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

Potential mechanisms underlying the association between feeding and eating disorders and autism

There is a reliable association between autism and Feeding and Eating Disorders. Concerningly, where these two conditions co-occur, clinical outcomes of Feeding and Eating Disorders are significantly worse, and treatment less effective, than when the Feeding and Eating Disorders occur in neurotypical individuals. Problematically, the reason for the association between autism and Feeding and Eating Disorders is poorly understood, which constrains advances in clinical care. This paper outlines several possible mechanisms that may underlie the observed association and suggests ways in which they may be empirically tested. Mechanisms are split into those producing an artefactual association, and those reflecting a genuine link between conditions. Artefactual associations may be due to conceptual overlap in both diagnostic criteria and measurement, Feeding and Eating Disorders causing transient autistic traits, or the association being non-specific in nature. A genuine association between autism and Feeding and Eating Disorders may be due to common causal factors, autism directly or indirectly causing Feeding and Eating Disorders, and Feeding and Eating Disorders being a female manifestation of autism.

Theory of mind in chronic migraine with medication overuse assessed with the MASC

Theory of Mind (ToM) is the ability to infer one's own and others' mental states. Growing research indicates that ToM is impaired in Chronic Migraine with Medication Overuse (CM + MO). However, the research in this field has been conducted using static scenario-based tasks, often failing to test mentalization in everyday situations and measuring only performance accuracy. We filled this gap by administering the Movie for the Assessment of Social Cognition (MASC) to subjects with CM + MO compared to episodic migraine (EM). This test allows us to assess both affective and cognitive ToM and which, in addition to being accurate, also analyzes the type of error in attribution of mental states, distinguishing between hypo-mentalization and hyper-mentalization. Thirty patients suffering from CM + MO and 42 from EM were enrolled. Results showed that CM + MO patients were less accurate in mental state attribution than EM. In addition, compared to EM, CM + MO individuals were more impaired in the affective ToM dimensions and committed more errors of hypo-mentalization. In conclusion, the application of MASC in patients with CM + MO allowed for the detection of an alteration in their ability to correctly draw conclusions about other people's mental states. This latter contributes critically to appropriate social reactions and also, possibly, to satisfactory social interactions.

Alexithymia and negative emotions among nursing students: a moderated mediation model

Nursing students, who comprise a high percentage of China's college students, experience many psychological problems; however, few studies explored the mechanisms underlying these problems. This cross-sectional study explored the relationships and mechanisms of depression, anxiety, stress, and narrative disorders in senior nursing students. Questionnaires were administered to 380 senior nursing students in Hubei Province using the Sociodemographic Questionnaire, Toronto Alexithymia-20 Scale, Perceived Social Support Scale, 10-Item Connor-Davidson Resilience Scale, and Depression-Anxiety-Stress Scale. After controlling for sociodemographic variables, Hayes' PROCESS macros were used to test how psychological resilience moderates the relationships among narrative disorders, negative affect, and perceived social support. Bootstrap confidence intervals tested for indirect effects. Correlation analyses revealed that alexithymia was correlated significantly positively with depression-anxiety-stress (r = 0.57, 0.56, and 0.58, resp.) and significantly negatively with perceived social support (r = 0-0.46). Psychological resilience was correlated significantly negatively with alexithymia (r=-0.39) and depression-anxiety-stress (r=-0.31, -0.30, and-0.32, resp.) but significantly positively with perceived social support(r = 0.50). Perceived social support was correlated significantly negatively with depression-anxiety-stress (r=-0.33, -0.34, and - 0.42 resp.). Stress was correlated significantly positively with anxiety and depression (r = 0.81 and 0.77, resp.). Psychological resilience was a partial mediator between depression and dysphoria (β=-0.08, p < 0.05). Dysphoria directly predicted anxiety (β = 0.31) and stress (β = 0.37); moreover,alexithymia predicted depression not only directly but also through the mediating effect of psychological resilience. Therefore, educators and clinical administrators must promote and recognise negative emotions among nursing students to help ensure the nursing workforce's stability.

Investigating the Effects of Transdiagnostic Processes on Anxiety and Depression Symptoms in Autistic Young People: the Mediating Role of Emotion Dysregulation

Internalising symptoms are elevated in autism compared to the general population. Few studies have investigated emotional dysregulation (ED) as a potential mediator between specific transdiagnostic processes and anxiety and depression symptoms in autistic youth. In a sample of 94 autistic young people aged 5-18 years referred to a specialist clinic for an autism evaluation, we tested the effects of ED as a mediator between cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia with anxiety and depression symptoms, using structural equation modelling. Effect sizes were compared to a non-autistic comparison group (n = 84). CI and alexithymia did not significantly predict depression symptoms in autistic young people, directly nor via ED. Relationships between CI/alexithymia and depression were fully mediated by ED in the non-autistic sample. There was a direct effect of CI on anxiety in the non-autistic group but not in those with a diagnosis. IU predicted depression symptoms in the autism group; and ED mediated this relationship only in those who did not receive a diagnosis. IU directly predicted anxiety in both groups and this relationship did not occur via ED. The finding of a direct pathway from IU to anxiety and depression in autistic youth is consistent with the literature. The finding that CI did not predict anxiety or depression in those with autism is novel, as was the finding that ED mediated relationships between alexithymia and anxiety/depression symptoms in both samples. The findings may have important implications for the delivery of psychological interventions for autistic youth.

Examining a model of anxiety in autistic adults

ABSTRACT

Anxiety disorders commonly occur in autism. Existing studies implicate intolerance of uncertainty, alexithymia, sensory processing differences and emotion regulation difficulties as influencing factors of anxiety in autism. To date, a few studies have considered the combination of these factors within the same sample. This study used structural equation modelling to test the prediction that intolerance of uncertainty and emotion regulation constitute more direct causes of anxiety in autism that mediate the influences of sensory processing difference and alexithymia as more sequential contributing factors. Autistic (n = 86) and non-autistic adults (n = 100) completed a battery of self-report questionnaires. Only when applied to each group separately, the broad predictions of the model were confirmed for the autistic group following data-driven additions of paths between sensory processing difference and anxiety and alexithymia implying that sensory processing difference contribute indirectly as well as directly to individual differences in anxiety. For the non-autistic group, model fit could only be achieved after removing autism-related traits and sensory processing differences as predictors of anxiety. These results suggest that aetiology and expression of anxiety in autism partially overlap with what is observed in the general population except that sensory processing differences appear to play a relatively unique role in the context of autism.

Alexithymia modulates emotion concept activation during facial expression processing

Alexithymia is characterized by difficulties in emotional information processing. However, the underlying reasons for emotional processing deficits in alexithymia are not fully understood. The present study aimed to investigate the mechanism underlying emotional deficits in alexithymia. Using the Toronto Alexithymia Scale-20, we recruited college students with high alexithymia (n = 24) or low alexithymia (n = 24) in this study. Participants judged the emotional consistency of facial expressions and contextual sentences while recording their event-related potentials. Behaviorally, the high alexithymia group showed longer response times versus the low alexithymia group in processing facial expressions. The event-related potential results showed that the high alexithymia group had more negative-going N400 amplitudes compared with the low alexithymia group in the incongruent condition. More negative N400 amplitudes are also associated with slower responses to facial expressions. Furthermore, machine learning analyses based on N400 amplitudes could distinguish the high alexithymia group from the low alexithymia group in the incongruent condition. Overall, these findings suggest worse facial emotion perception for the high alexithymia group, potentially due to difficulty in spontaneously activating emotion concepts. Our findings have important implications for the affective science and clinical intervention of alexithymia-related affective disorders.

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

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

Neurotypical, but not autistic, adults might experience distress when looking at someone avoiding eye contact: A live face-to-face paradigm

LAY ABSTRACT

What is already known about the topic?Autistics are usually reported to share less eye contact than neurotypicals with their interlocutors. However, the reason why autistics might pay less attention to eyes looking at them is still unknown: some autistics express being hyper-aroused by this eye contact, while some eye-tracking studies suggest that eye contact is associated with hypo-arousal in autism.What this paper adds?This study is based on a highly controlled live face-to-face paradigm, combining a wearable eye-tracker (to study eye behaviours) with electrodermal activity sensors (to assess potential stress). We draw a nuanced picture of social attention in autism, as our autistic participants did not differ from our neurotypical group in their eye behaviours nor their skin conductance responses. However, we found that neurotypicals, compared to autistics, seemed to be much more distressed when their interlocutor did not gaze at them during the experiment.Implications for practice, research or policy:Our study encourages to consider social interaction difficulties in autism as a relational issue, instead as an individual deficit. This step might be first taken in research, by implementing paradigms sensitive to the experimenter's role and attitude.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Social cognition in chronic migraine with medication overuse: a cross-sectional study on different aspects of mentalization and social relationships

BACKGROUND

Social cognition refers to all mental operations to decipher information needed in social interactions. Here we aimed to outline the socio-cognitive profile of Chronic Migraine with Medication Overuse (CM + MO), given they are recognized to be at risk of socio-cognitive difficulties. Given the multidimensionality of this construct, we considered: (1) socio-cognitive abilities, (2) socio-cognitive beliefs, (3) alexithymia and autism traits, and (4) social relationships.

METHODS

Seventy-one patients suffering from CM + MO, 61 from episodic migraine (EM), and 80 healthy controls (HC) were assessed with a comprehensive battery: (1) the Faux Pas test (FP), the Strange Stories task (SS), the Reading Mind in the Eyes test (RMET), (2) the Tromsø Social Intelligence Scale, (3) the Toronto Alexithymia Scale, the Autism Spectrum Quotient, (4) the Lubben Social Network Scale, the Friendship Scale.

RESULTS

CM + MO: (1) performed similar to EM but worse than HC in the FP and SS, while they were worse than EM and HC in the RMET; (2) were similar to EM and HC in social intelligence; (3) had more alexithymic/autistic traits than EM and HC; (4) reported higher levels of contact with their family members but felt little support from the people around them than HC.

CONCLUSIONS

CM + MO results characterized by a profile of compromised socio-cognitive abilities that affects different dimensions. These findings may have a relevant role in multiple fields related to chronic headache: from the assessment to the management.

Sex-specific mechanisms for eating disorder risk in men and women with autistic traits: the role of alexithymia

BACKGROUND

A poorly understood relationship exists between eating disorders (ED) and autism spectrum conditions (ASC: henceforth 'autism'). ED are more prevalent in autistic people and people with high autistic traits, and autistic features are prognostic of longer illness. Aiming to understand what increases the risk of ED in relation to autism and autistic traits, previous research has implicated alexithymia as a causal mechanism in this relationship. These studies could not, however, disentangle whether alexithymia explains the relationship between ED pathology and autistic traits directly or through its impact on anxious/depressive symptoms, which in turn result in higher ED symptomatology. Moreover, despite evidence for sex differences in the aetiology of ED, little research has examined the impact of sex on these relationships.

METHODS

Focusing on the association between autistic traits and ED psychopathology, we examined independent mediating effects of alexithymia and anxious/depressive symptoms, as well as sequential mediation effects where alexithymia affects ED psychopathology via its impact on anxious/depressive symptoms. Participants were 198 men and 265 women with formally diagnosed and suspected ED, who completed an online survey of standardised scales.

RESULTS

In men, higher autistic traits were associated with ED psychopathology sequentially via greater alexithymia and through that, greater depressive/anxious symptoms. In women, alexithymia mediated the relationship between autistic traits and ED psychopathology both directly and sequentially through its impact on anxious/depressive symptoms. Interestingly, depressive/anxious symptoms also mediated that relationship independently from alexithymia.

CONCLUSIONS

While cross-sectional, these findings suggest that the relationship between autistic traits and ED symptomatology is mediated by other variables. In support of its proposed role in the aetiology of ED, alexithymia was directly associated with ED symptoms in women. It also affected ED symptoms indirectly, in all participants, via its effect on depressive/anxious symptoms. Interventions focusing on alexithymia may facilitate recovery not only via their effect on ED, but via their effect on other forms of state psychopathology which contribute to the maintenance and development of ED. Sex differences, however, reflect that alternative therapeutic targets for men and women may be beneficial.

Prevalence of and factors associated with alexithymia among patients with chronic obstructive pulmonary disease in China: a cross-sectional study

BACKGROUND

Alexithymia is a common psychological disorder. However, few studies have investigated its prevalence and predictors in patients with chronic obstructive pulmonary disease (COPD). Therefore, we aimed to determine the prevalence and predictors of alexithymia in Chinese patients.

METHODS

This cross-sectional study included 842 COPD patients to assess the prevalence and predictors of alexithymia using the 20-item Toronto Alexithymia Scale (TAS-20). We used the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression, the modified British Medical Research Council dyspnea Rating Scale (mMRC) to assess dyspnea, St. George's Respiratory Questionnaire (SGRQ) to assess quality of life, and the age-adjusted Charlson comorbidity index (ACCI) to assess comorbidities. Alexithymia-related predictors were identified using univariate and multivariate logistic regression analyses.

RESULTS

The prevalence of alexithymia in COPD patients was 23.6% (199/842). Multivariate analysis showed that age [odds ratio (OR) 0.886; 95% confidence interval (CI) 0.794-0.998], body mass index (OR 0.879; 95% CI 0.781-0.989), HADS-anxiety (OR 1.238; 95% CI 1.097-1.396), HADS-depression (OR 1.178; 95% CI 1.034-1.340), mMRC (OR 1.297; 95% CI 1.274-1.320), SGRQ (OR 1.627; 95% CI 1.401-1.890), ACCI (OR 1.165; 95% CI 1.051-1.280), and GOLD grade (OR 1.296; 95% CI 1.256-1.337) were independent predictors for alexithymia in patients with COPD.

CONCLUSIONS

The prevalence of alexithymia was high in Chinese COPD patients. Anxiety, depression, dyspnea, quality of life, comorbidities, and disease severity are independent risk factors, and age and BMI are predictive factors for alexithymia in COPD patients.

Attention-deficit hyperactivity disorder traits are a more important predictor of internalising problems than autistic traits

Autism Spectrum Disorder (ASD) and Attention-Deficit Hyperactivity Disorder (ADHD) are both linked to internalising problems like anxiety and depression. ASD and ADHD also often co-occur, making their individual statistical contributions to internalising disorders difficult to investigate. To address this issue, we explored the unique associations of self-reported ASD traits and ADHD traits with internalising problems using a large general population sample of adults from the United Kingdom (N = 504, 49% male). Classical regression analyses indicated that both ASD traits and ADHD traits were uniquely associated with internalising problems. Dominance and Bayesian analyses confirmed that ADHD traits were a stronger, more important predictor of internalising problems. However, brief depression and anxiety measures may not provide a comprehensive index of internalising problems. Additionally, we focused on recruiting a sample that was representative of the UK population according to age and sex, but not ethnicity, a variable that may be linked to internalising disorders. Nevertheless, our findings indicate that while ASD and ADHD uniquely predict internalising problems, ADHD traits are a more important statistical predictor than ASD traits. We discuss potential mechanisms underlying this pattern of results and the implications for research and clinical practice concerning neurodevelopmental conditions.

Ansiedad y trastornos del espectro del autismo: notas para la intervención psicoeducativa

Se analizan de forma narrativa las relaciones entre comportamiento sensorial atípico, intolerancia a la incertidumbre y regulación emocional como generadores de los trastornos de ansiedad en niños y niñas autistas. El objetivo es estudiar el origen de la ansiedad en los niños y niñas autistas con la finalidad de determinar cuál o cuáles pueden ser los procedimientos de intervención más adecuados. Se han revisado algunos de los programas de intervención cognitivo-conductuales más utilizados en niños y niñas autistas y las adaptaciones realizadas a los mismos. Se observa un divorcio entre los programas psicoeducativos escolares y los programas clínicos de intervención para el tratamiento de la ansiedad. Como conclusión, se recomienda que en los programas psicoeducativos escolares se incorporen acciones proactivas en forma de programas de intervención cognitivo-conductuales para evitar o aminorar los efectos negativos de la ansiedad en el aprendizaje e inclusión escolar de los niños y las niñas autistas.

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

Background

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

Method

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

Results

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

Limitations

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

Discussion

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

Supplementary Information

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

Differences in social brain function in autism spectrum disorder are linked to the serotonin transporter: A randomised placebo-controlled single-dose crossover trial

BACKGROUND

Alterations in the serotonergic control of brain pathways responsible for facial emotion processing in people with autism spectrum disorder (ASD) may be a target for intervention. However, the molecular underpinnings of autistic-neurotypical serotonergic differences are challenging to access in vivo. Receptor-Enriched Analysis of functional Connectivity by Targets (REACT) has helped define molecular-enriched functional magnetic resonance imaging (fMRI) brain networks based on a priori information about the spatial distribution of neurochemical systems from available PET templates.

METHODS

We used REACT to estimate the dominant fMRI signal related to the serotonin (5-HT) transporter (SERT) distribution during processing of aversive facial emotion in adults with and without ASD. We first predicted a group difference in baseline (placebo) functioning of this system. We next used a single 20 mg oral dose of citalopram, a serotonin reuptake inhibitor, to test the hypothesis that network activity in people with and without ASD would respond differently to inhibition of SERT. To confirm the specificity of our findings, we also repeated the analysis with 5-HT1A, 5-HT1B, 5-HT2A and 5-HT4 receptor maps.

RESULTS

Using REACT with the SERT map, we found a baseline group difference in the SERT-enriched response to faces in the ventromedial prefrontal cortex. A single oral dose of citalopram 'shifted' the response in the ASD group towards the neurotypical baseline but did not alter response in the control group. Similar differences in SERT-enriched response were observed after controlling for other 5-HT maps.

CONCLUSIONS

Our findings suggest that the SERT-enriched functional network is dynamically different in ASD during processing of socially relevant stimuli. Whether this acute neurobiological response to citalopram in ASD translates to a clinical target will be an important next step.

Anxiety and Trauma-Related Disorders in Children on the Autism Spectrum

PURPOSE OF REVIEW

To summarize recent findings regarding anxiety and trauma-related disorders in children diagnosed with autism spectrum disorder (autism), focusing on the distinct ways in which these conditions may be expressed, as well as advances in evidence-based assessment and treatment.

RECENT FINDINGS

Current findings suggest both anxiety and trauma-related disorders may be more prevalent, yet more complicated to address in autistic relative to non-autistic children. Overlapping symptoms and distinct manifestations of these disorders pose challenges for the accurate identification, assessment, and treatment of anxiety and trauma-related disorders in autistic children. Emerging evidence recommends adapting traditional assessment and treatment approaches to better meet the needs of autistic children. Recent research suggests autism-centered conceptualizations, which accommodate complexity in how anxiety and trauma-related disorders are experienced and expressed by autistic people, are needed to enhance the psychiatric care of this population.

What Is Autistic Burnout? A Thematic Analysis of Posts on Two Online Platforms

Background

Compared with adults in the general population, autistic adults are more likely to experience poor mental health, which can contribute to increased suicidality. While the autistic community has long identified autistic burnout as a significant mental health risk, to date, only one study has been published. Early research has highlighted the harmful impact of autistic burnout among autistic adults and the urgent need to better understand this phenomenon.

Methods

To understand the lived experiences of autistic adults, we used data scraping to extract public posts about autistic burnout from 2 online platforms shared between 2005 and 2019, which yielded 1127 posts. Using reflexive thematic analysis and an inductive "bottom-up" approach, we sought to understand the etiology, symptoms, and impact of autistic burnout, as well as prevention and recovery strategies. Two autistic researchers with self-reported experience of autistic burnout reviewed the themes and provided insight and feedback.

Results

We identified eight primary themes and three subthemes across the data. (1) Systemic, pervasive lack of autism awareness. (1.1) Discrimination and stigma. (2) A chronic or recurrent condition. (3) Direct impact on health and well-being. (4) A life unlived. (5) A blessing in disguise? (6) Self-awareness and personal control influence risk. (6.1) "You need enough balloons to manage the weight of the rocks." (7) Masking: Damned if you do, damned if you don't. (8) Ask the experts. (8.1) Stronger together. The overarching theme was that a pervasive lack of awareness and stigma about autism underlie autistic burnout.

Conclusions

We identified a set of distinct yet interrelated factors that characterize autistic burnout as a recurring condition that can, directly and indirectly, impact autistic people's functioning, mental health, quality of life, and well-being. The findings suggest that increased awareness and acceptance of autism could be key to burnout prevention and recovery.

Alexithymic and autistic traits in children and adolescents: A systematic review of the current state of knowledge

LAY ABSTRACT

In this study, we aim to explore the ability of autistic children to process emotions and respond to a range of feelings in relation to a triad of difficulties known as alexithymia, namely children's difficulties to recognize, describe, and distinguish emotions. Alexithymia is common in autistic adults but we know very little about children. To understand this condition better, within a large group of studies, first we study the extent to which alexithymia difficulties are present in autistic children. In reviewing the literature, we also present the assessment measures implemented in each study, their limitations, and potential effects on our understanding of findings. This knowledge will help us understand the extent to which alexithymia is present in autistic children and how it may be related to their emotional difficulties. Also, it will allow us to further detect challenges early on in children's lives so that we recommend interventions that teach autistic children how to recognize, describe, and distinguish emotions in themselves and in others. Such interventions may include family members of autistic children to assist interactions with their child. Supporting children from an early age will help them develop skills that will ready them for school and life and it will enhance their ability to build supportive relationships and meet their fullest potential.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Effect of Alexithymia on Internet Addiction Among College Students: The Mediating Role of Metacognition Beliefs

Background: Previous studies have found that alexithymia plays an important role in the pathogenesis of Internet addiction. However, the effect of alexithymia on both metacognition and Internet addiction has yet to be examined. Methods: The Toronto Alexithymia Scale, Metacognition Questionnaire, and Internet Addiction Test were used to assess a sample of 356 college students. A parallel mediator effect analysis was applied to test the hypothesis that metacognition mediates the relationship between alexithymia and Internet addiction. Results: The parallel multiple mediator models showed that alexithymia predicted the five dimensions of metacognition and Internet addiction, and that three dimensions-cognitive confidence, positive beliefs about worry, and the need to control thoughts-partially mediated this relationship. Conclusion: Alexithymia could directly and indirectly predict Internet addiction via metacognition.

Integration and Causality in Enactive Approaches to Psychiatry

In this paper I address what has been called the integration problem in psychiatry. This problem is tied to conceptions of causality and explanatory levels in our understanding of mind. I take an interdisciplinary enactive perspective to develop a 3-fold method for exploring the dynamics of integration, based on a concept of dynamical causation and a non-hierarchical (level-free) notion of gestalt. I also consider Autism Spectrum Disorder (ASD) as a test case.

Alexithymia and Autistic Traits: Associations With Social and Emotional Challenges Among College Students

Background: Alexithymia is a multifaceted personality construct defined by marked difficulties in identifying and describing feelings and in externally oriented thinking. Given its intrinsic role in social-emotional processing, alexithymia is now recognized as a trans-diagnostic trait in a range of neurodevelopmental disorders, including autism. Research has pinpointed to the co-occurrence of autism with characteristics typical of alexithymic normative samples, such as social-communication difficulties and decreased emotion regulation abilities. Nonetheless, the role of individual facets of alexithymia in predicting challenges in social communication functioning is still understudied. Methods: In total, 275 young adults completed the Toronto Alexithymia Scale, the Autism Spectrum Quotient (short form), the Interpersonal Competence Questionnaire, and the Difficulties in Emotion Regulation Scale self-reported questionnaires for assessing alexithymic and autistic traits, social-communication abilities, and emotion regulation difficulties. We used regression models to establish cross-sectional associations between autism, alexithymia, and social-emotional difficulties. Also, we ran a parallel mediation analysis to determine whether the relationship between autistic traits and emotion regulations challenges are mediated by Alexithymia facets. Results: Analysis showed a significant positive association between autistic traits and alexithymic traits and between autistic traits and emotion regulation difficulties while, as expected, autistic traits were negatively correlated with social skills. A significant relationship was found among the participants' levels of alexithymia and their interpersonal skills with two of three alexithymic subscales significantly contributing to the model. Similarly, a significant relationship was found among alexithymia subscales and emotion regulation difficulties with all three alexithymia subscales being statistically significant. Finally, analysis on two mediator models indicated a significant effect of autistic traits on social skills mediated by alexithymic traits as well as a significant indirect effect of autistic traits on emotion regulation difficulties mediated by alexithymic traits. Conclusion: The results of this study provide evidence of the influence of different alexithymic facets on the relationship between autistic traits and social-emotional challenges in young adults. Longitudinal studies may explore further alexithymia and its associations with social-emotional difficulties in autism as well as the potential implications of these findings in intervention and treatment programs.

The Mediating Effects of Alexithymia, Intolerance of Uncertainty, and Anxiety on the Relationship Between Sensory Processing Differences and Restricted and Repetitive Behaviours in Autistic Adults

Distress caused by sensory processing differences for autistic individuals may be reduced by repetitive behaviours (RRB), including repetitive motor (RMB) and insistence on sameness (ISB) behaviours. Intolerance of uncertainty (IU) and anxiety mediate the relationship between sensory processing and RRB in autistic children. We replicated this model in autistic adults, extending it to include alexithymia. Serial mediation, using data from 426 autistic adults, identified significant direct effects from sensory processing to RMB and ISB, and indirect effects through alexithymia-IU-anxiety for RMB, and IU alone, and alexithymia-IU for ISB. Different mechanisms may underpin RMB and ISB. Alexithymia alongside, IU and anxiety, should be considered when understanding the relationship between sensory processing and RRB, and when offering interventions to support autistic people.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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