Verbal measures of alexithymia: what do they measure

Objective and Subjective Measurement of Alexithymia in Adults with Autism

High rates of alexithymia, a condition characterised by difficulties identifying and describing emotions, are frequently reported in both children and adults with autism spectrum disorder (ASD). However, the dilemma of measuring alexithymia via self-report has rarely been addressed. In this study, we compared objective and subjective measures of alexithymia in adults with ASD and typically developing adults. We found significantly higher levels of alexithymia in the ASD sample as measured by both self-report on the Toronto Alexithymia Scale (TAS-20) and by the observer rated Alexithymia Provoked Response Scale (APRQ). However, the two measures did not correlate with each other. We explore the different facets of the alexithymia construct that these two measures may be distinguishing.

Psychophysiological and Neural Support for Enhanced Emotional Reactivity in Female Adolescents With Nonsuicidal Self-injury

BACKGROUND

Nonsuicidal self-injury (NSSI) is prevalent in adolescent populations worldwide. Emotion dysregulation is believed to contribute to NSSI, but underlying mechanisms are less known. We combined psychophysiological and neural data with subjective self-report in close temporal proximity to examine the mechanisms underlying emotion processing in adolescents with NSSI relative to control adolescents without a psychiatric diagnosis.

METHODS

Thirty female adolescents with NSSI and 30 age-matched female control subjects were included in this case-control study. Participants were presented with negative affective pictures during a functional magnetic resonance imaging scan. In a separate facial electromyography session, the same participants were shown positive and negative affective images and also provided ratings of valence and arousal.

RESULTS

Participants with NSSI responded to affective images with greater positive (e.g., zygomatic) and greater negative (e.g., corrugator) reactivity. We found no differences in self-reported affect in response to the images. Analyses of the negative picture-viewing functional magnetic resonance imaging data showed a significant positive correlation between anterior insula response and the averaged electromyography magnitude in NSSI, but not in control subjects.

CONCLUSIONS

Adolescents with NSSI show enhanced emotional reactivity that is associated with anterior insula responding, but no abnormalities in self-reported affect. This discrepancy between self-report and objective measures of emotional reactivity potentially indicates a suppression of the emotional reaction in adolescents with NSSI. Moreover, the current data suggest potential targets for novel therapeutic approaches that can be combined with existing clinical treatment, such as real-time electromyography-based biofeedback focusing on emotional awareness, labeling, and expressing emotional experiences.

Emotion regulation group skills training for adolescents and parents: A pilot study of an add-on treatment in a clinical setting

Difficulties with emotion regulation have been identified as an underlying mechanism in mental health. This pilot study aimed at examining whether group skills training in emotion regulation for adolescents and parents as an add-on intervention was feasible in an outpatient child and adolescent psychiatric clinic. We also investigated if the treatment increased knowledge and awareness of emotions and their functions, increased emotion regulation skills and decreased self-reported symptoms of anxiety and depression. Six skills training groups were piloted with a total of 20 adolescents and 21 adults. The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired-samples t test was used to compare differences between before-and-after measures for adolescents and parents separately. The primary outcome measure, Difficulties in Emotion Regulation Scale, showed significant improvement after treatment for both adolescents and parents. For adolescents, measures of alexithymia were significantly reduced. Also, emotional awareness was significantly increased. Measures of depression and anxiety did not change. In conclusion, group skills training as an add-on treatment can be feasible and effective but further studies are needed.

Nonsuicidal Self-Injury Disorder in Adolescents: Clinical Utility of the Diagnosis Using the Clinical Assessment of Nonsuicidal Self-Injury Disorder Index

Nonsuicidal self-injury disorder (NSSID) is a condition in need of further study, especially in adolescent and clinical populations where it is particularly prevalent and studies are limited. Twenty-nine clinical self-injuring adolescents were included in the study. The Clinical Assessment of Nonsuicidal Self-Injury Disorder Index (CANDI) was used to assess prevalence of NSSID. The NSSID diagnosis criteria were met by 62.1% of adolescents. The impairment or distress criterion was least often met. Criteria B and C (assessing reasons for NSSI and cognitions/emotions prior to NSSI) were confirmed by 96-100% of all participants. Adolescents with NSSI in this clinical sample had several comorbidities and high levels of psychopathology. NSSID occurred both in combination with and independently of borderline personality disorder traits as well as suicide plans and attempts. Those with NSSID had a significantly higher cutting frequency than those not meeting full NSSID criteria. Other NSSI characteristics, comorbidity, psychopathology, and trauma experiences did not differ between groups. CANDI was a feasible tool to assess NSSID in adolescents. It is important to use structured measures to assess the validity of the NSSID diagnosis across development in both community and clinical samples. The clinical utility of the NSSID diagnosis is discussed.

Emotion regulation group skills training: a pilot study of an add-on treatment for eating disorders in a clinical setting

BACKGROUND

Emotion regulation difficulties appear to play a role in the development and maintenance of several eating disorders. This pilot study aimed at examining whether a short add-on group skills training in emotion regulation for young adults with different eating disorders was feasible in a psychiatric clinical setting. We also investigated if the treatment increased knowledge of emotions, and decreased self-reported difficulties with emotion regulation, alexithymia, symptoms of eating disorder, anxiety and depression, as well as clinical impairment.

METHODS

Six skills training groups were piloted with a total of 29 participants (M = 21.41 years, SD = 1.92). The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired samples t-test was used to compare differences between before-and-after measures.

RESULTS

The primary outcomes measures difficulties in emotion regulation (p <  0.001) and alexithymia (p <  0.001) showed significant improvement after treatment. The total eating disorder score (p = 0.009) was also significantly reduced, as was clinical impairment (p <  0.001). Acceptance/valued direction, identifying primary emotions and learning about secondary emotions was rated as especially helpful.

CONCLUSIONS

This preliminary pilot study showed that group training targeting emotion regulation skills was feasible and appreciated by participants, as well as being potentially promising as an adjunctive treatment for different eating disorders. Further controlled studies are needed.

TRIAL REGISTRATION

The study was retrospectively registered NCT04148014 on October 30th 2019.

Alexithymia and emotional reactions to odors

Alexithymia is a psychological construct characterized by deficits in processing emotional stimuli. However, little is known about the processing of odours in alexithymia, even though there is extensive proof that emotion and olfaction are closely linked. The present study is aimed at investigating how alexithymic individuals process emotions conveyed by odors. Emotional responses to unpleasant, neutral odors and clean air were collected through self-report ratings and psychophysiological measures in a sample of 62 healthy participants with high (HA), medium (MA) and low (LA) levels of alexithymia. Moreover, participants performed tests on odors identification and threshold and completed questionnaires assessing olfactory imagery and awareness. Two main results have been found: first, HA and MA groups showed altered physiological responses to odors, compared to LA, while no differences among the groups were observed in odor ratings; and second, affective and cognitive alexithymia components were differently associated with the performance on olfactory tests, skin conductance response to odors, reaction times in the rating task, and scores on olfactory questionnaires. We conclude that alexithymia is characterized by altered physiological reactions to olfactory stimuli; moreover, we stress the importance of evaluating the different alexithymia components since they affect emotional stimuli processing in different ways.

Normal interoceptive accuracy in women with bulimia nervosa

Previous studies suggest that patients suffering from bulimia nervosa (BN) have difficulties in perceiving internal bodily signals, mostly assessed by self-report questionnaires. Whether interoception is, in this case, attenuated or not remains an open question. Therefore, interoceptive processes were examined in twenty-three patients with current BN and were compared to healthy participants. We investigated Interoceptive Accuracy (IAc) assessed by the heartbeat detection task and Interoceptive Awareness (IA) assessed by the Eating Disorder Inventory-2. Patients with BN and healthy participants did not differ in terms of IAc when controlling for BMI, depression and anxiety, whereas IA among BN patients was found to have decreased. Although IAc and IA were not related among controls, we observed an inverse correlation in BN, suggesting that an abnormal overlap between these two levels of interoceptive signal processing is present in BN. The current study introduces a new perspective concerning the role of interoceptive processes in BN and generates further questions regarding the therapeutic utility of methods targeting the interaction between different levels of interoception in the treatment of BN.

Alexithymic Trait, Painful Heat Stimulation, and Everyday Pain Experience

BACKGROUND

Alexithymia was found to be associated with a variety of somatic complaints, including somatoform pain symptoms. This study addressed the question of whether the different facets of alexithymia are related to responses in heat pain stimulation and its interrelations with levels of everyday pain as assessed by self-report.

METHODS

In the study, sensitivity to heat pain was assessed in 50 healthy female participants. Alexithymia facets were assessed by the Toronto Alexithymia Scale. Pain threshold and tolerance were determined using a testing the limits procedure. Participants, furthermore, rated subjective intensities and unpleasantness of tonic heat stimuli (45.5-47.5°C) on visual analog scales and on a questionnaire. Possible confounding with temperature sensitivity and mood was controlled. Everyday pain was assessed by self-report addressing everyday pain frequency, intensity, and impairment experienced over the last 2 months.

RESULTS

Main results were that the facets of alexithymia were differentially associated with pain perception. The affective scale "difficulties in describing feelings" was associated with hyposensitivity to pain as indicated by higher pain tolerance scores. Furthermore, everyday pain frequency was related to increased alexithymia values on the affective scale "difficulties in identifying feelings," whereas higher values on the cognitive alexithymia scale "externally oriented thinking" were related to lower pain impairment and intensity.

CONCLUSION

We conclude that the different facets of alexithymia are related to alternations in pain processing. Further research on clinical samples is necessary to elucidate whether different aspects of alexithymia act as a vulnerability factor for the development of pain symptoms.

Electrophysiologic evidence for multilevel deficits in emotional face processing in patients with bulimia nervosa

BACKGROUND

Empirical evidence suggests substantial deficits regarding emotion recognition in bulimia nervosa (BN). The aim of the current study was to investigate electrophysiologic evidence for deficits in emotional face processing in patients with BN.

METHODS

Event-related potentials were recorded from 13 women with BN and 13 matched healthy controls while viewing neutral, happy, fearful, and angry facial expressions. Participants' recognition performance for emotional faces was tested in a subsequent categorization task. In addition, the degree of alexithymia, depression, and anxiety were assessed via questionnaires.

RESULTS

Categorization of emotional faces was hampered in BN (p = .01). Amplitudes of event-related potentials differed during emotional face processing: face-specific N170 amplitudes were less pronounced for angry faces in patients with BN (mean [M] [standard deviation {SD}] = 1.46 [0.56] µV versus M [SD] = -1.23 [0.61] µV, p = .02). In contrast, P3 amplitudes were more pronounced in patients with BN as compared with controls (M [SD] = 2.64 [0.46] µV versus M [SD] = 1.25 [0.39] µV, p = .04), independent of emotional expression.

CONCLUSIONS

The study provides novel electrophysiologic data showing that emotional faces are processed differently in patients with BN as compared with healthy controls. We suggest that deficits in early automatic emotion classification in BN are followed by an increased allocation of attentional resources to compensate for those deficits. These findings might contribute to a better understanding of the impaired social functioning in BN.

The relationship between alexithymia and psychological factors in systemic lupus erythematosus

BACKGROUND

Alexithymia has been described as an important dimension in several medical diseases. Systemic lupus erythematosus (SLE) is a chronic condition characterized by unpredictable clinical manifestations. Our aim is to reveal which factors (psychological factors and quality of life dimensions) are associated with alexithymia in SLE patients.

METHODS

Fifty-three sequential SLE patients (ACR criteria) and 41 asthma patients were studied by means of validated scales for alexithymia (Toronto Alexithymia Scale), psychopathology (Brief Symptom Inventory, Hospital Anxiety and Depression Scale), personality dimensions (NEO-FFI), and quality of life (Short Form-36 Health Survey). Systemic lupus erythematosus patient's clinical and laboratorial evaluation was performed by indicators of activity (Systemic Lupus Erythematosus Disease Activity Index) of accumulated damage (Systemic Lupus International Collaborating Clinics/ACR Damage Index), length of disease, and therapy.

RESULTS

An association between alexithymia and psychopathological symptoms, and personality and quality of life dimensions was found. By means of multiple regression analysis, openness and depression were the 2 predictors for alexithymia in SLE patients. We found a high prevalence rate of alexithymia in SLE patients; however, when controlling for depression symptoms (Hospital Anxiety and Depression Scale-Depression, <7), we found a lower percentage of alexithymic traits than that of the total sample of SLE.

CONCLUSION

Alexithymia was associated with psychological distress and with quality of life impairment. Understanding the role of psychological factors in SLE patients may contribute to a more comprehensive perspective of the disease, its impact on patient's daily routine, and how patients adapt emotionally to a chronic disease.

Differential effects of alexithymia subscales on autonomic reactivity and anxiety during social stress

OBJECTIVES

Alexithymia is characterized by a difficulty in identifying and describing one's emotions. Recent research has associated differential effects of the alexithymia facets to hypothalamic-pituitary-adrenal (HPA) axis markers during stress. This study aimed to analyze how the facets of alexithymia interact with autonomic reactivity as well as self- and observer-rated anxiety during a social stress task.

METHODS

With the use of a public-speaking paradigm, skin conductance levels (SCLs) and heart rate (HR) during the defined periods of baseline, preparation, stress, and recovery were assessed in 60 volunteers (42 females, mean age 22.8) categorized as having either high (HDA) or low (LDA) degrees of alexithymia.

RESULTS

We found smaller SCLs during preparation and speech in the HDA group. Regression analyses indicated that only the alexithymia facet "difficulty in describing feelings" (DDF) was associated with smaller electrodermal responses. In the HDA group, self- and observer-rated anxiety was higher in the HDA than in the LDA group, which was attributable to higher scores in the subscales "difficulty in identifying feelings" (DIF) and "externally oriented thinking" (EOT).

CONCLUSIONS

Our data support and specify the decoupling hypothesis of alexithymia by showing that the facets of alexithymia are differentially related to autonomic reactivity as well as self- and observer-rated anxiety during social stress.

Chronic idiopathic urticaria and anxiety symptoms

Chronic idiopathic urticaria (CIU) is a frequently disabling disease with a negative influence on the quality of life, and can cause psychopathological symptoms, such as anxiety. Our aim is to study further anxiety symptoms on CIU patients. Both CIU patients and the control group were studied by means of validated scales for psychopathology symptoms, psychological variables and quality of life. In this study, we reported high levels of anxiety symptoms. We found statistically significant correlations between anxiety symptoms, some personality dimensions, insecure attachment styles, alexithymia and with some quality of life dimensions. CIU patients exhibit high levels of psychological distress that could potentiate difficulties at several domains, namely social, emotional, general health perception and interpersonal relationships.

Does the 20-item Toronto Alexithymia Scale measure alexithymia? A study of natural language use

Construct validity of the 20-item Toronto Alexithymia Scale (TAS-20) was investigated by analyzing natural language use. It was hypothesized that the TAS-20 should be related to a lower use of emotion words and fewer references to social processes. 32 clinical interviews with mental health outpatients were analyzed with four categories of the computerized Linguistic Inquiry and Word Count dictionary: positive emotions, negative emotions, references to others, and communication words. The Difficulty Identifying Feelings subscale was positively related to negative emotion words, the Difficulty Describing Feelings subscale showed no relevant associations, and the Externally Oriented Thinking subscale was related to reduced use of positive emotion words and social process words. It is concluded that in this sample, the Externally Oriented Thinking subscale provides the best operationalization of the alexithymia construct.

Reduced perception of bodily signals in anorexia nervosa

OBJECTIVE

Interoceptive awareness is known to be impaired in eating disorders. To date, it has remained unclear whether this variable is related to the construct of interoceptive sensitivity. Interoceptive sensitivity is considered to be an essential variable in emotional processes. The objective of the study was to elucidate this potential relationship and to clarify whether general interoceptive sensitivity is reduced in anorexia nervosa.

METHODS

Using a heartbeat perception task, interoceptive sensitivity was assessed in 28 female patients with anorexia nervosa and 28 matched healthy controls. Questionnaires assessing interoceptive awareness (EDI) and several other variables were also administered.

RESULTS

Patients with anorexia nervosa displayed significantly decreased interoceptive sensitivity. They also had more difficulties in interoceptive awareness.

CONCLUSIONS

In addition to a decreased ability to recognize certain visceral sensations related to hunger, there is a generally reduced capacity to accurately perceive bodily signals in anorexia nervosa. This highlights the potential importance of interoceptive sensitivity in the pathogenesis of eating disorders.

Deficits in early emotional reactivity in alexithymia

Alexithymia is characterized by a difficulty in identifying and describing one's emotions. This study addressed the question of whether alexithymic tendencies are related to limited affective reactivity to briefly presented emotional stimuli. Skin conductance responses were assessed and backward masking was used to minimize elaborated processing of emotional pictures. Results indicated that alexithymic tendencies are associated with smaller electrodermal responses to briefly presented negative pictures. These effects were driven by difficulties in identifying and communicating emotions whereas externally orientated thinking was unrelated to affective reactivity. We conclude that there is an early processing deficit in response to negative stimuli in participants with high scores in alexithymia. Differences in the early emotional reactivity to arousing material could contribute to difficulties in emotional processes related to alexithymia.

Impaired central processing of emotional faces in anorexia nervosa

OBJECTIVES

To elucidate the potential relationship between classification of emotional faces and impaired central processing in eating disorders and to investigate the potential mediatory role of alexithymia and depression in this relationship.

METHODS

Visual-evoked potentials (VEPs) to emotional faces and classification performance were assessed in 12 anorexic females and matched healthy controls.

RESULTS

Patients with anorexia nervosa showed no modulation of emotional face processing and displayed significantly increased N200 amplitudes in response to all emotional categories and decreased VEPs in response to unpleasant emotional faces in the P300 time range as compared with healthy controls. They also made more mistakes in emotional face recognition, in particular, for neutral, sad, and disgusted content.

CONCLUSIONS

There are marked differences in evoked potentials and emotion recognition performances of patients with anorexia nervosa and controls in facial processing. Differences in brain dynamics might contribute to difficulties in the correct recognition of facially expressed emotions, deficits in social functioning, and in turn the maintenance of eating disorders.

An investigation of the construct validity of the 20-Item Toronto Alexithymia Scale through the use of a verbalization task

OBJECTIVE

The construct validity of the 20-Item Toronto Alexithymia Scale (TAS-20) was examined through a verbalization task requiring participants to discuss a past distressing event.

METHODS

Verbalizations were transcribed and coded for the frequency and number of different negative and positive emotion words used. Relationships between the TAS-20 and these variables were examined.

RESULTS

Controlling for negative affect (NA), the difficulty identifying feelings (DIF) subscale was positively associated with the frequency of negative emotion words used and negatively associated with the frequency and number of different positive emotion words used during the verbalization task. High, compared with low, scoring TAS-20 participants used a lower frequency of and fewer different positive emotion words.

CONCLUSION

The TAS-20 may be measuring negative emotional expressivity separate from negative affectivity, as well as a reduced capacity to access and elaborate upon positive emotion. Findings are discussed in regard to improving the conceptualization and measurement of emotional deficits in alexithymia.

Conversion disorder and multiple chemical sensitivity: a comparative study of psychological defense strategies

This study compared psychological defensive strategies in two groups of patients with multiple chemical sensitivity (n = 10) and conversion disorder (n = 10) by means of the projective perceptual Defense Mechanism Test. We attempted to create a model for personality assessment based on the test data of prior patients, in which new patients could successively be tested. The overall results indicated that it was possible to separate the clinical groups significantly from a control group and from each other. In comparison to the controls, the clinical groups were characterized by patterns that were more nonemotionally adapted as well by a lateness of perception, but the ways in which the clinical groups maintained this difference were not the same. The multiple chemical sensitivity group was characterized above all by blocking maneuvers, while the main defensive strategy of the conversion disorder group was distortion of content.