Structure of the twenty-item Toronto Alexithymia Scale

Factors Associated With Pain Catastrophizing in Patients With Chronic Neuropathic Pain: A Cross-Sectional Study

BACKGROUND

Pain catastrophizing is a significant factor in the recovery of patients with chronic pain. This topic has not received the warranted attention in clinical practice, while the outcomes of pain interventions have been suboptimal. This study explores the current situation of pain catastrophizing in patients with chronic neuropathic pain, its influencing factors, and further analyzes the complex relationship between these factors.

METHODS

A cross-sectional study design was used to select preoperative patients hospitalized in the pain and spine surgery departments of two tertiary hospitals in Shandong Province, China, between February and August 2022. The Pain Catastrophizing Scale, Toronto Alexithymia Scale, Connor-Davidson Resilience Scale-Short, Somatization Sub-Scale of Symptom Checklist 90, and a sociodemographic questionnaire were used to evaluate participants' pain catastrophizing, alexithymia, psychological resilience, somatization, and relevant sociodemographic variables, respectively. Descriptive statistics, correlation, univariate, and multivariate analyses were employed throughout this process.

RESULTS

Pain catastrophizing in patients with chronic neuropathic pain was affected by pain severity, disease type, alexithymia, psychological resilience, and somatization (p < .05). The mediating effect values of psychological resilience and somatization between alexithymia and pain catastrophizing were both 0.05, with 95% confidence intervals of (0.02, 0.09) and (0.02, 0.07), respectively.

CONCLUSIONS

Pain severity, disease type, alexithymia, psychological resilience, and somatization all had a significant effect on pain catastrophizing. Healthcare workers must provide timely and accurate assessments of patients' pain levels to help prevent the onset of pain catastrophizing. Adopting measures to improve alexithymia and somatization symptoms, and focusing on enhancing patients' psychological resilience can also help reduce the level of pain catastrophizing. Cognitive behavioral therapy may be an effective treatment method for pain catastrophizing.

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

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

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.

The hospice as a learning space: a death education intervention with a group of adolescents

Background

The denial of death in Western society deprives young people of the tools to derive meaning from experiences of death and dying. Literature shows that death education may allow them to become familiar with this topic without causing negative effects. This article describes the effects of a death education course with adolescents, wherein participants were given the opportunity to meet palliative doctors and palliative psychologists at school and in a hospice, where they were able to converse with the families of the dying.

Methods

This study used mixed methods and included an evaluation of a death education intervention with longitudinal follow-up of outcomes. The course involved 87 secondary school students (experimental group) aged between 16 and 20 years. We also recruited a control group of 76 similarly-aged students to observe differences. The variables we examined were: alexithymia, representation of death, value attributed to life and spirituality. These were measured with the following instruments: the Toronto Alexithymia Scale-20, the Testoni Death Representation Scale, the Personal Meaning Profile and the Spiritual Orientation Inventory, respectively. To better understand how the students perceived the experience, we asked the experimental group to answer some open-ended questions. Their answers were analysed through thematic analysis.

Results

The study showed that death education and the hospice experience did not produce negative effects, but rather allowed students to decrease alexithymia, improving their ability to recognise and express emotions. Thematic analysis revealed that all participants perceived the experience as very positive.

Conclusions

Our findings affirm that death education programs can be successfully implemented in high schools, and that they can usefully involve local hospices and palliative care professionals, especially physicians and psychologists.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00747-w.

A meta-analytic study examining the relationship between alexithymia and dissociation in psychiatric and nonclinical populations

Alexithymia and dissociation have been consistently linked in the literature, particularly in psychiatric populations. Both arise from a disconnection between conscious aspects of self-experiences and perceptions at both the mental self and bodily levels. This results in difficulty integrating thoughts, feelings and experiences into consciousness and memory, negatively impacting emotion awareness/regulation and reflective functioning. We conducted a meta-analysis to examine the strength of the relationship between alexithymia and dissociation in both clinical and non-clinical populations. Studies using two common measures of these constructs were included (i.e., the Toronto Alexithymia Scale - TAS, and the Dissociative Experiences Scale - DES). Analyzing the effect sizes derived from 19 studies (including a total of 4664 participants) revealed moderate to strong relationships between alexithymia and dissociation. The strength of the association was higher in clinical and younger aged non clinical populations. These findings are discussed in the context of treatment recommendations..

Panic Disorder as Unthinkable Emotions: Alexithymia in Panic Disorder, a Croatian Cross-Sectional Study

OBJECTIVES

Previous research on alexithymia has led to controversy over its prevalence in panic disorder. The aim of this study was to assess the difference in the prevalence of alexithymia in panic disorder and other anxiety disorders.

DESIGN AND METHODS

We performed a cross-sectional study on a sample of 71 patients diagnosed with panic disorder and 113 patients diagnosed with other anxiety disorders; both groups were 18-50 years old. Primary outcome was the 20-item Toronto Alexithymia Scale (TAS) score. Secondary outcome was the prevalence of alexithymia defined as a TAS score ≥61.

RESULTS

Patients diagnosed with panic disorder had a 25% higher score on the TAS subscale of difficulty identifying feelings than patients diagnosed with other anxiety disorders. The prevalence of alexithymia was 27% in patients with panic disorder and 13% in patients with other anxiety disorders. Patients diagnosed with panic disorder had significantly higher odds for alexithymia.

CONCLUSIONS

The results of our study support the hypothesis of higher prevalence of alexithymia in individuals with panic disorder than in individuals with other anxiety disorders. In addition, difficulty identifying feelings as a salient feature of alexithymia is higher in panic disorder than in other anxiety disorders.

The associations between alexithymia and both non-suicidal self-injury and risky drinking: A systematic review and meta-analysis

BACKGROUND

Nonsuicidal self-injury (NSSI; direct harm to the body without suicidal intent) and risky drinking are two behaviours that serve emotion regulatory functions. When underlying emotional problems are untreated, individuals may shift between NSSI and risky drinking. Both behaviours are associated with alexithymia, difficulties identifying and describing emotions and retaining an externally orientated thinking style. However, it is unknown to what extent the associations are similar and under what circumstances (e.g. sex, age) they may differ.

METHOD

To compare both associations we conducted an extensive review using several databases. Overall, 20 NSSI-related articles and 33 risky drinking-related articles met the inclusion criteria.

RESULTS

A meta-analysis revealed significant positive associations between total alexithymia scores, difficulties identifying feelings, difficulties describing feelings and both NSSI and risky drinking. However, these associations appear stronger for NSSI. Further, externally orientated thinking was associated with risky drinking but not NSSI. Age had opposing moderating effects on the relationships, with the association between alexithymia and NSSI being stronger in younger samples and the association between alexithymia and risky drinking being stronger in older samples. Further, the association between alexithymia and NSSI was stronger for female only samples compared to male only samples.

LIMITATIONS

The review was limited to English articles. High levels of heterogeneity were observed. The majority of the studies included were cross-sectional.

CONCLUSION

These results imply that NSSI and risky drinking may have both shared and distinguishable correlates. Alexithymia can be targeted in treatment to potentially reduce the likelihood of individuals shifting between behaviours to regulate their emotions.

Importance of considering interoceptive abilities in alexithymia assessment

Background

Recent studies have shown that people with high alexithymia scores have decreased interoceptive abilities, which can be associated with psychological and physical disorders. Early assessments of the alexithymia trait included the evaluation of these abilities through the dimension measuring the difficulty in identifying and distinguishing between feelings and bodily sensations (the 26-item Toronto Alexithymia Scale; TAS-26). The revised version of the TAS, the TAS-20, contains a three-factor solution that does not involve a dimension assessing interoceptive abilities. However, the three items allowing the evaluation of these abilities are still present in the TAS-20. In this context, we hypothesized that the 3 items which assess interoceptive abilities in the TAS-20 should constitute an independent factor. In addition to exploring the internal structure of the TAS-20, we examined its external validity by assessing the relationships between the new factors and self-reported measures of personality trait and psychological and physical health.

Method

Two online studies (N = 253 and N = 287) were performed. The participants completed the TAS-20 and a set of psychological questionnaires (e.g., anxiety, depression) and health questions (e.g., “Do you suffer from a somatic disorder?”). The structure of the TAS-20 was examined using exploratory factor analysis (EFA), followed by an investigation of the relationships between the resulting new factors and other psychological and health data using regressions. In both studies, EFA revealed a new structure of the questionnaire consisting of four dimensions: (1) difficulty in the awareness of feelings, (2) externally oriented thinking, (3) difficulty in interoceptive abilities, and (4) poor affective sharing. The first factor was positively associated with all self-reported psychological and personality trait measures while the third factor was associated more with somatic disorders and medication intake.

Results

Our results suggest the presence of a new latent factor in the assessment of alexithymia that reflects interoceptive abilities specifically related to health and personality trait outcomes. In accordance with the results and the literature, it seems important to include an assessment of interoceptive abilities when considering the evaluation of alexithymia. The next step would be to develop a valid measure of these abilities.

Maladaptive Personality Functioning and Psychopathological Symptoms in Problematic Video Game Players: A Person-Centered Approach

BACKGROUND

A need exists to increase our understanding of the association between maladaptive personality traits, psychopathological symptoms, game preference, and different types of video game use. In the present study, we used a person-centered approach to identify different subtypes of video game players and we explored how they differ in personality profiles, clinical symptoms, and video game usage.

METHODS

We assessed problematic gaming via the nine-item Internet Gaming Disorder Scale and self-reported screen time playing video games in a sample of 366 adolescents and young adult gamers. Participants also completed measures on maladaptive personality domains (Personality Inventory for DSM-5 Brief Form), alexithymia (Toronto Alexithymia Scale-20 items), and psychopathological symptoms (DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure) and reported which genre of video games they preferred.

RESULTS

Using a person-centered, cluster-analytic approach, we identified four clusters of video game players (Occasional, Passionate, Preoccupied, and Disordered) presenting peculiar combinations of problematic gaming scores and time spent online playing video games. Non-problematic gamers (Occasional and Passionate) represented the majority of the sample (62.3% of the participants). Highly involved gamers who exhibited excessive screen time playing video games (Disordered gamers) presented the highest level of maladaptive personality traits and psychopathological symptoms, and were characterized by the greatest use of Multiplayer Online Battle Arena (MOBA) games.

CONCLUSION

These results have clinical implications on suggesting the importance to determining whether or not problematic gaming activities reflect a dysfunctional emotion-focused coping strategy to avoid inner unpleasant emotional or a more generally compromised emotional and social functioning.

A systematic review and meta-analysis of the association between alexithymia and suicide ideation and behaviour

BACKGROUND

Alexithymia reflects a difficulty with identifying and expressing emotions. This experience has been proposed as having an association with suicide ideation and behaviour. This review aimed to synthesise the evidence to establish the bivariate and multivariate relationships between alexithymia, and its subcomponents, with suicide ideation and behaviour.

METHODS

Search terms related to alexithymia and suicide ideation and behaviour were searched across nine prominent databases in May 2018. Studies were eligible for inclusion if they reported original empirical quantitative findings from adult samples, used a validated measure of alexithymia, and any measure of suicide ideation or behaviour.

RESULTS

Thirty-four studies were eligible for inclusion in this review. The review found a large effect size for the relationship between alexithymia and suicide ideation (r = 0.54, 95% CI= 0.40-0.65) and a small effect size for the relationship between alexithymia and suicide behaviour (r = 0.25, 95% CI = 0.16-0.34).

LIMITATIONS

A high level of heterogeneity was found in the meta-analysis meaning that results should be interpreted with caution.

CONCLUSION

A positive association was found between alexithymia and suicide ideation and, to a lesser extent, behaviour across a range of clinical and general population samples. This review has potentially important clinical implications, and promotes the need for suicide prevention to focus on emotion regulation skills.

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.

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.

The influence of alexithymia on mobile phone addiction: The role of depression, anxiety and stress

BACKGROUND

Alexithymia is an important predictor of mobile phone addiction. Enhancing and improving college students' mental health can reduce the rate of mobile phone addiction. However, it is not clear about the role of depression, anxiety and stress in the relationship between college students' alexithymia and mobile phone addiction.

METHODS

A total of 1105 college students were tested with the Toronto Alexithymia Scale, the Depression Anxiety Stress Scale and the Mobile Phone Addiction Index.

RESULTS

An individual's level of alexithymia was significantly correlated with depression, anxiety, stress and mobile phone addiction. Alexithymia had a significantly positive prediction effect on mobile phone addiction, and depression, anxiety, and stress on mobile phone are positive predictors. Depression, anxiety or stress had partially mediating effects between alexithymia and mobile phone addiction. Alexithymia not only directly had a positively impact on mobile phone addiction, but both also had an indirect effect on mobile phone addiction through depression, anxiety or stress.

LIMITATIONS

Limitations included sampling method and modest sample size, self-report measures, and unmeasured potential confounders.

CONCLUSION

Alexithymia is an important correlate of mobile phone addiction, and depression, anxiety or stress is an important mediator in this relationship.

Cross-cultural validation of the 20-item Toronto Alexithymia Scale in Chinese adolescents

WHAT IS KNOWN ON THE SUBJECT?: The TAS-20 is the most widely used self-reported questionnaire to assess the level of alexithymia in students and community and clinical samples. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The TAS-20-C exhibited high levels of reliability and validity, indicating that it is appropriate for the assessment of alexithymia in Chinese adolescents. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Screening adolescents who are at risk of alexithymia through the TAS-20 could help to perform necessary and effective precautions to decrease the adverse effects of alexithymia, such as the risks of developing depressive mood and behavioral problems.

ABSTRACT

Purpose The aim of this study was to examine the psychometric properties of the Chinese version of the 20-item Toronto Alexithymia Scale (TAS-20-C) in a sample of Chinese adolescents. Method Adolescents (n = 1260) recruited from three schools in mainland China completed the TAS-20-C, the somatization subscale of the Symptom Checklist 90 (SCL-90) and Center for Epidemiological Studies Depression Scale (CES-D). Five different factorial models of the TAS-20 were tested using confirmatory factor analysis (CFA). Cronbach's α, mean inter-item correlations and predictive validity were also evaluated. Results Among those five different factorial models, the four-factor structure model was suitable and invariant across gender and age in this sample. The TAS-20-C demonstrated adequate internal reliability. Gender and age accounted for insignificant amounts of variability in total TAS-20-C and factor scores. TAS-20-C total and subscale scores were correlated significantly with SCL-90 somatization subscale and CES-D. Girls scored higher than boys on difficulty identifying feelings (DIF) and pragmatic thinking (PR) subscales. DIF and lack of subjective significance or importance of emotions (IMs) subscale scores were higher among younger than among middle and older adolescents. Implications for Practice Validating the TAS-20 in adolescents is quite important to use it in evaluating adolescents' alexithymia, and screen those at risk of alexithymia.

Interactions between the salience and default-mode networks are disrupted in cocaine addiction

Cocaine dependence is a complex neuropsychiatric disorder manifested as dysregulation of multiple behavioral, emotional, and cognitive constructs. Neuroimaging studies have begun to identify specific neurobiological circuit impairments in cocaine-dependent (CD) individuals that may underlie these symptoms. However, whether, where, and how the interactions within and between these circuits are disrupted remain largely unknown. We used resting-state fMRI and modularity network analysis to identify brain modules of a priori interest (default-mode network [DMN], salience network [SN], executive control network [ECN], medial temporal lobe [MTL], and striatum) in 47 CD and 47 matched healthy control (HC) participants and explored alterations within and between these brain modules as a function of addiction. At the module level, intermodule connectivity decreased between DMN and SN in CD. At the nodal level, several regions showed decreased connections with multiple modules in CD: the rostral anterior cingulate connection strength was reduced with SN and MTL; the posterior cingulate had reduced connections with ECN; and the bilateral insula demonstrated decreased connections with DMN. Furthermore, alexithymia, a personality trait previously associated with addiction, correlated negatively with intramodule connectivity within SN only in cocaine users. Our results indicate that cocaine addiction is associated with disrupted interactions among DMN, MTL, and SN, which have been implicated, respectively, in self-referential functions, emotion and memory, and coordinating between internal and external stimuli, providing novel and important insights into the neurobiological mechanisms of cocaine addiction.

Factorial structure of the 20-item Toronto Alexithymia Scale in a large sample of somatoform patients

Although a strong association between alexithymia and somatization has been postulated in numerous studies, no systematic study has investigated the psychometric properties of the 20-item Toronto Alexithymia Scale (TAS-20) in a sample of patients with somatoform disorder yet. The purpose of this study was to ensure a valid assessment by the German version of the TAS-20 in somatoform samples. We investigated whether the original three-factor model proposed by Bagby et al. (1994a), which is widely used in clinical research and practice, is replicable in a large sample of somatoform patients (n=806). Using confirmatory factor analysis (CFA) the goodness-of-fit of the originally proposed factor structure was compared to three factor models generated with exploratory factor analysis (EFA) and other factorial solutions derived from the literature. Our results demonstrate that the original three-factor model is not replicable in somatoform patients. Instead, the four-factor model by Franz et al. (2001b) described the data best. However, none of the models met all criteria of confirmatory factor analysis. Our results indicate that the three-factor model is not robust in the German version of the TAS-20. At this state of research we recommend to use the TAS-20 sum-score as a measure of alexithymia in somatoform patients in clinical practice.

Alexithymia and empathy predict changes in autonomic arousal during affective stimulation

BACKGROUND

Alexithymia, the inability to describe one's own emotions, is linked to deficits in empathy, manifesting as a diminished capacity to recognize or understand the emotions and mental states of others. Several brain centers of autonomic control and interoception that are activated in empathy are thought to misfunction in alexithymia. We hypothesized that individual differences in autonomic changes under affective stimulation might be associated with differences in alexithymia and empathy.

METHODS

We studied 21 healthy volunteers, comparing their alexithymia and empathy scores with changes in their sympathetic autonomic arousal, indexed by the palmar skin potential level, during 3 tasks: playing a computer game, performing mental arithmetic, and watching a negative emotional valence video.

RESULTS

Both autonomic and subjective sense of arousal increased at the beginning of each task and then gradually subsided over the course of the task. Higher autonomic arousal at the onset of the computer game was associated with higher empathy scores, and at the onset of the negative video with higher scores for both empathy and alexithymia. Alexithymia delayed the habituation of autonomic arousal during the computer game, while the empathy score was related to a faster decline in arousal during the negative video task.

CONCLUSIONS

High alexithymia and high empathy scores were linked to increased autonomic arousal at the onset of emotional stimulation, but were distinguishable in the rates of habituation of the evoked arousal. Our data provide insight into the relationships among interacting psychological traits, physiologic regulation, and the arousal dimension of emotional experience.

The relationship between alexithymia, shame, trauma, and body image disorders: investigation over a large clinical sample

BACKGROUND

The connections between eating disorders (EDs) and alexithymia have not been fully clarified. This study aims to define alexithymia's connections with shame, trauma, dissociation, and body image disorders.

METHODS

We administered the Dissociative Experience Scale-II, Trauma Symptom Inventory, Experience of Shame Scale, Toronto Alexithymia Scale-20, and Body Uneasiness Test questionnaires to 143 ED subjects. Extensive statistical analyses were performed.

RESULTS

The subjects showed higher scores on alexithymia, shame, dissociation, and traumatic feelings scales than the nonclinical population. These aspects are linked with each other in a statistically significant way. Partial correlations highlighted that feelings of shame are correlated to body dissatisfaction, irrespective of trauma or depressed mood. Multiple regression analysis demonstrates that shame (anorexic patients) and perceived traumatic conditions (bulimic and ED not otherwise specified) are associated with adverse image disorders.

CONCLUSION

Shame seems to hold a central role in the perception of an adverse self-image. Alexithymia may be interpreted as being a consequence of previous unelaborated traumatic experiences and feelings of shame, and it could therefore be conceptualized as a maladaptive-reactive construct.

Alexithymia and eating disorders: a critical review of the literature

Alexithymia is characterized by difficulties identifying feelings and differentiating between feelings and bodily sensations, difficulties communicating feelings, and a concrete cognitive style focused on the external environment. Individuals with eating disorders have elevated levels of alexithymia, particularly difficulties identifying and describing their feelings. A number of theoretical models have suggested that individuals with eating disorders may find emotions unacceptable and/or frightening and may use their eating disorder symptoms (i.e., restricting food intake, bingeing, and/or purging) as a way to avoid or cope with their feelings. The current critical review synthesizes the literature on alexithymia and eating disorders and examines alexithymia levels across eating disorders (i.e., anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified), the role of alexithymia in binge eating disorder, and the influence of alexithymia on the development of eating disorders as well as treatment outcome. The clinical implications of the research conducted to date and directions for future research are discussed.

Kellner's emotional inhibition scale: a clinimetric approach to alexithymia research

BACKGROUND

Emotional inhibition has been an enduring concept in the psychosomatic literature explaining the onset and course of medical disorders. Currently the personality style of alexithymia is a focus of this dimension in psychosomatic theory, while actual conscious emotional inhibition, which may overlap with alexithymia, has received less attention. In the early 80s Robert Kellner developed the Emotional Inhibition Scale (EIS), a self-rating scale for emotional inhibition based on clinimetric principles. In this study we explored whether the EIS differentiated a sample of cardiac recipients from normal controls, as well as the associations between the EIS and 2 measures of alexithymia, i.e. the Toronto Alexithymia Scale-20 (TAS-20) and the Diagnostic Criteria for Psychosomatic Research (DCPR). We also examined whether the EIS and the TAS-20 were differently related to depressive symptoms measured by the Symptom Questionnaire (SQ).

METHODS

Ninety-five heart-transplanted patients and a sample of normal controls, matched for sociodemographic variables, were administered the EIS (total score and 4 subscales concerning 'verbal inhibition', 'timidity', 'disguise of feelings', and 'self-control'), the TAS-20, the SQ, and the Structured Interview according to the DCPR for alexithymia.

RESULTS

Cardiac recipients did not display significant differences compared to normal controls in observer (DCPR) and self-rated (TAS-20) measures of alexithymia. There were, however, significant differences in EIS with regard to 'disguise of feelings'. In both groups the EIS 'verbal inhibition' and 'timidity' subscales were positively associated with the TAS-20, while the EIS 'disguise of feelings' and 'self-control' subscales were independent of alexithymia. Depressive symptoms were more related to TAS-20 than EIS total scores.

CONCLUSIONS

Our results suggest that emotional inhibition and alexithymia are distinct phenomena even though they may share certain features. The EIS appears to be relatively independent of depressed mood and will be useful in assessing the individual's conscious management of affect in future psychosomatic research.

Alexithymia and suicide ideation in a sample of patients with binge eating disorder

OBJECTIVE

The goal of this cross-sectional study was to evaluate the relationships between alexithymia and suicide ideation in 80 adult outpatients with a DSM-IV diagnosis of binge eating disorder (BED).

METHODS

Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20); suicide ideation was assessed with the Scale of Suicide Ideation (SSI); severity of BED was assessed with the Binge Eating Scale (BES); and depressive and anxiety symptoms were evaluated, respectively, with the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Rating Scale (Ham-A).

RESULTS

Prevalence of current suicide ideation was 27.5% (n = 22) in this sample and 10 subjects (12.5%) had attempted suicide at some time in their lives. Subjects with alexithymia had more significant suicide ideation, a higher prevalence of current suicide ideation, and more previous suicide attempts than those without alexithymia. In a linear regression model, higher MADRS scores and higher scores on the Difficulty in Identifying Feelings/Difficulty in Describing Feelings dimensions of the TAS-20 were associated with increased suicide ideation.

DISCUSSION

Suicidal behavior is no less common in BED than in other eating disorders. Individuals with BED may show increased suicide ideation, especially in the presence of alexithymia and depressive symptoms, even if these symptoms are subclinical. The authors also discuss limitations of this study and future research needs.

The match-mismatch model of emotion processing styles and emotion regulation strategies in fibromyalgia

OBJECTIVE

Individuals differ in their style of processing emotions (e.g., experiencing affects intensely or being alexithymic) and their strategy of regulating emotions (e.g., expressing or reappraising). A match-mismatch model of emotion processing styles and emotion regulation strategies is proposed and tested. This model specifies that for people high on affect intensity, emotion expression is more adaptive than reappraisal, whereas for alexithymic people, reappraisal is more adaptive than expression. The present study tested this model in 403 women with fibromyalgia (mean age 46.5±12.3 years).

METHODS

In a cross-sectional design, we assessed affect intensity (Berkeley Expressivity Questionnaire), alexithymia (Toronto Alexithymia Scale-20), cognitive reappraisal (Emotion Regulation Questionnaire), and emotion expression (Emotional Approach Coping Scales), as well as the impact of fibromyalgia (Fibromyalgia Impact Questionnaire).

RESULTS

Multiple regression analyses with interaction terms indicated that among people high on affect intensity, emotion expression - but not cognitive reappraisal - was associated with less fibromyalgia impact. No support was found for the hypothesis that among alexithymic people, cognitive reappraisal would be more adaptive than emotion expression.

CONCLUSION

Findings suggest that for women with fibromyalgia who experience their emotions intensely, an emotional disclosure or expression intervention may be beneficial. This hypothesis requires verification in experimental studies.

Emotion processing and regulation in women with morbid obesity who apply for bariatric surgery

Emotional eating, the tendency to eat when experiencing negative affect, is prevalent in morbid obesity and may indicate that ways to deal with emotions are disturbed. Our aim was to compare emotion processing and regulation between 102 women with morbid obesity who apply for bariatric surgery and 102 women from the general population (control group) and to examine in the group with morbid obesity the association of emotion processing and regulation with emotional eating. The group with morbid obesity reported higher scores on difficulty identifying feelings (alexithymia, p = 0.002) and suppression of emotions (p = 0.003) than the control group. In the women with morbid obesity, more negative affect and a higher difficulty identifying feelings were correlated with more emotional eating (r = 0.36 and r = 0.35, p < 0.001). Our study suggests that negative emotions and unhealthy emotion processing may play a role in emotional eating, and it indicates the possible relevance of emotion processing and emotional regulation as initiating or perpetuating mechanisms in morbid obesity.

Alexithymia and personality disorder functioning styles in paranoid schizophrenia

OBJECTIVES

Personality disorder functioning styles might contribute to the inconclusive findings about alexithymic features in schizophrenia. We therefore studied the relationship between alexithymia and personality styles in paranoid schizophrenia.

METHODS

We administered the Chinese versions of the Toronto Alexithymia Scale (TAS-20), the Parker Personality Measure (PERM), the Positive and Negative Syndrome Scale as well as the Hamilton Anxiety and Depression Scales to 60 paranoid schizophrenia patients and 60 healthy control subjects.

RESULTS

Patients scored significantly higher on the Positive and Negative Syndrome Scale, TAS 'difficulty identifying feelings' and 'difficulty describing feelings', Hamilton Depression Scale and most PERM scales. In healthy subjects, difficulty identifying feelings predicted the PERM 'dependent' style, and the Hamilton Anxiety Scale predicted difficulty identifying feelings and difficulty describing feelings. In patients, difficulty identifying feelings nonspecifically predicted all the PERM scales; by contrast, the PERM 'antisocial' style predicted difficulty identifying feelings, the 'avoidant' style predicted difficulty describing feelings, and the 'histrionic' and 'paranoid (-)' styles predicted 'externally oriented thinking'.

CONCLUSIONS

Personality disorder functioning styles - instead of anxiety, depression, psychotic symptoms or disease duration - were specifically associated with alexithymia scales in our patients, which sheds light on a cognitive-personological substrate in paranoid schizophrenia on the one hand, and calls for a longitudinal design to discover how premorbid or postacute residual personality styles contribute to the sluggish disorder on the other.

Pitfalls in respiratory allergy management: alexithymia and its impact on patient-reported outcomes

OBJECTIVES

Alexithymia is a personality trait characterized by a limited ability to identify and express emotions and it represents a possible risk factor for disease development and management. The objective of the study is to evaluate alexithymia in patients with persistent asthma and comorbid rhinitis and its relation with patient-reported outcomes (PROs).

METHODS

Alexithymia, quality of life, illness perception, and stress were assessed, as well as rhinitis symptoms and asthma control in out-patients classified according to GINA and ARIA guidelines.

RESULTS

Out of 115 patients, 19% turned out to be alexithymic (TAS-20 ≥ 61). Concerning alexithymia level, no difference was detected between males and females (χ(2) = 0.317) and among GINA levels (χ(2) = 0.22). Alexithymics had significantly lower Asthma Control Test scores when compared with non-alexithymics (15.86 vs. 19; p = .02). Alexithymics had a worse quality of life (p< .001) and, concerning illness perception, they ascribed to respiratory allergy symptoms that are not strictly disease related and referred to asthma and rhinitis more serious negative consequences (p < .001) and emotional representations (p < .035). Moreover, they had lower illness coherence (p < .001) and lived their disease as a cyclical rather than a chronic disorder (p < .035). As regards stress, alexithymics reported less energy (p < .001), higher levels of tension (p < .001), depression (p < .001), confusion (p > .001), and inertia (p < .001).

CONCLUSION

Alexithymia is present in a relevant percentage of subjects and, as it can modulate illness perception, quality of life, and stress, it should be considered in disease management.

Prevalence and prediction of re-experiencing and avoidance after elective surgical abortion: a prospective study

OBJECTIVE

This study investigated short-term re-experiencing and avoidance after elective surgical abortion. In addition, it was prospectively investigated whether peritraumatic dissociation and pre-abortion dissociative tendencies and alexithymia predict re-experiencing and avoidance.

METHOD

In a prospective observational design, Dutch-speaking women presenting for first trimester elective surgical abortion completed self-report measures for dissociative tendency and alexithymia. Peritraumatic dissociation was measured immediately post-abortion. Re-experiencing and avoidance were measured 2 months post-abortion.

RESULTS

Participants reported moderately elevated levels of re-experiencing and avoidance that exceeded a clinical cut-off point for 19.4% of the participants. Peritraumatic dissociation predicted intrusion and avoidance at 2 months. In addition, avoidance was predicted by the alexithymic aspect of difficulty describing feelings.

CONCLUSIONS

Re-experiencing and avoidance after elective surgical abortion represent a significant clinical problem that is predicted by peritraumatic dissociation and alexithymia. Psychological screening and intervention might be a useful adjunct to elective abortion procedures.

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

The most widely used instrument to measure alexithymia is the 20-item Toronto Alexithymia Scale (TAS-20). However, different factor structures have been found in different languages. This study tests six published factor models and metric invariance across clinical and nonclinical samples. It also investigated whether there is a method effect of the negatively keyed items. Second-order models with alexithymia as a higher order factor are tested. Confirmatory factor analyses showed that the original factor model with three factors-difficulty identifying feelings (DIF); difficulty describing feelings (DDF) and externally oriented thinking (EOT)-is the best fitting model. Partial measurement invariance across samples was illustrated but requires further study. A weakness of the model is the low internal consistency of the third factor. Because models with a method factor had a better fit, future reconsideration of the negatively formulated items seems necessary. No evidence was found for the second-order models.

Assessing Reliability and Validity of the Farsi Version of the Toronto Alexithymia Scale in a Sample of Substance-Using Patients

The aim of this study was to estimate reliability and factorial validity of the Farsi version of the Toronto Alexithymia Scale–20 (TAS–20) for 321 substance-abusing patients (187 men and 134 women). All were asked to complete the Farsi version of the Toronto Alexithymia Scale–20, the Emotional Intelligence Scale, and The Mental Health Inventory. Analysis supported the internal consistency, test-retest reliability, concurrent validity, and three-factor structure of the Farsi version of the TAS–20 for substance users. The factors are similar to the three reported previously and were labeled as Difficulty Identifying Feelings, Difficulty Describing Feelings, and Externally oriented Thinking. These results provide evidence for applicability of the TAS–20 and its cross-cultural validity

Emotions and emotional approach and avoidance strategies in fibromyalgia

OBJECTIVE

Disturbances in emotional functioning may contribute to psychological and physical symptoms in patients with fibromyalgia. This study examined emotions and emotion-regulation strategies in women with fibromyalgia and in controls, and how these variables relate to symptoms of fibromyalgia.

METHODS

We compared 403 women with fibromyalgia to 196 control women using self-report questionnaires.

RESULTS

Negative emotions and the use of emotional-avoidance strategies were elevated, and positive emotions were reduced, in fibromyalgia patients; the alexithymia scale "difficulty identifying feelings" showed a large deviation from normal. Emotional-approach measures were not deviant. In the fibromyalgia sample, emotional-avoidance strategies were highly correlated with more mental distress and were modestly correlated with more pain and fatigue, while emotional-approach strategies were only minimally related to better functioning. We tested two interaction models. The intense experiencing of emotions was related to more pain only in patients who lack the ability to process or describe emotions. Although fibromyalgia patients showed deficits in the experiencing of positive affect, positive affect did not buffer the association between pain and negative affect.

CONCLUSION

This study demonstrates increased negative emotions and decreased positive emotions, as well as increased emotional-avoidance strategies, in women with fibromyalgia. Research should test whether interventions that reduce emotional avoidance lead to health improvements in women with fibromyalgia.

Cross-cultural validation of a Chinese translation of the 20-item Toronto Alexithymia Scale

BACKGROUND

The purpose of the present study was to develop a Chinese translation of the 20-item Toronto Alexithymia Scale (TAS-20-C) and examine its reliability and factorial validity.

METHODS

The original English version of the TAS-20 was first translated into Chinese and then backtranslated and modified until cross-language equivalence was established. This version was then completed by 870 undergraduate students and 179 clinical patients in China. Internal reliability, retest reliability, and factorial validity were evaluated.

RESULTS

The TAS-20-C showed adequate internal and retest reliability in both samples. Average TAS-20-C scores in Chinese samples were slightly higher than, but comparable to, TAS-20 scores in English-speaking Canadian samples; as well, scores were higher in the clinical sample than in the student sample. Finally, confirmatory factor analysis supported the 3-factor structure of the TAS-20 in both samples.

CONCLUSIONS

The TAS-20-C is a promising instrument for reliable and valid measurement of alexithymia in China.

Alexithymia and its relationships with body checking and body image in a non-clinical female sample

The aim of the present study was to evaluate in a non-clinical sample of undergraduate women, the relationships between alexithymia, body checking and body image, identifying predictive factors associated with the possible risk of developing an Eating Disorder (ED). The Toronto Alexithymia Scale (TAS-20), Body Checking Questionnaire (BCQ), Eating Attitudes Test (EAT-26), Body Shape Questionnaire (BSQ), Interaction Anxiousness Scale (IAS), Rosenberg Self-Esteem Scale (RSES) and the Beck Depression Inventory (BDI) were completed by 254 undergraduate females. We found that alexithymics had more consistent body checking behaviors and higher body dissatisfaction than nonalexithymics. In addition, alexithymics also reported a higher potential risk for ED (higher scores on EAT-26) when compared to nonalexithymics. Difficulty in identifying and describing feelings subscales of TAS-20, Overall appearance and Specific Body Parts subscales of BCQ as well as lower self-esteem was associated with higher ED risk in a linear regression analysis. Thus, a combination of alexithymia, low self-esteem, body checking behaviors and body dissatisfaction may be a risk factor for symptoms of ED at least in a non-clinical sample of university women.

Alexithymia, risk factor or consequence of work-related stress?

BACKGROUND

Primary alexithymia has been proposed as a trait-like risk factor for various psychiatric disorders. Alternatively, secondary alexithymia has been conceptualized as an inadequate coping reaction to a stressful situation. This study investigated the level and the type of alexithymia associated with occupational stress.

METHOD

On 2 occasions, 69 patients with work-related stress and 62 healthy participants completed self-report instruments to measure alexithymia (20-item Toronto Alexithymia Scale), burnout complaints (Maslach Burnout Inventory) and general distress complaints (Depression Anxiety Stress Scales, Checklist Individual Strength). Group differences in alexithymia were analyzed using ANOVAs. The type of alexithymia was investigated by (a) determining absolute and relative stability, (b) exploring state dependence by adjusting alexithymia for burnout and distress complaints and (c) associating recovery of complaints with change in alexithymia.

RESULTS

Alexithymia was significantly elevated among patients. In the patient group, absolute stability of two alexithymia dimensions (identifying feelings, describing feelings) and relative stability of one alexithymia dimension (identifying feelings) was lower than in the healthy group. Cross-sectional group differences became small and nonsignificant after adjustment for distress complaints. Among patients, change in alexithymia was moderately associated with symptom recovery.

CONCLUSION

Elevated alexithymia among patients with occupational stress is highly state dependent, which indicates the presence of secondary alexithymia.

Unidimensionality and bandwidth in the Center for Epidemiologic Studies Depression (CES-D) Scale

In this study, we compared classical test theory (CTT) and item response theory (IRT) approaches in analyzing the Center for Epidemiological Studies Depression (CES-D) Scale (Radloff, 1977). Standard item analyses, as well as Rasch (1960) analyses, both revealed item departures from unidimensionality in a sample of 2,455 older persons responding to the CES-D. Positive affect items in the scale performed poorly overall, their removal reducing the scale's bandwidth only slightly. Modeling depression scores derived from Rasch measures and raw totals showed subtle but important differences for statistical inference. The assessment of depressive risk was slightly enhanced by using 16-item scale measures obtained from the results of the Rasch analysis as the dependent variable. Confirmatory factor analysis and parallel analysis verified the advantages of removing positively worded items. IRT and CTT techniques proved to be complementary in this study and can be usefully combined to improve measuring depression.

Alexithymia and body image in adult outpatients with binge eating disorder

OBJECTIVE

The current study elucidates the relations between alexithymia and body image in patients with binge eating disorder (BED).

METHOD

One hundred one patients with BED were evaluated. Alexithymia was measured with the Toronto Alexithymia Scale (TAS-20). The severity of BED was measured with the Binge Eating Scale (BES). Body concerns were assessed with the Body Shape Questionnaire-Short Version (BSQ-S), the Body Uneasiness Test (BUT), and the Body Attitude Test (BAT). Additional measures were the Rosenberg Self-Esteem Scale (RSES) and the Beck Depression Inventory (BDI).

RESULTS

The prevalence of alexithymia in our sample was 39.6% (n = 40) and individuals with alexithymia showed higher scores on all rating scales. Higher body dissatisfaction, lower self-esteem, depressive symptoms, and the Difficulty in Identifying Feelings/Difficulty in Describing Feelings subscales of the TAS-20 were predictors of the severity of BED in the linear regression analysis.

CONCLUSION

Alexithymia was associated with more severe BED. Individuals with alexithymia and BED exhibited significantly poorer appearance evaluation and body satisfaction as well as higher depressive symptoms than individuals without alexithymia.

A new conceptualization of alexithymia in the general adult population: implications for research involving older adults

OBJECTIVE

The purpose of this study is to test the validity of existing conceptualizations of the alexithymia concept, with particular reference to aging.

METHODS

Two hundred and forty-eight healthy adults completed measures of alexithymia and psychosocial functioning; younger and older adults (n=121) also completed a measure of emotional responsiveness.

RESULTS

Older adults engaged in less introspective thought traditionally thought to denote increased alexithymia. However, reduced introspection was associated with improved mental wellbeing, and, thus, could not be construed as a deficit. Difficulty identifying and describing emotions did not differentiate older and younger adults, but were both associated with heightened depression, anxiety, and poor perceived quality of life.

CONCLUSIONS

In clinical practice and research, the Toronto Alexithymia Scale (TAS) is almost exclusively used, with "total" score typically used to index alexithymia. As one of the subscales of the TAS measures reduced introspection, calculating total scores may not be appropriate and may particularly overestimate levels of alexithymia in older adulthood.

The 20-item Toronto Alexithymia Scale: validation of factor solutions using confirmatory factor analysis on physiotherapy out-patients

OBJECTIVE

Whilst the 20-item Toronto Alexithymia Scale (TAS-20) was developed to measure three intercorrelated dimensions, there is some debate as to whether the scale is best served by a two- or three-factor construct. In particular, there is some doubt as to whether clinical data exhibit the third factor. This study uses data from a sample of physiotherapy (physical therapy) out-patients in the UK to validate the factorial structure of a set of models postulated in the literature, including the three-factor model hypothesized by Bagby et al. (1994).

METHOD

Data were collected from a sample of physiotherapy out-patients (N=242). Specialist factor analysis software (LISREL 8.54) was used to perform confirmatory factor analyses on a range of models proposed in the literature.

RESULTS

The analysis supports the three-factor model assumed by Bagby et al. (1994), as well as most of the two-factor models suggested in the literature.

CONCLUSIONS

This new set of clinical data supports most of the two- and three-factor models postulated in the recent literature, including the three-factor model advocated by Bagby et al. (1994).

Insight and alexithymia in adult outpatients with obsessive-compulsive disorder

OBJECTIVE

To elucidate the relationships between insight and alexithymia in a sample of adult outpatients with obsessive-compulsive disorder (OCD).

METHODS

112 adult outpatients with OCD were tested. Severity of OCD was assessed with the first 10-items of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and score for item # 11 on the Y-BOCS was considered as a measure of insight. Alexithymia was measured with 20-item Toronto Alexithymia Scale (TAS-20). Additional measures were Maudsley Hospital Obsessive Compulsive Inventory (MOCI) and Montgomery Asberg Depression Rating Scale (MADRS).

RESULTS

Of the patients, 29.5% showed poor or no insight. Patients with poor or no insight were more alexithymic than patients with excellent, good and moderate insight. TAS-20 total score and subfactors positively correlated with score for item # 11 on the Y-BOCS, severity of OCD and MADRS scores. In stepwise regression model, MADRS scores, factor 3 of TAS-20 (Externally Oriented Thinking), somatic and hoarding-saving obsessions were significantly associated with lower insight.

CONCLUSIONS

Results show a relationship between poor or absent insight and high alexithymia levels in OCD patients.

Psychometric properties of the Toronto Alexithymia Scale (TAS-20) for substance users

OBJECTIVE

To determine the psychometric properties of the Toronto Alexithymia Scale (TAS-20), an established self-report measure of alexithymia, for a substance user sample participating in a clinical trial of outpatient cognitive-behavioral therapies (N=230).

METHODS

Confirmatory and exploratory factor analyses were used to determine the number and nature of the factors underlying the TAS-20 in a sample of substance users. Structural equation modeling was used to determine the predictive validity of the TAS-20.

RESULTS

A factor structure comparable, but not identical, with TAS-20 psychometric results with other populations was found; alpha coefficients were .88 for the feelings factor, .62 for the external thinking factor, and .87 for the total score. Although, on average, the substance users did not appear to have elevated alexithymia scores compared with the undergraduate students, alexithymia predicted less treatment engagement, i.e., fewer sessions attended and weaker helping alliance. Alexithymia also predicted alcohol use outcomes but not drug use outcomes. The relation between alexithymia and drinking outcome was conditional on whether the patient was using solely alcohol at baseline.

CONCLUSION

The TAS-20 has reasonably good psychometric properties in this sample, which might be improved by dropping several marginal questionnaire items. Alexithymia appears to attenuate substance abuse treatment engagement. More clinical and research experience with this construct and specific instrument in substance user samples is needed.