good utility. Clinical and research applications are discussed.

Is the Assessment of Personality Comparable in Persons Who Have and Have Not Experienced Depressive, Anxiety, and Substance Use Disorders? An Examination of Measurement Invariance

Numerous studies have focused on characterizing personality differences between individuals with and without psychopathology. For drawing valid conclusions for these comparisons, the personality instruments used must demonstrate psychometric equivalence. However, we are unaware of any studies that examine measurement invariance in personality across individuals with and without psychopathology. This study conducted tests of measurement invariance for positive emotionality, negative emotionality, and disinhibition across individuals with and without histories of depressive, anxiety, and substance use disorders. We found consistent evidence that positive emotionality, negative emotionality, and disinhibition were assessed equivalently across all comparisons with each demonstrating strict invariance. Overall, results suggest that comparisons of personality measures between diagnostic groups satisfy the assumption of measurement invariance and these scales represent the same psychological constructs. Thus, mean-level comparisons across these groups are valid tests.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predicting symptoms in major depression after inpatient treatment: the role of alexithymia

Alexithymia has been considered to have a negative influence on the course of symptoms in various psychiatric disorders. Only a few studies of depressed patients have examined whether alexithymia predicts the outcome of therapeutic interventions or the course of symptoms in naturalistic settings. This prospective study investigated whether alexithymia is associated with depressive symptoms after a multimodal inpatient treatment. Forty-five inpatients suffering from acute major depression were examined in the initial phase of treatment and then again after seven weeks. Patients took part in a multimodal treatment programme comprising psychodynamic-interactional oriented individual and group therapy. The majority of patients were taking antidepressants during study participation. To assess alexithymia and depressive symptoms, the 20-item Toronto Alexithymia Scale (TAS-20), the Beck Depression Inventory II (BDI-II) and the Hamilton Depression Scale (HAMD) were administered at baseline and follow-up. When controlling for baseline depressive symptoms along with trait anxiety, high scores in the externally oriented thinking (EOT) facet of alexithymia at baseline predicted high severity of depressive symptoms at follow-up (for self-reported as well as interviewer-based scores). Inpatients suffering from major depression with a more pronounced external cognitive style might benefit less from a routine multimodal treatment approach (including psychodynamic interactional therapy, antidepressant medication, and complementary therapies). Intervention programmes might modify or account for alexithymic characteristics to improve the course of depressive symptoms in these patients.

Controlling the emotional heart: heart rate biofeedback improves cardiac control during emotional reactions

When regulating negative emotional reactions, one goal is to reduce physiological reactions. However, not all regulation strategies succeed in doing that. We tested whether heart rate biofeedback helped participants reduce physiological reactions in response to negative and neutral pictures. When viewing neutral pictures, participants could regulate their heart rate whether the heart rate feedback was real or not. In contrast, when viewing negative pictures, participants could regulate heart rate only when feedback was real. Ratings of task success paralleled heart rate. Participants' general level of anxiety, emotion awareness, or cognitive emotion regulation strategies did not influence the results. Our findings show that accurate online heart rate biofeedback provides an efficient way to down-regulate autonomic physiological reactions when encountering negative stimuli.

Learned cardiac control with heart rate biofeedback transfers to emotional reactions

Emotions involve subjective feelings, action tendencies and physiological reactions. Earlier findings suggest that biofeedback might provide a way to regulate the physiological components of emotions. The present study investigates if learned heart rate regulation with biofeedback transfers to emotional situations without biofeedback. First, participants learned to decrease heart rate using biofeedback. Then, inter-individual differences in the acquired skill predicted how well they could decrease heart rate reactivity when later exposed to negative arousing pictures without biofeedback. These findings suggest that (i) short lasting biofeedback training improves heart rate regulation and (ii) the learned ability transfers to emotion challenging situations without biofeedback. Thus, heart rate biofeedback training may enable regulation of bodily aspects of emotion also when feedback is not available.

Reliability and factor structure in an adolescent sample of the Dutch 20-item Toronto Alexithymia Scale

This study investigated the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) in an adolescent sample (N = 406, ages 12 to 17). This is rarely done even though the TAS-20 is used in adolescent research. Five published factor models were tested. For good fitting models, a second-order model with alexithymia as a higher-order factor and metric invariance across sex and age groups was tested. Confirmatory factor analyses showed that the original three-factor model and a four-factor model provided acceptable fit. Both models were invariant across sex, but not across age. Second-order models did not provide good fit. Reliability was good for the "Difficulty identifying feelings" subscale and acceptable for the "Difficulty describing feelings" subscale, but not for the "Externally oriented thinking" subscale. Measuring alexithymia with the TAS-20 in adolescents thus seems problematic, especially in younger age groups.

Interpersonal problems and cognitive characteristics of interpersonal representations in alexithymia: a study using a self-report and interview-based measure of alexithymia

In this study, associations between alexithymia, interpersonal problems, and cognitive-structural aspects of internal interpersonal representations were examined. Alexithymia was measured using the Toronto Structured Interview for Alexithymia (TSIA) and the 20-item Toronto Alexithymia Scale (TAS-20). To measure interpersonal problems, the dominance and affiliation dimension scores of the Inventory of Interpersonal Problems were used, and cognitive-structural characteristics of interpersonal representations were measured using the Social Cognition and Object Relations Scale (SCORS). As hypothesized, alexithymia was related to cold and withdrawn, but not to dominant or submissive, interpersonal functioning. In terms of the SCORS, alexithymia was negatively related to complexity of interpersonal representations, both in TAT and in interview narratives, indicating a link between alexithymia and mentalization. However, alexithymia was related only to the dimension of social causality when this dimension was scored on TAT narratives. Overall, the TSIA provides the most consistent and stable results after controlling for negative affectivity.

Alexithymia and severe psychopathology: a study on psychiatric inpatients

BACKGROUND

The influence of severe psychopathology on alexithymic features has been poorly studied. This study aimed at investigating whether alexithymia is affected by the presence of psychosis and the severity of psychopathology.

SAMPLING AND METHODS

199 consecutive adult psychiatric inpatients, 60 of whom received a Structured Clinical Interview for DSM-IV Axis I diagnosis of psychotic disorder, were administered the 20-item Toronto Alexithymia Scale (TAS-20) and the 24-item Brief Psychiatric Rating Scale (BPRS). A random sample of 50 patients was reassessed at discharge. For all analyses, the Holm-Bonferroni correction was applied when appropriate to account for multiple testing.

RESULTS

The TAS-20 showed good internal consistency, acceptable relative stability, and good absolute stability both in patients with and without a psychotic disorder. Internal consistency and relative stability were higher in nonpsychotic than in psychotic patients. Mean TAS-20 score at admission did not differ between psychotic and nonpsychotic patients, and the TAS-20 score showed only a nonsignificant correlation (rho = 0.26) with BPRS score. Alexithymia at discharge was mostly explained (60%) by alexithymia at admission, while it was only modestly explained (4%) by BPRS scores at admission and discharge, with the latter being the only significant predictor. Changes in BPRS scores between admission and discharge explained a nonsignificant proportion (16%) of changes in TAS-20 scores and a moderate (21%) proportion of changes in difficulty identifying feelings.

CONCLUSION

Despite some limitations, these findings suggest that the severity of psychopathology and the presence of a psychotic disorder only modestly influence alexithymic characteristics, and that the TAS-20 may provide a reliable assessment of alexithymia in patients with severe psychopathology, except the most severely impaired ones.

Alexithymia, social detachment and cognitive processing

Using lexical content analysis (linguistic inquiry and word count), the hypotheses that social detachment and impaired cognitive processing are typical for alexithymia are investigated. Based on clinical interviews with 32 outpatients (mixed diagnoses), we found support for the hypotheses for the externally oriented thinking facet of alexithymia only.

Genetic influences on alexithymia and their relationship with depressive symptoms

OBJECTIVE

The factors involved in the etiology of alexithymia are still unclear. While a few studies suggested substantial genetic influences on alexithymia, it remains to be determined if these influences are independent of genetic influences on other mental health variables correlated with alexithymia, such as depression. This study is aimed at confirming previous findings of a genetic contribution to alexithymia, examining whether there are genetic or environmental influences common to alexithymia facets, and investigating whether genetic influences on alexithymia are independent of genetic influences on depression.

METHODS

The 20-item Toronto Alexithymia Scale and a validated measure of depression were administered to a sample of 729 twins (45% males) aged 23-24 years drawn from the population-based Italian Twin Register. Genetic structural equation modeling was performed with the Mx program.

RESULTS

Genetic factors accounted for 42% of individual differences in alexithymia. Unshared environmental factors explained the remaining proportion of variance. There was a substantial (0.65) genetic correlation between alexithymia and depression. The inclusion of depression as a covariate in the genetic models reduced the heritability estimate for alexithymia to 33%.

CONCLUSIONS

Despite some limitations, this study corroborates the notion that genetic factors contribute substantially to individual differences in alexithymia, with unshared environmental factors also playing an important role. Also, it suggests a genetic link between alexithymia and depression.

Alexithymia is common among adolescents with severe disruptive behavior

This study aimed to examine alexithymic features and associations between alexithymia and psychiatric symptoms among adolescents living in a closed institution because of severe behavioral problems. Forty-seven adolescents (29 boys and 18 girls) aged 15 to 18 years completed the 20-item Toronto Alexithymia Scale (TAS-20) Questionnaire and the Youth Self-Report, whereas their foster parents completed the Child Behavior Checklist. The TAS-20 scores of the participants were compared with those of an extensive population sample (N = 6000) matched by age and birth year. Reform school adolescents are significantly more alexithymic than the control group, and the TAS-20 scores are correlated with numerous psychiatric problems, mainly in the internalizing spectrum, but also with thought problems and self-reported aggression. Promoting abilities in identifying and describing feelings is important when treating delinquent adolescents.

Alexithymia tendencies and mere exposure alter social approachability judgments

People have a fundamental motivation for social connection and social engagement, but how do they decide whom to approach in ambiguous social situations? Subjective feelings often influence such decisions, but people vary in awareness of their feelings. We evaluated two opposing hypotheses based on visual familiarity effects and emotional awareness on social approachability judgments. These hypotheses differ in their interpretation of the familiarity or mere exposure effect with either an affective or cognitive interpretation. The responses of our 128-student sample supported the cognitive interpretation. Lower emotional awareness or higher alexithymia was associated with higher approachability judgments to familiarized faces and lower approachability judgments to novel faces. These findings were independent of the Big Five personality factors. The results indicate that individual differences in emotional awareness should be integrated into social decision-making models. The results also suggest that cognitive-perceptual alterations may underlie the poorer social outcomes associated with alexithymia.

Alexithymia and posttraumatic stress: subscales and symptom clusters

This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difficulty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed.

Interpersonal problems in alexithymia: A study in three primary care groups

OBJECTIVES

The present study investigated the relation between alexithymia and interpersonal problems in a sample of primary care patients with either chronic fatigue syndrome (CFS); a chronic cardiovascular or auto-immune disease; or a minor medical condition. It was hypothesized that the relation between cold interpersonal functioning would account for the differences in alexithymia scores between the patient groups.

DESIGN AND METHODS

Participants were 155 primary care patients that were recruited through 52 general practitioners: 52 CFS patients; 52 patients with a chronic cardiovascular or auto-immune disease; 51 patients with a minor medical condition. Interpersonal problems were assessed by means of the Inventory of Interpersonal Problems and alexithymia was assessed by means of the Toronto Alexithymia Scale.

RESULTS

CFS patients and patients with a chronic cardiovascular or auto-immune disease have substantially higher alexithymia scores than patients with a minor medical condition. Alexithymia is positively related to cold and distant interpersonal functioning; negatively related to self-sacrificing and overly accommodating in relation to others; and positively related to vindictiveness and self-centredness. The relation between alexithymia and these interpersonal problems accounts for the differences in alexithymia scores between the patient groups.

CONCLUSIONS

Alexithymia and interpersonal problems should be considered together, in terms of one deficient affect regulatory system, and the relation between alexithymia and specific illness conditions is secondary to this. Clinical assessment of patients with problems in naming and discussing affective states should never be isolated from an examination of their interpersonal problems, and vice versa. Mentalization-based therapy is recommended for patients with problems in naming affective states, interpersonal problems, and concomitant CFS or other alexithymia-related diseases.

A confirmatory factor analysis of the Toronto Alexithymia Scale (TAS-20) in an alcohol-dependent sample

Confirmatory factor analyses were conducted to evaluate the factorial validity of the Toronto Alexithymia Scale in an alcohol-dependent sample. Several factor models were examined, but all models were rejected given their poor fit. A revision of the TAS-20 in alcohol-dependent populations may be needed.